Drain Insertion Research Articles

Risk factors and management of biliary stones after living donor liver transplant and its effect on graft outcome.

BackgroundBile stones are associated with numerous complications in liver transplant recipients. Endoscopic retrograde cholangiopancreatography (ERCP) has been proven to be safe and highly effective in dealing with most post-transplant biliary complications.ObjectiveThe objective of this study was to identify the possible risk factors for bile stone formation on top of biliary stricture, the effects of stones on graft outcomes, and their management.MethodsThis case–control study included 83 patients who underwent living donor liver transplant (LDLT) and suffered from postoperative biliary stricture with or without stones. Patients were divided into two groups. Group 1 (n = 55) included patients with biliary strictures with no stones and group 2 (n = 28) included patients who developed stones on top of biliary strictures. Data about the recipient and donor characteristics, surgical technique, blood lipid profile, immunosuppressive drugs, post-transplant complications, and interventions were collected from the medical records.ResultsThe frequency of hepatitis C virus (HCV) was significantly higher in group 2 compared to group 1 (71.4% vs. 47.3%, p = 0.036). The body mass index (BMI) of the donors was significantly higher in group 2 than in group 1 (25.17 ± 2.53 vs. 23.68 ± 2.63, p = 0.015). Episodes of acute rejection were significantly higher in group 2 than in group 1 (21.4% vs. 5.5%, p = 0.027). The ERCP was sufficient in most of the cases (89.2%) to ensure biliary drainage. The identified independent risk factors for biliary stones included HCV, biliary drain, donor's BMI, and serum cholesterol level.ConclusionPositive HCV, biliary drain insertion, donor's BMI, and serum cholesterol level were independent risk factors for developing bile stones on top of biliary strictures. Biliary stones were associated with high episodes of acute graft rejection, and they could be successfully managed by the ERCP modality.

255 International Variation in Intraperitoneal Drain Placement and Outcomes After Elective Colorectal Surgery: A Matched, Prospective, Cohort Study

Abstract Background Currently, many surgeons place intraperitoneal drains after elective colorectal surgery. However, Enhanced Recovery After Surgery (ERAS) guidelines recommend against their routine use due to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Method COMPlicAted intra-abdominal collectionS after colorectal Surgery (COMPASS) was a prospective, international, cohort study which enrolled consecutive adult patients undergoing elective colorectal surgery (February-March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time-to-diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time-to-discharge; 30-day major postoperative complications (Clavien–Dindo grade ≥3). After propensity-score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 [44.2%] female; median age 67.0 years). The drain insertion rate was 51.9% (n=937). After matching, drains were not associated with reduced rates (OR 1.33, 95% CI: 0.79–2.23, p=0.287) or earlier detection of collections (HR 0.87, 95% CI: 0.33–2.31, p=0.780). Although not associated with worse major postoperative complications (OR 1.09, 95% CI: 0.68–1.75, p=0.709), drains were associated with delayed hospital discharge (HR 0.58, 95% CI: 0.52–0.66, p<0.001) and increased risk of SSIs (OR 2.47, 95% CI: 1.50–4.05, p<0.001). Conclusions Intraperitoneal drain placement after elective colorectal surgery remains widespread. Drains were not associated with earlier detection of collections but were associated with prolonged length of stay and increased SSI risk.

The impact of simulation-based mastery learning, booster session timing and clinical exposure on confidence in intercostal drain insertion: a survey of internal medicine trainees in Scotland

