Is there still a need for prophylactic intra-abdominal drainage in elective major gastro-intestinal surgery?

Advantages comparison of peritoneal drainage versus no drainage after laparoscopic appendectomy for complicated appendicitis: a meta-analysis

BACKGROUND

Peritoneal drainage (PD) following laparoscopic appendectomy(LA) has long been considered beneficial for appendicitis patients, especially those with complicated appendicitis. However, recent research has raised doubts about the advantages of PD, as it not only fails to reduce postoperative complications but also prolongs the operative duration and hospital stay and incurs higher medical expenses. Given this controversy, we conducted a meta-analysis to determine whether drainage is necessary after LA for complicated appendicitis. This meta-analysis had registered in PROSPERO(ID: CRD42023472382).

OBJECTIVE

This study assessed current evidence regarding the efficacy, safety, and potential benefits of drainage versus no drainage following LA for complicated appendicitis.

METHODS

We conducted a comprehensive search of PubMed, Springer, and the Cochrane Library using the search terms "appendicitis", "laparoscopic appendectomy", and "drain" or "drainage" for studies published between January 1, 2000, and December 31, 2022. We employed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria for study inclusion and exclusion. Primary outcomes included postoperative intra-abdominal abscess, postoperative intestinal obstruction, postoperative stump leakage, wound infection and postoperative visual analog scale(VAS) score, while secondary outcomes consisted of operative time, postoperative recovery time and total hospitalization duration. Studies with at least two outcomes were considered for meta-synthesis. Depending on I2 values, fixed- or random effects models were used for data synthesis. Pooled odds ratios (OR) and weighted mean differences (WMD) were calculated for outcome comparisons between PD and no peritoneal drainage (NPD). Sensitivity analysis and meta-regression were performed to assess and investigate inter-study heterogeneity.

RESULTS

After conducting our literature search and screening, twelve studies were analyzed, comprising 3374 cases. During the comparison of primary outcomes between PD and NPD, the incidence of wound infection and postoperative VAS score were significantly higher in the PD group(P < 0.05). While during the comparison of secondary outcomes, the operative duration, postoperative recovery time and hospitalization duration were significantly longer in the PD group than in the NPD group(P < 0.05).

CONCLUSION

PD following LA for complicated appendicitis not only increases the incidence wound infection and aggravate patients' postoperative pain, but also prolongs the operative duration, postoperative recovery time and hospitalization duration. Therefore, routine PD after LA for acute complicated appendicitis is not recommended.

Early small bowel obstruction as a complication of abdominal drain in colon cancer surgery: a case report and literature review

Introduction

Early postoperative small bowel obstruction (EPSBO) is an obstruction that occurs within 4 weeks after the initial surgery. Routine prophylactic abdominal drainage does not provide any benefit in colon cancer surgery. The cause of EPSBO due to the abdominal drainage tube is infrequent.

Case presentation

A 72-year-old male patient was diagnosed with sigmoid carcinoma and underwent laparoscopic left colectomy. A surgical drain was placed in the pouch of Douglas through the incision of the right iliac fossa trocar site. On the fourth day, he began to flatus, and the abdominal pain decreased. However, on the ninth day after surgery, the patient had more abdominal pain, could not pass gas and defecate, and the abdomen was more distended. An abdominal computed tomography (CT) scan showed a dilated loop of the small intestine above the transition site with a drainage sonde and no dilation of the loop below the sonde. The patient was indicated to remove the sonde. He could pass gas and defecate the next day again and was relieved of the abdominal distention.

Discussion

Once an EPSBO is considered, it is essential to think of the bowel obstruction caused by the drainage tube in the case of abdominal drainage. It is necessary to have a contrast CT scan to examine.

Conclusion

EPSBO due to intra-abdominal drainage is a rare condition that presents a challenge in diagnosis and treatment. Diagnosis usually begins on the fourth postoperative day, mainly in operations in the lower transverse mesentery, including drainage placement after laparoscopic surgery.

Role of pelvic drain and timing of urethral catheter removal following RARP: a systematic review and meta-analysis

OBJECTIVES

To assess the clinical value of routine pelvic drain (PD) placement and early removal of urethral catheter (UC) in patients undergoing robot-assisted radical prostatectomy (RARP), as perioperative management such as the necessity of PD or optimal timing for UC removal remains highly variable.

