Transfusion Criteria for Fresh Frozen Plasma in Liver ResectionA 3 + 3 Cohort Expansion Study

Shintaro Yamazaki, MD; Tadatoshi Takayama, MD; Yuki Kimura, MD; Masamichi Moriguchi, MD; Tokio Higaki, MD; Hisashi Nakayama, MD; Masashi Fujii, MD; Masatoshi Makuuchi, MD

ABSTRACT

Objective  To establish transfusion criteria for use of fresh frozen plasma (FFP) in liver resection.

Background  Fresh frozen plasma has been transfused in liver resection without adequate supporting evidence, leading to unnecessary use.

Design  Prospective study using a phase 1 dose-escalation, 3 + 3 cohort expansion design, modified for FFP transfusion. We designated a serum albumin level of 3.0 g/dL (step 1) as the starting limit for no transfusion and reduced the level in 0.2-g/dL steps. Advancement to the next step was permitted when the albumin level equaled the target value for the previous step in 3 patients. If the albumin value on postoperative day 2 fell below the target value, 100 mL of albumin, 25%, was transfused on that day and on postoperative day 3. The study continued until high-grade postoperative complications occurred without transfusion. If 1 of 3 patients developed Clavien-Dindo grade II or higher complications, 3 more patients (3 + 3 cohort) were added to the same step.

Setting  Hepatobiliary pancreatic surgery center of a university hospital.

Patients  Patients with hepatocellular carcinoma who had had Child-Pugh class A liver function and an intraoperative blood loss of less than 1000 mL.

Intervention  Transfusion or no transfusion of FFP.

Main Outcome Measure  Reduction of transfusion rate in liver resection.

Results  Of the 213 consecutive patients with liver cancer enrolled, 172 patients (80.8%) fulfilled the inclusion criteria. Step progression proceeded until step 5 (albumin level, 2.2 g/dL) without high-grade complications, but step 2 (albumin level, 2.8 g/dL) required 63 patients to complete because 1 patient developed grade II complications (massive ascites). Step progression was broken off at step 5 in the 172nd patient because the postoperative day 2 albumin value did not fall below the step 4 level (2.4 g/dL), defined as the goal limit. The overall operative morbidity rate was 27.9%; the mortality rate was 0%. The FFP transfusion rate was significantly reduced from 48.6% in a previous series involving 222 patients (unpublished historical data from our institution) to 0.6% (1 of 172 patients) in the present study (P < .001). The postoperative hospital stay in the present study was significantly shorter than that in our previous series (13 vs 16 days; P = .01). Total medical costs were significantly reduced from a median of $21 061 (range, 10 032-59 410) to $17 267 (11 823-35 785; P = .04).

Conclusion  In liver resection, FFP transfusion is not necessary in patients with serum albumin levels higher than 2.4 g/dL on postoperative day 2.

Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review

Nicholas Habib, Samer Hassan, Rafik Abdou, Estelle Torbey, Homam Alkaied, Theodore Maniatis, Basem Azab, Michel Chalhoub and Kassem Harris*

Abstract

Gastroduodenal artery (GDA) aneurysms are rare but a potentially fatal condition if rupture occurs. They represent about 1.5% of all visceral artery (VAA) aneurysms and are divided into true and pseudoaneurysms depending on the etiologic factors underlying their development. Atherosclerosis and pancreatitis are the two most common risk factors. Making the diagnosis can be complex and often requires the use of Computed Tomography and angiography. The later adds the advantage of being a therapeutic option to prevent or stop bleeding. If this fails, surgery is still regarded as the standard for accomplishing a definite treatment.

Safety of Hepatic Resections in Obese Veterans John K. Saunders, MD; Alan S. Rosman, MD; Dena Neihaus, RN, MPA; Thomas H. Gouge, MD; Marcovalerio Melis, MD

ABSTRACT

Objective  To determine the effects of body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) on outcomes after liver resection performed at Veterans Affairs medical centers.

Design, Setting, and Patients  We queried the Veterans Affairs Surgical Quality Improvement Program database for liver resections (2005-2008) and grouped the patients into 5 BMI categories: normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9), obese class 1 (BMI 30.0-34.9), obese class 2 (BMI 35.0-39.9), and obese class 3 (BMI ≥40.0). Differences in risk factors and perioperative complications across groups were analyzed in univariate and multivariate analyses.

Results  Of 403 patients who underwent hepatectomy, 106 (26%) were normal weight, 161 (40%) were overweight, 94 (23%) were obese class 1, 31 (8%) were obese class 2, and 11 (3%) were obese class 3. Among these groups, higher BMI was associated with increased rates of hypertension (52%, 61%, 77%, 77%, and 73%, respectively; P = .002) and diabetes (18%, 27%, 36%, 39%, and 45%, respectively; P = .04) and lower incidence of smokers (53%, 35%, 30%, 16%, and 9%, respectively; P < .001). The BMI groups were similar in demographic characteristics and metrics correlating with preexisting liver disease. There were no differences across BMI groups in overall and specific morbidity or in length of stay. Compared with the other groups, obese class 3 patients received more blood transfusions (mean [SD], 4.3 [2.7] in obese class 3 patients vs 1.1 [0.2] in normal-weight patients; P = .02) and had a higher 30-day mortality (27% in obese class 3 patients vs 6% in normal-weight patients; P = .05). Multivariate analyses confirmed obese class 3 as an independent predictor of postoperative mortality.

