Routine Sub-hepatic Drainage versus No Drainage after Laparoscopic Cholecystectomy: Open, Randomized, Clinical Trial. Indian J Surg. 2013;75:22-27. [PMID: 24426378 DOI: 10.1007/s12262-012-0452-5]

Reduction Mammaplasty: Closed Suction Drains Do Not Reduce Hematoma or Seroma But Increase Infection Risk

BACKGROUND

While there is mounting evidence that closed suction drains are not necessary, there is a paucity of literature to demonstrate that drains are harmful after breast reduction. The purpose of this study was to investigate the effect of drains on postoperative seroma, hematoma, and infection, as well as elucidate any risk factors that may be implicated in the development of these complications.

METHODS

A retrospective cohort study was conducted of all reduction mammaplasty procedures at our university medical center between 2010-2020. Pedicle type, skin incision, drain utilization, breast excision mass, sternal notch to nipple distance, and inframammary fold to nipple distance were analyzed with postoperative outcomes including hematoma, seroma, infection, dehiscence, nipple necrosis, and fat necrosis.

RESULTS

This study included 944 female patients undergoing reduction mammaplasty. Median age was 39.0 years, median body mass index was 31.9 kg/m2, and median breast mass resected was 742 grams per side. Drain utilization did not significantly reduce postoperative hematoma (P = 0.196), seroma (P = 0.185), nipple necrosis (P = 0.511), or fat necrosis (P = 0.113), but drain utilization significantly increased postoperative surgical site infection (P = 0.011). Patients with breast mass removed over 1500 g had significantly higher risk of hematoma (P = 0.002), fat necrosis (P < 0.001), and nipple necrosis (P < 0.001) compared to patients with less than 1500 g removed. In patients with greater than 1500 g resected, drain utilization did not significantly decrease risk of hematoma (P = 0.086) or seroma (P = 0.497).

CONCLUSIONS

Breast reduction greater than 1500 g per side significantly increased risk of hematoma, nipple necrosis, and fat necrosis. Drain utilization did not demonstrate any advantageous effects, rather it increased risk of infection. Future multicenter study will be needed to confirm these findings across different patient referral networks and practice patterns.

The Rationale of sub-hepatic drainage on a specialist biliary unit: a review of 6140 elective and urgent laparoscopic cholecystectomies and bile duct explorations

BACKGROUND

Drains are used to reduce abdominal collections after procedures where such risk exists. Using abdominal drains after cholecystectomy has been controversial since the open surgery era. Universally accepted indications and agreement exist that routine drainage is unnecessary but the role of selective drainage remains undetermined. This study evaluates the indications and benefits of sub-hepatic drainage in patients undergoing laparoscopic cholecystectomy (LC) and bile duct exploration (BDE) in a specialist unit with a large biliary emergency workload.

METHODS

Prospectively collected data from 6,140 LCs with a 46.6% emergency workload over 30 years was reviewed. Demographic factors, pre-operative presentations, imaging and operative details in patients with and without drains were compared. Sub-hepatic drains were inserted after all transductal explorations, subtotal cholecystectomies, almost all open conversions and 94% of LC for empyemas. Adverse or beneficial postoperative drain-related outcomes were analysed.

RESULTS

Abdominal drains were utilised in 3225/6140 (52.5%). Patients were significantly older with more males. 59.4% were emergency admissions. Preoperative imaging showed thick-walled gallbladders in 25.2% and bile duct stones or dilatation in 36.2%. At operation they had cystic duct stones in 19.8%, acute cholecystitis, empyema or mucocele in 28.4% and operative difficulty grades III or higher in 59%. 38% underwent BDE, 5.4% had fundus-first dissection and the operating times were longer ( 80 vs.45 min). Drain related complications were rare; 3 abdominal pains after anaesthetic recovery settling when drains were removed, 2 drain site infections and one re-laparoscopy to retrieve a retracted drain. 55.8% of 43 bile leaks and 35% of 20 other collections in patients with drains resolved spontaneously.

CONCLUSIONS

The utilisation of drains in this study was relatively high due to the high emergency workload and interest in BDE. While drains allowed early detection of bile leakage, avoiding some complications and monitoring conservative management to allow early reinterventions, the study has identified operative criteria that could potentially limit drain insertion through a selective policy.

