Prolonged Drainage Research Articles

Multimodal Thromboprophylaxis in Patients With a History of Venous Thromboembolism Undergoing Primary and Revision Knee Arthroplasty.

Background: Patients with a history of venous thromboembolism (VTE) undergoing total knee arthroplasty (TKA) are at a high risk of postoperative VTE. Purpose: In this high-risk population, we sought to evaluate the safety and efficacy of multimodal thromboprophylaxis. The regimen consisted of discontinuation of procoagulant medications, VTE risk stratification, regional anesthesia, rapid mobilization, perioperative use of pneumatic compression devices, vigorous ankle dorsiflexion during the recovery period, and chemoprophylaxis tailored to the patient's risk of VTE. Methods: We conducted a retrospective chart review of 141 consecutive patients with a history of VTE who underwent 177 elective TKA procedures between 2005 and 2019 by 2 arthroplasty surgeons at a single institution. The patients had a history of deep venous thrombosis (DVT) (n = 127; 72%), pulmonary embolism (PE) (n = 20; 11%), or both (n = 30; 17%). Postoperative chemoprophylaxis included aspirin (n = 20; 11%), anticoagulation (n = 135; 77%), or a combination of aspirin and anticoagulation (n = 21; 12%). Complications within 120 days, including VTE events, wound complications, bleeding, and unplanned readmissions, were recorded, as was 1-year mortality. Results: Five patients (2.8%) developed symptomatic DVT (3 distal, 2 proximal), and 4 patients (2.3%) developed symptomatic PE. The most common postdischarge complications were wound infection (n = 6; 3.4%) and stiffness requiring manipulation under anesthesia (n = 5; 2.8%). There was 1 emergency room visit and 13 unplanned readmissions; 3 patients developed intra-articular hematomas or prolonged wound drainage and recovered uneventfully. All patients were alive 1 year after surgery. Conclusion: The findings of this retrospective study suggest that multimodal prophylaxis may be safe and effective in patients with a history of VTE undergoing primary and revision TKA. More rigorous study is warranted.

The Failed Bidirectional Glenn Shunt: Risk Factors for Poor Outcomes and the Role of Early Reoperation.

Background: Bidirectional Glenn shunt (BDG) failure carries high morbidity and mortality but the clinical factors associated with failure and the optimal management strategy are understudied. Methods: A total of 217 patients undergoing BDG at our institution between 1989 and 2020 were retrospectively reviewed and categorized as success or failure. Failure was defined as the need for reoperation (BDG takedown, reoperation for correction of cardiac defect, and/or transplantation) at any time postoperatively; operative mortality (death attributable to BDG malfunction occurring during the index hospitalization for BDG or within 30 days of discharge); or late mortality (death directly attributable to BDG malfunction occurring prior to Fontan or next-stage palliation). Univariate and binary logistic regression analyses were performed. Results: BDG failure occurred in 14 (6.5%) patients. Univariate predictors were: hypoplastic left heart syndrome (P = .037), right ventricular (RV) dominance (P = .010), greater pre-BDG pulmonary vascular resistance (PVR) (P = .012), concomitant atrioventricular valve repair (P = .020), prolonged pleural drainage (P = .001), intensive care unit (P<.001) and hospital (P = .002) stays, and extracorporeal membrane oxygenation (ECMO) requirement (P<.001). Multivariate predictors were: RV dominance (P = .002), greater PVR (P = .041), ICU (P<.001) and hospital (P = .020) stays, and need for ECMO (P<.001). As many as 10 of 14 (71%) patients with BDG failure died. Reoperation was performed for 10 patients with BDG failure. Five reoperation patients survived until discharge, with four patients alive at last follow-up (mean 7.9 years). Survivors underwent reoperation earlier than nonsurvivors (36 vs. 94 days). Conclusions: BDG failure carries high mortality, but preoperative predictors and postoperative indicators of failure exist. Early BDG takedown and insertion of aorta-pulmonary shunt may allow survival.

