Conservation of both hematocrit and liver regeneration in hepatectomies: a vascular occlusion approach in rats / Hepatectomia hemoconservadora no rato: preservação do hematócrito e da regeneração hepática

ABSTRACT Background: Hepatectomies promote considerable amount of blood loss and the need to administrate blood products, which are directly linked to higher morbimortality rates. The blood-conserving hepatectomy (BCH) is a modification of the selective vascular occlusion technique. It could be a surgical maneuver in order to avoid or to reduce the blood products utilization in the perioperative period. Aim: To evaluate in rats the BCH effects on the hematocrit (HT) variation, hemoglobin serum concentration (HB), and on liver regeneration. Methods: Twelve Wistar rats were divided into two groups: control (n=6) and intervention (n=6). The ones in the control group had their livers partially removed according to the Higgins and Anderson technique, while the rats in the treatment group were submitted to BCH technique. HT and HB levels were measured at day D0, D1 and D7. The rate between the liver and rat weights was calculated in D0 and D7. Liver regeneration was quantitatively and qualitatively evaluated. Results: The HT and HB levels were lower in the control group as of D1 onwards, reaching an 18% gap at D7 (p=0.01 and p=0.008, respectively); BCH resulted in the preservation of HT and HB levels to the intervention group rats. BCH did not alter liver regeneration in rats. Conclusion: The BCH led to beneficial effects over the postoperative HT and serum HB levels with no setbacks to liver regeneration. These data are the necessary proof of evidence for translational research into the surgical practice.

RESUMO Racional: As hepatectomias compreendem considerável perda sanguínea e utilização de hemoderivados, o que diretamente estão relacionados com maior morbimortalidade. A hepatectomia hemoconservadora (HH) é modificação da técnica de oclusão vascular seletiva em hepatectomia. Ela pode ser alternativa cirúrgica para evitar ou diminuir o uso de hemoderivados no perioperatório. Objetivo: Avaliar os efeitos da HH sobre o volume globular (VG), concentração de hemoglobina (HB) e sobre a regeneração hepática em ratos. Métodos: Dois grupos de ratos Wistar foram constituídos: controle (n=6) e intervenção (n=6). Os do grupo controle foram submetidos à hepatectomia parcial de Higgins e Anderson e os do grupo Intervenção à HH. VG e HB foram medidos nos dias D0, D1 e D7. A relação peso do fígado/peso do rato foi calculada em D0 e D7. A regeneração hepática foi analisada qualitativamente e quantitativamente. Resultados: Houve diminuição dos níveis de VG e HB nos ratos do grupo controle a partir de D1, atingindo decréscimo de 18% em D7 (p=0,01 e p=0,008 respectivamente); a HH permitiu a manutenção dos níveis de VG e HB nos ratos do grupo intervenção. A HH não alterou a regeneração hepática. Conclusão: HH resultou em níveis maiores de VG e HB pós-operatórios sem alterar a regeneração hepática. Pode-se considerar estes dados como a prova necessária para a translação à pesquisa clinicocirúrgica.

A Paradigm Shift: Perioperative Iron and Erythropoietin Therapy for Patient Blood Management / 한양의대학술지

Allogeneic blood transfusion is often restricted due to its adverse effects, a lack of blood supply, and religious or cultural constraints. As a result, patient blood management (PBM) has been gaining attention. PBM is an evidence-based, patient-centered bundle of technologies that manages perioperative anemia and reduces bleeding during surgery. PBM improves the postoperative prognoses. Perioperative anemia is the main concern in PBM; therefore, to diagnose and treat it is important. This review focuses on the perioperative use of oral or intravenous iron and erythropoietin (EPO), in relevant fields such as cardiac surgery, orthopedics, and neurosurgery. IV administration of iron has been controversial due to safety concerns, such as increased risk of infection. However, using IV iron appropriately is beneficial in most surgical settings. Although recombinant human EPO may increase thromboembolic risks, this can be mitigated through various methods including limiting the target Hb level, using it in combination with IV iron, or prophylaxis for deep venous thrombosis. EPO is recommended in patients undergoing cardiac or orthopedic surgery. As PBM becomes globally implemented, the blood management methods, including tranexamic acid, hemostatic agents, and cell salvage have become more variable as well. Among them, administration of iron and EPO would be the most common pharmacologic choices based on current practice. However, controversy still exists. Therefore, further studies on iron and EPO are needed to ensure better and safer patient care.

