|Year : 2013 | Volume
| Issue : 2 | Page : 267-271
Post-operative abdominal drainage following major upper gastrointestinal surgery: Single drain versus two drains
Shailesh V Shrikhande, Savio G Barreto, Guruprasad Shetty, Kunal Suradkar, Yashodhan D Bodhankar, Sumeet B Shah, Mahesh Goel
Department of Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||13-Jun-2013|
Shailesh V Shrikhande
Department of Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Traditionally, surgeons have resorted to placing drains following major gastrointestinal surgery. In recent years, the value of routine drainage has been questioned, especially in the light of their role in post-operative pain, infection, and prolonged hospital stay. The aim of this study was to compare the peri-operative outcomes following the use of a single versus two drains for gastric and pancreatic resections.
Materials and Methods: Patients undergoing resections for gastric and pancreatic malignancies were included in the study. Patients were subdivided into two groups depending on the number of drains placed, viz. one drain (Group 1) or two drains (Group 2). Clinico-pathologic outcomes were recorded and compared.
Results: Of the 285 patients included in the analysis, group 1 consisted of 226 patients while group 2 included 59 patients. Overall, drains alerted the surgeon to existence of complications in 62% of patients - 70% in group 1 and 44.4% in group 2 (P < 0.19). The morbidity and mortality rates in groups 1 and 2 were 25.2% and 3.9%, and 23.7% and 0%, respectively (P < 0.61 and P < 0.12). There were no drain-related complications. Median hospital stay was significantly lower in group 1 (11 vs. 14 days) (P < 0.001).
Conclusion: The insertion of drains did aid in the detection of complications following gastric and pancreatic surgery. Two drains offer no further advantage over one drain in terms of detection of complications. While the number of drains did not contribute to, or reduce, the morbidity and mortality in the two groups, the use of one drain significantly reduced hospital stay. Taken together, these findings support the prophylactic insertion of a single intra-abdominal drain following gastric and pancreatic resections.
Keywords: Gastrectomy, morbidity, outcomes, pancreatectomy, pancreatoduodenectomy
|How to cite this article:|
Shrikhande SV, Barreto SG, Shetty G, Suradkar K, Bodhankar YD, Shah SB, Goel M. Post-operative abdominal drainage following major upper gastrointestinal surgery: Single drain versus two drains. J Can Res Ther 2013;9:267-71
|How to cite this URL:|
Shrikhande SV, Barreto SG, Shetty G, Suradkar K, Bodhankar YD, Shah SB, Goel M. Post-operative abdominal drainage following major upper gastrointestinal surgery: Single drain versus two drains. J Can Res Ther [serial online] 2013 [cited 2020 Feb 18];9:267-71. Available from: http://www.cancerjournal.net/text.asp?2013/9/2/267/113380
| > Introduction|| |
Abdominal drainage following major gastrointestinal surgery has often been a matter of contention. ,, The debated issues are whether to drain or not, , or whether to remove the intraoperatively inserted drain early or late, and the implications of this. , Despite the only randomized controlled trial more than a decade ago, which concluded that closed suction abdominal drainage following pancreatic resection should not be considered mandatory, to this day, upper gastrointestinal and hepato-pancreato-biliary surgeons around the world continue to place abdominal drains intraoperatively. ,,,,
The rationale behind abdominal drainage following major abdominal surgery has been the value afforded by drains in forewarning the surgeon of potential intra-abdominal complications.  Traditionally, surgeons have resorted to placing multiple drains. However, drains have been implicated in the causation of local pain, ascending infection via the drain, , and interference with patient ambulation. While on the one hand, the nature of the drainage tubes has improved over time, viz. they are more malleable and hence cause less discomfort, less allergenic owing to the inert material used, and their availability in smaller diameters, criticism against the use of the narrower, softer drains has focused on their inability to function effectively as they risk getting blocked. 
The aim of the current study was to compare the use of a single versus two drains placed intraoperatively following major gastric and pancreatic resections - more specifically focusing on the following factors:
- Ability of the drains to alert the surgeon to an impending or developed intra-abdominal complication,
- The impact of the number of drains on the length of post-operative hospital stay, and
- The morbidity directly ensuing from the intraoperatively placed drain.
| > Materials and Methods|| |
Patients undergoing gastric and pancreatic resections for malignancy at the Department of Gastrointestinal and Hepatobiliary and Pancreatic Surgical Oncology of the Tata Memorial Centre, Mumbai between 1 st November 2008 and 30 th April 2011, were evaluated retrospectively from a prospectively maintained database. All surgeries were performed by, or under the supervision of, the consultant surgeons in the unit.
