Surgical Drain Placement Research Articles

Comparing fourth-year medical students’ procedural surgical skill learning outcomes between third-person point-of-view video lectures and first-person point-of-view immersive virtual reality: a pilot study of surgically implanting a subdermal drain on cadavers

The use of virtual reality (VR) training in medical school education has increased over the last decade partly due to coronavirus-19 (COVID-19) and due to technology advancements in this integrative area. As medical students are being trained in new pedagogical interventions, it is important to drill-down and focus on the areas of most translational concern for assessing their competency and proficiency. Thus, the present pilot study sought to evaluate a group of fourth-year medical students’ ability to learn a modified medical school curriculum on implementing a subdermal drain by first learning how to stitch on a silicone model (i.e., proper stitching only) and then being randomly assigned to either a third-person point-of-view (TP-POV) or first-person point-of-view (FP-POV) immersive VR group to learn how to conduct the surgical procedure (i.e., conceptually and procedurally). Then, the participants’ surgical procedural motor skills were assessed on a single attempt to demonstrate their competency and proficiency on a cadaver. The results showed that the pedagogical learning differences in FP-POV immersive VR improved the cleanliness and accuracy of the surgical dissection movement and drain placement with 100% proficiency in the first attempt at implementing this surgical technique on a cadaver. Additionally, there was statistically significant improvement in the dissection movement (p < 0.05*) and the tension test (p < 0.01**) in the FP-POV group compared to the TP-POV group, even with a small sample size in the present pilot study. These findings offer unique training opportunities to be considered when designing future VR curriculum with the suggested use of repeated-measures designs on the surgical procedural motor skills to assess learning curves and their potential translations in reducing operating room errors, costs, planning and scheduling times, and surgery overlaps, thereby positively contributing to a more efficient and safer OR surgical experience by staff and patients in the near future.

Controversies and Future Directions in Management of Acute Appendicitis: An Updated Comprehensive Review.

Globally, acute appendicitis has an estimated lifetime risk of 7-8%. However, there are numerous controversies surrounding the management of acute appendicitis, and the best treatment approach depends on patient characteristics. Non-operative management (NOM), which involves the utilization of antibiotics and aggressive intravenous hydration, and surgical appendectomy are valid treatment options for healthy adults. NOM is also ideal for poor surgical candidates. Another important consideration is the timing of surgery, i.e., the role of interval appendectomy (IA) and the possibility of delaying surgery for a few hours on index admission. IA refers to surgical removal of the appendix 8-12 weeks after the initial diagnosis of appendicitis. It is ideal in patients with a contained appendiceal perforation on initial presentation, wherein an initial nonoperative approach is preferred. Furthermore, IA can help distinguish malignant and non-malignant causes of acute appendicitis, while reducing the risk of recurrence. On the contrary, a decision to delay appendectomy for a few hours on index admission should be made based on the patients' baseline health status and severity of appendicitis. Post-operatively, surgical drain placement may help reduce postoperative complications; however, it carries an increased risk of drain occlusion, fistula formation, and paralytic ileus. Furthermore, one of the most critical aspects of appendectomy is the closure of the appendiceal stump, which can be achieved with the help of endoclips, sutures, staples, and endoloops. In this review, we discuss different aspects of management of acute appendicitis, current controversies in management, and the potential role of endoscopic appendectomy as a future treatment option.

Analysing predictors of surgical site infections in patients undergoing emergency surgery for traumatic pulmonary haemorrhage.