METHODS

Multiple databases were searched for articles published before March 2022 according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. Studies were deemed eligible if they investigated the differential rate of postoperative complications between patients with/without routine PD placement and with/without early UC removal, defined as UC removal at 2-4 days after RARP.

RESULTS

Overall, eight studies comprising 5112 patients were eligible for the analysis of PD placement, and six studies comprising 2598 patients were eligible for the analysis of UC removal. There were no differences in the rate of any complications (pooled odds ratio [OR] 0.89, 95% confidence interval [CI] 0.78-1.00), severe complications (Clavien-Dindo Grade ≥III; pooled OR 0.95, 95% CI 0.54-1.69), all and/or symptomatic lymphocele (pooled OR 0.82, 95% CI 0.50-1.33; and pooled OR 0.58, 95% CI 0.26-1.29, respectively) between patients with or without routine PD placement. Furthermore, avoiding PD placement decreased the rate of postoperative ileus (pooled OR 0.70, 95% CI 0.51-0.91). Early removal of UC resulted in an increased likelihood of urinary retention (OR 6.21, 95% CI 3.54-10.9) in retrospective, but not in prospective studies. There were no differences in anastomosis leakage and early continence rates between patients with or those without early removal of UC.

CONCLUSIONS

There is no benefit for routine PD placement after standard RARP in the published articles. Early removal of UC seems possible with the caveat of the increased risk of urinary retention, while the effect on medium-term continence is still unclear. These data may help guide the standardisation of postoperative procedures by avoiding unnecessary interventions, thereby reducing potential complications and associated costs.

Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022

BACKGROUND

Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature.

METHODS

A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system.

RESULTS

A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy.

CONCLUSIONS

These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.

Is left lateral sectionectomy of the liver without operative site drainage safe and effective?

Backgrounds/Aims

Despite its limited benefits, operative site drainage after elective hepatectomy is routinely used. This study aimed to investigate the safety and effectiveness of left lateral sectionectomy without operative site drainage.

Methods

This study retrospectively collected data from 31 patients who underwent elective left lateral sectionectomy between January 2017 and June 2020. Based on whether operative site drainage was used, the patients were divided into two groups: drainage and non-drainage of the operative site and a comparative analysis was conducted.

Results

A total of 31 patients underwent left lateral sectionectomy during the study period. Of these, 22 patients were diagnosed with hepatocellular carcinoma; three, with intrahepatic cholangiocarcinoma; three, with liver metastasis; and three, with benign liver disease. Ten patients underwent laparoscopy. No significant differences were observed between the open and laparoscopic surgery groups. In the univariate analysis, there were no significant differences in the pre-, intra-, and postoperative clinicopathological factors between the non-drainage and drainage groups. The hospitalization period in the non-drainage group was significantly shorter than in the drainage group (8.44 days vs. 5.87 days, p < 0.05). In the operative site drainage non-use group, there were no cases of intraperitoneal fluid collection requiring additional procedures.

Conclusions

Routine use of surgical drainage for left lateral sectionectomy of the liver to prevent intraperitoneal fluid collection is unnecessary.

Early removal of drains and lines after liver transplantation to reduce the length of hospital stay and enhance recovery - A systematic review of the literature and expert panel recommendations

BACKGROUND

The timing of removing abdominal drains, central venous catheters (CVC), and urinary catheters (UC) on post liver transplantation (LT) outcomes is not well elucidated.

OBJECTIVES

To provide international expert panel recommendations and guidelines on time of drain and catheter removal as a part of an ERAS protocol to reduce the length of hospital stay and enhance recovery.

METHODS

Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Papers considered were those reporting one or more outcomes of interest related to drainage and line removal in the setting of LT. POSPERO Protocol ID: CRD42021238349 RESULTS: On analyzing five relevant studies pertaining to drains in patients undergoing LT (four retrospectives and one prospective), the length of hospital and/or ICU stay was similar or shorter, and postoperative morbidity and mortality were lower in those without drains. No studies pertaining specifically to the time of removal of drains, CVC's, or UC's in LT were found. Studies in patients undergoing major abdominal surgery or hepatectomies recommend early removal of CVC and UC to reduce catheter-associated infections.

