Routine Drainage Research Articles

Omission of intraoperative drain placement during robotic partial nephrectomy and robotic radical prostatectomy is safe: an analysis of 18,000 patients

PurposePlacement of a drain during robotic assisted partial nephrectomy (RAPN) and robotic assisted radical prostatectomy (RARP) is standard practice for many urologists and can aid in assessment and management of complications such as urine leak, lymphocele, or bleeding. However, drain placement can cause discomfort and delay patient discharge, with questionable benefit. We aim to assess the correlation between drain placement with post operative complications.MethodsThe NSQIP targeted database was queried for patients who underwent RAPN or RARP from 2019 to 2021. Our primary outcomes included 30-day complication rates stratified by intraoperative drain placement. Secondary outcomes included procedure-specific complications, length of stay (LOS), and readmissions. Multivariable regression analyses, with Bonferroni correction, were performed for each post-operative complication.ResultsWe identified 4738 and 13,948 patients who underwent RAPN and RARP, respectively. Drains were not placed in 2258 (47.7%) and 6700 (48%) patients, respectively. On adjusted multivariable analysis in the RAPN cohort, omission of drain placement was associated with decreased LOS (β -0.45; 99.58% CI [-0.59, -0.32]) but no difference in overall complication rates. After adjusted analysis in the RARP cohort, omission of drain placement was associated with decreased risk of any complication (OR 0.73 [0.62–0.87]), infectious complication (OR 0.66 [0.49–0.89]), and LOS (β -0.30 [-0.37, -0.24]).ConclusionsUsing a large contemporary database, this study demonstrates that omission of drains during RAPN and RARP was safe without increased risk of postoperative complications. Despite inherent selection bias in this cohort, our data suggests that routine drain placement is not necessary for these procedures.

Comparative Assessment of Outcomes: Abdominal Drain vs. No Abdominal Drain after Left Pancreatectomy-A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aimed to compare outcomes between abdominal drain placement and no drain placement post-pancreatectomy. Left pancreatectomy (LP) is a surgical procedure commonly employed for various pancreatic conditions, often associated with postoperative complications like post-operative pancreatic fistula (POPF). While routine abdominal drainage following LP has been standard practice, recent evidence suggests potential benefits of omitting this approach. A comprehensive search was conducted on PubMed, Cochrane, and Embase from inception up to 15 March 2024, yielding nine studies comprising 15,817 patients. Data were extracted from randomized and non-randomized studies reporting primary and secondary outcomes. The analysis was performed in Revman. Risk ratios were calculated with 95% confidence intervals, and a P-value of <0.05 was considered statistically significant. A total of 13,081 patients underwent drain placement after left pancreatectomy, and 2,736 patients were included in the no-drain group. Out of the total, 45.1% (n=7140) patients were male, with 45.9% (n=6012) males in the drain group and 41.2% (n=1128) males in the no-drain group. Major morbidity, defined as Clavien-Dindo grade ≥III complications, was significantly lower in the no-drain group (relative risk [RR]: 0.77, 95% confidence interval [CI]: 0.64-0.93, P=0.006). Similarly, lower rates of postoperative pancreatic fistula (POPF) (RR: 0.51, 95% CI: 0.38-0.67, P<0.00001), readmission (RR: 0.75, 95% CI: 0.59-0.96, P=0.02), and surgical site infections (RR: 0.82, 95% CI: 0.70-0.95, P=0.009) were observed in the no-drain group. Additionally, a shorter length of hospital stay was noted in this group (mean difference MD: -1.65, 95% CI: -2.50 to -0.81, P=0.0001). Omitting routine drainage after left pancreatectomy is associated with reduced complications and shorter hospital stays, supporting its potential benefits in improving postoperative outcomes.

Drainage and irrigation on demand may decrease severe septic complications and mortality in pancreatic resections.

