Long-tunneled versus short-tunneled external ventricular drain: a quasi-experimental study in a cohort of pediatric patients.

OBJECTIVE: The primary aim of this study was to compare external ventricular drain (EVD)-related infection rates and mechanical complications between long-tunneled EVDs (LTEVDs) with an interposed valve and short-tunneled EVDs (STEVDs) in a cohort of pediatric patients. The second objective was to compare hospital resources used for LTEVDs versus STEVDs in the same cohort of patients and the same study period. METHODS: The study consisted of a quasi-experimental investigation comparing a prospective group of patients who received LTEVDs with a retrospective (historic) cohort of patients treated with STEVDs. The prospective nonrandomized quasi-experimental protocol of the LTEVD cohort included patients who needed an EVD for more than 3 days. Data were recorded prospectively as the patients were added to the study, until reaching the sample size established by the protocol. The comparison group of the STEVD cohort was retrospectively collected from patients' records. Patients were included consecutively, from newest to oldest, starting with the last STEVD inserted at the authors' hospital until reaching the sample size established in the protocol. The inclusion and exclusion criteria for both groups were the same. RESULTS: One hundred thirty-four patients were included in this quasi-experimental study; there were 67 in each group. LTEVDs reduced the odds of having an EVD-related infection by 92% (OR 0.08, 95% CI 0.01-0.39; p = 0.002). Compared to STEVDs, the LTEVDs reduced by 69% the odds of having a CSF leak (OR 0.31, 95% CI 0.10-0.91; p = 0.03). Neither CSF blockage (OR 0.12, 95% CI 0.01-1.08; p = 0.06) nor displacement (OR 0.73, 95% CI 0.15-3.43; p = 0.69) showed a statistically significant difference between groups. More resources were allocated to STEVDs than to LTEVDs in most areas considered in this study. CONCLUSIONS: Compared to STEVDs, LTEVDs are a cost-effective and safe method to reduce EVD-related infection rates and other complications in pediatric patients. The authors believe that reducing the infection rate and complications and giving the patient more independence outweighs the additional costs that this new technique may entail.

Assessing the incidence of complications and malignancies in the long-term management of benign biliary strictures with a percutaneous transhepatic drain.

ABSTRACT: Percutaneous drainage catheters (PDCs) are required for the management of benign biliary strictures refractory to first-line endoscopic treatment. While biliary patency after PDC placement exceeds 75%, long-term catheterization is occasionally necessary. In this article, we assess the outcomes of patients at our institution who required long-term PDC placement.A single-institution retrospective analysis was performed on patients who required a PDC for 10 years or longer for the management of a benign biliary stricture. The primary outcome was uncomplicated drain management without infection or complication. Drain replacement was performed every 4 to 12 weeks as an outpatient procedure.Nine patients (three males and six females; age range of 48-96 years) required a long-term PDC; eight patients required the long-term PDC for an anastomotic stricture and one for iatrogenic bile duct stenosis. A long-term PDC was required for residual stenosis or patient refusal. Drain placement ranged from 157 to 408 months. In seven patients, intrahepatic stones developed, while in one patient each, intrahepatic cholangiocarcinoma or hepatocellular carcinoma occurred.Long-term PDC has a high rate of complications; therefore, to avoid the need for using long-term placement, careful observation or early surgical interventions are required.

Role of thoracic ultrasonography in pleurodesis pathways for malignant pleural effusions (SIMPLE): an open-label, randomised controlled trial.

