Initial Drainage Procedure Research Articles

Endoscopic step up: When and how

The management of (peri)pancreatic collections has undergone a paradigm shift from open surgical drainage to minimally invasive endoscopic, percutaneous, or surgical interventions. Minimally invasive interventions are associated with less morbidity and mortality compared to open necrosectomy. The (peri)pancreatic collections are currently treated with a “step-up approach” of an initial drainage procedure followed, if necessary, by a more invasive debridement. The step-up approach for management of (peri)pancreatic collections is mainly of two types, namely, surgical and endoscopic. Surgical step up includes initial image-guided percutaneous catheter drainage followed, if necessary, by minimally invasive video-assisted retroperitoneal debridement. Endoscopic step-up approach includes endoscopic transluminal drainage followed, if necessary by direct endoscopic necrosectomy. The development of endoscopic ultrasound and lumen apposing metal stents (LAMSs) has revolutionized the endoscopic management of (peri)pancreatic collections. Compared to surgical step-up approach, endoscopic step-up treatment approach has been reported to be associated with less new-onset organ failure, pancreatic fistula, enterocutaneous fistula, or perforation of visceral organ and shorter hospital/intensive care unit stay. This review will mainly focus on indications, techniques, timing, and recent advances related to endoscopic step-up approach in management of symptomatic(peri)pancreatic collections.

Performance of Initial Biliary Drainage in Patients with Unresectable Perihilar Cholangiocarcinoma

Introduction: Patients with unresectable perihilar cholangiocarcinoma (pCCA) require biliary drainage to relieve symptoms and allow for palliative systemic chemotherapy. The aim of this study was to establish the success, complication, and mortality rates of the initial biliary drainage procedure in patients with unresectable pCCA.

Predicting the Need for Step-Up Therapy After EUS-Guided Drainage of Pancreatic Fluid Collections With Lumen-Apposing Metal Stents

A significant proportion of individuals with pancreatic fluid collections (PFCs) require step-up therapy after endoscopic drainage with lumen-apposing metal stents. The aim of this study is to identify factors associated with PFCs that require step-up therapy. A retrospective cohort study of patients undergoing endoscopic ultrasound-guided drainage of PFCs with lumen-apposing metal stents from April 2014 to October 2019 at a single center was performed. Step-up therapy included direct endoscopic necrosectomy, additional drainage site (endoscopic or percutaneous), or surgical intervention after the initial drainage procedure. Multivariable logistic regression was performed using a backward stepwise approach with a P ≤.2 threshold for variable retention to identify factors predictive for the need for step-up therapy. One hundred thirty-six patients were included in the final study cohort, of whom 69 (50.7%) required step-up therapy. Independent predictors of step-up therapy included: collection size measuring ≥10 cm (odds ratio [OR], 8.91; 95% confidence interval [CI], 3.36-23.61), paracolic extension of the PFC (OR, 4.04; 95% CI, 1.60-10.23), and ≥30% solid necrosis (OR, 4.24; 95% CI, 1.48-12.16). In a sensitivity analysis of 81 patients with walled-off necrosis, 51 (63.0%) required step-up therapy. Similarly, factors predictive of the need for step-up therapy for walled-off necrosis included: collection size measuring ≥10 cm (OR, 6.94; 95% CI, 1.76-27.45), paracolic extension of the PFC (OR, 3.79; 95% CI, 1.18-12.14), and ≥30% solid necrosis (OR, 7.10; 95% CI, 1.16-43.48). Half of all patients with PFCs drained with lumen-apposing metal stents required step-up therapy, most commonly direct endoscopic necrosectomy. Individuals with PFCs ≥10 cm in size, paracolic extension, or ≥30% solid necrosis are more likely to require step-up therapy and should be considered for early endoscopic reintervention.

Peripancreatic Fluid Collections After Pancreas Transplant: Safety and Efficacy of Percutaneous Drainage.

