Management Of Leaks Research Articles

Role of interventional radiology in the management of postoperative gastrointestinal leakage

Role of interventional radiology in the management of postoperative gastrointestinal leakage

Current practice on the use of prophylactic drain after gastrectomy in Italy: the Abdominal Drain in Gastrectomy (ADiGe) survey

Evidence against the use of prophylactic drain after gastrectomy are increasing and ERAS guidelines suggest the benefit of drain avoidance. Nevertheless, it is unclear whether this practice is still widespread. We conducted a survey among Italian surgeons through the Italian Gastric Cancer Research Group and the Polispecialistic Society of Young Surgeons, aiming to understand the current use of prophylactic drain. A 28-item questionnaire-based survey was developed to analyze the current practice and the individual opinion about the use of prophylactic drain after gastrectomy. Groups based on age, experience and unit volume were separately analyzed. Response of 104 surgeons from 73 surgical units were collected. A standardized ERAS protocol for gastrectomy was applied by 42% of the respondents. Most of the surgeons, regardless of age, experience, or unit volume, declared to routinely place one or more drain after gastrectomy. Only 2 (1.9%) and 7 surgeons (6.7%) belonging to high volume units, do not routinely place drains after total and subtotal gastrectomy, respectively. More than 60% of the participants remove the drain on postoperative day 4–6 after performing an assessment of the anastomosis integrity. Interestingly, less than half of the surgeons believe that drain is the main tool for leak management, and this percentage further drops among younger surgeons. On the other hand, drain’s role seems to be more defined for duodenal stump leak treatment, with almost 50% of the surgeons recognizing its importance. Routine use of prophylactic drain after gastrectomy is still a widespread practice even if younger surgeons are more persuaded that it could not be advantageous.

Post-paracentesis Ascitic Fluid Leak in Patients with Cirrhosis of Liver and its Management: A Prospective Study

Ascites is the most common complication of decompensated cirrhosis of liver requiring paracentesis for diagnostic and therapeutic purposes. The ascitic fluid leak can develop after paracentesis in patients with cirrhosis leading to significant morbidity if persistent. We aimed to study the incidence and predictors of post-paracentesis leak in patients with ascites. In this prospective study, patients with cirrhosis undergoing therapeutic paracentesis were followed up, and those patients who developed persistent leak were included as cases. Controls were randomly selected in a 2:1 ratio from the group of patients who did not develop leak. Clinical and laboratory parameters were compared between the two groups. A total of 256 patients underwent 1126 sessions of therapeutic abdominal paracentesis over a period of 14 months. Post-paracentesis leak was seen in 55 (4.8%) patients while only 20 (1.7%) patients had persistent leak. The management of leak was in a stepwise manner initially with tincture benzoin with tight dressing followed by topical cyanoacrylate adhesive and followed by autologous blood patch in those not responding. The persistent leak group had higher proportion of patients with parietal edema, higher PT-INR and Child-Pugh score, lower mid-upper arm circumference, short physical performance battery score, and handgrip strength. On multivariate analysis, only the presence of parietal edema was an independent predictor of post-paracentesis persistent leak (odds ratio 10.35, 95% confidence interval 1.61-66.54, P=0.014). Persistent leak after paracentesis develops in a minority of patients with cirrhosis. The presence of parietal edema is a risk factor for persistent leak. The majority of these patients can be managed in a stepwise approach.

A novel resilience modeling method for community system considering natural gas leakage evolution

With rising natural gas demand, the issue of emergency management of gas leaks in communities is becoming more prominent. Resilience engineering is a successful approach to improving the system's ability in dealing with emergencies. In contrast to natural disasters such as floods and tornadoes, the consequences of a gas leak are closely related to the accident's evolutionary path. However, few reported works have taken the evolution of disasters into account in the assessment of resilience. Conventional methods fail to quantify the public safety performance of a disturbance caused by a natural gas leak. This work presents a novel dynamic approach to assessing resilience that incorporates the evolution of an incident and its interaction with emergency measures. A network structuring model of accident evolution is developed by the Functional Resonance Analysis Method (FRAM) to analyze the potential accident propagation. The explosion consequence of gas leakage escalation is simulated based on Computational Fluid Dynamics (CFD), and the personnel injury criterion is adopted to quantify the temporal and spatial variation characteristics of the system degradation. Then, the dynamic Bayesian network (DBN) is then used to track the interactions between accidents and emergency measures. Taking a real accident case (Shiyan underground gas explosion) as an example, the case study indicates that the proposed method can identify and prioritize emergency measures, as well as provide strong support for decision-making and arrangements in emergency management.

