Drain Insertion Research Articles

EGS P25 Patient outcomes after percutaneous cholecystostomy at Dorset County Hospital

Abstract Background No guideline for percutaneous cholecystostomy exists at Dorset County Hospital, nor has an audit looking into patient outcomes after percutaneous cholecystostomy previously been carried out. This audit aims to identify the indications for cholecystostomy insertion, timing of insertion, complications thereafter, timing of any tubograms, and follow-up of patients after cholecystostomy. No universal management guidelines for percutaneous cholecystostomy currently exist, though studies have proposed treatment algorithms. Methods Retrospective cohort audit of all patients who underwent cholecystostomy insertion at Dorset County Hospital over 6 years from January 2017 – December 2022. Data was provided by the local radiology department of all abdominal drains inserted in this period, with further information collected from discharge summaries, clinic letters and tubogram data on local clinical systems. Data was inputted to and analysed on Microsoft excel. Results Between 2017 – 2022, 38 cholecystostomy drains were inserted. More men than women received drains, with a mean age of 71.8 at insertion. Inpatient stay varied from 2-71 days, with mean of 3 days between admission and drain insertion. 30 patients avoided cholecystectomy, whilst 34% of patients were re-admitted with drain-related or underlying pathology-associated complications. Conclusions Indications for drain insertion are in keeping with medical literature as a means of biliary sepsis control. Cholecystostomy was the definitive gallstone disease procedure for most patients. Most also had tubograms, yet tubogram timings varied significantly likely reflecting the lack of universally accepted management guidelines. This audit identified patients who have benefited from cholecystostomy insertion, allowing creation of a local management guideline for patients with biliary sepsis who undergo percutaneous cholecystostomy.

EGS P16 Laparoscopic cholecystectomy for acute cholecystitis versus diagnostic laparoscopy for suspected appendicitis: comparative time of admission to theatre and impact on reaching national guidance

Abstract Background Early laparoscopic cholecystectomy for acute cholecystitis reduces intra-operative complications. National AUGIS guidelines therefore propose laparoscopic cholecystectomy should be performed within 72 hours of diagnosis. Locally, laparoscopic cholecystectomies for acute cholecystitis are preferentially performed within Emergency General Surgery (EGS) theatres whilst diagnostic laparoscopies for suspected appendicitis within CEPOD. Access to EGS is anecdotally challenging when compared with CEPOD. Patients with acute cholecystitis may subsequently experience longer times from admission to theatre. This project aimed to compare patient timelines from admission/booking to theatre and evaluate the impact on reaching national AUGIS guidance, intra-operative findings and intra-operative drain insertions. Methods Retrospective analysis of patient records at a single tertiary centre was performed. All patients that underwent a laparoscopic cholecystectomy for imaging-confirmed acute cholecystitis (n=66) alongside patients who underwent diagnostic laparoscopy +/- appendicectomy for suspected acute appendicitis (February-June 2022) (n = 62) were included. Time from admission/booking to theatre was determined and independent t-tests performed for statistical comparison. Associations between prolonged waiting times (>72 hours) and severity of intra-operative findings (Parkland scores) (ordinal regression analysis) / intra-operative drain insertion (Chi squared analysis) were analysed. Results Patients undergoing laparoscopic cholecystectomies waited significantly longer from both admission to theatre and booking to theatre compared to patients undergoing diagnostic laparoscopy for suspected appendicitis (71.4 hours vs. 33.33 hours, mean difference 38.07 hours, p=<0.001; 26.93 hours vs. 15.57 hours, mean difference 11.36 hours, p=0.002;). 63.6% of laparoscopic cholecystectomies were performed within 72 hours of admission. Waiting over 72 hours for laparoscopic cholecystectomy was not associated with increased severity of intra-operative findings (higher Parkland scores) (estimate 0.40, p=0.519) or drain insertion (Chi-squared 0.886a, p=0.347). Mean age 57.2 years (range 19-93) and 36.3 (range 8-86) for cholecystectomy versus diagnostic laparoscopy, respectively. Conclusions Patients awaiting laparoscopic cholecystectomy experience significantly longer waiting times from admission and booking to theatre when compared to those awaiting diagnostic laparoscopy for suspected appendicitis. Local concordance with national AUGIS guidance is variable and a proportion of patients with acute cholecystitis wait beyond 72 hours for laparoscopic cholecystectomy. Waiting >72 hours within this tertiary centre is not, however, reflected by intra-operative findings or intra-operative drain insertion. Completion of laparoscopic cholecystectomies within CEPOD should be considered for cases of acute cholecystitis to minimise wait times.

