Timing for removing prophylactic drains after liver resection: an evaluation of drain removal on the third and first postoperative days

Early drain removal after hepatectomy based on bile leakage prediction using drainage fluid volume and direct bilirubin level

AIMS

This study aimed to determine the value of the drainage fluid volume and direct bilirubin level for predicting significant bile leakage (BL) after hepatectomy and establish novel criteria for early drain removal.

METHODS

Data from 351 patients who underwent hepatic resection at Gunma University in Japan between October 2018 and March 2022 were retrospectively analyzed. Clinical characteristics and surgical outcomes of patients with and without significant BL were compared. Criteria for early drain removal were determined and verified.

RESULTS

Bile leakage occurred in 27 (7.1%) patients; 8 (2.3%) had grade A leakage and 19 (5.4%) had grade B leakage. The optimal cut-off value for the drainage fluid direct bilirubin level on postoperative day (POD) 2 was 0.16 mg/dL, which had the highest area under the curve and negative predictive value (NPV). Patients with BL had significantly larger drainage volumes on POD 2. The best cut-off value was 125 mL because it had the greatest NPV. Patients in both the primary and validation (n = 90) cohorts with bilirubin levels less than 0.16 mg/dL and drainage volumes less than 125 mL did not experience leakage.

CONCLUSIONS

A drainage fluid volume less than 125 mL and direct bilirubin level less than 0.16 mg/dL on POD 2 are criteria for safe early drain removal after hepatectomy.

Clinical impact of various drain-fluid data for the postoperative complications after hepatectomy: criteria of prophylactic drain removal on postoperative day 1

PURPOSE

Prophylactic drains reported to be useful to treat postoperative bile leakage (POBL) and reduce re-intervention after hepatectomy. However, prophylactic drains should remove in the early postoperative period. This study aimed to assess the association between postoperative complications and the drain-fluid data on postoperative day (POD) 1.

METHODS

Medical records of 530 patients who underwent hepatectomy were retrospectively reviewed. We evaluated the drain-fluid data on POD 1, such as bilirubin (BIL), aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) and drain discharge volume. These variables were compared between patients with and without postoperative complications such as POBL and abdominal abscess not due to POBL.

RESULTS

POBL was found in 44 patients (8.3%), PHLF was in 51 patients (9.6%), and abdominal abscess not due to POBL was in 21 patients (4.0%). Regarding POBL, drain-fluid BIL concentration and drain discharge volume was higher in the POBL group (p < 0.001 and p < 0.001, respectively). However, drain-fluid AST, ALT, and ALP concentrations were not different between two groups. As to the abdominal abscess not due to POBL, all drain-fluid data were not significantly different. Multivariate analysis for predicting POBL showed that the drain-fluid BIL concentration ≥ 2.68 mg/dL was an independent predictor (p < 0.001). In the subgroup analyses according to the type of hepatectomy, the drain-fluid BIL concentration was an independent predictor for POBL after both non-anatomical and anatomical hepatectomy.

CONCLUSION

The drain-fluid BIL concentration on POD 1 is useful in predicting POBL after hepatectomy.

On-Site Monitoring of Postoperative Bile Leakage Using Bilirubin-Inducible Fluorescent Protein

Background

Bile leakage is the most common postoperative complication associated with hepatobiliary and pancreatic surgery. Until now, however, a rapid, accurate diagnostic method for monitoring intraoperative and postoperative bile leakage had not been established.

Method

Bilirubin levels in drained abdominal fluids collected from 23 patients who had undergone hepatectomy (n = 22) or liver transplantation (n = 1) were measured using a microplate reader with excitation/emission wavelengths of 497/527 nm after applying 5 µM of UnaG to the samples. UnaG was also sprayed directly on hepatic raw surfaces in swine hepatectomy models to identify bile leaks by fluorescence imaging.

Results

The bilirubin levels measured by UnaG fluorescence imaging showed favorable correlations with the results of the conventional light-absorptiometric methods (indirect bilirubin: rs = 0.939, p < 0.001; direct bilirubin: rs = 0.929, p < 0.001). Approximate time required for bilirubin measurements with UnaG was 15 min, whereas it took about 40 min with the conventional method at a hospital laboratory. Following administration of UnaG on hepatic surfaces, the fluorescence imaging identified bile leaks not only on the resected specimens but also in the abdominal cavity of the swine hepatectomy models.

Conclusion

Fluorescence imaging techniques using UnaG may enable real-time identification of bile leaks during hepatectomy and on-site rapid diagnosis of bile leaks after surgery.

Electronic supplementary material

The online version of this article (10.1007/s00268-020-05774-x) contains supplementary material, which is available to authorized users.