Persistent Drainage Research Articles

¿Por qué supura una cavidad de mastoidectomía? nuestra experiencia y revisión de la literatura

The main goal for performing surgery for chronic otitis media is to eliminate the disease and improve hearing whenever possible. Persistent drainage of a mastoid cavity means failure of surgery and of achieving the goal. In this study, we present our department’s attitude for suppurative mastoid cavities as well as the reasons that do not allow adequate control of them.

OMENTAL INTERPOSITION FOR REPAIR OF A VESICO-ACETABULAR FISTULA

An 84-year-old woman underwent revision of a previous right total hip replacement for degenerative joint disease. Shortly after surgery the metallic hip prosthesis became infected and required removal. The acetabular space was preserved using polymethyl-methacrylate cement. Persistent cellulitis and drainage of clear yellow fluid from the hip incision led to suspicion of a vesico-acetabular fistula. Urethral catheter bladder drainage for 4 weeks was unsuccessful and, subsequently, the patient was referred to our facility. A computerized tomography cystogram confirmed the diagnosis of vesico-acetabular (fig. 1, A). Cystoscopy revealed a solitary fistulous tract between the right lateral bladder wall and acetabular hemispheric shell which was cannulated using a 5Fr ureteral catheter (fig. 2). Through an infraumbilical extraperitoneal incision, the right lateral aspect of the bladder was mobilized off of the adhesed pelvic sidewall and the fistula was identified. A longitudinal cystotomy was made at the dome allowing bladder exploration and precise excision of the cannulated fistulous tract. The most challenging aspect of this procedure involved dissection and excision of the fistulous tract in its entirety as it coursed towards the acetabulum. After dissection to well vascularized tissue, a multilayered tension-free bladder closure was performed. To secure the repair, omentum was mobilized through a small peritoneotomy and interposed between the right pelvic sidewall and bladder. A cystogram (Fig. 1) after 3 weeks of continuous uninterrupted bladder drainage revealed successful closure of the vesico-acetabular (fig. 1, B).

Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program

Background. Deep wound infection (DWI) in total knee (TKA) and total hip (THA) arthroplasty has been shown to highly correlate with superficial surgical site infection (SSSI). Although several studies have reported hospital factors that predispose to SSSI, patient factors have not been clearly elucidated. Methods. All patients undergoing TKA ( n=1181) and THA ( n=1124) surgery during the period 1977–1995 at our institution were observed at the end of a 30-day post-operative period. Thirty-three patients that developed SSSI during this period constituted the study group. The control group was composed of 64 matched subjects that did not develop SSSI. A chart review was applied to abstract DWI cases during the first 18 post-operative months for the study group and for an average of 6.7 years for the control group (range 5–18.2 years). Potential risk factors for SSSI were used as predictors of SSSI in a logistic regression analysis. Results. During the 18-month observation period 19 out of the 33 study subjects (58%) developed DWI. No DWI was registered in the control group (the difference was significant, p<0.0001). Of the nine pre-operative, five intra-operative, and five post-operative factors examined, only hematoma formation (odds ratio=11.8; p=0.001) and days of post-operative drainage (odds ratio=1.32; p=0.01) were significant predictors of SSSI. The cases consumed more health care resources at all stages of the medical process. Conclusions. Our results (1) confirm the strong correlation between the probability of developing DWI and SSSI; (2) indicate that hematoma formation and persistent post-operative drainage increase the risk of SSSI. We hypothesize that post-operative monitoring of patients for hematoma and persistent drainage enables earlier intervention that may lower the risk of developing SSSI and subsequent DWI.

