Uses of drain in abdominal surgery
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Transcript of Uses of drain in abdominal surgery
by
Dr.Imran Sadiq
King Abdul Aziz Naval Base Hospital
First recorded use of drains is attributed to Hippocrates (460-377 BC ) for Empyema
Lorenz Heister of Numberg (1683-1758 ) introduce the principle of capillary (action) drainage .
Eugene Koeberle of Strasbourg(1865) used a glass tube drain .
Heaton ( 1889 ) is credited with introducing suction drainage .
Murphy ( 1947 ) introduced a technique for intermittent suction .
Closed-system , continuous suction introduced by Baron (1950 ) .
1. Active Drains
Closed
JP(Jackson-Pratt Drain),
Redivac Suction Drain
Open
Sump Drain
FLUID
AIR
1. Passive Drains
Closed
NGT, Foleys catheter,
T-Tube, Nelaton Drain etc.
Open
Penrose drains,
corrugated Drains
Active Drain Passive Drain
Function Works by negativepressure created by compressible drums or mechanical evacuation system
Depends upon pressure differentials & gravity
Pressure Gradient Negative Pressure Normal
Drain Exit site Dependent Position is not necessary
Dependent position for best function
Retrograde Infection Lower incidence Higher incidence
Fluid collection Decreased incidence because negative pressure improves tissue apposition & obliterates dead space
Increased incidence because of limited effect on dead space
Obstruction of Drain More common Less common
Pressure necrosis Greater incidence Less common
In 1905 Yates claimed “ drainage of General Peritoneal cavity is physically and physiologically impossible”.
Gravitz’s stated “ Peritoneum is able to reabsorb secretions and combat bacteria.”
Review of literature/Research work.
This is the most sophisticated way to get benefit from the work and experiences of others in this era.
1992
“the conscientious,explicit,judicious use of current best evidence in making decisions about the care of individual patients.”
( conscientious -------- attentive, Luborious,Pain taking)
( Explicit------------------ Obvious)
( Judicious--------------- Logical,Rational)
Its basic principles are that all practical decisions made should
Be based on Research studies.
That the Research studies are selected and interpreted according to some specific norms
characteristic for EBP.
The results should be analyzed and compared with standards.
How to Review the literature/Research work?
Which Research work is Reliable and practicable?
Anything present in support of an assertion (statement).
Evidence is comprised of research findings delivered from the systemic collection of Data through observation & experiment and the formulation of Question & testing of Hypothesis.
There are certain scales to measure Evidence (levels of Evidence )
Recommendations are made by different Research Groups.
CodeQuality of Evidence
Definition
A High
Further research is very unlikely to change our confidence in the estimate of effect.•Several high-quality studies with consistent results•In special cases: one large, high-quality multi-centre trial
B Moderate
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.•One high-quality study•Several studies with some limitations
C Low
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.•One or more studies with severe limitations
D Very Low
Any estimate of effect is very uncertain.•Expert opinion•No direct research evidence
Grading of Recommendations Assessment, Development
and Evaluation (GRADE)•Source: GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group 2007(modified by EBM guideline editorial team)
A: Randomized controlled trials.
B:Controlled trials, no randomization.
C: Observational trials.
D: Opinion of the expert panel
University of Michigan Practice Guideline:
Cochrane collaboration: A worldwide association of groups who create and maintain systematic reviews of the literature for specific topic areas.
Cochrane Review
USPSTF ( US Preventive Services Task Force)
AHRQ ( Agency of Health Care Research & Quality)
A systematic Review & Meta-Analysis
Source. Ann Surg. Dec,2004; 240 (246)
Author from Switzerland, Department of Visceral & Transplant Surgery, University Hospital.
Review of Articles Comparing Prophylactic Drainage Vs No Drainage in GI Surgery from 1966 to 2004.
17 RCTs for Hepato-pancreatico-biliary Surgery.
None for upper GI Tract
13 for Lower GI Tract.
All studies were classified according to their level of Evidence and then graded (A,B,C,D) as suggested by Oxford Centre for EBM.
Studies were compared for the following end points: mortality, overall complication rates, leakage rates, infection rates (wound, intra-abdominal collections, abscess), pulmonary complication rates, reoperation rates, and hospital stay.
