Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. French Association for Surgical Research.

OBJECTIVE: We investigated the role of drainage in the prevention of complications after elective rectal or anal anastomosis in the pelvis. Anastomotic leakage after colorectal resection is more prevalent when the anastomosis is in the distal or infraperitoneal pelvis than in the abdomen. The benefit of pelvic drains versus their potential harm has been questioned. Drain-related complications include (1) those possibly benefiting from drainage (leakage, intra-abdominal infection, bleeding) and (2) those possibly caused by drainage (wound infection or hernia, intestinal obstruction, fistula). METHODS: Between September 1990 and June 1995, 494 patients (249 men and 245 women), mean age 66 +/- 15 (range 15 to 101) years, with either carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another disorder located anywhere from the right colon to the midrectum undergoing resection followed by rectal or anal anastomosis were randomized to undergo either drainage (n = 248) with 2 multiperforated 14F suction drains or no drainage (n = 246). The primary end point was the number of patients with one or more postoperative drain-related complications. Secondary end points included severity of these complications as assessed by the rate of related repeat operations and associated deaths as well as extra-abdominally related morbidity and mortality. RESULTS: After withdrawal of 2 patients (1 in each group) both groups were comparable with regard to preoperative characteristics and intraoperative findings. The overall leakage rate was 6.3% with no significant difference between those with or without drainage. There were 18 deaths (3.6%), 8 (3.2%) in those with drainage and 10 (4%) in those without drainage. Five patients with anastomotic leakage died (1%), 3 of whom had drainage. There were 32 repeat operations (6.5%) for anastomotic leakage 11 in the group with drainage and 4 in the group with no drainage. The rate of these and the other intra-abdominal and extra-abdominal complications did not differ significantly between the 2 groups. CONCLUSION: Prophylactic drainage of the pelvic space does not improve outcome or influence the severity of complications.

Omentoplasty in the prevention of anastomotic leakage after colonic or rectal resection: a prospective randomized study in 712 patients. French Associations for Surgical Research.

OBJECTIVE: To investigate the role of omentoplasty (OP) in the prevention of anastomotic leakage after colonic or rectal resection. SUMMARY BACKGROUND DATA: It has been proposed that OP--wrapping the omentum around the colonic or rectal anastomosis--reinforces intestinal sutures with the expectation of lowering the rate of anastomotic leakage. However, there are no prospective, randomized trials to date to prove this. METHODS: Between September 1989 and March 1994, a total of 705 patients (347 males and 358 females) with a mean age of 66 +/- 15 years (range, 15-101) originating from 20 centers were randomized to undergo either OP (n = 341) or not (NO, n = 364) to reinforce the colonic anastomosis after colectomy. Patients had carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another affliction located anywhere from the right colon to and including the midrectum. Patients undergoing emergency surgery were not included. Random allotment took place once the resection and anastomosis had been performed, the surgeon had tested the anastomosis for airtightness, and the omental flap was deemed feasible. Patients were divided into four strata: ileo- or colocolonic anastomosis, supraperitoneal ileo- or colorectal anastomosis, infraperitoneal ileo- or colorectal anastomosis, and ileo- or coloanal anastomosis. The primary end point was anastomotic leakage. Secondary end points included intra- and extraabdominal related morbidity and mortality. Severity of anastomotic leakage was based on the rate of repeat operations and related deaths. RESULTS: Both groups were comparable in terms of preoperative characteristics. Intraoperative findings were similar, except that there were significantly more septic operations and abdominal drainage performed in the NO group (p < 0.05 and p < 0.01, respectively). Thirty-five patients (4.9%) had postoperative anastomotic leakage, 16 in the OP group (4.7%) and 19 in the NO group (5.2%). There were 32 deaths (4.5%), 17 (4.9%) in the OP group and 15 (4.2%) in the NO group. Five patients with anastomotic leakage died (0.8%), 2 of whom had OP. There were 37 repeat operations (30%), 12 (6 in each group) for anastomotic leakage. Repeat operation was associated with fatal outcome in 14% of cases. The rate of these and the other intra- and extraabdominal complications did not differ significantly between the two groups. CONCLUSION: OP to reinforce colorectal anastomosis decreases neither the rate nor the severity of anastomotic failure.

Prophylactic abdominal drainage after elective colonic resection and suprapromontory anastomosis: a multicenter study controlled by randomization. French Associations for Surgical Research.

