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BackgroundLaparoscopic cholecystectomy is considered the gold standard for the treatment of gallbladder lithiasis; nevertheless, the incidence of bile duct injuries (BDI) is still high (0.3–0.8%) compared to open cholecystectomy (0.2%). In 1995, Strasberg introduced the \"Critical View of Safety\" (CVS) to reduce the risk of BDI. Despite its widespread use, the scientific evidence supporting this technique to prevent BDI is controversial.MethodsBetween March 2017 and March 2019, the data of patients submitted to laparoscopic cholecystectomy in 30 Italian surgical departments were collected on a national database. A survey was submitted to all members of Italian Digestive Pathology Society to obtain data on the preoperative workup, the surgical and postoperative management of patients and to judge, at the end of the procedure, if the isolation of the elements was performed according to the CVS. In the case of a declared critical view, iconographic documentation was obtained, finally reviewed by an external auditor.ResultsData from 604 patients were analysed. The study population was divided into two groups according to the evidence (Group A; n = 11) or absence (Group B; N = 593) of BDI and perioperative bleeding.The non-use of CVS was found in 54.6% of procedures in the Group A, and 25.8% in the Group B, and evaluating the operator-related variables the execution of CVS was associated with a significantly lower incidence of BDI and intraoperative bleeding.ConclusionsThe CVS confirmed to be the safest technique to recognize the elements of the Calot triangle and, if correctly performed, it significantly impacted on preventing intraoperative complications. Additional educational programs on the correct application of CVS in clinical practice would be desirable to avoid extreme conditions that may require additional procedures.

Background Inadvertent intraoperative hypothermia (core temperature < 36 °C) is a common but preventable adverse event. This study aimed to determine whether active intraoperative warming reduced bleeding in patients undergoing major operations: open thoracic surgery and hip replacement surgery. Methods / Design The study was a pilot, prospective, parallel two-arm randomized controlled trial. Eligible patients were randomly allocated to two groups: passive warming (PW), with application of a cotton blanket (thermal insulation), or active warming (AW), with a forced-air warming system. The primary endpoint was intraoperative blood loss, and secondary endpoints were surgical-site infection, cardiovascular events, and length of stay in the post-anesthesia care unit, intensive care unit, and hospital. Results Sixty-two patients were enrolled. Forced-air active warming maintained intraoperative normothermia in all AW subjects, whereas intraoperative hypothermia occurred in 21/32 (71.8%) of PW patients ( p  = 0.000). The volume of blood loss was more in the PW group (682 ± 426 ml) than in the AW group (464 ± 324 ml) ( p  < 0.021), and the perioperative hemoglobin value declined more in the PW group (28.6 ± 17.5 g/L) than in the AW group (21.0 ± 9.9 g/L) ( p  = 0.045). However, there were no difference in other clinical outcomes between two groups. Conclusion Intraoperative active warming is associated with less blood loss than passive warming in open thoracic and hip replacement operations in this pilot study. Trial registration This trial was registered with Clinicaltrials.gov (Identifier: NCT02214524 ) on 27 August 2014.

BackgroundEndoscopic submucosal dissection (ESD) is commonly used to treat early gastric cancer (EGC). The effects of Helicobacter pylori (HP) infection on ESD and the potential benefits of preoperative eradication of HP remain unclear. The study aims to evaluate the impact of HP infection on bleeding and lesion detection during ESD in patients with EGC.MethodsWe retrospectively analyzed 634 consecutive patients who underwent ESD for EGC at our center between January 2018 and January 2023. Logistic regression was used to assess the impact of HP infection status on intraoperative bleeding and lesion detection rates. We developed a predictive model based on selected indicators and evaluated its performance using the ROC curve.ResultsHP-positive patients experienced a higher rate of intraoperative bleeding (28.8%) compared with HP-negative patients (8.9%) (P < 0.001). HP-positive patients also had longer procedure time (median: 58.5 vs. 50.0 min, P < 0.001) and postoperative hospital stays (median: 4.35 vs. 4.07 days, P = 0.036). Multivariate analysis identified HP-positive (OR = 4.84), multiple lesions (OR = 1.81), specimen size > 40 mm (OR = 3.67), and submucosal invasion (OR = 2.27) as independent risk factors for intraoperative bleeding. The predictive model achieved an AUC of 0.807 (95%CI 0.761–0.852), with a sensitivity of 72.1% and specificity of 75.9%. Preoperative HP eradication was associated with an increased rate of lesion detection (OR = 2.82).ConclusionsEradicating HP before ESD in patients with EGC reduces intraoperative bleeding and improves lesion detection. Preoperative HP eradication is therefore recommended in patients with EGC.