OGBN P41 Cholecystostomy drain for Acute Cholecystitis and its further management: A retrospective observational study from a University Hospital

Abstract Background Acute Cholecystitis (AC) is one of the most common surgical pathologies. The gold standard treatment of AC is cholecystectomy which can be high-risk in those with poor physiological reserve or sepsis with haemodynamic instability. Therefore, percutaneous cholecystostomy (PC) can be considered as an alternative management strategy. PC has long been used with no definitive protocol for delivery or management of patient recovery. This single center study of patients who had cholecystostomy in our trust aims to create an efficient protocol for PC drains. Methods We conducted a retrospective observational study of patients who had cholecystostomy in the Royal Devon and Exeter Hospital between 2019 and 2023. Data from 20 patients was obtained from patient records. Severity and duration of symptoms on presentation, frailty, co-morbidities, cholecystostomy technical approach, length of stay and complications were recorded and analysed. Regarding the post-insertion period, investigations, post-cholecystostomy management plan and discharge were assessed. We conducted a literature review to compare our results to the usual practice. Data are expressed as median and results were considered to be statistically significant where p≤0.05. Results PC patients were high-risk candidates (median frailty score 4) with 90% being elderly (Age > 65, median age 77). The majority were septic (median WCC 17.9 and CRP 255). Upon drain insertion, median CCI (Charlson Co-morbidity Index) was 4.5. Four cholecystostomies were transhepatic ,three were transperitoneal with the rest unrecorded.Complications included displacement, leakage, and infection (Clavien Dindo 3,2).Old age was associated with more complications (p<0.006) and drain dislocation (p<0.022). Seventeen patients were discharged with drains in, one dislodged. Two patients died. Post-insertion investigations, drain duration and follow-up differed for all patients with no protocol followed. Six patients subsequently underwent cholecystectomy. Conclusions The management of PC and the follow-up differs from one patient to another, as there is currently no definite protocol. Old age is associated with a higher rate of complications related related to cholecystostomy. Further studies should investigate the optimal duration of the drain, timing of the tubogram, subsequent removal of the cholecystostomy drain or cholecystectomy.

Comparison of endoscopic bilateral areolar and robotic-assisted bilateral axillo-breast approach thyroidectomy in differentiated thyroid carcinoma: a propensity-matched retrospective cohort study

BackgroundRobot-assisted and endoscopic thyroidectomy are superior to conventional open thyroidectomy in improving cosmetic outcomes and postoperative quality of life. The procedure of these thyroidectomies was similar in terms of surgical view, feasibility, and invasiveness. However, it remains uncertain whether the robotic-assisted bilateral axilla-breast approach (BABA) was superior to the endoscopic bilateral areolar approach (BAA) thyroidectomy. This study aimed to investigate the clinical benefit of these two surgical procedures to evaluate the difference between these two surgical procedures by comparing the pathological and surgical outcomes of endoscopic BAA and robotic-assisted BABA thyroidectomy in differentiated thyroid carcinoma.MethodsFrom November 2018 to September 2021, 278 patients with differentiated thyroid carcinoma underwent BABA robot-assisted, and 49 underwent BAA approach endoscopic thyroidectomy. Of these patients, we analyzed 42 and 135 patients of endoscopic and robotic matched pairs using 1:4 propensity score matching and retrospective cohort study methods. These two groups were retrospectively compared by surgical outcomes, clinicopathological characteristics, and postoperative complications.ResultsThe mean operation time was significantly longer in the EG than in the RG (p < 0.001), The number of retrieved lymph nodes was significantly lower in the ET group than in the RT group (p < 0.001). The mean maximum diameter of the thyroid was more expansive in the EG than in the RG (p = 0.04). There were no significant differences in the total drainage amount and drain insertion days between the two groups (p = 0.241, p = 0.316, respectively). Both groups showed that cosmetic satisfaction (p = 0.837) and pain score (p = 0.077) were similar. There were no significant differences in complication frequencies.ConclusionRobotic and endoscopic thyroidectomy are similar minimally invasive thyroid surgeries, each with its advantages, both of which can achieve the expected surgical outcomes.Trial registrationRetrospectively registered.

Abstract 106: CHANTER Syndrome: A Case Report Of A 59 Year Old Man With Positive Outcome

