DRAINS IN COLORECTAL SURGERY

Transcription

1 DRAINS IN COLORECTAL SURGERY D R BRENDAN and D BEBINGTON MBChB (Zim), FCS (SA) Honorary Lecturer: Department of Surgery, University of the Witwatersrand Colorectal Surgeon, Colorectal Unit, Wits Donald Gordon Medical Centre Providers of medical care are increasingly being asked to justify their decisions at every step. The outcome of each action taken must be understood to the best of the clinician s ability. They should be able to explain the benefit of their action with the best evidence available. The use of drains in colorectal surgery has been practiced by generations of surgeons without questioning their value. This presentation reviews our current understanding of the use of drains in colorectal surgery with provision of the best evidence of practice. PROPHYLACTIC USE OF DRAINS IN COLORECTAL SURGERY The reason drains are placed in colorectal surgery varies. They may be placed in the hope that they drain any collection preemptively. However experience show that the drains are often walled off 1, not attending to the drainage of the site intended and may even be a portal for external bacterial flora to the peritoneal cavity 2. It could be argued that blood in the drain may herald significant bleeding in the post-operative period but this is an unreliable sign. Drains have more recently been shown to be of value to improve postoperative comfort by decreasing the intraabdominal pressure (this coming particularly from the laparoscopic surgical literature) 3. A lot less clear has been whether drains impact favorably or unfavorably on the propensity for a large bowel anastomosis to fail. There is understandably a wealth of rather bewildering literature on this topic most of which is underpowered and nonrandomised.

2 The conclusions of the larger randomised studies are not always concordant and it is for this reason it is of value to consider the metanalyses on this topic. In the past 10 years there have been two meta-analyses 4,5 reviewing the use of drains in colorectal surgery. Both approach the issue broadly with no or little stratification of the type of colorectal cases assessed and in particular intra and extra-peritoneal anastomoses are included in the Randomised Controlled Trials (RCT) selected. Generally speaking there is no justification for the use of drains in colorectal surgery, irrespective of the nature of the drain. These analyses give us a blanket statement for all colorectal surgeries. Closer scrutiny suggests that within the population of patients operated on for colorectal pathology, subgroups behave very differently with regard their need for drainage. The two circumstances where the need for drainage is different are extraperitoneal anastomoses (low anterior resections) and the drainage of the subcutaneous space on closure of open wounds of the anterior abdominal wall. Leaks following Low Anterior Resections (LAR) are the Achilles heel of these operations with a reported incidence between 0-36% in series. Their origin is multifactorial 6 and is too extensive a topic to include in this review. Whether drains ameliorate outcome has been debated and best evidence to date would suggest they do. Off the back of the Dutch TME trial Peeters et al have suggested that the placement of drains after neoadjuvant DXT and LAR improves the incidence of leak favorably (incidence of 9.6% with drains and 32.5% without drains) 7. Large RTCs would give strength to this notion but best evidence supports the use of drains in this situation. Drains placed within the abdominal cavity may be of value but even in a setting of advantage the question arises; are they safe? Do they intrinsically carry a prohibitive associated complication rate?

3 Complications related to drains are rare and as a consequence are difficult to comment on apart from to say their issues should not deter the surgeon from placing drains. Problems with drains do occur in certain circumstances: when large stab incisions are used on placing them, increased intra-abdominal pressure, poor tissue healing and where intra-abdominal drains are left for prolonged periods. Most of the literature in this regard is to be found in case reports and personal opinion with one interesting exception 12. In Manz s experimental study from 1970 he points out an increased complication rate with prolonged drainage and recommends early drain removal. A further Swedish study alludes to greater financial costs incurred by leaving drains in, with longer hospital stays and with poorer mobilisation 13. Contrary to the advice that would follow from these two papers there has been work which suggests the incidence of leaks in colorectal surgery has a bimodal distribution on a post-op timeline 14, and that the more distant of these peaks is at 26 days post-op. The duration with which drains are left in is therefore not clearly defined by the literature. The drainage of the superficial surgical site is a slightly more contentious topic with the initial larger studies suggesting no difference in reported surgical site sepsis (SSIs) between those patients with drains and those without 8,9. The potential drawbacks in these studies have been difficulties with randomisation and poor standardisation of drainage technique as well as being too small to draw conclusions. These papers, however, have been followed by a single large study which has more effectively dealt with the difficulties of randomisation and which would suggest that drainage of the subcutaneous space is of benefit after elective colorectal surgery 10. Closure of stomas carries a higher risk then access incisions (8% of loop stomas closed for prior colorectal malignancies will complicate with wound sepsis) 11.

4 There is no evidence for or against the use of superficial drains in the abdominal wall wounds after stoma closure but there are suggestions that intra-abdominal drains are in fact counterproductive in this specific setting. THERAPEUTIC USE OF DRAINS IN COLORECTAL SURGERY If abscesses develop, the therapeutic approach needs to be individualised, with the clinical situation and response to treatment being the surgeon s guide. Diversion is often required in the setting of a post-operative leak, but diversion will not result in resolution of an established abscess and drainage will be an inevitable requirement. CT guided drainage with the help of an experienced interventional radiologist is of great assistance in intra-peritoneal collections 15. However, in the circumstance of leaks in association with a LAR the collection is often sealed within the pelvis and so trans-anal drainage with a Foley s catheter through the anastomosis is often the best approach 16. In washing out these pelvic cavities the surgeon is well advised to do so with minimal pressure to prevent localised sepsis being forced into the peritoneal cavity. The surgeon may have undertaken to perform the low rectal surgery without bowel preparation and in this situation trans-anal drainage of a collection should be done with meticulous avoidance of pushing faces into the abscess cavity. THE INTRALUMINAL APPROACH TO THE ANASTOMOSIS AT RISK Intra-colonic sleeves have been described in the literature as long ago as In principle these internal covers do not decrease the chances of a leak but may limit the contamination initiated by such a complication. Recently the C-SEAL has been introduced as a similar device for the protection of the stapled anastomosis in LARs. Although they have been enthusiastically hailed as an alternative to covering stomas optimism has been dampened by described complication and by poor evidence for their advantages.

