Jackson-Pratt Drain Research Articles

The “T-Suspension Tape” for Liver and Gallbladder Retraction in Bariatric Surgery: Feasibility, Technique, and Initial Experience

Safe and effective retraction of the liver is essential in providing adequate working space and a proper view of the stomach during laparoscopic bariatric surgery. Conventional liver retractors are expensive, require additional ports, resulting in pain and scarring, and cannot be utilized for single-port surgeries. To overcome these limitations we present a novel technique, using an indigenous "T-suspension tape," for liver and gallbladder retraction. A retrospective analysis of the first 12 bariatric procedures using the "T-suspension tape" for liver retraction is presented here. The tape was created using the Teflon(®) (Dupont, Wilmington, DE) tail of a Jackson-Pratt drain secured to a Prolene™ (Ethicon, Blue Ash, OH) suture on a long straight needle. The liver was retracted by transparenchymal passage of the needle, which was exteriorized and secured to the anterior abdominal wall. There were 11 female patients and 1 male patient. The mean age was 30 years (range, 20-42 years), and the mean preoperative body mass index was 37.37 kg/m(2) (range, 33.14-48.98 kg/m(2)). There were six laparoscopic sleeve gastrectomies (including one single-incision procedure), two laparoscopic Roux-en-Y gastric bypasses, four laparoscopic adjustable gastric banded plications, and three concomitant cholecystectomies. Mean time for retraction was 4 minutes 33 seconds (range, 38 seconds to 20 minutes 20 seconds). The liver and also the gallbladder could be effectively retracted, providing excellent working space and visualization of the entire stomach. There were no complications or conversions associated with this technique. The "T-tape suspension" technique is simple, safe, and inexpensive and provides efficient retraction of the liver and gallbladder during bariatric surgery.

MEN I Associated Insulinoma and Zollinger Ellison Syndrome Presenting with Syncope

Purpose: A 24-year-old woman with a history of prolactinoma, neurofibromas and parathyroid hyperplasia reported a 3-month history of fainting episodes. She was found to have a FS glucose <30, an elevated serum insulin of 130 mU/ml, a normal C-peptide and CT scan revealed an enhancing 3.4-cm pancreatic body lesion. An insulinoma was suspected and the patient had a subtotal pancreactectomy with pathology identifying a 3.5-cm well-differentiated neuroendocrine tumor and two smaller 1.5- and 0.5-cm nodules in the pancreatic tail all with immunostaining positive for insulin and negative for PTH and gastrin, consistent with Beta cell tumor. The patient had persistent JP drain output concerning for a pancreatic duct leak. ERCP was performed which was notable for LA class C distal esophagitis, clean based fundic ulcer and multiple clean based duodenal ulcers including a large 2-cm ulcer adjacent to the ampulla. Serum gastrin level was elevated at 3,324 pg/ml, consistent with Zollinger-Ellison Syndrome with a constellation of findings suggestive of multiple neuroendocrine neoplasm I (MEN I). The diagnosis of insulinoma is often delayed due to the non-specific symptoms. Nearly 90% of insulinomas are solitary, benign and less than 1.5 cm in diameter. However, those associated with MEN I are usually multiple. Reports indicate CT imaging can identify tumors less than 1 cm with a sensitivity of 40-73% and MRI increases that number to 85-95%. EUS can identify lesions as small as 5 mm with sensitivity approaching 95%. This patient's presentation and history suggested MEN I in which efforts to identify the more aggressive, multiple lesions could be made utilizing EUS. We recommend further studies evaluating the role of pre-operative EUS tumor localization in suspected MEN I associated neuroendocrine tumors.Figure: Enhancing mid pancreatic lesion.Figure: [776] Pathology specimen demonstrates pale 3.5 cm mass in the pancreatic body.

