Preoperative hemogram as a predictive factor for iron deficit and/or transfusion in patients scheduled for arthroplasty.

INTRODUCTION: anemia and iron deficiency predispose to an increased risk of transfusion with a consequent increase in morbidity and mortality. The study analyzes whether blood cell count parameters in addition to detecting anemia can predict iron deficiency and/or transfusional risk in patients undergoing mostly to scheduled primary hip and knee arthroplasty. OBJECTIVE: To analyze how blood cell count parameters predict iron deficiency and/or transfusional risk in patients undergoing programmed arthroplasty. MATERIAL AND METHODS: The analytical and transfusion results of 522 patients undergoing arthroplasty have been prospectively collected between 2013 and 2019 and the discriminative and predictive capacity of the basic parameters of the red cells have been analyzed; hemoglobin (Hb), mean cell volume, mean cell hemoglobin (HCM) and red blood cell distribution width (RDW) for the identification of presurgical iron deficiency and postsurgical transfusion. RESULTS: Anaemia was detected in 6.6%, "suboptim" Hb (<13 g/dL) in 14.5% and iron deficiency in 32.4%. Anemia detects only 13.8% of ID. After logistic regression analysis, the multivariate model significantly related Hb (p = .004), mean corpuscular hemoglobin (MCH) (p = .026), and the red cell distribution width (RDW) (p = .001) with ID; but mean corpuscular volume (MCV) is not significant. Hb, age and transferrin saturation index have been the only risk factors for transfusional risk of the parameters analyzed. CONCLUSIONS: The hemogram contains parameters that correlate with iron deficiency, however, mean cell volume, so widely used for the orientation of iron deficiency, is not valid as a discriminator of iron deficiency in this group of patients. Low Hb and transferrin saturation index are modifiable predictors for transfusion risk.

Preoperative hemogram as a predictive factor for iron deficit and/or transfusion in patients scheduled for arthroplasty. / El hemograma como factor predictivo de déficit de hierro y/o transfusión en paciente pendiente de artroplastia.

INTRODUCTION: Anemia and iron deficiency predispose to an increased risk of transfusion with a consequent increase in morbidity and mortality. The study analyzes whether blood cell count parameters in addition to detecting anemia can predict iron deficiency and/or transfusional risk in patients undergoing mostly to scheduled primary hip and knee arthroplasty. OBJECTIVE: To analyze how blood cell count parameters predict iron deficiency and/or transfusional risk in patients undergoing programmed arthroplasty. MATERIAL AND METHODS: The analytical and transfusion results of 522 patients undergoing arthroplasty have been prospectively collected between 2013 and 2019 and the discriminative and predictive capacity of the basic parameters of the red cells have been analyzed; hemoglobin (Hb), mean cell volume, mean cell hemoglobin (HCM) and red blood cell distribution width (RDW) for the identification of presurgical iron deficiency and postsurgical transfusion. RESULTS: Anaemia was detected in 6.6%, "suboptim" Hb (<13g/dL) in 14.5% and iron deficiency in 32.4%. Anemia detects only 13.8% of ID. After logistic regression analysis, the multivariate model significantly related Hb (p=.004), mean corpuscular hemoglobin (MCH) (p=.026), and the red cell distribution width (RDW) (p=.001) with ID; but mean corpuscular volume (MCV) is not significant. Hb, age and transferrin saturation index have been the only risk factors for transfusional risk of the parameters analyzed. CONCLUSIONS: The hemogram contains parameters that correlate with iron deficiency, however, mean cell volume, so widely used for the orientation of iron deficiency, is not valid as a discriminator of iron deficiency in this group of patients. Low Hb and transferrin saturation index are modifiable predictors for transfusion risk.

Long-term outcome after laparoscopic splenectomy related to hematologic diagnosis.

