Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. French Association for Surgical Research

Risk factors for failure of percutaneous drainage and need for reoperation following symptomatic gastrointestinal anastomotic leak

BACKGROUND

Few studies have evaluated the role of computed tomography-guided percutaneous drainage (PD) in the management of gastrointestinal (GI) anastomotic leaks.

METHODS

Ten-year review of an interventional radiology database identified patients with symptomatic GI anastomotic leaks. Clinical, laboratory, radiographic, and operative characteristics following a technically successful PD which then failed and required reoperation for anastomotic leak were compared with those successfully treated with PD.

RESULTS

Sixty-one patients met study inclusion criteria. Fifty patients (82%) successfully underwent therapeutic PD of a perianastomotic fluid collection, with median follow-up of 16 months. Eleven patients (18%), at a median interval of 16 days, required reoperation following PD. A forward logistic regression showed cardiopulmonary disease (P = .03) and cancer surgery (P = .01) to be factors independently associated with the need for reoperation. The level of the anastomosis, initial fecal diversion/stoma, fluid collection size, and microbiology of aspirate did not predict failure of PD.

CONCLUSIONS

Cardiopulmonary disease and cancer surgery appear to be independent predictors for failure of PD and need for reoperation following a symptomatic GI anastomotic leak.

Operative drainage following pancreatic resection: analysis of 1122 patients resected over 5 years at a single institution

BACKGROUND

The only prospective randomized trial evaluating the use of intraperitoneal drainage following pancreatic resection was published from our institution approximately 10 years ago. The current study sought to evaluate the evolution of practice over the last 5 years.

PATIENTS AND METHODS

Between June 2006 and June 2011, there were 1122 resections performed. Six surgeons were evenly grouped and compared by practice pattern: routine drainers (drains placed > 95%), selective drainers, and routine nondrainers (drains placed ∼15%). Prospectively recorded preoperative, operative, and morbidity data were assessed in uni- and multivariate models.

RESULTS

Our operative drainage rate was 49% and decreased over time (62% 2006-2008 vs 37% 2009-2011, P < 0.001). Patients without operative drains had significantly lower grade ≥3 overall morbidity (26% vs 33%; P = 0.01), shorter hospital stays (7 vs 8 days; P < 0.01), fewer readmissions (20% vs 27%; P = 0.01), and lower rates of grade ≥3 pancreatic fistula (16% vs 20%; P = 0.05). Similar reoperation (both <1%), interventional radiology procedures (15% vs 19%; P = 0.1), and mortality rates (2% vs 1%; P = 0.3) were seen in both groups. There were no differences between the routine drainers group (n = 248) and the nondrainers group (n = 478) in grade ≥3 fistula or need for interventional radiology-guided procedures.

CONCLUSIONS

In this study, operative drains were used nearly half of the time and were associated with longer hospital stay, and higher grade ≥3 morbidity, fistula, and readmission rates. They did not decrease the need for reintervention or alter mortality rates. Routine prophylactic drainage after pancreatic resection could be safely abandoned.

Is it time to abandon routine operative drain use? A single institution assessment of 709 consecutive pancreaticoduodenectomies

BACKGROUND

Routine use of operative (primary) drains after pancreaticoduodenctomy (PD) remains controversial. We reviewed our experience with PD for postoperative (secondary) drainage and postoperative pancreatic fistula (POPF) rates based on use of primary drains.

STUDY DESIGN

We identified consecutive patients who underwent PD between 2005 and 2012 from our pancreatectomy database. Primary closed suction drains were placed at the surgeon's discretion. Patient and operative factors were assessed, along with POPF, complications, and secondary drain placement rates.

RESULTS

There were 709 PDs performed, and 251 (35%) patients had primary drains placed. Age, sex, body mass index, and comorbidities were similar among groups; however, drained patients had slightly larger pancreatic ducts (mean diameter 3.8 mm vs 2.2 mm; p < 0.01). The overall secondary drainage rate was 7.1%. Primary drain placement did not affect the need for secondary drainage (with primary drain, 8.4% vs without primary drain 6.3%, p = 0.36), reoperation (5.6% vs 5.7%, p = 1.00), readmission (17.5% vs 16.8%, p = 0.89), or 30-day mortality (2.0% vs 2.5%, p = 0.80). When compared with the no drain group, patients with primary drains experienced higher rates of overall morbidity (68.1% vs 54.1%, p < 0.01) and significant POPF (16.3% vs 7.6%; p < 0.01), as well as longer hospital stays (13.8 days vs 11.3 days; p < 0.01). On multivariate analysis, primary drain placement remained an independent risk factor for pancreatic fistula formation (hazard ratio 3.3, p < 0.01), but did not have an impact on secondary drainage rates (p = 0.85).

CONCLUSIONS

Placement of closed suction drains during pancreaticoduodenectomy does not appear to decrease the rate of secondary drainage procedures or reoperation, and may be associated with increased pancreatic fistula formation and overall morbidity. These data support foregoing routine primary operative drainage at time of pancreaticoduodenectomy.

Management of failed low colorectal and coloanal anastomosis

The most serious early complication after rectal resection with low anastomosis is anastomotic leakage (AL). AL may compromise the long-term conservation of the anastomosis and also worsen oncological results. The aim of this review was to identify those factors that contribute to the prevention of AL and to delineate the various treatment options (endoscopic, perineal surgical approach, abdominal surgical approach) for chronic AL or anastomotic stricture. Treatments for AL or anastomotic stricture should be protected by proximal diversion of fecal flow, ideally by a diverting stoma created at the time of the initial proctectomy. Local approaches to surgical treatment should include perineal examination under general anesthesia by the surgeon and drainage of the fistula. Trans-abdominal interventions should be reserved for high AL and for failure of perineal procedures. Although they have only limited indications for the treatment of AL, endoscopic treatments can be used in a complementary manner to surgical treatment. Balloon dilation is the first-line treatment for anastomotic strictures.

Drainage by urostomy bag after blockage of abdominal drain in patients with cirrhosis undergoing hepatectomy

Abdominal drainage was previously recommended as a post-hepatectomy procedure for patients with cirrhosis. This report introduces a simple technique that prevents leakage of ascitic fluid after cirrhotic hepatectomy complicated by blockage of the abdominal drain. In 59 patients who had had cirrhotic hepatectomy complicated by leakage of ascites in the drain site after drainage removal between January 2001 and April 2011, 31 underwent suture ligation (sutured group) and 28 were given urostomy bag at the abdominal drainage site (drainage group). The mean length of postoperative hospital stay in the drainage group was shorter than in the sutured group (16.11+/-2.61 vs 34.23+/-4.86 days, P=0.000). Meanwhile, the drainage group showed decreased postoperative complications, including leakage of ascites, wound infection, and collection of ascites. Drainage by urostomy bag can prevent prolonged leakage of ascitic fluid after the blockage of abdominal drains in patients undergoing cirrhotic hepatectomy.