Preoperatively, all patients were investigated in the same manner with routine blood investigations, including blood counts, liver and renal functions, ECG, and tumor markers (serum carbohydrate antigen 19-9, serum carcino-embryonic antigen), and an abdominal computed tomography (CT) scan for staging the tumor. A side-viewing endoscopy/endoscopic ultrasonography and biopsy were used selectively. In cases of pancreatic malignancies with a negative biopsy but a strong clinical suspicion of a malignancy, the team went ahead with a pancreatoduodenectomy (PD), with or without an intra-operative frozen section. Endoscopic retrograde cholangio-pancreatography (ERCP) and stenting were performed preoperatively only in the presence of biliary obstruction and resultant cholangitis, in which case surgery was thereafter delayed for 4-6 weeks post-stenting (based on previous work by the same group). 
Drain placement details
After informed consent, as per the unit policy of placing drains intraoperatively, one surgeon placed one drain (group 1) while the other placed two drains (group 2) in a standardized fashion outlined below.
Following gastric resections
Group 1: A single Portex® tube (size 28) drain was placed in the Morrison's pouch.
Group 2: Two Portex® tube drains (size 28) were routinely placed; one in the Morrison's pouch on the right side and the other on the left side in the region of the gastrojejunostomy/esophagojejunostomy.
Following pancreatic resections
Group 1: A single Portex® tube drain was placed in the Morrison's pouch.
Group 2: Two Portex® tube drains were routinely placed one each in the Morrison's pouch on the right side and in the infracolic region of the duodenojejunal window on the left side.
No specific intra-operative criteria (for e.g. firm pancreas/satisfactory post-PPPD anastomosis/incomplete donut after stapled anastomosis after total gastrectomy etc.) were considered while deciding the number of drains to be placed.
Criteria for drain removal
For gastric resections: The single drain was removed after the effluent reduced to <30 ml/day (usually around 5 th POD). In case of 2 drains, the gastrojejunal side drain was removed a day after initiation of oral solid diet (usually around 4 - 7 post-operative day). All possibilities of post-operative sepsis were considered and excluded by close clinical examination and blood work up (complete blood count etc).
For pancreatic resections: 1 drain/2 drains removed if drain amylase on day 7 was within normal limits - however, if not within normal limits, the drain was retained till the volume reduced to <30 cc or in case of complications - the drain color returned to serous nature from the earlier appearance (bilious/hemorrhagic/pancreatic juice like).
All procedures were performed in a standardized fashion and included proximal, subtotal, and total gastrectomies for gastric cancer and PD and distal pancreatectomies (DP) for pancreatic cancers. The technique of gastrectomy with D2 lymphadenectomy and PD have both been previously described in publications from the same group. ,,,
Clinical, pathologic, and surgical details were recorded.
All patients were administered an antibiotic dose of cefaperazone + sulbactam 2 gm (for gastric resections - augmentin was used) prior to the procedure. In patients who underwent pancreatic resections, the patients were also given a dose of 0.1 mg of octreotide 2 hours prior to commencing the pancreatic anastomosis, and this was continued for 7 days postoperatively, in a dosage of 0.1 mg, 3 times a day.
Peri-operative mortality was defined as deaths taking place while the patient was still admitted in-hospital. Deaths were included irrespective of whether they arose as a result of the surgery or other causes (i.e., to include cardiac-related deaths). Post-operative complications have been defined as per the ISGPS definitions [14-16] as well as our previous publications. ,,, Drain-related complications (perforations, incarcerated drain requiring local exploration/laparotomy/laparoscopy for removal), if any, were specifically recorded. Hospital stay was defined as the period from the day of surgery to discharge of the patient from the index hospital admission.
| > Statistical Analysis|| |
All statistical Analysis were performed using the Statistical Product and Service Solutions, SPSS 18.0 for Windows. Nominal data is provided as number (%) and continuous data as median (range). Mann-Whitney U test was used for statistical analysis. Z-test was used for comparison of proportions.
| > Results|| |
Two Hundred Eighty-Five patients were included in the study. These included 200 male and 85 female patients with a median age of 55 years (range 15-84). One Hundred Forty-Seven patients had gastric cancers while 138 had pancreatic cancers.
Amongst the patients with gastric cancers, 97 patients underwent a subtotal gastrectomy, while 29 and 21 patients, respectively, underwent proximal and total gastrectomies. The histologies included 144 adenocarcinomas, 2 gastrointestinal stromal tumors (GIST), and 1 squamous cell carcinoma.
While 126 patients and 12 patients, respectively, underwent PDs and DPs for 113 adenocarcinomas, 10 neuroendocrine tumors, 10 cystic tumors, and 5 other tumors.
There were 226 patients enrolled in group 1 and 59 patients in group 2. [Table 1] summarizes the pertinent surgical data in the two groups. The overall rate for detection of major complication by drains was 62%.
