1
|
Brucchi F, Mehmeti M, Lauricella S, Faillace G. The use of intra-abdominal prophylactic drainage in laparoscopic cholecystectomy: does it change in relation to surgical expertise? A multicenter case-control retrospective study on postoperative outcomes. Minerva Surg 2024; 79:155-160. [PMID: 37851006 DOI: 10.23736/s2724-5691.23.09934-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
BACKGROUND The routine use of abdominal drainage (AD) after laparoscopic cholecystectomy (LC) is still controversial. The aim of this expertise-based study is to evaluate the efficacy of prophylactic AD in terms of postoperative complications and analyze the factors linked to AD placement. METHODS This case-control retrospective study included patients with cholelithiasis who underwent LC with AD (AD group) and LC without drainage (no-AD group) in two Italian centers. Allocation to groups was non-randomized and based on surgeons' decisions. Patient's characteristics, operative results, postoperative outcomes, surgeon's expertise related data were compared between the two groups with univariate and multivariate analysis. RESULTS Patients in the two groups were comparable for age, sex ratio, and morbidity. Length of postoperative hospital stay (LOS) in the no-AD group was shorter than the AD group. Patients in the AD group had a higher rate of wound infection. No difference in postoperative pain measured 7 days after the surgery was found. Our results show an association between the first operator's expertise and age and the decision of placing the AD. The operative time seems to be the principal factor impacting the decision whether to place or not the AD. CONCLUSIONS Our results indicate that it is feasible not to insert routine AD after elective LC for cholelithiasis. The use of AD seems to cause more cases of postoperative wound infections, prolongs the LOS and the operative time. The drain placement choice seems to change in relation to the surgeon's expertise.
Collapse
Affiliation(s)
- Francesco Brucchi
- State University of Milan, Milan, Italy -
- Department of General Surgery, Hospital of Sesto San Giovanni, Sesto San Giovanni, Milan, Italy -
| | - Megi Mehmeti
- Department of General Surgery, Hospital of Sesto San Giovanni, Sesto San Giovanni, Milan, Italy
| | | | - Giuseppe Faillace
- Department of General Surgery, Edoardo Bassini Hospital, Cinisello Balsamo, Milan, Italy
| |
Collapse
|
2
|
Koraş Sözen K, Bolat H, Güntürk İ. The Effects of Sex Hormones on Postoperative Pain in Patients with Laparoscopic Cholecystectomy. Surg Laparosc Endosc Percutan Tech 2024; 34:14-19. [PMID: 38241658 DOI: 10.1097/sle.0000000000001259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/19/2023] [Indexed: 01/21/2024]
Abstract
OBJECTIVE There are many factors that affect postoperative pain. This study determines the effect of preoperative sex hormone levels on postoperative pain levels in patients undergoing laparoscopic cholecystectomy. PATIENTS AND METHODS This study included a total of 89 patients who met the study inclusion criteria. The patients were divided into 3 groups based on their sex and pre and postmenopausal periods: male patients (n = 28), postmenopausal female patients (n = 31), and female patients with normal cycles (n = 30). Normal-cycle women were also regrouped based on their follicular and luteal phases. Data were collected using a descriptive characteristics form, a patient follow-up form, and the Visual Analog Scale. RESULTS Venous blood samples taken from the patients before surgery were used to measure their levels of estradiol (EST), testosterone (TES), and progesterone levels. Male patients had lower pain levels than female patients. The male patients' Visual Analog Scale scores were inversely related and correlated strongly with their TES levels ( P < 0.05). However, subgroup analyses suggested that their EST level played a primary role in males and that the EST/TES ratio was determinant in the late postoperative period. In female patients, the EST/progesterone ratio was the most determining factor for the level of pain felt in the postmenopausal period, whereas there was no change in the premenopausal period at different stages of the menstrual cycle. CONCLUSIONS Sex hormones were found to be effective in predicting postoperative pain severity.
Collapse
Affiliation(s)
- Kezban Koraş Sözen
- Department of Surgical Nursing, Zubeyde Hanim Faculty of Health Sciences
| | - Haci Bolat
- Department of General Surgery, Faculty of Medicine
| | - İnayet Güntürk
- Department of Midwifery, Nigde Zubeyde Hanim School of Health, Nigde Omer Halisdemir University, Nigde, Turkey
| |
Collapse
|
3
|
Cillara N, Podda M, Cicalò E, Sotgiu G, Provenzano M, Fransvea P, Poillucci G, Sechi R. A Prospective Cohort Analysis of the Prevalence and Predictive Factors of Delayed Discharge After Laparoscopic Cholecystectomy in Italy: The DeDiLaCo Study. Surg Laparosc Endosc Percutan Tech 2023; 33:463-473. [PMID: 37526464 PMCID: PMC10545073 DOI: 10.1097/sle.0000000000001207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/19/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND The concept of early discharge ≤24 hours after Laparoscopic Cholecystectomy (LC) is still doubted in Italy. This prospective multicentre study aims to analyze the prevalence of patients undergoing elective LC who experienced a delayed discharge >24 hours in an extensive Italian national database and identify potential limiting factors of early discharge after LC. METHODS This is a prospective observational multicentre study performed from January 1, 2021 to December 31, 2021 by 90 Italian surgical units. RESULTS A total of 4664 patients were included in the study. Clinical reasons were found only for 850 patients (37.7%) discharged >24 hours after LC. After excluding patients with nonclinical reasons for delayed discharge >24 hours, 2 groups based on the length of hospitalization were created: the Early group (≤24 h; 2414 patients, 73.9%) and the Delayed group (>24 h; 850 patients, 26.1%). At the multivariate analysis, ASA III class ( P <0.0001), Charlson's Comorbidity Index (P=0.001), history of choledocholithiasis (P=0.03), presence of peritoneal adhesions (P<0.0001), operative time >60 min (P<0.0001), drain placement (P<0.0001), pain ( P =0.001), postoperative vomiting (P=0.001) and complications (P<0.0001) were independent predictors of delayed discharge >24 hours. CONCLUSIONS The majority of delayed discharges >24 hours after LC in our study were unrelated to the surgery itself. ASA class >II, advanced comorbidity, the presence of peritoneal adhesions, prolonged operative time, and placement of abdominal drainage were intraoperative variables independently associated with failure of early discharge.
