Late Removal Research Articles

Comparison of early and late removal of the urinary catheter after rectal cancer surgery

Comparison of early and late removal of the urinary catheter after rectal cancer surgery

Comparison of early and late removal of the urinary catheter after rectal cancer surgery.

This study is aiming to compare the results of early and late removal of urinary catheters after rectal cancer surgery. Patients who undergone rectal cancer surgery in a single center were included in this prospective randomized study. The timing of the urinary catheter removal was randomized by a computer-assisted program and divided into 2 groups, which are early (first 48 h) and late (after 48 h). The primary outcome of this study was to compare the urinary retention and re-catheterization rates between patients with early and those with late catheter removal. Sixty-six patients were included in this study. The median age was 60 (31-88 years), and the patient group was predominantly male (n: 40, 60.9%). Urinary retention after catheter removal developed in 8 (12%) of 66 patients. There was no difference between the two groups in terms of the need for re-catheterization (14% vs. 10%, p: 0.63). All the patients who required re-catheterization (n: 8) and were discharged with a urinary catheter (n: 4) were male. When the male and female patients were evaluated separately, there was no difference in urinary retention in the early or late groups. Early or late removal of the catheter does not play a role in the development of urinary retention in patients undergoing rectal cancer surgery.

Intraperitoneal prophylactic drain after pancreaticoduodenectomy: an Italian survey

Intraperitoneal prophylactic drain (IPD) use in pancreaticoduodenectomy (PD) is still controversial. A survey was designed to investigate surgeons’ use of IPD in PD patients through 23 questions and one clinical vignette. For the clinical scenario, respondents were asked to report their regret of omission and commission regarding the use of IPD elicited on a scale between 0 (no regret) and 100 (maximum regret). The threshold model and a multilevel mixed regression were applied. One hundred three (97.2%) respondents confirmed using at least two IPDs. The median regret due to the omission of IPD was 84 (67–100, IQR). The median regret due to the commission of IPD was 10 (3.5–20, IQR). The CR-POPF probability threshold at which drainage omission was the less regrettable choice was 3% (1–50, IQR). The threshold was lower for those surgeons who performed minimally invasive PD (P = 0.048), adopted late removal (P = 0.002), perceived FRS able to predict the risk (P = 0.006), and IPD able to avoid relaparotomy P = 0.036). Drain management policies after PD remain heterogeneous among surgeons. The regret model suggested that IPD omission could be performed in low-risk patients.

Safety and efficacy of early versus late removal of LAMS for pancreatic fluid collections.

Background and study aims Optimal timing for removal of lumen-apposing metal stents (LAMS) for effective drainage of pancreatic fluid collections (PFC) while minimizing adverse events (AE) is unknown. Outcomes of early (≤ 4 weeks) or delayed (> 4 weeks) LAMS removal on both clinical efficacy and the incidence of AE were assessed. Patients and methods This was a retrospective analysis of a prospectively maintained registry of PFC drainage between November 2016 and September 2021. Clinical success was defined as a 75% decrease in fluid collection volume with no need for reintervention at 6 months. AE were defined using the American Society for Gastrointestinal Endoscopy lexicon. Multiple logistic regression analysis was performed to determine variables associated with clinical success and AE. Results A total of 108 consecutive PFCs were included. LAMS deployment was technically successful in 103 of 108 cases (95.4%). Failure was associated with collection diameter ≤ 4 cm (odds ratio [OR] 24.0, P = 0.005) and presence of more than 50% necrotic material (OR 20.1, P = 0.01). Stents were left in place for a median of 48 days. Patients with early stent removal (< 4 weeks) had clinical success in 70.0% of cases, which was significantly less than in the group with delayed stent removal (96.4%, P = 0.03). On multiple regression analysis, clinical failure was associated with early stent removal (OR 25.5, P = 0.003). AEs occurred in 8.7% of cases (9/103). There were no predictors of AE. Notably, delayed stent removal did not predict the occurrence of AE. Conclusions Early LAMS removal (< 4 weeks) did not prevent AEs but did lead to increased clinical failure.

Investigating the interplay between segregation and integration in developing cortical assemblies.

