Search Results (22)

Background: Segmental arterial mediolysis (SAM) is a rare, non-inflammatory, non-atherosclerotic, non-hereditary arteriopathy of unknown etiology that typically affects medium-sized visceral arteries. The absence of reliable diagnostic criteria poses a significant challenge. Consequently, the diagnosis of SAM should be considered in the setting of a distinctive combination of clinical features, angiographic findings, and histopathology. Renal artery involvement is uncommon, and its occurrence in the donor graft during kidney transplantation (KT) has not previously been reported. Case presentation: We report the case of a kidney graft from a deceased donor in her seventh decade of life, transplanted into a recipient in her seventh decade of life. Donor–recipient ABO compatibility was confirmed, and both complement-dependent cytotoxicity crossmatch and flow cytometry crossmatch were negative. Cold ischemia time was 14 h, and warm ischemia time was 20 min. Immediately after declamping, massive thrombosis of the graft renal artery was observed and confirmed using an intraoperative flowmeter. The arterial anastomosis was taken down, the thrombus was removed, the artery was flushed with heparin, and the anastomosis was reconstructed using interrupted sutures. Despite revision, no arterial flow was detected, and the graft was deemed unsalvageable and explanted. Histopathological examination showed thinning of the tunica media, reduced smooth muscle cells on desmin staining, medial-adventitial dissection, and occlusive thrombosis, findings considered likely attributable to SAM. Conclusions: This case suggests that occult donor arterial wall disease compatible with SAM may present catastrophically during KT and may lead to immediate graft loss despite standard surgical salvage attempts. Although no validated strategy currently exists to screen for or prevent occult SAM in asymptomatic donors, awareness of this entity may assist transplant surgeons and pathologists in the evaluation of unexplained early graft arterial thrombosis, donor-graft vascular pathology, and communication with centres receiving paired organs from the same donor. Full article

Patient Blood Management (PBM) has evolved from a transfusion-centered practice to a structured, patient-focused perioperative strategy aimed at improving surgical outcomes while preserving blood resources. In the operating room, where bleeding risk is anticipated and modifiable, PBM requires proactive intervention rather than reactive transfusion. This review synthesizes current evidence on perioperative blood conservation strategies specifically relevant to surgeons and anesthesiologists. Preoperative optimization begins with systematic identification and correction of anemia, most commonly iron deficiency, using appropriately timed oral or intravenous iron therapy and, in selected cases, erythropoiesis-stimulating agents. Careful management of anticoagulant and antiplatelet therapies, early recognition of acquired or inherited coagulopathies, and protocol-driven reversal strategies further reduce perioperative hemorrhagic risk. Intraoperatively, blood conservation depends on meticulous surgical technique, respect for anatomical planes, minimally invasive approaches, and the judicious use of advanced energy devices and topical hemostatic agents. Pharmacologic interventions—particularly tranexamic acid administered with appropriate timing and dosing—have demonstrated consistent reductions in blood loss and transfusion requirements across multiple surgical disciplines. Goal-directed coagulation management guided by viscoelastic testing allows targeted correction of specific hemostatic deficits while minimizing unnecessary blood product exposure. Acute normovolemic hemodilution and intraoperative cell salvage provide additional benefit in selected high-blood-loss procedures. Collectively, these multimodal strategies shift perioperative care from product-driven transfusion toward physiology-based blood conservation. When embedded within institutional protocols and supported by multidisciplinary collaboration, perioperative PBM reduces transfusion exposure, decreases morbidity, shortens hospital stay, and promotes sustainable stewardship of blood resources without compromising patient safety. Full article

Objectives: To evaluate the acceptability and feasibility of intraoperative cell salvage (ICS) in women with ovarian cancer. A prospective multicenter randomized controlled feasibility trial. Setting: Four U.K. cancer centers. Women FIGO stage III/IV ovarian cancer supported by CT scan evidence. We randomized women to receive ICS or donor blood (as required) during surgery for ovarian cancer. The acceptability and feasibility of ICS in women with ovarian cancer having cytoreductive surgery; rates of recruitment for a larger trial and the likely completeness of resource use and outcome data; and blinding of allocation for participants and outcome assessors. A total of 57 women were included; the rate of recruitment was 1.4 cases per month, which closely aligns with the target, and 66% of the eligible patients were recruited. Overall, 91% of women completed the 30-day follow-up, and 75% completed the six-week follow-up. Mean (SD) blood loss in the ICS group was 1022 mL (SD 929 mL) and 924 mL (SD 646 mL) in the control group. A total of 16 (62%) of the participants undergoing surgery in the ICS arm received ICS reinfusion. Of the ten participants in the intervention group who did not receive ICS, six participants lost a significant volume of blood requiring transfusion. In the donor blood group, 14 of the 29 participants received donor blood. In the ICS group, 20/24 (83%) of participants, and 23/24 (96%) of research nurses did not know their group allocation. In the control group, 24/28 (86%) and 25/29 (86%) of participants and research nurses did not know the group allocation. Our study provides clinical evidence of the feasibility and acceptability of using ICS in ovarian cancer surgery and provides useful insights into the use of ICS within clinical trials. Women are open to having ICS as an alternative to blood transfusion. An appropriately powered randomized controlled trial is now required. Full article

