Drain or No Drain Following Pancreaticoduodenectomy: The Unsolved Dilemma

BACKGROUND AND AIMS

There is no consensus regarding the routine placement of intra-abdominal drains after pancreaticoduodenectomy. We aim to determine the effects of intraperitoneal drain placement during pancreaticoduodenectomy on 30-day postoperative morbidity and mortality.

METHODS

Patients who underwent pancreaticoduodenectomy for pancreatic tumors were identified from the 2014-2015 American College of Surgeons-National Surgical Quality Improvement Program Database. Univariate and multivariate analyses adjusting for known prognostic variables were performed. A subgroup analysis was performed based on the risk for development of postoperative pancreatic leak determined by the pancreatic duct caliber, parenchymal texture, and body mass index.

RESULTS

A total of 6858 patients with pancreatic tumors who underwent pancreaticoduodenectomy were identified in the 2014-2015 American College of Surgeons-National Surgical Quality Improvement Program Database dataset. In all, 87.4% of patients had intraperitoneal drains placed. A 30-day mortality rate was higher in the no-drain group (2.9% vs. 1.7%, P = 0.003). Patients in the drain group had a higher incidence of overall morbidity (49.5% vs. 41.2%, P = 0.0008), delayed gastric emptying (18.1% vs. 13.7%, P = 0.004), pancreatic fistulae (19.4% vs. 9.9%, P ⩽ 0.0001), and prolonged length of hospital stay over 10 days (43.7% vs. 34.9%, P < 0.0001). Subgroup analysis based on risk categories revealed a higher 30-day mortality rate in the no-drain group among patients with high-risk features (3.1% vs. 1.6%, P = 0.02). Delayed gastric emptying and pancreatic fistula development remained significantly higher in the drain group only in the high-risk category. Prolonged length of hospital stay and composite morbidity remained higher in the drain group regardless of the risk category.

CONCLUSION

To our knowledge, this is the largest study to date that aims at clarifying the pros and cons of the intraperitoneal drain placement during pancreaticoduodenectomy for pancreatic tumors. We showed a higher 30-day mortality rate if drain insertion was omitted during pancreaticoduodenectomy in patients with softer pancreatic textures, smaller pancreatic duct caliber, and body mass index over 25. Postoperative 30-day morbidity rate was higher if a drain was inserted regardless of the risk category. Further randomized controlled trials with prospective evaluation of stratification factors for fistula risk are needed to establish a clear recommendation.

Opioid-free anesthesia: what about patient comfort? A prospective, randomized, controlled trial

BACKGROUND

We investigated the effect of a pern-operative opioid-free approach on postoperative patient comfort in patients undergoing breast cancer surgery.

SUBJECTS AND METHODS

From September 2014 to July 2015, 66 female patients of the Belgian Oncology Institut Jules Bordet were recruited. They were randomized into two groups: the first group received anesthesia with opioids for their breast cancer surgery, and the second group received opioid-free anesthesia. Patient comfort was evaluated 24 hours postoperatively through the QoR-40 score, with a difference of 15 points considered as being clinically relevant. Postoperative analgesia was provided through a piritramide patient-controlled analgesia device, during the first 24 hours. The hypothesis of this study was that opioid-free anesthesia would improve quality of recovery after anesthesia.

RESULTS

A statistically significant difference in postoperative QoR-40 score was observed between groups [Mean (SD) QoR-40 of 182.1/200 (13.9) in the opioid-free group, and 175.6/200 (14.80) in the opioid group; P = 0.04]. The clinical relevance of this finding is questionable, insofar as the difference of 15 points was not met. A statistically significant difference in postoperative piritramide usage was observed (8.1 (6.6) in the opioid-free group, and 13.1 (9.4) in the opioid group; P = 0.03).

CONCLUSIONS

This randomized controlled trial shows, for the first time, equal comfort during the immediate postoperative period in patients having received opioid-free and conventional anesthesia for their breast cancer surgery. Opioid-free anesthesia in this indication appears safe, and may be associated with slightly reduced pain during the first 24 postoperative hours.

Solitary cavernous lymphangioma of the duodenum: a case report

Duodenal lymphangioma is an extremely rare benign tumor of the gastrointestinal tract. In this case report, we describe the case of a 39-year-old Lebanese female with cystic lymphangioma of the duodenum diagnosed by exploratory laparotomy and immunohistochemical analysis. Herein our findings are described.

Portomesenteric venous gas: A late complication of pneumatosis intestinalis

BACKGROUND

The pneumatosis intestinalis is an entity with multiple aetiologies and may be associated with a fatal outcome when present on plain radiographs. When associated with the presence of portomesenteric venous gas (PMVG) it is typically the result of bowel ischaemia.

METHODS AND RESULTS

We are presenting a case of a 43 year old male who presented with a two days history of haematemesis, generalised abdominal pain and distension. Computed tomography (CT) scan revealed a gross amount of air within the portal venous system and small bowel dilatation to the level of distal ileum was also seen with associated pneumatosis intestinalis. Emergency laparotomy was conducted which demonstrated a simple band adhesion resulting in bowel ischaemia. The patient was making a good post-operative recovery complicated only by sub-therapeutic treatment of schizophrenia.

CONCLUSION

The presence of gas within the portal venous system and PI in adults can indicate severe life-threatening disease. This requires early surgical intervention in those patients with a clinical suspicion of bowel ischaemia, and with radiological signs. This may avoid significant mortality.

[Pathophysiology, assessment and treatment of laryngopharyngeal reflux]

Laryngopharyngeal reflux is a prevalent, yet incompletely understood, ENT disorder accounting for 8 to 10% of patients consulting ENT. This clinical entity, increasingly considered as different from gastroesophageal reflux disease, may greatly affect the quality of life of patients through vocal and digestive symptoms. Debate persists concerning pathophysiology, diagnosis, and treatment. The aim of this review is to study the current literature about the pathophysiology, diagnosis, treatment, and the outcomes in the follow-up.

[Transgender voice and communication treatment: Review of the literature]

Transgender persons constitute a small but growing population in ENT department: as a matter of fact, many voice parameters significantly contribute to the perception of gender (fundamental frequency, supraglottic resonance patterns, etc.). The persons involved in transition processes may therefore aim at changing their own voice properties, either by means of speech therapy or by medical intervention (hormonotherapy and/or surgery). The current voice assessment and outcome measures for this population before and after treatment are nevertheless still lacking validity. A well-accepted general framework including self-perception, subjective assessment of the practitioner and objective measures is not well documented. This review is therefore meant as a contribution to the development of a state of the art in the field.

Carbon Monoxide Poisoning: A Patient with Bilateral Internuclear Ophthalmoplegia and Exotropia

Carbon monoxide poisoning, which occurs in poorly ventilated areas, is associated with different symptoms and signs. This report describes an 8-year-old girl with severe carbon monoxide intoxication, scattered retinal nerve fiber layer and subhyaloid hemorrhages, and exotropia with bilateral internuclear ophthalmoplegia.

Splenic injury as a complication of colonoscopy and polypectomy. Report of a case and review of the literature

Injury to the spleen is a rare complication of colonoscopy and polypectomy. The danger of this unusual complication is real and its early recognition and proper management are essential to a favorable outcome. A case of injury to the spleen requiring splenectomy following colonoscopy and polypectomy is reported and discussed. Review of the literature by the authors revealed only six similar cases.