Comparison of Postoperative Bleed Rates and Location of Bleed Between Vessel Sealing Devices after Laparoscopic Sleeve Gastrectomy.

Background: Laparoscopic sleeve gastrectomy (SG) is a commonly performed bariatric procedure. At our institution, two vessel sealing devices, Thunderbeat® (Olympus) and Maryland LigaSure™ (Covidien) are utilized for intraoperative dissection. Methods: A retrospective review of all patients who underwent primary SG from July 2013 through August 2022 was performed to evaluate postoperative bleeding (POB) rates between the two devices. The primary outcome measured was POB as defined by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), with secondary outcomes including reoperation, source of bleed, and overall safety. Results: A total of 8157 underwent SG. Average BMI and age were 43.2 kg/m2 and 37.1 years, respectively. A total of 6600 (80.9%) were female. Thunderbeat® was utilized in 5143 (63%) cases and Maryland LigaSure™ was used in 3014 (37%) cases. There was no significant difference in overall bleeding between the Thunderbeat® (18/5143, .35%) and the Maryland LigaSure™ (19/3014, .63%; P = .0689). However, there was a difference noted when comparing reoperation for bleeding between Thunderbeat® (9/5143, .17%) and Maryland LigaSure™ (13/3014, .43%; P = .0291). Furthermore, the location of bleeding in the reoperations was more common from the cut edge of the mesentery compared to the staple line with the Maryland LigaSure™ versus the Thunderbeat® (P = .038). Conclusions: The Thunderbeat® device is comparatively more hemostatic than the Maryland LigaSure™ for SG. The location of postoperative bleed may be related to vessel sealing devices used.

Routine extended (30 days) chemoprophylaxis for patients undergoing laparoscopic sleeve gastrectomy may reduce Portomesenteric vein thrombosis rates.

BACKGROUND: Venous thromboembolism (VTE), including Portomesenteric vein thrombosis (PMVT), is a major complication of sleeve gastrectomy (SG). We changed our practice in July 2021 to routinely discharge all SG patients postoperatively with extended chemoprophylaxis for 30 days. OBJECTIVES: Evaluate the efficacy and safety of routine extended chemoprophylaxis compared to 2 prior timeframes using selective extended chemoprophylaxis. SETTING: University Hospital. METHODS: Between 2012-2018, SG patients were discharged on extended chemoprophylaxis for patients deemed "high-risk" for VTE, including patients with body mass index (BMI) >50, and previous VTE. Between 2018-2021, extended chemoprophylaxis was broadened to include patients with positive preoperative thrombophilia panels (including Factor VIII). After 2021, all SG were routinely discharged on extended chemoprophylaxis. The typical regimen was 30 days Lovenox BID (40-mg twice daily for BMI> 40, 60-mg twice daily for BMI >60). Outcomes evaluated were rate of VTE/PMVT and postoperative bleed, including delayed bleed. RESULTS: A total of 8864 patients underwent SG. Average age and BMI were 37.5 years and 43.0 kg/m2, respectively. The overall incidence of PMVT was 33/8864 (.37%). Converting from selective extended chemoprophylaxis (Group 1) to routine extended chemoprophylaxis (Group 3) decreased the rate of PMVT from .55% to .21% (P = .13). There was a significantly higher overall bleeding rate (.85%), including delayed bleeds (.34%) in the routine extended chemoprophylaxis patients (P < .05). These bleeds were mainly managed nonoperatively. CONCLUSIONS: Routine extended (30 day) chemoprophylaxis for all SG may reduce PMVT rate but lead to a higher bleeding rate post-operatively. The vast majority of the increased bleeds are delayed and can be managed non-operatively.

Platelet adenosine diphosphate receptor inhibition provides no advantage in predicting need for platelet transfusion or massive transfusion.

