Additional Drainage Research Articles

A systematic review of the optimal drainage technique for septic hip arthritis in children.

The hip is one of the most commonly affected joints in paediatric septic arthritis. Drainage can be performed using arthrocentesis (articular needle aspiration), arthroscopy or arthrotomy. The objective of this systematic review was to identify the most effective drainage technique for septic hip arthritis in the paediatric population. The electronic MEDLINE, EMBASE and Cochrane databases were systematically searched for original articles that reported outcomes of arthrocentesis, arthroscopy or arthrotomy for septic arthritis of the paediatric hip. Outcome parameters were additional drainage procedures, clinical outcomes and radiological sequelae. The quality of each of the included studies was assessed with the Methodological Index for Non-randomized Studies (MINORS) score. Out of 2428 articles, 19 studies with a total of 406 hip joints were included in the systematic review. Additional arthroscopy or arthrotomy was performed in 15% of the hips treated with arthrocentesis, in 14% after arthroscopy and in 3% after arthrotomy. Inferior clinical outcomes and more radiological sequelae were seen in patients treated with an arthrotomy. A meta-analysis could not be performed due to the diversity and low quality of the studies (MINORS median 4 [range 2-15]). This systematic review gives a comprehensive overview of the available literature on treatment for septic hip arthritis in children. Arthrocentesis and arthroscopic procedures may have a higher risk of additional drainage procedures in comparison with arthrotomy. However, arthrotomy might be associated with inferior outcomes in the longer term. The included studies are diverse and the scientific quality is generally low.

Clinical and Cost Profile of Controlled Grade B Postoperative Pancreatic Fistula: Rationale for Their Consideration as Low Risk

BackgroundDespite standardization, the 2016 ISGPF criteria are limited by their wider applicability and oversimplification of grade B POPF. This work applied the 2016 ISGPF grading criteria within a US academic cancer center to verify clinical and fiscal distinctions and sought to improve grading criteria for grade B POPF. MethodsThe 2008–2018 cost and NSQIP data from pancreaticoduodenectomy to postoperative day 90 were merged. All POPFs were coded by 2016 ISGPF criteria. The Clavien-Dindo Classification (CD) defined complication severity. On sub-analyses, grade B POPFs were divided into those with adequate drainage and those requiring additional drainage. Chi-square, ANOVA, and Fisher’s least significant difference test were employed. ResultsTwo hundred thirty-two patients were in the final analyses, 72 (31%) of whom had POPFs: 16 (7%) biochemical leaks, 54 (23%) grade B (28% required additional drainage), and 2 (1%) grade C. There was no significant difference in length of stay, CD, readmission, or cost in patients without a POPF, with biochemical leak or grade B POPF. On sub-analyses, 92% of adequately drained grade B POPFs had CD 1–2 and readmission equivalent to patients without POPF (p > 0.05). One hundred percent of grade B POPF requiring drainage had CD 3–4a, and 67% were readmitted. Cost was significantly increased in grade B POPF requiring additional drainage (p = 0.02) and grade C POPF (p < 0.01). ConclusionsThis analysis did not confirm an incremental increase in morbidity and cost with POPF grade. Sub-analyses enabled accurate clinical and cost distinctions in grade B POPF; adequately drained grade B POPF are low risk and clinically insignificant.

Arthrocentesis, arthroscopy or arthrotomy for septic knee arthritis in children: a systematic review.

PurposeSeptic knee arthritis in children can be treated by arthrocentesis (articular needle aspiration) with or without irrigation, arthroscopy or arthrotomy followed by antibiotics. The objective of this systematic review was to identify the most effective drainage technique for septic arthritis of the knee in children.MethodsThe electronic PubMed, Embase and Cochrane databases were systematically searched for original articles that reported outcomes of arthrocentesis, arthroscopy or arthrotomy for septic arthritis of the knee. The quality of all included studies was assessed with the Methodological Index for Non-Randomized Studies (MINORS) criteria. This systematic review was performed and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.ResultsOut of 2428 articles, 11 studies with a total of 279 knees were included in the systematic review. The quality of evidence was low (MINORS median 4 (2 to 7)). A meta-analysis could not be performed because of the diversity and low quality of the studies. In septic knee arthritis, additional drainage procedures were needed in 54 of 156 (35%) knees after arthrocentesis, in four of 96 (4%) after arthroscopy and in two of 12 (17%) after arthrotomy. ConclusionIncluded studies on treatment strategies for septic arthritis of the knee in children are diverse and the scientific quality is generally low. Knee arthroscopy might have a lower risk of additional drainage procedures as compared with arthrocentesis and arthrotomy, with acceptable clinical outcomes and no radiological sequelae.Level of evidenceIV