Background: Achieving adequate margins in pelvic bone tumor resection remains difficult, as conventional navigation provides no direct three-dimensional margin feedback. We proposed an innovative dangerous region generation method based on 3D image resampling and anisotropic distance transform, integrated with computer-assisted navigation, to enhance surgical margin accuracy. This study aimed to evaluate its oncological safety, functional outcomes, and perioperative efficacy in pelvic tumor surgery. Methods: The study was conducted on 19 patients (8 males, 11 females) with primary pelvic bone tumors between May 2018 and June 2024. The age range was 19 to 66 years (mean age: 62.67 years). Histological diagnoses included chondrosarcoma (n = 6), giant cell tumor (n = 4), osteosarcoma (n = 1), chordoma (n = 2), Ewing sarcoma (n = 3), spindle cell sarcoma (n = 1), chondromyxoid fibroma (n = 1), and peripheral nerve sheath tumor (n = 1). The feasibility of the dangerous region generation method for computer-assisted pelvic tumor resection surgery was assessed by general results, oncological and functional results. Results: All patients successfully underwent surgery with a mean operative time of 252 min and average intraoperative blood loss of 1358 mL. The mean hospital stay was 22 days, and all patients completed follow-up (mean, 37 months). Two patients developed postoperative wound complications, which resolved after debridement. Adequate surgical margins were achieved in all cases. The 5-year overall survival rate was 75.6%, increasing to 80.0% among patients with wide-margin resections. At the final follow-up, the mean MSTS score among 16 limb-salvage patients was 26.6, corresponding to an average functional recovery of 88.5%. Most patients exhibited a normal gait and were able to ambulate without assistive devices. Conclusions: This dangerous region generation method, when combined with computer-assisted techniques for pelvic bone tumor resection, is feasible and can achieve favorable clinical outcomes. Full article

Background/Objectives: Scoliosis surgery in pediatric patients, particularly those with neuromuscular disorders, is associated with increased perioperative risk due to respiratory insufficiency, cardiovascular comorbidities, and nutritional deficiencies. This review aims to summarize current evidence-based approaches to anesthetic management in this vulnerable population. Methods: A comprehensive literature review was conducted focusing on anesthetic strategies and multidisciplinary protocols used in the perioperative care of children with neuromuscular conditions undergoing scoliosis surgery. Emphasis was placed on intraoperative neurophysiological monitoring (IONM), blood conservation techniques, and Enhanced Recovery After Surgery (ERAS) principles. Results: Key management strategies include individualized preoperative risk assessment, use of total intravenous anesthesia (TIVA) to preserve IONM signal integrity, and the implementation of blood conservation methods such as antifibrinolytic therapy and intraoperative cell salvage. Additional perioperative considerations include maintaining normothermia, careful positioning, and multimodal analgesia. Postoperative care should incorporate structured respiratory support and early mobilization within the ERAS pathway to promote recovery and reduce complications. Conclusions: The perioperative care of pediatric patients with neuromuscular scoliosis undergoing spinal surgery requires a multidisciplinary and individualized anesthetic approach. Adherence to evidence-based protocols, including TIVA, blood management strategies, and ERAS principles, is essential for minimizing perioperative complications and improving outcomes in this high-risk group. Full article