BACKGROUND: Pleurodesis is done as an in-patient procedure to control symptomatic recurrent malignant pleural effusion (MPE) and has a success rate of 75-80%. Thoracic ultrasonography has been shown in a small study to predict pleurodesis success early by demonstrating cessation of lung sliding (a normal sign seen in healthy patients, lung sliding indicates normal movement of the lung inside the thorax). We aimed to investigate whether the use of thoracic ultrasonography in pleurodesis pathways could shorten hospital stay in patients with MPE undergoing pleurodesis. METHODS: The Efficacy of Sonographic and Biological Pleurodesis Indicators of Malignant Pleural Effusion (SIMPLE) trial was an open-label, randomised controlled trial done in ten respiratory centres in the UK and one respiratory centre in the Netherlands. Adult patients (aged ≥18 years) with confirmed MPE who required talc pleurodesis via either a chest tube or as poudrage during medical thorascopy were eligible. Patients were randomly assigned (1:1) to thoracic ultrasonography-guided care or standard care via an online platform using a minimisation algorithm. In the intervention group, daily thoracic ultrasonography examination for lung sliding in nine regions was done to derive an adherence score: present (1 point), questionable (2 points), or absent (3 points), with a lowest possible score of 9 (preserved sliding) and a highest possible score of 27 (complete absence of sliding); the chest tube was removed if the score was more than 20. In the standard care group, tube removal was based on daily output volume (per British Thoracic Society Guidelines). The primary outcome was length of hospital stay, and secondary outcomes were pleurodesis failure at 3 months, time to tube removal, all-cause mortality, symptoms and quality-of-life scores, and cost-effectiveness of thoracic ultrasonography-guided care. All outcomes were assessed in the modified intention-to-treat population (patients with missing data excluded), and a non-inferiority analysis of pleurodesis failure was done in the per-protocol population. This trial was registered with ISRCTN, ISRCTN16441661. FINDINGS: Between Dec 31, 2015, and Dec 17, 2019, 778 patients were assessed for eligibility and 313 participants (165 [53%] male) were recruited and randomly assigned to thoracic ultrasonography-guided care (n=159) or standard care (n=154). In the modified intention-to-treat population, the median length of hospital stay was significantly shorter in the intervention group (2 days [IQR 2-4]) than in the standard care group (3 days [2-5]; difference 1 day [95% CI 1-1]; p<0·0001). In the per-protocol analysis, thoracic ultrasonography-guided care was non-inferior to standard care in terms of pleurodesis failure at 3 months, which occurred in 27 (29·7%) of 91 patients in the intervention group versus 34 (31·2%) of 109 patients in the standard care group (risk difference -1·5% [95% CI -10·2% to 7·2%]; non-inferiority margin 15%). Mean time to chest tube removal in the intervention group was 2·4 days (SD 2·5) versus 3·1 days (2·0) in the standard care group (mean difference -0·72 days [95% CI -1·22 to -0·21]; p=0·0057). There were no significant between-group differences in all-cause mortality, symptom scores, or quality-of-life scores, except on the EQ-5D visual analogue scale, which was significantly lower in the standard care group at 3 months. Although costs were similar between the groups, thoracic ultrasonography-guided care was cost-effective compared with standard care. INTERPRETATION: Thoracic ultrasonography-guided care for pleurodesis in patients with MPE results in shorter hospital stay (compared with the British Thoracic Society recommendation for pleurodesis) without reducing the success rate of the procedure at 3 months. The data support consideration of standard use of thoracic ultrasonography in patients undergoing MPE-related pleurodesis. FUNDING: Marie Curie Cancer Care Committee.

Improving Opioid Stewardship in Pediatric Emergency Medicine.

OBJECTIVES: Poor opioid stewardship contributes to opioid misuse and adverse health outcomes. We sought to decrease opioid prescriptions in children 0 to 18 years treated for pain after fractures and cutaneous abscess drainage from 13.5% to 8%. Our secondary aims were to reduce opioid prescriptions written for >3 days from 41% to 10%, eliminate codeine prescriptions, increase safe opioid storage and disposal discharge instructions from 0% to 70%, and enroll all emergency department (ED) physicians in the state prescription drug monitoring program. METHODS: We implemented an intervention bundle on the basis of 4 key drivers at a pediatric ED: ED-wide education, changes in the electronic medical record, discharge resources, and process standardization. Two plan-do-study-act cycles were performed. Interventions included provider feedback on prescribing, safe opioid storage and disposal instructions, and streamlined electronic medical record functions. Run charts were used to analyze the effect of interventions on outcomes. Our balance measure was return ED or clinic visits for inadequate analgesia within 3 days. RESULTS: During the intervention period, 249 of 3402 (7.3%) patients with fractures and cutaneous abscesses were prescribed opioids. The percentage of opioid prescriptions >3 days decreased from 41% to 13.2% (P < .0001), codeine prescription dropped from 1.1% to 0% (P = .09), opioid discharge instructions increased 0% to 100% (P < .0001), and all physicians enrolled in the prescription drug monitoring program. There was no change in return visits for uncontrolled analgesia compared with the baseline (P = .79). CONCLUSIONS: A comprehensive opioid stewardship program can improve opioid prescribing practices of ED physicians and deliver information on safe storage and disposal of prescription opioids with a negligible effect on return visits for uncontrolled pain.