OBJECTIVE. The purpose of this study was to evaluate the safety and efficacy of percutaneous drainage of peripancreatic fluid collections after pancreas transplant and to determine factors predicting a successful clinical outcome. MATERIALS AND METHODS. This single-center retrospective study included 28 patients who underwent percutaneous drainage for peripancreatic collections after transplant between January 2008 and December 2018. Clinical success was defined as drainage resulting in resolution of symptoms. Primary clinical success was defined as symptom resolution after the initial drainage procedure, and secondary success was defined as symptom resolution after additional drainage procedures. Operative intervention or death was considered clinical failure. Patient, collection, and procedural factors were assessed for their potential impact on the clinical outcome. RESULTS. Clinical success was achieved in 23 of 28 drainage procedures (82.1%), with primary success in 15 procedures. Of the five patients with failed drainage procedures, three required pancreatectomies, one required surgical washout, and one died from a disseminated infection. The median duration of drainage in the clinical success group was 25 days (range, 3-136 days), and patients with longer drainage periods had more successful outcomes (p = .04). Graft pancreatitis was diagnosed in five patients (17.9%) and was not associated with drainage outcome (p = .21). Collections were positive for bacterial growth in 13 patients (46.4%) and were high in amylase in 12 (42.9%). We observed drainage failure in collections with polymicrobial growth and in the presence of fistulas (p = .05 and p = .07, respectively). Patients with successful outcomes had smaller collection volumes (p = .045). No complications attributed to drainage were encountered. CONCLUSION. Percutaneous drainage is safe and effective for management of peripancreatic fluid collections after pancreas transplant.

When Should We Perform Endoscopic Drainage and Necrosectomy for Walled-Off Necrosis?

Endoscopic drainage and necrosectomy are now accepted treatment approaches for patients with symptomatic walled-off pancreatic necrosis (WON). The current recommendations advocate step-up approaches for the treatment of symptomatic WON. Previous recommendations stipulated that endoscopic intervention should be delayed until more than four weeks after the onset. Recent data on early drainage have been increasing and this option might be considered in well-encapsulated cases, but the percutaneous route is preferred if the drainage is performed within two weeks after onset or in nonencapsulated cases. Recently, additional drainage methods, such as the multiple gateway technique and multiple stent placement, have been developed to open up multiple dead spaces in the WON cavity. Endoscopic necrosectomy could be performed via the transluminal route or percutaneous route after failed initial and additional drainage procedures. The use of novel lumen-apposing stents is a promising treatment option that could reduce the number of steps, the procedure time, and the overall number of necrosectomies.

Percutaneous nephrostomy versus JJ ureteric stent as the initial drainage method in kidney stone patients presenting with acute kidney injury: A prospective randomized study.

To compare percutaneous nephrostomy tube versus JJ stent as an initial urinary drainage procedure in kidney stone patients presenting with acute kidney injury. Between January 2017 and January 2019, 143 patients with acute kidney injury secondary to obstructive kidney stone were prospectively randomized into the percutaneous nephrostomy tube group (71 patients) and JJ stent group (72 patients) at Beni-Suef University Hospital, Beni-Suef, Egypt. Exclusion criteria included candidates for acute dialysis, fever (>38°C), pyonephrosis, pregnancy and uncontrolled coagulopathy. The period required for serum creatinine normalization, failure of insertion, operative and fluoroscopy time were recorded. Definitive stone management for proximal ureteral stones >1.5cm consisted of percutaneous nephrolithotomy for the percutaneous nephrostomy group and ureteroscopic laser lithotripsy for the JJ stent group. For stone size <1.5cm, ureteroscopy or shockwave lithotripsy was carried out for both groups. Percutaneous nephrolithotomy was carried out for renal stones >2cm, and shockwave lithotripsy for stones <2cm. Distal and mid ureteral stones were treated by ureteroscopy. The percutaneous nephrostomy group had shorter operative time (P=0.001). There was no significant difference in the recovery period for normalization of serum creatinine between both groups (P=0.120). Procedural failure, ureteric mucosal injury and perforations increased in the case of male sex, stone size >1.5cm and upper ureteric stones in the JJ stent group. Procedural failure, pelvic perforations and intraoperative bleeding increased in case of male sex, mild hydronephrosis and stone size >2.5cm in the percutaneous nephrostomy group. Suprapubic pain, urethral pain and lower urinary tract symptoms were significant in the JJ stent group. The presence of a JJ stent directed us toward ureteroscopy (P=0.002) and the presence of a percutaneous nephrostomy directed us toward percutaneous nephrolithotomy (P=0.001). Percutaneous nephrostomy facilitates subsequent percutaneous nephrolithotomy, especially when carried out by a urologist, and it has a higher insertion success rate, a shorter operative time and a lesser incidence of postoperative urinary tract infection than a JJ stent. A JJ stent facilitates subsequent ureteroscopy, but operative complications can increase in the case of proximal ureteral stones >1.5cm.

