Drain In Place Research Articles

2344 A Case of TACE: A Rare Complication of Transarterial Chemoembolization

INTRODUCTION: Transarterial chemoembolization (TACE) represents a proven therapy providing survival advantage in patients with large, unresectable hepatocellular carcinoma (HCC) not amenable to transplant or ablative therapies. Here we discuss a case of post-TACE liver abscess, a rare complication of this procedure. CASE DESCRIPTION/METHODS: A 65-year-old male with 10-year history of alcoholic cirrhosis (MELD-Na 12) presented for follow-up after a recent TACE procedure. Despite initial HCC isolation to segment 3, the patient had refused surgical intervention at the time of initial diagnosis. The mass rapidly enlarged, with new satellite lesions in segments 5 and 6. TACE of the left gastric artery supplying the HCC was performed 7 months after initial diagnosis, with subsequent ultrasound-guided HCC microwave ablation of a 7 cm segment 3 mass. One month after TACE, the patient presented to the emergency department with 2 weeks of weakness, fevers, and an episode of dizziness leading to a fall. Admission studies were notable for marked leukocytosis and blood cultures yielding Streptococcus lutetiensis. The patient was started on broad-spectrum antibiotics and scheduled for further imaging for evaluation of bacteremia source. CT abdomen revealed multifocal hepatic abscesses and a large 7 cm abscess communicating with distal stomach/proximal duodenum. On day 6 of hospitalization, IR placed a CT-guided hepatic abscess drain. Abscess culture was positive for E.coli and Enterococcus, and blood cultures from day after the procedure grew out extended spectrum beta-lactamase E.coli. He was started on a 3-week course of Ertapenem and discharged home with JP drain in place for follow-up in 3 weeks. JP drain was removed 10 days after discharge, and follow-up CT showed a significant decrease in the left hepatic lobe abscess with a small residual collection several centimeters above the drain. Ertapenem was discontinued after total of 5 weeks of antibiotic therapy. DISCUSSION: Liver abscess is an uncommon complication of TACE, occurring in about 2% of cases. Here our patient received the recommended therapy of percutaneous abscess drainage and parenteral antibiotics, resulting in a resolution of symptoms. Recognition of this complication is critical, as post-TACE liver abscess mortality has been estimated to be as high as 13.3%. Recent studies have even suggested prophylactic antibiotics when performing chemoembolization, with results showing promise, though this is not currently a routine or recommended practice.

2115 Novel Use of a Bare Metal Self Expanding Stent for Biliary Drainage Following Hepatic Cystectomy

INTRODUCTION: Bile leak following a partial hepatectomy or cystectomy is not uncommon. Perihepatic collections following surgery are largely managed in two ways: Image-guided percutaneous drainage or endoscopic retrograde cholangiopancreatography (ERCP). Intervention during ERCP may include sphincterotomy with placement of a plastic 7 or 10 Fr stent. While metal stents have been indicated in cases of biliary stenosis, no cases to date have presented the use of a covered self-expanding metal stent (cSEMS) for maximizing drainage. We present the case of a 78 yo female with polycystic liver disease who had a cSEMS placed after the formation of a perihepatic bile collection following a liver cyst resection. CASE DESCRIPTION/METHODS: This is a 78 year old female with a history of polycystic liver disease (PLD). Patient had previous resection of large liver cyst approximately one year earlier. She developed recurrence of a large liver cyst requiring surgical intervention and underwent laparoscopic liver cyst resection of the right lobe. Within one week of surgery, increased biliary drainage prompted a return to the hospital. Gastroenterology was consulted and took the patient for ERCP. A 10 mm covered self-expanding metal stent was placed in the common bile duct under direct visualization of the sphincter in conjunction with fluoroscopy imaging. This was done instead of Fr stents with the expectation that a large metal stent would afford improved biliary drainage and divert away from parenchymal leakage. The patient did well following the procedure and was discharged with percutaneous drain in place. Follow up CT of the abdomen and pelvis was performed 5 weeks following placement of biliary stent. The study demonstrated that the drain and stent were in good position. There was an interval decrease in size of perihepatic collection. DISCUSSION: A bile leak is often found due to increased output or change in fluid output from a surgical drain as was seen in this patient. If endoscopic intervention is undertaken, current practice involves placement of plastic stents. Literature demonstrates the use of cSEMS in patients who present with biliary stricture secondary to malignancy. Comparisons of plastic versus metal stents in this population show migration rates were lower in the metal stent arm. While there was no comparison of their drainage capabilities, they do demonstrate the feasibility of cSEMS placement in other patient populations where plastic stent placement has been standard.

