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

Abdominal drainage to prevent intraperitoneal abscess after appendectomy for complicated appendicitis

RATIONALE

This is the third update of a Cochrane review first published in 2015 and last updated in 2021. Appendectomy, the surgical removal of the appendix, is performed primarily for acute appendicitis. People who undergo appendectomy for complicated appendicitis, defined as gangrenous or perforated appendicitis, are more likely to suffer postoperative complications in comparison to uncomplicated appendicitis. The routine use of abdominal drainage to reduce postoperative complications after appendectomy for complicated appendicitis is controversial.

OBJECTIVES

To evaluate the benefits and harms of abdominal drainage in reducing intraperitoneal abscess after appendectomy (irrespective of open or laparoscopic) for complicated appendicitis; to compare the effects of different types of surgical drains; and to evaluate the optimal time for drain removal.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, two other databases, and five trials registers, together with reference checking, citation searching, and contact with study authors, to identify studies for inclusion in the review. The latest search date was 12 October 2023.

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in people with complicated appendicitis comparing (1) use of drain versus no drain, (2) open drain versus closed drain, or (3) different schedules for drain removal. We excluded studies in which not all participants received antibiotics after appendectomy.

OUTCOMES

Our critical outcome was intraperitoneal abscess. Important outcomes were wound infection, morbidity, mortality, and hospital stay.

RISK OF BIAS

We used the Cochrane RoB 1 tool to assess the risk of bias in RCTs and quasi-RCTs.

SYNTHESIS METHODS

We synthesised the results for each outcome in a meta-analysis using the random-effects model, except for the Peto odds ratio, which only has a fixed-effect model. We planned to use the Synthesis Without Meta-analysis (SWiM) approach to report studies when it was not possible to undertake a meta-analysis of effect estimates. We used GRADE to assess the certainty of evidence for each outcome.

INCLUDED STUDIES

We included eight studies (five RCTs and three quasi-RCTs) with a total of 739 paediatric and adult participants, of which 370 participants were randomised to the drainage group and 369 participants to the no-drainage group. The studies were conducted in North America, Asia, and Africa and published between 1973 and 2023. The majority of participants had perforated appendicitis with local or general peritonitis. All participants received antibiotic regimens after open or laparoscopic appendectomy. All studies were at overall high risk of bias.

SYNTHESIS OF RESULTS

Use of drain versus no drain We assessed the certainty of the evidence for 30-day mortality as moderate due to imprecision. We assessed the certainty of the evidence for all other outcomes as very low, downgraded mainly due to high risk of bias, inconsistency, and imprecision. The evidence is very uncertain regarding the effects of abdominal drainage versus no drainage on intraperitoneal abscess at 30 days (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.55 to 2.12; 7 studies, 671 participants; very low-certainty evidence), wound infection at 30 days (RR 1.76, 95% CI 0.89 to 3.45; 7 studies, 696 participants), and morbidity at 30 days (RR 1.84, 95% CI 0.14 to 24.50; 2 studies, 124 participants) in paediatric and adult participants undergoing open or laparoscopic appendectomy for complicated appendicitis. Approximately 113 (57 to 221 participants) out of 1000 participants in the drainage group developed intraperitoneal abscess, compared with 104 out of 1000 participants in the no-drainage group. There were seven deaths in the drainage group (N = 291) compared with one in the no-drainage group (N = 290); abdominal drainage probably increases the risk of 30-day mortality (Peto odds ratio 4.88, 95% CI 1.18 to 20.09; 6 studies, 581 participants; moderate-certainty evidence) in paediatric and adult participants undergoing open appendectomy for complicated appendicitis. Abdominal drainage may increase hospital stay by 1.58 days (95% CI 0.86 to 2.31; 5 studies, 516 participants; very low-certainty evidence) in paediatric and adult participants undergoing open or laparoscopic appendectomy for complicated appendicitis, but the evidence is very uncertain. Open drain versus closed drain No studies compared open drain versus closed drain for complicated appendicitis. Early versus late drain removal No studies compared early versus late drain removal for complicated appendicitis.

AUTHORS' CONCLUSIONS

The evidence is very uncertain whether abdominal drainage prevents intraperitoneal abscess, wound infection, or morbidity in paediatric and adult participants undergoing open or laparoscopic appendectomy for complicated appendicitis. Abdominal drainage may increase hospital stay in paediatric and adult participants undergoing open or laparoscopic appendectomy for complicated appendicitis, but the evidence is very uncertain. Consequently, there is no evidence for any clinical improvement with the use of abdominal drainage in people undergoing open or laparoscopic appendectomy for complicated appendicitis. The increased risk of mortality with drainage comes from eight deaths observed in paediatric and adult participants undergoing open appendectomy for complicated appendicitis. Larger studies are needed to more reliably determine the effects of drainage on mortality outcomes.

FUNDING

This Cochrane review was funded by the National Natural Science Foundation of China (Grant No. 81701950, 82172135), Natural Science Foundation of Chongqing (Grant No. CSTB2022NSCQ-MSX0058, cstc2021jcyj-msxmX0294), Medical Research Projects of Chongqing (Grant No. 2018MSXM132, 2023ZDXM003, 2024jstg028), and the Kuanren Talents Program of the Second Affiliated Hospital of Chongqing Medical University.

REGISTRATION

Registration: not available. Protocol and previous versions available via doi.org/10.1002/14651858.CD010168, doi.org/10.1002/14651858.CD010168.pub2, doi.org/10.1002/14651858.CD010168.pub3, and doi.org/10.1002/14651858.CD010168.pub4.

Longitudinal quality of life assessment after laparoscopic colorectal cancer surgery using the Gastrointestinal Quality of Life Index questionnaire: A multicentre prospective study

AIM

The aim of this study was to validate the Gastrointestinal Quality of Life Index (GIQLI) and assess its effectiveness in measuring changes in postoperative quality of life (QOL) after laparoscopic colorectal cancer surgery, including factors affecting early QOL impairment.

METHOD

This multicentre prospective study enrolled patients who underwent laparoscopic colorectal cancer surgery between November 2021 and February 2023. Participants completed the GIQLI and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire for Colorectal Cancer (EORTC QLQ-CR29) questionnaires preoperatively and at 1 and 3 weeks, 6 months and 1 year postoperatively. We evaluated GIQLI reliability, identified risk factors associated with early postoperative QOL impairment and assessed longitudinal changes in QOL to determine the timing of postoperative recovery.

RESULTS

The GIQLI showed high reliability, with a preoperative intraclass correlation coefficient of 0.930 (95% CI 0.899-0.951) and Cronbach alpha values >0.9 at all time points. The mean global GIQLI score decreased from 106.2 ± 14.7 preoperatively to 92.7 ± 15.2 at 1 week postoperatively (p < 0.001), recovered to 104.6 ± 13.8 at 6 months postoperatively (versus preoperatively, p > 0.99) and increased to 113.4 ± 13.3 at 1 year postoperatively (versus preoperatively, p < 0.001). Early T-stage (T1-2; OR 2.82, 95% CI 1.25-6.40, p = 0.013) and intra-abdominal drain use (OR 3.95, 95% CI 1.09-14.28, p = 0.036) were significant risk factors for substantial impairment of QOL at 1 week postoperatively. The predicted recovery period to 95% of preoperative QOL was 6.4 weeks (95% CI 6.00-8.30 weeks).

CONCLUSION

The GIQLI reliably assessed longitudinal changes in QOL after laparoscopic colorectal cancer surgery and demonstrated QOL recovery within 2 months postoperatively, providing guidance for patient counselling and optimizing postoperative care.

Enhanced rehabilitation after surgery: principles in the treatment of emergency complicated colorectal cancers - a narrative review

Enhanced Recovery After Surgery (ERAS) protocols are used in elective colorectal surgeries and have shown improved recovery for many patients. However, using these protocols in emergency colorectal surgery, especially in complicated cases of obstructive colorectal cancer, is still debated. This review examined the ERAS principles that can be adapted for emergencies. We reviewed the literature on applying ERAS principles in emergency colorectal cancer surgery. We analyzed key strategies used before, during, and after surgery. The aim of ERAS in emergency colorectal surgery is to reduce physical stress from urgent surgical conditions. Before surgery, the focus should be on early patient recovery, managing blood sugar levels, and providing patient education when possible. Minimally invasive techniques, careful fluid management, and effective pain relief during surgery are intraoperative key points. After surgery, early feeding, patient mobilization, and minimizing the use of medical devices are encouraged. Studies have shown that using ERAS in emergencies can lower mortality, reduce hospital stays, and influence patient recovery rates, although it may lead to higher initial costs. Still, following ERAS in emergencies is inconsistent due to logistical issues and patient health changes. More people are starting to recognize the benefits of ERAS in obstructive colorectal cancer surgery. Although there is less evidence compared to elective procedures, new studies suggest that organized steps for care can improve patient outcomes. Further research is needed to improve ERAS emergency protocols and identify patients suitable for this approach so that healthcare resources can be used better.