Recurrence after endoscopic treatment of pancreatic pseudocysts- a long-term follow-up

Background: Pancreatic pseudocysts (PPC) are collections of fluid encapsulated within a well-defined inflammatory wall that develop during pancreatic inflammation. Internal drainage represents the standard of care in lesions. Only limited data are available on long-term results. Thus, the aim of the present study was to analyse the long-term outcome after endoscopic drainage of PPC. Methods: Patient data were retrospectively collected. We assessed the clinical short-term outcome within 30 days after initial drainage procedure, medium-term outcome within 6 months after initial drainage procedure and long-term outcome. We performed statistical analysis to identify possible risk factors for recurrence of PPC. Results: We identified 51 patients with initially successful endoscopic drainage of the PPC. Among this cohort, 43 patients were available for assessment of medium-term results. In 82.9% of these 43 patients the drainage could be removed after successful treatment of the PPC. Thirty patients were available for long term follow-up with a mean observation period of 42.2 months. 7 of these had recurrent PPC. Approximately half of the recurrent cysts arose in different anatomical regions and most patients with recurrence had chronic pancreatitis. Conclusion: For most patients endoscopic drainage of PPC is sufficient. However, recurrences occur. Because most of these occur in chronic pancreatitis and different anatomical locations we conclude that these might be new PPC and not persistence of old PPC.

Long-term results after endoscopic drainage of pancreatic pseudocysts: A single-center experience

BackgroundPancreatic pseudocysts (PPC) are collections of fluid encapsulated within a well-defined inflammatory wall that develop during pancreatic inflammation. Internal drainage represents the standard of care in lesions that persist and lead to symptoms and complications. Only limited data are available on long-term results and recurrence of PPC after drainage procedures. Thus, the aim of the present study was to analyse the long-term outcome after endoscopic drainage of PPC. Material and methodsPatient data were retrospectively collected by review of clinical records of the University Medical Center Mannheim. We assessed the clinical short-term outcome (results in the first 30 days after initial drainage procedure), medium-term outcome (results 6 months after initial drainage procedure) and long-term outcome (results after stent removal). We performed statistical analysis to identify possible risk factors for recurrence of PPC. ResultsWe identified 51 patients with initially successful endoscopic drainage of the PPC (n = 51/53, 96%). Among this cohort, 43 patients were available for assessment of medium-term results. In 82.9% of these 43 patients the drainage could be removed after successful treatment of the PPC. Thirty patients were available for long term follow-up with a mean observation period of 42.2 months (SD 32.8 months). Among these patients, seven (n = 7/30, 23.3%) had recurrent PPC. Approximately half of the recurrent cysts arose in different anatomical regions and most patients with recurrence had chronic pancreatitis. ConclusionEndoscopic drainage represents an effective treatment for PPC. Approximately one quarter of the patients developed recurrent PPC. Half of recurrent PPC developed in different pancreatic regions than the initial PPC.

