Original

Article
Journal of Experimental and Integrative Medicine 2012; 2(1):47-54

Is there a role of abdominal drainage in primarily repaired

perforated peptic ulcers?
Maulana M. Ansari1, Arif Akhtar1, Shahla Haleem2, Musharraf Husain1, Ajay Kumar1
Departments of 1Surgery and 2Anaesthesiology, Jawaharlal Nehru Medical College, Aligarh Muslim University,
Aligarh, Uttar Pradesh, India.

Summary
Objective: To compare the survival and post-op complications following primary Key words:
closure of perforated peptic ulcer by omental patch technique in 4 groups of patients as Abdominal drain;
follows: two-drain group, one-drain subhepatic group, one-drain pelvic group and no- Peptic ulcer;
drain group. Perforated ulcer;
Methods: This is a prospective case-controlled clinical study performed in the Prophylactic drainage
Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh, India. A
total of 114 patients with perforated peptic ulcer who underwent emergency laparotomy
with primary closure by omental patch technique were studied in 4 groups as mentioned Correspondence:
above. Tube drains were used throughout the study. M.M. Ansari
Results: Mean age of patients was 45±12.7 years (range 15- 75) with M:F ratio of 5:1. B-27, Silver Oak Avenue, Street No. 4,
Clinical profile of patients matched in the 4 groups. Post-operative fever, vomiting, Dhorra Mafi, Aligarh,
laparotomy wound infection, wound dehiscence and intraperitoneal collection were Uttar Pradesh, 202002 - India.
significantly lower in the no-drain group as compared to drain groups. There was found no mma_amu@yahoo.com
significant difference between the no-drain and drain groups with respect to the post-
operative abdominal distension, pain, intraabdominal sepsis, gastro-intestinal leak, adult Received: June 23, 2011
respiratory distress syndrome and mortality. Drain-related complications were recorded in Accepted: September 26, 2011
36.8% of patients with tube drain(s). Published online: November 20, 2011
Conclusion: Peptic perforation closure with omental patch technique is safe without
prophylactic drainage and a high rate of drain-related morbidity negates the concept of the J Exp Integr Med 2011; 2:47-54
routine drainage after this procedure. One drain placement is as good as the two drain DOI:10.5455/jeim.201111.or.015
placement and sub-hepatic drain is more useful than the pelvic drain.

Introduction
Prophylactic drainage of the peritoneal cavity
after gastro-intestinal (GI) surgery has been widely
practiced since the mid-1800s, with the dictum of
Lawson Tait, the 19th century British surgeon,
"When in doubt, drain", well known to all surgical
trainees [1]. However, in the modern era of
evidence-based medicine, several well-constructed
prospective studies failed to show any benefit from
prophylactic abdominal drainage after a variety of
intraabdominal procedures such as colo-rectal
resection [2-4], open or laparoscopic
cholecystectomy [5-13], radical hysterectomy and
pelvic lymphadenectomy [14], retroperitoneal
lymphadenectomy [15], liver resection [16-19],
pancreatic resection [20-22], or gastrectomy [23,
24]. Moreover, surgically placed drains are not
without risk of complications [3, 15, 25-29]. To the
best of our knowledge, only one prospective
controlled study has appeared in the English
literature, which has documented that the routine
use of drains is neither safe nor effective in patients
of perforated duodenal ulcer treated by omental
patch closure [27]. Therefore, our aim is to assess
the value of intraperitoneal drainage placement in
patients with perforated peptic ulcer, a frequently
encountered surgical emergency in tropical
countries.
Materials and methods
Patients
Patients with perforated peptic ulcer (PPU) who
underwent surgery in Jawaharlal Nehru Medical
College Hospital, Aligarh Muslim University,
Aligarh, India, formed the body of the present
prospective study during a period from January
2009 to November 2010. All PPU patients who
underwent primary closure by omental patch
technique were included in the present study.
Patients were randomly allocated before start of the
laparotomy to one of the following four groups:
two-drain group (control group), one-drain
subhepatic group, one-drain pelvic group, and no-
drain group.