Endoscopic Transpapillary Gallbladder Drainage for Acute Cholecystitis.

The mainstay of management of acute cholecystitis has been surgical, with percutaneous gallbladder drainage in patients deemed high risk for surgical intervention. Endoscopic management of acute cholecytitis with transpapillary and transmural drainage of the gall bladder is emerging as a viable alternative in high-risk surgical patients. In this article, we discuss the background, current status, technical challenges and strategies to overcome them, adverse events, and outcomes of endoscopic transpapillary gallbladder drainage for management of acute cholecystitis.

Prophylactic Wound Drainage in Renal Transplant: A Survey of Practice Patterns in Australia and New Zealand.

OBJECTIVES: Drains are used routinely in many centers at the conclusion of kidney transplant, despite a paucity of evidence to guide practice in kidney transplant. Studies have not shown benefit from prophylactic drain placement following other major abdominal and vascular operations, and usage is consequently declining. Our aim was to understand practice patterns and rationale for behavior in drain placement and management in kidney transplant. MATERIALS AND METHODS: We conducted an online survey of surgeons who routinely perform kidney transplants across Australia and New Zealand. RESULTS: The response rate was 66% (43/66). Of respondents, 61% reported routine drain insertion, whereas 21% seldom inserted drains. Concerns about bleeding and anticoagulation (63%) and routine practice (58%) were the dominant reasons for drain insertion. The factors selected as most significant in determining drain removal were both volume and time (44%) and volume alone (33%). A volume of < 50 mL/day (51%) was the most commonly reported threshold for removal. The postoperative period of days 3 to 5 was the most commonly selected time point for drain removal (63%). Seventy-four percent of respondents would consider enrolling their patients in a randomized controlled trial to determine the benefits and harms of drain insertion. CONCLUSIONS: Although drain insertion is a common practice, transplant surgeons in Australia and New Zealand reported sufficient uncertainty concerning the potential benefits and harms to warrant design and conduct of a randomized controlled trial.

Incidence and extent of sinus procedures in treatment of pediatric orbital cellulitis.

INTRODUCTION: It is unknown the optimal extent of sinus surgery in pediatric patients with orbital cellulitis. Our aim was to determine the nationwide incidence of sinus procedures used to treat pediatric orbital cellulitis. Additionally, we sought to identify patient-factors that influence a multi-procedural approach. METHODS: Cross-sectional analysis of 15,260 cases of primary pediatric orbital cellulitis identified in the Kids' Inpatient Database (KID) from January 1, 2003 to December 31, 2012. Cases were included if they contained a primary diagnosis code of orbital cellulitis. Frequency of sinus procedures in relation to pediatric age cohort were noted (≤8 years versus 9-20 years). Comorbidities, cost, and length-of-stay were compared between age cohorts. Multivariate models investigated patient-factors associated with multiple sinus procedures and patient-factors that affected hospital costs and length-of-stay. RESULTS: Children ≤8 years of age constituted 67% of cases (n = 10,290). 1103 cases (7.2%) were treated with at least one defined sinus procedure; and, 712 of these cases documented more than one sinus procedure. The younger cohort (≤8 years) exhibited fewer sinus procedures and a lower rate of reoperation (4.6% vs 12.8%, p < .001; 5.1% vs 7.7%, p < .001, respectively). Presence of cellulitis/abscess of the face was the strongest predictor of multiple sinus procedures (OR = 1.982, p = .033). Patients with acute sinusitis and those >8 years had similarly increased odds of a multi-procedural approach (OR = 1.333, p = .049; OR = 1.367, p = .032, respectively). Multivariate analysis of cost and length-of-stay found that patients >8 years incurred 14% longer hospital stays and an increase in costs of 9% compared to younger patients (p = .001, p = .039; respectively). The secondary diagnosis with the largest effect on length-of-stay and cost was an intracranical abscess (OR = 2.352, p < .001; OR = 2.752, p < .001; respectively). CONCLUSION: In a nationwide population of pediatric patients with primary orbital cellulitis there was an incidence of sinus surgery in 7.2% of cases - with patients over 8 years having a 2.8-fold increase compared to younger patients. Additionally, nearly two-thirds of patients treated with sinus surgery had multiple sinus procedures. The high incidence of multiple sinus procedures suggests that further prospective studies are needed to elucidate the extent of drainage associated with the best patient outcomes.