Mo1566 Utility of Double Balloon Enteroscopy in Patients With Surgically Altered Bowel Anatomy After Bariatric Surgery

database were reviewed to collect data. Results: 25 patients (17 women/8 men, mean age 45.3 10.6 years) were included. Post-operative collections occured after sleeve gastrectomy in 20 patients and after gastric bypass in 5. A median of 48 days (range 5-1071) elapsed between initial surgery and transfistulary stenting. 11 patients were treated by transfistulary stenting as primary treatment, while 14 patients had previously failed treatment attempts with one or more endoscopic methods (endoprosthetics, clips and/or fistula plugs). Internal drainage was initially maintained by placement of 2 double pigtail stents (7 or 8.5 Fr ) in 21 patients or by one stent and a naso-cystic catheter in 4. In 5 patients, transfistulary stenting was combined with percutaneous drainage. No complication occurred during the initial drainage procedure. In 6 patients, trans-fistulary stenting was not successful and surgery was necessary. Clinical success was achieved in 19 patients (76%). In 7 successfully treated patients, stents are still in place after a median stenting duration of 102 days (range 41-1620) and no complication has occurred. In 4 patients with spontaneous stent migration, no complication has occurred after a median follow-up duration of 137.5 days (range 85-390). In 8 patients, the plastic stents have been removed after a median stent indwell duration of 186.3 days (range 24-773) and no complication has occurred after a median follow-up duration of 159.4 days (range 5-461). In these patients, stents were either removed electively (2 patients) or because of dysphagia or symptomatic stent-induced esophageal ulcerations (6 patients). Conclusions: Trans-fistulary drainage of post-bariatric abdominal collections is safe and is associated with high success rates. This technique seems promising and can be considered either in previously untreated patients when a collection is present and not properly drained percutaneously or after failure of other endoscopic treatments. Mo1566 Utility of Double Balloon Enteroscopy in Patients With Surgically Altered Bowel Anatomy After Bariatric Surgery Shabnam Sarker, Shajan Peter, Ivan Jovanovic, Helmut Neumann, Monkemuller Klaus* Basil I Hirschowitz Endoscopic Center of Excellence, University of Alabama, Birmingham, AL Background: Endoscopic investigation of the gastrointestinal (GI) luminal and pancreatobiliary tracts in patients with surgically-altered GI anatomy after bariatric surgery is challenging and often impossible. The advent of balloon-assisted enteroscopy (BAE) has increased our ability to navigate through the surgically altered bowel. Despite the existence of BAE since more than a decade there is few data available on it potential utility for evaluation post-obesity-surgery patients. Aims: To evaluate the diagnostic yield, success and complications rates of double-balloon enteroscopy (DBE) in consecutive patients with GI problems necessitating endoscopic evaluation. Materials and Methods: Single-center, observational, cohort study of consecutive patients with post-obesity-surgery undergoing DBE during a 24-months period. Patients’ demographics, procedure indications, findings, endoscopic interventions, and post-procedural recovery data were recorded. Results: A total of 435 DBE were performed at our institution during the 24-months study period. Sixty-five patients (14.9%) with post-obesity surgery were evaluated using DBE. The types of surgery were: RYGB, gastric sleeve, lap-band. The indications for DBE was obscure GI bleeding (OGIB) (nZ18), ERCP (nZ31), and evaluation of and abdominal pain or diarrhea (nZ10) and placement of direct feeding jejunostomy (nZ6). The excluded stomach could be reached in 87% of patients with Roux-en Y gastric bypass. The overall diagnostic yield of DBE-ERCP was 68% (stones, nZ7, sphincter stenosis, nZ6, bile leak, nZ4, bile duct stricture, nZ4, failed ERCP, nZ10). The yield of DBE for abdominal pain was 40% (nZ4: gastric erosions, gastro-gastric fistula, anastomotic stricture and erosions) and DBE for obscure GI bleeding (61%). Of the 18 patients with OGIB, 10 had active or a source of bleeding at the time of DBE. In all but one case, the bleeding was occurring at the site of the anastomosis, (hepaticojejunal, jejunojejunal, or gastrojejunal anastomosis). Of these patients 4 patients had arteriovenous malformations at the anastomotic site, 5 had ulcers or erosions, and 2 were bleeding secondary to Dieulafoy’s lesions. A total of one complication (3%) was observed (small bowel perforation after application of argon plasma coagulation to the jejunojejunal anastomosis). One patient had actively bleeding duodenal ulcer at the excluded bulb, which was treated with injection and clip. Conclusions: DBE is a feasible and relatively safe technique to evaluate the small intestines, stomach and biliary tract and associated with reasonably high diagnostic and therapeutic yield in patients with surgically altered bowel anatomy in the setting of bariatric surgery.