The human brain is an intricate structure composed of interconnected modular networks, whose organization is known to balance the principles of segregation and integration, enabling rapid information exchange and the generation of coherent brain states. Segregation involves the specialization of brain regions for specific tasks, while integration facilitates communication among these regions, allowing for efficient information flow. Several factors influence this balance, including maturation, aging, and the insurgence of neurological disorders like epilepsy, stroke, or cancer. To gain insights into information processing and connectivity recovery, we devised a controllable in vitro model to mimic and investigate the effects of different segregation and integration ratios over time. We designed a cross-shaped polymeric mask to initially establish four independent sub-populations of cortical neurons and analyzed how the timing of its removal affected network development. We evaluated the morphological and functional features of the networks from 11 to 18 days in vitro (DIVs) with immunofluorescence techniques and micro-electrode arrays (MEAs). The removal of the mask at different developmental stages of the network lead to strong variations in the degree of intercommunication among the four assemblies (altering the segregation/integration balance), impacting firing and bursting parameters. Early removal (after 5 DIVs) resulted in networks with a level of integration similar to homogeneous controls (without physical constraints). In contrast, late removal (after 15 DIVs) hindered the formation of strong inter-compartment connectivity, leading to more clustered and segregated assemblies. A critical balance between segregation and integration was observed when the mask was removed at DIV 10, allowing for the formation of a strong connectivity among the still-separated compartments, thus demonstrating the existence of a time window in network development in which it is possible to achieve a balance between segregation and integration.

Early versus late removal of the I-Gel in paediatric patients with mild upper respiratory tract symptoms undergoing ambulatory ilioinguinal surgery: A prospective observational study.

The optimal timing of I-Gel removal in children with mild respiratory symptoms remains controversial. Consequently, we tried to assess the impact of early versus late I-Gel removal on the incidence of perioperative respiratory adverse events among children aged one to five years undergoing ambulatory surgery under general anaesthesia with I-Gel airway ventilation. The anaesthesia protocol was the same for all patients. Children were divided into two groups according to the approach of I-Gel removal (early versus late). The incidence of perioperative respiratory adverse events after the I-Gel removal was the main outcome, and a multivariable regression was performed to investigate the implication of the I-Gel removal in perioperative respiratory adverse events. According to our study, the incidence of perioperative respiratory adverse events was not correlated to the timing of I-Gel removal. However, prolonged postoperative oxygen support can be seen when the I-Gel is removed in anaesthetized children.

Early versus late removal drainage in patients who underwent pancreatic resection: a comprehensive systematic review and meta-analysis using trial sequential analysis

Early versus late removal drainage in patients who underwent pancreatic resection: a comprehensive systematic review and meta-analysis using trial sequential analysis

Early vs late drain removal after pancreatic resection-a systematic review and meta-analysis.

Reducing clinically relevant post-operative pancreatic fistula (CR-POPF) incidence after pancreatic resections has been a topic of great academic interest. Optimizing post-operative drain management is a potential strategy in reducing this major complication. Studies involving pancreatic resections, including both pancreaticoduodenectomy (PD) and distal pancreatic resections (DP), with intra-operative drain placement were screened. Early drain removal was defined as removal before or on the 3rd post-operative day (POD) while late drain removal was defined as after the 3rd POD. The primary outcome was CR-POPF, International Study Group of Pancreatic Surgery (ISGPS) Grade B and above. Secondary outcomes were all complications, severe complications, post-operative haemorrhage, intra-abdominal infections, delayed gastric emptying, reoperation, length of stay, readmission, and mortality. Nine studies met the inclusion criteria and were included for analysis. The studies had a total of 8574 patients, comprising 1946 in the early removal group and 6628 in the late removal group. Early drain removal was associated with a significantly lower risk of CR-POPF (OR: 0.24, p < 0.01). Significant reduction in risk of post-operative haemorrhage (OR: 0.55, p < 0.01), intra-abdominal infection (OR: 0.35, p < 0.01), re-admission (OR: 0.63, p < 0.01), re-operation (OR: 0.70, p = 0.03), presence of any complications (OR: 0.46, p < 0.01), and reduced length of stay (SMD: -0.75, p < 0.01) in the early removal group was also observed. Early drain removal is associated with significant reductions in incidence of CR-POPF and other post-operative complications. Further prospective randomised trials in this area are recommended to validate these findings.