Open Cholecystectomy numerous RCTs and Meta-analysis by Lewis et al, failed to demonstrate a reduction of post-operative complications by routine drainage. (Level 1a)
Lap. Cholecystectomy 2 RCTs, 4 of 34 (11.7%) of drained had complications while in non drained 2 of 33 (6.1%) had complications.(Level 1a)
No RCT prospective study
One non Randomized Prospective Cohort study (level 2b)
“The role of Prophylactic Drains after Surgery for Perforated Duodenal Ulcer.”
Total pts. 119
Omental Patch Technique
75 pts. With Drain
44 pts. Without drain
Drainage neither reduced the incidence of intra abdominal fluid collection including abscess formation nor the duration of Hospital stay.
But there were a significant number of Drain related complications such as
Drain Tract infection (10.7%)
Acute Intestinal obstruction (2.7%)
Meta analysis
8 RCTs on Abdominal/Pelvic Drainage vs no Drainage
3 RCTs has Level 1b
5 RCTs has Level 2b
717 pts. with Drain
673 pts. without Drain
Majority of studies on Elective Surgery
2 studies include Emergency cases
A slight advantage for non drained patients in respect to clinical leakage (OR 1.38; CI 0.77–2.49) and wound infections (OR 1.41; CI 0.87–2.29) was documented, although this advantage was not statistically significant.
Moreover, the meta-analysis by Urbach et al showed that in only 1 of 20 clinical leakages pus or feces emerged through the drain,indicating that drains have a low sensitivity (5%) to detect clinical leakage.
Open Appendectomy
Five RCTs on prophylactic drainage for gangrenous and perforated appendicitis were identified (level of evidence 2b).
The results showed higher wound infection rates in drained patients (range 43–85%) than in non drained patients (range 29–54%).
The pattern of intra-abdominal infections was not uniform among the studies, as 2 studies reported slightly higher intra-abdominal infection rates in non drained patients,1 study a higher rate in drained .
Meta-analysis including series with gangrenous or perforated appendicitis only.
Four RCTs (all level 2b) were included in the meta-analysis with the end point wound infection, whereas data from 3 RCTs were available for the end points intra-abdominal infection and fecal fistula .
The analysis calculated an OR for wound infections of 1.75 (CI 0.96–3.19). The OR for fecal fistulas of 12.4 (CI 1.14–135) favors the no-drainage group, whereas the OR for the end point intra-abdominal infection of 1.43 (CI 0.39–5.29) favors neither group.
Cochrane ReviewPublished on 3rd Sep. 2013
12 RCTs 1831 participants 915 pts with drain 916 pts without drain 9 RCTs include elective cholecystectomies 1 RCT include Acute cholecystitis 2 RCTs include both elective & emergency
cholecystectomies
There was no significant or clinically important differences in the short-term mortality, serious complications, quality of life, length of hospital stay, operating time, return to normal activity, or return to work in the trials that reported these outcomes.
The proportion of patients who were discharged as day-procedure laparoscopic cholecystectomy seemed significantly lower in the drain group than in the 'no drain' group .
Journal of Minimal Access Surgery; 2012,Jul-Sep
Suez Canal Hospital RCT (Prospective) Single Blind (Team Accessing Results) Level of Evidence 1b Group A with Drain ( closed Passive Drain) Group B without Drain Assessment. Post op Pain ,wound infection
& Hospital stay
Post op Pain VAS no difference at 24,48hrs & 1week.
Hospital Stay
Group A 1--3 days
Group B 1-- 2days
East & Centeral African Journal of Surgery
Vol.16,No 2,Jul/Aug 2011;62-71
Prospective RCT
90 pts.
Pts with generalized Peritonitis were excluded
45 pts. With drain (closed without suction)
45 pts. Without drain
Other complications included fecal fistula (2patients), intraperitoneal abscess (3 patients) and paralytic ileus (1 patient) all of them occurring in patients with drains.
Many GI operations can be performed safely without prophylactic drainage. Drains should be omitted after colonic, or rectal resection with primary anastomosis and appendectomy for any stage of appendicitis (recommendation grade A).
Currently, there is no evidence to support the use of drain after laparoscopic cholecystectomy (recommendation grade A).Further well-designed randomised clinical trials are required.
In any surgical procedure, good hemostasis,
appropriate antibiotics use and precise surgical
technique with minimal tissue trauma limit the need
for operative drain placement.