Critically sick patients (pulse rate > 100/min,
blood pressure < 90mm Hg (systolic), deranged
arterial blood gases or deranged renal/cardio-

www.jeim.org 47
 Ansari et al: Abdominal drainage in perforated peptic ulcers
pulmonary function), patients presenting after 72
hours of onset of symptoms and patients with past
history of similar illness were excluded from the
study. Patients with perforation >2 cm in size and
patients with frank pyoperitoneum (presence of
frank yellow pus in the peritoneal cavity) were also
excluded from the study. Patients who died within
24 hours of emergency laparotomy were also
excluded from further consideration in the study
because the role of drain/no drain could not be
assessed in them.
Surgical technique
At laparotomy through midline incision, liberal
peritoneal lavage with 3-6 litres of normal saline
was first carried out, and peptic perforation was
closed by interrupted sutures of Polyglactin 910
(Vicryl®) with an omental pedicle. In all cases of
gastric ulcer perforation, a biopsy from the ulcer
margin was obtained for histopathological
examination to rule out malignancy. Intraabdominal
drain(s) were placed as per the random allocation.
Abdominal wounds were closed in two layers: (1)
tendinous fascio-muscular layer with monofilament
polypropylene (Prolene®), and (2) skin with
monofilament Nylon (Ethilon®).
Postoperative care
All patients were kept nil per orally with Ryle’s
tube gastric aspiration till passage of flatus and/or
bowel movement. Combination antibiotics
(ceftriaxone + amikacin + metronidazole) were
given to cover aerobic (Gram negative & positive)
and anaerobic bacteria. Patients were assessed on
atleast twice daily basis for vital signs, abdominal
condition and return of bowel function, with a high
index of suspicion for intra-operative fluid
collection or abscess. In the drainage groups, details
were noted in terms of daily drainage, drain-related
complications and time of drain removal.
Abdominal ultrasonography (USG) was carried
out in all patients on post-op day 3-5. When
collection was detected on first USG in a patient,
repeat USG was done after 48-72 hours to
determine decrease or increase in the collection.
When collection was not detected on first USG in a
patient, USG was repeated whenever
intraabdominal collection or abscess was suspected
on clinical grounds. If a drain was accidentally
pulled out at any time in the postoperative period,
check USG was carried out after 24-48 hours of the
drain pull-out. Significant intraperitoneal collection
was considered to be present when fluid was
detected on USG at two or more than two
sites/places in the peritoneal cavity. This was based
on the study of Sirlin et al [30] who proposed a
48 DOI:10.5455/jeim.201111.or.015
simple ultrasonographic method of fluid
quantification by counting the number of the
peritoneal recesses filled with fluid in the following
manner in which each patient was assigned a fluid
score of 0-5:
Score of 0: no fluid
Score of 1: fluid in one peritoneal recess
Score of 2: fluid in two peritoneal recesses
Score of 3: fluid in three peritoneal recesses
Score of 4: fluid in four peritoneal recesses
Score of 5: fluid in five peritoneal recesses
Gastrografin meal study was done in selected
patients when gastro-duodenal leak was clinically
suspected. Drains were removed after 24 hours of
total/near-total stoppage of drainage. Less than
20 ml of drainage was considered as near-total or
negligible drainage. Patients were regularly
followed in the out-patient department after
discharge from the hospital.
Non-purulent serous/serosanguinous collection
without local/systemic signs of infection was
labelled as the intraabdominal collection. Purulent
collection (frank yellow pus) in the abdomen with
or without local/systemic signs of infection was
labelled as the intraabdominal sepsis.
Body of the present study
A total of 151 patients presented with perforated
peptic ulcer. Critically sick patients (n=4) and
patients with presentation after 72 hours of
symptoms (n=17), frank pyoperitoneum (n= 8) or
large perforations of >2 cm in size (n=5) were
excluded from the present study. Another eleven
patients after recruitment (7, 1, 1 and 2 patients in
the two-drain group, one-drain subhepatic group,
one-drain pelvic group and no-drain group,
respectively) died within 24 hours of emergency
laparotomy and they were also excluded from
further consideration in the study. Therefore, only
114 patients formed the body of the present study
after the clinical diagnosis of PPU was confirmed
on laparotomy and primary omental patch closure
was done. There were 19 patients in no-drain group,
12 patients in one-drain sub-hepatic group, 10
patients in one-drain pelvic group and 73 patients in
two-drain group.