Identifying predictors for surgical site infections (SSIs) after emergency surgical treatment for traumatic pulmonary haemorrhage (TPH) is crucial for improving patient outcomes. This study aims to ascertain these predictors. In this comprehensive retrospective study, conducted from January 2020 to December 2023 at our institution, 75 patients were analysed, including a case group of 25 patients with SSIs and a control group of 50 without SSIs post-TPH surgery. Inclusion criteria focused on patients aged 18 and above undergoing thoracotomy or minimally invasive thoracic surgery for TPH. Exclusion criteria included compromised immune systems, chronic pulmonary diseases, prior thoracic surgery or active infections at admission. We assessed several predictors: anaemia; operation time over 2 h; hospital stay over 5 days; intraoperative blood loss exceeding 500 mL; body mass index (BMI) ≥25 kg/m2; age ≥ 50 years; use of surgical drains; the presence of open wounds; diabetes mellitus and non-prophylactic antibiotic use. Statistical analysis involved univariate and multivariate logistic regression, using SPSS Version 27.0. Univariate analysis revealed significant associations between SSIs and surgical drain placement, diabetes mellitus, open wounds and non-prophylactic antibiotic use (p < 0.01). Multivariate analysis confirmed these factors as significant predictors of SSIs, with notable odds ratios. Other variables like anaemia, extended hospital stay, excessive intraoperative blood loss, older age and higher BMI did not significantly predict SSIs. Significant predictors for SSIs following TPH surgery include surgical drain placement, diabetes mellitus, open wounds and non-prophylactic antibiotic use. Identifying and managing these risks is crucial in clinical practice to reduce SSIs incidence and improve patient outcomes.

Incidence and outcomes of postoperative fluid collections after minimally invasive distal pancreatectomy without placement of surgical drain. A prospective observational cohort study.

There is uncertainty about the role of prophylactic intra-abdominal drains after distal pancreatectomy. In the present study, we aimed to describe the long-term outcomes of postoperative pancreatic collections in patients who underwent a minimally invasive distal pancreatectomy (MIDP) without surgical drain placement. From 2018 to 2022, consecutive patients who underwent a MIDP were recorded. Patients were followed at 90 days, 6 months, and in the long term. The use of interventional procedures and antibiotic therapy were documented, and the overall evolution of the collections was assessed. A total of 91 patients underwent MIDP; 11 were excluded; 80 were analyzed. Median age was 63 (51-73) years; 61.3% were women. Most lesions (71.3%) were malignant; 15 patients received neoadjuvant therapy. Procedures were laparoscopic (87.5%) or robotic (12.5%). Incidence of postoperative pancreatic collections was 33%; 10 patients were symptomatic. Interventional endoscopic (n = 3) or percutaneous (n = 3) procedures were required. At a follow-up of 24 (17.5-33.1) months, 18 collections resolved completely, eight partially, and one increased. Patients who undergo MIDP without surgical drain placement develop well-tolerated pancreatic collections. Although a minority may require endoscopic or percutaneous drainage, the majority can be managed conservatively and resolve spontaneously in the long term.

A Sodium Oxychlorosene-Based Infection Prevention Protocol Safely Decreases Postoperative Wound Infections in Adult Spinal Deformity Surgery.

This study sought to determine the efficacy of a complex multi-institutional sodium oxychlorosene-based infection protocol for decreasing the rate of surgical site infection after instrumented spinal surgery for adult spinal deformity (ASD). Infection prevention protocols have not been previously studied in ASD patients. A retrospective analysis was performed of patients who underwent posterior instrumented spinal fusion of the thoracic or lumbar spine for deformity correction between January 1, 2011, and May 31, 2019. The efficacy of a multi-modal infection prevention protocol was examined. The infection prevention bundle consisted of methicillin-resistant Staphylococcus aureus testing, chlorhexidine gluconate bathing preoperatively, sodium oxychlorosene rinse, vancomycin powder placement, and surgical drain placement at the time of surgery. About 254 patients fit the inclusion criteria. Among these patients, nine (3.5%) experienced post-surgical deep-wound infection. Demographics and surgical characteristics amongst infected and non-infected cohorts were similar, although diabetes trended towards being more prevalent in patients who developed a postoperative wound infection (p=0.07). Among 222 patients (87.4%) who achieved a minimum of two years of follow-ups, 184 patients (82.9%) experienced successful fusion, comparing favorably with pseudarthrosis rates in the ASD literature. Rates of pseudarthrosis and proximal junction kyphosis were similar amongst infected and non-infected patients. An intraoperative comprehensive sodium oxychlorosene-based infection prevention protocol helped to provide a low rateof infection after major deformity correction without negatively impacting other postoperative procedure-related metrics.

