Drain Site Research Articles

ThP4.13 - To drain or not to drain?! Selective Abdominal Drainage Reduces Morbidity and Re-interventions in Laparoscopic Cholecystectomy and Bile Duct Exploration

Abstract Aims To evaluate the indications and benefits of sub-hepatic drainage after laparoscopic cholecystectomy(LC) and bile duct exploration (LCBDE). Methods Utilisation of drains in a prospective database of LC and LCBDE was reviewed. The occurrence of postcholecystectomy bile leakage (PCBL) and abdominal collections was analysed. Results 52.5 % of 6140 patients had drains. PCBL occurred in 43 (1.3%). 20 leaks had choledochotomy LCBDE; 16 before drain removal (10 settling spontaneously, 3 requiring ERCP, 3 relaparoscopy). All 4 occurring after drain removal required percutaneous drains (PCD) or ERCPs. 12 leaks had transcystic explorations; 10 before drain removal (8 settling spontaneously, 1 ERCP, 1 PCD) and 2 after drain removal (1 settled, 1 needed ERCP). 11 PCBLs had LC only; 9 still had drains (6 settled, 1 PCD, 1 ERCP, 1 relaparoscopy) and 2 after drain removal needing relaparoscopy and ERCP. Drains allowed early detection and spontaneous resolution in 24 patients (55.8%) and early detection and intervention prevented serious morbidity in 11 (25.6%). 7 of 8 PCBLs after drain removal required reintervention. 2915 (47.5%) had no drains. 6 had PCBL (0.2%); 5 needing multiple reinterventions; 3 PCD, 2 ERCPs and 3 relaparoscopies. Drains caused complications in six patients (0.18%); one retracted into the abdomen needing relaparoscopy, two drain site infections and 3 had significant pain disappearing when drains were removed. Collections other than PCBL occurred in 19 patients; 8 with drains and 11 after drain removal. They were treated conservatively (9), by PCD (8) or relaparoscopy (2). Conclusions Careful selective abdominal drainage after advanced biliary surgery allows early detection of collections, minimising morbidity and reintervention.

The analgesic effects of combined bilateral parasternal block and serratus anterior plane block for coronary artery bypass grafting surgery

BackgroundSevere pain occurs after cardiac surgery in the sternum and chest tubes sites. Although analgesia targeting the sternum is often prioritized, the analgesia of the drain site is sometimes overlooked. This study of patients undergoing coronary artery bypass grafting (CABG) aimed to provide optimized analgesia for both the sternum and the chest tubes area by combining parasternal block (PSB) and serratus anterior plane block (SAPB).MethodsEthics committee approval (E.Kurul-E2-24-6176, 07/02/2024) was received for the study. Then, the trial was registered on www.clinicaltrials.gov (https://clinicaltrials.gov/) under the identifier NCT05427955 on 17/03/2024. Twenty patients between the ages of 18–80, with ASA physical status classification II-III, undergoing coronary artery bypass grafting CABG with sternotomy, were included. While the patients were under general anesthesia, PSB was performed through the second and fourth intercostal spaces, and SAPB was performed over the sixth rib. The primary outcome was VAS (Visual Analog Scale) during the first 12 h after extubation. The secondary outcomes were intraoperative remifentanil consumption and block-related side effects.ResultsThe average age of the patients was 64 years. Five patients were female, and 15 were male. For the sternum area, only one patient had resting VAS scores of 4, while the VAS scores for resting for the other patients were below 4. For chest tubes area, only two patients had resting VAS scores of 4 or above, while the resting VAS scores for the other patients were below 4. The patients’ intraoperative remifentanil consumption averaged 2.05 mg. No side effects related to analgesic protocol were observed in any of the patients.ConclusionsIn this preliminary study where PSB and SAPB were combined in patients undergoing CABG, effective analgesia was achieved for the sternum and chest tubes area.

Rescue Transsplenic Gastric Varices Embolization in a Patient of Massive Gastric Variceal Bleed Secondary to Complete Splanchnic Portal Venous System Thrombosis

AbstractEndoscopic sclerotherapy is the first-line modality to manage gastric variceal bleeding; however, knowledge of other treatment options is also essential, especially in case of failure of the endoscopic approach. We are reporting a rare case of successful rescue gastric varices embolization through the transsplenic route in a gastric varices bleeding patient who presented with massive hematemesis and blood from the ileostomy drain site secondary to complete splanchnic portal venous system thrombosis when all other treatment options were not feasible or unsafe. Proper cross-sectional imaging evaluation, knowledge of treatment options, and understanding of intraprocedural challenges are essential for managing gastric varices.

