Author Archives: John

Role of Drain Placement in Major Hepatectomy

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“The use of drains in surgery has been practiced for many years. Prophylactic drainage of the abdominal cavity is employed to prevent the formation of collections and abscesses and for early detection of complications. For years, there has been debate as to whether the use of prophylactic drains has more advantages than disadvantages. For many procedures such as routine colon resection, cholecystectomy, and appendectomy, the use of prophylactic drains has been abandoned as studies have shown that drains do not lower the rate of postoperative complications. However, there is still debate of whether to leave a drain routinely after major liver resection.”

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Postoperative atrial fibrillation: Predictors and risk of mortality

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“Atrial fibrillation, the most common sustained dysrhythmia, is a common postoperative complication. Previous studies have shown that the incidence, prevalence, and associated morbidity and mortality increase progressively with age.
Development of POAF and mortality is dependent upon a wide range of factors not limited to age and medical comorbidities. Although a patient may be at an increased risk for POAF this does not mean they are at an increased risk for mortality.”

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Use of lytics in patients with pleural empyema

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“Parapneumonic effusions evolve through a spectrum of three stages. The initial exudative stage (stage 1; analogous to simple parapneumonic effusion) is characterised by an increased outpouring of fluid into the pleural space mediated by capillary permeability. If left
untreated, persistent inflammation with the associated rise in fluid plasminogen activator inhibitor causes a decrease in fluid fibrinolytic concentrations. During this second stage (stage 2; fibrinopurulent stage), as the effusion becomes infected, septations and adhesions
induced by fibrin deposition divide the space into pockets or locules. With the proliferation of fibroblasts and the formation of a pleural peel, lung expansion becomes restricted and can result in a non-expandable lung. It is important to initiate all medical treatment before this
final so-called organising stage (stage 3) ensues.”

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Management of Empyema

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“Empyema thoracis, from the Greek, is defined as ‘‘pus in the chest.’’ The most common precursor of empyema is bacterial pneumonia and subsequent parapneumonic effusion. Other causes of empyema include bronchogenic carcinoma, esophageal rupture, blunt or penetrating chest trauma, mediastinitis with pleural extension, infected congenital cysts of the airway and esophagus, extension from sources below the diaphragm, cervical and
thoracic spine infections, as well as postsurgical etiologies.”

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Postoperative Inflammatory Response in Crohn’s Patients

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“Crohn’s Disease is an inflammatory bowel disease with a multifactorial pathophysiology. Genetic, immune, gut microbiota, and other environmental factors play a role in the occurrence and maintenance of bowel inflammation. Unfortunately, despite the development of new drugs, about half of all CD patients will need surgery during their disease course.”

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B-SAFE landmarks

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“The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include:
(1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations
(2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury
(3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy
(4) proper gallbladder retraction
(5) safe use of various energy devices
(6) understanding the critical view of safety, including its doublet view and documentation
(7) awareness of various error traps (e.g., fundus first technique)
(8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases
(9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy
(10) understanding the concept of time-out.”

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Bismuth classification, detection, and management of Bile Duct Injury during laparoscopic cholecystectomy

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“Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4–1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success.”

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