Developments in Postoperative Analgesia in Open and Minimally Invasive Thoracic Surgery Over the Past Decade

Whether through minimally invasive or conventional open techniques, thoracic surgery is often reported to be one of the most painful surgical procedures due to the incision of intercostal and respiratory muscles, rib injury or resection, and placement of surgical drains. Some of the more severe complications related to poor analgesia include prolonged intensive care unit stay, mechanical ventilation, pneumonia, and the development of chronic postoperative pain syndromes. Over the past few decades, much progress has been made in recognizing the importance of multimodal analgesic techniques. These may include a variety of regional anesthetic techniques such as epidural anesthesia, fascial plane blocks, and intrapleural catheters, as well as the utilization of opioid and opioid-sparing oral regimens. This article provides an up-to-date review of pain management following thoracic surgery, emphasizing multimodal techniques and enhanced recovery pathways. In our review, we included articles published between 2010 and 2022. PubMed and Google Scholar were researched using the keywords thoracic, cardiac, pain control, thoracic epidural analgesia, fascial plane blocks, multimodal analgesia, and Enhanced Recovery after Surgery in thoracic surgery. Over 100 articles were then reviewed. We excluded articles not in English and articles that were not pertinent to cardiac or thoracic surgery. Eventually, 53 articles were included in the review, composed of clinical trials, case series, and retrospective cohort studies. A variety of pain control methods employed in thoracic and cardiac surgery range from opioids and opioid-sparing medications, such as acetaminophen and gabapentin, to regional techniques, such as fascial plane blocks to epidural anesthesia. Multimodal anesthesia combining regional and opioid-sparing analgesics and their combination in enhanced recovery protocols were shown to provide adequate pain control, decrease opioid consumption and lead to shorter lengths of stay. Postoperative pain control remains one of the biggest challenges in the care of thoracic surgery patients. Analgesic plans must be individualized for each patient. Multimodal analgesia remains the gold standard; however, more studies are still warranted. Finding the optimal combination of opioid and non-opioid pain medication and local anesthetic delivered via suitable regional technique will improve the outcomes and lead to successful patient recovery.

Drain versus no drain in elective open incisional hernia operations: a registry-based analysis with 39,523 patients

PurposeElective open incisional hernia operations are a frequently performed and complex procedure. Prophylactic drainage is widely practised to prevent local complications, but nevertheless the benefit of surgical drain placement remains a controversially discussed subject. Objective of this analysis was to evaluate the current status of patient care in clinical routine and outcome in this regard.MethodsThe study based on prospectively collected data of the Herniamed Register. Included were all patients with elective open incisional hernia between 1/2005 and 12/2020 and completed 1-year follow-up. Multiple linear and logistic regression analysis was performed to assess the relation of individual factors to the outcome variables.ResultsAnalysed were data from 39,523 patients (28,182 with drain, 11,341 without). Patients with drain placement were significantly older, had a higher BMI, more preoperative risk factors, and a larger defect size. Drained patients furthermore showed a significant disadvantage in the outcome parameters intraoperative complications, general complications, postoperative complications, complication-related reoperations, and pain at the 1-year follow-up. No significant difference was observed with respect to the recurrent rate.ConclusionWith 71.3%, the use of surgical drainages has a high level of acceptance in elective open incisional hernia operations. The worse outcome of patients is associated with the use of drains, independent of other influencing factors in the model such as patient or surgical characteristics. The use of drains may be a surrogate parameter for other unobserved confounders.