Identification of the internal anal opening and seton placement improves the outcome of deep postanal space abscess

This study aimed to determine if successful seton placement at the initial drainage procedure improves outcomes in the management of deep postanal space abscesses. A retrospective review was performed of all patients who underwent initial drainage of a DPA space abscess between December 2002 and August 2010. A seton was placed through the internal opening if it could be identified. Thirty-two patients of median age 41 (21-64) years formed the study group. Twenty-four (75.0%) had a seton inserted at the initial drainage procedure. The patients underwent a total of 56 operations. The median interval from the initial to the final operation was 5 (2-18) months with 17 (70.8%) patients having the final operation within 6 months. In the 8 (25.0%) patients whose internal opening could not be found, 26 operations were required with a median interval from the initial to the final surgery of 11 (3-24) months. Patients who had a seton successfully inserted at drainage underwent significantly earlier definitive surgery and required fewer operations (P < 0.038). Identification of an internal opening with placement of a seton at the initial drainage procedure is associated with earlier definitive surgery and fewer operations.

Sonoelastographic Characteristics of Abscess Induration Associated With Therapy Failure

Sonoelastography can visualize components of skin and soft tissue abscesses, including the abscess cavity and surrounding induration, related to the patient's response to the infection. We speculate that characteristics of the induration surrounding an abscess may predict which abscesses will eventually fail therapy. We conducted a prospective trial of patients with a suspected skin abscess requiring surgical drainage who were enrolled from the emergency department of an urban tertiary care center. In this pilot study, all patients underwent incision and drainage for the suspected abscesses. Abscesses (n = 56) were imaged in orthogonal planes (long-axis and transverse to the body part) using B-mode sonography and elastography before incision and drainage. Telephone follow-up using a standardized questionnaire was performed 7 to 10 days after the initial drainage procedure to determine therapy failure. Physicians blinded to patient outcome analyzed the sonograms for predetermined image characteristics of the abscess induration. All patients underwent incision and drainage, but 16.1% of patients failed therapy. Asymmetry of the surrounding induration was associated with therapy failure. A higher percentage of patients who failed therapy had asymmetry (66%; 95% confidence interval, 35.1%-88.3%) versus those who were successfully treated (12.8%; 95% confidence interval, 5.6%-25.6%; P = .003). In all patients, the mean volumes ± SD of the abscess cavity and induration were 2.2 ± 3.7 and 19.9 ± 24.7 cm, respectively, with a mean volume ratio (induration to abscess cavity) of 31.9 to 1. We describe sonographic characteristics of the abscess induration imaged with sonoelastography that are associated with therapy failure. We found that patients with asymmetric induration visualized with sonoelastography have higher rates of therapy failure.

Clinical benefit of radiation therapy and metallic stenting for unresectable hilar cholangiocarcinoma

