Daily Drainage Research Articles

PS02.209: PROGNOSTIC VALUE OF CHEST-TUBE AMYLASE IN DETECTING EARLY ANASTOMOTIC LEAKAGE AFTER IVOR-LEWIS ESOPHAGECTOMY

Abstract Background Intrathoracic anastomotic leaks after esophagectomy are a significant cause of postoperative morbidity and death. Early detection and timely management is crucial but existing diagnostic methods are either invasive or have a low sensitivity. The aim of this study was to evaluate the effectiveness of daily drain amylase levels in detecting early anastomotic leaks after Ivor-Lewis esophagectomy compared with C-Reactive Protein (CRP) levels. Methods Between June 2015 and September 2017, 126 Ivor-Lewis esophagectomies for cancer were performed in our surgical department. In 80 of these patients, drain amylase levels were collected as long a right-sided chest-tube was in place. Chest-tubes were removed at a secretion volume < 300 ml/24 h. CRP levels were measured daily. If bile was detected in the chest-tube and/or after re-exploration of the chest, no further data were collected. Early anastomotic leaks were defined as occurring as long as the chest tubes were in site, in the mean the 5th postoperative day (POD). According to the collected data, drain amylase levels > 350 U/l, and CRP > 30 mg/dl were considered positive. Sensitivity and specificity in detecting anastomotic insufficiency for both drain amylase and CRP were calculated. Results A clinically significant anastomotic leak occurred in 7,1% (9/126) of all esophagectomy patients with 0,8% (1/126) postoperative 30-days mortality. An early anastomotic disruption occurred in 4 of the 80 analysed patients. Three of them had a positive chest-drain amylase level and none a positive CRP level on POD1. The same three patients had on POD 2 a positive CRP level or presented bile in the chest-tube. The fourth patient presented at POD 2 bile in the chest tubes. On POD 1 he presented neither positive amylase nor CRP. The sensitivity and specificity for drain amylase and CRP within the first 3 POD was 0,75 and 0,98 vs 0,75 and 0,85 respectively. The accuracy for both amylase and CRP were calculated at 0,97 vs 0,85. Conclusion Chest-tube amylase levels after Ivor-Lewis esophagectomy are more accurate for the detection of early esophageal anastomotic leaks than CRP. This could facilitate early detection of anastomotic leaks up to 24 hours earlier than elevated blood CRP levels. Disclosure All authors have declared no conflicts of interest.

Combination of Measurement Methods for a Wide-Range Description of Hydraulic Soil Properties

Established measurement methods for hydraulic soil properties cover a limited soil moisture range. Simulations of soil water dynamics based on such observations are therefore rarely representative for all conditions from saturation to drought. Recent technical developments facilitate efficient and cheap collecting of soil water characteristics data, but the quantitative benefit of extended measurement campaigns has not been adequately tested yet. In this study, a combination of four methods to measure water retention and hydraulic conductivity at different moisture ranges was applied. Evaporation method, dewpoint psychrometry, hood infiltrometer experiments, and falling head method for saturated conductivity were conducted at two experimental sites in eastern Austria. Effects of including the particular methods in the measurement strategy were examined by visual evaluation and a 1D-modelling sensitivity study including drainage, infiltration and drought conditions. The evaporation method was considered essential due to its broad measurement range both for water retention and hydraulic conductivity. In addition to that, the highest effect on simulated water balance components was induced by the inclusion of separate conductivity measurements near saturation. Water content after three days of drainage was 15 percent higher and the transpiration rate in a drought period was 22 percent higher without near-saturated conductivity measurements. Based on relative comparisons between different combinations, we suggested combining evaporation method and hood infiltrometer experiments as the basis for representative predictions of soil water dynamics.