External application of mirabilite before surgery can reduce the inflammatory response and accelerate recovery in mild acute biliary pancreatitis

ObjectiveMild acute biliary pancreatitis (MABP) is one of the most common diseases that require surgical treatment. Previous studies have focused on the timing of laparoscopic cholecystectomy (LC) for MABP. However, the impact of its inflammatory response process on the clinical outcome has been rarely reported. This study aimed to investigate the effect of preoperative external application of mirabilite on the inflammatory response and clinical efficacy in MABP.MethodsMedical records of patients undergoing LC due to MABP from November 2017 to June 2022 were retrospectively reviewed. Prior to surgery, the control group received the same baseline treatment measures as the study group. The difference was the addition of external application of mirabilite in the study group.ResultsA total of 75 patients were included in the final analysis: 38 patients in the mirabilite group and 37 patients in the control group. Repeated-measures ANOVA (P < 0.01) showed that the white blood cell count (WBC) on the 3rd day of admission and the WBC and C-reactive protein (CRP) level on the 5th day of admission decreased rapidly and significantly in the mirabilite group, compared with the control group. The mirabilite group had earlier anal exhaust time. The number of patients in the mirabilite group and control group with gallbladder wall ≥ 3 mm before the operation was 16 (42.11%) vs. 24 (64.86%), p = 0.048, respectively; and the number of cases with surgical drain placement was 2 (5.26%) vs. 9 (24.32%), p = 0.020, respectively. The intraoperative modified American Fertility Society (mAFS) score of adhesions was lower in the mirabilite group (1.08 ± 0.59 points) than in the control group (1.92 ± 0.60 points), p = 0.000. The mirabilite group, compared to the control group, p = 0.000, had a short waiting time for surgery (5.68 ± 0.70 days vs. 6.54 ± 0.59 days), short operation time (38.03 ± 5.90 min vs. 48.51 ± 8.37 min), and reduced hospitalization time (8.95 ± 0.96 days vs. 9.84 ± 1.07 days).ConclusionThis study demonstrated that preoperative external application of mirabilite can reduce the inflammatory response, decrease the edema and peribiliary adhesions at the surgical site, and accelerate recovery in MABP.

Adverse Events of Surgical Drain Placement: An Analysis of the NSQIP Database.

Surgical site drainage is important to prevent hematoma, seroma, and abscess formation. However, the placement of drain placement also predispose patients to several postoperative complications. The aim of this study is to clarify the risk-benefit profile of surgical drain placement. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Procedure-Targeted Databases were used to identify patients who underwent hepatectomy, pancreatectomy, nephrectomy, cystectomy, and prostatectomy. Patients who underwent each procedure were divided into 2 groups based on intraoperative drain placement. Propensity score-matched cohorts of these 2 groups were compared in terms of postoperative adverse events, readmission, reoperation, and length of stay. Hepatectomy patients with drains experienced organ space infections (P < .001), sepsis (P < .001), and readmission (P = .021) more often than patients without drains. Patients who underwent pancreatectomy and had drains placed experienced wound dehiscence less frequently than those without drains (P = .04). For hepatectomy, pancreatectomy, nephrectomy, and prostatectomy populations, patients with drains had longer lengths of stay (P < .05). Matched populations across all procedures did not differ in terms of reoperation rate. Prophylactic surgical drain placement may be associated with increased infectious complications and prolonged length of stay. Further studies are needed to elucidate the complete adverse event profile of surgical drains. Nonetheless, outcomes may be improved with better patient selection or advancements in drain technology.

Surgical Drain Placement Technique and Its Effects Following Total Laryngectomy

Surgical Drain Placement Technique and Its Effects Following Total Laryngectomy

Comparing Outcomes of CT-Guided Percutaneous Pericardial Drainage with Surgical Pericardial Window in Patients with Symptomatic Pericardial Effusions