Ghost ileostomy in anterior resection for rectal carcinoma: is it worthwhile?

BACKGROUND

There is no consensus in the literature as to whether all patients who undergo anterior resection of the rectum with total mesorectal excision should have a defunctioning stoma or only those at high risk of anastomotic dehiscence.

OBJECTIVE

The aim of this retrospective study was to evaluate the results of placing a removable Silastic band around the ileum during the abdominal phase to exteriorize it and create a loop ileostomy postoperatively without the need for laparotomy in case of an anastomotic complication. This approach is known as "ghost ileostomy."

INTERVENTIONS

A vascular loop was passed around the terminal ileum through a window adjacent to the ileal wall. The loop was then exteriorized, through the abdominal wall, without tension, and secured to the skin on a rod. Two 24F Silastic drains were placed next to the anastomosis (anteriorly and posteriorly).

PATIENTS

From May 1997 to May 2011, 168 patients underwent anterior resection of the rectum with total mesorectal excision plus ghost ileostomy.

RESULTS

Symptomatic anastomotic dehiscence was observed in 20 of 168 patients (11.96%) and developed on postoperative days 4 to 12 (median, postoperative day 7). In 13 of 20 cases, an ileostomy was fashioned with the patient under local anesthesia, and there was no need for relaparotomy. In 5 of 20 cases, the complication resolved with conservative management. In 2 of 20 cases, the patient's clinical condition rapidly deteriorated, generalized peritonitis developed, and surgical reintervention with abdominal toilette and colostomy was required.

CONCLUSIONS

Ghost ileostomy allows selective loop ileostomy formation after low anterior resection of the rectum without the need for laparotomy in most cases. However, the technique should be reserved for instances in which the risk of leak is relatively low, such as anastomoses performed in the absence of neoadjuvant therapy. The role of routine ghost ileostomy following higher-risk anastomoses remains to be determined.

Complications of colorectal anastomoses: leaks, strictures, and bleeding

Intestinal anastomosis is an essential part of surgical practice, and with it comes the inherent risk of complications including leaks, strictures, and bleeding, which result in significant morbidity and occasional mortality. Understanding the myriad of risk factors and the strength of the data helps guide a surgeon as to the safety of undertaking an operation in which a primary anastomosis is to be considered. This article reviews the risk factors, management, and outcomes associated with anastomotic complications.

Utility of closed suction pelvic drains at time of large bowel resection for ovarian cancer

OBJECTIVE

To test the hypothesis that the use of closed suction pelvic drains placed at time of large bowel resection (LBR) for ovarian cancer (OC) decreases morbidity following anastomotic leak (AL).

METHODS

Consecutive cases of LBR for OC between 01/01/1994 and 06/20/2011 were retrospectively identified. Drains were routinely used until bowel movement. AL was defined as: 1) feculent fluid from drains/wound/vagina, 2) radiographic evidence of AL, or 3) AL found at reoperation. Descriptive statistics, Wilcoxon rank-sum, Pearson's chi-square and Fisher's exact test were used.

RESULTS

43 cases met inclusion criteria. AL was characterized by method of diagnosis as follows: change in drain output only (DO, n=8); change in drain output associated with ambiguous clinical signs/symptoms (D-SSX, n=11); or clinical signs/symptoms only (SSX, n=24). The sensitivity of drains in diagnosing AL was 50%. Time to diagnosis was earlier in DO/D-SSX (median 7 vs. 11 days, P=0.003), however, no significant differences were observed in rates of reoperation, length of stay, time to chemotherapy (TTC), and 30- and 90-day mortality between DO/D-SSX and SSX. Comparing cases where no drains were placed (n=5) vs. those with drain (n=38), we observed no differences in outcomes. TTC though statistically significant (47 vs. 59 days, P=0.023) was not clinically significant.

CONCLUSIONS

Though a change in drain output correlated with earlier diagnosis, this did not appear to impact overall outcomes. We did not find strong evidence supporting routine prolonged drainage after LBR for OC. Additionally, absence of change in drain output does not rule out presence of AL.

To drain or not to drain in Roux-en-Y hepatojejunostomy for children with choledochal cysts in the laparoscopic era: a prospective randomized study

BACKGROUND/PURPOSE

Routine drain placement after choledochal cyst (CDC) excision and Roux-en-Y hepatojejunostomy (RYHJ) is commonly practiced to predict and prevent bile/pancreatic leaks and hemorrhage. Recently, laparoscopic excision of CDC has decreased postoperative morbidity. The necessity of drainage has been questioned. We undertook a prospective randomized trial to assess the need for drainage.

METHOD

Between 2009 and 2011, 121 CDC children were randomized into 2 groups before the laparoscopic RYHJ: drainage group (n = 61) and nondrainage group (n = 60). Patients without severe cyst inflammation, perforated bile peritonitis, common/left/right hepatic duct strictures requiring ductoplasty, or distal cyst deeply embedded in pancreas were included. Normal activity resumption, postoperative hospital stay, complications, and pain scores were analyzed.

RESULTS

One hundred patients were recruited according to the selection criteria (drainage/nondrainage, 50/50). Normal activity resumption was significantly faster and the postoperative hospital stay was significantly shorter in the nondrainage group. The pain score in the drainage group was significantly higher. On postoperative days 2 and 3, 14% and 38% of the nondrainage group patients were pain free, whereas all the drainage group patients still suffered from pain (P < .01 and P < .001, respectively). The median follow-up period was 12.5 months in the drainage group and 12 months in the nondrainage group. None of the patients developed bile/pancreatic/intestinal leaks.

CONCLUSION

With the laparoscopic approach, no drainage is needed after RYHJ for the majority of CDC children in expert hands. It minimizes postoperative pain and complications, and facilitates recovery.

[Significance of drains in surgery]

Placing drains is one the most common procedures following operations in surgical disciplines. The indication for placing a drain is, however, usually based on a traditional belief rather than being evidence-based. This paper presents an overview of the literature regarding the indications and the evidence level for placing drains following operations in visceral, vascular, thoracic and orthopeedic surgery as well as traumatology. In visceral surgery the indications for placing drains could be clarified over the past decades but in other surgical fields the level of evidence needs further investigation and clarification through future studies. The available data suggest that in most cases a prophylactic drainage can be avoided. In addition, drains may lead to increased morbidity and higher treatment costs.

Routine peritoneal drainage of the surgical bed after elective distal pancreatectomy: is it necessary?