Aggressive versus symptom-guided drainage of malignant pleural effusion via indwelling pleural catheters (AMPLE-2): an open-label randomised trial

Indwelling pleural catheters are an established management option for malignant pleural effusion and have advantages over talc slurry pleurodesis. The optimal regimen of drainage after indwelling pleural catheter insertion is debated and ranges from aggressive (daily) drainage to drainage only when symptomatic. AMPLE-2 was an open-label randomised trial involving 11 centres in Australia, New Zealand, Hong Kong, and Malaysia. Patients with symptomatic malignant pleural effusions were randomly assigned (1:1) to the aggressive (daily) or symptom-guided drainage groups for 60 days and minimised by cancer type (mesothelioma vs others), performance status (Eastern Cooperative Oncology Group [ECOG] score 0-1 vs ≥2), presence of trapped lung, and prior pleurodesis. Patients were followed up for 6 months. The primary outcome was mean daily breathlessness score, measured by use of a 100 mm visual analogue scale during the first 60 days. Secondary outcomes included rates of spontaneous pleurodesis and self-reported quality-of-life measures. Results were analysed by an intention-to-treat approach. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12615000963527. Between July 20, 2015, and Jan 26, 2017, 87 patients were recruited and randomly assigned to the aggressive (n=43) or symptom-guided (n=44) drainage groups. The mean daily breathlessness scores did not differ significantly between the aggressive and symptom-guided drainage groups (geometric means 13·1 mm [95% CI 9·8-17·4] vs 17·3 mm [13·0-22·0]; ratio of geometric means 1·32 [95% CI 0·88-1·97]; p=0·18). More patients in the aggressive group developed spontaneous pleurodesis than in the symptom-guided group in the first 60 days (16 [37·2%] of 43 vs five [11·4%] of 44, p=0·0049) and at 6 months (19 [44·2%] vs seven [15·9%], p=0·004; hazard ratio 3·287 [95% CI 1·396-7·740]; p=0·0065). Patient-reported quality-of-life measures, assessed with EuroQoL-5 Dimensions-5 Levels (EQ-5D-5L), were better in the aggressive group than in the symptom-guided group (estimated means 0·713 [95% CI 0·647-0·779] vs 0·601 [0·536-0·667]). The estimated difference in means was 0·112 (95% CI 0·0198-0·204; p=0·0174). Pain scores, total days spent in hospital, and mortality did not differ significantly between groups. Serious adverse events occurred in 11 (25·6%) of 43 patients in the aggressive drainage group and in 12 (27·3%) of 44 patients in the symptom-guided drainage group, including 11 episodes of pleural infection in nine patients (five in the aggressive group and six in the symptom-guided drainage group). We found no differences between the aggressive (daily) and the symptom-guided drainage regimens for indwelling pleural catheters in providing breathlessness control. These data indicate that daily indwelling pleural catheter drainage is more effective in promoting spontaneous pleurodesis and might improve quality of life. Cancer Council of Western Australia and the Sir Charles Gairdner Research Advisory Group.

A comparative study between Retzius-sparing robot-assisted laparoscopic radical prostatectomy and conventional robot-assisted laparoscopic radical prostatectomy

Objective To compare the postoperative outcomes and early continence rate between conventional robot-assisted laparoscopic radical prostatectomy (RARP) and Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RSRARP). Methods The date from 50 patients who underwent RSRARP and 122 patients who underwent conventional RARP between 2016 September to 2017 included study. Ninety-two patients (forty-six patients in RARP group and forty-six patients in RSRARP group) were collected by propensity-score matching which were performed using eight preoperative variables. Preoperative data of patients in RSRARP group [patients age (67.1±5.7) years, BMI (24.6±2.7)kg/m2, tPSA 10.7 ng/ml (0-40.7 ng/ml), Gleason score 7 points (6-9 points), prostate volume 31.9 ml (10.0-95.4 ml), ECOG score 0 points (0-1 points), urinary domain of EPIC 94.8 points (63.9-100 points), clinical stage from T1cN0M0 to T3aN0M0] and conventional RARP group [patients age (67.2±6.7) years, BMI (25.2±3.1)kg/m2, tPSA 10.7 ng/ml (0-40.7 ng/ml), Gleason score 7 points (6-9 points), prostate volume 36.8 ml (8.9-81.0 ml), ECOG score 0 points (0-1 points), urinary domain of EPIC 95.8 points (63.9-100.0 points), clinical stage from T1cN0M0 to T3aN0M0] had no significant differences. We reviewed console time, estimated blood loss, the rate of leakage, complications, average daily drainage, pathological result, continence, urinary domain of EPIC one month, two months and three months after operation. Results All 92 cases were successfully performed robotically. Mean operation time was significantly more in RARP group than in RSRARP group [(223.9±48.9)min vs. (198.91±34.2)min, P 0.05). Early continence rate one week and one month after surgery was significantly higher in RSRARP group than in RARP group (78% vs. 35%, 91% vs. 79%, P 0.05). Conclusions RSRARP were time-saving, safe and effective for the surgical treatment of localized prostate cancer. It seemed to yield a better outcome regarding early return to urinary continence postoperatively. Key words: Prostatic cancer; Radical prostatectomy; Robot; Retzius space; Continence