Introduction Cerebellar, Hippocampal, and Basal Nuclei Transient Edema with Restricted Diffusion (CHANTER) syndrome was first described in 2019 [1] as a pattern of radiographic findings that are distinct from ischemic, anoxic, or toxic brain injury. Pathophysiology is still uncertain, but some proposed theories include a primary metabolic etiology or a mitochondrial failure of gray matter. Clinically, patients typically present with altered level of consciousness. Radiographically, diffusion weighted imaging shows restriction in the bilateral hippocampi, bilateral cerebelli, and basal nuclei. The cerebral cortex, thalamus, and subcortical white matter are usually spared. Despite the morbid clinical picture on presenation, positive outcomes were reported with early intervention. We describe a case of CHANTER syndrome in a 59 year old man with history of illicit substance abuse. Methods Case report with electronic medical record review. Results 59‐year‐old man with history of illicit substance abuse including cocaine, opioid, and phencyclidine presented to the hospital after being found down at a drug store. Patient did not respond to Naloxone and was eventually intubated due to respiratory compromise. Non‐contrast CT head showed hypoattenuation of the bilateral cerebellar hemispheres with mild effacement of the fourth ventricle. MRI brain showed diffusion signal abnormalities with corresponding T2 FLAIR hyperintensities in the bilateral cerebellar hemispheres, bilateral hippocampi, and bilateral basal ganglia with some involvement of the left occipital lobe suggestive of CHANTER syndrome. As vasogenic edema worsened, hydrocephalus ensued requiring administration of hypertonic saline and eventual external ventricular drain (EVD) insertion in the neurocritical care unit. Despite initial improvement in his level of consciousness after the EVD insertion, his intracranial pressure (ICP) continued to increase and midazolam and ketamine infusion drips were added. A fine balance between lowering the ICP and avoiding respiratory suppresion with sedating infusions was maintained. Consecutive MRI brain images over the course of the following 4 weeks of his stay showed decrease of the abnormal diffusion weighted imaging signal along with improvement in his overall mental status and eventual discharge 12 weeks from his initial presentation. Conclusion This case further strengthens the relationship between CHANTER syndrome and illicit substance use as a likely etiology along with other cases in the literature. Aggressive management in the neurocritical care to control vasogenic edema and avoid ICP elevation is essential to give patients the highest chance of recovery. Clinical improvement At least partial reversal of the radiographic findings of CHANTER syndrome can be attained with treatment, however, unclear if complete reversal is possible.

A multi-institutional European comparative study of open versus robotic-assisted laparoscopic ureteral reimplantation in children with high grade (IV–V) vesicoureteral reflux

Traditionally, open ureteral reimplantation (OUR) has been the standard treatment for primary vesicoureteral reflux (VUR) requiring reimplantation. Robotic-assisted laparoscopic ureteral reimplantation (RALUR) is gaining popularity and high success rates have been reported. In this multi-institutional study, we aimed to compare the perioperative and postoperative outcomes of OUR and RALUR for high-grade (IV+V) VUR in children. A retrospective evaluation was performed collecting data from 135 children (0-18 years) who underwent high grade VUR surgical correction at nine European institutions between 01/01/2009 and 01/12/2020, involving either open or robotic approaches. Institutional review board approval was obtained. Patients with lower grades of VUR (≤III), previous history of open or endoscopic ureteral surgery, neurogenic bladder, or refluxing megaureter in need of ureteral tapering were excluded. Pre-, peri- and post-operative data were statistically compared. Overall, 135 children who underwent either OUR (n=68), or RALUR (n=67) were included, and their clinic and demographic features were collected. The mean age of the open group was 11 months (interquartile range [IQR] 9.9-16.6 months), in the RALUR group it was 59 months (IQR 29-78mo) (p<0.01); the open cohort had a weight of 11kg (IQR 9.9-16.6kg) while the RALUR group had 19kg (IQR 13-25kg) (p<0.01). No significant differences were found for intraoperative (1.5% vs 7.5%, p=0.09) or for postoperative complication rates (7.4% vs 9%, p=0.15). Favorable outcomes were reported in the RALUR group: shorter time to stooling (1 vs 2 days), fewer indwelling urethral catheter days (1 vs 5 days), perioperative drain insertion time (1 vs 5 days) and a shorter length of hospital stay (2 vs 5 days) (p<0.01). The success rate was 94.0% and 98.5% in the open and RALUR groups, respectively. The long-term clinical success rates from both groups was comparable:42 vs 23 months for open and RALUR, respectively. This study reported a large multicentric experience focusing on high grade VUR. Furthermore, this study compares favorably to OUR in a safety analysis. There was also a trend towards higher success rates with RALUR utilizing an extravesical approach which has not been previously reported. RALUR is an efficacious and safe platform to use during ureteral reimplantation for high grade VUR. The overall peri-operative and post-operative complication rates are at least equivalent to OUR, but it is associated with a faster functional recovery and time to discharge. Medium to long term success rates are also equivalent to OUR.