To compare short-term outcomes of CT-guided percutaneous pericardial drainage (PPD) versus subxiphoid surgical pericardial window (PW) drainage and analyze the risk factors associated with their outcomes. A retrospective chart review of patients who underwent either percutaneous drainage with drainage catheter placement or PW with surgical drain placement for symptomatic pericardial effusion between January 1, 2006 and August 31, 2016 was performed after institutional review board approval (decision number 16-783). The primary objective was to test for associations between the short-term (≤30 days post procedure) complication and recurrence rates in patients with symptomatic pericardial effusions. The secondary objectives were to test for associations between short-term complications with changes in vital signs. Of the 257 procedures included in the final analysis, 142 were in the percutaneous drainage group. Short-term complication rate was significantly greater (p < 0.001) in patients undergoing PW, 17% (19/114), as compared with PPD, 2% (3/142). The estimated odds of having complications in the PW cohort was 9 times greater than the percutaneous drainage cohort (OR=9.3, 95% CI: 2.7-32.3). No significant difference was observed between whether or not a patient experienced a short-term recurrence and any of the explanatory variables (patient demographics, imaging, and vital signs). CT-guided PPD is a safer alternative to surgical PW as it leads to fewer complications without a significant difference in recurrence rate of pericardial effusion.

Technique for Robotic Pancreaticojejunostomy.

Minimally invasive, robotic techniques for hepatobiliary procedures offer the potential for accelerated recovery and reduced opioid usage. Robotic pancreaticoduodenectomy is a technically challenging procedure with a complex reconstruction. In this regard, standardization of the pancreaticojejunostomy technique is critical for safe adoption of robotic technology in pancreatic surgery. We demonstrate the primary steps and associated principles to perform a robotic pancreaticojejunostomy using a modified Blumgart/Nagakawa technique. Key steps to this procedure include: 1) exposure and positioning of the pancreatic remnant and jejunal limb; 2) transpancreatic suture placement using augmented sutures with bulldog clamps for organization; 3) duct-to-mucosa anastomosis with well-defined order of suture placement and knot-tying for optimal exposure, tissue handling, and technical ease; 4) completion of the anterior row of transpancreatic sutures using Lapra-TY clips for gentle, but firm tissue apposition; and 5) placement of omental flap and surgical drains in proximity to the reconstruction. We described our technique for performing a robotic pancreaticojejunostomy, which compensates for the technical limitations of the robotic approach. These adjustments in combination with the magnified surgical vision and augmented skill associated with the robotic platform allow for safe and reliable performance of the pancreaticojejunostomy technique.

Drain Versus No Drain in Open Mesh Repair for Incisional Hernia, Results of a Prospective Randomized Controlled Trial

BackgroundOpen mesh repair of incisional hernia is associated with different local complications, particularly bleeding and seroma formation. Traditionally, drains have been placed perioperatively to prevent these complications, despite the lack of scientific evidence or expert consensus. We formulated the hypothesis that the absence of drainage would reduce number of patients presenting collections or complications. The present study aimed to compare postoperative complication rates after open mesh repair for incisional hernia with or without prophylactic wound drainage.MethodsProspective randomized study using standardized surgical technique and drain placement. The primary endpoint was the evaluation of residual fluid collection with ultrasound on postoperative day 30. Other complications, subdivided into medical and surgical, were analyzed as secondary endpoints.ResultsThere were 144 patients randomized (70 with drain, 74 without drain). No difference was identified between both groups for fluid collection at 30 days (60.3% vs. 62%, p = 0.844). However, less surgical complications were identified in the drain group (21.7% vs. 42.7%, p = 0.007), with a lower wound dehiscence rate (1.5% vs. 9.3%, p = 0.041).ConclusionsProphylactic drainage in open incisional hernia repair does not objectively reduce the rate of postoperative fluid collections. Therefore, our results do not support the use of routine drainage in incisional hernia repair.Trial registrationTrial registration on clinicaltrials.gov (NCT00478348).