Impact of Drain Removal Timing and Prophylactic Antibiotic Agents on Surgical Site Infections in Head and Neck Reconstruction

Background: Regarding drain removal timing in head and neck reconstruction, each institution applies its criteria, and a clear consensus has not been established. This pre-post study aims to identify risk factors for surgical site infection (SSI) after reconstructive surgical procedure for head and neck cancer, specifically examining the influence of drain removal timing. Patients and Methods: A cohort of 220 patients undergoing reconstructive surgical procedure was analyzed. Patients had closed suction drains removed on post-operative day (POD) 2 or POD3. The primary endpoint was SSI incidence within 30 days after operation. Secondary endpoints included the incidence of hematoma and lymphorrhea within 30 days after operation and drain tip culture results. Statistical analyses were performed using Fisher exact test and logistic regression models. Results: SSIs occurred in 14.5% of patients, with no significant difference between the POD2 (14.6%) and POD3 (14.5%) groups. No substantial differences were found for hematoma and lymphorrhea. The positive rate of drain tip cultures was significantly greater in the POD3 group (38.2%) compared with the POD2 group (18.0%). Multi-variable analysis showed no correlation between SSI and POD3 drain removal (odds ratio [OR], 0.728; p = 0.471). However, significant SSI risk factors included oral cavity lesions (OR, 3.510; p = 0.003) and ampicillin prophylaxis (OR, 5.266; p < 0.001). Conclusions: Oral cavity lesions and ampicillin prophylaxis were substantial SSI risk factors in reconstructive surgical procedure for head and neck cancer. However, drain removal timing did not significantly affect SSI incidence or other complications. Considering benefits such as shorter hospital stays and less chance of retrograde bacterial invasion, removing drains on POD2 is preferable compared with removal on POD3. Further research is needed to refine prophylactic protocols and enhance patient outcomes.

Prophylactic Drain Placement and Postoperative Invasive Procedures After Gastrectomy: The Abdominal Drain After Gastrectomy (ADIGE) Randomized Clinical Trial

Importance

Evidence suggests that prophylactic abdominal drainage after gastrectomy for cancer may reduce postoperative morbidity and hospital stay but this evidence comes from small studies with a high risk of bias. Further research is needed to determine whether drains safely meet their primary purpose of identifying and managing postoperative intraperitoneal collections without the need for reoperation or additional percutaneous drainage.

Objective

To determine whether avoiding routine abdominal drainage increased postoperative invasive procedures.

Design, Setting, and Participants

The Abdominal Drain in Gastrectomy (ADIGE) Trial was a multicenter prospective randomized noninferiority trial. Enrollment spanned from December 2019 to January 2023. Follow-up evaluations were completed at 30 and 90 days. Eleven centers within the Italian Research Group for Gastric Cancer, encompassing both academic medical centers and community hospitals, were included. Patients with gastric cancer undergoing subtotal or total gastrectomy with curative intent were eligible, excluding those younger than 18 years, with serious comorbidities, or undergoing procedure types outside the scope of the study. Of 803 patients assessed for eligibility, 404 were randomized and 390 were included in final analyses.

Interventions

Patients were randomized 1:1 into prophylactic drain or no drain arms.

Main Outcomes and Measures

The primary end point was a modified intention-to-treat (mITT) analysis measuring reoperation or percutaneous drainage within 30 postoperative days. The null hypothesis was rejected when the 90% CI upper limit of the proportion difference did not exceed 3.56%. The calculated sample size to achieve 80% power with a 10% dropout rate was 404 patients (202 in each group). Surgeons and patients were blinded until gastrointestinal reconstruction.

Results

Of the 404 patients randomized 226 (57.8%) were male; the median (IQR) age was 71 (62-78) years. Intraoperative identification of nonresectable disease occurred in 14 patients, leading to their exclusion from the study, leaving 390 patients. In the mITT analysis, 15 patients (7.7%) in the drain group needed reoperation or percutaneous drainage by postoperative day 30 vs 29 (15%) in the no drain group, favoring the drain group (difference, 7.2%; 90% CI, 2.1-12.4; P = .02). Of note, the difference in the primary composite end point was entirely due to a similar difference in reoperation (5.1% in the drain group vs 12.4% in the no drain group; P = .01). Drain-related complications occurred in 4 patients.

Conclusions and Relevance

The findings of this study indicate that refraining from prophylactic drain use after gastrectomy heightened the risk of postoperative invasive procedures, discouraging its avoidance. Future studies identifying high-risk groups could optimize prophylactic drainage decisions.

Trial Registration

ClinicalTrials.gov Identifier: NCT04227951.

No drains versus drains after perforated peptic ulcer repair: A randomized controlled trail

PURPOSE

The study aimed to evaluate safety of omitting the intraabdominal drains after perforated peptic ulcer repairs.

MATERIALS AND METHODS

We conducted a prospective, randomized, controlled trial from January 2022 to January 2024 at the Emergency surgery department. Patients with perforated peptic ulcers were evaluated for eligibility. They were randomly assigned into two groups. In group A: two intraabdominal drains (pelvic and hepatorenal). in group B: no intraabdominal drains. The primary outcome was hospital length of stay (LOS), and the secondary outcomes included parameters of recovery and 30-day morbidities. The data were analyzed using SPSS 16 ®.

RESULTS

Thirty five patients were in the no drain group, while 36 patients were in the drain group. Patients in the no drains group had significantly earlier bowel motion (21.6 vs 28.69 hours; p = 0.004), fluid diet (73.54 vs 86.78 hours; p 0.001), and solid intake (84.4 vs. 98 hours; p 0.001), less pain severity (p = 0.0001) and shorter hospital stay (4.74 vs 5.75 days; p 0.001). A significant less morbidity, including surgical site infection (p = 0.01), and respiratory complications (p 0.0001), were in the no drain group. There was no difference of fever duration nor wound dehiscence.

CONCLUSIONS

Omitting the intraabdominal drains is safe after peptic ulcer perforation repair. It can improve outcomes. The study was registered at ClinicalTrials.gov Identifier: NCT06084741.

Effect of prophylactic abdominal drainage on postoperative pain in laparoscopic hemicolectomy for colon cancer: a single-center observational study in Korea

Purpose

This study aimed to evaluate the effect of prophylactic abdominal drainage (AD) in laparoscopic hemicolectomy, focusing on assessing postoperative pain outcomes.

Methods

Patients were categorized into two groups: those with and without AD (AD group vs. no-AD group). A numerical rating scale (NRS) was used to assess postoperative pain on each postoperative day (POD). Further, the inverse probability of treatment weighting (IPTW) method was used to reduce intergroup bias.

Results

In total, 204 patients who underwent laparoscopic hemicolectomies by a single surgeon between June 2013 and September 2022 at a single institution were retrospectively reviewed. After adjusting for IPTW, NRS scores on POD 2 were significantly lower in the no-AD group (3.2 ± 0.8 vs. 3.4 ± 0.8, p = 0.043). Further examination of postoperative outcomes showed no statistically significant differences in complications between the AD (17.3%) and no-AD (12.4%) groups (p = 0.170). The postoperative length of hospital stay was 7.3 ± 2.8 days in the AD group and 6.9 ± 3.0 days in the no-AD group, with no significant difference (p = 0.298). Time to first flatus was 3.0 ± 0.9 days in the AD group and 2.7 ± 0.9 days in the no-AD group, with no significant difference (p = 0.078). Regarding readmission within 1 month, there were four cases each in the AD (2.3%) and no-AD (1.7%) groups, with no significant difference (p = 0.733).

Conclusion

Laparoscopic hemicolectomy without AD resulted in no significant differences in postoperative clinical outcomes, except for postoperative pain. This finding suggests that prophylactic AD may exacerbate postoperative pain.

Controversies and Future Directions in Management of Acute Appendicitis: An Updated Comprehensive Review

Globally, acute appendicitis has an estimated lifetime risk of 7-8%. However, there are numerous controversies surrounding the management of acute appendicitis, and the best treatment approach depends on patient characteristics. Non-operative management (NOM), which involves the utilization of antibiotics and aggressive intravenous hydration, and surgical appendectomy are valid treatment options for healthy adults. NOM is also ideal for poor surgical candidates. Another important consideration is the timing of surgery, i.e., the role of interval appendectomy (IA) and the possibility of delaying surgery for a few hours on index admission. IA refers to surgical removal of the appendix 8-12 weeks after the initial diagnosis of appendicitis. It is ideal in patients with a contained appendiceal perforation on initial presentation, wherein an initial nonoperative approach is preferred. Furthermore, IA can help distinguish malignant and non-malignant causes of acute appendicitis, while reducing the risk of recurrence. On the contrary, a decision to delay appendectomy for a few hours on index admission should be made based on the patients' baseline health status and severity of appendicitis. Post-operatively, surgical drain placement may help reduce postoperative complications; however, it carries an increased risk of drain occlusion, fistula formation, and paralytic ileus. Furthermore, one of the most critical aspects of appendectomy is the closure of the appendiceal stump, which can be achieved with the help of endoclips, sutures, staples, and endoloops. In this review, we discuss different aspects of management of acute appendicitis, current controversies in management, and the potential role of endoscopic appendectomy as a future treatment option.