A PROSPECTIVE STUDY OF SURGICAL SITE INFECTION IN A TERTIARY CARE CENTER IN NORTH INDIA

BACKGROUND: Surgical Site Infections (SSI) is dened as an infection related to an operative procedure that occurs at or near the surgical incision within 30 days of the procedure, or within 90 days if prosthetic material is implanted at surgery—is among the most common preventable complication after surgery. OBJECTIVES: To study the incidence and risk factors of SSI in our hospital and to nd out the areas which need concern and methods to reduce SSI. METHODOLOGY: Study was conducted over a period of 1 year. A total of 300 cases of General Surgery presented to our hospital were included in the study. A few host factors, wound factors and surgery related factors that cause SSI were studied. Swabs from infected surgical wounds were sent to the department of Microbiology for pus culture and sensitivity. Antibiotic sensitivity test was done by Kirby-Bauer disc diffusion method. RESULTS: Certain associated factors such as increased duration of surgeries (&gt;2hours) and prolonged drain placement were found to be signicantly associated with occurrence of SSI and the surgeries with class 1 (clean) wound showed minimum risk of infection. Escherichia coli (28.75%) was the commonest pathogen, followed by Pseudomonas aeruginosa (27%) and Staphylococcus aureus (20%) .The incidence of SSI in the hospital is 7%. CONCLUSIONS: The results of the study revealed that in order to decrease the incidence of SSI we need to: a) If possible try to reduce the duration of the surgeries performed b) should give emphasis on drain care c) co-morbidities should be looked for and managed prior to surgery d) a regular monitoring should be done in both emergency and elective operation theatres in order to reduce the risk of SSI.

Q Fever Vertebral Osteomyelitis Complicating Vertebroplasty.

Query (Q) fever is a zoonotic bacterial infection caused by Coxiella burnetii. In a minority of patients, chronic disease can occur after acute infection. Endocarditis and infections of aneurysms or vascular prostheses are the most common forms of chronic Q fever in adults. We report a case of an elderly female patient with chronic Q fever vertebral osteomyelitis at the site of her previous cement vertebroplasty, complicated by paravertebral abscess. Patient treatment required prolonged drainage in addition to the long duration of antibiotic treatment by doxycycline and hydroxychloroquine. Osteomyelitis is a rare clinical presentation in adults with chronic Q fever. However, it is important to consider Q fever in the differential diagnosis of culture-negative osteomyelitis, especially in countries where C. burnetii is endemic, such as Israel.

Subcutaneous barbed suture, as an adjunct to staples, reduces post-operative wound drainage in total knee arthroplasty

BackgroundProlonged wound drainage (>72 h), has been associated with increased risk of surgical site infection and prolonged hospital admission. This study reviews the outcome in three different wound closure methods, following total knee arthroplasty. We also analysed the cost effectiveness of these methods. MethodsA total of 69 patients undergoing total knee arthroplasty: 22 with stapled skin closure; 21 with tissue adhesive and stapled skin closure and 26 with subcutaneous barbed suture instead of a non barbed suture with stapled skin closure, were studied to review the number of dressing changes, prolonged wound drainage (>72 h), length of hospital stay and delayed discharge (>5 days). Statistical analysis was conducted using Minitab Statistical Software® and statistical significance was set at p < 0.05. ResultsThe median hospital stay for the staples only group was 4 days (inter-quartile range [IQR] 3–5), for the adhesive group was 4 days ([IQR] 3–6) and for the barbed suture group was 3 days ([IQR] 3–4) (p = 0.009). The rates of prolonged wound drainage for the staples only group was 8 (36.4%), for the adhesive group was 4 (19.0%) and for barbed suture group was 0 (0%) (p = 0.004). ConclusionThe use of subcutaneous barbed sutures was associated with reduced number of wound dressing changes, reduced risk of prolonged wound drainage and shorter hospital stay, as well as conferring a saving of at least £236.60 per patient, compared to the other two skin closure methods.

