Drainage is unnecessary after elective liver resection

Prevention of deep abdominal complications with omentoplasty on the raw surface after hepatic resection. The French Associations for Surgical Research

BACKGROUND

Several methods have been suggested to treat the hepatic raw surface after resection. Among these, omentoplasty (OP) has been employed occasionally but there are no clinical studies that clearly demonstrate its usefulness.

METHODS

Of 172 randomized patients undergoing hepatic resection between January 1991 and December 1994, 5 were withdrawn for protocol violation, leaving 167 who were randomly allotted to undergo OP (n = 87) on the hepatic raw surface or not (NO; n = 80). This procedure was performed for malignant tumor in 125 cases, benign tumor in 33, and for other causes in 15. Six patients had more than two types of lesions, and 32 patients had associated cirrhosis. Sixty-five major and 102 minor hepatic resections were performed. The main outcome measures studied were the number of patients with deep abdominal complications (DAC; deep bleeding or hematoma, deep infection, with or without pus discharge through drains, bile leakage), as well as repeat operations and postoperative death. Patients were divided into two strata according to the site of the lesion with respect to the diaphragm: (1) in contact (posterosuperior segments II, VII and VIII) or (2) not in contact (anterior segments III, IV, V, and VI).

RESULTS

Both groups were comparable as regards patient demographics, intraoperative procedures, intraoperative search for bile leaks and intraoperative transfusion requirements. Fewer patients had DAC in OP (n = 11) than in NO (n = 15) (difference not significant). Ten patients (6%) required repeat operations: 4 in OP without immediate mortality and 6 in NO, 3 followed by death. One further patient in OP required repeat operation after discharge and died. Four patients died in OP and 7 in NO, 1 and 4 of DAC, respectively (not significant). Deep abdominal complications were significantly associated with major hepatic resection (P <0.05) whereas postoperative death was significantly correlated with cirrhosis (P <0.05).

CONCLUSIONS

OP on the raw surface after hepatic resection lowers the rate of all complications related to DAC (except biliary leaks) and their severity (repeat operations and death) but not significantly so. OP is not recommended as a routine measure to complete elective hepatic resections.

Extended left hepatectomy (left hepatic trisegmentectomy) in childhood

BACKGROUND/PURPOSE

Extended left hepatectomy, also referred to as left hepatic trisegmentectomy, in which segments II, III, IV, V, and VIII are excised, is rarely performed in children. Experience with 7 such resections is reported to describe the anatomy, technique, indications, and outcomes of the operation.

METHODS

The medical records of all pediatric patients treated at our institution over the last 15 years who underwent extended left hepatectomy were reviewed. Demographic information as well as operative, pathological, and follow-up data were analyzed.

RESULTS

Seven patients underwent extended left hepatectomy over this period. There were 5 boys and 2 girls ranging in age between 4 months and 9 years with a median age of 3.1 years. Follow-up ranged from 8 months to 5 years with a median of 3.5 years. Diagnoses included hepatoblastoma (HB, n = 3), focal nodular hyperplasia (FNH, n = 1), leiomyosarcoma (LMS, n = 1), hepatocellularcarcinoma (HCC, n = 1), and metastatic neuroblastoma (NB, n = 1). All surgical margins were grossly negative. Median operative blood loss was 13 mL/kg (range, 5 to 32 mL/kg), and mean hospital stay was 9 days (range, 7 to 12 days). No major intra- or postoperative complications were encountered, and there was no perioperative mortality. The 3 HB patients, 1 FNH patient, 1 LMS patient, and 1 NB patient are without evidence of disease, whereas the 1 child with HCC died of recurrent and distant disease. The 6 surviving children have normal hepatic function.

CONCLUSION

Although technically challenging and rarely performed, extended resection of the left hepatic lobe is feasible in children and can yield curative results with minimal morbidity.

An audit of breast reduction without drains

Fifty consecutive patients who underwent breast reduction have been audited to determine whether or not using drains adversely affected their outcome. The mean age of the patients was 32 years and the mean mass of breast tissue excised was 750 g. There were two early complications (within 30 days postoperatively): one seroma and one minor wound dehiscence. Both were dealt with on an outpatient basis. There was one late complication of a breast abscess 6 weeks postoperatively.These results are comparable with previously published series of breast reduction surgery using wound drainage, suggesting that the absence of drains does not adversely affect postoperative recovery.