Perceptions of Surgical Drains among Breast Reconstruction Patients and Health Care Staff: A Qualitative Survey Study.

Surgical drains are a key component for recovery in breast reconstruction procedures. However, they are often cumbersome and carry a risk of infection with prolonged use. We aimed to develop a more thorough understanding of patient and health care provider perspectives on surgical drains, to inform future efforts in improving the breast reconstruction patient experience. Twenty-nine breast reconstruction patients and eight plastic surgery providers were recruited to complete surveys focused on surgical drains. Likert scales ranging from 1 to 5 were developed to gauge how bothersome drains felt, as well as concern for infection. Ordinal variable and categorical multiple-choice analyses were applied as appropriate. Fifteen (51.7%) patients underwent implant-based breast reconstruction, and 14 (48.3%) patients underwent autologous breast reconstruction. The most common duration of drain placement was 2 weeks (N = 13). The surgical site infection (SSI) rate requiring antibiotics was 28% (N = 8). On a scale of 1 to 5, both patients (median = 3) and providers (median = 2.5) viewed drains as bothersome. Patients were "frequently" concerned about infection risk (median = 3). Other high-frequency patient concerns included general pain and discomfort. Surgical drains are a common component of breast reconstruction procedures and are viewed as cumbersome by both patients and providers. Patients expressed concerns about drain site pain, discomfort, and tugging on clothing. Patients and providers both believed that drains could contribute to SSI. Overall, these data provide insight to drive future improvements in the patient drain experience.

Use of a mobile application to monitor drain sites and surgical wounds after discharge from acute care - a feasibility study in Singapore

PurposeThis study aimed to demonstrate the compliance, feasibility, and acceptability of telehealth monitoring among surgical patients discharged with wounds or drains. MethodologyThis is a cross-sectional feasibility study. Post- surgical breast, plastic, and hepatobiliary patients with wounds and/or surgical drains were recruited using convenience sampling. The control group received conventional care which consisted of daily telephone follow-up. The intervention group used a mobile wound application to take wound and drain images, report drainage amount and symptoms. Compliance was assessed by measuring the percentage of actual to expected patient entries, feasibility was assessed by comparing detection of abnormalities and unexpected hospital visits, and acceptability was assessed by subjective feedback from nurses and patients from the intervention group. Results59 patients were recruited, with 30 patients in the control group and 29 patients in the intervention group. 9 specialty nurses were involved in the patients’ post- discharge care. The mean compliance rate for the hepatobiliary, breast and plastic patients were 89.9%, 89.5% and 75.9% respectively. 4 patients from the intervention group (13.8%) and 6 patients from the control group (20.1%) were flagged as having potential abnormalities. As for unexpected hospital visits, there were 2 (6.9%) in the intervention group and 1 (3.4%) in the control group. 25 patients and 9 specialty nurses responded to the feedback survey. 22 patients (88%) did not face any application issues. 18 patients (72%) preferred to self-report symptoms via the application rather than to call the nurses and reported feeling safe knowing that they are remotely monitored. Most nurses found the app convenient and timesaving (n=7, 78%), with monitoring through pictures as more accurate than phone conversation (n=8, 89%). ConclusionThe results suggest that use of a mobile application by surgical patients discharged with wounds or drains is feasible and serves as a viable monitoring tool.

Drain or not drain? A surgical dilemma using suction drain for drain site metastasis in a patient with uterine sarcoma

Drain or not drain? A surgical dilemma using suction drain for drain site metastasis in a patient with uterine sarcoma

The impact of an intervention to reduce dispersal from wastewater drain sites on carbapenem-resistant Pseudomonas aeruginosa colonization and bloodstream infection on a hematopoietic cell transplant and hematologic malignancy unit.

