Drain Insertion Research Articles

Assessment of Surgical Outcome of Trocar versus Blunt Dissection Technique for Intercostal Drainage Insertion: A Prospective Interventional Study

Introduction: Chest tube insertion is a common procedure designed to alleviate the accumulation of air, fluid, pus, or blood in the pleural cavity. Despite being a bedside procedure often performed by emergency residents, Intercostal Drain (ICD) tube insertion carries associated risks, if not executed with care. Complications such as misplacement, organ injury, bleeding and pain are noteworthy concerns. Aim: To assess surgical outcome of Trocar versus Blunt dissection technique for ICD insertion. Materials and Methods: The present prospective interventional study was conducted in the Department of General Surgery, M S Ramaiah Hospitals, Bengaluru, India, from September 2018 and August 2020, with a sample size of 64 after obtaining Institutional Ethical Committee approval. Patients requiring ICD insertion were divided into two groups: Blunt (group A) and Trocar (group B) dissection, with 32 participants in each group. Demographic, clinical and diagnostic data were meticulously documented. Statistical analyses, including descriptive statistics, t-tests and Chi-square test, were employed to compare variables such as insertion time, complications and pain scores. Both groups were assessed for the time required for insertion and complications with each method during and after the procedure. Results: The mean age among subjects with the Blunt dissection method and Trocar method was 45.53±14.85 years and 45.06±10.46 years, respectively. In the Blunt dissection technique, 6 (18.8%) were females and 26 (81.3%) were males, while of those who underwent the Trocar method of insertion, 7 (21.9%) were females and 25 (78.1%) were males. The present study findings revealed that the Trocar method demonstrates comparable surgical outcomes to the Blunt dissection method. Trocar insertion proves notably quicker, especially in obese patients. The time taken for insertion was significantly longer (p-value<0.001) with the Blunt dissection method (17.53±8.835 min) compared to the Trocar method (2.31±0.998 min). Significantly more pain was experienced by patients with the Blunt dissection method compared to the Trocar method on day 1 (p-value<0.001). There was no statistically significant difference found between Visual Analog Scale (VAS) score and method of insertion postprocedure. There was a statistically significant difference found between malposition and method of insertion. With the conventional method of insertion, 43.8% of patients had malposition, whereas with the Trocar method of insertion, 18.8% had malposition. Postprocedural complications, including bleeding and infection rates, were comparable between the two methods. Conclusion: In conclusion, the Trocar method exhibits similar surgical outcomes to the Blunt dissection method, with added advantages of reduced insertion time and reduced malposition. Proper training plays a pivotal role in mitigating potential complications, making the Trocar method a clinically viable option for ICD procedures.

Pleuro-cutaneous fistula complicating chest drain insertion for melioidosis empyema

Melioidosis is a rare cause of empyema. Pleurocutaneous fistula is a pathologic communication between the pleural space and the subcutaneous tissues. Here we’re presenting a case of a Pleurocutaneous fistula complicating chest drain insertion for melioidosis empyema. Fifty-year-old fisherman from Mannar Sri Lanka presented with predominant thoracic empyema. Pleural fluid culture isolated the Burkholderia pseudomallei. A chest drain was inserted for the empyema. Subcutaneous emphysema was noted following the removal of the chest drain and it worsened over time. CECT Chest revealed the right Pleuro-cutaneous fistula, which was complicated by hemopneumothorax and trapped lung. Surgical management was refused by the patient for fistula correction and trapped lung. The fistula was successfully closed with an autologous blood patch. Melioidosis can present with predominant thoracic empyema. Pleuro-cutaneous fistula can complicate the chest drain insertion in the patient with melioidosis empyema which can be treated with an Ultrasound-guided autologous blood patch.

Management of Cerebrospinal Fluid Leakage by Pump-Regulated Volumetric Continuous Lumbar Drainage Following Anterior Cervical Decompression and Fusion for Ossification of the Posterior Longitudinal Ligament.

Cerebrospinal fluid (CSF) leakage is a major concern related to anterior cervical decompression and fusion for ossification of the posterior longitudinal ligament (OPLL). We propose a management algorithm for CSF leakage following anterior cervical decompression and fusion for OPLL involving the use of pump-regulated volumetric continuous lumbar drainage. We retrospectively reviewed patients who underwent anterior cervical decompression and fusion for OPLL and were managed with the proposed algorithm between March 2018 and July 2022. The proposed management algorithm for CSF leakage by pump-regulated volumetric continuous lumbar drainage was as follows. On exposure of the arachnoid membrane with or without CSF leakage, a dural sealant patch was applied to manage the dural defect. In case of persistent CSF leakage despite application of the dural sealant patch, patients underwent pump-regulated volumetric continuous lumbar drainage. Fifty-one patients were included in the study. CSF leakage occurred in 14 patients. Of these 14 patients, 9 patients underwent lumbar drain insertion according to the proposed management algorithm. Successful resolution of CSF leakage was observed in 8 of the 9 patients who underwent lumbar drainage. All patients were encouraged to ambulate without concern of CSF overdrainage due to gravity, because it could be avoided with pump-regulated volumetric continuous CSF drainage. Therefore, complications associated with absolute bed rest or CSF overdrainage were not observed. The proposed management algorithm with pump-regulated volumetric continuous lumbar drainage showed safety and efficacy for management of CSF leakage following anterior decompression and fusion for OPLL.

