Drain Placement Research Articles

Megakaryoblasts in pleural fluid in neonate with transient leukaemia of Down's syndrome.

Twin baby boy born at 35+2 weeks gestation with a birth weight of 2070 grams via emergency cesarean section secondary to abnormal CTG and foetal distress. Full blood count obtained at birth showed haemoglobin 159 g/L, total white cell count 99.54 × 109/L platelet count 779 × 109/L. Manual differential showed an absolute neutrophil count of 2.01 × 109/L absolute lymphocyte count of 45.27 × 109/L and blast count of 50.3 × 109/L (50%). Initial peripheral blood smear morphology review revealed a thrombocytosis, platelet anisocytosis and micromegakaryocytes. It also demonstrated neutropenia, myeloid left shift, large blasts with a high N/C ratio and nucleoli. Additionally, numerous nucleated red blood cells were seen with marked red cell dysplasia including binucleate forms and abnormal haemoglobinisation. There was no prenatal diagnosis of Down's syndrome (DS). The above blood results along with the baby's clinical signs raised suspicion of DS and subsequently transient leukaemia of DS. This baby was then transferred to the regional neonatal intensive care unit on day 2 of life. On admission, he was noted to have bilateral pleural effusion, synthetic liver dysfunction with elevated creatinine and ammonia levels as well as ascites. He was intubated, and ventilated and required inotropic support. Due to adverse features of elevated white cell count, hepatosplenomegaly, pleural effusion as well as ascites [1] and following the multidisciplinary team (MDT) discussion and parental consent, the patient was commenced on low dose cytarabine for 7 days. He tolerated that well, however, did experience mild cytopenias and pyrexic episodes, followed by recovery during the following two weeks with a reduction in pleural effusions, hepatosplenomegaly and reduction in oxygen requirement which enabled successful extubation and commencement of continuous positive airway pressure. Unfortunately, on day 19 of life he was noted to have slowly increasing oxygen requirements with re-accumulation of pleural effusions and increasing hepatosplenomegaly as well as increasing blast count in peripheral blood. He proceeded to require intubation and ventilation again as well as placement of a chest drain to remove pleural fluid to improve respiratory compliance. A review of pleural fluid morphology had shown frequent ‘blast-like’ cells; these were medium-sized with a high N/C ratio with finely condensed chromatin nucleoli and budded basophilic cytoplasm thought to most likely represent megakaryoblasts [2]. As a result of the deterioration, a decision by MDT was made to give another cycle of low-dose cytarabine on days 1 through 5. Following the second cycle of cytarabine, the patient again experienced mild cytopenias and pyrexic episodes, was treated with antibiotics and supportive management and transfusions of packed red cells. He had complete count recovery and no blast population identified morphologically on peripheral blood film on day 26 of the second cycle of cytarabine. His GATA1 mutation was subsequently found to be positive. He continued to improve and was discharged home on day 67 of life Figures 1-3. Karolina Chmielowiec—wrote the manuscript, Gary Beattie—manuscript review, obtained image, obtained and analysed flow cytometry data, Kathryn Clarke—manuscript review, obtained and analysed flow cytometry, Ellen McCloy—manuscript review, morphology review, Bethany Mitchell—manuscript review, morphology review, Christine Macartney—manuscript review, supervising consultant. All authors discussed the results and commented on the manuscript. None. The authors declare no conflict of interest. No funding was required for this submission. Not applicable. Not Applicable. Not Applicable All authors have contributed to the acquisition, analysis and interpretation of data as well as either drafting the paper or revising it critically. All authors approved the submitted and final versions. For original data, please contact [email protected]

Colecistectomias - análise dos casos operados em dois anos em um hospital escola: um estudo transvesal retrospectivo

Objectives: To select all cholecystectomies performed in the last two years, to analyze the epidemiological profile of patients and compare cases of elective or emergency surgery regarding the need for drainage, reoperation, incidence of postoperative complications and complications of the surgical wound. Materials and methods: 942 cholecystectomies were performed at Hospital Universitário Evangélico Mackenzie in Curitiba between 01/01/2018 and 12/31/2019. The data obtained were analyzed by graphs and frequency tables. For association calculations, ANOVA, Man-Whitney and chi- square tests were performed. Significance adopted: 5%. Results: Of the operated patients, 75.9% are women. On average, patients were 48.2 years old. Urgent surgeries were performed in 34.9% of patients, while elective surgeries occurred in 65.1% of cases. There was a greater need for placement of an abdominal drain in urgent procedures (p = 0.001). There was a greater need for reoperation in patients who needed an abdominal drain in the first surgery (p = 0.004). There were also more complications in the postoperative period in patients operated urgently (p = 0.004). There was even more complication in the postoperative period of patients who required a drain placement (p = 0.001). There was a greater need for reoperation in patients with postoperative complications (p = 0.001). There were more complications at the surgical wound of patients who underwent reoperation (p = 0.001). Conclusion: Patients undergoing elective surgery evolve with less need for drainage, postoperative complications, reoperation and complications of the surgical wound.