Collapse
Affiliation(s)
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Italy
| | - Enrico Cicalò
- Department of Architecture, Design and Urban Planning, University of Sassari, Italy
| | - Giovanni Sotgiu
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Italy
| | | | - Pietro Fransvea
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | | | | |
Collapse
|
4
|
Cai H, Du J, Luo C, Li S. External application of mirabilite before surgery can reduce the inflammatory response and accelerate recovery in mild acute biliary pancreatitis. BMC Gastroenterol 2023; 23:264. [PMID: 37532999 PMCID: PMC10394763 DOI: 10.1186/s12876-023-02901-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 07/24/2023] [Indexed: 08/04/2023] Open
Abstract
OBJECTIVE Mild acute biliary pancreatitis (MABP) is one of the most common diseases that require surgical treatment. Previous studies have focused on the timing of laparoscopic cholecystectomy (LC) for MABP. However, the impact of its inflammatory response process on the clinical outcome has been rarely reported. This study aimed to investigate the effect of preoperative external application of mirabilite on the inflammatory response and clinical efficacy in MABP. METHODS Medical records of patients undergoing LC due to MABP from November 2017 to June 2022 were retrospectively reviewed. Prior to surgery, the control group received the same baseline treatment measures as the study group. The difference was the addition of external application of mirabilite in the study group. RESULTS A total of 75 patients were included in the final analysis: 38 patients in the mirabilite group and 37 patients in the control group. Repeated-measures ANOVA (P < 0.01) showed that the white blood cell count (WBC) on the 3rd day of admission and the WBC and C-reactive protein (CRP) level on the 5th day of admission decreased rapidly and significantly in the mirabilite group, compared with the control group. The mirabilite group had earlier anal exhaust time. The number of patients in the mirabilite group and control group with gallbladder wall ≥ 3 mm before the operation was 16 (42.11%) vs. 24 (64.86%), p = 0.048, respectively; and the number of cases with surgical drain placement was 2 (5.26%) vs. 9 (24.32%), p = 0.020, respectively. The intraoperative modified American Fertility Society (mAFS) score of adhesions was lower in the mirabilite group (1.08 ± 0.59 points) than in the control group (1.92 ± 0.60 points), p = 0.000. The mirabilite group, compared to the control group, p = 0.000, had a short waiting time for surgery (5.68 ± 0.70 days vs. 6.54 ± 0.59 days), short operation time (38.03 ± 5.90 min vs. 48.51 ± 8.37 min), and reduced hospitalization time (8.95 ± 0.96 days vs. 9.84 ± 1.07 days). CONCLUSION This study demonstrated that preoperative external application of mirabilite can reduce the inflammatory response, decrease the edema and peribiliary adhesions at the surgical site, and accelerate recovery in MABP.
Collapse
Affiliation(s)
- Hao Cai
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
- Department of Hepatobiliary Surgery, Suining Hospital of Traditional Chinese Medicine, Suining city, Sichuan Province, 629000, China
| | - Jian Du
- Department of Hepatobiliary Surgery, Suining Hospital of Traditional Chinese Medicine, Suining city, Sichuan Province, 629000, China
| | - Cheng Luo
- Department of Hepatobiliary Surgery, Suining Hospital of Traditional Chinese Medicine, Suining city, Sichuan Province, 629000, China
| | - Shengwei Li
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| |
Collapse
|
5
|
Lee SJ, Choi IS, Moon JI, Yoon DS, Choi WJ, Lee SE, Sung NS, Kwon SU, Bae IE, Roh SJ, Kim SG. Optimal drain management following complicated laparoscopic cholecystectomy for acute cholecystitis: a propensity-matched comparative study. JOURNAL OF MINIMALLY INVASIVE SURGERY 2022; 25:63-72. [PMID: 35821685 PMCID: PMC9218398 DOI: 10.7602/jmis.2022.25.2.63] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/10/2022] [Indexed: 04/24/2023]
Abstract
PURPOSE This study was performed to investigate the effect of drain placement on complicated laparoscopic cholecystectomy (cLC) for acute cholecystitis (AC). METHODS This single-center retrospective study reviewed patients with AC who underwent cLC between January 2010 and December 2020. cLC was defined as open conversion, subtotal cholecystectomy, adjacent organ injury during surgery, operation time of ≥90 minutes, or estimated blood loss of ≥100 mL. One-to-one propensity score matching was performed to compare the surgical outcomes between patients with and without drain on cLC. RESULTS A total of 216 patients (mean age, 65.8 years; 75 female patients [34.7%]) underwent cLC, and 126 (58.3%) underwent intraoperative abdominal drainage. In the propensity score-matched cohort (61 patients in each group), early drain removal (≤postoperative day 3) was performed in 42 patients (68.9%). The overall rate of surgical site infection (SSI) was 10.7%. Late drain removal demonstrated significantly worse surgical outcomes than no drain placement and early drain removal for overall complications (13.1% vs. 21.4% vs. 47.4%, p = 0.006), postoperative hospital stay (3.8 days vs. 4.4 days vs. 12.7 days, p < 0.001), and SSI (4.9% vs. 11.9% vs. 31.6%, p = 0.006). In the multivariate analysis, late drain removal was the most significant risk factor for organ space SSI. CONCLUSION This study demonstrated that drain placement is not routinely recommended, even after cLC for AC. When placing a drain, early drain removal is recommended because late drain removal is associated with a higher risk of organ space SSI.
