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Laboratory model for surgical drainage
Letters to the Editor
813
Re: racial disparities in outcomes after appendectomy for acute appendicitis To the Editor: 1
Scarborough et al reported that black patients have a higher rate of complications after appendectomy than whites do even after adjustment for comorbidities, appendiceal rupture, and laparoscopic approach. Their careful study of more than 39,000 patients is an important contribution to the body of literature about health care disparities among racial groups. The authors suggest that future research about covariates, such as insurance status, hospital factors, and participation by house officers, may help to elucidate the causes of these inequalities. Some of these factors have previously been evaluated. Based on their analysis of almost 100,000 hospital discharges, Braveman et al2 reported 18 years ago that individuals without health insurance were significantly more likely to experience a ruptured appendix than insured patients. After adjustment for multiple variables, black race and poverty were each significantly associated with a higher likelihood of appendiceal rupture. Similarly, hospitals with high volumes of adult admissions were associated with This letter reflects the views of the author and should not be construed to represent the Food and Drug Administration’s views or policies.
an increased risk of ruptured appendicitis. Although the authors did not specifically mention the participation of residents in appendectomy, they found that teaching hospitals were associated with a slightly decreased risk of a ruptured appendix. Racial disparities in health outcomes constitute a serious, persistent, and poorly understood problem. Even large, well-designed studies provide an incomplete picture. In light of the worsening health economics crisis, the quest to identify measurable and modifiable risk factors for poor outcomes is not a matter of ideology but one of necessity. Emily Jane Woo, M.D., M.P.H. US Food and Drug Administration Rockville, MD, USA
References 1. Scarborough JE, Bennett KM, Pappas TN. Racial disparities in outcomes after appendectomy for acute appendicitis. Am J Surg 2012;204: 11–7. 2. Braveman P, Schaaf VM, Egerter S, et al. Insurance-related differences in the risk of ruptured appendix. N Engl J Med 1994;331:444 –9.
Laboratory model for surgical drainage To the Editor: 1
Swartz et al tested the ability of the Jackson-Pratt (JP) flat and round silicone drains with the suction bulb (Cardinal Health, Dublin, OH) to evacuate 150 mL of canned soups imitating serous fluid, purulent fluid, or fluid with debris collected in a ballistic gel cavity. The average time to loss of vacuum of the bulb and the average volume of fluid left in the cavity when the drain did not function were recorded. The round drain evacuated serous fluid more quickly than the flat drain (18 vs 20 s) with no difference in residual volume, whereas in purulent fluid drainage the flat drain was superior to the round drain in terms of drainage time (138 vs 326 s) and residual volume (44 vs 49 mL). These findings suggest differing performance of the surgical drains in differing conditions, but do not guide the choice of a surgical drain in clinical settings because drain choice should be based on overall clinical benefits rather than short-term drainage effect. Although the JP low-negative-pressure drains can be used for abdominal drainage, they are placed more commonly after mastectomy. In the randomized controlled trials comparing 2 types of drainage system after modified radical mastectomy,2,3 drainage volume was not associated with rate of wound complications and less drainage volume tended to reduce the length of hospital stay,
suggesting that the theory “much is more” is not always applied to surgical drainage, particularly not to prophylactic drainage. Although the advantage of closed abdominal drainage over open abdominal drainage has been shown in prospective trials, some surgeons avoid the use of closed suction drains in the abdominal cavity because of the potential risk of prolonged drainage and subsequent drain-related complications such as fistula and delayed bleeding, and achieved comparable results using the Penrose drain.4 Swartz et al1 had apprehensions that the JP bulb failed to collect fluid well before reaching its purported volume. Nurses and patients seem to have known this because, according to the guidelines for care for the JP drain,5 the bulb should be emptied when it is half full. Swartz et al1 mentioned that they developed a reproducible laboratory model to assess the drains in repeated short-duration drainage episodes. In clinical practice, the JP drain will stay in place until less than 30 mL of serous or serosanguineous fluid can be collected in 24 hours,6 although the surgeon will decide to reoperate to find the bleeding site and stop bleeding if it drains bloody fluid of more than 100 mL an hour. To translate the laboratory findings into clinical practice, extending the duration of a drainage episode at a lower drainage speed would be warranted.
814
The American Journal of Surgery, Vol 204, No 5, November 2012 Tetsuji Fujita, M.D. Department of Surgery Jikei University School of Medicine Tokyo, Japan http://dx.doi.org/10.1016/j.amjsurg.2012.03.004
References 1. Swartz AL, Azuh O, Obeid LV, et al. Developing an experimental model for surgical drainage investigations: an initial report. Am J Surg 2012;203:388 –91.
2. Chintamani, Singhal V, Singh J, et al. Half versus full vacuum suction drainage after modified radical mastectomy for breast cancer-a prospective randomized clinical trial [ISRCTN24484328]. BMC Cancer 2005; 5:11. 3. Ezeome ER, Adebamowo CA. Closed suction drainage versus closed simple drainage in the management of modified radical mastectomy wounds. S Afr Med J 2008;98:712–5. 4. Sánchez-Ortiz R, Madsen LT, Swanson DA, et al. Closed suction or Penrose drainage after partial nephrectomy: does it matter? J Urol 2004;171:244 – 6. 5. Clinical Center National Institute of Health. How to Care for the Jackson-Pratt Drain. Available at: http://www.cc.nih.gov/ccc/patient_ education/pepubs/jp.pdf. Accessed: May 28, 2012. 6. Durai R, Ng PC. Surgical vacuum drains: types, uses, and complications. AORN J 2010;91:267–71.