Propensity Score-Matched Analysis of Revisional/Conversional Roux-en-Y Gastric Bypass vs Sleeve Gastrectomy in Patients with Hypoalbuminemia

INTRODUCTION: Hypalbuminemia (HA) may place patients at increased risk when undergoing revisional/conversional bariatric surgery. The primary aim of this study was to assess complication in patients with HA undergoing Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy as revisional/conversional bariatric surgery. METHODS: Revisional/conversional bariatric procedures were extracted from the MBSAQIP database from 2015 to 2019. Nearest neighbor 1:1 propensity score matching (PSM) was performed on 23 covariates with E analysis to assess point estimate confounding. Outcomes were assessed via bivariate analysis and univariate regression. RESULTS: There were 4,825 revisional/conversional patients with HA who underwent the RYGB (n = 2,636) or sleeve gastrectomy (n = 2,189) procedure. PSM yielded 1,928 patient pairs with no difference in perioperative demographics. Matched patients who underwent the RYGB procedure were more likely to be readmitted within 30 days (9.18% vs 5.45%; p < 0.001, E = 2.07), have longer procedure time (137 minutes, interquartile range [IQR] 101–185] vs 93 minutes IQR [68–130]; p < 0.001), a reoperation (3.58% vs 1.61%; p < 0.001, E = 2.32), unplanned ICU admission (2.39% vs 0.99%; p = 0.001, E = 2.22), nonadmitting emergency room visit (8.04% vs 5.08%; p < 0.001, E = 1.83), and anastomotic leak complication (2.70% vs 1.40%; p = 0.007, E = 1.74). Patients who underwent RYGB procedure also had a higher incidence of surgical drain placement (36.10% vs 24.43%; p < 0.001, E = 2.41) and postoperative organ space infection (1.30% vs 0.57%; p = 0.03, E = 1.50). (Figure) CONCLUSION: Patients with HA who undergo a revisional/conversional operation are at increased risk of serious postoperative complication, and RYGB revisional/conversional procedures represent a higher-risk group for certain complications.Figure

Endoscope-Assisted Evacuation of Nonacute Subdural Hematoma: A Technical Case Series and Systematic Review

Chronic subdural hematoma or nonacute subdural hematoma (NASH) remains a common neurosurgical disease, with an incidence of 1.7-20.6:100,000 individuals. Surgical evacuation of chronic subdural hematoma can be complicated by inadequate drainage and recurrence rates up to 20%-30% in some series. We examine the safety and efficacy of endoscope-assisted NASH evacuation and review the literature on the technique. A consecutive, single-center series of endoscope-assisted NASH evacuations was reviewed to assess patient factors, imaging, and recurrence. A systematic literature review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 9 patients who underwent endoscope-assisted NASH evacuation were included. This technique showed some improved evacuation of hematoma, removal of membranes, coagulation of at-risk blood vessels, directed placement of surgical drains, visualization of embolization efficacy, coagulation of friable membranes, and removal of acute clot. Only 1 episode of NASH recurrence (11.1%) was seen at the last follow-up. A systematic review of 14 studies with 1353 patients identified the use of membranectomy in 57% of cases and a recurrence rate of 0%-8.8%. Endoscopic visualization can be a useful adjunct in the modern treatment of NASH. Reduced risk of recurrence was seen compared with those of historical surgical drainage methods including burr holes (20-30%). The inclusion of endoscopic visualization in the modern era with middle meningeal artery embolization may potentially combine methods that can dramatically reduce the recurrence of NASH.

The European Hernia Society Prehabilitation Project: A Systematic Review of Intra-Operative Prevention Strategies for Surgical Site Occurrences in Ventral Hernia Surgery.