Treatment of complications of hepatic hydatid disease by ERCP

Background: The aim of this study was to evaluate the effectiveness of endoscopic sphincterotomy for preoperative and postoperative complications of hepatic hydatid disease. Methods: Nineteen patients underwent endoscopic treatment for complications of hepatic hydatid disease. Indications for ERCP in 5 patients treated before surgery (Group A) were obstructive jaundice in 1 and acute cholangitis in 4. In 14 patients treated after surgery (Group B), the indication was acute cholangitis in 6, obstructive jaundice 2, and persistent external drainage in 6 patients. Observations: In group A, ERCP detected hydatid vesicles within the bile duct. All patients underwent endoscopic sphincterotomy and clearance of the duct with no complications. The 6 patients in Group B with persistent external drainage had biliary fistulas that resolved after endoscopic treatment within 10 to 20 days. Among the 8 patients with postoperative obstructive jaundice or acute cholangitis, 7 had cyst remnants obstructing the bile duct and 1 had findings of sclerosing cholangitis. All underwent endoscopic sphincterotomy and clearance of the bile duct without complications. After treatment, all patients, with the exception of the one with sclerosing cholangitis, remained asymptomatic. Conclusion: Endoscopic sphincterotomy is a safe and effective treatment for biliary complications of hepatic hydatid disease.

Duplication of the external auditory canal: a report of three cases

Objective: Malformations of the first branchial cleft are uncommon and only sporadically reported in the literature. They may present as inflammatory openings on the neck, bland cysts or fistula associated with the external auditory canal. In this retrospective study, clinical features and anatomical relationships are described in three pediatric cases. Therapeutical guidelines for surgical management of first branchial cleft anomalies are discussed. Patients: Between 1997 and 1999 three patients aged 9 months, 2 and 7 years with first branchial cleft anomalies were included in this study. All patients were treated surgically, wide exposure and superficial parotidectomy was necessary for complete removal in two of three cases. Results: Exploring patients histories revealed previous infections with repeated incision and drainage procedures as well as inadequate operative resections. Clinically, purulent drainage from the ear, swelling in the parotid area and abscess formation with persistent drainage after incision in the neck or parotid area were noted. Conclusions: From our case series two of three patients underwent inadequate incision and drainage procedures to combat infection followed by scar tissue formation. Because of the variable relation to the facial nerve this led to difficulties in identifiying and protecting the nerve during definite surgery. Management of first branchial cleft anomalies must include the facilities to achieve ear surgery and superficial parotidectomy including facial nerve exposure.

Deep Wound Infections After Neuromuscular Scoliosis Surgery

A retrospective case-control study evaluating risk factors for infection, causative organisms, and results of treatment in patients with cerebral palsy or myelomeningocele who underwent fusion for scoliosis was performed. To identify risk factors for infection, and to characterize the infections in terms of infecting organisms and response to treatment. No previous studies have analyzed risk factors or causative organisms, nor have they indicated results of treatment for infections in this group of patients. After a 10-year retrospective review of 210 surgically treated patients, deep wound infections developed in 16 patients with myelomeningocele and 9 patients with cerebral palsy. These patients were studied extensively for possible risk factors, along with 50 uninfected patients matched for age, diagnosis, and year of surgery. Statistical testing was performed to identify risk factors. The courses of the infections were characterized in terms of organisms isolated and response to treatment. Treatment was performed in a stepwise fashion and classified in terms of the most successful step: debridement and closure, granulation over rods, or instrumentation removal. Of the 10 risk factors tested, 2 were found to be significant: degree of cognitive impairment and use of allograft. Findings showed that 52% of the infections were polymicrobial. Gram-negative organisms were isolated as commonly as gram-positive organisms. The most common organisms were coagulase-negative Staphylococcus, Enterobacter, Enterococcus, and Escherichia coli.- Debridement and closure were successful in 11 of 25 patients with deep wound infection. Of the 14 patients with infection not resolved by serial debridements and closure, 2 were managed successfully by allowing the wound to granulate over rods, and 7 required rod removal for persistent wound drainage. There were three symptomatic pseudarthroses. Infections resulting from gram-positive organisms were most often managed successfully with debridement and closure (P = 0.012). Patients with cerebral palsy or myelomeningocele who have severe cognitive impairment, and those who received allograft may be at increased risk for infection. Infections are more often polymicrobial and caused by gram-negative organisms than is typical for elective orthopedic procedures. This suggests an enteric source. Treatment with debridement and closure was not always successful. Patients in whom infection develops are then at increased risk for pseudarthrosis.