Timing of invasive species removal influences nonnative biotic resistance and trajectories of community reassembly

Abstract As biological invasions increasingly threaten biodiversity, the removal of invasive nonnative species emerges as a possibility to recover the structure and function of native communities. Yet, we have limited knowledge of how communities assemble after nonnative removals. Since most ecosystems are invaded by multiple nonnative species, the impact of their removal likely depends on the interactions among nonnative species which, in turn, are contingent on the environmental context in which they occur. We evaluated the community assembly after the targeted removal of two highly invasive shrubs, Sweetbriar rose (Rosa rubiginosa) and Scotch broom (Cytisus scoparius). The removal was performed at two different times in the growing season (early or late removal) in field and mesocosm communities. In search of general patterns across species, we modelled species responses as a function of their origin (i.e. native/nonnative) and functional traits. We found evidence for negative and asymmetric interactions between dominant invasive species that translated into changes in the abundances of the rest of the species in the community. Depending on the identity of the removed species, the removal of invasive species affected community assembly by promoting other nonnative species or hindering the performance of native species. These effects were modulated by the timing of removal and did not depend on leaf or seed traits. Synthesis. Accounting for nonnative interactions and their temporal dependency should improve our inferences about assembly processes and the effectiveness of nonnative removal aimed at reducing the accumulation of nonnatives.

Clinical and radiological results of early pin removal in pediatric radial neck fractures treated with stepwise percutaneous leverage technique.

The aim of this study was to compare radiological and clinical results between early (≤3 weeks) and late (>3 weeks) removal of pins in patients treated with the stepwise percutaneous leverage technique for radial neck fractures. 37 patients (aged 3-15) who underwent fixation with stepwise percutaneous leverage technique for Judet class III and class IV radial neck fractures between 2003 and 2019 were included in this retrospective study. Patients were divided into two groups according to the time of pin removal; 19 had early pin removal (≤3 weeks) and 18 had late pin removal (>3 weeks). The patients' radiological results were graded using the Metaizeau classification and their clinical results were evaluated by measuring their range of motion (ROM) and Mayo elbow performance scores (MEPS) at postoperative follow-ups. Statistical tests, including the Mann-Whitney U and Chi-square tests, were performed to compare the demographic factors and outcomes. The mean time of removal of pins for all patients was 21 (10-43) days. The mean time for early and late removal was 15.1 (10-21) and 27.6 (22-43) days, respectively. There was no statistically significant difference between groups radiologically according to the Metaizeau classification (P = .723). Furthermore, no statistically significant difference was found in the ROM (extension/flexion: P = .620, pronation/supination: P = .578) or MEPS (P = .695) between groups. This study has shown us that early removal of pins in patients with pediatric radial neck fractures treated with stepwise percutaneous leverage technique demonstrated good radiological and clinical results comparable to late pin removal. Level of Evidince: Level IV, Therapeutic Study.

FEASIBILITY OF EARLY CATHETER REMOVAL FOLLOWING TRANSURETHRAL PROSTATECTOMY: A CASE SERIES

Introduction: Benign prostatic hyperplasia (BPH) is a benign growth of the prostate that develops as a strictly age-related phenomenon in nearly all men from about age 40. Transurethral prostatectomy remains the gold standard. Postoperative care for transurethral resection of the prostate (TURP) includes bladder irrigation with prolonged case immobilisation . Traditionally, catheters are removed approximately 4 days after TURP. This study evaluates the feasibility and safety of early (day 1) catheter removal after transurethral resection of the prostate. Materials And Methods: It is a prospective study. A total of 35 patients who underwent Trans-Urethral Resection of Prostate (TURP) for benign prostatic hyperplasia (BPH) who fullled the inclusion criteria. Patients were randomised by simple random sampling technique and were divided into two groups. 18 cases were assigned for early removal group and their catheter was removed on POD-1 of surgery. 17 cases were taken as control (late removal) group, their catheter was removed on the 4-5th day of surgery as conventionally done. Data of both groups were compared and analysed for statistical signicance using Chi square test and Student 't' test. We set up that early junking of urethral catheter redounded in Result: statistically signicant reduction in length of post-operative sanitarium stay which indicate early mobilisation of the case, lower post-operative pain, early discharge and reduced cost burden on the sanitarium. Also, there was reduced prevalence in urinary tract infections in early junking group which may indicate reduced threat of urethral strictures in future

