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Mori H, Maehira H, Nitta N, Maekawa T, Ishikawa H, Takebayashi K, Kojima M, Kaida S, Miyake T, Tani M. Clinical impact of various drain-fluid data for the postoperative complications after hepatectomy: criteria of prophylactic drain removal on postoperative day 1. Langenbecks Arch Surg 2024; 409:209. [PMID: 38980432 DOI: 10.1007/s00423-024-03401-0] [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: 05/03/2024] [Accepted: 07/02/2024] [Indexed: 07/10/2024]
Abstract
PURPOSE Prophylactic drains reported to be useful to treat postoperative bile leakage (POBL) and reduce re-intervention after hepatectomy. However, prophylactic drains should remove in the early postoperative period. This study aimed to assess the association between postoperative complications and the drain-fluid data on postoperative day (POD) 1. METHODS Medical records of 530 patients who underwent hepatectomy were retrospectively reviewed. We evaluated the drain-fluid data on POD 1, such as bilirubin (BIL), aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) and drain discharge volume. These variables were compared between patients with and without postoperative complications such as POBL and abdominal abscess not due to POBL. RESULTS POBL was found in 44 patients (8.3%), PHLF was in 51 patients (9.6%), and abdominal abscess not due to POBL was in 21 patients (4.0%). Regarding POBL, drain-fluid BIL concentration and drain discharge volume was higher in the POBL group (p < 0.001 and p < 0.001, respectively). However, drain-fluid AST, ALT, and ALP concentrations were not different between two groups. As to the abdominal abscess not due to POBL, all drain-fluid data were not significantly different. Multivariate analysis for predicting POBL showed that the drain-fluid BIL concentration ≥ 2.68 mg/dL was an independent predictor (p < 0.001). In the subgroup analyses according to the type of hepatectomy, the drain-fluid BIL concentration was an independent predictor for POBL after both non-anatomical and anatomical hepatectomy. CONCLUSION The drain-fluid BIL concentration on POD 1 is useful in predicting POBL after hepatectomy.
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Affiliation(s)
- Haruki Mori
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, 520-2192, Shiga, Japan
| | - Hiromitsu Maehira
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, 520-2192, Shiga, Japan.
| | - Nobuhito Nitta
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, 520-2192, Shiga, Japan
| | - Takeru Maekawa
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, 520-2192, Shiga, Japan
| | - Hajime Ishikawa
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, 520-2192, Shiga, Japan
| | - Katsushi Takebayashi
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, 520-2192, Shiga, Japan
| | - Masatsugu Kojima
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, 520-2192, Shiga, Japan
| | - Sachiko Kaida
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, 520-2192, Shiga, Japan
| | - Toru Miyake
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, 520-2192, Shiga, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, 520-2192, Shiga, Japan
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2
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Nigam A, Hawksworth JS, Winslow ER. Minimally Invasive Robotic Techniques for Hepatocellular Carcinoma Resection: How I Do It. Surg Oncol Clin N Am 2024; 33:111-132. [PMID: 37945137 DOI: 10.1016/j.soc.2023.06.009] [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] [Indexed: 11/12/2023]
Abstract
The adoption of minimally invasive techniques for hepatocellular resection has progressively increased in North America. Cumulative evidence has demonstrated improved surgical outcomes in patients who undergo minimally invasive hepatectomy. In this review, the authors' approach and methodology to minimally invasive robotic liver resection for hepatocellular carcinoma is discussed.
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Affiliation(s)
- Aradhya Nigam
- Department of Surgery, Medstar Georgetown University Hospital, 3800 Reservoir Road, NW, 4PHC, Washington, DC 20007, USA
| | - Jason S Hawksworth
- Division of Abdominal Organ Transplantation, Columbia University Irving Medical Center, 622 West 168th Street, PH14-105, New York, NY 20032, USA.
| | - Emily R Winslow
- Department of Transplant Surgery, Medstar Georgetown University Hospital, 3800 Reservoir Road, NW, 2PHC, Washington, DC 20007, USA
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Ishinuki T, Shinkawa H, Kouzu K, Shinji S, Goda E, Ohyanagi T, Kobayashi M, Kobayashi M, Suzuki K, Kitagawa Y, Yamashita C, Mohri Y, Shimizu J, Uchino M, Haji S, Yoshida M, Ohge H, Mayumi T, Mizuguchi T. Recent evidence for subcutaneous drains to prevent surgical site infections after abdominal surgery: A systematic review and meta-analysis. World J Gastrointest Surg 2023; 15:2879-2889. [PMID: 38222020 PMCID: PMC10784836 DOI: 10.4240/wjgs.v15.i12.2879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/23/2023] [Accepted: 11/27/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Surgical site infections (SSIs) increase mortality, hospital stays, additional medical treatment, and medical costs. Subcutaneous drains prevent SSIs in gynecological and breast surgeries; however, their clinical impact in abdominal surgery remains unclear. AIM To investigate whether subcutaneous drains were beneficial in abdominal surgery using a systematic review and meta-analysis. METHODS The database search used PubMed, MEDLINE, and the Cochrane Library. The following inclusion criteria were set for the systematic review: (1) Randomized controlled trial studies comparing SSIs after abdominal surgery with or without subcutaneous drains; and (2) Studies that described clinical outcomes, such as SSIs, seroma formation, the length of hospital stays, and mortality. RESULTS Eight studies were included in this meta-analysis. The rate of total SSIs was significantly lower in the drained group (54/771, 7.0%) than in the control group (89/759, 11.7%), particularly in gastrointestinal surgery. Furthermore, the rate of superficial SSIs was slightly lower in the drained group (31/517, 6.0%) than in the control group (49/521, 9.4%). No significant differences were observed in seroma formation between the groups. Hospital stays were shorter in the drained group than in the control group. CONCLUSION Subcutaneous drains after abdominal surgery prevented SSIs and reduced hospital stays but did not significantly affect seroma formation. The timing of drain removal needs to be reconsidered in future studies.
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Affiliation(s)
- Tomohiro Ishinuki
- Department of Nursing, Surgical Sciences, Sapporo Medical University, Sapporo 060-8556, Hokkaido, Japan
| | - Hiroji Shinkawa
- Department of Hepatobiliary-Pancreatic Surgery, Osaka Metropolitan University Graduate School of Medicine, Abeno-Ku 545-0051, Japan
| | - Keita Kouzu
- Department of Surgery, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Seiichi Shinji
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo 113-8602, Japan
| | - Erika Goda
- Department of Nursing, Japan Health Care University, Sapporo 062-0053, Japan
| | - Toshio Ohyanagi
- Department of Liberal Arts and Sciences, Center for Medical Education, Sapporo Medical University, Sapporo 060-8556, Japan
| | - Masahiro Kobayashi
- Department of Clinical Pharmacokinetics, Research and Education Center for Clinical Pharmacy, Kitasato University, Tokyo 108-8641, Japan
| | - Motomu Kobayashi
- Department of Anesthesiology, Hokushinkai Megumino Hospital, Eniwa 061-1395, Japan
| | - Katsunori Suzuki
- Department of Infectious Disease Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu 807-8555, Japan
| | - Yuichi Kitagawa
- Department of Gastrointestinal Surgery, National Center for Geriatrics and Gerontology, Obu 474-8511, Japan
| | - Chizuru Yamashita
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University, Toyoake 470-1192, Japan
| | - Yasuhiko Mohri
- Department of Gastrointestinal Surgery, Mie Prefectural General Medical Center, Yokkaich 510-8561, Japan
| | - Junzo Shimizu
- Department of Surgery, Toyonaka Municipal Hospital, Toyonaka 560-8565, Japan
| | - Motoi Uchino
- Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya 663-8501, Japan
| | - Seiji Haji
- Department of Surgery, Soseikai General Hospital, Kyoto 612-8473, Japan
| | - Masahiro Yoshida
- Department of Hepato-Biliary-Pancreatic & Gastrointestinal Surgery, International University of Health and Welfare, Ichikawa 272-0827, Japan
| | - Hiroki Ohge
- Department of Infectious Disease, Hiroshima University Hospital, Hiroshima 734-8551, Japan
| | - Toshihiko Mayumi
- Department of Intensive Care Unit, Chukyo Hospital, Japan Community Health Care Organization, Nagoya 457-8510, Japan
| | - Toru Mizuguchi
- Department of Nursing, Surgical Sciences, Sapporo Medical University, Sapporo 060-8556, Hokkaido, Japan
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Abdominal drainage is contraindicated after uncomplicated hepatectomy: Results of a meta-analysis of randomized controlled trials. Surgery 2023; 173:401-411. [PMID: 36424196 DOI: 10.1016/j.surg.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/18/2022] [Accepted: 10/24/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND No conclusive recommendations exist regarding use of abdominal drainage in hepatectomy. The practice of abdominal drainage remains commonplace despite unfavorable outcomes reported by randomized controlled trials. We aimed to compare the impact of abdominal drainage on outcomes of hepatectomy. METHODS A systematic search of electronic information sources and bibliographic reference lists was conducted. A combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits in each of the above databases was applied. Overall perioperative and wound-related complications, bile leak, intra-abdominal collections (including those requiring an intervention), and the length of hospital stay were the evaluated outcome parameters. RESULTS Seven randomized controlled trials reporting 1,064 patients undergoing hepatectomy with (n = 533) or without (n = 531) placement of abdominal drain were included. Patients in both groups were of comparable age (P = .23), sex (P = .49), proportion of major hepatectomy (P = .93), minor hepatectomy (P = .96), cirrhosis (P = .78), and malignant pathologies (P = .61). Drainage after hepatectomy was associated with significantly higher overall complications (RR: 1.37, P = .0003) and wound-related complications (risk ratio: 2.29, P = .01) compared to no drainage. Moreover, there was no significant difference in bile leak (risk ratio: 2.15, P = .19), intra-abdominal collections (risk ratio: 1.13, P = .70), intra-abdominal collections requiring interventions (risk ratio: 1.19, P = .71), or length of hospital stay (mean difference: 0.37, P = .67) between the 2 groups. The trial sequential analysis confirmed conclusiveness of the findings. CONCLUSION Abdominal drainage after hepatectomy increases overall and wound-related complications, without any reduction in the risk of intra-abdominal collections needing an intervention. Routine drainage after an uncomplicated hepatectomy should be avoided, with the possible exception of the presence of a bilioenteric anastomosis.
