Passive versus active drainage following neck dissection: a non-randomised prospective study. Eur Arch Otorhinolaryngol. 2009;266:121-124. [PMID: 18548264 DOI: 10.1007/s00405-008-0723-8]

Nutritional management of chyle leak after head and neck surgery: a systematic review and proposed protocol for management

PURPOSE

Chyle leaks are a rare complication of neck surgery causing local damage, impairing healing and compromising free flaps. High output leaks can result in electrolyte imbalances and malnutrition. Nutritional management such as restricting the absorption of triglycerides is believed to reduce chyle, allowing spontaneous resolution of a leak. Dietary preparations and management can aid in reducing chyle production. There are no clear guidelines to aid nutritional decision-making in this complex scenario.

METHODS

A systematic review of the literature was carried out to identify studies evaluating nutritional management of chyle leaks in patients after neck dissections.

RESULTS

Ten studies were identified evaluating the role of nutritional therapy in the management of patients with chyle leaks after neck dissections. The level of evidence was low. Several studies identified that low volume leaks (defined as < 1000 mls per day) often resolved by dietary management and other conservative measures. High volume leaks rarely resolved with conservative measures alone. Parenteral nutrition had an established role in this context.

CONCLUSIONS

There is limited evidence to guide dietary restriction and introduction of oral diet in patients with chyle leak after major head and neck surgery. Based on available evidence, local guidelines for the nutritional management of patients identified with a chyle leak were produced and adopted by the Trust and the head and neck MDT. A national database for voluntary contribution of prospective data would help to generate better quality management protocols.

Closed-suction compared with Penrose drainage after free flap reconstruction in the head and neck

Microsurgical free flaps are common in head and neck reconstruction, and their techniques and outcomes have continuously improved during the past decades. However, there are variations in practice among surgeons between the use of closed-suction drainage systems and Penrose drains. The proponents of Penrose drains propose that the negative pressure generated by the closed-suction drainage system may harm the microvascular anastomosis. We know of no previous studies that have compared the two drains for microvascular free flap reconstruction, so our aim was to compare them in a single-centre, retrospective review of all patients who had microvascular free flap reconstruction of the head and neck region in our department between 1 November 2010 and 1 September 2017. During this period 84 patients had 87 free flap reconstructions in the head and neck, 43 of which had Penrose, and 44 closed-suction, drainage. We compared the number of complications between the groups including haematomas, seromas, wound infections, anastomostic thrombosis, anastomotic revision, and need for re-exploration. There were no significant differences between the groups, despite a trend toward fewer negative explorations in the closed-suction group. There were no differences in complications between suction and passive drainage systems after microvascular free flaps, which suggests that closed suction drainage could be safely used after free flap reconstruction in the head and neck.

Anesthesia and Enhanced Recovery After Head and Neck Surgery

Enhanced recovery protocols have been developed from gastrointestinal, colorectal, and thoracic surgery populations. The basic tenets of head and neck enhanced recovery are: a multidisciplinary team working around the patient, preoperative carbohydrate loading, multimodal analgesia, early mobilization and oral feeding, and frequent reassessment and auditing of protocols to improve patient outcomes. The implementation of enhanced recovery protocols across surgical populations appear to decrease length of stay, reduce cost, and improve patient satisfaction without sacrificing patient quality of care or changing readmission rates. This article examines evidence-based enhanced recovery interventions and tailors them to a major head and neck surgery population.

The efficacy of active drainage for preventing postoperative organ/space surgical site infections in patients with Crohn's disease

PURPOSE

Patients with Crohn's disease (CD) show a higher incidence of surgical site infections (SSIs) after bowel resection in comparison to other patient populations because CD patients commonly suffer from anemia, malnutrition, and immunosuppression. In comparison to conventional passive drainage, active drainage using a closed-suction drain reportedly reduces postoperative wound-related complications in several diseases. In the present study, we aimed to investigate the incidence of SSI and to identify the risk factors for SSI in patients with CD.

METHODS

We retrospectively analyzed the patient characteristics and perioperative data of 106 CD patients who underwent bowel resection at our institution between January 2000 and June 2016. We statistically analyzed the incidence of different types of SSI (overall, incisional, and organ/space) in relation to patient-related and surgery-related risk factors.

RESULTS

Overall postoperative SSIs were diagnosed in 19 patients (17.9%), including incisional SSI (n = 16; 15.1%), organ/space SSI (n = 7; 6.6%), and both (n = 4; 3.8%). A long operative time (p = 0.036) and colonic involvement (p = 0.011) were significantly associated with the overall risk of developing an SSI. Active drainage significantly reduced the incidence of organ/space SSI (p = 0.037).

CONCLUSION

Intraabdominal active drainage was more useful than passive drainage for preventing organ/space SSI development.

Intra-abdominal drainage following pancreatic resection: A systematic review

AIM

To study all the aspects of drain management in pancreatic surgery.