Nitrate and phosphorus transport through subsurface drains under free and controlled drainage

Controlled drainage (CD) is a structural conservation practice in which the drainage outlet is managed in order to reduce drain flow volume and nutrient loads to water bodies. The goal of this study was to evaluate the potential of CD to improve water quality for two different seasons and levels of outlet control, using ten years of data collected from an agricultural drained field in eastern Indiana with two sets of paired plots. The Rank Sum test was used to quantify the impact of CD on cumulative annual drain flow and nitrate-N and phosphorus loads. CD plots had a statistically significant (at 5% level) lower annual drain flow (eastern pair: 39%; western pair: 25%) and nitrate load (eastern pair: 43%; western pair: 26%) compared to free draining (FD) plots, while annual soluble reactive phosphorus (SRP) and total phosphorus (TP) loads were not significantly different. An ANCOVA model was used to evaluate the impact of CD on daily drain flow, nitrate-N, SRP and TP concentrations and loads during the two different periods of control. The average percent reduction of daily drain flow was 68% in the eastern pair and 58% in the western pair during controlled drainage at the higher outlet level (winter) and 64% and 58% at the lower outlet level (summer) in the eastern and western pairs, respectively. Nitrate load reduction was similar to drain flow reduction, while the effect of CD on SRP and TP loads was not significant except for the increase in SRP in one pair.These results from a decade-long field monitoring and two different statistical methods enhance our knowledge about water quality impacts of CD system and support this management practice as a reliable system for reducing nitrate loss through subsurface drains, mainly caused by flow reduction.

The volume threshold of 300 versus 100 ml/day for chest tube removal after pulmonary lobectomy: a meta-analysis

In this meta-analysis, we conducted a pooled analysis of clinical studies comparing the efficacy of a volume threshold of 300 ml/day before removing a chest tube (CT) versus 100 ml/day after a lobectomy. According to the recommendations of the Cochrane Collaboration, we established a rigorous study protocol. We performed a systematic electronic search of PubMed, Embase, Cochrane Library, Web of Science databases, CNKI, the Wanfang database, CBMdisc and Google Scholar to identify articles to include in our meta-analysis. A literature search was performed using relevant keywords. A meta-analysis was performed using RevMan© software. Five studies, published between 2014 and 2015, including 615 patients (314 patients who had the CT removed when daily drainage was <300 ml and 301 patients who had the CT removed when daily drainage was <100 ml) met the selection criteria. From the available data, the patients using the volume threshold of 300 ml/day had a significantly decreased duration of drainage [MD = -44.07; 95% confidence interval (CI) -64.45 to -23.68; P < 0.0001] and hospital stay after operation (MD = -2.25; 95% CI -3.52 to -0.97; P = 0.0006) compared with patients using a volume threshold of 100 ml/day after a pulmonary lobectomy. However, no significant differences were observed in postoperative complications, such as pleural fluid reaccumulation [Odds ratio (OR) = 1.73; 95% CI = 0.74-4.07; P = 0.21] and atelectasis (OR = 0.97; 95% CI = 0.52-1.81; P = 0.93). Thoracentesis rates after removing the CT also showed no significant difference (OR = 1.53; 95% CI 0.55-4.22; P = 0.41). Our results showed that a higher volume threshold, up to 300 ml/day, is effective in reducing hospitalization times and duration of drainage in patients who undergo a lobectomy. Moreover, the volume threshold of 300 ml/day does not increase the occurrence of postoperative atelectasis, pleural fluid reaccumulation and thoracentesis rates. However, this review is limited by the methodological quality of the included trials, and additional studies according to the recommendations of Cochrane Library are appreciated.

The influence of the trocar choice on post-operative acute pain after thoracoscopy.

