Laparoscopic Cholecystectomy Versus Percutaneous Catheter Drainage for Acute Cholecystitis in High Risk Patients (CHOCOLATE): Multicentre Randomised Clinical Trial

Loozen CS, et al. Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial. BMJ. 2018 Oct 8; 363:k3965.

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what this study adds

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Prophylactic cerebrospinal fluid drainage for thoracic endovascular aortic repair (TEVAR)

Mazzeffi M, et al. Contemporary Single-Center Experience With Prophylactic Cerebrospinal Fluid Drainage for Thoracic Endovascular Aortic Repair in Patients at High Risk for Ischemic Spinal Cord Injury. J Cardiothorac Vasc Anesth. 2018 Apr;32(2): 883-889.

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Flowchart TEVAR high risk ISCI outcomes_complications

Fig 2. Flowchart showing patient outcomes and complications in the cohort. SCI, spinal cord injury; SCPP, spinal cord perfusion pressure; TEVAR, thoracic endovascular aortic repair.

In summary, in a contemporary cohort of 102 patients undergoing TEVAR with a high risk for ischemic SCI, prophylactic CSF drainage was associated with a 2% paraplegia rate and 3.9% rate of drain-related complications. No patient with a drain-related complication had permanent injury, and only 1 patient required surgical intervention for spinal cord compression from epidural hematoma. Three patients with new paraplegia after surgery improved with targeted MAP increases and CSF drainage aimed to increase SCPP by 25%, whereas 1 patient’s symptoms never improved. These data further support the safety of prophylactic lumbar CSF drainage in patients undergoing TEVAR with a high risk for ischemic SCI.”

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Step-up vs open necrosectomy for pancreatitis: the PANTER trial’s 2019 followup

One discussion this week included the question of step-up approach versus open necrosectomy for pancreatitis.


Summary: 

BACKGROUND: The 2010 randomized PANTER trial in (infected) necrotizing pancreatitis found a minimally invasive step-up approach to be superior to primary open necrosectomy for the primary combined endpoint of mortality and major complications, but long-term results are unknown.

NEW FINDINGS: With extended follow-up, in the step-up group, patients had fewer incisional hernias, less exocrine insufficiency and a trend towards less endocrine insufficiency. No differences between groups were seen for recurrent or chronic pancreatitis, pancreatic endoscopic or surgical interventions, quality of life or costs.

IMPACT: Considering both short and long-term results, the step-up approach is superior to open necrosectomy for the treatment of infected necrotizing pancreatitis.

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Early vs late drain removal after pancreatectomy

One discussion this week included early vs late drain removal in pancreatectomy.


References: Beane JD, et al. Variation of drain management after pancreatoduodenectomy: early versus delayed removal. Annals of Surgery. 2017 Oct. doi: 10.1097/SLA.0000000000002570

Deminski J, et al. Early removal of intraperitoneal drainage after pancreatoduodenectomy in patients without postoperative fistula at POD3: results of a randomized clinical trial. Journal of Visceral Surgery. 2019 Jan 31. pii: S1878-7886(18)30084-5. doi: 10.1016/j.jviscsurg.2018.06.006

Summary:  Early drain removal after pancreatoduodenectomy, when guided by postoperative day (POD) 1 drain fluid amylase (DFA-1), is associated with reduced rates of clinically relevant postoperative pancreatic fistula (CR-POPF).

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