Reliability of Home Sleep Apnea Testing for Diagnosing Obstructive Sleep Apnea in Patients With Spontaneous Cerebrospinal Fluid Leaks.

To establish the prevalence of obstructive sleep apnea (OSA) in patients with spontaneous cerebrospinal fluid (sCSF) leaks and demonstrate the reliability of home sleep apnea testing (HSAT) to screen for OSA in this population. A literature review was performed to assess data on OSA prevalence in sCSF leaks. An institutional retrospective review was performed of 20 patients with sCSF leaks whomet inclusion criteria. Patients without prior sleep studies were prospectively administered sleep studies, either HSATor polysomnogram (PSG). Twenty patients met the inclusion criteria. Two patients had prior sleep studies while 18 patients obtained prospective sleep studies following diagnosis and prior to management of sCSF leaks. Nineteenpatients (95%) had evidence of mild or greater OSA. This study re-demonstrates the high prevalence of OSA in patients with sCSF leaks, consistent with current literature, and investigates the reliability of HSAT for diagnosis of OSA in this population.

ENDOBRONCHIAL VALVES FOR TREATMENT OF PERSISTENT AIR LEAK AFTER SECONDARY SPONTANEOUS PNEUMOTHORAX IN PATIENTS WITH CYSTIC FIBROSIS

ENDOBRONCHIAL VALVES FOR TREATMENT OF PERSISTENT AIR LEAK AFTER SECONDARY SPONTANEOUS PNEUMOTHORAX IN PATIENTS WITH CYSTIC FIBROSIS

CLINICAL AND ECONOMIC BURDEN ASSOCIATED WITH PROLONGED AIR LEAKS AMONG PATIENTS UNDERGOING THORACIC RESECTION: A RETROSPECTIVE DATABASE ANALYSIS

CLINICAL AND ECONOMIC BURDEN ASSOCIATED WITH PROLONGED AIR LEAKS AMONG PATIENTS UNDERGOING THORACIC RESECTION: A RETROSPECTIVE DATABASE ANALYSIS

S106 Management of Post-Cholecystectomy Bile Leaks: Predictors for Persistent Leak After Initial ERCP