The use of intra-abdominal prophylactic drainage in laparoscopic cholecystectomy: does it change in relation to surgical expertise? A multicenter case-control retrospective study on postoperative outcomes

BACKGROUND

The routine use of abdominal drainage (AD) after laparoscopic cholecystectomy (LC) is still controversial. The aim of this expertise-based study is to evaluate the efficacy of prophylactic AD in terms of postoperative complications and analyze the factors linked to AD placement.

METHODS

This case-control retrospective study included patients with cholelithiasis who underwent LC with AD (AD group) and LC without drainage (no-AD group) in two Italian centers. Allocation to groups was non-randomized and based on surgeons' decisions. Patient's characteristics, operative results, postoperative outcomes, surgeon's expertise related data were compared between the two groups with univariate and multivariate analysis.

RESULTS

Patients in the two groups were comparable for age, sex ratio, and morbidity. Length of postoperative hospital stay (LOS) in the no-AD group was shorter than the AD group. Patients in the AD group had a higher rate of wound infection. No difference in postoperative pain measured 7 days after the surgery was found. Our results show an association between the first operator's expertise and age and the decision of placing the AD. The operative time seems to be the principal factor impacting the decision whether to place or not the AD.

CONCLUSIONS

Our results indicate that it is feasible not to insert routine AD after elective LC for cholelithiasis. The use of AD seems to cause more cases of postoperative wound infections, prolongs the LOS and the operative time. The drain placement choice seems to change in relation to the surgeon's expertise.

Adverse Events of Surgical Drain Placement: An Analysis of the NSQIP Database

BACKGROUND

Surgical site drainage is important to prevent hematoma, seroma, and abscess formation. However, the placement of drain placement also predispose patients to several postoperative complications. The aim of this study is to clarify the risk-benefit profile of surgical drain placement.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Procedure-Targeted Databases were used to identify patients who underwent hepatectomy, pancreatectomy, nephrectomy, cystectomy, and prostatectomy. Patients who underwent each procedure were divided into 2 groups based on intraoperative drain placement. Propensity score-matched cohorts of these 2 groups were compared in terms of postoperative adverse events, readmission, reoperation, and length of stay.

RESULTS

Hepatectomy patients with drains experienced organ space infections (P < .001), sepsis (P < .001), and readmission (P = .021) more often than patients without drains. Patients who underwent pancreatectomy and had drains placed experienced wound dehiscence less frequently than those without drains (P = .04). For hepatectomy, pancreatectomy, nephrectomy, and prostatectomy populations, patients with drains had longer lengths of stay (P < .05). Matched populations across all procedures did not differ in terms of reoperation rate.

DISCUSSION

Prophylactic surgical drain placement may be associated with increased infectious complications and prolonged length of stay. Further studies are needed to elucidate the complete adverse event profile of surgical drains. Nonetheless, outcomes may be improved with better patient selection or advancements in drain technology.

Abdominal drainage after elective colorectal surgery: propensity score-matched retrospective analysis of an Italian cohort

BACKGROUND

In Italy, surgeons continue to drain the abdominal cavity in more than 50 per cent of patients after colorectal resection. The aim of this study was to evaluate the impact of abdominal drain placement on early adverse events in patients undergoing elective colorectal surgery.

METHODS

A database was retrospectively analysed through a 1:1 propensity score-matching model including 21 covariates. The primary endpoint was the postoperative duration of stay, and the secondary endpoints were surgical site infections, infectious morbidity rate defined as surgical site infections plus pulmonary infections plus urinary infections, anastomotic leakage, overall morbidity rate, major morbidity rate, reoperation and mortality rates. The results of multiple logistic regression analyses were presented as odds ratios (OR) and 95 per cent c.i.

RESULTS

A total of 6157 patients were analysed to produce two well-balanced groups of 1802 patients: group (A), no abdominal drain(s) and group (B), abdominal drain(s). Group A versus group B showed a significantly lower risk of postoperative duration of stay >6 days (OR 0.60; 95 per cent c.i. 0.51-0.70; P < 0.001). A mean postoperative duration of stay difference of 0.86 days was detected between groups. No difference was recorded between the two groups for all the other endpoints.

CONCLUSION

This study confirms that placement of abdominal drain(s) after elective colorectal surgery is associated with a non-clinically significant longer (0.86 days) postoperative duration of stay but has no impact on any other secondary outcomes, confirming that abdominal drains should not be used routinely in colorectal surgery.

[Acute appendicitis in adults]

Acute appendicitis in adults. Clinical guidelines.

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care

BACKGROUND

This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care.

METHODS

Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL.

RESULTS

Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process.

CONCLUSIONS

These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Treatment and Prevention of Postoperative Leakage after Gastrectomy for Gastric Cancer

Anastomotic leakage is one of the common causes of serious morbidity and death after gastrectomy. The use of surgical treatment for leakage decreased due to the development of nonsurgical management. However, if nonsurgical management fails to control the spread of intra-abdominal infection, emergency surgical treatment is required. The authors wished to determine in which cases surgical treatment is needed for postoperative leakage and to identify treatment and prevention strategies. If a patient's vital signs are stable, local abscesses can be cured by conservative treatment after percutaneous drain insertion; if there is no improvement in anastomotic leakage, endoscopic treatment such as clipping, vacuum, and stent placement can be performed. If a patient's vital signs are unstable or patient shows diffuse peritonitis, surgical treatment should be performed. A surgical plan can be established according to leakage location. The duodenal stump may first require conservative treatment. It is recommended that surgical treatment be attempted first for anastomotic leakage of gastrojejunostomy site and gastric stump in remnant stomach. In conclusion, the need for surgical treatment is determined depending on vital signs and presence of diffuse peritonitis. During surgical treatment, a strategic approach is required according to the patient's condition and the anatomical location of leakage.

Prophylactic drainage versus non-drainage following gastric cancer surgery: a meta-analysis of randomized controlled trials and observational studies

BACKGROUND

The role of prophylactic drainage (PD) in gastrectomy for gastric cancer (GC) is not well-established. The purpose of this study is to compare the perioperative outcomes between the PD and non-drainage (ND) in GC patients undergoing gastrectomy.

METHODS

A systematic review of electronic databases including PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Infrastructure was performed up to December 2022. All eligible randomized controlled trials (RCTs) and observational studies were included and meta-analyzed separately. The registration number of this protocol is PROSPERO CRD42022371102.

RESULTS

Overall, 7 RCTs (783 patients) and 14 observational studies (4359 patients) were ultimately included. Data from RCTs indicated that patients in the ND group had a lower total complications rate (OR = 0.68; 95%CI:0.47-0.98; P = 0.04; I² = 0%), earlier time to soft diet (MD =  - 0.27; 95%CI: - 0.55 to 0.00; P = 0.05; I² = 0%) and shorter length of hospital stay (MD =  - 0.98; 95%CI: - 1.71 to - 0.26; P = 0.007; I² = 40%). While other outcomes including anastomotic leakage, duodenal stump leakage, pancreatic leakage, intra-abdominal abscess, surgical-site infection, pulmonary infection, need for additional drainage, reoperation rate, readmission rate, and mortality were not significantly different between the two groups. Meta-analyses on observational studies showed good agreement with the pooled results from RCTs, with higher statistical power.

CONCLUSION

The present meta-analysis suggests that routine use of PD may not be necessary and even harmful in GC patients following gastrectomy. However, well-designed RCTs with risk-stratified randomization are still needed to validate the results of our study.

Potential clinical utility of intraoperative fluid amylase measurement during pancreaticoduodenectomy

BACKGROUNDS/AIMS

Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a source of major morbidity and mortality. Early diagnosis and treatment of POPF is mandatory to improve patient outcomes and clinical risk scores may be ombined with postoperative drain fluid amylase (DFA) values to stratify patients. The aim of this pilot study was to etermine if intraoperative fluid amylase (IFA) values correlate with DFA1 and POPF.

METHODS

In patients undergoing PD from February to November 2020, intraoperative samples of intra-abdominal fluid adjacent to the pancreatic anastomosis were taken and sent for fluid amylase measurement prior to abdominal closure. Data regarding patient demographics, postoperative DFA values, complications, and mortality were prospectively collected.

RESULTS

Data were obtained for 52 patients with a median alternative Fistula Risk Score (aFRS) of 9.9. Postoperative complications occurred in 20 (38.5%) patients (five Clavien grade ≥ 3). There were eight POPFs and two patients died (pneumonia/sepsis). There was a significant correlation between IFA and DFA1 (R2 = 0.713; p < 0.001) and DFA3 (p < 0.001), and the median IFA was higher in patients with POPF than patients without (1,232.5 vs. 122; p = 0.0003). IFA > 260 U/L predicted POPF with sensitivity, specificity, positive and negative predictive values of 88.0%, 75.0%, 39.0%, and 97.0%, respectively. The incidence of POPF was 43.0% in high-risk (high aFRS/IFA) and 0% in lowrisk patients (low aFRS/IFA).