BACKGROUND

Recent literature suggests that peritoneal drainage (PD) is not helpful after elective pancreatectomy and may be detrimental. Data specific to distal pancreatectomy (DP) have not received prior evaluation.

METHODS

We performed a retrospective review of patients who underwent DP. Factors examined included postoperative morbidity and the need for therapeutic intervention.

RESULTS

Sixty-nine patients had DP, 30 without PD. Thirty-four patients suffered 45 complications, most were intra-abdominal in nature. Twelve, 19, and 3 patients required radiologic drainage, reoperation, or both, respectively. There was no difference between groups relative to intra-abdominal complications or the need for therapeutic intervention. Of 39 patients undergoing PD, 19 had abdominal morbidity. The drain was useful in identifying and/or treating the complication in 3 patients.

CONCLUSIONS

First, PD after DP does not confer a reduction in morbidity or the need for therapeutic intervention versus patients with no drains. Second, the presence of a drain infrequently was helpful in detecting complications. Third, a multi-institutional, randomized study is recommended.

Routine drain placement in Roux-en-Y gastric bypass: an expanded retrospective comparative study of 755 patients and review of the literature

Routine drain use after laparoscopic Roux-en-y gastric bypass (LRYGB) is still practiced by many bariatric surgeons. After a patient in our program experienced intestinal obstruction secondary to a drain, we reevaluated our practice and hypothesized drains would be of no benefit and potentially harmful after LRYGB. Retrospective record review of all patients undergoing LRYGB from August 2005 to August 2009 was performed. As we changed our practice in December 2006, we have two comparable groups: one with a drain placed at surgery and one without. All operations were otherwise performed in an identical fashion by three fellowship-trained university surgeons. We compared outcomes between the two groups, particularly regarding gastrojejunal (GJ) leaks. Jejunojejunal (JJ) leaks, unlikely to be captured by these drains, were not studied. A total of 755 LRYGBs were performed during the study period, the first 272 patients with routine drains and the subsequent 483 without. Demographics were statistically similar between the two groups. There were four GJ leaks in the drain group (1.47%) and three in the nondrain group (0.62%). Among the drain patients, two required operation and two were treated nonoperatively. Among the nondrain patients, two required operation and one was treated nonoperatively. The leak and reoperation rates between the groups were not statistically different (p = 0.154 and p = 0.514). Routine drains likely have no benefit after LRYGB. Clinical parameters such as tachycardia, fever, oliguria, and increasing abdominal pain should guide further investigation for and treatment of a leak.

Is intraabdominal drainage necessary after laparotomy for typhoid intestinal perforation?

PURPOSE

This study was designed to compare the safety and effectiveness of routine drainage and nondrainage after emergency laparotomy for typhoid intestinal perforation (TIP).

METHODS

A retrospective review of children 15 years or younger who underwent surgery for TIP from 2002 to 2009 was performed. All children underwent resuscitation and laparotomy and were given antibiotics but were then divided into 2 groups: group I (n = 81), postoperative peritoneal drainage, and group II, (n = 66) no drainage.

RESULTS

There was no demographic difference between the groups (e.g., mean age 9.6 vs 9.0 years; P = .21). There was no significant difference in mean time for return of bowel function (3.8 vs 4.0 days; P = .6), rate of surgical site infection (63% vs 70%; P = .39), wound dehiscence (36% vs 27%; P = .27), anastomotic leak (2.5% vs 1.5%; P = .27), enterocutaneous fistula formation (10% vs 6.1%; P = .40), intraabdominal abscess formation (4% vs 9%; P = .18), or mean length of hospital stay (22 vs 19 days; P = .26).

CONCLUSION

The results of this study clearly show that routine peritoneal drain placement after laparotomy for TIP is unnecessary, and such drains are not effective in reducing the rate of postoperative complications.

Incidence of and risk factors for anastomotic leakage after laparoscopic anterior resection with intracorporeal rectal transection and double-stapling technique anastomosis for rectal cancer

BACKGROUND

Laparoscopic rectal cancer surgery involving rectal division with intracorporeal stapling devices is technically difficult. This study aimed to identify risk factors for anastomotic leakage associated with laparoscopic anterior resection for rectal cancer.

METHODS

We studied 363 patients who underwent laparoscopic anterior resection with intracorporeal rectal transection and double-stapling technique (DST) anastomosis for rectal cancer between July 2005 and February 2010. Twenty-two independent clinical variables were examined by univariate and multivariate analyses. The outcome of interest was clinical anastomotic leakage.

RESULTS

Anastomotic leakage was identified in 13 (3.6%) patients. Multivariate analysis identified middle/lower rectal cancer (odds ratio, 9.446) and lack of pelvic drain (odds ratio, 3.814) as independent predictive factors for anastomotic leakage. The number of cartridges used for rectal division had no significant impact on anastomotic leakage.

CONCLUSIONS

Laparoscopic anterior resection involving intracorporeal rectal transection and DST anastomosis is safe if performed using an appropriate technique.

Placement of prophylactic drains after laparotomy may increase infectious complications in neonates

PURPOSE

The aim of this study was to determine if the placement of prophylactic drains influences the incidence of postoperative adverse events in neonates.

METHODS

Neonatal patients undergoing laparotomy between April 2000 and December 2007 were prospectively assigned to aggressive peritoneal cavity lavage, without the placement of prophylactic drains, before abdominal closure (non-drainage group, n = 111). The historical control group consisted of neonates who underwent laparotomy with routine prophylactic drain placement between January 1993 and March 2000 (drainage group, n = 87). The incidence of postoperative adverse events was compared between the two groups.

RESULTS

There were no significant differences in the incidence of overall complications (drainage, 48%; non-drainage, 36%: p = 0.08), infectious complications (drainage, 34%; non-drainage, 26%: p = 0.20) or surgical site infections (drainage, 20%; non-drainage, 14%: p = 0.25) between the two groups. In the subgroup analysis, the incidences of total postoperative complications and infectious complications were significantly higher in the drainage group compared with the non-drainage group for upper gastrointestinal tract operations (52 vs. 20%; 39 vs. 6.7%) (p = 0.04 and 0.02, respectively).

CONCLUSION

Prophylactic drainage did not reduce the incidence of postoperative complications, and the placement of drains may possibly increase the incidence of infectious complications.

Abdominal drainage versus no drainage post gastrectomy for gastric cancer

BACKGROUND

Gastrectomy remains the primary therapeutic method for resectable gastric cancer. Thought of as an important measure to reduce post-operative complications and mortality, abdominal drainage was used widely after gastrectomy for gastric cancer in previous decades. The benefits of abdominal drainage have been questioned by researchers in recent years.

