They say in literature that we are moving towards an era of no drains placement. But, many surgeons all around the world put a drain. I just want to know how many follow the practice of placing a drain post operative?
In our centre we usually do place drains following gastrectomy. We insert two drains. One is placed near the anastomosis, and the second drain is placed in the small pelvis. If a splenectomy is recuired, then we add an extra drain in the splenic "cavity". It provides a good control of bleeding. Recommendations on no drains seem resonable, though most of us are affraid that some bleeding or pancreatic leak might occure and we want to know it as fast as possible, and drains provide such assurence. Studies on "no drains" or early removal of drains as in ERAS protocols are encouraging but leaving drains has few downsides, and they can be removed whenever they are no longer needed.
We usally place drains after parcial pancreatectomy two drain, one in in the upper abdomen near the resection and the other one in the left gutter, we are selective in placing drains after gastrectomy, some time we dont use unless is a total gastrectomy
I personally belive that the nimber of drains is not important. I strongly belive that surgical drains are a very important tool in major abdominal surgery. Of course the number of drains depends also by the kind of drain is used.
There are several study focused on the amilase level in the drain and the timing for drain removal. Anyway, no studies evaluate the role of the volume even if the amilase levels are normal. Is the volume from drains an important factor? We don´t really know. New studies are more than welcome!
Last year, I was working on a retrospective study to compare the placement of one drains versus two drains as they were different protocols followed by two different surgeons at Tata Memorial Centre.
We believed that most of the surgeons in this world place drains to be on the safer side, even though it has been studied that drains play no role in detection of complications.
We thought that even if the world was moving towards "no drain" practice, our manuscript would help those who believe in placing drain as an indicator for complications.
But most of the journals rejected our idea even though there are still a lot of doctors who place drains in the world!
I do believe there should be stricter and meticulous studies for the drains to solve the age-old question!
Dear Kunal, I think the principal reason to not consider your article for publication is the concept that drains are important in detection of complications. Actually, with the currently available imaging and laboratory there is no complication that cannot be diagnosed without drains. So drains place less and less role (if any) in detection of complication in current surgery. However the big question for me is: whether drains are able to alleviate the consequences of complications in particular operation in order to reduce mortality, need of reintervention and hospital costs. This is an open question and interesting area for research.
We were fortunate enough to get it published but had to go through a lot of hoops and rejections. We basically looked at the 4 Biggest morbidities in pancreatic surgery;
1. Post op Pancreatic Fistula
2. Hemorrhage
3. Bile leaks
4. Delayed Gastric emptying
These 4 morbidities dictate the post-op course of the patient and in clinical setting, are difficult to diagnose early. I agree imaging and labs do help but maybe not in the early stages. Drains may be useful in such cases and were considered to be good indicators. In our study we found out that drains helped us 2/3rds of the time to detect a complication and hence were useful.
Dear Kunal, actually I believe no one disagree with you that drains are helpful in detection of complications. The problem is that it seems as a backward research. To concept not to drain was proven as a safe in many fields of surgery by several trials along the years. All of them try to prove that drains can be safely avoided (in units with capability for good quality imaging and laboratory, as well as with possibility to address some of complications by interventional radiology). The final goal was to spare from unnecessary drains the vast majority of pts who do not develop complication. And this was done in many centers and types of operations. The importance of drains was proven historically and drainage was the standard for many decades. We do not need to move back and prove again its usefulness in detecting complications, which was I would like to say. On the other hand I am not aware for a study exploring the value of the primarily placed drains in terms of control of particular complication compared with “no-drain” policy. And this is a big area for research. In which situation primarily placed drains are capable to control the complication without the need of reintervention (surgical or radiological) and are they clinically and financially beneficial? That is interesting for us and is what we exploring now regarding this subject. I hope you agree even partially :)
Me too Kunal. For example let me to share some our unpublished data from ongoing series of PD, where we are focused on the outcome of the pts with significant leaks. We try to reduce the consequences of leaks of pancreatojejunostomy (PJ) with the use of a combination of some well proven (external stenting), not so proven (wrapping the vessels with tailored omentum) and unproven (two drains – at both the upper and lower edges of PJ) measures. PJ is two-layered, duct-to-mucosa. We have 7 grade B and 2 grade C pancreatic fistula to analyze. No patient with any intraabdominal bleeding. All patients with grade B recovered without further intervention, except antibiotics if become septic (3pts). Two pts with grade C fistula had signs of peritonitis and we just do lavage and repositioning of the drains in them. No mortality, no readmissions. It is too early to make any conclusive statements about this approach but it seems to work. In other words we avoided any reintervention in 7 of 9 pts. It looks cheap and safe but should be proven.
I put always two or three tubular drains in major open abdominal surgery. No EBM or controlled trials study leads my behaviour, only my sense of security.
This is exactly what we had thought. Doctors all around the world do insert drains for security reason even if it was proved that drains are not that useful. But, surgeons do use it everywhere.
Our study was to determine if there was any difference between the single drain versus two drains!
But, it is surely for debate and a huge area for research!
A recent randomized trial of drains vs. no-drains in pancreaticoduodenectomy was cancelled by Safety Monitoring Board because of a 4 times increased mortality in the no-drain group. Look at the paper in Annals of Surgery:
Interesting discussion,as for as PD is concerned one subcoastal drain postioning near the PJ ,I personally feel is essential.It just not for security purpose only but it also helps to drian should there be any leak.This prevents many a times other interventions.
I would normally, would not leave a drain following an elective gastrectomy, although if is an emergency gastrectomy for perforation with pus involved then i will leave a jackson pratt drain.
For Pancreatectomy i almost always leave a drain, unless is an elective distal pancreatectomy I may elect not to leave one, again i will leave a clse drain.
I usually leave two drains in total gastrectomy with D2 Lymphadenectomy, one sub hepatic and one on the spleen. In subtotal gastrectomy with D1 Lymphadenectomy, I usually not leave a drain, but in D2 lymphadenectmy, I believe that a sub hepatic drain in usefull.
In pancreatectomy, I usually leave two drains in central and one in distal
I have used no drain after subtotal gastrectomy and only one fine and round Blake drain with a low-pressure suction system after total gastrectomy. These last, in order to offer soft diet as soon as possible after testing the anastomosis by drinking color solution (methylene blue).