Collapse
Affiliation(s)
- Seung Jae Lee
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - In Seok Choi
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
- Corresponding author In Seok Choi, Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, 158 Gwanjeodong-ro, Seo-gu, Daejeon 35365, Korea, Tel: +82-42-600-9142, Fax: +82-42-543-8956, E-mail: , ORCID: https://orcid.org/0000-0002-9656-3697
| | - Ju Ik Moon
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Dae Sung Yoon
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Won Jun Choi
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Sang Eok Lee
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Nak Song Sung
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Seong Uk Kwon
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - In Eui Bae
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Seung Jae Roh
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| | - Sung Gon Kim
- Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea
| |
Collapse
|
6
|
Calini G, Brollo PP, Quattrin R, Bresadola V. Predictive Factors for Drain Placement After Laparoscopic Cholecystectomy. Front Surg 2022; 8:786158. [PMID: 35187046 PMCID: PMC8847274 DOI: 10.3389/fsurg.2021.786158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/29/2021] [Indexed: 12/07/2022] Open
Abstract
PurposeCurrently, surgical drainage during a laparoscopic cholecystectomy (LC) is still placed in selected patients. Evidence of the non-beneficial effect of the surgical drain comes from studies with a heterogeneous population. This preliminary study aims to identify any clinical, demographic, or intraoperative predictive factors for a surgical drain placement during LC as the first step to identify population for a prospective randomized study.MethodThe study was conducted in a single referral center and academic hospital between 2014 and 2018. Patients who underwent unconverted LC were divided into two groups: Group A (drain) and Group B (no drain). We explored baseline, preoperative, intraoperative characteristics, and postoperative outcomes.ResultsBetween 409 patients who underwent LC: 90 (22%) patients were in Group A (drain). Age >64 years, male sex, cholecystitis, Charlson comorbidity index (CCI) ≥ 1, experienced surgeon, intraoperative technical difficulties, need for an additional trocar, operative time >60 min, and estimated blood loss >10 ml were predictive factors at univariate analysis. While at multivariate analysis, cholecystitis (odds ratio [OR]: 2.8, 95% CI:1.5–5.1; p < 0.001), CCI ≥ 1 (OR:1.9, 95% CI:1.0–3.5; p = 0.05), intraoperative technical difficulties (OR: 3.6, 95% CI:1.8–6.2; p < 0.001), need of an additional trocar (OR: 2.5, 95% CI: 1.4–4.4; p < 0.005), and estimated blood loss >10 ml (OR: 3.0, 95% CI:1.7–5.3; p < 0.0001) were predictive factors for a surgical drain placement during LC.ConclusionsThis study identified predictive factors that currently drive the surgeons to a surgical drain placement after LC. Randomized prospective studies are needed to define the use of drain placement in these selected patients.