2073 A Rare Case of S. Constellatus Bacteremia Secondary to a Perianal Abscess in an Individual With Crohn's Disease

INTRODUCTION: Organisms of the Streptococcus anginosus group consists of three distinct streptococcal species: Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus. These organisms are commonly associated with abscesses, but polymicrobial infections in the setting of an immunocompromised patient can infrequently cause bacteremia. Here we report the case of a 37-year-old male with Crohn’s disease who was found to have bacteremia secondary to a perianal abscess due to a co-infection of Streptococcus constellatus and Parvimonas micra. CASE DESCRIPTION/METHODS: A 37-year-old male with Crohn’s disease who presented with fever, leukocytosis and rectal pain was found to have bacteremia due to a polymicrobial infection of Streptococcus constellatus and Parvimonas micra. A CT abdomen and pelvis performed excluded any acute abdominopelvic disease. A MRI was done to determine a source of infection which showed a left perianal abscess measuring 3.2 × 1.6 × 4.7 cm. Our patient underwent an examination under anesthesia with biopsy, anoscopy and surgical drainage with seton placement. He received intravenous antibiotic therapy with Ceftriaxone and Metronidazole for three days and was discharged on a two week course of oral Augmentin after two repeat blood cultures were negative. Patient continues to have the seton drain in place six months from surgery with no complications or reoccurrence of infection. DISCUSSION: This case report sheds light on a rarely described pathogen causing bacteremia and provides a comprehensive approach to diagnosis and management. S. constellatus is a common cause of abscesses in the alimentary tract but rarely causes infection in blood. Co-infection with an anaerobe in the setting of an immunocompromised individual such as Crohn's disease increases the likelihood for blood infections. Bacteremia from this group must prompt evaluation for possible intra-abdominal abscess, deep-seated head and neck infection, brain abscess and endocarditis to determine the underlying source of infection. Treatment of infections due to the S. anginosus group consist of abscess drainage and antimicrobial therapy with Ceftriaxone being the preferred agent.

Outcomes after Peripancreatic Fluid Drainage in Patients with Simultaneous Pancreas-Kidney Transplantation

PurposeTo determine the clinical outcomes of patients who underwent image-guided drainage of peripancreatic fluid collections after simultaneous pancreas-kidney (SPK) transplantation. Materials and MethodsA retrospective review of all patients who underwent peripancreatic fluid collection drainage after SPK, from January 2000 to August 2017, at a single institution was performed. Patient characteristics, surgical technique, medication regimen, microbial analysis, and clinical outcomes were reviewed. Thirty-one patients requiring a total of 41 drainages were included in this study. The median age was 44 years (range 30–58 years), and median time between SPK and drainage was 28 days (range 8 to 3,401 days). Fisher’s exact test, unpaired Student t-tests, and Pearson correlations were used for statistical analysis. ResultsFever (51%) and abdominal pain (31%) were the most common presenting symptoms. The average amount of fluid drained at the time of drain placement was 97 mL (SD 240 mL). The average time spent with a drain in place was 33 days (SD 31 days). Microorganisms were isolated in the fluid of 22 of 41 drainages (54%), with mixed gastrointestinal flora being the most common. No further intervention was needed in 34 of 41 drainages (82%). However, drainage failed in 5 of 31 patients (16%), requiring surgical intervention with removal of the pancreas transplant. ConclusionsPercutaneous drainage of peripancreatic fluid collections after SPK transplantation is a safe and effective treatment option.

