Perioperative blood loss after embolization of hypervascular musculoskeletal tumors outside of the spine: A single-center ten year experience and systematic review of the literature.

PURPOSE: To evaluate outcomes following trans-arterial embolization of hypervascular appendicular bony tumors in patients undergoing orthopedic resection by performing a systematic review including data from the authors' institution. MATERIALS AND METHODS: From April 2008 to August 2018, 73 patients (59 males, mean age 58.1 years) with musculoskeletal tumors presented for embolization for preoperative devascularization prior to orthopedic surgery. A retrospective chart review was performed to identify demographic, procedural and surgical data. A systematic review of the Pubmed, Medline, and Web of Science databases was performed to identify studies in which pre-operative embolization was performed of appendicular MSK tumors, and with measurements of estimated blood loss. All the variables listed above were recorded. A patient level analysis was performed to determine average estimated blood loss. RESULTS: 58 patients (47 men, 11 women, range 21-84 years) were included in our institutional analysis. The median EBL was 500 mL (range 100-3000). There was no difference in EBL between RCC (719.6 ± 626.1) and non-RCC groups (855.6 ± 657.5); p = 0.44. The median intra-operative transfusion requirement was 1.0 unit (range 0-8 ± 2.06). From 1984 to 2015, 9 studies were identified that provided data for a total of 118 patients (46 males, 42 females, range 10-82 years). The mean and median post-surgical EBL across all patients was 976.9 ± 78.5 (SE) and 725 mL (range 10-7000), respectively. There were no complications related to non-target embolization. CONCLUSION: Preoperative trans-arterial embolization of hypervascular MSK neoplasms appears to be safe and effective in minimizing peri- and post-operative bleeding while keeping transfusion requirements low.

A comparison of long-term outcomes of portal versus systemic venous drainage in pancreatic transplantation: a systematic review and meta-analysis.

Pancreas transplantation venous effluent can be drained via the portal vein or the systemic circulation; however, no recommendation exists for the ideal technique. A systematic review of the literature from 1989 through 2014 using PubMed, CINHAL, and Cochrane Library for portal versus systemic venous drainage was undertaken. Only studies on humans and published in English were considered. Measures of glycemic control and total cholesterol were synthesized for meta-analysis utilizing random-effects models. Of 166 articles retrieved, 15 articles were included for meta-analysis. Patient and graft survival were comparable in a large database study as well as in the only randomized control study. No differences in complications were seen when exocrine drainage was enteric for the systemic venous group. Fasting insulin (-34.13 pmol/mL, p < 0.001) was significantly lower within the portal drained group; however, fasting blood glucose levels (-3.4 mg/dL, p = 0.32) and hemoglobin A1C levels (mean difference 0.124%, p = 0.25) were comparable. Total cholesterol levels (-3.62 mg/dL, p = 0.447), as well as other measures of lipids, showed no difference. Based on this systematic review and meta-analysis, there is no evidence of differences in outcomes or metabolic control in patients undergoing pancreatic transplant with portal venous drainage compared to the systemic venous drainage.

A covert complication of arteriovenous fistulas.

Our patient is a 65-year-old man with a history of hypertension, aortic stenosis, and end-stage renal disease on hemodialysis who presented with worsening dyspnea. On examination, he exhibited signs of volume overload and had a radiocephalic arteriovenous fistula (AVF) with a significantly palpable thrill. Coronary angiogram showed normal coronary arteries. Cardiac catheterization revealed a cardiac output of 10.6 L/min by thermodilution. Ultrasound of the AVF access demonstrated an abnormally high velocity with flow >5 L/min. The patient was diagnosed with high-output heart failure (HOHF) secondary to his arteriovenous fistula. HOHF is an uncommon entity associated with certain pathologic states such as hyperthyroidism, skeletal and dermatologic disorders. It is defined as a high cardiac output >8 L/min, resting cardiac index >2.5-4.0 L/min per m2, and low systemic vascular resistance. Cardiac catheterization is often required for definitive diagnosis. The increased cardiac output may result in overt heart failure in patients with underlying heart disease. Treatment of HOHF secondary to an extracardiac shunt involves flow reduction procedures, ligation, or peritoneal dialysis. Our patient was successfully treated with AVF banding. Early recognition of this complication is critical, as many cases are reversible. 8 L/min, resting cardiac index >2.5-4.0 L/min per m2 and low systemic vascular resistance, is an uncommon entity associated with conditions such as hyperthyroidism, skeletal disorders, and dermatologic disorders. It is an often-missed complication in patients with arteriovenous fistulas, particularly those with underlying heart disease. The Kidney Foundation guidelines recommend arteriovenous fistula monitoring by physical examination and monthly flow measurements for patients at risk.>.

Prerecovery liver biopsy in the brain-dead donor: a case-control study of logistics, safety, precision, and utility.

Prerecovery liver biopsy (PLB) can potentially to decrease futile recovery and increase utilization of marginal brain-dead donor (BDD) livers. A case-control study was conducted to examine the logistics, safety, histological precision, and liver utilization associated with PLB in BDDs. Twenty-three cases between January 2008 and January 2013 were compared to 2 groups: 48 sequential and 69 clinically matched controls. Compared to the sequential controls, the cases were older (53 versus 46 years), heavier (30.2 versus 25.8 kg/m2), had higher prevalences of hypertension (78.3% versus 44.7%) and alcohol use (56.5% versus 23.4%), and a lower United Network for Organ Sharing expected organ yield (0.73 versus 0.81 livers/donor; P < 0.05 for all). Baseline characteristics were similar between cases and clinical controls. Donor management time was longer for the cases (22.4 hours) versus sequential controls (16.5 hours, P = 0.01) and clinical controls (15.9 hours, P = 0.01). Complications for cases (8.7%) were not different from either group of controls (18.8% for sequential controls, P = 0.46; 17.4% for clinical controls, P = 0.50). The agreement between the donor hospital and study pathologists was substantial regarding evaluation of steatosis (κ = 0.623) and fibrosis (κ = 0.627) and moderate regarding inflammation (κ = 0.495). The proportions of livers that were transplanted were similar for the cases and the clinical controls (60.9% versus 59.4%). In contrast, the proportion of donors for whom liver recovery was not attempted was higher (30.4% versus 8.7%), and the proportion of attempted liver recoveries that did not result in transplantation was lower (8.7% versus 31.9%). These differences were significant at P = 0.009. Overall, PLB is logistically feasible with only a minimal delay and is safe, its interpretation at donor hospitals is reproducible, and it appears to decrease futile liver recovery.