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Yasuda S, Hokuto D, Kamitani N, Matsuo Y, Doi S, Nakagawa K, Nishiwada S, Nagai M, Terai T, Sho M. Pre- and postoperative C-reactive protein as a risk factor of organ/space surgical site infection after hepatectomy. LANGENBECK'S ARCHIVES OF SURGERY 2023; 408:13. [PMID: 36622470 DOI: 10.1007/s00423-023-02760-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 11/07/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Organ/space surgical site infection (SSI) is one of the most common complications of liver resection, with significant impact on morbidity and mortality, so patients at high risk should be identified early. This study aimed to determine whether pre- and postoperative C-reactive protein (CRP) levels could predict organ/space SSIs. METHODS The hospital records of consecutive patients who underwent hepatectomy without biliary reconstruction at our institutions between 2008 and 2015 were reviewed retrospectively. Preoperative, intraoperative, and postoperative variables were compared between patients with or without organ/space SSIs. Its risk factors were also determined. RESULTS Among 443 identified patients, 55 cases (12.5%) developed organ/space SSIs; they more frequently experienced other complications and bile leakage (47.3% vs. 16.6%, p = 0.001; 40.0% vs. 8.5%, p < 0.001, respectively). Postoperative CRP elevation from postoperative day (POD) 3 to 5 was significantly more frequent in the SSI group (21.8% vs. 4.9%, p < 0.001). Multivariate analysis identified preoperative CRP ≥ 0.2 mg/dL (odds ratio (OR), 2.01, p = 0.044], preoperative cholangitis (OR, 15.7; p = 0.020), red cell concentrate (RCC) transfusion (OR, 2.61, p = 0.018), bile leakage (OR, 9.51; p < 0.001), and CRP level elevation from POD 3 to 5 (OR, 3.81, p = 0.008) as independent risk factors for organ/space SSIs. CONCLUSIONS Preoperative CRP elevation and postoperative CRP trajectory are risk factors for organ/space SSIs after liver resection. A prolonged CRP level elevation at POD 5 indicates its occurrence. If there were no risk factors and no CRP elevation at POD 5, its presence could be excluded.
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Affiliation(s)
- Satoshi Yasuda
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan.
| | - Daisuke Hokuto
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Naoki Kamitani
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Yasuko Matsuo
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Shunsuke Doi
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Kenji Nakagawa
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Satoshi Nishiwada
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Taichi Terai
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, 840 Shijo-Cho Kashihara-Shi, Nara, 634-8522, Japan
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Sugimoto M, Gotohda N, Kudo M, Kobayashi S, Takahashi S, Konishi M. Laparoscopic liver resection can be performed safely without intraoperative drain placement. Surg Endosc 2022; 36:9019-9031. [PMID: 35680665 DOI: 10.1007/s00464-022-09364-x] [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: 10/28/2021] [Accepted: 05/22/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Laparoscopic liver resection (LLR) has become a standardized procedure with advances in surgical techniques and perioperative management in the last decade; however, the necessity of routine drain placement in LLR has not been fully investigated. This study aimed to evaluate the need for intraoperative drain placement (IDP) in LLR. METHODS A total of 607 patients who underwent LLR for liver tumor at our institution between January 2015 and August 2021 were studied. Clinicopathological data, including intraoperative factors and postoperative outcomes, were compared between patients with and without IDP before and after propensity score matching. Variables shown to be different between the two groups were used for matching. Then, risk analysis for additional drainage procedure after surgery was performed in the original and matched cohorts. RESULTS Of the 607 patients, 4 (0.7%) and 14 (2.3%) developed incisional and organ/space surgical site infections, respectively, and 9 (1.5%) required additional drainage procedure after surgery. Ninety-three patients (15.3%) underwent IDP. The incidence and severity of postoperative complications were similar between patients with and without IDP in both the original and matched cohorts. In the matched cohort, simultaneous colectomy (odds ratio, 14.051, 95% confidence interval, 1.103-178.987; P = 0.042), rather than IDP (odds ratio, 1.836, 95% confidence interval, 0.157-21.509; P = 0.629), was independently associated with the risk of additional drainage procedure after surgery. CONCLUSIONS This study demonstrated that LLR could be performed safely without IDP.
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Affiliation(s)
- Motokazu Sugimoto
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwa-no-ha, Kashiwa, Chiba, 277-8577, Japan.
| | - Naoto Gotohda
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwa-no-ha, Kashiwa, Chiba, 277-8577, Japan
| | - Masashi Kudo
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwa-no-ha, Kashiwa, Chiba, 277-8577, Japan
| | - Shin Kobayashi
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwa-no-ha, Kashiwa, Chiba, 277-8577, Japan
| | - Shinichiro Takahashi
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwa-no-ha, Kashiwa, Chiba, 277-8577, Japan
| | - Masaru Konishi
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwa-no-ha, Kashiwa, Chiba, 277-8577, Japan
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7
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Noh BG, Park YM, Seo HI. Is left lateral sectionectomy of the liver without operative site drainage safe and effective? Ann Hepatobiliary Pancreat Surg 2022; 26:313-317. [PMID: 35995584 PMCID: PMC9721248 DOI: 10.14701/ahbps.22-026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 12/15/2022] Open
Abstract
Backgrounds/Aims Despite its limited benefits, operative site drainage after elective hepatectomy is routinely used. This study aimed to investigate the safety and effectiveness of left lateral sectionectomy without operative site drainage. Methods This study retrospectively collected data from 31 patients who underwent elective left lateral sectionectomy between January 2017 and June 2020. Based on whether operative site drainage was used, the patients were divided into two groups: drainage and non-drainage of the operative site and a comparative analysis was conducted. Results A total of 31 patients underwent left lateral sectionectomy during the study period. Of these, 22 patients were diagnosed with hepatocellular carcinoma; three, with intrahepatic cholangiocarcinoma; three, with liver metastasis; and three, with benign liver disease. Ten patients underwent laparoscopy. No significant differences were observed between the open and laparoscopic surgery groups. In the univariate analysis, there were no significant differences in the pre-, intra-, and postoperative clinicopathological factors between the non-drainage and drainage groups. The hospitalization period in the non-drainage group was significantly shorter than in the drainage group (8.44 days vs. 5.87 days, p < 0.05). In the operative site drainage non-use group, there were no cases of intraperitoneal fluid collection requiring additional procedures. Conclusions Routine use of surgical drainage for left lateral sectionectomy of the liver to prevent intraperitoneal fluid collection is unnecessary.
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Affiliation(s)
- Byeong Gwan Noh
- Department of Surgery, Biomedical Research Institute and Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Young Mok Park
- Department of Surgery, Biomedical Research Institute and Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Hyung-Il Seo
- Department of Surgery, Biomedical Research Institute and Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea,Corresponding author: Hyung-Il Seo, MD, PhD Department of Surgery, Biomedical Research Institute and Pusan National University Hospital, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan 49241, Korea Tel: +82-51-240-7238, Fax: +82-51-247-1365, E-mail: ORCID: https://orcid.org/0000-0002-4132-7662
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8
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Kalisvaart M, de Jonge J, Abt P, Orloff S, Muiesan P, Florman S, Spiro M, Raptis DA, Eghtesad B. The role of T-tubes and abdominal drains on short-term outcomes in liver transplantation - A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14719. [PMID: 35596705 PMCID: PMC10078006 DOI: 10.1111/ctr.14719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 04/20/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND This systematic review and expert panel recommendation aims to answer the question regarding the routine use of T-tubes or abdominal drains to better manage complications and thereby improve outcomes after liver transplantation. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel to assess the potential risks and benefits of T-tubes and intra-abdominal drainage in liver transplantation (CRD42021243036). RESULTS Of the 2996 screened records, 33 studies were included in the systematic review, of which 29 (six RCTs) assessed the use of T-tubes and four regarding surgical drains. Although some studies reported less strictures when using a T-tube, there was a trend toward more biliary complications with T-tubes, mainly related to biliary leakage. Due to the small number of studies, there was a paucity of evidence on the effect of abdominal drains with no clear benefit for or against the use of drainage. However, one study investigating the open vs. closed circuit drains found a significantly higher incidence of intra-abdominal infections when open-circuit drains were used. CONCLUSIONS Due to the potential risk of biliary leakage and infections, the routine intraoperative insertion of T-tubes is not recommended (Level of Evidence moderate - very low; grade of recommendation strong). However, a T-tube can be considered in cases at risk for biliary stenosis. Due to the scant evidence on abdominal drainage, no change in clinical practice in individual centers is recommended. (Level of Evidence very low; weak recommendation).
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Affiliation(s)
- Marit Kalisvaart
- Department of General Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Jeroen de Jonge
- Erasmus MC Transplant Institute, Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Peter Abt
- Department of Surgery, Division of Transplantation, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Susan Orloff
- Department of Surgery, Division of Abdominal Organ Transplantation/ Hepatobiliary Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Paolo Muiesan
- Policlinico di Milano Ospedale Maggiore
- Fondazione IRCCS Ca' Granda, Milan, Italy
| | - Sander Florman
- The Recanati Miller Transplantation Institute, Mount Sinai School of Medicine, New York, New York, USA
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Bijan Eghtesad
- Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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- Department of General Surgery & Transplantation, University Hospital Zurich, Zurich, Switzerland
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9
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Seshadri A, Appelbaum R, Carmichael SP, Cuschieri J, Hoth J, Kaups KL, Kodadek L, Kutcher ME, Pathak A, Rappold J, Rudnick SR, Michetti CP. Management of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open 2022; 7:e000936. [PMID: 35991906 PMCID: PMC9345092 DOI: 10.1136/tsaco-2022-000936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/20/2022] [Indexed: 11/04/2022] Open
Abstract
Management of decompensated cirrhosis (DC) can be challenging for the surgical intensivist. Management of DC is often complicated by ascites, coagulopathy, hepatic encephalopathy, gastrointestinal bleeding, hepatorenal syndrome, and difficulty assessing volume status. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews practical clinical questions about the critical care management of patients with DC to facilitate best practices by the bedside provider.
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Affiliation(s)
- Anupamaa Seshadri
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rachel Appelbaum
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Samuel P Carmichael
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Joseph Cuschieri
- Department of Surgery, San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Jason Hoth
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Krista L Kaups
- Department of Surgery, UCSF Fresno, Fresno, California, USA
| | - Lisa Kodadek
- Surgery, Yale University School of Medicine, New Haven, Connecticut, USA,Department of Surgery, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Matthew E Kutcher
- Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Abhijit Pathak
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joseph Rappold
- Department of Surgery, Maine Medical Center, Portland, Oregon, USA
| | - Sean R Rudnick
- Department of Gastroenterology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
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10
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Watanabe N, Mizuno T, Yamaguchi J, Yokoyama Y, Igami T, Onoe S, Uehara K, Sunagawa M, Ebata T. A proposal of drain removal criteria in hepatobiliary resection. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:974-982. [PMID: 35666607 DOI: 10.1002/jhbp.1194] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Standardized criteria for the drain removal in hepatobiliary resection are lacking. We evaluated the outcomes of delayed removal policy in this extended surgery. METHODS Patients undergoing hepatectomy with biliary reconstruction between 2012 and 2018 were retrospectively reviewed. The drains were removed on postoperative day (POD) 7 when the drainage fluid was grossly serous, biochemically normal, and negative for bacterial contamination as assessed by Gram staining; additionally, no abnormal fluid collection was confirmed by computed tomography. Clinically relevant abdominal complications (CRACs), including biliary leakage, pancreatic fistula or intra-abdominal abscess, served as the primary outcome measure. RESULTS Among 374 study patients, surgical drains were removed in 166 (44.3%) patients who met the criteria. Of these patients, 16 (9.6%) patients required additional drainage afterwards due to CRAC. Drains were retained and exchanged in 208 (55.6%) patients who did not meet the criteria. Of them, exchanged drains were soon removed in 34 patients due to no signs of CRAC. The diagnostic ability of the criteria revealed 0.916 sensitivity, 0.815 specificity, and 0.866 accuracy. CONCLUSION The four findings on POD 7 worked well as criteria for drain removal, and these criteria may be helpful in drain management after hepatobiliary resection.