Urinary and double incontinence in older women with hip fracture - risk of death and predictors of incident symptoms among survivors in a 1-year prospective cohort study

ObjectivesTo investigate the association of urinary incontinence (UI) and double incontinence (DI, concurrent UI and fecal incontinence) with one-year mortality among older female hip fracture patients and to identify predictors of incident UI and DI. DesignA prospective cohort study Setting and subjects1,468 female patients aged ≥ 65 treated for their first hip fracture during the period 2007–2019 MethodsContinence status was elicited at baseline and one-year post-fracture. Age- and multivariable-adjusted Cox proportional hazards and multinomial logistic regression models were used to determine the associations of incontinence with one-year mortality and to examine the associations of baseline predictors with incident UI and DI respectively. ResultsOf the women with no incontinence, UI and DI, 78 (13%), 159 (23%) and 60 (34%), died during follow-up. UI (HR 1.72, 95% CI 1.31–2.26) and DI (HR 2.61, 95% CI 1.86–3.66) were associated with mortality after adjusting for age. These associations lost their predictive power in multivariable analysis while age over 90, living in an institution, impaired mobility, poor nutrition, polypharmacy, and late removal of urinary catheter remained associated with mortality. Of continent women, 128 (21%) developed UI and 23 (4%) DI during follow-up. In multivariable analysis, impaired mobility was associated with incident UI (OR 2.56, 95% CI 1.48–4.44) and DI (OR 4.82, 95% CI 1.70–13.7), as well as living in an institution (OR 3.44, 95% CI 1.56–7.61 and OR 3.90, 95% CI 1.17–13.0). Conclusions and ImplicationsUnderlying vulnerability likely explains differences in mortality between continence groups and development of incident UI and DI.

Early detection of violating Mobile Apps: A data-driven predictive model approach

Mobile app stores are the key distributors of mobile applications. They regularly apply vetting processes to the deployed apps. Yet, some of these vetting processes might be inadequate or applied late. The late removal of applications might have unpleasant consequences for developers and users alike. Thus, in this work we propose a data-driven predictive approach that determines whether the respective app will be removed or accepted. It also indicates the features' relevance that help the stakeholders in the interpretation. In turn, our approach can support developers in improving their apps and users in downloading the ones that are less likely to be removed. We focus on the Google App store and we compile a new data set of 870,515 applications, 56% of which have actually been removed from the market. Our proposed approach is a bootstrap aggregating of multiple XGBoost machine learning classifiers. We propose two models: user-centered using 47 features, and developer-centered using 37 features, the ones only available before deployment. We achieve the following Areas Under the ROC Curves (AUCs) on the test set: user-centered = 0.792, developer-centered = 0.762.

Adverse effects of long-term drain placement and the importance of direct aspiration: a retrospective cohort study

Long-term placement of prophylactic drains may result in retrograde infections. To investigate the association between the timing of drain removal and clinical outcomes. This retrospective, single-centre cohort study evaluated 110 patients who underwent elective gastrointestinal or hepatopancreatobiliary surgery and developed subsequent organ/space surgical site infection (SSI) between 2016 and 2020. The difference between the culture-positive species of prophylactic drains and direct aspiration was evaluated; whether the prophylactic drains functioned effectively at the time of SSI diagnosis; and whether the empirical antibiotics administered before drainage were effective against all the detected bacteria. Finally, clinical outcomes were compared between early (i.e. cases wherein the prophylactic drain had already been removed or replaced at the time of SSI diagnosis) and late (removal after diagnosis) drain removal. The prophylactic drains functioned effectively in only 27 (25%) patients at the time of SSI diagnosis. Due to the results of direct aspiration cultures, 43% of patients required antibiotic escalation. The median time to drain removal or first replacement was seven postoperative days. The early removal group included 43 patients (39%). Compared with early removal, late removal resulted in a higher frequency of vancomycin use (7.0% vs 22.4%; P= 0.037). Prolonged prophylactic drain placement is associated with complicated infections requiring vancomycin; therefore, the drains should be removed as soon as possible. Additionally, obtaining the cultures of direct aspiration should be actively considered, as escalation of antimicrobial therapy is often performed based on culture results.