V1890 ROBOT-ASSISTED PARTIAL CYSTECTOMY FOR BLADDER CANCER OF A BLADDER DIVERTICULUM

You have accessJournal of UrologyOncology, Bladder Oncology1 Apr 2012V1890 ROBOT-ASSISTED PARTIAL CYSTECTOMY FOR BLADDER CANCER OF A BLADDER DIVERTICULUM Wooju Jeong, Quoc-Dien Trinh, Khurshid R. Ghani, Jesse D. Sammon, Jay Jhaveri, Shyam Sukumar, Ali Dabaja, Emil Kheterpal, Fred Muhletaler, Mani Menon, and Piyush K. Agarwal Wooju JeongWooju Jeong Detroit, MI More articles by this author , Quoc-Dien TrinhQuoc-Dien Trinh Detroit, MI More articles by this author , Khurshid R. GhaniKhurshid R. Ghani Detroit, MI More articles by this author , Jesse D. SammonJesse D. Sammon Detroit, MI More articles by this author , Jay JhaveriJay Jhaveri Detroit, MI More articles by this author , Shyam SukumarShyam Sukumar Detroit, MI More articles by this author , Ali DabajaAli Dabaja Detroit, MI More articles by this author , Emil KheterpalEmil Kheterpal Detroit, MI More articles by this author , Fred MuhletalerFred Muhletaler Detroit, MI More articles by this author , Mani MenonMani Menon Detroit, MI More articles by this author , and Piyush K. AgarwalPiyush K. Agarwal Detroit, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.2045AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The incidence of bladder diverticula is 1.7%, while the incidence of urothelial carcinoma within these diverticula ranges from 0.8 to 13%. In this video, we report our technique of robot-assisted partial cystectomy for urothelial cancer located within a bladder diverticulum. METHODS Our patient was a 64 year-old male who presented with a history of prostate cancer on active surveillance. He underwent a cystoscopy for increasing post-void residual, which revealed an incidental bladder tumor within a diverticulum. This tumor turned out to be a high-grade pTa lesion. A transperitoneal robot-assisted laparoscopic approach was used to mobilize the bladder. The bladder lesion was marked with a hook cautery circumferentially. Simultaneous cystoscopic monitoring was performed to ensure a margin of resection of 2 cm around the lesion. Bladder reconstruction and bilateral pelvic lymph node dissection were subsequently completed. RESULTS Our console time was 5 hours with an estimated blood loss of 50 mL. No JP drain was placed. There were no intra or post-operative complications. Diet was resumed on postoperative day 1 and the patient was discharged on postoperative day 1. Pathological examination revealed an urothelial carcinoma pTaN0Mx with low grade and negative surgical margins. He is doing well with no sign of recurrence at three months of follow-up. CONCLUSIONS Robot-assisted laparoscopic partial cystectomy is technically feasible and represents an alternative to open and conventional laparoscopic approaches. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e762-e763 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wooju Jeong Detroit, MI More articles by this author Quoc-Dien Trinh Detroit, MI More articles by this author Khurshid R. Ghani Detroit, MI More articles by this author Jesse D. Sammon Detroit, MI More articles by this author Jay Jhaveri Detroit, MI More articles by this author Shyam Sukumar Detroit, MI More articles by this author Ali Dabaja Detroit, MI More articles by this author Emil Kheterpal Detroit, MI More articles by this author Fred Muhletaler Detroit, MI More articles by this author Mani Menon Detroit, MI More articles by this author Piyush K. Agarwal Detroit, MI More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1434 IDENTIFYING COLLECTING SYSTEM ENTRY AND THE INTEGRITY OF REPAIR DURING OPEN PARTIAL NEPHRECTOMY: COMPARISON OF TWO TECHNIQUES