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Affiliation(s)
- Nobuyuki Watanabe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Junpei Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shunsuke Onoe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kay Uehara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaki Sunagawa
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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11
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Liver drains after surgery: what is the real practice? An international snapshot from the Li.DR.A.S. survey. Updates Surg 2022; 74:1317-1326. [PMID: 35657558 DOI: 10.1007/s13304-022-01301-w] [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: 02/24/2022] [Accepted: 05/16/2022] [Indexed: 10/18/2022]
Abstract
Despite current evidence, the use of drains in liver surgery is still controversial. We conducted an international survey to investigate the clinical use of drains in the E-AHPBA, A-HPBA and A-PHPBA communities. An open survey of 30 questions was prepared on Google-Form and distributed by email to all members. One hundred and ninety-one HPB surgeons responded to the survey. One hundred and twelve surgeons (58.6%) reported routine use of abdominal drains after liver resections. Eighty-eight (46.1%) responded that removal was driven by low volume and low bilirubin levels in the drains. For minor liver resection, 97 (50.8%) surgeons reported using drains selectively; in contrast, 134 (70.2%) surgeons prefer to use a drain always after major procedures. Among patients with cirrhosis, 87 (45.5%) surgeons reported routine drains placement, while 84 (44.0%) considered drains selectively. A no-drain policy was most prevalent among surgeons from North America (80%) versus Asian-Pacific (70.0%), European and African (60.8%), and South American (61.5%) surgeons. Among minimally invasive surgeons, 74.2% reported drain use only in selected cases versus 35.0% among surgeons who performed open surgery. The practice of draining after liver surgery is still highly variable among centers and surgeons around the world, with a high variability according to the underlying liver condition and planned surgical approach.
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12
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Su J, Deng C, Yin HM. Drain-site hernia after laparoscopic rectal resection: A case report and review of literature. World J Clin Cases 2022; 10:2637-2643. [PMID: 35434063 PMCID: PMC8968592 DOI: 10.12998/wjcc.v10.i8.2637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/27/2021] [Accepted: 02/10/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Drain-site hernia (DSH) has an extremely low morbidity and has rarely been reported. Small bowel obstruction is a frequent concurrent condition in most cases of DSH, which commonly occurs at the ≥ 10 mm drain-site. Here we report a rare case of DSH at the lateral 5 mm port site one month postoperatively without visceral incarceration. Simultaneously, a brief review of the literature was conducted focusing on the risk factors, diagnosis, and prevention strategies for DSH.
CASE SUMMARY A 76-year-old male patient was admitted to our institution with intermittent abdominal pain and a local abdominal mass which occurred one month after laparoscopic radical resection of rectal cancer one year ago. A computed tomography scan showed an abdominal wall hernia at the 5 mm former drain-site in the left lower quadrant, and that the content consisted of the large omentum. An elective herniorrhaphy was performed by closing the fascial defect and reinforcing the abdominal wall with a synthetic mesh simultaneously. The postoperative period was uneventful. The patient was discharged seven days after the operation without surgery-related complications at the 1-mo follow-up visit.
CONCLUSION Emphasis should be placed on DSH despite the decreased use of intra-abdominal drainage. It is recommended that placement of a surgical drainage tube at the ≥ 10 mm trocar site should be avoided. Moreover, it is advisable to have a comprehensive understanding of the risk factors for DSH and complete closure of the fascial defect at the drainage site for high-risk patients.
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Affiliation(s)
- Jin Su
- Department of General Surgery, Zhuzhou Central Hospital, The Affiliated Zhuzhou Hospital of Xiangya Medical College of Central South University, Zhuzhou 412000, Hunan Province, China
| | - Cheng Deng
- Division of Science and Education, Zhuzhou Central Hospital, The Affiliated Zhuzhou Hospital of Xiangya Medical College of Central South University, Zhuzhou 412000, Hunan Province, China
| | - Hui-Ming Yin
- Department of General Surgery, the Second Affiliated Hospital of Hunan University of Traditional Chinese Medicine, Changsha 410000, Hunan Province, China
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13
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Kaibori M, Matsui K, Shimada M, Kubo S, Hasegawa K. Update on perioperative management of patients undergoing surgery for liver cancer. Ann Gastroenterol Surg 2021; 6:344-354. [PMID: 35634181 PMCID: PMC9130899 DOI: 10.1002/ags3.12529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 11/12/2022] Open
Abstract
Hepatocellular carcinoma is often accompanied by chronic hepatitis or cirrhosis. Preoperative evaluation of liver function and postoperative nutritional management are critical in patients with hepatocellular carcinoma who undergo liver surgery. Although the incidence of postoperative complications and death has declined in Japan over the last 10 years, postoperative complications have not been fully overcome. Therefore, surgical procedures and perioperative management must be improved. Accurate preoperative evaluations of liver function, nutrition, inflammation, and body skeletal muscle are required. Determination of the optimal surgical procedure should consider not only tumor characteristics but also the physical reserve of the patient. Nutritional management of chronic liver disorders, especially maintaining protein synthesis for postoperative protein/energy, is important. Prophylactic antibiotics are recommended for short‐term use within 24 hours after surgery. Abdominal drainage is recommended for patients with cirrhosis who may develop large amounts of ascites, who are at risk of postoperative bleeding, or who may have bile leakage due to a large resection area. Postoperative exercise therapy may improve insulin resistance in patients with chronic liver damage. Implementation of an early/enhanced recovery after surgery program is recommended to reduce biological invasive responses and achieve early independence of physical activity and nutrition intake. We review the latest information on the perioperative management of patients undergoing liver resection for hepatocellular carcinoma.
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Affiliation(s)
- Masaki Kaibori
- Department of Surgery Kansai Medical University Osaka Japan
| | - Kosuke Matsui
- Department of Surgery Kansai Medical University Osaka Japan
| | - Mitsuo Shimada
- Department of Surgery Tokushima University Tokushima Japan
| | - Shoji Kubo
- Department of Hepato‐Biliary‐Pancreatic Surgery Osaka City University Graduate School of Medicine Osaka Japan
| | - Kiyoshi Hasegawa
- Hepato‐Biliary‐Pancreatic Surgery Division Department of Surgery Graduate School of Medicine The University of Tokyo Tokyo Japan
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14
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Onda S, Furukawa K, Yanagaki M, Igarashi Y, Shiba H, Ikegami T. How to Manage Drains in Major Hepatectomy in the Recent Era. J Gastrointest Surg 2021; 25:2433-2434. [PMID: 34255292 DOI: 10.1007/s11605-021-05077-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 06/19/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Shinji Onda
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Mitsuru Yanagaki
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yosuke Igarashi
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroaki Shiba
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
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15
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Vincenzi P, Gaynor JJ, Chen LJ, Figueiro J, Morsi M, Selvaggi G, Tekin A, Vianna R, Ciancio G. No Benefit of Prophylactic Surgical Drainage in Combined Liver and Kidney Transplantation: Our Experience and Review of the Literature. Front Surg 2021; 8:690436. [PMID: 34322515 PMCID: PMC8311022 DOI: 10.3389/fsurg.2021.690436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/08/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Contrasting results have emerged from limited studies investigating the role of prophylactic surgical drainage in preventing wound morbidity after liver and kidney transplantation. This retrospective study analyzes the use of surgical drain and the incidence of wound complications in combined liver and kidney transplantation (CLKTx). Methods: A total of 55 patients aged ≥18 years were divided into two groups: the drain group (D) (n = 35) and the drain-free group (DF) (n = 20). Discretion to place a drain was based exclusively on surgeon preference. All deceased donor kidneys were connected to the LifePort Renal Preservation Machine® prior to transplantation, in both simultaneous and delayed technique of implantation of the renal allograft. The primary outcome was the development of superficial/deep wound complications during the study follow-up. Secondary outcomes included the development of delayed graft function (DGF) of the transplanted kidney, primary non-function (PNF) and early allograft dysfunction (EAD) of the transplanted liver, graft failure, graft and patient survival, overall post-operative morbidity rate and length of hospital stay. Results: With a median follow-up of 14.4 months after transplant, no difference in the incidence of superficial/deep wound complications, except for hematomas, in collections size, intervention rate, PNF, EAD, graft failure and patient survival, was observed between the 2 groups. Significantly lower level of platelets, higher INR values, DGF, morbidity rates and length of hospital stay were reported post-operatively in the D group. Pre-operative hypoalbuminemia and longer CIT were included in the propensity score for receiving a drain and were associated with a significantly higher rate of developing a hematoma post-transplant. Conclusions: Absence of the surgical drain did not appear to adversely affect wound morbidity compared to the prophylactic use of drains in renal transplant patients during CLKTx.
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Affiliation(s)
- Paolo Vincenzi
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States.,Division of Liver and Intestinal Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Jeffrey J Gaynor
- Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Linda J Chen
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Jose Figueiro
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Mahmoud Morsi
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States.,Division of Liver and Intestinal Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Gennaro Selvaggi
- Division of Liver and Intestinal Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Akin Tekin
- Division of Liver and Intestinal Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Rodrigo Vianna
- Division of Liver and Intestinal Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Gaetano Ciancio
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States.,Department of Urology, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
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16
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Liu X, Chen K, Chu X, Liu G, Yang Y, Tian X. Prophylactic Intra-Peritoneal Drainage After Pancreatic Resection: An Updated Meta-Analysis. Front Oncol 2021; 11:658829. [PMID: 34094952 PMCID: PMC8172774 DOI: 10.3389/fonc.2021.658829] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/28/2021] [Indexed: 12/19/2022] Open
Abstract
Introduction Prophylactic intra-peritoneal drainage has been considered to be an effective measure to reduce postoperative complications after pancreatectomy. However, routinely placed drainage during abdominal surgery may be unnecessary or even harmful to some patients, due to the possibility of increasing complications. And there is still controversy about the prophylactic intra-peritoneal drainage after pancreatectomy. This meta-analysis aimed to analyze the incidence of complications after either pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) in the drain group and no-drain group. Methods Data were retrieved from four electronic databases PubMed, EMBASE, the Cochrane Library and Web of Science up to December 2020, including the outcomes of individual treatment after PD and DP, mortality, morbidity, clinically relevant postoperative pancreatic fistula (CR-POPF), bile leak, wound infection, postoperative hemorrhage, delayed gastric emptying (DGE), intra-abdominal abscess, reoperation, intervened radiology (IR), and readmission. Cochrane Collaboration Handbook and the criteria of the Newcastle-Ottawa scale were used to assess the quality of studies included. Results We included 15 studies after strict screening. 13 studies with 16,648 patients were analyzed to assess the effect of drain placement on patients with different surgery procedures, and 4 studies with 6,990 patients were analyzed to assess the effect of drain placement on patients with different fistula risk. For patients undergoing PD, the drain group had lower mortality but higher rate of CR-POPF than the no-drain group. For patients undergoing DP, the drain group had higher rates of CR-POPF, wound infection and readmission. There were no significant differences in bile leak, hemorrhage, DGE, intra-abdominal abscess, and IR in either overall or each subgroup. For Low-risk subgroup, the rates of hemorrhage, DGE and morbidity were higher after drainage. For High-risk subgroup, the rate of hemorrhage was higher while the rates of reoperation and morbidity were lower in the drain group. Conclusions Intraperitoneal drainage may benefit some patients undergoing PD, especially those with high pancreatic fistula risk. For DP, current evidences suggest that routine drainage might not benefit patients, but no clear conclusions can be drawn because of the study limitations.