BackgroundIntercostal chest drain (ICD) insertion is a skill that medical trainees lack confidence in performing. This study explores the impact of a national programme of Simulation-Based Mastery Learning (SBML) on procedural confidence, including the impact of time intervals between booster sessions and interim clinical experience.MethodsInternal Medicine Trainees in Scotland were surveyed about confidence and clinical experience with ICD insertion before and immediately after SBML and booster session. Data were matched and analysed using paired sample t-tests. Short interval and long interval groups were compared using Student’s unpaired t-test. The impact of interim clinical experience was assessed using Analysis of Variance.ResultsMean confidence in ICD insertion rose following SBML, fell between initial and booster session, and increased again following booster session (P = < 0.001). 33 of 74 trainees had successfully inserted an ICD between sessions. Fall in confidence was unaffected by the time interval between training sessions, but was mitigated by interim clinical experience.ConclusionsSBML boosts trainee confidence in ICD insertion. However, there is evidence of confidence decay, possibly due to a lack of clinical experience between sessions. More research is needed to explore barriers to transfer of skills from simulated to real-world environments.

Surgical site infection in a tertiary care hospital

Background: Surgical Site Infections (SSI) is the third most commonly conveyed nosocomial infection which has an adverse impact on the hospital as well as on the patient. A continuous surveillance is called for, to keep a check on the incidence of SSI. Objectives: a) to study the incidence of SSI in our hospital; b) To study the risk factors of SSI in our hospital; c) To identify the areas in our hospital, which need to be strengthened and deal with proactive measures to curb the incidence of SSI. Methodology: It was a Prospective study conducted for 6 months in our hospital. 131 cases of Surgery were included in the study. All patients who are operated in general surgery department of VMKVMCH between July 2021 – December 2021. A few host factors, wound factors and surgery related factors that cause SSI were studied. Swabs were collected from the infected surgical wounds and processed by the conventional microbiological methods. Antimicrobial susceptibility was done by Kirby-Bauer disc diffusion method. Results: Prolonged surgery (&gt;2hours) and insertion of drain were found to be significantly associated with occurrence of SSI and the clean surgeries showed minimum risk of infection.

TU8.3 The optimal timing of Laparoscopic cholecystectomy following percutaneous cholecystostomy in Acute cholecystitis

Abstract Introduction Percutaneous cholecystostomy (PC) is an effective option for high risk and/or delayed presented Acute cholecystitis (AC). However, the optimal timing for subsequent laparoscopic cholecystectomy (LC) as a definitive treatment remains controversial. Methods This study includes 41 patients underwent LC following PC for severe AC. We compared the length of tube insertion, period from PC till LC and period from PC removal till LC against co-morbidities, another attack of AC, subsequent pancreatitis/jaundice and operative difficulties in terms of intraoperative adhesions, drain insertion, conversion to open, length of operation. Results The median time of length of tube insertion was 36 days (range 5–208) while the median time of PC insertion till LC was 144 days (range 31–744) and for period from PC removal till LC was 78 days (range 0–714). Patients with prolonged tube insertion (more than a month) showed higher risk of developing subsequent pancreatitis and or jaundice (P=0.04) while intraoperative adhesions was associated with prolonged time from tube insertion till operation (more than 4 months). There was no significant association between neither the length of tube insertion, period from PC insertion till LC nor period from PC removal till LC and other studied parameters. Conclusion Prolonged time of PC insertion and/or prolonged time form PC insertion till LC in patients with AC have higher risk of pancreatitis and surgical difficulties. Further studies including larger number of patients’ sample is warranted to confirm the outcomes and determine the optimal time of LC following PC in those patients.

TU8.2 Percutaneous cholecystostomy for acute calculous cholecystitis an observational study from a single institute