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a 1st-line treatment for post-cholecystectomy bile leaks (PCBL). Despite appropriate initial ERCP interventions that optimize transpapillary bile flow, PCBL can persist. We aim to evaluate baseline clinical factors associated with persistent PCBL after initial ERCP. Methods: We created a retrospective database of patients with PCBL referred for ERCP at Indiana University Health (IUH) University Hospital. Data collected included endoscopic reports, fluoroscopic imaging, patient demographics, type of PCBL, ERCP timing and interventions, technical success, and treatment outcomes. A high-grade bile leak (HG-BL) was defined as visualization of contrast extravasation from the bile duct before filling of intrahepatic biliary branches with contrast. The PCBL was deemed to be persistent if > 1 interventional ERCP was required for the leak to resolve on cholangiogram. (Figure) Results: From 2011 to 2021, 369 cases of PCBL were referred for ERCP. After excluding cases with transected bile ducts (n=21) and patients lost to follow up (n=15), 333 cases were included in data analysis (Image 1). 21 patients received their initial ERCP at an outside hospital. All patients received biliary sphincterotomy with stenting unless there was coagulopathy or Roux-en-Y gastric bypass (n=12). Univariate logistic regression analysis identified male gender, steroids use at time of ERCP, presence of duodenal stricture, a HG-BL, Strasberg class D PCBL, presence of biloma, presence of abdominal drain, presence of biliary stricture, and initial ERCP performed at outside hospital to be significant variables for persistent PCBL (Table). On multivariate analysis, presence of a HG-BL (OR 7.08, CI 1.96 – 25.58, p = 0.003) and initial ERCP performed at an outside facility (OR 29.14, CI 3.35 – 253.63, p=0.002) remained significantly associated with persistent PCBL. Being a female gender (OR 0.30, CI 0.11 – 0.85, P = 0.022) remained significant for higher odds of PCBL resolution after initial ERCP. Conclusion: Our study suggests that a HG-BL in a male patient may justify more aggressive ERCP interventions or more prolonged stent indwell time. As a tertiary referral hospital, we had a significant referral bias in our cohort, which could have acted as a confounder causing statistical significance for lower initial ERCP success rates at outside medical facilities. The relatively high volume of ERCP cases at our center may also have contributed to better ERCP outcomes.Figure 1.: Flowchart of the Study Table 1. - Univariate analysis of clinical variables for persistent PCBL after initial ERCP treatment Variables Initial ERCP failure OR (95% CI) P value Patient Characteristics Female 25/204 (12.25%) 0.49 (0.27 – 0.86) 0.013 Age 55 years old or more 34/175 (19.43%) 1.60 (0.90-2.86) 0.112 Median BMI (IQR) 32.0 (26.0, 36.0) 1.00 (0.98 – 1.03) 0.874 On diabetic treatment 13/58 (22.41%) 1.81 (0.93 – 3.53) 0.083 On steroids 4/6 (66.67%) 10.18 (1.82 – 57.00) 0.008 Major papilla within duodenal diverticulum 11/57 (19.30%) 1.46 (0.73 – 2.93) 0.282 Duodenal stricture/stenosis 5/10 (50.00%) 5.17 (1.45 – 18.48) 0.011 Location and timing of ERCP Procedure ERCP performed > 3 days 48/273 (17.58%) 1.00 (0.47 – 2.12) 0.994 Initial ERCP performed at outside facility 17/21 (80.95%) 30.94 (9.96 -96.06) < 0.001 Bile leak characteristics Strasberg Class A bile leaks 44/302 (14.57%) 0.26 (0.12 – 0.54) < 0.001 Strasberg Class D bile leaks 10/31 (32.26%) 2.70 (1.19 – 6.12) 0.018 Bile leak from cystic duct* 34/192 (17.71%) 1.25 (0.70 – 2.24) 0.446 Bile leak from duct of Luschka 4/104 (3.85%) 0.21 (0.09 – 0.50) < 0.001 Bile leak from common bile duct/common hepatic duct 7/25 (28.00%) 2.66 (1.13 – 6.27) 0.025 High-grade bile leak 25/63 (39.68%) 4.80 (2.58 – 8.95) < 0.001 Concomitant biloma present 27/115 (23.48%) 2.06 (1.13 – 3.76) 0.018 Percutaneous abdominal drain present 42/204 (20.59%) 2.02 (1.07 – 3.82) 0.030 Presence of biliary stones 5/67 (7.46%) 0.34 (0.13 – 0.88) 0.026 Presence of biliary stricture 7/21 (33.33%) 2.63 (1.01 – 6.84) 0.048 ERCP interventions Biliary sphincterotomy performed 56/325 (17.23%) 1.04 (0.22 – 4.88) 0.960 Biliary sphincterotomy alone 2/6 (33.33%) 2.46 (0.44 – 13.73) 0.306 Biliary stenting alone 2/12 (16.67%) 0.96 (0.21 – 4.51) 0.960 Bridging biliary stents 20/134 (14.93%) 0.78 (0.43 – 1.43) 0.426 Multiple biliary plastic stents 6/55 (10.91%) 0.55 (0.22 – 1.36) 0.198 Self-expandable metal stent 2/11 (18.18%) 1.09 (0.23 – 5.21) 0.910 *Reference group. IQR, interquartile range; IUH, Indiana University Health.