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Affiliation(s)
- Xinxin Liu
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Kai Chen
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Xiangyu Chu
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Guangnian Liu
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Yinmo Yang
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Xiaodong Tian
- Department of General Surgery, Peking University First Hospital, Beijing, China
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17
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Predictors of complications after liver surgery: a systematic review of the literature. HPB (Oxford) 2021; 23:645-655. [PMID: 33485797 DOI: 10.1016/j.hpb.2020.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/21/2020] [Accepted: 12/11/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Numerous potential predictors of adverse outcomes have been reported but their performance and utilization in practice seem heterogenous. This study aimed to systematically review the literature on the role and value of predictors of complications after hepatectomy. METHODS A systematic review following the PRISMA guidelines was performed. Studies on liver transplant were excluded. Only studies assessing overall or major complications were included. RESULTS A total of 10'965 abstracts were screened. After application of exclusion criteria, 72 articles including 68'480 patients were included. A total of 72 markers with 48 pre-, 9 intra- and 15 postoperative factors were identified as predictors of complications. Preoperative and intraoperative predictive markers retrieved several times with the highest odds ratios (OR) were ASA score (OR range: 1.3-7.5, significant in 8 studies) and intraoperative need for red blood cell transfusion (OR range: 1.2-17.1, significant in 24 studies), respectively. CONCLUSION Numerous markers have been described to predict the complication risk after hepatectomy. Because of their intrinsic characteristics, most markers such as ASA score and need for red blood cell transfusion are of limited clinical interest. There is a clear need to identify new biomarkers and to develop scores that could easily be implemented in clinical practice.
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18
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Tzedakis S, Fuks D. A Japanese multi-institutional randomized controlled trial (ND-Trial). Hepatobiliary Surg Nutr 2021; 10:226-228. [PMID: 33898562 DOI: 10.21037/hbsn-21-57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Stylianos Tzedakis
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France.,University of Paris, Paris, France
| | - David Fuks
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France.,University of Paris, Paris, France
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19
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Drain Placement After Uncomplicated Hepatic Resection Increases Severe Postoperative Complication Rate: A Japanese Multi-institutional Randomized Controlled Trial (ND-trial). Ann Surg 2021; 273:224-231. [PMID: 33064385 DOI: 10.1097/sla.0000000000004051] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the clinical impact of a no-drain policy after hepatic resection. SUMMARY OF BACKGROUND DATA Previous randomized controlled trials addressing no-drain policy after hepatic resection seem inconclusive because they did not adopt appropriate study design to validate its true clinical impact. METHODS This unblinded, randomized controlled trial was done at 7 Japanese institutions. Patients undergoing hepatic resection without biliary reconstruction were randomized to either D group or ND group. When the risk of postoperative bile leakage or hemorrhage were considered high, the patients were excluded during the operation. Primary endpoint was the postoperative complication of C-D grade 3 or higher within 90 postoperative days. A noninferiority of ND group to D group was assessed, and if it was confirmed, a superiority was assessed. RESULTS Between May 2015 and July 2017, a total of 400 patients were finally included in the per-protocol set analysis: 199 patients in D group and 201 patients in ND group. Intraoperatively, 37 patients were excluded from the final enrollment because of high risk of bile leakage or hemorrhage. Postoperative complication rate of C-D grade 3 or higher was 8.0% (16/199) in the D group and 2.5% (5/201) in the ND group. The risk difference was -5.5% (95% confidence interval: -9.9% to -1.2%) and fulfilled the prescribed noninferiority margin of 4%. No postoperative mortality was experienced in both groups. Bile leakage was diagnosed in 8.0% (16/199) of the D group and none in the ND group (P < 0.001). In none of the subgroups classified based on 8 potentially relevant factors, drain placement was favored in terms of C-D grade 3 or higher complication. CONCLUSIONS Drains should not be placed after uncomplicated hepatic resections.
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20
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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.
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21
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Dezfouli SA, Ünal UK, Ghamarnejad O, Khajeh E, Ali-Hasan-Al-Saegh S, Ramouz A, Salehpour R, Golriz M, Chang DH, Mieth M, Hoffmann K, Probst P, Mehrabi A. Systematic review and meta-analysis of the efficacy of prophylactic abdominal drainage in major liver resections. Sci Rep 2021; 11:3095. [PMID: 33542274 PMCID: PMC7862226 DOI: 10.1038/s41598-021-82333-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/15/2021] [Indexed: 12/18/2022] Open
Abstract
Prophylactic drainage after major liver resection remains controversial. This systematic review and meta-analysis evaluate the value of prophylactic drainage after major liver resection. PubMed, Web of Science, and Cochrane Central were searched. Postoperative bile leak, bleeding, interventional drainage, wound infection, total complications, and length of hospital stay were the outcomes of interest. Dichotomous outcomes were presented as odds ratios (OR) and for continuous outcomes, weighted mean differences (MDs) were computed by the inverse variance method. Summary effect measures are presented together with their corresponding 95% confidence intervals (CI). The certainty of evidence was evaluated using the Grades of Research, Assessment, Development and Evaluation (GRADE) approach, which was mostly moderate for evaluated outcomes. Three randomized controlled trials and five non-randomized trials including 5,050 patients were included. Bile leakage rate was higher in the drain group (OR: 2.32; 95% CI 1.18-4.55; p = 0.01) and interventional drains were inserted more frequently in this group (OR: 1.53; 95% CI 1.11-2.10; p = 0.009). Total complications were higher (OR: 1.71; 95% CI 1.45-2.03; p < 0.001) and length of hospital stay was longer (MD: 1.01 days; 95% CI 0.47-1.56 days; p < 0.001) in the drain group. The use of prophylactic drainage showed no beneficial effects after major liver resection; however, the definitions and classifications used to report on postoperative complications and surgical complexity are heterogeneous among the published studies. Further well-designed RCTs with large sample sizes are required to conclusively determine the effects of drainage after major liver resection.
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Affiliation(s)
- Sepehr Abbasi Dezfouli
- Head of the Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Umut Kaan Ünal
- Head of the Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Omid Ghamarnejad
- Head of the Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Elias Khajeh
- Head of the Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Sadeq Ali-Hasan-Al-Saegh
- Head of the Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Ali Ramouz
- Head of the Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Roozbeh Salehpour
- Head of the Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Mohammad Golriz
- Head of the Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - De-Hua Chang
- Department of Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany
| | - Markus Mieth
- Head of the Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Katrin Hoffmann
- Head of the Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
- Liver Cancer Center Heidelberg (LCCH), Heidelberg, Germany
| | - Pascal Probst
- Head of the Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Arianeb Mehrabi
- Head of the Division of Liver Surgery and Visceral Transplantation, Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
- Liver Cancer Center Heidelberg (LCCH), Heidelberg, Germany.
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22
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Hobeika C, Cauchy F, Weiss E, Chopinet S, Sepulveda A, Dondero F, Khoy-Ear L, Grigoresco B, Dokmak S, Durand F, Le Roy B, Paugam-Burtz C, Soubrane O. Practical model to identify liver transplant recipients at low risk of postoperative haemorrhage, bile leakage and ascites. BJS Open 2021; 5:6073666. [PMID: 33609380 PMCID: PMC7893463 DOI: 10.1093/bjsopen/zraa031] [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: 07/21/2020] [Revised: 09/22/2020] [Accepted: 09/28/2020] [Indexed: 12/13/2022] Open
Abstract
Background This study aimed to identify a subgroup of recipients at low risk of haemorrhage, bile leakage and ascites following liver transplantation (LT). Methods Factors associated with significant postoperative ascites (more than 10 ml/kg on postoperative day 5), bile leakage and haemorrhage after LT were identified using three separate multivariable analyses in patients who had LT in 2010–2019. A model predicting the absence of all three outcomes was created and validated internally using bootstrap procedure. Results Overall, 944 recipients underwent LT. Rates of ascites, bile leakage and haemorrhage were 34.9, 7.7 and 6.0 per cent respectively. The 90-day mortality rate was 7.0 per cent. Partial liver graft (relative risk (RR) 1.31; P = 0.021), intraoperative ascites (more than 10 ml/kg suctioned after laparotomy) (RR 2.05; P = 0.001), malnutrition (RR 1.27; P = 0.006), portal vein thrombosis (RR 1.56; P = 0.024) and intraoperative blood loss greater than 1000 ml (RR 1.39; P = 0.003) were independently associated with postoperative ascites and/or bile leak and/or haemorrhage, and were introduced in the model. The model was well calibrated and predicted the absence of all three outcomes with an area under the curve of 0.76 (P = 0.001). Of the 944 patients, 218 (23.1 per cent) fulfilled the five criteria of the model, and 9.6 per cent experienced postoperative ascites (RR 0.22; P = 0.001), 1.8 per cent haemorrhage (RR 0.21; P = 0.033), 4.1 per cent bile leak (RR 0.54; P = 0.048), 40.4 per cent severe complications (RR 0.70; P = 0.001) and 1.4 per cent 90-day mortality (RR 0.13; P = 0.004). Conclusion A practical model has been provided to identify patients at low risk of ascites, bile leakage and haemorrhage after LT; these patients could potentially qualify for inclusion in non-abdominal drainage protocols.
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Affiliation(s)
- C Hobeika
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris and Université de Paris, Clichy, France
| | - F Cauchy
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris and Université de Paris, Clichy, France
| | - E Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris and Université de Paris, Clichy, France
| | - S Chopinet
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris and Université de Paris, Clichy, France
| | - A Sepulveda
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris and Université de Paris, Clichy, France
| | - F Dondero
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris and Université de Paris, Clichy, France
| | - L Khoy-Ear
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris and Université de Paris, Clichy, France
| | - B Grigoresco
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris and Université de Paris, Clichy, France
| | - S Dokmak
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris and Université de Paris, Clichy, France
| | - F Durand
- Department of Hepatology, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris and Université de Paris, Clichy, France
| | - B Le Roy
- Department of Digestive and Oncological Surgery, Centre Hospitalier Universitaire Nord Saint-Etienne, Saint-Priest en Jarez, France
| | - C Paugam-Burtz
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris and Université de Paris, Clichy, France
| | - O Soubrane
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris and Université de Paris, Clichy, France
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Veziant J, Selvy M, Buc E, Slim K. Evidence-based evaluation of abdominal drainage in pancreatic surgery. J Visc Surg 2021; 158:220-230. [PMID: 33358121 DOI: 10.1016/j.jviscsurg.2020.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pancreatic fistula is the most common and dreaded complication after pancreatic resection, responsible for high morbidity and mortality (2 to 30%). Prophylactic drainage of the operative site is usually put in place to decrease and/or detect postoperative pancreatic fistula (POPF) early. However, this policy is currently debated and the data from the literature are unclear. The goal of this update is to analyze the most recent evidence-based data with regard to prophylactic abdominal drainage after pancreatic resection (pancreatoduodenectomy [PD] or distal pancreatectomy [PD]). This systematic review of the literature between 1990 and 2020 sought to answer the following questions: should drainage of the operative site after pancreatectomy be routine or adapted to the risk of POPF? If a drainage is used, how long should it remain in the abdomen, what criteria should be used to decide to remove it, and what type of drainage should be preferred? Has the introduction of laparoscopy changed our practice? The literature seems to indicate that it is not possible to recommend the omission of routine drainage after pancreatic resection. By contrast, an approach based on the risk of POPF using the fistula risk score seems beneficial. When a drain is placed, early removal (within 5 days) seems feasible based on clinical, laboratory (C-reactive protein, leukocyte count, neutrophile/lymphocyte ratio, dosage and dynamic of amylase in the drains on D1, D3±D5) and radiological findings. This is in line with the development of enhanced recovery programs after pancreatic surgery. Finally, this literature review did not find any specific data relative to mini-invasive pancreatic surgery.