A comparative study of postoperative complications after hepatectomy in patients with and without chronic liver disease

BACKGROUND

Although hepatic resection is the most reliable treatment for hepatocellular carcinoma, impaired liver function because of cirrhosis or chronic hepatitis contributes to relatively high rates of postoperative complications. We have reviewed a series of hepatectomies at our institution and investigated risk factors for complications after hepatectomy in patients with impaired liver compared with patients with normal liver.

METHODS

From October 1994 to March 1998, 277 hepatectomies for hepatocellular carcinoma, cholangiocellular carcinoma, metastatic liver tumors, and other hepatic diseases were performed. In an attempt to clarify the safety of hepatectomy for the impaired liver at our institution, we did a comparative study of postoperative complications after hepatectomy in 2 groups: patients with impaired livers (187 hepatectomies) and patients with normal livers (90 hepatectomies).

RESULTS

Of the 277 hepatectomies, bile leakage occurred in 25 patients (16 in impaired livers vs 9 in normal livers), abdominal infection in 45 patients (30 vs 15 patients), wound infection in 13 patients (9 vs 4 patients), pleural effusion in 52 patients (35 vs 17 patients), atelectasis in 26 patients (17 vs 9 patients), pneumonia in 4 patients (3 vs 1 patients), ileus in 6 patients (3 vs 3 patients), intra-abdominal hemorrhage in 3 patients (0 vs 3 patients), and hyperbilirubinemia in 5 patients (4 vs 1 patients). Hepatic insufficiency and hospital death were not experienced in this series. The mean postoperative hospital stay was 22.9 days (23.5 vs 23.1 days), and except for intra-abdominal hemorrhage there was no statistically significant difference between the 2 groups.

CONCLUSIONS

Hepatectomy for the impaired liver is now as safe a procedure as for the normal liver, provided the overall guidelines outlined in our algorithm are followed.

Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. French Association for Surgical Research

OBJECTIVE

We investigated the role of drainage in the prevention of complications after elective rectal or anal anastomosis in the pelvis. Anastomotic leakage after colorectal resection is more prevalent when the anastomosis is in the distal or infraperitoneal pelvis than in the abdomen. The benefit of pelvic drains versus their potential harm has been questioned. Drain-related complications include (1) those possibly benefiting from drainage (leakage, intra-abdominal infection, bleeding) and (2) those possibly caused by drainage (wound infection or hernia, intestinal obstruction, fistula).

METHODS

Between September 1990 and June 1995, 494 patients (249 men and 245 women), mean age 66 +/- 15 (range 15 to 101) years, with either carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another disorder located anywhere from the right colon to the midrectum undergoing resection followed by rectal or anal anastomosis were randomized to undergo either drainage (n = 248) with 2 multiperforated 14F suction drains or no drainage (n = 246). The primary end point was the number of patients with one or more postoperative drain-related complications. Secondary end points included severity of these complications as assessed by the rate of related repeat operations and associated deaths as well as extra-abdominally related morbidity and mortality.

RESULTS

After withdrawal of 2 patients (1 in each group) both groups were comparable with regard to preoperative characteristics and intraoperative findings. The overall leakage rate was 6.3% with no significant difference between those with or without drainage. There were 18 deaths (3.6%), 8 (3.2%) in those with drainage and 10 (4%) in those without drainage. Five patients with anastomotic leakage died (1%), 3 of whom had drainage. There were 32 repeat operations (6.5%) for anastomotic leakage 11 in the group with drainage and 4 in the group with no drainage. The rate of these and the other intra-abdominal and extra-abdominal complications did not differ significantly between the 2 groups.

CONCLUSION

Prophylactic drainage of the pelvic space does not improve outcome or influence the severity of complications.

Omentoplasty in the prevention of deep abdominal complications after surgery for hydatid disease of the liver: a multicenter, prospective, randomized trial. French Associations for Surgical Research

BACKGROUND

Omentoplasty (OP) is thought to fill residual cavity, to assist healing of raw surfaces, and to promote resorption of serosal fluid and macrophagic migration in septic foci. Results published to date, whether retrospective or prospective, are not controlled and are discordant.

