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84]

Original Article

Post-operative abdominal drainage

following major upper gastrointestinal
surgery: Single drain versus two drains
ABSTRACT Shailesh V.
Background: Traditionally, surgeons have resorted to placing drains following major gastrointestinal surgery. In recent years, the value Shrikhande,
of routine drainage has been questioned, especially in the light of their role in post-operative pain, infection, and prolonged hospital Savio G. Barreto,
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 Guruprasad
pancreatic resections. Shetty,
Kunal Suradkar,
Materials and Methods: Patients undergoing resections for gastric and pancreatic malignancies were included in the study. Patients
Yashodhan D.
were subdivided into two groups depending on the number of drains placed, viz. one drain (Group 1) or two drains (Group 2). Clinico-
Bodhankar,
pathologic outcomes were recorded and compared. Sumeet B. Shah,
Results: Of the 285 patients included in the analysis, group 1 consisted of 226 patients while group 2 included 59 patients. Overall, Mahesh Goel
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
Department of Hepato-
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).
Pancreato-Biliary
There were no drain-related complications. Median hospital stay was significantly lower in group 1 (11 vs. 14 days) (P < 0.001). Surgical Oncology,
Conclusion: The insertion of drains did aid in the detection of complications following gastric and pancreatic surgery. Two drains offer Tata Memorial
no further advantage over one drain in terms of detection of complications. While the number of drains did not contribute to, or reduce, Hospital, Mumbai,
Maharashtra, India
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. For correspondence:
Dr. Shailesh V.
Shrikhande,
KEY WORDS: Gastrectomy, morbidity, outcomes, pancreatectomy, pancreatoduodenectomy Department of Hepato-
Pancreato-Biliary
Surgical Oncology,
Tata Memorial
INTRODUCTION drain,[8,9] and interference with patient ambulation. Hospital, Ernest Borges
While on the one hand, the nature of the drainage Marg, Parel, Mumbai,
Abdominal drainage following major tubes has improved over time, viz. they are more Maharashtra, India.
E-mail:
gastrointestinal surgery has often been a matter malleable and hence cause less discomfort, less
shailushrikhande@
of contention.[1-3] The debated issues are whether allergenic owing to the inert material used, and their hotmail.com, shailesh.
to drain or not, [2,3] or whether to remove the availability in smaller diameters, criticism against shrikhande@
intraoperatively inserted drain early or late, the use of the narrower, softer drains has focused pancreaticcancerindia.
and the implications of this. [1,4] Despite the on their inability to function effectively as they risk org
only randomized controlled trial more than a getting blocked.[2]
decade ago, which concluded that closed suction
abdominal drainage following pancreatic resection The aim of the current study was to compare
should not be considered mandatory, to this day, the use of a single versus two drains placed
upper gastrointestinal and hepato-pancreato- intraoperatively following major gastric and
biliary surgeons around the world continue to place pancreatic resections - more specifically focusing
Access this article online
abdominal drains intraoperatively.[1,2,4-6] on the following factors: Website: www.cancerjournal.net
DOI: 10.4103/0973-1482.113380
The rationale behind abdominal drainage following 1) Ability of the drains to alert the surgeon to PMID: *****
major abdominal surgery has been the value afforded an impending or developed intra-abdominal Quick Response Code:

by drains in forewarning the surgeon of potential complication,

intra-abdominal complications.[7] Traditionally, 2) The impact of the number of drains on the
surgeons have resorted to placing multiple drains. length of post-operative hospital stay, and
However, drains have been implicated in the 3) The morbidity directly ensuing from the
causation of local pain, ascending infection via the intraoperatively placed drain.

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Shrikhande, et al.: Drains in abdominal surgery
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 30th 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).[10]
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
268
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 5th 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.[5,11-13]
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.[5,11-13] 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.
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Shrikhande, et al.: Drains in abdominal surgery

RESULTS bowel ischemia, wound problems, etc. In 14 of 20 patients

Patient demography
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.
(70%) with complications, the drain effluent did alert to the
existence of a complication.
Group 2
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.[17]
There were no drain-related complications.