CONCLUSIONS

Based more on expert recommendation, we propose that abdominal drains, if placed during LT, should be removed by postoperative day 5 after LT, based on quantity and fluid characteristics (Quality of Evidence; Low to Moderate | Grade of Recommendation; Strong). Larger studies are needed to more reliably determine indications for early drain and line removal in an ERAS protocol setting.

Antimicrobial Challenge in Acute Care Surgery

The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients' morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.

The Role of Abdominal Drain Cultures in Managing Abdominal Infections

Intra-abdominal infections (IAI) are common in hospitalized patients, both in and outside of the intensive care unit. Management principles include antimicrobial therapy and source control. Typically, these infections are polymicrobial, and intra-operative samples will guide the targeted antimicrobial therapy. Although the use of prophylactic abdominal drains in patients undergoing abdominal surgery is decreasing, the use of drains to treat IAI, both in surgical and non-surgical strategies for abdominal infection, is increasing. In this context, samples from abdominal drains are often used to assist in antimicrobial decision making. In this narrative review, we provide an overview of the current role of abdominal drains in surgery, discuss the importance of biofilm formation in abdominal drains and the mechanisms involved, and review the clinical data on the use of sampling these drains for diagnostic purposes. We conclude that biofilm formation and the colonization of abdominal drains is common, which precludes the use of abdominal fluid to reliably diagnose IAI and identify the pathogens involved. We recommend limiting the use of drains and, when present, avoiding routine microbiological sampling.

Feasibility of totally laparoscopic gastrectomy without prophylactic drains in gastric cancer patients

BACKGROUND

Prophylactic drains have been used to remove intraperitoneal collections and detect complications early in open surgery. In the last decades, minimally invasive gastric cancer surgery has been performed worldwide. However, reports on routine prophylactic abdominal drainage after totally laparoscopic distal gastrectomy are few.

AIM

To evaluate the feasibility performing totally laparoscopic distal gastrectomy without prophylactic drains in selected patients.

METHODS

Data of patients with distal gastric cancer who underwent totally laparoscopic distal gastrectomy with and without prophylactic drainage at China National Cancer Center/Cancer Hospital from February 2018 to August 2019 were reviewed. The outcomes between patients with and without prophylactic drainage were compared.

RESULTS

A total of 457 patients who underwent surgery for gastric cancer were identified. Of these, 125 patients who underwent totally laparoscopic distal gastrectomy were included. After propensity score matching, data of 42 pairs were extracted. The incidence of concurrent illness was higher in the drain group (42.9% vs 31.0%, P = 0.258). The overall postoperative complication rates were 19.5% and 10.6% in the drain (n = 76) and no-drain groups (n = 49), respectively; there were no significant differences between the two groups (P > 0.05). The difference between the two groups based on the need for percutaneous catheter drainage was also not significant (9.8% vs 6.4%, P = 0.700). However, patients with a larger body mass index (≥ 29 kg/m²) were prone to postoperative complications (P = 0.042). In addition, the number of days from surgery until the first flatus (4.33 ± 1.24 d vs 3.57 ± 1.85 d, P = 0.029) was greater in the drain group.

CONCLUSION

Omitting prophylactic drainage may reduce surgery time and result in faster recovery. Routine prophylactic drains are not necessary in selected patients. A prophylactic drain may be useful in high-risk patients.

Feasibility of totally laparoscopic gastrectomy without prophylactic drains in gastric cancer patients

BACKGROUND

Prophylactic drains have been used to remove intraperitoneal collections and detect complications early in open surgery. In the last decades, minimally invasive gastric cancer surgery has been performed worldwide. However, reports on routine prophylactic abdominal drainage after totally laparoscopic distal gastrectomy are few.

AIM

To evaluate the feasibility performing totally laparoscopic distal gastrectomy without prophylactic drains in selected patients.

METHODS

Data of patients with distal gastric cancer who underwent totally laparoscopic distal gastrectomy with and without prophylactic drainage at China National Cancer Center/Cancer Hospital from February 2018 to August 2019 were reviewed. The outcomes between patients with and without prophylactic drainage were compared.