To determine the efficacy of external beam radiotherapy (EBRT), with or without intraluminal brachytherapy (ILBT), in patients with non-resected locally advanced hilar cholangiocarcinoma. We analyzed 64 patients with locally advanced hilar cholangiocarcinoma, including 25 who underwent resection (17 curative and 8 non-curative), 28 treated with radiotherapy, and 11 who received best supportive care (BSC). The radiotherapy group received EBRT (50 Gy, 30 fractions), with 11 receiving an additional 24 Gy (4 fractions) ILBT by iridium-192 with remote after loading. ILBT was performed using percutaneous transhepatic biliary drainage (PTBD) route. Uncovered metallic stents (UMS) were inserted into non-resected patients with obstructive jaundice, with the exception of four patients who received percutaneous transhepatic biliary drainage only. UMS were placed endoscopically or percutaneously, depending on the initial drainage procedure. The primary endpoints were patient death or stent occlusion. Survival time of patients in the radiotherapy group was compared with that of patients in the resection and BSC groups. Stent patency was compared in the radiotherapy and BSC groups. No statistically significant differences in patient characteristics were found among the resection, radiotherapy, and BSC groups. Three patients in the radiotherapy group and one in the BSC group did not receive UMS insertion but received PTBD alone; cholangitis occurred after endoscopic stenting, and patients were treated with PTBD. A total of 16 patients were administered additional systemic chemotherapy (5-fluorouracil-based regimen in 9, S-1 in 6, and gemcitabine in 1). Overall survival varied significantly among groups, with median survival times of 48.7 mo in the surgery group, 22.1 mo in the radiotherapy group, and 5.7 mo in the BSC group. Patients who underwent curative resection survived significantly longer than those who were not candidates for surgery (P = 0.0076). Cumulative survival in the radiotherapy group was significantly longer than in the BSC group (P = 0.0031), but did not differ significantly from those in the non-resection group. Furthermore, the median survival time of patients in the radiotherapy group who were considered for possible resection (excluding the seven patients who were not candidates for surgery due to comorbid disease or age) was 25.9 mo. Stent patency was evaluated only in the 24 patients who received a metallic stent. Stent patency was significantly longer in the radiotherapy than in the BSC group (P = 0.0165). Biliary drainage was not eliminated in any patient. To determine the efficacy of ILBT, we compared survival time and stent patency in the EBRT alone and EBRT plus ILBT groups. However, we found no significant difference in survival time between groups or for stent patencies. Hemorrhagic gastroduodenal ulcers were observed in 5 patients (17.9%), three in the EBRT plus ILBT group and two in the EBRT alone group. Ulcers occurred 5 mo, 7 mo, 8 mo, 16 mo, and 29 mo following radiotherapy. All patients required hospitalization, but blood transfusions were unnecessary. All 5 patients recovered following the administration of anti-ulcer medication. Radiotherapy improved patient prognosis and the patency of uncovered metallic stents in patients with locally advanced hilar cholangiocarcinoma, but ILBT provided no additional benefits.

Modern History of Surgical Management of Lung Abscess: From Harold Neuhof to Current Concepts

Harold Neuhof was one of the pioneers of thoracic surgery in the early decades of the last century. Inspired by his preceptor Howard Lilienthal he proposed an entirely new concept for surgery on acute lung abscess. The aim of his one-stage procedure was adequate drainage of the abscess cavity. His approach proved to be the first major breakthrough in the treatment of acute lung abscess. Therapy of pulmonary abscess was again radically changed by the advent of antibiotics in the late 1940s. However, the basic principles of Neuhof's concept still influence modern-day management of putrid lung abscess.

Laparoscopic drainage of intraabdominal abscess after appendectomy: an alternative to laparotomy in cases not amenable to percutaneous drainage

Purpose Postoperative abscesses after appendectomy occur in 3% to 20% of cases and are more common in cases of perforated appendicitis. Smaller abscesses are often amenable to antibiotic therapy, but surgical drainage remains the mainstay of treatment for larger collections. Surgical options generally include percutaneous drainage and open laparotomy. Laparoscopic drainage of these abscesses has not been well characterized in the pediatric population. Objective The aim of this study was to describe our experience with laparoscopic drainage of postappendectomy abscesses that were not amenable to percutaneous drainage. Methods This study is a retrospective review of all pediatric patients who underwent laparoscopic appendectomy for acute appendicitis at a tertiary pediatric medical center during a 4-year period (2006-2009). The review focuses on patients who developed abscesses after appendectomy, were unable to undergo percutaneous drainage, and were treated with laparoscopic abscess drainage. Results Twelve patients (7 male and 5 female) underwent laparoscopic drainage of postappendectomy abscesses. The mean age was 8.5 years old (range, 3-14 years). A clinical diagnosis of postoperative abscess was made when fevers, pain, and leukocytosis persisted despite broad-spectrum antibiotics. Computed tomography was performed in all patients. Abscesses ranged between 3 and 11 cm in size. The mean length of time between initial appendectomy and drainage procedure was 10 days. There were no complications specifically related to the laparoscopic drainage procedure. The mean length of the drainage procedure was 77 minutes (range, 30-196 minutes). The mean hospital length of stay after laparoscopic drainage was 6.5 days (range, 3-13 days) with patients maintained on intravenous antibiotics until afebrile and without leukocytosis. Conclusion Laparoscopic drainage is a safe and effective alternative for intraabdominal abscesses that occur after laparoscopic appendectomy. We recommend it as an alternative to open laparotomy when percutaneous drainage is not an option.