You have accessJournal of UrologyKidney Cancer: Localized III1 Apr 20121434 IDENTIFYING COLLECTING SYSTEM ENTRY AND THE INTEGRITY OF REPAIR DURING OPEN PARTIAL NEPHRECTOMY: COMPARISON OF TWO TECHNIQUES Sammy Moussly, Sandhya R. Rao, Michelle Pacheco, Philippe E. Spiess, and Wade J. Sexton Sammy MousslySammy Moussly TAMPA, FL More articles by this author , Sandhya R. RaoSandhya R. Rao TAMPA, FL More articles by this author , Michelle PachecoMichelle Pacheco TAMPA, FL More articles by this author , Philippe E. SpiessPhilippe E. Spiess TAMPA, FL More articles by this author , and Wade J. SextonWade J. Sexton TAMPA, FL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1907AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Nephron sparing surgery is the current treatment standard for most small renal masses. The resection of deeply endophytic tumors often entails entry into the collecting system which if not recognized and repaired may lead to the development of a postoperative urinary fistula. Some investigators advocate the placement of an externalized ureteral catheter with retrograde dye injection to recognize calyceal entry and/or to test the integrity of the repair whereas others use needle injection of dye directly into the proximal ureter. This study compares the two techniques with regard to perioperative outcomes. METHODS We retrospectively reviewed the records of 259 consecutive patients who underwent open partial nephrectomy from 2005 to 2010. Patients undergoing laparoscopic or robotic assisted partial nephrectomy were not included in the review. Externalized ureteral catheters were placed preoperatively in 110 patients (Group 1) and needle injection of methylene blue was used in 120 patients (Group 2). No assessment of collecting system integrity was performed in 29 patients (Group 3). We compared intraoperative parameters including tumor size, EBL, ischemia time, operative time, recognized entry into the collecting system as well as the incidence of postoperative urinary leaks. RESULTS The average tumor size was 3.1 cm in Group 1, 3.6 cm in Group 2 and 3.8 cm in Group 3 (p=0.04 between groups 1 and 2); mean EBL was 320 cc, 351 cc and 376 cc (p =0.5); mean warm ischemia time was 19.6 mins, 27 mins and 22.5 mins (p<0.001); mean operative time was 193.5 mins, 221 mins and 290 mins (p<0.001); and the mean hospital stay was 5 days in each of the groups. Collecting system entry was recognized in 69 cases (63%) in Group 1 compared to 91 (76%) in Group 2 and 11 (38%) in Group 3 (p=0.07). Postoperative urine leak requiring any form of management (prolonged JP drain, JJ stent, Foley catheter) occurred in 11 patients from group 1 and 6 from group 2. (p=0.07). None of the patients in group 3 developed a urinary leak. CONCLUSIONS The perioperative leak rate in patients undergoing partial nephrectomy is unaffected by the intraoperative technique of identifying calyceal entry and the integrity of subsequent collecting system repair. Postoperative urine leaks are uncommon (6.6% in this series) despite recognized entry into the collecting system in the majority of patients (66%, 171 of 259). © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e582 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sammy Moussly TAMPA, FL More articles by this author Sandhya R. Rao TAMPA, FL More articles by this author Michelle Pacheco TAMPA, FL More articles by this author Philippe E. Spiess TAMPA, FL More articles by this author Wade J. Sexton TAMPA, FL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

2136 IS UROLOGIC SURGICAL TRAINING BENFICIAL IN THE POSTOPERATIVE CARE OF THE RENAL TRANSPLANT PATIENT?

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation, Vascular Surgery I1 Apr 20122136 IS UROLOGIC SURGICAL TRAINING BENFICIAL IN THE POSTOPERATIVE CARE OF THE RENAL TRANSPLANT PATIENT? Hannah Kerr, Antonia Harford, and Michael Davis Hannah KerrHannah Kerr Albuquerque, NM More articles by this author , Antonia HarfordAntonia Harford Albuquerque, NM More articles by this author , and Michael DavisMichael Davis Albuquerque, NM More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.2306AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Historically, urologists have had a dominant role in renal transplantation. However, with the advent of other abdominal organ transplants, this procedure has become the purview of general surgeons. At UNM, renal transplantation is performed by the Division of Urology. We analyzed our experience to ascertain whether renal transplant recipients benefited postoperatively from the surgical expertise of a urologic renal transplant surgeon. METHODS We retrospectively reviewed 172 renal transplants from 2006–2010, looking at operative procedures up to 36 months after transplant that related to the transplant outcome. We compared the procedures that required a urologist to the procedures that any trained renal transplant surgeon could perform. RESULTS 132 of 172 patients (77%) required at least 1 subsequent surgical procedure. 178 procedures were performed. Of these, 144 (81%) were urologic procedures, and 34 (19%) were procedures that any trained renal transplant surgeon could perform. See table. Urologic Procedures Number General Transplant Surgery Procedures Number Cystoscopy/stent removal 119 Removal of PD catheter 15 Native nephrectomy 5 Revision of ureteroneocystotomy 2 TURP/TUIP 4 Seroma/lymphocele drainage 5 Radical orchiectomy 1 Removal of JP drain 2 Ileal conduit stoma revision 1 Transplant nephrectomy 5 Bladder biopsy 1 Wound dehiscence closure 1 Retrograde pyelograms 5 Adrenalectomy 1 Re-stenting 5 Open renal biopsy 3 Deflux injection 2 Dorsal slit 1 Total 144(81%) 34(19%) CONCLUSIONS Our data demonstrates that renal transplant patients benefit from the expertise of a urologist. A number of secondary operations/procedures are performed post-transplant which influence graft outcome. The advantage of having a urologist as the renal transplant surgeon is that care does not have to be coordinated with another specialist. The ultimate benefit is long term continuity of surgical care for these complex patients. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e862-e863 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hannah Kerr Albuquerque, NM More articles by this author Antonia Harford Albuquerque, NM More articles by this author Michael Davis Albuquerque, NM More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Brachytherapy catheter spacing and stabilization technique

