Accuracy of point-of-care testing devices for haemoglobin in the operating room: meta-analysis.

BACKGROUND: Point-of-care tests (POCT) for haemoglobin are increasingly used to guide intraoperative transfusion. However, their accuracy compared to central laboratory tests is unknown. The objective was to perform a systematic review and meta-analysis of method comparison studies assessing the accuracy of POCT versus central laboratory haemoglobin tests in patients undergoing surgery. METHODS: Electronic databases were searched from inception to April 2020 (updated August 2023). Any methodological approach comparing haemoglobin measurements between POCT and central laboratory in patients undergoing surgery under anaesthesia in the operating room were included. Data abstraction was guided by PRISMA and risk of bias was assessed by QUADAS-2. Data were extracted independently and in duplicate by two reviewers. Outcomes included mean differences between POCT and central laboratory haemoglobin with associated standard deviations and 95% limits of agreement (LOA). RESULTS: Of 3057 citations, 34 studies were included (n = 2427, 6857 paired measurements). Several devices were compared (pulse co-oximetry, n = 25; HemoCue, n = 10; iSTAT, n = 6; blood gas analysers, n = 10; haematology analyser, n = 2). Median sample size was 41 patients, and 11 studies were funded by device manufacturers. Fifteen of 34 studies had low risk of bias. Pooled mean differences (95% LOA) were: pulse co-oximeters 2.3 g/l (-25.2-29.8), HemoCue -0.3 g/l (-11.1-10.5), iSTAT -0.3 g/l (-8.4-7.8) and blood gas analysers -2.6 g/l (-17.8-12.7). CONCLUSION: All POCT examining intraoperative haemoglobin measurement yielded pooled mean difference LOAs larger than the allowable limit difference of ±4 g/dl. Intraoperative haemoglobin measured by POCT should not be considered interchangeable with central laboratory values and caution is necessary when using these tests to guide intraoperative transfusion.

Phlebotomy resulting in controlled hypovolemia to prevent blood loss in major hepatic resections (PRICE-2): study protocol for a phase 3 randomized controlled trial.

INTRODUCTION: Blood loss and red blood cell (RBC) transfusion in liver surgery are areas of concern for surgeons, anesthesiologists, and patients alike. While various methods are employed to reduce surgical blood loss, the evidence base surrounding each intervention is limited. Hypovolemic phlebotomy, the removal of whole blood from the patient without volume replacement during liver transection, has been strongly associated with decreased bleeding and RBC transfusion in observational studies. This trial aims to investigate whether hypovolemic phlebotomy is superior to usual care in reducing RBC transfusions in liver resection. METHODS: This study is a double-blind multicenter randomized controlled trial. Adult patients undergoing major hepatic resections for any indication will be randomly allocated in a 1:1 ratio to either hypovolemic phlebotomy and usual care or usual care alone. Exclusion criteria will be minor resections, preoperative hemoglobin <100g/L, renal insufficiency, and other contraindication to hypovolemic phlebotomy. The primary outcome will be the proportion of patients receiving at least one allogeneic RBC transfusion unit within 30 days of the onset of surgery. Secondary outcomes will include transfusion of other allogeneic blood products, blood loss, morbidity, mortality, and intraoperative physiologic parameters. The surgical team will be blinded to the intervention. Randomization will occur on the morning of surgery. The sample size will comprise 440 patients. Enrolment will occur at four Canadian academic liver surgery centers over a 4-year period. Ethics approval will be obtained at participating sites before enrolment. DISCUSSION: The results of this randomized control trial will provide high-quality evidence regarding the use of hypovolemic phlebotomy in major liver resection and its effects on RBC transfusion. If proven to be effective, this intervention could become standard of care in liver operations internationally and become incorporated within perioperative patient blood management programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT03651154 . Registered on August 29 2018.

The impact of prophylactic negative pressure wound therapy on surgical site infections in pancreatic resection: A systematic review and meta-analysis.

