COMPLICATIONS OF INTRA ABDOMINAL DRAINS: A SINGLE CENTER EXPERIENCE

Objective: To compare frequency of intra-abdominal complications in drainage and non-drainage group among patents who underwent intra-abdominal surgeries. Study Design: Comparative prospective study. Place and Duration of Study: Department of Surgery, Pakistan Ordinance Factory, Wah Cantt, from Mar 2018 to Jul 2018. Methodology: There were 32 patients, 16 in each group. Patients were selected through the process of consecutive sampling. Patients were randomly divided into two groups (random number table method); group A patients underwent intra-abdominal drain while group B was non-drainage group. Patients were followed up for 7 days and observed for complications. Results: Total 32 patients were included in the study. There were 14 (43.8%) males and 18 (56.3%) females. Mean age of patients was 43.2 ± 9.5 years. Drain group showed significantly low anastomosis leakage (p=0.02), wound infection (p=0.05), mortality (p=0.04), pulmonary complications (p=0.05) and bleeding (p=0.03) as compared to the non-drain group. Conclusion: Intra-abdominal drains are associated with several complications. Anastomosis leakage is the most common complication following pulmonary complications and bleeding. However, drains help in early detection of complications and timely management of such complications leads to better outcome of a surgical procedure.

Successful transcatheter embolization of splenic artery pseudoaneurysm in acute necrotising pancreatitis.

Splenic artery pseudoaneurysm is a rare condition commonly arises as a sequelae of pancreatitis. Pseudoaneurysm is clinically silent until it ruptures. Thus, untreated pseudoaneurysm carries a high mortality rate up to 90%. We present a case of necrotising pancreatitis complicated with unruptured splenic artery pseudoaneurysm, which was found incidentally from computed tomography (CT) of abdomen. Patient was presented with symptomatic anemia and bleeding from the abdominal drain. We proceeded with embolization of pseudoaneurysm by using Histoacryl glue, resulting in successful complete resolution of pseudoaneurysm with good patient outcome. Transcatheter embolization is considered the current treatment of choice for pseudoaneurysm as it provides an alternative to conventional surgery due to its high successful rate. In this case report, we want to shed light on an alternative treatment approach of the splenic artery pseudoaneurysm.

Hydroperitoneum: A complication of mini PCNL in pediatric age group? -A case report

Renal stones constitute 40% of renal disorders in Pakistan with silent stones constituting up to 3%. Nephrolithotomy and Pyelolithotomy were the only surgical options available for the treatment of large renal stones, with high rate of complications. Percutaneous nephrolithotomy (PCNL) has now become the mainstay of treatment for large renal stones over the past 30 years. Recent advances in equipment and technology has made PCNL the gold standard for this disease, resulting in removal of stones with shorter recovery time and decreased morbidity and mortality, and with few complications Case Discussion A boy aged 13 years, underwent mini PCNL for treatment of left side renal stone causing hydronephrosis, previously evaluated by KUB X-Rray and non contrast CT scan. His retrograde-percutanous access to the collecting system was done under fluoroscopic guidance. At the end of procedure, patient revealed taut and distended abdomen. Aspiration revealed presence of intraperitoneal fluid. Patient was effectively treated with immediate placement of abdominal drain with improvement of clinical presentation Conclusion Hydroperitoneum is a rare complication of conventional PCNL. Based on our experience and review of published literature, our case of hydroperitoneum after mini PCNL, is the first of its kind. A high degree of sensitivity and knowledge of this complication during PCNL in children would help identify and manage this complication in future. We recommend examination of abdomen post-PCNL in every child before he/she is brought out of anesthesia.