RESULTS

A total of 457 patients who underwent surgery for gastric cancer were identified. Of these, 125 patients who underwent totally laparoscopic distal gastrectomy were included. After propensity score matching, data of 42 pairs were extracted. The incidence of concurrent illness was higher in the drain group (42.9% vs 31.0%, P = 0.258). The overall postoperative complication rates were 19.5% and 10.6% in the drain (n = 76) and no-drain groups (n = 49), respectively; there were no significant differences between the two groups (P > 0.05). The difference between the two groups based on the need for percutaneous catheter drainage was also not significant (9.8% vs 6.4%, P = 0.700). However, patients with a larger body mass index (≥ 29 kg/m2) were prone to postoperative complications (P = 0.042). In addition, the number of days from surgery until the first flatus (4.33 ± 1.24 d vs 3.57 ± 1.85 d, P = 0.029) was greater in the drain group.

CONCLUSION

Omitting prophylactic drainage may reduce surgery time and result in faster recovery. Routine prophylactic drains are not necessary in selected patients. A prophylactic drain may be useful in high-risk patients.

Prophylactic Intra-Peritoneal Drainage After Pancreatic Resection: An Updated Meta-Analysis

Introduction

Prophylactic intra-peritoneal drainage has been considered to be an effective measure to reduce postoperative complications after pancreatectomy. However, routinely placed drainage during abdominal surgery may be unnecessary or even harmful to some patients, due to the possibility of increasing complications. And there is still controversy about the prophylactic intra-peritoneal drainage after pancreatectomy. This meta-analysis aimed to analyze the incidence of complications after either pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) in the drain group and no-drain group.

Methods

Data were retrieved from four electronic databases PubMed, EMBASE, the Cochrane Library and Web of Science up to December 2020, including the outcomes of individual treatment after PD and DP, mortality, morbidity, clinically relevant postoperative pancreatic fistula (CR-POPF), bile leak, wound infection, postoperative hemorrhage, delayed gastric emptying (DGE), intra-abdominal abscess, reoperation, intervened radiology (IR), and readmission. Cochrane Collaboration Handbook and the criteria of the Newcastle-Ottawa scale were used to assess the quality of studies included.

Results

We included 15 studies after strict screening. 13 studies with 16,648 patients were analyzed to assess the effect of drain placement on patients with different surgery procedures, and 4 studies with 6,990 patients were analyzed to assess the effect of drain placement on patients with different fistula risk. For patients undergoing PD, the drain group had lower mortality but higher rate of CR-POPF than the no-drain group. For patients undergoing DP, the drain group had higher rates of CR-POPF, wound infection and readmission. There were no significant differences in bile leak, hemorrhage, DGE, intra-abdominal abscess, and IR in either overall or each subgroup. For Low-risk subgroup, the rates of hemorrhage, DGE and morbidity were higher after drainage. For High-risk subgroup, the rate of hemorrhage was higher while the rates of reoperation and morbidity were lower in the drain group.

Conclusions

Intraperitoneal drainage may benefit some patients undergoing PD, especially those with high pancreatic fistula risk. For DP, current evidences suggest that routine drainage might not benefit patients, but no clear conclusions can be drawn because of the study limitations.

Laparoscopic splenectomy after trauma: Who, when and how. A systematic review

Importance:

A deep knowledge of the indication for laparoscopic splenectomy (LS) in trauma case can lead trauma surgeon to offer in a wider number of situations a minimally invasive approach to a common injuries.

Objective:

To present and review the advantages and disadvantages of laparoscopic approach for spleen trauma and to identify patient whose can benefit from a minimally invasive approach versus patient that need open surgery to assess the whole severity of trauma.

Evidence Review:

A systematic review was performed according to the PRISMA statement in order to identify articles reporting LS after trauma. A literature search was performed through MEDLINE (through PubMed), Embase and Google Scholar from January 1990 to December 2018. Studies conducted on animals were not considered. All other laparoscopic procedures for spleen trauma were excluded.

Results:

Nineteen articles were included in this study, reporting 212 LS after trauma. The most study includes blunt trauma patient. All LS were performed in haemodynamically stable patient. Post-operative complications were reported in all articles with a median post-operative morbidity rate of 30 patients (14.01%), including 16 (7.5%) post-operative deaths.

Conclusions and Relevance:

This article reports the feasibility and safety of a minimally invasive approach for common trauma injuries which can help non-advanced laparoscopic skill trauma surgeon to develop the best indication to when to adopt this kind of approach.