Abstract Introduction Although percutaneous cholecystostomy (PC) is generally accepted as a bridge to definitive therapy for acute cholecystitis (AC), which remains cholecystectomy, some patients did not undergo cholecystectomy mostly due to contraindications to surgery. Here, we aimed to audit our clinical practice from a single institute. Methods 153 patients presented with AC and initially managed with PC were included. The proportion of patients who did not undergo subsequent LC and their characteristics were analysed. Results 27% (41/153) of the study cohort underwent LC while the remaining patients (n=112) did not receive any surgical intervention.22/122(20%) were presented with AC and coexisting hepatobiliary malignancy. The mean age of the remaining patients (n=90) was 75±13 years and the median length of drain insertion of those patients 40 days. The majority (57%) was presented with sever AC while 8% had AC with adjacent liver abscess. 55% of those patients did not develop any further attacks of AC after PC removal while 25% deemed unfit for surgery. The rest of the patients (20%) either refused the operation or died before LC. The American Society of Anaesthesiologists (ASA) score was 3 IV in 9% of patients (8/90). 15% (13/90) experienced post PC complications including either blocked stent, pain and cellulitis around tube. The 60-day mortality rate of patients who did not underwent LC was 11% (10/90). Conclusion The majority of AC patients treated initially with PC did not undergo subsequent LC. PC in high surgical risk patients with AC could be consider as definitive treatment.

TU8.1 Evaluation of drain insertion after appendicectomy for complicated appendicitis: A systematic review and meta-analysis of 17 studies

Abstract Introduction Surgical drains are used to reduce post-appendicectomy collections. However, they can cause considerable discomfort or increase the risk of surgical site infection (SSI), among other problems. Our aim is to review the literature systematically and conduct a meta-analysis to assess the advantages of using drains (DG) versus no drain (NDG) in complicated appendicitis. Methods This systematic review was conducted in accordance with the Cochrane Handbook for Systematic Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. All randomized control trials, comparative observational studies comparing outcomes of drain or no drain after appendicectomy for patients with complicated appendicitis were considered. Results Seventeen studies (n=4255 patients) who underwent appendicectomy for complicated appendicitis with drain (DG=1580) without a drain (NDG=2657) were included. There was no difference between the two groups regarding abdominal collection [Odd ratio (OR)=1.41, P=0.13] and mortality [ risk difference (RD)= 0.01, p= 0.18]. NDG was superior to the DG regarding SSI [OR=1.93, P= 0.0001], faecal fistula [OR=4.76, P= 0.03], Intestinal obstruction [OR=2.40, P= 0.04], and ileus [ OR=2.07, P=0.01]. The No-drain group showed statistically significant shorter LOS when compared to the drain group [MD 1.79, 95% CI (1.25, 2.34), P= 0.00001]. Conclusion In conclusion, this meta-analysis has shown that drains have no effect on the development of intra-abdominal collections in complicated appendicitis, but it can significantly increase the risk of post-operative complications such as fistula, surgical site of infection (SSI), bowel obstruction, ileus, and prolonged hospital length of stay.

Hemoglobin Drop and the Need for Transfusion in Primary Knee Arthroplasty.

BackgroundBlood loss is still a serious adverse effect of total knee replacement (TKR), resulting in Hemoglobin drop and a higher need for blood transfusions. Multiple modalities are used to reduce intra-operative blood loss and hemoglobin drop for this procedure, such as placing a drain intraoperatively and Tranexamic acid (TXA) administration. This study aimed to investigate factors associated with hemoglobin loss and blood transfusion increased demand.Patients and methodsWe retrospectively looked at 223 patients who underwent primary unilateral or staged bilateral knee arthroplasty by a single surgeon from January 2013 until April 2018 in Salmaniya Medical Complex (SMC), Bahrain. We looked into patients' demographics such as age, gender, preoperative hemoglobin and hematocrit, postoperative hemoglobin and hematocrit, drain insertion intra-operatively, and the administration of Intravenous tranexamic acid intra-operatively. Eighty-three patients had a drain inserted intra-operatively, and sixty-nine patients received intra-venous Tranexamic acid during the procedure.ResultsOut of 223 patients, 152 patients were included after applying exclusion criteria. The mean hemoglobin (Hb) loss in patients who had a drain inserted was 2.186 g/dL, while patients who received tranexamic acid had a mean of 1.609 g/dL. Multivariable regression analysis revealed that increased blood transfusion requirements postoperatively were significantly associated with reduced pre-operative Hemoglobin levels (p-value .004). Univariable analysis of the hemoglobin drop showed that the use of TXA would reduce Hb loss while a drain would increase Hb drop (p-value .003 and .002, respectively). Moreover, univariable analysis of blood transfusion requirements showed reduced pre-operative Hb, and placing a drain would increase blood transfusion demand (p-value <.001, .044 respectively), while administration of tranexamic acid would reduce blood transfusion demand (p-value 0.05).ConclusionReducing the need for blood transfusion following primary total knee arthroplasty can be achieved by maintaining preoperative hemoglobin levels, administering tranexamic acid intra-operatively, and avoiding placing an intra-articular drain.

