Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-analyses

Drain Placement After Uncomplicated Hepatic Resection Increases Severe Postoperative Complication Rate: A Japanese Multi-institutional Randomized Controlled Trial (ND-trial)

OBJECTIVE

To assess the clinical impact of a no-drain policy after hepatic resection.

SUMMARY OF BACKGROUND DATA

Previous randomized controlled trials addressing no-drain policy after hepatic resection seem inconclusive because they did not adopt appropriate study design to validate its true clinical impact.

METHODS

This unblinded, randomized controlled trial was done at 7 Japanese institutions. Patients undergoing hepatic resection without biliary reconstruction were randomized to either D group or ND group. When the risk of postoperative bile leakage or hemorrhage were considered high, the patients were excluded during the operation. Primary endpoint was the postoperative complication of C-D grade 3 or higher within 90 postoperative days. A noninferiority of ND group to D group was assessed, and if it was confirmed, a superiority was assessed.

RESULTS

Between May 2015 and July 2017, a total of 400 patients were finally included in the per-protocol set analysis: 199 patients in D group and 201 patients in ND group. Intraoperatively, 37 patients were excluded from the final enrollment because of high risk of bile leakage or hemorrhage. Postoperative complication rate of C-D grade 3 or higher was 8.0% (16/199) in the D group and 2.5% (5/201) in the ND group. The risk difference was -5.5% (95% confidence interval: -9.9% to -1.2%) and fulfilled the prescribed noninferiority margin of 4%. No postoperative mortality was experienced in both groups. Bile leakage was diagnosed in 8.0% (16/199) of the D group and none in the ND group (P < 0.001). In none of the subgroups classified based on 8 potentially relevant factors, drain placement was favored in terms of C-D grade 3 or higher complication.

CONCLUSIONS

Drains should not be placed after uncomplicated hepatic resections.

The Rare Case of Perirenal Abscess in a Child-Possible Mechanisms and Methods of Treatment: A Case Report and Literature Review

Renal and perirenal abscesses are very rare in children. They can be present as an acute emergency condition or insidiously as a chronic disease. The diagnosis is not so obvious, and it is a big challenge, especially when it can simulate a kidney tumor. The treatment can be conservative, preferably with targeted antibiotics, or surgical, consisting primarily of drainage. This publication aims to present a clinical case in which both diagnosis and treatment were a big challenge for the entire treatment team. A 10-year-old male patient was admitted to the hospital because of mild abdominal pain and a temperature of 37.5 °C. The symptoms lasted for a week. In the computed tomography (CT), the lesion's dimensions were 11.1 × 8.2 × 25 cm, and inflammation, abscess, cyst, and abdominal tumor have been suggested. The decision about surgical treatment was made. An enormous abscess near the right kidney was localized. The patient's condition stabilized after surgery. Unfortunately, due to persistent purulent reservoirs, a second laparotomy was necessary. During the extensive diagnostic cystourethrography performed, vesicoureteral reflux was visualized. In conclusion, though a perinephric abscess is very rare in children, it should be taken into consideration in patients with non-specific abdominal symptoms. The imaging using ultrasound and CT scan with contrast enhancement is crucial to recognize and properly treat the condition. In terms of a small abscess, the only antimicrobial treatment using antibiotics of a broad spectrum can be considered. However, the drainage of an abscess, either percutaneous or open, should be used. For the large abscess, the open drainage seems to be a primary method of treatment. The importance of cooperation in a multidisciplinary team is crucial, as the diagnosis and treatment of underlying causes are essential.

Systematic review and meta-analysis of the efficacy of prophylactic abdominal drainage in major liver resections

Prophylactic drainage after major liver resection remains controversial. This systematic review and meta-analysis evaluate the value of prophylactic drainage after major liver resection. PubMed, Web of Science, and Cochrane Central were searched. Postoperative bile leak, bleeding, interventional drainage, wound infection, total complications, and length of hospital stay were the outcomes of interest. Dichotomous outcomes were presented as odds ratios (OR) and for continuous outcomes, weighted mean differences (MDs) were computed by the inverse variance method. Summary effect measures are presented together with their corresponding 95% confidence intervals (CI). The certainty of evidence was evaluated using the Grades of Research, Assessment, Development and Evaluation (GRADE) approach, which was mostly moderate for evaluated outcomes. Three randomized controlled trials and five non-randomized trials including 5,050 patients were included. Bile leakage rate was higher in the drain group (OR: 2.32; 95% CI 1.18-4.55; p = 0.01) and interventional drains were inserted more frequently in this group (OR: 1.53; 95% CI 1.11-2.10; p = 0.009). Total complications were higher (OR: 1.71; 95% CI 1.45-2.03; p < 0.001) and length of hospital stay was longer (MD: 1.01 days; 95% CI 0.47-1.56 days; p < 0.001) in the drain group. The use of prophylactic drainage showed no beneficial effects after major liver resection; however, the definitions and classifications used to report on postoperative complications and surgical complexity are heterogeneous among the published studies. Further well-designed RCTs with large sample sizes are required to conclusively determine the effects of drainage after major liver resection.

Evidence-based evaluation of abdominal drainage in pancreatic surgery

Pancreatic fistula is the most common and dreaded complication after pancreatic resection, responsible for high morbidity and mortality (2 to 30%). Prophylactic drainage of the operative site is usually put in place to decrease and/or detect postoperative pancreatic fistula (POPF) early. However, this policy is currently debated and the data from the literature are unclear. The goal of this update is to analyze the most recent evidence-based data with regard to prophylactic abdominal drainage after pancreatic resection (pancreatoduodenectomy [PD] or distal pancreatectomy [PD]). This systematic review of the literature between 1990 and 2020 sought to answer the following questions: should drainage of the operative site after pancreatectomy be routine or adapted to the risk of POPF? If a drainage is used, how long should it remain in the abdomen, what criteria should be used to decide to remove it, and what type of drainage should be preferred? Has the introduction of laparoscopy changed our practice? The literature seems to indicate that it is not possible to recommend the omission of routine drainage after pancreatic resection. By contrast, an approach based on the risk of POPF using the fistula risk score seems beneficial. When a drain is placed, early removal (within 5 days) seems feasible based on clinical, laboratory (C-reactive protein, leukocyte count, neutrophile/lymphocyte ratio, dosage and dynamic of amylase in the drains on D1, D3±D5) and radiological findings. This is in line with the development of enhanced recovery programs after pancreatic surgery. Finally, this literature review did not find any specific data relative to mini-invasive pancreatic surgery.

Pure laparoscopic donor nephrectomy without routine drainage does not increase postoperative morbidity

Purpose

We aimed to define the feasibility of the omission of routine insertion of a drain after pure laparoscopic donor nephrectomy (PLDN). We compared the outcomes between those with and without routine drain insertion.

Materials and Methods

From July 2014 to October 2018, 178 PLDN were consecutively performed by a single surgeon. Since October 2016, we stopped routine insertion of a drain after PLDN. Thus, the former 80 drained routinely were defined as the Drainage group and the latter 98 were defined as the Non-drainage group. One patient drained non-routinely in the Non-drainage group was excluded from the final analysis. Operative and convalescence parameters and intra- and postoperative complications were compared between the groups. Intra- and postoperative complications within 90 days of surgery were graded using the Satava and Clavien–Dindo classifications, respectively.

Results

Baseline characteristics were similar between the groups, except for concomitant surgery, American Society of Anesthesiologists score, and preoperative glomerular filtration rate. All operative and convalescence parameters were similar between the groups, except for postoperative glomerular filtration rate. The rates of overall intra- (22.5% versus 28.9%, p=0.337) and postoperative (62.5% versus 59.8%, p=0.713) complications were similar between the groups. The rates of potentially drain-related postoperative complications were also similar between the groups (36.3% versus 33.0%, p=0.650). Two patients per group suffered from major drain-related complications (2.5% versus 2.1%).

