Prophylactic intraabdominal drains do not confer benefit in pediatric perforated appendicitis: Results from a quality improvement initiative

Background/purposeProphylactic, intraabdominal drains have been used to prevent intraabdominal abscess (IAA) after perforated appendicitis. We hypothesized that routine drain placement would reduce the IAA rate in pediatric perforated appendicitis.MethodsA 27-month quality improvement (QI) initiative was conducted: closed-suction, intraabdominal drains were placed intraoperatively in pediatric (age < 18) perforated appendicitis patients. QI patients were compared to controls admitted during the preceding 8 months and following 4 months.The primary outcome was 30-day IAA rate. Univariate and multivariate analyses were performed.ResultsTwo hundred seventy QI patients were compared to 109 controls. There was 100% compliance during 21 of 27 months of the QI initiative; only 7 QI patients did not receive drains. IAA occurred in 20.0% of QI patients and 22.9% of control (p = 0.52). After adjustment, the QI initiative was not associated with reduced odds of IAA (OR 0.83, 95% CI 0.48–1.44). Median length of stay was longer in QI patients during the index admission (p = 0.03) and over 30 postoperative days (p = 0.03), but these relationships did not persist after adjustment.ConclusionsA QI initiative investigating prophylactic, intraabdominal drain placement in perforated appendicitis did not reduce the IAA rate. We recommend against routine drain placement in pediatric perforated appendicitis.Level of evidenceLevel III.     

Evaluation of a water-soluble contrast protocol for nonoperative management of pediatric adhesive small bowel obstruction

Background/purpose

We examined outcomes before and after implementing an enteral water-soluble contrast protocol for management of pediatric adhesive small bowel obstruction (ASBO).

“Quick” MRIs without contrast in the setting of pediatric abscess drainage: A comparative analysis of clinical outcomes

Background/PurposeTo assess the use of “quick” MRI without contrast in the setting of percutaneous drain management in pediatric patients.MethodsA retrospective medical record review was conducted to compare “quick” MRI without contrast to CT in the pediatric percutaneous drain placement setting. The study included 111 patients under 18-years-old having undergone percutaneous drain placement between January 2014 and January 2019. The “quick” MRI protocol consists of axial single-shot-fast-spin-echo (SSFSE) and fat-saturated SSFSE coronal sequences. Primary clinical outcomes included number of additional drain placement procedures, complications, length of hospitalization, and repeat drainage within 6 months following drain-free interval. The use of “quick” MRI post-procedurally was also investigated.ResultsPatients with pre-drain “quick” MRIs instead of CTs had no significant difference in the need for additional drain placement (p = 1), length of hospitalization (p = 0.275), or drainage complications (p = 0.728). Patients receiving “quick” MRI for follow-up imaging post-drain placement had no greater rate of repeat drainage within 6 months of initial drain discontinuation (p = 0.90) when compared to patients having CT.ConclusionsPre and post-drainage procedure “quick” MRIs were found to be equivalent to CT in regard to several key clinical outcomes.     

Pancreaticoduodenectomy: Role of interventional radiologists in managing patients and complications

