Is hydronephrosis a risk factor for complications in conventional percutaneous nephrolithotomy?

Objective: To assess Hydronephrosis as a Risk Factor for complications in Conventional Percutaneous Nephrolithotomy. Study Design: Cross Sectional Descriptive study. Setting: Kidney Centre Post Graduate Training Centre, Karachi. Period: January to December 2020. Material & Methods: This study was done to know post-operative complications including bleeding, infection, and incomplete stone clearance in patients with or without hydronephrosis undergoing percutaneous nephrolithotomy. After applying the inclusion/ exclusion criteria it was found that the patients with hydronephrosis had less bleeding as compared to the no hydronephrosis group. In the same way, they also had fewer nephrostomy tubes placed, and chest drain insertion. All other complications were approximately the same in each group. Patients were selected using non-probability consecutive sampling technique. Percentage and frequencies were determined for quantitative variables. Mean and standard deviation were determined for quantitative variables. Results: Total 300 cases were studied fulfilling inclusion criteria. There were 70.07% male and 29.3% female cases. Age range of the patients was 18-60 years. There were 52.7% cases with hydronephrosis, placed in one group and 47.3% cases were without hydronephrosis placed in other group. Most common complication was postoperative bleeding reported in 48.9% cases with hydronephrosis as compared to 56.2% cases without hydronephrosis. Mean operative time was 115.7 ± 41.9 minutes in patients with hydronephrosis and 135 ± 35.4 minutes in patients without hydronephrosis. Conclusion: Patients with hydronephrosis experienced less postoperative complications, after PCNL as compared to those without hydronephrosis.

A randomised controlled trial of intrapleural balloon intercostal chest drains to prevent drain displacement

BackgroundChest drain displacement is a common clinical problem, occurring in 9–42% of cases and results in treatment failure or additional pleural procedures conferring unnecessary risk. A novel chest drain with an integrated intrapleural balloon may reduce the risk of displacement.MethodsProspective randomised controlled trial comparing the balloon drain to standard care (12 F chest drain with no balloon) with the primary outcome of objectively-defined unintentional or accidental chest drain displacement.Results267 patients were randomised (primary outcome data available in 257, 96.2%). Displacement occurred less frequently using the balloon drain (displacement 5/128, 3.9%; standard care displacement 13/129, 10.1%) but this was not statistically significant (Odds Ratio (OR) for drain displacement 0.36, 95% CI 0.13 to 1.0, χ2 1df=2.87, p=0.09). Adjusted analysis to account for minimisation factors and use of drain sutures demonstrated balloon drains were independently associated with reduced drain fall out rate (adjusted OR 0.27, 95% CI 0.08 to 0.87, p=0.028). Adverse events were higher in the balloon arm than the standard care arm (balloon drain 59/131, 45.0%; standard care 18/132, 13.6%; χ2 1df=31.3, p<0.0001).ConclusionBalloon drains reduce displacement compared with standard drains independent of the use of sutures but are associated with increased adverse events specifically during drain removal. The potential benefits of the novel drain should be weighed against the risks, but may be considered in practices where sutures are not routinely used.

Selective Bronchial Occlusion for Treatment of a Bronchopleural Fistula in an Extremely Preterm Infant

Neonatal pulmonary air leak commonly occurs as a complication of mechanical ventilation in infants with underlying hyaline membrane disease. They can commonly be managed conservatively or with the application of a chest drain, but some severe cases pose a significant challenge in finding an alternative therapeutic solution. Selective bronchial occlusion represents an unconventional rescue therapy for treating bronchopleural fistula resistant to the standard therapy. A 27-week gestation preterm infant ventilated for respiratory distress syndrome developed tension right-sided pneumothorax. Conventional modalities of treatment were tried and were unsuccessful. Intermittent selective bronchial occlusion with a Fogarty’s catheter and high-frequency oscillatory ventilation resulted in considerable improvement in the infant’s clinical condition and radiographic findings.