To evaluate the impact of an intervention to limit dispersal from wastewater drain (WWD) sites on meropenem-nonsusceptible Pseudomonas aeruginosa patient and environmental colonization and bloodstream infection (BSI) on a hematopoietic cell transplant (HCT) and hematologic malignancy (HM) unit. This quasi-experimental study included pre/postintervention point-prevalence surveys in July 2019 and June 2020, respectively. The retrospective cohort included HCT/HM patients with P. aeruginosa BSI between 2012 and 2022. Adult HCT/HM unit at an academic center. This study included consenting HCT/HM patients on the unit at the time of the point-prevalence surveys. HCT/HM patients with P. aeruginosa BSI between 2012 and 2022. A quality improvement intervention targeting WWD sites was conceived and implemented on a HCT/HM unit. Pre and postintervention colonization samples were obtained from patients and environmental sites, cultivated on selective media, then characterized by susceptibility testing. Whole-genome sequencing and phylogenetic analysis were performed on select isolates. The impact of the intervention on colonization and BSI was evaluated, as was relatedness among isolates. Although colonization of WWD sites with meropenem-nonsusceptible P. aeruginosa was widespread before and after this intervention, we observed a substantial decline in patient colonization (prevalence rate ratio, 0.35; 95% confidence interval [CI], 0.04-3.12) and BSI (incidence rate ratio, 0.67; 95% CI, 0.31-1.42) after the intervention. Among 3 predominant sequence types (ST-111, ST-446, and ST-308), there was striking genetic conservation within groups and among environmental colonization, patient colonization, and BSI isolates. An intervention targeting WWD sites on a HCT/HM unit had a meaningful impact on meropenem-nonsusceptible P. aeruginosa patient colonization and BSI.

Karydakis operation for pilonidal sinus disease in overweight and obese patients. A study of the efficacy of the procedure in 136 patients.

Objective: To test the efficacy of the Karydakis procedure in overweight and obese patients and to check the recurrence rates in our patients. Study Design: Multicenter Prospective study. Setting: Sughra Shafi Medical Complex Narowal. Period: May 2011 to July 2021. Material & Methods: Total 146 patients were selected for this study a formal informed consent was taken. Ten patients were lost from follow up and excluded from study. Results: Out of remaining 136 patient 130 were male and only 6 were female. Mean age of the patient was 23 year and 5 months (range 16 years to 49 years). Thirty five patients had a single sinus in the midline, Seventy two had multiple sinuses in the midline, and 38 patients had lateral tract either on the right or on the left side in addition midline sinuses. Mean operating time was 39 minutes (range 23 – 70 minutes), mean blood loss was 26 ml (10 – 70ml) and mean hospital stay was 3 days (range 2- 7 days). There were a total of 21 (15 .05 %) complications. Seven(4.29) patients developed major wound infection requiring opening of the sutures and regular dressing till the wound became healthy to be closed by secondary suturing. Seven patients developed minor wound infection, 6 patients developed seroma and 3 patients had leakage of serous fluid from drain site for a couple of days. There were only 5 (3.67%) recurrences in mean follow up period of 23 months (range 11 months to 4 years). Two (1.47%) recurrence were observed in patient with BMI of below 35 and 3 recurrences (2.20%) were observed in patient with BMI of >35. All of them occurred in obese patient who could not maintain their personal hygiene according to advice given to them. Majority of the patient were satisfied with the procedure. Conclusion: We concluded that Karydakis operation has good outcome in overweight and obese patients. It addresses the etiological factors of the disease, is less time consuming as compared to other flap operation, is not associated with wound scar in the midline, can be easily performed by surgeons in training, is associated with minimum complications, has minimum recurrence rate on short and long term follow up, avoid the painful prolong dressing regimen and well accepted by the patients.

Evisceration and Consequent Gangrene of Vermiform Appendix from a Drain Site: A Case Report

Evisceration and Consequent Gangrene of Vermiform Appendix from a Drain Site: A Case Report

407 Robotic Assisted Cholecystectomy and Common Bile Duct Exploration for Single Stage Management of Complex Gallstone Disease