Although the mortality rate after pancreaticoduodenectomy has decreased, the morbidity rate remains high. Major morbidity is often managed with the aid of interventional radiologists. The objective of this study was to evaluate the cooperative roles of interventional radiologists and pancreatic surgeons in complex pancreatic surgery, specifically pancreaticoduodenectomy. Our pancreaticoduodenectomy database was reviewed for all patients undergoing pancreaticoduodenectomy between January 1, 1995 and December 31, 2000. The interventional radiologic procedures for each patient were evaluated. A total of 1061 patients underwent pancreaticoduodenectomy. The overall mortality and morbidity rates were 2.3% and 35%, respectively. Five hundred ninety patients (56%) had no interventional radiologic procedures, whereas 471 patients (44%) had interventional radiologic procedures. Of those, 342 (32%) had preoperative biliary drainage (PBD) and 129 (12%) required postoperative interventional radiologic procedures. Percutaneous aspiration/catheter drainage was required in 84 patients for intra-abdominal abscess, biloma, or lymphocele, with 24 requiring two or more abscess drains. Thirty-nine patients underwent postoperative PBD for bile leaks due to anastomotic disruption, undrained biliary segments, or T-tube/ bile stent dislodgment. Eighteen patients had hemobilia/gastrointestinal bleeding treated by angiography with embolization. The reoperation rate for the entire cohort of 1061 patients was 4.1% (n = 43). Nineteen of the 129 patients (15%) requiring postoperative radiologic intervention required reoperation. Although 4 of 18 patients who required embolization for bleeding subsequently required surgical intervention for the same reason, only 4 of 84 patients undergoing abscess drainage later required operation for anastomotic disruption or unsuccessful percutaneous drainage. As would be expected, the patients who required postoperative radiologic intervention (n = 129) had a higher incidence of postoperative complications including pancreatic fistula (20% vs. 6%, P <0.01), bile leakage (22% vs. 1%, P< 0.01), and wound infection (16% vs. 8%, P < 0.01). With the complications in these 129 patients, the postoperative mortality rate was only 6.2% compared to 1.7% in patients who did not require radiologic intervention (n = 932, P< 0.01). The median postoperative length of stay was 15 days in those patients requiring postoperative radiologic intervention, 10 days in those not requiring intervention (P< 0.01; postoperative interventional radiology vs. no postoperative interventional radiology), and 29.5 days for patients needing reoperation. Interventional radiologists play a critical role in the management of some patients undergoing pancreaticoduodenectomy. Although complications such as anastomotic leaks, abscess formation, and bleeding can result in increased mortality and a longer hospital stay, the skills of the interventional radiology team provide expert management of some life-threatening complications, thus avoiding reoperation, speeding recovery times, and minimizing morbidity. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation).     

Role of interventional radiology in the management of complications after pancreaticoduodenectomy

BACKGROUND: This study evaluated the role of interventional radiology (IR) procedures to manage complications after pancreaticoduodenectomy. METHODS: A retrospective review was made of the records of patients with postsurgical complications managed with IR. RESULTS: Among the 440 patients reviewed, the mortality, morbidity and reoperation rates were 1.6%, 36%, and 2%, respectively. Complications occurred in 159 patients, of which 39 (25%) required > or = 1 IR procedures. Of those 39 patients, 72% underwent percutaneous drainage of an intra-abdominal abscess, 18% underwent percutaneous biliary drainage, and 10% underwent angiography for gastrointestinal bleeding or pseudoaneurysm. The reoperation rate among the 159 patients with complications was 6% (n = 9). Reoperation was avoided in 90% of patients receiving IR. Four patients underwent reoperation despite IR for persistent abscess, pancreatic fistula, anastomotic disruption, or mesenteric venous bleeding. CONCLUSIONS: The majority of complications occurring after pancreaticoduodenectomy can be managed effectively using IR, thus minimizing morbidity and the need for reoperation.     

Complicated appendicitis: Immediate operation or trial of nonoperative management?

Background

The optimal treatment for complicated appendicitis remains controversial. We sought to compare clinical outcomes of patients with complicated appendicitis treated with an immediate operation or a trial of nonoperative management.

What are the true advantages of a pediatric appendicitis clinical pathway?

Multiple protocols have been described for pediatric appendicitis, but few have been compared with off-protocol treatment. We performed such a comparison. Children treated for appendicitis by three pediatric surgeons over a 28-month period were studied. A protocol of primary wound closure without drains, standardized use of antibiotics, and patient discharge according to pre-determined clinical criteria was compared with individualized drain use, antibiotic selection, and discharge timing. Three hundred ninety-seven children were treated, 43 per cent on pathway (Group I) and 57 per cent off pathway (Group II). The two groups showed similar incidence of acute (45% vs 46%), complicated (50% vs 49%), and normal (5%) appendix. Among patients with simple appendicitis, Group I had less postoperative antibiotic use (16% vs 80% P < 0.001), shorter hospital stays (1.44 vs 1.89 days, P = 0.001), and decreased hospital charges (dollars 9,289 vs dollars 10,751, P = 0.001). Among patients with complicated appendicitis, Group I had less drain placement (4% vs 27%, P < 0.001), less use of discharge antibiotics (13% vs 39%, P < 0.001), and no readmission (0% vs 5%, P = 0.05). Infectious complications were similar between the two groups. A clinical pathway decreases the use of unnecessary antibiotics, hospital stay, and charges for simple appendicitis. It decreases the use of unnecessary drains, and eliminates readmissions after complicated appendicitis.     