CONCLUSIONS

IFA correlated with POPF and may be a useful adjunct to clinical risk scores to stratify patients during PD. Larger, prospective studies are needed to determine whether IFA has clinical utility.

High adherence to enhanced recovery pathway independently reduces major morbidity and mortality rates after colorectal surgery: a reappraisal of the iCral2 and iCral3 multicenter prospective studies

Background:

Enhanced recovery after surgery (ERAS) offers lower overall morbidity rates and shorter hospital stay after colorectal surgery (CRS); high adherence rates to ERAS may significantly reduce major morbidity (MM), anastomotic leakage (AL), and mortality (M) rates as well.

Methods:

Prospective enrollment of patients submitted to elective CRS with anastomosis in two separate 18- and 12-month periods among 78 surgical centers in Italy from 2019 to 2021. Adherence to ERAS pathway items was measured upon explicit criteria in every case. After univariate analysis, independent predictors of primary endpoints (MM, AL, and M rates) were identified through logistic regression analyses, presenting odds ratios (OR) and 95% confidence intervals.

Results:

An institutional ERAS status was declared by 48 out of 78 (61.5%) participating centers. The median overall adherence to ERAS was 75%. Among 8,359 patients included in both studies, MM, AL, and M rates were 6.3%, 4.4%, and 1.0%, respectively. Several patient-related and treatment-related variables showed independently higher rates for primary endpoints: male gender, American Society of Anesthesiologists class III, neoadjuvant treatment, perioperative steroids, intra- and/or postoperative blood transfusions, length of the operation >180’, surgery for malignancy. On the other hand, ERAS adherence >85% independently reduced MM (OR, 0.91) and M (OR, 0.25) rates, whereas no mechanical bowel preparation independently reduced AL (OR, 0.68) rates.

Conclusions:

Among other patient- or treatment-related variables, ERAS adherence >85% independently reduced MM and M rates, whereas no mechanical bowel preparation independently reduced AL rates after CRS.

Abdominal drainage is contraindicated after uncomplicated hepatectomy: Results of a meta-analysis of randomized controlled trials

BACKGROUND

No conclusive recommendations exist regarding use of abdominal drainage in hepatectomy. The practice of abdominal drainage remains commonplace despite unfavorable outcomes reported by randomized controlled trials. We aimed to compare the impact of abdominal drainage on outcomes of hepatectomy.

METHODS

A systematic search of electronic information sources and bibliographic reference lists was conducted. A combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits in each of the above databases was applied. Overall perioperative and wound-related complications, bile leak, intra-abdominal collections (including those requiring an intervention), and the length of hospital stay were the evaluated outcome parameters.

RESULTS

Seven randomized controlled trials reporting 1,064 patients undergoing hepatectomy with (n = 533) or without (n = 531) placement of abdominal drain were included. Patients in both groups were of comparable age (P = .23), sex (P = .49), proportion of major hepatectomy (P = .93), minor hepatectomy (P = .96), cirrhosis (P = .78), and malignant pathologies (P = .61). Drainage after hepatectomy was associated with significantly higher overall complications (RR: 1.37, P = .0003) and wound-related complications (risk ratio: 2.29, P = .01) compared to no drainage. Moreover, there was no significant difference in bile leak (risk ratio: 2.15, P = .19), intra-abdominal collections (risk ratio: 1.13, P = .70), intra-abdominal collections requiring interventions (risk ratio: 1.19, P = .71), or length of hospital stay (mean difference: 0.37, P = .67) between the 2 groups. The trial sequential analysis confirmed conclusiveness of the findings.

CONCLUSION

Abdominal drainage after hepatectomy increases overall and wound-related complications, without any reduction in the risk of intra-abdominal collections needing an intervention. Routine drainage after an uncomplicated hepatectomy should be avoided, with the possible exception of the presence of a bilioenteric anastomosis.

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.

[Surgical wound closure in advanced peritonitis]

To date, mortality in widespread peritonitis is still high (15-20%) and increased up to 70-80% in case of septic shock. Surgeons actively discuss wound closure technique in these patients considering intraoperative findings and severity of illness. The authors present scientific data and opinions of national and foreign surgeons regarding the methods of laparotomy closure. There are still no generally accepted criteria for choosing the method of laparotomy closure in secondary widespread peritonitis. Indications and clinical efficacy of each procedure require additional research.

Is routine drainage necessary after thyroid surgery? A randomized controlled trial study

Objective

To evaluate whether no drainage has an advantage over routine drainage in patients with thyroid carcinoma after unilateral thyroid lobectomy and central neck dissection.

Methods

A total of 104 patients with thyroid cancer who underwent unilateral thyroid lobectomy and central lymph node dissection were randomly assigned into no drainage tube (n=52) and routine drainage tube (n=52) placement groups. General information of each patient was recorded, including the postoperative drainage volume/residual cavity fluid volume, postoperative complications, incision area comfort, and other data, and the thyroid cancer-specific quality of life questionnaire (THYCA-QoL) and patient and observer scar assessment scale (POSAS) were evaluated after surgery. At the 3-6 month follow-up exam, the differences between the two groups were compared based on univariate analysis.

Results

Significant differences were not observed in the general and pathological information (including sex, age, body weight, body mass index (BMI), incision length, specimen volume, Hashimoto's thyroiditis, and number of lymph nodes dissected), operation time, and postoperative complications (postoperative bleeding, incision infection, lymphatic leakage, and temporary hypoparathyroidism) between the two groups. The patients in the non-drainage group had a shorter hospital stay (2.11 ± 0.33 d) than the patients in the drainage group (3.38 ± 0.90 d) (P<0.001). The amount of cervical effusion in patients in the non-drainage group (postoperative 24h: 2.20 ± 1.24 ml/48 h: 1.53 ± 1.07 ml) was significantly less than that in the drainage group (postoperative 24 hours: 22.58 ± 5.81 ml/48 h: 36.15 ± 7.61 ml) (all P<0.001). The proportion of incision exudation and incision numbness in the non-drainage group was lower than that in the drainage group (all P<0.05), and the pain score (VAS) and neck foreign body sensation score (FBST) decreased significantly (P<0.05). During the 3- and 6-month follow-up exams, significant differences were not observed between the THYCA-QoL and drainage groups and the non-drainage group, although the scarring and POSAS values were lower than those in the drainage group. In addition, the length of stay and cost of hospitalization in the non-drainage group were lower than those in the drainage group (P<0.05).

Conclusion

Routine drainage tube insertion is not needed in patients with unilateral thyroid lobectomy and central neck dissection.

Current practice on the use of prophylactic drain after gastrectomy in Italy: the Abdominal Drain in Gastrectomy (ADiGe) survey

Evidence against the use of prophylactic drain after gastrectomy are increasing and ERAS guidelines suggest the benefit of drain avoidance. Nevertheless, it is unclear whether this practice is still widespread. We conducted a survey among Italian surgeons through the Italian Gastric Cancer Research Group and the Polispecialistic Society of Young Surgeons, aiming to understand the current use of prophylactic drain. A 28-item questionnaire-based survey was developed to analyze the current practice and the individual opinion about the use of prophylactic drain after gastrectomy. Groups based on age, experience and unit volume were separately analyzed. Response of 104 surgeons from 73 surgical units were collected. A standardized ERAS protocol for gastrectomy was applied by 42% of the respondents. Most of the surgeons, regardless of age, experience, or unit volume, declared to routinely place one or more drain after gastrectomy. Only 2 (1.9%) and 7 surgeons (6.7%) belonging to high volume units, do not routinely place drains after total and subtotal gastrectomy, respectively. More than 60% of the participants remove the drain on postoperative day 4-6 after performing an assessment of the anastomosis integrity. Interestingly, less than half of the surgeons believe that drain is the main tool for leak management, and this percentage further drops among younger surgeons. On the other hand, drain's role seems to be more defined for duodenal stump leak treatment, with almost 50% of the surgeons recognizing its importance. Routine use of prophylactic drain after gastrectomy is still a widespread practice even if younger surgeons are more persuaded that it could not be advantageous.

Evaluation of Drain Insertion After Appendicectomy for Complicated Appendicitis: A Systematic Review and Meta-Analysis

This meta-analysis aims to evaluate the comparative outcomes of drain insertion versus no drain after appendicectomy for complicated appendicitis. A systematic search of PubMed, Cochrane Library and Scopus was conducted, and all studies comparing drain versus no drain after appendicectomy for complicated appendicitis were included. Abdominal collection, surgical site infection (SSI), bowel obstruction, faecal fistula, paralytic ileus, length of hospital stay (LOS) and mortality were the evaluated outcome parameters for the meta-analysis. Seventeen studies reporting a total number of 4,255 patients who underwent appendicectomy for complicated appendicitis with (n=1,580) or without (n=2,657) drain were included. There was no significant difference between the two groups regarding abdominal collection (odds ratio (OR)=1.41, P=0.13). No-drain group was superior to the drain group regarding SSI (OR=1.93, P=0.0001), faecal fistula (OR=4.76, P=0.03), intestinal obstruction (OR=2.40, P=0.04) and paralytic ileus (OR=2.07, P=0.01). There was a difference regarding mortality rate between the two groups (3.4% in the drain group vs 0.5% in the no-drain group, risk difference (RD)=0.01, 95% CI (-0.01, 0.04), P=0.36). In conclusion, this meta-analysis has shown that drains have no effect on the development of intra-abdominal collections in complicated appendicitis, but it can significantly increase the risk of postoperative complications such as fistula, surgical site infection (SSI), bowel obstruction, ileus and length of hospital stay.