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Affiliation(s)
- J Veziant
- Department of digestive and hepato-biliary surgery, university hospital center of Clermont-Ferrand, Clermont-Ferrand, France.
| | - M Selvy
- Department of digestive and hepato-biliary surgery, university hospital center of Clermont-Ferrand, Clermont-Ferrand, France
| | - E Buc
- Department of digestive and hepato-biliary surgery, university hospital center of Clermont-Ferrand, Clermont-Ferrand, France
| | - K Slim
- Department of digestive and hepato-biliary surgery, university hospital center of Clermont-Ferrand, Clermont-Ferrand, France; Groupe francophone de réhabilitation améliorée après chirurgie (GRACE), Beaumont, France
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Ohge H, Mayumi T, Haji S, Kitagawa Y, Kobayashi M, Kobayashi M, Mizuguchi T, Mohri Y, Sakamoto F, Shimizu J, Suzuki K, Uchino M, Yamashita C, Yoshida M, Hirata K, Sumiyama Y, Kusachi S. The Japan Society for Surgical Infection: guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018. Surg Today 2021; 51:1-31. [PMID: 33320283 PMCID: PMC7788056 DOI: 10.1007/s00595-020-02181-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide. METHODS We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies. RESULTS There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese. CONCLUSIONS The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients.
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Affiliation(s)
- Hiroki Ohge
- Department of Infectious Diseases, Hiroshima University Hospital, Hiroshima, Japan.
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Seiji Haji
- Department of Surgery, Soseikai General Hospital, Kyoto, Japan
| | - Yuichi Kitagawa
- Department of Infection Control, National Center for Geriatrics and Gerontology, Aichi, Japan
| | - Masahiro Kobayashi
- Laboratory of Clinical Pharmacokinetics, School of Pharmacy, Kitasato University, Tokyo, Japan
| | - Motomu Kobayashi
- Perioperative Management Center, Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | - Toru Mizuguchi
- Division of Surgical Science, Department of Nursing, Sapporo Medical University, Sapporo, Japan
| | - Yasuhiko Mohri
- Department of Surgery, Mie Prefectural General Medical Center, Mie, Japan
| | - Fumie Sakamoto
- Infection Control Division, Quality Improvement Center, St. Luke's International Hospital, Tokyo, Japan
| | - Junzo Shimizu
- Department of Surgery, Toyonaka Municipal Hospital, Osaka, Japan
| | - Katsunori Suzuki
- Division of Infection Control and Prevention, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Motoi Uchino
- Division of Inflammatory Bowel Disease Surgery, Department of Gastroenterological Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Chizuru Yamashita
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Aichi, Japan
| | - Masahiro Yoshida
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare, School of Medicine, Chiba, Japan
| | | | | | - Shinya Kusachi
- Department of Surgery, Tohokamagaya Hospital, Chiba, Japan
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Ellis RJ, Brajcich BC, Ko CY, Cohen ME, Bilimoria KY, Yopp AC, D’Angelica MI, Merkow RP. Hospital variation in use of prophylactic drains following hepatectomy. HPB (Oxford) 2020; 22:1471-1479. [PMID: 32173175 PMCID: PMC8385641 DOI: 10.1016/j.hpb.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/12/2020] [Accepted: 02/14/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prophylactic drainage following hepatectomy is frequently performed despite evidence that drainage is unnecessary. It is unknown to what extent drain use is influenced by hospital practice patterns. The objectives of this study were to identify factors associated with the use of prophylactic drains following hepatectomy and assess hospital variation in drain use. METHODS Retrospective cohort study of patients following hepatectomy without concomitant bowel resection or biliary reconstruction from the ACS NSQIP Hepatectomy Targeted Dataset. Factors associated with the use of prophylactic drains were identified using multivariable logistic regression and hospital-level variation in drain use was assessed. RESULTS Analysis included 10,530 patients at 130 hospitals. Overall, 42.3% of patients had a prophylactic drain placed following hepatectomy. Patients were more likely to receive prophylactic drains if they were ≥65 years old (adjusted odds ratio [aOR]: 1.34, 95%CI: 1.16-1.56), underwent major hepatectomy (aOR: 1.42, 95%CI 1.15-1.74), or had an open resection (aOR 1.94, 95%CI 1.49-2.53). There was notable hospital variability in drain use (range: 0%-100% of patients), and 77.5% of measured variation was at the hospital level. CONCLUSION Prophylactic drains are commonly placed in both major and minor hepatectomy. Hospital-specific patterns appear to be a major driver and represent a target for improvement.
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Affiliation(s)
- Ryan J. Ellis
- American College of Surgeons, Chicago, IL,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Brian C. Brajcich
- American College of Surgeons, Chicago, IL,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Clifford Y. Ko
- American College of Surgeons, Chicago, IL,Department of Surgery, University of Chicago Medicine, Chicago, IL,Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
| | | | - Karl Y. Bilimoria
- American College of Surgeons, Chicago, IL,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Adam C. Yopp
- Department of Surgery, Division of Surgical Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael I. D’Angelica
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ryan P. Merkow
- American College of Surgeons, Chicago, IL,Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
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26
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Early drain removal after hepatectomy: an underutilized management strategy. HPB (Oxford) 2020; 22:1463-1470. [PMID: 32220515 DOI: 10.1016/j.hpb.2020.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 03/01/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent data suggest that routine drainage is unnecessary in patients undergoing hepatectomy, but many surgeons continue to utilize drains. We compared the outcomes of patients undergoing early versus routine drain removal after hepatectomy. METHODS Patients having drains placed during major (≥3 segments) or partial hepatectomy (≤2 segments) were identified in the 2014-16 ACS-NSQIP database. Propensity matching between early (POD 0-3) and routine (POD 4-7) drain removal and multivariable regressions were performed. RESULTS Early drain removal was performed in 661 (40%) of patients undergoing a partial hepatectomy and 211 (22%) of major hepatectomy patients. After matching, 719 early and 719 routine drain removal patients were compared. Early drain removal patients had lower overall (12 vs 19%, p < 0.001) and serious (9 vs 13%, p < 0.03) morbidity as well as fewer bile leaks (2.1% vs 5.0%, p < 0.003). Length of stay was two days shorter (4 vs 6 days, p < 0.01) and readmissions were less frequent (5.4 vs 8.1%, p = 0.02) for patients undergoing early drain removal. CONCLUSION Early drain removal is associated with fewer overall and serious complications, shorter length of stay and fewer readmissions. Early drain removal after hepatectomy is an underutilized management strategy.
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27
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Kono Y, Ishizawa T, Kokudo N, Kuriki Y, Iwatate RJ, Kamiya M, Urano Y, Kumagai A, Kurokawa H, Miyawaki A, Hasegawa K. On-Site Monitoring of Postoperative Bile Leakage Using Bilirubin-Inducible Fluorescent Protein. World J Surg 2020; 44:4245-4253. [PMID: 32909125 PMCID: PMC7599156 DOI: 10.1007/s00268-020-05774-x] [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] [Accepted: 08/28/2020] [Indexed: 11/25/2022]
Abstract
Background Bile leakage is the most common postoperative complication associated with hepatobiliary and pancreatic surgery. Until now, however, a rapid, accurate diagnostic method for monitoring intraoperative and postoperative bile leakage had not been established. Method Bilirubin levels in drained abdominal fluids collected from 23 patients who had undergone hepatectomy (n = 22) or liver transplantation (n = 1) were measured using a microplate reader with excitation/emission wavelengths of 497/527 nm after applying 5 µM of UnaG to the samples. UnaG was also sprayed directly on hepatic raw surfaces in swine hepatectomy models to identify bile leaks by fluorescence imaging. Results The bilirubin levels measured by UnaG fluorescence imaging showed favorable correlations with the results of the conventional light-absorptiometric methods (indirect bilirubin: rs = 0.939, p < 0.001; direct bilirubin: rs = 0.929, p < 0.001). Approximate time required for bilirubin measurements with UnaG was 15 min, whereas it took about 40 min with the conventional method at a hospital laboratory. Following administration of UnaG on hepatic surfaces, the fluorescence imaging identified bile leaks not only on the resected specimens but also in the abdominal cavity of the swine hepatectomy models. Conclusion Fluorescence imaging techniques using UnaG may enable real-time identification of bile leaks during hepatectomy and on-site rapid diagnosis of bile leaks after surgery. Electronic supplementary material The online version of this article (10.1007/s00268-020-05774-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yoshiharu Kono
- Hepatobiliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo, 113-8655, Japan
| | - Takeaki Ishizawa
- Hepatobiliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo, 113-8655, Japan.,Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Norihiro Kokudo
- Hepatobiliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo, 113-8655, Japan
| | - Yugo Kuriki
- Laboratory of Chemistry and Biology, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Ryu J Iwatate
- Laboratory of Chemical Biology and Molecular Imaging, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mako Kamiya
- Laboratory of Chemical Biology and Molecular Imaging, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Japan Science and Technology Agency, PRESTO, Saitama, Japan
| | - Yasuteru Urano
- Laboratory of Chemistry and Biology, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan.,Laboratory of Chemical Biology and Molecular Imaging, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Japan Agency for Medical Research and Development, CREST, Tokyo, Japan
| | - Akiko Kumagai
- Laboratory for Cell Function Dynamics, RIKEN Centre for Brain Science, 2-1 Hirosawa, Wako, Saitama, 351-0198, Japan
| | - Hiroshi Kurokawa
- Laboratory for Cell Function Dynamics, RIKEN Centre for Brain Science, 2-1 Hirosawa, Wako, Saitama, 351-0198, Japan
| | - Atsushi Miyawaki
- Laboratory for Cell Function Dynamics, RIKEN Centre for Brain Science, 2-1 Hirosawa, Wako, Saitama, 351-0198, Japan.
| | - Kiyoshi Hasegawa
- Hepatobiliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo, Tokyo, 113-8655, Japan.