Safety and efficacy of peripheral nerve blocks to treat refractory headaches after aneurysmal subarachnoid hemorrhage - A pilot observational study.

Headache after aneurysmal subarachnoid hemorrhage (HASH) is common, severe, and often refractory to conventional treatments. Current treatment standards include medications including opioids, until the pain is mitigated. Peripheral nerve blocks (PNBs) may be an effective therapeutic option for HASH. We conducted a small before-and-after study of PNBs to determine safety, feasibility, and efficacy in treatment of HASH. We conducted a pilot before-and-after observational study and collected data for 5 patients in a retrospective control group and 5 patients in a prospective intervention PNB group over a 12-month period. All patients received a standard treatment of medications including acetaminophen, magnesium, gabapentin, dexamethasone and anti-spasmodics or anti-emetics as needed. Patients in the intervention group received bilateral greater occipital, lesser occipital, and supraorbital PNBs in addition to medications. The primary outcome was pain severity, measured by Numeric pain rating scale (NPRS). All patients were followed for 1 week following enrollment. The mean ages in the PNB group and control group were 58.6 and 57.4, respectively. One patient in the control group developed radiographic vasospasm. Three patients in both groups had radiographic hydrocephalus and IVH, requiring external ventricular drain (EVD) placement. The PNB group had an average reduction in mean raw pain score of 2.76 (4.68, 1.92 p = 0.024), and relative pain score by 0.26 (0.48, 0.22 p = 0.026), compared to the control group. The reduction occurred immediately after PNB administration. PNB can be a safe, feasible and effective treatment modality for HASH. Further investigations with a larger sample size are warranted.

Role of pelvic drain and timing of urethral catheter removal following RARP: a systematic review and meta-analysis.

To assess the clinical value of routine pelvic drain (PD) placement and early removal of urethral catheter (UC) in patients undergoing robot-assisted radical prostatectomy (RARP), as perioperative management such as the necessity of PD or optimal timing for UC removal remains highly variable. Multiple databases were searched for articles published before March 2022 according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. Studies were deemed eligible if they investigated the differential rate of postoperative complications between patients with/without routine PD placement and with/without early UC removal, defined as UC removal at 2-4 days after RARP. Overall, eight studies comprising 5112 patients were eligible for the analysis of PD placement, and six studies comprising 2598 patients were eligible for the analysis of UC removal. There were no differences in the rate of any complications (pooled odds ratio [OR] 0.89, 95% confidence interval [CI] 0.78-1.00), severe complications (Clavien-Dindo Grade ≥III; pooled OR 0.95, 95% CI 0.54-1.69), all and/or symptomatic lymphocele (pooled OR 0.82, 95% CI 0.50-1.33; and pooled OR 0.58, 95% CI 0.26-1.29, respectively) between patients with or without routine PD placement. Furthermore, avoiding PD placement decreased the rate of postoperative ileus (pooled OR 0.70, 95% CI 0.51-0.91). Early removal of UC resulted in an increased likelihood of urinary retention (OR 6.21, 95% CI 3.54-10.9) in retrospective, but not in prospective studies. There were no differences in anastomosis leakage and early continence rates between patients with or those without early removal of UC. There is no benefit for routine PD placement after standard RARP in the published articles. Early removal of UC seems possible with the caveat of the increased risk of urinary retention, while the effect on medium-term continence is still unclear. These data may help guide the standardisation of postoperative procedures by avoiding unnecessary interventions, thereby reducing potential complications and associated costs.

Drain placement in retromuscular ventral hernia repair: a systematic review and meta-analysis.

Drain placement in retromuscular ventral hernia repair is controversial. Although it may reduce seroma formation, there is a concern regarding an increase in infectious complications. We aimed to perform a meta-analysis on retromuscular drain placement in retromuscular ventral hernia repair. We performed a literature search of Cochrane, Scopus and PubMed databases to identify studies comparing drain placement and the absence of drain in patients undergoing retromuscular ventral hernia repair. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4. Heterogeneity was assessed with I2 statistics. 3808 studies were screened and 48 were thoroughly reviewed. Four studies comprising 1724 patients were included in the analysis. We found that drain placement was significantly associated with a decrease in seroma (OR 0.34; 95% CI 0.12-0.96; P = 0.04; I2 = 78%). Moreover, no differences were noted in surgical site infection, hematoma, surgical site occurrences or surgical site occurrences requiring procedural intervention. Based on the analysis of short-term outcomes, retromuscular drain placement after retromuscular ventral hernia repair significantly reduces seroma and does not increase infectious complications. Further prospective randomized studies are necessary to confirm our findings, evaluate the optimal duration of drain placement, and report longer-term outcomes.