Abstract Aim Laparoscopic cholecystectomy and common bile duct exploration (LC-CBDE) is an alternative to endoscopic retrograde cholangiopancreatography (ERCP) for treatment of choledocholithiasis. The ‘Achilles heel’ of LC-CBDE is the choledochotomy incision and closure following duct clearance. Robotic assisted surgery (RAS) aspires to overcome these technical challenges by providing improved views (3D enhancement) and articulated instruments potentially improving surgical precision. We aim to scrutinise the outcomes of an early series of robotic assisted cholecystectomy and common bile duct exploration (RC-CBDE) cases performed at our institution. Method Retrospective analysis from a specialist benign pancreatico-biliary unit in the United Kingdom was undertaken from April 2022 – December 2022 inclusive. All patients who underwent RC-CBDE for complicated gallstone disease were included. Collated data included patient demographics, perioperative investigations, intraoperative approach, and postoperative outcomes. Results 10 patients were identified. Median (IQR) age was 51 (33 – 66) years. Median (IQR) BMI was 26 (21 – 32) kg/m2. Median (IQR) Charlson Co-morbidity Index (CCI) was 1 (0 – 4). 4 patients were operated on during the acute presentation, with median (IQR) bilirubin 51 (34 – 252.5). Median (IQR) operative time was 176 (124 – 222) minutes. Median (IQR) post-operative length of stay was 4 (1 – 5) days. One patient required reintervention for port site hernia repair from drain site. Conclusions RC-CBDE is a safe and effective treatment for choledocholithiasis with equivocal outcomes to LC-CBDE. Benefits of RAS include enhanced views and ergonomics aiding precise closure of choledochotomy, which may both reduce complications and promote wider uptake of common bile duct exploration – a previously underutilised, technically-challenging operative procedure.

480 Clinical outcome of patients underwent cholecystostomies for acute gall-bladder related pathologies

Abstract Percutaneous cholecystostomy is an important and effective temporising procedure in patients with acute cholecystitis who are too unwell to undergo early cholecystectomy. We are seeing a rising number of cholecystostomies performed during the pandemic due to various reasons. However, evidence regarding drain indication, timing and management is lacking with varied practice within and between trusts. We have conducted this study to understand current practice employed at our unit and associated patient outcomes. In this retrospective study, we identified 138 patients who underwent image-guided percutaneous cholecystostomy between 1st January 2020 and 31st July 2022 in all hospitals within our trust. Data was collected from electronic records including drain details, immediate and late complications, biliary-related morbidity and mortality, subsequent re-admissions and definitive management. This is one of the largest studies ever conducted on cholecystostomies. Median length of time with a drain in situ was 35 days (IQR 28 days). 13 (9.8%) experienced minor immediate complications including pain during and after insertion, 51 (3.8%) experienced late complications including formation of cholecysto-cutaneous fistulous tracts and drain site infections. Hospital mortality secondary to biliary pathology was 6.8%. 28.6% had undergone definitive treatment at time of writing (median wait-time 23.5 weeks) and 25.6% were still awaiting a procedure. 29 (21.8%) patients had at least one re-admission related to their gallbladder pathology, with an average admission length of 15 days. No association was found between length of drain in situ and rates of complication and readmissions. The substantial mortality and readmission rates warrant a greater need for early/extra cholecystectomy lists in this era of gall-bladder pathologies.

Increased risk for incisional hernia following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

The incidence of incisional hernias (IH) after midline laparotomy varies from 11% to 20%. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is potentially prone to hernias because a Xiphoid to pubis laparotomy incision performed on patients who have undergone previous abdominal surgeries with the addition of chemotherapy and its related adverse effects. We performed a retrospective analysis on a prospectively maintained single institution database from March 2015 to July 2020. The inclusion criteria were patients who underwent CRS-HIPEC and had at least 6 months postoperative follow-up with post-operative cross-sectional imaging study. Two hundred and one patients were included in the study. All patients underwent CRS-HIPEC with resection of previous scar and umbilectomy. Fifty-four patients were diagnosed with IH (26.9%). The major risk factors for IH in multivariate analysis were higher American society of Anesthesiologists score (ASA) (OR 3.9, P = 0.012), increasing age (OR 1.06, P = 0.004) and increasing BMI (OR 1.1, P = 0.006). Most of the hernia sites were median (n = 43, 79.6%). Eleven (20.4%) patients had lateral hernias due to stoma incisions or drain sites. Most of the median hernias were at the level of the resected umbilicus 58.9% (n = 23). Five (9.3%) of the patients with IH necessitated an urgent surgical repair. We have demonstrated that more than a quarter of the patients after CRS-HIPEC suffer from IH and up to 10% of them may require surgical intervention. More research is needed to find the appropriate intraoperative interventions to minimize this sequela.