Benefits of conservative management of a retained appendicolith after laparoscopic appendectomy: A case series

IntroductionAcute appendicitis is a disease with multifactorial etiology and frequently includes lumen obstruction. Appendicoliths can pose a challenge during the appendectomy procedure if not identified.MethodsThis is a prospective case series at our academic institution involving two medically free patients with intra-abdominal abscess formation secondary to an overlooked appendicolith who were treated conservatively with a follow up period of one year for each patient.ResultsComplications of a retained appendicolith are serious and include intra-abdominal abscess, perihepatic abscess, and delayed wound healing through fistula formation, most surgeons would undergo surgical removal with preoperative localization of the appendicolith using different modalities. In contrast, conservative management is an emerging approach to managing such conditions. The conservative approach involves percutaneous retrieval and the IR-guided draining of an intra-abdominal collection. In our cases, percutaneous drainage and intravenous antibiotics were a successful treatment, with no abscess recurrence in over a year.ConclusionWe suggest that patients with appendicoliths presenting with appendicitis should undergo appendicolith removal to prevent the risk of recurrent abscess formation. We also consider that the conservative management of patients with appendicoliths presenting with recurrent abdominal pain and abscesses after appendectomy is a better and safer approach than the surgical removal of a dropped appendicolith, as the risks of the surgical procedure complications can be avoided.     

Improved survival after introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms

BACKGROUND: The study was conducted to demonstrate improved survival (30-day mortality) after the introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms (rAAA). Numerous authors have successfully demonstrated reduced mortality in patients with rAAA using endovascular techniques. Comparison of endovascular aneurysm repair (EVAR) with open repair for rAAA may be misleading, however, because EVAR cannot be performed on all patients, and selection bias may explain the superior performance of any given surgical or endovascular strategy. We developed a model to predict mortality in patients before the introduction of EVAR (preprotocol population), applied this model to predict 30-day mortality among prospective patients (postprotocol population), and compared observed vs expected results. METHODS: We assessed 126 patients with rAAA. Primary outcome was 30-day mortality. Potential confounding variables were age, sex, presurgical lowest recorded systolic blood pressure (SBP), and glomerular filtration rate (GFR). A logistic regression model incorporating significant confounders was used to evaluate changes in 30-day mortality for all patients with rAAA after introduction of the EVAR protocol. Separate logistic regressions were done to compare 30-day mortality for preprotocol vs patients receiving EVAR and preprotocol vs patients receiving postprotocol open repair. Cumulative sum (CUSUM) analysis was used to assess shifts in the performance of the rAAA program over time. RESULTS: Significant confounders were SBP, absence of SBP, and GFR. Logistic regression found evidence of lower mortality after the protocol was introduced, 17.9% vs 30.0% (odds ratio [OR], 0.385; 95% confidence interval [CI], 0.141 to 0.981; P = .046). Comparison of all open repairs (preprotocol and postprotocol) and EVAR demonstrated decreased risk for EVAR of 5.0% vs 28.3% (OR, 0.109; 95% CI, 0.013 to 0.906; P = .0084). Unstable patients (SBP 相似文献   