Indocyanine green fluorescent cholangiography improves the clinical effects of difficult laparoscopic cholecystectomy.

Near-infrared fluorescent cholangiography (NIRFC) with indocyanine green (ICG) as the developer yields clear visualization of the extrahepatic bile ducts and is effective in identifying key structures. Here, we analyzed and compared the surgical outcomes of fluorescent and conventional laparoscopy in cholecystectomy of various difficulties and then assessed the value of NIRFC. This retrospective study collected clinical data from partial patients who underwent laparoscopic cholecystectomy (LC) at the Department of Hepatobiliary and Pancreatic Surgery, Zhongnan Hospital of Wuhan University between 2020 and 2021. The study subjects were classified into ICG-assisted and white-light laparoscopy. Two cohorts with homogeneous baseline status were selected based on 1:1 ratio propensity score matching (PSM). Multivariate logistic regression analysis was performed to predict independent risk factors for LC difficulty. Thereafter, the matched cases were classified into difficult and easy subgroups by combining difficulty score and gallbladder disease type, and then the surgical outcomes of the two groups were compared. This study included a total of 624 patients. The patients were classified into the ICG group (n = 218) and the non-ICG group (n = 218) after a 1:1 ratio PSM. Our data showed significant differences between the groups in operative time (P = 0.020), blood loss (P = 0.016), length of stay (P = 0.036), and adverse reaction (P = 0.023). Stratified analysis demonstrated that ICG did not significantly improve the surgical outcomes in simple cases (n = 208). On the other hand, in difficult cases (n = 228), NIRFC shortened operative time (P = 0.003) and length of stay (P = 0.015), reduced blood loss (P = 0.028) and drain placement rate (P = 0.015), and had fewer adverse reactions (P = 0.023). The data showed that five cases were converted to laparotomy while two cases had minor bile leaks in the non-ICG group. There was no bile duct injury (BDI) in all the cases. Furthermore, high BMI, history of urgent admission and abdominal surgery, palpable gallbladder, thickened wall, and pericholecystic collection were risk factors for surgical difficulty. ICG-assisted NIRFC provides real-time biliary visualization. In complicated conditions such as acute severe inflammation, dense adhesions, and biliary variants, the navigating ability of fluorescence can enhance the operation progress, reduce the possibility of conversion or serious complications, and improve the efficiency and safety of difficult LC.

Prediction of delayed cerebral ischemia after cerebral aneurysm rupture using explainable machine learning approach.

Aneurysmal subarachnoid hemorrhage results in significant mortality and disability, which is worsened by the development of delayed cerebral ischemia. Tests to identify patients with delayed cerebral ischemia prospectively are of high interest. We created a machine learning system based on clinical variables to predict delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage patients. We also determined which variables have the most impact on delayed cerebral ischemia prediction using SHapley Additive exPlanations method. 500 aneurysmal subarachnoid hemorrhage patients were identified and 369 met inclusion criteria: 70 patients developed delayed cerebral ischemia (delayed cerebral ischemia+) and 299 did not (delayed cerebral ischemia-). The algorithm was trained based upon age, sex, hypertension (HTN), diabetes, hyperlipidemia, congestive heart failure, coronary artery disease, smoking history, family history of aneurysm, Fisher Grade, Hunt and Hess score, and external ventricular drain placement. Random Forest was selected for this project, and prediction outcome of the algorithm was delayed cerebral ischemia+. SHapley Additive exPlanations was used to visualize each feature's contribution to the model prediction. The Random Forest machine learning algorithm predicted delayed cerebral ischemia: accuracy 80.65% (95% CI: 72.62-88.68), area under the curve 0.780 (95% CI: 0.696-0.864), sensitivity 12.5% (95% CI: -3.7 to 28.7), specificity 94.81% (95% CI: 89.85-99.77), PPV 33.3% (95% CI: -4.39 to 71.05), and NPV 84.1% (95% CI: 76.38-91.82). SHapley Additive exPlanations value demonstrated Age, external ventricular drain placement, Fisher Grade, and Hunt and Hess score, and HTN had the highest predictive values for delayed cerebral ischemia. Lower age, absence of hypertension, higher Hunt and Hess score, higher Fisher Grade, and external ventricular drain placement increased risk of delayed cerebral ischemia. Machine learning models based upon clinical variables predict delayed cerebral ischemia with high specificity and good accuracy.