Blood transfusion and increased perioperative risk in coronary artery bypass grafts

Abstract Objective: To correlate blood transfusions and clinical outcomes during hospitalization in coronary artery bypass grafting surgery (CABG). Methods: Transfusion, clinical and hematological data were collected for 1,378 patients undergoing isolated or combined CABG between January 2011 and December 2012. The effect of blood transfusions was evaluated through multivariate analysis to predict three co-primary outcomes: composite ischemic events, composite infectious complications and hospital mortality. Because higher risk patients receive more transfusions, the hospital mortality outcome was also tested on a stratum of low-risk patients to isolate the effect of preoperative risk on the results. Results: The transfusion rate was 63.9%. The use of blood products was associated with a higher incidence of the three coprimary outcomes: composite infectious complications (OR 2.67, 95% CI 1.70 to 4.19; P<0.001), composite ischemic events (OR 2.42, 95% CI 1.70 to 3.46; P<0.001) and hospital mortality (OR 3.07, 95% CI 1.53 to 6.13; P<0.001). When only patients with logistic EuroSCORE ≤ 2% were evaluated, i.e., low-risk individuals, the mortality rate and the incidence of ischemic events and infectious complications composites remained higher among the transfused patients [6% vs. 0.4% (P<0.001), 11.7% vs. 24,3% (P<0.001) and 6.5% vs. 12.7% (P=0.002), respectively]. Conclusion: The use of blood components in patients undergoing CABG was associated with ischemic events, infectious complications and hospital mortality, even in low-risk patients.

Tratamento cirúrgico e seguimento a longo prazo das micoses subcutâneas causadas por fungos demáceos: cromoblastomicose, feoifomicose e eumicetoma / Surgical treatment and long-term follow-up of subcutaneous mycoses caused by dematiaceous fungi: chromoblastomycosis, phaeohyphomycosis and eumicetoma

Introdução: As micoses subcutâneas provocadas por fungos demáceos (MSCFD)são classificadas conforme sua apresentação no tecido: cromoblastomicose com presença de corpúsculos fumagoides, feoifomicose com hifas septadas demáceas e eumicetoma com grãos compostos por hifas septadas demáceas. Diversos tratamentos são propostos, entre eles a exérese cirúrgica. O tratamento cirúrgico é mais indicado nos casos em que há infecção localizada e passível de exérese, com bons resultados terapêuticos e baixa taxa de recidiva. Objetivo: Apresentar a experiência de um serviço dermatológico no tratamento cirúrgico dos casos de MSCFD, discutindo as abordagens cirúrgicas e seus resultados. Métodos: Estudo retrospectivo com análise descritiva dos casos atendidos no período de abril de 2014 a dezembro de 2016 em clínica dermatológica da cidade de São Paulo. Foram incluídos todos os casos com diagnóstico de MSCFD que foram submetidos à terapêutica cirúrgica com exérese total da lesão. Resultados: Foram totalizados sete casos: dois de eumicetoma, um de cromoblastomicose e quatro de feoifomicose. De todos os casos apenas um não foi abordado em regime de centro cirúrgico ambulatorial. Todos evoluíram sem sequelas e sem recidivas no seguimento clínico. Conclusões: A remoção da lesão cutânea é um boa opção terapêutica nos casos de MSCFD em que o procedimento cirúrgico for viável.

Introduction: Subcutaneous mycoses caused by dematiaceous fungi are classified according to their characteristics in the tissue: chromoblastomycosis (with the presence of fumagoid corpuscles), phaeohyphomycosis (with dematiaceous septate hyphae) and eumicetoma (with grains composed of septate hyphae). Several treatments are proposed, among them, surgical excision. Surgical treatment is more indicated in cases where there is localized infection and where excision is possible, yielding good therapeutic outcomes and low recurrence rates. Objective: To describe the experience of a dermatological service in the surgical treatment of subcutaneous mycosis cases caused by dematiaceous fungi, discussing the surgical approach and its results. Methods: A retrospective study was carried out with the descriptive analysis of cases treated from April 2014 to December 2016, at a dermatological clinic in the Brazilian Southeast city of São Paulo. All cases diagnosed with subcutaneous mycoses caused by dematiaceous fungi were included and surgically treated with total exeresis of the lesion. Results: A total of 7 cases were analyzed ­ 2 eumicetomas, 1 chromoblastomycosis and 4 phaeohyphomycoses. Only one on the cases was not treated at an ambulatory surgical center. All cases progressed without sequelae or recurrences during the clinical follow-up. Conclusions: When surgical treatment is possible, the exeresis of the lesion is a good therapeutic option in cases of subcutaneous mycoses caused by dematiaceous fungi.