BackgroundVentral hernia repair is one of the most commonly performed surgical procedures worldwide. To reduce the risk of complications, pre- and intra-operative strategies have received increasing focus in recent years. To assess possible preventive surgical strategies, this European Hernia Society endorsed project was launched. The aim of this review was to evaluate the current literature focusing on pre- and intra-operative strategies for surgical site occurrences (SSO) and specifically surgical site infection (SSI) in ventral hernia repair.MethodsA systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases used were Pubmed and Web of Science. Original retrospective or prospective human adult studies describing at least one intra-operative intervention to reduce SSO after ventral hernia repair were considered eligible.ResultsFrom a total of 4775 results, a total of 18 papers were considered suitable after full text reading. Prehospital chlorhexidine gluconate (CHG) scrub appears to increase the risk of SSO in patients undergoing ventral hernia repair, while there is no association between any type of surgical hat worn and the incidence of postoperative wound events. Intraoperative measures as prophylactic negative pressure therapy, surgical drain placement and the use of quilt sutures seem beneficial for decreasing the incidence of SSO and/or SSI. No positive effect has been shown for antibiotic soaking of a synthetic mesh, nor for the use of fibrin sealants.ConclusionThis review identified a limited amount of literature describing specific preventive measures and techniques during ventral hernia repair. An advantage of prophylactic negative pressure therapy in prevention of SSI was observed, but different tools to decrease SSIs and SSOs continuously further need our full attention to improve patient outcomes and to lower overall costs.

Risk Factors for Predicting Increased Surgical Drain Output in Patients After Anterior Cervical Decompression and Fusion

Tje objective of this study was to identify factors that are independently associated with increased surgical drain output (ISDO) in patients who have undergone anterior cervical decompression (discectomy/corpectomy) and fusion (anterior cervical discectomy and fusion [ACDF]/anterior cervical corpectomy and fusion [ACCF]). Consecutive patients who underwent ACDF/ACCF with surgical drain placement at a single academic institution between January 2013 and December 2017 were identified from the medical records. Patients were categorized into normal or ISDO groups, with ISDO defined as a total drain output of 100ml or more. The demographic distribution and clinical data of these 2 groups were incorporated into univariate and multivariate analyses to investigate the predictive factors of ISDO. A total of 791 patients with ACDF/ACCF met the inclusion criteria. The average drain output for this cohort was 104.9±55.9ml. Among all patients in the study, 378 patients had ISDO (drain output >100ml). Our analysis identified the following independent predictors of ISDO in all patients: male sex (P < 0.001), age 50years or older (P= 0.018), the number of discs involved (P < 0.001), and C3 involvement (P= 0.002). Among the patients undergoing ACDF, male sex (P < 0.001), the number of discs involved (P < 0.001), and C3 involvement (P= 0.004) were significant predictors of ISDO. Among those undergoing ACCF, male sex (P < 0.001) and the number of discs involved (P < 0.001) were significant predictors of ISDO. Male sex, age 50years or older, the number of discs involved, and C3 involvement were significant risk factors for ISDO following anterior cervical decompression and fusion. Patients with these risk factors may benefit from surgical drain placement.

Cholecystitis: association between ultrasound findings and surgical outcomes

To identify sonographic signs of cholecystitis that correlate with surgical outcomes. Three hundred and thirty-three consecutive patients who underwent cholecystectomy between 22/06/2014 and 1/3/2016 and underwent abdominal ultrasound (US) within 7 days of surgery were included. Individual US signs, including gallstones, gallbladder distention, wall thickening, pericholecystic fluid, and abscess, were graded by two radiologists, 1 and 2. Outcomes included operative duration (OD), drain placement, partial cholecystectomy, conversion from laparoscopic to open cholecystectomy, surgical pathology, bile leak, infection, and 30-day readmission. US signs and outcomes were analysed using analysis of variance, chi-square test, or odds ratios (OR). Radiologist 1 reported 141/333 and radiologist 2 reported 128/333 patients showed gallbladder distention. For the subset with OD, radiologist 1 reported 140/320 and radiologist 2 reported 126/320 patients showed gallbladder distention. Distention was predictive of increased OD (radiologist 1, +23.2 minutes, p<0.0001; radiologist 2, +19.4 minutes, p=0.0003). Cases with gallbladder distention were more likely to have surgical drain placement (OR= 2.60; 95% confidence interval [CI]: 1.12-6.08, p=0.027 radiologist 1; OR=2.59; 95% CI: 1.13-5.95, p=0.025 radiologist 2). Wall thickening was present in 126/333 patients reported by radiologist 1 and 120/333 by radiologist 2. Cases with wall thickening were more likely to have drain placement (OR=2.66; 95% CI: 1.16-6.13, p=0.021 radiologist 1; OR=3.49; 95% CI: 1.49-8.16, p=0.004 radiologist 2). For the subset with OD, wall thickening was present for 121/320 reported by radiologist 1 and 116/320 by radiologist 2 and predicted longer OD (radiologist 1, +15.9 minutes, p=0.0033; radiologist 2, +13.3 minutes, p=0.0143). Gallbladder distention and wall thickening on US correlate with prolonged OD and surgical drain placement in patients with cholecystitis.

