Impact of intra-abdominal drains in emergency gastrointestinal surgery: a scoping review.

INTRODUCTION: Intra-abdominal drains are often placed in emergency gastrointestinal surgery procedures with the aim to prevent the formation of intra-abdominal collections (IAC) and aid in their early detection. However, the evidence for this is debated. This scoping review aims to evaluate the current evidence for their use in this setting. METHODS: A literature search was performed using MEDLINE via PubMed, Scopus, Web of Science, Cochrane Library, and ClinicalTrials.gov. Primary studies published between January 2000 and September 2023 that assessed intra-abdominal drain placement and post-operative IAC formation in emergency gastrointestinal surgery were included. RESULTS: A total of 26 articles were identified. There was no strong evidence to suggest that prophylactic intra-abdominal drain placement influences the formation of IAC in emergency gastrointestinal procedures. There was a suggestion that drain placement may increase the rate of surgical site infection and length of hospital stay. However, current studies on the topic are of poor quality and high risk of bias. CONCLUSION: The undifferentiated use of drains in emergency gastrointestinal surgery should not be encouraged. Drain placement should be specific to the clinical context. Higher quality research is warranted to better understand the influence drain placement has on post-operative outcomes.

Don't Forget About New Pathology.

Appendicitis is an inflammatory condition of the appendix. Patients typically present with migratory right iliac fossa pain, reduced appetite, fever, nausea and vomiting. Despite its characteristic presentation, diagnosis remains challenging, particularly in cases where there has been unrelated prior surgery which may obscure the clinical picture. We present a case of a 59-year-old male who had three previous needle aspirations following a pelvic and inguinal lymph node dissection for metastatic melanoma subsequently presenting with a further episode of right iliac fossa pain. This case underscores the diagnostic challenges that may arise in individuals with a history of surgical interventions, emphasizing the importance of a comprehensive approach to ensure the timely and accurate identification of appendicitis.

The Straw Pressure Gradient and Gravity (SPGG) Technique: A Safe and Cost-Effective Technique for Laparoscopic Suction.

Suction devices are frequently used during laparoscopic surgery. However, their cost and limitations can be significant, depending on the clinical case, theatre setting and national health system. Furthermore, the continuous need to reduce the costs of the consumables in minimally invasive surgical procedures and their environmental burden creates extra pressure on the healthcare systems globally. Therefore, we present a new technique for laparoscopic suctioning, the Straw Pressure Gradient and Gravity (SPGG) technique. It is a safe, cost-effective and environmentally friendly technique compared to traditional suction devices. The technique involves using a sterile, single-use Suction Catheter 12-16 French after positioning the patient according to the targeted collection. The catheter is inserted via the laparoscopic port nearest the collection and directed using laparoscopic graspers. The outer end needs to be clamped to avoid fluid spillage, and the catheter tip is placed in the collection. Then after the clamp is released, the fluid will be successfully drained due to the pressure gradient into a pot placed at a lower level than the intra-abdominal collection. Minimal wash can be performed via the gas vent by using a syringe. SPGG is a safe and easy-to-learn technique that requires similar skills as placing an intra-abdominal drain during laparoscopy. It is softer than rigid, traditional suction devices and atraumatic. It can be used for suction, irrigation, collection of fluid for sampling and as a drain in case of an intraoperative indication. SPGG is a cost-effective device as it is cheaper than the average disposable suction device system and has multiple uses, which can significantly decrease the annual cost of laparoscopies. It can also reduce the number of consumables and lighten the environmental burden of laparoscopic procedures.

Peritoneal lavage during laparoscopic appendectomy for complex appendicitis is associated with increased post-operative morbidity.