Conclusions  Obesity did not increase postoperative complications after liver resection in veterans. After adjusting for other clinical factors, extreme obesity (BMI ≥40.0) was an independent risk factor for increased mortality.

Maneuvers to Decrease Laparoscopy-Induced Shoulder and Upper Abdominal Pain A Randomized Controlled Study

Hsiao-Wen Tsai, MD; Yi-Jen Chen, MD, PhD; Chiu-Ming Ho, MD, PhD; Shu-Shya Hseu, MD; Kuan-Chong Chao, MD; Shen-Kou Tsai, MD, PhD; Peng-Hui Wang, MD, PhD

Objective  To evaluate the effectiveness of the pulmonary recruitment maneuver (PRM) and intraperitoneal normal saline infusion (INSI) in removing postlaparoscopic carbon dioxide from the abdominal cavity to decrease laparoscopy-induced abdominal or shoulder pain after surgery.

Design, Setting, and Patients  A prospective, randomized, controlled trial was conducted at Taipei Veterans General Hospital, Taipei, Taiwan, from August 1, 2009, through June 30, 2010. One hundred fifty-eight women undergoing laparoscopic surgery for benign gynecologic lesions were randomly assigned to 3 groups: the PRM group (n = 53), the INSI group (n = 54), and the control group (n = 51).

Interventions  Postoperative maneuvers included PRM and INSI.

Main Outcome Measures  Evaluation of pain, including abdominal pain and shoulder pain, was performed at 12, 24, and 48 hours postoperatively.

Results  The frequency of postoperative shoulder pain at 24 and 48 hours was significantly decreased in the INSI group compared with that of either the PRM or control group (40.7% and 24.1% in the INSI group vs 66.0% and 50.9% in the PRM group [P = .009 and .004, respectively] or vs 72.5% and 54.9% in the control group [both P < .001]). Both methods significantly reduced the frequency of upper abdominal pain compared with the control condition (73.6% in the PRM group at 24 hours [P = .03] or 72.2% at 24 hours [P .02] and 44.4% at 48 hours [P = .01] in the INSI group vs 90.2% at 24 hours and 68.6% at 48 hours in the control group).

Conclusions  Both PRM and INSI could effectively reduce pain after laparoscopic surgery, but INSI might be better for both upper abdominal and shoulder pain.

Trial Registration  clinicaltrials.gov

Preoperative Very Low-Calorie Diet and Operative Outcome After Laparoscopic Gastric BypassA Randomized Multicenter Study

Yves Van Nieuwenhove, MD, PhD; Zilvinas Dambrauskas, MD, PhD; Alvaro Campillo-Soto, MD; Francois van Dielen, MD, PhD; René Wiezer, MD; Ignace Janssen, MD; Michael Kramer, MD; Anders Thorell, MD, PhD

ABSTRACT

Hypothesis  A 14-day very low-calorie diet (VLCD) regimen before a laparoscopic gastric bypass procedure will improve perioperative and postoperative outcomes.

Design  Multicenter, randomized, single-blind study.

Setting  Five high-volume bariatric centers in Sweden, the Netherlands, Lithuania, Spain, and Belgium.

Patients  Two hundred ninety-eight morbidly obese patients undergoing laparoscopic gastric bypass from March 1, 2009, through December 5, 2010.

Intervention  Patients were randomly allocated to a 2-week preoperative VLCD regimen or no preoperative dietary restriction (control group).

Main Outcome Measures  Operating time, surgeon's perceived difficulty of the operation, liver lacerations, intraoperative bleeding and complications, 30-day weight loss, and morbidity.

Results  Mean (SD) preoperative weight change was −4.9 (3.6) kg in the VLCD group vs −0.4 (3.2) kg in the control group (P < .001). Although the surgeon's perceived difficulty of the procedure was lower in the VLCD group (median [interquartile range], 26 [15-42] vs 35 [18-50] mm on a visual analog scale; P = .04), no differences were found regarding mean (SD) operating time (81 [21] vs 80 [23] min; P = .53), estimated blood loss (P = .62), or intraoperative complications (P = .88). At the 30-day follow-up, the number of complications was greater in the control compared with the VLCD group (18 vs 8; P = .04).

Conclusions  Although weight reduction with a 14-day VLCD regimen before laparoscopic gastric bypass performed in high-volume centers seems to reduce the perceived difficulty of the procedure, only minor effects on operating time, intraoperative complications, and short-term weight loss could be expected. However, the finding of reduced postoperative complication rates suggests that such a regimen should be recommended before bariatric surgery.