Treatment of intra-abdominal sepsis

Twenty-three surgeons at three McGill University hospitals were interviewed about their treatment of intra-abdominal sepsis. They described their use of antibiotics, operative practices and other treatment of generalized peritonitis and intra-abdominal abscesses. If more than 75% of respondents used a given method, its use was considered "uniform" unless substantial interhospital variation existed for that method. Treatment was variable in 18 situations. Only four of these involved systemic antibiotic use--drug regimens in appendicitis and intra-abdominal abscess, and duration of antibiotic therapy following appendicitis and perforated duodenal ulcer. The other 14 examples of variation were in operative management. In generalized peritonitis, they were: use of diagnostic paracentesis; abdominal lavage with saline alone versus saline plus antibiotic use; whether the peritoneum should ever be left open; the use or avoidance of drains; primary versus delayed wound closure in appendicitis, bowel perforation and trauma with gastrointestinal perforation and, finally, wound lavage with saline alone or with antibiotics. Treatment of intra-abdominal abscesses varied in regard to the diagnostic and therapeutic roles of percutaneous needle aspiration, the preferred route of drainage of a pelvic abscess, the use of an extra- or trans-serosal approach to a subphrenic abscess, local versus full abdominal exploration for a single abscess and the type of drain used. The authors conclude that operative management of intra-abdominal sepsis varies widely among surgeons. This fact invalidates many "controlled" trials of antibiotics and should focus attention less on drugs and more on surgical treatment.     

Effectiveness of a transrectal prostate needle biopsy protocol with risk-tailored antimicrobials in a veterans cohort

Purpose

To prospectively implement a prostate biopsy protocol to identify high-risk patients for bleeding or infectious complications and use risk-tailored antimicrobials, patient education, and postbiopsy monitoring with the objective of reducing complications.

Perforated appendicitis: prospective outcome analysis for 150 children

BACKGROUND/PURPOSE: Controversy persists in the management of perforated appendicitis with regard to antibiotic choice and duration, operative timing, drain utilization, and wound closure. For 2 decades at the authors' institution, patients were treated with ampicillin, gentamicin, and clindamycin for 10 inpatient days, with drains in the abdomen, resulting in lower complication rates than most other published series. Managed care pressures have led to less aggressive medical management regimens with length of stay and financial factors viewed as principal outcome measures with little emphasis on clinical outcomes. In addition, there are little prospective data on clinical outcomes. The authors sought to determine whether our previously documented excellent quality outcomes could be maintained when modifications aimed at decreasing cost and length of stay in our protocol were instituted. METHODS: The authors monitored prospectively clinical outcomes in patients with perforated appendicitis treated according to their clinical practice guidelines over a 43-month period. Patients received a single antibiotic, piperacillin-tazobactam, intravenously for 10 days. They were permitted to go home with a percutaneous intravenous catheter for the final 5 days if medical and social criteria were met. Other practices from our earlier protocol were continued, including immediate operation, placement of Penrose drains, and primary wound closure. RESULTS: Of 150 patients treated on our protocol, major complications included intraabdominal abscess in 5 (3.3%), cecal fistula in 2 (1.3%), phlegmon in 3 (2.0%), wound infection in 4 (2.7%), and no small bowel obstructions requiring operation. None of these complications, nor their aggregate, were significantly more common than those reported in 373 patients treated over 11 years on the authors' prior protocol (chi2, P > .05). CONCLUSIONS: Prospective outcome analysis of our protocol shows that a single broad-spectrum antibiotic (allowing portions of therapy to be delivered less expensively on an outpatient basis) effectively can treat postoperative appendicitis with very few infectious complications. These outcome data provide baseline against which future protocols can be compared. All treatment modifications aimed at decreasing costs must be analyzed to ensure quality of care is not unduly compromised.     

Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial

Introduction

Perforated appendicitis is a common condition in children, which, in a small number of patients, may be complicated by a well-formed abscess. Initial nonoperative management with percutaneous drainage/aspiration of the abscess followed by intravenous antibiotics usually allows for an uneventful interval appendectomy. Although this strategy has become well accepted, there are no published data comparing initial nonoperative management (drainage/interval appendectomy) to appendectomy upon presentation with an abscess. Therefore, we conducted a randomized trial comparing these 2 management strategies.

Methods

After internal review board approval (#06 11-164), children who presented with a well-defined abdominal abscess by computed tomographic imaging were randomized on admission to laparoscopic appendectomy or intravenous antibiotics with percutaneous drainage of the abscess (when possible), followed by interval laparoscopic appendectomy approximately 10 weeks later. This was a pilot study with a sample size of 40, which was based on our recent volume of patients presenting with appendicitis and abscess.