Early drain removal after hepatectomy: an underutilized management strategy

Background: Randomized controlled trials and a Cochrane Review suggest that routine drainage is not necessary in patients undergoing hepatectomy. Contemporary ACS-NSQIP data suggest that 50% of patients undergoing hepatectomy in North America receive abdominal drains, and early drain removal is not widely practiced. Recent single center analyses from Japan demonstrates that drain removal by POD 2 or 3 is safe and may result in fewer organ space infections as well as shorter length of stay. Thus, the aim of this analysis is to compare the outcomes of North American patients who have early (POD 0-3) versus routine (POD 4-7) drain removal. Methods: Patients undergoing major hepatectomy (≥ 3 segments) or partial hepatectomy (≤ 2 segments) were identified in the 2014–16 ACS-NSQIP Procedure Targeted Participant Use File. Patients undergoing concomitant biliary reconstruction or colon resection were excluded. Only patients who had one or more drains placed at surgery were analyzed. Patients who had drains in place for more than 7 days also were excluded so that early drain removal (POD 0-3) could be compared to routine drain removal (POD 4-7) in patients without early bile leaks or other complications. Patients were stratified by extent of hepatectomy and propensity score matched for multiple demographic, comorbidity, laboratory, procedure and pathologic variables. Outcomes of early and routine drain removal patients were compared by Mann-Whiting U and chi-square test. Results: Of 2,599 patients, 1,654 (64%) underwent a partial (PH) and 945 (36%) had a major hepatectomy (MH). Early drain removal was performed in 661 (40%) of PH and 211 (22%) of MH patients. Multiple outcomes were significantly (p < 0.01) better in the early drain removal patients, but these patients were less likely (p < 0.01) to have hepatitis, a prior biliary stent, neoadjuvant therapy, a major hepatectomy, a Pringle maneuver, a concurrent ablation, perioperative transfusions, or malignant pathology. Therefore, 779 early drain removal patients were matched to 779 routine drain removal patients (Table). Early drain removal patients had significantly less (p < 0.02) overall and serious morbidity, fewer pneumonias and required fewer postoperative biliary drainage procedures. Length of stay was 2 days shorter, (p<0.001) and readmissions were 3% lower (p < .01) in early drain removal patients. Conclusion: Early drain removal (POD 0-3) is performed in only one-third of hepatectomy patients who receive drains. Routine drain removal (POD 4-7) is practiced in a variety of patients some of whom are perceived to be at higher risk for complications. After controlling for these factors, early drain removal is associated with lower overall and serious morbidity as well as shorter length of stay and fewer readmissions. Early drain removal after hepatecomy is an underutilized management strategy.

Endoscopic Ultrasound-Guided Gallbladder Drainage After Roux-En-Y Gastric Bypass: It Can Hide, but It Can‘t Run!

In patients with acute cholecystitis who are non-operative candidates, percutaneous cholecystostomy (PC) catheter placement is used for gallbladder decompression Removal of the catheter can lead to recurrence of cholecystitis. Leaving drain in place can cause infection, pain and dislodgment. Routine catheter maintenance and exchanges adversely affect quality of life. EUS-guided approach may be used to convert PC drainage to internal biliary drainage. 33-year-old woman with a history of Roux-en-Y gastric bypass presented with septic shock. She was actively abusing alcohol (MCV 105), malnourished (Albumin 2.0), coagulopathic (INR 2.0), thrombocytopenic (Platelets 58 k), and requiring frequent large volume paracentesis Abdominal CT scan showed acute acalculous cholecystitis. Patient started on broad spectrum antibiotics, vasopressors, deemed to be a prohibitive operative candidate and underwent placement of an 8 French decompression PC catheter (Fig 1) by Interventional Radiology. Due to severe discomfort from the PC catheter, taken for conversion to internal biliary drainage via endoscopic ultrasound. Stricture found at the G-J anastomosis. Contrast injected across the stricture, confirming a patent jejunal limb. Stricture was dilated to 18 mm. EUS scope maneuvered into the jejunal limb, gallbladder visualized endosonographically. Hyperechoic material consistent with sludge seen within an enlarged gallbladder. Site within the jejunum chosen, where gallbladder wall was within 1 cm (Fig 2). Gallbladder punctured with a 19 gauge FNA needle under EUS guidance. 10 mm by 10 mm cautery-enhanced LAMS placed creating a cholecystojejunostomy. 7 Fr by 4 cm plastic double pigtail stent placed through LAMS to maintain patency of the metal stent and prevent the backwall of gallbladder from impacting the metal stent causing bleeding or dislodgement (Fig 3). The patient did well following EUS-guided cholecystojejunostomy. 3 weeks later, a cholecystogram was performed. Contrast flowed from a decompressed gallbladder and into the jejunum across a patent cholecystojejunostomy via the LAMS. The PC catheter was then removed. The patient did well and was discharged home. EUS guided-conversion of percutaneous gallbladder drainage to internal drainage via a cholecystojejunostomy using a LAMS in a non-surgical patient with Roux-en-y gastric bypass is feasible, although the procedure is technically challenging and requires more expertise compared to primary EUS-guided gallbladder drainage.1702_A Figure 1 No Caption available.1702_B Figure 2 No Caption available.1702_C Figure 3 No Caption available.Watch the video: https://goo.gl/rfav8w

