STOMATOLOGY EDU JOURNAL 2017, Volume 4, Issue 3 SEJ_3-2017_Online - Page 37

Table 3. Transfusion rate in Le Fort I single jaw osteotomy without concomitant procedures: predonation policy versus no predonation policy. Le Fort I single-jaw osteotomy without additional complex procedures (segmentation or additional procedures) Patients (n) Predonation policy 118 Patients (n) Type of blood used in with transfusion transfusion 35 Autologous including 1 % transfused patients 24% autologous+ homologous No predonation policy 408 19 Homologous 6,6% Total 526 54 - 11,2% concentrates from foreign donors were required after the autologous blood donation already had been given. In our own series of 1281 consecutive bilateral sagittal split procedures, spanning a period from 1989–2012, no case of transfusion need was seen correlated to the SSO. Except for excessive loss due to unforeseen vascular injury during BSSO, no transfusion need is to be expected in BSSO surgery, even if the surgery is of a long duration. No cross- match or predonation policy is required. 3.1.2. Le Fort I single-jaw surgery without additional complex procedures Considering single-jaw Le Fort I osteotomies without segmentation or explicit statement of additional procedures, several articles fulfilled this criterion (Ash and Mercuri, 1985; Böttger, 2007; Carry et al., 2001; de Lange et al., 2008; Dickerson et al., 1993; Dolman et al., 2000; Flood et al., 1990; Garg et al., 2011; Golia et al., 1985; Hegtvedt et al., 1987; Kok-Leng Yeow and Por, 2008; Landes et al., 2008; Lenzen et al., 1999; Martini et al., 2004; Moenning et al., 1995; Mohorn et al., 1995; Panula et al., 2001; Praveen et al., 2001; Puelacher et al., 1998; Umstadt et al., 2000; Yu et al., 2000; Zellin et al., 2004) 4,7,9,10-14,16-19,22,24,26-33 (Table 2). The papers by Kok-Leng Yeow and Por (2008), 29 Praveen et al. (2001), 32 and Martini et al. (2004) 16 did not have a transfusion rate for this subgroup and were discarded. The study by Mohorn et al. (1995) 31 had a defined group of Le Fort I osteotomies, but these were retrieved from other authors, so this report was also discarded. The paper by Umstadt et al. (2000) 22 was classified as a no-predonation policy because not one single patient received any autologous blood. If transfusions were needed, homologous blood was given. In the paper by Puelacher one patient received both autologous blood and additional homologous units. as seen in Table 3. In all other cases of autologous transfusion in Table 3, the available autologous units were sufficient. A statistical analysis was done in the SAS program, with 95% exact confidence intervals calculated for the individual studies. The overall transfusion rates and corresponding 95% confidence intervals were statistically estimated using a probit-normal model. A significant difference between predonation and no predonation policy could be shown (p=0.0166). The intra-study correlation was found to be significant. The intra-study correlation in the no predonation policy group was 0.06 (p=0.2896). The intra-study Stomatology Edu Journal correlation in the predonation policy group was 0.31 (p=0.0662). The statement can be made that when predonation of autologous blood has occurred, the risk of being transfused is higher and does not exclude the need for additional homologous transfusion in case the transfusion need exceeds the available units of autodonated blood. Figure 1 shows an error-bar chart using the SAS statistical program, and displays the % of transfusion as a dot and its associated confidence interval as a horizontal line. This effectively communicates the precision associated with each effect size and the general pattern of results. The comparison of the available mean blood losses between the predonation and no-predonation policy groups supports the statement that predonation in single Le Fort I surgery without additional procedures results in more mean blood loss measured in the predonation group than in the other group (Table 4). As far as hypotension is concerned, the entire range of blood pressure control is found without relation to blood loss (normotension, mild controlled hypotension, moderate controlled hypotension, deep controlled hypotension). The liberal reinfusion of autologous blood in these series needs to be met with skepticism. However, a need remains of about 4.5 % requiring a blood transfusion in single-jaw Le Fort I procedures without additional complex procedures in the no-predonation policy group, according to a probit-normal statistical model. One should be careful with percent values of blood transfusion in the literature. Kramer et al. (2004) 32 indicate a transfusion need of 1.1% in 1000 Le Fort I operations (11 patients transfused), prospectively studied. It should be noted that the 1.1% occurred in bimaxillary operations; the authors explicitly state that hemorrhage after Le Fort I osteotomy was documented only when transfusions of erythrocyte concentrates from foreign donors were required after autologous blood donation already had been given. The total transfusion need in this large series of Le Fort I cannot be recovered. 3.1.3. Le Fort I single-jaw surgery with additional procedures A total of 211 Le Fort I single-jaw surgical cases qualify as ‘complex’, either because they concerned cleft patients or because of multi-piece segmentation with an additional bone-grafting, mostly an iliac crest graft. Of interest, the recent literature does not provide many papers describing performance of Le Fort I single-jaw surgery: Schaberg et al., 1976; 34 Ash TRANSFUSION NEED IN ORTHOGNATHIC surgery - A REVIEW 187