Conclusions

PLDN without routine drainage can be performed safely without an increase in postoperative morbidity.

Management of COMPlicAted intra-abdominal collectionS after colorectal Surgery (COMPASS): protocol for a multicentre, observational, prospective international study of drain placement practices in colorectal surgery

AIM

Postoperative drains have historically been used for the prevention and early detection of intra-abdominal collections. However, current evidence suggests that prophylactic drain placement following colorectal surgery has no significant clinical benefit. This is reflected in the enhanced recovery after surgery (ERAS) guidelines, which recommend against their routine use. The Ileus Management International study found more than one-third of participating centres across the world routinely used drains in the majority of colorectal resections. The aim of the present study is to audit international compliance with ERAS guidelines regarding the use of postoperative drains in colorectal surgery.

METHOD

This prospective, multicentre audit will be conducted via the student- and trainee-led EuroSurg Collaborative network across Europe, South Africa and Australasia. Data will be collected on consecutive patients undergoing elective and emergency colorectal surgery with 30-day follow-up. This will include any colorectal resection, formation of colostomy/ileostomy and reversal of stoma. The primary end-point will be adherence to ERAS guidelines for intra-abdominal drain placement. Secondary outcomes will include the following: time to diagnosis of intra-abdominal postoperative collections; output and time to removal of drains; and 30-day postoperative complications defined by the Clavien-Dindo classification.

CONCLUSION

This protocol describes the methodology for the first international audit of intra-abdominal drain placement after colorectal surgery. The study will be conducted across a large collaborative network with quality assurance and data validation strategies. This will provide a clear understanding of current practice and novel evidence regarding the efficacy and safety of intra-abdominal drain placement in colorectal surgical patients.

Abdominal Drainage in the Prevention and Management of Major Intra-Abdominal Complications after Total Gastrectomy for Gastric Carcinoma

Purpose

The role of prophylactic abdominal drainage in total gastrectomy is not well-established. This study aimed to evaluate the efficacy of abdominal drainage in the prevention and management of major intra-abdominal complications after total gastrectomy for gastric carcinoma.

Materials and Methods

We retrospectively reviewed the data of 499 patients who underwent total gastrectomy for gastric carcinoma in a high-volume institution. The patients were divided into drainage and non-drainage groups and compared for the development and management of major intra-abdominal complications, including anastomotic leak, abdominal bleeding, abdominal infection, and pancreatic fistulas.

Results

The drainage group included 388 patients and the non-drainage group included 111 patients. The 2 groups showed no significant differences in clinicopathological characteristics or operative procedures, except for more frequent D2 lymphadenectomies in the drainage group. After surgery, the overall morbidity (drainage group vs. non-drainage group: 24.7% vs. 28.8%, P=0.385) and incidence of major intra-abdominal complications (6.4% vs. 6.3%, P=0.959) did not significantly differ between the two groups. The non-drainage group showed no significant increase in the incidence rate of major intra-abdominal complications in the subgroups divided by age, sex, comorbidity, operative approach, body mass index, extent of lymphadenectomy, and pathological stage. Abdominal drainage had no significant impact on early diagnosis, secondary intervention or reoperation, or recovery from major intra-abdominal complications.

Conclusions

Prophylactic abdominal drainage showed little demonstrable benefit in the prevention and management of major intra-abdominal complications of total gastrectomy for gastric carcinoma.

Systematic review and meta-analysis of surgical drain management after the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy: draining-tract-targeted works better than standard management

Purpose

Drains’ role after pancreaticoduodenectomy (PD) is debated by proponents of no drain, draining selected cases, and early drain removal. The aim of the study was to assess the effect of “standard” and “draining-tract-targeted” management of abdominal drains still in situ after diagnosing a postoperative pancreatic fistula (POPF).

Methods

PubMed and Scopus were searched for “pancreaticoduodenectomy or pancreatoduodenectomy or duodenopancreatectomy,” “Whipple,” “proximal pancreatectomy,” “pylorus-preserving pancreatectomy,” and “postoperative pancreatic fistula or POPF.”. Main outcomes included clinically relevant (CR) POPF, grade-C POPF, overall mortality, POPF-related mortality, and CR-POPF-related mortality. Secondary outcomes were incidence of radiological and/or endoscopic interventions, reoperations, and completion pancreatectomies.

Results

Overall, 12,089 studies were retrieved by the search of the English literature (01/01/1990–31/12/2018). Three hundred and twenty-six studies (90,321 patients) reporting ≥ 100 PDs and ≥ 10 PD/year were finally included into the study. Average incidences were obtained by averaging the incidence rates reported in the single articles. Pooled incidences were calculated by combining the number of events and the total number of patients considered in the various studies. These were then meta-analyzed using DerSimonian and Laird’s (1986) method. Pearson’s chi-squared test was used to compare pooled incidences between groups. Post hoc testing was used to see which groups differed. The meta-analyzed incidences were compared using a fixed effect for moderators. “Draining-tract-targeted” management showed a significant advantage over “standard” management in four clinically relevant outcomes out of eight according to pool analysis and in one of them according to meta-analysis.

Conclusion

Clinically, “draining-targeted” management of POPF should be preferred to “standard” management.

Electronic supplementary material

The online version of this article (10.1007/s00423-020-02005-8) contains supplementary material, which is available to authorized users.

Hospital variation in use of prophylactic drains following hepatectomy

BACKGROUND

Prophylactic drainage following hepatectomy is frequently performed despite evidence that drainage is unnecessary. It is unknown to what extent drain use is influenced by hospital practice patterns. The objectives of this study were to identify factors associated with the use of prophylactic drains following hepatectomy and assess hospital variation in drain use.

METHODS

Retrospective cohort study of patients following hepatectomy without concomitant bowel resection or biliary reconstruction from the ACS NSQIP Hepatectomy Targeted Dataset. Factors associated with the use of prophylactic drains were identified using multivariable logistic regression and hospital-level variation in drain use was assessed.

RESULTS

Analysis included 10,530 patients at 130 hospitals. Overall, 42.3% of patients had a prophylactic drain placed following hepatectomy. Patients were more likely to receive prophylactic drains if they were ≥65 years old (adjusted odds ratio [aOR]: 1.34, 95%CI: 1.16-1.56), underwent major hepatectomy (aOR: 1.42, 95%CI 1.15-1.74), or had an open resection (aOR 1.94, 95%CI 1.49-2.53). There was notable hospital variability in drain use (range: 0%-100% of patients), and 77.5% of measured variation was at the hospital level.

CONCLUSION

Prophylactic drains are commonly placed in both major and minor hepatectomy. Hospital-specific patterns appear to be a major driver and represent a target for improvement.

Early drain removal after hepatectomy: an underutilized management strategy

BACKGROUND

Recent data suggest that routine drainage is unnecessary in patients undergoing hepatectomy, but many surgeons continue to utilize drains. We compared the outcomes of patients undergoing early versus routine drain removal after hepatectomy.

METHODS

Patients having drains placed during major (≥3 segments) or partial hepatectomy (≤2 segments) were identified in the 2014-16 ACS-NSQIP database. Propensity matching between early (POD 0-3) and routine (POD 4-7) drain removal and multivariable regressions were performed.