Statistical analysis
Student t-test and Ƶ-test of proportion were used
for the statistical analysis through the statistical
software SPSS version 17.
Results
Overall mean age of the 114 patients studied in
the present series was found 45 ± 12.72 years
(range 15-75 years) and more than half of the
 Journal of Experimental and Integrative Medicine 2012; 2(1):47-54

patients (57.1%) were between 30 and 50 years. statistical intergroup differences (p>0.05) among
Individual group mean age was 44.94 ± 15.5, the four groups. In majority of the patients at
44.83 ± 25.0, 46.7 ± 17.5 and 44.94 ± 37.5 years in laparotomy (76.3%), amount of non-purulent
the two-draingroup (n=73), one-drain subhepatic contamination was found between 500 to 1000 ml.
group (n=12), one-drain pelvic group (n=10) and Intergroup differences were statistically
no-drain group (n=19), respectively. Intergroup insignificant (p>0.05) among the four groups
differences among the four groups were found not (Table 1).
statistically significant (p>0.05). The overall Out of 114 patients studied, 53 patients
male:female (M:F) ratio was 5:1. Individual group developed moderate to high grade of fever in the 1st
M:F ratio was 5.6:1, 3:1, 9:1 and 3.8:1 in the two- post-operative week. The difference between no-
drain group, one-drain subhepatic group, one-drain drain and drain groups was found statistically
pelvic group and no-drain group, respectively. significant (p<0.05), but there was no statistical
Intergroup differences among the four groups were difference among the three drain groups (p>0.05).
found statistically significant (p<0.05) but within Twenty-one patients had post-operative abdominal
the age group of 30-50 years which constituted the distension beyond 48 hours suggestive of prolonged
major portion of the present study, the intergroup ileus and the intergroup differences were
differences among the four groups were found not statistically insignificant among the four groups
significant (p>0.05). (p>0.05). Only 8 out of 114 patients had one or two
Majority of patients (69.3%) in our study vomiting in the early post-operative period only in
presented between 48 to 72 hours of onset of the two-drain and one-drain subhepatic groups.
symptoms while 15.8% of patients presented There was no instance of vomiting in the one-drain
between 24-48 hours of onset. Only 14.9% of our pelvic and no-drain groups (Table 2).
patients presented within 24 hours of onset. There In the first two days after operation, 103 patients
was no statistical difference among the four groups had significant diffuse abdominal pain but only
(p>0.05). Pre-pyloric area was the most common nineteen patients required narcotic analgesics for
site of PPU in the present study in general as well relief; 12, 2, 2, and 3 patients in the two-drain
as individually in all the four groups. Pre-pyloric group, one-drain subhepatic group, one-drain pelvic
PPU was present in more than 75% of the total group and no-drain group, respectively. Intergroup
patients. Duodenal perforation was found least differences were not found statistically significant
common constituting about 9% of total sample size (p>0.05). Patients who developed wound infection
as well as individually in each study groups. (n=61), continued to have localized pain in and
Majority of patients (82.5%) had perforation of around the wound until clearance of the infection
<1 cm in size and only 17.5% of patients had (Table 2).
perforation of 1-2 cm in size. There was no
Table 1: Pre-operative and intra-operative findings
Groups*
Pre-operative and intra-operative One-drain One-drain
Two-drain No-drain p-value
findings subhepatic pelvic
n (%) n (%)
n (%) n (%)
0 - 24 11 (15.1) 2 (16.7) 1(10) 3 (15.8) >0.05
Duration of
24 – 48 11 (15.1) 2 (16.7) 2 (20) 3 (15.8) >0.05
presentation (hours)
48 - 72 51 (69.8) 8 (66.6) 7 (70) 13 (68.4) >0.05
Pre-pyloric 56 (76.7) 9 (75) 8 (80) 15 (78.9) >0.05
Site of perforations Pyloric 10 (13.7) 2 (16.7) 1(10) 3 (15.8) >0.05
Duodenal 7 (9.6) 1 (8.3) 1 (10) 1 (5.3) >0.05
<1 cm 60 (82.2) 10 (83.3) 8 (80) 16 (84.2) >0.05
Size of perforations
1-2 cm 13 (17.8) 2 (16.7) 2 (20) 5 (15.8) >0.05
<500 mL 10 (13.7) 2 (16.7) 2 (20) 3 (15.8) >0.05
Peritoneal
500-1000 mL 57 (78.1) 9 (75) 7 (70) 14 (73.7) >0.05
contaminations
>1000 mL 6 (8.2) 1 (8.3) 1 (10) 2 (10.5) >0.05
*Number of patients was 73, 12, 10 and 19 in the two-drain group, one-drain subhepatic group, one-drain pelvic group and no-drain group,
respectively.

