102,176 research outputs found
Invite comment on Pucciarelli and Spolverato: The fate of the rectum after organ sparing approach to rectal cancer
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Endoscopic Ultrasound May Misclassify the Nodal Status of a Small Subset of Patients with Early Gastric Cancer In Reply to Chen and colleagues
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ASO Author Reflections: Local Excision Following Neoadjuvant Therapy for Rectal Cancer: A Compromise Between TME and Watch-and-Wait in Patients with Major Response
No full textEffect of Relative Decrease in Blood Hemoglobin Concentrations on Postoperative Morbidity in Patients Who Undergo Major Gastrointestinal Surgery
No full textIMPORTANCE Delta hemoglobin (Delta Hb), defined as the difference between the preoperative hemoglobin (Hb) level and the nadir Hb level during a patient's hospitalization, may be associated with adverse outcomes even if the absolute level of Hb remains greater than the transfusion threshold of 7 g/dL. OBJECTIVE To evaluate the association between Delta Hb and morbidity in patients who undergo major gastrointestinal surgery as an independent factor or combined with the nadir Hb concentration. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of prospectively collected data on patients who underwent pancreatic, hepatic, or colorectal resection from January 1, 2010, through April 30, 2014, at Johns Hopkins Hospital were included in the study. Data regarding the Delta Hb concentration following surgery, nadir Hb level, and overall perioperative blood use were obtained and analyzed. Multivariable-adjusted logistic regression models were used to identify the preoperative factors associated with Delta Hb and the effect of Delta Hb on perioperative morbidity. The study and data analysis took place from January 22 through February 20, 2015. INTERVENTIONS Major gastrointestinal surgery and packed red blood cell transfusion. MAIN OUTCOMES AND MEASURES Overall morbidity and ischemic-specific complications. RESULTS Of the 4669 patients who underwent major gastrointestinal surgery, the median Delta Hb level after surgery was 40%. Patients with multiple comorbidities (American Society of Anesthesiologists Physical Status score of 3-4: odds ratio [OR], 1.96; 95% CI, 1.30-2.97; P = 3 coexisting medical conditions: OR, 1.62; 95% CI, 1.08-2.42; P = .001) and those who underwent pancreatic surgery (OR, 1.98; 95% CI, 1.18-3.33; P = .01) were at increased risk of having a Delta Hb of 50% or greater. Compared with patients who had a Delta Hb level of less than 50% and a nadir Hb level of 7 g/dL or greater, patients with a Delta Hb level of 50% or greater whose nadir Hb level was less than 7 g/dL were at a high risk of developing postoperative complications (OR, 6.60; 95% CI, 4.34-10.03; P <.001); in particular, a Delta Hb level of 50% or greater was strongly correlated with a risk of ischemic complications, even if the nadir Hb level was 7 g/dL or greater (OR, 5.68; 95% CI, 1.44-22.39; P = .01). CONCLUSIONS AND RELEVANCE A Delta Hb level of 50% or greater following gastrointestinal surgery was associated with complications, especially ischemic adverse events, even if the nadir Hb level remained at 7 g/dL or greater
Variation in triggers and use of perioperative blood transfusion in major gastrointestinal surgery
No full textBackground: The decision to perform intraoperative blood transfusion is subject to a variety of clinical and laboratory factors. This study examined variation in haemoglobin (Hb) triggers and overall utilization of intraoperative blood transfusion, as well the impact of transfusion on perioperative outcomes. Methods: The study included all patients who underwent pancreatic, hepatic or colorectal resection between 2010 and 2013 at Johns Hopkins Hospital, Baltimore, Maryland. Data on Hb levels that triggered an intraoperative or postoperative transfusion and overall perioperative blood utilization were obtained and analysed. Results: Intraoperative transfusion was employed in 437 (15.6 per cent) of the 2806 patients identified. Older patients (odds ratio (OR) 1.68), patients with multiple co-morbidities (Charlson co-morbidity score 4 or above; OR 1.66) and those with a lower preoperative Hb level (OR 4.95) were at increased risk of intraoperative blood transfusion (all P < 0.001). The Hb level employed to trigger transfusion varied by sex, race and service (all P < 0.001). A total of 105 patients (24.0 per cent of patients transfused) had an intraoperative transfusion with a liberal Hb trigger (10 g/dl or more); the majority of these patients (78; 74.3 per cent) did not require any additional postoperative transfusion. Patients who received an intraoperative transfusion were at greater risk of perioperative complications (OR 1.55; P = 0.002), although patients transfused with a restrictive Hb trigger (less than 10 g/dl) showed no increased risk of perioperative morbidity compared with those transfused with a liberal Hb trigger (OR 1.22; P = 0.514). Conclusion: Use of perioperative blood transfusion varies among surgeons and type of operation. Nearly one in four patients received a blood transfusion with a liberal intraoperative transfusion Hb trigger of 10 g/dl or more. Intraoperative blood transfusion was associated with higher risk of perioperative morbidity