Aim: Appendicitis is one of the most common paediatric surgical pathologies seen by paediatric surgeons worldwide. Laparoscopic appendectomy is undertaken for all cases of appendicitis in our institute. Intraperitoneal lavage following appendectomy is the conventional way of managing complicated appendicitis; however, some surgeons debate the efficacy of this practice. The aim of this study was to compare outcomes of intraperitoneal lavage versus suction only in children with complicated appendicitis. Methods: Data were collected retrospectively between January 2018 and January 2019. All patients undergoing laparoscopic appendectomy for complex appendicitis were included and divided into two groups, patients who had suction only and those who had lavage and suction. Outcome parameters studied were the length of stay (LOS), number of temperature spikes > 37.7 (TS), operative times (OT) and readmission for intra-abdominal collections. Comparison between the two groups was performed using two sample t-test with unequal variance, significance was set at P < 0.05. Results: A total of 115 patients were included (lavage n = 52, Suction n = 63). The LOS (P = 0.0054), TS (0.0109), OT (P < 0.0001) were significantly higher in the lavage group compared to the suction-only group. Overall rates of readmission were similar between groups, however, readmission for the confirmed intra-abdominal collection was more common in the lavage group. Conclusion: Based on our study, it appears that there is no advantage in performing an intraperitoneal lavage for complex appendicitis. It resulted in a prolonged stay, more post-operative TS and longer operative duration. The likelihood of being readmitted with an intra-abdominal collection following a lavage was higher compared to suction only.

COVID-19 With an Initial Presentation of Intraperitoneal Hemorrhage Secondary to Spontaneous Splenic Rupture.

The WHO declared coronavirus disease 2019 (COVID-19) a global pandemic in early 2020. As the pandemic has continued to evolve over a period of several months, many cases of unusual presentations are now emerging, which pose a greater challenge for physicians in terms of quickly identifying COVID-19 patients based on initial signs and symptoms. In this report, we present one such unusual presentation in a patient with sudden intraperitoneal hemorrhage and spontaneous splenic rupture with COVID-19 as the likely etiology and contributing factor. The patient was a 75-year-old Caucasian woman who presented to the emergency department (ED) with complaints of severe left-sided abdominal pain for several days without any preceding trauma. A CT of the abdomen/pelvis revealed a large amount of fluid in the abdomen, which raised suspicion of bleeding. An exploratory laparotomy revealed splenic rupture with hemoperitoneum, and the patient subsequently underwent an emergent splenectomy. The patient's COVID-19 antigen test returned positive during the surgery and was subsequently confirmed with a polymerase chain reaction (PCR) test. COVID-19 has been found to result primarily in respiratory symptoms through its ability to invade endothelial cells via angiotensin-converting enzyme 2 affinity. It is speculated that this mechanism may cause a predisposition to micro-thromboses, which can eventually lead to manifestations such as large lymphoid organ thrombosis. Based on this case presentation and the evolving literature on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), spontaneous splenic rupture is an emergent differential diagnosis that should be considered in COVID-19 patients presenting with gastrointestinal complaints such as abdominal pain and nausea.

The role of postoperative antibiotics in preventing surgical site infections in uncomplicated appendicitis.

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In patients who underwent appendicectomy for uncomplicated appendicitis is the use of postoperative antibiotics associated with lower rates of surgical site infections? The search has been devised and 6 studies were deemed to be suitable to answer the question. The outcome assessed was the efficiency of postoperative antibiotic therapy in decreasing the rate of surgical site infections in uncomplicated appendicitis. Authors recommend against the use of postoperative antibiotics based on the supported evidence. Hence, its usage was not associated with lower rates of surgical site infections. On the contrary, it might increase the cost, postoperative morbidity and length of stay.

A Step-Up Approach to Infected Abdominal Fluid Collections: Not Just for Pancreatitis.

Background: More than 145,500 abdominal abscesses occur annually in the U.S. Percutaneous catheter drainage (PCD) is the primary treatment for clinically significant intra-abdominal collections (IACs), but only approximately 90% of all IACs are treatable with PCD. This leaves a significant number of patients facing long courses of management, including multiple interventions. Minimally invasive debridement techniques are now employed regularly for the treatment of infected necrosis caused by acute pancreatitis. We describe the use of minimally invasive videoscopic debridement techniques employed as part of a "step-up" approach to resolve IACs of other etiologies that are unresponsive to PCD. Methods: Data of all patients undergoing this procedure at a tertiary referral academic center from 2015 to 2017 after failure of different PCD techniques were analyzed retrospectively. Results: Four men and two women, mean age 54.6 years (range 26-70 years), with refractory IACs (mean drainage time 91.3 days; mean number of drainage procedures 4.6) following a variety of surgical interventions and inflammatory conditions underwent either video-assisted retroperitoneal debridement or sinus tract endoscopic debridement with a rigid or flexible endoscope. Technical success was achieved in all cases, and clinical success was observed in five cases. No immediate procedural complications were detected. The mean hospital stay and post-procedure drainage times were 5.5 and 25.2 days, respectively. There were no recurrent IACs. Conclusion: Minimally invasive debridement techniques can safely resolve IACs refractory to standard PCD techniques. Employment of these techniques as part of a step-up approach may reduce the morbidity and duration of drainage for the thousands of patients treated annually who have refractory IACs, whatever their etiology.