Is an enhanced recovery program (ERP) after rectal surgery as feasible as after colonic surgery? A multicentre Francophone study of 870 rectal resections

BACKGROUND

Enhanced recovery program (ERP) is well-established in colorectal surgery. Rectal surgery (RS) is known to be associated with high morbidity and prolonged hospital stay, which might explain why ERPs are less applied in this specific group of patients. The aim of this large-scale study was to assess the feasibility of an ERP in RS compared with colonic surgery.

METHODS

This study was a retrospective analysis of a prospective database including 3740 patients eligible for colorectal resection from February 2014 to January 2017 in 75 European Francophone centres. Patients were divided into two groups (colon group C vs. rectum group R). The main endpoint was compliance with ERP components. A subgroup analysis was performed in patients for whom a defunctioning stoma (DS) was required after RS.

RESULTS

A total of 3740 patients were included. There were 2870 patients in group C and 870 patients in group R. The overall compliance rate for ERPs was 81.71% in group C and 79.09% in group R. Patients were significantly less mobilized within 24 h in group R. Specific recommendations for RS concerning bowel preparation and abdominal drainage were significantly less implemented. Overall morbidity was significantly higher in group R. Mean length of stay (LOS) was significantly shorter in group C. In the sub-group analysis, a DS was significantly associated with fewer compliance with early mobilization and early feeding, leading to significantly longer LOS (group R).

CONCLUSION

ERP is safe and effective in RS, despite the well-known higher morbidity and LOS compared with colonic surgery. DS could be a limiting factor in ERP implementation after RS.

Futility of abdominal drain in elective laparoscopic splenectomy

PURPOSE

Despite the implementation of minimally invasive surgery and enhanced recovery protocols, the use of drain in elective splenectomy is still controversial. The aim of this study was to assess whether the abdominal drain can impact on short-term outcome after elective laparoscopic splenectomy.

METHODS

This is a retrospective analysis of a consecutively collected database including all patients who underwent elective laparoscopic splenectomy in our institution between January 2001 and June 2019. Postoperative complications were defined according to a priori criteria and graded according to Clavien-Dindo classification. All complications that occurred during hospitalization or within 30 days after discharge were considered. Primary endpoint was postoperative morbidity, and secondary endpoint was postoperative hospital length of stay.

RESULTS

One hundred and sixty-one patients were analysed. Intraperitoneal drain was placed in 75 (46.6%) patients. Postoperative complications occurred in 36 (22.4%) patients, while 8 (4.9%) patients had major complications. Median postoperative length of stay was 4 days. At multivariate analysis, only malignancy was significantly associated with the onset of complications (OR 3.50; 95% CI 1.1-11.0; p = 0.032). Malignancy, ASA > 2, conversion to open surgery, presence of drain and longer operation were significantly associated with prolonged length of stay. Patients with drain showed a greater unadjusted risk of abdominal collections (RR 10.32; 95% CI 1.3-79.6; p = 0.006).

CONCLUSION

Abdominal drain did not reduce morbidity and prolonged the length of stay following elective laparoscopic splenectomy. Therefore, the present study does not support the routine use of drain in such procedure.

To drain or not to drain: intraperitoneal closed-suction drainage placement during cesarean delivery

INTRODUCTION

Intraperitoneal closed suction drains are occasionally placed during cesarean delivery. This study aims to ascertain the prevalence, associated factors, outcome, and risks of intraperitoneal closed-suction drain placed during cesarean delivery.

MATERIAL AND METHODS

A retrospective cohort study of all women undergoing cesarean delivery in a single center from 2005 to 2015. We excluded cases of cesarean hysterectomy and women who had hollow viscus injury. Cesarean deliveries were categorized into two groups based on intraperitoneal drain use: drain + and drain-.The study aims were to describe: (1) drain use prevalence; (2) factors associated with drain use; (3) interval to relaparotomy due to intraperitoneal bleeding and outcome of drain use; and (4) unique drain-related adverse outcome. Statistics: univariate, multivariable, and inverse probability treatment weighting (IPTW) analysis.

