Postoperative pancreatic fistula (POPF) is one of the major complications after pancreaticoduodenectomy. There have been many studies into the risk factors determining POPF. Some studies have reported a higher peri-operative fluid balance associated with POPF, however, the pertinent findings remain controversial. The aims of this study were to determine risk factors of clinically relevant-post operative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy and an association between peri-operative fluid balance and the incidence of CR-POPF. This is a retrospective cohort study included all adult patients who underwent an elective open pancreaticoduodenectomy in our center from 2005 to 2018. Patients who did not have POPF related data were excluded from study. We divided patients into CR-POPF and no CR-POPF group. Peri-operative data including amount and type of fluid were compared between two groups. Logistic regression analysis was used to identify the independent risk factors of CR-POPF. There were 223 pancreaticoduodenectomies done in our center during that period. The incidence of CR-POPF was 15.2 %. Patients in CR-POPF group had significant higher BMI, higher serum globulin level, smaller pancreatic duct diameter and higher cumulative fluid balance per body weight (FBPBW) at post-operative day 3. Multivariable analysis showed BMI >23 kg/m2, diagnosis other than pancreatic duct adenocarcinoma or chronic pancreatitis and higher cumulative FBPBW at post-operative day 3 were the independent risk factors for CR-POPF. Post-operative fluid balance was the post-operative modifiable risk factor to reduce CR-POPF. Higher positive post-operative fluid balance should be avoided especially in higher CR-POPF risk patients.

Objective: To assess the efficacy and safety of hypovolemic phlebotomy (HP) versus conventional management (control group) in achieving low central venous pressure (CVP) to reduce blood loss during open liver resections. Background: Excessive blood loss increases perioperative complications and worsens patient outcomes. HP is used to reduce blood loss and the need for allogenic transfusions. This study compares intraoperative blood loss between HP and conventional techniques in liver resection. Methods: This prospective, randomized controlled trial, conducted between 2020 and 2024, evaluated intraoperative blood loss as the primary endpoint, with secondary endpoints of allogenic transfusion and postoperative outcomes. Results: One hundred participants were randomized to either the HP or control groups, with similar baseline characteristics. The HP group had significantly lower blood loss during parenchymal transection [300 (250–500) vs. 500 (300–750) mL, difference=150, 95% CI: 50-275; P =0.02], shorter time to achieve low CVP [50 (30–100) vs. 107.5 (45–150) minutes, difference=−75.0, 95% CI: −95.0 to −56.0; P = 0.01], and a lower surgical bleeding score [2 (1–3) vs. 2 (2–4), difference=−1.0, 95% CI: −1.0 to −0.5; P =0.01]. Transfusion rates and postoperative complications were similar. HP was an independent protective against blood loss >500 mL (AOR=0.19, 95% CI: 0.04-0.80; P =0.02). Conclusions: HP significantly reduces intraoperative blood loss and enhances bleeding control by achieving a low CVP more quickly. It is an effective technique for minimizing blood loss and improving outcomes in open liver resections.

Background: Open liver resection necessitates a substantial upper abdominal inverted-L incision, resulting in severe pain and compromising patient recovery. Despite the efficacy of epidural analgesia in providing adequate postoperative analgesia, the potential epidural-related adverse effects should be carefully considered. This study aims to compare the efficacy and safety of continuous epidural analgesia and intravenous analgesia in open liver resection. Methods: A retrospective study was conducted, collecting data from patients who underwent open liver resection between 2007 and 2017. Propensity score matching was implemented to mitigate confounding variables, with patients being matched in a 1:1 ratio based on propensity scores. The primary outcome was the comparison of postoperative morphine consumption at 24, 48, and 72 hours between the two groups. Secondary outcomes included pain scores, postoperative outcomes, and epidural-related adverse effects. Results: A total of 612 patients were included, and after matching, there were 204 patients in each group. Opioid consumption at 24, 48, and 72 hours postoperatively was statistically lower in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001). However, there was no significant difference in pain scores (p = 0.422). Additionally, perioperative hypotension requiring treatment, as well as nausea and vomiting, were significantly higher in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001). Conclusions: Epidural analgesia is superior to intravenous morphine in terms of reducing postoperative opioid consumption within the initial 72 h after open liver resection. Nevertheless, perioperative hypotension, which necessitates management, should be approached with consideration and vigilance. Trial registration: The study was registered in the Clinical Trials Registry at www.clinicaltrials.gov/, NCT number: NCT06301932.

Malignant hyperthermia is a rare pharmacogenetic disorder triggered by depolarizing muscle relaxant and potent volatile anesthetic agents. An MH crisis is an emergency and life-threatening event requiring early recognition and prompt management. Dantrolene is the specific antagonist of MH. The authors report the case of a 9-year-old boy who underwent an emergency bronchoscopy to remove a foreign body and developed masseter rigidity after succinylcholine and sevoflurane exposure. The anesthesia team diagnosed an MH event, and the event was managed immediately with supportive treatment, dantrolene, being administered within 10 minutes. The patient survived and had a good outcome without any complications. We suggest that it is essential for anesthesia providers to recognize the need for intraoperative vigilance, prompt recognition, and treatment, and dantrolene sodium should be readily available in every hospital.

Purpose: Liver resection is the current treatment for hepatic neoplasms but may be associated with intraoperative hemorrhage and the need for blood transfusions. The aim of this study is to identify the risk factors for predicting the requirement of a perioperative blood transfusion in open liver resection. Methods: A total of 808 consecutive patients who had undergone elective open liver resection from 2006 to 2017 were retrospectively reviewed using the database. Baseline characteristics and intraoperative data were collected. Perioperative blood transfusion was defined as the transfusion of allogenic packed red cells during surgery and the 48 h following surgery. An analysis of logistic regression was used to determine the independent risk factors for blood transfusion in open liver resection. Results: Three hundred and seventy-seven patients (46.7%) received perioperative packed red cell transfusions. The independent risk factors associated with perioperative blood transfusion included ASA classification >2, preoperative anemia (Hb<12 g/dl for women, Hb<13 g/dl for men), thrombocytopenia (platelet count<100×10³/mm³), albumin4 cm., major liver resection, and surgeon experience performing <50 cases of major open liver resection. Conclusion: Preoperative risk factors may be utilized to assess and predict patients who require perioperative blood transfusions following liver resection. Modifiable risk factors may also be treated prior to surgery. Furthermore, patient blood management and methods to minimize blood loss and blood transfusions during surgery should be implemented in patients who require high-risk transfusions.