Defining Which Patients Are at High Risk for Recurrence of Soft Tissue Sarcoma
No full textSeveral studies have investigated the prognosis of soft tissue sarcomas and the influence of a variety of factors, such as size, histology subtype, malignancy grade, site, margins, on overall survival, recurrence-free survival, incidence of local and distant spreading. The impact of genomic and expression profiling on long-term outcomes of patients with sarcomas has been also evaluated in order to fill the knowledge gap of this heterogeneous disease. Nomograms represent a prognostic tool that extends the standard staging systems on an individualized basis, taking into account tumor- and patient-related factors. They are used to assist the health provider and the patients in the decision-making process, for patient counseling, treatment decision-making, follow-up scheduling, and clinical trial eligibility determination. None of the available nomograms include molecular characterization of sarcomas. In the future, omics signatures might be incorporated into prognostic nomograms possibly improving their performance. In the present review, we focus on the complexity of prognostic and predictive factors for extremity and trunk wall as well as for retroperitoneal soft tissue sarcomas, while exploring the available prognostic models
Potential Economic Impact of Using a Restrictive Transfusion Trigger Among Patients Undergoing Major Abdominal Surgery
No full textIMPORTANCE Transfusion practice among surgeons varies despite several evidence-based recommendations supporting the restrictive use of blood products. OBJECTIVE To define the economic impact of liberal blood transfusions as assessed through an analysis of hemoglobin (Hb) triggers. DESIGN, SETTING, AND PARTICIPANTS Using a prospective database, data on Hb levels that triggered a transfusion and overall blood product use were obtained for patients undergoing pancreas, liver, or colorectal surgery between January 1, 2010, and August 31, 2013, at Johns Hopkins Hospital. An economic analysis was performed using a range of costs for a single unit of packed red blood cells (PRBCs) based on actual institutional acquisition costs (760/unit). Guidelines define a liberal Hb trigger as transfusion of PRBCs for an intraoperative Hb level of 10 g/dL or greater or a postoperative Hb level of 8 g/dL or greater (to convert to grams per liter, multiply by 10.0). MAIN OUTCOMES AND MEASURES Numbers of surgical patients who received PRBC transfusion, estimated cost per transfusion, and estimated cost of excessive blood transfusions. RESULTS Among 3027 patients, 942 (31.1%) received at least 1 PRBC transfusion, intraoperatively in 264 patients (8.7%), postoperatively in 429 (14.2%), or both in 249 (8.2%). A total of 4000 units of PRBCs (range, 0-167 units/patient) were transfused in the intraoperative (1581 units [39.5%]) and postoperative (2419 units [60.5%]) periods. Estimated total costs of PRBC transfusion ranged from 3 040 000, with marked variation in costs per patient across procedure type and surgeon. Among the 942 patients who received a transfusion, 456 units (11.4%) were transfused using a liberal trigger (intraoperative, 122 patients [13.0%]; postoperative, 79 patients [8.4%]). By adopting a restrictive trigger, total overall PRBC transfusion costs may have been reduced by 346 560 during the 44-month study period or 94 516 per year for patients undergoing a pancreas, liver, or colorectal resection. CONCLUSIONS AND RELEVANCE More than 1 in 10 units of PRBCs were transfused using a liberal Hb trigger. Patient blood management programs should aim to identify and reduce liberal transfusion practice in the surgical patient
Identifying Variations in Blood Use Based on Hemoglobin Transfusion Trigger and Target among Hepatopancreaticobiliary Surgeons
No full textBACKGROUND: Transfusion practice among surgeons varies despite several trials supporting the restrictive use of blood products. We sought to define the variation in surgeon transfusion hemoglobin (Hb) triggers and targets among patients undergoing hepatopancreaticobiliary (HPB) procedures, as well as assess perioperative outcomes among patients receiving transfusions under a restrictive vs liberal transfusion strategy. STUDY DESIGN: Using prospectively collected data, variations in transfusion Hb triggers, targets, and overall use of blood were examined among 1,554 patients undergoing an HPB procedure by 1 of 11 surgeons at Johns Hopkins Hospital between 2009 and 2013. Perioperative outcomes were compared among patients treated with a restrictive (Hb = 8 g/dL) transfusion strategy. RESULTS: Among the 1,554 patients included in the cohort, 504 (32.4%) received at least 1 transfusion of red cells. Patients who received a transfusion were older and had more medical comorbidities (both p 0.05). CONCLUSIONS: Nearly 1 in 3 patients undergoing an HPB procedure received a blood transfusion in the perioperative period. Transfusion use, indication ("trigger"), and dose ("target") varied among surgeons. The use of a restrictive transfusion strategy did not affect perioperative outcomes. (C) 2014 by the American College of Surgeon
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