Group Specific Peri-Operative Data
Fifty-Seven of 226 patients (25.2%) developed complications while the mortality rate was 3.9% (9/226). Out of 57 complications, 43 were procedure-related, but only 20 of 43 could have been potentially detected by the drains (e.g. duodenal stump leaks, hemorrhage etc. for gastrectomy group, and pancreatic anastomotic leak and fistula (POPF), biliary leaks, hemorrhage etc. for pancreatectomy group) as opposed to the remaining 23 patients who experienced complications such as delayed gastric emptying, gastric outlet obstruction, bowel ischemia, wound problems, etc. In 14 of 20 patients (70%) with complications, the drain effluent did alert to the existence of a complication.
Fourteen of 59 patients (23.7%) developed complications without any mortality. Thirteen of 14 complications were procedure-related, but only 9 patients' complications could have been potentially detected by the drains as opposed to the remaining 4 patients. In 4 of 9 patients (44.4%), the drains did alert the surgeons to the existence of an underlying complication.
[Table 2] provides a classification of the severity of complications according to the classification described by Dindo et al. 
There were no drain-related complications.
|Table 2: Classification of surgical complications (as per the Dindo-Clavien system)|
Click here to view
| > Discussion|| |
The results of our study indicate the following:
The role of drainage of the abdominal cavity following upper gastrointestinal surgery is evolving. Traditional surgical teaching has focused on the role of intra-abdominal drainage, following gastrointestinal surgery including aiding the egress of peritoneal fluid contaminated by the gastrointestinal flora that may be retained within the peritoneal after gastrointestinal surgery, serving as an early indicator of impending intra-abdominal complications post-operatively and finally even playing an often important role of a controlled fistula. , However, even since the early days, surgeons have questioned the need for the dogmatic practice of routine prophylactic drainage of the abdominal cavity. , Furthermore, drains have been implicated in the causation local pain often resulting with interference with patient ambulation - as demonstrated from studies on drains in patients undergoing colon and rectal resections. , Drains are also associated with a risk of ascending infection via the drain. ,
- Intraoperatively placed drains following gastric and pancreatic resections are able to alert the surgeon to an impending or developed intra-abdominal complication. There is no difference in the detection rate between a single and two drains.
- The number of drains significantly influences median hospital stay, such that more the number of drains, longer is the hospital stay.
- No drain-related morbidity was noted.
While the quality of the material used to produce the drains has improved over time coupled with a reduction in the size of the drains, criticism against the use of thinner, softer drains has focused on their inability to always function effectively as they risk getting blocked. 
Petrowsky et al.  in their systematic analysis on the use of prophylactic drains following gastrointestinal surgery found that there were no studies exploring the role of routine prophylactic abdominal drainage in gastric surgery while in the case of pancreatic surgery, there was only one randomized controlled trial on the role of drainage following pancreatic surgery.  This study by Conlon et al.  studied the role of "closed suction drainage" following pancreatic resectional surgery. The conclusions of the study indicated that drainage following pancreatic resectional surgery should not be considered mandatory.
The other important aspect of abdominal drainage relates to the duration of drainage. A prospective, non-randomized study  comparing early drain removal (post-operative day 4) versus delayed drain removal (post-operative day 8) conducted over two different time periods suggested that early drain removal was associated with reduced morbidity following pancreatic resections, including a reduction in intra-abdominal infections.
In 2006, Buchler and Friess  suggested the need for clearer evidence to support the routine use of drains in an attempt to answer the question whether drain insertion after gastrointestinal surgery was yet another classic example of surgical dogma over modern evidence-based medicine. While they did concede that the evidence against the routine insertion of drains was lacking, they felt that one potential compromise could be the early removal of drains.
Despite the single randomized trial  published more than a decade ago which questioned the routine use of abdominal drainage, surgeons continue to use drains as clearly evidenced in literature. ,,,,, Our present study thus assumes significance owing to the lack of sufficient data on routine prophylactic drain insertion for gastric and pancreatic resectional surgery. The results indicate that drains do help in alerting the surgeon to the presence of an intra-abdominal complication. We have been able to show that reducing the number of drains inserted from two to one can be just as useful with no increase in morbidity or mortality and in fact with a reduced length of hospital stay. Perhaps correct drain placement and use of medium (size 28) caliber drain (to prevent blocking) was crucial in the context of our results.