A new portable chest drainage device

Background. Persistent air leak is a frequent complication in lung operation. The Heimlich valve is the standard system for venting the pleural cavity. The device achieves good results and is well tolerated, but the main problem is when air leak is associated with fluid leakage.Methods. In order to improve the outpatient management of persistent air and fluid drainage after resectional procedures, we developed an original device. It is a portable system provided with a one-way valve connected to the chest tube for drainage of air and fluid, a reservoir for collecting fluid, and a one-way exhaust valve to evacuate air from the bag.Results. We analyze the advantages of our device versus the Heimlich valve in the first series of 18 selected patients. Our system is drier and cleaner, easier to manage, and ambulatory visits are seldom needed. There is also a cost savings.Conclusions. Our device enhances ambulation, independence, and the quality of life of the patients, and decreases the need for hospital and outpatient care.

Timing of surgery/catheter intervention in common congenital cardiac defects.

A large load of children with congenital heart disease (CHD) exists in our country. Fortunately facilities for treatment of almost all types of defects are available, although in few centres only. Many children are however, referred late for correction making them either high risk for surgery or inoperable due to development of irreversible pulmonary vascular obstructive disease. Therefore, it is important to recognise the ideal time of intervention in different types of CHD. A child with large atrial septal defect should have its closure by 3 to 4 years of age; on the other hand, a large ventricular septal defect (VSD) producing congestive heart failure needs very early surgery. Infants with small VSD may be medically managed as chances of spontaneous closure are high. Ligation of patent ductus arteriosus should be done at about one year of age if there is no pulmonary arterial hypertension or congestive heart failure. Similarly, coarctation should be dealt with either balloon dilatation or surgery at about one year of age provided the left ventricular function is normal and blood pressure in upper limb is well under control. For tetralogy of Fallot, correction is best done at about 9 months to one year of age. In case the child is symptomatic early, either a palliative shunt is done or total correction is performed if anatomy is suitable. In admixture lesions like transposition of great arteries (TGA), persistent truncus arteriosus or total anomalous pulmonary venous drainage, a very early intervention is needed so as to avoid development of severe hypoxia and early pulmonary vascular obstructive changes. Arterial switch operation is best performed in first two to three weeks of life for TGA with intact ventricular septum cases. Knowledge of natural history of the CHD is essential to plan for optimal timing of surgery or catheter intervention.

Outcomes of Primary and Secondary Treatment of Pericardial Effusion in Patients With Malignancy

To evaluate the treatment strategies for primary and secondary management of malignancy-related pericardial effusions. Retrospective review of Mayo Clinic Rochester charts and external records of patients with pericardial effusion associated with malignant disease who required treatment between February 1979 and June 1998 was performed. Telephone interviews with patients, their families, or their physicians were conducted to determine the outcomes of treatment. Recurrence of pericardial effusion and survival were the main outcome measures. Of 1002 consecutive pericardiocenteses performed during the period under study, 341 were performed in 275 patients with confirmed malignant disease. Patients were followed up for a minimum of 190 days, unless death occurred first. Of 275 patients, recurrence of pericardial effusion or persistent drainage necessitated secondary management in 59 (43 of 118 simple pericardiocenteses, 16 of 139 pericardiocenteses with extended catheter drainage, and 0 of 18 pericardial surgery following temporizing pericardiocentesis). Recurrence was strongly and independently predicted by absence of pericardial catheter for extended drainage, large effusion size, and emergency procedures. Recurrence after secondary management occurred in 12 patients: 11 underwent successful pericardiocentesis with extended catheter drainage, and 1 had pericardial surgery. Median survival of the cohort was 135 days, and 26% survived the first year after diagnosis of pericardial effusion. Male sex, positive fluid cytology for malignant cells, lung cancer, and clinical presentation of tamponade or hemodynamic collapse were independently associated with poor survival. Echocardiographically guided pericardiocentesis with extended catheter drainage appears to be safe and effective for both primary and secondary management of pericardial effusion in patients with malignancy.