Determining the Role of Time in Removing Mastoid Pressure Bandages after Tympanoplasty or Tympanomastoidectomy

Background: Mastoid Pressure Dressing (MPD) has been commonly used by otolaryngologists from 1960 as a post-operative care after mastoid or middle ear surgeries. MPD may be removed after the first day or 5 days after the surgery but it is not clear whether early or late removal is associated with less side effects. To clarify the optimal time of MPD removal, we conducted this prospective study. Methods: A total of 56 patients, including 19 males and 37 females with the mean age of 38.23±15.9 years, were included in this study. Among these, 31 patients underwent early MPD removal (after one day) and for the other 25 patients, MPD was removed five days following the surgery, Tympanoplasty or Tympanomastoidectomy. Results: There was no significant difference between the two groups in gender distribution or mean age. In addition, no significant between-group difference was detected in developing hematoma and sleep disturbance, but patients with late MPD removal showed higher rates of headache and erythema. Conclusion: Current study suggests that MPD may be removed as soon as possible after the surgery due to its side effects inducing headache and irritation.

Chronic Dysphagia in Patients Treated with Head and Neck Intensity-Modulated Radiotherapy: Incidence, Risk Factors and Implications

<h3>Purpose/Objective(s)</h3> Late dysphagia after head and neck radiotherapy is an important driver of poor quality-of-life. We aimed to identify risk factors associated with long-term gastrostomy tube (g-tube) dependence in patients with head and neck squamous cell carcinoma treated with definitive or postoperative radiotherapy. <h3>Materials/Methods</h3> A retrospective cohort analysis of patients with head and neck squamous cell carcinoma treated with definitive or adjuvant intensity-modulated radiotherapy was performed. Patients with locoregional or distance recurrence were excluded from the analysis. G-tube dependence was used as a surrogate marker for late dysphagia, and its placement and removal from initial presentation to last follow-up was tracked. The risk of g-tube dependence from years one through five was calculated, and factors associated with 1- and 2-year g-tube use were analyzed with multivariable logistic regression. <h3>Results</h3> Our analytic cohort consisted of 421 survivors with head and neck squamous cell cancer treated from 2001 to 2018. A total of 210 patients required a g-tube with 80, 124, and 13 g-tubes placed before, during, and after radiotherapy, respectively. The median follow-up of the entire cohort was 4 years (IQR 3-5), with 314, 222, and 124 patients at-risk in years 3, 4 and 5. The Kaplan-Meier g-tube dependence rate at 1 and 2 years after radiotherapy were 11% and 6%, respectively, and 5%, 3% and 2% at three, four and five years, respectively. On multivariable regression analysis on 1-year g-tube dependence, history of depression or anxiety (odds ratio, OR, 95% confidence interval, CI, 3.86 [1.47, 10.3]), clinical T3/T4 stage (3.75 [1.60, 9.30]), clinical N2 or N3 stage (3.66 [1.03, 14.4]), baseline swallowing impairment to both solids and liquids (11.1 [3.22, 41.8]), and intra-treatment weight loss greater than 10% (3.75 [1.51, 9.81]) were significant predictors. A total of 390 patients had adequate follow-up data for the 2-year analysis. On multivariable analysis, age (1.06 [1.00, 1.14]), clinical N2/N3 stage (15.2 [1.72, 393]), and baseline swallowing impairment to both solids and liquids (95% confidence interval: 41.5 [5.59, 551]) were significantly associated with increased odds of 2-year g-tube dependence. Definitive vs. adjuvant treatment was not significantly associated with 1 or 2-year g-tube dependence. Out of 22 patients with g-tube dependence at two years after radiotherapy, only six (27%) patients had a known tube removal in the years to follow. <h3>Conclusion</h3> The overall incidence of prolonged g-tube dependence is low but not trivial, and the vast majority of patients with dependence at two years remained dependent permanently. We have identified a cohort at highest risk for long-term use, for whom early interventions should be targeted since late removal becomes progressively more unlikely.