Predictive Factors for Drain Placement After Laparoscopic Cholecystectomy.

PurposeCurrently, surgical drainage during a laparoscopic cholecystectomy (LC) is still placed in selected patients. Evidence of the non-beneficial effect of the surgical drain comes from studies with a heterogeneous population. This preliminary study aims to identify any clinical, demographic, or intraoperative predictive factors for a surgical drain placement during LC as the first step to identify population for a prospective randomized study.MethodThe study was conducted in a single referral center and academic hospital between 2014 and 2018. Patients who underwent unconverted LC were divided into two groups: Group A (drain) and Group B (no drain). We explored baseline, preoperative, intraoperative characteristics, and postoperative outcomes.ResultsBetween 409 patients who underwent LC: 90 (22%) patients were in Group A (drain). Age >64 years, male sex, cholecystitis, Charlson comorbidity index (CCI) ≥ 1, experienced surgeon, intraoperative technical difficulties, need for an additional trocar, operative time >60 min, and estimated blood loss >10 ml were predictive factors at univariate analysis. While at multivariate analysis, cholecystitis (odds ratio [OR]: 2.8, 95% CI:1.5–5.1; p < 0.001), CCI ≥ 1 (OR:1.9, 95% CI:1.0–3.5; p = 0.05), intraoperative technical difficulties (OR: 3.6, 95% CI:1.8–6.2; p < 0.001), need of an additional trocar (OR: 2.5, 95% CI: 1.4–4.4; p < 0.005), and estimated blood loss >10 ml (OR: 3.0, 95% CI:1.7–5.3; p < 0.0001) were predictive factors for a surgical drain placement during LC.ConclusionsThis study identified predictive factors that currently drive the surgeons to a surgical drain placement after LC. Randomized prospective studies are needed to define the use of drain placement in these selected patients.

Clinical Course of Patients with Post-operative Pancreatic Fistulas: Does Time Heal All Wounds?

Introduction: Management of clinically significant post-operative pancreatic fistulas (cs-POPF) can vary depending on institutional and surgeon preferences. Objective data regarding number of interventions, type and time to complete resolution for POPFs are sparse. Methods: The authors conducted a retrospective analysis of patients who developed a CS-POPF (Grades B,C) after Whipple over a 10-year period (2010-2019). 30-day postoperative outcomes, including symptoms and complications, were evaluated. Data regarding re-admissions and interventions performed until the resolution of POPF were compiled. Results: 1155 patients underwent Whipple during this period and 92 patients were recognized to have cs- POPFs. Average age of patients was 62 years (±11) and average BMI was 29 (±5) kg/m2. Mean blood loss was 354mL (±435). 60 patients had an ISGPS Grade B fistula and 32 had Grade C fistula. 32% of patients needed a second admission within 30 days of discharge. 78 patients needed an IR guided drain and 77 had a long-term central line placed. 33 patients needed a re-operation with washout and placement of new surgical drains being the most common. At last follow-up 8 patients (9%) had died with an unresolved POPF. 80 patients had documented resolution of their POPF with mean resolution time being 59 days. Conclusions: Patient who develop a cs-POPF have a prolonged clinical course. Operative interventions were needed in one third of patients. IR guided drainage was the mainstay of interventions. Complete resolution of cs-POPF can take up to 2 months. These objective data can guide expectations surrounding this devastating complication.