Collapse
Affiliation(s)
- Giacomo Calini
- Department of Medicine, General Surgery Department and Simulation Center, Academic Hospital of Udine, University of Udine, Udine, Italy
| | - Pier Paolo Brollo
- Department of Medicine, General Surgery Department and Simulation Center, Academic Hospital of Udine, University of Udine, Udine, Italy
| | - Rosanna Quattrin
- Department of Organization of Hospital Services, Academic Hospital of Udine, Udine, Italy
| | - Vittorio Bresadola
- Department of Medicine, General Surgery Department and Simulation Center, Academic Hospital of Udine, University of Udine, Udine, Italy
- *Correspondence: Vittorio Bresadola ; orcid.org/0000-0002-0098-3540
| |
Collapse
|
7
|
Fathi F, Kamani F, Farahmand AM, Rafieian S, Vahedi M. Effect of routine abdominal drainage on postoperative pain after uncomplicated laparoscopic cholecystectomy for cholelithiasis: A randomised controlled trial. Ann Med Surg (Lond) 2022; 74:103353. [PMID: 35198175 PMCID: PMC8844757 DOI: 10.1016/j.amsu.2022.103353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/26/2022] [Accepted: 02/01/2022] [Indexed: 11/02/2022] Open
Abstract
This is a prospective randomized controlled trial to investigate the effect of routine abdominal drainage on postoperative pain after uncomplicated laparoscopic cholecystectomy for cholelithiasis. This study was a single-center randomized controlled trial performed at the general surgery ward of Taleghani hospital, in Tehran, Iran, from July 2018 to October 2018. Patients were randomly divided into two parallel groups, one receiving routine abdominal drainage and the other receiving no treatment. Postoperative pain was measured by the Universal Pain Assessment Tool (UPAT) 0, 2, 4, 6, 12, and 24 h postoperatively. A total of 60 patients (30 patients in the study and control groups) were included. GLM repeated measure analysis showed a significant time*treatment effect for routine abdominal drainage in decreasing UPAT scores from baseline to 24 h after surgery (F = 4.59, df = 3.98, P-value = 0.001). Our findings demonstrated that abdominal drainage significantly reduces postoperative pain 0, 2, 4, 6, and 12 h after surgery (P-value<0.05). We also showed that abdominal drainage increases the time to first morphine sulfate administration and decreases the total dose of morphine sulfate administration (P-value<0.001). Moreover, we demonstrated that abdominal drainage decreases the average postoperative pain (P-value<0.001) and does not lead to any considerable side effects. However, 24 h after surgery, no significant pain-relieving effect was evident for abdominal drainage. In conclusion, insertion of abdominal drainage leads to decreased postoperative pain. Future studies need to investigate the optimal time for removal of the abdominal drain. This trial was prospectively registered in the Iranian Registry of Clinical Trials with a registration ID of IRCT20130706013875N2.
Collapse
|
8
|
Effect of pelvic drain displacement on anastomotic leakage-related morbidity after rectal cancer surgery. JOURNAL OF MINIMALLY INVASIVE SURGERY 2021; 24:158-164. [PMID: 35600101 PMCID: PMC8977382 DOI: 10.7602/jmis.2021.24.3.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/28/2021] [Accepted: 09/04/2021] [Indexed: 11/12/2022]
Abstract
Purpose Drain insertion after proctectomy is common in clinical practice, although the effectiveness of drains has been questioned. However, drains are commonly displaced after surgery. We hypothesized that drain displacement is associated with clinical outcomes and aimed to assess differences in clinical outcomes, such as overall morbidity, including anastomotic leakage (AL), reintervention rates, length of hospital stay, and mortality rates, between patients who experienced displaced drains and those who did not. Methods Rectal cancer patients who underwent proctectomy at a single institution between January 2015 and December 2020 were retrospectively reviewed. Clinical characteristics were compared between patients who experienced displaced drains and those who did not. The primary endpoint was the occurrence of reintervention in patients with AL. The secondary endpoints were overall morbidity rates, AL rates, length of hospital stay, and mortality within 30 days. Results Among 248 patients who underwent proctectomy, 93 (37.5%) experienced displaced drains. A higher proportion of patients who experienced displaced drains required reintervention due to AL than those who did not experience displaced drains (odds ratio, 3.61; 95% confidential interval, 1.20–10.93; p = 0.016). However, no significant difference was found in the overall morbidity rate, mortality, and length of hospital stay between the groups. Conclusion Drain displacement does not worsen outcomes such as overall morbidity rate, mortality, and length of hospital stay after proctectomy but is associated with an increase in the need for reintervention in patients with AL.
Collapse
|
9
|
Anweier N, Apaer S, Zeng Q, Wu J, Gu S, Li T, Zhao J, Tuxun T. Is routine abdominal drainage necessary for patients undergoing elective hepatectomy? A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24689. [PMID: 33578602 PMCID: PMC10545016 DOI: 10.1097/md.0000000000024689] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/30/2020] [Accepted: 01/01/2021] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES To evaluate comparative outcomes of routine abdominal drainage (RAD) and non-routine abdominal drainage (NRAD) during elective hepatic resection for hepatic neoplasms. MATERIALS AND METHODS We systematically searched MEDLINE, EMBASE, The Cochrane Library, Web of Science. The searching phrases included "liver resection," "hepatic resection," "hepatectomy," "abdominal drainage," "surgical drainage," "prophylactic drainage," "intraperitoneal drainage," "drainage tube," "hepatectomy," "abdominal drainage" and "drainage tube." Two independent reviewers critically screened literature, extracted data and assessed the risk of bias. Post-operative morbidity and mortality were the outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effect model. RESULTS We have identified 9 RCTs and 3 comparative studies reporting total of 5726 patients undergoing elective hepatectomy under RAD (n = 3084) or NRAD (NRAD group, n = 2642). RAD was associated with significantly higher overall complication rate [odds risk = 1.79, 95% CI (1.10, 2.93), P = .02] and biliary leakage rate [odds risk = 2.41, 95% CI (1.48, 3.91), P = .0004] compared with NRAD. Moreover, it significantly increased hospital stays [mean difference = 0.95, 95% CI (0.02, 1.87), P = .04] compared with NRAD. RAD showed no difference regarding intra-abdominal hemorrhage, wound complications, liver failure, subphrenic complications, pulmonary complications, infectious complications, reoperation and mortality compared with NRAD. CONCLUSIONS Although routine abdominal drainage may help surgeons to observe post-operative complication, it seems to be associated with increased post-operative morbidity and longer hospital stays. Non-routine abdominal drainage may be an appropriate option in selected patients undergoing hepatic resection. Higher level of evidence is needed.