Images at 1 month follow-up show the intact stent and residual air surrounding the pancreas with drains in place

Images at 1 month follow-up show the intact stent and residual air surrounding the pancreas with drains in place

EUS-guided drainage of postsurgical fluid collections using lumen-apposing metal stents: a multicenter study

Postsurgical fluid collections (PSFCs) are traditionally drained either percutaneously or surgically. Endoscopic drainage offers several advantages compared with either percutaneous or surgical approaches, including avoiding repeat surgery or the need to have a percutaneous drain in place for weeks. There are very little data regarding the use of lumen-apposing metal stents (LAMSs) in the drainage of PSFCs. We aim to study the technical and clinical success and adverse events (AEs) of using LAMSs in the drainage of PSFCs. Collaborators from 8 centers retrospectively reviewed their endoscopic databases to find procedures using LAMSs for drainage of PSFCs. Technical success (successful placement of LAMSs into the fluid collection), clinical success (complete resolution of the fluid collection on repeat imaging or endoscopy), and intraprocedure and postprocedure AEs were measured. Forty-seven patients were identified with PSFCs after various surgeries. Thirteen patients had failed previous percutaneous or surgical drainage attempts. Fluid collections averaged 78.6mm (range, 47-150mm) in size. The most common site of stent placement was transgastric, followed by rectum and duodenum. Technical success rate was 93.6% and clinical success rate 89.3%. The intraprocedural AE rate was 4.25% and postprocedural AE rate 6.4%. There was 1 death unrelated to the procedure. The use of LAMSs to drain PSFCs has a high technical and clinical success rate with low AEs. For collections that are favorably located adjacent to the stomach, duodenum, or rectum, LAMS placement is a viable alternative to repeat surgery or percutaneous drainage.

Duration of indwelling drain following instrumented posterolateral fusion of the lumbar spine does not predict surgical site infection requiring reoperation

The objective of this study was to determine the incidence and predictors of reoperation for surgical site infections (SSI) among patients whose lumbar, closed wound suction drains were removed in the inpatient setting prior to hospital discharge (pre-discharge cohort) versus after inpatient discharge during the first follow up visit (post-discharge cohort). All patients who were admitted for first-time, posterolateral decompression and fusion for degenerative lumbar spine disease were retrospectively reviewed at a single institution. In order to eliminate biases, neither the pre-discharge nor post-discharge cohorts experienced any intra-/postoperative sentinel events other than the primary outcome measure: reoperation for SSI. Of 209 patients in the pre-discharge (n=130) and post-discharge (n=79) cohorts, 15 patients required reoperation for SSI. Although time to drain discontinuation was significantly longer in the post-discharge (8.28days) than the pre-discharge (4.65days) cohorts (p<0.001), the incidences of reoperation for SSI did not significantly differ (6.33 vs 7.69%, respectively, p=0.711). In a multivariable regression, only smoking (OR=5.75, p=0.007) and depression (OR=4.11, p=0.040) predicted reoperation for SSI. Neither time to drain removal nor setting of drain removal was a predictor of reoperation for SSI. Although time to drain discontinuation was expectedly longer in the post-discharge versus pre-discharge cohorts, the incidences of reoperation for SSI did not significantly differ. Neither time to drain removal nor setting of drain removal predicted reoperation for SSI. These results suggest that patients may be safely discharged from the hospital with the surgical drain in place.

