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

Laser applications and autofluorescence

The diagnostic pathway for oral suspicious lesions usually starts with the clinical examination based on inspection and palpation of the oral mucosa. Such a phase is strongly related to the experience of the operator. Moreover, oral epithelial dysplasia and early oral carcinomas may already be present within areas of macroscopically intact oral mucosa. A great interest for techniques potentially improving the diagnostic accuracy has developed in several fields of surgical oncology in order to increase the specificity and sensitivity of the conventional diagnostic pathway. The development of noninvasive methods for real-time screening of neoplastic changes in oral cavity may be associated with the improvement of patients' quality of life and survival rate. The analysis of tissue autofluorescence (AF) for improving sensitivity and specificity in cancer diagnosis has been proposed for different organs, including colon, lung, cervix, and esophagus. Particularly, there are several evidences supporting the effectiveness of this technique in head and neck cancer diagnosis. Autofluorescence shows high specificity and sensitivity for oral cancer and precancerous lesions: 72.4% and 63.79%, respectively. It can also provide valuable information for diagnosis, for planning of margin resection in surgical excision, and for monitoring the therapeutic response during follow-up. Direct visual fluorescence examination (DVFE) is based on the action of irradiation of specific wavelengths, between 375 and 440 nm, which excites some natural fluorochromes which show fluorescence in the range of the green color. The analysis of the lesions with AF tools must be performed in a dark environment to avoid the interference of white light wavelengths and to improve the quality of recorded images. Healthy oral mucosa emits fluorescence, detectable as green light. Cell and tissues within dysplastic and malignant lesions display modifications of the amount, distribution, and chemical-physical properties of the endogenous fluorophores. This results in an autofluorescence pattern variation that can be potentially used at diagnostic level. Loss of autofluorescence (LAF) seems to increase in correspondence to the progression of dysplasia, and altered tissue appears dark (brown to black). LAF in dysplasia and carcinoma seems to be connected to different mechanisms, such as altered metabolic activity of dysplastic keratinocytes, altered structure of subepithelial collagen, and absorbance of light by increased blood circulation due to inflammatory phenomena in dysplastic tissue and cancer. AF can be used for guiding incisional biopsy and in the excision to identify the resection margins