Vaginal vault drainage as an effective and feasible alternative in laparoscopic hysterectomy.

ObjectiveInfected pelvic hematoma is a serious complication of hysterectomies. Pelvic drainage can help reduce complications. In this study, we evaluated the efficacy and safety of vaginal vault drainage in patients who underwent laparoscopic hysterectomy for benign gynecological diseases.MethodsPatients who underwent laparoscopic hysterectomy and pelvic drain insertion for benign gynecological diseases between January 2008 and December 2015 were enrolled retrospectively in the study. They were grouped according to drain insertion sites, that is, through the abdomen (group 1) and vaginal vault (group 2). The postoperative outcomes were compared between the two groups.ResultsA total of 504 women were included. No significant differences were observed in the prevalence of postoperative fever, readmission, and reoperation between the two groups.ConclusionGiven the discomfort associated with holding and removing the abdominal drain, inserting a closed pelvic gravity drain through the vaginal vault appears to be a feasible alternative to an abdominal drain.

Pneumomediastinum in the COVID-19 era: to drain or not to drain?

Pneumomediastinum (PNM) is a rare clinical finding, usually with a benign course, which is managed conservatively in the majority of cases. However, during the COVID-19 pandemic, an increased incidence of PNM has been observed. Several reports of PNM cases in COVID-19 have been reported in the literature and were managed either conservatively or surgically. In this study, we present our institutional experience of COVID-19 associated PNM, propose a management algorithm, and review the current literature. In total, 43 Case Series were identified, including a total of 747 patients, of whom 374/747 (50.1%) were intubated at the time of diagnosis, 168/747 (22.5%) underwent surgical drain insertion at admission, 562/747 (75.2%) received conservative treatment (observation or mechanical ventilation. Inpatient mortality was 51.8% (387/747), while 45.1% of the population recovered and/or was discharged (337/747). In conclusion, with increased incidence of PNM in COVID-19 patients reported in the literature, it is still difficult to assign a true causal relationship between PNM and mortality. We can, however, see that PMN plays an important role in disease prognosis. Due to increased complexity, high mortality, and associated complications, conservative management may not be sufficient, and a surgical approach is needed.

The Prevalence and Etiology of Surgical Site Infections Following Gastrointestinal Tract Surgery: A Cross-Sectional Study From a Tertiary Care Hospital.

BackgroundSurgical site infection (SSI) is the most commonly occurring infection in postoperative patients. This study is conducted to evaluate the prevalence of SSI in patients following gastrointestinal tract surgery and identify the risk factors.MethodA cross-sectional study was conducted at the Jinnah Postgraduate Medical Centre (JPMC), Karachi, Pakistan, between December 2021 and May 2022. A total of 132 patients participated in the study who were at least 18 years older and had undergone the gastrointestinal surgical procedure. Patients who refused to give consent, died after the procedure, and were diagnosed with SSI after they were discharged were excluded from the study. We performed a chi-squared test.ResultA total of 132 patients were included in the study, of which 63 (47.7%) were males, while 69 (52.3%) were females. SSI was more commonly found among the age group of 41-70 years with 29 (38.7%) patients. Presurgical features including hemoglobin of >11 mg/dL, albumin of >3.5 g/dL, blood glucose of <80 mg/dL, and emergency surgery were found to be associated with the SSI having a significant p-value. Similarly, the surgical and postsurgical features significantly associated with the SSI having a significant p-value were the presence of surgical trauma, wound irrigation with normal saline, malignancy, bowel preparation, longer duration of the surgery, intraoperative hypotension, operative site, drain insertion, and the absence of a second antibiotic.ConclusionThe early identification and management of the demographical, presurgical, surgical, and postsurgical risk factors can help reduce the incidence of SSIs. Bowel preparation should be encouraged, and unnecessary delays during the surgical process leading to increased procedure time should be avoided. Extra precaution needs to be provided for the patients highly susceptible to SSIs.

