Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the Multidisciplinary Management of Morbidly Adherent Placenta.

BACKGROUND: Morbidly adherent placentation (MAP) increases the risk for obstetric hemorrhage. Cesarean hysterectomy is the prevalent perioperative approach. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive and relatively simple endovascular procedure to temporarily occlude the aorta and control below diaphragm bleeding in trauma. It has been effectively used to reduce obstetric hemorrhage. OBJECTIVES: To evaluate whether REBOA during cesarean delivery (CD) in women with morbidly adherent placentation is a safe and effective treatment modality. METHODS: We introduced REBOA for CD with antepartum diagnosis of MAP in 2019 and compared these patients (RG) to a standard approach group (SAG) treated in our center over the preceding year, as a control. All relevant data were collected from patient electronic files. RESULTS: Estimated blood loss and transfusion rates were significantly higher in SAG; 54.5% of SAG patients received four RBC units or more vs. one administered in RG. No fresh frozen plasma, cryoprecipitate, or platelets were administered in RG vs. mean 3.63, 6, and 3.62 units, respectively in SAG. Ten SAG patients (90.9%) underwent hysterectomy vs. 3 RG patients (30%). Five SAG patients (45%) required post-surgical intensive care unit (ICU) admission vs. no RG patients. Bladder injury occurred in five SAG cases (45%) vs. 2 RG (20%). One RG patient had a thromboembolic event. Perioperative lactate levels were significantly higher in SAG patients. CONCLUSIONS: Use of REBOA during CD in women with MAP is safe and effective in preventing massive bleeding, reducing the rate of hysterectomy, and improving patient outcome.

Sarcopenia defined by muscle quality rather than quantity predicts complications following laparoscopic right hemicolectomy.

PURPOSE: While sarcopenia has prognostic value in elective colorectal surgery for predicting peri-operative morbidity and mortality, its role in elective laparoscopic surgery is poorly defined. METHODS: A retrospective single-center analysis of patients undergoing elective laparoscopic right hemicolectomy for adenocarcinoma between January 2010 and December 2016. Univariate analysis compared the robustness of total psoas index (TPI) with Hounsfield unit average calculation (HUAC) calculated from pre-operative CT imaging in predicting post-operative complications. Multivariate analysis compared these measures with American Society of Anesthesiologists (ASA) grade and Charlson scores in predicting post-operative complications. RESULTS: Of the 580 patients identified, 185 met the inclusion criteria (91 males and 94 females, with a median age of 68). Using TPI and HUAC, 46 and 44 patients respectively were identified as sarcopenic, including 18 patients that were identified by both measures. HUAC-defined sarcopenia was significantly associated with pre-operative comorbidities, peri-operative mortality, and a greater incidence of respiratory, cardiac, and serious post-operative complications (Clavien-Dindo ≥ 3). Those with HUAC-defined sarcopenia aged > 75 were at particular risk of morbidity (OR 5.52, p = 0.002). No such relationships were found with TPI-defined sarcopenia. Only HUAC remained predictive of post-operative complications on multivariate analysis. CONCLUSION: Sarcopenia is a novel methodology for stratifying surgical risk in elective colorectal cancer surgery. HUAC has a high prognostic accuracy for the prediction of complications following laparoscopic colorectal surgery compared with TPI, ASA grade, and Charlson score.

Delaying laparoscopic surgery in pregnant patients with an equivocal acute appendicitis: a step-wise approach does not affect maternal or fetal safety.

BACKGROUND: Accurate and timely diagnoses of acute appendicitis (AA) during pregnancy avoids maternal and fetal morbidity and mortality. We present our experience of using an initial transabdominal ultrasound (US) performed at presentation to diagnose AA in pregnant patients as well as the value of a delayed repeat study in those who remain equivocal. We explore the sensitivity and specificity of this algorithm as well as the maternal and fetal safety of this approach. METHODS: Of the 225 patients identified within the study period who underwent laparoscopic appendectomy, 216 met the inclusion criteria and were retrospectively analyzed. If the US performed on presentation revealed AA, surgery was performed. Patients with a non-diagnostic US were admitted with surgery performed if there was clinical and/or biochemical deterioration. Patients who remained equivocal underwent a repeat delayed study. The results of the initial versus delayed studies were compared. Maternal and fetal complications were recorded and contrasted. RESULTS: Of the 216 patients included, 164 (75.9%) had AA, 14 (6.5%) had complicated AA and 38 (17.6%) had a normal appendix. Initial US was diagnostic for 125/216 (57.9%) of patients and 19/34 (55.8%) of patients who underwent a delayed repeat study. The remaining patients underwent empirical surgery. The pooled sensitivity and specificity of US for the cohort was 79.2% and 92.1%, respectively. There was no difference in proxies of maternal or fetal safety between the groups. CONCLUSION: US is a useful tool for diagnosing AA in pregnancy. In this cohort, performing a delayed repeat US during a period of observation in those patients who remained otherwise equivocal increased the diagnostic yield of the US. Delaying surgery in this specific group of patients does not affect maternal or fetal safety.