The necessity of routine drain placement in pancreatic resections is controversial. Some randomized controlled trials have shown that the omission of drainage is safe for some patients, whereas reintervention rates and mortality rates are substantial for others. The present study aimed to assess fistula-associated outcomes in the setting of routine drain placement and drain irrigation on demand. Between 01/2017 and 12/2022, perioperative and outcome data from patients who underwent consecutive pancreatoduodenectomies (PD, n = 253) or distal pancreatectomies (DP, n = 72) were prospectively collected in the electronic StuDoQ database and analysed. All patients underwent intraoperative drain placement. Drains were removed starting at postoperative day 2 in PD or at day 5 in DP after testing for amylase concentration. In case of high amylase levels or macroscopically suspicious pancreatic fistulas, drain irrigation was started. Nondrained fluid collections underwent percutaneous radiologic or transluminal endoscopic evacuation. Clinically relevant pancreatic fistulas were detected in 53 of 325 patients (POPF grade B 16.3%, grade C 1.2%). 43.3% of those had drain irrigation. Additional interventional or endoscopic drainage was necessary in 14 and 5 patients, respectively (overall 5.8%), and were observed in 4.0% of patients with PD and in 12.5% with DP (p = 0.009). Delayed fistula-associated postpancreatectomy haemorrhage (PPH) was present in 1.2% (4/325) of patients. The fistula- and delayed PPH-associated reoperation rate was 1.5% (5/325). The 30-day and in-hospital mortality rates were both 1.5% (5/325), and the rate of fistula-associated mortality was 0.6% (2/325). The overall 90-day mortality rate was 4.5%. In pancreatectomies, a standardized drainage protocol including on-demand drain irrigation results in very low fistula-associated morbidity and mortality and an infrequent need for interventional or surgical reintervention as compared to previously published drainage studies.

Pain management after laparoscopic cholecystectomy: A systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations.

Laparoscopic cholecystectomy can be associated with significant postoperative pain that is difficult to treat. We aimed to evaluate the available literature and develop updated recommendations for optimal pain management after laparoscopic cholecystectomy. A systematic review was performed using the procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials and systematic reviews published in the English language from August 2017 to December 2022 assessing postoperative pain after laparoscopic cholecystectomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. From 589 full text articles, 157 randomised controlled trials and 31 systematic reviews met the inclusion criteria. Paracetamol combined with NSAIDs or cyclo-oxygenase-2 inhibitors should be given either pre-operatively or intra-operatively, unless contraindicated. In addition, intra-operative intravenous (i.v.) dexamethasone, port-site wound infiltration or intraperitoneal local anaesthetic instillation are recommended, with opioids used for rescue analgesia. As a second-line regional technique, the erector spinae plane block or transversus abdominis plane block may be reserved for patients with a heightened risk of postoperative pain. Three-port laparoscopy, a low-pressure pneumoperitoneum, umbilical port extraction, active aspiration of the pneumoperitoneum and saline irrigation are recommended technical aspects of the operative procedure. The following interventions are not recommended due to limited or no evidence on improved pain scores: single port or mini-port techniques, routine drainage, low flow insufflation, natural orifice transluminal endoscopic surgery (NOTES), infra-umbilical incision, i.v. clonidine, nefopam and regional techniques such as quadratus lumborum block or rectus sheath block. Several interventions provided better pain scores but are not recommended due to risk of side effects: spinal or epidural anaesthesia, gabapentinoids, i.v. lidocaine, i.v. ketamine and i.v. dexmedetomidine.

Review of Gender Affirming Mastectomy Surgery: Comparing Drains Versus No Drains.