Acute cardiac tamponade during atrial flutter ablation: improved hemodynamics after positive pressure ventilation: a case report

IntroductionAcute cardiac tamponade is a rare event during any type of interventional or surgical procedure. It can occur during electrophysiology procedures due to radiofrequency ablation, lead or catheter manipulation, transseptal puncture, laser lead extractions, or left atrial appendage occlusion device positioning. Cardiac tamponade is difficult to study in a prospective manner, and case reports and case series are important contributions to understanding the best options for patient care.Case summaryAn 87-year-old Caucasian male patient breathing spontaneously developed acute tamponade during an atrial flutter ablation. Pericardial drain insertion was difficult, and hypotension failed to respond to epinephrine boluses. The patient became hypoxemic and hypercarbic, requiring intubation. Unexpectedly, the blood pressure markedly increased postintubation and remained in a normal range until the pericardium was drained.ConclusionSpontaneous ventilation is considered important to maintain venous return to the right heart during cardiac tamponade. However, spontaneous ventilation reduces venous return to the left heart and worsens the paradoxical pulse in tamponade. Intravenous vasopressors are thought to be ineffective during cardiac tamponade. Our patient maintained pulmonary blood flow as indicated by end-tidal carbon dioxide measurements but had no measurable systemic blood pressure during spontaneous ventilation. Our case demonstrates that tracheal intubation and positive pressure ventilation can transiently improve left heart venous return, systemic perfusion, and drug delivery to the systemic circulation.

A retrospective study of ludwig’s angina at the maxillofacial unit of the komfo anokye teaching hospital-kumasi, Ghana.

Introduction: Ludwig’s angina is a potentially life-threatening diffuse cellulitis involving the sublingual, submental, and submandibular spaces bilaterally and causing progressive airway obstruction. The microbiology of Ludwig’s angina is polymicrobial, but commonly isolated is Streptococcal spp. Aim: The current study aimed to retrospectively evaluate the prevalence of Ludwig’s angina at the Maxillofacial Unit of the Komfo Anokye Teaching Hospital, Ghana. Materials & Methods: A 2-year retrospective analysis of patient records from January 2012 to December 2013 was undertaken. The studied variables included the aetiology, symptoms, signs, and treatment modalities. Descriptive analysis was done using charts, frequency, and tables.Results: The total number of admissions for maxillofacial space infections was 224, comprising 128 males and 96 females. The number of patients with Ludwig’s angina was 56, giving a prevalence rate of 25.0%. The commonest source of infection was of odontogenic origin (94.6%), and the teeth most involved were the first lower molars (37.5%). The predominant microorganisms isolated were E.coli, Klebsiella, and Pseudomonas spp. The majority of patients (94%) were managed medically and surgically with incision, drainage, and insertion of drains as well as extraction of affected teeth. The commonest antibiotic combination was amoxicillin/clavulanate potassium with metronidazole (65.5%), followed by crystalline penicillin with metronidazole (12.7%). Conclusion: The commonest cause of Ludwig’s angina was odontogenic, and the microorganisms cultured were E. coli, Klebsiella, and Pseudomonas. The commonest antibiotic combination used for treatment was amoxicillin/clavulanate potassium with metronidazole.

Efficacy of single burr hole with irrigation and sub-dural drain in the evacuation of chronic subdural hematoma

BackgroundChronic subdural hematoma (CSDH) remains one of the most common types of traumatic and spontaneous intracranial hematomas. The optimal method of treatment has not been definitely established. Surgical treatment options includes craniotomy, trephination, burrhole drainage and twist drill perforation. This study aimed at the evaluation of the clinical and radiological outcome after the efficacy of single burr hole with irrigation and sub-dural drain in the aim of successful evacuation of CSDH.ResultsA total of 53 patients were included in this study, the mean age of patients was 61.53 + 13.81 years. Results of the paired t test showed that the Glasgow coma scale has significantly improved by 0.89 points (p < 0.001) and that the average motor power has significantly improved for all individuals by 0.4 points (p = 0.043). We found that older aged patients have significantly less improvements in the postoperative motor power (r = − 0.317, p = 0.02) and require longer hospital stay (r = 0.32, p = 0.0197).ConclusionsA single burr hole with irrigation and leaving a subdural drain is safe procedure in managing subdural hematoma. We did not experience major adverse events related to drain insertion and efficient evacuation of collection and no obvious increase in mortality or morbidity rates.

Drainless thyroid surgeries including goiter or central neck dissection: a case-control study.