5 There are many animal studies and the clinical trials are small. The only two reasonably sized studies were abandoned because of adverse outcome created by the devices under assessment. Not only this, some of the sleeves are difficult to place. It is for these reasons these techniques have never really taken off 19. DRAINS AS A MEANS TO MONITOR ANASTOMOSES Traditionally the presence of pus or colonic content has alerted the practitioner to the presence of a leak. Recently there has been interest in biomarkers from drains to improve leak pickup. A number of biomarkers have been explored. Not all of them can be used practically and not all of them are cheap enough to be practical 17. Possibly the most promising biomarkers are Interleukin-6 (IL-6) alone or in combination with Matrix Metalloproteinase 9 (MMP9). They are significantly raised from day two onwards and on rudimentary metanalysis show increasing statistical difference from controls in days two to six 18. Hopefully these new markers, as an adjunct to traditional clinical assessment, will enable the clinicians to predict the anastomosis at risk. This may increase the rapidity with which interventional decisions are made or even prompt therapy before serious complications unfold. The place each agent will have in clinical practice will be the subject of great interest in the community of colorectal surgeons in the years ahead. At present no suggestions or guidelines can be given. CONCLUSION Attending to leaks and abscess related to anastomoses is an imperative for any surgeon doing elective colorectal surgery. The origin of this complication is complex and dependent on a large number of variables 6. It is only in dogged reappraisal of outcomes that surgeons have any hope to decrease their complication rates. Abscesses and leaks are no exception. The judicious application of drains is one of many ways for a surgeon to close the loop of intervention arising from audit 20.

6 REFERENCES 1. Launay-Savary MV, Sim K, Evidence based analysis of prophylactic drainage. Ann. Chir 2006; 13(5): Epub 2005 Dec 5 (French). 2. Chylak J, Michalska W, Dews M, Marcinisk R, Lange M. Comparison of bacterial flora found in the peritoneal cavity after intraabdominal surgery. Med Sci Monit 2000; 6(2): Albanopoulos K, Alevizos L, Linardoutsos D, Menenakos E, Stamou K, Vlakos K, Zografos G, Leandro E, Routine Abdominal Drains after Laparoscopic Sleeve Gastrectomy: A Retrospective Review of 353 Patients. Obesity Surgery. 2011;21(6): de Jesus EC, Karliczek A, Matos D, Castro AA, Atallah ÁN. Prophylactic anastomotic drainage for colorectal surgery. Cochrane Database of Systematic Reviews 2004;2:Art.No.CD DOI: / CD pub2. 5. Urbach DR, Kennedy ED, Cohen MM. Colon and rectal anastomoses do not require routine drainage: a systematic review and metaanalysis. Ann Surg. 1999;229(2): Vignali A, Fazio VW, Lavery IC, et al. Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients. J Am Coll Surg. 1997;185(2): Peeters KC, Tollenaar RA, Marijnen CA, Klein Kranenbarg E, Steup WH, Wiggers T, Rutten HJ, Velde CJ. Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg. 2005;92(2): Baier PK, Gluck NC, Baumgartner U, Adam U, Fischer A, Hopt UTSubcutaneous Redon drains do not reduce the incidence of surgical site infections after laparotomy. A randomised controlled trial on 200 patients. Int J Color Dis. 2010;25: Kaya E, Paksoy E, Ozturk E, SigirliD, BilgelH Subcutaneous closedsuction drainage does not affect surgical site infection rate following elective abdominal operations: a prospective randomised clinical trial. Acta Chir Belg. 2010;110: Numata M, Godai T, Masuda M. A prospective randomised controlled trial of subcutaneous passive drainage for the prevention of superficial surgical site infections in open and laparoscopic colorectal surgery. Int J Colorectal Dis 2014;29(3): Pub Jan Pokorny H, Herkner H, Jakesz R, Herbst F. Mortality and complications after stoma closure. Arch Surg. 2005;140(10): Manz CW, LaTendresse C, Sako Y. The detrimental effects of drains on colonic anastomoses: an experimental study. Dis Colon Rectum. 1970; 13(1): Hoffmann J, Shokouh-Amiri MH, Damm P, Jensen R. A prospective, controlled study of prophylactic drainage after colonic anastomoses. Dis Colon Rectum. 1987; 30(6): Kingham TP, Pachter HL. Colonic anastomotic leak: risk factors, diagnosis, and treatment. J Am Coll Surg. 2009; 208(2): Khurrum Baig M, Hua Zhao R, Batista O, Uriburu JP, Singh JJ, Weiss EG, Nogueras JJ, Wexner SD. Percutaneous post-operative intraabdominal abscess drainage after elective colorectal surgery. Tech Coloproctol. 2002; 6(3):

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