Medicolegal Characteristics of Cardiac Tamponade Litigation: A Review of the LexisNexis Academic Database.

OBJECTIVE: To review, describe, and analyze medicolegal literature involving cases of cardiac tamponade. BACKGROUND: Currently, there are no studies known to these authors assessing the outcome patterns of medicolegal cases involving patients with cardiac tamponade. This potentially lethal condition may have serious consequences on both patients and clinicians. Thus, the literature was reviewed for patterns of liability and medical outcomes in patients who developed cardiac tamponade. METHODS: Legal case opinions were reviewed from LexisNexis Academic that contained the search term "tamponade"; case characteristics, litigation outcomes, and medical outcomes were identified. RESULTS: 230 case opinions were reviewed. 143 involved cardiac tamponade. Of these cases, 77 were medical malpractice cases, 30 were criminal cases, 11 were insurance claims, and the rest were other types. In malpractice cases, 35 (45%) patients were male, 69 (90%) formally named at least one doctor as a defendant, 54 (70%) claimed iatrogenicity as a cause of tamponade, and surgeons were the most commonly named defendants at 36 cases (47%). Open surgical drainage was the most common treatment at 28 (36%) cases and death was the outcome in 60 (78%) cases. Judgements were in favor of at least one doctor in 29 (42%) cases, against at least one doctor in 13 (19%) cases, and 12 (17%) cases involved a settlement by a physician. CONCLUSIONS: This study describes previously unknown medicolegal characteristics of cardiac tamponade cases.

Chest tube removal algorithm is associated with decreased chest tube duration in pediatric cardiac surgical patients.

OBJECTIVE: Management of chest tubes in adult and pediatric patients is highly variable. There are no published guidelines for pediatric cardiac surgical patients. Our center undertook a quality improvement project aimed at reducing chest tube duration and length of stay in postsurgical pediatric cardiac patients. METHODS: A work group identified 2 opportunities for reducing chest tube duration: standardizing removal criteria and increasing frequency of assessment for removal. An algorithm was created, and chest tube assessments were increased to twice daily. All postsurgical cardiac patients were managed according to the algorithm. Outcome measure reporting was limited to patients age 1 month to 18 years with a biventricular surgical procedure. Outcome measures included chest tube duration, cardiac intensive care unit and hospital length of stay, and cost of hospitalization. Process measure was documentation of chest tube assessments. The balancing measure was chest tube reinsertions. RESULTS: Between April 2016 and July 2018, 126 patients aged 1 month to 18 years underwent a biventricular surgical procedure. Mean chest tube duration decreased from 61 to 47 hours. Cardiac intensive care unit length of stay decreased from 141 hours to 89 hours, hospital length of stay decreased from 266 to 156 hours, and average hospitalization cost decreased from $75,881 to $48,118. There was no increase in chest tube reinsertions. CONCLUSIONS: Implementation of a chest tube removal algorithm for pediatric cardiac surgery patients resulted in decreased chest tube duration and was associated with decreased length of stay and costs without an increase in reinsertions. More significant impact may be attainable with more aggressive approach to removal.

Endoscopic versus surgical treatment for pancreatic pseudocysts: Systematic review and meta-analysis.