Evaluation of an Integrated Smart Sensor System for Real-Time Characterization and Digitalization of Postoperative Abdominal Drain Output: A Pilot Study

Background: For centuries, surgeons have relied on surgical drains during postoperative care. Despite all advances in modern medicine and the area of digitalization, as of today, most if not all assessment of abdominal secretions excreted via surgical drains are carried out manually. We here introduce a novel integrated Smart Sensor System ( Smart Drain) that allows for real-time characterization and digitalization of postoperative abdominal drain output at the patient’s bedside. Methods: A prototype of the Smart Drain was developed using a sophisticated spectrometer for assessment of drain output. The prototype measures 10 × 6 × 6 cm and therefore easily fits at the bedside. At the time of measurement with our Smart Drain, the drain output was additionally sent off to be analyzed in our routine laboratory for typical markers of interest in abdominal surgery such as bilirubin, lipase, amylase, triglycerides, urea, protein, and red blood cells. A total of 45 samples from 19 patients were included. Results: The measurements generated were found to correlate with conventional laboratory measurements for bilirubin (r = .658, P = .000), lipase (r = .490, P = .002), amylase (r = .571, P = .000), triglycerides (r = .803, P = .000), urea (r = .326, P = .033), protein (r = .387, P = .012), and red blood cells (r = .904, P = .000). Conclusions: To our best knowledge, for the first time we describe a device using a sophisticated spectrometer that allows for real-time characterization and digitalization of postoperative abdominal drain output at the patient’s bedside.

Fatal pancreatic fistula after laparoscopic distal pancreatectomy for intraductal papillary mucinous carcinoma with pancreaticobiliary maljunction and sphincterotomized papilla: a case report

Background Pancreatic juice is constantly activated by contaminated bile in patients with pancreaticobiliary maljunction (PBM). Here, we report a case of laparoscopic distal pancreatectomy for a patient with PBM and sphincterotomized papilla, resulting in fatal pancreatic fistula. Case presentation A 79-year-old man was diagnosed with pancreatic intraductal papillary mucinous neoplasm and common bile duct stones. Endoscopic sphincterotomy was performed prior to surgery. The pancreatic duct was simultaneously visualized when the contrast agent was injected into the common bile duct. Sudden bleeding was observed from the abdominal drain on postoperative day (POD) 6. Emergent stent graft placement and coil embolization were performed for bleeding from the splenic artery. On POD 9, the drainage fluid changed to yellowish in color with bile contamination. For internal drainage of the digestive fluid, endoscopic retrograde biliary tube and pancreatic drainage tube were placed. On POD 24, second emergent coil embolization was performed for bleeding from the left gastric artery. On POD 25, open abdominal drainage was performed. On POD 32, third emergent coil embolization was performed for bleeding from the gastroduodenal artery. Subsequently, remnant pancreatic resection was performed. On POD 39, massive bleeding was again observed from the abdominal drain. Emergency arterial portography revealed bleeding in the right wall of the superior mesenteric vein. The patient died of hemorrhagic shock on the same day. Conclusions The extreme risk of severe pancreatic fistula after distal pancreatectomy should be considered in patients with PBM and sphincterotomized papilla. In this extraordinary situation, surgeons should promptly decide whether to resect the remnant pancreas to prevent losing the patient.

EP.WE.484Conservative management of post-operative chyle leak after surgery for a large adrenal cavernous haemangioma

Post-operative chyle leak is a rare but recognised complication after abdominal surgeries particularly those involving dissection adjacent to the retroperitoneal lymph nodes and/or lymphatic systems. There are limited cases of post-operative chyle leak associated with adrenal surgery reported in the literature with no consensus on its management. Lymphatics of the adrenal gland drain into the thoracic duct via regional lymph nodes or directly into the cisterna chyli, posterior to the aorta. If not adequately managed, chyle leak can be associated with hypovolemia, electrolyte imbalances, malnutrition and immunosuppression. These consequences can be attributed to the loss of fluid, electrolytes, lipids, proteins, and immunoglobulins. We hereby report a case of post-operative chyle leak in a 79-year-old male who underwent an open left adrenalectomy, left nephrectomy, splenectomy and distal pancreatectomy for a large, 20.8cm left adrenal cavernous haemangioma. Chyle leak was confirmed on post-operative day 7 based on high levels of triglycerides in the abdominal drain output. Intra-operatively there was no evidence of lymphatic damage. However, the major abdominal surgery involving retroperitoneal viscera close to the lymphatic trunk predisposed the patient to this complication. The patient was managed conservatively with the aim of decreasing chyle production by dietary manipulation and use of somatostatin. Enteral nutrition was continued with a strict low-fat diet and regular dietician input. These strategies contributed to the gradual resolution of chyle leak and the patient’s recovery.

Safety and feasibility of a nurse-led ambulatory abdominal paracentesis service.