OBJECTIVES

The objectives of this review were to access the benefits and harms of routine abdominal drainage post gastrectomy for gastric cancer.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (Central/CCTR) in The Cochrane Library (2010, Issue 10), including the Specialised Registers of the Cochrane Upper Gastrointestinal and Pancreatic Diseases (UGPD) Group; MEDLINE (via Pubmed, 1950 to October, 2010); EMBASE (1980 to October, 2010); and the Chinese National Knowledge Infrastructure (CNKI) Database (1979 to October, 2010).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing abdominal drain versus no drain in patients who had undergone gastrectomy (not considering the scale of gastrectomy and the extent of lymphadenectomy; irrespective of language, publication status, and the type of drain). We excluded RCTs comparing one drain with another.

DATA COLLECTION AND ANALYSIS

From each trial, we extracted the data on the methodological quality and characteristics of the included studies, mortality (30-day mortality), re-operations, post-operative complications (pneumonia, wound infection, intra-abdominal abscess, anastomotic leak, drain-related complications), operation time, length of post-operative hospital stay and initiation of soft diet. For dichotomous data, we calculated the risk ratio (RR) and 95% confidence intervals (CI). For continuous data, we calculated mean differences (MD) and 95% CI. We tested heterogeneity using the Chi(2) test. We used a fixed-effect model for data analysis with RevMan software but we used a random-effects model if the P value of the Chi(2) test was less than 0.1.

MAIN RESULTS

We included four RCTs involving 438 patients (220 patients in the drain group and 218 in the no-drain group).There was no evidence of a difference between the two groups in mortality (RR 1.73, 95% CI 0.38 to 7.84); re-operations (RR 2.49, 95% CI 0.71 to 8.74); post-operative complications (pneumonia: RR 1.18, 95% CI 0.55 to 2.54; wound infection: RR 1.23, 95% CI 0.47 to 3.23; intra-abdominal abscess: RR 1.27, 95% CI 0.29 to 5.51; anastomotic leak: RR 0.93, 95% CI 0.06 to 14.47); and initiation of soft diet (MD 0.15 day, 95% CI -0.07 to 0.37). However, the addition of a drain prolonged the operation time (MD 9.07 min, 95% CI 2.56 to 15.57) and post-operative hospital stay (MD 0.69 day, 95% CI 0.18 to 1.21) and lead to drain-related complications. Additionally, we should note that 30-day mortality and re-operations are very rare events and, as a result, very large numbers of patients would be required to make any sensible conclusions about whether the two groups were similar. The overall quality of the evidence according to the GRADE approach was "Very Low" for mortality and re-operations, and "Low" for post-operative complications, operation time, and post-operative length of stay.

AUTHORS' CONCLUSIONS

We found no convincing evidence to support routine drain use after gastrectomy for gastric cancer.

Laparoscopy-assisted distal gastrectomy for early gastric cancer with versus without prophylactic drainage

PURPOSE

Little has been reported on routine prophylactic abdominal drainage after gastrectomy, especially after laparoscopy-assisted distal gastrectomy (LADG). We conducted this retrospective study on patients undergoing LADG to evaluate the benefit of routine drainage in LADG procedures.

METHODS

The subjects were 21 patients who underwent surgery for early gastric cancer (EGC) between January 2004 and March 2008. They comprised 10 who underwent LADG with drainage before January 2006 and 11 who underwent LADG without drainage after February 2006. We compared patient and tumor characteristics, operative results, and postoperative outcomes between the groups.

RESULTS

The no-drain group of patients were able to eat their first meal significantly sooner than the drain group patients (P < 0.01); however, the time to start ambulating, passing flatus, and drinking was similar in the two groups. There were no significant differences between the groups in the postoperative complication rate or the postoperative hospital stay. The drain did not seem to add benefit, and no complications due to the lack of drain placement were noted in the no-drain group.

CONCLUSION

Routine prophylactic abdominal drainage after LADG for EGC may not be necessary.

Routine drainage for orthotopic liver transplantation

BACKGROUND

Routine use of abdominal drainage in patients undergoing liver transplantation is controversial.

OBJECTIVES

To assess the benefits and harms of routine abdominal drainage after orthotopic liver transplantation versus no drainage and to address different drain types.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and the MetaRegister of Controlled Trials until March 2011 to identify the randomised trials.

SELECTION CRITERIA

We planned to include only randomised clinical trials (irrespective of language, blinding, or publication status) addressing this issue.

DATA COLLECTION AND ANALYSIS

Two authors identified the trials for inclusion independently. Two authors planned to collect the data independently. We planned to analyse the data with both the fixed-effect and the random-effects model using RevMan Analysis. For each outcome we planned to calculate the risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis whenever possible.

MAIN RESULTS

We did not identify any randomised clinical trials addressing this issue.

AUTHORS' CONCLUSIONS

There is currently no evidence to conclude whether routine abdominal drainage is useful or harmful in patients undergoing orthotopic liver transplantation. Evidence from non-randomised studies of high risk of bias showed conflicting results on the impact of routine drainage in orthotopic liver transplantation on serious adverse events, showing that this question is an important clinical research question. Well-designed randomised clinical trials with adequate sample size to decrease systematic errors and to decrease random errors are necessary.

Risk factors and outcomes for anastomotic leakage in colorectal surgery: a single-institution analysis of 1576 patients

BACKGROUND

Anastomotic leakage is associated with high mortality, high reoperation rate, and increased hospital length of stay. Although many studies have examined the risk factors for anastomotic leak, large prospective series that report on long-term survival rates are lacking.

METHODS

Data of 1576 patients who underwent primary resection and anastomosis for colorectal adenocarcinoma at a single institution from 1984 to 2004 were prospectively collected. Anastomotic leaks (LEK) were classified as radiological (RAD), local (LOC), or generalised (GEN). Logistic regression analysis of 21 variables was undertaken. Overall survival, cancer-related survival, and disease-free survival were analysed using the Kaplan-Meier method.

RESULTS

Mean age of the patients was 67 years (SD = 12.5) and 834 (52.9%) were male. An LEK was more likely when relatively major gynaecological (tubo-oophorectomy, P = 0.004; hysterectomy, P = 0.006) or urological (total cystectomy, P = 0.014) procedures were performed during the same operative session. Other significant factors were anterior resection (P < 0.001), anastomosis using an intraluminal stapling device (P = 0.005), abdominal drain via laparoscopic port (P = 0.024), postoperative blood transfusion (P < 0.001), primary cancer site at the rectum (P = 0.016), and TNM stage of T2 or higher (P = 0.026). Having an LEK showed significant impact on overall (P = 0.021), cancer-related (P = 0.006), and disease-free (P = 0.001) survival.