PurposeContemporary predictive tools for miniaturized percutaneous nephrolithotomy (mPCNL) mainly focus on stone clearance but not perioperative complications, especially infection and hemorrhage. This study aimed to evaluate whether the Mayo adhesive probability (MAP) score, an index of the perinephric fat characteristics, can predict postoperative fever and intraoperative hemorrhage in mPCNL.MethodsThis is a retrospective study recruiting 159 mPCNL patients from July 2018 to January 2022. MAP scores were recorded using preoperative computed tomography. Postoperative complications included postoperative fever and intraoperative bleeding, defined as hemoglobin drop.ResultsOver half patients had the MAP score ≧ 3. Men, elderly, chronic kidney disease, and diabetes were associated with a higher MAP score. The patients with a higher MAP score were more likely to have postoperative fever after mPCNL. On multivariate analysis, preoperative positive urine culture (OR 2.68) and a higher MAP score (OR 2.28) were both significantly associated with postoperative fever. ROC curves analysis of the combination of these two factors on predicting postoperative fever showed AUC values were 0.731 (0.652–0.810). Moreover, a higher MAP score (OR 2.30) and longer operative time (OR 2.16) were significantly associated with higher hemoglobin drop on multivariate analysis.ConclusionA high MAP score was associated with postoperative fever and intraoperative hemorrhage in patients undergoing mPCNL. The MAP score can be a novel and easy predictive tool to help endourologists improve the awareness of mPCNL safety.

Mayo adhesive probability (MAP) score is one of the commonest tool to predict the adherence status of perirenal fat. The association between MAP score and intraoperative hemorrhage in patients undergoing micropercutaneous nephrolithotomy was comfirmed in a recent well designed study. We aimed to investigate if MAP score may predict the possibility for significant intraoperative bleeding in supine percutaneous nephrolithotomy (PCNL) performed with a 26 Fr rigid nephroscope. In this observational retrospective study, demographic, clinical, laboratory, radiological, perioperative (operation duration, hospitalization, intraoperative bleeding, success) and MAP score (perinephric fat stranding, posterior perinephric fat thickness and total MAP score) data of all patients who underwent supine PCNL between June 2021 and July 2023 were evaluated. The patients were divided into 2 groups according to their MAP scores (79 [54.1%] patients with MAP score < 3 [low MAP score] and 67 [54.1%] patients with MAP score ≥ 3 [high MAP score]). The rate of patients with intraoperative bleeding was 47.8% in the patient group with a high MAP score, while it was 22.8% in the patient group with a low MAP score (p = 0.002). In multivariate logistic regression analysis, anticoagulant drug use history (OR = 2.525; 95% CI = 1.025–6.224; p = 0.044), presence of multiple stones (OR = 3.015; 95% CI = 1.205–7.543; p = 0.018), calyx localization of the stone (OR = 2.871;95% CI = 1.166–7.068; p = 0.022), higher renal parenchymal thickness (OR = 1.119; 95% CI = 1.049–1.193; p = 0.001) and MAP score > 3 (OR = 3.486; 95% CI = 1.579–7.696; p = 0.002) were defined as independent risk factors for significant intraoperative bleeding. In clinical practice, the MAP score can be used to predict bleeding before PCNL.

Background Septorhinoplasty (SRP) is one of the most commonly performed procedures in the world for functional and aesthetic purposes. The present study was aimed to compare the effects of hypocapnia and hypercapnia regarding the total amount of intraoperative bleeding, surgical field quality, and surgeon satisfaction level. Methods In this randomized prospective clinical study, eighty patients with American Society of Anesthesiologists I–II and were 18–45 years old scheduled for septorhinoplasty were randomly allocated to group hypocapnia [end-tidal carbon dioxide (EtCO 2 ) 30 ± 2 mmHg] and group hypercapnia (EtCO 2 40 ± 2 mmHg). We evaluated the total amount of intraoperative bleeding, the surgical field quality, surgeon satisfaction level, hemodynamics and peri- and postoperative adverse events. Results Group hypocapnia significantly reduced the total amount of intraoperative bleeding ( p  < 0.001). The surgical field quality and surgeon satisfaction level in group hypocapnia were significantly better than group hypercapnia ( p  < 0.001). EtCO 2 levels of group hypocapnia were significantly lower than group hypercapnia at all time points ( p  < 0.001 for all time points). There were no significant differences between the groups in terms of heart rate and mean arterial pressure at all time points. There were no significant differences between the groups in terms of adverse events Conclusions The results of this double-blind randomized clinical trial showed that reducing the amount of intraoperative bleeding for patients with hypocapnia undergoing SRP through known methods (e.g., reverse Trendelenburg head-up position, positive end-expiratory pressure limiting, controlled hypotension, and use of topical vasoconstrictors, corticosteroids, and tranexamic acid) would improve the quality of the surgical field and raise the surgeon satisfaction level. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

This study aimed to evaluate the impact of postoperative intra-abdominal infectious complications (PICs) on survival after surgery for gastric cancer. A total of 152 patients who underwent curative gastrectomy for gastric cancer were included. The effect of clinicopathological features and PICs on recurrence-free survival (RFS) and overall survival (OS) were investigated. The median age was 67 years. The pathological stage was stage I (61), II (40), and III (51). Thirty-two patients (21.1%) had PICs: 9, pancreatic fistula; 14, anastomotic leakage; and 17, intra-abdominal abscess. The five-year RFS and OS rates were significantly lower in patients with PICs than in those without PICs (63.4 vs. 85.6%; p < 0.01 and 56.4 vs. 80.3%; p < 0.01, respectively). In multivariate analysis, intraoperative blood loss was an independent prognostic factor for PICs. Patients with PICs had worse clinical outcomes. Reducing intraoperative bleeding may improve the prognosis of gastric cancer. •PICs are postoperative intra-abdominal infectious complications in gastric cancer.•Gastric cancer patients with PICs have worse clinical outcomes.•Intraoperative bleeding is an independent risk factor for PICs.