A comparative study of treatment of chronic subdural hematoma — burr hole drainage versus continuous closed drainage

The incidence of chronic subdural hematoma (CSDH) is about 5 per 100000 per year in the general population & is higher for those aged 70 years and older. The recurrence rates after the initial drainage procedure range from 5% to 30%, and the treatment strategies for reducing the recurrence rates are the focus of the current research. The aim of this study was to evaluate the results of treatment, especially in terms of recurrence, following surgery for the CSDH obtained with “one time burr-hole drainage” (OTD) vs “continuous closed drainage”, using subdural drain (CD). Patients with diagnosis of CSDH, operated at our center during the period from September 2008 through March 2010 were prospectively studied. The patients randomized to two arms, group 1 underwent OTD and group 2 underwent CD. Patients were analyzed by evaluating their hospital clinical, laboratory and radiological data. Recurrence of CSDH was defined as reappearance of clinical symptoms after a minimum period of one month post surgery, with evidence of CSDH in the same site on plain CT head. Clinical outcome was measured using Glasgow outcome score (GOS). Fifty one patients with chronic subdural hematoma were randomized. OTD was done in 26 patients and 25 patients underwent CD. Males outnumbered the females (45 vs. 6). Age ranged from 17 to 85 years (mean 53 ± 15 years). While 47 patients had GCS of 9–15, remaining 4 (7%) had GCS of 8 or less. Deranged coagulation profile was recorded in 9 patients. Imaging showed 9% patients with bilateral CSDH and in 14% patients had isodense CSDH. Hospital stay ranged from 2 to 24 days (mean 3 ± 4 days). Patients with deficit at admission usually had neurological deficit at discharge. GOS at 6 months was better in continuous drainage group (48% vs 44%) but had more complications. Symptomatic recurrence was noticed in 10 (19%) patients; recurrence was lower in the patients in CD group (n= 4, 16%) than in the OTD group (n= 6, 23%) but this was not statistically significant (p value - 0.60). Our study shows that continuous drainage of chronic subdural hematoma does not offer any advantage over simple burr hole drainage.

Double‐barrel stenting in infracochlear approach for drainage of petroux apex cholesterol granulomas

Double‐barrel stenting in infracochlear approach for drainage of petroux apex cholesterol granulomas

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) skin infections

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has become increasingly important as a cause of skin and soft tissue infections (SSTIs), particularly abscesses, in patients seen in the emergency department setting. The antibiotic sensitivity profile of Staphylococcus aureus isolates from SSTIs has changed over time in many geographic locations. Whether antibiotics are needed in the management of skin abscesses, and, if so, when, is controversial. A number of studies have looked at antibiotic therapy in conjunction with incision and drainage in managing abscesses. Factors evaluated were resolution of infection, need for change in antibiotic therapy, hospitalization after initial outpatient management, need for an additional drainage procedure, and recurrence of infection within 30 days after the initial incision and drainage procedure. For abscesses, clinical failure was associated with lack of adequate incision and drainage and not antibiotic use, regardless of the size of the abscess or the choice of antibiotic therapy. For other soft tissue infections, when antibiotic susceptibility data were available for the infection (impetigo or cellulitis with purulent drainage but no abscess), there was no difference in clinical resolution of MRSA infection even if the infecting organism was resistant to the antibiotic chosen for therapy. CA-MRSA has become an important cause of SSTIs. Current data suggest that most abscesses can be treated successfully with incision and drainage alone. Antibiotic choice is more crucial for management of cellulitis and should be guided by the prevalence of CA-MRSA in the community and its antibiotic susceptibility profile.