Background: Massive intraoperative blood loss (IBL) is a serious complication in complex spine surgeries such as deformity correction, multilevel fusion, tumor resection, and revision procedures. While no strict definition exists, blood loss exceeding 1500 mL or 20% of estimated blood volume is generally considered clinically significant. Excessive bleeding increases the risk of hemodynamic instability, transfusion-related complications, postoperative infection, and prolonged hospitalization. Methods: This narrative review summarizes the current understanding of the incidence, risk factors, anatomical vulnerabilities, and evidence-based strategies for managing IBL in spine surgery through comprehensive literature analysis of recent studies and clinical guidelines. Results: Key risk factors include patient characteristics (anemia, obesity, advanced age, medication use), surgical variables (multilevel instrumentation, revision status, operative time), and pathological conditions (hypervascular tumors, severe deformity). Perioperative medication management is critical, requiring discontinuation of NSAIDs (5–7 days), antiplatelet agents (5–7 days), and NOACs (48–72 h) preoperatively to minimize bleeding risk. The thoracolumbar junction and hypervascular spinal lesions are especially prone to bleeding due to dense vascular anatomy. Evidence-based management strategies include comprehensive preoperative optimization, intraoperative hemostatic techniques, antifibrinolytic agents, topical hemostatic products, cell salvage technology, and structured transfusion protocols. Conclusions: Effective management of massive IBL requires a multimodal approach combining preoperative risk assessment and medication optimization, intraoperative hemostatic strategies including tranexamic acid administration, advanced monitoring techniques, and coordinated transfusion protocols. Particular attention to perioperative management of anticoagulant and antiplatelet medications is essential for bleeding risk mitigation. Understanding patient-specific risk factors, surgical complexity, and anatomical considerations enables surgeons to implement targeted prevention and management strategies, ultimately improving patient outcomes and reducing complications in high-risk spine surgery procedures. Full article

A 75-year-old Jehovah’s Witness with recent ST-elevation myocardial infarction (STEMI) underwent percutaneous coronary intervention (PCI) with stenting of the proximal LAD. She was later diagnosed with gallbladder cancer and required urgent surgery but firmly refused allogeneic blood transfusion. This posed a major challenge, as the surgery was expected to cause significant bleeding, and the patient had undergone coronary stenting within the previous three months, which is when the risk of stent thrombosis is highest if dual antiplatelet therapy (DAPT) is interrupted. After conducting a careful multidisciplinary discussion and obtaining informed consent, both aspirin and clopidogrel were discontinued five days preoperatively. Through comprehensive blood conservation strategies—including acute normovolemic hemodilution (ANH), intraoperative cell salvage, and robotic-assisted minimally invasive surgery—the patient successfully underwent extended cholecystectomy without transfusion. This case highlights the possibility of safe, completely transfusion-free major surgery in patients with recent PCI and high thrombotic risk when individualized perioperative planning is applied. Full article

Background: The advent of immunotherapy has significantly improved survival outcomes in advanced non-small cell lung cancer (NSCLC). In this evolving context, salvage surgery has emerged as a potential curative strategy, despite the risk of serious complications. This study aimed to evaluate the safety and efficacy of surgical resection following chemo-immunotherapy in patients with initially unresectable NSCLC. Methods: We retrospectively analyzed patients with stage III–IVB NSCLC who underwent salvage surgery at our institution between January 2019 and June 2024. All cases were initially deemed unresectable by a multidisciplinary tumor board. Perioperative complications, complete (R0) resection rate, major pathologic response (MPR), complete pathologic response (pCR), progression-free survival (PFS), and overall survival (OS) were analyzed. Results: Twenty-one patients (thirteen males, eight females; median age: 68 years [IQR: 9]) were included. Reasons for initial unresectability were metastatic disease (28.6%), N2 bulky disease (14.3%), local invasiveness (33.3%), or a combination of factors (23.7%). Chemo-immunotherapy was administered in 19 patients (90.5%), while 2 (9.5%) received immunotherapy alone, with a median of four treatment cycles (IQR: 1). Complete (R0) resection was achieved in all patients (100%). Anatomical resections were performed in 17 patients (81%), predominantly lobectomies (66.7%). There were no intraoperative or major postoperative complications, and 30-day mortality was zero. Median hospital stay was 7 days (IQR: 4). pCR and MPR were achieved in 33.3% and 14.3% of patients, respectively. After a median follow-up of 17 months (IQR: 19), the estimated 3-year PFS and OS were 50.9% and 66.3%, respectively. Recurrences included locoregional (4.8%), distant (14.3%), and combined (14.3%). Cox regression analysis identified stage III at diagnosis (OR: 0.292; 95% CI: 0.093–0.912; p = 0.034) and achieved pCR or MPR (OR: 0.113; 95% CI: 0.013–0.959; p = 0.046) as independent predictors of improved PFS. Conclusions: Salvage surgery after chemo-immunotherapy in initially unresectable NSCLC appears to be a safe and effective strategy in selected patients, offering favorable pathological responses and encouraging mid-term oncologic outcomes. Full article