Gender-affirming mastectomy can improve mental health and gender expression. However, there is no consensus on routine drain usage in gender-affirming surgeries. The purpose of this study is to compare gender-affirming mastectomies with and without drains and review complications. An institutional review board-approved, retrospective review was performed to identify patients between 2017-2021 who had double-incision mastectomy, with or without nipple graft, and separated into drain and no-drain cohorts. Patient demographics, outcomes, and postoperative complications were analyzed, including unplanned return to the operating room, seromas, hematomas, postoperative infection, and postoperative antibiotic use. Univariate and multivariate analysis was performed. There were 359 patients that had a gender-affirming mastectomy surgery between 2017 and 2021. The mean age was 26.1 years old, and mean body mass index was 27.4. There were 144 patients (40.1%) who had a drain, and 215 patients (59.9%) without a drain. For postoperative complications of all patients, there were 12 (3.3%) unplanned returns to the operating room, 18 seromas (5.0%), 26 hematomas (7.2%), 50 (13.9%) postoperative antibiotic use, and 4 postoperative infections (1.1%). There were no significant differences found between drain use for all postoperative complications, but no-drain use was significantly associated with less prescribed postoperative antibiotics compared to drain use (3.7% and 29.0%, respectively; P < 0.001). Gender-affirming mastectomy surgeries are safe and effective treatment options. No-drain placement was not associated with increased postoperative complications. Surgeons may consider not prescribing routine postoperative antibiotics if using drains, and avoiding drains for gender-affirming mastectomies may be considered in selected individuals based on clinical judgment.

Laparoscopic cholecystectomy with or without drainage: a systematic review and meta-analysis

Background. The abdominal drainage with a prophylactic purpose was used by surgeons for decades because of the possibility to detect early signs of postoperative complications. However, the real value of routine drainage after abdominal surgery is still debated. There are discrepancies between studies supporting the drain placement only in patients with intraoperative complications and works showing a beneficial effect of prophylactic abdominal drainage on postoperative pain, nausea, and vomiting. However, there is still a lack of evidence on the use of routine abdominal drainage following laparoscopic cholecystectomy and its clinical value. Current guidelines do not mention the role of drainage after laparoscopic cholecystectomy. Objective: to evaluate whether conventional postoperative drainage is more effective than no drainage in patients with non-complicated benign gallbladder disease after laparoscopic cholecystectomy. Materials and methods. A search in the electronic databases MEDLINE, Scopus, Cochrane Library was conducted for randomized controlled trials reporting outcomes of laparoscopic cholecystectomy with and without an abdominal drainage until January 2024. The systematic review was conducted in accordance with the PRISMA guidelines and meta-analysis — using fixed and random effects models. Odds ratio (OR) with confidence interval (CI) for qualitative variables and mean difference (MD) with CI for continuous variables were calculated using IBM SPSS Statistics 29.0.2.0. Results. Forty-four randomized controlled trials invol­ving 5,185 patients (2,592 with drains vs 2,593 without them) were included in the meta-analysis. There were no statistically significant differences in the incidence of intra-abdominal fluid accumulation (OR = 0.87; 95% CI: 0.64–1.19; p = 0.39) between two groups. Abdominal drains did not reduce the overall incidence of nausea and vomiting (OR = 1.51; 95% CI: 0.85–2.70; p = 0 .16) or shoulder pain (OR = 0.90; 95% CI: 0.58–1.41; p = 0.65). The abdominal drain group reported significantly higher pain scores (MD = 0.67; 95% CI: 0.37–0.98; p &lt; 0.001) than patients without drains. Abdominal drainage increased operative time (MD = 3.82; 95% CI: 1.93–5.70; p &lt; 0.001) but not the length of hospital stay after surgery (MD = 0.42; 95% CI: –0.02–0.85; p = 0.06). Wound infection (OR = 3.26; 95% CI: 2.35–4.51; p &lt; 0.001), fever (OR = 4.40; 95% CI: 2.57–7.8554; p &lt; 0.001) and pneumonia (OR = 4.74; 95% CI: 2.25–9.97; p &lt; 0.001) were found to be associated with the use of abdominal drains. Conclusions. Currently, there is no evidence to support the use of routine drainage after laparoscopic cholecystectomy in non-complicated benign gallbladder disease. No drainage after laparoscopic cholecystectomy is safe and associated with fewer complications. Postoperative recovery is improved if drain is not used. Further well-designed randomized clinical trials are required to confirm this finding.