Atypical Mycobacterial Infection in Post Abdomino-Thoracic Trauma: A Case Report

Objective/Background: SSIs remain a significant cause of morbidity and mortality after surgery. One in eight patients develop SSI after exploratory laparotomies making it one of the major factors responsible for post-operative mortality and morbidity. Atypical mycobacteria are responsible for a spectrum of diseases ranging from superficial skin infections to widely disseminated systemic infections. Health care associated infections due to non-tuberculous mycobacteria is on the rise due to contaminated hospital water supplies, solutions, improperly sterilized instruments and devices. Our case is of an atypical mycobacterial infection in a patient with abdomino-thoracic trauma who underwent multiple surgeries. Case presentation: A 24 year old gentleman presented with a penetrating stab injury to the abdomen and left hemi-thorax following an assault. Patient underwent an emergency exploratory laparotomy which revealed a 4 x 4 cm defect in the left hemi-diaphragm, through which the stomach was herniating into the left thoracic cavity. During the 2nd post-operative week, patient developed empyema thorax, for which pigtail drain was placed initially and later thoracotomy with decortication and intercostal drainage were performed. Following discharge after 2 weeks, he presented with fever, body pain and pus discharge from the previously inserted intercostal drain site. Pus obtained was positive for acid fast bacilli and gene expert was negative. Atypical mycobacterial infection was diagnosed based on high index of suspicion and he received treatment for 6 months. Conclusion: This case highlights that identification of atypical mycobacterial infections in post-operative patients require a high index of suspicion. Management requires multi-drug approach and surgical intervention wherever necessary. Even with the existing sterilization techniques and preventive measure, atypical mycobacterial infection cannot be completely eliminated from a hospital set-up and hence must be considered in all nosocomial infections.

Post-Operative Outcomes of Laparoscopic Appendectomy in Acute Complicated Appendicitis: A Single Center Study.

Acute appendicitis (AA) is a surgical emergency because of inflammation in the appendix leading to swelling, whereas acute complicated appendicitis is characterized by a gangrenous or perforated appendix with or without periappendicular abscess, peritonitis, and an appendicular mass. The laparoscopic approach in complicated acute appendicitis is a viable alternative method but is not practiced in all cases because of technical difficulties and unpredictable complications. Thus, the present study aimed to evaluate the primary and secondary outcome predictors of laparoscopic appendectomy in complicated appendicitis. A single-center prospective observational study was carried out after the approval of the Institutional Ethics Committee (IEC). A total of 87 complicated acute appendicitis patients were included in the study. Clinico-demographic features such as age, gender, duration of surgery, post-operative pain, and hospital stay were monitored in different age groups of <20, 20-39, and >40 years, and the primary and secondary outcomes of laparoscopic surgery in acute complicated appendicitis were measured. Acute complicated appendicitis cases were observed mostly in people older than 42 years in the total study population. Laparoscopic appendectomy was conducted in all 87 acute complicated appendicitis patients, and the major surgical outcome predictors were monitored, such as mean operating time (87.9 minutes), post-operative pain (3.9 scores), and post-operative stay (6.7 days). Post-operative complications such as drain site infection (1.14%), enterocutaneous fistula (2%), and intra-abdominal abscess (7%) were observed. Based on our observations, a laparoscopic appendectomy can be considered a viable alternative with an acceptable complication rate. Operative time varies from 84 to 94 minutes in different age groups and with the extent of the disease.