Unilateral versus Bilateral Endoscopic Nasobiliary Drainage and Subsequent Metal Stent Placement for Unresectable Malignant Hilar Obstruction: A Multicenter Randomized Controlled Trial.

(1) Background: Endoscopic management of hilar biliary obstruction is still challenging. Compared with unilateral drainage, bilateral drainage could preserve larger functional liver volume and potentially improve clinical outcomes. To evaluate the effectiveness of bilateral drainage, we conducted this multicenter randomized controlled study. (2) Methods: Patients with unresectable malignant hilar biliary obstruction were assigned to unilateral or bilateral group. At first, patients underwent endoscopic nasobiliary drainage (ENBD), and subsequently underwent self-expandable metallic stent (SEMS) deployment. Primary outcomes were the functional success rate of ENBD and time to recurrent biliary obstruction (TRBO) after SEMS deployment. (3) Results: During the study period, 38 and 39 patients were enrolled in the unilateral and bilateral groups. The functional success rate was similar in the uni- and bi-ENBD group (57% vs. 56%; p = 0.99), but the rate of additional drainage was higher in uni-ENBD group. Although TRBO and overall survival time after SEMS deployment were not different between the groups (p = 0.11 and 0.78, respectively), the incidence of early adverse events tended to be higher in the bi-SEMS group (5.3% vs. 28%; p = 0.11). (4) Conclusions: Our study failed to demonstrate the superiority of bilateral over unilateral biliary drainage in terms of functional success rate and TRBO.

Extension: Long-term Follow-up Study of an Endoscopic versus Surgical Step-up Approach for Infected Necrotizing Pancreatitis

Introduction: The TENSION trial (published in 2018) found that the endoscopic step-up approach in patients with infected necrotizing pancreatitis does not reduce mortality or major complications. However, it prevents pancreatic fistulas and shortens hospital stay, as compared to the surgical step-up approach. Nonetheless, the question remains whether long-term outcomes (>6 months) differ between both approaches. The aim of this study is to compare long-term clinical outcomes after the endoscopic and surgical step-up approach. Methods: TENSION trial participants were prospectively evaluated by interviews and pancreatic function measurements after a follow-up period of at least 5 years. Endpoints were similar to those of the original TENSION trial. The primary endpoint was composed of death and major complications, occurring between randomization and end of long-term follow-up. Secondary endpoints included the individual components of the primary endpoint, pancreatic fistula, exocrine and endocrine insufficiency, total hospital stay, reinterventions, and quality of life (QoL). Results: The mean follow-up period was 7 years (84±11 months). The primary endpoint occurred in 29 patients (57%) from the endoscopy group and in 27 patients (57%) from the surgery group (RR 0.99, 95% CI 0.70–1.40). No difference was found in overall mortality (15 patients (29%) vs. 7 (15%) respectively; RR 1.89, 95% CI 0.89–4.42). During long-term follow-up, the first patient died 2.5 years after randomization, and all but one deaths were not related to pancreatitis (5 out of 6 (83%) vs. 1 (100%); RR 0.83, 95% CI 0.58–1.19). In the endoscopy group, fewer pancreatic fistulas (8% vs. 36%; RR 0.25, 95% CI 0.09–0.69) and additional drainages were observed during follow-up (7% vs. 24%; RR 0.29, 95% CI 0.09–0.99). The endoscopy group reported higher physical health scores (SF-36) at 3 months after randomization (42±11 vs. 36±10, P=0.04), however, long-term QoL scores did not differ (EQ-5D 0.80±0.23 vs. 0.86±0.17, P=0.24). Conclusion: During the long-term follow-up of TENSION trial participants, we found no differences in mortality and major complications between the endoscopic and surgical step-up approach for infected necrotizing pancreatitis. However, the endoscopic step-up approach results in fewer pancreatic fistulas, additional drainage procedures, and a faster physical recovery. These results confirm that, if both techniques are feasible, the endoscopic approach should be preferred.