The effect of abdominal drainage on post-operative morbidity; a prospective cohort study

The aim of this study was to investigate the effect of drains used in current clinical practice on operation parameters and post-operative morbidity. The comprehensive data obtained through the prospective design were analysed in detail according to whether abdominal drainage was applied. Abdominal drainage was present in 44.1% of patients who met the inclusion criteria. Drains were placed significantly more frequently during oncologic surgery (p = .007). The mean mobilisation (p = .001), first flatus (p = .001), and first oral intake (p = .029) times were longer in the drain group than those in the non-drain group. In patients who underwent oncological surgeries, no significant differences were observed except for the pre-operative duration of bowel preparation (p = .006) and first flatus time (p = .003). Our results suggest that drain placement in gynecological procedures does not provide an additional advantage.IMPACT STATEMENTWhat is already known on this subject? Post-operative drainage of the abdominal cavity has been controversial for many years. However, whether abdominal drainage provides an additional benefit in lower and upper abdominal surgical procedures remains unclear.What do the results of this study add? Most studies have examined post-operative pain and surgical site infections. We examined the relationship between abdominal drainage and demographic and pre-/post-operative clinical features in detail. We demonstrated that abdominal drainage in gynecological procedures may not provide an additional advantage.What are the implications of these findings for clinical practice and/or further research? The present study provides valuable information that can guide physicians in deciding whether to use post-operative abdominal drainage. This topic warrants investigation with randomised data in the future.

Laparoscopic appendectomy for complicated appendicitis in children: does the post-operative peritoneal drain make any difference? A pilot prospective randomised controlled trial

PURPOSE

This was a pilot randomised, prospective study, which aimed to determine and compare the post-operative complications of paediatric patients undergoing laparoscopic appendectomy (LA) for complicated appendicitis, with and without a peritoneal drain.

METHODS

Patients younger than 13 years, undergoing LA for complicated appendicitis at the Dr George Mukhari Academic Hospital (DGMAH), over a 15-month period during 2019-2020 were enrolled. Randomisation was achieved by a blocked randomisation plan. Patients were randomised in a 1:1 ratio into the "drain" (D) and "no drain" (ND) groups.

RESULTS

Thirty-four patients were included in this study; seventeen in each group. The complication rate was 26%. Intra-abdominal collection accounted for 89% of the complications. The complication rate in the "D" group was 18% and 35% in the "ND" group, with no statistically significant difference. Complication rates were higher (38%) in patients with generalised pus when compared to localised pus (7%), although not statistically significant. The mean theatre time, hospital stay, and duration of antibiotic use did not differ significantly between the groups.

CONCLUSION

From our study, the post-operative peritoneal drain did not make any statistically significant difference in patient outcome. The amount of intra-abdominal contamination is more likely to contribute in the development of complications.

TRIAL REGISTRATION NUMBER

SMUREC/M/15/2019: PG.

Enhanced recovery after bariatric surgery: an Italian consensus statement

Background

Enhanced recovery after bariatric surgery (ERABS) is an approach developed to improve outcomes in obese surgical patients. Unfortunately, it is not evenly implemented in Italy. The Italian Society for the Surgery of Obesity and Metabolic Diseases and the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care joined in drafting an official statement on ERABS.

Methods

To assess the effectiveness and safety of ERABS and to develop evidence-based recommendations with regard to pre-, intra-, and post-operative care for obese patients undergoing ERABS, a 13-member expert task force of surgeons and anesthesiologists from Italian certified IFSO center of excellence in bariatric surgery was established and a review of English-language papers conducted. Oxford 2011 Levels of Evidence and U.S. Preventive Services Task Force Grade Definitions were used to grade the level of evidence and the strength of recommendations, respectively. The supporting evidence and recommendations were reviewed and discussed by the entire group at meetings to achieve a final consensus.

Results

Compared to the conventional approach, ERABS reduces the length of hospital stay and does not heighten the risk of major post-operative complications, re-operations, and hospital re-admissions, nor does it increase the overall surgical costs. A total of 25 recommendations were proposed, covering pre-operative evaluation and care (7 items), intra-operative management (1 item, 11 sub-items), and post-operative care and discharge (6 items).

Conclusions

ERABS is an effective and safe approach. The recommendations allow the proper management of obese patients undergoing ERABS for a better outcome.

International survey among surgeons on laparoscopic right hemicolectomy: the gap between guidelines and reality

INTRODUCTION

To assess the current approaches and perioperative treatments of laparoscopic right hemicolectomy (LRHC) and to highlight similarities and differences with international guidelines and scientific evidence, we conducted a survey for surgeons across the globe.

METHODS

All digestive and colorectal surgeons registered with the database of the Research Institute against Digestive Cancer (IRCAD) were invited to take part in the survey via email and through the social media networks of IRCAD.

RESULTS

There were a total of 440 respondents from 78 countries. Most surgeons worked in the European region (38.6%) followed by the Americas (34.1%), the Eastern Mediterranean region (13.0%), the South-East Asian region (5.9%), the Western Pacific region (4.8%), and Africa (3.2%) respectively. Over half of the respondents performed less than 25% of right hemicolectomies laparoscopically where 4 ports are usually used by 68% of the surgeons. The medial-to-lateral, vessel-first approach is the approach most commonly used (74.1%). The most common extraction site was through a midline incision (53%) and an abdominal drain tube is routinely used by 52% of the surgeons after surgery. A total of 68.6% of the responding surgeons perform the majority of the anastomoses extracorporeally. Finally, we found that the majority of responders (60.7%) routinely used mechanical bowel preparations prior to LRHC.

CONCLUSION

Regarding several topics related to LRHC care, a discrepancy was observed between the current medical practice and the recommendations from RCTs and international guidelines and significant regional differences were observed.

Procedures Never Explained in Textbooks: How to Correctly Convert a Closed-Suction Drain to a Closed-Gravity Drain, and How to Correctly Remove a Closed-Suction Drain Off Suction

OBJECTIVE

To describe a novel method to convert a closed-system suction drain to a highly efficient closed-system gravity-dependent drain and demonstrate its efficacy in an ex-vivo model.

METHODS

We reviewed the 5 top-selling urology and surgery text/reference books for information on drainage systems. An ex-vivo model was designed with a reservoir of fluid connected to a Jackson-Pratt bulb drain. We measured the volume of fluid drained from the reservoir into the bulb while on-suction and off-suction. This was repeated using a novel modified bulb, where the bulb's outflow stopper was replaced with a one-way valve oriented to allow release of pressure from the bulb.

RESULTS

With the bulb on-suction, drainage was maintained regardless of the height of the drain relative to the reservoir. With the bulb off-suction, closed passive gravity-dependent drainage occurred only when the drain was below the fluid reservoir; drainage ceased at minimal volumes. With addition of a one-way valve and maintenance of the bulb below the level of the reservoir, drainage proceeded to completion.

CONCLUSION

How surgical drains work is not described in the leading urology and general surgery textbooks/reference books. Closed-system suction drains cannot be used to achieve passive gravity-dependent drainage without allowing release of displaced air from the bulb-lumen. The novel modified drain we describe affords reversible closed-system suction and passive drainage.

ERAS program adherence-institutionalization, major morbidity and anastomotic leakage after elective colorectal surgery: the iCral2 multicenter prospective study

BACKGROUND

Enhanced recovery after surgery (ERAS) programs influence morbidity rates and length of stay after colorectal surgery (CRS), and may also impact major complications and anastomotic leakage rates. A prospective multicenter observational study to investigate the interactions between ERAS program adherence and early outcomes after elective CRS was carried out.

METHODS

Prospective enrolment of patients submitted to elective CRS with anastomosis in 18 months. Adherence to 21 items of ERAS program was measured upon explicit criteria in every case. After univariate analysis, independent predictors of primary endpoints [major morbidity (MM) and anastomotic leakage (AL) rates] were identified through logistic regression analyses including all significant variables, presenting odds ratios (OR).

RESULTS

Institutional ERAS protocol was declared by 27 out of 38 (71.0%) participating centers. Median overall adherence to ERAS program items was 71.4%. Among 3830 patients included in the study, MM and AL rates were 4.7% and 4.2%, respectively. MM rates were independently influenced by intra- and/or postoperative blood transfusions (OR 7.79, 95% CI 5.46-11.10; p < 0.0001) and standard anesthesia protocol (OR 0.68, 95% CI 0.48-0.96; p = 0.028). AL rates were independently influenced by male gender (OR 1.48, 95% CI 1.06-2.07; p = 0.021), intra- and/or postoperative blood transfusions (OR 4.29, 95% CI 2.93-6.50; p < 0.0001) and non-standard resections (OR 1.49, 95% CI 1.01-2.22; p = 0.049).