Mode establishment and preliminary clinical application of anterior cervical surgery in outpatient setting

To establish the mode of anterior cervical surgery in outpatient setting, and evaluate its preliminary effectiveness. A clinical data of patients who underwent anterior cervical surgery between January 2022 and September 2022 and met the selection criteria was retrospectively analyzed. The surgeries were performed in outpatient setting ( n=35, outpatient setting group) or in inpatient setting ( n=35, inpatient setting group). There was no significant difference between the two groups ( P>0.05) in age, gender, body mass index, smoking, history of alcohol drinking, disease type, the number of surgical levels, operation mode, as well as preoperative Japanese Orthopaedic Association (JOA) score, visual analogue scale score of neck pain (VAS-neck), and visual analogue scale score of upper limb pain (VAS-arm). The operation time, intraoperative blood loss, total hospital stay, postoperative hospital stay, and hospital expenses of the two groups were recorded; JOA score, VAS-neck score, and VAS-arm score were recorded before and immediately after operation, and the differences of the above indexes between pre- and post-operation were calculated. Before discharge, the patient was asked to score satisfaction with a score of 1-10. The total hospital stay, postoperative hospital stay, and hospital expenses were significantly lower in the outpatient setting group than in the inpatient setting group ( P<0.05). The satisfaction of patients was significantly higher in the outpatient setting group than in the inpatient setting group ( P<0.05). There was no significant difference between the two groups in operation time and intraoperative blood loss ( P>0.05). The JOA score, VAS-neck score, and VAS-arm score of the two groups significantly improved at immediate after operation when compared with those before operation ( P<0.05). There was no significant difference in the improvement of the above scores between the two groups ( P>0.05). The patients were followed up (6.67±1.04) months in the outpatient setting group and (5.95±1.90) months in the inpatient setting group, with no significant difference ( t=0.089, P=0.929). No surgical complications, such as delayed hematoma, delayed infection, delayed neurological damage, and esophageal fistula, occurred in the two groups. The safety and efficiency of anterior cervical surgery performed in outpatient setting were comparable to that performed in inpatient setting. Outpatient surgery mode can significantly shorten the postoperative hospital stay, reduce hospital expenses, and improve the patients' medical experience. The key points of the outpatient mode of anterior cervical surgery are minimizing damage, complete hemostasis, no drainage placement, and fine perioperative management.

Effect of drain placement on postoperative radiology following burrhole drainage of chronic subdural hematoma

Objective: The effect of drain placement on postoperative radiology following burrhole drainage of chronic subdural hematoma (ChSDH) is a topic that has been rarely addressed in literature. The present study was designed to study the effects of postoperative drain placement on different radiological parameters following ChSDH evacuation. Materials &amp; Methods We studied the data of 117 patients operated with burrhole drainage of ChSDH and divided the patients into two groups. In the first group a postoperative subdural drain had been placed while the second was the no drainage group. The pre- and postoperative CT brain of the patients were analyzed and the change in the hematoma width and midline shift was noted. Results: In the drainage group 12 (18.2%) patients had recurrence. In the no drainage group also 12 (23.5%) patiens had recurrence. The difference in recurrence wasn’t significant (p=0.4775). The mean change in the width of the hematoma was 0.95 ± 0.37 mm in the drainage group, while in the no drainage group this was 0.51 ± 0.37 mm. This difference was very significant (p &lt; 0.0000001). The mean change in the midline shift was 0.51 ± 0.21 mm in the drainage group, while in the no drainage group this was 0.26 ± 0.22 mm and this difference again was very significant (p &lt; 0.0000001). Conclusion The placement of a subdural drain following burrhole evacuation of ChSDH leads to significantly decreased postoperative hematoma width and mass effect providing the radiological corroboration for drain placement.