BACKGROUND: Laparoscopic splenectomy (LS) has been demonstrated as an effective and safe treatment for hematological disorders requiring spleen removal, especially in cases of normal-sized spleens. However, although results are promising, long-term outcome data are lacking. We reviewed our clinical experience with LS in a series of 255 cases, with particular attention to the long-term outcome related to the disease process requiring LS. METHODS: From February 1993 to October 2003, LS was attempted in 255 patients (100 males and 155 females with a mean age of 45 +/- 19 years) and clinical information was recorded in a prospective database. Indications for splenectomy included idiopathic thrombocytopenic purpura (ITP) (n = 115), HIV-ITP (n = 9), Evans syndrome (n = 6), autoimmune hemolytic anemia (AIHA) (n = 13), hereditary spherocytosis (HS) (n = 19), hematologic malignancy (n = 66), thrombotic thrombocytopenic purpura (n = 1), and others (n = 26). Long-term postoperative follow-up evaluation was obtained through clinical notes, follow-up visits by the referring hematologist, and by phone interviews both with patients and with the referring hematologist. RESULTS: A total of 186 patients (73%) were available for a mean follow-up of 35 months (range, 1-104). Of the ITP patients, 87 (76%) were followed up, with a remission rate of 89% (complete remission in 75%). A similar remission rate was observed in ITP-HIV; in patients available for follow-up (78%), complete remission was achieved in 83%. In Evans, complete remission was achieved in all patients available for follow-up (67%). Clinical response for hemolytic disease ranged between 70% for AIHA and 100% for HS. In the malignant group, the late mortality rate was 22%. The mortality rate in the miscellaneous group was 5%. No cases of splenectomy-related sepsis occurred during follow-up. CONCLUSIONS: LS offers advantages for all types of splenic diseases requiring surgery. It provides not only good clinical short-term outcome but also satisfactory long-term hematological results.

Mid term analysis of safety and quality of life after the laparoscopic repair of paraesophageal hiatal hernia.

BACKGROUND: Initial experience with the laparoscopic repair of paraesophageal and type III mixed hiatal hernias showed that it is safe and feasible, with excellent immediate and short-term results. However, after a longer follow-up, a recurrence rate of < or =40% has been demonstrated. Data related to the outcome of paraesophageal hernia repair and the recurrence rate are still lacking. Quality-of-life scores may offer a better means of assessing the impact of surgical treatment on the overall health status of patients. Therefore, we performed prospective evaluation of anatomic and/or symptomatic recurrences after paraesophageal or large hiatal hernia repair. In addition, we investigated the correlation between recurrence and the patient's quality of life. METHODS: All patients after who had undergone repair of paraesophageal of mixed hiatal hernia were identified prospectively from a database consisting of all patients who had had laparoscopic operations for gastroesophageal pathology at our hospital between February 1998 and December 2002. The preoperative symptoms were taken from patients' clinical files. In March 2003, all patients with > or =6 months of follow-up had a barium swallow and were examined for radiological and clinical signs of recurrence. Thereafter, the patients' quality of life after surgery was evaluated using three standard questionnaires (Short Form 36 [SF-36], Glasgow Dyspepsia Severity Score [GDSS], and Gastrointestinal Quality of Life Index [GIQLI]. RESULT: During the study period, 46 patients had been operated on. The mean age was 63 years (range, 28-93). Thirty seven of them had a follow-up of > or =6 months. Eight patients (21%) had postoperative gastrointestinal symptoms. Barium swallow was performed in 30 patients (81%) and showed a recurrence in six of them (20%). According to SF-36 and GDSS, the patients' postoperative quality of life reached normal values and did not differ significantly from the standard values for the Spanish population of similar age and with similar comorbidities. Successfully operated patients reached a GIQLI value comparable to the standard population. However, symptomatic patients had significantly lower GIQLI scores than the asymptomatic or the Rx-recurrent group. CONCLUSION: The laparoscopic treatment of large paraesophageal and mixed hiatal hernias is not only feasible and safe but also offers a good quality of life on a midterm basis. However, the anatomic and functional recurrence rate is high. The next step is to identify the subset of patients who are at risk of failure and to establish technical alternatives that would ensure the durability of the repair.