Parapneumonic pleural effusion: early versus late thoracoscopy

ABSTRACTObjective: To evaluate the best time to perform thoracoscopy for the treatment of complicated parapneumonic pleural effusion in the fibrinopurulent phase in patients ≤ 14 years of age, regarding the postoperative evolution and occurrence of complications.Methods: This was a retrospective comparative study involving patients with parapneumonic pleural effusion presenting with septations or loculations on chest ultrasound who underwent thoracoscopy between January of 2000 and January of 2013. The patients were divided into two groups: early thoracoscopy (ET), performed by day 5 of hospitalization; and late thoracoscopy (LT), performed after day 5 of hospitalization.Results: We included 60 patients, 30 in each group. The mean age was 3.4 years; 28 patients (46.7%) were male; and 47 (78.3%) underwent primary thoracoscopy (no previous simple drainage). The two groups were similar regarding gender, age, weight, and type of thoracoscopy (p > 0.05 for all). There was a significant difference between the ET and the LT groups regarding the length of the hospital stay (14.5 days vs. 21.7 days; p < 0.001). There were also significant differences between the groups regarding the duration of fever in days; the total number of days from admission to the initiation of drainage; and the total number of days with the drain in place. Eight patients (13.6%) had at least one post-thoracoscopy complication, there being no difference between the groups. There were no deaths.Conclusions: Performing ET by day 5 of hospitalization was associated with shorter hospital stays, shorter duration of drainage, and shorter duration of fever, although not with a higher frequency of complications, requiring ICU admission, or requiring blood transfusion.

Isolated Pyrexia: The Hunt for Disease in a Patient Without Discernible Risk Factors

Hepatic abscesses are relatively rare and require prompt recognition and early intervention to reduce morbidity and mortality, which may be significant if left untreated. We present a case of pyogenic liver abscess with atypical presentation and absence of discernable risk factors. 59-year-old male with a history of hypertension and hyperlipidemia presented to the emergency department with complaints of daily fevers for approximately 4 days reaching a maximum temperature of 104.1°F. The fevers did not follow any particular pattern, were partially relieved by acetaminophen, and were associated with fatigue but no chills. He denied any abdominal or chest pain, dyspnea, nausea, vomiting, diarrhea, constipation, dysuria, headache, neck stiffness, rash, arthralgia, joint swelling, back pain, sore throat or any other symptom. He had no recent medication changes, history of prosthetic joint or valve replacement, or history of surgery. He underwent annual dental evaluations with no recent dental cleanings and was up to date on his screening colonoscopy with follow up in 8 years. On physical exam, his vital signs were normal except tachycardia to 113 beats per minute and a temperature of 102.9F. He was alert and in no acute distress. His physical exam was absent for any abnormality with unremarkable head, neck, cardiac, lung, abdominal, extremity and skin exam. Laboratory analysis was significant for elevated liver enzymes and a mild leukocytosis. An abdominal ultrasound showed a lobulated circumscribed heterogeneous mass suspicious for malignancy or abscess that was later confirmed on CT scan. He was found to have elevated ESR, CRP, and procalcitonin values with an undetectable alpha fetoprotein. Antibiotics were initiated and he underwent percutaneous hepatic drain placement. Blood cultures were positive for streptococcus intermedius. Dental evaluation via xray panorex and CT neck studies were negative for dental infection. Transthoracic and transesophageal echo evaluation were negative for endocarditis. He improved and discharged home with hepatic drain in place and antibiotic infusions until he showed clinical evidence of resolution of infection. This case illustrates a potentially lethal infectious process that presented in an atypical manner and without known risk factors. It emphasizes the significance of maintaining clinical suspicion for occult abscess and prompt but appropriate imaging if there are no clear foci of infections with respect to history.Figure 1Figure 2

Nursing a canine patient with a pneumothorax — a patient care report

This article will describe and evaluate the nursing care provided for a canine patient that had a chest drain in place due to a tension pneumothorax. It is evident that nursing a patient with a chest drain involves implementing and carrying out a number of nursing interventions to ensure a high standard of nursing care is maintained and to reduce the risk of any complications. The relevant nursing interventions included: pain management, management of the chest drain, preventing patient interference and observation of the patient for potential complications associated with the chest drain. Recommendations for future practice have been suggested and based on available literature, these include: implementation of a pain scoring assessment and changing the patient's thoracic bandage twice daily to allow earlier recognition of any signs of infection.