Closed Suction Drain Placement Using a Carroll Tendon Retriever.

The technique used for closed suction drain placement in plastic surgery is dependent on surgeon preference and experience. Drains assist in preventing accumulation of inflammatory seroma fluid, but they also present a possible nidus for infection, which is particularly concerning in implant-based breast reconstruction. Murray et al.1 retrospectively reviewed 200 cases of breast reconstruction with tissue expander placement and found that subcutaneous tunneling is one factor that may defend against infection by means of in vivo protection of the prosthesis from the drain. This clinical practice is echoed in the neurosurgery literature, where several studies have shown that long subcutaneous tunneling decreases the incidence of surgical site infection in neurosurgical procedures.2,3 Yoshida et al.4 recently described a method of drain placement into the breast pocket utilizing a liposuction cannula. While their method is innovative and effective, we would like to propose another technique with the similar advantage of using readily available operating room instruments but that is simpler and more ergonomic. The method utilizes a Carroll tendon retriever, commonly referred to as a tendon passer by plastic and hand surgeons, to place a tunneled closed-suction drain for implant-based breast reconstruction through a long subcutaneous plane with minimal disruption and stress to surrounding tissues. We begin by selecting a drain insertion site lateral to the breast pocket at the level of the inframammary fold to allow for at least 5 cm of subcutaneous tunneling. This location permits the scar to be hidden by a bra. After creating a stab incision, the surgeon inserts a Carroll tendon retriever with jaws closed and advances it manually with gentle, constant pressure through the subcutaneous plane into the breast pocket. The jaws are then opened to grasp the external end of the drain and draw it out from the upper outer breast pocket through the tunnel. The drain is secured with nonabsorbable suture and dressed with a sterile adhesive dressing. [See Video (online), which demonstrates the use of a Carroll tendon retriever to facilitate drain placement into a breast pocket.] {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video.","caption":"This video demonstrates the use of a Carroll tendon retriever to place a drain tube into a breast pocket.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_acjzm5ek"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} The Carroll tendon retriever has several advantages over other common methods of placing tunneled drains. This technique facilitates atraumatic creation of a long subcutaneous tunnel. In contrast to either a tonsil or a hemostat, both of which have a shank that splays widely toward the handle in the tissue, the Carroll tendon retriever has a static, narrow body that forms a uniform-sized tunnel. Its blunt tip makes it a safer alternative to using a trocar for drain placement. Lastly, the Carroll tendon retriever is well known to plastic and hand surgeons and is reusable and reasonably inexpensive. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No direct funding was provided for this study.

The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery

BackgroundLaparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery. MethodsA committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol. ResultsA consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index.There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures.An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count. ConclusionThirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.