Purpose/ObjectivesTo facilitate catheter spacing, implant stability, and patient comfort during multicatheter interstitial brachytherapy. Methods and MaterialsUniform and consistent spacing of multiple interstitial implant catheters can be difficult because individual catheters may become displaced during the course of treatment. The authors have developed a brachytherapy catheter fixation method using Jackson-Pratt (JP) drains that can be used within wounds to maintain catheter spacing or on the skin surface for applicator fixation. JP drains are threaded over the implant needles to space and stabilize the implant geometry. The needles are then replaced with the usual brachytherapy catheters. ResultsSurgically directed (“open”) placement of implant catheters is less prone to displacement when a drain connects and spaces the catheters in the wound. Fixation on the skin surface can also be achieved with the JP drains, which make the friction buttons optional. The soft drain material helps avoid discomfort and pressure injury sometimes associated with hard plastic buttons. Small (10 French) round JP drains are suitable for breast, and head and neck sites and larger 7×10-mm flat JP drains for extremity sarcomas, abdominal, or thoracic tumors. ConclusionsThe complex brachytherapy devices fashioned from widely available surgical drains effectively guide and maintain geometry for multicatheter interstitial implants. Stable implant geometry leads to more reliable implementation of brachytherapy dosimetry. Patient comfort is improved and soft tissue injury from hard-edged buttons is avoided.

Developing an experimental model for surgical drainage investigations: an initial report

BackgroundWe sought to pilot and initiate validation of a surgical drainage model. MethodsWe designed a laboratory model to compare Jackson-Pratt surgical drains using 3 soups to emulate body fluids of serous, purulent, and necrotic debris. Each drain was trialed with each of the 3 fluids. Time and completeness of drainage were recorded. A survey of surgical residents and faculty was performed for convenience sampling. ResultsUnder serous conditions, the round Jackson-Pratt drained the cavity quicker, but left a larger residual volume of fluid. Under purulent conditions, the round Jackson-Pratt was slower and drained less fluid. With debris fluid, the round Jackson-Pratt was quicker with less residual fluid whereas the flat type clogged each time. Survey results showed adequate concordance with surgeons in agreement on soup choice. ConclusionsThe Jackson-Pratt drains perform differently depending on the drainage situation. The surgical community requires improved drain data to drive practice patterns.

Stentless pediatric robotic pyeloplasty

Open dismembered pyeloplasty remains the standard of care for the correction of ureteropelvic junction obstruction in children. We describe our experience with a tubeless, stentless pediatric robotic pyeloplasty technique. Between October 2008 and September 2009, 12 consecutive children underwent robotic dismembered pyeloplasty. Ureteral stents or nephrostomy tubes were not used. Operative time, hospital stay, days of Jackson-Pratt drainage, and complications were analyzed. Postoperative renal ultrasonography was obtained at 4-6 weeks after surgery. The mean patient age was 9.1 years (3.5-16). The mean operative and console times were 178 (122-250) and 129 (96-193) minutes, respectively. The Jackson-Pratt drain was removed after a mean of 1.8 days (1-4). The mean hospital stay was 2.4 days (1-4.5). There were no complications. Mean follow up was 16 months (12-24 months). All patients had complete resolution of symptoms. Hydronephrosis either completely resolved or significantly decreased in all cases. In cases without complete resolution of hydronephrosis, 99m Tc-MAG-3 diuretic renography showed preservation of renal function without obstruction. Robot-assisted laparoscopic pyeloplasty can be safely performed without internal indwelling stent drainage. In children, this avoids the need for additional anesthesia and stent-related morbidity.