Collapse
|
10
|
Sampaio MAF, Sampaio SLP, Leal PDC, Moura ECR, Alvares LGGS, DE-Oliveira CMB, Torres OJM, Martins MDG. ACERTO PROJECT: IMPACT ON ASSISTANCE OF A PUBLIC EMERGENCY HOSPITAL. ACTA ACUST UNITED AC 2021; 33:e1544. [PMID: 33470374 PMCID: PMC7812687 DOI: 10.1590/0102-672020200003e1544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 04/13/2020] [Indexed: 02/06/2023]
Abstract
Background: In Brazil, the goal-based approach was named Project ACERTO and has obtained
good results when applied in elective surgeries with shorter hospitalization
time, earlier return to activities without increased morbidity and
mortality. Aim: To analyze the impact of ACERTO on emergency surgery care. Methods: An intervention study was performed at a trauma hospital. Were compared 452
patients undergoing emergency surgery and followed up by the general surgery
service from October to December 2018 (pre-ACERTO, n=243) and from March to
June 2019 (post-ACERTO, n=209). Dietary reintroduction, volume of infused
postoperative venous hydration, duration of use of catheters, probes and
drains, postoperative analgesia, prevention of postoperative vomiting, early
mobilization and physiotherapy were evaluated. Results: After the ACERTO implantation there was earlier reintroduction of the diet,
the earlier optimal caloric intake, earlier venous hydration withdrawal,
higher postoperative analgesia prescription, postoperative vomiting
prophylaxis and higher physiotherapy and mobilization prescription were
achieved early in all (p<0.01); in the multivariate analysis there was no
change in the complication rates observed before and after ACERTO (10.7% vs.
7.7% (p=0.268) and there was a decrease in the length of hospitalization
after ACERTO (8,5 vs. 6,1 dias (p=0.008). Conclusion: The implementation of the ACERTO project decreased the length of hospital
stay, improved medical care provided without increasing the rates of
complications evaluated.
Collapse
Affiliation(s)
| | | | - Plinio da Cunha Leal
- Postgraduate Program in Adult Health, Federal University of Maranhão, São Luís, MA, Brazil
| | - Ed Carlos Rey Moura
- Postgraduate Program in Adult Health, Federal University of Maranhão, São Luís, MA, Brazil
| | | | | | | | | |
Collapse
|
11
|
Cirocchi R, Kwan SH, Popivanov G, Ruscelli P, Lancia M, Gioia S, Zago M, Chiarugi M, Fedeli P, Marzaioli R, Di Saverio S. Routine drain or no drain after laparoscopic cholecystectomy for acute cholecystitis. Surgeon 2020; 19:167-174. [PMID: 32713729 DOI: 10.1016/j.surge.2020.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/29/2020] [Accepted: 04/04/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is considered to be the gold standard in the early management of acute cholecystitis however, recommendations for routine drain insertion in the acute setting are unavailable. STUDY DESIGN A systematic review of literature review and metanalysis was conducted. All studies comparing drain versus no drain after LC for acute cholecystitis were included. RESULTS Seven studies, with 1274 patients, were included. Postoperative wound infection rates (relative risk (RR) 0.30, 95% confidence interval (CI) 0.10 to 0.88; I2 = 0%) and postoperative abdominal collection requiring drainage (RR 1.20, 95% CI 0.35 to 4.12; I 2 = 0%) were lower in the no-drain group, but this was only significant for wounded infections on subgroup analysis of RCTs. Length of stay hospital (mean difference (MD) -0.49, 95% CI -0.89 to -0.09; I 2 = 69%) and operative time (MD -8.13, 95% CI -13.87 to -2.38; I 2 = 92%) were significantly shorter in the no drain group however this was in the context of significant heterogeneity. CONCLUSION The available data suggests that acute cholecystitis is not an indication for routine drain placement after LC. However, these results must be interpreted with caution due to the limitations of the included studies. In effect, the main issue of this meta-analysis lies on the limitations of the included studies themselves, because of a considerable heterogeneity among the included works, particularly for the inclusion criteria of patients and reported severity of acute cholecystitis. Further work is required to produce evidence which will definitively alter clinical practice. LEVEL OF EVIDENCE Level 2a (systematic review of cohort studies). Oxford CEBM levels of evidence.
Collapse
Affiliation(s)
- Roberto Cirocchi
- Department of Surgical Science, University of Perugia, Perugia, Italy.
| | - Sherman H Kwan
- Department of General Surgery, Royal Perth Hospital, Perth, Western Australia, Australia.
| | - Georgi Popivanov
- Department of Surgery, Military Medical Academy, Sofia, Bulgaria.
| | - Paolo Ruscelli
- Emergency Surgery Unit, Faculty of Medicine and Surgery, Torrette Hospital, Polytechnic University of Marche, Ancona, Italy.
| | - Massimo Lancia
- Department of Surgical Science, University of Perugia, Perugia, Italy.
| | - Sara Gioia
- Department of Surgical Science, University of Perugia, Perugia, Italy.
| | - Mauro Zago
- Department of General Surgery, San Pietro Polyclinic, Ponte San Pietro, Italy.
| | | | - Piergiorgio Fedeli
- School of Law - Legal Medicine, University of Camerino, Camerino, Italy.