Outcomes of Primary and Secondary Treatment of Pericardial Effusion in Patients With Malignancy

Objective To evaluate the treatment strategies for primary and secondary management of malignancy-related pericardial effusions. Patients And Methods Retrospective review of Mayo Clinic Rochester charts and external records of patients with pericardial effusion associated with malignant disease who required treatment between February 1979 and June 1998 was performed. Telephone interviews with patients, their families, or their physicians were conducted to determine the outcomes of treatment. Recurrence of pericardial effusion and survival were the main outcome measures. Results Of 1002 consecutive pericardiocenteses performed during the period under study, 341 were performed in 275 patients with confirmed malignant disease. Patients were followed up for a minimum of 190 days, unless death occurred first. Of 275 patients, recurrence of pericardial effusion or persistent drainage necessitated secondary management in 59 (43 of 118 simple pericardiocenteses, 16 of 139 pericardiocenteses with extended catheter drainage, and 0 of 18 pericardial surgery following temporizing pericardiocentesis). Recurrence was strongly and independently predicted by absence of pericardial catheter for extended drainage, large effusion size, and emergency procedures. Recurrence after secondary management occurred in 12 patients; 11 underwent successful pericardiocentesis with extended catheter drainage, and 1 had pericardial surgery. Median survival of the cohort was 135 days, and 26% survived the first year after diagnosis of pericardial effusion. Male sex, positive fluid cytology for malignant cells, lung cancer, and clinical presentation of lamponade or hemodynamic collapse were independently associated with poor survival. Conclusion Echocardiographically guided pericardiocentesis with extended catheter drainage appears to be safe and effective for both primary and secondary management of pericardial effusion in patients with malignancy. To evaluate the treatment strategies for primary and secondary management of malignancy-related pericardial effusions. Retrospective review of Mayo Clinic Rochester charts and external records of patients with pericardial effusion associated with malignant disease who required treatment between February 1979 and June 1998 was performed. Telephone interviews with patients, their families, or their physicians were conducted to determine the outcomes of treatment. Recurrence of pericardial effusion and survival were the main outcome measures. Of 1002 consecutive pericardiocenteses performed during the period under study, 341 were performed in 275 patients with confirmed malignant disease. Patients were followed up for a minimum of 190 days, unless death occurred first. Of 275 patients, recurrence of pericardial effusion or persistent drainage necessitated secondary management in 59 (43 of 118 simple pericardiocenteses, 16 of 139 pericardiocenteses with extended catheter drainage, and 0 of 18 pericardial surgery following temporizing pericardiocentesis). Recurrence was strongly and independently predicted by absence of pericardial catheter for extended drainage, large effusion size, and emergency procedures. Recurrence after secondary management occurred in 12 patients; 11 underwent successful pericardiocentesis with extended catheter drainage, and 1 had pericardial surgery. Median survival of the cohort was 135 days, and 26% survived the first year after diagnosis of pericardial effusion. Male sex, positive fluid cytology for malignant cells, lung cancer, and clinical presentation of lamponade or hemodynamic collapse were independently associated with poor survival. Echocardiographically guided pericardiocentesis with extended catheter drainage appears to be safe and effective for both primary and secondary management of pericardial effusion in patients with malignancy.

Systematic management of chyle fistula: The Southwestern experience and review of the literature

Postoperative cervical chyle fistula after neck dissection is a complication with potentially serious morbidity. Once it is recognized, treatment decisions to optimize patient care can be difficult. Different management strategies have been advocated on the basis of institutional and personal experience. In this study we comprehensively review the published protocols and retrospectively review our experience in the management of 15 patients with chyle fistula. All patients in this study were given a trial of nonoperative management with nutritional modification, pressure dressings, and closed drainage. Medical management ultimately failed in 3 patients (20%). Two patients had prolonged courses of medical management with associated complications. An analysis of our data supports early operative intervention if the peak 24-hour drainage is greater than 1000 mL without a prompt response to medical management. Persistent low-output drainage after 10 days is associated with a prolonged management course and treatment-related complications. Optimal treatment of these patients is unclear. (Otolaryngol Head Neck Surg 2000;122:31-8.)

Fistula-in-ano after episiotomy

Background: In the past 2 years, we treated three women with fourth-degree lacerations or episiotomy infections presenting with persistent pain and drainage not responding to standard treatment. Cases: These women were referred for evaluation 5 weeks, 3.5 months, and 2 years postpartum. After diagnosing fistula-in-ano, we treated them with fistulotomy and curettage, which resolved the problem. Conclusion: When a patient presents with pain or drainage at her episiotomy site, fistula-in-ano should be considered.