OBJECTIVE: This systematic review and meta-analysis aims to compare surgical and endoscopic treatment for pancreatic pseudocyst (PP). METHODS: The researchers did a search in Medline, EMBASE, Scielo/Lilacs, and Cochrane electronic databases for studies comparing surgical and endoscopic drainage of PP s in adult patients. Then, the extracted data were used to perform a meta-analysis. The outcomes were therapeutic success, drainage-related adverse events, general adverse events, recurrence rate, cost, and time of hospitalization. RESULTS: There was no significant difference between treatment success rate (risk difference [RD] -0.09; 95% confidence interval [CI] [0.20,0.01]; P = .07), drainage-related adverse events (RD -0.02; 95% CI [-0.04,0.08]; P = .48), general adverse events (RD -0.05; 95% CI [-0.12, 0.02]; P = .13) and recurrence (RD: 0.02; 95% CI [-0.04,0.07]; P = .58) between surgical and endoscopic treatment.Regarding time of hospitalization, the endoscopic group had better results (RD: -4.23; 95% CI [-5.18, -3.29]; P < .00001). When it comes to treatment cost, the endoscopic arm also had better outcomes (RD: -4.68; 95% CI [-5.43,-3.94]; P < .00001). CONCLUSION: There is no significant difference between surgical and endoscopic treatment success rates, adverse events and recurrence for PP. However, time of hospitalization and treatment costs were lower in the endoscopic group.

Safety, Accuracy, and Cost Effectiveness of Bedside Bolt External Ventricular Drains (EVDs) in Comparison with Tunneled EVDs Inserted in Theaters.

OBJECTIVES: External ventricular drain (EVD) placement is required frequently in neurosurgical patients to divert cerebrospinal fluid and monitor intracranial pressure. The usual practice is the tunneled EVD technique performed in operating theaters. EVD insertion through a bolt in intensive care also is described. We employ both practices in our institute. Herein, we compare the indications, accuracy, safety, and costs of the 2 techniques. METHODS: This was a retrospective cohort study of a prospectively maintained EVD database of all patients undergoing first frontal EVD placement between January 2010 and December 2015. Those patients with preceding cerebrospinal fluid infection were excluded. We compared bolt EVD with tunneled EVD techniques in terms of accuracy of EVD tip location by analyzing computed tomography scans to grade catheter tip location as optimal (ipsilateral frontal horn) or otherwise suboptimal, and complications that include infection and revision rates. RESULTS: In total, 579 eligible patients aged 3 months to 84 years were identified; 430 had tunneled EVDs and 149 bolt EVDs. The most frequent diagnosis was intracranial hemorrhage (73% bolt vs. 50.4% tunneled group; P < 0.001). Other diagnoses included tumor (4.7% bolt vs. 19.1% tunneled; P < 0.001) and traumatic brain injury (17.5% bolt vs. 17.4% tunneled). In the bolt EVD group 66.4% of EVD tips were optimal, compared with 61.0% in the tunneled group (P = 0.33). Infection was confirmed in 15 (10.0%) bolt EVDs compared with 61 (14.2%) tunneled EVDs (P = 0.2). Each bolt EVD kit costs £260, whereas placing a tunneled one in the theater costs £1316. CONCLUSIONS: Bedside bolt EVD placement is safe, accurate, and cost effective in selective patients with hemorrhage-related hydrocephalus.

Conscious Sedation for Pediatric Peritonsillar Abscess: Comparison of Anesthetic Approaches.

OBJECTIVE: To compare the efficacy, safety, and cost of incision and drainage (I&D) for pediatric patients with peritonsillar abscesses (PTAs) under conscious sedation (CS) versus unsedated (awake) and general anesthesia (GA). STUDY DESIGN: Case series with chart review. SETTING: Tertiary pediatric hospital. SUBJECTS AND METHODS: Records for all pediatric patients (<18 years) treated for PTAs in the emergency department from 2005 to 2015 were reviewed and stratified into awake, CS, and GA groups for comparison. The primary outcome measure was procedure tolerance, with secondary measures including return to the emergency department within 15 days, complications, and facility costs associated with treatment. RESULTS: A total of 188 patients were identified. The median age was 14 years (interquartile range, 9-16). Awake drainage with injected local anesthetic was used in 115 children; 62 underwent CS; and 11 underwent GA. Over 92% of the children tolerated I&D regardless of anesthesia, with no difference among groups ( P = .60). None of those who underwent I&D via CS returned to the emergency department within 15 days of the procedure, as compared with 5.2% for the awake group and 9.1% for the GA group ( P = .06). None in the GA or awake group had a complication associated with the procedure, as opposed to 9.6% in the CS group ( P = .02). Complications included apnea and dental trauma (2 children each) and transient hypotension and desaturation (1 each). Cost was highest in the GA group and lowest for the awake group ( P < .0001). CONCLUSION: CS for PTA I&D is a viable treatment option with tolerance and success similar to that of the awake and GA groups. Complications were observed for those who underwent CS, but they were manageable.

