Colon and rectal anastomoses do not require routine drainage: a systematic review and meta-analysis

OBJECTIVE: Many surgeons continue to place a prophylactic drain in the pelvis after completion of a colorectal anastomosis, despite considerable evidence that this practice may not be useful. The authors conducted a systematic review and meta-analysis of randomized controlled trials to determine if placement of a drain after a colonic or rectal anastomosis can reduce the rate of complications. METHODS: A search of the Medline database of English-language articles published from 1987 to 1997 was conducted using the terms "colon," "rectum," "postoperative complications," "surgical anastomosis," and "drainage." A manual search was also conducted. Four randomized controlled trials, including a total of 414 patients, were identified that compared the routine use of drainage of colonic and/or rectal anastomoses to no drainage. Two reviewers assessed the trials independently. Trial quality was critically appraised using a previously published scale, and data on mortality, clinical and radiologic anastomotic leakage rate, wound infection rate, and major complication rate were extracted. RESULTS: The overall quality of the studies was poor. Use of a drain did not significantly affect the rate of any of the outcomes examined, although the power of this analysis to exclude any difference was low. Comparison of pooled results revealed an odds ratio for clinical leak of 1.5 favoring the control (no drain) group. Of the 20 observed leaks among all four studies that occurred in a patient with a drain in place, in only one case (5%) did pus or enteric content actually appear in the effluent of the existing drain. CONCLUSIONS: Any significant benefit of routine drainage of colon and rectal anastomoses in reducing the rate of anastomotic leakage or other surgical complications can be excluded with more confidence based on pooled data than by the individual trials alone. Additional well-designed randomized controlled trials would further reinforce this conclusion.     

A skin blister method to study epidermal nerves in peripheral nerve disease

Skin is a reservoir of sensory and autonomic nerve fibers that are potential indicators of peripheral nerve disease. Biopsies of skin have shown that sensory nerves in the most superficial layer of skin, the epidermal nerve fibers (ENFs), are reduced in patients with polyneuropathy. This report describes a minimally invasive skin blister method to isolate, image, and obtain quantitative analysis of ENFs. Blisters are made by applying a suction capsule to skin. The epidermal roof of the blister is excised, immunostained, whole mounted, and analyzed for ENF number and distribution. A reduction in number and abnormal distribution of ENFs are early indicators of peripheral nerve disease. Illustrations of skin blister and skin biopsy specimens from patients with different types of peripheral nerve disorders are included. These patients were chosen because their findings demonstrate the complementary information obtained by the blister and biopsy methods and the potential of the blister procedure to evaluate single nerve lesions and polyneuropathy and to follow the progress of ENF degeneration and regeneration.     

The pathogenesis and modulation of the post-treatment reactive encephalopathy in a mouse model of Human African Trypanosomiasis

Drug treatment of late-stage human African Trypanosomiasis (HAT) in which the central nervous system (CNS) is involved may be complicated by a severe post-treatment reactive encephalopathy (PTRE) which can be fatal in up to 10% of cases. In order to understand the immunopathogenesis of this complication, an experimental mouse model has been developed that mirrors many of the pathological features of the PTRE in humans, and which allows various anti-inflammatory therapeutic regimes to be evaluated. Following the development of the PTRE in this model a number of cytokines are increased within the CNS including tumour necrosis factor (TNF) alpha, interleukins 1, 4 and 6, and macrophage inflammatory protein (MIP)-1. These cytokines appear at the same time as astrocyte activation which is an early event occurring before the development of the marked meningoencephalitic inflammatory response. The immunosuppressant drug azathioprine prevents but does not reduce the severity of an established PTRE and has a minimal effect on astrocyte activation. The ornithine decarboxylase inhibitor eflornithine prevents the induction, and ameliorates the severity, of the PTRE, and also reduces the degree of astrocyte activation. The Substance P antagonist RP-67,580 ameliorates the severity of an established PTRE, and also reduces astrocyte activation, indicating an important role of SP in the generation of the inflammatory response. Continued use of this mouse model should lead to further enhancement of our understanding of the pathogenesis of the PTRE and to improved drug regimes to prevent and/or treat it.     

Continuous quality improvement in health maintenance organizations: an application of the HEDIS model

One aspect of the Clinton Healthcare Reform programme is to assist health maintenance organizations (HMOs) in collecting and analysing data for the purpose of continuous quality improvement. The HEDIS 2.0 quality performance measurement model is currently in use and endorsed by the National Committee for Quality Assurance (NCQA). Outlines a process using HEDIS 2.0 by which an HMO can identify crucial problem areas and track the success of the solution process. Discusses the use of other relevant statistical tools.