Estimated blood loss (EBL) is an increasingly important factor used to predict outcomes, such as morbidity and mortality, length of stay, and readmissions, after major abdominal operations. However, blood loss is difficult to estimate, with frequent under- and overestimations, consequences of which can be potentially dangerous for individual patients and confounding for scoring systems relying on EBL. We hypothesized that EBL is often inaccurate and have pro-spectively enrolled consecutive patients undergoing major elective intra-abdominal operations. Actual hemoglobin levels were measured and used to calculate the measured blood loss (MBL), which was compared with the EBL, as estimated both by surgeons (sEBL) and anesthesiologists (aEBL). Of 23 eligible cases at interim analysis, pancreaticoduodenectomy (n = 8) was the most common, followed by colectomy (n = 3), hepatectomy (n = 3) and gastrectomy (n = 2), biliary excision and reconstruction (n = 2), combined gastrectomy + colectomy (n = 1), radical nephrectomy (n = 1), open cholecystectomy (n = 1), pancreatic debridement (n = 1), and exploratory laparotomy (n = 1). aEBL overestimated MBL by 192 mL (143%) on average. The aEBL was significantly greater than the MBL ( P = 0.004), whereas the sEBL was significantly less than the MBL ( P = 0.009). In conclusion, surgeons significantly underestimate and anesthesiologists significantly overestimate EBL. This finding impacts not only immediate patient care but also the interpretation of scoring systems relying on EBL.

ImportanceCancer screening deficits during the first year of the COVID-19 pandemic were found to persist into 2021. Cancer-related deaths over the next decade are projected to increase if these deficits are not addressed.ObjectiveTo assess whether participation in a nationwide quality improvement (QI) collaborative, Return-to-Screening, was associated with restoration of cancer screening.Design, Setting, and ParticipantsAccredited cancer programs electively enrolled in this QI study. Project-specific targets were established on the basis of differences in mean monthly screening test volumes (MTVs) between representative prepandemic (September 2019 and January 2020) and pandemic (September 2020 and January 2021) periods to restore prepandemic volumes and achieve a minimum of 10% increase in MTV. Local QI teams implemented evidence-based screening interventions from June to November 2021 (intervention period), iteratively adjusting interventions according to their MTVs and target. Interrupted time series analyses was used to identify the intervention effect. Data analysis was performed from January to April 2022.ExposuresCollaborative QI support included provision of a Return-to-Screening plan-do-study-act protocol, evidence-based screening interventions, QI education, programmatic coordination, and calculation of screening deficits and targets.Main Outcomes and MeasuresThe primary outcome was the proportion of QI projects reaching target MTV and counterfactual differences in the aggregate number of screening tests across time periods.ResultsOf 859 cancer screening QI projects (452 for breast cancer, 134 for colorectal cancer, 244 for lung cancer, and 29 for cervical cancer) conducted by 786 accredited cancer programs, 676 projects (79%) reached their target MTV. There were no hospital characteristics associated with increased likelihood of reaching target MTV except for disease site (lung vs breast, odds ratio, 2.8; 95% CI, 1.7 to 4.7). During the preintervention period (April to May 2021), there was a decrease in the mean MTV (slope, −13.1 tests per month; 95% CI, −23.1 to −3.2 tests per month). Interventions were associated with a significant immediate (slope, 101.0 tests per month; 95% CI, 49.1 to 153.0 tests per month) and sustained (slope, 36.3 tests per month; 95% CI, 5.3 to 67.3 tests per month) increase in MTVs relative to the preintervention trends. Additional screening tests were performed during the intervention period compared with the prepandemic period (170 748 tests), the pandemic period (210 450 tests), and the preintervention period (722 427 tests).Conclusions and RelevanceIn this QI study, participation in a national Return-to-Screening collaborative with a multifaceted QI intervention was associated with improvements in cancer screening. Future collaborative QI endeavors leveraging accreditation infrastructure may help address other gaps in cancer care.

Objective: Estimated blood loss (EBL) is an important factor predicting clinical outcomes, but is frequently underand over-estimated, which can be dangerous for individual patients, and confounding for scoring systems, relying on EBL. Methods: We performed direct measurement of hemoglobin (hgb) levels of suction-canister volumes after collecting all blood from sponges and the field with dilute heparin-saline. Hgb levels were then used to calculate the measured blood loss (MBL), which was compared to the EBL, as estimated both by surgeons (sEBL) and anesthesiologists (aEBL). Power calculation predicted 83% power to detect a difference of 100 mL with a sample size of 35. An interim analysis was performed midway through the study. A paired t-test was used to compare MBL with EBL. Results: Of 23 eligible cases at interim analysis, pancreaticoduodenectomy (n = 8) was the most common. Median ASA score was 3 (range 2e4) and 96% of patients had comorbidities (median 3/patient). Median length of stay was 8 days (range 2e34), operative time was 5:14 (range 2:05e9:01), and complications occurred in 48%, and were Clavien grade >2 in 22%. The aEBL overestimated MBL by 192 mL (143%) on average, and was significantly greater than MBL (P = 0.004), while the sEBL was significantly less than MBL (P = 0.009). Conclusion: Surgeons underestimate and anesthesiologists overestimate EBL. This difference shown here is clinically substantial and statistically significant, and impacts not only immediate patient care but also the interpretation of scoring systems relying on EBL as a variable that may in fact be frequently inaccurate.

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A man in his 40s presented with sudden left-sided abdominal pain that was sharp, severe, and associated with emesis. He denied fevers, dizziness, or recent trauma. He had no notable medical or surgical history. He was afebrile with normal vital signs. He was well nourished, alert, and in no acute distress. Results of an abdominal examination revealed normoactive bowel sounds, no distention, but tenderness on the left side. Computed tomography (CT) of the abdomen and pelvis with intravenous contrast revealed a 12 × 13 × 11-cm left-sided adrenal mass (Figure 1). Results of laboratory examination revealed plasma levels of metanephrines, normetanephrines, cortisol, renin, and aldosterone within reference limits.Quiz at jamasurgery.com