CONCLUSION

In this prospective study, advanced tumour stage, distal site, and need for postoperative blood transfusion were associated with increased rates of anastomotic leakage. In addition to their high risk of immediate postoperative morbidity and mortality, both localized and generalized leaks had similarly negative impacts on overall, cancer-related, and disease-free survival.

The surgical anatomy and etiology of gastrointestinal fistulas

BACKGROUND

Fistulas are abnormal communications between two epithelial surfaces, either between two portions of the intestine, between the intestine and some other hollow viscus, or between the intestine and the skin of the abdominal wall. The etiology of intestinal fistulas is in most cases a result of multiple contributing factors. Despite significant advances in their management over the past decades, intestinal fistulas remain a major clinical problem, with a high overall mortality rate of up to 30% due to the high rate of complications. This paper aims to describe classification systems based on the anatomy, physiology and etiology that may be helpful in the clinical management of intestinal fistulas.

METHODS

On the basis of anatomical differences, fistulas can be classified based by the site of origin, by site of their openings, or as simple or complex. Physiologic classification as low, moderate or high output fistulas is most useful for the non-surgical approach. Concerning the etiology, we classified the possible causes as (postoperative) trauma, inflammation, infection, malignancy, radiation injury or congenital.

CONCLUSION

Fistula formation can cause a number of serious or debilitating complications ranging from disturbance of fluid and electrolyte balance to sepsis and even death. They still remain an important complication following gastrointestinal surgery.

Drain vs No Drain After Colorectal Surgery

In colorectal surgery, drains are expected to prevent hematoma, fluid collection, or abscess formation, to act as an indicator of postoperative complication, or to minimize the severity of complication-related symptoms. Routine drainage has not been advocated by meta-analyses as they failed to demonstrate any benefit in reducing anastomotic leak rate, minimizing symptoms, or serving as a warning function. Moreover, some reports even showed that drain itself is an independent risk factor of anastomosis. The introduction of total mesorectal excision (TME) for rectal cancer surgery has given further concern to this controversial issue, that the use of drain decreased anastomotic failure rate and the need for surgical re-intervention. While controversy still remains, the choice of using drain is left to the individual surgeon's preference in daily practice. Therefore, surgeons should be well acquainted with purpose of drainage (prophylaxis, information, or treatment), characteristics (materials), clinical application of drain (type of drainage system, timing of removal), surgical outcomes after using drain (incidence of postoperative complication), and drain-related complications. If drains are used, careful observation with proper use is crucial for the management. It is important that the duration of drainage should not be inadequately extended. Any complications directly associated with the use of drain should be avoided. New concepts of drain have been proposed as diagnostic tool using biomarkers, and as preventive device against anastomotic leak. This article overviews the available, published data on the use of drain in colorectal surgery.

Standardized pelvic drainage of anastomotic leaks following anterior resection without diversional stomas

BACKGROUND

Anastomotic leakage is a serious complication in rectal cancer surgery. More than one third of rectal cancer patients with low anterior resection (LAR) will receive defunctional stomas during primary operation.

METHODS

Six hundred thirty-nine consecutive rectal cancer patients, whose tumors were located 5 to 12 cm from the anal verge, were treated with LAR. A standardized pelvic drainage for all these patients and selective irrigation for patients with leakage were conducted, and defunctional stoma was used as a salvage modality. All the anastomoses were all extraperitonealized during primary operations.

RESULTS

The anastomotic leakage rate was 7.04%. Male gender and location of tumor were found to be risk factors for leakage in patients with LAR. The overall stoma rate was 1.88%. Nearly 75% of leakage could be cured by irrigation-suction without surgical intervention. Severe complications, such as peritonitis, fistula, and obstruction, were strong predictors of irrigation failure.

CONCLUSIONS

Extraperitonealized anastomosis and pelvic drainage obtained a very low rate of defunctional stoma for LAR. Pelvic irrigation-suction was an effective modality to resolve anastomotic leakage.

Multicentre analysis of oncological and survival outcomes following anastomotic leakage after rectal cancer surgery

BACKGROUND

The association between diverting stomas and symptomatic anastomotic leakage after rectal cancer surgery was studied, as well as the impact of leakage on local recurrence, distant metastasis, and disease-free, overall and cancer-specific survival.

METHODS

Data from the Swedish Rectal Cancer Trial, Dutch TME trial, CAO/ARO/AIO-94 trial, EORTC 22921 trial and Polish Rectal Cancer Trial were pooled (n = 5187). All eligible patients without distant metastases at the time of low anterior resection were selected (n = 2726); overall survival was studied in patients aged 75 years or less (n = 2480). Multivariable models were used to study the association between diverting stomas and anastomotic leakage, and between leakage and recurrence or survival.

RESULTS

Some 9.7 per cent of patients were diagnosed with a symptomatic anastomotic leak; diverting stomas were negatively associated with leakage (11.6 per cent without and 7.8 per cent with a stoma; P = 0.002). Anastomotic leakage was negatively associated with overall survival in the multivariable analysis (hazard ratio (HR) 1.29 (95 per cent confidence interval 1.02 to 1.63); P = 0.034), but not with cancer-specific survival (HR 1.12 (0.83 to 1.52); P = 0.466).

CONCLUSION

Diverting stomas were associated with less symptomatic anastomotic leakage. Oncological outcome was not significantly influenced by leakage, but overall survival was reduced.

Proximal diversion at the time of ileal pouch-anal anastomosis for ulcerative colitis: current practices of North American colorectal surgeons

PURPOSE

Pelvic sepsis is a serious complication after ileal pouch-anal anastomosis for ulcerative colitis that may lead to pouch failure or poor function. Although a temporary loop ileostomy may be created at the time of ileal pouch-anal anastomosis to prevent or minimize the consequences of an anastomotic leak, research has suggested that an ileostomy can be safely omitted in selected patients. The purpose of this study was to examine the use of proximal diversion by colorectal surgeons at the time of ileal pouch-anal anastomosis for ulcerative colitis.

METHODS

A questionnaire was mailed to all practicing fellows of The American Society of Colon and Rectal Surgeons in North America. Surgeons were asked to describe their typical practice for a number of clinical scenarios.

RESULTS

Questionnaires were mailed to 913 American Society of Colon and Rectal Surgeons fellows, and 63 percent responded. For a patient who has had a prior colectomy and is not taking steroids, 27 percent of surgeons would perform ileal pouch-anal anastomosis alone, and 73 percent would perform ileal pouch-anal anastomosis with a loop ileostomy. For a patient who has not had previous surgery and is taking prednisone 40 mg/day, 16 percent of surgeons would perform a subtotal colectomy with an end ileostomy, 82 percent would perform a total proctocolectomy and ileal pouch-anal anastomosis with a loop ileostomy, and 2 percent would perform a total proctocolectomy and ileal pouch-anal anastomosis without an ileostomy. There was no relationship between practice setting, annual ileal pouch-anal anastomosis volume, or years in practice and surgeon response for either scenario.