Natural history of percutaneous drainage of postoperative collection following colorectal surgery: in which patients can follow-up imaging be dispensed with before drain removal?

INTRODUCTION: Colorectal surgery is complicated by postoperative collections in up to 25% of cases depending on local conditions. The aim of this study was to identify predictive factors of success of percutaneous drainage of collections in order to avoid follow-up imaging. PATIENTS AND METHODS: All consecutive patients between January 2009 and December 2016, who had undergone elective or emergency colorectal surgery (colorectal surgery and appendectomy) complicated by a postoperative collection treated by percutaneous drainage with follow-up imaging prior to drain removal, were included in this single-center and retrospective study. The primary objective was to assess predictive factors of success of the first attempt of percutaneous drainage of collections. Secondary objectives were to describe the natural history of percutaneous drainage of postoperative collections after colorectal surgery and the overall success rate of percutaneous drainage. RESULTS: Fifty-three patients underwent percutaneous drainage of a postoperative collection during the study period and were included in this study. Complete resolution of the collection was observed on the first follow-up radiological examination in 36 patients (58%). In multivariate analysis, post-appendectomy collections (OR = 3.19 (1.14-9.27), p = 0.002) and reduction of the leukocyte count (OR = 3.22 (1.28-8.1), p = 0.013) were significantly associated with success of percutaneous drainage. CONCLUSION: This is the first study to address that follow-up imaging prior to drain removal might not be necessary in patients undergoing drainage of post-appendectomy collections and/or with more than 30% reduction of the leukocyte count at the first follow-up examination.

EUS-Guided Transrectal Evacuation of Organized Pelvic Collection Following Roux-en-Y Gastric Bypass After Failure of Radiological and Surgical Approach.

INTRODUCTION: Postoperative collections are an important cause of morbidity following obesity surgery. Surgical revision is most often required if general sepsis is present. Conservative treatment consists of broad spectrum antibiotics and percutaneous drainage of any collection. EUS drainage is a new technique that is gaining momentum allowing an easy access to collections close to the GI tract. MATERIALS AND METHODS: We present the case report of a 39-year-old woman who underwent to robotic Roux-en-Y gastric bypass for morbid obesity. She developed a jejuno-jejunal dehiscence treated with revision surgery. Afterward, a pelvic collection/hematoma was highlighted; however, neither percutaneous approach nor surgery succeeded in draining it. RESULTS: EUS-guided deployment of a fully covered lumen-apposing metal stent was performed. Subsequently, two necrosectomies were required to remove necrotic tissue and clots from the perirectal cavity. Finally, three double pigtail stents were deployed to promote healing. The patient spontaneously expelled the stents with the stool, and she is asymptomatic after a follow-up of 3 months. CONCLUSION: EUS transmural rectal drainage may represent a sound option for the treatment of pelvic postoperative collections. FCLAMS deployment guarantees a rapid drainage allowing to perform an endoscopic necrosectomy.

Endoscopic transmural management of abdominal fluid collection following gastrointestinal, bariatric, and hepato-bilio-pancreatic surgery.