813
Re: racial disparities in outcomes after appendectomy for acute appendicitis To the Editor: 1
Scarborough et al reported that black patients have a higher rate of complications after appendectomy than whites do even after adjustment for comorbidities, appendiceal rupture, and laparoscopic approach. Their careful study of more than 39,000 patients is an important contribution to the body of literature about health care disparities among racial groups. The authors suggest that future research about covariates, such as insurance status, hospital factors, and participation by house officers, may help to elucidate the causes of these inequalities. Some of these factors have previously been evaluated. Based on their analysis of almost 100,000 hospital discharges, Braveman et al2 reported 18 years ago that individuals without health insurance were significantly more likely to experience a ruptured appendix than insured patients. After adjustment for multiple variables, black race and poverty were each significantly associated with a higher likelihood of appendiceal rupture. Similarly, hospitals with high volumes of adult admissions were associated with This letter reflects the views of the author and should not be construed to represent the Food and Drug Administration’s views or policies.
an increased risk of ruptured appendicitis. Although the authors did not specifically mention the participation of residents in appendectomy, they found that teaching hospitals were associated with a slightly decreased risk of a ruptured appendix. Racial disparities in health outcomes constitute a serious, persistent, and poorly understood problem. Even large, well-designed studies provide an incomplete picture. In light of the worsening health economics crisis, the quest to identify measurable and modifiable risk factors for poor outcomes is not a matter of ideology but one of necessity. Emily Jane Woo, M.D., M.P.H. US Food and Drug Administration Rockville, MD, USA
References 1. Scarborough JE, Bennett KM, Pappas TN. Racial disparities in outcomes after appendectomy for acute appendicitis. Am J Surg 2012;204: 11–7. 2. Braveman P, Schaaf VM, Egerter S, et al. Insurance-related differences in the risk of ruptured appendix. N Engl J Med 1994;331:444 –9.
Laboratory model for surgical drainage To the Editor: 1
Swartz et al tested the ability of the Jackson-Pratt (JP) flat and round silicone drains with the suction bulb (Cardinal Health, Dublin, OH) to evacuate 150 mL of canned soups imitating serous fluid, purulent fluid, or fluid with debris collected in a ballistic gel cavity. The average time to loss of vacuum of the bulb and the average volume of fluid left in the cavity when the drain did not function were recorded. The round drain evacuated serous fluid more quickly than the flat drain (18 vs 20 s) with no difference in residual volume, whereas in purulent fluid drainage the flat drain was superior to the round drain in terms of drainage time (138 vs 326 s) and residual volume (44 vs 49 mL). These findings suggest differing performance of the surgical drains in differing conditions, but do not guide the choice of a surgical drain in clinical settings because drain choice should be based on overall clinical benefits rather than short-term drainage effect. Although the JP low-negative-pressure drains can be used for abdominal drainage, they are placed more commonly after mastectomy. In the randomized controlled trials comparing 2 types of drainage system after modified radical mastectomy,2,3 drainage volume was not associated with rate of wound complications and less drainage volume tended to reduce the length of hospital stay,
suggesting that the theory “much is more” is not always applied to surgical drainage, particularly not to prophylactic drainage. Although the advantage of closed abdominal drainage over open abdominal drainage has been shown in prospective trials, some surgeons avoid the use of closed suction drains in the abdominal cavity because of the potential risk of prolonged drainage and subsequent drain-related complications such as fistula and delayed bleeding, and achieved comparable results using the Penrose drain.4 Swartz et al1 had apprehensions that the JP bulb failed to collect fluid well before reaching its purported volume. Nurses and patients seem to have known this because, according to the guidelines for care for the JP drain,5 the bulb should be emptied when it is half full. Swartz et al1 mentioned that they developed a reproducible laboratory model to assess the drains in repeated short-duration drainage episodes. In clinical practice, the JP drain will stay in place until less than 30 mL of serous or serosanguineous fluid can be collected in 24 hours,6 although the surgeon will decide to reoperate to find the bleeding site and stop bleeding if it drains bloody fluid of more than 100 mL an hour. To translate the laboratory findings into clinical practice, extending the duration of a drainage episode at a lower drainage speed would be warranted.
814
The American Journal of Surgery, Vol 204, No 5, November 2012 Tetsuji Fujita, M.D. Department of Surgery Jikei University School of Medicine Tokyo, Japan http://dx.doi.org/10.1016/j.amjsurg.2012.03.004
References 1. Swartz AL, Azuh O, Obeid LV, et al. Developing an experimental model for surgical drainage investigations: an initial report. Am J Surg 2012;203:388 –91.
2. Chintamani, Singhal V, Singh J, et al. Half versus full vacuum suction drainage after modified radical mastectomy for breast cancer-a prospective randomized clinical trial [ISRCTN24484328]. BMC Cancer 2005; 5:11. 3. Ezeome ER, Adebamowo CA. Closed suction drainage versus closed simple drainage in the management of modified radical mastectomy wounds. S Afr Med J 2008;98:712–5. 4. Sánchez-Ortiz R, Madsen LT, Swanson DA, et al. Closed suction or Penrose drainage after partial nephrectomy: does it matter? J Urol 2004;171:244 – 6. 5. Clinical Center National Institute of Health. How to Care for the Jackson-Pratt Drain. Available at: http://www.cc.nih.gov/ccc/patient_ education/pepubs/jp.pdf. Accessed: May 28, 2012. 6. Durai R, Ng PC. Surgical vacuum drains: types, uses, and complications. AORN J 2010;91:267–71.