RESULTS

Early drain removal was performed in 661 (40%) of patients undergoing a partial hepatectomy and 211 (22%) of major hepatectomy patients. After matching, 719 early and 719 routine drain removal patients were compared. Early drain removal patients had lower overall (12 vs 19%, p < 0.001) and serious (9 vs 13%, p < 0.03) morbidity as well as fewer bile leaks (2.1% vs 5.0%, p < 0.003). Length of stay was two days shorter (4 vs 6 days, p < 0.01) and readmissions were less frequent (5.4 vs 8.1%, p = 0.02) for patients undergoing early drain removal.

CONCLUSION

Early drain removal is associated with fewer overall and serious complications, shorter length of stay and fewer readmissions. Early drain removal after hepatectomy is an underutilized management strategy.

Surgical Drains After Laparoscopic Donor Nephrectomy: Needed or Not?

BACKGROUND Routine placement of prophylactic drains after laparoscopic donor nephrectomy has been suggested and has become common practice in some centers. However, there is a lack of evidence proving the surgical benefits of routine drain placement in laparoscopic donor nephrectomy. Here, we assessed the effect of surgical drain placement on recovery, length of hospital stay, and complication rates of live kidney donors. MATERIAL AND METHODS This retrospective study included all live donor nephrectomies performed at a single institution from January 2010 to January 2017. Surgeries were performed by 2 surgeons; one routinely placed a closed suction drain after LDN whereas the other did not. Patients operated on by these 2 surgeons were enrolled in either the drain or no drain group. Demographic data, preoperative and postoperative creatinine levels, estimated blood loss (EBL), surgical time, surgical complications, and length of hospital stay were compared. RESULTS The study included 272 patients. Three were converted to open donor nephrectomy and were excluded (1.1%). Among the 269 patients, 156 (57.9%) had surgical drains and 113 (42.1%) did not. Mean surgical time, estimated blood loss, and duration of hospital stay did not significantly differ between groups. Postoperative complications were encountered in 17 of the patients, but the overall complication rate did not differ between patients with vs. those without surgical drains. CONCLUSIONS There was no significant difference between the drain and no drain groups in terms of length of hospital stay, complication rates, or postoperative creatinine levels. Thus, placement of a surgical drain in the setting of an LDN is not justified based on our single-center experience.

The factors related to failure of Enhanced Recovery after Surgery (ERAS) in colon cancer surgery

PURPOSE

Enhanced Recovery after Surgery has been proven effective for patients with gastrointestinal cancer. But radical enhanced recovery could also lead to adverse clinical outcomes. Compared with reports on the estimation of successful implementation of enhanced recovery, studies on risk factors of enhanced recovery failure are still lacking.

METHODS

A retrospective analysis was carried out on 102 patients in ERAS who underwent elective colon cancer surgery. This study included 102 patients with colon cancer between 2015 and 2019, defining enhanced recovery failure as postoperative length of stay over 10 days, stay in ICU over 24 h after surgery, reoperation, death, or unplanned readmission within 30 days after surgery. Univariate and multivariate analyses were performed to explore potential risk factors of failure.

RESULTS

Aged ≥ 75, open operation, number of drainage tube over 1, re-urethral catheterization, and Clavien-Dindo grade over 2 were associated with ERAS failure, according to univariate analysis. Multivariate analysis showed that age ≥ 75 [OR 7.231; P = 0.009]; open operation (OR 3.599; P = 0.021); and number of drainage tube over 1 (OR 3.202; P = 0.020) were independent risk factors for ERAS failure.

CONCLUSIONS

We found age ≥ 75, open operation, and number of drainage tube over 1 are independent risk factors associated with ERAS failure after colon cancer surgery.

Evaluation of enhanced recovery after surgery program components implemented in laparoscopic appendectomy: prospective randomized clinical study

BACKGROUND

Laparoscopic appendectomy (LA) is a widely used surgical procedure. Patients often suffer from considerable postoperative pain and indigestion, which prolongs their in-hospital stay. Almost 10% of patients develop postoperative complications. The enhanced recovery after surgery (ERAS) program has proven its efficacy in elective surgery and could hypothetically improve LA outcomes. Currently, there is no ERAS program for LA.

METHODS

A modified ERAS (mERAS) protocol was studied in a prospective, randomized nonblinded clinical trial. The mERAS group consisted of 50 patients; the control group, of 54 patients. The mERAS protocol included a patient information brochure; minimizing drain use; local anesthesia; low-pressure pneumoperitoneum; early mobilization and oral diet. The primary outcome was postoperative length of stay (pLOS).

RESULTS

Modified protocol reduced median pLOS to 1.25 days vs 2 days in the controls (p < 0.0001). Twenty-one (42%) mERAS patients and 4 (7.4%) controls were discharged within 24 h (p < 0.001) after surgery; 0 readmissions were reported. Postoperative pain intensity assessed on the visual analogue scale was significantly lower in the mERAS group [mERAS vs control 0 h, 2 h, 6 h, 12 h and 24 h after surgery: 2.33 ± 2.12 vs 4.19 ± 2.08 (p < 0.0001), 2.27 ± 1.91 vs 4.02 ± 1.89 (p < 0.0001), 2.28 ± 1.98 vs 3.70 ± 1.57 (p = 0.0001), 1.98 ± 1.72 vs 3.43 ± 1.54 (p < 0.0001) and 1.80 ± 1.74 vs 3.00 ± 1.27 (p = 0.032), respectively)]. The severity of shoulder and neck pain was lower but its incidence was similar. Peristalsis recovery was achieved earlier in the study group (median (min-max))-mERAS 7 (2-34) h vs control 11 (3-43) h; p = 0.009) but did not affect the time of the first flatus 23 (2-72) h vs 29 (6-70) h, respectively; p = 0.499).

CONCLUSIONS

The modified ERAS program for LA has advantages over the traditional approach.

REGISTRATION

This trial was registered at ClinicalTrials.gov as NCT03754777 (27/11/2018).

What are the risk factors of failure of enhanced recovery after right colectomy? Results of a prospective study on 140 consecutive cases

PURPOSE

Nausea and vomiting is the main cause of failure of enhanced recovery protocol (ERP) after right hemicolectomy.

METHODS

From January 2013 to January 2018, all patients undergoing right hemicolectomy were prospectively included. Patients undergoing emergency surgery, additional complex procedure or temporary stoma, nasogastric tube (NGT) maintenance, or abdominal drainage were excluded. Failure of ERP was defined as nausea/vomiting precluding oral feeding after POD3 and/or the occurrence of postoperative ileus requiring NGT and/or length of stay (LOS) ≥ 8 days except for patients awaiting admission in rehabilitation unit. Risk factors of failure of ERP were identified using univariate and multivariate analysis.

RESULTS

Among 306 patients undergoing right hemicolectomy, 140 fulfilled the inclusion criteria. Postoperative morbidity was 31%, and the mortality rate was nil. The mean postoperative hospital stay was 7 days (range 2-30). Successful ERP was achieved in 83 patients (59%). Causes of failure were major nausea/vomiting precluding oral feeding after POD3 in 36, postoperative ileus requiring NGT in 16 and LOS ≥ 8 days in 36. On multivariate analysis, preoperative anemia (OR 5.2; CI 95%, 1.3-21.1, p = 0.02) and platelet anti-aggregant/anti-coagulant (OR 4.5; CI 95%, 1.7-12.1, p = 0.003) were associated with the risk of failure of ERP.

CONCLUSION

This study shows that anemia and medication with antiplatelet/anticoagulation therapy increase the risk of failure of ERP after right hemicolectomy that translates most of the time by nausea/vomiting and postoperative ileus. The presence of these factors should lead to adapt the strategy to improve outcome rather than be considered as contraindication to ERP.