Results

On presentation, there were no differences between the 2 groups regarding age, weight, body mass index, sex distribution, temperature, leukocyte count, number of abscesses, or greatest 2-dimensional area of abscess in the axial view. Regarding outcomes, there were no differences in length of total hospitalization, recurrent abscess rates, or overall charges. There was a trend toward a longer operating time in patients undergoing initial appendectomy (61 minutes versus 42 minutes mean, P = .06).

Conclusions

Although initial laparoscopic appendectomy trends toward a requiring longer operative time, there seems to be no advantages between these strategies in terms of total hospitalization, recurrent abscess rate, or total charges.     

Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection

OBJECTIVE: To test the hypothesis that routine intraperitoneal drainage is not required after pancreatic resection. SUMMARY BACKGROUND DATA: The use of surgically placed intraperitoneal drains has been considered routine after pancreatic resection. Recent studies have suggested that for other major upper abdominal resections, routine postoperative drainage is not required and may be associated with an increased complication rate. METHODS: After informed consent, eligible patients with peripancreatic tumors were randomized during surgery either to have no drains placed or to have closed suction drainage placed in a standardized fashion after pancreatic resection. Clinical, pathologic, and surgical details were recorded. RESULTS: One hundred seventy-nine patients were enrolled in the study, 90 women and 89 men. Mean age was 65.4 years (range 23-87). The pancreas was the tumor site in 142 (79%) patients, with the ampulla (n = 24), duodenum (n = 10), and distal common bile duct (n = 3) accounting for the remainder. A pancreaticoduodenectomy was performed in 139 patients and a distal pancreatectomy in 40 cases. Eighty-eight patients were randomized to have drains placed. Demographic, surgical, and pathologic details were similar between both groups. The overall 30-day death rate was 2% (n = 4). A postoperative complication occurred during the initial admission in 107 patients (59%). There was no significant difference in the number or type of complications between groups. In the drained group, 11 patients (12.5%) developed a pancreatic fistula. Patients with a drain were more likely to develop a significant intraabdominal abscess, collection, or fistula. CONCLUSION: This randomized prospective clinical trial failed to show a reduction in the number of deaths or complications with the addition of surgical intraperitoneal closed suction drainage after pancreatic resection. The data suggest that the presence of drains failed to reduce either the need for interventional radiologic drainage or surgical exploration for intraabdominal sepsis. Based on these results, closed suction drainage should not be considered mandatory or standard after pancreatic resection.     

Placement of metallic biliary endoprostheses in complex hilar tumours

PurposeTo assess the technical success, clinical success and complications after 1 month of percutaneous biliary drainage with the placement of several metallic endoprostheses in complex hilar liver tumours.Materials and methodsThis is a retrospective study, on a homogenous target population of 68 consecutive patients, who underwent multiple percutaneous biliary drainage for complex hilar tumour (Bismuth type II, III and IV) between August 1998 and August 2010. Patients benefiting from previous endoscopic drainage were excluded from the study. The clinical data, biological data, imaging and interventional radiology procedures were studied.ResultsThe rate of success of the technique was 98.5% and the clinical rate of success was 84% after 1 week and 93% after 1 month. The rate of minor and major complications was 25 and 13% respectively.ConclusionMultiple percutaneous biliary drainage in complex hilar tumour is a safe and effective first intention procedure.     

Protocolized management of infants with congenital diaphragmatic hernia: effect on survival

Background/Purpose

In 2006, we introduced a new protocol for congenital diaphragmatic hernia (CDH) management featuring nitric oxide in the delivery room, gentle ventilation, lower criteria for extracorporeal membrane oxygenation (ECMO), and appropriately timed operative repair on ECMO. Our goals were to assess outcomes after institution of this protocol and to compare results with historical controls.

Methods

Charts were reviewed of all newborns admitted to a large metropolitan children's hospital from 2002 to 2009 with a diagnosis of CDH. Data were recorded regarding delivery, ECMO, operative repair, length of stay, comorbidities/anomalies, complications, and survival. Postprotocol outcomes were compared to those from the preprotocol era and to data from the international CDH Registry.