Abdominal Wall Reconstruction: The Uncertainty of the Impact of Drain Duration upon Outcomes

Drains are commonly used after abdominal wall reconstruction (AWR) to prevent seroma formation. Drain management is subjective, and the merits and drawbacks of drains are not well understood. After receiving Institutional Review Board approval, we queried our prospectively maintained surgical database for AWR cases from 2009 to 2012 to ascertain if the number of days postoperatively that drains are left in place impacts the incidence of surgical site complications. Number of drains, drain duration, wound complications, and interval to development of complications were recorded. Wound complications were defined as superficial cellulitis, seroma, hematoma, superficial infection, and deep infection. Among 117 AWRs, we investigated the 64 cases with Centers for Disease Control grade one wound classification. Longest drain duration varied widely (2-171 days postoperatively; mean = 22 days). Cases were divided into four groups based on duration prior to removal of all drains: ≤7 days (n = 18), 8 to 14 days (n = 16), 15 to 28 days (n = 18), or ≥29 days (n = 12). No significant relationship was found between incidence of seroma/hematoma and days postoperatively of last drain removal. Wound complications increased linearly with drain time. Using logistic regression to adjust for obesity (body mass index >35kg/m(2)), drain duration >2 weeks and operative time >220 minutes, only body mass index >35 remained an independent predictor of wound occurrence, P < 0.05. Wound complications occur frequently after AWR. Wound infections occur more commonly among patients with drains in place for more than 2 weeks. Strategies to reduce drain duration require furthermore investigation.

Why Cannot Suction Drains Prevent Postoperative Spinal Epidural Hematoma?

BackgroundPostoperative spinal epidural hematoma (POSEH) is different from spontaneous or post-spinal procedure hematoma because of the application of suction drains. However, it appeared that suction drains were not effective for prevention of POSEH in previous studies. The purpose of this study was to test our hypothesis that POSEH can be caused by hypercoagulability.MethodsThis was an experimental study. One hundred fifty milliliters of blood was donated from each of the 12 consecutive patients who underwent spine surgery and infused into 3 saline bags of 50 mL each. One of the 3 bags in each set contained 5,000 units of thrombin. All of them were connected to 120 ± 30 mmHg vacuum suctions: drainage was started 8 minutes after connection to the vacuum system for 12 normal blood bags (BV8) and 12 thrombin-containing blood bags (TBV8) and 15 minutes after connection for the remaining 12 normal blood bags (BV15). The amount of initial and remaining hematoma at 20 minutes, 120 minutes, and 24 hours after vacuum application were measured by their weight (g). The primary endpoint was the difference between BV8 and TBV8. The secondary end point was the difference between BV8 and BV15.ResultsThe remaining hematoma in TBV8 was significantly greater than that in BV8 at all measurement points: 46.3 ± 12.4 vs. 17.0 ± 1.3 (p = 0.000) at 20 minutes; 33.0 ± 8.2 vs. 16.3 ± 1.2 (p = 0.000) at 120 minutes; and 26.1 ± 4.0 vs. 15.8 ± 1.6 (p = 0.000) at 24 hours after vacuum application. The remaining hematoma of BV15 was significantly greater than that of BV8 at all measurement points: 30.0 ± 12.0 vs. 17.0 ± 1.3 (p = 0.002) at 20 minutes; 24.2 ± 7.6 vs. 16.3 ± 1.2 at 120 minutes (p = 0.002); and 22.2 ± 6.6 vs. 15.8 ± 1.6 (p = 0.004) at 24 hours after vacuum application.ConclusionsWith a suction drain in place, the amount of remaining hematoma could be affected by coagulability. Thrombin-containing local hemostatics and the length of time elapsed before the commencement of suction resulted in hypercoagulability, indicating these two factors could be causes of POSEH.

Conversion of Percutaneous Cholecystostomy to Internal Transmural Gallbladder Drainage Using an Endoscopic Ultrasound-Guided, Lumen-Apposing Metal Stent.

Patients with acute cholecystitis sometimes require placement of percutaneous cholecystostomy catheters, either as a bridge to surgery or as primary therapy. In patients who cannot undergo surgery, subsequent removal of the catheter can lead to recurrence of cholecystitis, whereas leaving the drain in place can cause adverse events. We investigated internalization of percutaneous cholecystostomy drainage catheters, using endoscopic ultrasound (EUS)-guided placement of lumen-apposing metal stents (LAMS) as an alternative treatment strategy. Seven patients (median age, 57 years; 6 men) underwent EUS-guided cholecystoenterostomy for internalization of gallbladder drainage with EUS-guided placement of a 10- or 15-mm LAMS. All had initially been treated with placement of a percutaneous cholecystostomy catheter for cholecystitis and were later deemed unfit for cholecystectomy. Technical success was achieved in all patients in 1 endoscopic session, with subsequent removal of all percutaneous drains. Two patients required placement of self-expandable metal stents within the LAMS to successfully bridge the gallbladder and gastrointestinal lumen. No adverse events occurred after a median follow-up of 2.5 months. EUS-guided cholecystoenterostomy using a LAMS is therefore a viable option for internal gallbladder drainage in patients who have a percutaneous cholecystostomy catheter and are poor candidates for cholecystectomy.