Do not get stumped: multimodality imaging findings of early and late post-cholecystectomy complications

Cholecystectomy is the most performed intra-abdominal surgical procedure in the US, with 1.2 million performed annually, and is predominantly performed laparoscopically. Although largely safe, laparoscopic cholecystectomy results in higher rates of abdominal symptoms consisting of abdominal pain and dyspepsia, which may persist or recur, collectively known as post-cholecystectomy syndrome. This article aims to (1) provide an overview of post-cholecystectomy syndrome with an emphasis on biliary complications and emergent imaging findings, (2) illustrate the spectrum of imaging findings of early and late post-cholecystectomy complications, (3) enumerate the role of various imaging modalities in evaluating post-cholecystectomy complications and address the role of selective trans-catheter coil embolization in managing bile leaks, and (4) discuss pearls and pitfalls in imaging following cholecystectomy. While common first-line imaging modalities for post-cholecystectomy complications include CT and sonography, ERCP and MRCP can delineate the biliary tree with greater detail. Scintigraphy has a higher sensitivity and specificity than CT or sonography for diagnosing bile leak and may preclude the need for ERCP. Post-operative complications include biliary duct injury or leak, biliary obstruction, remnant gallbladder/cystic duct stones and inflammation, biliary dyskinesia, papillary stenosis, and vascular injury. Subtle cases resulting in lethal outcomes, such as hemorrhage from the gallbladder bed without major vessel injury, have also been described. Cases presented will include biliary complications such as post-cholecystectomy stump cholecystitis, nonbiliary complications such as subcapsular hematoma, and normal post-surgical findings such as oxidized regenerated cellulose. Post-operative biliary complications can cause significant morbidity and mortality, and thus familiarity with the expected post-surgical appearance of the gallbladder fossa and biliary tract, as well as understanding the spectrum of complications and associated multimodality imaging findings, are essential for emergency radiologists and those practicing in the acute care setting to direct appropriate patient management. Furthermore, many of the postoperative complications can be managed by noninvasive percutaneous interventional procedures, from drain placement to cystic artery and cystic duct stump embolization.

A systematic review on the efficacy of tranexamic acid in head and neck surgery.

Intraoperative and postoperative blood loss is a major risk in head and neck (H&N) surgery. Recently the use of tranexamic acid (TXA) has been investigated by multiple studies for reducing intraoperative and postoperative bleeding, however reported results are variable. To determine the safety and efficacy of TXA use in H&N surgery. Systematic review of MEDLINE, EMBASE, CINAHL, Cochrane Library, PubMed, ClinicalKey, and Clinicaltrials.gov according to the PRISMA guidelines. Studies were included if they reported on intraoperative bleeding, volume or duration of postoperative drain or return to theatre rate for postoperative haemorrhage in adult populations following use of TXA. Risk of bias assessment with Cochrane Risk of Bias (RoB2) tool for randomised controlled trials and Newcastle-Ottawa Scale tool for non-randomised studies. Sixteen studies were identified (114 407 patients). Eight studies evaluated TXA in major H&N surgery and eight studies in tonsillectomy. Primary outcomes were reduction in intraoperative or postoperative bleeding. Secondary outcomes included the duration of postoperative drain placement and return to theatre rate. No adverse events were reported in any patients. TXA is effective in reducing intraoperative blood loss in tonsillectomy. However, the effect on posttonsillectomy haemorrhage was unclear. Insufficient evidence exists of benefit of TXA on intraoperative bleeding in major H&N procedures. Postoperative drainage volumes were significantly reduced in most major H&N studies. The duration of drain placement and risk of blood transfusion was unchanged in most cases. TXA use is safe in H&N patients. Whilst sufficient evidence exists to support the use of TXA in tonsillectomy, insufficient evidence exists to recommend use in major H&N surgery.

Drain placement in paediatric complicated appendicitis: a systematic review and meta-analysis.

Children undergoing appendicectomy for complicated appendicitis are at an increased risk of post-operative morbidity. Placement of an intra-peritoneal drain to prevent post-operative complications is controversial. We aimed to assess the efficacy of prophylactic drain placement to prevent complications in children with complicated appendicitis. A systematic review was performed in accordance with PRISMA guidelines. Cochrane, MEDLINE and Web of Science databases were searched from inception to November 2022 for studies directly comparing drain placement to no drain placement in children ≤ 18years of age undergoing operative treatment of complicated appendicitis. A total of 5108 children with complicated appendicitis were included from 16 studies; 2231 (44%) received a drain. Placement of a drain associated with a significantly increased risk of intra-peritoneal abscess formation (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.16-2.24, p = 0.004) but there was no significant difference in wound infection rate (OR 1.46, 95% CI 0.74-2.88, p = 0.28). Length of stay was significantly longer in the drain group (mean difference 2.02days, 95% CI 1.14-2.90, p < 0.001). Although the quality and certainty of the available evidence is low, prophylactic drain placement does not prevent intra-peritoneal abscess following appendicectomy in children with complicated appendicitis.