Article Commentary: Evolving Colon Injury Management: A Review

The colon is the second most commonly injured intra-abdominal organ in penetrating trauma. Management of traumatic colon injuries has evolved significantly over the past 200 years. Traumatic colon injuries can have a wide spectrum of severity, presentation, and management options. There is strong evidence that most non-destructive colon injuries can be successfully managed with primary repair or primary anastomosis. The management of destructive colon injuries remains controversial with most favoring resection with primary anastomosis and others favor colonic diversion in specific circumstances. The historical management of traumatic colon injuries, common mechanisms of injury, demographics, presentation, assessment, diagnosis, management, and complications of traumatic colon injuries both in civilian and military practice are reviewed. The damage control revolution has added another layer of complexity to management with continued controversy.

ERAS in minimally invasive hepatectomy

Open hepatectomy is associated with significant post-operative morbidity and mortality profile. The use of minimally invasive approach for hepatectomy can reduce the post-operative complication profile and total length of hospital stay. Enhanced recovery after surgery (ERAS) programs involve evidence-based multimodal care pathways designed to achieve early recovery for patients undergoing major surgery. This review will discuss the published evidence, challenges and future directions for ERAS in minimally invasive hepatectomy.

Comparison of laparoscopic cholecystectomy with and without abdominal drainage in patients with non-complicated benign gallbladder disease: A protocol for systematic review and meta analysis

OBJECTIVE

To evaluate whether conventional postoperative drainage is more effective than not providing drainage in patients with non-complicated benign gallbladder disease following laparoscopic cholecystectomy (LC).

METHODS

A search of the electronic databases MEDLINE, EMBASE, Web of science, Cochrane Library, and Chinese Biomedical Database (CBM) was conducted for randomized controlled trials (RCTs) reporting outcomes of LC surgery with and without an abdominal drain.

RESULTS

Twenty-one RCTs involving 3246 patients (1666 with drains vs 1580 without) were included in the meta-analysis. There were no statistically significant differences in the rates of incidence of intra-abdominal fluid (RR: 1.10; 95% CI: 0.81-1.49; P = .54) or post-surgical mortality (RR: 0.44; 95% CI: 0.04-4.72; P = .50) between the two groups. Abdominal drains did not reduce the overall incidence of nausea and vomiting (RR: 1.16; 95% CI: 0.95-1.42; P = .15) or shoulder tip pain (RR: 1.03; 95% CI: 0.76-1.38; P = .86). The abdominal drain group displayed significantly higher pain scores (MD: 1.07; 95% CI: 0.69-1.46; P < .001) than the non-drainage patients. Abdominal drains prolonged the duration of the surgical procedure (MD: 5.69 min; 95% CI: 2.51-8.87; P = .005) and postoperative hospital stay (MD: 0.47 day; 95% CI: 0.14-0.80; P = .005). Wound infection was found to be associated with the use of abdominal drains (RR: 1.97; 95% CI: 1.11-3.47; P = .02).

CONCLUSIONS

Currently, there is no evidence to support the use of routine drainage after LC in non-complicated benign gallbladder disease. Further well-designed randomized clinical trials are required to confirm this finding.

[Still no evidence for drains in bariatric surgery]

BACKGROUND

Registry data show that placement of a drain during bariatric surgery is still the normal practice in many surgical departments. Retrospective studies and a review article could show that the routine placement of a drain in bariatric surgery is useless and also potentially dangerous. Due to the lack of randomized controlled studies there is insufficient evidence on this topic in the literature.

OBJECTIVE

In order to further question the use of drains in bariatric interventions, the prospective in-house databank of patients who received a gastric sleeve (SG) or a Roux-en‑Y gastric bypass (RYGB) between January 2010 and June 2016 was retrospectively evaluated.

SETTING

A German university hospital.

METHODS

During the investigation period a total of 361 operations (219 gastric bypasses and 142 gastric sleeve operations) were carried out. A change in the internal treatment pathway with respect to the placement of drains in 2013 led to the formation of two groups: one where a drain was routinely placed in operations (n = 166) and a second group where a drain was not routinely placed (n = 195). The demographic data were statistically adjusted between the two groups using multiple regression analysis. The results of the operation and the 30-day morbidity were compared. Complications were evaluated according to the Clavien-Dindo classification.

RESULTS

In the group with no drain, complications occurred in seven patients. In the group with drainage there were 6 complications. The insufficiency and reoperation rates were not statistically significantly different between the two groups. The average postoperative hospital stay was 1.3 days longer in patients with a drain. Multivariate analysis showed that the placement of a drain was the greatest risk factor for a longer hospital stay.

CONCLUSION

Placement of a drain during bariatric interventions should only be considered on an individual basis. The routine placement should be discouraged.

Enhanced recovery after surgery for gastric cancer (ERAS-GC): optimizing patient outcome

Significant advances were achieved, in last decades, in the management of surgical patients with gastric cancer. This has led to the concept of enhanced recovery after surgery (ERAS) with the objective of reducing the length of hospital stay, accelerating postoperative recovery and reducing the surgical stress. The ERAS protocols have many items, including the pre-operative patient education, early mobilization and feeding starting from the first postoperative day. This review aims to highlight possible advantages on postoperative functional recovery outcomes after gastrectomy in patients undergoing an ERAS program, current lack of evidences and future perspectives.

Single-Port Laparoscopic Repair of Perforated Duodenal Ulcers

BACKGROUND

Laparoscopic single-port surgery has widely been introduced for the treatment of various abdominal conditions. But controversies still exist regarding its potential advantages and risks, especially for emergency surgery. The aim of this study was to evaluate the results of a single-port laparoscopic repair using straight laparoscopic instruments for the treatment of perforated duodenal ulcers.

METHODS

A prospective consecutive case series was conducted including all patients with a perforated duodenal ulcer who underwent a laparoscopic single-port repair at a single institution from January 2012 to June 2018. The operation was performed through a single port using conventional straight laparoscopic instruments and intra-corporeal knot tying techniques.

RESULTS

Out of 75 patients, simple closure of the perforation without omental patch was accomplished in 96% of cases. Conversion to an open operation was required in one patient (1.3%) due to a posterior duodenal perforation, and additional trocar placement was needed in another patient (1.3%). The mean incision length was 2.0 ± 0.2 cm. The mean operation time was 63.0 ± 26.6 min. Meantime a nasogastric tube remained in place was 2.9 ± 0.8 days. Mean duration of analgesic use was 2.8 ± 0.8 days. The rate of postoperative complications was 2.7%, including two patients with wound infections. There were no instances of intestinal leak or abscess. The postoperative hospital stay was 5.7 ± 1.2 days.

CONCLUSION

Laparoscopic single-port repair using conventional straight laparoscopic instruments with intra-corporeal knot tying technique was safe and feasible for patients with perforated duodenal ulcers with low risk factors. This method offers results comparable to those expected with the standard multiport laparoscopic approach with the addition of improved cosmetic outcomes.

Drain in laparoscopic cholecystectomy in acute calculous cholecystitis: a randomised controlled study

BACKGROUND

There is paucity of evidence regarding the role of drain in laparoscopic cholecystectomy (LC) in acute calculous cholecystitis (ACC), and surgeons have placed the drains based on their experiences, not on evidence-based guidelines. This study aims to assess the value of drain in LC for ACC in a randomised controlled prospective study.