RESULTS

After applying the inclusion and exclusion criteria, 16 581 (99.3%) cesareans were included. An intraperitoneal drain was used in 1264 (7.6%) cesareans, ranging from 4.4 to 18.8% in women with no and four or more cesareans, respectively. Comparing the drain + and drain- groups, multivariable analysis revealed that the factors associated with the use of a drain included (OR, 95%CI) uterine rupture (5.14, 3.15-8.38), intrapartum fever (2.65, 1.87-3.75), previous cesareans (2.29, 2.00-2.68), second-stage cesarean (2.21, 1.64-2.74), preterm delivery (1.89, 1.63-2.19), spontaneous onset of labor (1.42, 1.24-1.63), and maternal age greater than 35 years (1.35, 1.19-1.54); p < .001 for all. Of the forty-four women (0.27%) who underwent relaparotomy for intraperitoneal bleeding, there were fourteen in the intraperitoneal drain group. Inverse probability treatment weighting analysis demonstrated that median (interquartile range) times (hours) to relaparotomy were significantly shorter in the drain + group [3.5 (3.3-10.0) versus 12.5 (7.9-15.6), p < .001] and that puerperal fever incidence was higher in the drain + group (2.2 vs. 1.4%, p < .001). The incidence of relaparotomy to remove a retained drain or drain fragment was 0.48% (6/1264).

CONCLUSIONS

Drain use in our study resulted in a shorter time to relaparotomy for intraperitoneal hemorrhage. However, it was associated with a higher risk for puerperal fever and a 0.5% risk for relaparotomy for removal of the drain.KEY MESSAGEIntraperitoneal drain placed during cesarean is used more often in complicated surgeries and is associated with a shorter interval to relaparotomy.

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. 

Dislocation of intra-abdominal drains after pancreatic surgery: results of a prospective observational study

PURPOSE

The use of intra-abdominal drains after major surgical procedures represents a well-established but controversial practice. No data are available regarding both the occurrence and the potential impact of their postoperative accidental dislocation. The aim of this study is to assess the actual rate of dislocation of intra-abdominal drains postoperatively and to evaluate its clinical impact.

METHODS

This is a prospective observational study using major pancreatic surgery as a model. Ninety-one consecutive patients undergoing pancreatoduodenectomy (PD) or distal pancreatectomy (DP) underwent low-dose, non-enhanced computed tomography (LDCT) on postoperative days (POD) 1 and 3 in a blinded fashion to assess the position of drains. We compared the outcomes of patients with dislocated and correctly placed drains.

RESULTS

Overall, drains were dislocated in 30 patients (33%), without differences between PD and DP. Most of dislocations were already present on POD 1 (77%). Postoperative complications occurred in 57% of patients, and the rate of postoperative pancreatic fistula (POPF) was 27%. The dislocated cohort had lesser morbidity (40% vs. 66%; relative risk (RR), 0.35; 95% CI, 0.14-0.86; P = 0.020), and the rate of POPF (3% vs. 39%, respectively; RR, 0.05; 95% CI, 0.01-0.42; P < 0.001). After PD, patients with dislocated drains had a shorter hospital stay (12 vs. 20 days; P = 0.015). No significant differences in terms of need for percutaneous drainage procedures, abdominal collections, or grade C POPFs were found between the groups.

CONCLUSIONS

Dislocation of intra-abdominal drains is an early and frequent event after major pancreatic resection. Its occurrence might protect against the negative effects of maintaining drainage, eventually leading to better postoperative outcomes. This data reinforces the knowledge that surgical drains might be detrimental in selected cases.

Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery

Enhanced Recovery After Surgery (ERAS) is an evidence-based paradigm shift in perioperative care, proven to lower both recovery time and postoperative complication rates. The role of ERAS in several surgical disciplines was reviewed. In colorectal surgery, ERAS protocol is currently well established as the best care. In gastric surgery, 2014 saw an establishment of ERAS protocol for gastrectomies with resulting meta-analysis showing ERAS effectiveness. ERAS has also been shown to be beneficial in liver surgery with many centers starting implementation. The advantages of ERAS in pancreatic surgery have been strongly established, but there is still a need for large-scale, multicenter randomized trials. Barriers to implementation were analyzed, with recent studies concluding that successful implementation requires a multidisciplinary team, a willingness to change and a clear understanding of the protocol. Additionally, the difficulty in accomplishing necessary compliance to all protocol items calls for new implementation strategies. ERAS success in different patient populations was analyzed, and it was found that in the elderly population, ERAS shortened the length of hospitalization and did not lead to a higher risk of postoperative complications or readmissions. ERAS utilization in the emergency setting is possible and effective; however, certain changes to the protocol may need to be adapted. Therefore, further research is needed. There remains insufficient evidence on whether ERAS actually improves patients’ course in the long term. However, since most centers started to implement ERAS protocol less than 5 years ago, more data are expected.