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 Ansari et al: Abdominal drainage in perforated peptic ulcers

Table 2: Post-operative complications

Groups
Post-operative complications Two-drain One-drain subhepatic One-drain pelvic No-drain p-value
n (%) n (%) n (%) n (%)
Fever (n= 53) 40 (54.8) 5 (41.7) 7 (70) 1 (5.3) <0.05
Distension (n=21) 14 (19.2) 2 (16.7) 2 (20) 3 (15.8) NS
Vomiting (n=8) 7 (10.3) 1 (8.3) 0 (0) 0 (0) -
Abdominal pain (n=103) 67 (91.8) 11 (91.7) 9 (90) 16 (84.2) NS
Wound infection (n=61) 43 (58.9) 7 (58.3) 6 (60) 5 (26.3) <0.05
Partial dehiscence* (n=35) 28 (38.4) 2 (16.7) 4 (40) 1 (5.3) <0.05
Complete dehiscence* (n=19) 18 (24.7) 0 (0) 1 (10) 0 (0) -
Peritoneal collection (n=37) 26 (35.6) 5 (41.7) 4 (40) 2 (10.5) <0.05
Abdominal sepsis (n=11) 7 (9.6) 1 (8.3) 1 (10) 2 (10.5) NS
Gastro-duodenal leak (n=7) 4 (5.4) 1 (8.3) 1 (10) 1 ((5.3) NS
Adult respiratory distress
6 (8.2) 1 (8.3) 1 (10) 2 (10.5) NS
syndrome (n=10)
Drain complications** (n=35) 26 (35.6) 6 (50) 3 (33.3) NA NS
Late post-op mortality (n=10) 6 (8.2) 1 (8.3) 1 (10) 2 (10.5) NS
*Dehiscence of laparotomy wound; **Excluding pain, restriction of mobility and accidental pull-outs; NA = not applicable; NS = not
significant.

Laparotomy wound infection was observed in 61
out of 114 patients and intergroup differences were
statistically significant (p<0.05). Incidence of the
wound infection in the no-drain group was half of
those recorded in the three drain groups. Intergroup
differences among the three drain groups were
found not significant (p>0.05). Partial wound
dehiscence occurred in 35 out of 114 patients.
Intergroup differences were found significant
statistically (p<0.05). Nineteen out of 114 patients
developed complete wound dehiscence but there
was no instance of complete wound dehiscence in
one-drain subhepatic and no-drain groups.
Difference between the two-drain and one-drain
pelvic groups were found significant (p <0.05)
(Table 2).
Significant intraperitoneal fluid collections were
detected in a significant number of 37 patients
(Table 2). Intergroup differences among the four
groups were statistically significant (p<0.05).
However, differences among the three drain groups
were found not significant (p>0.05). Minimal
intraperitoneal collection at only one site
(subhepatic space, 3; paracolic gutter, 3; pelvis, 2)
was seen in 8 patients. Intergroup differences
among the four groups were statistically not
significant (p>0.05). Majority of them (6 out of the
8 patients; 75%) resolved spontaneously within 5-8
days without intervention and only 2 out of the 5
patients with minimal collection in the 2-drain
group required percutaneous drainage (PCD).