Acute post-operative pain following thoracic surgery procedures is still an unresolved problem despite the introduction of minimally invasive procedures such as video assisted surgery. Until now it is never investigated if different surgical instruments could influence post-operative pain. The aim of our study is to investigate the role of different type of trocar on post-operative pain in minimally invasive thoracic surgery. This was a prospective randomized single center study. We identified 53 patients randomized into three groups underwent single port thoracoscopy for malignant pleural effusion with drainage of the fluid and talc poudrage. The three groups differ for the trocar type, rigid, flexible and wound protector. We compared the postoperative pain between the three groups in which there was no statistical difference. Rigid trocar seems to give a more stable level of pain during the days, flexible trocar gains more pain in the first few hours, however the pain at discharge decreases significantly, reaching the similar values, in all the three groups. The association between pain at discharge and operative time or days of drainage was analyzed by means of linear regression, no statistically significant difference was found. Our study showed that different type of trocars during video assisted thoracic surgery (VATS) produces similar level of acute postoperative pain. In future, further randomized study with a great number of patients enrolled needs to confirm our results.

Randomized study of percutaneous ureteroscopic plasma column electrode decortication and laparoscopic decortication in managing simple renal cyst.

BackgroundTo assess the safety and efficacy of a novel technology referred to as percutaneous ureteroscopic plasma column electrode (PCE) by comparing laparoscopic decortication in the management of simple renal cyst (SRC).MethodsBetween March 2016 and June 2017, 53 patients with SRCs were randomized to divided into two groups, the PCE group (24 patients), or laparoscope group (29 patients). The operative time, blood loss, days of drainage, catheter, and hospital stay and complications were compared with the two groups. All patients were followed- up to 6 months after treatment.ResultsNo patients had intraoperative complications such as hemopneumothorax, adjacent organ injury, infection or hemorrhage shock. In the PCE group and laparoscope group: the mean operation time was 34.1±8.2 vs. 58.4±16.7 min (P<0.05). The mean blood loss was 2.0±1.16 vs. 9.7±4.09 mL (P<0.05). The mean postoperative indwelling drainage tube time was 2.5±1.5 vs. 2.9±1.09 d (P>0.05). The mean intra-urethral indwelling catheter time was 2.1±0.88 vs. 2.0±1.15 d (P>0.05). The mean postoperative hospital stay was 3.0±1.7 vs. 3.7±1.53 (P>0.05). One patient in electrode group was suffered from rupture of the collecting system during the operation, and was treated by indwelling D-J stent. During follow up, no cysts recurrence was found.ConclusionsPercutaneous ureteroscopic PCE decortication is a safe, minimally invasive and effective therapy to treat SRCs, with equal efficacy and advantages in shortening the operation time and reducing the amount of intraoperative bleeding compared with laparoscopic decortication.