Successful Endoscopic Closure of the Appendiceal Orifice

Introduction: Colocutaneous fistulas are severe complications that traditionally are repaired surgically with resection of the fistula followed by end-to-end anastomosis of the bowel. Given the high morbidity of surgery, an alternative approach to consider is endoscopic fistula closure with clips, which is a minimally invasive approach and is safe with high success rates.1–5 Currently, there are no reports in the literature describing endoscopic closure of the appendiceal orifice. This video case report describes a technique for placement of an over the endoscope clip at the appendiceal orifice to effectively close a colocutaneous fistula. Materials and Methods: The patient was a 69-year-old male with Marfan's syndrome who was 5 months status post primary repair of a duodenal perforation with feculent peritonitis. His early postoperative course was complicated by a persistent leak from an unknown source. One month postoperatively, imaging showed a large retroperitoneal abscess that required percutaneous drain placement. At that time, surgical endoscopy was consulted for duodenal evaluation and found no clear evidence of a leak from the duodenum. A percutaneous endoscopic gastrostomy tube with a jejunal feeding extension was placed. Four months after his index operation, he presented to the clinic with a change in drain output character that was suspicious for an enterocutaneous fistula. Fistulogram with contrast injected into the patient's percutaneous drainage catheter demonstrated continuity with the colon in the right lower quadrant. He was taken for a colonoscopy and fluoroscopy for further evaluation of the colocutaneous fistula. After injection of saline at the drain site, saline was seen trickling into the cecum from the appendiceal orifice. The decision was made to close the orifice with a 12/6T over-the-endoscope clip. The percutaneous retroperitoneal drain was removed 5 days postoperatively and he was discharged home 7 days postoperatively on a low residue diet. Results: At 1 month follow-up, the patient was doing well on a regular diet with no abdominal pain or fevers. A routine imaging scan performed 7 weeks postoperatively showed no recurrent retroperitoneal fluid collection. His gastrojejunal feeding tube was removed. Conclusion: Over-the-endoscope clipping of the appendiceal orifice to repair a colocutaneous fistula is technically feasible and appears safe. Endoscopic therapy spared this patient from a potential ileocecectomy. To date, no other similar procedures have been performed by our department in other patients. Further study is necessary to establish the safety of this procedure before its implementation as standard practice. A.H. has no disclosures. E.M.P. is a lecturer for BD, Medtronic, Ovesco, and Boston Scientific. E.M.P. is a consultant for Boston Scientific, Actuated Biomedical, Baxter, Wells Fargo, Cook Biotech, Neptune Medical, Surgimatrix, CMR Surgical, Boehringer Laboratories, Allergan, and Noah Medical. J.S.W. is a consultant for Boston Scientific. Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure. Runtime of video: 5 mins 20 secs This video was accepted as a video presentation at the 2023 Society of Gastrointestinal and Endoscopic Surgery on March 29 to April 1, 2023.

Medyan Sternotomili Kardiyak Cerrahide Ultrason Kılavuzluğunda Yüzeysel Serratus Anterior Plan Bloğu: Retrospektif Çalışma

Objective: As part of multimodal analgesia regimen in cardiac surgery, the serratus anterior plane block (SAPB) is a technique regularly used in minimally invasive surgical interventions with thoracotomy. The aim of our study is to determine the analgesic efficacy of SAPB for cardiac surgery performed with sternotomy. Methods: A total of 99 patients who underwent SAPB (Group SAP, n=43) and conventional analgesia (Group C, n=56) for coronary artery bypass graft (CABG) surgery were compared retrospectively. Demographic data, postoperative opioid use, highest pain scores, nausea-vomiting, time to start oral intake, extubation time, lenght of intensive care unit and hospital stay were recorded. Results: Total opioid requirement, expressed in oral morphine equivalent within the first 24 hours after extubation, was found to be significantly lower in patients with SAPB (p=0.022). Similarly, both the highest reported pain scores at rest and during mobilization and also the nausea scores were found to be significantly lower in Group SAP during the same period (p=0.007, p=0.048, p=0.004). Extubation (p=0.025) and oral intake initiation time p=0.030) were shorter in Group SAP. Conclusion: By providing analgesia of the chest tube drain site, SAPB application was associated with lower opioid consumption, pain, and nausea-vomiting among patients who underwent CABG with median sternotomy. Because of this benefit, superficial SAPB may be part of opioid-reducing multimodal analgesia in cardiac surgery. Keywords: Serratus anterior plane block, fascial plane blocks, coronary artery bypass surgery, postoperative analgesia

Management of Persistent Cerebrospinal Fluid Leak With an Epidural Blood Patch Following Removal of Lumbar Drain and Failed Neurosurgical Intervention: Case Report

BACKGROUND: Persistent cerebrospinal fluid (CSF) leak is a complication of a dural puncture that can be idiopathic, traumatic, or iatrogenic in nature. CASE REPORT: We present a case of a 43-year-old woman, diagnosed with a spontaneous CSF rhinorrhea that was treated with temporary placement of a lumbar drain. Upon discharge, the patient experienced a persistent CSF leak from the lumbar drain site, as well as a positional headache and vertigo that persisted even after application of reinforcement sutures at the lumbar drain site by the neurosurgery team. The patient was subsequently treated with an epidural blood patch (EBP) at L3-L4 interspace with autologous venous blood injected into the epidural space. During the follow-up 2 weeks after the intervention, there was a complete resolution of her symptoms, as well as the CSF leakage. CONCLUSIONS: A CSF leak after lumbar drain removal that persists even after neurosurgical intervention can be successfully treated with an EBP. KEY WORDS: CSF leak, rhinorrhea, epidural blood patch, lumbar drain, case report