Are drain essentials in kidney transplantation? Analysis of risk factors affecting the postoperative drainage

ObjectiveThe routine drain placement following renal transplantation is currently under debate. Its benefit is uncertain and may cause complications, particularly infectious ones. Some renal transplant patients have low-productive drains, that might be unnecessary. The objective of this study is to bring to light factors influencing drain volume in kidney transplantation. Materials and methodsAll kidney transplant patients in Tours between 2019 and 2020 were included. The characteristics of the two groups were analyzed: patients with low-productive redons (quantification less than 100mL/24h,) and patients with productive redons (≥ 100mL/24h). Univariate and multivariate analyses by logistic regression were performed to look for risk factors associated with productive drainage. ResultsOne hundred and eighty-nine patients were included (67 in the low-productive group and 122 in the productive group). The results in the productive group showed a significantly higher proportion of retransplantation (P=0.015), overweight (P=0.012), low residual diuresis (P=0.041), and a significantly lower proportion of preemptive transplantation (P=0.008) and peritoneal dialysis (P=0.037). After an adjustment, the following variables remained significantly associated with greater drainage: overweight (OR=2.42, P=0.014; 95% CI [1.2–4.94]); retransplantation (OR=3.98, P=0.027; 95% CI [1.27–15.45]), and preemptive transplant (OR=0.22, P=0.013; 95% CI [0.06–0.7]). ConclusionThe non-implementation of a redon in renal transplantation could be considered, in a selected population of non-overweight patients, with significant residual diuresis for a first transplantation which should be preemptive. This could lead to a randomized controlled trial to determine the real benefits of a routine drain replacement in kidney transplantation. Level of evidenceIV.

SAGES guideline for the diagnosis and treatment of appendicitis.

Appendicitis is an extremely common disease with a variety of medical and surgical treatment approaches. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians and patients in decisions regarding the diagnosis and treatment of appendicitis. A systematic review was conducted from 2010 to 2022 to answer 8 key questions relating to the diagnosis of appendicitis, operative or nonoperative management, and specific technical and post-operative issues for appendectomy. The results of this systematic review were then presented to a panel of adult and pediatric surgeons. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Conditional recommendations were made in favor of uncomplicated and complicated appendicitis being managed operatively, either delayed (>12h) or immediate operation (<12h), either suction and lavage or suction alone, no routine drain placement, treatment with short-term antibiotics postoperatively for complicated appendicitis, and complicated appendicitis previously treated nonoperatively undergoing interval appendectomy. A conditional recommendation signals that the benefits of adhering to a recommendation probably outweigh the harms although it does also indicate uncertainty. These recommendations should provide guidance with regard to current controversies in appendicitis. The panel also highlighted future research opportunities where the evidence base can be strengthened.

Comparing the effectiveness of full-vacuum and half-vacuum drainage in reducing seroma after modified radical mastectomy: a meta-analysis.

Owing to limited outpatient support for drain management, delayed discharge after mastectomy is more prevalent in developing countries. Utilising half-vacuum (HV) suction drains for routine drainage after mastectomy could lead to a reduced incidence of seroma and a shorter hospital stay. This systematic review and meta-analysis compared the outcomes of HV against full-vacuum (FV) suction drains in patients who underwent modified radical mastectomy for breast cancer. Differences between the two groups in length of hospital stay, total volume of drain effluent and incidence of seroma were assessed. RevMan 5.4 was used to calculate the odds ratio (OR) and relative risk (RR) for dichotomous data, and the mean difference (MD) for continuous data. Nine randomised controlled trials were included in this review. Using HV drains reduced both the mean length of hospital stay (MD: -2.30 days, 95% confidence interval [CI]: -4.10 to -0.49 days, I2=97%) and the mean total volume of effluent (MD: -132.61ml, 95% CI: -207.32ml to -57.91ml, I2=88%) compared with FV drains. However, there was no statistically significant difference in incidence of seroma between the two groups (RR: 0.67, 95% CI: 0.30 to 1.46, I2=65%). Likewise, there was no difference in rate of seroma occurrence on sensitivity analysis (OR: 1.29, 95% CI: 0.72 to 2.33, I2=74%). There was no difference in the incidence of seroma between HV and FV suction drainage. Conversely, a reduction in the length of hospital stay and the total volume of drain effluent was observed for mastectomy patients with a HV drain.

