Intraoperative Adjuncts in Colorectal Surgery

Prophylactic Intra-abdominal Drainage is Associated With Lower Postoperative Complications in Patients With Crohn's Disease: A Randomized Controlled Trial

BACKGROUND

Prophylactic intraoperative drains have been shown not superior for patients underwent intestinal surgery. However, for patients with Crohn's disease (CD), this needs further exploration.

METHODS

In this pilot study, CD patients were randomly assigned to drain (n = 50) and no-drain (n = 50) groups. The primary endpoint was the rate of postoperative prolonged ileus (PPOI). The secondary endpoints were postoperative abdominal ascites, postoperative systemic inflammatory response syndrome (SIRS) and C-reactive protein (CRP) levels.

RESULTS

The incidences of PPOI and postoperative abdominal ascites were significantly lower in the drain group (12% vs 44%; 0% vs 24%, both P < .05). Postoperative SIRS incidence and CRP levels were significantly increased in the no-drain group [36% vs 10%; 54.9 vs 34.3 mg/L, both P < .05]. In multivariate analysis, prophylactic drainage was the independent protective factor for PPOI and postoperative LOS.

CONCLUSIONS

Prophylactic drainage may be associated with improved clinical outcomes in CD patients.

Routine placement of abdominal drainage in pouch surgery does not impact on surgical outcomes

The evidence does not support the routine use of abdominal drainage (AD) in colorectal surgery. However, there is no data on the usefulness of AD, specifically, after ileal pouch-anal anastomosis (IPAA). The aim of this study is to assess post-operative outcomes of patients undergoing IPAA with or without AD at a high volume referral center. A retrospective analysis of prospectively collected data of consecutive patients undergoing IPAA with AD (AD group) or without AD (NAD group) was performed. Baseline characteristics, operative, and postoperative data were analyzed and compared between the two groups. A total of 97 patients were included in the analysis, 46 were in AD group and 51 in NAD group. AD group had a higher BMI (23.9 ± 3.9 kg/m² vs 21.9 ± 3.0 kg/m²; p = 0.007) and more commonly underwent two-stage proctocolectomy with IPAA compared to the NAD group (50.0% vs 3.9%; p < 0.001). There was no difference in anastomotic leak rate (6.5% AD vs 5.9% NAD group; p = 1.000), major post-operative complication (8.6% vs 7.9%; p = 0.893); median length of stay [IQR] (5 [5-7] days vs 5 [4-7] days; p = 0.305) and readmission < 90 days (8.7% vs 3.9%; p = 0.418). The use of AD does not impact on surgical outcome after IPAA and question the actual benefit of its routine placement.

A Meta-Analysis of Randomized Controlled Trials on the Use of Suction Drains Following Rectal Surgery

BACKGROUND

Anastomotic leakage is one of the most feared complications of rectal resections. The role of drains in limiting this occurrence or facilitating its early recognition is still poorly defined. We aimed to study whether the presence of prophylactic pelvic drains affects the surgical outcomes of patients undergoing rectal surgery with extraperitoneal anastomosis.

METHODS

PubMed, EMBASE, and the Cochrane Library were systematically searched for randomized controlled trials comparing drained with undrained anastomoses following rectal surgery. We evaluated possible differences on the relative incidences of anastomotic leakage, pelvic collection or sepsis, bowel obstruction, reoperation rate, and overall mortality. A meta-analysis of relevant studies was performed with RevMan 5.3.

RESULTS

A total of 760 patients from 4 randomized controlled studies were considered eligible for data extraction. The use of drains did not show any advantage in terms of anastomotic leak (OR 0.99), pelvic complications (OR 0.87), reintervention (OR 0.84) and mortality. Contrariwise, the incidence of postoperative bowel obstruction was significantly higher in the drained group (OR 1.61).

CONCLUSIONS

The routine utilization of pelvic drains does not confer any significant advantage in the prevention of postoperative complications after rectal surgery with extraperitoneal anastomosis. Moreover, a higher risk of postoperative bowel obstruction can be of concern.

To Drain or Not to Drain Infraperitoneal Anastomosis After Rectal Excision for Cancer: The GRECCAR 5 Randomized Trial

OBJECTIVE

To assess the effect of pelvic drainage after rectal surgery for cancer.

BACKGROUND

Pelvic sepsis is one of the major complications after rectal excision for rectal cancer. Although many studies have confirmed infectiveness of drainage after colectomy, there is still a controversy after rectal surgery.

METHODS

This multicenter randomized trial with 2 parallel arms (drain vs no drain) was performed between 2011 and 2014. Primary endpoint was postoperative pelvic sepsis within 30 postoperative days, including anastomotic leakage, pelvic abscess, and peritonitis. Secondary endpoints were overall morbidity and mortality, rate of reoperation, length of hospital stay, and rate of stoma closure at 6 months.

RESULTS

A total of 494 patients were randomized, 25 did not meet the criteria and 469 were analyzed: 236 with drain and 233 without. The anastomotic height was 3.5 ± 1.9 cm from the anal verge. The rate of pelvic sepsis was 17.1% (80/469) and was similar between drain and no drain: 16.1% versus 18.0% (P = 0.58). There was no difference of surgical morbidity (18.7% vs 25.3%; P = 0.83), rate of reoperation (16.6% vs 21.0%; P = 0.22), length of hospital stay (12.2 vs 12.2; P = 0.99) and rate of stoma closure (80.1% vs 77.3%; P = 0.53) between groups. Absence of colonic pouch was the only independent factor of pelvic sepsis (odds ratio = 1.757; 95% confidence interval 1.078-2.864; P = 0.024).

CONCLUSIONS

This randomized trial suggests that the use of a pelvic drain after rectal excision for rectal cancer did not confer any benefit to the patient.

To drain or not to drain extraperitoneal colorectal anastomosis? A systematic review and meta-analysis

AIM

Anastomotic leakage is the one of the most serious complications in rectal cancer surgery and is associated with high mortality, morbidity and an increased incidence of local recurrence. Although many studies have compared drained and undrained colorectal anastomoses, to date the role of pelvic drainage in extraperitoneal colorectal anastomosis remains undefined.

METHOD

We carried out a systematic review of the literature, performing an unrestricted search in MEDLINE and Embase up to 30 October 2012. Reference lists of retrieved articles and review articles were manually searched for other relevant studies. We performed a meta-analysis of the data currently available on the incidence of extraperitoneal anastomotic leakage, according to the presence or absence of pelvic drainage.

RESULTS

Overall, eight studies - three randomized clinical trials (RCTs) and five non-RCTs, comprising a total of 2277 patients - were included in the meta-analysis. Pelvic drainage was demonstrated to reduce both the leak rate and the rate of reintervention in patients who underwent anterior rectal resection with extraperitoneal colorectal anastomosis (OR = 0.51, 95% CI: 0.36-0.73; and OR = 0.29, 95% CI: 0.18-0.46, respectively) compared with patients without drainage. Overall mortality and infection rates were also evaluated, but a nonsignificant correlation was found with the presence of drainage.

CONCLUSION

The meta-analysis shows that the presence of a pelvic drain reduces the incidence of extraperitoneal colorectal anastomotic leakage and the rate of reintervention after anterior rectal resection.