| | - Rinaldo Marzaioli
- Department of Emergency and Organ Transplantation (DETO), University Medical School "A. Moro" Bari, Bari, Italy.
| | - Salomone Di Saverio
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom; University of Insubria, Surgery I unit, University Hospital of Varese, Italy.
| |
Collapse
|
12
|
Nishida Y, Otagiri N, Yoshifuku S, Misawa K, Ko K, Sasahara K, Mishima O, Tauchi K. Gram staining of gallbladder bile samples is useful for predicting surgical site infection in acute cholecystitis patients undergoing an early cholecystectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:962-967. [DOI: 10.1002/jhbp.790] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/02/2020] [Accepted: 06/11/2020] [Indexed: 12/11/2022]
Affiliation(s)
| | | | | | - Kenji Misawa
- Department of Surgery Aizawa Hospital Matsumoto Japan
| | - Kenju Ko
- Department of Surgery Aizawa Hospital Matsumoto Japan
| | | | - Osamu Mishima
- Department of Surgery Aizawa Hospital Matsumoto Japan
| | | |
Collapse
|
13
|
Futility of abdominal drain in elective laparoscopic splenectomy. Langenbecks Arch Surg 2020; 405:665-672. [PMID: 32594236 DOI: 10.1007/s00423-020-01915-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/22/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Despite the implementation of minimally invasive surgery and enhanced recovery protocols, the use of drain in elective splenectomy is still controversial. The aim of this study was to assess whether the abdominal drain can impact on short-term outcome after elective laparoscopic splenectomy. METHODS This is a retrospective analysis of a consecutively collected database including all patients who underwent elective laparoscopic splenectomy in our institution between January 2001 and June 2019. Postoperative complications were defined according to a priori criteria and graded according to Clavien-Dindo classification. All complications that occurred during hospitalization or within 30 days after discharge were considered. Primary endpoint was postoperative morbidity, and secondary endpoint was postoperative hospital length of stay. RESULTS One hundred and sixty-one patients were analysed. Intraperitoneal drain was placed in 75 (46.6%) patients. Postoperative complications occurred in 36 (22.4%) patients, while 8 (4.9%) patients had major complications. Median postoperative length of stay was 4 days. At multivariate analysis, only malignancy was significantly associated with the onset of complications (OR 3.50; 95% CI 1.1-11.0; p = 0.032). Malignancy, ASA > 2, conversion to open surgery, presence of drain and longer operation were significantly associated with prolonged length of stay. Patients with drain showed a greater unadjusted risk of abdominal collections (RR 10.32; 95% CI 1.3-79.6; p = 0.006). CONCLUSION Abdominal drain did not reduce morbidity and prolonged the length of stay following elective laparoscopic splenectomy. Therefore, the present study does not support the routine use of drain in such procedure.
Collapse
|
14
|
Efficacy of Hand and Foot Massage in Anxiety and Pain Management Following Laparoscopic Cholecystectomy: A Controlled Randomized Study. Surg Laparosc Endosc Percutan Tech 2019; 30:111-116. [PMID: 31855924 DOI: 10.1097/sle.0000000000000738] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study was planned and performed to evaluate the effect of foot and hand massage on pain and anxiety management, which is one of the nonpharmacological pain relief methods in patients who undergo laparoscopic cholecystectomy. The present study was designed and conducted in the randomized controlled manner to determine the impacts of foot and hand massage on postoperative pain and anxiety scores of patients who receive laparoscopic cholecystectomy. The universe of the study consisted of the patients who received laparoscopic cholecystectomy between April 2018 and January 2019. The study was completed with 196 patients as 63 patients in the foot massage group, 65 patients in the hand massage group, and 68 patients in the control group. To collect the data, the "Descriptive Characteristics Form," "Visual Analog Scale," and "State-Trait Anxiety Inventory" were used. The pain intensity of patients in the foot massage group and hand massage group were less than in the control group at 90 and 150 minutes after intervention (P<0.05). A significant reduction was determined in the need for analgesics for the patients in the foot massage group and hand massage group compared with the control group (P<0.05). A significant positive relationship was found between pain intensity and state anxiety levels in patients of the foot massage group and hand massage group. Foot and hand massage are influential in decreasing pain and anxiety levels after surgeries for patients who undergo laparoscopic cholecystectomy.
Collapse
|
15
|
Bostanci MT, Saydam M, Kosmaz K, Tastan B, Bostanci EB, Akoglu M. The effect on morbidity of the use of prophylactic abdominal drain following elective laparoscopic cholecystectomy. Pak J Med Sci 2019; 35:1306-1311. [PMID: 31488997 PMCID: PMC6717480 DOI: 10.12669/pjms.35.5.291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background and Objective To evaluate the clinical role of the routine use of a drain in an elective laparoscopic cholecystectomy operation applied to patients with symptomatic cholelithiasis not showing acute inflammation. Method Following laparoscopic removal of the gallbladder, patients were separated into two groups of 30 each, either with subhepatic drain placement or without. The presence of subhepatic fluid collection was evaluated with transabdominal ultrasonography (USG) at 24 hours postoperatively and on the 7th day. The other parameters evaluated were postoperative morbidity, shoulder and abdominal pain. Results No statistically significant difference was found between the two groups in respect of demographic characteristics and operative details. The median pain score was determined to be statistically significantly higher in the group with a drain applied compared to the group without a drain (p=0.007). In the comparison between the groups of fluid collection on USG at 24 hours and shoulder pain persisting until the 7th day, although seen less in the group with no drain applied, no statistically significant difference was determined (p=0.065, p=0.159). In the examinations made on the 7th day, no hematoma or significant fluid collection was determined on USG and no wound infection was observed in any patient of either group. Conclusion The routine application of prophylactic subhepatic drain in laparoscopic cholecystectomy procedure did not show any benefit to the patient.