A42A palliative care skills study day is an effective way of meeting palliative care registrar curriculum Direct Observation of Procedural Skills (DOPs) requirements

The new Speciality Training curriculum for Palliative Medicine from August 2022 identifies key procedural skills that, for the first time, can be performed in a simulation (SIM) skills lab to demonstrate proficiency [1]. These include tracheostomy care, managing non-invasive ventilation (NIV) and the management of indwelling ascitic drains. These skills can be difficult to acquire in non-hospital settings like hospices and in the community. A bespoke, pilot palliative care skills day was organized to assess the suitability for theory, skills training and subsequent opportunity to demonstrate proficiency by sign off against curriculum competencies. A total of 11 palliative care trainees from the Northern Deanery attended a pilot SIM study day in March 2023. Three parallel workshops were planned – tracheostomy care, the insertion and management of ascitic drains and managing NIV. Each workshop was delivered by local experts in the area (non- palliative care professionals) with experience of teaching and training other professionals. assessing internal medicine trainees. Trainers were briefed on learning outcomes prior to the session by two palliative care consultants, and the clinical context of each session was set within relevant palliative care environments for e.g. the care of a patient in a hospice, in the community or in a hospital. Trainee confidence was assessed before and after SIM training with the use of 10-point Likert scales and free text comments. Overall self-reported trainee confidence and competence scores increased for all three workshops (Paracentesis 7 to 8.8 out of 10, NIV 4.5 to 8.6, tracheostomy care 3.8 to 8.9). All trainees agreed it was an effective and educational way of addressing curriculum objectives; and agreed it should be a rolling programme offered regionally. Trainees commented on the positive learning environment, the small group sizes, the benefit of being taught by experts and having the opportunity to be assessed for curriculum requirements. Trainees who had previously achieved competencies commented on the benefit of refreshing skills. One area for development identified was the lack of standardization on DOPs forms about the level of proficiency required. This will be fed back to the regional training committee for the future. Trainees identified further clinical skills that could be addressed in a skills lab and hence, a second skills day will be organized. SIM training is an effective tool for delivering training around procedural skills for palliative care registrars. It also brings opportunity to demonstrate proficiency in specific practical skills. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

A88Designing a Multidisciplinary Chest Drain Course

In 2008 the National Patient Safety Agency reported 12 patient deaths directly related to chest drain insertion over a 3-year period. Since then there have been calls from publications highlighting the need for better education for clinicians [1]. Simulation has been shown to improve chest drain insertion technique [2], and multi-disciplinary simulation can encourage teamwork and communication skills [3]. Given that this procedure is an essential requirement for anaesthetic, intensive care, emergency medicine and internal medicine trainees, we decided to introduce a multi-disciplinary simulation course for the insertion of chest drains. A basic needs analysis was carried out with stakeholders. Initially the course was designed to run for half a day, with a maximum of 12 candidates and a minimum of 3 faculty. A course timetable, course manual, equipment list and pre- and post-course feedback questionnaires were created. The course begins with a lecture, followed by three simulation-based workshops, which the candidates rotate between. These cover seldinger and surgical chest drain insertion, and the basics of chest ultrasound, using ultrasoundable chest drain manikins. Feedback from the first course in July 2022 suggested that there should be a designated faculty team leader and healthy volunteers for the ultrasound workshop. We implemented this feedback and ran the course again in December 2022. Candidates were asked to rate their post course confidence at performing the procedure, with a score ranging between 1 and 7 (each number was assigned a qualitative value with 1 being unable to perform the procedure and 7 being extremely confident in performing the procedure). After the first course, the average score was 5 points. After the second, the average increased to 5.5. The course ran for a third time in April 2023, during which the duration of the workshops was increased and a lecture on aftercare was added. The average post course confidence score was 5.7. All candidates felt that the session fully met the learning objectives and would recommend the course to others. After implementing changes to our course including assigning a faculty team leader, recruiting healthy volunteers, increasing the time spent in workshops and adding a session on aftercare, there has been an improvement in the candidates’ average post course confidence at performing chest drains and qualitative candidate feedback was positive. We would recommend our course structure to others designing a chest drain course. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

A4Development and evaluation of a chest cavity simulation model for teaching surgical chest drain insertion