Density of aortopulmonary collaterals predicts in-hospital outcome in tetralogy of Fallot with pulmonary stenosis.

OBJECTIVESThe aim of this study was to characterize the anatomy of aortopulmonary collateral (APC) arteries in tetralogy of Fallot and pulmonary stenosis and to determine whether APC density identified on preoperative multidetector cardiac computed tomography predicts in-hospital outcome.METHODSThe retrospective single-centre study includes consecutive 135 (2015–2019) patients who underwent one-stage repair. Preoperative multidetector cardiac computed tomography, echocardiography and clinical outcomes were reviewed. The cut-off value of indexed total distal APC cross-sectional area (APC-CSA) was identified by receiver operating characteristic curve. Logistic regression was used for predictors analysis.RESULTSThe median age and body weight were 19.7 (10.1–89.7) months and 10 (8.3–18) kg. A total of 337 APCs were detected with only one demonstrating severe stenosis. There was a strong and significant correlation between mean APC diameter per patient and age (r = 0.70, P < 0.001). APCs were imaged but mainly received no interventions. In-hospital mortality was similar between patients with high (indexed APC-CSA ≥3.0 mm2/m2) and low (<3.0 mm2/m2) APC density (P = 0.642). Significantly greater patients with high indexed APC-CSA experienced the in-hospital composite outcome of death, arrest, renal/hepatic injury, lactic acidosis or extracorporeal membrane oxygenation (P = 0.007). High APC density was associated with greater dosing (P = 0.008) and longer (P = 0.01) use of inotropic support, prolonged pleural drainage (P = 0.013), longer ventilation (P = 0.042), intensive care unit (P = 0.014) and hospital (P = 0.027) duration. No reintervention and death occurred in the follow-up with the median duration of 24.4 (11–36.6) months. Multivariable analysis showed the Nakata index (P = 0.05) and high APC density (P = 0.02) independently predicted the composite outcome.CONCLUSIONSIn tetralogy of Fallot and pulmonary stenosis, APCs are likely to be dilated bronchial arteries. Preoperative multidetector cardiac computed tomography-derived APC density was as important as Nakata index in predicting the occurrence of in-hospital composite outcome. The APC-CSA of 3.0 mm2/m2 maybe considered as a threshold for risk stratification.

Large ventral hernias: to drain… And what to drain… That is the question!

Drain placement is common practice in repair of ventral hernias, specifically complex hernias. There is little-to-no evidence for benefit of drains and best practice in-terms of number, position, duration of use and type of drains. This study investigates drain profile in open repair of large ventral hernias. A retrospective two-centres audit with data collected via electronic and paper-based medical records from the 1 February 2015 to 29 June 2020. All elective and emergency cases were included. Main outcomes included surgical site infection (SSI), seroma and hematoma formation. A total of 186 patients included, out of those 128(68.5%) had drain placed. Drain placement had a higher incidence of SSI (20.3% in drain group and 15.5% in no drain group), however, drains were more likely to be placed in complex ventral hernias. Drain practice varied significantly between surgeons, however, there was a clear trend to higher SSI rates with longer duration of drain use (specifically longer than 5 days, p-value: 0.05) and higher drain output on removal (specifically higher than 150 ml/24 h, p-value 0.004), furthermore, prolonged use did not decrease risk of seroma formation. Drain position, number of drains and suction pressure did not affect seroma or SSI rates. Our data suggests no clear benefits of drain usage in most ventral hernia repairs. Prolonged drain use led to higher risk of SSI and did not decrease rate of seroma formation. If used, we recommend use of short drain duration<5 days. Further RCTs to evaluate drain placement in large ventral hernias are needed.