Majority of surgeons around the world still prefer to drain despite contrary information being provided by evidence-based medicine. On this background, despite the shortcoming that our study is not a randomized controlled trial, the results of this retrospective analysis of a prospective database assume significance in day-to-day clinical practice.
| > Conclusion|| |
The insertion of drains did aid in the detection of complications following gastric and pancreatic surgery. Two drains offer no further advantage over one drain in terms of detection of complications. While the number of drains did not contribute to, or reduce, the morbidity and mortality in the two groups, the use of one drain significantly reduced hospital stay. Taken together, these findings support the prophylactic insertion of a single intra-abdominal drain following gastric and pancreatic resections.
| > References|| |
|1.||Bassi C, Molinari E, Malleo G, Crippa S, Butturini G, Salvia R, et al. Early versus late drain removal after standard pancreatic resections: Results of a prospective randomized trial. Ann Surg 2010;252:207-14. |
|2.||Buchler MW, Friess H. Evidence forward, drainage on retreat: Still we ignore and drain!? Ann Surg 2006;244:8-9. |
|3.||Conlon KC, Labow D, Leung D, Smith A, Jarnagin W, Coit DG, et al. Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection. Ann Surg 2001;234:487-93. discussion 93-4. |
|4.||Kawai M, Tani M, Terasawa H, Ina S, Hirono S, Nishioka R, et al. Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection: Prospective study for 104 consecutive patients. Ann Surg 2006;244:1-7. |
|5.||Barreto G, D'Souza MA, Shukla PJ, Shrikhande SV. The gray zone between postpancreaticoduodenectomy collections and pancreatic fistula. Pancreas 2008;37:422-5. |
|6.||Yeo C. Pancreatic surgery 101: Drain, no drain, early drain removal, or late drain removal. What are the data? Where do we go from here? Ann Surg 2010;252:215-6. |
|7.||Wente MN, Shrikhande SV, Kleeff J, Muller MW, Gutt CN, Buchler MW, et al. Management of early hemorrhage from pancreatic anastomoses after pancreaticoduodenectomy. Dig Surg 2006;23:203-8. |
|8.||Nora PF, Vanecko RM, Bransfield JJ. Prophylactic abdominal drains. Arch Surg 1972;105:173-6. |
|9.||Raves JJ, Slifkin M, Diamond DL. A bacteriologic study comparing closed suction and simple conduit drainage. Am J Surg 1984;148:618-20. |
|10.||Jagannath P, Dhir V, Shrikhande S, Shah RC, Mullerpatan P, Mohandas KM. Effect of preoperative biliary stenting on immediate outcome after pancreaticoduodenectomy. Br J Surg 2005;92:356-61. |
|11.||Shrikhande SV, Barreto G, Shukla PJ. Pancreatic fistula after pancreaticoduodenectomy: The impact of a standardized technique of pancreaticojejunostomy. Langenbecks Arch Surg 2008;393:87-91. |
|12.||Shrikhande SV, Shukla PJ, Qureshi S, Siddachari R, Upasani V, Ramadwar M, et al. D2 lymphadenectomy for gastric cancer in Tata Memorial Hospital: Indian data can now be incorporated in future international trials. Dig Surg 2006;23:192-7. |
|13.||Shukla PJ, Barreto SG, Mohandas KM, Shrikhande SV. Defining the role of surgery for complications after pancreatoduodenectomy. ANZ J Surg 2009;79:33-7. |
|14.||Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: An international study group (ISGPF) definition. Surgery 2005;138:8-13. |
|15.||Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, et al. Delayed gastric emptying (DGE) after pancreatic surgery: A suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007;142:761-8. |
|16.||Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, et al. Postpancreatectomy hemorrhage (PPH): An International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007;142:20-5. |
|17.||Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-13. |
|18.||Dougherty SH, Simmons RL. The biology and practice of surgical drains. Part 1. Curr Probl Surg 1992;29:559-623. |
|19.||Dougherty SH, Simmons RL. The biology and practice of surgical drains. Part II. Curr Probl Surg 1992;29:633-730. |
|20.||Delbert P. Recherches experimentale sur la lavage au peritoneum. Ann Gynekol Obstet 1889;32:165-97. |
|21.||Ott V. Die drainage nach laparotomyie -experimentelle untersuchung. Medicinsky Westnick No. 1978. Zentralbl Gynaek 1879;3:86-7. |
|22.||Jesus EC, Karliczek A, Matos D, Castro AA, Atallah AN. Prophylactic anastomotic drainage for colorectal surgery. Cochrane Database Syst Rev 2004; 4:CD002100. |
|23.||Urbach DR, Kennedy ED, Cohen MM. Colon and rectal anastomoses do not require routine drainage: A systematic review and meta-analysis. Ann Surg 1999;229:174-80. |
|24.||Petrowsky H, Demartines N, Rousson V, Clavien PA. Evidence-based value of prophylactic drainage in gastrointestinal surgery: A systematic review and meta-analyses. Ann Surg 2004;240:1074-84. discussion 84-5. |
[Table 1], [Table 2]