Surgical chest drain insertion is indicated in pneumothorax or haemothorax secondary to thoracic trauma. It is a mandatory emergency procedure that is incorporated as a part of the core medical training curriculum [1]. However, sparse training opportunities result in low clinician competency and increased risk of complications. While simulation training can offer a solution, the affordability of commercial models and hygiene and ethical implications of animal carcasses are significant limiting factors. The aim of this project is to build a reusable, high-fidelity, low-cost human chest cavity model excluding animal use for simulation-based teaching of surgical chest drain insertion. To construct the model, plaster gauze, metal wires and u-channel rubber trims were used to build a ribcage. Soy-protein-based sausage casing was used to create the pleural layers, and the muscles and subcutaneous fat were represented with ADAMgel (Aqueous Dietary fibre Antifreeze Mix gel), a novel material with tactility and dissection sensation similar to human soft tissue [2]. Synthetic chamois leather was used to represent skin. The resulting model allowed locating the safe triangle using anatomical landmarks, blunt dissection of muscles, pleural puncturing and advancement and suturing of the chest tube. The model cost less than £130, and it could be repaired after over 20 uses with less than £15. Verbal consent on study participation was obtained from all participants who performed chest drain insertion on the model and evaluated its fidelity and educational value using an anonymized Likert scale questionnaire. All questionnaire responses were converted to numerical values for data quantification, as shown in Median and range of questionnaire responses collected from study participants Sixteen senior clinicians with multiple experience on chest drain insertion and 11 junior clinicians with limited experience took part in the study. Anatomical and haptic fidelity of the model was evaluated very highly amongst experienced clinicians. Junior doctors stated increased confidence in performing the procedure, overall assessing the model as an appropriate learning tool. Twenty participants with previous training experience compared the quality of this model to other commercial or animal-based models, and 18 rated this model to be of the same or superior quality. This chest cavity model is suitable for simulation training of chest drain insertion. Importantly, the model excluded the use of animals under the principle of replacing, refining and reducing animal use in research [3]. Further training opportunities that utilize this model can increase clinician competence in the procedure, which can improve clinical practice and reduce patient mortality. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

Percutaneous transhepatic gallbladder drainage versus endoscopic gallbladder stenting for managing acute cholecystitis until laparoscopic cholecystectomy.

Gallbladder drainage by methods such as percutaneous transhepatic gallbladder drainage (PTGBD) or endoscopic gallbladder stenting (EGBS) is important in the early management of moderate to severe acute cholecystitis. In patients undergoing laparoscopic cholecystectomy (LC) for acute cholecystitis after a month or more of gallbladder drainage, the clinical course was compared between patients initially treated with PTGBD or EGBS. Among 331 patients undergoing LC for cholecystitis between 2018 and 2022, 43 first underwent 1 or more months of gallbladder drainage. The median interval between drainage initiation and LC was 89 days (range, 28-261) among 34 patients with PTGBD and 70 days (range, 62-188) among nine with EGBS (p = 0.644). During this waiting period, PTGBD was clamped in six patients and removed in five. Cholecystitis relapsed in three PTGBD patients (9%) and four EGBS patients (44%; p = 0.026). Relapses were managed with medications. Cholecystectomy duration (p = 0.022), intraoperative blood loss (p = 0.026), frequency of abdominal drain insertion (p = 0.023), and resort to bailout surgery such as fundus-first approaches (p = 0.030) were significantly greater in patients with EGBS. Postoperative complications were somewhat likelier (p = 0.095) and postoperative hospital stays were longer (p = 0.007) in the EGBS group. Among patients whose LC was performed 1 or more months after initiation of drainage, daily living during the waiting period associated with drainage was well supported by EGBS, but LC and the postoperative course were more complicated than in PTGBD patients.

Re-expansion Pulmonary Edema: A Rare Complication of Chest Drain Insertion in Spontaneous Pneumothorax.

Re-expansion pulmonary edema (RPE) after chest drain insertion is rare. The objective of this clinical case report is to highlight the importance of this chest drain insertion complication. A 35-year-old man presented to the emergency department with a chief complaint of shortness of breath and pleuritic chest pain. Further physical examination and radiographic investigations showed a left-sided hemipneumothorax. A chest drain was inserted, but subsequently the patient developed worsening shortness of breath, desaturation, and coughed out pink frothy sputum. Repeated chest radiographic and computed tomographic thorax findings suggested RPE. A nonrebreathable mask with high-flow oxygen was given to the patient to maintain his oxygen saturation. The patient was referred to the cardiothoracic team and was admitted to the hospital. Despite conservative management in the ward, the patient underwent lung decortication. Postdecortication, the left-sided lung re-expanded well, and the patient was discharged home. This case highlighted this rare, potentially fatal complication of chest drain insertion for spontaneous pneumothorax.

A Retrospective Study of Pediatric Posterior Fossa Tumors: Was the Outcome Different in Patients Undergoing Elective versus Emergency Surgery?