CONCLUSIONS

The majority of surgeons create a temporary loop ileostomy at the time of ileal pouch-anal anastomosis for ulcerative colitis.

Abdominal drains in liver transplantation: useful tool or useless dogma? A matched case-control study

On the basis of the growing evidence from randomized trials that routine prophylactic drainage is unnecessary in liver surgery or even harmful in chronic liver disease, we challenged the concept of prophylactic drainage in orthotopic liver transplantation (OLT). Since September 2006, we omitted drains in every patient who underwent OLT, regardless of the procedure. Thirty-five cadaveric OLTs were performed during a 12-month period. These patients were matched 1:2 with 70 patients who had prophylactic drainage after OLT according to donor/recipient age, recipient gender, recipient body mass index, and Model for End-Stage Liver Disease (MELD) score. Endpoints were postoperative morbidity, in-hospital mortality, intensive care unit (ICU), and hospital stay. Complications were graded according to a therapy-oriented classification (grades I-V). Both groups (no drainage, n = 35; drainage, n = 70) were comparable in terms of median donor age (47.5 versus 51.0 years), recipient age (50.6 versus 52.0 years), MELD score (18 versus 14), and body mass index (25.3 versus 26 kg/m(2)). Because of the increasing shortage of organs, more marginal grafts were used in the recent period (ie, no-drainage group): 49% (17/35) versus 27% (19/70; P = 0.04). Major complications were not different between groups: grade 3a (endoscopic/radiological intervention) in 20% (7/35) versus 16% (11/70; not significant), grade 3b (surgical intervention) in 23% (8/35) versus 17% (12/70; not significant), grade 4a (ICU therapy, intermittent hemodialysis) in 34% (12/35) versus 21% (15/70; not significant), grade 4b (multiorgan failure) in 14% (5/35) versus 10% (7/70; not significant), and grade 5 (death) in 6% (2/35) versus 7% (5/70; not significant). This matched case study challenges the dogma of prophylactic drainage after OLT. A no-drain strategy provided no disadvantages despite increased use of extended criteria donors in the no-drainage group. Prophylactic drainage appears unnecessary on a routine basis.

The effect of endoscopic treatment on healing of anastomotic leaks after anterior resection of rectal cancer

BACKGROUND

Despite surgical advances, anastomotic leaks remain a major complication after rectal resection. Endoscopic techniques are increasingly used as an alternative or in addition to conventional operative therapy of anastomotic leakage. We have analyzed the impact of endoscopic treatment on the outcome of patients with leaks after resection of rectal cancer.

METHODS

From January 2000 to December 2005, rectal resection was performed in 274 patients with rectal cancer. Anastomotic leakage was observed in 29 patients (11%). Nine of these patients received a protective ileostomy. The remaining 20 patients underwent either conventional operative or endoscopic treatment. Both groups were analyzed regarding complications, necessity of operative reintervention, hospitalization, anastomotic healing time, and stoma reversal rate.

RESULTS

The endoscopic group included 13 patients who underwent endoscopic debridement in combination with stenting, endoluminal vacuum therapy, or fibrin injection. The remaining 7 patients underwent reoperation-secondary ileostomy creation (n = 4), Hartmann procedure (n = 2), or anastomotic repair (n = 1). Stoma creation was necessary in 7 of 13 patients (54%) in the endoscopic group and in 6 of 7 patients (86%) in the operative group. There were no significant differences regarding postoperative septicemia (39 vs 43%), duration of intensive care (13 vs 11 days), or time of hospitalization (25 vs 26 days) for endoscopic and conventional therapies. Mean healing time of the anastomotic leak in the endoscopic and conventional group was 105 and 173 days, respectively. The stoma reversal rate was similar in both groups (50 vs 57%), but the overall rate of patients without colostomy was higher in the endoscopic group (77 vs 57%).

CONCLUSION

Endoscopic therapy in combination with effective operative drainage may support healing of anastomotic leaks after rectal resection. However, the majority of patients require operative reintervention with bowel diversion despite endoscopic treatment.

Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery

SUMMARY BACKGROUND DATA

The role of a defunctioning stoma in patients undergoing low anterior resection for rectal cancer is still the subject of controversy. Recent studies suggest reduced morbidity after low anterior rectal resection with a defunctioning stoma.

METHODS

Retrospective and prospective studies published between 1966 and 2007 were systematically reviewed. Randomized controlled trials (RCTs) comparing anterior resections with or without defunctioning stoma were included in a meta-analysis. The pooled estimates of clinically relevant anastomotic leakages and of reoperations were analyzed using a random effects model (odds ratio and 95% confidence interval, CI).

RESULTS

Relevant retrospective single (n = 18) and multicenter (n = 9) studies were identified and included in the systematic review. Analysis of incoherent data of the leakage rates in these nonrandomized studies demonstrated that a defunctioning stoma did not influence the occurrence of anastomotic failure but seemed to ameliorate the consequences of the leak. Four RCTs were included in the meta-analysis. The odds ratio for clinically relevant anastomotic leakage was 0.32 (95% CI 0.17-0.59), revealing a statistically significant benefit conferred through a defunctioning stoma (Z = 3.65, P = 0.0003). The odds ratio for reoperation because of leakage-caused complications was 0.27 (95% CI 0.14-0.51), with significantly fewer reoperations in patients with a defunctioning stoma (Z = 3.95, P < 0.0001). Overall mortality rates were comparable regardless of the presence of a defunctioning stoma.

CONCLUSION

A defunctioning stoma reduces the rate of clinically relevant anastomotic leakages and is thus recommended in surgery for low rectal cancers.

Incidence, consequences, and risk factors for anastomotic dehiscence after colorectal surgery: a prospective monocentric study

BACKGROUND

Anastomotic dehiscence is the most severe surgical complication after large bowel resection. This study was designed to assess the incidence, to observe the consequences, and to identify the risk factors associated with anastomotic leakage after colorectal surgery.

MATERIALS AND METHODS

All procedures involving anastomoses of the colon or the rectum, which were performed between November 2002 and February 2006 in a single institution, were prospectively entered into a computerized database.