Closure of Ascites Leaks with Fibrin Glue Injection in Patients with End-Stage Liver Disease

Ascites leaks (AL) in patients with end-stage liver disease (ESLD) are associated with significant morbidity and mortality regardless if they are medically or surgically managed. In a pilot study, 14 ESLD patients with AL underwent treatment with fibrin glue injection around the leak after failing conservative therapy. The end point of this study was the cessation of AL in the short term and the maintenance of a leak-free abdomen in the long term, allowing for medical optimization of the patients. Median age of the 10 men and 4 women was 50 (range 26-67) years. Underlying ESLDs were chronic hepatitis C (n=5), alcoholic LD (n=2), cryptogenic cirrhosis (n=2), and miscellaneous (n=5). There were six leaking incisions posthernia repair (three umbilical and three inguinal), two leaking/ruptured umbilical hernias, four leaking paracentesis sites, one leaking Jackson-Pratt (JP) drain canal, and one leaking laparoscopic trocar site. Average AL volume per day was 1000 (range 400-2000) mL. All leaks were immediately resolved with a 3-5 mL fibrin glue injection. Five recurred and required a second injection (four within 24 hours). Mental status improved in 7 patients (West Haven Criteria: grade II to I [n=6], grade III to I [n=1]). Median model of end-stage liver disease scores improved from 23 (range 8-33) to 20 (range 14-26). There were no infections, bleeds, or other injection-related complications. Average follow-up for these patients was 441.6 days (range 2-852). Five patients underwent liver transplant (LT) median 15 (range 4-270) days postinjection; 2 of them died. Another 3 patients died (2 from sepsis and 1 from metastatic cancer). Fibrin glue injection for the control of AL is a simple and safe bedside procedure that quickly controls AL, allowing for patient recovery in anticipation of further care.

Retained drains causing a bronchoperitoneal fistula: a case report

IntroductionBronchoperitoneal fistulas are extremely rare. We present a case where retained surgical drains from a previous surgery resulted in erosion and fistula formation. This condition required an extensive surgical procedure and advanced ventilator techniques.Case presentationA 24-year-old African-American man presented to our Emergency Department with a one-week history of fever, dyspnea, cough, and abdominal pain. A computed tomography scan of his chest and abdomen revealed bilateral lower lobe pneumonia and two retained Jackson-Pratt drains in the right upper quadrant. He was taken to the operating room for drain removal, a right hemicolectomy, debridement of a duodenal injury, a Roux-en-y duodenojejunostomy, and an end ileostomy. He subsequently became increasing hypoxemic in the intensive care unit and a bronchoperitoneal fistula was diagnosed. He required high-frequency oscillatory ventilation followed by lung isolation, and was successfully resuscitated using these techniques.ConclusionTo the best of our knowledge, this is the first known case report of a bronchoperitoneal fistula caused by retained surgical drains. This is also the first known report that details successful management of this condition with advanced ventilatory techniques. This case highlights the importance of follow-up for trauma patients since retained surgical drains have the potential to cause life-threatening complications. When faced with this condition, clinicians should be aware of advanced ventilatory methods that can be employed in the intensive care unit. In this case, these techniques proved to be life-saving.

Veress Needle: A Simple Liver Retraction Technique for Lap Band Positioning in (Single Incision Laparoscopic Technique) SILS