MP73-06 A PROSPECTIVE EVALUATION ON THE CATHETER SCIENCE M3 “MINI CATHETER” FOR PATIENTS WITH PROSTATIC OBSTRUCTION

You have accessJournal of UrologyBenign Prostatic Hyperplasia: Surgical Therapy & New Technology II1 Apr 2018MP73-06 A PROSPECTIVE EVALUATION ON THE CATHETER SCIENCE M3 “MINI CATHETER” FOR PATIENTS WITH PROSTATIC OBSTRUCTION Gaines Hammond Gaines HammondGaines Hammond More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2370AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The Catheter Science M3 “Mini Catheter” has been developed for management of urinary obstruction. The M3 is a short catheter segment which is attached to a monofilament suture which runs thru the lumen of the urethra. The device tip is a Coude tip with a guide wire channel and 3 wings to stabilize the device and prevent expulsion. This temporary device by bridging the obstructive prostate, allows for normal volitional voiding with a functioning bladder and external urinary sphincter. METHODS This is an IRB approved single arm, prospective study is designed to produce valid scientific evidence regarding: 1. Safety and efficacy of the Catheter Science M3 “Mini Catheter” in establishing urinary drainage 2. The study purpose is to measure the rate of catheter-related urinary tract infections in patients with the M3 in place as compared to the known anticipated infection rate for patients with a Foley in place over a similar period of time. 3. Monitor the following: Voluntary Micturition Post Void Residual Continence Migration of the device Ease of removal ComfortC. To determine the rate of each anticipated Urinary Tract Adverse Event requiring intervention and unanticipated adverse device effects through 2 weeks post removal of the device. RESULTS From June 2017 thru November 2017, 45 M3 Catheters we're placed in 28 patients who were in chronic urinary retention managed with either Foley Catheter or CIC. This group represents a cumulative experience with the M3 Mini Catheter > 500 catheter days. The average duration of device was placed was > 20 days. 12 patients had the device for a complete 28 days. Weekly evaluation of the presence or absence of infection with independent analysis of UA and Culture and Sensitivity revealed a 72 % infection rate prior to placement of a M3 “Mini Catheter.”In patients with the device in place for 28 continuous days of M3 drainage revealed a 18% infection rate. The Foley Catheter expected infection rate at 28 days is > 95%. This represents a 77% reduction from the expected infection rate for a Foley Catheter. The Voided Volume, Peak Flow Rate (Qmax) and post placement Post Void Residual avearage revealed: Voided Volume 385 cc Qmax. 13 cc/sec PVR. 15 ccNo encrustations were observed at removal. All devices were placed and removed in the office with comfort and ease of placement.No significant adverse Events were noted during the study. CONCLUSIONS The M3 “Mini Catheter” demonstrated a substantial reduction in infection rate over the 28 day period as compared to expected infection rates with either a Foley or CIC. (>95% vs 18%) The device is easy to place and remove and does not require an external collection device. The device was not spontaneously expelled or retrograde migration back into the bladder. The device was reported as comfortable with improvement on IPSS scores. No devices were removed due to discomfort, irritation, hematuria, encrustations, or inability to drain the bladder. No incintinence was reported in patients with a device placed proximal to the urinary sphincter. In conclusion: The M3 “Mini Catheter” has demonstrated in this pilot study, to be an attractive alternative device to either a Foley Catheter or Clean Intermittent Catheter for managing urinary retention in this group of patients. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e993 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Gaines Hammond More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Mid-term survival outcome of single-port video-assisted thoracoscopic anatomical lung resection: a two-centre experience.

Single-port video-assisted thoracoscopic surgery (SPVATS) anatomical resection has been shown to be a feasible technique for lung cancer patients. Whether SPVATS has equivalent or better oncological outcomes for lung cancer patients remains controversial. The purpose of this study was to evaluate the perioperative and mid-term survival outcomes of SPVATS in 2 different medical centres. We retrospectively reviewed patients who underwent SPVATS anatomical resections between January 2014 and February 2017 in Coruña University Hospital's Minimally Invasive Thoracic Surgery Unit (Spain) and Chang Gung Memorial Hospital (Taiwan). Survival outcomes were assessed by pathological stage according to the American Joint Committee on Cancer (AJCC) 7th and 8th classifications. In total, 307 patients were enrolled in this study. Mean drainage days and postoperative hospital stay were 3.90 ± 2.98 and 5.03 ± 3.34 days. The overall 30-day mortality, 90-day morbidity and mortality rate were 0.7%, 20.1% and 0.7%, respectively. The 2-year disease-free survival and 2-year overall survival of the cohort were 80.6% and 93.4% for 1A, 68.8% and 84.6% for 1B, 51.0% and 66.7% for 2A, 21.6% and 61.1% for 2B, 47.6% and 58.5% for 3A, respectively, following the AJCC 7th classification. By the AJCC 8th classification, these were 92.3% and 100% for 1A1, 73.7% and 91.4% for 1A2, 75.2% and 93.4% for 1A3, 62.1% and 85.9% for 1B, 55.6% and 72.7% for 2A, 47.1% and 64.2% for 2B and 42.1% and 60.3% for 3A. Our preliminary results revealed that SPVATS anatomical resection achieves acceptable 2-year survival outcomes for early-stage lung cancer and is consistent with AJCC 8th staging system 2-year survival data. For advanced stage non-small-cell lung cancer patients, further evaluation is warranted.

Safety of Simultaneous Bilateral Pulmonary Resection for Metastatic Lung Tumors.