BACKGROUND: Post-operative collections are a recognized source of morbidity after abdominal surgery. Percutaneous drainage is currently considered the standard treatment but not all collections are accessible using this method. Since the adoption of EUS, endoscopic transmural drainage has become an attractive option in the management of such complications. The present study aimed to assess the efficacy, safety and modalities of endoscopic transmural drainage in the treatment of post-operative collections. METHODS: Data of all patients referred to our dedicated multidisciplinary facility from 2014 to 2017 for endoscopic drainage of symptomatic post-operative collections after failure of percutaneous drainage or when it was deemed impossible, were retrospectively analyzed. RESULTS: Thirty-two patients (17 males and 15 females) with a median age of 53 years old (range 31-74) were included. Collections resulted from pancreatic (n = 10), colorectal (n = 6), bariatric (n = 5), and other type of surgery (n = 11). Collection size was less than 5 cm in diameter in 10 (31%), between 5 and 10 cm in 17 (53%) ,and more than 10 cm in 5 (16%) patients. The median time from surgery to endoscopic drainage was 38 days (range 6-360). Eight (25%) patients underwent endoscopic guided drainage whereas 24 (75%) patients underwent EUS-guided drainage. Technical success was 100% and clinical success was achieved in 30 (93.4%) after a mean follow-up of 13.5 months (1.2-24.8). Overall complication was 12.5% including four patients who bled following trans-gastric drainage treated with conservative therapy. CONCLUSIONS: The present series suggests that endoscopic transmural drainage represents an interesting alternative in the treatment of post-operative collection when percutaneous drainage is not possible or fails.

Endoscopic Drainage of Intra-Abdominal Collection after Bariatric Surgery.

INTRODUCTION: Symptomatic intra-abdominal collection after bariatric surgery occurs in up to 5% of cases. Surgical, percutaneous, or endoscopic drainage are the feasible approaches. MATERIALS AND METHODS: In this video, we show the case report of a 50-year-old woman who underwent to gastric omega bypass on a previous sleeve gastrectomy. After 3 weeks, she presented a well-organized liquid collection just behind the longitudinal staple line of the gastric pouch. No passage of contrast from the gastrointestinal tract to the collection was highlighted. Endoscopic ultrasound drainage approach failed due to tightness of the gastric pouch. Therefore, direct endoscopic drainage was successfully performed using CT scan images as guidance and according to fluoroscopic visualization of the staple line. RESULTS: The patient fully recovered, and she was discharged 48 h after endoscopy with complete normalization of inflammatory markers (CRP and leukocytosis). Upper GI endoscopy has been scheduled in 3 months in order to plan the removal of the stents. CONCLUSIONS: We managed such surgical complication creating a fistula between the gastric remnant and the collection achieving an internal drainage of the intra-abdominal fluid collection. The concept of internally drain any fluid collection with endoscopically delivered double pigtails plastic stents is gaining momentum and has been demonstrated effective in the management of leak following bariatric and upper GI surgery too.

Manejo percutáneo de colecciones abdominales en el hospital distrital de Villa Elisa / Percutaneous treatment of abdominal collections in the district hospital of Villa Elisa

Los abscesos abdominales se definen como colecciones localizadas que presentan pus, gérmenes en el frotis o crecen en el cultivo. Estas adquieren importancia cuando se hacen sintomáticas. En el manejo actual, el drenaje percutáneo es el tratamiento de elección por múltiples ventajas, reservándose el drenaje quirúrgico para ciertos casos. Esto se debe al avance de la tecnología de los métodos auxiliares de diagnóstico por imágenes, especialmente la ecografía.Objetivo: demostrar la factibilidad del manejo percutáneo de colecciones intra-abdominales en un hospital periférico de baja complejidad y con disponibilidad de ecógrafo.Diseño: retrospectivo, longitudinal, observacional, cuantitativo, no aleatorio, con componente analítico.Pacientes y método: pacientes con diagnóstico de colección intra-abdominal de distintas etiologías, internados en el Servicio de Cirugía del Hospital Distrital de Villa Elisa, desde junio de 2014, hasta setiembre de 2015.Resultados: 5 pacientes estudiados, 60% del sexo femenino, el cuadro de presentación fue conformado por dolor abdominal, distensión, plastrón palpable y fiebre. Laboratorialmente, leucocitosis con neutrofilia. En todos se realizó el drenaje de la colección bajo pantalla ecográfica con catéteres multipropósito de 10Fr, con la técnica del trocar. Se obtuvo el éxito en el tratamiento en el 80% de los casos. Conclusión: el manejo de colecciones abdominales es factible en hospitales periféricos de baja complejidad.