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28
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Yee EJ, Al-Temimi MH, Flick KF, Kilbane EM, Nguyen TK, Zyromski NJ, Schmidt CM, Nakeeb A, House MG, Ceppa EP. Use of primary surgical drains in synchronous resection for colorectal liver metastases: a NSQIP analysis of current practice paradigm. Surg Endosc 2020; 35:4275-4284. [PMID: 32875421 DOI: 10.1007/s00464-020-07917-6] [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: 06/07/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND There are no studies examining the use of subhepatic drains after simultaneous resection of synchronous colorectal liver metastases (sCRLM). This study aimed to (1) describe the current practices regarding primary drain placement, (2) evaluate drain efficacy in mitigating postoperative complications, and (3) determine impact of drain maintenance duration on patient outcomes. METHODS The ACS-NSQIP targeted data from 2014 to 2017 were analyzed. Propensity score of surgical drain versus no drain cohorts was performed. Main study outcomes were mortality, major morbidity, organ/space surgical site infection (SSI), secondary drain/aspiration procedure, and any septic events. Additional univariate/multivariate logistic analyses were performed to identify associations with drain placement and duration. Major hepatectomy was defined as formal right hepatectomy and any trisectionectomy. RESULTS 584 combined liver and colorectal resection (CRR) cases were identified. Open partial hepatectomy with colectomy was the most common procedure (70%, n = 407). Nearly 40% of patients received surgical drains (n = 226). Major hepatectomy, lower serum albumin, and no intraoperative portal vein occlusion (Pringle maneuver) were significantly associated with drain placement (p < 0.05). In the matched cohort (n = 190 in each arm), patients with surgical drains experienced higher rates of major morbidity (30% vs 12%), organ/space SSI (16% vs 6%), postoperative drain/aspiration procedures (9% vs 3%), and sepsis/septic shock (12% vs 4%) (all p < 0.05). Patients with severely prolonged drain removal, defined as after postoperative day 13 (POD13), had higher risk of postoperative morbidity compared to those with earlier drain removal (p < 0.01). 30-day mortality rate was not significantly different between the two groups. CONCLUSION Primary surgical drains were placed in a substantial percentage of patients undergoing combined resection for sCRLM. This case-matched analysis suggested that surgical drains are associated with an increase in postoperative morbidity. Postoperative drain maintenance past 13 days is associated with worse outcomes compared to earlier removal.
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Affiliation(s)
- Elliott J Yee
- Division of Surgical Oncology, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mohammed H Al-Temimi
- Division of Surgical Oncology, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Katelyn F Flick
- Division of Surgical Oncology, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Trang K Nguyen
- Division of Surgical Oncology, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas J Zyromski
- Division of Surgical Oncology, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - C Max Schmidt
- Division of Surgical Oncology, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Attila Nakeeb
- Division of Surgical Oncology, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael G House
- Division of Surgical Oncology, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eugene P Ceppa
- Division of Surgical Oncology, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA. .,Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA.
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Clinical impact of intraoperative bile leakage during laparoscopic liver resection. Surg Endosc 2020; 35:4134-4142. [PMID: 32780232 DOI: 10.1007/s00464-020-07880-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 08/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite the increasing number of laparoscopic liver resection (LLR) procedures, postoperative bile leakage (POBL) remains a major complication. We occasionally experienced intraoperative bile leakage (IOBL) during LLR and managed it within the restrictions of laparoscopic surgery. However, there have been no reports about IOBL in LLR. We therefore investigated the impact of IOBL on postoperative outcomes and its predictive factors. METHODS We reviewed 137 patients who underwent LLR from April 2016 to March 2019 at our institute and assigned them to IOBL-positive or IOBL-negative groups. We compared clinicopathological characteristics and perioperative outcomes. Patients were further divided into four groups according to IOBL pattern, and the frequency of POBL in each was calculated. Predictors of IOBL were identified using multivariate logistic regression analysis. RESULTS There were 30 and 107 patients in the IOBL-positive and IOBL-negative groups, respectively. In the IOBL-positive group, operative time and postoperative hospital stays were significantly longer (P < 0.001). The frequency of POBL was significantly higher in the IOBL-positive group (P = 0.006). The IOBL-positive group was divided into two subgroups: IOBL from the transected parenchyma (IOBL-TP, n = 18) and from the main Glissonean pedicle (IOBL-mGP, n = 12). The IOBL-negative group was divided into two subgroups: bile staining in the mGP (BS-mGP, n = 9) and no change (NC, n = 98). POBL occurred in 11% (n = 2/18) of patients with IOBL-TP, 25% (n = 3/12) of those with IOBL-mGP, 11% (n = 1/9) of those with BS-mGP, and 1% (n = 1/98) of those with NC. Age, diabetes mellitus, indocyanine green retention rate, and Glissonean approach were predictors of IOBL (P < 0.05). CONCLUSIONS IOBL was relatively common during LLR and resulted in a higher incidence of POBL. Depending on the predictive factors, IOBL must be promptly identified and appropriately managed.
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Taniguchi K, Matsuyama R, Yabushita Y, Homma Y, Ota Y, Mori R, Morioka D, Endo I. Prophylactic drain management after pancreaticoduodenectomy without focusing on the drain fluid amylase level: A prospective validation study regarding criteria for early drain removal that do not include the drain fluid amylase level. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:950-961. [DOI: 10.1002/jhbp.746] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/26/2020] [Accepted: 04/01/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Koichi Taniguchi
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Ryusei Matsuyama
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Yasuhiro Yabushita
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Yuki Homma
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Yohei Ota
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Ryutaro Mori
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Daisuke Morioka
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
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A prospective study of the effect of terlipressin on portal vein pressure and clinical outcomes after hepatectomy: A pilot study. Surgery 2020; 167:926-932. [DOI: 10.1016/j.surg.2020.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/09/2020] [Accepted: 01/16/2020] [Indexed: 12/14/2022]
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32
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The safety of omitting prophylactic abdominal drainage after laparoscopic liver resection: Retrospective analysis of 100 consecutive cases. Ann Med Surg (Lond) 2020; 53:12-15. [PMID: 32280459 PMCID: PMC7136585 DOI: 10.1016/j.amsu.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/09/2020] [Accepted: 03/19/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction Whether prophylactic abdominal drainage after laparoscopic liver resection (LLR) is necessary remains unclear. This study aimed to evaluate the safety of omitting prophylactic abdominal drainage after LLR. Methods A retrospective analysis of 100 consecutive patients who underwent LLR at Osaka Rosai Hospital from April 2011 to November 2018 was performed. During this period, prophylactic abdominal drainage was routinely omitted during LLR without biliary anastomosis. The primary endpoint was the frequency of additional abdominal drainage. The secondary endpoint was the rate of postoperative complications. Results Ninety-six patients (96%) underwent partial resection or lateral segmentectomy, and 89 patients (89%) were Child-Pugh grade A. The median operative time was 102 (range, 31-274) minutes. The median blood loss was minimal (range, 0-280 ml), and blood transfusion was performed for one patient (1%). One case (1%) was converted to open surgery. Additional abdominal drainage was required for one patient (1%) with an intraabdominal abscess. Postoperative complications were seen in 5 patients (5%). High-grade complications (≥grade III according to the Clavien-Dindo classification) were seen in two patients (2%). There were no cases of reoperation or perioperative death. The median postoperative hospital stay was 8 (range, 4-65) days. Conclusions Prophylactic abdominal drainage could be safely omitted for selected patients and operative procedures.
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Ichida A, Kono Y, Sato M, Akamatsu N, Kaneko J, Arita J, Sakamoto Y, Kokudo N, Hasegawa K. Timing for removing prophylactic drains after liver resection: an evaluation of drain removal on the third and first postoperative days. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:454. [PMID: 32395498 PMCID: PMC7210192 DOI: 10.21037/atm.2020.04.04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Conventionally, drains are removed from postoperative day (POD) 7 to POD 14 at our institute after hepatectomy (control group). This study was conducted to evaluate the outcomes of drain removal in the early postoperative period. Methods Recently, we defined criteria for the early removal of drains: (I) a drain-fluid bilirubin level of below 3 mg/dL; (II) a drain discharge volume of less than 500 mL/day; and (III) no macroscopic signs of bleeding or infection. For patients meeting these criteria, drains were removed on POD 3 between January 2012 and February 2013 (POD 3 group) and on POD 1 between February and December 2013 (POD 1 group). The outcomes of these groups were then retrospectively compared. Results The median duration of the postoperative hospital stay was shorter in the POD 3 group (11 days) than in the control group (14 days) (P<0.0001). The incidence of drain infection was lower in the POD 3 group (1.2%) than in the control group (5.7%). Meanwhile, the incidences of bile leakage and complications were higher in the POD 1 group than in the POD 3 group. However, the incidences were almost the same when patients whose drains were actually removed on the predefined POD were compared. The intraoperative findings were also considered when removing the drains. Conclusions Drain removal on POD 3 may reduce the length of the postoperative hospital stay and the incidence of drain infection without impairing safety. To remove drains safely on POD 1, however, the intraoperative findings should also be considered.
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Affiliation(s)
- Akihiko Ichida
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshiharu Kono
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masumitsu Sato
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Kaneko
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Arita
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Kyorin University Hospital, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Peritoneal drainage or no drainage after pancreaticoduodenectomy and/or distal pancreatectomy: a meta-analysis and systematic review. Surg Endosc 2019; 34:4991-5005. [DOI: 10.1007/s00464-019-07293-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 11/28/2019] [Indexed: 12/11/2022]
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Antimicrobial prophylaxis for 1 day versus 3 days in liver cancer surgery: a randomized controlled non-inferiority trial. Surg Today 2019; 49:859-869. [DOI: 10.1007/s00595-019-01813-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/08/2019] [Indexed: 12/27/2022]
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Perihilar Glissonian Approach for Anatomical Parenchymal Sparing Liver Resections: Technical Aspects: The Taping Game. Ann Surg 2019; 267:537-543. [PMID: 27984211 DOI: 10.1097/sla.0000000000002100] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To present technical details for central hepatectomy and right anterior and posterior sectionectomies using perihilar Glissonian approach for anatomical delineation and selective inflow occlusion. BACKGROUND Central tumors and those deeply located in the right liver may require extensive resections because of their proximity to major vascular structures. In such cases, anatomical more limited resections such as central hepatectomy or sectionectomies may provide an alternative to extensive surgery by assuring both parenchymal sparing and suitable oncologic resection. METHODS We present the global concept for performing a perihilar Glissonian approach and its application to each individual anatomical procedure. This includes detailed descriptions, illustrations, and videos demonstrating the technique. RESULTS This technique was applied since 1991 for anatomical parenchymal resections including central hepatectomy (resection of segments 4, 5, and 8), right anterior sectionectomy (resection of segments 5 and 8), and right posterior sectionectomy (resection of segments 6 and 7). The feasibility rate of the Glissonian approach was 88%. CONCLUSIONS Perihilar Glissonian approach is a safe and reproducible technique that enables anatomical parenchymal preserving liver resections for selected central and right-sided deeply located tumors.
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Chinese Expert Consensus on Enhanced Recovery After Hepatectomy (Version 2017). Asian J Surg 2019; 42:11-18. [DOI: 10.1016/j.asjsur.2018.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 01/22/2018] [Accepted: 01/31/2018] [Indexed: 12/14/2022] Open
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Chen ZS, Zhu SL, Qi LN, Li LQ. A combination of subcuticular suture and enhanced recovery after surgery reduces wound complications in patients undergoing hepatectomy for hepatocellular carcinoma. Sci Rep 2018; 8:12942. [PMID: 30154493 PMCID: PMC6113254 DOI: 10.1038/s41598-018-31287-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 08/09/2018] [Indexed: 01/27/2023] Open
Abstract
The aim of this study was to examine whether using subcuticular sutures during initial hepatectomy for hepatocellular carcinoma is associated with shorter postoperative length of hospital stay (PLOS) than using staples for patients treated in the enhanced recovery after surgery (ERAS) approach. A total of 376 patients were randomized to receive either subcuticular sutures or staples (188 per group), and the two groups were compared in terms of the incidence of wound complications and PLOS. Independent risk factors for PLOS were identified by multivariate analysis. Sutures were associated with significantly lower incidence of wound infection (4.3% vs. 13.3%, P = 0.020) and significantly shorter PLOS (7.97 vs. 8.45 days, P = 0.048). Independent risk factors for wound infection after hepatectomy were advanced age, increased preoperative body mass index, decreased preoperative serum albumin, and skin closure using staples. These results suggest that subcuticular sutures may be more effective than staples for conducting hepatectomy in patients with hepatocellular carcinoma who receive ERAS care.