63 Background: Ascites is a common complication of cancer. Symptomatic ascites contributes to cancer-related morbidity and is distressing for patients (pts). Therapeutic abdominal paracentesis (TAP) provides symptom relief but requires specialized procedural knowledge and is usually performed in the inpatient setting with several days of hospitalization. Additionally, high hospital bed occupancy during the COVID-19 pandemic prevented timely admission for TAP. An Advanced Practice Nurse (APN)-led ambulatory TAP service was introduced at our center, with the aim of improving access to TAP and reducing hospital bed occupancy. Methods: A multidisciplinary team developed workflows and safety guidelines for TAP to enable right-siting of pts in a cancer day care unit. Pts were scheduled for radiologically guided insertion of abdominal drains in the morning before 10am to allow adequate time for drainage. Pre-procedure clinical examination and safety checks were performed by APNs in the day unit. Following the procedure, abdominal fluid was drained with concurrent administration of 20% IV albumin. Drains were removed by the APN and pts were examined before discharge on the same day. Data for all cancer pts requiring TAP in the day unit and hospital from 1 Jan to 30 Nov 2020 were extracted from the electronic medical record system. The primary outcome was length-of-stay (LOS). The primary safety outcome was adverse events in the day unit. Continuous data were compared using the t-test. Data analysis was done in SPSS version 22. Results: The number of TAPs performed in the day unit and general ward requiring hospitalization were 102 and 133, respectively. There was a significant reduction in average LOS with TAPs performed in the day unit vs. hospitalization (1.48 vs. 5.82 days, p<0.001) (Table). The mean difference was 4.34 (95% confidence interval 3.33 - 5.34) days saved per pt, or a saving of 443 inpatient bed days. The TAP day unit service encountered 10 adverse events (AEs) requiring admission to the ward for continued drainage. AEs were borderline baseline blood pressure, pt frailty and inability to care for an indwelling catheter. There were no infective or bleeding complications. The majority of TAPs (86.8%) were performed in one day, with the remainder over 2-days with the abdominal drain left in-situ and reattendance at the day unit the next day for further drainage. Differences in average length-of-stay with TAP in the hospital vs. day unit. Conclusions: An APN-led ambulatory abdominal paracentesis service is a safe alternative to inpatient paracentesis. Optimal utilization of a day unit enabled reduced LOS for pts with advanced cancer. This reduction in LOS was critical during a pandemic where bed demand was high. This was possible from advanced scheduling and control over the day unit capacity.[Table: see text]

EP.TH.282Adherence to ERAS® Society recommendations following elective colonic surgery (2012) in regard to urinary drainage, postoperative nutritional care and intra-abdominal drainage

Aims Evaluating adherence to ERAS® recommendations for post-operative urinary drainage, nutritional care and intra-abdominal drain placement in elective colorectal surgery. Methods Approval was obtained by the audit department of a university teaching hospital. Data was collected prospectively over a seven-week period for nineteen (n = 19) patients. Results were compared against the standard set by the ERAS® Society (2012). Results Right colonic surgery (n = 5): catheter removed on post-operative day (POD) 1 n = 1 (20%), normal diet started on POD 0 or 1 n = 3 (60%), IV fluids discontinued on POD 1 n = 3 (60%) and n = 4 (80%) did not have a drain placed. High anterior resection or left/subtotal colectomy (n = 9): catheter removed on POD 1 n = 3 (33%), normal diet started on POD 0 or 1 n = 4 (44%), IV fluids discontinued on POD 1 n = 3 (33%) and n = 2 (22%) did not have a drain placed. Low rectal surgery (n = 4*, *one patient, n = 1, excluded from all domains except intra-abdominal drainage due to immediate post-op complication): catheter removed on POD 3 n = 4 (100%), normal diet started on POD 0 or 1 n = 2 (50%), IV fluids discontinued on POD 1 n = 1 (25%) and all patients had a drain placed n = 5 (100%). Conclusions Adherence for urinary drainage in low rectal surgery and intra-abdominal drainage for right colonic surgery was satisfactory. Multiple areas of improvement were identified, in order to optimise compliance, and recommendations were generated. The exception may be drains for lower rectal surgery where recent data has recommended selective drain placement.