CONCLUSIONS

This study disclosed wide room for improvement in compliance to several ERAS program items. It failed to detect any significant association between institutionalization and/or adherence rates to ERAS program with primary endpoints. These outcomes were independently influenced by gender, intra- and postoperative blood transfusions, non-standard resections, and standard anesthesia protocol.

Intraperitoneal drain placement and outcomes after elective colorectal surgery: international matched, prospective, cohort study

Background

Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice.

Methods

COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien–Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement.

Results

Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001).

Conclusion

Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk.

Impact of surgical drain output monitoring on patient outcomes in hepatopancreaticobiliary surgery: A systematic review

BACKGROUND AND OBJECTIVE

Surgical drains are widely utilized in hepatopancreaticobiliary surgery to prevent intra-abdominal collections and identify postoperative complications. Surgical drain monitoring ranges from simple-output measurements to specific analysis for constituents such as amylase. This systematic review aimed to determine whether surgical drain monitoring can detect postoperative complications and impact on patient outcomes.

METHODS

A systematic review was performed, and the following databases searched between 02/03/20 and 26/04/20: MEDLINE, EMBASE, The Cochrane Library, and Clinicaltrials.gov. All studies describing surgical drain monitoring of output and content in adult patients undergoing hepatopancreaticobiliary surgery were considered. Other invasive methods of intra-abdominal sampling were excluded.

RESULTS

The search returned 403 articles. Following abstract review, 390 were excluded and 13 articles were included for full review. The studies were classified according to speciality and featured 11 pancreatic surgery and 2 hepatobiliary surgery studies with a total sample of 3262 patients. Postoperative monitoring of drain amylase detected pancreatic fistula formation and drain bilirubin testing facilitated bile leak detection. Both methods enabled early drain removal. Improved patient outcomes were observed through decreased incidence of postoperative complications (pancreatic fistulas, intra-abdominal infections, and surgical-site infections), length of stay, and mortality rate. Isolated monitoring of drain output did not confer any clinical benefits.

CONCLUSIONS

Surgical drain monitoring has advantages in the postoperative care for selected patients undergoing hepatopancreaticobiliary surgery. Enhanced surgical drain monitoring involving the testing of drain amylase and bilirubin improves the detection of complications in the immediate postoperative period.

Randomized Controlled Trial Comparing the Short-term Outcomes of Enhanced Recovery After Surgery and Conventional Care in Laparoscopic Distal Gastrectomy (GISSG1901)

OBJECTIVE

This study aimed to compare the effects of ERAS and conventional programs on short-term outcomes after LDG.

SUMMARY OF BACKGROUND DATA

Currently, the ERAS program is broadly applied in surgical areas. Although several benefits of LDG with the ERAS program have been covered, high-level evidence is still limited, specifically in advanced gastric cancer.

METHODS

The present study was designed as a randomized, multicenter, unblinded trial. The enrollment criteria included histologically confirmed cT2-4aN0-3M0 gastric adenocarcinoma. Postoperative complications, mortality, readmission, medical costs, recovery, and laboratory outcomes were compared between the ERAS and conventional groups.

RESULTS

Between April 2019 and May 2020, 400 consecutive patients who met the enrollment criteria were enrolled. They were randomly allocated to either the ERAS group (n = 200) or the conventional group (n = 200). After excluding patients who did not undergo surgery or gastrectomy, 370 patients were analyzed. The patient demographic characteristics were not different between the 2 groups. The conventional group had a significantly longer allowed day of discharge and postoperative hospital stay (6.96 vs 5.83 days, P < 0.001; 8.85 vs 7.27 days, P < 0.001); a longer time to first flatus, liquid intake and ambulation (3.37 vs 2.52 days, P < 0.001; 3.09 vs 1.13 days, P < 0.001; 2.85 vs 1.38 days, P < 0.001, respectively); and higher medical costs (6826 vs 6328 $, P = 0.027) than the ERAS group. Additionally, patients in the ERAS group were more likely to initiate adjuvant chemotherapy earlier (29 vs 32 days, P = 0.035). There was no significant difference in postoperative complications or in the mortality or readmission rates. Regarding laboratory outcomes, the procalcitonin and C-reactive protein levels on postoperative day 3 were significantly lower and the hemoglobin levels on postoperative day 5 were significantly higher in the ERAS group than in the conventional group.

CONCLUSION

The ERAS program provides a faster recovery, a shorter postoperative hospitalization length, and lower medical costs after LDG without increasing complication and readmission rates. Moreover, enhanced recovery in the ERAS group enables early initiation of adjuvant chemotherapy.

Neutrophil extracellular trap formation index predicts occurrences of deep surgical site infection after laparotomy

Background

Deep surgical site infections (DSSIs) are serious complications after laparotomy. Neutrophil extracellular traps (NETs) play a vital role in the development of DSSI. Here, we focused on a new approach to predicting the occurrence of DSSI through the detection of the NET formation index (NFI), and compared its prediction ability with other clinical infection indicators.

Methods

Patients who received laparotomy were prospectively enrolled in this study. General information, APACHE II score, SOFA score, and serum infection indicators were recorded. The postoperative abdominal drainage fluid was collected within 3 days after the operation for quantification of the NFI.

Results

A total of 92 consecutive patients were included, with 22 patients were diagnosed with DSSI. The NFI in the DSSI group was 32.70%±19.33% while the corresponding index was 10.70%±8.25% in the non-DSSI group (P<0.01). The mean APACHE II and SOFA score had significant differences between the two groups. The NFI was positively correlated with the APACHE II score (P<0.01, r=0.269) and SOFA score (P=0.013, r=0.258). Patients with a high NFI (NFI >13.86%) had a higher risk of developing DSSI. According to the receiver operating characteristic (ROC) curve, the area under the ROC curve (AUC) of the NFI, C-reactive protein (CRP) and procalcitonin (PCT) were 0.912, 0.748 and 0.731, respectively.

Conclusions

In this cohort of surgical patients, the quantification of the NFI had a considerable predictive value for early identification of DSSI. The NFI in drainage fluid turned out to be a more sensitive and specific predictor of DSSI than serum infection indicators including CRP and PCT.

Severe Abdominal Wall Infection After Subcostal Transversus Abdominis Plane Block: A Case Report

Transversus abdominis plane (TAP) blocks are increasingly used for perioperative analgesia in patients undergoing abdominal surgeries. TAP blocks are easy to perform, reliably effective, and have an excellent safety profile. Nevertheless, we report a patient who underwent an open cholecystectomy and right hemicolectomy where a subcostal TAP block possibly contributed to an unusual abdominal wall abscess that lead to a prolonged and complicated postoperative course.

A novel multi-modal approach for prevention and treatment of anastomotic leakage after low anterior resection in rectal cancer patients

BACKGROUND

The objective of the clinical trial is to determine whether our novel multimodal approach can improve the anastomotic leakage (AL) in patients undergoing low anterior resection (LAR) for rectal cancer.

METHODS

From September 2019 to December 2020, a total of 33 patients who underwent LAR in our hospital were divided to receive a defunctioning stoma (DS) or multi-modal approach. The multi-modal approach consists of three intraoperative preventive measures (pelvic floor peritoneum closure, transanal drainage tube and abdominal drains) combined with a standardised pathway for early detection and active management of AL. The short-term indicators observed postoperatively were as follows: (1) incidence of AL; (2) additional operation time after LAR; (3) ileostomy complications; (4) postoperative hospital stay; (5) mortality. Long-term endpoints comprise: (1) Wexner incontinence scale; (2) anorectal manometry measurements.

RESULTS

No significant difference was observed in the rates of postoperative AL between both groups (P>0.05). Remarkable divergences in the ileostomy complications, Wexner score, and manometric evaluation were not noted between the groups (P>0.05). Both the maximal resting pressure and maximal squeezing pressure at 6 month were significantly decreased relative to the values noted before treatment (P<0.001).

DISCUSSION

In conclusion, the multi-modal approach achieves the same effect as DS in the prevention and management of AL during LRA with shorter operation time, meanwhile overcomes the adverse impact brought by DS. Therefore, our multiinterventional program may be used to replace the DS procedure during LRA.

Monitoring drainage flow rate facilitates prompt intervention with re-laparoscopy for postoperative bleeding after laparoscopic gynecologic surgery: A case-control study

INTRODUCTION

We aimed to identify the characteristics of cases involving postoperative bleeding after laparoscopic gynecologic surgery, and to clarify the optimal cutoff value of postoperative drainage and vital sign trends for predicting the need for re-laparoscopy.