FISTULA-IN-ANO AFTER EPISIOTOMY

Background In the past 2 years, we treated three women with fourth-degree lacerations or episiotomy infections presenting with persistent pain and drainage not responding to standard treatment. Cases These women were referred for evaluation 5 weeks, 3.5 months, and 2 years postpartum. After diagnosing fistula-in-ano, we treated them with fistulotomy and curettage, which resolved the problem. Conclusion When a patient presents with pain or drainage at her episiotomy site, fistula-in-ano should be considered.

The role of peritoneal drainage for intestinal perforation in infants with and without necrotizing enterocolitis

Background/Purpose : This report reviews our experience using peritoneal drainage (PD) as initial therapy for intestinal perforation in premature infants with and without necrotizing enterocolitis (NEC). Methods : A chart review was conducted of 18 consecutive premature infants who underwent PD for intestinal perforation from 1995 to 1998. Infants were divided into two groups. Group 1 consisted of eight infants who had intestinal perforation without evidence of NEC. Group 2 consisted of 10 infants who had perforation associated with evidence of NEC. A cohort of 10 infants with intestinal perforation treated with primary laparotomy between 1990 and 1995 was identified by chart review for historical control. Results : All infants improved immediately after PD. In group 1, all survived. Seven (88%) recovered systemically after PD. Of these, five (63%) never required laparotomy. Two (25%) required delayed laparotomy. One infant (12%) failed to continue to improved 48 hours after PD and underwent urgent laparotomy and recovered. In group 2, eight (80%) infants survived. Six (60%) recovered from NEC after PD, but five required delayed laparotomy for obstruction or persistent drainage. Four infants (40%) failed to progress from their initial improvement after PD. Three underwent laparotomy; two recovered and one had total intestinal necrosis and died. The fourth infant died without exploration and total intestinal necrosis was discovered during autopsy. Thus, seven of eight survivors (88%) in group 2 required laparotomy at some point in their course. Conclusions : In premature infants with intestinal perforation, PD allows acute improvement and usually systemic recovery. In infants without evidence of NEC, PD may afford definitive treatment. In contrast, infants with evidence of NEC will likely require laparotomy, but initial PD may allow systemic stabilization and recovery of much of the involved intestine before laparotomy.

Percutaneous treatment of hepatic hydatid cysts: an alternative to surgery.

Percutaneous treatment of hydatid cysts is relatively new, and the data related to it are limited. The purpose of this study was to provide additional data to strengthen the proof of its effectiveness. One hundred sixty-eight hepatic cysts in 111 patients were treated using a percutaneous approach under sonographic and fluoroscopic guidance. Cysts smaller than 5 cm in diameter were treated with a one-stage procedure that consisted of puncture of the cyst, aspiration of fluid, and injection and reaspiration of hypertonic saline solution. Larger cysts were treated with a two-stage procedure that consisted of the one-stage procedure followed by catheterization and sclerotherapy with alcohol. The mean observation time was 19 months (range, 1-48 months). Follow-up examinations showed progressive shrinkage and solidification of the cysts. Early complications occurred in 32 (28.8%) of the 111 patients, including fatal anaphylaxis in one patient, biliary fistula in seven, infection of the cyst in four, persistent serous drainage from the cyst in two, intraperitoneal leakage of cyst fluid in two, urticaria in seven, fever without evidence of infection in seven, and pleural effusion in two. Late complications occurred in four (3.8%) of the 104 patients who underwent follow-up examinations, including local recurrence in three patients and intrabiliary rupture of a cyst in one patient. Our experience indicates that percutaneous treatment is efficient in the management of hepatic hydatid cysts and that this technique should be considered an alternative to surgery.

Effectiveness of endoscopic sphincterotomy in complicated hepatic hydatid disease