Bronchopleural Fistula after Surgery: Therapeutic Efficacy of Bronchial Occluders

목적수술 후 발생하는 기관지늑막루에 대한 bronchial occluder device (이하 BOD)의 유용성 및 효과성을 평가하고자 한다.대상과 방법2009년도부터 2019년까지 폐암 및 폐결핵으로 수술 후 발생한 7명의 기관지늑막루 환자들 중에 BOD 치료를 실시한 6명의 환자를 대상으로 하였다. 폐암 환자가 5명, 폐결핵 환자는 1명이었다. 남자가 5명, 여자가 1명이었으며 59세에서 74세(평균: 69세)이었다. 진단은 전산화단층기관지 촬영과 기관지내시경으로 실시하였다. 시술은 진단 후 1주에서 2주 사이에 실시하였다. 치료에 사용된 BOD의 기술적 성공 및 임상적 성공을 평가하였다. 시술 후 임상적 치료 효과와 생존 기간 및 부가적인 치료에 대하여 알아보았다.결과총 6명 환자 모두에서 시술을 성공적으로 실시하였다. 임상성공 5명에서 있었고, 1명에서는 임상부분성공이 있었다. 임상실패한 경우는 없었다. 기구의 이동이나 천공의 합병증은 없었다. 2명은 전산화단층기관지 촬영으로, 4명은 기관지내시경으로 기관지늑막루를 진단하였다. 수술은 폐엽절제술(lobectomy) 2명, 폐이엽절제술(bilobectomy) 2명, 그리고 전폐절제술(pneumonectomy) 2명이었다. 수술 후 진단까지 걸린 시간은 1개월에서 34개월(평균: 10개월)이었다. 4명(59~103일: 평균 80.5일)은 사망하였고 2명(313일, 3331일)은 생존하였다. 사망 원인이 2명은 기저질환의 악화, 1명은 폐부종 및 흉수, 1명은 폐렴이었다. 한 명에서 부가적인 카테타 배액술, 2명에서 흉관 삽입을 유지하였다.결론폐절제 수술 후 발생할 수 있는 기관지늑막루 치료에 있어서 BOD는 유용하고 효과적인 치료 방법이다.

Needles in the Pay Stack ADNOC Exploring Tight-Oil Rock, Triples Production In First Pilot

In the midst of an industry downturn last year, the Abu Dhabi National Oil Company (ADNOC) reached a new oil production ceiling of 4 million B/D. The UAE’s largest producer has no intentions of slowing down. By decade’s end, ADNOC expects to have raised its maximum daily output by another million barrels. To cross that milestone, the company has set its sights on mastering the tight, thin, and unconventional formations that dot the UAE’s subsurface landscape. One of the places where such developments are hoped to unfold soon is known as Field Q. Found in southeastern Abu Dhabi, Field Q sits above a tight carbonate reservoir that holds an estimated 600 million bbl of oil. But with a permeability ranging from 1 to 3 millidarcy and poor vertical communication, the reservoir and its barrels have proven difficult to cultivate economically - until recently. ADNOC has published new details of its first onshore pilot of a “fishbone stimulation” that involved using more than a hundred hollow needles to pierce as far as 40 ft into the reservoir rock. The additional drainage netted by the fishbone needles boosted production threefold in the test well, as compared with its traditionally completed neighbors on the same pad. ADNOC ran the pilot in the summer of 2019 and by the end of the year saw enough production data to launch a wider 10-well pilot that remains underway. Based on a longer-term data set from these wells, the company will decide whether to leap into a fieldwide deployment of the niche completions technology. In the meantime, the petrotechnical team in charge of the test projects have issued roundly positive reviews of the fishbone technique in two recently presented technical papers (SPE 202636; SPE 203086) from the Abu Dhabi International Petroleum Exhibition &amp; Conference (ADIPEC). “There is a chance that the fishbone-stimulated wells can avoid the drilling of multiple wells targeting different sublayers in the same zone,” said Rama Rao Rachapudi, listing one of several of the technology’s advantages over other approaches that were considered. The senior petroleum engineer with ADNOC, who is one of several authors of the papers that cover both the drilling and completions aspects of the pilot, shared during ADIPEC that his onshore team found motivation to test the technology after bringing in a batch of dis-mal appraisal wells. The fishbone system, also known as multilateral jetting stimulation technology, has been a specialized application ever since it was introduced just over a decade ago. Underscoring the potential impact of the current round of pilots on the technology’s adoption rate, ADNOC noted there were only around 30 worldwide fishbone deployments prior to this project. Most of those have been in the Middle East’s naturally fractured and layered carbonate formations - just like those of Field Q.