A SCORING SYSTEM TO PREDICT THE RISK OF SURGICAL SITE INFECTIONS AFTER SPINAL SURGERY

ABSTRACT Objective This retrospective clinical study was carried out to generate and cross-validate a scoring system for the identification of patients at risk of SSIs after spinal surgery. Methods A retrospective study was conducted, which included patients who underwent spinal surgery. The potential variables for SSIs were extracted from the database, including preoperative, intraoperative and postoperative risk factors for univariate and multivariate regression analyses. Results A total of 2347 patients were included in this retrospective clinical study. Postoperative SSIs were observed in 53 patients (2.2%). The multivariate logistic regression analysis revealed the following risk factors for SSIs after spinal surgery: diabetes mellitus ( P =0.029), body mass index ( P =0.008), low serum calcium concentration ( P =0.012), low pre- and postoperative albumin ( P =0.023, P =0.037), more than three operated segments ( P =0.008), operation time of more than 180 minutes ( P =0.019), estimated blood loss ( P =0.011), low postoperative hemoglobin ( P =0.017) and prolonged drainage time ( P =0.025). Each of these factors contributed 1 point to the risk score. The predicted rates of incidence for the low-, intermediate-, high-, and extremely high-risk categories in the validation set were 1.4%, 12%, 41.6%, and 66.6%, respectively. Conclusions Our scoring system allows for easy and validated risk stratification of SSIs after spinal surgery. Level of evidence III; Cross-sectional Observational Study.

Predictors of Lymphatic Complications Following Renal Transplant: A Prospective Study Involving Predominantly Living Donor Transplants From India.

IntroductionLymphatic complications (LC) are common (up to 33%) and troublesome after renal transplantation. Different studies have established varying medical and surgical risk factors, mostly by retrospective analysis on deceased donor renal transplants (DDRTs). The end-point is mostly lymphocele, with few reports documenting the equally important lymphorrhea.MethodsIn our prospective analytical study done over three years, most were living donor renal transplant (LDRT) pairs by a single team. The primary outcome measure was lymphocele and/or prolonged drainage for more than 15 days, with a six-month follow-up. The variables recorded were age, gender, hemodialysis duration, etiology, relationship, human leucocyte antigen (HLA) mismatch, induction regimen, acute rejection, warm ischemia time (WIT), and delayed graft function (DGF). Univariate analysis was by chi-square and t-tests as applicable, while logistic regression (both simultaneous and forward stepwise) was used for risk factor prediction.ResultsEligible cases were 150, with 145 (97%) LDRT pairs. Donors were mostly female (122/150; 81%) with mean age (~43 years) higher than recipient age (~33 years). The common etiologies were diabetes (31%), hypertension (23%), and IgA nephropathy (11%). Most donors were mothers (37%) and wives (31%), and 28% of LDRT pairs had HLA mismatch >3. Mean duration of hemodialysis was about 18 months, and mean WIT was 52 minutes. Both DGF (B coefficient= -1.69, p<0.000) and WIT (B=-0.038, p=0.024) were significant predictors of the primary outcome, while drain removal before 15 days predicted lymphocele significantly (B=-2.4, p<0.000). ConclusionsLDRT has specific risk factors for lymphatic complications, which may be related to extent of recipient vascular dissection, arterial anastomotic time, and early drain removal.

Predictors for Prolonged Drain Use Following Autologous Breast Reconstruction.