Collapse
Affiliation(s)
- Mustafa Taner Bostanci
- Mustafa Taner Bostanci, Department of General Surgery, Diskapi Yildirim Beyazıt Training and Research Hospital, Ankara, Turkey
| | - Mehmet Saydam
- Mehmet Saydam, Department of General Surgery, Diskapi Yildirim Beyazıt Training and Research Hospital, Ankara, Turkey
| | - Koray Kosmaz
- Koray Kosmaz, Department of General Surgery, Ankara Training and Research Hospital, Ankara, Turkey
| | - Baki Tastan
- Baki Tastan, Department of General Surgery, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Erdal Birol Bostanci
- Erdal Birol Bostanci, Department of Gastroenterological Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Musa Akoglu
- Musa Akoglu, Department of Gastroenterological Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| |
Collapse
|
16
|
Optimising Surgical Technique in Laparoscopic Cholecystectomy: a Review of Intraoperative Interventions. J Gastrointest Surg 2019; 23:1925-1932. [PMID: 31240555 DOI: 10.1007/s11605-019-04296-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 06/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is one of the most commonly performed procedures worldwide but there is considerable variance amongst surgeons regarding intraoperative technique. This review aims to provide a comprehensive summary, with evidence-based recommendations, of intraoperative interventions in LC. METHODS A literature search was performed using PubMed, EMBASE, Google Scholar and Cochrane Review databases. Articles were screened for eligibility with inclusion criteria based on study design, surgical approach, surgical timing, pathology and intervention type. The most contemporary, comprehensive or relevant articles were used as the primary evidence for the final analysis and discussion. RESULTS A total of 25 systematic reviews and/or meta-analyses and 19 individual trials were identified from the literature and grouped into ten clinical intervention topics. Three intraoperative interventions offer clinical benefit and are recommended: wound/intraperitoneal local anaesthetic, low-pressure pneumoperitoneum and manoeuvres to reduce residual pneumoperitoneum. No benefit was demonstrated for routine subhepatic drain placement and gallbladder aspiration. Techniques which appear to demonstrate improvements but do not translate into clinical efficacy are the use of warmed/humidified carbon dioxide, installation of intraperitoneal saline and the use of advanced imaging techniques. Techniques demonstrating equipoise, and for which no recommendations can be made, are type of energy source and cystic duct occlusion methods. DISCUSSION This review highlights and suggests specific intraoperative techniques during uncomplicated LC that should be employed, avoided or considered by the individual surgeon. Optimising surgical technique in this way can lead to improved patient outcomes.
Collapse
|
17
|
Tachezy M, Izbicki JR. [Evidence for standard surgical procedures: appendicitis, diverticulitis and cholecystitis]. Chirurg 2019; 90:351-356. [PMID: 30635701 DOI: 10.1007/s00104-018-0779-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute appendicitis, cholecystitis and sigmoid diverticulitis are the most common inflammatory visceral surgical emergencies. According to the principles of evidence-based medicine, treatment methods and surgical indications should be constantly questioned and validated by high-quality clinical studies. OBJECTIVE To identify and classify the current evidence on surgical treatment of acute appendicitis, cholecystitis and sigmoid diverticulitis. MATERIAL AND METHODS Targeted literature search in Medline, the Cochrane Library and study registers (clinicaltrials.gov). RESULTS AND CONCLUSION The indications for surgery are changing due to increasing numbers of high-quality clinical studies. Conservative treatment seems to be feasible in the early stages. In contrast, many surgical steps have not yet been sufficiently validated. Furthermore, there is a great need for high-quality, prospective randomized clinical trials, so that promotion of studies and the study culture in surgery should continue to be of greatest interest.
Collapse
Affiliation(s)
- M Tachezy
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - J R Izbicki
- Klinik für Allgemein‑, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| |
Collapse
|
18
|
Picchio M, De Cesare A, Di Filippo A, Spaziani M, Spaziani E. Prophylactic drainage after laparoscopic cholecystectomy for acute cholecystitis: a systematic review and meta-analysis. Updates Surg 2019; 71:247-254. [PMID: 30945148 DOI: 10.1007/s13304-019-00648-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 03/25/2019] [Indexed: 12/26/2022]
Abstract
In the literature, there is a large evidence against the use of drains in laparoscopic cholecystectomy (LC) in elective surgery. However, evidence is lacking in the setting of acute cholecystitis (AC). The present meta-analysis was performed to assess the role of drains to reduce complications and improve recovery in LC for AC. An electronic search of the MEDLINE, Science Citation Index Expanded, SpringerLink, Scopus, and Cochrane Library database from January 1990 to July 2018 was performed to identify randomized clinical trials (RCTs) that compare prophylactic drainage with no drainage in LC for AC. Odds ratio (OR) with confidence interval (CI) for qualitative variables and mean difference (MD) with CI for continuous variables were calculated. Three RCTs were included in the meta-analysis, involving 382 patients randomized to drain (188) versus no drain (194). Morbidity was similar in both the study groups (OR 1.23; 95% CI 0.55-2.76; p = 0.61) as well as wound infection rate (OR 1.98; 95% CI 0.53-7.40; p = 0.31) and abdominal abscess rate (OR 0.62; 95% CI 0.08-4.71; p = 0.31). Abdominal pain 24 h after surgery was less severe in the no drain group (MD 0.80; 95% CI 0.46-1.14; p < 0.000). A significant difference in favor of the no drain group was found in the postoperative hospital stay (MD 1.05; 95% CI 0.87-1.22; p < 0.000). No significant difference was present with respect to postoperative fluid collection in the subhepatic area and operative time. The present study shows that prophylactic drain placement is useless to reduce complications in LC performed to treat AC. Postoperative recovery is improved if drain is not present.