Significant intraperitoneal collections at two sites
(subhepatic space and pelvis, 3; subhepatic space
and right paracolic gutter, 6; right paracolic gutter
and pelvis, 4; left paracolic gutter and pelvis, 2)
were seen in a total of 15 patients: 11, 2, 2 and 0
patients in the two-drain group, one-drain
subhepatic group, one-drain pelvic group and no-
drain group, respectively. Intergroup differences
among the four groups were statistically significant
(p<0.05). Majority of them (9 out of the 15 patients;
60%) resolved spontaneously within 5-8 days
without intervention, but 3 out of 11 patients in the
two-drain group required PCD while 2 out of 11
patients in the two-drain group and one of the two
patients in the one-drain subhepatic group required
laparotomy, peritoneal toileting and lavage with
placement of large-size tubes for peritoneal
drainage.
Intraperitoneal collections at more than two sites
(mild, 12; moderate, 1; severe, 1) were observed in
14 patients; 10, 2, 1 and 1 patients in the two-drain
group, one-drain subhepatic group, one-drain pelvic
group and no-drain group, respectively. Intergroup
differences among the four groups were statistically
significant (p<0.05). All resolved spontaneously
(12 out of the 14 patients; 85.7%) except for the
two patients with moderate to severe collections in
the two-drain group who required laparotomy,
peritoneal toileting and lavage with placement of
large-size tubes for peritoneal drainage.
Intraperitoneal collections were suspected
clinically in 21 patients in late post-operative period

50 DOI:10.5455/jeim.201111.or.015
 Journal of Experimental and Integrative Medicine 2012; 2(1):47-54
beyond 5 days after surgery but were confirmed on
USG in only 16 patients (11, 2, 1 and 2 patients in
the two-drain group, one-drain subhepatic group,
one-drain pelvic group and no-drain group,
respectively). Intergroup differences among the
four groups were statistically insignificant (p>0.05).
Four patients had recurrent collection after
percutaneous drainage (PCD) due to luminal
blockage of the percutaneous catheters. Surgical
interventions were needed in 9 patients (PCD 4 and
laparotomy 5); 6, 1, 1 and 1 patients in the two-
drain group, one-drain subhepatic group, one-drain
pelvic group and no-drain group, respectively. In
seven patients, collections resolved on conservative
treatment including flushing of the drainage tubes.
It is of interest to note that no significant
intraperitoneal collection was detected on check
USG in any of the six patients in whom drain was
accidentally pulled out in the postoperative period.
Frank intraabdominal sepsis was detected in 11
patients (Table 2) and the intergroup differences
among the four groups were found statistically
insignificant (p>0.05). In 3 patients who died in the
late post-operative period, abdominal sepsis was
secondary to gastro-duodenal leak and was
associated with adult respiratory distress syndrome
(2 patients in the two-drain group and 1 patient in
the one-drain pelvic group).
In 7 patients, gastro-duodenal leak developed
within 2-4 days of operation (Table 2). There was
no statistical difference (p>0.05) between two-drain
and no-drain groups as well as between one-drain
subhepatic and pelvic groups. All patients
underwent emergency laparotomy and repeat
closure with triple ostomy procedure (gastrostomy,
retrograde decompression catheter jejunostomy in
the first loop of jejunum and feeding catheter
jejunostomy in the second loop of jejunum) was
carried out. Three out of these 7 patients died
within 5 days of re-operation (2 patients in the two-
drain group and 1 patient in the one-drain pelvic
group).
Ten patients developed adult respiratory distress
syndrome in the post-operative period (Table 2).
Intergroup differences were statistically
insignificant (p>0.05). Four of these patients (2, 1
and 1 patients in the two-drain group, one-drain
subhepatic group and no-drain group, respectively)
survived while 6 patients (4, 1 and 1 patients in the
two-drain group, one-drain subhepatic group and
no-drain group, respectively) succumbed to death.
Ten out of 114 patients expired in the late post-
operative period (Table 2) after a mean of 5.0 ± 2.1
days (range 3-9 days). Intergroup differences with
www.jeim.org
respect to the mortality were found not significant
(p>0.05). Major cause of death in this subgroup was
ARDS (adult respiratory distress syndrome) with
frank wound sepsis (n=9) and intraabdominal sepsis
in 6 patients (4, 1 and 1 patients in the two-drain
group, one-drain subhepatic group and one-drain
pelvic group, respectively). Abdominal sepsis was
associated with gastro-duodenal leak in 3 patients
who died (2 patients in the two-drain group and 1
patient in the one-drain pelvic group). The two
patients in no-drain group who expired on 5th and
8th post-operative days did not show any significant
peritoneal collection on the scheduled abdominal
USG on 3rd post-operative day.