STUDY DESIGN

The authors investigated whether OP, either filling the residual cavity after unroofing, or covering the hepatic raw surface after pericystectomy, could reduce the rate or severity of deep abdominal complications (DAC) after surgical treatment of hydatid disease of the liver. Between January 1993 and December 1996, 115 consecutive patients (51 males and 64 females, mean age 42+/-16 years [range 10 to 80 years]) with previously unoperated uni- or multilocular hydatid disease of the liver, complicated or not, without other abdominal hydatid disease, were randomly allotted to OP (n = 58) or not (NO) (n = 57) after unroofing, total, or partial pericystectomy. Patients were divided into 2 strata according to the site of the cyst with respect to the diaphragm: a) posterosuperior segments II, VII, and VIII or b) anterior segments III, IV, V, and VI. Main outcomes measures included deep bleeding, hematoma, infection, or bile leakage. Subsidiary measures included wound complications, extraabdominal complications, duration of operation, and length of hospital stay.

RESULTS

Both groups were comparable regarding patient demographics, cyst characteristics, intraoperative procedures, search for bile leaks, and intraoperative transfusion requirements. On the other hand, more patients (86%) in NO had associated drainage of the abdominal cavity than in OP (64%) and the duration of operation was 9 minutes longer in OP, but neither of these differences was statistically significant. Less DAC occurred in OP (10%) than in NO (23%) (a posteriori gamma risk < 0.05) and fewer deep abdominal abscesses (0 versus 11%) (p < 0.03). Median duration of hospital stay, however, was similar.

CONCLUSIONS

OP decreases the rate of DAC and especially deep abdominal abscess after surgical treatment (unroofing or pericystectomy) for hydatid disease of the liver and should be recommended in this setting.

Is intra-abdominal drainage necessary after pancreaticoduodenectomy?

Closed suction drains after pancreaticoduodenectomy are theoretically used to drain potential collections and anastomotic leaks. It is unknown whether such drains are effective, harmful, or affect the outcome after this operation. Eighty-nine consecutive patients underwent pancreaticoduodenectomy for presumed periampullary malignancy and were retrospectively reviewed. Thirty-eight had no intra-abdominal drains and 51 had drains placed at the conclusion of the operation. We analyzed patient, nutritional, laboratory, and operating room factors with end points being complications and length of hospital stay. Intra-abdominal complications were defined as intra-abdominal abscess and pancreatic or biliary fistula. Postoperative interventions were defined as CT-guided drainage and reoperation. Analysis was by Student's t test and chi-square test. Two of eight surgeons contributed 92% of the patients without drains. The groups were equivalent with respect to demographic, nutritional, and operative factors. Time under anesthesia was significantly shorter in the group without drains (P = 0.0001). There was no statistical difference in the rate of fistula, abscess, CT drainage, or length of hospital stay. Intra-abdominal drainage did not significantly alter the risk of fistula, abscess, or reoperation or the necessity for CT-guided intervention after pancreaticoduodenectomy. Routine use of drains after pancreaticoduodenectomy may not be necessary and should be subjected to a randomized trial.

Prospective randomized trial of systemic antibiotics in patients undergoing liver resection

BACKGROUND

Systemic antibiotics are administered frequently after hepatectomy to prevent infective complications, but their effectiveness is uncertain.

METHODS

A total of 127 patients with liver tumours were prospectively randomized into two groups after hepatectomy: in group 1 (62 patients) no antibiotics were given until the appearance of infective complications; in group 2 (65 patients) intravenous cephazolin 1 g every 6 h and gentamicin 80 mg every 8 h were given for 7 days. On the day before surgery all patients received bowel preparation by clear liquid diet and oral antibiotics (neomycin 1 g and erythromycin 1 g, given together in three doses).

RESULTS

The infective complication rate was 23 per cent in both groups (P = 0.95). The hospital costs were higher in group 2 (P < 0.001). Of the group 1 patients, 51 (82 per cent) did not require antibiotic treatment. No patient in either group died after hepatectomy.

CONCLUSION

Postoperative systemic antibiotics cannot prevent infective complications, and their routine use after hepatectomy is unnecessary and costly. The use of antibiotics should be delayed until infective complications and persistent septic symptoms occur.