Surgical drains are routinely used following autologous reconstruction, but are often cited as the leading cause of peri-operative discomfort. This study defined routine drain use duration and assessed the risk factors for prolonged breast and abdominal drain use during microvascular breast reconstruction, measures which have never previously been defined. Patients who underwent an abdominal microvascular free flap were included. Demographics, comorbidities, and operation-related characteristics were retrospectively collected in a prospectively maintained database. Statistical analysis utilized chi-square independent t-test, and linear regression analyses. One hundred forty-nine patients comprising 233 breast flaps were included. Average breast and abdominal drain duration were 12.9 ± 3.9 and 17.7 ± 8.2 days, respectively. Prolonged breast and abdominal drain duration were defined as drain use beyond the 75th percentile at 14 and 19 days, respectively. Multivariable regression revealed hypertension was associated with an increased breast drain duration by 1.4 days (p = 0.024), axillary dissection with 1.7 days (p = 0.026), African-American race with 3.1 days (p < 0.001), Hispanic race with 1.6 days (p = 0.029), return to the OR with 3.2 days (p = 0.004), and each point increase in BMI with 0.1 days (p = 0.028). For abdominal drains, each point increase in BMI was associated with an increased abdominal drain duration by 0.3 days (p = 0.011), infection with 14.4 days (p < 0.001), and return to the OR with 5.7 days (p = 0.007). Elevated BMI, hypertension, and axillary dissection increase risk for prolonged breast drain requirement in autologous reconstruction. African-American and Hispanic populations experience prolonged breast drain requirement after controlling for other factors, warranting further study.

Multilayer Watertight Closure to Address Adverse Events From Primary Total Knee and Hip Arthroplasty: A Systematic Review of Wound Closure Methods by Tissue Layer.

BackgroundWound closure is a key, and often underrecognized, component of hip and knee arthroplasty. Methods for wound closure are an important consideration to better avoid wound-related adverse events; however, there is a lack of consensus on optimal methods. The objective of the following review was twofold: to characterize the wound closure methods used by layer in the total knee arthroplasty and total hip arthroplasty literature and summarize optimal wound-healing strategies to address the risk of adverse events.MethodsA systematic literature review was performed to identify total knee arthroplasty and total hip arthroplasty randomized controlled trials and nonrandomized studies reporting wound closure methods by layer and wound-healing adverse events (including superficial, deep, or periprosthetic joint infections, wound dehiscence, or prolonged wound drainage). Studies on revision procedures were excluded. Wound closure methods and adverse events were summarized qualitatively as meta-analyses were not possible because of study heterogeneity.ResultsForty studies met the inclusion criteria: 22 randomized controlled trials and 18 observational studies. Across studies, 6 categories and 22 unique techniques for closure were identified. Conventional closure methods exhibited large ranges of adverse event rates. Studies of multilayer barbed sutures with topical skin adhesives and polyester mesh or multilayer antimicrobial sutures reported narrow ranges of adverse events rates.ConclusionsConsiderable variability exists for wound closure methods, with a wide range reported in adverse events. Recent technologies and methods for standardized watertight, multilayer closure show promise for avoiding adverse events and unnecessary health-care costs; however, higher quality, comparative studies are required to enable future meta-analyses.Level of EvidenceTherapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Chylous ascites in colorectal surgery: A systematic review

BACKGROUNDChylous ascites is a rare complication in colorectal surgery with limited evidence. AIMTo systematically review all available evidence to describe the incidence, clinical presentation, risk factors and management strategies.METHODSThe systematic review was performed through PubMed, MEDLINE, EMBASE and Cochrane and cross-checked up to November 2020. The data collated included: Demographics, indications (benign vs malignant), site of disease, surgical approach, extent of lymphadenectomy, day to and method of diagnosis of chylous ascites and management strategies. RESULTSA total of 28 studies were included in the final analysis (426 cases). Patient age ranged from 31 to 89 years. All except one case were performed for malignancy. Of the 426 cases, 195 were right-colonic, 121 left-colonic, 103 pelvic surgeries and 7 others. The majority were diagnosed during the same inpatient stay by recognition of typical drain appearance and increased volume. Three cases were diagnosed during outpatient visits with increased abdominal distention and subsequently underwent paracentesis. Most cases were managed successfully non-operatively (fasting with prolonged drainage, total parenteral nutrition, somatostatin analogues or a combination of these). Only three cases required surgical intervention after failing conservative management and subsequently resolved completely. Risk factors identified include: Right-colonic surgery/ tumour location, extent of lymphadenectomy and number of lymph nodes harvested. CONCLUSIONChylous ascites after colorectal surgery is a relatively rare complication. Whilst the majority of cases resolved without surgical intervention, preventative measures should be undertaken such as meticulous dissection and clipping of lymphatics during lymphadenectomy to prevent morbidity.