Background:The aim of this study was to evaluate the results of endoscopic sphincterotomy in patients with hepatic hydatid cysts that have ruptured into the biliary tract. Methods:Over a 10-year period, 25 patients (11 men, 14 women, mean age 60 years) underwent treatment; 13 with no prior surgery were treated for biliary obstruction. Postoperative treatment was undertaken in 12 cases because of persistent drainage (8), duct obstruction (3), and postoperative pancreatitis (1). Results:In patients who had not undergone previous surgery, cholangiographic findings were hydatid vesicles in the biliary tract (6), dilation of the biliary tract (3), biliary fistula (2), distal stenosis (1), and purulent bile content after sphincterotomy (1). In all of these cases, sphincterotomy resolved duct obstruction with no complications. All patients with persistent postoperative drainage had a fistula tract between the biliary duct and the cavity, which was resolved by endoscopic treatment in all 8. The 3 patients with postoperative biliary obstruction had hydatid vesicles in the biliary tract, one with a long stenosis resembling sclerosing cholangitis, whereas the patient with postoperative pancreatitis had a distal stenosis. Satisfactory results were obtained with endoscopic sphincterotomy, although 1 patient required a biliary prosthesis. Conclusion:Endoscopic sphincterotomy resolves biliary obstruction and postoperative fistulae in most patients with hepatic hydatid cysts that have ruptured into the biliary tract. In some cases, a biliary prosthesis may be required. (Gastrointest Endosc 1998;48:593-7.)

Effects of transient and persistent cerebrospinal fluid drainage on sleep disordered breathing in patients with idiopathic adult hydrocephalus syndrome

OBJECTIVESTo examine sleep disordered breathing including obstructive sleep apnoea in patients with idiopathic adult hydrocephalus syndrome (IAHS) and to study the effects of CSF drainage and shunting procedure on sleep...

New Classification for the Accessory Pancreatic Duct by ERP.

The head of the pancreas is formed embryologically from two anlage. The pancreatic duct system in the head is a complex structure. We devised a new classification for the accessory pancreatic duct (APD) based on the junctional point of the APD and the main pancreatic duct (MPD) in addition to the shape of the APD, which was found to be applicable to most cases. We reviewed 385 random endoscopic retrograde pancreatograms of normal pancreatic head of the pancreas which demonstrated satisfactory imaging of the entire APD. All accessory duct pancreatograms could be classified into four types according to the length of the MPD from the orifice to the junction with the APD, as well as the shape of the APD. The APD joined with the MPD at the neck portion in the long type, between the first inferior and superior branches of the MPD in the intermediate type, and near the first inferior branch of the MPD in the short type. The APD had an arched course over the MPD in the ansa type. The APD of the long type frequently exhibited a straight course from the upper dorsal pancreatic duct, representing a persistent main drainage duct of the dorsal pancreatic primordium. This novel clasification may be adapted to most cases and may reflect the embryogenesis of the APD.

A Modification of Hepatic Portoenterostomy (Kasai Operation) for Biliary Atresia

Background: Although the proportion of patients with biliary atresia remaining jaundice-free after hepatic portoenterostomy (i.e., Kasai operation) has recently been increasing, in many cases repeated reoperation is required to achieve this result. Also, with assessment of jaundice using 2.0 mg/dL of serum total bilirubin as the cutoff, progressive liver fibrosis has occurred in longterm survivors, making liver transplantation necessary. Reoperations result in difficulty in removing the liver for this purpose and cause an increase in the probability of sequelae. Study Design: We have performed a new modification of the Kasai operation on a series of patients using the Cavitron ultrasonic suction aspirator (CUSA) for obtaining persistent biliary drainage. We assessed the results using < 1.5 mg/dL of serum total bilirubin as the criterion for jaundice-free patients. Results: Since 1988, 39 patients were available for review of their clinical results to evaluate our new modification. Thirty patients (77%) were completely and continuously free of jaundice, without living-related liver transplantation or reoperation, and the maximum level of total bilirubin was < 1.1 mg/dL. Conclusions: Our new approach to Kasai operations using CUSA as an integral aid to freeing the biliary remnants and facilitating enteric anastomosis is effective for persistent and complete disappearance of jaundice, without complicated reconstruction or reoperation, and decreases the need for liver transplantation.

Wound complications in total knee arthroplasty.

Wound problems are a dreaded complication following TKA and ideally are avoided. Preventative measures include proper choice of the skin incision, gentle handling of the soft tissues, meticulous hemostasis, and wound closure without excessive tension. Should persistent wound drainage or soft-tissue necrosis occur, early intervention is imperative as delay risks deep infection and failure of the TKA. Cases associated with full-thickness soft-tissue necrosis often require transfer of well-vascularized tissue such as a medial gastrocnemius myocutaneous flap reconstruction.