PATIENTS AND METHODS

All patients with mild and moderate ACC undergoing LC were assessed. Preoperatively, patients with choledocholithiasis, Mirizzi syndrome and biliary stent were excluded. Intraoperatively or postoperatively, patients with complications, partial cholecystectomies and malignancies were excluded. Patients were randomised using computer-generated random numbers into two groups at the end of cholecystectomy before closure. Requirement of radiologically guided (ultrasonography () or CT) percutaneous aspiration/drainage of symptomatic intra-abdominal collection or reoperation; continuation of parenteral antibiotics beyond 24 hours or change in antibiotics empirically or based on peritoneal fluid culture sensitivity; requirement of postoperative USG or CT scan based on postoperative clinical course; wound infection rates; postoperative pain using numeric rating scale at 6 and 24 hours; and the duration of hospital stay in both groups were noted.

RESULTS

Forty-two out of 50 consecutive patients were randomised into two equal groups. Pain score at 6 and 24 hours was less in patients without drain. All other complication rates and duration of stay were similar in both groups.

CONCLUSIONS

Drains should not be placed routinely after LC in ACC as it increases pain and does not help in detecting or decreasing complications.

The use of intra-abdominal drain in minimally invasive right colectomy: a propensity score matched analysis on postoperative outcomes

PURPOSE

No evidences supporting or not the use of intra-abdominal drain (AD) in minimally invasive right colectomies have been published. This study aims to assess the outcomes on its use after robotic or laparoscopic right colectomies.

METHODS

This is a multicenter propensity score matched study including patients who underwent minimally invasive right colectomy with (AD group) or without (no-AD group) the use of AD between February 1, 2007, and January 31, 2018. AD patients were matched to no-AD patients in a 1:1 ratio. Main outcomes were postoperative morbidity and mortality and anastomotic leak.

RESULTS

A total of 653 patients were included. Of 149 (22.8%) no-AD patients, 124 could be matched. The rate of postoperative complications (AD n = 26, 21% vs. no-AD n = 26, 21%; p = 1.000), mortality (AD n = 2, 1.6% vs. no-AD n = 1, 0.8%; p = 1.000), anastomotic leak (AD n = 2, 1.6% vs. no-AD n = 5, 4.0%; p = 0.453), and wound infection (AD n = 9, 7.3% vs. no-AD n = 6, 4.8%; p = 0.581) did not significantly differ between the groups. Time to oral feeding was significantly shorter in the no-AD group [2 (1-3) vs. 3 (2-3), p = 0.0001]. The median length of hospital stay was 8 (IQR 7-9) in the AD group while it was 6 (IQR 5-9) in the no-AD group (p = 0.010).

CONCLUSIONS

In conclusion, the use of AD after minimally invasive right colectomies has no influence on postoperative morbidity and mortality rates.

Bowel and Bladder Injury Repair and Follow-up After Gynecologic Surgery

Bowel and bladder injuries are relatively rare, but there can be serious complications of both open and minimally invasive gynecologic procedures. As with most surgical complications, timely recognition is key in minimizing serious patient morbidity and mortality. Diagnosis of such injuries requires careful attention to surgical entry and dissection techniques and employment of adjuvant diagnostic modalities. Repair of bowel and bladder may be performed robotically, laparoscopically, or using laparotomy. Repair of these injuries requires knowledge of anatomic layers and suture materials and testing to ensure that intact and safe repair has been achieved. The participation of consultants is encouraged depending on the primary surgeon's skill and expertise. Postoperative care after bowel or bladder injury requires surveillance for complications including repair site leak, abscess, and fistula formation.

Association Between Compliance to an Enhanced Recovery Protocol and Outcome After Elective Surgery for Gastric Cancer. Results from a Western Population-Based Prospective Multicenter Study

BACKGROUND

The association between compliance to an enhanced recovery protocol (ERAS) and outcome after surgery for gastric cancer has been poorly investigated, particularly in Western patients. The aim of the study was to evaluate whether the rate of adherence to the ERAS program was correlated with outcome and time of discharge.

METHODS

A prospective, observational, multicenter study was designed to be performed at Italian referral centers for gastric surgery. The protocol was discussed and approved by the Italian Research Group on Gastric Cancer. Twenty-three ERAS domains were applied. A multivariate logistic regression was used to assess the association between ERAS compliance and overall and major complication rates. The Poisson regression model (measured as mean ratios) was used to assess the association of ERAS compliance rate and length of stay (LOS).

RESULTS

Eight centers participated and 290 subjects with a median age of 73 years were enrolled. The overall rates of adherence to pre-, intra-, and postoperative ERAS items were 69.8%, 60.3%, and 82.5%, respectively. At the multivariate model, there was an association between overall rate of morbidity and an overall ERAS compliance rate greater than 70% (OR 0.413; 95% CI 0.235-0.7240; P 0.002). A similar association was found for major complications (OR 0.328; 95% CI 0.151-0.709; P 0.005). The Poisson regression showed that in patients with ERAS compliance rate >70%, LOS was reduced of approximately 20% (mean ratio 0.812; 95% CI 0.694-0.950; P 0.009).

CONCLUSIONS

These results suggest a moderate compliance to an ERAS program and a significant association between adherence and outcomes.

The effect on morbidity of the use of prophylactic abdominal drain following elective laparoscopic cholecystectomy

Background and Objective

To evaluate the clinical role of the routine use of a drain in an elective laparoscopic cholecystectomy operation applied to patients with symptomatic cholelithiasis not showing acute inflammation.

Method

Following laparoscopic removal of the gallbladder, patients were separated into two groups of 30 each, either with subhepatic drain placement or without. The presence of subhepatic fluid collection was evaluated with transabdominal ultrasonography (USG) at 24 hours postoperatively and on the 7th day. The other parameters evaluated were postoperative morbidity, shoulder and abdominal pain.

Results

No statistically significant difference was found between the two groups in respect of demographic characteristics and operative details. The median pain score was determined to be statistically significantly higher in the group with a drain applied compared to the group without a drain (p=0.007). In the comparison between the groups of fluid collection on USG at 24 hours and shoulder pain persisting until the 7th day, although seen less in the group with no drain applied, no statistically significant difference was determined (p=0.065, p=0.159). In the examinations made on the 7th day, no hematoma or significant fluid collection was determined on USG and no wound infection was observed in any patient of either group.

Conclusion

The routine application of prophylactic subhepatic drain in laparoscopic cholecystectomy procedure did not show any benefit to the patient.

Preventive strategies for anastomotic leakage after colorectal resections: A review

Anastomosis is a crucial step in radical cancer surgery. Despite being a daily practice in gastrointestinal surgery, anastomotic leakage (AL) stands as a frequent postoperative complication. Because of increased morbidity, mortality, combined with longer hospital stay, the rate of re-intervention, and poor oncological outcomes, AL is considered the most feared and life-threatening complication after colorectal resections. Furthermore, poor functional outcomes with a higher rate of a permeant stoma in 56% of patients this could negatively affect the patient’s quality of life. This a narrative review which will cover intraoperative anastomotic integrity assessment and preventive measures in order to reduce AL. Although the most important prerequisites for the creation of anastomosis is well-perfused and tension-free anastomosis, surgeons have proposed several preventive measures, which were assumed to reduce the incidence of AL, including antibiotic prophylaxis, intraoperative air leak test, omental pedicle flap, defunctioning stoma, pelvic drain insertion, stapled anastomosis, and general surgical technique. However, lack of clear evidence of which preventive measures is superior over the other combined with the fact that the decision remains based on the surgeon’s choice. Despite the advances in surgical techniques, AL remains a serious health problem associated with increased morbidity, mortality with additional cost. Many preventative measures were employed with no clear evidence supporting the superiority of stapled anastomosis over hand-Sewn anastomosis, coating of the anastomosis, or pelvic drain. Defunctioning stoma, when justified it could decrease the leakage-related complications and the incidence of reoperation. MBP combined with oral antibiotics still recommended.

