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To Drain or Not to Drain? Not After Major Hepeatectomy
Andreas Karachristos1, Senthil Jayarajan2, Vanessa Thompson3, Bruce L. Hall2, Clifford Ko4, Henry Pitt*1
1Temple University Health System, Philadelphia, PA; 2Washington University, St. Louis, MO; 3American College of Surgeons, Chicago, IL; 4UCLA, Los Angeles, CA
Background: Five randomized trials and a Cochran Systematic Review have not supported the routine use of drains in hepatic surgery. In these trials less than 500 patients were randomized, and less than half of these patients underwent a major hepatic resection. In part because of the paucity of good evidence, experienced liver surgeons at major centers continue to routinely insert drains in uncomplicated hepatectomies. Therefore, the aim of this analysis was to utilize a large multi-institution database to compare the outcomes of major hepatic resections in patients who did and did not have drains placed at surgery.
Methods: The 2013 American College of Surgeons-National Surgical Quality Improvement Program hepatectomy database was queried. Major hepatectomies coded as right, left or extended were included in the analysis. Partial resections (less than three segments) were excluded. Liver resections with concomitant operations with increased risk for complications, including colectomies and hepaticojejunostomies, also were excluded. In addition, contaminated and dirty cases as well as those with missing data on drain placement and bile leaks were excluded. Primary outcomes are overall and serious morbidity, 30-day mortality, superficial, deep and organ space infections as well as a composite wound infection and sepsis metric, bile leak, unplanned reoperations, length of stay and readmissions. Univariable comparisons between patients with and without drains were performed with chi-square and Student’s t-test as appropriate. Multivariable regression models were created to evaluate the possible association of multiple varibales including bile leak with all major outcomes.
Results: Of 2,291elegible hepatectomies, 800 (35%) were major resections. Of these operations, 519 (65%) had one or more drains placed, and 281 (35%) had no operatively placed drains. The drain and no drain groups were similar with respect to multiple preoperative variables including age, gender, race, BMI, diabetes, smoking, COPD, heart failure, ASA class, steroid usage, preoperative albumin and diagnosis. However, operative time was 38 minutes longer in the drained patients (p<0.001). Outcomes are summarized in the Table. In the multivariable analysis bile leakage was an independent predictor of multiple adverse outcomes. In addition, hypertension influenced overall morbidity and mortality while diabetes was associated with increased infectious complications.
Conclusions: Drain placement after major hepatectomy does not improve overall or serious morbidity, mortality, surgical site infections, reoperation, length of stay or readmissions. Drains are associated with more bile leaks which, in turn, contribute to multiple adverse outcomes. Routine drain placement is not warranted after major hepatectomy.
| Outcome | Drain (%) | No Drain (%) | P Value | | Overall Morbidity* | 36.2 | 38.1 | 0.60 | | Serious Morbidity* | 19.1 | 18.5 | 0.84 | | 30-day Mortality | 2.5 | 3.9 | 0.26 | | Superficial SSI | 3.3 | 2.1 | 0.35 | | Deep SSI | 1.2 | 0.0 | 0.07 | | Organ Space SSI | 6.4 | 5.0 | 0.42 | | Composite SSI* | 10.4 | 6.8 | 0.09 | | Composite+Sepsis* | 12.9 | 9.6 | 0.16 | | Bile leak | 7.3 | 0.4 | <0.001 | | Reoperation | 3.9 | 3.6 | 0.83 | | Length of Stay (d)* | 7.8 | 7.5 | 0.54 | | Readmission* | 9.1 | 8.4 | 0.84 |
Composite SSI=Superficial+Deep+Organ Space Infection *Outcomes where bile leak was an independent predictor of an adverse event
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