Assessing sustainable waste management practices in Rajshahi City Corporation: an analysis for local government enhancement using IoT, AI, and Android technology.

This study addresses the pressing challenge of inefficient waste management practices within the Rajshahi City Corporation (RCC), Bangladesh. Despite rapid urbanization and escalating waste generation rates, RCC struggles with diverse waste disposal practices, limited supervision, irregular waste collection schedules, and inadequate disposal infrastructure. In this context, this study examines the possible improvements that could be made by combining the Internet of Things (IoT), artificial intelligence (AI), and Android application to improve waste management methods in the RCC. The study's foundation is a vast amount of information gathered from residents, with particular attention paid to waste disposal methods, the role of the local government, the frequency of waste collection, and public attitudes toward waste management. The results point to a complicated waste management environment with a range of waste disposal practices, little supervision, irregular waste collection, and insufficient disposal methods. The importance of RCC in waste management is emphasized, highlighting the need for proactive measures including effective monitoring, constant waste collection, and routine drain cleaning. Additionally, it is suggested that combining IoT, AI, and Android technology is a possible way to improve waste management procedures. These technologies have the potential to increase productivity, lessen their negative effects on the environment, and produce cleaner, more sustainable urban environments.

Routine closed-suction drainage reduces seromas following totally extraperitoneal (TEP) inguinal hernia repair: A meta-analysis.

The value of prophylactic closed-suction drainage in totally extraperitoneal inguinal hernia repair (TEP) is still a matter of controversy. We conducted a meta-analysis of studies examining postoperative seroma rates in patients with or without routine placement of closed-suction drainage tubes. A systematic literature search was conducted for trials comparing the outcome of TEP with or without routine drainage placement. Data regarding postoperative outcomes were extracted and compared by meta-analysis. The odds ratio and standardized mean differences with 95% confidence intervals were calculated. Four studies were identified, involving a total of 1626 cases (Drain: n = 1251, no Drain: n = 375). There was a statistically significant difference noted between the 2 groups regarding postoperative seroma formation favoring the Drain group (odds ratio = 0.12; 95% confidence intervals [0.05, 0.29]; P < .001; 4 studies; I2 = 72%). For the remaining secondary endpoints postoperative urinary retention, recurrence, mesh infection and in-hospital length of stay no statistically significant difference was noted between the 2 study groups. Current evidence suggests that patients who underwent TEP with routine closed-suction drain placement developed significantly fewer seromas without any additional morbidity or prolongation of in-hospital stay.

Prophylactic Peri-Nephric Drain Placement in Renal Transplant Surgery: A Systematic Review and Meta-Analysis.

Renal transplantation is common worldwide, with >25,000 procedures performed in 2022. Usage of prophylactic perinephric drains is variable in renal transplantation; drains are associated with risks, and there is a lack of consensus regarding benefit of routine drain placement in these patients. This meta-analysis assessed whether prophylactic drainage reduced need for reintervention postoperatively. This systematic review and meta-analysis was carried out using the Preferred Reporting Items in Systematic Reviews and Meta-Analysis, and prospectively registered on PROSPERO. Summary statistics for outcomes of interest underwent meta-analyses to a confidence interval (CI) of 95% and are presented as Forest Plots for Odds Ratio (OR). A systematic literature search in June 2023 revealed 1,540 unique articles across four databases. Of these, four retrospective cohort studies were selected. Meta-analysis of three studies showed no significant reduction in reintervention rate with pre-emptive drain placement, OR = 0.59 (95% CI: 0.16-2.23), p = 0.44. Meta-analysis did not show a significant reduction in perinephric collections with prophylactic drain insertion OR = 0.55 (95% CI: 0.13-2.37), p = 0.42. Finally, there is not good evidence that drain placement reduces superficial wound complications or improves 12-month graft survival. Further work is needed, including well-designed, prospective studies to assess the risks and benefits of drain placement in these patients. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023422685, Identifier PROSPERO CRD42021255795.