Iatrogenic Complications and Management of Biliary Interventions

AbstractIatrogenic complications can result from both diagnostic and therapeutic hepatobiliary interventions such as percutaneous transhepatic cholangiography, percutaneous biliary drain placement, percutaneous liver biopsy, transarterial liver-directed therapies for malignancy, and liver transplantation. In many of these procedures, the proximity of the biliary ductal system to the hepatic arteries and portal veins predisposes to injury. In other procedures, compromised arterial supply to the biliary system, errors related to complexity of the procedures, or the fragility of the structures themselves may be the root cause. Understanding the etiology of these iatrogenic complications as well as the management options is essential for a multidisciplinary team tasked with managing patients with complex hepatobiliary diseases.

A Comparative Study Between Mastectomy Flap Quilting Sutures with Axillary Drain Versus Conventional Sutures with Axillary and Pectoral Drain in Reducing Post-Modified Radical Mastectomy Seroma Formation.

The aim of this study was to compare quilting suture with axillary drain versus conventional sutures with axillary and pectoral drain on the formation of seroma after modified radical mastectomy with axillary lymph node dissection. The study was undertaken among 90 female patients with breast cancer who were candidates for modified radical mastectomy with axillary clearance. The intervention group (N = 43) with quilting and axillary drain placement and the control group (N = 33) without quilting with axillary and pectoral drain placement. All the patients were followed up for complications pertaining to this procedure. There were no significant differences between the two groups with regard to demographic characteristics, comorbidities, pre-operative chemotherapy, post-operative pathological findings, lymph node involvement or clinical staging. The incidence of seroma formation on follow-up was significantly lower in the intervention group than that in the control group (23% versus 58%; p < 0.05) whereas there was no significant difference with respect to flap necrosis, superficial skin necrosis and wound gaping between the two groups. Furthermore, it took a shorter duration for seroma to resolve in the intervention group (4days versus 9days; p < 0.001) with a smaller duration of hospital stay (4days versus 9days; p < 0.001). The use of quilting sutures for flap fixation in order to obliterate dead space post-modified radical mastectomy with placement of axillary drain significantly reduced seroma formation along with shorter duration of wound drainage and a smaller hospital stay with only slightly increased operative time. Therefore, we recommend quilting of flap as a routine step after mastectomy.

MP69-17 NECESSITY OF PROPHYLACTIC DRAINAGE TUBE IN RETROPERITONEAL LAPAROSCOPIC NEPHROURETERECTOMY WITH OPEN DISTAL URETERECTOMY: A MATCHED-PAIR ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023MP69-17 NECESSITY OF PROPHYLACTIC DRAINAGE TUBE IN RETROPERITONEAL LAPAROSCOPIC NEPHROURETERECTOMY WITH OPEN DISTAL URETERECTOMY: A MATCHED-PAIR ANALYSIS Hiroki Hagimoto, Mutsushi Kawakita, and Toshinari Yamasaki Hiroki HagimotoHiroki Hagimoto More articles by this author , Mutsushi KawakitaMutsushi Kawakita More articles by this author , and Toshinari YamasakiToshinari Yamasaki More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003332.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To assess the necessity of prophylactic drain placement in retroperitoneal laparoscopic nephroureterectomy with open distal ureterectomy for upper tract urothelial cancer. METHODS: Between July 2011 and March 2021, 200 patients with localized clinical Tis-T3 upper urinary tract urothelial carcinoma underwent laparoscopic nephroureterectomy with open distal ureterectomy. After removing the specimen, drainage tubes were placed on the renal beds and/or in the retrovesical spaces. Drain tubes were omitted for most patients after 2017. We compared the postoperative outcomes between the patients with drain placement (D+ group) and without drain placement (D- group) by propensity score matching. RESULTS: A total of 164 patients (90 in the D+ group and 74 in the D- group) were enrolled, and matched pairs of 108 patients were analyzed. There was no significant difference in the incidence of complications according to Clavien–Dindo grade in the two groups after the propensity score matching. There was no significant difference in the incidence of postoperative lymphocele (n=5 vs. 9, p=0.395) and symptomatic lymphocele (n=1 vs. 1, p=1) between the two groups. The length of hospital stay was significantly shorter in the D- group (11 vs. 8 days, p<0.0001). CONCLUSIONS: Omitting the drainage tube after laparoscopic radical nephroureterectomy does not increase postoperative complications or lymphocele and shortens the post-hospital stay. Source of Funding: No funding © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e971 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hiroki Hagimoto More articles by this author Mutsushi Kawakita More articles by this author Toshinari Yamasaki More articles by this author Expand All Advertisement PDF downloadLoading ...

PD42-04 BLOOD THINNERS: DO THEY NEED TO BE HELD FOR IPP SURGERY?

