by

Dr.Imran Sadiq

King Abdul Aziz Naval Base Hospital

First recorded use of drains is attributed to Hippocrates (460-377 BC ) for Empyema

Lorenz Heister of Numberg (1683-1758 ) introduce the principle of capillary (action) drainage .

Eugene Koeberle of Strasbourg(1865) used a glass tube drain .

Heaton ( 1889 ) is credited with introducing suction drainage .

Murphy ( 1947 ) introduced a technique for intermittent suction .

Closed-system , continuous suction introduced by Baron (1950 ) .

1. Active Drains

Closed

JP(Jackson-Pratt Drain),

Redivac Suction Drain

Open

Sump Drain

FLUID

AIR

1. Passive Drains

Closed

NGT, Foleys catheter,

T-Tube, Nelaton Drain etc.

Open

Penrose drains,

corrugated Drains

Active Drain Passive Drain

Function Works by negativepressure created by compressible drums or mechanical evacuation system

Depends upon pressure differentials & gravity

Pressure Gradient Negative Pressure Normal

Drain Exit site Dependent Position is not necessary

Dependent position for best function

Retrograde Infection Lower incidence Higher incidence

Fluid collection Decreased incidence because negative pressure improves tissue apposition & obliterates dead space

Increased incidence because of limited effect on dead space

Obstruction of Drain More common Less common

Pressure necrosis Greater incidence Less common

In 1905 Yates claimed “ drainage of General Peritoneal cavity is physically and physiologically impossible”.

Gravitz’s stated “ Peritoneum is able to reabsorb secretions and combat bacteria.”

Review of literature/Research work.

This is the most sophisticated way to get benefit from the work and experiences of others in this era.

1992

“the conscientious,explicit,judicious use of current best evidence in making decisions about the care of individual patients.”

( conscientious -------- attentive, Luborious,Pain taking)

( Explicit------------------ Obvious)

( Judicious--------------- Logical,Rational)

Its basic principles are that all practical decisions made should

Be based on Research studies.

That the Research studies are selected and interpreted according to some specific norms

characteristic for EBP.

The results should be analyzed and compared with standards.

How to Review the literature/Research work?

Which Research work is Reliable and practicable?

Anything present in support of an assertion (statement).

Evidence is comprised of research findings delivered from the systemic collection of Data through observation & experiment and the formulation of Question & testing of Hypothesis.

There are certain scales to measure Evidence (levels of Evidence )

Recommendations are made by different Research Groups.

CodeQuality of Evidence

Definition

A High

Further research is very unlikely to change our confidence in the estimate of effect.•Several high-quality studies with consistent results•In special cases: one large, high-quality multi-centre trial

B Moderate

Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.•One high-quality study•Several studies with some limitations

C Low

Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.•One or more studies with severe limitations

D Very Low

Any estimate of effect is very uncertain.•Expert opinion•No direct research evidence

Grading of Recommendations Assessment, Development

and Evaluation (GRADE)•Source: GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group 2007(modified by EBM guideline editorial team)

A: Randomized controlled trials.

B:Controlled trials, no randomization.

C: Observational trials.

D: Opinion of the expert panel

University of Michigan Practice Guideline:

Cochrane collaboration: A worldwide association of groups who create and maintain systematic reviews of the literature for specific topic areas.

Cochrane Review

USPSTF ( US Preventive Services Task Force)

AHRQ ( Agency of Health Care Research & Quality)

A systematic Review & Meta-Analysis

Source. Ann Surg. Dec,2004; 240 (246)

Author from Switzerland, Department of Visceral & Transplant Surgery, University Hospital.

Review of Articles Comparing Prophylactic Drainage Vs No Drainage in GI Surgery from 1966 to 2004.

17 RCTs for Hepato-pancreatico-biliary Surgery.

None for upper GI Tract

13 for Lower GI Tract.

All studies were classified according to their level of Evidence and then graded (A,B,C,D) as suggested by Oxford Centre for EBM.

Studies were compared for the following end points: mortality, overall complication rates, leakage rates, infection rates (wound, intra-abdominal collections, abscess), pulmonary complication rates, reoperation rates, and hospital stay.