Routine drain placement after hepaticojejunostomy in benign biliary stricture - is it necessary?

Routine drain placement after hepaticojejunostomy in benign biliary stricture - is it necessary?

Characteristics of Klebsiella pneumoniae pyogenic liver abscess from 2010–2021 in a tertiary teaching hospital of South China

Pyogenic liver abscess (PLA) is a severe and potentially fatal infectious disease. Klebsiella pneumoniae (K. pneumoniae) is the predominant pathogen responsible for PLA. This study aims to investigate the clinical characteristics and prognostic factors of K. pneumoniae-induced pyogenic liver abscess (KP-PLA), particularly those caused by carbapenem-resistant K. pneumoniae (CRKP). Analyses were performed on PLA patients from January 2010 to December 2021, to investigate the differences of K. pneumoniae from other etiologically infected PLA patients. Univariate and multivariate logistic regression analyses were used to compare prognostic factors between patients with carbapenem-resistant K. pneumoniae PLA (CRKP-PLA) and patients with carbapenem-sensitive K. pneumoniae PLA. Univariate analysis demonstrated a significant association between KP-PLA and factors including diabetes mellitus (P < 0.001), cholecystitis and cholelithiasis (P = 0.032), single abscess (P = 0.016), and abscesses with a diameter over 50 mm (P = 0.004). The CRKP group exhibited a higher prevalence of therapeutic interventions before K. pneumoniae infection, including abdominal surgery, mechanical ventilation, sputum suction, tracheal cannula, routine drainage of the abdominal cavity, and peripherally inserted central venous catheters (P < 0.05). Multivariate logistic regression analysis revealed that admission to the intensive care unit was an independent risk factor associated with CRKP-PLA (odds ratio 36; 95% confidence interval 1.77-731.56; P = 0.020). The KP-PLA patients were significantly associated with diabetes and were more likely to have single abscesses larger than 50 mm. PLA patients with a history of admission to intensive care unit or invasive therapeutic procedures should be given special consideration if combined with CRKP infection.

Evaluation of viscosities of typical drainage fluids to promote more evidence-based catheter size selection

Percutaneous drainage is a first-line therapy for abscesses and other fluid collections. However, experimental data on the viscosity of body fluids are scarce. This study analyses the apparent viscosity of serous, purulent and biliary fluids to provide reference data for the evaluation of drainage catheters. Serous, purulent and biliary fluid samples were collected during routine drainage procedures. In a first setup, the apparent kinematic viscosity of 50 fluid samples was measured using an Ubbelohde viscometer. In a second setup, the apparent dynamic viscosity of 20 fluid samples obtained during CT-guided percutaneous drainage was measured using an in-house designed capillary extrusion experiment. The median apparent kinematic viscosity was 0.96 mm2/s (IQR 0.90–1.15 mm2/s) for serous samples, 0.98 mm2/s (IQR 0.97–0.99 mm2/s) for purulent samples and 2.77 mm2/s (IQR 1.75–3.70 mm2/s) for biliary samples. The median apparent dynamic viscosity was 1.63 mPa*s (IQR 1.27–2.09 mPa*s) for serous samples, 2.45 mPa*s (IQR 1.69–3.22 mPa*s) for purulent samples and 3.50 mPa*s (IQR 2.81–3.90 mPa*s) for biliary samples (all differences p < 0.01). Relative to water, dynamic viscosities were increased by a factor of 1.36 for serous fluids, 2.26 for purulent fluids, and 4.03 for biliary fluids. Serous fluids have apparent viscosities similar to water, but biliary and purulent fluids are more viscous. These data can be used as a reference when selecting the drainage catheter size, with 8F catheters being appropriate for most percutaneous drainage cases.

Surgical Techniques and Related Perioperative Outcomes After Robot-assisted Minimally Invasive Gastrectomy (RAMIG): Results From the Prospective Multicenter International Ugira Gastric Registry.