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Affiliation(s)
- Zu-Shun Chen
- Department of Hepatobiliary Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, 530021, China
| | - Shao-Liang Zhu
- Department of Hepatobiliary Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, 530021, China
| | - Lu-Nan Qi
- Department of Hepatobiliary Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, 530021, China
| | - Le-Qun Li
- Department of Hepatobiliary Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, 530021, China.
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Bleszynski MS, Bressan AK, Joos E, Morad Hameed S, Ball CG. Acute care and emergency general surgery in patients with chronic liver disease: how can we optimize perioperative care? A review of the literature. World J Emerg Surg 2018; 13:32. [PMID: 30034510 PMCID: PMC6052581 DOI: 10.1186/s13017-018-0194-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/10/2018] [Indexed: 12/15/2022] Open
Abstract
The increasing prevalence of advanced cirrhosis among operative candidates poses a major challenge for the acute care surgeon. The severity of hepatic dysfunction, degree of portal hypertension, emergency of surgery, and severity of patients’ comorbidities constitute predictors of postoperative mortality. Comprehensive history taking, physical examination, and thorough review of laboratory and imaging examinations typically elucidate clinical evidence of hepatic dysfunction, portal hypertension, and/or their complications. Utilization of specific scoring systems (Child-Pugh and MELD) adds objectivity to stratifying the severity of hepatic dysfunction. Hypovolemia and coagulopathy often represent major preoperative concerns. Resuscitation mandates judicious use of intravenous fluids and blood products. As a general rule, the most expeditious and least invasive operative procedure should be planned. Laparoscopic approaches, advanced energy devices, mechanical staplers, and topical hemostatics should be considered whenever applicable to improve safety. Precise operative technique must acknowledge common distortions in hepatic anatomy, as well as the risk of massive hemorrhage from porto-systemic collaterals. Preventive measures, as well as both clinical and laboratory vigilance, for postoperative hepatic and renal decompensation are essential.
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Affiliation(s)
| | - Alexsander K Bressan
- 2Department of Surgery, University of Calgary, Foothills Medical Centre, 1403 - 29 Street NW, Calgary, Alberta Canada
| | - Emilie Joos
- 1Department of Surgery, University of British Columbia, Vancouver, Canada
| | - S Morad Hameed
- 1Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Chad G Ball
- 2Department of Surgery, University of Calgary, Foothills Medical Centre, 1403 - 29 Street NW, Calgary, Alberta Canada
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Nondrainage after Laparoscopic Cholecystectomy for Acute Calculous Cholecystitis Does Not Increase the Postoperative Morbidity. BIOMED RESEARCH INTERNATIONAL 2018; 2018:8436749. [PMID: 30065946 PMCID: PMC6051323 DOI: 10.1155/2018/8436749] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 05/23/2018] [Accepted: 06/06/2018] [Indexed: 12/03/2022]
Abstract
Background It is now established that prophylactic drainage is not needed after laparoscopic cholecystectomy (LC) for chronic calculous cholecystitis. However, the benefit of drains versus their potential harm for acute calculous cholecystitis (ACC) following laparoscopic LC has been questioned. Therefore, we conducted a comparative study to assess the need for drainage. Methods Between January 2014 and October 2016, 212 patients with ACC undergoing LC undergo either drainage (n= 106) or no drainage (n= 106). The primary end points were the number of patients with postoperative drain-related complications, early and late Visual Analogue Scale (VAS) score, and hospital stay. Secondary end points included estimated blood loss, postoperative recovery, analgesia requirement, and cosmetic satisfaction result. Results There was no bile duct injury and mortality in both groups. The overall complication rate was 12.5% with no significant difference between those with or without drainage (P=0.16). Normal activity resumption was significantly faster and the postoperative hospital stay was slightly shorter in the nondrainage group (P =0.03 and P= 0.04, respectively). The early VAS score in the drainage group was significantly higher (p< 0.05). There were no significant differences between the two groups in postoperative hematology test, late VAS score, and patient satisfaction of cosmetic outcome. Conclusion Routine drainage for patients with ACC after LC may not be justified with similar drain-related complications compared with nondrainage group.
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Ishioka K, Hokuto D, Nomi T, Yasuda S, Yoshikawa T, Matsuo Y, Akahori T, Nishiwada S, Nakagawa K, Nagai M, Nakamura K, Ikeda N, Sho M. Significance of bacterial culturing of prophylactic drainage fluid in the early postoperative period after liver resection for predicting the development of surgical site infections. Surg Today 2018; 48:625-631. [PMID: 29380135 DOI: 10.1007/s00595-018-1629-8] [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: 10/10/2017] [Accepted: 01/18/2018] [Indexed: 11/29/2022]
Abstract
PURPOSES The relationship between the results of bacterial drainage fluid cultures in the early postoperative period after liver resection and the development of surgical site infections (SSIs) is unclear. We evaluated the diagnostic value of bacterial cultures of drainage fluid obtained on postoperative day (POD) 1 after liver resection. METHODS The cases of all consecutive patients who underwent elective liver resection from January 2014 to December 2016 were analyzed. The association between a positive culture result and the development of SSIs was analyzed. RESULTS A total of 195 consecutive patients were studied. Positive drainage fluid cultures were obtained in 6 patients (3.1%). A multivariate analysis revealed that a positive drainage fluid culture was an independent risk factor for SSIs (odds ratio: 8.04, P = 0.035), and combined resection of the gastrointestinal tract was a risk factor for a positive drainage fluid culture (P = 0.006). Among the patients who did not undergo procedures involving the gastrointestinal tract, there was no association between drainage fluid culture positivity and SSIs. CONCLUSIONS The detection of positive culture results for drainage fluid collected on POD 1 after liver resection was associated with SSIs. However, among patients who did not undergo procedures involving the gastrointestinal tract, it was not a predictor of SSIs.
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Affiliation(s)
- Kohei Ishioka
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Daisuke Hokuto
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Takeo Nomi
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Satoshi Yasuda
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Takahiro Yoshikawa
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Yasuko Matsuo
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Takahiro Akahori
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Satoshi Nishiwada
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kenji Nakagawa
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kota Nakamura
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Naoya Ikeda
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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Comparison of Adverse Events and Outcomes Between Patients With and Without Drain Insertion After Hepatectomy: A Propensity Score-Matched, Multicenter, Prospective Observational Cohort Study in Japan (CSGO-HBP-001). World J Surg 2018; 42:2561-2569. [DOI: 10.1007/s00268-018-4461-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Risk prediction model for major complication after hepatectomy for malignant tumour - A validated scoring system from a university center. Surg Oncol 2017; 26:446-452. [PMID: 29113664 DOI: 10.1016/j.suronc.2017.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 08/29/2017] [Indexed: 01/27/2023]
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Sugawara T, Shindoh J, Nishioka Y, Hashimoto M. Total bilirubin amount in drainage fluid can be an early predictor for severe biliary fistula after hepatobiliary surgery. Biosci Trends 2017; 11:588-594. [PMID: 29070759 DOI: 10.5582/bst.2017.01208] [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: 11/05/2022]
Abstract
The ratio of the bilirubin concentration in abdominal drainage fluid to the serum bilirubin concentration (d-Bil/s-Bil) has been used as a predictor of biliary fistula (BF) formation after hepatobiliary surgery. The d-Bil/s-Bil ratio is highly influenced by the amount of drainage and is not always reliable, especially when the amount of drainage is large. In this study, the usefulness of the d-Bil/s-Bil ratio and total bilirubin amount in the drainage fluid (TBA) (bilirubin concentration in the drainage fluid x the amount of drainage) as predictors of severe BF (sBF) formation was evaluated retrospectively from the data of 306 patients who had undergone hepatobiliary surgery. Of the 306 patients, 201 patients were included in the training set and the remaining 105 in the validation set, to determine the best parameter to predict sBF formation after hepatobiliary surgery. Receiver-operating characteristic curve analysis revealed that the predictive power of TBA was superior to that of the d-Bil/s-Bil ratio throughout the postoperative period, and that the TBA on postoperative day (POD) 1 showed the highest discriminatory power in the training set (area under the curve, 0.789; cutoff value, 470 mg/day). The TBA on POD 1 also showed the highest predictive power for sBF formation in the validation set, with a sensitivity of 100%, specificity of 97.1%, and accuracy of 97.1%. In conclusion, TBA may be a more reliable predictor of sBF than the conventionally used d-Bil/s-Bil ratio. Early prediction of sBF may be useful for early removal of unnecessary prophylactic drainage tubes after hepatobiliary surgery.
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Affiliation(s)
- Toshitaka Sugawara
- Hepatobiliary-Pancreatic Surgery Division, Department of Digestive Surgery, Toranomon Hospital
| | - Junichi Shindoh
- Hepatobiliary-Pancreatic Surgery Division, Department of Digestive Surgery, Toranomon Hospital.,Okinaka Memorial Institute for Medical Disease
| | - Yujiro Nishioka
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo
| | - Masaji Hashimoto
- Hepatobiliary-Pancreatic Surgery Division, Department of Digestive Surgery, Toranomon Hospital
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Nakagawa K, Tanaka K, Nojiri K, Sawada Y, Kumamoto T, Ueda M, Minami Y, Mochizuki Y, Morioka D, Kubota T, Kamiya N, Yoshida K, Yonemoto N, Endo I. Predictive factors for bile leakage after hepatectomy for hepatic tumors: a retrospective multicenter study with 631 cases at Yokohama Clinical Oncology Group (YCOG). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:33-41. [PMID: 28156076 DOI: 10.1002/jhbp.411] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND International Study Group of Liver Surgery (ISGLS) proposed the standardized definition for bile leakage (BL) after hepatectomy (Hx) at 2011 to precisely perceive incidence and predictive factors of this critical condition. METHODS We conducted a multicenter retrospective study using the ISGLS definition of BL after Hx. RESULTS Perioperative data regarding 631 patients undergoing elective Hx for hepatic tumors without biliary reconstruction performed between January 2009 and December 2011 were analyzed. BL was observed in 30 patients (4.8%). (Grade A, 8 (1.3%); B, 21(3.3%); C, 1 (0.2%)). Five independent predictors (diagnosis of liver metastases, prolonged operation, high risk procedures defined as Hx with broad exposure of the hilar Glissonean sheath, low platelet count and high serum total bilirubin on postoperative day 1) for grade B/C BL were elucidated by the multivariate analysis. When the study cohorts were divided into groups by number of accompanying these predictors, the more the accompanying independent predictors, the higher the incidence of BL. Notably, incidence of BL exceeded 40% in patients with four or more of these predictors. CONCLUSIONS Risk stratification for BL after Hx can be achievable using independent predictors clarified in this study. However, proper management for high risk patients remains to be elucidated.