BACKGROUND: Surgical site infections (SSI) cause significant morbidity. Prophylactic negative pressure wound therapy (NPWT) may promote wound healing and decrease SSI. The objective is to evaluate the effect of prophylactic NPWT on SSI in patients undergoing pancreatectomy. METHODS: Electronic databases were searched from inception until April 2022. Randomized controlled trials (RCTs) comparing prophylactic NPWT to standard dressings in patients undergoing pancreatectomy were included. The primary outcome was the risk of SSI. Secondary outcomes included the risk of superficial and deep SSI and organ space infection (OSI). Random effects models were used for meta-analysis. RESULTS: Four single-centre RCTs including 309 patients were identified. Three studies were industry-sponsored, and two were at high risk of bias. There was no significant difference in the risk of SSI in patients receiving NPWT vs. control (14% vs. 21%, RR = 0.72, 95%CI = 0.32-1.60, p = 0.42, I2 = 53%). Likewise, there was no significant difference in the risk of superficial and deep SSI or OSI. No significant difference was found on subgroup analysis of patients at high risk of wound infection or on sensitivity analysis of studies at low risk of bias. CONCLUSION: Prophylactic NPWT does not significantly decrease the risk of SSI among patients undergoing pancreatectomy. Insufficient evidence exists to justify the routine use of NPWT.

Outcomes of Patients Undergoing Elective Bowel Resection Before and After Implementation of an Anemia Screening and Treatment Program.

BACKGROUND: Patients with anemia undergoing elective colorectal cancer surgery are known to have significantly higher rates of postoperative complications and worse outcomes. OBJECTIVE: This study aimed to improve rates of anemia screening and treatment in patients undergoing elective colon and rectal resections through a quality improvement initiative. DESIGN: We compared a historical cohort of patients before implementation of our anemia screening and treatment quality improvement program to a prospective cohort after implementation. SETTINGS: This study was conducted at a tertiary care hospital. PATIENTS: This study included all adult patients with a new diagnosis of colon or rectal cancer without evidence of metastatic disease between 2017 and 2019. INTERVENTIONS: The interventions include the anemia screening and treatment quality improvement program. MAIN OUTCOME MEASURES: The primary outcome was hospital cost per admission. RESULTS: This study includes a total of 84 patients who underwent elective colon or rectal resection before implementation of our anemia quality improvement project and 88 patients who underwent surgery after. In the preimplementation cohort 44 of 84 patients (55.9%) were anemic compared to 47 of 99 patients (54.7%) in the postimplementation cohort. Rates of screening (25%-86.4%) and treatment (27.8%- 63.8%) were significantly increased in the postimplementation cohort. Mean total cost per admission was significantly decreased in the postimplementation cohort (mean cost $16,827 vs $25,796; p = 0.004); this significant reduction was observed even after adjusting for relevant confounding factors (ratio of means: 0.74; 95% CI, 0.65-0.85). The mechanistic link between treatment of anemia and reductions in cost remains unknown. No significant difference was found in rates of blood transfusion, complications, or mortality between the groups. LIMITATIONS: The study limitation includes before-after design subjected to selection and temporal biases. CONCLUSIONS: We demonstrate the successful implementation of an anemia screening and treatment program. This program was associated with significantly reduced cost per admission. This work demonstrates possible value and benefits of implementation of an anemia screening and treatment program. See Video Abstract at http://links.lww.com/DCR/C15 .RESULTADOS DE LOS PACIENTES SOMETIDOS A RESECCIÓN INTESTINAL ELECTIVA ANTES Y DESPUÉS DE LA IMPLEMENTACIÓN DE UN PROGRAMA DE DETECCIÓN Y TRATAMIENTO DE ANEMIA. ANTECEDENTES: Se sabe que los pacientes anémicos que se someten a una cirugía electiva de cáncer colorrectal tienen tasas significativamente más altas de complicaciones posoperatorias y peores resultados. OBJETIVO: Mejorar las tasas de detección y tratamiento de la anemia en pacientes sometidos a resecciones electivas de colon y recto a través de una iniciativa de mejora de calidad. DISEO: Comparamos una cohorte histórica de pacientes antes de la implementación de nuestro programa de detección de anemia y mejora de la calidad del tratamiento con una cohorte prospectiva después de la implementación. ENTORNO CLINICO: Hospital de atención terciaria. PACIENTES: Todos los pacientes adultos con un nuevo diagnóstico de cáncer de colon o recto sin evidencia de enfermedad metastásica entre 2017 y 2019. INTERVENCIONES: Detección de anemia y programa de mejora de la calidad del tratamiento. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario fue el costo hospitalario por ingreso. RESULTADOS: Un total de 84 pacientes se sometieron a resección electiva de colon o recto antes de la implementación de nuestro proyecto de mejora de calidad de la anemia y 88 pacientes se sometieron a cirugía después. En la cohorte previa a la implementación, 44/84 (55,9 %) presentaban anemia en comparación con 47/99 (54,7 %) en la cohorte posterior a la implementación. Las tasas de detección (25 % a 86,4 %) y tratamiento (27,8 % a 63,8 %) aumentaron significativamente en la cohorte posterior a la implementación. El costo total medio por admisión se redujo significativamente en la cohorte posterior a la implementación (costo medio $16 827 vs. $25 796, p = 0,004); esta reducción significativa se observó incluso después de ajustar los factores de confusión relevantes (proporción de medias: 0,74, IC del 95 %: 0,65 a 0,85). El vínculo mecánico entre el tratamiento de la anemia y la reducción de costos sigue siendo desconocido. No hubo diferencias significativas en las tasas de transfusión de sangre, complicaciones o mortalidad entre los grupos. LIMITACIONES: El diseño de antes y después está sujeto a sesgos temporales y de selección. CONCLUSIONES: Demostramos la implementación exitosa de un programa de detección y tratamiento de anemia. Este programa se asoció con un costo por admisión significativamente reducido. Este trabajo demuestra el valor y los beneficios posibles de la implementación de un programa de detección y tratamiento de la anemia. Consulte Video Resumen en http://links.lww.com/DCR/C15 . (Traducción- Dr. Francisco M. Abarca-Rendon ).