Effect of inclination on thermal performance of a louver-finned aluminum heat exchanger having a drainage channel

Heat exchangers are frequently installed at an inclined angle to reduce the height of the air-conditioning unit. The inclination may deteriorate the thermal performance of the heat exchanger, and the effect will be more severe for an aluminum heat exchanger compared with a conventional fin-and-tube heat exchanger. However, the literature shows very limited investigations on this subject. In this study, a series of tests were conducted for a newly-developed aluminum heat exchanger, which has an additional drainage channel at downstream of the fin. Results showed that the pressure drop increased as inclination angle increased. However, the heat transfer coefficient showed a minimum behavior at approximately 45° inclination angle. This was true both for dry and wet conditions. The effect of inclination angle on the ratio between wet and dry j and f factor was not significant, which suggested that the inclination did not alter the condensate pattern on the louver fin (louver-bridging, fin-bridging, etc.) significantly. Comparison of the thermal efficiency indices (j/f1/3) of the present sample with those of the conventional sample (having no drainage channel) showed that the thermal performance improvement is significant under wet condition, which confirms the excellent condensate drainage of the present sample.

725. Influence of An Emerging Pathogen, Streptococcus anginosus, on Clinical Outcomes in Pediatric Appendiceal Abscess

BackgroundEscherichia Coli is the most common primary pathogen in appendiceal abscess, but an increasing number involve Streptococcus anginosus (SA) as the primary isolate. Ten years of data from a regional medical center was reviewed to track changes in the microbiology and outcomes of this condition. We believe that SA is emerging as a significant pathogen in appendiceal abscess in children and it is associated with increased morbidity compared to more commonly encountered pathogens.MethodsA medical records search was done (IRB#5194) for patients below age 18 from 1/2008 to 12/2017 with acute appendicitis with local/generalized peritonitis or peritoneal abscess. There were 557 records retrieved, of which 201 had appendiceal abscess. The records were further divided based on the type of operation and timing of abscess development. There were 104 laparoscopic, 34 open, 4 drain alone, 53 interval management with a drain, and 6 interval without a drain. The focus of the study is laparoscopic and open post operative abscess. 56 of the laparoscopic cases developed a postoperative abscess of whom 45 had culture and sensitivity data. 25 of the open cases developed a postoperative abscess of whom 24 had culture and sensitivity data.ResultsOf the 45 postoperative abscesses following laparoscopic procedure, the most common isolate was E. coli (34) followed by SA (13). Of the 24 postoperative abscesses following open procedure, the most common isolate was also E. Coli (17) followed by SA (6). Patients are divided into those who had any culture of SA (SA group), vs those who did not (non-SA group). For laparoscopic cases there was no difference between additional procedures needed. However for open procedures, the SA group had an average of 2.33 additional procedures needed compared to the 0.94 additional procedures for the non-SA group (p=0.024). Major adverse outcomes included one death from sepsis, abdominal compartment syndrome, and one patient needing bilateral salpingectomy, all in the SA group.ConclusionSA has emerged as an important and virulent pathogen in complex appendicitis in pediatric patients. It is sensitive to commonly used antibiotics, but is associated with increased risks of reoperation, additional drainage and adverse outcome for the sicker patients who require an open procedure.Disclosures All Authors: No reported disclosures

Dynamic extracorporeal life support: A novel management modality in temporary cardio-circulatory assistance.