METHODS

Of 6366 patients with gynecologic benign pathologies who underwent laparoscopic surgery at our institution between 2009 and 2018, 13 (0.2%) required re-laparoscopy for postoperative bleeding. After reviewing the perioperative course in the re-laparoscopy group, we examined the postoperative total drainage volume (mL), drainage flow rate (mL/h), and vital sign trends in the re-laparoscopy group (n = 13) and among patients with substantial drainage volume ≥300 mL at 12 hours postoperatively but who did not need re-laparoscopy (observation group, n = 107).

RESULTS

In the re-laparoscopy group, initial laparoscopic surgery included uterine surgery (myomectomy, n = 7; hysterectomy, n = 1), adnexal surgery (n = 3), and uterine plus adnexal surgery (n = 2). Postoperative bleeding sites included the uterine wound (n = 6), adnexal wound (n = 5), umbilical trocar site (n = 1), and mesentery (n = 1). The re-laparoscopy and observation groups did not differ regarding initial surgical characteristics or postoperative vital sign trends. For distinguishing between the re-laparoscopy and observation groups, the drainage flow rate was superior to total drainage volume. Continuous excessive drainage (flow rate >50 mL/h) at 3 hours postoperatively was associated with a remarkably increased risk for re-laparoscopy (odds ratio, 40.07; 95% confidence interval, 5.44 to 1776.41, P < 0.001).

CONCLUSION

In cases with continuous excessive drainage later than 3 hours postoperatively (flow rate >50 mL/h) should be considered for exploratory re-laparoscopy to enable prompt diagnosis and intervention.

Laparoscopy in Emergency: Why Not? Advantages of Laparoscopy in Major Emergency: A Review

A laparoscopic approach is suggested with the highest grade of recommendation for acute cholecystitis, perforated gastroduodenal ulcers, acute appendicitis, gynaecological disorders, and non-specific abdominal pain (NSAP). To date, the main qualities of laparoscopy for these acute surgical scenarios are clearly stated: quicker surgery, faster recovery and shorter hospital stay. For the remaining surgical emergencies, as well as for abdominal trauma, the role of laparoscopy is still a matter of debate. Patients might benefit from a laparoscopic approach only if performed by experienced teams and surgeons which guarantee a high standard of care. More precisely, laparoscopy can limit damage to the tissue and could be effective for the reduction of the overall amount of cell debris, which is a result of the intensity with which the immune system reacts to the injury and the following symptomatology. In fact, these fragments act as damage-associated molecular patterns (DAMPs). DAMPs, as well as pathogen associated molecular patterns (PAMPs), are recognised by both surface and intracellular receptors of the immune cells and activate the cascade which, in critically ill surgical patients, is responsible for a deranged response. This may result in the development of progressive and multiple organ dysfunctions, manifesting with acute respiratory distress syndrome (ARDS), coagulopathy, liver dysfunction and renal failure. In conclusion, none of the emergency surgical scenarios preclude laparoscopy, provided that the surgical tactic could ensure sufficient cleaning of the abdomen in addition to resolving the initial tissue damage caused by the “trauma”.

Abdominal drain amylase on the first day after pancreatectomy: a predictive factor for pancreatic fistula

OBJECTIVE

To analyze abdominal drain on the first postoperative day and evaluate its predictive nature for the diagnosis of Pancreatic Fistula exclusion, seeking to establish a cutoff point from which lower values demonstrate safety in excluding the possibility of this complication.

METHODS

From August 2017 to June 2020, data from 48 patients undergoing pancreatic resection were collected and analyzed from a prospective cohort. The patients were divided into two groups, one group consisting of patients who did not develop PF (Group A), and the other composed of patients who developed PF (Group B). The receiver operation characteristic curve was constructed, and cutoff points were evaluated by calculating sensitivity and specificity.

RESULTS

Group A brought 30 patients together (62.5%) and Group B brought 18 patients together (37.5%). The 444 U/L value was the most satisfactory cutoff point for the receiver operation characteristic curve (CI 0.690-0.941), with a sensitivity of 94.4% and a specificity of 60%, thus being able to select 18 of 30 patients who did not succumb to PF.

CONCLUSIONS

Abdominal drain on the first postoperative day can be used as a predictive factor in the diagnosis of PF exclusion (CI 0.690-0.941), with the value of 444 U/L being the best performance cutoff point.

Abdominal drainage to prevent intra-peritoneal abscess after appendectomy for complicated appendicitis

BACKGROUND

This is the second update of a Cochrane Review first published in 2015 and last updated in 2018. Appendectomy, the surgical removal of the appendix, is performed primarily for acute appendicitis. Patients who undergo appendectomy for complicated appendicitis, defined as gangrenous or perforated appendicitis, are more likely to suffer postoperative complications. The routine use of abdominal drainage to reduce postoperative complications after appendectomy for complicated appendicitis is controversial.

OBJECTIVES

To assess the safety and efficacy of abdominal drainage to prevent intraperitoneal abscess after appendectomy (irrespective of open or laparoscopic) for complicated appendicitis; to compare the effects of different types of surgical drains; and to evaluate the optimal time for drain removal.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, Web of Science, the World Health Organization International Trials Registry Platform, ClinicalTrials.gov, Chinese Biomedical Literature Database, and three trials registers on 24 February 2020, together with reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared abdominal drainage versus no drainage in people undergoing emergency open or laparoscopic appendectomy for complicated appendicitis. We also included RCTs that compared different types of drains and different schedules for drain removal in people undergoing appendectomy for complicated appendicitis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We used the GRADE approach to assess evidence certainty. We included intraperitoneal abscess as the primary outcome. Secondary outcomes were wound infection, morbidity, mortality, hospital stay, hospital costs, pain, and quality of life.

MAIN RESULTS

Use of drain versus no drain We included six RCTs (521 participants) comparing abdominal drainage and no drainage in participants undergoing emergency open appendectomy for complicated appendicitis. The studies were conducted in North America, Asia, and Africa. The majority of participants had perforated appendicitis with local or general peritonitis. All participants received antibiotic regimens after open appendectomy. None of the trials was assessed as at low risk of bias. The evidence is very uncertain regarding the effects of abdominal drainage versus no drainage on intraperitoneal abscess at 30 days (risk ratio (RR) 1.23, 95% confidence interval (CI) 0.47 to 3.21; 5 RCTs; 453 participants; very low-certainty evidence) or wound infection at 30 days (RR 2.01, 95% CI 0.88 to 4.56; 5 RCTs; 478 participants; very low-certainty evidence). There were seven deaths in the drainage group (N = 183) compared to one in the no-drainage group (N = 180), equating to an increase in the risk of 30-day mortality from 0.6% to 2.7% (Peto odds ratio 4.88, 95% CI 1.18 to 20.09; 4 RCTs; 363 participants; low-certainty evidence). Abdominal drainage may increase 30-day overall complication rate (morbidity; RR 6.67, 95% CI 2.13 to 20.87; 1 RCT; 90 participants; low-certainty evidence) and hospital stay by 2.17 days (95% CI 1.76 to 2.58; 3 RCTs; 298 participants; low-certainty evidence) compared to no drainage. The outcomes hospital costs, pain, and quality of life were not reported in any of the included studies. There were no RCTs comparing the use of drain versus no drain in participants undergoing emergency laparoscopic appendectomy for complicated appendicitis. Open drain versus closed drain There were no RCTs comparing open drain versus closed drain for complicated appendicitis. Early versus late drain removal There were no RCTs comparing early versus late drain removal for complicated appendicitis.

AUTHORS' CONCLUSIONS

The certainty of the currently available evidence is low to very low. The effect of abdominal drainage on the prevention of intraperitoneal abscess or wound infection after open appendectomy is uncertain for patients with complicated appendicitis. The increased rates for overall complication rate and hospital stay for the drainage group compared to the no-drainage group are based on low-certainty evidence. Consequently, there is no evidence for any clinical improvement with the use of abdominal drainage in patients undergoing open appendectomy for complicated appendicitis. The increased risk of mortality with drainage comes from eight deaths observed in just under 400 recruited participants. Larger studies are needed to more reliably determine the effects of drainage on morbidity and mortality outcomes.

Revisiting the Value of Drains After Low Anterior Resection for Rectal Cancer: a Multi-institutional Analysis of 996 Patients

BACKGROUND

Intraoperative pelvic drains are often placed during low anterior resection (LAR) to evacuate postoperative fluid collections and identify/control potential anastomotic leaks. Our aim was to assess the validity of this practice.

METHODS

Patients from the US Rectal Cancer Consortium (2007-2017) who underwent curative-intent LAR for a primary rectal cancer were included. Patients were categorized as receiving a closed suction drain intraoperatively or not. Primary outcomes were superficial surgical site infection (SSI), deep SSI, intraabdominal abscess, anastomotic leak, and need for secondary drain placement. Three subgroup analyses were conducted in patients who received neoadjuvant chemoradiation, had a diverting loop ileostomy (DLI), and had low anastomoses < 6 cm from the anal verge.