Results

Comparison of the protocolized group (n = 43) to the historical group (n = 51) revealed no significant differences in gestational age, birth weight, Apgar scores, or comorbidities. New treatment strategies substantially improved survival to discharge (67% preprotocol, 88% postprotocol; P = .015). Among ECMO patients, survival increased to 82% (20% preprotocol; P = .002).

Conclusions

Our new protocol significantly improved survival to discharge for newborns with CDH. Institution of such a protocol is valuable in improving outcomes for patients with CDH and merits consideration for widespread adoption.     

Liver Resection: To Drain or not to Drain?

Purpose: A prospective, randomized trial was performed to determine if intra-abdominal drainage catheters are necessary after elective liver resection.Patients and Methods: Between April 1992 and April 1994, 120 patients subjected to liver resection, stratified by extent of resection and by surgeon, were randomized to receive or not receive operative closed-suction drainage. Operative blood loss was not an exclusion criteria, and no patient who consented to the study was excluded.Results: Eighty-seven patients (73%) had resection of one hepatic lobe or more (27 lobectomies, 54 trisegmentectomies, and 6 bilobar atypical resections) and 33 had less than a lobectomy (8 wedge resections or enucleations, 9 segmentectomies, and 16 bisegmentectomies). Eighty-four patients (70%) had metastatic cancer and 36 patients (30%) had primary liver pathology. There were no differences in outcome, including length of hospital stay (no drain, 13.4 ± 0.9 days; drain, 13.1 ± 0.8 days; P not significant [NS]), mortality (no drain, 3.3%; drain, 3.3%), complication rate (no drain, 43%; drain, 48%; n= NS), or requirement for subsequent percutaneous drainage (no drain, 18%; drain, 8%; P= NS). All infected collections (n= 3) occured in operatively drained patients. Two other complications were directly related to the operatively placed drains. One patient developed a subcutaneous abscess at the drain site, and a second developed a subcutaneous drain tract tumor recurrence as the only current site of recurrence.Conclusion: In the first 50 consecutive resections performed since the conclusion of this trial, only 4 patients (8%) have required subsequent percutaneous drainage. We conclude that abdominal drainage is unnecessary after elective liver resection,     

Resource utilization and outcomes from percutaneous drainage and interval appendectomy for perforated appendicitis with abscess

Objective

Given the perceived technical demands of laparoscopic appendectomy and the expected postoperative morbidity in patients with a well-defined abscess, initial percutaneous drainage has become an attractive option in this patient population. This strategy allows for a laparoscopic appendectomy to be performed in an elective manner at the convenience of the surgeon. However, the medical burden on the patient and on the quality of patient outcomes has not been described in the literature. Therefore, we audited our experience with initial percutaneous drainage followed by laparoscopic interval appendectomy to evaluate the need for a prospective trial.

Methods

After institutional review board approval, a retrospective chart review was performed on all children who presented with perforated appendicitis and a well-defined abscess and were treated by initial percutaneous aspiration/drainage followed by interval appendectomy between January 2000 and September 2006. Continuous variables are listed with standard deviation.

Results

There were 52 patients with a mean age of 9.0 ± 3.9 years and weight of 34.4 ± 18.8 kg. The mean duration of symptoms at presentation was 8.4 ± 7.6 days. Percutaneous aspiration only was performed in 2 patients. The mean volume of fluid on initial aspiration/drain placement was 76.3 ± 81.1 mL. The mean time to appendectomy was 61.9 ± 25.2 days. The laparoscopic approach was used in 49 patients (94.2%), of which one was converted to an open operation. The mean length of hospitalization after interval appendectomy was 1.4 ± 1.4 days. A recurrent abscess developed in 17.3% of the patients. Six patients (11.5%) required another drainage procedure. The mean total charge to the patients was $40,414.02. There were 4 significant drain complications (ileal perforation, colon perforation, bladder perforation, and buttock/thigh necrotizing abscess). The child with the ileal perforation after drain placement is the only patient who failed initial nonoperative therapy.

Conclusions

The use of initial percutaneous aspiration/drainage of periappendiceal abscess followed by interval appendectomy is an effective approach. However, this management poses complication risks and uses considerable resources. Therefore, this strategy should be compared with early operation in a prospective trial.