S1106 Analysis of Reported Adverse Events Related to Over the Scope Clips: A MAUDE Database Analysis

Introduction: Over-the-scope clips (OTSC) have been increasingly used in the management of bleeding, perforations, fistulae, and anastomotic leaks in the gastrointestinal tract. However, since their Food and Drug Administration (FDA) approval in 2010, data on the adverse events of OTSC systems has been lacking. Our study aims to report and analyze adverse events and device failures associated with OTSC systems using the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database. Methods: We analyzed the post-marketing surveillance data from the FDA MAUDE database of the two OTSC systems available in the United States: The Padlock clip system and the Ovesco OTSC from April 2017 through May 2022. Results: Thirty-six medical device reporting claims were found from May 2017 through May 2022. Adverse events were classified as device-related problems and patient-related adverse events. Thirty-six device-related problems were reported, along with sixteen device-related adverse events (Table). Most device-related problems were reported in the Padlock defect closure system (n=23), followed by the Padlock pro clip system (n=8) and Ovesco OTSC clip system (n=5). The most common device-related problem was related to the failure of deployment of OTSC (n=14), followed by material protrusion or extrusion (n=6). The most common patient adverse events were perforation (n=4), bleeding (n=3), esophageal laceration (n=3) and luminal stenosis (n=2). Three out of four perforations were in the Padlock pro select closure system. All four patients required surgical management of the perforation. No deaths related to the use of OTSC were reported. Conclusion: Using the data from a publicly available database, the overall adverse events from OTSC systems remain low. Failure of OTSC deployment and perforation were the most common device-related problem and patient-related adverse events, respectively. The identification of common adverse events has the potential to optimize device design and patient outcomes. It is important for endoscopists to be mindful of these potential adverse events when using over-the-scope clips. Table 1. - Device-related problems and adverse events Device-related problems Number Failure of OTSC deployment 14 Other 8 Separation problems 3 Detachment of the device 2 Protrusion or extrusion of over the scope clip system 6 Defective device component 2 Failure of positioning of the device 1 Total 36 Patient related- adverse events Number Gastro-gastric fistula 1 Perforation 4 Local trauma 1 Pain 1 Bleeding 3 Pyloric stenosis 1 Colonic stenosis 1 Esophageal laceration 3 Ulcer 1 Total 16

S1112 Endoscopic Management of Esophageal Perforations and Leaks: A Multi-Center Study