Collapse
Affiliation(s)
- Marcello Picchio
- Department of Surgery, Hospital "P. Colombo", Via Orti Ginnetti 7, 00049, Velletri, Italy.
- Via Giulio Cesare, 58, 04100, Latina, Italy.
| | - Alessandro De Cesare
- Department of Surgery, Sapienza University of Rome-Polo Pontino, Via Firenze, 04019, Terracina, Italy
| | - Annalisa Di Filippo
- Department of Surgery, Sapienza University of Rome-Polo Pontino, Via Firenze, 04019, Terracina, Italy
| | - Martina Spaziani
- Department of Surgery, Sapienza University of Rome-Polo Pontino, Via Firenze, 04019, Terracina, Italy
| | - Erasmo Spaziani
- Department of Surgery, Sapienza University of Rome-Polo Pontino, Via Firenze, 04019, Terracina, Italy
| |
Collapse
|
19
|
[Evidence-based perioperative medicine]. Chirurg 2019; 90:357-362. [PMID: 30627766 DOI: 10.1007/s00104-018-0776-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Perioperative medical interventions are an integral part of modern surgical management. In addition to the main manual aspects of surgical interventions, surgeons must also be familiar with preoperative and postoperative medical interventions. This ranges from the indications for perioperative anticoagulation, handling of drainage, adjusting the perioperative analgesia, prescribing an antibiotic prophylaxis to deciding whether a preoperative bowel preparation is necessary. Therefore, this article exemplifies some areas in perioperative medicine. Based on the best available evidence, it should always be critically assessed whether these perioperative interventions really contribute to the success of the treatment.
Collapse
|
20
|
Does Peritoneal Suction Drainage Reduce Pain After Gynecologic Laparoscopy? Surg Laparosc Endosc Percutan Tech 2018; 28:73-76. [DOI: 10.1097/sle.0000000000000490] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
21
|
Gilbert A, Ortega-Deballon P, Di Giacomo G, Cheynel N, Rat P, Facy O. Intraperitoneal drains move. J Visc Surg 2017; 155:105-110. [PMID: 29102315 DOI: 10.1016/j.jviscsurg.2017.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The use of surgical drains is the subject of much debate but they continue to be commonly used. The phenomenon of drain migration from their desired position following surgery has not been studied. The aim of this study was to evaluate the incidence of the displacement of surgical drains among patients undergoing abdominal gastrointestinal surgery. PATIENTS AND METHODS We performed a review of all patients who underwent an early CT-scan postoperatively after abdominal gastrointestinal surgery prior to drain mobilization, between January 2013 and April 2016 in the Dijon University Hospital Center. Pre-and intra-operative data (number, type and position of drains) and postoperative data (imaging and evolution) were collected retrospectively. RESULTS This study included 125 patients. Thirty-five (28%) were found to have a displacement of at least one drain from its original position. Forty-one (19.8%) of the 207 studied drains had moved. Postoperative morbidity was not higher in patients with displaced drains (P=0.51). None of all the studied preoperative and operative factors have been found to be a risk factor for drain displacement. CONCLUSION Surgical drains displacement is frequently encountered in patients undergoing digestive abdominal surgery. In our experience, this phenomenon does not seem to have any clinical implications. When a benefit is expected from the use of surgical drains, intraperitoneal fixation appears to be necessary.
Collapse
Affiliation(s)
- A Gilbert
- Service de chirurgie générale, digestive, cancérologique et urgences, CHU François-Mitterrand, 14, rue Paul-Gaffarel, 21000 Dijon, France.
| | - P Ortega-Deballon
- Service de chirurgie générale, digestive, cancérologique et urgences, CHU François-Mitterrand, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - G Di Giacomo
- Service de chirurgie générale, digestive, cancérologique et urgences, CHU François-Mitterrand, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - N Cheynel
- Service de chirurgie générale, digestive, cancérologique et urgences, CHU François-Mitterrand, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - P Rat
- Service de chirurgie générale, digestive, cancérologique et urgences, CHU François-Mitterrand, 14, rue Paul-Gaffarel, 21000 Dijon, France
| | - O Facy
- Service de chirurgie générale, digestive, cancérologique et urgences, CHU François-Mitterrand, 14, rue Paul-Gaffarel, 21000 Dijon, France
| |
Collapse
|