Emergency medicine undergraduate simulation training during the COVID-19 pandemic: A course evaluation

ObjectiveReduction in patient-facing teaching encounters has limited practical exposure to Emergency Medicine for medical students. Simulation has traditionally provided an alternative to patient-facing learning, with increasing integration in courses. Rapid advancements in technology facilitate simulation of realistic complex simulations encountered in the emergency setting. This study evaluated the efficacy of high-fidelity simulation in undergraduate emergency trauma medicine teaching. MethodsA consultant trauma expert delivered an introductory lecture, followed by consultant-led small group transoesophageal echocardiogram (TOE) and chest drain simulations, and a splinting station. Participants then responded to a major trauma incident with simulated patients and high-fidelity mannequins. Pre- and post-surveys were administered to assess change in delegates’ trauma surgery knowledge and confidence. DesignOne-group pretest-posttest research design. SettingA higher education institution in the United Kingdom. ParticipantsA convenience sample of 50 pre-clinical and clinical medical students. ResultsRecall of the boundaries of the safe triangle for chest drain insertion improved by 46% (p < 0.01), and knowledge of cardinal signs of a tension pneumothorax improved by 26% (p = 0.02). There was a 22% increase in knowledge of what transoesophageal echocardiograms (TOEs) measure (p = 0.03), and 38% increased knowledge of contraindications for splinting a leg (p < 0.01). The average improvement in knowledge across all procedures when compared to baseline was 35.8% immediately post-simulation and 22.4% at six-weeks post-simulation. Confidence working in an emergency setting increased by 24% (p < 0.001) immediately, and by 27.2% (p < 0.001) at six weeks. ConclusionsThe findings suggest that simulation training within emergency medicine can result in significant increases in both competency and confidence. Benefits were observed over a six-week period. In the context of reduced patient-facing teaching opportunities, emergency medicine simulation training may represent an invaluable mechanism for delivery of teaching.

Mechanical Complications of External Ventricular and Lumbar Drains

External ventricular drain (EVD) and lumbar drain insertion are 2 of the most commonly performed neurosurgical procedures worldwide for acute hydrocephalus. Mechanical complications, such as obstruction or cerebrospinal fluid (CSF) leakage, are often seen and may contribute toward significant patient morbidity. Different CSF drainage methods are advocated to reduce the incidence of complications, but evidence regarding comparative effectiveness is limited. In this single-center prospective cohort study, the incidence of mechanical complications and associated interventional factors, including choice of drain, collecting system, and location, were studied in patients requiring CSF diversion for acute hydrocephalus. Univariate analyses were performed to explore trends within the data, followed by a repeated-measures mixed-effects regression to determine the independent influence of drain device on mechanical failure. Sixty-one patients required CSF diversion between January 2020 and March 2021, via 3 different drain types (lumbar drain, tunneled, and bolted EVD) and 2 collection systems (LiquoGuard 7 and AccuDrain), performed in either theater or intensive care. Twenty-one patients (39%) experienced a mechanical complication, with blockage being the most common. Multivariate analyses showed that bolted EVDs (odds ratio, 0.08; confidence interval, 0.01-0.58) and LiquoGuards (OR, 0.23; CI, 0.08-0.69) were significantly associated with fewer mechanical complications compared with tunneled EVDs and gravity-based collection systems, respectively (P ≤ 0.01). Drain device has an influence on the occurrence of EVD-related complications. These preliminary findings suggest that choosing bolted EVDs and motor-assisted drainage can reduce drain-associated mechanical failure. A randomized controlled trial comparing drain devices is required to confirm these findings.

Pathogenesis of peritoneal drain complications; a case report of evolving adnexal evisceration following difficult retrieval of a retained peritoneal drain

Background: Intra-peritoneal drainage dates back to the time of Hippocrates when long bone tissue, metal, and glass tubes were employed. The benefit of routine intra-peritoneal drainage however remains debatable in contemporary times. Retained drains may be outward manifestations of more sinister or latent complications and how an entrapped surgical drain is removed, may determine the occurrence of further complications. Case Presentation: We report here the case of a 32-year-old primipara who had a retained improvised peritoneal drain, which was inserted during the cesarean section for continued oozing of serosanguineous fluid. Omental tissue found at laparoscopy, to have plugged a fenestration in the drain, was promptly relieved. A loop of the Fallopian tube was however later observed trapped in another fenestration and herniating into the stab incision of the drain tube towards the exterior, this was freed with an atraumatic laparoscopic grasper and drain tube retrieval completed under laparoscopic visualization. Conclusion: Insertion of the peritoneal drain during cesarean section should be carefully considered, when necessary; it should be done with the most appropriate drainage systems. Retrieval of the peritoneal drain is a risk factor for visceral herniation. Entrapped drains should be retrieved, under direct visualization, to prevent iatrogenic injuries.