Hand-assisted laparoscopic splenectomy (HALS) in cases of splenomegaly: a comparison analysis with conventional laparoscopic splenectomy.

BACKGROUND: Laparoscopic splenectomy (LS) is considerably more difficult to perform when the spleen is enlarged. The new technique of hand-assisted designed technique aimed to assist laparoscopic surgery allows the surgeon to insert his or her hand into the abdomen while maintaining the pneumoperitoneum, thus recovering the tactile sensation lost in conventional laparoscopic surgery. OBJECT: In this study, we compared the immediate results of conventional LS and hand-assisted LS (HALS) in cases of splenomegaly. METHODS: Between February 1993 and August 2001, 200 LS were attempted at two university hospitals. In 56 cases, splenomegaly (final spleen weight >700 g) was observed clinically or detected on radiological examination. We compared the first 36 patients operated on by conventional LS (group I) with the last consecutive 20 patients, who underwent HALS (group II). The study parameters were operative time, conversion rate, transfusion rate, morbidity and length of hospital stay. RESULTS: The groups were comparable in terms of age (58 +/- 13 [ranges, l9-82] vs 58 +/- 16 years [range, 44-84] (ns), diagnosis, and spleen weight (1425 +/- 884 [range, 700-3400]) vs 1753 +/- 1124 g [range, 720-4500] (ns). HALS was associated with less morbidity (36% vs 10%) (ns), a shorter operative time (177 +/- 52 [range, 95-300]) vs 135 +/- 53 min [range, 85-270] (p <0.009), and a shorter hospital stay (6.3 +/- 3.3 [range, 3-14]) vs 4 +/- 1.2 [range, 2-7] days (p <0.05). CONCLUSION: In cases of splenomegaly, HALS assisted laparoscopic surgery significantly facilitates the surgical maneuvers during LS while maintaining the advantages of a purely laparoscopic approach.

Results of laparoscopic splenectomy for treatment of malignant conditions.

BACKGROUND: Laparoscopic splenectomy (LS) is widely accepted for treatment of benign diseases, but there are few reports of its use in cases of haematological malignancy. In addition, comparative studies with open operation are lacking. Malignant haematological diseases have specific clinical features-notably splenomegaly and impaired general health-which can impact on the immediate outcome after LS. The immediate outcome of LS comparing benign with malignant diagnoses has been analysed in a prospective series of 137 operations. PATIENTS AND METHODS: Between February 1993 and April 2000, 137 patients with a wide range of splenic disorders received LS. Clinical data and immediate outcome were prospectively recorded,and age, diagnosis, operation time, perioperative transfusion requirement, spleen weight, conversion rate, accessory incision, hospital stay and complications were analysed. RESULTS: The series included 100 benign cases and 37 suspected malignancies. In patients with malignant diseases the mean age was greater (37 years [3-85] vs 60 years [27-82], p<0.01), LS took longer (138 min [60-400] vs 161 min [75-300], p<0.05) and an accessory incision for spleen retrieval was required more frequently (18% vs 93%, p<0.01) because the spleen was larger (279 g [60-1640] vs 1210 g [248-3100], p <0.01). However, the rate of conversion to open operation (5% vs 14%), postoperative morbidity rate (13% vs 22%) and transfusion requirement (15% vs 26%) did not differ between benign and malignant cases. Hospital stay was longer in malignant cases (3.7 days [2-14] vs 5 days [2-14], p<0.05). CONCLUSION: LS is a safe procedure in patients with malignant disease requiring splenectomy in spite of the longer operative time and the higher conversion rate.

Applicability of laparoscopic surgery for colorectal disease.