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Affiliation(s)
- Kazuya Nakagawa
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Kuniya Tanaka
- Department of Surgery, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Kazunori Nojiri
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Yu Sawada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Takafumi Kumamoto
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Michio Ueda
- Department of Surgery, Gastroenterological Center, Yokohama City University, Yokohama, Japan
| | - Yuta Minami
- Department of Surgery, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | | | - Daisuke Morioka
- Department of Surgery, Yokohama Ekisaikai Hospital, Yokohama, Japan
| | - Toru Kubota
- Department of Surgery, Saiseikai Yokohamashi Nanbu Hospital, Yokohama, Japan
| | | | - Kenichi Yoshida
- Department of Surgery, Saiseikai Wakakusa Hospital, Yokohama, Japan
| | - Naohiro Yonemoto
- Department of Biostatistics, Center for Novel and Exploratory Clinical Trials, Yokohama City University, Yokohama, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
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Wong-Lun-Hing EM, van Woerden V, Lodewick TM, Bemelmans MH, Olde Damink SW, Dejong CH, van Dam RM. Abandoning Prophylactic Abdominal Drainage after Hepatic Surgery: 10 Years of No-Drain Policy in an Enhanced Recovery after Surgery Environment. Dig Surg 2017; 34:411-420. [PMID: 28343221 PMCID: PMC5872559 DOI: 10.1159/000455246] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 12/05/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Routine prophylactic abdominal drainage after hepatic surgery is still being debated, as it may be unnecessary, possibly harmful, and uncomfortable for patients. This study evaluated the safety of a no-drain policy after liver resection within an Enhanced Recovery after Surgery (ERAS) programme. METHODS All hepatectomies performed without prophylactic drainage during 2005-2014 were included. Primary end points were resection-surface-related (RSR) morbidity, defined as the presence of postoperative biloma, hemorrhage or abscess, and reinterventions. Secondary end points were length of stay, total postoperative morbidity, the composite end point of liver surgery-specific complications, readmissions, and 90-day mortality. Uni- and multivariate analyses were performed to identify independent risk factors for RSR morbidity. A systematic search was performed to compare the results of this study to literature. RESULTS A total of 538 resections were included in the study. The RSR complication and reintervention rate was 15 and 12%, respectively. Major liver resection (≥3 segments) was an independent risk factor for the development of RSR morbidity (OR 3.01, 95% CI 1.61-5.62; p = 0.001) and need for RSR reintervention (OR 3.02, 95% CI 1.59-5.73; p = 0.001). CONCLUSION RSR morbidity, mortality, and reintervention rates after liver surgery without prophylactic drainage in patients, treated within an ERAS programme, were comparable to previously published data. A no-drain policy after partial hepatectomy seems safe and feasible.
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Affiliation(s)
- Edgar M. Wong-Lun-Hing
- Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Victor van Woerden
- Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Toine M. Lodewick
- Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands,ESCAM (European Surgical Centre Aachen Maastricht), Maastricht, The Netherlands
| | - Marc H.A. Bemelmans
- Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands,ESCAM (European Surgical Centre Aachen Maastricht), Maastricht, The Netherlands
| | - Steven W.M. Olde Damink
- Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands,ESCAM (European Surgical Centre Aachen Maastricht), Maastricht, The Netherlands,Nutrim School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Cornelis H.C. Dejong
- Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands,ESCAM (European Surgical Centre Aachen Maastricht), Maastricht, The Netherlands,Nutrim School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands,GROW, School for Oncology and Developmental Biology, Maastricht, The Netherlands
| | - Ronald M. van Dam
- Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands,ESCAM (European Surgical Centre Aachen Maastricht), Maastricht, The Netherlands,*Ronald M. van Dam, Department of Surgery, Maastricht University Medical Centre, PO Box 5800, NL-6202 AZ Maastricht (The Netherlands), E-Mail
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Role of Drain Placement in Major Hepatectomy: A NSQIP Analysis of Procedure-Targeted Hepatectomy Cases. World J Surg 2017; 41:1110-1118. [PMID: 27738836 DOI: 10.1007/s00268-016-3750-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The value of drain placement in hepatic surgery has not been conclusive. The aim of this study was to determine whether drain placement during major hepatectomy was associated with negative postoperative outcomes and whether its placement reduced the need for secondary procedures. METHODS The American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Hepatectomy Database was used to identify patients who underwent major hepatectomy. Patients were divided into two groups based on the placement of a drain during the procedure. Propensity score-matched cohorts of patients who underwent major hepatic resection with or without drain placement were created accounting for patient characteristics. The primary outcomes were 30-day postoperative complications including bile leak, post-hepatectomy liver failure, and invasive intervention as well as mortality and readmission. RESULTS A total of 1005 patients underwent major hepatectomy; 500 patients (49.8 %) had prophylactic drains placed at the conclusion of the procedure. Drain placement was associated with any complication (p < 0.001), blood transfusion (p < 0.001), renal insufficiency (p = 0.02), bile leak (p < 0.001), invasive intervention (p = 0.02), length of stay (p = 0.001), and readmission (p < 0.001). In the matched cohort, drain placement was associated with any complication (p < 0.001), blood transfusion (p < 0.001), superficial surgical site infection (SSI) (p = 0.028), bile leak (p < 0.001), and longer length of stay (0.03). In addition, placement of a prophylactic drain did not decrease the rate of postoperative bile leaks requiring therapeutic intervention (p = 0.21) (Table 2). In multivariate analysis, drain placement was independently associated with any complication (p < 0.001), blood transfusion (p = 0.02), bile leak (p < 0.001), invasive intervention (p = 0.011), superficial surgical site infection (SSI) (p = 0.039), and hospital readmission (p = 0.005) (Table 3). Placement of a prophylactic drain did not decrease the rate of postoperative bile leaks requiring therapeutic intervention (p = 0.15). CONCLUSION Drain placement after major hepatectomy may lead to increased postoperative complications including bile leak, superficial surgical site infection, and hospital length of stay and does not decrease the need for secondary procedures in patients with bile leaks.
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The safety of the early removal of prophylactic drainage after liver resection based solely on predetermined criteria: a propensity score analysis. HPB (Oxford) 2017; 19:359-364. [PMID: 28117230 DOI: 10.1016/j.hpb.2016.12.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 12/01/2016] [Accepted: 12/03/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prophylactic drainage after liver resection remains a common practice amongst hepatic surgeons. However, there is little information about the optimal timing of drain removal. METHODS From April 2008 to December 2012 (conventional group), the drains were removed based on the treating surgeon's view. From January 2013 to April 2016 (ERP group), the drains were removed on POD 3 if the bile concentration of the drain discharge was less than three times the serum bilirubin on POD 3, and the amount of drain discharge was <500 ml on POD 3. The postoperative outcomes of the two groups were compared using one-to-one propensity score-matching analysis. RESULTS One hundred nine patients were extracted from ERP group (n = 226) and conventional group (n = 246). The time to drain removal was significantly shorter in the ERP group than in the conventional group (3 days vs. 5 days, P < 0.001). The frequency of delayed bile leakage or the appearance of symptomatic abdominal fluid collection after drain removal did not differ between the two groups (3% vs. 4%, P = 0.791). CONCLUSION Drain removal on POD 3 based on the volume and bile concentration is safe.
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Chok KS, Ng KK, Cheung TT, Chan AC, Chan SC, Lo CM. Resection of T4 hepatocellular carcinomas with adjacent structures, is it justified? Hepatobiliary Pancreat Dis Int 2017; 16:52-57. [PMID: 28119259 DOI: 10.1016/s1499-3872(16)60172-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND T4 hepatocellular carcinoma (HCC) with invasion to adjacent structure(s) may require resection of not only the tumor but also the invaded structure(s). This study aims to assess whether such combined resection for T4 HCC is justifiable. METHODS Adult patients with T4 HCC were divided into three groups. Group 1: tumors and invaded adjacent structures were resected together if histopathologically confirmed tumor invasion; group 2: same as group 1 but histopathologically confirmed tumor adhesion; group 3: tumor resection only. Group comparisons were made. RESULTS Totally 144 patients were included in the study. There were 71, 14 and 59 patients in groups 1, 2 and 3, respectively. The groups were comparable in demographics, complication and survival. Ten hospital deaths occurred (5, 0 and 5 in groups 1, 2 and 3, respectively; P=0.533). The 5-year overall survival (hospital mortality excluded) was 17.8% in group 1, 14.3% in group 2, and 28.9% in group 3 (P=0.191). The 5-year disease-free survival was 10.4% in group 1 and 14.5% in group 3 (no data for group 2 yet) (P=0.565). On multivariate analysis, macrovascular invasion and poor differentiation were risk factors for survival whereas combined resection did not impact patients' survival. CONCLUSIONS Combined resection achieved survival outcomes similar to tumor resection only. Patients with tumor invasion and those with tumor adhesion had comparable survival after combined resection. At centers with the required expertise, combined resection should be attempted to treat T4 HCCs with clinically suspected invasion of adjacent structures.
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Affiliation(s)
- Kenneth Sh Chok
- Department of Surgery, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China.
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Gavriilidis P, Hidalgo E, de'Angelis N, Lodge P, Azoulay D. Re-appraisal of prophylactic drainage in uncomplicated liver resections: a systematic review and meta-analysis. HPB (Oxford) 2017; 19:16-20. [PMID: 27576007 DOI: 10.1016/j.hpb.2016.07.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 07/12/2016] [Accepted: 07/15/2016] [Indexed: 12/12/2022]
Abstract
AIM The benefit of prophylactic drainage after uncomplicated hepatectomy remains controversial. The aim of this study was to update the existing evidence on the role of prophylactic drainage following uncomplicated liver resection. METHODS Cochrane, Medline (Pubmed), and Embase were searched. The Medline search strategy was adopted for all other databases. A grey literature search was performed. Meta-analyses were performed with Review Manager 5.3. Primary outcomes were mortality and ascitic leak, secondary outcomes were infected intra-abdominal collection, chest infection, wound infection of the surgical incision, biliary fistula, and length of stay. RESULTS The incidence of ascitic leak was higher in the drained group (Odds Ratio = 3.33 [95% Confidence Interval: 1.66-5.28]). Infected intra-abdominal collections, wound infections, chest infections, biliary fistula, length of stay and mortality were not statistically different between groups. CONCLUSIONS The routine utilisation of drains after elective uncomplicated liver resection does not translate into a lower incidence of postoperative complications. Therefore, based on the current available evidence, routine abdominal drainage is not recommended in elective uncomplicated hepatectomy.
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Affiliation(s)
- Paschalis Gavriilidis
- Department of HPB and Transplant Surgery, St James's University Hospital, Beckett Str, Leeds LS9 7TF, UK; Department of HPB Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Ernest Hidalgo
- Department of HPB and Transplant Surgery, St James's University Hospital, Beckett Str, Leeds LS9 7TF, UK
| | - Nicola de'Angelis
- Department of HPB Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France
| | - Peter Lodge
- Department of HPB and Transplant Surgery, St James's University Hospital, Beckett Str, Leeds LS9 7TF, UK
| | - Daniel Azoulay
- Department of HPB Surgery and Liver Transplantation, Henri Mondor Hospital, Créteil, France; INSERM U 955, Créteil, France.
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