Effect of routine abdominal drainage on postoperative pain after uncomplicated laparoscopic cholecystectomy for cholelithiasis: A randomised controlled trial

This is a prospective randomized controlled trial to investigate the effect of routine abdominal drainage on postoperative pain after uncomplicated laparoscopic cholecystectomy for cholelithiasis. This study was a single-center randomized controlled trial performed at the general surgery ward of Taleghani hospital, in Tehran, Iran, from July 2018 to October 2018. Patients were randomly divided into two parallel groups, one receiving routine abdominal drainage and the other receiving no treatment. Postoperative pain was measured by the Universal Pain Assessment Tool (UPAT) 0, 2, 4, 6, 12, and 24 h postoperatively. A total of 60 patients (30 patients in the study and control groups) were included. GLM repeated measure analysis showed a significant time*treatment effect for routine abdominal drainage in decreasing UPAT scores from baseline to 24 h after surgery (F = 4.59, df = 3.98, P-value = 0.001). Our findings demonstrated that abdominal drainage significantly reduces postoperative pain 0, 2, 4, 6, and 12 h after surgery (P-value<0.05). We also showed that abdominal drainage increases the time to first morphine sulfate administration and decreases the total dose of morphine sulfate administration (P-value<0.001). Moreover, we demonstrated that abdominal drainage decreases the average postoperative pain (P-value<0.001) and does not lead to any considerable side effects. However, 24 h after surgery, no significant pain-relieving effect was evident for abdominal drainage. In conclusion, insertion of abdominal drainage leads to decreased postoperative pain. Future studies need to investigate the optimal time for removal of the abdominal drain.

This trial was prospectively registered in the Iranian Registry of Clinical Trials with a registration ID of IRCT20130706013875N2.

The Japan Society for Surgical Infection: guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018

BACKGROUND

The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide.

METHODS

We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies.

RESULTS

There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese.

CONCLUSIONS

The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients.

Routine drain or no drain after laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

Laparoscopic cholecystectomy (LC) is considered to be the gold standard in the early management of acute cholecystitis however, recommendations for routine drain insertion in the acute setting are unavailable.

STUDY DESIGN

A systematic review of literature review and metanalysis was conducted. All studies comparing drain versus no drain after LC for acute cholecystitis were included.

RESULTS

Seven studies, with 1274 patients, were included. Postoperative wound infection rates (relative risk (RR) 0.30, 95% confidence interval (CI) 0.10 to 0.88; I2 = 0%) and postoperative abdominal collection requiring drainage (RR 1.20, 95% CI 0.35 to 4.12; I 2 = 0%) were lower in the no-drain group, but this was only significant for wounded infections on subgroup analysis of RCTs. Length of stay hospital (mean difference (MD) -0.49, 95% CI -0.89 to -0.09; I 2 = 69%) and operative time (MD -8.13, 95% CI -13.87 to -2.38; I 2 = 92%) were significantly shorter in the no drain group however this was in the context of significant heterogeneity.

CONCLUSION

The available data suggests that acute cholecystitis is not an indication for routine drain placement after LC. However, these results must be interpreted with caution due to the limitations of the included studies. In effect, the main issue of this meta-analysis lies on the limitations of the included studies themselves, because of a considerable heterogeneity among the included works, particularly for the inclusion criteria of patients and reported severity of acute cholecystitis. Further work is required to produce evidence which will definitively alter clinical practice.

LEVEL OF EVIDENCE

Level 2a (systematic review of cohort studies). Oxford CEBM levels of evidence.

Comparison of laparoscopic cholecystectomy with and without abdominal drainage in patients with non-complicated benign gallbladder disease: A protocol for systematic review and meta analysis

OBJECTIVE

To evaluate whether conventional postoperative drainage is more effective than not providing drainage in patients with non-complicated benign gallbladder disease following laparoscopic cholecystectomy (LC).

METHODS

A search of the electronic databases MEDLINE, EMBASE, Web of science, Cochrane Library, and Chinese Biomedical Database (CBM) was conducted for randomized controlled trials (RCTs) reporting outcomes of LC surgery with and without an abdominal drain.

RESULTS

Twenty-one RCTs involving 3246 patients (1666 with drains vs 1580 without) were included in the meta-analysis. There were no statistically significant differences in the rates of incidence of intra-abdominal fluid (RR: 1.10; 95% CI: 0.81-1.49; P = .54) or post-surgical mortality (RR: 0.44; 95% CI: 0.04-4.72; P = .50) between the two groups. Abdominal drains did not reduce the overall incidence of nausea and vomiting (RR: 1.16; 95% CI: 0.95-1.42; P = .15) or shoulder tip pain (RR: 1.03; 95% CI: 0.76-1.38; P = .86). The abdominal drain group displayed significantly higher pain scores (MD: 1.07; 95% CI: 0.69-1.46; P < .001) than the non-drainage patients. Abdominal drains prolonged the duration of the surgical procedure (MD: 5.69 min; 95% CI: 2.51-8.87; P = .005) and postoperative hospital stay (MD: 0.47 day; 95% CI: 0.14-0.80; P = .005). Wound infection was found to be associated with the use of abdominal drains (RR: 1.97; 95% CI: 1.11-3.47; P = .02).

CONCLUSIONS

Currently, there is no evidence to support the use of routine drainage after LC in non-complicated benign gallbladder disease. Further well-designed randomized clinical trials are required to confirm this finding.