Abdominal abscess are defined as localized collections of pus, germs visualizated in a frotis or grow in culture. These become important when they become symptomatic. Actually, percutaneous drainage is the gold standard, reserving the surgery approach for a few special cases. This is due to the advanced of technology, particularly the ultrasound. Objective: to demonstrate the feasibility of percutaneous management of intraabdominal collections in a peripheral low complexity hospital, with ultrasound availability. Design: retrospective, longitudinal, observational, quantitative, no randomized, with analytical component. Patients and methods: patients with diagnosis of intraabdominal collections, admitted in surgery service of the Hospital Distrital of Villa Elisa, from June of 2014 to September of 2015. Results: 5 patients studied, 60% female, with clinical of abdominal pain, distension, palpation of abdominal mass or fever. Laboratorial findings neutrophilic leukocytosis. In all cases, percutaneous drainage was made it under ultrasound view, using 10 Fr multipurpose catheter, using trocar technique. Success was possible in 80% of the cases. Conclusion: the management of abdominal collections is possible in peripheral low complexity hospitals.

Postoperative abdominal collections drainage: Percutaneous versus guided by endoscopic ultrasound.

BACKGROUND AND AIM: Postoperative fluid collections (POFC) have high mortality. Percutaneous drainage (PD) is the preferred treatment modality. Drainage guided by endoscopic ultrasound (EUS-GD) represents a good alternative. The aim of the present study was to compare clinical success and complication rates of EUS-GD versus PD. METHODS: Data collected prospectively were analyzed in a retrospective manner. Patients with POFC from October 2008 to November 2013 were included. All collections were drained percutaneously or by EUS-GD. RESULTS: Sixty-three procedures in 43 patients with POFC were analyzed; 13 patients were drained using EUS-GD and 32 patients with PD. Two patients assigned initially to the PD group were reassigned to EUS-GD. Surgery procedures most often related to the collections were intestinal reconnection, distal pancreatectomy, biliary-digestive bypass, and exploratory laparotomy. Technical success (100% vs 91%; P = 0.25), clinical success (100% vs 84%; P = 0.13), recurrence (31% vs 25%; P = 0.69), hospital stay days (median 22 vs 27; P = 0.35), total costs (8328 ± 1600 USD vs 11 047 ± 1206 USD; P = 0.21), complications (0% vs 6%; P = 0.3), and mortality (8% vs 6%; P = 0.9) were each evaluated in the EUS-GD and PD groups, respectively. In the PD group one death was related to the procedure. CONCLUSIONS: EUS-GD is as effective and safe as PD in patients with POFC. The advantage of not requiring external drainage and a trend to higher clinical success and lower total costs must be considered.

Drenaje percutáneo de colecciones abdominales / Percutaneous drainage of abdominal collections

Gracias a los grandes adelantos en las imágenes diagnósticas la radiología intervencionista ha tenido grandes avances en los últimos años; el drenaje percutáneo de colecciones abdominales es hoy en día un procedimiento ampliamente utilizado para el tratamiento definitivo de patologías tan variadas como abscesos abdominales, complicaciones de pancreatitis y apendicitis, drenaje de hematomas, linfoceles, bilomas, quistes y tumores necróticos; también se han demostrado su seguridad y efectividad para el drenaje de colecciones en el tórax, el bazo y el retroperitoneo. En los pacientes críticamente enfermos el DPC permite una rápida mejoría del cuadro clínico para ser llevados a cirugía en mejores condiciones y simplificar los procedimientos quirúrgicos. Para el radiólogo estos procedimientos representan la oportunidad de reforzar su papel como clínico en el seguimiento estrecho de estos pacientes

Interventional radiology has greatly progressed in recent years due to the great advances of diagnostic imaging. Percutaneous drainage (PCD) of abdominal collections is presently a widely employed procedure for definitive treatment of diverse entitles such as abdominal abscesses, complications of pancreatitis and appendicitis, evacuation of hematomas, Iymphoceles, bilomas, necrotic cysts and tumors. It has also shown safety and effectiveness for draining collections in the thorax, spleen and retroperitoneum. In critically III patients PCD allows a quick improvement of the clinical situation so that surgery, If needed, can be performed In better conditions and this procedure becomes simpler. For radiologists this Interventions represent the opportunity to Improve their clinical evaluation of patients