Introduction: Endoscopic advancements in stenting and tissue plication have proven to be viable alternatives to surgical management of esophageal perforations and are increasingly being used in clinical practice. We aim to assess the efficacy and outcome of different endoscopic treatment modalities in patients with esophageal perforations. Methods: We performed a retrospective analysis of patients with esophageal perforations from an endoscopic database since 2007. Patients with esophageal fistula, stricture, or stenosis were excluded. Patients were categorized into four treatment groups: primary closure (endoscopic suturing), primary bypass (stenting), combination (suturing defect and stenting), and conservative therapy (NPO, trans-nasal feeding tubes). Baseline demographics, patient characteristics, and treatment modality outcomes were collected. Predictors of success were identified using logistic regression. Results: 95 patients (mean age 64 ±15, 67% male) with esophageal perforations were included. The most common etiology was iatrogenic after dilatations or endoscopic myotomy (40%). 64% of perforations were in the distal esophagus. Regardless of strategy employed, 49% of patients had successful endoscopic repair of perforation. Only 7 patients required subsequent operative intervention. The combination approach achieved the greatest clinical success (66%), defined as no need for surgical intervention, when compared to the other modalities (primary bypass 35%, closure 57%, and conservative 25%, p=0.05). Patients with concomitant systemic inflammatory response syndrome had greater clinical success if they were treated with combination approach compared to primary bypass approach (18% vs. 64%, p=0.01). If the perforation was greater than or equal to 20mm, combination therapy had greater clinical success compared to primary bypass approach (0% vs. 50%, p=0.04). Early stent migration was associated with greater need for rescue surgery (p=0.02). (Table) Conclusion: Esophageal perforations can be managed effectively with endoscopic therapy. Larger, prospective trials are needed to clarify ideal individualized endoscopic strategies. Patients with systemic inflammatory response and/or perforation ≥20 mm are managed most effectively with combination therapy. Table 1. - Demographics, Presentation and Outcomes by Treatment Group Variables (%) All (n=95) Primary bypass (n=43) Primary closure (n=12) Combination(n=29) Conservative(n=11) Demographics All Primary bypass (n=43) Primary closure (n=12) Combination (n=29) Conservative (n=11) p-value Age (± SD) 63 ±14 66 ±13 61 ±13 61 ±15 64 ±15 0.23 Sex (Male) 64(67) 16(70) 10 (83) 19(65) 7(63) 0.61 History of EC 14 (16) 6(26) 1(8.3) 3(10) 2(18) 0.31 History of Radiotherapy 15 (19) 6(26) 0(0) 4(14) 2(18) 0.245 Diabetes 14(15) 2(9) 7 (43) 3(10) 2(18) 0.686 Hypertension 48(51) 12(52) 7(58) 13(45) 5(46) 0.927 Sleep apnea 16(17) 5(22) 2(17) 5(17) 0(0) 0.45 Site of Perforation Proximal 4(9.3) 0 2(6.9) 6(54.5) Middle 7(6.3) 3(25.0) 7(24.1) 0 Distal 29 (67.4) 8(66.7) 20(69.0) 5(45.5) Etiology of perforation SpontaneousIatrogenicFood impactionAnastomotic leakEsophageal cancer Boerhaave syndrome 7(16.3)22(51.2)2(4.7) 4(9.3) 2(4.7)6(14.0) 1(8.3)9(75.0)1(8.3) 0 01(8.3) 021(72.4)2(6.9) 3(10.3) 01(3.4) 2 (18.2)7(63.6)1(9.1) 0 01(9.1) Symptoms at time of diagnosis DysphagiaChest painAbdominal painFeverOther 10(23.3)11(25.6)1(2.3) 4(9.3)10(23.3) 1(8.3)4(33.3)0 1(8.3)2(16.7) 4(13.8)4(13.8)1(3.4) 5(17.2)8(27.6) 4(36.4)1(9.1)1(9.1) 02(18.2) Outcomes by Treatment Group Pittsburgh Perforation Severity Score (n=47) 3.17 ±2.1 3.59 ±2.2 2.5±2.0 2.72±1.8 3.45±2.25 0.225 Operative intervention required 7(5.7) 2(4.7) 1(8.3) 3(10.3) 1(9.1) 0.95 Mortality 9(7.4) 4(9.3) 0 3(10.3) 2(18.2) 0.652 SIRS 44(36.1) 19(44.2) 4(33.3) 16 (55.2) 5(45.5) 0.635 Stent migration 11 10(23.3) 0 2(6.9) 0 0.182 LOS* (days) 16±15 19 ±15 11±10 18±19 7.9±7.0 0.123 LOF* (months) 4.6±4.1 4.25±1.5 6±8.8 3.5±2.1 9.3±6.4 0.07 *LOS – Length Of Stay In The Hospital; LOF - Time From Diagnosis To Last-Follow Up; SIRS - Systemic Inflammatory Response Syndrome)

The diagnosis of cerebrospinal fluid leakage after microvascular decompression surgery and management via lumbar drain