Single Chest Drain Practice Reduces Discharge Opioid Prescriptions in Thoracic Surgery

Introduction Chest drains are placed following pulmonary resection to promote lung re-expansion. The superiority of two chest drains at preventing postoperative complications has not been established, and practice remains largely dictated by surgeon preference. We sought to compare patient outcomes based on number of chest drains used. Methods This is a retrospective analysis including patients undergoing lobectomies and segmentectomies between March 2016 and April 2020. Patients were categorized based on number of chest drains placed and were matched 1:1 using the nearest neighbor (greedy) technique. Our primary outcome was opioid prescriptions at discharge (in morphine equivalent daily dose [MEDD]). Associations were tested using multilevel mixed-effects regression to account for variability between surgeons. Results A total of 1,094 patients met inclusion criteria. Single chest drain was used in 922 patients, whereas 172 had two chest tubes. After matching, there were 111 patients in each group. In multilevel mixed-effects logistic regression, patients treated with a single chest drain received fewer opioid prescriptions (β: −194 MEDD, 95% confidence interval [CI]: −302 to −86 MEDD, p < 0.01), were more likely to be opioid-free at hospital discharge (odds ratio [OR] = 2.11, 95% CI: 1.08–4.12, p = 0.03), and had lower readmission rates within 30 days (OR = 0.33, 95% CI: 0.13–0.84, p = 0.02). Single chest drain practice did not affect the risk of pulmonary complications and there was no statistically significant difference in length of hospital stay (3 days [interquartile range: 2–5] vs. 4 days [3–6], p = 0.08). Conclusion Single chest drain practice in lobectomies and segmentectomies was associated with less opioid prescription requirement without any increase in complications.

P-OGC27 Chyle Leak following Oesophagectomy: ‘A Retrospective 10-year Single-Site Experience of a Tertiary Centre.’

Background Chyle leak is a relatively uncommon but well-recognised complication following Oesophagectomy which carries significant morbidity and mortality if not treated actively. Evidence suggests the incidence rate of chyle leak post oesophagectomy can range from 0.4% to 21%. The aim of this study was to describe our experience in managing this complication. Methods This was a retrospective study, using the electronic database, to analyse our incidence of chyle leak in all patients who underwent elective oesophagectomy from April 2009 to December 2019 in a Tertiary Upper GI cancer centre. The diagnosis was confirmed by high persistent chest drain output, the colour of the fluid produced in the chest drain and its ‘content’ including fluid triglyceride levels and the presence of chylomicrons. Results Between 2009-2019, a total of 550 patients underwent Oesophagectomy. The median length of stay was 13 (Range 3 to 148) days. The median age was 63 years (45 to 82) with M:F 2:1. Chyle leak was identified in 24 patients (4.4%); Patients who were managed surgically were 83.3%(n = 20) with a median LOS of 20 days (Range 11 to 148) and mortality of 5%(n = 1). 16.7%(n = 4) were managed conservatively with a median LOS of 31 days (Range 14 to 51) and mortality of 0%. All 24 patients with chyle leak had neoadjuvant chemotherapy as part of treatment with radical intent. Conclusions Low mortality rates with chyle leak can be achieved with a high index of suspicion and early surgical intervention. This is crucial in reducing the length of stay in hospital and morbidity. Conservative management is suitable in low volume chyle leak and cases clinically responding to medical management.

