Journal of Surgical Oncology 2002;79:124±125

DOI 10.1002/jso.10056

HOW I DO IT

Postoperative Drainage in Patients With Malignant

Ascites: A Safe Method
GREGORY KOURAKLIS, MD*
Second Department of Propedeutic Surgery, Medical School University of Athens, Greece

INTRODUCTION
Effective palliation of malignant ascites remains a
dif®cult management problem. Ascites is one of the risk
factors in¯uencing wound dehiscence, especially in
patients with malignancy, immunodepression, abdominal
irradiation, or repetitive surgical procedures through the
same incision [1]. In addition, in patients with ascites
who require a colostomy for treatment of intestinal
pathologic conditions, ascitic leak can also occur around
the colostomy and consequently risk for intraperitoneal
contamination [2]. Thus, the leak of ascitic ¯uid from
surgical incisions is thought to be associated with a very
high mortality rate. The usual method of postoperatively
inserting a drain in those patients may lead to an ascitic
®stula. Our personal method of postoperative drainage for
patients with ascites is simple, speedy, safe, and does not
need previous treatment of the ascites.
Fig. 1. The drain enters at an angle through the incision, penetrating
the abdominal muscles, going over the peritoneum for 6±8 cm, and
then entering the abdominal cavity.
OPERATIVE TECHNIQUE
When we are faced with a patient with ascites who
requires an abdominal operation or a colostomy, we have canal. By this method, there is no possibility of leak from
found that placement of an intraperitoneal drain provides the incision or around colostomy or risk for intraper-
short-term drainage of ascitic ¯uid, decreases intra- itoneal contamination or wound dehiscence.
abdominal pressure, and allows the incision and the Thirteen high-risk patients with ascites were operated
colostomy site to seal. At the end of the main operative on for malignant diseases and postoperative drainage by
procedure, a small incision is made at the lateral this method; good results were obtained. Six patients
abdominal wall. A ®ne curved clamp is entered at an underwent intestinal resection with colostomy to treat
angle through the incision, penetrating the external obstruction, four patients underwent choledochoenteric
oblique, the internal oblique, and the transversus muscles. bypass to treat common bile duct obstruction, and three
Then, it goes over the peritoneum for 6±8 cm, and after patients were operated on for recurrent ovarian cancer.
that, it enters the abdominal cavity (Fig. 1). Then, two Drains were removed at a mean of 10 days, and no patient
stitches with 1-0 Vicryl are placed around the drainage had a postoperative ascitic leak, infected ascites, or
tube and are left untied (Fig. 2). Ten days later, after
*Correspondence to: Gregory Kouraklis, MD, 122 Vasilisis So®as Avenue,
complete healing of the abdominal incision and colost- Athens 11526, Greece. Fax No.: 30-1-7791456.
omy, the abdominal drainage is removed and the two E-mail: gkouraklis@hotmail.com
stitches are tied to avoid any leakage from the drainage Accepted 19 October 2001

ß 2002 Wiley-Liss, Inc.


Fig. 2. Two stitches are placed around the drainage tube and are left untied until the removal of the drain.
wound dehiscence for a follow-up period of 5 to 63
months (mean, 31 months).
DISCUSSION
An incisional ascitic leak has long been believed to be
a morbid if not uniformly fatal complication after
abdominal operations [3]. Midline incisions were more
often associated with recalcitrant leaks with fatal
complications than were transverse incisions, and the
ascitic leaks were generally detected near the ®fth
postoperative day [4]. Controlling ascites with diuretics
is a slow process and is often impossible in patients with
hypoalbuminemia, liver disease, and portal hypertension.
Peritoneovenous shunts are useful in controlling ascitic
leaks, but they are contraindicated in dirty or contami-
nated abdominal cases, thereby limiting their usefulness
[5]. Our technique provides short-term drainage of ascitic
¯uid and decreases intra-abdominal pressure, allowing
the surgical incision to seal. The subtraction of the drain
Postoperative Drainage in Ascites 125
and the tying of the two stitches does not permit the
creation of an ascitic ®stula.
In conclusion, postoperative drainage by our method in
patients with ascites is a safe and easy technique that
avoids complications caused by ascites and allows good
postoperative results while eliminating high morbidity.
We believe this approach is worthy of consideration by
others for use in this dif®cult group of patients.
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