Laparoscopic gastrectomy with and without prophylactic drains in gastric cancer: a propensity score-matched analysis

BACKGROUND

The number of patients who are undergoing laparoscopic gastrectomy for treating gastric cancer is increasing. Although prophylactic drains have been widely employed following the procedure, there are few studies reporting the efficacy of prophylactic drainage. Therefore, this study assessed the efficacy of prophylactic drains following laparoscopic gastrectomy for gastric cancer.

METHODS

Data of patients who received laparoscopic gastrectomy for treating gastric cancer in our institution between April 2011 and March 2017 were reviewed, and the outcomes of patients with and without a prophylactic drainage were compared. Propensity score matching was used to minimize potential selection bias.

RESULTS

A total of 779 patients who underwent surgery for gastric cancer were reviewed; of these, 628 patients who received elective laparoscopic gastrectomy were included in this study. After propensity score matching, data of 145 pairs of patients were extracted. No significant differences were noted in the incidence of postoperative complications between the drain and no-drain groups (19.3% vs 11.0%, P = 0.071). The days after the surgery until the initiation of soft diet (6.3 ± 7.4 vs 4.9 ± 2.9 days, P = 0.036) and the length of postoperative hospital stay (15.7 ± 12.9 vs 13.0 ± 6.3 days, P = 0.023) were greater in the drain group than those in the no-drain group.

CONCLUSIONS

This study suggests that routinely using prophylactic drainage following laparoscopic gastrectomy for treating gastric cancer is not obligatory.

In vivo validation of a miniaturized electrochemical oxygen sensor for measuring intestinal oxygen tension

Recent advances in the fields of electronics and microfabrication techniques have led to the development of implantable medical devices for use within the field of precision medicine. Monitoring visceral surface tissue O₂ tension (PTo2) by means of an implantable sensor is potentially useful in many clinical situations, including the perioperative management of patients undergoing intestinal resection and anastomosis. This concept could provide a means by which treatment could be tailored to individual patients. This study describes the in vivo validation of a novel, miniaturized electrochemical O₂ sensor to provide real-time data on intestinal PTo2. A single O₂ sensor was placed onto the serosal surface of the small intestine of anesthetized rats that were exposed to ischemic (superior mesenteric artery occlusion) and hypoxemic (alterations in inspired fractional O₂ concentrations) insults. Control experiments demonstrated that the sensors can function and remain stable in an in vivo environment. Intestinal PTo2 decreased following superior mesenteric artery occlusion and with reductions in inspired O₂ concentrations. These results were reversible after reinstating blood flow or by increasing inspired O₂ concentrations. We have successfully developed an anesthetized rat intestinal ischemic and hypoxic model for validation of a miniaturized O₂ sensor to provide real-time measurement of intestinal PTo2. Our results support further validation of the sensors in physiological conditions using a large animal model to provide evidence of their use in clinical applications where monitoring visceral surface tissue O₂ tension is important.NEW & NOTEWORTHY This is the first report of real-time continuous measurements of intestinal oxygen tension made using a microfabricated O₂ sensor. Using a developed rodent model, we have validated this sensor's ability to accurately measure dynamic and reversible changes in intestinal oxygenation that occur through ischemic and hypoxemic insults. Continuous monitoring of local intestinal oxygenation could have value in the postoperative monitoring of patients having undergone intestinal surgery.

Prophylactic Wound Drainage in Renal Transplantation: A Systematic Review

Background

Adult kidney transplantation is most commonly into an extraperitoneal potential space, and surgically placed drains are used routinely in many centers. There is limited evidence of clinical benefit for prophylactic drainage in other major abdominal and vascular surgery. Transplantation is, however, a unique setting combining organ dysfunction and immunosuppression, and the risks and benefits of prophylactic drain placement are not known. This study attempts to examine existing literature to determine whether prophylactic intraoperative drains have an impact on the likelihood of perigraft fluid collections and other wound-related complications following kidney transplantation.

Methods

A literature search of MEDLINE and EMBASE was conducted to identify published comparative studies, including recipients receiving prophylactic drains to recipients in whom drains were omitted. The main outcomes were the incidence of peritransplant fluid collections and wound-related complications. Meta-analysis was performed on these data.

Results

Four retrospective cohort studies were deemed eligible for quantitative analysis and 1 additional conference abstract was included in qualitative discussion. A total of 1640 patients, 1023 with drains and 617 without, were included in the meta-analysis. There was a lower rate of peritransplant collections associated with the drain group (RR 0.62; 95% confidence interval, 0.42-0.90). There was no significant difference in the incidence of wound-related complications between the groups (RR 0.85; 95% confidence interval, 0.34-2.11).

Conclusions

These data associate a higher rate of peritransplant fluid collections with omission of prophylactic drainage, without a difference in the incidence of wound-related complications. Further research is required to definitively determine the impact of drains in this patient group.

When a Drain is the Culprit: An Unexpected Case of Small Bowel Obstruction with Biliary Peritonitis

Although postoperative abdominal drains are useful in therapeutic settings, their prophylactic role is debatable. We herein describe the case of a 30-year-old male who underwent bile duct resection with hepaticojejunostomy for cholangiocarcinoma. On postoperative day four, the patient developed biliary peritonitis. Explorative laparotomy revealed an obstruction of the afferent limb caused by an intestinal loop around a Jackson-Pratt (JP) drain. Removal of the drain resolved the obstruction which led to a significant improvement of the patient’s clinical state. To the best of our knowledge, this is the second report of a bowel obstruction from a surgical drain. When placing abdominal drains, surgeons must take into consideration their indication as well as possible related complications, including intestinal obstruction. 

Impact of Drain Placement and Duration on Outcomes After Pancreaticoduodenectomy: A National Surgical Quality Improvement Program Analysis

BACKGROUND

The decisions to routinely place a drain after pancreaticoduodenectomy and how long to leave the drain remain controversial due to conflicting evidence and significant variations in clinical practice. This study aims to address those questions by using a large national database and a rigorous analytical model.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program 2015-2016 Pancreatectomy Participant Use Data Files were used to identify patients who had undergone pancreaticoduodenectomy (n = 7583). Univariable and multivariable binomial regression analyses were performed to control for potential confounders and various preoperative risk factors. Cox regression with drain as a time-dependent covariate, conditional on having a drain placed, was used to examine the association between the drain remaining in place and morbidities.

RESULTS

Of 7583 patients, drains were placed in 6666 (87.9%). Drain placement decreased the risk of developing serious morbidity (relative risk [RR] 0.73, 95% confidence interval [CI] 0.65-0.82), overall morbidity (RR 0.79, 95% CI 0.72-0.87), and organ space surgical site infection (RR 0.72, 95% CI 0.61-0.85). Drain placement did not change the risk of developing a clinically relevant postoperative pancreatic fistula (RR 0.96, 95% CI 0.78-1.19). However, for those with drains placed, length of drainage was independently associated with serious morbidity (hazard ratio [HR] 3.06, 95% CI 2.65-3.53), overall morbidity (HR 2.48, 95% CI 2.20-2.80), and organ space surgical site infection (HR 1.47, 95% CI 1.23-1.74).

CONCLUSIONS

Routine drain placement following pancreaticoduodenectomy may decrease postoperative complications, including serious morbidity, overall morbidity, and organ space surgical site infections; however, length of drainage was associated with increased risk of the previously-named complications. These results support the routine placement and early removal of intraoperative surgical drains in pancreaticoduodenectomy.

Is a drain necessary after anterior resection of the rectum? A systematic review and meta-analysis

OBJECTIVE

The anastomotic leak rate in colorectal surgery is highest in patients receiving anterior rectal resections. The placement of prophylactic pelvic drains remains a routine option for preventing postoperative leaks, despite increasing evidence suggesting no clinical benefit. The present study seeks to identify a consensus on the use of prophylactic drains in anterior rectal resections.