What causes post‐traumatic empyema?

Empyema post chest trauma is a morbid condition requiring operative intervention (thoracotomy and decortication). It is hypothesized that patients who have a complicated initial pleural drainage procedure are at increased risk of developing an empyema. All patients who underwent operative decortication for post-traumatic empyema over a 24 month period (July 2003 to June 2005) were included in the study. Data were collected on demographics, intercostal catheter (ICC) insertion, prehospital chest decompression and associated injuries. A matched group of patients who had ICC inserted for chest trauma and did not develop an empyema were used as controls. Fourteen patients had decortications for post-traumatic empyema. Two of three pneumocaths and one ICC were placed within the lung. Five other patients had multiple 'attempts' at ICC insertion. Only two patients had a single uncomplicated ICC inserted. The empyema and control group were well matched in terms of age (mean age 40 years in each group, P = 0.83), injury severity score (36.4 vs 35.3, P = 0.85) and presence of chest, abdominal and multi-system injury. The empyema group had significantly longer median hospital stay (12.8 vs 28.7 days, P = 0.05). The control group had less initial ICC inserted (median of 1.0 vs 2.0, P = 0.02). Only one patient had a complicated ICC insertion, and two uncomplicated pneumocaths were placed. Patients with complex chest injuries in whom difficulties in initial pleural drainage are encountered are at increased risk of developing a post-traumatic empyema and have a prolonged hospital stay.

Ventricular reservoirs and ventriculoperitoneal shunts for premature infants with posthemorrhagic hydrocephalus: an institutional experience

The aim of the study was to analyze the outcome of surgical treatment for posthemorrhagic hydrocephalus in premature infants. From 1990 to 2006, 32 premature infants underwent surgical treatment for posthemorrhagic hydrocephalus, and their charts were retrospectively reviewed to analyze the complications and outcome with respect to shunt revisions. Multivariate analysis and time series were used to identify factors that influence the outcome in terms of shunt revisions. The mean gestational age was 27+/-3.3 weeks, and mean birth weight was 1192+/-660 g. Temporary reservoir placement was performed in 15 patients, while 17 underwent permanent CSF diversion with a ventriculoperitoneal (VP) shunt. In 2 patients, reservoir tapping alone was sufficient to halt the progression of hydrocephalus; 29 patients received VP shunts. The mean follow-up period was 37.3 months. The neonates who received VP shunts first were significantly older (p=0.02) and heavier (p=0.04) than those who initially underwent reservoir placement. Shunts were revised in 14 patients; 42% of patients in the reservoir group had their shunts revised, while 53% of infants who had initially received a VP shunt required a revision. The revision rate per patient in the reservoir group was half that in the direct VP shunt group (p=0.027). No patient in the reservoir group had >2 revisions. Shunt infections developed in 3 patients (10.3%), and 2 patients in the reservoir group died of nonneurological issues related to prematurity. Birth weight and age are useful parameters in decision making. Preterm neonates with low birth weights benefit from initial CSF drainage procedures followed by permanent CSF diversion with respect to the number of shunt revisions.

Retroperitoneoscopic Nephrectomy for Nephrocolonic Fistula Due to Tuberculous Nonfunctioning Kidney

The aim of this paper was to evaluate feasibility of retroperitoneoscopic nephrectomy in a patient with nephrocolonic fistula due to tuberculosis. A 20-year-old female had presented with high-grade fever. Percutaneous drainage of the kidney for pyonephrosis was performed as an initial drainage procedure. Retrograde pyelography revealed a nephrocolonic fistula. Retroperitoneoscopic nephrectomy with intracorporeal suturing of the defect in the colon was performed. Operative time was 245 minutes and blood loss was 170 mL. Total hospital stay was 7 days. Histopathology of the removed kidney confirmed the diagnosis of tuberculosis. At 1 year of follow-up, she gained 5 kg of body weight after a complete course of antituberculous drugs. Retroperitoneoscopic nephrectomy for tuberculous nephrocolonic fistula is feasible and safe.