How does the application of surgical components in enhanced recovery programs for colorectal surgery change over time?

BACKGROUND

Enhanced recovery programs (ERP) improve post-operative outcomes in proportion to how fully they are implemented. Maintaining an optimal level of application of all the ER components is thus essential. Our aim was to assess the sustainability of ER surgical components 2 years after their first implementation.

METHOD

Patients undergoing elective colorectal resections were included in a prospective database. To retrospectively analyze compliance with ERP over a period of 24 months, the following components were considered: colonic preparation, surgical approach, nasogastric tube omission and absence of abdominal drainage.

RESULTS

2565 patients with a mean age of 63.6 ± 14.4 years from 63 colorectal centers were included. There were 1853 (72.2%) colectomies and 558 (21.7%) rectal resections. The median duration of hospital stay was 5 days [Interquartiles 4-8]. Overall morbidity was 21.9%, surgical morbidity was 8.1%, including 2.8% anastomotic fistulae. Overall, the ERP component most often applied with was postoperative nasogastric tube omission (93.6%), followed by laparoscopic approach (81.7%), absence of drainage (74.9%), and colonic preparation omission (67.3%). Implementation of surgical components significantly decreased over time: less laparoscopy (from 86.8% to 76.6%, p < 0.001), less drain omission (from 88.7% to 72%, p < 0.001), less nasogastric tube omission (from 100% to 93.4%, p = 0.002) and less colonic preparation omission (from 73.6% to 65.6%, p = 0.01).

CONCLUSION

This large-scale study found that implementation of surgical components in ERP decreased over time. Further efforts are needed to sustain compliance with ERP and surgical teams should focus on repeated audits.

Intraperitoneal drains move

INTRODUCTION

The use of surgical drains is the subject of much debate but they continue to be commonly used. The phenomenon of drain migration from their desired position following surgery has not been studied. The aim of this study was to evaluate the incidence of the displacement of surgical drains among patients undergoing abdominal gastrointestinal surgery.

PATIENTS AND METHODS

We performed a review of all patients who underwent an early CT-scan postoperatively after abdominal gastrointestinal surgery prior to drain mobilization, between January 2013 and April 2016 in the Dijon University Hospital Center. Pre-and intra-operative data (number, type and position of drains) and postoperative data (imaging and evolution) were collected retrospectively.

RESULTS

This study included 125 patients. Thirty-five (28%) were found to have a displacement of at least one drain from its original position. Forty-one (19.8%) of the 207 studied drains had moved. Postoperative morbidity was not higher in patients with displaced drains (P=0.51). None of all the studied preoperative and operative factors have been found to be a risk factor for drain displacement.

CONCLUSION

Surgical drains displacement is frequently encountered in patients undergoing digestive abdominal surgery. In our experience, this phenomenon does not seem to have any clinical implications. When a benefit is expected from the use of surgical drains, intraperitoneal fixation appears to be necessary.

Role of Drain Placement in Major Hepatectomy: A NSQIP Analysis of Procedure-Targeted Hepatectomy Cases

BACKGROUND

The value of drain placement in hepatic surgery has not been conclusive. The aim of this study was to determine whether drain placement during major hepatectomy was associated with negative postoperative outcomes and whether its placement reduced the need for secondary procedures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Hepatectomy Database was used to identify patients who underwent major hepatectomy. Patients were divided into two groups based on the placement of a drain during the procedure. Propensity score-matched cohorts of patients who underwent major hepatic resection with or without drain placement were created accounting for patient characteristics. The primary outcomes were 30-day postoperative complications including bile leak, post-hepatectomy liver failure, and invasive intervention as well as mortality and readmission.

RESULTS

A total of 1005 patients underwent major hepatectomy; 500 patients (49.8 %) had prophylactic drains placed at the conclusion of the procedure. Drain placement was associated with any complication (p < 0.001), blood transfusion (p < 0.001), renal insufficiency (p = 0.02), bile leak (p < 0.001), invasive intervention (p = 0.02), length of stay (p = 0.001), and readmission (p < 0.001). In the matched cohort, drain placement was associated with any complication (p < 0.001), blood transfusion (p < 0.001), superficial surgical site infection (SSI) (p = 0.028), bile leak (p < 0.001), and longer length of stay (0.03). In addition, placement of a prophylactic drain did not decrease the rate of postoperative bile leaks requiring therapeutic intervention (p = 0.21) (Table 2). In multivariate analysis, drain placement was independently associated with any complication (p < 0.001), blood transfusion (p = 0.02), bile leak (p < 0.001), invasive intervention (p = 0.011), superficial surgical site infection (SSI) (p = 0.039), and hospital readmission (p = 0.005) (Table 3). Placement of a prophylactic drain did not decrease the rate of postoperative bile leaks requiring therapeutic intervention (p = 0.15).