Management of Primary Spontaneous Pneumothorax in a Third-Level Pediatric Surgical Center: A Retrospective Study.

IntroductionThe management of primary spontaneous pneumothorax (PSP) in pediatrics remains controversial. The aim of this study was to investigate the risk of recurrence after non-surgical treatment vs. surgery, the difference in the length of stay (LOS) between various treatment options, and the role of computed tomography (CT) in the management of PSP.Materials and MethodsWe retrospectively reviewed patients admitted to our Pediatric Surgery Unit for an episode of PSP between June 2009 and July 2020. Medical records including clinical presentation at admission, diagnostics, treatments, complications, and LOS were collected.ResultsTwenty-three patients (22 males and 1 female) were included in this study. Median age was 15.65 (range 9–18). Chest X-rays were performed in all patients and showed 5 small (22%) and 18 large (78%) PSP. Chest drain was used for large PSP (≥2 cm) if the patient was clinically unstable. Eleven patients (48%) were managed non-operatively with observation alone and a recurrence rate of 18%, chest drain was used in 11 patients with a recurrence rate of 36%, and surgery was deemed necessary as a first treatment choice in one case. Six patients (27%) had an episode of relapse after non-operative management or chest drain placement. Following surgery, a relapse occurred in 2 of the 6 patients. Chest drain insertion was associated with a longer LOS than observation alone (6.36 vs. 2.4 days), and surgery resulted in a longer LOS than other types of treatment (P = 0.001).ConclusionAccording to our experience, small PSP or clinically stable larger PSP can be treated conservatively with observation alone. Operative management should be taken into consideration in children with large symptomatic PSP, persistent air leak, and/or relapse after chest drain insertion.

The need for an institution-specific normal pressure hydrocephalus management protocol.

Background: Despite the publication of international guidelines, the management of normal pressure hydrocephalus (NPH) varies due to clinician preference and varying clinical evidence. An audit was performed to review the current pathways used in clinical practice with the aim of formulating an institution-specific protocol to optimize and standardize care.Methods: An internal audit was performed on the management of patients with NPH who presented to the Princess Alexandra Hospital, Brisbane between January 2016 and February 2019.Results: Forty-one patients were included in the study. Lumbar puncture (LP) was the main diagnostic test used (63.4%). About 14.6% underwent lumbar drain (LD) insertion instead. About 12.2% did not undergo either LP or LD before definitive treatment. Only 60% of all patients underwent ventriculoperitoneal shunt insertion. Overall, five treatment pathways were noted. LP + VP shunt showed the greatest average improvement in Montreal Cognitive Assessment (MoCA) or Mini-Mental State Examination (MMSE) (+3.8 ± 3.18), followed by LD + VP shunt (+3.25 ± 3.52) and sole treatment with LP (+1.83 ± 1.18). Both pre and post intervention assessment of gait and cognition were only performed in 31% and 48.8% of patients, respectively. Four types of cognitive assessment were used (MOCA 46.4%, MMSE 46.4%, Rowland Universal Dementia Assessment Scale 3.6%, and Addenbrooke’s Cognitive Examination-III 3.6%). MoCA showed greater cognition improvement (2.07) compared to MMSE (1.3) post intervention. There was no consistent objective gait assessment test used.Conclusion: The multiple NPH treatment pathways, low rate of pre and post objective symptom assessment, and lack of standardized gait and cognitive assessment tests demonstrate a clear need for an institution-specific NPH management protocol to standardize diagnostic workup, definitive management, and allied health assessment.