METHODS

We conducted a systematic review according to the PRISMA guidelines. We searched the Cochrane Central Registry of Controlled Trials, EMBASE, Web of Science, and PubMed (MEDLINE) for relevant articles on drain management in pancreatic surgery. The reference lists of relevant studies were screened to retrieve any further studies. We included all articles that reported clinical studies on human subjects with elective pancreatic resection and that compared various strategies of intra-abdominal drain management, such as drain vs no drain, selective drain use, early vs late drain extraction, and the use of different types of drains.

RESULTS

A total of 19 studies concerned with drain management in pancreatic surgery involving 4194 patients were selected for this systematic review. We included studies analyzing the outcomes of pancreatic resection with and without intra-abdominal drains, studies comparing early vs late drain removal and studies analyzing different types of drains. The majority of the studies reporting equal or superior results for pancreatic resection without drains were retrospective and observational with significant selection bias. One recent randomized trial reported higher postoperative morbidity and mortality with routine omission of intra-abdominal drains. With respect to the timing of drain removal, all of the included studies reported superior results with early drain removal. Regarding the various types of drains, there is insufficient evidence to determine which type of drain is more suitable following pancreatic resection.

CONCLUSION

The prophylactic use of drains remains controversial. When drains are used, early removal is recommended. Further trials comparing types of drains are ongoing.

Is routine drainage necessary after pancreaticoduodenectomy?

With the development of imaging technology and surgical techniques, pancreatic resections to treat pancreatic tumors, ampulla tumors, and other pancreatic diseases have increased. Pancreaticoduodenectomy, one type of pancreatic resection, is a complex surgery with the loss of pancreatic integrity and various anastomoses. Complications after pancreaticoduodenectomy such as pancreatic fistulas and anastomosis leakage are common and significantly associated with patient outcomes. Pancreatic fistula is one of the most important postoperative complications; this condition can cause intraperitoneal hemorrhage, septic shock, or even death. An effective way has not yet been found to avoid the occurrence of pancreatic fistula. In most medical centers, the frequency of pancreatic fistula has remained between 9% and 13%. The early detection and routine drainage of anastomotic fistulas, pancreatic fistulas, bleeding, or other intra-abdominal fluid collections after pancreatic resections are considered as important and effective ways to reduce postoperative complications and the mortality rate. However, many recent studies have argued that routine drainage after abdominal operations, including pancreaticoduodenectomies, does not affect the incidence of postoperative complications. Although inserting drains after pancreatic resections continues to be a routine procedure, its necessity remains controversial. This article reviews studies of the advantages and disadvantages of routine drainage after pancreaticoduodenectomy and discusses the necessity of this procedure.

A prospective randomized controlled trial of subcutaneous passive drainage for the prevention of superficial surgical site infections in open and laparoscopic colorectal surgery

INTRODUCTION

A number of studies have evaluated the effects of subcutaneous drainage during digestive surgery. All of the previous studies assessed the usefulness of active-suctioning drain, including two randomized controlled studies which found no benefit for the placement of active-suctioning drains in digestive surgery. The utility of passive drainage has not been evaluated previously. The purpose of this study was to evaluate the efficacy of subcutaneous passive drainage system for preventing surgical site infections during major colorectal surgery.

PATIENTS AND METHODS

A total of 263 patients who underwent major colorectal surgery were enrolled in this study. Patients were randomly assigned to receive subcutaneous passive drainage or no drainage. The primary outcome measured was the incidence of superficial surgical site infections. The secondary outcomes measured were the development of hematomas, seromas, and wound dehiscence.

RESULTS

Finally, a total of 246 patients (124 underwent passive drainage, and 122 underwent no drainage) were included in the analysis after randomization. There was a significant difference in the incidence of superficial surgical site infections between patients assigned to the passive drainage and no drainage groups (3.2 % vs 9.8 %, respectively, P = 0.041). There were no cases that developed a hematoma, seroma, or wound dehiscence in either group. A subgroup analysis revealed that male gender, age ≥75 years, diabetes mellitus, American Society of Anesthesiologists (ASA) status ≥2, blood loss ≥100 ml, and open access were factors that were associated with a beneficial effect of subcutaneous passive drainage.

CONCLUSIONS

Subcutaneous passive drainage provides benefits over no drainage in patients undergoing major colorectal surgery.

Prevention of complications in neck dissection

BACKGROUND

The neck dissection has remained a pivotal aspect of head and neck cancer management for over a century. During this time its role has expanded from a purely therapeutic option into an elective setting, in part promoted by efforts to reduce its morbidity.

OBJECTIVES

This review will consider the potential complications of neck dissection and on the basis of the available evidence describe both their management and prevention.

CONCLUSION

Although the neck dissection continues to provide clinicians with a method of addressing cervical disease, its reliability and safety can only be assured if surgeons remain cognisant of the potential complications and aim to minimise such morbidity by appropriate management in the peri-operative period.