236.7: Prophylactic Ureteric Stents in Renal Transplant Recipients; Is Early Removal Associated With Higher Rates of Urological Complications. A Retrospective Analysis of a Single Institution

Background: Renal transplantation is the most effective treatment for end stage renal disease. Urological complications are the most common surgical complication following transplant surgery and can adversely affect patient’s outcomes. Prophylactic ureteric stenting has been demonstrated to reduce urological complications significantly. Recently there has been a trend toward shorter duration of ureteric stent placement due to the associated risk of urinary tract infection. The aim of this study was to determine if early ureteric stent removal was associated with higher rates of urological complications. Patients and Methods: We included all adult patients who underwent renal transplantation at Auckland city hospital over a 12-month period from August 2018 to August 2019. Patient characteristics, surgical and timing of stent removal data was collected. The primary outcome event was hydronephrosis requiring intervention. Secondary outcomes consisted of other urological complications requiring intervention (including perinephric collection and urine leak), total urological complications and urinary tract infections. We performed a multivariate analysis using a logistic regression model to adjust for various patient and surgical variables. Results: There was a total of 118 patients included in the analysis, 52 had their ureteric stents removed early (post-operative day 4) and 66 had late removal (4 weeks). All patients undergoing renal transplantation had a ureteric stent placed and timing and method of removal was determined by the surgeon at time of surgery. 17.8% of the patients in this study had hydronephrosis that required intervention, and this was observed more frequently in patients with early stent removal (OR 8.36, p value 0.001).[JA1] Perinephric collections requiring intervention were also observed more frequently with early stent removal (OR 6.05, p value 0.011). We reported a high rate of urological complications (26%) in this population, with higher rates in the early removal group (OR 3.48, p value 0.013). Urinary tract infection rates were lower in the early removal group (OR 0.32, p value 0.058). Conclusion: We found a very strong correlation with the early removal of ureteric stents and the development of hydronephrosis requiring intervention following renal transplantation. We recommend this practice needs to be reviewed and further assessed with preferably a larger randomized prospective analysis.

Comparison of Access Site Complications After Early or Late Sheath Removal in Patients with PCI, Regardless of ACT Levels.

Background: Despite the lack of supporting data, many clinics perform sheath removal 4-6 hours after femoral percutaneous coronary intervention to reduce the risk of possible access site complications. This study aims to examine the effects of sheath removal immediately after the procedure on access site complications and patient comfort.Methods:This prospective study included 349 patients who underwent percutaneous coronary intervention via the femoral site and 6 French guiding catheters. The sheath in the early group was removed immediately after the procedure without checking the activated clotting time levels but after 4 hours in the late group. Access site complications were recorded and patient comfort was evaluated using the Visual Analog Scale.Results:Patients were divided into 2 groups: patients in the early removal group (n = 171) and in the late removal group (n = 178). There was no statistically significant difference between the 2 groups in terms of access site complications. Three patients in the early removal group and 4 patients in the late removal group developed a hematoma. Six patients in the early removal group and 10 patients in the late removal group showed ecchymosis. The Visual Analog Scale score was statistically significantly lower in the early removal group compared with that in the late removal group [2 (1-3) vs. 3 (2-4), P < .001].Conclusion:This study shows that immediate sheath removal is safe and more comfortable for patients with percutaneous coronary intervention who received weight-adjusted dose of heparin, regardless of the percutaneous coronary intervention levels after the procedure.

Neuronal Activities in the Rostral Ventromedial Medulla Associated with Experimental Occlusal Interference-Induced Orofacial Hyperalgesia.