Preoperative embolization for meningiomas is controversial regarding its effectiveness in reducing intraoperative blood loss and operative time. In contrast, some reports have documented improved surgical outcomes in large meningiomas. In this study, we retrospectively compared the outcomes of craniotomy for meningiomas with/without preoperative embolization with diluted N-butyl-2-cyanoacrylate (NBCA) primarily in a single institution. Data (World Health Organization grade, Simpson grade, maximum tumor diameter, intraoperative bleeding, operative time, history of hypertension, and time from embolization to craniotomy) of patients with initial intracranial meningiomas were compared with or without preoperative embolization from January 2015 to April 2022. The embolization group consisted of 56 patients and the nonembolization group included 76 patients. Diluted NBCA (13% concentration for all patients) was used in 51 of 56 patients (91.1%) who underwent transarterial embolization. Permanent neurological complications occurred in 2 (3.6%) patients. Intraoperative bleeding was significantly lower in the embolization group for a maximum tumor diameter ≥40 mm (155 vs. 305 ml, respectively, p < 0.01). In the nonembolization group, for a maximum tumor diameter ≥30 mm, patients with hypertension had more intraoperative bleeding than non-hypertensive ones. Despite its limitations, the present results showed that, under certain conditions, preoperative embolization for intracranial meningiomas caused less intraoperative bleeding. The safety of treatment was comparable with that reported in the Japan Registry of NeuroEndovascular Therapy 3 (JR-NET3) with a complication rate of 3.7% for preoperative embolization of meningiomas, despite the treatment focused on the liquid embolization material. •The rate of preoperative embolization with diluted NBCA for meningiomas: 91.1%.•Permanent neurological complications: 3.6%.•Preoperative embolization may reduce intraoperative bleeding in certain patients.

BackgroundNowadays, minimizing the surgical complications of rhinoplasty has gained more importance. Results from previous trials show that Tranexamic acid (TXA) reduces intraoperative bleeding, one of the major complicating factors during rhinoplasty.ObjectiveTo contribute to previous evidence by re-evaluating the efficacy of TXA, specifically in reducing intraoperative blood loss and increasing surgical field quality in rhinoplasty.Study Design and MethodsA randomized placebo-controlled trial was conducted (IRCT20111219008458N2). The outcomes included total intraoperative blood loss, measured by the total volume of fluid collected by suction and gauzes, subtracted by volume of used irrigation fluids, and the quality of surgical field, measured by surgeon’s satisfaction on a 5-point Likert scale. Demographics, blood coagulation measures, and clinical data were also collected and were held as covariates in analysis. After blinding, randomization, and group allocations, the intervention group received TXA 10mg/kg and the placebo group normal saline in equal volumes.ResultsData of a total of 80 patients were gathered and analyzed. The total intraoperative blood loss was insignificantly lower (mean difference [95% CI]:  − 3.6 ( − 19.19, 11.99), P = 0.65) and surgeon’s satisfaction was insignificantly higher (mean difference [95% CI]: 0.18 ( − 0.11, 0.46), P = 0.22) in TXA group. Results were confirmed by multivariable analysis.ConclusionIn contrast to most of the previous studies, this study showed only a statistically insignificant decrease in total intraoperative blood loss in patients receiving TXA compared to placebo. Further studies are required to more precisely estimate the efficacy of TXA in reducing blood loss during rhinoplasty.Level of evidence: Level I, randomized controlled trial.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Purposes The purpose of this study was to compare the financial burden of surgery for retroperitoneal sarcoma (RPS) and gastric cancer (GC). Methods All patients who underwent surgery for GC or RPS between 2020 and 2021 at Nagoya University Hospital were included. The clinical characteristics, surgical fees per surgeon, and surgical fees per hour were compared between the two groups. Results The GC and RPS groups included 35 and 63 patients, respectively. In the latter group, 37 patients (59%) underwent tumor resection combined with organ resection; the most common organ was the intestine (n = 23, 37%), followed by the kidney (n = 16, 25%). The mean operative time (248 vs. 417 min, p < 0.001) and intraoperative blood loss (423 vs. 1123 ml, p < 0.001) were significantly greater in the RPS group than in the GC group. The mean surgical fee per surgeon was USD 1667 in the GC group and USD 1022 in the RPS group (p < 0.001) and USD 1388 and USD 777 per hour, respectively (p < 0.001). Conclusions The financial burden of surgical treatment for RPS is unexpectedly higher than that for GC.