Abstract Background: Pediatric posterior fossa tumors (pPFTs) may present acutely with features of increased intracranial pressure that need urgent intervention or with stable symptoms requiring elective management. In this article, we have analyzed the outcomes of pPFTs managed under three arms: (1) emergency tumor resection (A), (2) elective tumor resection (B), and (3) pre-resection cerebrospinal spinal fluid (CSF) diversion followed by elective tumor resection (C). Materials and Methods: We retrospectively reviewed our database from July 2012 to March 2020 for pediatric patients (age ≤16 years) with PFTs. The patients were classified into three groups based on the timing and type of intervention. Their result was assessed as the primary (postoperative complications) and secondary outcomes (post-resection CSF diversion, CSF diversion failure, residual tumor, and survival). A P value &lt; 0.05 was considered significant (SPSS version 22.0, IBM, New York). Results: A total of 154 patients (M:F = 2.42:1) were included with a mean age of 8.1 (SD ± 4.2)-years (range 1–16). Group B (n = 72/46.8%) had a significantly higher number of patients as compared to the group A (n = 40/26%) and group C (n = 42/27.3%) (χ2 test, P value = 0.02). The primary outcomes were comparable between group A and group B. A higher incidence of preoperative external ventricular drain insertion and post-resection CSF diversion failure was noted in group A as compared to group B (P value &lt; 0.01). Group C had a significantly higher proportion of patients with residual tumor (n = 19/48.7%) as compared to group A (n = 11/29.7%, P value = 0.09) and group B (n = 20/ 29.4%,P value &lt; 0.05). The post-resection CSF diversion failure rate was significantly higher in group C than in the other two groups (P value &lt; 0.05). Conclusion: The pre-resection CSF diversion subgroup had a poorer outcome as compared to elective and emergency tumor resection. The outcomes of elective and emergency resection of pPFTs were comparable, except for the higher risk of shunt failure in the emergency cohort.

Minimally invasive recipient procedure in kidney transplantation.

There are several procedural variations for kidney transplant donors, including open, laparoscopic, hand-assisted, and robotic methods, with either an intra- abdominal or retroperitoneal approach. Conversely, fewer options are available for the recipient procedure. We introduce a method that involves a small incision, with the goal of being less invasive for recipients. Our current method was introduced in April 2022. As of July 2023, we have completed 27 cases. We analyzed several factors in these 27 cases, including the size of the incision, rewarming time, anastomosis time, graft function, analgesic use, and complications. The average incision size was 73 mm. The time taken for anastomosis was 24. 1 minutes, while the rewarming time averaged 43.1 minutes. There were no instances of primary nonfunction. One case necessitated postoperative dialysis three times due to heart failure. Following stent removal, one patient developed grade 1 hydronephrosis. There was one instance of bleeding from the drain insertion site. Another case involved a clamp injury to the external iliac artery, which necessitated stent insertion on the fourth postoperative day. Compared to procedures performed using conventional methods, the use of analgesics was less in these cases. Our minimally invasive technique, which involves a small incision, is a feasible alternative that could potentially be less invasive than traditional methods.

How to manage a ureteral injury after anterior lumbar spine interbody fusion surgery

BackgroundAnterior lumbosacral interbody fusion (ALIF) surgery is a predominant approach used in various indications such as treating discogenic back pain, spondylolisthesis, degenerative lumbar scoliosis, intervertebral foraminal stenosis, or spondylolysis. In comparison with posterior conventional approach, ALIF surgery has several advantages: direct access to the spine without muscle dissection, reduced blood loss, decreased postoperative pain, and improved fusion rates. Rare complications following ALIF surgery need to be reported, therefore the authors present an uncommon case of a ureteral injury diagnosed early after surgery and its management. Management of a urinomaHerein, we present a case of a 35-year-old man who presented with abnormal abdominal pains 4 days after ALIF surgery. He was diagnosed with a distal left iatrogenic ureteral fistula on a contrast enhanced CT. After the initial endoscopic approach with double J stent and urinary catheter drainage insertion had failed, the injury was finally treated with ureterovesical reimplantation. At the last follow-up, the patient did well without any clinical or biological urinary sequelae after this grade IIIb complication on the Clavien Dindo Scale. ConclusionAlthough ureteral lesions during ALIF surgery are extremely uncommon, surgeons must be cautious when dissecting the retroperitoneal area. A methodical identification of the ureter might guarantee the security of each surgery, especially for patients who have undergone previous abdominal interventions.

Utility of routine chest radiographs after chest drain removal in paediatric cardiac surgical patients-a retrospective analysis of 1076 patients.

Chest drains are routinely placed in children following cardiac surgery. The purpose of this study was to determine the incidence of a clinically relevant pneumothorax and/or pleural effusion after drain removal and to ascertain if a chest radiograph can be safely avoided following chest drain removal. This single-centre retrospective cohort study included all patients under 18 years of age who underwent cardiac surgery between January 2015 and December 2019 with the insertion of mediastinal and/or pleural drains. Exclusion criteria were chest drain/s in situ ≥14 days and mortality prior to removal of chest drain/s. A drain removal episode was defined as the removal of ≥1 drains during the same episode of analgesia ± sedation. All chest drains were removed using a standard protocol. Chest radiographs following chest drain removal were reviewed by 2 investigators. In all, 1076 patients were identified (median age: 292 days, median weight: 7.8 kg). There were 1587 drain removal episodes involving 2365 drains [mediastinal (n = 1347), right pleural (n = 598), left pleural (n = 420)]. Chest radiographs were performed after 1301 drain removal episodes [mediastinal (n = 1062); right pleural (n = 597); left pleural (n = 420)]. Chest radiographs were abnormal after 152 (12%) drain removal episodes [pneumothorax (n = 43), pleural effusion (n = 98), hydropneumothorax (n = 11)]. Symptoms/signs were present in 30 (2.3%) patients. Eleven (<1%) required medical management. One required reintubation and 2 required chest drain reinsertion. The incidence of clinically significant pneumothorax/pleural effusion following chest drain removal after paediatric cardiac surgery is low (<1%). Most patients did not require reinsertion of a chest drain. It is reasonable not to perform routine chest radiographs following chest drain removal in most paediatric cardiac surgical patients.