Extracorporeal life support (ECLS) is a temporary mechanical assistance method employed in acute respiratory, cardiocirculatory, and cardio-respiratory failure, refractory to conventional treatments. Patient's hemodynamic, respiratory and metabolic condition, or situations related to ECLS support or performance, may change during ECLS treatment. Provision of an additional drainage or perfusion cannula, or even of an additional associated device, for example, transaortic suction device or intra-aortic balloon pump (IABP), may be required to improve the ECLS/patient interaction and effects. Besides such a modified ECLS mode, however, a potential asset is represented by the "dynamic ECLS," which is the change of the flow direction (drainage or perfusion) in the already implanted cannula during the ECLS run. This particular management may be achieved in venous femoral or jugular cannulation, but it finds an even more appealing potential with the pulmonary artery (PA) cannulation. The PA allows the institution of a multitasking ECLS circuit, ranging from enhanced left ventricle (LV) unloading (drainage from the PA) to a right ventricular support or "central" veno-venous ECLS (perfusing the PA), tailored according to the patient hemodynamic, gas exchange, metabolic state, underlying cardiac involvement, and ECLS performance. Dynamic ECLS may, therefore, represent an additional option in ECLS management, particularly including the PA cannulation. Based on this new dynamic management of ECLS mode, we propose the Extracorporeal Life Support Organization nomenclature update.

When Should We Perform Endoscopic Drainage and Necrosectomy for Walled-Off Necrosis?

Endoscopic drainage and necrosectomy are now accepted treatment approaches for patients with symptomatic walled-off pancreatic necrosis (WON). The current recommendations advocate step-up approaches for the treatment of symptomatic WON. Previous recommendations stipulated that endoscopic intervention should be delayed until more than four weeks after the onset. Recent data on early drainage have been increasing and this option might be considered in well-encapsulated cases, but the percutaneous route is preferred if the drainage is performed within two weeks after onset or in nonencapsulated cases. Recently, additional drainage methods, such as the multiple gateway technique and multiple stent placement, have been developed to open up multiple dead spaces in the WON cavity. Endoscopic necrosectomy could be performed via the transluminal route or percutaneous route after failed initial and additional drainage procedures. The use of novel lumen-apposing stents is a promising treatment option that could reduce the number of steps, the procedure time, and the overall number of necrosectomies.

Klatskin tumor complicated by obstructive jaundice and cholangitis in real practice: unresectable tumor or incurable patient?

The objective was to determine the effectiveness of biliary drainage/stenting before admission to the specialized Department of hepatobiliary surgery in patients with Klatskin tumors and the possibility of subsequent specific treatment. Methods and materials . During 2015-2019, 58 patients with Klatskin tumor (Bismuth - Corlette types: I - in 4 pts; II - 6; III - 36; IV - 12) were hospitalized with biliary drainage/stenting performed in outside hospitals because of obstructive jaundice. In 45 (78 %) patients due to uncontrolled cholangitis and /or obstructive jaundice, correction and/or additional drainage of the bile ducts was required: resetting from external to external-internal (n=23), additional drainage of the left lobe and Siv (n=16), removal of endoscopic stents and new percutaneous drainage (n=6). 48 patients received combination of intraductal photodynamic and regional chemotherapy. After 2-8 (average 3) cycles of specific therapy, 14 (24 %) patients underwent surgery: right hemigepatectomy - 4; left expanded hemigepatectomy - 4; left hemigepatectomy - 3; duct resection with Siv - 2; orthotopic liver transplantation - 1. Results. From the first appearance of obstructive jaundice to the beginning of specific treatment, it took 1 to 9 (average 3.1) months. The technical success of repeated endobiliary interventions was 100 %. There were no serious complications or mortality. Both the cholangitis and obstructive jaundice were controlled in 35 (78 %) patients. 14 out of 48 (30 %) patients showed a metabolic and biological response of the tumor to combined treatment (PET/CT with F 18FDG and CA-19.9) and underwent radical surgery. Specific therapy was not performed in 10 (17 %) patients with long-term jaundice and the development of biliary cirrhosis (n=6) and chronic cholangitis (n=4). Conclusion . Before the admission to the specialized Department, previously installed bile duct drains/stents were effective in 22 % of patients. Only adequate biliary drainage with regular x-ray monitoring allows to start aggressive specific therapy in 83 % of patients with Klatskin tumor. The advantage of photodynamic and regional chemotherapy after percutaneous biliary drainage is their repeatability with local control of tumor and the possibility of subsequent radical surgical treatment, including orthoptic liver transplantation.

