Sump Drainage Research Articles

Percutaneous drainage of abscesses and fluid collections: technique, results, and applications.

A combination of computed tomography, ultrasonography, and fluoroscopy was utilized to guide percutaneous catheter drainage of 58 abscesses and fluid collections in 51 patients. Cavities were evacuated in 53 cases, with surgery avoided in 44 of these. There were two failures and six recurrences. The mean duration of catheter drainage was seven days. Five complications occurred, including a small bowel fistula and a lacerated mesenteric vessel. Based on this experience, guidelines for drainage are presented, as well as principles for the critical step of access route planning. Double-lumen sump drainage catheters and the irrigation procedure have simplified and improved drainage. Causes and solutions for unsatisfactory results are defined.

Debridement pancreatectomy for pancreatic abscess

Experience with seven cases of pancreatic abscess is reviewed. All patients were treated with radical pancreatic debridement, large sump drainage with postoperative irrigation, gastrointestinal defunctionalization, antibiotic therapy and nutritional support. One patient died, for a mortality rate of 14 percent. We feel that this regimen will help maximize survival in patients with pancreatic abscess.

Drainage in elective cholecystectomy

This randomized, prospective study evaluates drainage of the subhepatic space in patients undergoing simple, uncomplicated cholecystectomy. One hundred twenty-two patients were divided into open (Penrose) drainage, closed sump drainage and no drainage groups. Open drainage resulted in increased morbidity and a longer postoperative hospital stay. The best results were in patients without drains. Subhepatic drainage is unnecessary in simple, uncomplicated cholecystectomy.

A clinical study on an appropriate treatment of acute pancreatitis

AbstractOne hundred thirty‐nine patients with acute pancreatitis were treated in our clinic during the past 14 years. Seventy‐seven patients had a surgical procedure and 62 patients were managed conservatively. Although 44 patients with edematous pancreatitis were treated with various surgical procedures, 11 patients with the hemorrhagic type had a sump drainage alone. Of the 16 patients with necrotizing pancreatitis, only 2 had a pancreatic resection. The overall operative mortality rate was 18%.Eighty‐five percent of the patients received antienzymatic drugs: Trasylol® (10–820 × 104), FOY (200–8,600 mg), and others. Dosage of these drugs was determined according to the severity of disease. Of 12 patients who were given 5‐FU, one had mild, 8 had moderate, and 3 had severe acute pancreatitis. Two hundred fifty to 500 mg of 5‐FU was administered daily for 2 to 24 days. Some other antienzymatic drugs were also given in 9 patients, in addition to 5‐FU. Ten patients revealed a beneficial effect from this treatment. Overall, 78% of patients showed a favorable course, 7% developed relapsing acute pancreatitis, and 4% had chronic pancreatitis after discharge from hospital. The mortality rate was 11%. The patients with hemorrhagic or necrotizing type had a higher mortality rate (27–37%) and less therapeutic effect than patients with an edematous type.These results indicate that early appropriate treatment is important to obtain a favorable therapeutic result.

Importance of peritoneal irrigation after surgical treatment of hemorrhagic, necrotizing pancreatitis.

AbstractThis is a report of 139 patients with hemorrhagic, necrotizing pancreatitis, 135 of whom were operated upon. The poorest results (mortality rate of 64%) were found in patients with total necrosis of the gland, while partial necrosis of the pancreas had a better outcome (33% mortality rate). The most favorable form of therapy was either local excision of necrotic pancreatic tissue (necrosectomy), or left resection of the pancreas, combined with postoperative irrigation and sump drainage of the peritoneal cavity. With this technique, the mortality rate of 72% seen with drainage of the peritoneal cavity alone was reduced to 33%.

Experiences in the management of pancreatic trauma.