Prophylactic drainage after laparoscopic cholecystectomy for acute cholecystitis: a systematic review and meta-analysis

In the literature, there is a large evidence against the use of drains in laparoscopic cholecystectomy (LC) in elective surgery. However, evidence is lacking in the setting of acute cholecystitis (AC). The present meta-analysis was performed to assess the role of drains to reduce complications and improve recovery in LC for AC. An electronic search of the MEDLINE, Science Citation Index Expanded, SpringerLink, Scopus, and Cochrane Library database from January 1990 to July 2018 was performed to identify randomized clinical trials (RCTs) that compare prophylactic drainage with no drainage in LC for AC. Odds ratio (OR) with confidence interval (CI) for qualitative variables and mean difference (MD) with CI for continuous variables were calculated. Three RCTs were included in the meta-analysis, involving 382 patients randomized to drain (188) versus no drain (194). Morbidity was similar in both the study groups (OR 1.23; 95% CI 0.55-2.76; p = 0.61) as well as wound infection rate (OR 1.98; 95% CI 0.53-7.40; p = 0.31) and abdominal abscess rate (OR 0.62; 95% CI 0.08-4.71; p = 0.31). Abdominal pain 24 h after surgery was less severe in the no drain group (MD 0.80; 95% CI 0.46-1.14; p < 0.000). A significant difference in favor of the no drain group was found in the postoperative hospital stay (MD 1.05; 95% CI 0.87-1.22; p < 0.000). No significant difference was present with respect to postoperative fluid collection in the subhepatic area and operative time. The present study shows that prophylactic drain placement is useless to reduce complications in LC performed to treat AC. Postoperative recovery is improved if drain is not present.

Comparison of mean pain scores for the patients with sub hepatic drainage to those without it after elective uncomplicated laparoscopic cholecystectomy

Objective:

The sub hepatic drain is often placed after laparoscopic cholecystectomy is considered to affect post operative infection, pain and sub hepatic collections. The objective of this study was to compare the degree of postoperative pain in patients with routine drainage with those without it after elective, uncomplicated laparoscopic cholecystectomy.

Methods:

This randomized control trial (RCT) was done over six months from 9^th June 2015 to 8^th December 2015 at Military Hospital Rawalpindi. Sample calculated with WHO calculator and consecutive non probability random sampling used to divide 170 patients undergoing laparoscopic cholecystectomy in two groups. One group had routine sub hepatic drain and other didn’t. Degree of postoperative pain was assessed according to VISUAL ANALOGUE SCALE by duty doctor at 24 hours. Data was collected and analyzed applying chi square test and p value was <.05 considered statistically significant.

Results:

Our results demonstrated that intensity of post operative pain in routine drainage group is higher as compared to non drainage group after elective, uncomplicated laparoscopic cholecystectomy.

Conclusion:

Routine placement of sub hepatic drain in elective uncomplicated laparoscopic cholecystectomy should be avoided to reduce post-operative pain.

Reporting of complications after laparoscopic cholecystectomy: a systematic review

BACKGROUND

Consistent measurement and reporting of outcomes, including adequately defined complications, is important for the evaluation of surgical care and the appraisal of new surgical techniques. The range of complications reported after LC has not been evaluated. This study aimed to identify the range of complications currently reported for laparoscopic cholecystectomy (LC), and the adequacy of their definitions.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for prospective studies reporting clinical outcomes of LC, between 2013 and 2016.

RESULTS

In total 233 studies were included, reporting 967 complications, of which 204 (21%) were defined. One hundred and twenty-two studies (52%) did not provide definitions for any of the complications reported. Conversion to open cholecystectomy was the most commonly reported complication, reported in 135 (58%) studies, followed by bile leak in 89 (38%) and bile duct injury in 75 (32%). Mortality was reported in 89 studies (38%).

CONCLUSION

Considerable variation was identified between studies in the choice of measures used to evaluate the complications of LC, and in their definitions. A standardised set of core outcomes of LC should be developed for use in clinical trials and in evaluating the performance of surgical units.

Abdominal drainage versus no abdominal drainage for laparoscopic cholecystectomy: A systematic review with meta-analysis and trial sequential analysis

The aim is to assess the benefits and harms of routine abdominal drainage in laparoscopic cholecystectomy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until August 2016. We included all randomised clinical trials comparing drainage versus no drainage after laparoscopic cholecystectomy irrespective of language and publication status. We used standard methodological procedures in accordance with the PRISMA guidelines. A total of 2398 participants were randomised to drain (1197 participants) versus 'no drain' (1201 participants) in 16 trials included in this article. Pain 24 h after surgery was less severe in the no drain group (MD1.31; 95% CI, 0.96 to 1.65; p < 0.00001). Abdominal drainage prolonged operative time (MD 5.77 min; 95% CI 4.98 min-6.57 min; p < 0.00001) but not the length of hospital stay (MD 0.21 days; 95% CI -0.00 days to 0.42 days; p = 0.05). No significant difference was present with respect to the intra-abdominal fluid, wound infection, nausea or vomit, mortality after operation. There is no significant advantage of drain placement after laparoscopic cholecystectomy. Further well designed randomized clinical trials should be carefully re-considered.