BACKGROUND: Thrombelastography platelet mapping is a useful assay to assess antiplatelet therapy. Inhibited response to the adenosine diphosphate receptor on platelets occurs early after injury, but recent work suggests this alteration occurs even with minor trauma. However, the utility of thrombelastography platelet mapping, specifically the percent of adenosine diphosphate receptor inhibition, in predicting outcomes and guiding platelet transfusion in trauma-induced coagulopathy remains unknown We assessed the role of percent of adenosine diphosphate-inhibition in predicting survival, requirement for massive transfusion or platelet transfusion in patients at risk for trauma-induced coagulopathy. METHODS: Thrombelastography platelet mapping was assessed in 303 trauma activation patients from 2014-2016 and in 89 healthy volunteers. Percent of adenosine diphosphate-inhibition is presented as median and interquartile range. We compared the area under the receiver operating characteristic curve of percent of adenosine diphosphate-inhibition, platelet count, and rapid thrombelastography maximum amplitude for in-hospital mortality, massive transfusion (>10 red blood cells or death/6 hours), and platelet transfusion (>0 platelet units or death/6 hour). RESULTS: Overall, 35 (11.5%) patient died, 27 (8.9%) required massive transfusion and 46, platelet transfusions (15.2%). Median percent of adenosine diphosphate-inhibition was 42.5% (interquartile range: 22.4-69.1%), compared with 4.3 % (interquartile range: 0-13.5%) in healthy volunteers (P < .0001). Patients that died, had a massive transfusion, or platelet transfusion had higher percent of adenosine diphosphate-inhibition than those that did not (P < .05 for all). However, percent of adenosine diphosphate-inhibition did not add significantly to the predictive performance of maximum amplitude or platelet count for any of the 3 outcomes, after adjustment for confounders. Subgroup analyses by severe traumatic brain injury, severe injury and requirement of red blood cells showed similar results. CONCLUSION: Adenosine diphosphate receptor inhibition did not add predictive value to predicting mortality, massive transfusion, or platelet transfusion. Thus, the role of thrombelastography platelet mapping as a solitary tool to guide platelet transfusions in trauma requires continued refinement.

Rapid thrombelastography thresholds for goal-directed resuscitation of patients at risk for massive transfusion.

BACKGROUND: Uncontrolled hemorrhage is a leading cause of mortality after trauma accounting for up to 40% of deaths. Massive transfusion protocols offer a proven benefit in resuscitation of these patients. Recently, the superiority of thrombelastography (TEG)-guided resuscitation over strategies guided by conventional clotting assays has been established. We seek to determine optimal thresholds for rapid (r)-TEG driven resuscitation. METHODS: The r-TEG data were reviewed for 190 patients presenting to our level 1 trauma center from 2010 to 2015. Criteria for inclusion were highest level trauma activation in patients 18 years or older with hypotension presumed due to acute blood loss. Exclusion criteria included isolated gunshot wound to the head, pregnancy, and chronic liver disease. Receiver operating characteristic (ROC) analysis was performed to test the predictive performance of r-TEG for massive transfusion requirement defined by need for (1) >10 units of RBCs total or death in the first 6 hours or (2) >4 units of RBCs in any hour within the first 6 hours. Cutpoint analysis was then performed to determine optimal thresholds for TEG-based resuscitation. RESULTS: The ROC analysis of r-TEG yielded areas under the curve (AUC) greater than 70% for all outputs with respect to both transfusion thresholds considered, with exception of activated clotting time and lysis at 30 minutes for greater than 4 U RBC in any hour in the first 6 hours. Optimal cutpoint analysis of the resultant ROC curves was performed and for each value, the most sensitive cutpoint was identified, respectively activated clotting time of 128 seconds or longer, angle (α) of 65 degrees or less, maximum amplitude of 55 mm or less, and lysis at 30 minutes of 5% or greater. CONCLUSIONS: Through ROC analysis of prospective TEG data, we have identified optimal thresholds to guide hemostatic resuscitation. These thresholds should be validated in a prospective multicenter trial. LEVEL OF EVIDENCE: Therapeutic study, level V.

Positron emission tomography (PET) has limited utility in the staging of pancreatic adenocarcinoma.

BACKGROUND: Positron emission tomography (PET) as an adjunct to conventional imaging in the staging of pancreatic adenocarcinoma is controversial. Herein, we assess the utility of PET in identifying metastatic disease and evaluate the prognostic potential of standard uptake value (SUV). METHODS: Imaging and follow-up data for patients diagnosed with pancreatic adenocarcinoma were reviewed retrospectively. Resectability was assessed based on established criteria, and sensitivity, specificity, and accuracy of PET were compared to those of conventional imaging modalities. RESULTS: For 123 patients evaluated 2005-2011, PET and CT/MRI were concordant in 108 (88 %) cases; however, PET identified occult metastatic lesions in seven (5.6 %). False-positive PETs delayed surgery for three (8.3 %) patients. In a cohort free of metastatic disease in 78.9 % of cases, the sensitivity and specificity of PET for metastases were 89.3 and 85.1 %, respectively, compared with 62.5 and 93.5 % for CT and 61.5 and 100.0 % for MRI. Positive predictive value and negative predictive value of PET were 64.1 and 96.4 %, respectively, compared with 75.0 and 88.9 % for CT and 100.0 and 91.9 % for MRI. Average difference in maximum SUV of resectable and unresectable lesions was not statistically significant (5.65 vs. 6.5, p = 0.224) nor was maximum SUV a statistically significant predictor of survival (p = 0.18). CONCLUSION: PET is more sensitive in identifying metastatic lesions than CT or MRI; however, it has a lower specificity, lower positive predictive value, and in some cases, can delay definitive surgical management. Therefore, PET has limited utility as an adjunctive modality in staging of pancreatic adenocarcinoma.