BACKGROUND: Only 4 controlled trials have investigated whether prophylactic abdominal drainage was of value after colonic resection. None have been able to find any statistically significant difference, but the number of patients was small and the beta error risk was high. OBJECTIVES: To compare patients who underwent abdominal drainage with those who did not for the rate and severity of complications after elective colonic resection followed immediately by anastomosis of the suprapromontory colon and to compare suction drains with nonsuction drains. PATIENTS: Between September 1990 and June 1995, 319 patients (135 men and 184 women), whose mean age was 67 years (range, 22-95 years), with carcinoma, benign tumors, or colitis, located anywhere between the ascending and sigmoid colons, were included in the study. Patients were comparable for demographic characteristics, except that there were more patients with ascites in the group that did not undergo abdominal drainage (P<.02). INTERVENTIONS: After 2 protocol violations, 156 patients were randomized to the abdominal drainage group and 161 to the no abdominal drainage group. All 317 anastomoses were tested for airtightness intraoperatively and repaired if leakage was found (n=71), and all patients with anastomoses received a routine diatrizoate sodium enema to detect infraclinical leakage. MAIN OUTCOME MEASURES: The postoperative complications possibly influenced by drainage included (1) deep complications for which drainage can lead to early diagnosis, such as generalized or localized peritonitis, intraabdominal hemorrhage, or hematoma; (2) complications believed to be enhanced by drainage, such as an operative wound (an abscess, disruption, or incisional hernia) or pulmonary (microatelectasis) and intestinal obstructions; and (3) complications directly due to the drains, such as ulcerations leading to fistulae, hemorrhages, drainage tract infections, difficulty in removal, intra-abdominal retention, and incisional disruptions. Subsidiary end points were the severity of these complications as assessed by the number of related subsequent operations and deaths. RESULTS: Twenty-six patients overall (8%) had postoperative complications possibly influenced by drainage (9% in the group that underwent abdominal drainage and 8% in the group that did not). This difference was not statistically significant (P<.90). One patient had a fistula directly imputable to drainage. There was no difference between suction and nonsuction drainage (P<.90). CONCLUSIONS: Routine abdominal drainage after colonic resection and immediate anastomosis decreases neither the rate nor the severity of anastomotic leakage. It can, occasionally, be detrimental.

Failures in outpatient tonsillectomy policy in children: a retrospective study in 311 children.

The literature suggests that outpatient tonsillectomy in children is a safe and cost-effective procedure. These conclusions have been based on the low rate of post-operative complications. Recent papers suggest contra-indications for ambulatory surgery in some patients. A retrospective study involving 311 children was performed in our Department. We defined two groups in which the out-patient policy had failed. The first group (43 children) comprised inpatient children scheduled because of an unhealthy preoperative state (12 patients), a sleep-apnea syndrome (5 children), a major associated procedure (3 patients), a social or family environment not reliable enough for postoperative supervision (19 patients) or because of parental refusal (4 patients). The second group (268 patients) was constituted of scheduled outpatients. In this group, the outpatient policy failed in 31 and children had to be kept overnight, because complications occurred. The main short-term complication was bleeding (13 patients). In 8, delayed complications were observed. Thus, according to the literature, children with concomitant heavy medical problems or with a poor social environment have to be managed as inpatients. For the others outpatient procedures were possible but parents should previously be informed of the possible overnight hospital supervision which is needed in 11.6% of cases. When comparing the youngest patients under 4 years of age with the others, although the preexisting medical and social conditions are important factors that may contraindicate ambulatory surgery, once the latter has been decided on, there is no significant difference between the two age groups regarding the number of children requiring overnight hospital supervision.

Heterogeneity of glucose-6-phosphate dehydrogenase deficiency in Algeria. Study in Northern Algeria with description of five new variants.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency was found in 3.2% of the male population living in the urban area of Algiers. The deficient subjects originated from multiple geographic regions of Northern Algeria, with prevalence of individuals of Berber-Kabyle origin. Red blood cell G6PD was partially purified and characterized in deficient males from 17 families, and six different variants were found. Among them, only one, the Gd(-) Kabyle variant, had been previously described. It was detected in nine families. The other five variants were new: Gd(-) Laghouat (four cases), Gd(-) Blida (one case), Gd(-) Thenia (one case), Gd(-) Titteri (one case), and Gd(-) Alger (two brothers). Strikingly, the common Mediterranean variant was not found. G6PD deficiency is heterogeneous in northern Algeria where autochtonous variants seem to prevail. The Kabyle variant may be common in this country.

[Glucose-6-phosphate dehydrogenase deficiency in Algeria]. / Le déficit en glucose-6-phosphate déshydrogénase en Algérie.

The normal level of G6PD activity of the red cells is 6.6 +/- 1.6 i.u/g Hb in men and 6.9 +/- 1.6 i.u./g Hb in women. The histogram of the distribution in the population is not symmetrical. G6PD deficiency is present in Algeria at the national level of 3% (+/- 0.5). The level is less high in the mountainous areas of arab culture, higher in the berber culture and in the Shara. Numerous new variants have been detected in Algeria. The G6PD deficiency predominating in Algeria is of Kabyle type, followed by Laghouat and El-Qued types. Types A-, A+ and Ibaden Austin of negro origin exist in the Sahara population. The Mediterranean type is not found in the Algerian population. The clinical manifestations are rare.

[Hemolytic anemia caused by glucose-6-phosphate dehydrogenase deficiency. Aprpos of 20 cases from 1969 to 1974]. / L'anémie hémolytique par déficit en glucose-6-phosphate déshydrogénase. A propos de 20 cas observés de 1969 à 1974.

Twenty hemolytic accidents due to G6PD deficiency in Algeria are reported: 13 cases of favism, 2 cases of neonatal jaundice, one drug accident (aspirin), 4 of unknown cause. These accidents concern above all children, were clinically severe and required transfusion.