The edition · General Surgery
Transvaginal drainage of tubo-ovarian abscess fails non-inferiority to laparoscopy — but spares a day in hospital
A French multicentre trial puts a number on the trade-off, robotic appendicectomy adds time and conversions without a visible benefit, and a small trial questions routine suction for traumatic pneumothorax.
The edition in brief
The PACTOL trial randomised 208 women with tubo-ovarian abscess across 19 French hospitals to ultrasound-guided transvaginal drainage or laparoscopy. Cure at six weeks was 72.5% versus 77.0% (difference −4.6 points, 95% CI −19.4 to 10.7), so non-inferiority was not shown; reintervention was more common after drainage (13.0% vs 3.3%), but hospital stay was a day shorter and pain settled faster. Drainage is a reasonable option if the woman accepts a higher chance of a second procedure. In 85,774 US appendicectomies, the robotic approach took a median 18 minutes longer and carried higher odds of conversion (OR 2.4), with the gap widest in obese patients and perforated appendicitis. In 1,926 pancreatoduodenectomies, the simple five-item modified Frailty Index predicted 90-day mortality as well as the eleven-item version (AUC 0.757 vs 0.761); severe frailty was associated with about three to four times the odds of death. The practice-changer: in a single-centre cluster-randomised study of 72 trauma patients, starting chest drains on water seal instead of suction shortened initial drain duration from 51 to 41 hours without more complications — enough to question routine suction, not yet to abandon it everywhere.
Transvaginal drainage of tubo-ovarian abscess: fewer bed-days, more reinterventions
Laparoscopy remains the more definitive route for tubo-ovarian abscess; transvaginal drainage is acceptable when the woman chooses it knowing reintervention is more likely.
Robotic appendicectomy adds 18 minutes and more conversions without a visible gain
Laparoscopic appendicectomy remains the efficient standard; the robot adds theatre time without a demonstrated patient benefit.
The five-item frailty index predicts death after Whipple as well as the eleven-item version
Use the simple five-item frailty index before a Whipple; it identifies patients less likely to be rescued from complications.
When Calot's triangle will not open, stop short on purpose
A planned subtotal cholecystectomy is safer than persisting towards a critical view that the inflammation will not give up.
Starting trauma chest drains on water seal shortened drain time without more complications
Suction is not required from the start for every trauma chest drain; water seal first is reasonable for simple pneumothorax.
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