Early Postoperative Complications of Gastrointestinal Surgery and Its Associated Factors in Yemeni Patients Treated in a Teaching Hospital: A Retrospective Monocentric Study.

BackgroundPostoperative complications (POCs) are significant concerns to surgeons because of their possible fatality or long-term disabilities. This study aimed to investigate the early POCs of gastrointestinal surgery and its associated factors in Yemeni patients treated in a teaching hospital in Sana'a University referral hospital.MethodA retrospective cross-sectional study from June 2016 to June 2020 was conducted at Al-Kuwait Teaching Hospital, Sana'a University, Yemen. The patients' characteristics, causative factors, primary treatment, and POCs were recorded from their medical profiles. Univariate analysis was utilized to identify the risk factors associated with gastrointestinal POCs within 30 postoperative days.ResultsThe 30-postoperative day mortality was 3.6%, and major POCs occurred in 22 (20%) patients. There is no statistically significant relationship between POCs and age, sex, smoking, khat chewing, comorbidities (diabetes mellitus, anemia, jaundice, heart disease), emergency cases, drain insertion, and operative time (p ˃ 0.05). There was a significant relationship between POCs and preoperative poor nutritional status, high American Society of Anesthesiologists (ASA) grade, need for blood transfusion, major abdominal surgeries, iatrogenic injury, small bowel resection, reoperation, and history of the previous laparotomy (p ≤ 0.05).ConclusionThere is a significant relationship between preoperative poor nutritional status, high ASA, need for blood transfusion, major abdominal surgeries, reoperation, small bowel resection, iatrogenic injury, previous laparotomy, and POCs across different gastrointestinal procedures. These factors should be assessed when auditing surgical outcomes.

Nasoseptal flap and rigid reconstruction in endoscopic endonasal skull base surgeries: The longitudinal experience of a single center.

Recently, endoscopic endonasal approaches (EEA) have been used for skull base defect reconstruction surgeries. The nasoseptal flap (NSF), a vascular pedicled flap, was introduced to decrease postoperative cerebrospinal fluid (CSF) leakage. This study aimed to outline the authors' institutional experience using NSF and rigid implants in anterior skull base defect reconstruction surgeries following EEA. A retrospective cohort review of patients who underwent NSF reconstruction following EEA in the Otorhinolaryngology and Neurosurgery Departments at King Saud University Medical City, Riyadh, Saudi Arabia, from January 2015 to May 2021, divided into 2time periods according to the reconstruction technique. Out of the 106 patients who underwent EEA, 77 underwent NSF reconstruction. The majority had expanded EEA (94.8%). The mean age was 40.21 ± 17.7years, and the female gender represented 61% of the sample. More than half of the sample underwent right NSF (57.1%). Meningioma was the most common diagnosis (45.5%). The clivus was the most frequent site of lesions (23.4%). The overall rate of postoperative CSF leakage and lumbar drainage (LD) insertion was 15.6% and 51.9%, respectively. The duration of LD was a median of four days. The overall failure rate was 13%, declining from 20% in the first period to 5.4% in the second period. Rigid implants were used significantly more in the first period than in the second period (67.5% versus 16.2%, P < 0.001). Meningitis, the highest postoperative complication, was reported in 6 patients (7.8%). One patient died three weeks postoperatively after massive nasal bleeding. No significant difference was found between either side of the NFS regarding the CSF leakage and failure rate. In the authors' experience, there has been an overt decline in failure rates and complications of EEA over the last three years due to increased experience among surgeons and a standardization of reconstruction techniques. Minimal reconstruction may provide satisfactory results by decreasing the use of rigid implants. An endoscopic endonasal approach with an NSF for anterior skull base defect reconstruction is considered a safe procedure with no significant difference between the sides of the flap.