Objective: In posterior fossa surgery such as microvascular decompression (MVD), cerebrospinal fluid (CSF) leakage is a crucial problem. In this study, we explored the accurate diagnosis and effective non-surgical management of postoperative CSF leakage.Methods: We reviewed 749 patients who underwent MVD surgery from August 2018 to April 2022. Although we significantly reduced the CSF leakage problem by using the triple-layer closing technique (TLCT), CSF leakage was still a problem in a few cases. We managed these patients with the same diagnostic flow and treatment regimen using a lumbar drain (LD).Results: Among the 749 patients in the cohort, 11 (1.4%) had CSF leakage, and each of those cases presented with rhinorrhea. Five patients (45.5%) had the symptom on the first day, two patients (18.2%) on the second day, one patient (9.1%) on the third day, and three patients (27.3%) on the fifth day after surgery. After conservative treatment including CSF drainage via LD for 5.4 days on average, none of the patients had recurrent symptoms suggesting CSF leakage; thus, there was no need for wound repair surgery.Conclusion: Despite diligent attempts to prevent CSF leakage in open microsurgery, leaks inevitably occur in some cases and are more frequent in posterior fossa surgery. Although we cannot fully prevent leakage, we should limit the complication to ensure that it does not progress into other severe problems, such as meningitis. A closing technique such as TLCT is useful, but the early diagnosis and management of CSF leakage with LD is also important.

Endoscopic cerebrospinal fluid leak repair combined with thecoperitoneal shunting for spontaneous cerebrospinal fluid rhinorrhea: MERF experience

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Spontaneous cerebrospinal fluid (CSF) rhinorrhoea is encountered as a diagnosis of exclusion in clinical practice once all other aetiologies have been meticulously ruled out and can mostly present from preformed pathways due to benign intracranial hypertension (BIH) over time. Such leaks need to be clearly located for planning appropriate repair along with adequate control of CSF pressure to avoid recurrence. Thus, the aim of our study was to review the efficacy and outcomes of a combined endoscopic multilayered repair along with simultaneous theco-peritoneal shunting (TPS) for patients with spontaneous CSF rhinorrhoea in the background of BIH.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Retrospective observational study analyzing the clinical presentations, surgical techniques and the immediate / long term outcomes of this combined approach.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;The&lt;strong&gt; &lt;/strong&gt;46 patients who had endoscopic CSF repair with TPS done between 2008-2019 were reviewed. The mean opening CSF pressure in these cases were &amp;gt;25 cm H&lt;sub&gt;2&lt;/sub&gt;O. The commonest site of leak was from cribriform plate followed by fovea ethmoidalis. Multilayered closure was done with autologous grafts along with TPS simultaneously. The 92% were successful, 6% had shunt problems needing revision shunts and 2% also needed revision endoscopic repair. &lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Overall outcomes shows that the combined approach was safe and effective in arresting the CSF leak in 98% patients. Therefore, the rationale for a combined approach for the management of spontaneous CSF leaks in the background of BIH stands proven based on our Institutional experience.&lt;/p&gt;

499. ICG GUIDED THORACIC DUCT CLIPPING FOR CHYLE LEAKS

Abstract Chylothorax and chyle leaks in neck are serious complications resulting from trauma or iatrogenic causes. Early and accurate clipping of thoracic duct is potentially life saving. ICG can be injected in groin node under USG guidance for fast visualisation and correct clipping of thoracic duct. On table confirmation and documentation of no lymph flow beyond the clip is feasible. 2.5 mg indocyanine green in injected intranodal via ultrasound guidance. Near infrared camera is utilised to view fluorescence imaging overlayed over thoracoscopic camera vision. Groin intranodal injection of ICG yields brilliantly fluorescent illumination of thoracic duct which is especially useful in cases of chyle leaks. Documentation of correct identification and post clipping termination of lymph flow beyond clip is feasible. ICG intranodal injection yields excellent visualisation of thoracic duct which is useful in management of chyle leaks.

Mechanism and management of leaks arising after left atrial appendage closure (LAAC).

This article reviews the latest available data in regard to the diagnosis, management, and intervention of both central and peri-device leaks that arise after left atrial appendage closure (LAAC). The aim of this article is to have a better understanding of both addressing leaks arising after LAAC, and which interventions and closure methods are best served for each type of residual leak based on etiology, size, and operator experience.