To the Editor:Sir,We read with interest the recent articles of Nguyen et al. [ 1]and of Reavis et al. [ 2] reporting their experience withadjustable gastric banding and sleeve gastrectomy, respec-tively, utilizing a novel minimally invasive surgical approach:single incision laparoscopic surgery (SILS).Recent publications confirm the rapid increase in the useof SILS, not only for bariatric surgery but for a wide rangeof routine laparoscopic procedures [3–10]. In most of thepublished reports, it is argued that SILS has the potentialadvantage of reduced post-operative pain and port-sitecomplications, as well as being virtually ‘scarless’. Optimalcosmetic outcomes would seem to be especially relevant topatientsundergoinggastricbanding,whoareoftendisappoint-ed with the degree of post-operative scarring. The standardapproach to band implantation typically requires a 3- to 4-cmincision for the access port site, together with three to foursmaller (5–10 mm) trocar incisions. Where technicallyfeasible, therefore, a SILS approach would appear to be anattractive alternative.A key problem in the application of SILS to gastricbanding (and other gastric surgeries) is how to achieveadequate retraction of the liver, without resorting to thestandard trocar placement.Huang et al., in order to retract left liver lobe for aSILS procedure of a gastric bypass, proposed a systemconsisting of a Jackson–Pratt drainage penetrated with a2-0 Prolene and fixed with Kelly clamps at the skin [11].As the author confirmed, mean time to carry out thisprocedure is 5 min.Hamzaoglu et al. [12], in order to carry out a singleincision Nissen fundoplication and considering a left liverretraction system of Sakaguchi et al’s lap gastrectomy [13],adopted a Penrose drain of 8 cm long and 1 cm large tiedwith two silk sutures of 10 cm in length and fixed at theskin externally. Also, in this case, the procedure isconsidered fixed and carried out for 5–7 min.Tanigawa [14] as well proposed, for a laparoscopicesophagogastric procedure, a 17-cm-long and 6-mm-largehand-made Penrose drain fixed with three heavy ties alongits length at the peritoneum.More recently, Ganta [15] proposed the ‘Ganta stitch’ forleft lobe liver retraction in single incision LapBand. Itconsists of a 2-0 Ethibond suture placed from the crura of

930 CLINICAL PATHWAY FOR DISCHARGE ON POSTOPERATIVE DAY ONE AFTER ROBOTIC PARTIAL NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: A potential benefit of minimally-invasive surgery is reduced hospital stay, but regardless of approach, the complexity of a procedure and potential complications can limit early discharge. Published lengths of stay after robotic partial nephrectomy (RPN) have not been significantly less than those after open surgery. We present a clinical pathway targeting discharge on postoperative day (POD) one after RPN attempting to take advantage of the potentially less morbid procedure with analysis of ability to adhere to the pathway. METHODS: We reviewed all patients undergoing RPN since institution of our clinical pathway. A total of four ports is used with specimen extraction typically at a periumbilical port site and bupivicaine injected at all incisions. Patients ambulate and take clear liquids the night of surgery. Intravenous narcotics are avoided with oral analgesics and ketorolac (renal function permitting) given for pain control. No stent is used and closed suction drains are avoided. The Foley catheter is removed and regular diet started the morning after surgery with discharge the same day. The pathway is used regardless of complexity of the resection. RESULTS: A total of 98 RPNs were performed in 90 consecutive patients with all placed on the pathway. Mean age was 57yrs (22–83yrs), mean BMI was 32kg/m2 (20–49kg/m2), and mean ASA score was 2.8. Mean and median tumor size were 2.9cm and 2.6cm (range, 0.4–9cm). Mean OR time was 198min and mean blood loss was 187mL with 2 transfusions (2%). Warm ischemia time overall was 11.6min (0–30.0min) and was 16.1min excluding off-clamp resections. Mean preoperative and discharge serum creatinine were 0.91mg/dL (0.43–2.79) and 1.15mg/dL (0.57–2.93), respectively. All patients ambulated the day of surgery, and none required intravenous narcotics. No stents were placed, and a JP drain was avoided in 82 patients (91%) with only one (1%) experiencing a minor urine leak managed with a Foley catheter for one week. Four ports were adequate in 75 patients (83%). Eighty-five of 90 patients (94%) were discharged on POD#1. Reasons for longer stay included pulmonary concerns, anemia, and negative exploratory laparotomy for suspected bowel injury in one patient each and patient preference in two. Only 4 of 85 patients discharged on POD#1 required readmission within 30 days of surgery (5%), including for fever, anorexia, ileus, and one at an outside facility for pneumonia. CONCLUSIONS: Discharge on POD#1 is feasible in most patients after RPN without increased complications and may represent an advantage over open surgery if such a clinical pathway is applied.

Strip of the Month: February 2011

Strip of the Month: February 2011

Multiple Magnet Ingestion as a Cause of Septic Peritonitis in a Dog

A 1 yr old male castrated Yorkshire terrier was referred after ingesting magnets. Dehydration, fever, tachycardia, and abdominal pain were noted on physical examination. Abdominal radiographs revealed two radiopaque foreign objects in close proximity to each other with decreased abdominal detail. Surgical exploration identified magnets adhered together in the omentum with perforations present in the transverse colon and stomach. The perforations were closed and a Jackson-Pratt continuous suction drain was placed. Septic peritonitis secondary to intestinal perforation from magnet ingestion was successfully treated with a combination of surgery and a closed suction drain.