Persistent subretinal fluid following diabetic tractional retinal detachment repair: risk factors, natural history, and management outcomes.

To study the natural history, anatomical and functional outcomes of persistent subretinal fluid (SRF) after pars plana vitrectomy (PPV) for diabetic tractional retinal detachment (TRD) and combined traction-rhegmatogenous retinal detachment (TRRD). Retrospective interventional case series of 43 patients (46 eyes) with persistent SRF following PPV for diabetic TRD or combined TRRD from January 2010 to December 2017 at single tertiary institution. Primary outcomes included best corrected visual acuity (BCVA) and central foveal thickness (CFT). Thirty-one eyes (67.4%) had macula-off TRD, 5 (10.9%) had fovea-threatening TRD and 10 (21.7%) had combined TRRD. The mean (± SD) duration of decreased vision was 48.0 ± 58.2weeks. The mean follow-up duration was 21 ± 13.2months. Residual macular SRF was detected by optical coherence tomography in all eyes at 3months and in 10 eyes (23.8%) at 12months after surgery. Only 3 eyes (6.5%) had persistent SRF at final follow up. The mean time to resolution was 10.6 ± 4.1months [range 6.0-23.0]. Thirteen eyes received additional intervention to address SRF. The mean CFT gradually improved until final follow-up (P-value < 0.001). The mean BCVA improved from 1.62 ± 0.88 LogMAR at presentation to 1.05 ± 0.76 LogMAR at final follow up. No statistically significant difference in final BCVA was found between eyes that had intervention and eyes that were observed (P value = 0.762). Persistent SRF after diabetic vitrectomy resolves slowly over time with gradual improvement in visual acuity. Additional drainage of persistent SRF may not be necessary.

Drain management after distal pancreatectomy based on a predictive model, including drainage fluid amylase and biochemical inflammatory markers: a preliminary study

Introduction Postoperative pancreatic fistula (POPF) is the Achilles’ heel of distal pancreatectomy. Surgeons use abdominal drains for early prediction, diagnosis, and timely management of POPF. The utility of drainage fluid in the prediction and diagnosis of POPF is a matter of debate. Patients and methods This is a retrospective cohort study of all patients who underwent distal pancreatectomy between January 2018 and January 2020. The present study aims to evaluate the association between drainage fluid amylase (DFA) and systemic inflammatory markers in the prediction of clinically relevant POPF. Results This study included 44 patients with a mean age of 40.3±16.3 years, and the female : male ratio was 2.7 : 1. POPF occurred in 11 (25%) patients. Of them, nine (20.5%) patients were managed by additional ultrasound-guided tube drainage. Higher drainage fluid amount and DFA-D1 were associated with a higher risk of POPF (P=0.036, and 0.009, respectively). The leukocytic count was significantly higher in POPF in the third postoperative day (POD) (P=0.032). POPF group had a significantly higher level of serum lactate dehydrogenase (LDH) on the fourth POD (P=0.001). Patients with high DFA-D1 (>330 IU/l), rising leukocytic count, and high serum LDH were significantly at higher risk of POPF (9/11 developed POPF, P=0.0001). Conclusion DFA-D1, rising leukocytic count, and high serum LDH level compromised a more robust predictive model for POPF. The cutoff value of DFA proposed by the ISGPF is applicable when combined with leukocytic count and serum LDH. Prospective large-scale studies are needed.

Stereotactic Radiation as Salvage Therapy for Recurrent Rathke Cleft Cysts.