An Unusual Cause of Hepatic Rupture

Introduction: The Liver is a highly vascular organ that is vulnerable to traumatic injury because of its size and fixed position in the right hypochondrium. We present a unique case of a patient who presented with hepatic rupture following vigorous coughing. Case description: An 83 year-old female with history of chronic obstructive pulmonary disease presented with epigastric pain, nausea and vomiting following an episode of vigorous cough on exposure to dust. She denied hematemesis, melena or fever. Physical examination: heart rate 102/min, and blood pressure 109/56 mm Hg, decreased breath sounds with bilateral wheezing, diffusely tender, distended abdomen with guarding but no rigidity. Laboratory data: Total bilirubin 4.5 mg/l, Aspartate transaminase 43 IU/l, Alanine transaminase 99 IU/l, Alkaline phosphatase 136 IU/l, Serum lipase 51 U/l, negative hepatitis panel. Chest X-ray showed no rib fractures. Computed tomography (CT) revealed large fluid collection posterior to the stomach, no bowel perforation or cholecystitis. CT guided drainage showed bilious fluid. She was initially managed conservatively with the drain in place but failed to improve. Endoscopic retrograde cholangiopancreatography (ERCP) showed an obvious leak of contrast from the left lobe of the liver flowing and draining through the drain. Sphincterotomy and stent placement were done during ERCP with significant improvement in her condition. Hepatobiliary (HIDA) scan after 4 weeks showed no bile leak and stent was removed. Discussion: Hepatic laceration is often a fatal complication of trauma, pregnancy, anticoagulant therapy, connective tissue disorders, liver infiltrative diseases, hepatocellular carcinomas, and rarely cough as in our case. Patients present with severe right upper quadrant pain, abdominal distention, anemia or hypotension. Suspicion of injury is raised from presentation, physical examination and laboratory findings. CT abdomen usually confirms the injury and defines injury grade. Biliary tree disruption is a frequent complication of non-operative management; diagnosis and evaluation of the leak site may be made by ERCP and HIDA scan. Drainage of the bile collection followed by close observation serves as definitive therapy, but some patients have persistent bilious drainage that can be managed by ERCP with sphincterotomy and/or biliary stent placement. Conclusion: Hepatic laceration, though life-threatening, is not a well-described complication of cough. This report provides a detailed account of such a complication along with an unlikely site of bile collection occurring secondary to vigorous coughing.Figure 1Figure 2Figure 3

Transluminal or Percutaneous Endoscopic Drainage and Debridement of Abscesses After Bariatric Surgery: a Case Series.

Since redo surgery is associated with a high risk of morbidity and mortality after bariatric surgery in case of leakage, we sought to evaluate whether endoscopic drainage and debridement of collections following bariatric surgery is an efficient step-up approach to the management of these complications. From 2007 to 2011, we retrospectively studied our cohort of nine cases treated by endoscopic drainage and debridement of abdominal abscesses secondary to postbariatric surgery leaks performed via the transluminal or percutaneous route. Three patients were treated by percutaneous endoscopic debridement of abscesses knowing that their leak was already closed by other endoscopic means and that their collection did not improve despite external drain in place. Six patients were treated by transluminal endoscopic drainage to perform necrosectomy as a first-line option or after failure of improvement after endoscopic treatment. The number of sessions required ranged from 1 to 3. Most severe patients had rapid improvement of their hemodynamic and respiratory conditions. In eight of the nine patients, we were able to close the fistula by stent, fistula plugs, or a macroclip. Resolution of collections was seen in seven out of nine patients, but two required further surgery. Endoscopic necrosectomy via the transluminal or percutaneous route is a feasible option in postbariatric surgery patients with necrotic abscesses not adequately managed by the classical combination of percutaneous drainage and stenting. Further wide-scale studies are needed to compare this non-surgical method with surgical necrosectomy in postbariatric surgery patients.

Effect of Lavage with Gentamicin vs. Clindamycin vs. Physiologic Saline on Drainage Discharge of the Axillary Surgical Bed after Lymph Node Dissection.