We investigated the safety of simultaneous bilateral lung resection for lung metastases. We retrospectively analyzed 185 patients with pulmonary metastases who underwent unilateral or bilateral pulmonary resection from August 2009 to December 2016 at a single institution. Single-stage bilateral lung resection was undertaken in 19 patients, and the other 166 patients underwent unilateral pulmonary resection, including 20 patients who underwent repeated resections for synchronous or metachronous metastases. Operative time and drainage days in the bilateral group were significantly longer than those in the unilateral group (220±20 vs. 152±6.9 min: p<0.01, and 2.79±0.3 vs. 2.08±0.1 days: p<0.01). Incidence of postoperative complications and postoperative in-hospital days did not differ between the two groups (p=0.33 and 0.66, respectively). The bilateral group was further divided into two groups, namely, those who underwent wedge resection on both sides (WW) and those who underwent wedge resection on one side and segmentectomy or lobectomy on an opposite side (WSL). Operative time in the WSL group was significantly longer than that in the WW group (260±19 vs. 201±18 min: p=0.03). However, there was no significant difference in duration of chest tube use and postoperative hospital days between the two groups (p=0.26 and p=0.89). No severe postoperative complications occurred in either group. One-stage bilateral pulmonary metastasectomy appears to be safe as long as only wedge resection is performed on at least one side.

Determinants of Survival After Emergency Intrapericardial Cisplatin Treatment in Cancer Patients with Recurrent Hemodynamic Instability After Pericardiocentesis

Pericardial effusion is associated with high mortality in oncology. The etiology of infectious pericarditis and iatrogenic effects of previous radio-/chemotherapy may be always suspected, especially when a subsequent episode is observed. The study included 17 hemodynamically-unstable patients with cancer due to recurrent pericardial bloody effusion after previous pericardiocentesis and analyzed survival determinants after intrapericardial chemotherapy with cisplatin. The mortality rate was not significantly associated with the level of N-terminal pro-B type natriuretic peptide, low hemoglobin (<12 g/dl), elevated white blood cell account (>104/μl), large volume (>1500 ml) and long duration (>8 days) of pericardial drainage, cardiac arrhythmias, positive culture test results nor fever occurring during cisplatin administration. Subsequent systemic anticancer therapy was the strongest factor determining a longer survival (hazard ratio(HR)=0.31, 95% confidence interval(CI)=0.11-0.9; p=0.03). Efficacy of rescue intrapericardial chemotherapy with cisplatin is independent of parameters of hemodynamic instability and levels of inflammatory markers in recurrent pericardial effusion.

The Use of External Ventricular Drainage to Reduce the Frequency of Wound Complications in Myelomeningocele Closure

Introduction: Myelomeningocele (MMC) is an open neural tube defect routinely surgically closed within 48 h of birth to prevent secondary infection. Up to 18% of patients experience wound complications, and 85% require shunting for hydrocephalus. We hypothesized that wound complications could be reduced by cerebrospinal fluid (CSF) diversion at the time of closure. Methods: Institutional review board approval was obtained to review records of the 88 patients who underwent MMC closure between January 2005 and June 2016 at the Children's Hospital of Pittsburgh. Twenty-three patients (26%) had an external ventricular drain (EVD) placed at the time of MMC closure and underwent 7-11 days of CSF drainage. Fourteen patients (16%) had a shunt placed at the time of MMC closure, and 51 (58%) had no form of CSF diversion at the time of MMC closure. Results: Patients with an EVD or shunt placed at the time of closure had no wound complications. In contrast, 8 patients (16%) without CSF diversion at closure developed wound complications (p = 0.048). Seven of the 8 wound complications occurred in the 71 patients with evidence of hydrocephalus at birth (p = 0.98). Of patients with evidence of hydrocephalus at the time of MMC closure, wound complications had a higher rate of occurrence among patients who did not receive a shunt or EVD at closure (p = 0.01). When comparing only patients with evidence of hydrocephalus at birth, the EVD group alone had a lower rate of wound complications than patients who did not receive CSF diversion at the time of closure (p = 0.031). Conclusions: These results suggest that addressing hydrocephalus at the time of MMC closure significantly reduces the likelihood of wound complications and may justify temporary CSF diversion at birth, at least in those patients manifesting hydrocephalus.

