Intraperitoneal drain placement and outcomes after elective colorectal surgery: international matched, prospective, cohort study

Despite current guidelines, intraperitoneal drain placement after elective colorectal surgery remains widespread. Drains were not associated with earlier detection of intraperitoneal collections, but were associated with prolonged hospital stay and increased risk of surgical-site infections.Background Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Methods COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien-Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001). Conclusion Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Bupivacaina ou bupivacaina e morfina intra-articular pós reconstrução do LCA Intra-articular bupivacaine or bupivacaine and morphine after ACL reconstruction

OBJETIVO: A cirurgia de reconstrução do LCA é hoje uma das mais realizadas e o controle da dor pós-operatória faz parte das prioridades do cirurgião. Dentro do arsenal de analgesia temos a aplicação intra-articular de drogas, sendo a mais estudada a bupivacaina associada ou não a morfina. Neste estudo comparamos a aplicação de bupivacaina associada ou não a morfina com grupo controle, após reconstrução do LCA com enxerto de tendões flexores. MÉTODOS: Quarenta e cinco pacientes foram randomizados em três grupos, sendo que no grupo I foi aplicado ao fim da cirurgia 20ml de soro fisiológico intra-articular, no grupo II 20ml de bupivacaina 0,25% e no grupo III bupivacaina 0,25% associado a 1mg de morfina. Os grupos foram avaliados quanto ao grau de dor pela escala analógica visual com 6, 24 e 48 horas de pós-operatório. RESULTADOS: O grupo III teve menos dor em todos os momentos, porém a dor não foi tão intensa em todos os grupos a ponto de necessitar medicações extras além do protocolo estabelecido. CONCLUSÃO: A aplicação intra-articular destas medicações pós-reconstrução do LCA com enxerto dos tendões flexores quando realizada sob anestesia raquideana não traz vantagens suficientes para fazer seu uso regularmente. Nível de Evidência II, Ensaio Clínico Randomizado de Menor Qualidade.<br>OBJECTIVE: Reconstructive surgery of the ACL is one of the most commonly performed surgeries today and the control of postoperative pain is part of the priorities of the surgeon. Within the arsenal of analgesia we have the intra-articular application of drugs, and the most studied one is bupivacaine with or without morphine. This study compared the application of bupivacaine with or without morphine with a control group after ACL reconstruction with flexor tendon graft. METHODS: Forty-five patients were randomized into three groups: in group I, 20 ml of saline were applied intra-articularly at the end of the surgery; in group II, 20 ml of bupivacaine 0.25%; and in group III, bupivacaine 0.25% associated with 1 mg of morphine. The groups were assessed for degree of pain by the Visual Analog Scale at 6, 24 and 48 hours postoperatively. RESULTS: Group III had less pain at all times, but the pain was not as intense in all groups to the point of needing extra medications beyond the established protocol. CONCLUSION: The intra-articular application of these medications after ACL reconstruction with flexor tendon graft when performed under spinal anesthesia is not useful enough to use regularly. Level of Evidence II, Lesser quality RCT