RESULTS

Of 996 patients 67% (n = 551) received a drain. Drain patients were more likely to be male (64 vs 54%), have a smoking history (25 vs 19%), have received neoadjuvant chemoradiation (73 vs 61%), have low tumors (56 vs 36%), and have received a DLI (80 vs 71%) (all p < 0.05). Drains were associated with an increased anastomotic leak rate (14 vs 8%, p = 0.041), although there was no difference in the need for a secondary drainage procedure to control the leak (82 vs 88%, p = 0.924). These findings persisted in all subset analyses. Drains were not associated with increased superficial SSI, deep SSI, or intraabdominal abscess in the entire cohort or each subset analysis. Reoperation (12 vs 10%, p = 0.478) and readmission rates (28 vs 31%, p = 0.511) were similar.

CONCLUSIONS

Although not associated with increased infectious complications, intraoperatively placed pelvic drains after low anterior resection for rectal cancer are associated with an increase in anastomotic leak rate and no reduction in the need for secondary drain placement or reoperation. Routine drainage appears to be unnecessary.

No Benefit of Prophylactic Surgical Drainage in Combined Liver and Kidney Transplantation: Our Experience and Review of the Literature

Background: Contrasting results have emerged from limited studies investigating the role of prophylactic surgical drainage in preventing wound morbidity after liver and kidney transplantation. This retrospective study analyzes the use of surgical drain and the incidence of wound complications in combined liver and kidney transplantation (CLKTx).

Methods: A total of 55 patients aged ≥18 years were divided into two groups: the drain group (D) (n = 35) and the drain-free group (DF) (n = 20). Discretion to place a drain was based exclusively on surgeon preference. All deceased donor kidneys were connected to the LifePort Renal Preservation Machine® prior to transplantation, in both simultaneous and delayed technique of implantation of the renal allograft. The primary outcome was the development of superficial/deep wound complications during the study follow-up. Secondary outcomes included the development of delayed graft function (DGF) of the transplanted kidney, primary non-function (PNF) and early allograft dysfunction (EAD) of the transplanted liver, graft failure, graft and patient survival, overall post-operative morbidity rate and length of hospital stay.

Results: With a median follow-up of 14.4 months after transplant, no difference in the incidence of superficial/deep wound complications, except for hematomas, in collections size, intervention rate, PNF, EAD, graft failure and patient survival, was observed between the 2 groups. Significantly lower level of platelets, higher INR values, DGF, morbidity rates and length of hospital stay were reported post-operatively in the D group. Pre-operative hypoalbuminemia and longer CIT were included in the propensity score for receiving a drain and were associated with a significantly higher rate of developing a hematoma post-transplant.

Conclusions: Absence of the surgical drain did not appear to adversely affect wound morbidity compared to the prophylactic use of drains in renal transplant patients during CLKTx.

Predictive and Diagnostic Biomarkers of Anastomotic Leakage: A Precision Medicine Approach for Colorectal Cancer Patients

Development of an anastomotic leak (AL) following intestinal surgery for the treatment of colorectal cancers is a life-threatening complication. Failure of the anastomosis to heal correctly can lead to contamination of the abdomen with intestinal contents and the development of peritonitis. The additional care that these patients require is associated with longer hospitalisation stays and increased economic costs. Patients also have higher morbidity and mortality rates and poorer oncological prognosis. Unfortunately, current practices for AL diagnosis are non-specific, which may delay diagnosis and have a negative impact on patient outcome. To overcome these issues, research is continuing to identify AL diagnostic or predictive biomarkers. In this review, we highlight promising candidate biomarkers including ischaemic metabolites, inflammatory markers and bacteria. Although research has focused on the use of blood or peritoneal fluid samples, we describe the use of implantable medical devices that have been designed to measure biomarkers in peri-anastomotic tissue. Biomarkers that can be used in conjunction with clinical status, routine haematological and biochemical analysis and imaging have the potential to help to deliver a precision medicine package that could significantly enhance a patient's post-operative care and improve outcomes. Although no AL biomarker has yet been validated in large-scale clinical trials, there is confidence that personalised medicine, through biomarker analysis, could be realised for colorectal cancer intestinal resection and anastomosis patients in the years to come.

Prophylactic intraabdominal drains do not confer benefit in pediatric perforated appendicitis: Results from a quality improvement initiative

BACKGROUND/PURPOSE

Prophylactic, intraabdominal drains have been used to prevent intraabdominal abscess (IAA) after perforated appendicitis. We hypothesized that routine drain placement would reduce the IAA rate in pediatric perforated appendicitis.

METHODS

A 27-month quality improvement (QI) initiative was conducted: closed-suction, intraabdominal drains were placed intraoperatively in pediatric (age < 18) perforated appendicitis patients. QI patients were compared to controls admitted during the preceding 8 months and following 4 months. The primary outcome was 30-day IAA rate. Univariate and multivariate analyses were performed.

RESULTS

Two hundred seventy QI patients were compared to 109 controls. There was 100% compliance during 21 of 27 months of the QI initiative; only 7 QI patients did not receive drains. IAA occurred in 20.0% of QI patients and 22.9% of control (p = 0.52). After adjustment, the QI initiative was not associated with reduced odds of IAA (OR 0.83, 95% CI 0.48-1.44). Median length of stay was longer in QI patients during the index admission (p = 0.03) and over 30 postoperative days (p = 0.03), but these relationships did not persist after adjustment.

CONCLUSIONS

A QI initiative investigating prophylactic, intraabdominal drain placement in perforated appendicitis did not reduce the IAA rate. We recommend against routine drain placement in pediatric perforated appendicitis.

LEVEL OF EVIDENCE

Level III.

Variation in Drain Management Among Patients Undergoing Major Hepatectomy

BACKGROUND

Although previous studies have suggested that drain management is highly variable, data on drain placement and timing of drain removal among patients undergoing hepatic resection remain scarce. The objective of the current study was to define the utilization of drain placement among patients undergoing major hepatic resection.

METHODS

The ACS NSQIP-targeted hepatectomy database was used to identify patients who underwent major hepatectomy between 2014 and 2017. Association between day of drain removal, timing of discharge, and drain fluid bilirubin on postoperative day (POD) 3 (DFB-3) was assessed. Propensity score matching (PSM) was used to compare outcomes of patients with a drain removed before and after POD 3.

RESULTS

Among 5330 patients, most patients had an abdominal drain placed at the time of hepatic resection (n = 3075, 57.7%). Of 2495 patients with data on timing of drain removal, only 380 patients (15.2%) had their drain removed by POD 3. Almost 1 in 6 patients (n = 441, 17.7%) were discharged home with the drain in place. DFB-3 values correlated poorly with POD of drain removal (R² = 0.0049). After PSM, early drain removal (≤ POD 3) was associated with lower rates of grade B or C bile leakage (2.1% vs. 7.1%, p = 0.008) and prolonged length of hospital stay (6.0% vs. 12.7%, p = 0.009) compared with delayed drain removal (> POD 3).

CONCLUSIONS

Roughly 3 in 5 patients had a drain placed at the time of major hepatectomy and only 1 in 7 patients had the drain removed early. This study demonstrated the potential benefits of early drain removal in an effort to improve the quality of care following major hepatectomy.

Comparison of Clinical Outcomes Between Chinese Patients Receiving Hepatectomy With or Without Enhanced Recovery After Surgery Strategy

Purposes: For the first time in China, the current study was designed to compare the clinical outcomes between Chinese patients receiving hepatectomy with or without the enhanced recovery after surgery (ERAS) strategy. Methods: The current study enrolled 250 patients who would receive hepatectomy. Patients were randomized into two groups: ERAS group (n = 125, ERAS strategy) and control (n = 125, conventional care). Mortality, length of hospital stay, readmission, and complications were assessed over 30 days after the operation. Results: The average age of the whole cohort was 65 (63-68) years, with 152 males (60.8%). There was no difference between two groups in baseline features, such as age, sex, medical history, Child-Pugh hepatic function, American Society of Anaesthesiologists physical status, operative type, hepatectomy type, and hepatic pathology (P > 0.05 for all). There was no occurrence of death in the two groups. Patients in the ERAS group had significantly less occurrence of post-operative complications and a shorter length of hospital stay (P < 0.05 for all). Deep vein thrombosis occurred in seven patients in the control group, but did not occur in the ERAS group (P < 0.05). Patients in the two groups had similar occurrence of readmission (P > 0.05). Conclusions: ERAS strategy significantly decreased the occurrence of operative complications and shortened the length of hospital stay without any increase in mortality or readmission in Chinese patients receiving hepatectomy.

The implementation of enhanced recovery after surgery protocols in ovarian malignancy surgery

The enhanced recovery after surgery (ERAS) refers to multimodal interventions to reduce the length of hospital stay and complications at various steps of perioperative care. It was first developed in colorectal surgery and later embraced by other surgical disciplines including gynecologic oncology. The ERAS Society recently published guidelines for gynecologic cancer surgeries to enhance patient recovery. However, limitations exist in the implementation of the guidelines in ovarian cancer patients due to the distinct characteristics of the disease. In the present review, we discuss the results that have been published in the literature to date regarding the ERAS protocols in ovarian cancer patients, and explain why more evidence needs to be specifically assessed in this type of malignancy among other gynecologic cancers.