Out of 95 patients with drains, 85 patients
persistently complained of significant pain at the
drain sites. Three forth of these patients (n=64)
belonged to the two-drain group but intergroup
differences were statistically insignificant among
the three drain groups (p>0.05). In the two-drain
group, pain was complained more frequently at the
subhepatic drain sites as compared to the pelvic
drain sites; pain at both sites in 35 patients, pain
only at subhepatic drain site in 20 patients and pain
only at pelvic drain site in 9 patients. In the two-
drain group, pelvic drain was put through the left
flank of abdomen and pain was complained in 53
out of 73 patients (72.6%). However, in the one-
drain pelvic group, the drain was put in the pelvis
through the right flank of the abdomen and pain
was complained in 9 out of 10 patients (90%).
Intergroup difference between these two groups
with respect to the drain into the pelvis was
statistically significant (p<0.05).
Thirty-five out of 95 patients with drain had
peritubal discharge/leakage with skin excoriation;
26, 6 and 3 patients in the two-drain group, one-
drain subhepatic group and one-drain pelvic group,
respectively. Intergroup differences were not
statistically significant (p>0.05). In the two-drain
group, peritubal discharge and skin excoriation was
more common at pelvic drain site as compared to
the subhepatic drain site (18 vs. 10 patients) and the
difference was statistically significant (p<0.05).
Only 8 out of 95 patients with drain developed
kinking of tube; 1 and 7 patients in one-drain
subhepatic group and two-drain group, respectively.
The difference between the two groups was
statistically insignificant (p>0.05). Within the two-
drain group, kinking was more commonly seen in
the subhepatic drain tube as compared to the pelvic
drain tube (6 vs. 1) and the difference was found
significant (p<0.05).
51
 Ansari et al: Abdominal drainage in perforated peptic ulcers
Blockage of the drain tubes was noted in 21 out
of 95 patients with drain; 16, 3 and 2 patients in the
two-drain group, one-drain subhepatic group and
one-drain pelvic group, respectively. The difference
was found not significant among the three groups
(p>0.05). In most instances, blockage was seen at
junction of the drain tube with the tube of the
collection bag. Blockage was due to fibrin flakes
(n=11) and thick exudates.
Accidental drain pull-out happened in 6 out of 95
patients with drain; 1 and 5 patients in the one-drain
pelvic group and two-drain group, respectively. In
the two-drain group, accidental drain pull-out
occurred with the right sided subhepatic drains
only. Two accidental pull-outs were seen during
patient transfer in the immediate post-operative
period due to the staff oversight and four pull-outs
were seen during patient’s ambulation in bed due to
cutting-through of the anchor sutures.
Significant restriction of mobility was noted in 93
out of 95 patients with drain. Only two patients in
the one-drain pelvic group did not have any
problem with respect to mobility. Intergroup
differences were found insignificant (p>0.05).
Mean times ± S.D. (range) of removal of
abdominal drains were 4.82 ± 1.25 (2-8) days for
the right drain and 6.26 ± 1.5 (3-10) days for the
left drain in the two-drain group, 5.13 ± 1.33 (3-8)
days in the one-drain subhepatic group and
6.44 ± 1.45 (4-10) days in the one-drain pelvic
group. Subhepatic drains served well and stopped
drainage earlier than the pelvic drains and removed
earlier. Difference between the removal times of the
subhepatic and pelvic drains was statistically
significant (p<0.05) not only within the two-drain
group but also between one-drain subhepatic and
one-drain pelvic groups.
Mean ± S.D. (range) time of discharge from the
hospital was 12.38 ± 5.14 (8-30) days in the two-
drain group, 8.75 ± 2.86 (7-10) days in the one-
drain subhepatic group, 11.0 ± 1.86 (7-16) days in
the one-drain pelvic group and 7.47 ± 1.21 (5-15)
days in the no-drain group. Intergroup differences
were statistically significant (p<0.05) with earlier
discharge in the no-drain group. However, there
was no statistical difference (p>0.05) between two-
drain group and one-drain pelvic group as well as
between one-drain subhepatic group and no-drain
group.