P-EGS25 Boerhaave’s Syndrome Secondary to Symptomatic COVID-19 Infection

Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has infected over 140 million people worldwide (1). COVID-19 symptoms primarily involve the respiratory system. However, recent data suggests that gastrointestinal symptoms occur in 11-61% of cases (2, 3).Boerhaave’s syndrome is a rare and dangerous disorder of the gastrointestinal tract, associated with a mortality rate of up to 50% (4). It most commonly occurs due to a lack of coordination between upper and lower oesophageal sphincters during forceful emesis, leading to an abrupt rise in intra-oesophageal pressures which leads to a transmural tear (5). Less commonly, a tear can be secondary to prolonged coughing (6). The majority of tears occur in the distal posterolateral third of the oesophagus and have an average length of 2.2 cm (7). Risk factors include males, excess alcohol or food consumption (6). We present a case of Boerhaave’s syndrome secondary to prolonged coughing, from COVID-19 infection. The tear was 8 cm in length in the mid anterior oesophagus. The patient survived a major operation and prolonged intensive care stay. Meloy et al. (8) published one case of oesophageal rupture in symptomatic COVID-19 – unfortunately the patient passed away before intervention. Methods A 75-year-old Caucasian female was day seven of COVID-19 infection and had been coping in the community with a continuous dry cough and mild shortness of breath. She presented to Accident and Emergency in the late afternoon when her cough developed into unremitting retching, vomiting, a global headache and epigastric pain disproportionate to presentation. No associated haematemesis or change in bowel habit. Past medical history was significant for hypertension, hypothyroidism, depression and anxiety. Previous surgical history included an open appendicectomy, cholecystectomy and resection of a melanoma. She was previously independent, consumed alcohol socially, a non-smoker and compliant with her regular medications.A CT chest with contrast demonstrated distal oesophageal rupture transversely with pneumomediastinum and extensive surgical emphysema in the neck and secondary bilateral pleural effusions, consistent with Boerhaave’s syndrome. The patient was taken to theatre the next morning for an oesophago-gastro-duodenoscopy (OGD), right posterolateral thoracotomy and primary repair of the oesophageal perforation.On endoscopy, an 8cm defect in the anterior oesophagus starting at the T4 vertebral level was identified and was repaired using tunnelled permanent mesh. During the surgery, mediastinitis was noted and washed out. The antimicrobial therapy was altered post-operatively to intravenous tazocin and fluconazole. Results The management of this patient was a huge multidisciplinary team achievement. She spent forty-six days recovering in ICU, intubated, ventilated and sedated with noradrenaline vasopressor support. The patient developed a severe acute kidney injury, requiring haemofiltration. The mediastinal fluid culture grew Enterococcus faecalis, sensitive to vancomycin and antibiotic therapy was adjusted accordingly. The patient’s recovery was burdened by seizures, whilst being weaned off sedation, and episodes of bradycardia and asystole, most of which were self-resolving except one requiring thirty seconds of cardio-pulmonary resuscitation. After chest drain removal, the patient redeveloped a right sided loculated pleural effusion so a further drain was inserted.A gastrografin contrast swallow study performed thirty-five days post-operatively demonstrated no evidence of contrast leak although some tracheobronchial aspiration. She was later stepped down to the ward and recovered very well. However, a component of post-ICU delirium and low mood was persistent. The patient had a repeat water-soluble contrast study on day 77 which demonstrated a contained anastomotic leak, managed conservatively. She was deemed medically ready for discharge at day 110. She was readmitted due to dysphagia secondary to a stricture at the site of mesh repair. OGD was performed and a stent was inserted. Conclusions COVID-19 infection may lead to an abnormal presentation of Boerhaave’s syndrome, with oesophageal tears being secondary to coughing, longer and more proximal.Peri-operative morbidity in COVID patients is elevated and clinicians should consider the short and long term implications of this to provide a holistic approach to care. Clinicians should maintain an awareness of the diversity of COVID-associated complications whilst ensuring that they do not succumb to the diagnostic overshadowing that becomes commonplace during a pandemic.

A simple size-tailored algorithm for the removal of chest drain following minimally invasive lobectomy: a prospective randomized study

Background The pleural space can resorb 0.11–0.36 ml/kg of body weight/hour (h) per hemithorax. There are only a limited number of studies on thresholds for chest drain removal (CDR) and all are based on arbitrary amounts, for example, 300 ml/day. We studied an individualized size-based threshold for CDR–specifically 5 ml/kg, a simple, easily applicable measure. Methods This is a single-center prospective randomized trial enrolling 80 patients undergoing VATS lobectomy. There were two groups: an experimental (E) group, in which once the daily output went down to 5 ml/kg the chest drain was removed and a control (C) group, with chest drain removal as per our current practice of less than 250 ml/day. Results The groups did not differ in pre- and peri- and postoperative characteristics, except for chest drain duration (mean, SD 2.02 ± 0.97 vs. 3.25 ± 1.39 days, p < 0.001) and length of hospital stay (median, IQR 4.5; 3 vs. 6; 2.75 days, p = 0.008) in favor of E group. The re-intervention rate was the same in both groups (once in each group). Conclusion The new threshold for chest drain removal following thoracoscopic lobectomy of 5 ml/kg/d leads to both shorter chest drainage and hospital stay without apparent increase in morbidity. (Clinical registration number: DRKS00014252).

Subxiphoid Video-Assisted Thoracoscopic Surgery for Lung Resection Under Spontaneous Ventilation: Case Report

This case report describes two patients that underwent successful video-assisted thoracoscopic surgery (VATS) lung resections under spontaneous ventilation using the uniportal subxiphoid approach. The authors performed lung wedge resection in both patients under local anesthesia without using of a Foley catheter, arterial line, or intercostal chest drain. Only intravenous drugs and an oxygen mask with reservoir bag were used. The postsurgical course for both patients was uneventful. Both were discharged on postoperative day 2 and were doing well at 1- and 3-month follow-ups. Keywords: Subxiphoid approach; Pulmonary resection; Lung cancer