Despite ample of evidence regarding feasibility of simple drainless thyroid surgeries, the evidence of feasibility of such procedures in goiters and central neck dissections remains limited. Patients undergoing total thyroidectomy (TT) between January 2017 and July 2022 were included. The study included two study groups: drainless TT with central neck dissection (CND) and drainless TT due to goiter, which were compared to two controls: non-goiter drainless TT and drained TT for goiter or with CND. Main outcome was post-operative seroma rate. 156 patients met the inclusion criteria for each of the group. No significant differences between groups were found for permanent hypocalcemia, and other complications. Post-operative seroma was found in nine patients (5.8%), all from study groups. No significant differences between groups were found for local infections, aspirations, post-discharge drain insertion. Complex drainless thyroid surgeries, including goiter and CND, are feasible and do not seem to significantly increase rate of post-operative seromas or infections.

A new simple and innovative technique for surgical drains fixation.

Seroma is a common complication post many plastic surgery procedures. To overcome this issue, drain insertion became a standard of care in many procedures. Existing methods for fixing the drain like the Roman sandal, purse string, and mesentery have limitations, including loosening and skin problems. A new, innovative, and efficient drain fixation technique is introduced in this paper. It involves using silk or similar non-absorbable sutures in a simple five-step process. This method ensures secure drain placement without undesirable outcomes. It avoids the need to force a knot over the skin, reducing the risk of skin damage or necrosis. In conclusion, the study introduces a straightforward, safe, and effective drain fixation method, reducing risks associated with fluid accumulation after surgery.

Factors Affecting Length of Stay in Patients With Traumatic Rib Fractures in a District General Hospital.

Abstract Objective The objective of this study was to ascertain which patient factors, injury and treatment variables contributed to an increased length of stay (LOS). Methods Retrospective data collection from a prospectively updated dataset was conducted from 01.01.23 to 31.08.23. All adult patients admitted to the general surgical department were included. Transfers directly from ED to an MTC, and paediatric patients were excluded. Outcome parameters were: age, gender, clinical frailty score (CFS), preinjury antiplatelet/anticoagulant use, mechanism of injury, number of ribs fractured, battle score, presence of intrathoracic injury, presence of flail chest, chest drain insertion, performance of analgesic nerve block, discussion with local MTC, total LOS, and 30-day mortality. Statistical analysis was performed to ascertain which of these variables significantly affected patient LOS. Results 92 patients were admitted to the DGH. Most were female (58.7%) and the median age was 73. Median LOS was 5.5 days. 7 patients died during admission, all with a CFS of 6 or over. Patients with a higher age, CFS, number of fractures, and battle score had a significantly longer LOS. Patients who underwent a nerve block also had a longer LOS than those who did not. Presence of intra-thoracic injury and placement of a surgical chest drain did not affect LOS. Conclusions LOS appears to be related to higher age, frailty, and battle score. To improve patient management at this DGH, it may be suggested that older patients with a high battle score be discussed with critical care and have early frailty team input.

Diagnosis and management of pleural infection.

Pleural infection remains a medical challenge. Although closed tube drainage revolutionised treatment in the 19th century, pleural infection still poses a significant health burden with increasing incidence. Diagnosis presents challenges due to non-specific clinical presenting features. Imaging techniques such as chest radiographs, thoracic ultrasound and computed tomography scans aid diagnosis. Pleural fluid analysis, the gold standard, involves assessing gross appearance, biochemical markers and microbiology. Novel biomarkers such as suPAR (soluble urokinase plasminogen activator receptor) and PAI-1 (plasminogen activator inhibitor-1) show promise in diagnosis and prognosis, and microbiology demonstrates complex microbial diversity and is associated with outcomes. The management of pleural infection involves antibiotic therapy, chest drain insertion, intrapleural fibrinolytic therapy and surgery. Antibiotic therapy relies on empirical broad-spectrum antibiotics based on local policies, infection setting and resistance patterns. Chest drain insertion is the mainstay of management, and use of intrapleural fibrinolytics facilitates effective drainage. Surgical interventions such as video-assisted thoracoscopic surgery and decortication are considered in cases not responding to medical therapy. Risk stratification tools such as the RAPID (renal, age, purulence, infection source and dietary factors) score may help guide tailored management. The roles of other modalities such as local anaesthetic medical thoracoscopy and intrapleural antibiotics are debated. Ongoing research aims to improve outcomes by matching interventions with risk profile and to better understand the development of disease.

High Output External Biliary Drainage Leading to Acute Kidney Injury in a Patient with Malignant Obstructive Jaundice: A Rare Case Report

Most patients with malignant obstructive jaundice present to the hospital in an advanced unresectable stage. Percutaneous transhepatic biliary drainage (PTBD) and stenting are the established , safe and effective way of palliative treatment aiming prolongation and improving the quality of the life. We report a rare case of high output external biliary drainage leading to AKI and electrolyte imbalance following insertion of PTB drain. Patient was managed with hemodialysis and subsequent self- expandable metallic stent (SEMS) placement. We highlight the importance of awareness of this complication and need of further studies regarding role of biliary interventions, associated complications and management.

EGS P25 Patient outcomes after percutaneous cholecystostomy at Dorset County Hospital

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

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

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

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

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

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

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

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

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

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

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

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

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

A88Designing a Multidisciplinary Chest Drain Course

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

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

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