Superiority of Step-up Approach vs Open Necrosectomy in Long-term Follow-up of Patients With Necrotizing Pancreatitis.

BACKGROUND & AIMS: In a 2010 randomized trial (the PANTER trial), a surgical step-up approach for infected necrotizing pancreatitis was found to reduce the composite endpoint of death or major complications compared with open necrosectomy; 35% of patients were successfully treated with simple catheter drainage only. There is concern, however, that minimally invasive treatment increases the need for reinterventions for residual peripancreatic necrotic collections and other complications during the long term. We therefore performed a long-term follow-up study. METHODS: We reevaluated all the 73 patients (of the 88 patients randomly assigned to groups) who were still alive after the index admission, at a mean 86 months (±11 months) of follow-up. We collected data on all clinical and health care resource utilization endpoints through this follow-up period. The primary endpoint was death or major complications (the same as for the PANTER trial). We also measured exocrine insufficiency, quality of life (using the Short Form-36 and EuroQol 5 dimensions forms), and Izbicki pain scores. RESULTS: From index admission to long-term follow-up, 19 patients (44%) died or had major complications in the step-up group compared with 33 patients (73%) in the open-necrosectomy group (P = .005). Significantly lower proportions of patients in the step-up group had incisional hernias (23% vs 53%; P = .004), pancreatic exocrine insufficiency (29% vs 56%; P = .03), or endocrine insufficiency (40% vs 64%; P = .05). There were no significant differences between groups in proportions of patients requiring additional drainage procedures (11% vs 13%; P = .99) or pancreatic surgery (11% vs 5%; P = .43), or in recurrent acute pancreatitis, chronic pancreatitis, Izbicki pain scores, or medical costs. Quality of life increased during follow-up without a significant difference between groups. CONCLUSIONS: In an analysis of long-term outcomes of trial participants, we found the step-up approach for necrotizing pancreatitis to be superior to open necrosectomy, without increased risk of reinterventions.

Safety and feasibility of early postmastectomy discharge and home drain care in a low resource setting.

BACKGROUND: Early postmastectomy discharge with a drain in place is standard practice in most developed countries. Its feasibility has not been evaluated in low resource settings like Nigeria. METHODS: Consenting patients undergoing mastectomy were discharged on the third postoperative day and assessed as outpatients for wound complications as well as their experience at home. Wound outcomes were compared with patients who had traditional long stay. RESULTS: Forty-five of the 58 patients who had a mastectomy during the study period participated in the early discharge program (77.6%). Of these, four patients (8.9%) had drain malfunction, seroma occurred in eight patients (17.8%), eight patients (17.8%) had wound infection, and six patients (13.3%) had flap necrosis. There was no readmission. Compared with long stay patients, postoperative stay was significantly shorter (3 vs 11 days; P < 0.01) with significant cost savings, while complication rates were not statistically different. All the patients in the early discharge group were confident operating their drains and preferred early discharge. Being around relatives, reduced cost, and fear of the hospital environment were common reasons cited for their preference. CONCLUSION: Our results support the implementation of an early postmastectomy discharge program in a low resource setting.

Assessment of treatment outcomes in patients with advanced hilar cholangiocarcinoma (stages III-IV): Clinical significance of interventional therapy.

