Laparoscopy-assisted distal gastrectomy for early gastric cancer with vs without prophylactic drainage. Surg Today. 2011;41:1049-1053. [PMID: 21773892 DOI: 10.1007/s00595-010-4448-0]

Prophylactic Drain Placement and Postoperative Invasive Procedures After Gastrectomy: The Abdominal Drain After Gastrectomy (ADIGE) Randomized Clinical Trial

Importance

Evidence suggests that prophylactic abdominal drainage after gastrectomy for cancer may reduce postoperative morbidity and hospital stay but this evidence comes from small studies with a high risk of bias. Further research is needed to determine whether drains safely meet their primary purpose of identifying and managing postoperative intraperitoneal collections without the need for reoperation or additional percutaneous drainage.

Objective

To determine whether avoiding routine abdominal drainage increased postoperative invasive procedures.

Design, Setting, and Participants

The Abdominal Drain in Gastrectomy (ADIGE) Trial was a multicenter prospective randomized noninferiority trial. Enrollment spanned from December 2019 to January 2023. Follow-up evaluations were completed at 30 and 90 days. Eleven centers within the Italian Research Group for Gastric Cancer, encompassing both academic medical centers and community hospitals, were included. Patients with gastric cancer undergoing subtotal or total gastrectomy with curative intent were eligible, excluding those younger than 18 years, with serious comorbidities, or undergoing procedure types outside the scope of the study. Of 803 patients assessed for eligibility, 404 were randomized and 390 were included in final analyses.

Interventions

Patients were randomized 1:1 into prophylactic drain or no drain arms.

Main Outcomes and Measures

The primary end point was a modified intention-to-treat (mITT) analysis measuring reoperation or percutaneous drainage within 30 postoperative days. The null hypothesis was rejected when the 90% CI upper limit of the proportion difference did not exceed 3.56%. The calculated sample size to achieve 80% power with a 10% dropout rate was 404 patients (202 in each group). Surgeons and patients were blinded until gastrointestinal reconstruction.

Results

Of the 404 patients randomized 226 (57.8%) were male; the median (IQR) age was 71 (62-78) years. Intraoperative identification of nonresectable disease occurred in 14 patients, leading to their exclusion from the study, leaving 390 patients. In the mITT analysis, 15 patients (7.7%) in the drain group needed reoperation or percutaneous drainage by postoperative day 30 vs 29 (15%) in the no drain group, favoring the drain group (difference, 7.2%; 90% CI, 2.1-12.4; P = .02). Of note, the difference in the primary composite end point was entirely due to a similar difference in reoperation (5.1% in the drain group vs 12.4% in the no drain group; P = .01). Drain-related complications occurred in 4 patients.

Conclusions and Relevance

The findings of this study indicate that refraining from prophylactic drain use after gastrectomy heightened the risk of postoperative invasive procedures, discouraging its avoidance. Future studies identifying high-risk groups could optimize prophylactic drainage decisions.

Trial Registration

ClinicalTrials.gov Identifier: NCT04227951.

Prediction of Post-Gastrectomy Pancreatic Complications: A Preoperative Imaging Study Based on Computed Tomography

BACKGROUND

Postoperative pancreas-related complications (PPRCs) are common after laparoscopic gastrectomy (LG) in patients with gastric cancer. We estimated the anatomical location of the pancreas on a computed tomography (CT) image and investigated its impact on the incidence of PPRCs after LG.

METHODS

We retrospectively reviewed the preoperative CT images of 203 patients who underwent LG for gastric cancer between January 2010 and December 2017. From these images, we measured the gap between the upper edge of the pancreatic body and the root of the common hepatic artery. We evaluated the potential relationship between PPRCs and the gap between pancreas and common hepatic artery (GPC) status using an analysis based on the median cutoff value and assessed the impact of GPC status on PPRC incidence. We performed univariate and multivariate analyses to identify predictive factors for PPRC.

RESULT

Postoperative pancreas-related complications occurred in 11 patients (5.4%). The median of the optimal cutoff GPC value for predicting PPRC was 0 mm; therefore, we classified the GPC status into two groups: GPC plus group and GPC minus group. Univariate analysis revealed that sex (male), C-reactive protein (CRP) > .07 mg/dl, GPC plus, and visceral fat area (VFA) > 99 cm2 were associated with the development of PPRC. Multivariate analysis identified only GPC plus as independent predictor of PPRC (hazard ratio: 4.60 [95% confidence interval 1.11-31.15], P = .034).