Does Caudate Resection Improve Outcomes of Patients Undergoing Curative Resection for Perihilar Cholangiocarcinoma? A Systematic Review and Meta-Analysis.

BACKGROUND: Margin-negative (R0) resection is the strongest positive prognostic factor in perihilar cholangiocarcinoma (PHC). Due to its anatomic location, the caudate lobe is frequently involved in PHC. This review aimed to examine the impact of caudate lobe resection (CLR) in addition to hepatectomy and bile duct resection for patients with PHC. METHODS: The MEDLINE, EMBASE, and Cochrane databases were systematically reviewed from inception to October 2021 to identify studies comparing patients undergoing surgical resection with hepatectomy and bile duct resection with or without CLR for treatment of PHC. Outcomes included the proportion of patients achieving R0 resection, overall survival (OS), and perioperative morbidity. RESULTS: Altogether, 949 studies were screened. The review included eight observational studies reporting on 1137 patients. The patients who underwent CLR had a higher likelihood of R0 resection (odds ratio [OR], 5.85; 95% confidence interval [CI], 2.64-12.95) and a better OS (hazard ratio [HR], 0.65; 95% CI, 0.54-0.79) than those who did not. The use of CLR did not increase the risk of perioperative morbidity (OR, 1.03; 95% CI, 0.65-1.63). CONCLUSIONS: Given the higher likelihood of R0 resection, improved OS, and no apparent increase in perioperative morbidity, this review supports routine caudate lobectomy in the surgical management of PHC. These results should be interpreted with caution given the lack of high-quality prospective data and the high probability of selection bias.

Does Intraoperative Frozen Section and Revision of Margins Lead to Improved Survival in Patients Undergoing Resection of Perihilar Cholangiocarcinoma? A Systematic Review and Meta-analysis.

BACKGROUND: Perihilar cholangiocarcinoma (PHC) is a rare malignancy that arises at the biliary confluence. Achieving a margin-negative resection (R0) is challenging given the anatomic location of tumors and remains the most important prognostic indicator of long-term survival. The objective of this study is to review the impact of intraoperative revision of positive biliary margins in PHC on oncologic outcomes. PATIENTS AND METHODS: Electronic databases were searched from inception to October 2021. Studies comparing three types of patients undergoing resection of PHC with intraoperative frozen section of the proximal and/or distal bile ducts were identified: those who were margin-negative (R0), those with an initially positive margin who had revised negative margins (R1R0), and those with a persistently positive margin with or without revision of a positive margin (R1). The primary outcome was overall survival (OS). Secondary outcomes included risk of postoperative complication. RESULTS: A total of 449 studies were screened. Ten retrospective observational studies reporting on 1955 patients were included. Patients undergoing successful revision of a positive proximal and/or distal bile duct margin (R1R0) had similar OS to those with a primary margin-negative resection (R0) [hazard ratio (HR) 0.93, 95% confidence interval (CI) 0.72-1.19, p = 0.56, I2 = 84%], and significantly better OS than patients with a positive final bile duct margin (R1) (HR 0.52, 95% CI 0.34-0.79, p = 0.002, I2 = 0%). There was no increase in the risk of postoperative complications associated with additional resection, although postoperative morbidity was inconsistently reported. CONCLUSIONS: This review supports routine intraoperative biliary margin evaluation during resection of PHC with revision if technically feasible.

Improving the treatment of pre-operative anemia in hepato-pancreato-biliary patients: a quality improvement initiative.