The clinical significance of palliative interventional therapy in the management of patients with advanced hilar cholangiocarcinoma (HCCA; stages III-IV) has yet to be studied. The present work was aimed to compare the clinical outcomes of the patients treated with surgery or interventional therapy.A total of 90 patients with advanced HCCA, who admitted Fuyang First People's Hospital from May 2015 to February 2016, were enrolled. Forty-five of them were assigned to the experimental group receiving biliary drainage as the interventional therapy, and the remaining 45 patients were designated as the conventional group receiving radical/palliative surgery. Before and after the treatment total bilirubin from blood was measured. The length of treatment and medical cost were also examined. All patients were followed up for at least 1 year after the treatment.For both the experimental and conventional groups, the serum bilirubin levels after treatment were significantly lower than those before treatment (P < .05); however, no significant differences between groups were seen. There were no significant differences between experimental and conventional groups in the incidence of postoperative complications and survival outcomes. Of note, the length of treatment of the experimental group was substantially shorter than that of the conventional group (P < .05). The medical expense of the experimental group was only about one-third of that of the conventional group (P < .05).Although the interventional therapy does not improve patients' survivals and reduce the incidence of complications, it significantly shortens the treatment length, reducing substantially the medical expense. This finding provides new insights into the treatment strategy for patients with advanced HCCA.

Pharmacokinetics and pharmacodynamics of linezolid in plasma/cerebrospinal fluid in patients with cerebral hemorrhage after lateral ventricular drainage by Monte Carlo simulation.

OBJECTIVE: We investigated the pharmacokinetic (PK) and pharmacodynamic (PD) parameters of linezolid in patients who had suffered cerebral hemorrhage after lateral ventricular drainage. MATERIALS AND METHODS: Ten patients with cerebral hemorrhage after lateral ventricular drainage with stroke-associated pneumonia who were given linezolid were enrolled. Plasma and cerebrospinal fluid (CSF) samples were taken at appropriate intervals after the first administration of linezolid and assayed by high-performance liquid chromatography (HPLC). Then, PK parameters were estimated, and a Monte Carlo simulation was used to calculate the probability of target attainments (PTAs) for linezolid achieving the PK/PD index at different minimal inhibitory concentrations (MICs). RESULTS: The maximum concentration of linezolid in plasma and CSF was reached at 1.00 h and 3.10 h, respectively. The average penetration of linezolid in CSF was 56.81%. If the area under the plasma concentration vs time curve from zero to the final sampling time (AUC0-24 h)/MIC ≥ 59.1 was applied as a parameter, the PTA of linezolid in plasma could provide good coverage (PTA ≥ 90%) only for pathogens with a MIC of ≤2 µg/mL, whereas it could be achieved in CSF with a MIC of ≤1 µg/mL. If %T > MIC ≥ 40% was applied as a parameter, the PTA of linezolid in plasma/CSF could provide good coverage if the MIC was ≤4 µg/mL. CONCLUSIONS: For patients with infection of the central nervous system and who are sensitive to the drug, the usual dosing regimens of linezolid can achieve a good therapeutic effect. However, for critically ill or drug-resistant patients, an increase in dose, the frequency of administration, or longer infusion may be needed to improve the curative effect.

Pleural effusions in hematologic malignancies and their management with indwelling pleural catheters.

PURPOSE OF REVIEW: Pleural effusions in patients with hematologic malignancy may represent malignant pleural effusion (MPE) or occur secondary to infection, treatment effects, and other common causes. The impact of MPE on prognosis in this cohort remains unclear. Indwelling pleural catheters (IPCs) are routinely placed for palliation of recurrent symptomatic MPEs, but perceived concerns over infection and bleeding may limit their use in patients with hematologic malignancies. However, recent evidence suggests IPCs are both well tolerated and effective in this cohort. In this review, the evaluation of pleural effusions in hematologic malignancies and their management with an IPC are outlined. RECENT FINDINGS: Two retrospective studies have been published regarding the use of IPCs in hematologic malignancies. Lymphomatous effusions are the most common cause of MPE in this cohort. The rates of complications and pleurodesis with IPC in hematologic malignancies are similar to those with solid organ tumors. SUMMARY: Pleural effusions in patients with hematologic malignancies may be managed safely with an IPC. Sterile technique, barrier protection, standardized algorithms for placement and removal, and quality assurance initiatives are crucial to centers that place IPCs for all patients. The safety of IPC in hematologic malignancies warrants a paradigm shift in the management of pleural disease for this cohort.

Evaluation of Drain Amylase Level after Pancreaticoduodenectomy with Special Reference to Delayed Pancreatic Fistula.

