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

Glomerulonefrite membranoproliferativa tipo II : caso clínico

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014Membranoproliferative glomerulonephritis type II or dense deposit disease is a rare form of glomerulonephritis, where the main pathophysiological mechanism is excess activation of the alternative pathway of complement, which results in the deposition of complement component in the glomerular basement membrane. This is a pattern of glomerular injury with specific changes in the renal biopsy, namely mesangial hypercelularity, endocapilar proliferation and double contour formation along the glomerular capillary walls. The main initial clinical manifestations are proteinuria and/or hematuria. We present the clinical case of a 49 year-old male, with corticoresistent nephrotic syndrome associated with chronic kidney disease. Analytically the patient presented nephrotic proteinuria, hypoalbuminemia, dyslipidemia and hypocomplementemia, manifesting clinically edema and hypertension. After excluding secondary causes and performing renal biopsy, the diagnosis of idiopathic membranoproliferative glomerulonephritis, with deposits of IgG, C3 and C1/dense deposit disease was made, with poor prognosis criteria for evolution to terminal kidney disease. Diuretic, antihypertensive and anticoagulant therapy were made, having been required the association of cyclophosphamide with corticotherapy for stabilization of renal function. Renal function monitoring and therapeutic efficacy should be continued regularly.A glomerulonefrite membranoproliferativa do tipo II ou doença de depósitos densos é uma forma rara de glomerulonefrite, onde o principal mecanismo fisiopatológico é a activação excessiva da via alternativa do complemento, o que resulta na deposição de múltiplos componentes do complemento na membrana basal glomerular. Trata-se de um padrão de lesão glomerular com alterações específicas na biópsia renal, nomeadamente hipercelularidade mesangial, proliferação endocapilar e formação de duplo contorno ao longo das paredes capilares glomerulares. As principais manifestações clínicas iniciais são proteinúria e/ou hematúria. É apresentado o caso clínico de um indivíduo do sexo masculino, de 49 anos, de raça melanodérmica, com síndrome nefrótico corticoresistente e associado a doença renal crónica. Analiticamente apresentava proteinúria nefrótica, hipoalbuminémia, dislipidémia e hipocomplementémia, manifestando edema e hipertensão arterial. Após exclusão de causas secundárias e realização de biópsia renal, foi feito o diagnóstico de glomerulonefrite membranoproliferativa idiopática, com depósitos de IgG, C3 e C1 / doença de depósitos densos, com critérios de mau prognóstico para evolução para doença renal terminal. Foi feita terapêutica diurética, anti-hipertensora e anticoagulante, tendo sido necessária a associação de ciclofosfamida com corticoterapia para estabilização da função renal. A vigilância da função renal e da eficácia terapêutica deve ser continuada regularmente

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

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

Safety and efficacy of intraperitoneal drain placement after emergency colorectal surgery. An international, prospective cohort study

Intraperitoneal drains are often placed during emergency colorectal surgery. However, there is a lack of evidence supporting their use. This study aimed to describe the efficacy and safety of intraperitoneal drain placement after emergency colorectal surgery. Method: COMPlicAted intra-abdominal collectionS after colorectal Surgery (COMPASS) is a prospective, international, cohort study into which consecutive adult patients undergoing emergency colorectal surgery were enrolled (from 3 February 2020 to 8 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 III-V). Multivariable logistic and Cox proportional hazards regressions were used to estimate the independent association of the outcomes with drain placement. Results: Some 725 patients (median age 68.0 years; 349 [48.1%] women) from 22 countries were included. The drain insertion rate was 53.7% (389 patients). Following multivariable adjustment, drains were not significantly associated with reduced rates (odds ratio [OR] = 1.56, 95% CI: 0.48-5.02, p = 0.457) or earlier detection (hazard ratio [HR] = 1.07, 95% CI: 0.61-1.90, p = 0.805) of collections. Drains were not significantly associated with worse major postoperative complications (OR = 1.26, 95% CI: 0.67-2.36, p = 0.478), delayed hospital discharge (HR = 1.11, 95% CI: 0.91-1.36, p = 0.303) or increased risk of SSIs (OR = 1.61, 95% CI: 0.87-2.99, p = 0.128). Conclusion: This is the first study investigating placement of intraperitoneal drains following emergency colorectal surgery. The safety and clinical benefit of drains remain uncertain. Equipoise exists for randomized trials to define the safety and efficacy of drains in emergency colorectal surgery