Patient groups DISCUSSION

There were 226 patients enrolled in group 1 and 59 patients
in group 2. Table 1 summarizes the pertinent surgical data The results of our study indicate the following:
in the two groups. The overall rate for detection of major
complication by drains was 62%. 1) Intraoperatively placed drains following gastric and
pancreatic resections are able to alert the surgeon to an
GROUP SPECIFIC PERI-OPERATIVE DATA impending or developed intra-abdominal complication.
There is no difference in the detection rate between a
Group 1 single and two drains.
Fifty-Seven of 226 patients (25.2%) developed complications 2) The number of drains significantly influences median
while the mortality rate was 3.9% (9/226). Out of 57 hospital stay, such that more the number of drains, longer
complications, 43 were procedure-related, but only 20 of is the hospital stay.
43 could have been potentially detected by the drains (e.g. 3) No drain-related morbidity was noted.
duodenal stump leaks, hemorrhage etc. for gastrectomy group,
and pancreatic anastomotic leak and fistula (POPF), biliary The role of drainage of the abdominal cavity following
leaks, hemorrhage etc. for pancreatectomy group) as opposed upper gastrointestinal surgery is evolving. Traditional
to the remaining 23 patients who experienced complications surgical teaching has focused on the role of intra-abdominal
such as delayed gastric emptying, gastric outlet obstruction, drainage, following gastrointestinal surgery including
aiding the egress of peritoneal fluid contaminated by the
Table 1: Surgical data of the two groups gastrointestinal flora that may be retained within the
peritoneal after gastrointestinal surgery, serving as an early
Group 1 Group 2
(n = 226) (n = 59) indicator of impending intra-abdominal complications post-
Surgeries operatively and finally even playing an often important role
Gastrectomies 113 34 of a controlled fistula.[18,19] However, even since the early
Pancreatectomies 113 25 days, surgeons have questioned the need for the dogmatic
Median hospital stay in days 11 (8-61) 14 (7-65) P < 0.001
(range) practice of routine prophylactic drainage of the abdominal
Morbidity rates cavity.[20,21] Furthermore, drains have been implicated in the
Overall 25.2% (57) 22% (13) P – NS* causation local pain often resulting with interference with
Major complications that should have been detected by drains patient ambulation – as demonstrated from studies on drains
Overall 20 9
Gastrectomy 4 3
in patients undergoing colon and rectal resections.[22,23] Drains
Pancreatectomy 16 6 are also associated with a risk of ascending infection via the
Major complications actually detected by drains drain.[8,9]
Overall 14 (70%) 4 (44%)
Gastrectomy 3 1
While the quality of the material used to produce the drains
Pancreatectomy 11 3
Drain-related complications 0 0 has improved over time coupled with a reduction in the size
Mortality rates of the drains, criticism against the use of thinner, softer drains
Overall 3.9% (9) 0 P – NS* has focused on their inability to always function effectively as
*NS - No significant differences between the two groups they risk getting blocked.[2]

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Shrikhande, et al.: Drains in abdominal surgery
Table 2: Classification of surgical complications (as per the Dindo-Clavien system[17])
Grade of Group 1 (n = 226)
complications
I 5 - Lymphorrhea
4 - Minor Respiratory complications
3 - POPF A
2 - Wound Problems
1 - Delayed Gastric Emptying - A
II 11 - Local collection
3 - Delayed Gastric Emptying - B
1 - Gastric outlet obstruction managed with Erythromycin
1 - Post-gastrectomy collection managed conservatively
III 6 - POPF -B
3 - Bleeding with re-exploration
2 - Pancreatic necrosis
1 - Pancreatic stump leak managed with pigtail insertion
1 - Biliary leak
1 - Enterocutaneous fistula
IV 2 - Duodenal blowout requiring re-exploration and ICU
support
1 - POPF C with bleeding and sepsis
V 4 - Major respiratory problem requiring ICU and ventilatory
support
1 - Multiple patchy bowel ischemia requiring re-exploration
1 - POPF grade C requiring re-exploration
1 - Liver failure secondary to pre-existing cirrhosis
1 - Pulmonary Embolism
1 - Post-operative hemorrhage
PTBD = Percutaneous transhepatic biliary drainage, ICU = Intensive care unit, LA = Local anesthetic, POPF = Post-pancreatectomy fistula
Petrowsky et al.[24] 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.[3] This study by Conlon et al.[3] 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[4] 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[2] 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.
270
Group 2 (n = 59)
1 - Deep vein thrombosis managed medically (heparin)
1 - Wound problems
2 - Gastric outlet obstruction managed with Erythromycin
1 - Local Collection
4 - POPF B
2 - Post Gastrectomy collection managed with pigtail insertion
1 - Biliary leak managed by PTBD and stenting under LA.
1 - Bowel Obstruction secondary to intussusceptions requiring
re-exploration
1 - Pancreatic anastomotic leak with bleeding requiring
angiography and embolization and ICU care
Nil
Despite the single randomized trial [3] published more
than a decade ago which questioned the routine use of
abdominal drainage, surgeons continue to use drains as
clearly evidenced in literature.[1,2,4-6,24] 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
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Shrikhande, et al.: Drains in abdominal surgery
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
Journal of Cancer Research and Therapeutics - April-June 2013 - Volume 9 - Issue 2
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.
Cite this article as: Shrikhande SV, Barreto SG, Shetty G, Suradkar
K, Bodhankar YD, Shah SB, et al. Post-operative abdominal drainage
following major upper gastrointestinal surgery: Single drain versus two
drains. J Can Res Ther 2013;9:267-71.
Financial Disclosures: None, Conflict of Interest: None.
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