You have accessJournal of UrologyCME1 Apr 2023PD42-04 BLOOD THINNERS: DO THEY NEED TO BE HELD FOR IPP SURGERY? Niki Parikh, Reza Roshandel, Ryan Griggs, Gerard Henry, Paul Perito, Coral Gables, Saint Helena, and Tobias Kohler Niki ParikhNiki Parikh More articles by this author , Reza RoshandelReza Roshandel More articles by this author , Ryan GriggsRyan Griggs More articles by this author , Gerard HenryGerard Henry More articles by this author , Paul PeritoPaul Perito More articles by this author , Coral GablesCoral Gables More articles by this author , Saint HelenaSaint Helena More articles by this author , and Tobias KohlerTobias Kohler More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003352.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) placement on active anticoagulation (AC) is controversial. Techniques utilized to decrease complications include use of malleable implant, partial inflation of IPP for hemostasis, and placement of drain; however risk and benefits must be weighed. We sought to assess outcomes of IPP in men on AC in a multi-institutional study. METHODS: Data from 3 high-volume implant centers was retrospectively analyzed. Demographics, comorbidities, secondary procedures, drain placement/output, and complications were recorded. Aspirin was excluded as it is not routinely held. Center 1 utilizes a penoscrotal approach without drain placement, center 2 a penoscrotal approach with drain placement (removal when output <50 mL/8 hours), and center 3 an infra-pubic approach with drain for 3 days. RESULTS: 202 patients were continued on AC throughout surgery. 112 patients were on clopidogrel, 35 warfarin, 38 apixaban, 1 enoxaparin, 15 rivaroxaban, and 1 on combination therapy with clopidogrel and enoxaparin. AC requirement included peripheral vascular disease (55%), CHF (11%), cardiac stents (11.6%), DVT/PE/history of thrombosis (7%), atrial fibrillation (11%), cardiac valves (2.2%), stroke (1.3%), and preventive (0.9%). Nine patients on AC (3.98%) experienced complications including 4 significant events (1.9%): 1 major retropubic bleed requiring transfusion, 3 IPP infections and 5 minor events: 3 minor hematomas, 1 minor wound dehiscence and 1 CT negative stroke event. Drain outputs for center 3 averaged 113 ml, 81 ml, and 30 ml of output per day respectively with a total average output average of 223 ml and experienced no hematomas nor infections. Drain output for center 2 averaged 121 ml with the majority or patients having the drain for only one day. Drain output was significantly higher than historical non-AC controls (121 vs. 72 ml p=.001) but there was no difference in hematoma rate. Three hematomas and 1 infection occurred in this group. AC type, revision surgery, scrotoplasty, or reservoir technique did not affect outcomes nor drainage (p>.05). Complication rate (IPP infection and hematoma rate) where not different when compared to large cohorts from respective institutions. CONCLUSIONS: In high-volume implant centers, major complication rate of 1.9% occurred in IPP patients on AC. Although IPP is feasible in this patient population, drain for 3 days and submuscular reservoir placement may be indicated. In most, elective IPP surgery should be delayed until it is safe to discontinue anticoagulation. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1112 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Niki Parikh More articles by this author Reza Roshandel More articles by this author Ryan Griggs More articles by this author Gerard Henry More articles by this author Paul Perito More articles by this author Coral Gables More articles by this author Saint Helena More articles by this author Tobias Kohler More articles by this author Expand All Advertisement PDF downloadLoading ...

Enterolith Causing Afferent Loop Perforation After Distal Gastrectomy

Afferent loop syndrome is a complication that occurs after the Billroth Ⅱ reconstruction or Roux-en-Y reconstruction and can also be caused by enteroliths. We experienced a case of duodenal perforation due to afferent loop syndrome caused by an enterolith, in which surgical removal of the enterolith and decompression of the duodenum were effective. A 73-year-old female who underwent distal gastrectomy and Roux-en-Y reconstruction for gastric cancer 14 years ago came to the hospital with acute abdominal pain and underwent emergency surgery for afferent loop syndrome and duodenal perforation due to enterolith. The patient underwent removal of the enterolith, drain placement, and placement of a decompression tube in the duodenum. Postoperatively, percutaneous drainage of the intra-abdominal abscess was necessary, but the patient was saved without reoperation. Afferent loop perforation may occur with obstruction due to enteroliths, and the surgical insertion of a tube to decompress the afferent loop is effective.

Outcomes of SUBGALEAL Drain Placement after two Burr-Holes Craniectomy for Chronic Subdural Hematoma.