A 30-year experience in the management of 283 consecutive patients with acute pancreatic trauma was reviewed. Of these injuries 224 were penetrating; 59 were from blunt trauma. Diagnosis was made by laparotomy in all patients, although elevated serum amylase suggested this injury in 23 (56%) of 41 patients with nonpenetrating injuries. Operative measures were initially involved with correction of associated injury when present (961 organ injuries in 278 patients: 3.5 injuries per patient). During the earlier years, Penrose drains were placed to the site of injury. Significant pancreatic complications (fistula in 13, suppurative pancreatitis or abscess in six, pseudocyst in three) were noted in 19 (46%) of the 41 patients so managed. Routine sump drainage dramatically reduced the incidence of pancreatic complications to 2% in the 198 patients having external drainage alone. Distal resection was performed in 29 patients, without later pancreatic insufficiency. Most disappointing were the results from Roux-en-Y internal drainage: fistula developed in five and lethal bacterial pancreatitis in three of the seven patients so treated. Five patients died from exsanguination during exploration for major vascular trauma, and all three patients undergoing pancreaticoduodenectomy succumbed within 20 hours after operation. The overall mortality was 13.8%, with only seven deaths out of the last 100 patients treated. Profound hemorrhagic shock and its complications (19), suppurative pancreatitis (eight), and post-traumatic respiratory insufficiency (three) accounted for 30 of the 39 fatalities.

A rectal sump in treatment of severe diarrhea

Successful use of a rectal sump drain in two patients with severe secretory diarrhea is briefly described

Closure of the pelvic and perineal wounds after removal of the rectum and anus.

Between January 1975 and July 1977, 26 patients, who underwent combined synchronous removal of the rectum and anus, were managed within guidelines aimed at achieving primary closure and healing of their operative wounds. The guidelines include preoperative mechanical and luminal antibiotic bowel preparation, perioperative systemic chemoprophylaxis, a combined synchronous ablative procedure in Lloyd-Davies position, short-term sump drainage of the presacral space, meticulous hemostatis, and primary closure of both the pelvic defect above (utilizing an omental pedicle graft to obliterate the pelvic dead space) and the perineal defect below (by primary suture or with gracilis myocutaneous flap). All wounds healed totally within the first six weeks postoperatively, with a mean time to healing of 3.5 weeks in the six patients whose wounds failed to heal primarily. There were no instances of late wound breakdown and follow-up from six months to two years.

Gunshot wounds of the left upper abdominal quadrant associated with multiple intraabdominal injuries

This study reviews low velocity gunshot wounds of the left upper quadrant of the abdomen and presents four cases recently treated at Boston City Hospital. All patients sustained multiple intraabdominal organ injuries and underwent prompt exploration. Hypotension on admission seemed to be the most reliable sign for a prolonged and complicated hospital course. The essential preoperative studies in stable patients should include a chest x-ray and intravenous pyelogram. Intraoperatively, injury to the body or tail or the pancreas is best managed by distal pancreatectomy and sump drainage. Exploration of the retroperitoneum is warranted for bleeding from the kidney. Initial maneuvers should be designed to control hemorrhage from the renal pedicle. If this is unsuccessful or the renal parenchyma is badly fragmented, nephrectomy should be performed. The complications noted in our patients, infection (pneumonia and left subphrenic abscess) and hemorrhage, are comparable to those reported in most large series. Pancreatic complications (fistulas, pseudocysts, and pancreatitis) were not noted.

Left Ventricular Decompression by Sump Drainage

Decompression of the left ventricle during cardiopulmonary bypass is a useful adjunct to open-heart operation, primarily to preserve myocardial tissue and also to improve the exposure of the operative field. The addition of sump drainage to left ventricular decompression systems enhances the usefulness of this established technique. Technical aspects of this sump drainage are detailed.