Body composition parameters predict pathological response and outcomes in locally advanced gastric cancer after neoadjuvant treatment: A multicenter, international study

Body composition profiles influence the prognosis of several types of cancer; however, the role of body composition in patients with locally advanced gastric cancer (LAGC) after neoadjuvant treatment (NT) has not been well characterized. A total of 213 patients with LAGC who underwent gastrectomy after NT at a high-volume institution from southern China were comprehensively evaluated for primary analysis. Additionally, 170 and 77 patients from Western China and Italy, respectively, were reviewed for external validation. The skeletal muscle index (SMI), skeletal muscle radiodensity (SMD), and the subcutaneous as well as the visceral adiposity index were assessed from clinically acquired CT scans at diagnosis and preoperatively. Overall, none of the body composition parameters significantly changed after NT. The pre-NT skeletal muscle radiodensity (SMD) and change in SMI (ΔSMI) were both significantly lower in the patients with poor response (tumor regression <50%; mean SMD: 43.5 vs 46.5, P=0.003; mean ΔSMI:-1.0 vs 2.2, P<0.001), and the cutoff values were calculated according to the Youden index as 43.7 and 1.2, respectively. Based on these 2 parameters, a novel model, the Skeletal Muscle Score (SMS), was proposed to predict the pathological response (AUC=0.764 alone and=0.822 in combination with the radiological response). Moreover, patients with an SMI loss >1.2 had a significantly prolonged drainage tube removal time (mean: 10.0 vs 8.2, P=0.003) and postoperative hospital stay (mean: 11.1 vs 9.8, P=0.048), as well as a significantly higher rate of postoperative complications (30.9% vs 16.7%, P=0.015). In the multivariate analysis, SMI loss >1.2 independently predicted poor overall survival (HR: 1.677, 95% CI 1.040-2.704, P=0.034) and recurrence-free survival (HR: 1.924, 95% CI 1.165-3.175, P=0.011). ΔSMI was also significantly associated with pathological response, surgical outcomes, and survival in the 2 external cohorts (P all<0.05). For LAGC, the pre-NT SMD and ΔSMI could accurately predict the pathological response after NT. An SMI loss >1.2 is closely associated with poorer outcomes and may indicate the need more supportive treatment.

Pulmonary tuberculosis presenting as tension pneumothorax

Although detection of spontaneous pneumothorax during evolvement active pulmonary tuberculosis is not uncommon, presentation of pulmonary tuberculosis as tension pneumothorax is rare. There is limited literature regarding pneumothorax complicating pulmonary tuberculosis. Pneumothorax due to tuberculosis can be managed by intercostal drainage in the majority; only a minority needs surgical intervention. Many patients need intercostal drainage for a prolonged period. We report a patient presenting with a tension pneumothorax who was found to have active pulmonary tuberculosis. His pneumothorax was managed successfully with prolonged intercostal drainage. Lessons we learnt during the management of this patient is discussed.

Case 2: Early-Onset Neonatal Sepsis in a Term Neonate

Case 2: Early-Onset Neonatal Sepsis in a Term Neonate

Heimlich Valve as an Ambulation Management of Persistent Pneumothorax or Fluidopneumothorax