Liver transplantation in Jehovah's Witnesses: two cases report / 대한마취과학회지

Liver transplantation is especially challenging in patients who are Jehovah's Witnesses because their religious beliefs prohibit the receipt of blood products. We present two cases of living donor liver transplantation performed in adult Jehovah's Witnesses in South Korea without the use of blood products. In the first case, preoperative erythropoiesisstimulation therapy increased hemoglobin levels from 8.1 to 13.1 g/dl after 9 weeks. In the second case, hemoglobin levels increased from 7.4 to 10.8 g/dl after 6 months of erythropoiesis-stimulation therapy. With the combination of acute normovolemic hemodilution, intraoperative cell salvage, and use of transfusion alternatives, liver transplantation was successfully performed without transfusion of blood products.

Disseminated cutaneous atypical mycobacteriosis by M. chelonae after sclerotherapy of varicose veins in a immunocompetent patient: a case report

Atypical mycobacteria are saprophytic organisms not transmitted from person to person, which affect mainly immunosuppressed but also immunocompetent individuals. We present a case of atypical mycobacteriosis after a vascular procedure, with widespread cutaneous lesions associated with polyarthralgia. Mycobacterium chelonae was identified by the polymerase chain reaction (PCR) method. The patient showed improvement after treatment with three antibiotics. Mycobacterium chelonae causes skin lesions after invasive procedures. The clinical form depends on the immune state of the host and on the entry points. The diagnosis is based essentially on culture and the mycobacteria is identified by PCR. We highlight the importance of investigating atypical mycobacteriosis when faced with granulomatous lesions associated with a history of invasive procedures.

Transfusion free radical antegrade modular pancreaticosplenectomy of metastatic neuroendocrine tumor of the pancreas in Jehovah's Witness patient

In a popular sense, Jehovah's Witnesses (JW) have their creeds, one of which is refusal of blood transfusion. Such refusal may impinge on their proper management, especially in critical situations. We present a case of successful bloodless multimodality therapy, which was performed for a JW. The patient was a 49-year-old woman and JW who had general weakness 7 days before admission. She was diagnosed with a pancreatic neuroendocrine tumor (PNET) with hepatic metastases. Transcatheter arterial chemoembolization and Sandostatin LAR injection were performed, and then she was given a transfusion-free Radical antegrade modular pancreatosplenectomy sequentially. We gave recombinant human erythropoietin and iron hydroxide sucrose complex daily for five days after surgery. She was discharged at postoperative day 12 without any surgical complications. Multimodality therapy is very important for optimal treatment of PNET. Along with intimate interdepartmental cooperation, careful patient selection and appropriate perioperative management could possibly enhance the surgical outcome.

Opções terapêuticas para minimizar transfusões de sangue alogênico e seus efeitos adversos em cirurgia cardíaca: Revisão sistemática / Therapeutic options to minimize allogeneic blood transfusions and their adverse effects in cardiac surgery: A systematic review

Introdução: O sangue alogênico é um recurso terapêutico esgotável. Novas evidências demonstram um consumo excessivo de sangue e uma diminuição das doações, resultando em estoques de sangue reduzidos em todo o mundo. As transfusões de sangue estão relacionadas a aumento na morbimortalidade e maiores custos hospitalares. Deste modo, torna-se necessário procurar outras opções de tratamento. Estas alternativas existem, porém são pouco conhecidas e raramente utilizadas. Objetivo: Reunir e descrever de maneira sistemática, objetiva e prática todas as estratégias clínicas e cirúrgicas, como opções terapêuticas eficazes para minimizar ou evitar transfusões de sangue alogênico e seus efeitos adversos nos pacientes submetidos à cirurgia cardíaca. Métodos: Foi efetuada uma pesquisa bibliográfica com busca ao descritor “Blood transfusion” (MeSH) e aos termos “Cardiac surgery” e “Blood management”. Estudos com títulos não relacionados diretamente ao tema da pesquisa, estudos que não continham nos resumos dados relacionados à pesquisa, estudos mais antigos que relataram estratégias repetidas foram excluídos. Resultados: Tratar anemia e plaquetopenia, suspender anticoagulantes e antiplaquetários, reduzir flebotomias rotineiras, técnica cirúrgica menos traumática com hipotermia e hipotensão moderada, hemostasia meticulosa, uso de agentes hemostáticos sistêmicos e tópicos, hemodiluição normovolêmica aguda, recuperação sanguínea intraoperatória, tolerância à anemia (oxigênio suplementar e normotermia), bem como várias outras opções terapêuticas mostram ser estratégias eficazes em reduzir transfusões de sangue alogênico. Conclusão: Existem múltiplas estratégias clínicas e cirúrgicas para otimizar a massa eritrocitária e o estado de coagulação, minimizar a perda de sangue e melhorar tolerância à anemia. Estes recursos terapêuticos deveriam ser incorporados à prática médica mundial, visando diminuir o consumo de hemocomponentes, ...