BACKGROUND: Pre-operative anemia is a common, but treatable, condition encountered by surgical patients. It has been associated with increased perioperative complications, length of stay, and blood transfusions. The aim of this project was to increase the treatment rate of pre-operative anemia to 75% of patients consented for major hepato-pancreato-biliary (HPB) surgery. METHODS: This was an interrupted time series study and a spread initiative from a similar project in a colorectal surgery population. Interventions included an anemia screening and treatment algorithm, standardized blood work, referral to a patient blood management program, and standardized oral iron prescriptions. The primary outcome measure was the change in pre-operative anemia treatment rate and the secondary outcome measure was the post treatment increase in hemoglobin. RESULTS: A total of 208 patients were included (n = 124 pre-intervention and n = 84 post-intervention). Anemia was present in 39.9% of patients. The treatment rate of pre-operative anemia increased to 44.1% from 28.6%. The mean hemoglobin increased from 110 g/L to 119 g/L in patients who were treated (p = 0.03). There was no significant increase or decrease in blood transfusions or mean number of red cell units transfused per patient. Screening rates for pre-operative anemia increased from 41.1 to 64.3% and appropriate referrals to the patient blood management program increased from 14.3 to 67.6%. CONCLUSIONS: This study demonstrates a small scale spread initiative focused on the treatment of pre-operative anemia. Although the goal to treat 75% of anemic patients was not reached, an effective referral pathway to an existing patient blood management program was developed, and a significant increase in the mean hemoglobin in anemic patients who have been treated pre-operatively was demonstrated.

Metastatic lung cancer presenting as gastric outlet obstruction: diagnosis and management with laparoscopic gastric bypass: a novel technique.

Metastatic tumours of the duodenum are relatively rare. Here we present a case of a 64-year-old Caucasian male who presented with a 3-week history of postprandial vomiting, weight-loss and epigastric discomfort. Imaging and biopsy revealed that the patient had a primary lung tumour in his right upper lung lobe as well as a duodenal metastasis leading to gastric outlet obstruction (GOO). The patient was stabilised and subsequently underwent a laparoscopic gastric bypass to palliate the gastric outlet obstruction. Appropriate management of metastatic GOO involves accurate diagnosis and treatment with either enteral stenting or laparoscopic gastric bypass. It is suggested that the decision whether to stent or surgically bypass the obstruction can be based on the patient's life expectancy and performance status. Regardless of the approach, palliating metastatic GOO can improve the quality of life of carefully chosen symptomatic patients. We describe a technique of laparoscopic palliative gastric bypass which has not been reported previously in the literature.

Signalling by Transforming Growth Factor Beta Isoforms in Wound Healing and Tissue Regeneration.

Transforming growth factor beta (TGFß) signalling is essential for wound healing, including both non-specific scar formation and tissue-specific regeneration. Specific TGFß isoforms and downstream mediators of canonical and non-canonical signalling play different roles in each of these processes. Here we review the role of TGFß signalling during tissue repair, with a particular focus on the prototypic isoforms TGFß1, TGFß2, and TGFß3. We begin by introducing TGFß signalling and then discuss the role of these growth factors and their key downstream signalling mediators in determining the balance between scar formation and tissue regeneration. Next we discuss examples of the pleiotropic roles of TGFß ligands during cutaneous wound healing and blastema-mediated regeneration, and how inhibition of the canonical signalling pathway (using small molecule inhibitors) blocks regeneration. Finally, we review various TGFß-targeting therapeutic strategies that hold promise for enhancing tissue repair.

Characterization of TGFß signaling during tail regeneration in the leopard Gecko (Eublepharis macularius).

INTRODUCTION: The transforming growth factor beta (TGFß)/activin signaling pathway has a number of documented roles during wound healing and is increasingly appreciated as an essential component of multi-tissue regeneration that occurs in amphibians and fish. Among amniotes (reptiles and mammals), less is known due in part to the lack of an appropriate model organism capable of multi-tissue regeneration. The leopard gecko Eublepharis macularius is able to spontaneously, and repeatedly, regenerate its tail following tail loss. We examined the expression and localization of several key components of the TGFß/activin signaling pathway during tail regeneration of the leopard gecko. RESULTS: We observed a marked increase in phosphorylated Smad2 expression within the regenerate blastema indicating active TGFß/activin signaling. Interestingly, during early regeneration, TGFß1 expression is limited whereas activin-ßA is strongly upregulated. We also observe the expression of EMT transcription factors Snail1 and Snail2 in the blastema. CONCLUSIONS: Combined, these observations provide strong support for the importance of different TGFß ligands during multi-tissue regeneration and the potential role of TGFß/activin-induced EMT programs during this process.