Pneumothorax or fluidopneumothorax is a critical condition when there is some air or/and fluid in the plural cavity. The symptoms may include shortness of breath, chest pain, blue discoloration of the skin or lips, increased heart rate, and loss of consciousness. Pleural cavity drainage is management therapy with the concept of Water Seal Drainage (WSD), which requires a long hospital stay. Heimlich valve is a non-return valve that allows fluid and air to exit the thoracic cavity (on inspiration) and prevents fluid and air from re-entering (during expiration). Heimlich valve is a viable, inexpensive, convenient, safe, effective, and efficient alternative in the management of ambulation of patients requiring prolonged pleural cavity drainage. The use of Heimlich valve is an alternative option for patients with persistent pneumothorax or fluidopneumothorax. It can shorten the time of treatment in the hospital, lowering treatment costs, and minimize the presence of nosocomial infections. Relative contraindications include fluidopneumothorax with massive pleural effusion or empyema. The risks and complications are dislodgement or improper reattachment, leaking valve, adhesion, and blockage, thus becoming tension pneumothorax or pleural cavity infection. Currently the latest innovation also improves the patient’s convenience, like Thoracic Vent, Pneumostat, or Mini Mobile Dry Seal Drain.

Features of the installation of a suprapubic cystostomy for laparoscopic treatment of patients with intraperitoneal bladder rupture

INTRODUCTION: In closed intraperitoneal bladder trauma, an alternative to laparotomy is laparoscopy. The rupture is closed with endoscopic sutures, and the bladder is drained with a urethral catheter. In the literature, the issue of the placement of a trocar cystostomy during laparoscopic treatment of patients with intraperitoneal bladder ruptures requiring prolonged drainage is insufficiently covered.&#x0D; PURPOSE OF THE STUDY: Determination of the optimal trocar cystostomy method during laparoscopic treatment of intraperitoneal bladder rupture.&#x0D; MATERIALS AND METHODS: Trocar cystostomy was performed in 8 patients with intraperitoneal bladder ruptures, among whom 7 had concomitant diseases of the prostate gland, and 1 had urethral stricture. Trocar cystostomy during laparoscopic surgery was performed in three different ways. Results. In the first method, the rupture of the bladder was initially sutured. Then, through the urethral catheter, the bladder was filled with saline. A trocar cystostomy was inserted through the suprapubic region. The second method consisted in the installation of a trocar cystostomy under the control of a laparoscope even before the suturing of the bladder rupture. In the third method proposed by us (patent No. 2592023), a Foley-type catheter with a balloon capacity of at least 200 ml was inserted into the abdominal cavity through the laparoscopic port. A catheter was inserted from the abdomen through an intraperitoneal rupture into the bladder. Inside the bladder, the catheter balloon was filled with saline. Then, through the suprapubic region, the anterior abdominal wall, the bladder and the inflated balloon of the catheter were pierced layer by layer with a trocar. Another catheter was inserted through the trocar into the bladder. After removal of the catheter with a ruptured balloon, the intraperitoneal rupture of the bladder was sutured.&#x0D; FINDINGS: According to the results of the study, the third method of inserting a trocar cystostomy turned out to be the most optimal and safe.