BACKGROUND: The advantages of laparoscopic colorectal surgery for selected patients have been well established. However, the applicability of laparoscopic surgery in the whole population of patients with colorectal disease is not well known. METHODS: A single-institution medical records review of 269 patients subjected to colorectal surgery was made. Of these, 206 open colorectal procedures were performed, and data were reviewed retrospectively. In addition, 63 patients were subjected to laparoscopy, and their data were recorded prospectively. An analysis of the existence of factors that contraindicate laparoscopic colorectal surgery was done. These factors were of two types: absolute (urgent intervention, severe cardiopulmonary disease, advanced liver cirrhosis, tumor invasion into adjacent organs, simultaneous major surgery) and relative (midrectal tumors, tumors in the transverse colon, bulky tumors, more than two previous infraumbilical operations, previous intestinal surgery, and previous peritonitis). RESULTS: Factors that could contraindicate the laparoscopic approach were found in 118 patients (44%). The most common were urgent intervention (40%), midrectal tumors (19%), locally advanced cancer (13%), previous intestinal surgery (13%), and tumors >10 cm (6%). We considered 25% of the contraindications to be absolute and 19% relative. Taking these exclusion criteria into consideration when selecting patients for laparoscopic surgery, the conversion rate in our initial laparoscopic series (63 cases) was 13%. CONCLUSION: The indication for laparoscopic surgery for patients with colorectal disease is superior to 60% (absolute 56%, relative 81%). When using appropriate selection criteria, the conversion rate may be maintained below 10%. Preoperative selection of patients with colorectal disease allows optimal use of the advantages of laparoscopic surgery.

Análisis de la aplicabilidad de la cirugía laparoscópica en la patología colorrectal / Analysis of the applicability of laparoscopic surgery for colorectal disease

Introducción. El abordaje laparoscópico del colon ofrece ventajas respecto a la cirugía abierta; sin embargo, no está bien establecida la aplicabilidad de esta opción técnica en el conjunto de pacientes afectados de enfermedades colorrectales quirúrgicas. Pacientes y métodos. Estudio retrospectivo de 269 pacientes sometidos a cirugía colorrectal. Se analizaron los factores que potencialmente contraindicaban la cirugía laparoscópica. Se consideraron contraindicaciones absolutas: intervención urgente, enfermedad cardiopulmonar severa, cirrosis hepática avanzada, invasión a órganos vecinos (T4) y cirugía mayor simultánea, y contraindicaciones relativas: tumor localizado en el tercio medio del recto, tumor del colon transverso o ángulo esplénico, tumor mayor de 10 cm, más de 2 laparotomías medias infraumbilicales, cirugía intestinal previa y antecedente de peritonitis difusa. Resultados. En 118 pacientes (44 por ciento) se observó alguna contraindicación: cirugía urgente (40 por ciento), tumores del recto medio (19 por ciento), cáncer localmente avanzado (13 por ciento), cirugía intestinal previa (13 por ciento) y tumores de más de 10 cm (6 por ciento). Un 25 por ciento eran contraindicaciones absolutas y un 19 por ciento relativas. Tomando en consideración estos criterios de exclusión, el índice de conversión en una serie inicial del 63 pacientes fue del 12 por ciento. Conclusión. Más del 66 por ciento del conjunto de pacientes con enfermedades colorrectales quirúrgicas pueden beneficiarse del abordaje laparoscópico. La utilización de estos criterios puede mantener una tasa de conversión menor del 10 por ciento (AU)

Complications of laparoscopic splenectomy.