Introdution: Allogeneic blood is an exhaustible therapeutic resource. New evidence indicates that blood consumption is excessive and that donations have decreased, resulting in reduced blood supplies worldwide. Blood transfusions are associated with increased morbidity and mortality, as well as higher hospital costs. This makes it necessary to seek out new treatment options. Such options exist but are still virtually unknown and are rarely utilized. Objective: To gather and describe in a systematic, objective, and practical way all clinical and surgical strategies as effective therapeutic options to minimize or avoid allogeneic blood transfusions and their adverse effects in surgical cardiac patients. Methods: A bibliographic search was conducted using the MeSH term “Blood Transfusion” and the terms “Cardiac Surgery” and “Blood Management.” Studies with titles not directly related to this research or that did not contain information related to it in their abstracts as well as older studies reporting on the same strategies were not included. Results: Treating anemia and thrombocytopenia, suspending anticoagulants and antiplatelet agents, reducing routine phlebotomies, utilizing less traumatic surgical techniques with moderate hypothermia and hypotension, meticulous hemostasis, use of topical and systemic hemostatic agents, acute normovolemic hemodilution, cell salvage, anemia tolerance (supplementary oxygen and normothermia), as well as various other therapeutic options have proved to be effective strategies for reducing allogeneic blood transfusions. Conclusion: There are a number of clinical and surgical strategies that can be used to optimize erythrocyte mass and coagulation status, minimize blood loss, and improve anemia tolerance. In order to decrease the consumption of blood components, diminish morbidity and mortality, and reduce hospital costs, these treatment strategies should be incorporated ...

A Single-Center Experience of Transfusion Free Surgical Treatment over 13 Years in Korea

OBJECTIVE: Patient' desire of transfusion free surgery has been increasing due to blood transfusion risks. We analyzed the perioperative parameters and perioperative management of transfusion free surgical treatment in Soonchunhyang University Seoul Hospital. METHODS: Operation quantity and blood unstoring count from blood bank between 2000 and 2012 were collected from chronological records. Perioperative parameters including preoperative hemoglobin level, postoperative hemoglobin level, and lowest hemoglobin level were collected from medical records. Perioperative blood management such as acute normovolemic hemodilution, intraoperative blood cell salvage, or hematinic agents and complication were assessed. RESULTS: A total of 3,088 patients underwent transfusion free surgery at Soonchunhyang University Seoul Hospital between 2000 and 2012. Postoperative hemoglobin level <5.0 g/dL were 33 patients. Four patients expired at postoperative period with serious perioperative complications. Average of expired patient's hemoglobin was 3.22 g/dL and overall mortality was 0.12%. Operation was increased as years go by. The amount of blood use bank wasn't increased in general patients with transfusion. CONCLUSION: Careful perioperative blood management for transfusion free surgical treatment was responsible for safety and results in good clinical outcomes. Overall transfusion rate was decreased in spite of increasing operation quantity.

Preoperative Erythropoietin Administration in Patients With Prostate Cancer Undergoing Radical Prostatectomy Without Transfusion

PURPOSE: In this study, we administered erythropoietin preoperatively to patients who underwent open radical prostatectomy without transfusion to increase their hemoglobin levels and investigated the efficacy of this procedure. MATERIALS AND METHODS: We evaluated 62 patients who underwent open radical prostatectomy performed by the same surgeon between June 2005 and January 2011. The 22 patients who refused transfusion were assigned to group 1; the patients who accepted transfusion were assigned to group 2. Before surgery, we administered erythropoietin beta to group 1 patients whose hemoglobin levels were <12 g/dL and retrospectively compared the clinical data of the two groups. We used the t-test and the chi-square test for statistical analysis. RESULTS: Mean preoperative hemoglobin levels in group 1 after erythropoietin administration (14.5 g/dL) were significantly higher than those in group 2 (13.59 g/dL, p=0.003). Moreover, the difference in the mean hemoglobin levels before and after surgery for group 1 patients (3.55 g/dL) significantly exceeded that for group 2 patients (2.08 g/dL, p=0.000). Additional analysis revealed no statistically significant differences in perioperative complications between the groups. CONCLUSIONS: Preoperative erythropoietin administration increased the safety margin of hemoglobin levels, and this strategy worked sufficiently well in our experience.