CONCLUSION

Drain placement after major hepatectomy may lead to increased postoperative complications including bile leak, superficial surgical site infection, and hospital length of stay and does not decrease the need for secondary procedures in patients with bile leaks.

Operative Site Drainage after Hepatectomy: A Propensity Score Matched Analysis Using the American College of Surgeons NSQIP Targeted Hepatectomy Database

BACKGROUND

Operative site drainage (OSD) after elective hepatectomy remains widely used despite data suggesting limited benefit. Multi-institutional, quality-driven databases and analytic techniques offer a unique source from which the utility of OSD can be assessed.

STUDY DESIGN

Elective hepatectomies from the 2014 American College of Surgeons (ACS) NSQIP Targeted Hepatectomy Database were propensity score matched on the use of OSD using preoperative and intraoperative variables. The influence of OSD on the diagnosis of postoperative bile leaks, rates of subsequent intervention, and other outcomes within 30 days were assessed using paired testing.

RESULTS

Operative site drainage was used in 42.2% of 2,583 eligible hepatectomies. There were 1,868 cases matched, with 7.2% experiencing a post-hepatectomy bile leak. The incidence of bile leak initially requiring intervention was no different between the OSD and no OSD groups (n = 32 vs n = 24, p = 0.278), and OSD was associated with a greater number of drainage procedures to manage post-hepatectomy bile leak (n = 27 in the OSD group, n = 13 in the no OSD group, p = 0.034, relative risk [RR] 2.1 [95% CI 1.1 to 4.0]). The OSD group had a greater mean length of stay (+0.8 days, p = 0.004) and more 30-day readmissions (p < 0.001, RR 1.6 [95% CI 1.2 to 2.1]). On multivariate analysis, post-hepatectomy bile leak and receipt of additional drainage procedures were stronger predictors of increased length of stay and readmissions than OSD.

CONCLUSIONS

In a propensity score matched cohort, OSD did not improve the rate of diagnosis of major bile leaks and was associated with increased interventions, greater length of stay, and more 30-day readmissions. These data suggest that routine OSD after elective hepatectomy may not be helpful in capturing clinically relevant bile leaks and has additional consequences.

Do Changes in Perioperative and Postoperative Treatment Protocol Influence the Frequency of Pulmonary Complications? A Retrospective Analysis of Four Different Bariatric Groups

The current understanding of prophylaxis of pulmonary complications in bariatric surgery is weak.

PURPOSE

The aim of this study was to observe how changes in perioperative and postoperative treatments affect the incidence of pulmonary complications in bariatric patients.

MATERIALS

This is a retrospective clinical study of 400 consecutive bariatric patients. The patients, who either underwent a sleeve gastrectomy or a Roux-en-Y gastric bypass, were divided consecutively into four subgroups with different approaches to perioperative treatment.

METHODS

The first group (patients 0-100) was recovered in the intensive care unit with minimal mobilization (ICU). They had a urinary catheter and a drain. The second group (patients 101-200) was similar to the first group, but the patients used a continuous positive airway pressure (CPAP) device intermittently (ICU-CPAP). The third group (patients 201-300) was recovered on a normal ward without a urinary catheter or a drain and used a CPAP device (ward-slow). The fourth group (patients 301-400) walked to the operating theater and was mobilized in the recovery room during the first 2 h after the operation (ward-fast). CPAP was also used. Primary endpoints were pulmonary complications, pneumonia, and infection, non-ultra descriptus (NUD).

RESULTS

The number of pulmonary complications among the groups was significantly different. A long operation time increased the risk for infection (p < 0.001 95 % CI from 2.02 to 6.59 %).

CONCLUSIONS

Operation time increases the risk for pulmonary complications. Changes in perioperative care toward the ERAS protocol may have a positive effect on the number of pulmonary complications.