RESULTS

One thousand eighteen colorectal resections and 811 anastomoses were performed over this 40-month period. The most frequent procedures were sigmoid (276) and right colectomies (217). The overall anastomotic leak rate was 3.8%. The mortality rate associated with anastomotic leak was 12.9%. In univariate analysis, the following parameters were associated with an increased risk for anastomotic dehiscence: (1) ASA score >or= 3 (p = 0.004), (2) prolonged (>3 h) operative time (p = 0.02), (3) rectal location of the disease (p < 0.001), (4) and a body mass index > 25 (p = 0.04). In multivariate analysis, ASA score >or= 3 (OR = 2.5; 95% CI 1.5-4.3, p < 0.001), operative time > 3 h [OR = 3.0; 95% CI 1.1-8.0, p = 0.02), and rectal location of the disease (OR = 3.75; 95% CI 1.5-9.0 (vs left colon), p = 0.003; OR = 7.69; 95% CI 2.2-27.3 (vs right colon), p = 0.001] were factors significantly associated with a higher risk of anastomotic dehiscence.

CONCLUSIONS

Three risk factors for anastomotic leak have been identified, one is patient-related (ASA score), one is disease-related (rectal location), the third being surgery-related (prolonged operative time). These factors should be considered in perioperative decision-making regarding defunctioning stoma formation.

Evaluation of selective defunctioning stoma after low anterior resection for rectal cancer

BACKGROUND

Anastomotic leakage is a major concern after resection for low rectal cancer. Therefore, the use of a defunctioning stoma (DS) has been suggested, but limited data exist to clearly determine the necessity of a routine diversion. In our department, the indication of DS was evaluated subjectively by the operating surgeon. The aim of this study was to evaluate the selective use of fecal diversion.

MATERIALS AND METHODS

Retrospective chart review of patients who underwent low anterior resection for carcinoma was performed. The incidence and consequences of clinical leaks were determined in these patients who were considered in two groups: defunctioning stoma and no defunctioning stoma.

RESULTS

From 1995 to 2005, 132 consecutive patients underwent low anterior resection; a DS was performed in 42 patients (31.8%). Median level of anastomosis was 4 cm in both groups. Overall clinical leakage rate was 9.8%: 7.1% (n = 3) with a DS and 11% (n = 10) without a stoma. Mortality rate was 1.5% (n = 2), both in the unprotected group. No patient in the diversion group required a permanent stoma, contrasting with four unprotected patients in which continuity could not be restored after break down of the anastomosis.

CONCLUSION

Finding lower clinical leakage rate in a probable higher risk group and better outcome when a leak occurs in our study constituted strong evidence of the effectiveness of a DS. Selective use of a DS based on subjective assessment at the time of surgery could not allow experienced surgeons to perform single-stage procedure safely. Construction of a DS seems useful for patients with distal rectal cancer.

Is prophylactic placement of drains necessary after subtotal gastrectomy?

AIM: To determine the evidence-based values of prophylactic drainage in gastric cancer surgery.

METHODS: One hundred and eight patients, who underwent subtotal gastrectomy with D1 or D2 lymph node dissection for gastric cancer between January 2001 and December 2005, were divided into drain group or no-drain group. Surgical outcome and post-operative complications within four weeks were compared between the two groups.

RESULTS: No significant differences were observed between the drain group and no-drain group in terms of operating time (171 ± 42 min vs 156 ± 39 min), number of post-operative days until passage of flatus (3.7 ± 0.5 d vs 3.5 ± 1.0 d), number of post-operative days until initiation of soft diet (4.9 ± 0.7 d vs 4.8 ± 0.8 d), length of post-operative hospital stay (9.3 ± 2.2 d vs 8.4 ± 2.4 d), mortality rate (5.4% vs 3.8%), and overall post-operative complication rate (21.4% vs 19.2%).

CONCLUSION: Prophylactic drainage placement is not necessary after subtotal gastrectomy for gastric cancer since it does not offer additional benefits for the patients.

Rehabilitación mutimodal en cirugía colorrectal. Sobre la resistencia al cambio en cirugía y las demandas de la sociedad

Perioperative management is one of the fields of surgery most hide bound by tradition and conventional attitudes are difficult to modify even in the face of strong scientific evidence. One of the advances that has most helped to improve the results of colorectal surgery is multimodal or fast-track rehabilitation, which aims to enhance recovery, reduce morbidity, and shorten the length of hospital stay. This modality is based on a multidisciplinary approach provided by surgeons, anesthesiologists and other staff and aims to decrease the response to physiopathological changes induced by surgical aggression. There is evidence to support the use of preoperative oral carbohydrate therapy and oral bowel preparation, the avoidance of intraoperative fluid excess, and the maintenance of normothermia on postoperative recovery. Other factors that can also reduce complications are epidural analgesia, avoidance of drainage and nasogastric decompression, early oral feeding, and minimally invasive surgery. There is strong evidence that the combined use of these and other measures enhances postsurgical recovery, although many of these measures are currently little used in daily practice.

Surgical outcome and long-term follow up after laparoscopic rectosigmoid resection in women with deep infiltrating endometriosis

The aim of this study was to assess the long-term outcome of treating severely symptomatic women with deep infiltrating intestinal endometriosis by laparoscopic segmental rectosigmoid resection. Detailed intraoperative and postoperative records and questionnaires (preoperatively, 1 month postoperatively and every 6 months for 3 years) were collected from 22 women. The estimated blood loss during surgery was 290 +/- 162 ml (range 180-600), and average hospital stay was 8 days (range 6-19). One woman required blood transfusion after surgery. Two cases were converted to laparotomy. One woman had early dehiscence of the anastomosis. Six months after surgery, there was a significant reduction of symptom scores (greater than 50% for most types of pain) related to intestinal localisation of endometriosis (P < 0.05). Score improvements were maintained during the whole period of follow up. Noncyclic pelvic pain scores showed significant reductions (P < 0.05) after 6 and 12 months, but there was a high recurrence rate later. Dysmenorrhoea and dyspareunia improved in 18/21 and 14/18 women with preoperative symptoms, respectively. Constipation, diarrhoea and rectal bleeding improved in all affected women for the whole period of follow up. Laparoscopic segmental rectosigmoid resection seems safe and effective in women with deep infiltrating colorectal endometriosis resulting in significant reductions in painful and dysfunctional symptoms associated with deep bowel involvement.

Routine pelvic drainage not required after open or robotic radical prostatectomy

OBJECTIVES

To determine whether radical prostatectomy requires urinary drainage.

METHODS

All patients with clinically localized prostate cancer had complete clinical and pathologic information recorded prospectively in a database. The criteria for omission of pelvic drainage were successful bladder neck preservation; urethrovesical anastomosis performed using 6 interrupted sutures in open cases or 12 continuous sutures in robotic cases; and a watertight urethrovesical anastomosis on irrigation. Most patients were discharged on the first or second postoperative day. The catheters were removed routinely on postoperative day 9.