METHODS

A systematic search was conducted of MEDLINE, Scopus, EMBASE, and Cochrane Library databases to identify clinical trials comparing the use of drainage to non-drainage in cases of colorectal anastomosis.

RESULTS

Three randomized clinical trials (RCTs) and two controlled clinical trials (CCTs) were identified that met the inclusion criteria, with a total of 1702 patients with rectal cancer who underwent anterior resection: 1206 with a pelvic drain and 496 without a pelvic drain. Meta-analysis showed that the use of a drain did not significantly improve the outcomes of anastomotic leaks; the overall reoperation rate during the 30-day postoperative period and the postoperative mortality were statistically lower in the drained group (OR 2.82, 95% CI 1.33 to 5.97; I2 = 0%).

CONCLUSIONS

The use of prophylactic pelvic drainage after anterior rectal resections does not provide significant benefits with respect to anastomotic leaks and overall complication rates. However, an approximately threefold reduction of the postoperative mortality of the drained patients was observed. Given the limitations of the present study, these findings warrant the use of a drain after anterior rectal resection. Nevertheless, due to the low quality of the available data, further multicenter trials with uniform inclusion criteria are needed to evaluate drain usage in the anterior rectal resection.

[Comparison of standard and fast track rehabilitation in patients with acute appendicitis. Intermediate results of multicenter prospective randomized trial]

AIM

To analyze outcomes of fast track rehabilitation in patients with acute appendicitis.

MATERIAL AND METHODS

Prospective, randomized multi-center trial including 86 patients was conducted. There were 38 patients in the main group and 48 in the control group. All patients underwent laparoscopic appendectomy under endotracheal anesthesia. Protocol included informing, no premedication, glucose infusion prior to surgery, antibiotics administration, mesoappendix excision, limited deployment of drainage tubes, intraabdominal prolonged anesthesia, minimal pneumoperitoneum, limited irrigation, minimum power monopolar electrocautery, antiemetics, early activation and eating (2 and 6 hours after surgery). Pain was evaluated by visual-analogue scale. Auscultative peristalsis was considered every 2 hours after surgery. Cortisol level was assessed preoperatively, in 6 and 12-24 hours after surgery in 11 (29%) and 15 (31%) patients of the main and control groups respectively. Discharge criteria: no leukocytosis, fever and pain syndrome requiring anesthesia, no signs of complications and patient's consent.

RESULTS

Terms of disease, gender, age and comorbidities were similar in all patients. Duration of surgery under minimal pneumoperitoneum and standard pressure was also similar: 69.2±3.98 and 70.9±3.89 min (p=0.762). Pain syndrome grade and need for analgesics were significantly lower in the main group within entire follow-up. Pain syndrome was absent at the 1^st postoperative day in 16 (42%) and 2 (4.1%) patients of both groups, respectively (score 0-1). Phrenic nerve syndrome was observed in 36.8% of the main group and 60.4% of the control group (p=0.05). Incidence of dyspepsia and terms of peristalsis onset were similar. Length of hospital-stay was 1.45 days in the main group and 3.15 days in the control group (p=0.002). In the main group 18 (47%) patients were discharged on the first day after surgery. There were only 4 (8.3%) patients with similar hospital-stay in the control group (p<0.001). There were no repeated hospitalizations. Postoperative cortisol concentration was similar in both groups as well as in complicated and uneventful postoperative period. In the main group postoperative intestinal paresis (Clavien-Dindo grade 2) occurred in 1 patient. In the control group 7 patients had postoperative infiltrate and 1 patient - intestinal paresis (Clavien-Dindo grade 2). Postoperative drainage tube was deployed in 3 out of 7 patients with postoperative infiltrates and 6 of them received antibiotic therapy. Medication was successfully applied in all patients with complications.

CONCLUSION

There are some advantages of FTR for AA including reduced pain syndrome, morbidity and less length of hospital-stay. Issue of cortisol concentration requires further trials.

Technical Aspects of Orthotopic Liver Transplantation-a Survey-Based Study Within the Eurotransplant, Swisstransplant, Scandiatransplant, and British Transplantation Society Networks

BACKGROUND

Orthotopic liver transplantation (OLT) has emerged as the mainstay of treatment for end-stage liver disease. However, technical aspects of OLT are still subject of ongoing debate and are widely based on personal experience and local institutional protocols.

METHODS

An international online survey was sent out to all liver transplant centers (n = 52) within the Eurotransplant, Swisstransplant, Scandiatransplant, and British Transplant Society networks. The survey sought information on center-specific OLT caseload, vascular and biliary reconstruction, graft reperfusion, intraoperative control of hemodynamics, and drain policies.

RESULTS

Forty-two centers gave a valid response (81%). Out of these, 50% reported piggy-back and 40.5% total caval replacement as their standard technique. While 48% of all centers generally do not apply veno-venous bypass (vvBP) or temporary portocaval shunt (PCS) during OLT, vvBP/PCS are routinely used in six centers (14%). Portal vein first reperfusion is used in 64%, followed by simultaneous (17%), and retrograde reperfusion (12%). End-to-end duct-to-duct anastomosis without biliary drain (67%) is the most frequently performed method of biliary reconstruction. No significant associations were found between the center caseload and the surgical approach used. The predominant part of the centers (88%) stated that techniques of OLT are not evidence-based and 98% would participate in multicenter clinical trials on these topics.

CONCLUSION

Technical aspects of OLT vary widely among European centers. The extent to which center-specific variation of techniques affect transplant outcomes in Europe should be elucidated further in prospective multicenter trials.

IMPLEMENTATION OF ENHANCED RECOVERY AFTER COLORECTAL SURGERY (ERAS) PROTOCOL: INITIAL RESULTS OF THE FIRST BRAZILIAN EXPERIENCE

BACKGROUND

Guidelines for enhanced recovery after surgery have their bases in colonic surgery, through the first protocols published in 2012. Since then, this practice has spread throughout the world, mainly due to improvements in surgical outcomes associated with resource savings.

AIM

To analyze the first prospective results after the implementation of the guidelines.

METHODS

Were retrospectively analyzed 48 patients operated in the institution prior to the standardization. This group was then compared with a series of 25 patients operated consecutively after the guidelines were implemented.

RESULTS

With a 68.6% compliance rate, hospital length of stay (p=0.002), use of abdominal drains (p<0.001) and mechanical bowel preparation (p<0.001) were reduced. Mortality rates, anastomotic fistula, abdominal abscesses and reoperations were also reduced, but without statistical significance.

CONCLUSION

Enhanced recovery after surgery protocols benefit patients care, resulting in better outcomes and possibly resource savings. Even with some limitations, its implementation is feasible in the Brazilian Public Health System.

ENHANCED RECOVERY (ERAS) AFTER LIVER SURGERY:COMPARATIVE STUDY IN A BRAZILIAN TERCIARY CENTER

BACKGROUND

After the publication of the first recommendations of ERAS Society regarding colonic surgery, the proposal of surgical stress reduction, maintenance of physiological functions and optimized recovery was expanded to other surgical specialties, with minimal variations.

AIM

To analyze the implementation of ERAS protocols for liver surgery in a tertiary center.

METHODS

Fifty patients that underwent elective hepatic surgery were retrospectively evaluated, using medical records data, from June 2014 to August 2016. After September 2016, 35 patients were prospectively evaluated and managed in accordance with ERAS protocol.