RUBBER SUMP DRAINAGE OF ENTEROCUTANEOUS FISTULAE

Effective sump drainage of high enterocutaneous fistulae, together with alimentary rest and total parenteral nutrition, is now an integral part of the modern management of patients with this condition. The low tissue reactivity of the plastic and polymer materials currently used in most drainage tubes appears however, to be counterproductive to the establishment of a discrete fistula track and control of the fistula. A case is made for the use of red rubber sump drains for enterocutaneous fistulae. The greater tissue reactivity of rubber is reviewed and confirmed by animal experimentation. A method of rubber sump drainage of enterocutaneous fistulae developed during the management of 83 such fistulae is described.

Management of Duodenal Wounds

A 30-year experience with 321 wounds of the duodenum was reviewed. Of the total, 302 had some form of perforation; 19 had intramural hematomas. All patients underwent laparotomy shortly after admission except six cases of radiographically diagnosed submucosal hematoma. Occasional dehiscence of the duodenal suture line and its life-threatening complications (six of 52 cases, or 12%) led to a policy of routine duodenal decompression by gastrostomy plus twin jejunostomies in 1962. Following use of the latter technique in 237 patients, only one leak occurred. By contrast, failure to decompress had an 8% leak rate; direct drainage of the suture line gave an even greater incidence of dehiscence or fistula, 23%. Associated pancreatic injuries were treated as separate wounds by sump drainage of distal pancreatectomy. None of three patients subjected to pancraticoduodenectomy for massive combined pancreatic and duodenal trauma survived. A long-armed T-tube was always inserted for recognized as well as suspected common duct wounds. Although most of the 41 deaths were due to major vascular trauma and sequelae of hemorrhagic shock, duodenal complications did contribute to significant morbidity and five mortalities during the earlier years of review.

Gallstone Perforation and Obstruction of the Duodenal Bulb

A 69-year-old woman had a large gallstone eroded through the wall of the gallbladder and into the duodenum. The gallstone became fixed within the cholecystoduodenal fistula and produced a duodenal obstruction. At the time of the diagnosis of this problem, the patient had had a three-week period of epigastric pain and prolonged vomiting. She was treated by removal of the stone and cholecystectomy. The duodenal fistula was closed in two layers, and a gastrojejunostomy and a truncal vagotomy were carried out to protect the duodenal suture line. A leak from the duodenal closure developed on the fourth day, but this subsided spontaneously after 15 days with the use of sump drainage. Six months later, the patient is doing well and has a normal duodenum and gastrojejunostomy as shown by upper gastrointestinal barium study.

Management of pancreatic trauma

The majority of patients who sustain penetrating blunt trauma to the pancreas can be managed with sump drainage, including those with gunshot wounds to the head of the pancreas. Pancreatico-duodenectomy may be indicated in 2 to 3 percent of cases of pancreatic injury. Patients who require resection of 80 percent or more of the pancreas and do not have splenic injury should be considered for a Roux-Y anastomosis to the distal pancreas after ductal injury has been proved. Severe injuries to the body of the pancreas are best managed by distal pancreatectomy. The mortality rate due to pancreatic injury has been less than 3 percent and rarely is the cause of death. To support this conclusion, few normotensive patients die, and no patient with an isolated pancreatic injury in our series died. The severity of injury often dictates the appropriate treatment. A conservative approach is indicated for most pancreatic injuries, resulting in shorter operating time and less blood loss in the unstable patient with multiple injuries. Most important is identification of ductal injury at the initial operation and institution of surgical drainage.

Pyeloplasty in infants and children with particular reference to the method of drainage post-operatively.

Sixty-three consecutive Anderson-Hynes pyeloplasties in infants and children have been reviewed with particular reference to any influence the method of drainage might have on the post-operative course and the final radiological result. Extra-anastomotic drainage usually with a sump drain, was used in 40 cases and pyelostomy drainage in 23 cases. Fewer post-operative complications were encountered in the former group. The final radiological result was not influenced by the method of drainage except that, in patients under 2 years of age, those with pyelostomy drainage fared rather better. It is concluded that (a) extra-anastomotic sump drainage is the method of choice following pyeloplasty in children over 2 years of age, and (b) in infants under 2 years of age pyelostomy drainage probably should be combined with a trans-anastomotic splint.