RESULTS

A pelvic drain was not placed in 78% of 325 consecutive patients. A drain was omitted in 73% of 225 open cases and 90% of 100 robotic cases. The recovery of continence and the complication rates were similar between the two groups with and without pelvic drainage. Complications occurred in 11% of the group with pelvic drainage and 6% in the group without pelvic drainage. In the past 2 years, 17 of 126 patients required pelvic drainage. The frequency of complications in robotic versus open procedures was similar (chi-square test, P >0.05).

CONCLUSIONS

Pelvic drainage may be omitted after radical prostatectomy when the urethrovesical anastomosis is performed well. Drainage omission could contribute to shortened hospital stays and reduced costs, without added complications. These benefits can be extended safely to patients undergoing open or robotic radical prostatectomy.

Prediction of postoperative complications after urgent laparotomy by intraperitoneal microdialysis: A pilot study

OBJECTIVE

The aim of the present study was to investigate the role of intraperitoneal microdialysis (IPM) techniques in monitoring the evolution of postoperative critically ill patients requiring urgent laparotomy.

SUMMARY BACKGROUND DATA

Postoperative intraabdominal sepsis is associated with an important degree of morbidity and mortality in acutely ill patients. Early diagnosis is critical to improve outcomes.

METHODS

: The study included 25 consecutive patients admitted to the intensive care unit (ICU) after urgent laparotomy. Measurements of microdialysate fluid were performed through a microdialysis catheter, positioned intraperitoneally, during the first 5 postoperative days and lactate/pyruvate (L/P) ratios calculated. Patients were followed until hospital discharge.

RESULTS

Ten patients had a complicated postoperative course, including 4 deaths (3 refractory shock, 1 mesenteric ischemia), 3 reinterventions (1 necrotic collection, 1 mesenteric ischemia, 1 biliary leak), 2 secondary peritonitis, and 1 intraabdominal collection. The IPM L/P ratio in these patients was already significantly higher during the first 24 postoperative hours compared with patients who had no complications (35 +/- 21 vs. 18 +/- 6, P < 0.01). An IPM L/P ratio above 22 on postoperative day 1 had a sensitivity of 0.64 and a specificity of 0.79 for complications. There were no significant differences between the two groups in pH, lactate, white blood cell count, or subcutaneous L/P ratio. No complication was associated with the technique.

CONCLUSIONS

IPM is safe and reliable and provides valuable information after urgent laparotomy. Persistently high L/P values should raise the possibility of serious postoperative complications.

A Pelvic Drain Can Often Be Avoided After Radical Retropubic Prostatectomy—An Update in 552 Cases

OBJECTIVES

The routine placement of a pelvic drain following radical retropubic prostatectomy (RRP) may not be required. We describe our experience in 552 consecutive RRPs to emphasise the safety of this approach and explain our rationale for avoiding a drain when possible.

METHODS

RRP was performed in 552 consecutive patients with clinically localised adenocarcinoma of the prostate between January 2002 and June 2005. Clinical and pathologic information was documented for each patient. After the prostate was removed and the anastomotic sutures tied, the bladder was gently filled with approximately 50 ml of saline through the urethral catheter. If there was no leak, a drain was not placed.

RESULTS

A drain was not placed in 419 (76%) of the 552 patients. We compared the postoperative complication rates in those with (D+) and without (D-) a drain. There were 27 (5%) immediate postoperative complications and no significant difference between the two groups (D+, 6%; D-, 5%; p=0.629): three (1%) patients who did not have a drain had a urinoma, one (1%) who had a drain had a lymphocele, and two (2%) who had a drain had a small pelvic haematoma.

CONCLUSIONS

If the bladder neck is preserved or meticulously reconstructed, there may be little extravasation and, thus, routine drainage is unnecessary. Our 4-year experience indicates that morbidity is not increased by omitting a drain from the pelvic cavity after RRP in properly selected cases.

Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection: prospective study for 104 consecutive patients

OBJECTIVE

The aim of this study was designed to determine whether the period of drain insertion influences the incidence of postoperative complications.

BACKGROUND DATA

The significance of prophylactic drains after pancreatic head resection is still controversial. No report discusses the association of the period of drain insertion and postoperative complications.

METHODS

A total of 104 consecutive patients who underwent pancreatic head resection were enrolled in this study. To assess the value of prophylactic drains, we prospectively assigned the patients into 2 groups: group I underwent resection from January 2000 to January 2002 (n = 52, drain to be removed on postoperative day 8); group II underwent resection from February 2002 to December 2004 (n = 52, drain to be removed on postoperative day 4). Postoperative complications in the 2 groups were compared.

RESULTS

The rate of pancreatic fistula was significantly lower in group II (3.6%) than in group I (23%) (P = 0.0038). The rate of intra-abdominal infections, including intra-abdominal abscess and infected intra-abdominal collections, was significantly reduced in group II (7.7%) compared with group I (38%) (P = 0.0003). Eighteen of 52 (34.6%) patients in group I had an inserted drain beyond 8 days, whereas only 2 of 52 (3.7%) patients in group II had an inserted drain beyond 4 days (P = 0.0002). Cultures of drainage fluid were positive in 16 of 52 (30.8%) patients in group I, and in 2 of 52 (3.7%) patients in group II (P = 0.0002). Intraoperative bleeding (> 1500 mL), operative time (> 420 minutes, and the period of drain insertion were significant risk factors for intra-abdominal infections (P = 0.043, 0.025, 0.0003, respectively). The period of drain insertion was the only independent risk factor for intra-abdominal infections by multivariate analysis (odds ratio, 6.7).

CONCLUSION

Drain removal on postoperative day 4 was shown to be an independent factor in reducing the incidence of complications with pancreatic head resection, including intra-abdominal infections.

[Rehabilitation after abdominal surgery]

A combined strategy of anesthetic and surgical care defines postoperative rehabilitation, which aims to accelerate recovery from surgery, shorten convalescence, and reduce postoperative morbidity. Preoperative and early postoperative oral feeding, a relatively "dry" fluid regimen, and the avoidance of or early removal of drains, gastric tubes and bladder catheters all contribute to decreasing postoperative morbidity after abdominal surgery. Postoperative pain control, prevention of nausea and vomiting, shortening the duration of postoperative ileus, and early ambulation can also help to decrease postoperative morbidity. The use of multimodal fast-track clinical rehabilitation programs should improve outcomes and quality of life, reduce hospital stays, and save money.

Anastomotic disruption after large bowel resection

Anastomotic disruption is a feared and serious complication of colon surgery. Decades of research have identified factors favoring successful healing of anastomoses as well as risk factors for anastomotic disruption. However, some factors, such as the role of mechanical bowel preparation, remain controversial. Despite proper caution and excellent surgical technique, some anastomotic leaks are inevitable. The rapid identification of anastomotic leaks and the timely treatment in these cases are paramount.