RESULTS

There was no difference in age, type of hepatectomy, laparoscopic surgery and postoperative complications between the groups. In ERAS group, it was observed a reduction in preoperative fasting and in the length of hospital stay by two days (p< 0.001). Carbohydrate loading, j-shaped incision, early oral feeding, postoperative prevention of nausea and vomiting and early mobilization were also significantly related to ERAS group. Oral bowel preparation, pre-anesthetic medication, sub-costal incision, prophylactic nasogastric intubation and abdominal drainage were more common in control group.

CONCLUSION

Implementation of ERAS protocol is feasible and beneficial for health institutions and patients, without increasing morbidity and mortality.

Tactics to Prevent Intra-Abdominal Infections in General Surgery

BACKGROUND

Abdominal infections following surgery have many severe consequences. Several effective, well-evaluated infection prevention and control processes exist to avoid these infections.

METHODS

This manuscript reviews and provides supporting evidence for common management strategies useful to avoid postoperative abdominal infection.

RESULTS

Prevention of abdominal infection begins with preparation of the environment using standard infection control practices. Peri-operative use of systemic antibiotics, an antibiotic bowel preparation in colorectal surgery, and effective antiseptic preparation of the surgical site all reduce infection rates. Peri-operative supplemental oxygenation, maintenance of core body temperature, and physiologic euglycemia will reduce both incisional and organ-space infections in the abdominal surgery patient. Strategic use of irrigation and drain placement may be useful in some circumstances.

CONCLUSION

Specific methods of prevention are documented to reduce intra-abdominal infections. Prevention requires a multi-disciplinary team including the surgeon, anesthesiologist, and all operating room personnel.

Drainage versus No Drainage after Laparoscopic Cholecystectomy for Acute Cholecystitis: A Meta-Analysis

To conduct a randomized controlled trial (RCT), meta-analysis to assess the effectiveness of drains in reducing complications after laparoscopic cholecystectomy (LC) for acute cholecystitis needs to be carried out. An electronic search of PubMed, Embase, Science Citation Index, and the Cochrane Library from January 1990 to January 2018 was performed to identify randomized clinical trials that compare prophylactic drainage with no drainage in LC for acute cholecystitis. The outcomes were calculated as odds ratios (ORs) with 95 per cent confidence intervals (CIs) using RevMan 5.2. Four RCTs, which included 796 patients, were identified for analysis in our study. There was no statistically significant difference in the rate of morbidities (OR = 1.23, 95% CI 0.55-2.76, P = 0.61). Abdominal pain was more severe in the drain group 24 hours after surgery (mean difference = 0.80, 95% CI 0.47-1.14; P < 0.00001). No significant difference was present with respect to wound infection rate and hospital stay. The use of abdominal drainage does not appear to be of any benefit in patients having undergone early LC for acute cholecystitis.

[Evolution of enhanced recovery after surgery: from the beginning of the study of stress to the introduction in emergency surgery]

Effectiveness of enhanced recovery program is being earnestly confirmed in various surgical areas. Certain aspects of fast track rehabilitation are analyzed in the article.

Is abdominal drainage after open emergency appendectomy for complicated appendicitis beneficial or waste of money? A single centre retrospective cohort study

Background

Appendicitis is a medical condition that causes painful inflammation of the appendix. For acute appendicitis, appendectomy is immediately required as any delay may lead to serious complications such as gangrenous or perforated appendicitis with or without localized abscess formation. Patients who had appendectomy for complicated appendicitis are more prone to develop post-operative complications such as peritoneal abscess or wound infection. Sometimes, abdominal drainage is used to reduce these complications. However, the advantage of the abdominal drainage to minimize post-operative complications is not clear. Therefore, the aim of this study was to investigate whether the use of abdominal drainage after open emergency appendectomy for complicated appendicitis (perforated appendicitis with localized abscess formation only) can prevent or significantly reduce post-operative complications such as intra-peritoneal abscess formation or wound infection.

Methods

In this retrospective cohort study, files and notes were reviewed retrospectively for patients who had open emergency appendectomy for complicated appendicitis (perforated appendicitis with localized abscess formation only) and who had already been admitted and discharged from the surgical wards of Kerbala medical university/Imam Hussein medical city hospital/Kerbala/Iraq. Patients were selected according to specific inclusion and exclusion criteria. Patients were divided into two groups; drainage and non-drainage groups. The drainage group had intra-abdominal drain inserted after the surgery, while the non-drainage group had no drain placed post-operatively. A comparison between both groups was done in terms of these parameters; (i) the development of post operative intra-peritoneal abscess and or wound infection. (ii) The length and cost of hospital stay. (iii) The mortality outcomes. Statistical analysis was done using Pearson Chi-square test, Independent sample t-test and Mann-Whitney U Test.

Results

Of 227 patients with open emergency appendectomy for complicated appendicitis, 114 had received abdominal drain after the surgery. Fifty out of 114 patients (43.9%) with abdominal drainage developed post-operative intra-peritoneal abscess (abdominal or pelvic) while 53 out of 113 patients (46.9%) without drainage developed the same complication (P = 0.65). It was also revealed that for patients with drainage, 42 patients (36.8%) had post-operative wound infection, whereas this number was 38 (33.6%) for patients without drainage (P = 0.61). On the other hand, the patients with drain had significantly longer length of hospital stay (mean length of stay: 4.99 days versus 2.12 days, P < 0.001) and significantly higher cost (median cost per patient: $120 versus $60, P < 0.001).

Conclusion

Installation of abdominal drainage after open emergency appendectomy for complicated appendicitis did not bring any considerable advantage in terms of prevention or significant reduction of post-operative intra-peritoneal abscess and wound infection. Rather, it lengthened the hospital stay and doubled the cost of operation.

•

The use of abdominal drain after open appendectomy for complicated appendicitis does not bring any considerable advantage in terms of prevention or significant reduction of post-operative intra-peritoneal abscess and wound infection.

•

Insertion of drain lengthens hospital stay and doubles the cost of operation.

•

No mortality complications had been identified in both drain and non drain groups.

Two-point measurement of amylase in drainage fluid predicts severe postoperative pancreatic fistula after gastric cancer surgery

BACKGROUND

Early identification of patients at risk of postoperative pancreatic fistula (POPF) allows appropriate management after gastrectomy. Although some reports have suggested a correlation between POPF and the concentration of amylase in drained abdominal fluid (D-AMY), this has not been proven to impact sufficiently on clinical decision-making. A sustained high level of D-AMY is often assumed to be due to unsatisfactory drainage or excessive pancreatic leakage. We assessed the clinical utility of measuring D-AMY on postoperative day (POD) 1 and POD3 for prediction of POPF.

METHODS

Starting in April 2014, 801 patients who underwent radical gastrectomy with prophylactic drain placement were consecutively enrolled. We routinely measured D-AMY on POD1 and POD3, and compared the incidence of problematic POPF and clinical factors including D-AMY. We also attempted to clarify whether such two-point D-AMY measurement was clinically useful for patient management after gastrectomy.

RESULTS

Fifty-one of the patients (6.4%) developed Clavien-Dindo grade III or worse POPF. Using D-AMY cutoffs of 2218 IU/L on POD1 and 555 IU/L on POD3, the patients were successfully classified. The highest risk group, in which D-AMY was higher than the cut-off value on both POD1 and POD3, showed a significantly high rate of occurrence (33/105, 31.4%) and high positive likelihood ratio (6.74). Multivariate analysis showed that classification into this highest risk group was an independent risk factor for development of severe POPF (odds ratio 15.2, 95% CI 7.92-29.0).

CONCLUSION

Two-point measurement of D-AMY may be an efficient tool for achieving individualized management of POPF following radical gastrectomy.