HYPOTHESIS: Analysis of the type and characteristics of complications after laparoscopic splenectomy may permit the identification of clinical factors with predictive value for the development of complications. DESIGN: Univariate and multivariate analysis of factors related to complications in a prospective series of laparoscopic splenectomies. SETTING: A large tertiary referral university-teaching general hospital. PATIENTS: One hundred twenty-two nonselected consecutive patients, in whom laparoscopic splenectomy was attempted between February 1993 and July 1999. INTERVENTION: Laparoscopic splenectomy. MAIN OUTCOME MEASURES: Immediate complications classified according to the Clavien score. Univariate and multivariate analyses were performed of complications related to age, sex, body mass index, and malignant nature of the hematologic disease; preoperative hematocrit and platelet count; operative time; operative position; need of accessory incision; transfusion status; learning curve; and existence of comorbid diseases. RESULTS: One hundred thirteen laparoscopic splenectomies were completed (conversion rate, 7.4%). Twenty patients (18%) developed 23 complications. All were Clavien type I or II, without mortality. One complication was intraoperative (diaphragmatic perforation), and 22 were postoperative: 6 pulmonary (26%), 3 fever (13%), 8 hemorrhagic (35%) (5 episodes of postoperative bleeding and 3 abdominal wall hematomas), and 6 others (26%). Ten (43%) of the 23 were technically related. Univariate analysis showed that complications were only related to age (mean +/- SD, 55 +/- 15 vs 39 +/- 17 years; P<.008) or transfusion (50% vs 11%; P<.001). Multivariate analysis showed that the learning curve (P<.005; 95% confidence interval, 2.46), age (P<.001; 95% confidence interval, 1. 04), spleen weight (P<.009; 95% confidence interval, 1.00), and malignant neoplasm diagnosis (P<.007; 95% confidence interval, 3.82) were independent predictors of complications. CONCLUSIONS: Laparoscopic splenectomy is feasible, and the incidence of severe complications is reduced. However, a high proportion of these complications are technique related. Laparoscopic splenectomy requires great technical care but offers major clinical advantages, even in less favorable situations, such as in patients with splenomegaly or with malignant neoplasms.

[Severe abdominal complications in patients treated with heart transplantation: the problem of clinical inexpressiveness]. / Complicaciones abdominales graves en los pacientes sometidos a trasplante cardíaco: el problema de la inexpresividad clínica.

INTRODUCTION: In transplanted patients, immunosuppressive drugs can mask habitual pathologies that impede their diagnoses and management. Abdominal pathology gives up to 2-20%, 50% of which is surgical, with a mortality of 10-40%. The most frequently detected pathologies are: acute pancreatitis, peptic ulceration and intestinal obstruction. OBJECTIVES: To determine the alarm parameters, more adequate diagnostic procedures and the most frequent causes of morbidity and mortality in order to attempt to avoid them. METHODS: In our center 225 heart transplantations were performed from May 1984 to October 1997. The severe abdominal complications, time of appearance, implication of immunosuppressive drugs and presence of rejection were studied in these patients. RESULTS: 35 severe abdominal complications were detected (incidence 12.9%), with the majority differing (> 1 year following transplant). The most frequently detected pathologies were digestive hemorrhages and perforations. Acute pancreatitis was 11%. The immunosuppressive drugs used were prednisona, cyclosporin and azathioprine. In 12 out of 29 patients the abdominal complication was in the context of acute rejection. CONCLUSIONS: Even with some non-specific abdominal symptoms in these group of patients it is important to rule out severe pathologies such as acute pancreatitis or empty viscera perforation. The detection of amylases and lypases in the blood and an echographic or tomographic abdominal study should be performed early with a digestive hemorrhage it is important to perform an endoscopy. If the surgical intervention seems imminent it's better to perform it without any delay, because it has been demonstrated that the delay is worse than the probable rejection.

Impact of hematological diagnosis on early and late outcome after laparoscopic splenectomy: an analysis of 111 cases.