To date, without placement of a drain, seroma formation cannot be avoided after axillary lymph node dissection (ALND). The purpose of this study was to evaluate the effect on drainage volume of pre-closure axillary lavage with physiologic saline, gentamicin solution, or clindamycin solution. A randomized study was performed between January 2013 and October 2014. Inclusion criteria were a diagnosis of breast neoplasm and plans to undergo an elective ALND because of axillary metastases. The patients were randomized into three groups: Two lavages with 500 mL of physiologic saline (Group 1), lavage with 500 mL of saline followed by lavage with 500 mL of a 240-mg gentamicin solution (Group 2), and lavage with 500 mL of saline followed by lavage with 500 mL of a 600-mg clindamycin solution (Group 3). A total of 51 patients were included. The mean number of days with a drain in place was 7.1±3 in Group 1, 4.1±1.2 in Group 2, and 6.4±2.1 in Group 3 (p<0.001). Total drainage volume before tube removal was 435.3±220.1 mL in Group 1, 155.2±82.4 mL in Group 2, and 352.3±212.9 mL in Group 3 (p=0.03). In a pairwise analysis, irrigation with gentamicin solution achieved a lower drainage volume and a reduction in the number of days of drainage maintenance compared with the other two groups. The post-operative output of the axillary drain is substantially lower in patients undergoing lavage of the surgical bed with a gentamicin solution than in patients undergoing lavage with physiologic saline or clindamycin solution.

Dual-modality drainage of infected and symptomatic walled-off pancreatic necrosis: Long-term clinical outcomes

Background Management options for symptomatic and infected walled-off pancreatic necrosis (WOPN) have evolved over the past decade from open surgical necrosectomy to more minimally invasive approaches. We reported the use of a combined percutaneous and endoscopic approach (dual modality drainage [DMD]) for the treatment of symptomatic and infected WOPN, with good short-term outcomes in a small cohort of patients. Objective To describe the long-term outcomes of 117 patients with symptomatic and infected WOPN treated by DMD. Design Review of a prospective, internal review board–approved database. Setting Single, North American, tertiary-care center. Patients All patients with symptomatic and infected WOPN treated by DMD at our institution between 2007 and 2012. Intervention DMD of symptomatic and infected WOPN. Main Outcome Measurements Disease-related mortality, pancreaticocutaneous fistula formation, need for early and late surgical intervention, procedure-related adverse events. Results A total of 117 patients underwent DMD for symptomatic and infected WOPN. A total of 103 have completed treatment, with all percutaneous drains removed. Ten patients are still undergoing treatment, and 4 patients died with percutaneous drains in place (3.4% disease-related mortality). For the patients completing therapy, the median duration of follow-up was 749.5 days. No patients required surgical necrosectomy or surgical treatment of DMD-related adverse events; 3 patients required late surgery for pain (n = 2) and gastric outlet obstruction (n = 1). There were no procedure-related deaths. In patients who have completed treatment, percutaneous drains have been removed in 100%; no patients have developed pancreaticocutaneous fistulas. Limitations Single-center design, lack of a comparison group. Conclusion DMD for symptomatic and infected WOPN results in favorable clinical outcomes; complete avoidance of pancreaticocutaneous fistulae, surgical necrosectomy, and major procedure-related adverse events, while maintaining single-digit disease-related mortality.

Retrospective Review of Pilonidal Sinus Patients With Early Discharge After Limberg Flap Procedure

The aim of this study was to evaluate the results of cases with pilonidal sinus (PS) disease that underwent Limberg flap (LF) transposition and to compare the short and long-term results of early discharge cases with those in the literature. A total of 345 patients who underwent rhomboid excision and LF transposition for PS were evaluated retrospectively. No major anesthetic or surgical complications occurred. Partial wound dehiscence, localized flap necrosis, hematoma, wound infection, and seroma rates were determined as 4.0, 2.1, 1.5, 3.3, and 3.7% respectively. All patients other than those with a hematoma or localized necrosis were discharged with a drain in place 24 hours after the operation. The recurrence rate was 3.9% after a mean 33.1-month follow-up (range, 6-72 months). As a result, we found that short and long-term results of patients who underwent LF and were discharged 24 hours after the operation were similar to those in the literature. We suggest that patients without postoperative complications, such as hematoma or flap necrosis, can be discharged early.