To gain insight into the global practice of robot-assisted minimally invasive gastrectomy (RAMIG) and evaluate perioperative outcomes using an international registry. The techniques and perioperative outcomes of RAMIG for gastric cancer vary substantially in the literature. Prospectively registered RAMIG cases for gastric cancer (≥10 per center) were extracted from 25 centers in Europe, Asia, and South-America. Techniques for resection, reconstruction, anastomosis, and lymphadenectomy were analyzed and related to perioperative surgical and oncological outcomes. Complications were uniformly defined by the Gastrectomy Complications Consensus Group. Between 2020 and 2023, 759 patients underwent total (n=272), distal (n=465), or proximal (n=22) gastrectomy (RAMIG). After total gastrectomy with Roux-en-Y-reconstruction, anastomotic leakage rates were 8% with hand-sewn (n=9/111) and 6% with linear stapled anastomoses (n=6/100). After distal gastrectomy with Roux-en-Y (67%) or Billroth-II-reconstruction (31%), anastomotic leakage rates were 3% with linear stapled (n=11/433) and 0% with hand-sewn anastomoses (n=0/26). Extent of lymphadenectomy consisted of D1+ (28%), D2 (59%), or D2+ (12%). Median nodal harvest yielded 31 nodes (interquartile range: 21-47) after total and 34 nodes (interquartile range: 24-47) after distal gastrectomy. R0 resection rates were 93% after total and 96% distal gastrectomy. The hospital stay was 9 days after total and distal gastrectomy, and was median 3 days shorter without perianastomotic drains versus routine drain placement. Postoperative 30-day mortality was 1%. This large multicenter study provided a worldwide overview of current RAMIG techniques and their respective perioperative outcomes. These outcomes demonstrated high surgical quality, set a quality standard for RAMIG, and can be considered an international reference for surgical standardization.

1052 Safety of Drain-Less Anterior Cervical Discectomy and Fusion (ACDF) and Effects on Length of Stay

Abstract Aim The use of drain in ACDF surgery is to avoid post-operative catastrophic haematomas compressing the airway. However, studies associate drains with dysphagia, infection and longer inpatient stays. This study assesses whether drain-less ACDF could avoid drain-site morbidity and reduce length of stay (LoS) without increasing complications. Method All consecutive adult patients who had ACDF under a single surgeon over a 4-year period were identified, where routine post-operative care did not involve drain placement when meticulous intra-operative haemostasis was achieved. Data was collected using electronic patient records. From Autumn 2020, patients were pre-operatively counselled on potential same-day discharge. This group of patients (PC) was compared with those without counselling (Control) for assessing secondary outcomes, including LoS and GP or A&amp;E attendance. Results Seventy-four patients were included in this study. None had post-operative drain placement and there were no reports of post-operative haematoma or return to theatre. There were 12 and 15 patients for PC and Control groups respectively. For same-day discharge, there were two patients in the PC group and none in Control group. Median LoS was also shorter in PC (1.0 day; IQR:1-1.3) compared to Control (2.0 days; IQR:1-3.5). Three patients from each group had persistent mild radicular symptoms, but none required GP or A&amp;E attendance within 6 weeks post-operatively. Conclusions Our results support that routine drain placement may not be required for safe ACDF surgery. Additionally, with appropriate counselling, shorter LoS can be achieved. This could help develop safe daycase surgery pathways, easing bed demands while improving access to treatment.

Chronic Pericardial Effusion: Causes and Management.

