Do Drains Contribute to Pancreatic Fistulae? Analysis of over 5000 Pancreatectomy Patients

INTRODUCTION

Conflicting evidence exists from randomized controlled trials supporting both increased complications/fistulae and improved outcomes with drain placement after pancreatectomy. The objective was to determine drain practice patterns in the USA, and to identify if drain placement was associated with fistula formation.

METHODS

Demographic, perioperative, and patient outcome data were captured from the most recent annual NSQIP pancreatic demonstration project database, including components of the fistula risk score. Significant variables in univariate analysis were entered into adjusted logistic regression models.

RESULTS

Of 5013 pancreatectomy patients, 4343 (87%) underwent drain placement and 18% of patients experienced a pancreatic fistula. When controlled for other factors, drain placement was associated with ducts < 3 mm, soft glands, and blood transfusion within 72 h of surgery. Age, obesity, neoadjuvant radiation, preoperative INR level, and malignant histology lost significance in the adjusted model. Drained patients experienced higher readmission rates (17 vs. 14%; p < 0.05) and increased (20 vs. 8%; p < 0.01) pancreatic fistulae. Fistula was associated with obesity, no neoadjuvant chemotherapy, drain placement, < 3 mm duct diameter, soft gland, and longer operative times. Drain placement remained independently associated with fistula after both distal pancreatectomy (OR = 2.84 (1.70, 4.75); p < 0.01) and pancreatoduodenectomy (OR = 2.29 (1.28, 4.11); p < 0.01).

CONCLUSIONS

Despite randomized controlled clinical trial data supporting no drain placement, drains are currently placed in the vast majority (87%) of pancreatectomy patients from > 100 institutions in the USA, particularly those with soft glands, small ducts, and perioperative blood transfusions. When these factors are controlled for, drain placement remains independently associated with fistulae after both distal and proximal pancreatectomy.

Hypoxic Air Inhalation and Ischemia Interventions Both Elicit Preconditioning Which Attenuate Subsequent Cellular Stress In vivo Following Blood Flow Occlusion and Reperfusion

Ischemic preconditioning (IPC) is valid technique which elicits reductions in femoral blood flow occlusion mediated reperfusion stress (oxidative stress, Hsp gene transcripts) within the systemic blood circulation and/or skeletal muscle. It is unknown whether systemic hypoxia, evoked by hypoxic preconditioning (HPC) has efficacy in priming the heat shock protein (Hsp) system thus reducing reperfusion stress following blood flow occlusion, in the same manner as IPC. The comparison between IPC and HPC being relevant as a preconditioning strategy prior to orthopedic surgery. In an independent group design, 18 healthy men were exposed to 40 min of (1) passive whole-body HPC (FiO₂ = 0.143; no ischemia. N = 6), (2) IPC (FiO₂ = 0.209; four bouts of 5 min ischemia and 5 min reperfusion. n = 6), or (3) rest (FiO₂ = 0.209; no ischemia. n = 6). The interventions were administered 1 h prior to 30 min of tourniquet derived femoral blood flow occlusion and were followed by 2 h subsequent reperfusion. Systemic blood samples were taken pre- and post-intervention. Systemic blood and gastrocnemius skeletal muscle samples were obtained pre-, 15 min post- (15PoT) and 120 min (120PoT) post-tourniquet deflation. To determine the cellular stress response gastrocnemius and leukocyte Hsp72 mRNA and Hsp32 mRNA gene transcripts were determined by RT-qPCR. The plasma oxidative stress response (protein carbonyl, reduced glutathione/oxidized glutathione ratio) was measured utilizing commercially available kits. In comparison to control, at 15PoT a significant difference in gastrocnemius Hsp72 mRNA was seen in HPC (−1.93-fold; p = 0.007) and IPC (−1.97-fold; p = 0.006). No significant differences were observed in gastrocnemius Hsp32 and Hsp72 mRNA, leukocyte Hsp72 and Hsp32 mRNA, or oxidative stress markers (p > 0.05) between HPC and IPC. HPC provided near identical amelioration of blood flow occlusion mediated gastrocnemius stress response (Hsp72 mRNA), compared to an established IPC protocol. This was seen independent of changes in systemic oxidative stress, which likely explains the absence of change in Hsp32 mRNA transcripts within leukocytes and the gastrocnemius. Both the established IPC and novel HPC interventions facilitate a priming of the skeletal muscle, but not leukocyte, Hsp system prior to femoral blood flow occlusion. This response demonstrates a localized tissue specific adaptation which may ameliorate reperfusion stress.

