Background Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Methods COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien–Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001). Conclusion Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk.

No abstract

A 78-year-old lady with a history of malignant melanoma on the dorsal aspect of her left foot, presented with a new fluorodeoxyglucose positron emission tomography (FDG-PET) avid lesion in her left fibular head. The patient had been diagnosed eight months previously with a 5.1mm Breslow thickness invasive melanoma. Following initial diagnosis, she underwent a wide local excision and sentinel lymph node biopsy (SLN). The melanoma was completely excised and SLN was negative for malignancy. Postoperatively, she underwent radiological staging with computed tomography scans (CT) of her thorax, abdomen, and pelvis. This showed scattered pulmonary nodules, and multiple indeterminate liver lesions. A PET scan was then performed, which showed an expansile, FDG-avid, lytic lesion in the left fibular head, suspicious for bone metastasis. Following discussion at the multidisciplinary team meeting, the patient underwent an open biopsy of the fibular head. Histology revealed non-necrotising epitheloid granulomata without evidence of malignancy. Ziehl-Neelsen and periodic acid Schiff stains were negative. The findings were suggestive of sarcoidosis. The patient revealed she had a previous diagnosis of pulmonary sarcoidosis 25 years prior, however, had no known extrapulmonary disease and was not attending a specialist. The pulmonary findings on CT were consistent with sarcoidosis. Sarcoidosis is a systemic inflammatory disease characterised by the development of non-caseating granulomata which typically affect the lungs and lymph nodes but can affect multiple organ systems. This case highlights the diagnostic uncertainty of an FDG-avid lesion on PET, necessitating diagnostic biopsy. Sarcoidosis is an uncommon but possible differential in this setting.

No abstract