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

La complessità strutturale dei distretti industriali: un approccio basato sulle similarità multi-dimensionali

La ricerca analizza l'agglomerazione territoriale a partire dalla premessa che l'intrinseca complessità socio economica dei cosiddetti distretti è un fattore cruciale nella definizione di percorsi di sviluppo locale. Con l'aiuto di una famiglia di reti neurali artificiali nota come Self-Organising Maps (SOM), lo studio ottiene una mappatura originale degli agglomerati produttivi in Italia, e quindi una caratterizzazione che va oltre il concetto di specializzazione e si basa sul concetto di multi -similarità dimensionale nella distribuzione delle risorse

Transduodenal papillostomy as a routine procedure in managing choledocholithiasis

The purpose of this study was to evaluate the results of transduodenal papillostomy as a routine procedure in managing choledocholithiasis in treating common bile duct (CBD) stones. From 1973 to 1978, 117 patients underwent transduodenal papillostomy for CBD lithiasis. The operation was carried out in standard manner, and all patients had preoperative telecholangioscopy, cholangiography, and biliary manometry. The mean age of patients was 53.7 years, and women predominated in a ratio of 4.5:1.0. Papillostomy was performed together with cholecystectomy for CBD stones in 111 patients (group 1). In five patients, we had to perform a choledochotomy to remove the stones after an unsuccessful papillostomy (group 2). Eight patients who previously had cholecystectomies underwent papillostomy for retained or recurrent stones (group 3), and three patients had a choledochoduodenostomy for recurrent stones after a previous cholecystectomy and papillostomy (group 4). Complications included two deaths in group 1 (1.9%). No mortality was observed in groups 2 to 4. Moreover, the overall morbidity was due to six cases of wound infection, one case of postoperative bleeding, one case of phlebitis, and three cases of cholangitis. The mean length of hospital stay was 12.9 days, considering all the groups. Lack of confidence with this procedure may explain the different results reported in the literature for transduodenal papillostomy, which on the basis of this study has been shown to be a valid alternative to supraduodenal choledochotomy in treating CBD stones