Persistent Vesicourethral Anastomotic Leak After Radical Prostatectomy: A Novel Endoscopic Solution

A vesicourethral anastomotic leak after radical prostatectomy is a common postoperative sequela. Rarely additional intervention is required for a persistent or high output urinary leak. We describe a novel solution to this uncommon complication. With the patient under general or spinal anesthesia the technique included 19Fr rigid cystoscopy in a partially distended bladder and insertion of 5Fr Single J® ureteral stents over a hydrophilic guidewire under fluoroscopic guidance. The 2 stents were exteriorized via the urethra beside an 18Fr Foley catheter. We monitored urine output and the relative amount of leak. The Jackson-Pratt drains were removed after leakage decreased to 50 ml or less per day. All patients underwent cystogram to ascertain leak resolution before stent removal. Time to continence was estimated using Kaplan-Meier analysis. Seven of 1,480 patients (0.5%) required intervention for a prolonged or high output anastomotic leak after radical prostatectomy. Mean time from surgery to stent insertion was 6.2 days (range 2 to 12). Stents were retained an average of 9 days (range 6 to 11), enabling complete resolution of the leak within a mean±SD of 1.8±0.9 days. Median time to recovery of urinary continence was 20±1.7 weeks. Temporary urinary diversion with exteriorized ureteral stents via the urethra is a safe, effective solution for a prolonged or high output anastomotic leak after radical prostatectomy. Recovery of urinary continence may be delayed in this setting but long-term urinary function appears to be unaffected in most patients.

Xanthogranulomatous Cholecystitis and Cholangitis: A Single Case Study

Purpose: Xanthogranulomatous cholecystitis (XGC) is a benign inflammatory disease of the gallbladder. The incidence of XGC is 1% to 2% and clinically mimics chronic cholecystitis. Although the incidence suggests that XGC is an unusual rather than rare condition, cases from the United States have seldom been reported. Xanthogranulomatous cholangitis is an even rarer entity, with a prevalence of 0.6%. It manifests as biliary strictures with associated wall thickening, and is indistinguishable from infiltrative cholangiocarcinoma. We present a unique case of xanthogranulomatous cholangitis in the setting of XGC. Case: A 37 yo gentleman presented with weight loss and diarrhea. Exam revealed jaundice and right upper quadrant (RUQ) tenderness. The bilirubin was elevated (4.4), prompting an MRCP that revealed an obstructive stone in the common bile duct (CBD). Because of adhesions and gallbladder necrosis on laparoscopy, the patient underwent an open cholecystectomy. Stones were removed from the CBD and the common hepatic duct (CHD) was found to be full of debris. A t-tube was placed and a JP drain was left in the gallbladder fossa. Pathology from the gallbladder revealed XGC. Worsening jaundice (bilirubin 13.8), RUQ pain, and vomiting complicated the post-operative course. T-tube cholangiogram revealed intrahepatic biliary ductal dilation and stricture of the CHD, suggestive of xanthogranulomatous cholangitis. A bile leak from the CBD was also identified and a percutaneous biliary drain was placed. The patient was also treated for acute pancreatitis secondary to an obstructing stone. The remainder of the hospital course was unremarkable and he was discharged with instructions for a follow-up ERCP. The patient was subsequently lost to follow-up. Discussion: In 1981, Goodman and Ishak described the first cases of XGC. While this entity has been frequently documented in India and Japan, where the incidence of gallstones is higher, only one case report has been published in the United States in the last 15 years. This entity is overlooked because it clinically resembles chronic cholecystitis. However, it can be easily confused with gallbladder cancer, a much graver condition. Similarly, information about xanthogranulomatous cholangitis has been limited to single case reports describing strictures mimicking malignancy. Although the majority of patients with painless jaundice are ultimately diagnosed with cancer, 5-10% harbor benign disease. It is impossible to grossly differentiate these cases; histopathology is necessary. Because XGC and xanthogranulomatous cholangitis can both be confused for malignant conditions, we must be aggressive in identifying and reporting these cases and variations thereof.