Intraoperative cell salvage (ICS) is a blood conservation technique utilized in major surgery, yet its application in oncologic procedures remains debated. Concerns persist about the theoretical risk of metastasis through reinfusion of tumor cells, despite the established disadvantages of allogeneic blood transfusion (ABT), such as transfusion-related reactions and immunosuppression. In this review, we discuss the historical development of ICS, the technical processes of ICS including leukocyte depletion filtration and irradiation, and experimental and clinical data regarding its safety and efficacy. In vitro studies suggest that tumor cells undergo significant structural alterations during ICS processing, and additional filtration further reduces cell load, although complete removal is not always achieved. Observational studies of predominantly moderate quality, aggregated in multiple systematic reviews, consistently report no increased recurrence rates or reduced disease-free and overall survival in patients receiving ICS. Accordingly, national and international guidelines endorse the use of ICS during oncologic surgery. Although high-quality data—preferably from randomized controlled trials—are lacking, and certainty of available evidence from observational studies is low, ICS appears to be effective and safe. The broader adoption of its use during oncologic surgery may be warranted to minimize reliance on ABT and its associated risks. Full article

Anal squamous cell carcinoma (ASCC) is a rare malignancy with an increasing incidence despite advancements in treatment. The primary treatment for localized ASCC is radiochemotherapy (RCT), which achieves high rates of tumor regression in most cases, but up to 30% of patients experience recurrence or persistent disease. Salvage surgery, such as an abdominoperineal resection (APR), is often used for recurrent disease but is associated with significant morbidity and limited oncological outcomes. Patients with small T1 tumors may also benefit from primary local excision. For patients with metastatic or unresectable recurrent ASCC, chemotherapy, particularly carboplatin and paclitaxel, remains the standard treatment. New therapeutic strategies, including immune checkpoint inhibitors like pembrolizumab, are showing promise, particularly in PD-L1-positive tumors. Clinical trials have suggested that immunotherapy offers a potential alternative for patients for whom conventional treatments have failed, though the overall response rates remain modest. Re-radiation and intraoperative radiotherapy combined with salvage surgery may improve the outcomes for select patients, though the data are still limited. The management of recurrent or persistent ASCC requires a personalized approach, incorporating both established and emerging therapies to optimize patient outcomes. Further research is needed to refine these treatment strategies. Full article

Background/Objective: The grade of recommendation for renal cell carcinoma (RCC) salvage treatment options is weak. The aim of the current study is to summarize available evidence about the surgical, oncological, and functional outcomes of salvage renal options after previous treatments for RCC. Methods: A systematic search (PROSPERO: CRD42024618629) was performed according to the PRISMA statement. A pooled analysis was performed to quantify the effect size (ES) for an overall postoperative Clavien–Dindo (CD) grade ≥ III and postoperative and intraoperative complications for either partial or radical nephrectomy (PN or RN) subgroups. Results: Overall, 11 studies involving 331 patients were included in the final analysis. The median age ranged from 44 to 75 years. Primary treatments for RCC included 267 (80.6%) PNs, 40 (12.0%) radiofrequency ablations (RFAs), 23 (6.9%) cryotherapies, and 1 (0.3%) stereotactic radiotherapy. Overall, the median time of local recurrence for RCC patients was from 25 to 99 months for PNs, 13 months for RFA and cryotherapy, and 6 months for stereotactic radiotherapy. The overall pooled analysis was associated with an ES of 0.28 for overall postoperative complications and of 0.11 for CD ≥ III postoperative complications (all p < 0.001). Within subgroup analyses, RN was invariably associated with less complications (the ES ranged from 0.05 to 0.17). Conclusions: The profile of oncological safety as well as the morbidity and mortality of salvage treatment options for RCC may justify considering such procedures in a salvage setting. Full article