The imbalanced conditions of pronociceptive ON-cells and antinociceptive OFF-cells in the rostral ventromedial medulla (RVM) alter nociceptive transmission and play an important role in the development of chronic pain. This study aimed to explore the neuroplastic mechanisms of the RVM ON-cells and OFF-cells in a male rat model of experimental occlusal interference (EOI)-induced nociceptive behavior reflecting orofacial hyperalgesia and in modified models involving EOI removal at early and later stages. We recorded the mechanical head withdrawal thresholds, orofacial operant behaviors, and the activity of identified RVM ON-cells and OFF-cells in these rats. EOI-induced orofacial hyperalgesia could be relieved by EOI removal around postoperative day 3; this effect could be inhibited by intra-RVM microinjection of the κ-opioid receptor agonist U-69593. EOI removal around postoperative day 8 did not relieve the orofacial hyperalgesia, which could, however, be reversed by intra-RVM microinjection of the NK-1 (neurokinin-1) receptor antagonist L-733060. The activity of ON-cells and OFF-cells did not change during both the initial 3 and 6 d of EOI. When EOI was removed on postoperative day 3, OFF-cell responses decreased, contributing to the reversal of hyperalgesia. When EOI lasted for 8 d or was removed on postoperative day 8, spontaneous activity and stimulus-evoked responses of ON-cell increased, contributing to the maintained hyperalgesia. In contrast, when the EOI lasted for 14 d, OFF-cell responses decreased, possibly participating in the maintenance of hyperalgesia with persistent EOI. Our results reveal that adaptive changes in the RVM were associated with orofacial pain following EOI placement and removal.SIGNIFICANCE STATEMENT A considerable proportion of patients experience chronic orofacial pain throughout life despite the therapies given or removal of potential etiologic factors. However, current therapies lack effectiveness because of limited knowledge of the chronicity mechanisms. Using electrophysiological recording, combined with a behavioral test, we found that the prevailing descending facilitation in the rostral ventromedial medulla (RVM) participates in the maintenance of orofacial hyperalgesia following late removal of nociceptive stimuli, while the prevailing descending inhibition from the RVM may contribute to the reversal of orofacial hyperalgesia following early removal of nociceptive stimuli. Thus, variable clinical outcomes of orofacial pain may be associated with descending modulation, and an optimal window of time may exist in the management of chronic orofacial pain.

Systematic review on the use and management of drainages in pancreatic surgery

Abstract Objective The use of drains in pancreatic surgery, both in distal pancreatectomy (DP) and partial pancreaticoduodenectomy (PD) is controversial. The aim of this meta-analysis was to assess the potential benefit of drainage use in pancreatic surgery on postoperative outcomes. Methods A systematic literature search was performed in MEDLINE, Web of Science and CENTRAL. All RCTs investigating the use and management of any drainage in patients undergoing pancreatectomy were included. Data on mortality, postoperative complications and length of hospital stay (LOS) were analysed. A random-effects model for Mantel-Haenzsel and inverse variance analysis was used. Cochrane RoB 2.0 tool and GRADE approach was used for assessment of risk of bias and certainty of evidence. Results Ten RCTs investigating drainage vs no drainage, timing of drainage removal or type of drainage in PD such as DP with a total of 2004 patients were included. Drainage vs no drainage: Three RCTs (two with PD and DP, one with PD only). Neither mortality (OR 1.57, 95%-CI: 0.62 to 3.93 p=0.34) nor overall complications (OR 0.88, 95%-CI: 0.71 to 1.08, p=0.21) differed between both groups (certainty of evidence: low). However, one trial was stopped prematurely because of higher 90-day mortality in the no drainage group. Early vs late drainage removal: Four RCTs (two with PD and DP, two with PD only). Early drain removal resulted in both a significant reduction of chyle leak (OR 0.22, 95%-CI: 0.06 to 0.59, p&amp;lt;0.01) as well as a shortening of LOS (mean difference -2.64 days, 95%CI: -4.63 to -0.65, p&amp;lt;0.01). For both outcomes the certainty of evidence was moderate. Mortality, postoperative pancreatic fistula and hemorrhage showed no difference between early vs late drainage removal (certainty of evidence: low). Active vs passive drainage: Three RCTs (one with PD and DP, two with PD only). None of the studies found any significant difference in outcome with regard to the type of drainage. Conclusion There is no evidence that drainages after pancreatic surgery should be standard of care. However, there is also no evidence that placing a drain leads to worse outcomes. If a drainage is used it should be removed early to avoid chyle leak and accelerate hospital discharge.