Octreotide Dosing in the Medical Management of Chyle Leak Following Otolaryngologic, Thoracic, and Trauma Surgery: A 9-Year Evaluation

Background: Chyle leak is a rare complication following otolaryngologic, thoracic, and trauma surgery wherein the thoracic duct is transected. Case reports and small case series describe octreotide for the medical management of chyle leak, but limited data exist to determine the ideal dose. Objective: To evaluate octreotide dosing in patients with acute chyle leak. Methods: This retrospective, single center, cohort study evaluated adult patients admitted to the otolaryngology, cardiothoracic, and trauma surgery teams over a 9-year period. Patients diagnosed with a chyle leak who received octreotide were eligible for inclusion. Groups were defined as successful medical management or failure requiring definitive surgery. The primary endpoint was daily octreotide dose between groups. Results: Forty-seven patients were included with 29 (61.7%) admitted to the otolaryngology service and 44 (93.6%) with surgical complication as the chyle leak cause. Thirty-two (68.1%) patients had successful medical management while 15 (31.9%) patients failed and required surgical intervention. There was no difference in median daily octreotide dose (250 [IQR, 170-288] µg vs 253 [IQR, 200-282] µg, P = .9). Octreotide weight-based dose, treatment duration, and route of administration were similar between groups. Daily drain output and complete bowel rest were significantly higher in the failure group. Daily drain output was identified as an independent risk factor for failure. Conclusion: Octreotide dose was similar in patients with and without successful medical management of chyle leak. Future studies are needed to determine optimal octreotide dosing and elucidate the relationship between octreotide, drain output, and surgical intervention need.

Use of sponge-assisted endoluminal vacuum therapy for the treatment of colorectal anastomotic leaks: expert panel consensus.

BackgroundAnastomotic leaks represent one of the most significant complications of colorectal surgery and are the primary cause of postoperative mortality and morbidity. Sponge-assisted endoluminal vacuum therapy (EVT) has emerged as a minimally invasive technique for the management of anastomotic leaks; however, there are questions regarding patient selection due to the heterogeneous nature of anastomotic leaks and the application of sponge-assisted EVT by surgeons.MethodSeven colorectal surgical experts participated in a modified nominal group technique to establish consensus regarding key questions that arose from existing gaps in scientific evidence and the variability in clinical practice. After a bibliographic search to identify the available evidence and sequential meetings with participants, a series of recommendations and statements were formulated and agreed upon.ResultsThirty-seven recommendations and statements on the optimal use of sponge-assisted EVT were elaborated on and unanimously agreed upon by the group of experts. The statements and recommendations answer 10 key questions about the indications, benefits, and definition of the success rate of sponge-assisted EVT for the management of anastomotic leaks.ConclusionAlthough further research is needed to resolve clinical and technical issues associated with sponge-assisted EVT, the recommendations and statements produced from this project summarize critical aspects to consider when using sponge-assisted EVT and to assist those involved in the management of patients with colorectal anastomotic leaks.

Risk Factors, Diagnosis and Management of Chyle Leak Following Esophagectomy for Cancers: An International Consensus Statement.

Objective:This Delphi exercise aimed to gather consensus surrounding risk factors, diagnosis, and management of chyle leaks after esophagectomy and to develop recommendations for clinical practice.Background:Chyle leaks following esophagectomy for malignancy are uncommon. Although they are associated with increased morbidity and mortality, diagnosis and management of these patients remain controversial and a challenge globally.Methods:This was a modified Delphi exercise was delivered to clinicians across the oesophagogastric anastomosis collaborative. A 5-staged iterative process was used to gather consensus on clinical practice, including a scoping systematic review (stage 1), 2 rounds of anonymous electronic voting (stages 2 and 3), data-based analysis (stage 4), and guideline and consensus development (stage 5). Stratified analyses were performed by surgeon specialty and surgeon volume.Results:In stage 1, the steering committee proposed areas of uncertainty across 5 domains: risk factors, intraoperative techniques, and postoperative management (ie, diagnosis, severity, and treatment). In stages 2 and 3, 275 and 250 respondents respectively participated in online voting. Consensus was achieved on intraoperative thoracic duct ligation, postoperative diagnosis by milky chest drain output and biochemical testing with triglycerides and chylomicrons, assessing severity with volume of chest drain over 24 hours and a step-up approach in the management of chyle leaks. Stratified analyses demonstrated consistent results. In stage 4, data from the Oesophagogastric Anastomosis Audit demonstrated that chyle leaks occurred in 5.4% (122/2247). Increasing chyle leak grades were associated with higher rates of pulmonary complications, return to theater, prolonged length of stay, and 90-day mortality. In stage 5, 41 surgeons developed a set of recommendations in the intraoperative techniques, diagnosis, and management of chyle leaks.Conclusions:Several areas of consensus were reached surrounding diagnosis and management of chyle leaks following esophagectomy for malignancy. Guidance in clinical practice through adaptation of recommendations from this consensus may help in the prevention of, timely diagnosis, and management of chyle leaks.