Open Cholecystectomy numerous RCTs and Meta-analysis by Lewis et al, failed to demonstrate a reduction of post-operative complications by routine drainage. (Level 1a)

Lap. Cholecystectomy 2 RCTs, 4 of 34 (11.7%) of drained had complications while in non drained 2 of 33 (6.1%) had complications.(Level 1a)

No RCT prospective study

One non Randomized Prospective Cohort study (level 2b)

“The role of Prophylactic Drains after Surgery for Perforated Duodenal Ulcer.”

Total pts. 119

Omental Patch Technique

75 pts. With Drain

44 pts. Without drain

Drainage neither reduced the incidence of intra abdominal fluid collection including abscess formation nor the duration of Hospital stay.

But there were a significant number of Drain related complications such as

Drain Tract infection (10.7%)

Acute Intestinal obstruction (2.7%)

Meta analysis

8 RCTs on Abdominal/Pelvic Drainage vs no Drainage

3 RCTs has Level 1b

5 RCTs has Level 2b

717 pts. with Drain

673 pts. without Drain

Majority of studies on Elective Surgery

2 studies include Emergency cases

A slight advantage for non drained patients in respect to clinical leakage (OR 1.38; CI 0.77–2.49) and wound infections (OR 1.41; CI 0.87–2.29) was documented, although this advantage was not statistically significant.

Moreover, the meta-analysis by Urbach et al showed that in only 1 of 20 clinical leakages pus or feces emerged through the drain,indicating that drains have a low sensitivity (5%) to detect clinical leakage.

Open Appendectomy

Five RCTs on prophylactic drainage for gangrenous and perforated appendicitis were identified (level of evidence 2b).

The results showed higher wound infection rates in drained patients (range 43–85%) than in non drained patients (range 29–54%).

The pattern of intra-abdominal infections was not uniform among the studies, as 2 studies reported slightly higher intra-abdominal infection rates in non drained patients,1 study a higher rate in drained .

Meta-analysis including series with gangrenous or perforated appendicitis only.

Four RCTs (all level 2b) were included in the meta-analysis with the end point wound infection, whereas data from 3 RCTs were available for the end points intra-abdominal infection and fecal fistula .

The analysis calculated an OR for wound infections of 1.75 (CI 0.96–3.19). The OR for fecal fistulas of 12.4 (CI 1.14–135) favors the no-drainage group, whereas the OR for the end point intra-abdominal infection of 1.43 (CI 0.39–5.29) favors neither group.

Cochrane ReviewPublished on 3rd Sep. 2013

12 RCTs 1831 participants 915 pts with drain 916 pts without drain 9 RCTs include elective cholecystectomies 1 RCT include Acute cholecystitis 2 RCTs include both elective & emergency

cholecystectomies

There was no significant or clinically important differences in the short-term mortality, serious complications, quality of life, length of hospital stay, operating time, return to normal activity, or return to work in the trials that reported these outcomes.

The proportion of patients who were discharged as day-procedure laparoscopic cholecystectomy seemed significantly lower in the drain group than in the 'no drain' group .

Journal of Minimal Access Surgery; 2012,Jul-Sep

Suez Canal Hospital RCT (Prospective) Single Blind (Team Accessing Results) Level of Evidence 1b Group A with Drain ( closed Passive Drain) Group B without Drain Assessment. Post op Pain ,wound infection

& Hospital stay

Post op Pain VAS no difference at 24,48hrs & 1week.

Hospital Stay

Group A 1--3 days

Group B 1-- 2days

East & Centeral African Journal of Surgery

Vol.16,No 2,Jul/Aug 2011;62-71

Prospective RCT

90 pts.

Pts with generalized Peritonitis were excluded

45 pts. With drain (closed without suction)

45 pts. Without drain

Other complications included fecal fistula (2patients), intraperitoneal abscess (3 patients) and paralytic ileus (1 patient) all of them occurring in patients with drains.

Many GI operations can be performed safely without prophylactic drainage. Drains should be omitted after colonic, or rectal resection with primary anastomosis and appendectomy for any stage of appendicitis (recommendation grade A).

Currently, there is no evidence to support the use of drain after laparoscopic cholecystectomy (recommendation grade A).Further well-designed randomised clinical trials are required.

In any surgical procedure, good hemostasis,

appropriate antibiotics use and precise surgical

technique with minimal tissue trauma limit the need

for operative drain placement.