To evaluate the efficacy and complications of subgaleal drain placement after two burr-holes evacuation of chronic subdural hematoma (CSDH). Descriptive study. The Neurosurgical unit of the Lady Reading Hospital, Peshawar, from April to November 2021. Sixty-four consecutive patients diagnosed with surgically significant unilateral chronic subdural hematoma were prospectively included after obtaining informed consent. All the patients underwent two burr-holes craniectomies and evacuation, followed by subgaleal drain placement. Patient demographics, pre- and postoperative clinical information including hematoma resolution and complications were collected. This study included 44 (69%) males and 20 (31%) females with a mean age of 70.1 ± 8 years. The most common presenting symptoms were headaches (70%) and confusion (68%). Eighteen patients (28%) were taking warfarin or other anticoagulants, whereas, 23 patients (36%) were taking antiplatelet medications at the time of presentation. Thirty-six (56.3%) patients had a history of head trauma. Warfarin use was statistically significant in the patients with no history of head injury. Fifty-five patients (85%) showed no significant recurrence on the 2 week postoperative computed tomography (CT) scan. None of the patients had intraparenchymal hematoma or contusion of iatrogenic origin on postoperative CT scans. Subgaleal drain placement after two burr-holes craniectomy led to high-resolution rates. However, no parenchymal injuries were attributed to the procedure. Chronic subdural hematoma, Subdural drain, Subperiosteal drain, Burr-hole craniostomy.

Keyhole retrosigmoid approach without watertight dural closure - Evaluation of a minimalistic approach.

The retrosigmoid craniotomy is a versatile surgical approach to the cerebellopontine angle though cerebrospinal fluid leak remains a concern, with a reported prevalence of 0-22 %. A host of closure materials and strategies have been proposed to achieve a watertight dural closure to varying degrees of success. We review our series of keyhole retrosigmoid craniotomies and describe our simple, standardized method of closure without watertight dural closure. A retrospective review of all retrosigmoid craniotomies performed by the senior author was completed. Closure was achieved by placing an oversized piece of gelatin in the subdural space. The dura is grossly approximated. An oversized sheet of collagen matrix is placed as an overlay followed by gelatin sponge in the craniectomy defect held in place with titanium mesh. The superficial layers are approximated. The skin is closed with a running sub-cuticular suture followed by skin glue. Patient demographics, cerebrospinal fluid leak risk factors, and surgical outcomes were determined. A total of 114 patients were included. There was one case (0.9 %) of CSF leak, which resolved with placement of a lumbar drain for 5 days. The patient had one defined risk factor (morbid obesity, BMI 41.0kg/m2). Obtaining a watertight dural layer closure has been the generally accepted strategy in preventing CSF leaks in a traditional retrosigmoid approach. In keyhole retrosigmoid approaches it may not be necessary by utilizing a simple gelfoam bolstered collagen matrix onlay technique potentially improving outcome measures including operative time.

768 The Device for Intraventricular Entry (DIVE) Guide: A Novel Solution to a Perpetual Problem

INTRODUCTION: Safe and reliable access to the ventricular system is a necessary skill in the neurosurgical armamentarium. The freehand technique for catheter placement remains an accepted method, yet the inaccuracy rate can be as high as 40%, with as many as 3 passes per procedure, and complication rates between 10-40%. A number of devices have been developed to assist with catheter placement, however, these devices inhibit ergonomics or require larger incisions and expensive navigation technology. METHODS: A novel device for ventricular entry, the DIVE guide, was designed by the first and senior author. 50 patients undergoing extra ventricular drain (EVD) or shunt placement were prospectively enrolled for DIVE assisted catheter placement under an IRB approved study with a non-significant risk (NSR) device designation. The primary outcome is catheter location on CT. Secondary outcomes include number of catheter passes, clinically significant hemorrhages and procedure-related infections. RESULTS: 50 patients were enrolled at a single academic center for ventricular access with DIVE assistance. Indications included subarachnoid or intraventricular hemorrhage, TBI, hydrocephalus, pseudotumor and post-surgical wound drainage. 76% (38/50) underwent right sided placement and 24% (12/20) underwent left. 100% (50/50) had successful cannulation in an average of 1.06 passes. Post procedure head CT confirmed ipsilateral frontal horn or 3rd ventricle placement (Kakarla Grade 1) in 92% (46/50) and 8% (4/50) in the contralateral lateral ventricle (Grade 2). There were no significant tract hemorrhages or procedural infections. CONCLUSIONS: This a prospective study to investigate the safety and efficacy of DIVE-assisted ventricular access. 100% of procedures had successful ventricular cannulation, with 92% achieving Kakarla Grade 1, in an average of 1.06 passes.