Defining the optimal bilirubin level before hepatectomy for hilar cholangiocarcinoma

Background In the management of operable hilar cholangiocarcinoma (HC) patients with hyperbilirubinemia, preoperative biliary drainage is a measure to bring down the bilirubin to a certain level so as to avoid adverse postoperative outcomes that would otherwise result from hyperbilirubinemia. A cutoff value of bilirubin level in this context is needed but has not been agreed upon without controversy. This retrospective study aimed to identify a cutoff of preoperative bilirubin level that would minimize postoperative morbidity and mortality. Methods Data of patients having hepatectomy with curative intent for HC were analyzed. Discriminative analysis was performed to identify the preoperative bilirubin level that would make a survival difference. The identified level was used as the cutoff to divide patients into two groups. The groups were compared. Results Ninety patients received hepatectomy with curative intent for HC. Their median preoperative bilirubin level was 23 μmol/L. A cutoff preoperative bilirubin level of 75 μmol/L was derived from Youden’s index (sensitivity 0.333; specificity 0.949) and confirmed to be optimal by logistic regression (relative risk 9.250; 95% confidence interval 1.932–44.291; p = 0.005), with mortality shown to be statistically different at 90 days (p = 0.008). Patients were divided into Group A (≤75 μmol/L; n = 82) and Group B (> 75 μmol/L; n = 8). Group B had a higher preoperative bilirubin level (p < 0.001), more intraoperative blood loss (3.12 vs 1.4 L; p = 0.008), transfusion (100% vs 42.0%; p = 0.011) and replacement (2.45 vs 0.0 L; p < 0.001), more postoperative renal complications (p = 0.036), more in-hospital deaths (50% vs 8.5%; p = 0.004), and more 90-day deaths (50% vs 9.8%; p = 0.008). Group A had a longer follow-up period (p = 0.008). The groups were otherwise comparable. Disease-free survival was similar between groups (p = 0.142) but overall survival was better in Group A (5-year, 25.2% vs 0%; p < 0.001). On multivariate analysis, preoperative bilirubin level and intraoperative blood replacement were risk factors for 90-day mortality. Conclusion A cutoff value of preoperative bilirubin level of 75 μmol/L is suggested, as the study showed that a preoperative bilirubin level ≤ 75 μmol/L resulted in significantly less blood replacement necessitated by blood loss during operation and significantly better patient survival after surgery.

Blood transfusion

Transfusion of blood components is a life-saving treatment for patients with severe haemorrhage and can also be used to replace coagulation factors and to ameliorate the effects of severe anaemia, thrombocytopenia, and impaired platelet function. With greater understanding of red cell, platelet, and leucocyte antigen structure and function, transfusion therapy has improved. In addition, understanding current and emerging infectious agents has ensured patient safety. Transfusion medicine has expanded over recent decades to include multiple disciplines, such as therapeutic apheresis, cellular therapy, and tissue banking. One of the most important technological improvements in transfusion therapy was the development of sterile, disposable, and flexible plastic containers that allow separation of whole blood into cellular (e.g. red cells, platelets) and noncellular (e.g. plasma, cryoprecipitate) components, known as apheresis. This technology allows the blood of a donor or patient to pass through an apparatus that separates out one particular constituent and returns the remainder to the circulation. Anticoagulants and additives currently used to collect blood allow storage of liquid suspensions of concentrated red cells for 35 to 42 days. These advances have essentially eliminated the use of whole blood. Blood transfusion is used to treat patients with severe anaemia, haemorrhage, thrombocytopenia, and coagulation disorders. Although the hazards of blood replacement are relatively small, the expected benefit of a transfusion must outweigh the risk to the patient. Therefore, a thorough understanding of the indications of blood transfusion is required to minimize unnecessary blood replacement and to prevent wastage of limited blood resources. Clinicians who prescribe blood transfusion must also be familiar with the risks and be able to recognize and treat transfusion reactions.

The coagulation disorders impact on “major burns” outcome

Introduction. The „major burns“ are critically ill patients with extended burn injuries, over 20% of the total body surface, IInd or IIIrd degree or with special location as face, neck, upper respiratory airways, or lesions that are associated with other traumatic injuries (1). One of the early systemic changes after the burn injury is the coagulation disorder, which influences the outcome. The posttraumatic coagulopathy is influenced primarily by the surface extension and degree of the burn lesion (2), but there are also systemic factors that are induced by the traumatic lesions and amplify the coagulopathy: the systemic inflammatory response, the tissue hypoperfusion, the acidosis (4). Other important factors, which may change the evolution of the major burnt, are: the initial excessive fluid resuscitation, the age, the gender, the comorbidities of the patient (5). Materials and methods. The authors conducted an analysis of the coagulation disorders in a case series of burned patients hospitalized in 2015, in the Intensive Care Unit of the Clinical Emergency Hospital of Bucharest. The prospective observational study included 11 patients hospitalized simultaneously. The study was approved by the internal ethical committee and the consent was obtained for the processing of clinical and laboratory anonymous data. It were analysed the demographic data, the severity of the burn lesions, injury severity score (ISS), the haemostatic pattern through the assessment of the complete blood count, classical coagulation tests, rotational thromelastometry (ROTEM). Results. Patients̒ median age was of 36.00±7.89 years, with variation between 21-45 years old. Men to women ratio was of 7:4. The estimated body surface was between 20-70%, with a mean value of 42.5%±12.03% (it was counted only the burns with degree 2 and 3). At the admission, the ISS score was variated between 17-61 points (of 75 points maximum (10)), with a mean value of 45 ±15.18 points. The lot was devided into two groups, with or without the presence of the posttraumatic coagulopathy criteria, on lab tests or ROTEM, despite blood replacement therapy. There were analysed the parameters which define the posttraumatic coagulopathy and their impact on the blood replacement therapy and mortality. Conclusions. The etiology of the coagulation disorder at the „major bunt“ is multifactorial, but regardless of the predominant cause, it worsens the patients̒ outcome, increases the need for transfusions and mortality. The optimization of the diagnostic methods for the coagulopathy can offer important data regarding the incidence and the severity, with the possibility for faster and targeted theraputic intervention to the patient̒s need.