Leakage Management after Laparoscopic Sleeve Gastrectomy: A Tertiary Center Experience in Saudi Arabia

Purpose: The goal of this study was to determine the optimal method for treating gastric leaks in terms of resolution rate, complications, admission to the intensive care unit (ICU), conversion to other surgical techniques, and mortality. Methods: A retrospective analysis of patients treated at King Abdul-Aziz Specialist Hospital between 2017 and 2021 for post-LSG leaks. Age, gender, body mass index (BMI), preoperative comorbidities, leak rate, the interval between surgery and leak, the onset and site of leak, as well as the management lines and outcomes, were collected. Results: The leak rate following Laparoscopic Sleeve Gastrectomy (LSG) at our hospital was 0.53 percent, and there were no statistically significant differences in the demographic characteristics of patients with and without leaks. Despite the fact that 87.5 percent of patients were women, this was not statistically significant (P-value:0.09). The mean± SD interval between surgery and leak is 14 ±18.4, with early and acute leaks being the most common. Failure of first-line management, stent migration, and esophageal stricture were the most commoncomplications of leak management in our study. The mean length of hospital stays was 42.4 ±17.1 days, and the mortality rate was 12.5%. Conclusions: Leak after LSG is a drastic complication associated with substantial morbidity and mortality if diagnosis and treatment are delayed. Depending on the patient’s condition, location of the leak, and the time of diagnosis,; leak management may involve conservative, endoscopic, or surgical approaches. There are numerous measures that could be taken to reduce the leak incidence rate. Keywords: Bariatric surgery; Sleeve Gastrectomy; Leak; Treatment; Outcomes

Prevention of and Countermeasures for Surgical Site Infection in the Field of Skull Base Surgery

In neurosurgery, perioperative surgical site infection(SSI)is associated with complicated postoperative management, prolonged hospital stay, and patient stress. In this article, we review SSI in the field of skull base surgery, including endoscopic endonasal surgery, and discuss ways to prevent SSI. In a craniotomy, in which the frontal sinus is revealed, prevention of cerebrospinal fluid(CSF)leakage by reliable repair of the dura and frontal sinus reduces SSI. In addition, prevention of postoperative CSF leakage by reliable skull base reconstruction in endoscopic endonasal surgery contributes to the prevention of SSI. Prophylactic antibiotics are often reported to be useful, and cephalosporin or sulbactam/ampicillin intravenous injections are generally used. There are insufficient data to recommend lumbar drainage for the management of SSI and postoperative CSF leak. Skull base surgery is often a clean-contaminated surgery, and serious complications can be prevented by proper understanding and performance of the appropriate method as required. However, no studies with a high level of evidence on SSI in the field of skull base surgery exist. New large randomized controlled trials are expected to evaluate the efficacy of prophylactic antibiotics in skull base surgery.

Air Leak Management in the Digital Age—We Still Need to Decipher the Data

Optimal Chest Drainage Method After Anatomic Lung Resection: A Prospective Observational StudyThe Annals of Thoracic SurgeryPreviewSeveral methods for chest drainage after pulmonary resection of malignant lung tumors exist, but consensus on the ideal method has not been reached. Full-Text PDF