“Axillary Space Obliteration”—An Effective Technique in Reducing Seroma Formation after Mastectomy and Axillary Dissection

Introduction: Seroma is the commonest complication of breast cancer surgery, and although its consequences most often cause no more than discomfort and anxiety, more important sequelae include flap necrosis and wound dehiscence. Seroma management can be difficult and frustrating for both the patient and surgeon. Numerous methods to reduce post-mastectomy seroma formation have been tried with no consistent success. Methods: Sixty patients were prepared for modified radical mastectomy. Of those, the study group contains 30 patients and the control group contains 30 patients. Study group had axillary space obliteration while the other had the conventional procedure; total drain outputs were recorded daily for all patients prior to drain removal. The drains were removed when the daily drainage was less than 30 ml. Results: This study contains 60 patients, and the study group contains 30 patients, and the control group contains 30 patients. Age, tumor size, No. of positive lymph nodes were of no significant differences to be more concise on the effect of axillary space obliteration. The mean of day of drain removal in the control group was 13.2 ± 1.0 days (9 - 18 days) with a mean of total drain output of (4700 ± 90.3 ml) (3722 - 4930) while the mean in the study group of day of drain removal was 7.1 ± 1.3 days (6 - 12) with a mean of total drain output of 1530 ± 422 ml (range 600 - 2100 ml) p . Conclusion: Obliteration of axillary space is a valuable procedure that significantly decreases seroma after mastectomy and axillary dissection.

Thoracoscopic evacuation compared with reinsertion of thoracostomy tube in persistent traumatic hemothorax

Objective Hemothorax is the most frequent complication from chest trauma. In most of the cases, chest tube will be sufficient for treatment, but in a minority of patients, more intervention will be needed to evacuate a retained hemothorax. We aimed in this study to compare between video-assisted thoracoscopy (VATS) evacuation of retained clotted blood and reinsertion of thoracostomy tube to explore the safety and complications of such techniques. Patients and methods A prospective randomized case–control study was conducted on patients who presented with retained hemothorax admitted to trauma unit from July 2017 to July 2018. Results During the time frame from July 2017 to July 2018, our trauma unit got 44 879 patients. Approximately 14 722 of them needed admission, with only 288 patients requiring primary chest tube for hemothorax, of which 35 patients met the inclusion criteria of this study. They were then divided into two groups: group A (16 patients) underwent evacuation by VATS. The operative time for VATS ranged from 24 to 130 min, with mean time 79.8 min (after VATS), and needed drainage days range from 2 to 7 days, with mean of 3.31 days. One (6.25%) patient need thoracotomy. No wound infection or empyema was present in group A. Control group (group B) included 19 patients in whom the chest tube was reinserted. The needed days of drainage range from 4 to 10 days, with mean 6.47 days, with significant value (P = 0.001). Three (15.78%) patients had wound infection at the site of thoracostomy tube. On follow-up, we noticed four (20.05%) patients with empyema. Conclusion Early VATS for evacuation of retained hemothorax is feasible and safe in trauma patients. Moreover, VATS evacuation leads to shorter hospital stay and less need for open thoracotomy in comparison with reinsertion of a chest tube.

Evaluation of the Safety and Efficacy of Percutaneous Transhepatic Gallbladder Drainage Combined with Laparoscopic Cholecystectomy for Treating Acute Complicated Cholecystitis

The rate of acute cholecystitis in patients with severe underlying diseases is currently increasing. Several studies have reported percutaneous transhepatic gallbladder drainage (PTGBD) combined with laparoscopic cholecystectomy (LC) as a safe and reliable therapeutic option in such patients. This study aimed to elucidate the optimal time interval between PTGBD and LC. In total, 65 patients with acute complicated cholecystitis from our hospital were divided into two groups, short-term LC (sLC) and postponed LC (pLC) group according to whether the procedure was performed within 5 days of gallbladder drainage or after 5 days, respectively. The complications after PTGBD, rate of conversion to open surgery, and complications and mortality after LC were compared between the groups. The sLC group showed significantly lesser operating time, blood loss, postoperative peritoneal drainage time, postoperative oral intake time, and complications compared to the pLC group (P < 0.05). Other factors such as the length of hospital stay (LOS), conversion to open cholecystectomy, and mortality were not statistically significant between the groups. Combined treatment with PTGBC and sLC showed superior outcomes compared to PTGBC and pLC for acute cholecystitis in severely ill patients, thus constituting a feasible and secure treatment option in specialized centers.