Chronic pericardial effusion is a common pericardial syndrome whose approach has been well standardised in recent years. The main challenge associated with this condition is the progression (sometimes unheralded) to cardiac tamponade Pericardial effusions may present either as an isolated finding or in the context of a specific etiology including autoimmune, neoplastic, or metabolic disease. Among investigations used during diagnostic work-up, echocardiography is of paramount importance for the diagnosis, sizing, and serial evaluation of the hemodynamic impact of effusions on heart diastolic function. In an individualised manner, advanced imaging including computed tomography and cardiac magnetic resonance imaging should be performed, especially if baseline tests are inconclusive. Triage of these patients according to the most recent 2015 European Society of Cardiology Guidelines for the diagnosis and management of pericardial diseases should take into account the presence of hemodynamic compromise or suspicion of malignant pericarditis as first step, C-reactive protein serum level measurement as second step, investigations for a specific condition known to be associated with pericardial effusion as third step, and finally the size and the duration of the effusion. Treatment depends on the evaluation of the above-mentioned parameters and should ideally be tailored to the individual patient. Prognosis of chronic pericardial effusions depends largely on the underlying etiology. According to novel data, the prognosis of individuals with idiopathic, chronic (> 3 months), large (> 2 cm), asymptomatic pericardial effusions is usually benign and a watchful waiting strategy seems more reasonable and cost-effective than routine drainage as previously recommended.

Are chest drains routinely required after thoracic surgery? A drainology study of on-table chest-drain removals

ObjectivesAdvances in perioperative management for thoracic surgery have accelerated the postoperative recovery of patients by decreasing postoperative pain and the incidence of complications. We aimed to study whether it's safe to remove chest drains on table in selected cases. MethodsThis was a 5-year retrospective analysis of protocolized chest-drain removal on the operating table. The chest drain was removed in patients undergoing sublobar/wedge lung resection and other minor thoracic procedure (pleural biopsy, mediastinal mass biopsy/resection) via a thoracoscopic approach (video-assisted thoracoscopic surgery). Chest drains were removed at the end of the operation if air leak as documented by the digital drain was less than 20 mL/min. Outcome data on postdrain removal pneumothorax, effusion, and need for further intervention were obtained by reviewing the postoperative chest films, all reported by a radiologist. ResultsBetween 2016 and 2021, 107 patients underwent drain removal in theater. Mean age (standard deviation) was 58 (17) years and 54 (50.5%) were male. Postdrain removal pneumothorax occurred in 22 patients (21%), pleural effusion in 6 (5.6%), and 21 of 22 postoperative pneumothoraces were managed conservatively without reinsertion of chest drain. As it is our standard policy to leave no pneumothorax in patients undergoing surgical management of primary spontaneous pneumothorax, only 1 such patient (0.9%) had a drain reinserted as a result. The median (interquartile) length of hospital stay was 1 day (1-2), and 14 patients (13%) were discharged on surgery day. ConclusionsOur results demonstrate that on table chest-drain removal in selected cases is safe and repeatable using a digital drain, challenging the practice of routine drain insertion after thoracic surgery.

Trends and Variations in Drain Use Following Pancreatoduodenectomy: Is Early Drain Removal Becoming More Common?

Although previous studies have noted the potential benefit of early drain removal (EDR) after pancreatoduodenectomy (PD), there is a paucity of data on the timing of drain removal utilizing a national database that reflect the "real world" setting. Given the ongoing controversy related to PD drain use and management, we sought to define trends in drain use among a large national cohort, as well as identify factors associated with EDR following PD. The ACS NSQIP targeted pancreatectomy database was used to identify patients who underwent PD between 2014 and 2020. The trend in proportion of patients with EDR (removal ≤ POD3) as well as predictors of EDR were assessed. Risk-adjusted postoperative outcomes were evaluated by multivariable regression analysis. Among 14,356 patients, 16.2% of patients (N = 2324) experienced EDR, and the proportion of patients with EDR increased by 68% over the study period (2014: 10.9% vs. 2020: 18.3%, p < 0.001). Higher drain fluid amylase on POD1-3 [LogWorth (LW) = 44.3], operative time (LW = 33.2), and use of minimally invasive surgery (LW = 14.0) were associated with EDR. Additionally, EDR was associated with decreased risk of overall and serious morbidity, PD-related morbidity (e.g., pancreatic fistula), reoperation, prolonged length of stay and readmission (all p < 0.05). Routine drain placement remains a common practice among most surgeons. EDR following PD increased over time was associated with lower post-operative complications and shorter LOS. Despite evidencethat EDR was safe and may even be associated with lower complications, only 1 in 6 patients were managed with EDR.