113 Best practices for repair of iatrogenic bladder injury in gynecologic surgery

Bladder injury, particularly of a mechanical nature, is the most frequent major complication of gynecologic surgery, and can occur in other types of surgery or after trauma. Despite its frequency, there is limited research on best practices for bladder injury repair. This literature review aims to summarize types of iatrogenic bladder injuries, guidelines on bladder injury repair, expected follow-up care, and areas for further research. Literature review of societal guidelines, recent research, and expert opinions. This review is divided into 5 sections: types of bladder injury, pathophysiology of wound healing, repair techniques, indwelling catheter placement, post-operative care, and the special case of injury during sling placement. We discuss the classification of bladder injury. Iatrogenic bladder injuries are classified by the American Association of Surgery for Trauma Injury Severity Scale from grade 1-5 (Fig 1). Bladder injuries of grade 1 or 2 should be managed with prolonged drainage with indwelling urethral catheter for at least 7-14 days, although there is no consensus on duration. Injuries of grades 3 and higher require surgical management. Animal models for healing of the urothelium are reviewed. Surgical techniques for repair are summarized, followed by a review of current guidelines for post-operative care. American and European Associations of Urology guidelines recommend cystogram after conservatively treated bladder injuries and surgically repaired extraperitoneal injuries, but do not recommend it after surgical repair of simple intraperitoneal injuries. However, there is conflicting data on postoperative cystograms requiring further research. Lastly, special attention is granted to injury during bladder sling placement, a common gynecologic procedure. There is a consensus on types of bladder injury that need to be repaired surgically versus managed conservatively with an indwelling urinary catheter. There is also relative standardization in suture types used for surgical repair. Polyglactin 910 is the preferred suture to use for repair in one or two layers, depending on defect size. There are also standard guidelines for recognition and management of bladder injury during sling placement. However, more research is needed to determine duration of indwelling urinary catheter and the risk-benefit ratio of cystograms prior to catheter removal. Further studies should be designed with a larger sample size than what has been investigated in the available literature.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The Impact of the Pulmonary Artery Index and Aortopulmonary Collateral Artery Coil Embolization on Intractable Pleural Effusions After a Fontan Surgery.

An intractable pleural effusion is a common comorbidity of a Fontan operation, occasionally leading to undesirable outcomes. The preventive effect of aortopulmonary collateral (APC) coil embolization against a pleural effusion before a Fontan operation is still controversial.This is a retrospective single-center study; among 227 Fontan cases, 57 cases with complete MRI data were analyzed at first. Factors associated with the duration of pleural drainage (median: 6 (2-41) days) and that of postoperative hospital stay (median: 25 (14-91) days) were analyzed using a multiple regression analysis. The pulmonary artery index (PAI; Nakata index) was associated with both the pleural drainage duration (P < 0.05, r2 = 0.17) and postoperative hospital stay (P < 0.05, r2 = 0.10).Thereafter, all the 227 patients were classified into the following three groups: Group A (12 patients in whom the embolization was performed within 30 days before the Fontan surgery), Group B (131 patients in whom the embolization was performed more than 30 days before the Fontan surgery), and Group C (84 patients in whom the embolization was not performed). Patients in Group A were found to be associated with the shortest length of both periods (P < 0.05).Lower PAI values were related to a prolonged pleural drainage duration and postoperative hospital stay. APC coil embolizations may reduce the risk if they are performed shortly (less than 30 days) before the operation.

Pre-Operative Bariatric Surgery Imparts An Increased Risk of Infection, Re-Admission and Operative Intervention Following Elective Instrumented Lumbar Fusion.

Retrospective cohort study. To evaluate the impact of bariatric surgery on patient outcomes following elective instrumented lumbar fusion. A retrospective review of a prospectively collected database was performed. Patients who underwent a bariatric procedure prior to an elective instrumented lumbar fusion were evaluated. Lumbar procedures were performed at a large academic medical center from 1/1/2012 to 1/1/2018. The primary outcome was surgical site infection (SSI) requiring surgical debridement. Secondary outcomes were prolonged wound drainage requiring treatment, implant failure requiring revision, revision secondary to adjacent segment disease (ASD), and chronic pain states. A randomly selected, surgeon and comorbidity-matched group of 59 patients that underwent an elective lumbar fusion during that period was used as a control. Statistical analysis was performed using Student's two-way t-tests for continuous data, with significance defined as P < .05. Twenty-five patients were identified who underwent bariatric surgery prior to elective lumbar fusion. Mean follow-up was 2.4 ± 1.9 years in the bariatric group vs. 1.5 ± 1.3 years in the control group. Patients with a history of bariatric surgery had an increased incidence of SSI that required operative debridement, revision surgery due to ASD, and a higher incidence of chronic pain. Prolonged wound drainage and implant failure were equivalent between groups. In the present study, bariatric surgery prior to elective instrumented lumbar fusion was associated increased risk of surgical site infection, adjacent segment disease and chronic pain when compared to non-bariatric patients.