Rathke cleft cysts (RCCs) are sellar-based cystic lesions that are often found incidentally but occasionally become symptomatic with significant visual and/or endocrine deficits. The standard of treatment is surgery, but rare cases of multiply recurrent RCCs can be refractory to surgical drainage, leading to significant morbidity. To demonstrate the safety and feasibility of fractionated stereotactic radiotherapy (SRT) as salvage therapy in multiply recurrent RCCs refractory to surgical drainage. An IRB-approved retrospective review at a single institution was conducted to identify and describe patients with multiply recurrent RCCs refractory to surgical drainage who underwent SRT. From 1994 to 2015, 6 patients (5 female) who underwent SRT for recurrent RCCs were identified. A total of 4 presented with visual deficits, and 2 presented with endocrine dysfunction and severe headaches prior to their initial drainage. All patients had initial postoperative improvement but then developed multiple, symptomatic recurrences. Median number of surgical drainage procedures prior to radiotherapy was 3. A total of 3 patients underwent LINAC-based SRT, and 3 had proton-based SRT. Treatment doses were 45 Gy over 25 fractions (n=5) and 50.4 Gy over 28 fractions (n=1). Median follow-up after radiation therapy was 69 mo (range 24-154 mo). In the follow-up period, stabilization of the RCC was achieved, although 2 patients required additional drainage procedures. Only 1 patient developed new hypothyroidism and hypoadrenalism after SRT. In rare cases of multiply recurrent RCCs refractory to repeat surgical drainage, stereotactic fractionated radiation therapy is a safe and effective salvage therapy.

Influence of the presence of open three-dimensional fiber structures on solid liquid cake filtration of limestone

Solid particles in a suspension can be separated effectively through cake filtration where the filter medium is decisive particularly during the initial stage when particle breakthrough can be high. To improve the filtrate quality and throughput, filtration aid additives are used, which are known to alter filter cake structure and thus reduce flow resistance but, in forming clusters, also stabilize fine particles that would otherwise pass through the filter (cake) easily. However, filter aids are costly, increase the complexity of the system and may have adverse effects for subsequent mechanical drying and washing. Instead of supplying additives, four alternative filter media were tested exhibiting an open, three-dimensional structure that reached deeply into the depth of the forming filter cake. An aqueous limestone suspension was investigated in a conventional laboratory test unit. Composite filter medium set-up delivered up to 15% faster filtration. The results indicate that the fiber structures give better performance that reach far into the cake and are oriented not only axially but also radially. In contrary to the initial hypothesis that an axial fiber structure would produce additional drainage channels along the surface of these fibers and thus support but deliquoring, the actual deliquoring performance with air blowing appeared to be slightly less efficient. Although not investigated yet, cake discharge with a 3-D filter layer present poses an additional challenge, rendering the concept of composite filters unpractical.

Canaloplasty with Suprachoroidal Drainage in Patients with Pseudoexfoliation Glaucoma – Four Years Results

ABSTRACT Purpose: To evaluate the long-term efficacy and safety of the modified canaloplasty technique with additional suprachoroidal drainage in patients with pseudoexfoliation glaucoma. Methods: This retrospective clinical trial included 131 patients with pseudoexfoliation glaucoma who underwent canaloplasty with suprachoroidal drainage (scD). One hundred and eleven of 131 patients underwent the follow-up examination after 48 months. Primary endpoints were the pressure-lowering and drug-sparing effect as well as the success rates. Secondary endpoints were intra- and postoperative complications and the occurrence of secondary surgical interventions. Results: The IOP was reduced by 45.8% after 12 months (from baseline 23.4 ± 5.1 mmHg to 12.7 ± 2.2 mmHg) and by 45.1% after four years (12.8 ± 2.2 mmHg) (p < .001). The mean number of IOP-lowering medication decreased significantly from 3.4 at baseline to 0.6 after 12 months and to 1.0 after four years. The IOP-reducing effect was even stronger in those cases in whom canaloplasty+ scD was combined with cataract surgery (49.4% after 12 months and 47.6% after four years). No serious complications were observed. Conclusions: The modified surgery technique of canaloplasty with suprachoroidal drainage is a safe and effective way of reducing IOP in patients with pseudoexfoliation glaucoma.