Background: ‘Downstream’ adverse outcomes associated with transfusion-related immune modulation (TRIM) occur postoperatively. The potential associations between these outcomes (and costs) and perioperative transfusion are often not considered by clinicians and therefore underestimated. When considering TRIM, many advantages of intraoperative cell salvage (ICS) were previously confirmed. Methods: The main aim of this retrospective observational study was to evaluate the cost implications associated with perioperative adverse outcomes following allogeneic blood transfusion (ABT). Secondly, further analysis considered downstream costs following ICS. This manuscript does not aim to provide evidence of improved outcomes following ICS compared to ABT. These outcomes were previously demonstrated. Instead, it is important to consider downstream cost implications if patients receive ABT, despite previously proven benefits related to ICS. Surgical patients (n = 2129) receiving blood transfusion at the Royal Brisbane and Women’s Hospital (Queensland, Australia) (2016–2018) were included: receiving ICS only (n = 115), allogeneic red blood cells (RBCs) only (n = 1944), or RBCs and ICS (n = 70). Data retrieved from eight hospital databases were exported, and a novel Structured Query Language (SQL) database was developed to link data points. Adverse outcomes previously associated with TRIM were assessed using International Classification of Diseases-10 (ICD-10) coded data. Generalised linear models were used to model costs and adjust for confounding factors. Results: Most adverse outcomes (≥3) occurred following RBCs and ICS (37.1%), followed by RBCs (23.7%) and ICS (16.5%). As potentially important determinants of overall expenditure, the lowest marginal mean intensive care stay (days, cost) was after ICS (2.1 days, AUD 10,027), followed by RBCs and ICS (3.8 days, AUD 18,089), and then RBCs (5.5 days, AUD 26,071). When considering blood products (other than packed red blood cells), the average cost per patient was lowest for ICS (AUD 48), followed by RBCs (AUD 533) and RBCs and ICS (AUD 819). Conclusions: We confirmed that the cost associated with allogeneic blood transfusion was significant; patients receiving packed red blood cells (pRBCs) experienced more adverse outcomes and higher hospital costs than those receiving ICS. These results are limited to retrospective data and require further prospective validation. Full article

Background: In this manuscript, the challenges encountered during research into patient outcomes following transfusion during spine surgery are explored. Method: A narrative review of transfusion research over decades. Results: An estimated 310 million major surgeries occur in the world each year, and 15% of these patients experience serious adverse outcomes (the United States of America, n 5,880,829). Many adverse outcomes are associated with allogeneic blood transfusion (ABT) and are potentially avoided by intraoperative cell salvage (ICS). The incidence of perioperative transfusion in patients who undergo spine surgery varies between 8 and 36%. Conclusions: Knowledge gaps remain due to the complexity of the field of study, confounding factors, the inability to define optimal transfusion triggers, challenges countered in study design, requirements for large sample sizes, and the inability to conduct randomised controlled trials (RCTs). The surgical complexity, subtle patient factors, and differences in policies and procedures across hospitals and countries are difficult to define and add further complexity. Solutions demand well-designed prospective collaborative research projects. Full article

(1) Background: The aim of this study was to evaluate the safety of intraoperative cell salvage (ICS) during reimplantation in the two-stage revision of septic hip arthroplasties. (2) Methods: As part of an internal quality control study, blood cultures were taken from the processed ICS blood during reimplantation and examined for possible bacterial load (study group). Due to a high rate of bacterial detection with uncertain clinical significance, consecutive ICS samples were also examined from patients undergoing aseptic revision hip arthroplasty (control group). Microbiological samples, patient and surgical characteristics and the follow-up data were analyzed retrospectively. (3) Results: 9 out of 12 (75%) patients in the study group and 5 out of 8 (63%) patients in the control group had positive ICS blood cultures. There was no significant difference between the groups (p = 0.642). The initial pathogens causing the periprosthetic joint infection (PJI) were not detected, but the bacterial spectrum resembled skin flora, with a high proportion of coagulase-negative staphylococci. No complications due to possible bloodstream-associated infections were observed. In summary, the detected pathogens were interpreted as contamination without clinical significance. (4) Conclusions: ICS in the context of reimplantation was considered a safe and recommendable procedure to optimize patient blood management. Full article

Intraoperative cell salvage reduces the need for allogeneic blood transfusion in complex cancer surgery, but concerns about the possibility of it re-infusing cancer cells have hindered its application in oncology. We monitored the presence of cancer cells on patient-salvaged blood by means of flow cytometry; next, we simulated cell salvage, followed by leucodepletion and irradiation on blood contaminated with a known amount of EpCAM-expressing cancer cells, assessing also residual cancer cell proliferation as well as the quality of salvaged red blood cell concentrates (RBCs). We observed a significant reduction of EpCAM-positive cells in both cancer patients and contaminated blood, which was comparable to the negative control after leucodepletion. The washing, leucodepletion and leucodepletion plus irradiation steps of cell salvage were shown to preserve the quality of RBCs in terms of haemolysis, membrane integrity and osmotic resistance. Finally, cancer cells isolated from salvaged blood lose their ability to proliferate. Our results confirm that cell salvage does not concentrate proliferating cancer cells, and that leucodepletion allows for the reduction of residual nucleated cells, making irradiation unnecessary. Our study gathers pieces of evidence on the feasibility of this procedure in complex cancer surgery. Nevertheless, it highlights the necessity of finding a definitive consensus through prospective trials. Full article