Management of pancreatic trauma.

Since 1950, 300 patients sustaining pancreatic injuries have been managed. Three-fourths of the injuries were due to penetrating trauma with a 20% mortality and one-fourth due to blunt trauma resulting in an 18% mortality. The pancreatic injury was responsible for death in only 3% of patients. Early onset of shock resulted in 38% mortality whereas only 4% of normotensive patients died. No patient died of an isolated pancreatic injury. Sepsis was the second most common cause of death following hemorrhage. Preoperative serum amylase was elevated more frequently following blunt trauma than penetrating trauma, but did not correlate with injury. There has been a tendency toward more frequent use of distal pancreatectomy for simple penetrating injuries without obvious ductal violation which increases operative time, blood loss and possible intra-abdominal abscess since resection usually requires splenectomy. Patients considered for an 80% distal resection are better managed with a Roux-en-Y limb to the distal pancreas since three patients developed diabetes following an 80% or greater resection. A conservative approach consisting of Penrose and sump drainage is adequate for most injuries.

Analysis of Factors Influencing Survival

Of patients with acute pancreatitis (AP), there remains a group who suffer life-threatening complications despite current modes of therapy. To identify factors which distinguish this group from the entire patient population, a retrospectiva analysis of 519 cases of AP occurring over a 5-year period was undertaken. Thirty-one per cent of these patients had a history of alcoholism and 47% had a history of biliary disease. The overall mortality was 12.9%. Of symptoms and signs recorded at the time of admission, hypotension, tachycardia, fever, abdominal mass, and abnormal examination of the lung fields correlated positively with increased mortality. Seven features of the initial laboratory examination correlated with increased mortality. Shock, massive colloid requirement, hypocalcemia, renal failure, and respiratory failure requiring endotracheal intubation were complications associated with the poorest prognosis. Among patients in this series with three or more of these clinical characteristics, maximal nonoperative treatment yielded a survival rate of 29%, compared to the 64% survival rate for a group of patients treated operatively with cholecystostomy, gastrostomy, feeding jejunostomy, and sump drainage of the lesser sac and retroperitoneum.

Pancreatic abscess following acute pancreatitis.

Pancreatic abscess is probably the most serious complication of acute pancreatitis. During the ten-year period from 1966 to 1975, twenty-eight patients with pancreatic abscess following acute pancreatitis were treated by surgical drainage. A review of these cases revealed that there was a lull in the clinical course of the antecedent pancreatitis prior to the time of surgical drainage in 70% of the cases. Despite an aggressive surgical approach, there were major postoperative problems in 26 patients. Sepsis persisted in 14 patients. Major gastrointestinal hemorrhage occurred in seven, intra-abdominal bleeding in nine, and fistulization in 13. Fourteen patients died (a mortality of 50%). The operative treatment of pancreatic abscess must be aggressive and persistent. In addition to extensive drainage with soft sump drains, vigilance must be exercised to avoid pressure against bowel or major vessels. Reoperation should be considered if postoperative improvement is not sustained.

Intraoperative Chaffin sump recto-colonic irrigation.

A simple method for intraoperative rectocolonic irrigation using the time-honored Chaffin sump drain is recommended. It assures an empty particulate matter-free bowel for anastomosis, washes out malignant cells, and provides proof of the integrity of anastomosis and decompression of the proximal bowel when indicated.

Use of pedicled omentum as an autogenous pack for control of hemorrhage in major injuries of the liver

Since massive hemorrhage from the traumatized liver is usually caused by disruption of the deeply situated hepatic veins, repair or resection is seldom practical. Instead, after appropriate debridement has been accomplished, such venous bleeding can rapidly and effectively be controlled by packing autogenous omentum, based on its respective gastroepiploic vessels, into the hepatic fracture crease. The liver edges are then oversewn, and sump drainage is installed. An experience with the use of this technique in 37 patients has demonstrated its almost uniform success.