Pancreaticoduodenectomy following endoscopic ultrasound-guided choledochoduodenostomy with electrocautery-enhanced lumen-apposing stents an ACHBT – SFED study

BackgroundAfter ERCP failure or if ERCP is declined for preoperative biliary drainage before pancreaticoduodenectomy, endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) with electrocautery-enhanced lumen-apposing stents (ECE-LAMS) might be needed. The aim of the present study was to assess the technical feasibility and short-term outcomes of pancreaticoduodenectomy (PD) following endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) with electrocautery-enhanced lumen-apposing stents (ECE-LAMS). MethodsA retrospective study of all EUS-CDS procedures with ECE-LAMS followed by PD performed in France since the availability of the device in 2016. Results21 patients underwent PD in 9 departments of surgery following EUS-CDS with ECE-LAMS. The median bilirubin level at endoscopic procedure was 292 μmol/L. A 6 mm diameter stent was used in 20 cases. No complications occurred during the procedure. During the waiting time, 1 patient had an acute pancreatitis post ERCP and 3 patients developed cholangitis, treated by either an additional percutaneous biliary drainage, or an endoscopic procedure to extract a bezoar occluding the stent, or antibiotics, respectively. PD with a curative intent was performed in all cases. Overall, postoperative mortality was nil and postoperative morbidity occurred in 17 patients (81%), including 3 with severe complications (14%). No patient developed postoperative biliary fistula. In the 21 patients followed at least 6 months, no biliary complications occurred, and no tumor recurrence developed on the hepaticojejunostomy/hepatic pedicle. ConclusionPancreaticoduodenectomy following EUS-CDS with ECE-LAMS is technically feasible with acceptable short-term postoperative outcome, including healing of biliary anastomosis.

Neurologic Outcomes in Open Thoracoabdominal Aortic Aneurysm Repair Performed Under Deep Hypothermic Circulatory Arrest With and Without Spinal Drainage

Spinal drainage is a well-accepted adjunct employed to reduce the incidence of spinal cord morbidity after open thoracoabdominal aortic aneurysm (TAAA) repair. However, major complications associated with spinal drains, such as epidural hematoma, can be devastating. Our practice has evolved to routine performance of extensive TAAA repair under cardiopulmonary bypass and deep hypothermic circulatory arrest (DHCA); the intraoperative hypothermia provides spinal cord and other organ protection. The aim of this study was to evaluate the utility of additional spinal cord drainage in preventing paraplegia under these circumstances.

Automated Gonioscopy Assessment of XEN45 Gel Stent Angle Location After Isolated XEN or Combined Phaco-XEN Procedures: Clinical Implications.

The purpose of this study was to assess success and safety outcomes of different levels of insertion of the XEN45 gel stent in the angle in standalone and combined procedures. This was a cross-sectional study of patients in whom XEN had been implanted without intraoperative gonioscopy. Automated gonioscopy was used for postoperative analysis of the XEN location, classified as anterior or posterior relative to the scleral spur. Absolute success was defined as ≥20% intraocular pressure decrease from baseline and ranging from 6 to 21 mm Hg without medication and qualified success if medicated. The need for additional drainage surgery was considered failure, but needling was allowed. Clinical data were retrieved from patient files. Gonioscopy-assisted XEN location was performed on 42 eyes of 33 patients (14 isolated and 28 combined procedures) on average 18±9 months after surgery. Absolute (32% vs. 35%; P>0.99) and qualified (44% vs. 65%; P=0.22) success was similar in both anterior and posterior placements, respectively. Kaplan-Meier survival analysis yielded similar median survival times for both groups. The distribution of XEN insertion level in the angle was similar in standalone and combined procedures (P=0.75). Although overall safety outcome measures did not differ significantly, the proportion of intraoperative and early postoperative complications was higher in posterior XEN placements (P=0.03). Different locations of XEN45 did not seem to significantly impact late success and safety outcomes, although stents inserted more posteriorly may be associated with a higher rate of early complications. Combined implantation of XEN with phacoemulsification does not seem to influence stent location in the iridocorneal angle in a setting without intraoperative gonioscopy.