No instance of malignancy was detected on the
histopathological examination of the biopsy
specimens of the perforated gastric ulcer margins in
any of the 104 patients (88 Prepyloric; 16 Pyloric).
52 DOI:10.5455/jeim.201111.or.015
Discussion
In the present study, clinical profile of the
patients matched among the four groups studied
(p>0.05) with respect to the age, sex (between 30-
50 years), clinical presentation, site of the
perforations, size of the perforations, and
intraperitoneal contamination. Post-operative fever
was recorded in about half of patients in the present
study with significant difference between no-drain
and drain groups. This finding supports the concept
of “Drain Fever” as reported in 1962 by Myers [31]
and can be attributed to the use of drain. But this
concept always remained controversial. Pai and
associates [27] did not find any statistical difference
between drainage and non-drainage groups with
respect to the post-operative fever.
Statistically insignificant difference in the
incidences of the post-operative abdominal
distension and pain between drain and no-drain
groups of the present study indicates that placement
of abdominal tube drains does not play any role in
their causation. Presence of vomiting episodes only
in the two-drain and one-drain subhepatic groups
and total absence of vomiting episodes in the no-
drain and one-drain pelvic groups suggests that
subhepatic drain does produce gastric over-activity
and/or reverse peristalsis directly through the
irritation by the drain contact with the adjacent
duodenum or indirectly through the irritation by the
drain contact with the adjacent liver, leading to
diaphragmatic irritation with resultant vomiting.
Wound infection and partial dehiscence was
significantly much lower in the no-drain group as
compared to the drain groups in the present study.
Our observations are in agreement with the
majority of other investigators [13, 32-34] who
found drains to be a risk factor for wound sepsis.
However, our findings do not agree with those of
Pai and associates [27] who observed no significant
difference in the main wound infection rates
between the drainage and non-drainage groups.
Present observations indicate that placement of a
pelvic drain increases the risk of complete wound
dehiscence and addition of a subhepatic drain as
was seen in the two-drain group increases the
likelihood of developing the complete wound
dehiscence. Absence of any instance of complete
wound dehiscence in the no-drain or one-drain
pelvic group suggests that either the drain
placement should be omitted altogether or only a
subhepatic drain should be used. However, Pai and
associates [27] did not record any statistical
difference in the complete wound dehiscence rates
between drained and non-drained groups.
 Journal of Experimental and Integrative Medicine 2012; 2(1):47-54
Incidence of single-site collection (termed
minimal collection) in the present study was similar
in the drain and no-drain groups. Present
observation of no or mild collection in 74.6% of our
patients agrees with that of 88% reported by Liu
and colleagues [28] after hepatic resection. Other
investigators did not highlight the distinction
between different degrees of the collections.
Incidence of collections at two or more than 2 sites
(termed significant collection) in the present study
was significantly lower than in the no-drain group
as compared to the drain groups. Furthermore, one-
drain groups also recorded significantly lower
incidence of significant collections in comparison
to the two-drain group. Our findings confirms the
suggestion that drain(s) may possibly stimulate
fluid collection by acting as foreign bodies and by
not allowing apposition of tissue surface, therefore
leaving a space which promotes continued
exudation and collection. Pai and associates [27]
recorded greater incidence of intraperitoneal
collections in the drainage group as compared to the
non-drainage group but the difference was not
statistically significant. Sagar and associates [35]
have shown that drains failed to allow egress of pus
in patients who leaked after rectal resection. Present
study confirms that intraperitoneal collections do
occur in a significantly high percentage of patients
(36.8%) even in presence of the tube drain(s).
Gold and colleagues [36] suggested that fluid
collection within seven days postoperatively in
asymptomatic patients would be of little clinical
significance as was also seen in the present study.
Majority of the collections occurring within 5 days
(73%) in our patients of both drain and no-drain
groups resolved spontaneously. In the present
study, intraperitoneal collections seen in the late
post-operative period beyond day 5 were not
significantly different between the drain and no-
drain groups but only half of these collections in
either group resolved spontaneously, indicating
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