Safety and efficacy of intraperitoneal drain placement after emergency colorectal surgery: An international, prospective cohort study.

Intraperitoneal drains are often placed during emergency colorectal surgery. However, there is a lack of evidence supporting their use. This study aimed to describe the efficacy and safety of intraperitoneal drain placement after emergency colorectal surgery. COMPlicAted intra-abdominal collectionS after colorectal Surgery (COMPASS) is a prospective, international, cohort study into which consecutive adult patients undergoing emergency colorectal surgery were enrolled (from 3 February 2020 to 8 March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included rate and time-to-diagnosis of postoperative intraperitoneal collections, rate of surgical site infections (SSIs), time to discharge and 30-day major postoperative complications (Clavien-Dindo III-V). Multivariable logistic and Cox proportional hazards regressions were used to estimate the independent association of the outcomes with drain placement. Some 725 patients (median age 68.0 years; 349 [48.1%] women) from 22 countries were included. The drain insertion rate was 53.7% (389 patients). Following multivariable adjustment, drains were not significantly associated with reduced rates (odds ratio [OR] = 1.56, 95% CI: 0.48-5.02, p = 0.457) or earlier detection (hazard ratio [HR] = 1.07, 95% CI: 0.61-1.90, p = 0.805) of collections. Drains were not significantly associated with worse major postoperative complications (OR = 1.26, 95% CI: 0.67-2.36, p = 0.478), delayed hospital discharge (HR = 1.11, 95% CI: 0.91-1.36, p = 0.303) or increased risk of SSIs (OR = 1.61, 95% CI: 0.87-2.99, p = 0.128). This is the first study investigating placement of intraperitoneal drains following emergency colorectal surgery. The safety and clinical benefit of drains remain uncertain. Equipoise exists for randomized trials to define the safety and efficacy of drains in emergency colorectal surgery.

Impact of early external ventricular drainage on functional outcome after traumatic brain injury: a bicentric retrospective cohort analysis

PurposeSeveral studies have confirmed that external ventricular drain decreases intracranial pressure (ICP) after traumatic brain injury (TBI). Considering its impact on ICP control and cerebral waste metabolites clearance, timing of external ventricular drain (EVD) insertion could improve CSF drainage efficiency. The aim of the study was to evaluate the impact of early EVD versus a later one on the 3-month outcome. MethodsFor this retrospective cohort study conducted in two regional trauma-center (Caen CHU Côte de Nacre and Beaujon Hospital) between May 2011 and March 2019, all patients with intracranial hypertension following TBI and treated with EVD were included. We defined the early EVD by drainage within the 24 h of the hospital admission and the late EVD insertion by drainage beyond 24 h. A poor outcome was defined as a Glasgow Outcome Scale of one or two at 3 months. ResultsAmong the cohort of 671 patients, we analyzed 127 patients. Sixty-one (48.0%) patients had an early insertion of EVD. In the early EVD group, the mean time to insertion was 10 h versus 55 h in the late EVD group. Among the analyzed patients, 69 (54.3%) had a poor outcome including 39 (63.9%) in the early group and 30 (45.5%) in the later one. After adjustment on prognostic factors, early EVD insertion was not associated with a decrease in a poor outcome at 3-months (OR = 1.80 [0.73–4.53]). ConclusionEarly insertion of EVD (<24 h) for intracranial hypertension after TBI was not associated with improved outcome at 3 months.