Left-sided chylothorax due to tuberculosis in an adult

A spontaneous chylothorax is rare. Chylothorax as a manifestation of tuberculosis (TB) is very rare even in countries where TB is endemic. We report a case of left sided chylothorax due to TB in a 50-year-old male alcoholic who presented with hypotension and hyponatremia. TB was diagnosed through histopathological examination of mediastinal lymph node biopsy. Initial conservative treatment with four days of tube thoracostomy drainage was effective but chylothorax recurred one week later after starting anti-TB drugs. Resolution of chylothorax was achieved with repeat tube thoracostomy drainage for four weeks and daily anti-TB therapy with isoniazid, ethambutol, rifampicin and pyrazinamide for two months followed by daily isoniazid and rifampicin for four months. Patient recovered well and chylothorax did not recur during the follow up period of three months.

Flash flood in Arau watershed, West Sumatera: a mitigation study

Flash flood often occurs in West Sumatera. In spite of heavy rain, flash floods are also caused by the landslide in the riverside that blocks the river as a natural dam. The natural dam can be broken at any time, depending on storage capacity. Flash flood occurs when the dam is broken. The aim of the research is to mitigate flash floods based on parameters influencing flood and landslide. The research was conducted in Arau watershed, West Sumatera. Parameters that have a direct proportion of floods are maximum daily rainfall, watershed shape, river gradient, drainage density, slope, and land cover. Parameters influencing landslides are antecedent soil moisture, slope, geologic type especially fault line, soil depth, and land cover. GIS is used to analyze the factors influencing flood and landslide spatially. The results show that more than 50% of the Arau watershed are slightly high and high vulnerability due to its natural condition. Furthermore, the locations of fault, especially in the riverside, should be noticed because this location could become a natural dam causing flash flood. In order to reduce flash flood impact, the natural dam should be opened as soon as possible.

Electrothermal Bipolar Vessel Sealing System Dissection Reduces Drainage Fluid Output or Time to Drain Removal Following Axillary and Ilio-Inguinal Node Dissection in Melanoma Patients: A Pilot Study

Background: Radical lymph node dissection (RLND) is the treatment of choice in stage III melanoma patients. Over half of the observed complications were related to post-operative serum collection affecting wound healing. The aim of this study was to evaluate the use of the LigaSureTM Small Jaw (LSJ) on postoperative drainage fluid volume and drainage permanence in patients undergoing RLND. Study design: This was a prospective single-center study in which consecutive melanoma patients underwent nodal dissection using the LSJ. Daily drainage volume and duration of drainage were recorded in post-operative course on days 3, 10 or 15 and day 20. Results: A total of 70 patients were included. Mean postoperative drainage volume was lower. Around two-thirds of patients had a drainage fluid volume of less than 50cc at 10 days. Mean time to drainage removal was 14.5 days. Conclusions: This is the first report of nodal dissection in patients with cutaneous melanoma using an electrothermal bipolar vessel sealing system. The technique was feasible, safe, and effective and resulted in reduced drainage fluid volume and drainage permanence.

Chylothorax and pleural effusion in contemporary extracardiac fenestrated fontan completion

BackgroundWe hypothesized that chylothorax could be a sign of intolerance to the Fontan physiology, and thus patients who develop chylothorax or pleural effusion have worse medium-term to long-term survival. MethodsA total of 324 patients who underwent the Fontan operation between 2000 and 2013 were included. Chylothorax was defined as ≥5 mL/kg/day of chylomicron-positive chest drainage fluid no earlier than postoperative day 5 or drainage with >80% lymphocytes. Outcomes were compared between the chylothorax and non-chylothorax groups by the Kaplan–Meier method and log-rank test. Independent predictors of chylothorax and number of days of any chest drainage were analyzed with multivariable logistic regression and multivariable generalized negative binomial regression for count data, respectively. ResultsChylothorax occurred in 78 patients (24%). Compared with the non-chylothorax group, the chylothorax group had a longer duration of chest tube requirement (median, 18 days vs 9 days; P < .000) and a longer length of hospital stay (median, 19 days vs 10 days; P < .000). Eight patients (10.3%) required thoracic duct ligation. The chylothorax group had lower freedom from death (P = .013) and from composite adverse events (P = .021). No predictor was found for chylothorax. Pulmonary atresia (P = .031) and pre-Fontan pulmonary artery pressure (P = .01) were predictive of prolonged pleural effusion (>14 days). ConclusionsOccurrence of chylothorax following the Fontan operation can be a marker of poorer medium-term clinical outcomes. It is difficult to predict occurrence of chylothorax owing to its multifactorial nature and involvement of lymphatic compensatory capacity that is unmasked only after the Fontan operation.