The Hsp72 and Hsp90α mRNA Responses to Hot Downhill Running Are Reduced Following a Prior Bout of Hot Downhill Running, and Occur Concurrently within Leukocytes and the Vastus Lateralis

The leukocyte heat shock response (HSR) is used to determine individual's thermotolerance. The HSR and thermotolerance are enhanced following interventions such as preconditioning and/or acclimation/acclimatization. However, it is unclear whether the leukocyte HSR is an appropriate surrogate for the HSR in other tissues implicated within the pathophysiology of exertional heat illnesses (e.g., skeletal muscle), and whether an acute preconditioning strategy (e.g., downhill running) can improve subsequent thermotolerance. Physically active, non-heat acclimated participants were split into two groups to investigate the benefits of hot downhill running as preconditioning strategy. A hot preconditioning group (HPC; n = 6) completed two trials (HPC1_HOTDOWN and HPC2_HOTDOWN) of 30 min running at lactate threshold (LT) on -10% gradient in 30°C and 50% relative humidity (RH) separated by 7 d. A temperate preconditioning group (TPC; n = 5) completed 30 min running at LT on a -1% gradient in 20°C and 50% (TPC1_TEMPFLAT) and 7 d later completed 30 min running at LT on -10% gradient in 30°C and 50% RH (TPC2_HOTDOWN). Venous blood samples and muscle biopsies (vastus lateralis; VL) were obtained before, immediately after, 3, 24, and 48 h after each trial. Leukocyte and VL Hsp72, Hsp90α, and Grp78 mRNA relative expression was determined via RT-QPCR. Attenuated leukocyte and VL Hsp72 (2.8 to 1.8 fold and 5.9 to 2.4 fold; p < 0.05) and Hsp90α mRNA (2.9 to 2.4 fold and 5.2 to 2.4 fold; p < 0.05) responses accompanied reductions (p < 0.05) in physiological strain [exercising rectal temperature (-0.3°C) and perceived muscle soreness (~ -14%)] during HPC2_HOTDOWN compared to HPC1_HOTDOWN (i.e., a preconditioning effect). Both VL and leukocyte Hsp72 and Hsp90α mRNA increased (p < 0.05) simultaneously following downhill runs and demonstrated a strong relationship (p < 0.01) of similar magnitudes with one another. Hot downhill running is an effective preconditioning strategy which ameliorates physiological strain, soreness and Hsp72 and Hsp90α mRNA responses to a subsequent bout. Leukocyte and VL analyses are appropriate tissues to infer the extent to which the HSR has been augmented.

Uncemented computer-assisted design-computer-assisted manufacture femoral components in revision total hip replacement

We prospectively evaluated the long-term outcome of 158 consecutive patients who underwent revision total hip replacement using uncemented computer-assisted design-computer-assisted manufacture femoral components. There were 97 men and 61 women. Their mean age was 63.1 years (34.6 to 85.9). The mean follow-up was 10.8 years (10 to 12).

The mean Oxford, Harris and Western Ontario and McMaster hip scores improved from 41.1, 44.2 and 52.4 pre-operatively to 18.2, 89.3 and 12.3, respectively (p < 0.0001, for each). Six patients required further surgery. The overall survival of the femoral component was 97% (95% confidence interval 94.5 to 99.7). These results are comparable to those of previously published reports for revision total hip replacement using either cemented or uncemented components.