Prophylactic intra-peritoneal drain placement following pancreaticoduodenectomy: A systematic review and meta-analysis

AIM: To conduct a meta-analysis comparing outcomes after pancreaticoduodenectomy (PD) with or without prophylactic drainage.

METHODS: Relevant comparative randomized and non-randomized studies were systemically searched based on specific inclusion and exclusion criteria. Postoperative outcomes were compared between patients with and those without routine drainage. Pooled odds ratios (OR) with 95%CI were calculated using either fixed effects or random effects models.

RESULTS: One randomized controlled trial and four non-randomized comparative studies recruiting 1728 patients were analyzed. Patients without prophylactic drainage after PD had significantly higher mortality (OR = 2.32, 95%CI: 1.11-4.85; P = 0.02), despite the fact that they were associated with fewer overall complications (OR = 0.62, 95%CI: 0.48-0.82; P = 0.00), major complications (OR = 0.75, 95%CI: 0.60-0.93; P = 0.01) and readmissions (OR = 0.77, 95%CI: 0.60-0.98; P = 0.04). There were no significant differences in the rates of pancreatic fistula, intra-abdominal abscesses, postpancreatectomy hemorrhage, biliary fistula, delayed gastric emptying, reoperation or radiologic-guided drains between the two groups.

CONCLUSION: Indiscriminate abandonment of intra-abdominal drainage following PD is associated with greater mortality, but lower complication rates. Future randomized trials should compare routine vs selective drainage.

Meta-analysis of drainage versus no drainage after laparoscopic cholecystectomy

BACKGROUND AND OBJECTIVES

Routine drainage after laparoscopic cholecystectomy is still controversial. This meta-analysis was performed to assess the role of drains in reducing complications in laparoscopic cholecystectomy.

METHODS

An electronic search of Medline, Science Citation Index Expanded, Scopus, and the Cochrane Library database from January 1990 to June 2013 was performed to identify randomized clinical trials that compare prophylactic drainage with no drainage in laparoscopic cholecystectomy. The odds ratio for qualitative variables and standardized mean difference for continuous variables were calculated.

RESULTS

Twelve randomized controlled trials were included in the meta-analysis, involving 1939 patients randomized to a drain (960) versus no drain (979). The morbidity rate was lower in the no drain group (odds ratio, 1.97; 95% confidence interval, 1.26 to 3.10; P = .003). The wound infection rate was lower in the no drain group (odds ratio, 2.35; 95% confidence interval, 1.22 to 4.51; P = .01). Abdominal pain 24 hours after surgery was less severe in the no drain group (standardized mean difference, 2.30; 95% confidence interval, 1.27 to 3.34; P < .0001). No significant difference was present with respect to the presence and quantity of subhepatic fluid collection, shoulder tip pain, parenteral ketorolac consumption, nausea, vomiting, and hospital stay.

CONCLUSION

This study was unable to prove that drains were useful in reducing complications in laparoscopic cholecystectomy.

Drainage vs. non-drainage after cholecystectomy for acute cholecystitis: a retrospective study

Many surgeons practice prophylactic drainage after cholecystectomy without reliable evidence. This study was conducted to answer the question whether to drain or not to drain after cholecystectomy for acute calculous cholecystitis. A retrospective review of all patients who had cholecystectomy for acute cholecystitis in Aseer Central Hospital, Abha, Saudi Arabia, was conducted from April 2010 to April 2012. Data were extracted from hospital case files. Preoperative data included clinical presentation, routine investigations and liver function tests. Operative data included excessive adhesions, bleeding, bile leak, and drain insertion. Complicated cases such as pericholecystic collections, mucocele and empyema were also reported. Patients who needed therapeutic drainage were excluded. Postoperative data included hospital stay, volume of drained fluid, time of drain removal, and drain site problems. The study included 103 patients allocated into two groups; group A (n  =  38) for patients with operative drain insertion and group B (n  =  65) for patients without drain insertion. The number of patients with preoperative diagnosis of acute non-complicated cholecystitis was significantly greater in group B (80%) than group A (36.8%) (P < 0.001). Operative time was significantly longer in group A. All patients who were converted from laparoscopic to open cholecystectomy were in group A. Multivariate analysis revealed that hospital stay was significantly (P < 0.001) longer in patients with preoperative complications. There was no added benefit for prophylactic drain insertion after cholecystectomy for acute calculous cholecystitis in non-complicated or in complicated cases.