Laparoscopic drainage of large liver abscess, postoperative course, safety and efficacy

Background: In the era of minimal invasive surgical techniques, laparoscopic drainage provides faster recovery, shorter hospital stay, less surgical site infection and better cosmesis than open surgical drainage does with added advantage of accurate positioning of drainage catheter and simultaneous treatment of the abscess and underlying abdominal pathology. Methods: A total of 33 patients of age group 18-65 years were enrolled. Diagnosis was made using ultrasonography and CECT abdomen and laparoscopic drainage done and drain placed. Adequacy of drainage of abscess was analyzed using ultrasonography on POD- 5, 20 and 30 and were followed upto 3 months. Day of intra-cavitary drain removal, duration of post operative hospital stay, complications after surgery, requirement of readmission and intervention after readmission were recorded and analyzed. Results: Out of 33 patients, 1 patient developed sinus tract formation at intracavitary drain site. 3 patients had inadequate drainage for which drain change was required. 33% (N=11) patients showed complete resolution of abscess at post operative day 20 where as 72.7% patients (N=24) showed complete resolution of abscess on post operative day 30. All 33 patients showed complete resolution of abscess after 3 months of surgery. Conclusions: Laparoscopic procedure provides every advantages of open surgical drainage of liver abscess while avoiding complications of open surgeries. It allows breakdown of loculations, drainage of viscid pus, necrotic tissues, adequate irrigation of abscess cavity and should be considered for patients with large, complex, septated or multiple abscesses and failed percutaneous drainage.

Using jointly calibrated fine-scale drain models across Denmark to assess the influence of physical variables on spatial drain flow patterns

Study regionDenmark Study focusTile drainage, widespread across agricultural areas in Denmark, significantly impacts the hydrological cycle. Tile drain flow dynamics and their spatial patterns are crucial for water managers to address water quality and quantity issues. However, these processes are challenging to simulate accurately. In this study, we developed 10 m resolution drain models in MIKE SHE for 26 drain sites across Denmark to predict drain flow spatial and temporal dynamics. Joint calibration of all drain models was conducted by evaluating PBIAS and KGE of simulated and observed drain flow. Subsequently, we performed a correlation analysis between physical parameters and spatial patterns of simulated drain fraction (DF, ratio of drain flow to recharge per grid cell). New hydrological insightsThe jointly calibrated models achieved average PBIAS and KGE of − 6.7% and 0.53 respectively, for drain flow predictions across 26 drain sites. The correlation of DF with topographical variables was highest on a national scale and on most of the drain sites, including Gyldenholm1–4, Norsminde1–11, and other Jylland drain sites. Lillebæk drain sites showed a high correlation with average clay content in 0–30 cm layer of soil. Thus, in addition to developing scalable fine-resolution drain models for Denmark, this study also identifies the control parameters for spatial patterns of drain flows across Denmark.

ПЕРЕВОЗКА ЖЕЛЕЗНОДОРОЖНЫМ ТРАНСПОРТОМ ВЯЗКИХ НЕФТЕПРОДУКТОВ В ЗИМНИХ УСЛОВИЯХ ПРИ ПРИМЕНЕНИИ ПРИНЦИПОВ КАТАЛИТИЧЕСКОГО РАЗОГРЕВА

The article investigates the problem of unloading solidifying petroleum products (such as boiler fuel oil) at a medium-capacity drain site. It is accepted that a filling train of 45 specialized 67-ton tank cars is placed under the drain, the train is en route for 7-8 days at negative air temperatures (up to -20 °C). Usually, from 3 to 5 tank cars are simultaneously put under unloading at a medium-capacity drain site, up to 10-12 hours are spent on heating them; for unloading, emptying the drain site and installing the next 5 tank cars - 2-2.5 hours more. The rest of the tank cars are put on the access roads, waiting in line. The oil product in them, initially having a low temperature, keeps cooling and passes into a highly viscous state. In addition to the delivery time (7-8 days), the train, as a rule, is under the unloading operation for 8-10 more days. In the method of processing proposed by the authors, tank cars can be heated already at the idle stage on the access roads, and the discharge is carried out at the drain site. In this case, the unloading time of the filling train is reduced to 15-20 hours.