Analysis of Evolution of Hydrocephalus in Posterior Fossa Tumors and Validation Study of the Modified Canadian Preoperative Prediction Rule for Hydrocephalus in Children and Frankfurt Grading System for Prediction of Cerebrospinal Fluid Diversion in Adults with Posterior Fossa Tumors

We sought to analyze the evolution of hydrocephalus and enumerate its predictive factors in posterior fossa tumors in children and adults. We also validated the modified Canadian Preoperative Prediction Rule for Hydrocephalus (mCPPRH) and Frankfurt grading systems as tools to predict cerebrospinal fluid (CSF) diversion in children and adults, respectively. A retrospective review of patients with posterior fossa tumors operated between 2012 and 2019 was performed. Clinical, radiologic, and operative data were obtained. Validation was performed for both scores via receiver operating characteristic (ROC) curves and evaluation of the area under the curve (AUC). We included 116 children and 343 adults in the study. Of the adults, 141 patients had intraaxial tumors and 172 had extraaxial tumors. The insertion of external ventricular drain (EVD), its duration, papilledema was noted to have significant influence on the need for permanent CSF diversion (P < 0.05) in children. The ROC for mCPPRH score was 0.659 (0.501-0.816), Age- 0.496 (0.334-0.658) and Evans index- 0.788 (0.654-0.922). In adults- Intraaxial tumours Age, Frankfurt score, duration of EVD, Diagnosis, Extent of resection and periventricular capping significant predictors and ROC age AUC 0.300 (0.193-0.407), Evans index 0.939 (0.888-0.990), and Frankfurt score 0.908 (0.853-0.964) (P < 0.05), whereas in extraaxial tumors Frankfurt grading, sex, duration of EVD, presence of perilesional edema and extent of resection (P < 0.05) ROC age AUC 0.439 (0.344-0.534), Evans index 0.941 (0.906-0.977), and Frankfurt score 0.847 (0.782-0.912). This is the first external validation study for the 2 predictive systems in use. mCPPRH demonstrated poor predictive accuracy, and Frankfurt grading system demonstrated good accuracy. EVD insertion and its duration was significantly predictive of the need for permanent CSF diversion.

Review of patients discharged post thoracic surgery with chest drain in situ and nurse-based follow-up clinic.

Persistent air leaks and prolonged drainage are recognized complications of thoracic surgery, increasing hospital stay and costs. Patients can be discharged with a chest drain and followed up in a nurse-led clinic. We reviewed such patients and the rate of readmission after discharge to assess the effectiveness of the drain follow-up clinic. We conducted a retrospective review of our prospective database spanning 22 months, from March 2019 to January 2021. The analysis focused on the indication and duration of chest drainage, complications, and readmission for any reason. 62 patients (representing 5% of all thoracic surgery patients) were discharged with a chest drain. The median age was 67 years (range 22-85 years), with 24 females and 38 males. 52% underwent video-assisted thoracoscopic surgery, 27% had a thoracotomy, and 21% had bedside chest drain insertion. Following discharge, the median duration of chest drainage was 11 days [interquartile range (IQR) 7-18.75 days]. Patients had 106 review episodes in the ward-based nurse-led clinic. The indications were prolonged air leak (71%; 72 clinic reviews), persistent fluid drainage following empyema evacuation (16%; 24 clinic reviews), and persistent fluid drainage for simple effusion (13%; 10 clinic reviews). The median length of drain stay was 30 days (IQR 19.75-54 days) for empyema, 10 days (IQR 6-16 days) for air leak, and 8 days (IQR 6.5-12 days) for simple effusion. 9 patients required readmission (14.5%), and empyema had developed in 3 patients (4.8%). Patients discharged with a chest drain in place can be followed up in a dedicated ward-based nurse-led monitoring clinic for optimal quality of care.

Ten Steps for NPH Management: Advancements in Diagnosis and Treatment of Adult Hydrocephalus

Abstract Objectives The authors of the present study intend to describe a straightforward protocol for normal pressure hydrocephalus diagnosis and management, with the employment of a multidisciplinary team approach effort. Methods Using a strict methodological approach for initial diagnosis, taking into consideration occupational therapy and physical therapy assessment, the authors have set out to elaborate a simple protocol for suspicion and, once diagnosed, treatment of normal pressure hydrocephalus. We have used the MoCA (Montreal Cognitive Assessment) and walking assessment that included speed, independence, and distance (SID), 10 m walk test, TUG (timed up and go) evaluation, 6-minute Walk Test, MiniBESTest, as the main factors for pre and post lumbar drainage assessment, after which, the alternatives were deliberated and followed, or not, by ventriculoperitoneal shunt insertion. Results The authors have described a protocol, consisting of ten easy steps, which involves a multidisciplinary team, including occupational therapy and physical therapy professionals, as well as neurologists and neurosurgeons for improved and objective assessment prior to insertion of lumbar drain and, thereafter, detecting the population at most benefit for ventriculoperitoneal shunt insertion. We have described the Ten Step Approach for Normal Pressure Hydrocephalus management, including from initial clinical presentation and imaging, to pre and post lumbar drainage, for lastly deciding upon necessity for ventriculoperitoneal shunt insertion. Conclusions A straightforward protocol for normal pressure hydrocephalus seems not only feasible, but simple to implement in most neurosurgical departments, with good accuracy of prediction of lumbar drainage assessment to shunting outcomes.