Uncemented custom computer-assisted design and manufacture of hydroxyapatite-coated femoral components

We present the 10- to 17-year results of 112 computer-assisted design computer-assisted manufacture femoral components. The total hip replacements were performed between 1992 and 1998 in 111 patients, comprising 53 men and 58 women. Their mean age was 46.2 years (24.6 to 62.2) with a mean follow-up of 13 years (10 to 17). The mean Harris Hip Score improved from 42.4 (7 to 99) to 90.3 (38 to 100), the mean Oxford Hip Score from 43.1 (12 to 59) to 18.2 (12 to 51) and the mean Western Ontario MacMasters University Osteoarthritis Index score from 57.0 (7 to 96) to 11.9 (0 to 85). There was one revision due to failure of the acetabular component but no failures of the femoral component. There were no revisions for aseptic loosening. The worst-case survival in this cohort of custom femoral components at 13.2 years follow-up was 98.2% (95% confidence interval 95 to 99). Overall survival of this series of total hip replacements was 97.3% (95% confidence interval 95 to 99).

These results are comparable with the best medium- to long-term results for femoral components used in primary total hip replacement with any means of fixation.

Early results of the Birmingham mid-head resection arthroplasty

We report the early results of 10 consecutive metal-on-metal resurfacing arthroplasties performed between May 2006 and July 2007 in young, active patients with gross femoral head defects. Failure was classified as revision for any reason. The mean age of our cohort at the time of surgery was 42.8 years and the minimal period of follow-up was 6.9 months. No patients were lost to follow-up. Up to the time of last review, there were no failures and all patients have returned to their preoperative levels of activity. This study shows promising early results of a bone-conserving, hydroxyapatite-coated, uncemented metal-on-metal bearing prosthesis in young, active patients with bony defects of the femoral head.

A displaced acetabular component causing femoral neck notching following hip resurfacing

We describe the case of a patient who developed a notch on the femoral neck following a hip resurfacing operation as a result of a displaced acetabular component. The acetabular cup displaced in the coronal plane and impinged on the femoral neck leading to a large notch in the inferior femoral neck.

Revision of the Birmingham Hip Resurfacing cup: technical notes and the use of a novel technique to overcome unique problems

The number of hip resurfacing procedures performed in the United Kingdom has doubled in the last four years reflecting its popularity among orthopaedic surgeons. Of the available options the Birmingham Hip Resurfacing (BHR) prosthesis has been the most popular choice in this country. Despite this revision rates have been shown to be higher in the resurfacing group compared to the total hip arthroplasty group particularly in the early postoperative period. Revision of the BHR acetabular component is technically demanding due to several unique design features of this component. We discuss these features and describe a novel reliable and reproducible technique for revision of the BHR cup.

An audit of orthopaedic referrals via Multi-Professional Triage Teams

INTRODUCTION

Multi-Professional Triage Teams (MPTTs) were created to reduce the caseload of hospital orthopaedic clinics and this prospective study evaluated referrals made to a district general hospital orthopaedic department from a lower limb MPTT clinic.

PATIENTS AND METHODS

Over 9 months, 277 referrals to a lower limb hospital orthopaedic clinic were assessed. The temporal delay to hospital clinic review between patients seen at the MPTT clinic and those referred directly by their general practitioner (GP) was analysed using an ANOVA test. A qualitative assessment of diagnoses given to patients reviewed at the MPTT clinic was performed.

RESULTS

The 132 patients initially reviewed at the MPTT clinic and subsequently referred to a hospital consultant waited significantly longer (140 days compared to 62 days by direct GP referral; P < 0.05) to see an orthopaedic consultant. Over three-quarters of this patient cohort incorrectly identified the healthcare professional conducting their consultation at the MPTT clinic. One-third of cases (31%) had no diagnosis made and 22% were assessed as having an incorrect diagnosis.

CONCLUSIONS

Time delays, patient confusion regarding professional roles and diagnostic indecision are significant problems for patients referred to hospital orthopaedic clinics from MPTT clinics. This risks sub-optimal patient care and may lead to future medicolegal implications.