Postoperative pancreatic fistula (PF) is a relatively frequent and occasionally fatal complication of pancreatoduodenectomy (PD). Several risk factors for PF have been reported, including high drain amylase level (D-AMY). Among the 140 consecutive patients who underwent PD, we analyzed 110 cases with D-AMY measurements over time after PD. According to the D-AMY change, we divided patients into five patterns and defined delayed PF cases. We analyzed clinical characteristics, including serum amylase and D-AMY, and examined the correlation between the period of drain insertion and PF grade. In 15 delayed PF cases, 12 cases were grade B or C, pancreatic cancer was less frequent, pancreatic ducts were smaller, and soft pancreas texture was more commonly observed. The D-AMY on postoperative day (POD) 1 was higher in cases of delayed PF compared with non-PF cases (P < 0.0001). In 28 cases with drain removal before POD 7, grade B or C PF was not observed afterward. The average D-AMY on POD 1 in cases with drain removal before POD 1 was significantly lower than in delayed PF cases. Although further studies are required to determine the most appropriate timing of drain removal, it is thought that intra-abdominal drains should be removed within seven days of PD in cases without signs of PF. On the other hand, delayed PF should be considered in cases of soft pancreas texture and/or high D-AMY on POD 1, even if D-AMY levels are low on POD 3 or decreasing on POD 5.

Pleural drainage using drainage bag for thoracoscopic lobectomy.

Objective This study was designed to compare the effectiveness and convenience of a drainage bag and a chest bottle following thoracoscopic lobectomy. Methods We conducted a test to ensure that the drainage bag was characterized by easy drainage and an antireflux effect. Thereafter, the drainage bag was used in all thoracic operations in our service. To understand the usefulness of the drainage bag, a retrospective cohort study enrolled 30 patients who had a drainage bag after thoracoscopic lobectomy and compared them with 30 similar patients operated on previously who had chest bottles. Variables studied included total drainage volume, duration of drainage, complications, and satisfaction of the care providers. Results There was no significant difference between the chest bottle and drainage bag groups respectively in terms of total drainage (697.5 ± 89.7 vs. 614.1 ± 76.6 mL, p = 0.483) or duration of drainage (4.23 ± 0.38 vs. 4.43 ± 0.38 days, p = 0.713). No device-related complication was observed. After our experience with the drainage bag, we abandoned use of the chest bottle. The drainage bag was more convenient for patients and promoted early ambulation as well improving cost effectiveness. Most care providers preferred to use the drainage bag (p = 0.000). Conclusion The drainage bag is superior to the chest bottle for postoperative drainage.

Prognostic Impact of Bacterobilia on Morbidity and Postoperative Management After Pancreatoduodenectomy: A Systematic Review and Meta-analysis.

BACKGROUND: Intraoperative bile analysis during pancreatoduodenectomy (PD) is performed routinely at specialized centers worldwide. However, it remains controversial if and how intraoperative bacterobilia during PD affects morbidity and its management. The aim of the study was a systematic review and meta-analysis of intraoperative bacterobilia and its impact on patient outcome after PD. METHODS: Five relevant outcomes of interest were defined, and a systematic review of the literature with meta-analysis was performed according to the PRISMA guidelines. RESULTS: A total of 28 studies (8523 patients) were included. The median incidence of bacterobilia was 58% (interquartile range 51-67%). The most frequently isolated bacteria were Enterococcus species (51%), Klebsiella species (28%), and Escherichia coli (27%). Preoperative biliary drainage was significantly associated with bacterobilia (86 vs. 25%; RR 3.27; 95% confidence interval (CI) 2.42-4.42; p < 0.001). The incidence of surgical site infections (SSI) was significantly increased in cases with bacterobilia (RR 2.84; 95% CI 2.17-3.73; p < 0.001). Postoperative pancreatic fistula, overall postoperative morbidity, and mortality were not significantly influenced. Identical bacteria in bile and the infectious sources were found in 48% (interquartile range 34-59%) of the cases. CONCLUSIONS: Bacterobilia is detected during almost every second PD and is associated with an increased rate of SSI. The microbiome from intraoperative bile and postoperative infectious sources match in ~50% of patients, providing the option of early administration of calculated antibiotics and the determination of resistance patterns.