BACKGROUND: Laparoscopic splenectomy (LS) is now regarded as the treatment of choice for autoimmune thrombopenia (ITP). However, there have been few reports describing the application of LS to other splenic diseases, such as malignant entities and conditions associated with splenomegaly. Hematological diseases have specific clinical features that can influence immediate outcome after LS. Although the long-term effects of LS are unknown, a risk of splenosis has been suggested. Therefore, we designed a study to analyze the impact of primary hematological disease on immediate and late outcome in a prospective series of LS patients. METHODS: We performed a prospective analysis of 111 LS done between February 1993 and March 1999. The patients were classified by hematological indications into the following four groups: (a) group 1, low platelet count. This group was further subdivided into group 1A, idiopathic thrombocytopenic purpura (ITP) (n = 48) and group 1B, HIV-related ITP (n = 8); (b) group 2, anemia. This group was further subdivided into group 2A, autoimmune hemolytic anemia (n = 8), and group 2B, spherocytosis (n = 11); (c) group 3, malignancy (n = 28); and (d) group 4, others (n = 8). Immediate outcomes were recorded prospectively. Hematological status and late complications were reviewed after a mean follow-up of 24 +/- 18 months. RESULTS: There were no significant differences between the groups in terms of conversion, transfusion requirements, and morbidity, although transfusion and morbidity were slightly higher in group 3. However, hospital stay was significantly longer in groups 3 and 4 than in groups 1 and 2. Long-term follow-up showed satisfactory hematological results in >/=75% of patients (group 1A, 82%; group 1B, 88%; group 2A, 88%; group 2B, 100%; group 3, 75%; group 4, 88%). Overall, late morbidity was 8.3% and mortality was 6.2%, mainly due to deaths in group 4 (six of 22 patients). CONCLUSION: LS is a safe and reproducible procedure for most hematological indications, with a similar immediate outcome for benign diseases and a long-term hematological response comparable to the standard results that have been observed in open series.

[Pseudoachalasia: a diagnosis to consider in the assessment of dysphagia]. / Seudoacalasia: un diagnóstico a considerar en la evaluación de la disfagia.

The diagnosis of achalasia is based on the patient's symptoms and on manometric studies although other diseases present similar symptomatology. To present an elderly woman clinically and manometrically diagnosed with achalasia of the cardia who was treated by dilatation. When the patient relapsed and was surgically treated she was found to have and esophageal adenocarcinoma. When considering a diagnosis of achalasia, alternative diagnoses (especially neoplasias) should be borne in mind, especially in unusual situations, such as rapid onset or in the elderly.

Effect of spleen size on splenectomy outcome. A comparison of open and laparoscopic surgery.

BACKGROUND: Laparoscopic splenectomy (LS) is gaining acceptance as an alternative to open splenectomy (OS). However, splenomegaly presents an obstacle to LS, and massive splenomegaly has been considered a contraindication. Analyses comparing the procedure with the open approach are lacking. The purpose of this study was to analyze the effect of spleen size on operative and immediate clinical outcome in a series of 105 LS compared with a series of 81 cases surgically treated by an open approach. METHODS: Between January 1990 and November 1998, 186 patients underwent a splenectomy for a wide range of splenic disorders. Of these patients, 105 were treated by laparoscopy (group I, LS; data prospectively recorded) and 81 were treated by an open approach (group II, OS analyzed retrospectively). Patients also were classified into three groups according to spleen weight: group A, <400 g; group B, 400-1000 g; and group C, >1000 g. Age, gender, operative time, perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia, length of stay, and morbidity were recorded in both main groups. RESULTS: Operative time was significantly longer for LS than for OS. However, LS morbidity, mortality, and postoperative stay were all lower at similar spleen weights. Spleens weighing more than 3,200 g required conversion to open surgery in all cases. When LS outcome for hematologic malignant diagnosis was compared with LS outcome for a benign diagnosis, malignancy did not increase conversion rate, morbidity, and transfusion, even though malignant spleens were larger and accessory incisions were required more frequently. Postoperative hospital stay was significantly longer in malignant than in benign diagnosis (5 +/- 2.4 days vs. 4 +/- 2.3 days; p < 0. 05). CONCLUSIONS: In patients with enlarged spleens, LS is feasible and followed by lower morbidity, transfusion rate, and shorter hospital stay than when the open approach is used. For the treatment of this subset of patients, who usually present with more severe hematologic diseases related to greater morbidity, LS presents potential advantages.