“Historically, prophylactic intraoperative peritoneal drain placement has been advocated after hepatectomy in order to identify and drain bile leaks and decrease the risk of potential perihepatic fluid collections and abscess formation postoperatively. Several small randomized trials have suggested, however, that routine abdominal drainage after elective liver resection may not be necessary.”
“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.”
One discussion this week involved etiologies of postpancreatectomy hemorrhage.
Reference: Yekebas EF, et al. Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1669 consecutive pancreatic resections. Annals of Surgery. 2007 Aug;246(2):269-280. doi:10.1097/01.sla.0000262953.77735.db
Summary: With the purpose of creating algorithms for managing postpancreatectomy hemorrhage (PPH), Yekebas et al (2007) restrospectively analyzed more than 1669 pancreatic resections conducted between 1992 and 2006. They concluded that the prognosis of postpancreatectomy hemorrhage (PPH) is primarily dependent on the presence of “preceding pancreatic fistula” (p.269).
“Prevalence of malnutrition in chronic liver disease ranges between 10% and 100%, depends on severity of liver disease. Prevalence is more in patients with alcoholic cirrhosis compared to nonalcoholic cirrhotics. 3 Malnutrition is seen in all clinical stages but is easier to detect in advanced stages of liver cirrhosis. Many patients have subtle changes such as fat soluble vitamin deficiency, anemia from iron, folate or pyridoxine deficiency, altered cell-mediated immune functions and minimal loss of muscle mass, while patients with end-stage liver disease have muscle wasting, decreased fat stores, and cachexia.”
This week’s discussion included risk scoring and management of postoperative pancreatic fistula.
Nahm CB, Connor SJ, Samra JS, Mittal A. Postoperative pancreatic fistula: a
review of traditional and emerging concepts. Clin Exp Gastroenterol. 2018 Mar
15;11:105-118.
Prediction: “Biochemical markers of POP after pancreatic resection are evident from the first postoperative day. These include serum amylase and lipase, and urinary trypsinogen-2. In an observational study of 61 patients undergoing pancreatic resection, the presence of POP on the first postoperative day as determined by these markers was found to be a strong predictor of the development of POPF (OR 17.81, 95% CI 2.17–145.9) [128]
Acute variceal bleeding is the major cause of mortality in patients with cirrhosis. The standard medical and endo-scopic treatment has reduced the mortality of variceal bleeding from 50% to 10–20%. The refractory variceal bleedis either because of failure to control the bleed or failure of secondary prophylaxis. The patients refractory to standardmedical therapy need further interventions. The rescue therapies include balloon tamponade, self-expanding metalstents (SEMS) placement, shunt procedures, including transjugular intrahepatic portosystemic shunt (TIPS),balloon-occluded retrograde transvenous obliteration (BRTO), and endoscopic ultrasound (EUS) guided coiling.
Cirrhotic liver disease is an important cause of peri-operative morbidity and mortality in general surgical patients. Early recog-nition and optimization of liver dysfunction is imperative before any elective surgery. Patients with MELD <12 or classified asChild A have a higher morbidity and mortality than matched controls without liver dysfunction, but are generally safe for electiveprocedures with appropriate patient education.
Surgical Focus 