A Novel Technique for Nipple-Sparing Mastectomy and Immediate Reconstruction in Patients with Macromastia

A Novel Technique for Nipple-Sparing Mastectomy and Immediate Reconstruction in Patients with Macromastia

Pre-operative Amicar (Epsilon-Aminocaproic Acid): Does it reduce total blood loss in lumbar pedicle screw spinal fusion?

Objective and Importance: Chronic low back pain and radiculopathy due to spondylolisthesis and spinal instability are frequent indications for decompressive lumbar laminectomy and spinal fusion with pedicle screw fixation. This procedure frequently involves a great deal of intra-operative blood loss for the patient. The objective of this study was to determine if pre-operative administration of Amicar (Epsilon-Aminocaproic Acid) reduced blood loss among patients who underwent open decompressive lumbar laminectomy and spinal fusion surgery.Study variables: 19 randomly selected patients were consented to receive Amicar preoperatively. Their intraoperative estimated blood loss as well as the Jackson-Pratt drain output were analyzed and compared to a matched group of retrospectively selected patients from our records.Technique: Data obtained from our patients were analyzed for various factors. After obtaining informed consent, patients involved in the groups were given one adult dose (5 gr IV) prior to surgery. The two groups were then compared to determine if Amicar had an effect on the EBL and other variables that might be related to blood loss.Conclusion: Although the Amicar-treated patients had lower amounts of blood loss and blood given, the differences were not significant. The non-significant differences could be due to the large observed variability for EBL and blood given in both groups and the small sample sizes for the two groups.

Jackson Pratt drain fluid-to-serum bilirubin concentration ratio for the diagnosis of bile leaks

Jackson Pratt (JP) drain fluid bilirubin levels may be assayed in the evaluation of possible bile leaks. Although fluid color and bilirubin level may prompt additional evaluation, there are no reference data available. To assess the JP drain fluid-to-serum bilirubin ratio in patients with documented bile leaks. Prospective case series. Tertiary referral center. Patients referred for ERCP for the management of documented bile leaks with a JP drain in place were included. Demographic data, bile leak etiology, and serum bilirubin levels were recorded. JP drain fluid was sent for color evaluation and bilirubin concentration. Control subjects included both patients after nonbiliary surgery with a JP drain in place and medical patients with ascites undergoing paracentesis. JP drain fluid-to-serum bilirubin concentration and fluid color evaluation was performed on 23 patients with documented bile leaks by ERCP and compared with 26 controls (16 surgical and 10 medical). The JP drain fluid/ascites-to-serum bilirubin ratio was significantly higher in those with bile leaks (mean ratio 45.6) compared with combined controls (mean ratio 0.9). Use of a cutoff JP drain fluid-to-serum bilirubin ratio of 5 would be 100% sensitive and specific for the prediction of a bile leak in the selected control group. There was overlap in fluid color evaluation between the groups. Controls did not include those with suspected bile leaks and negative technetium 99m-HIDA scintigraphy or ERCP findings. JP drain fluid-to-serum bilirubin concentration ratio greater than 5 seems to be highly sensitive and specific for the detection of a bile leak. Used along with clinical criteria, this ratio could be used to select patients to proceed directly to ERCP.

Laparoscopic Management of Ureterovaginal Fistula Post-Hysterectomy

Study Objective: This video is a synopsis of our management of ureterovaginal fistula diagnosed 7 days following hysterectomy. As fibrotic peritoneum overlying the injured ureter prohibits visualization, ureterolysis is initiated at the pelvic brim and continued distally. After precise localization of the defect, devitalized tissue is trimmed. The ureter is freed of adherent vaginal tissue, thereby disrupting the fistulous tract. To assure a tension-free repair, the ureter is freed from surrounding connective tissue. It is then repaired over stent using interrupted 6-0 Vicryl for a water-tight repair. The vaginal defect is closed, a JP drain placed, and a double-J stent is maintained for 6 weeks, following which an IVP is performed to confirm normal excretory function and evaluate for stricture. Reduced patient morbidity with immediate resolution of urinary leakage and patient anxiety are advantages over the current standard. Studies are needed to compare this repair with stenting and percutaneous nephrostomy and laparotomy when necessary.