CONCLUSION

The GPC is a simple and reliable predictor of PPRC after LG. Surgeons should evaluate GPC status on preoperative CT images before proceeding with laparoscopic gastric cancer surgery.

Prophylactic drainage versus non-drainage following gastric cancer surgery: a meta-analysis of randomized controlled trials and observational studies

BACKGROUND

The role of prophylactic drainage (PD) in gastrectomy for gastric cancer (GC) is not well-established. The purpose of this study is to compare the perioperative outcomes between the PD and non-drainage (ND) in GC patients undergoing gastrectomy.

METHODS

A systematic review of electronic databases including PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Infrastructure was performed up to December 2022. All eligible randomized controlled trials (RCTs) and observational studies were included and meta-analyzed separately. The registration number of this protocol is PROSPERO CRD42022371102.

RESULTS

Overall, 7 RCTs (783 patients) and 14 observational studies (4359 patients) were ultimately included. Data from RCTs indicated that patients in the ND group had a lower total complications rate (OR = 0.68; 95%CI:0.47-0.98; P = 0.04; I² = 0%), earlier time to soft diet (MD =  - 0.27; 95%CI: - 0.55 to 0.00; P = 0.05; I² = 0%) and shorter length of hospital stay (MD =  - 0.98; 95%CI: - 1.71 to - 0.26; P = 0.007; I² = 40%). While other outcomes including anastomotic leakage, duodenal stump leakage, pancreatic leakage, intra-abdominal abscess, surgical-site infection, pulmonary infection, need for additional drainage, reoperation rate, readmission rate, and mortality were not significantly different between the two groups. Meta-analyses on observational studies showed good agreement with the pooled results from RCTs, with higher statistical power.

CONCLUSION

The present meta-analysis suggests that routine use of PD may not be necessary and even harmful in GC patients following gastrectomy. However, well-designed RCTs with risk-stratified randomization are still needed to validate the results of our study.

Prophylactic Drain Versus No Drain in Curative Gastric Cancer Surgery-A Randomized Controlled Trial

BACKGROUND

The adoption of enhanced recovery after surgery protocols has questioned the placement of prophylactic drain after curative gastrectomy. A 2015 Cochrane meta-analysis did not find convincing evidence of routine drain placement in gastrectomy, but the quality of evidence was questioned. The present study compared short-term outcomes of prophylactic drain placement versus no drain in gastrectomy.

METHODOLOGY

The study is a prospective, non-inferiority, and randomized controlled trial. Histologically proven adenocarcinoma of the stomach undergoing curative gastrectomy with D2 lymphadenectomy was included in the study. Randomization was done intra-operatively. The primary outcome was a postoperative hospital stay. Secondary outcomes included the return of bowel function, achieving adequate enteral feeding, re-surgery, morbidity, and mortality.

RESULTS

One hundred fifty-seven patients were registered, of which 108 patients underwent curative surgery, and were randomized to 54 patients in each group. The median age was 55 years (range: 23-78) and 58.5 years (range: 35-80) in the drain and no drain group. No significant difference was noticed in primary or secondary outcomes in both groups.

CONCLUSION

Avoid placing a prophylactic drain is not inferior to drain placement following gastrectomy with D2 lymphadenectomy for stomach adenocarcinoma. So, routine prophylactic drain placement can be avoided.

Clinical significance of lipid droplets formed in the peritoneal fluid after laparoscopic surgery for gastric cancer

BACKGROUND

Several studies have previously reported that laparoscopic surgery using an energy sealing device generates hazardous surgical smoke. However, the droplets appearing on the surface of peritoneal fluid irrigated with saline, after dissection phase of laparoscopic gastrectomy were ignored for a long time. This study aimed to investigate the composition and clinical significance of these droplet particles.

METHODS

This study prospectively enrolled 15 patients with early gastric cancer (cT1NanyM0) who were scheduled for laparoscopic gastrectomy. Floating phases of peritoneal irrigation fluid containing droplets in dissected area were retrieved before and after surgical dissection. Using gas chromatography analysis, the areas under the peak were compared between the samples retrieved before and after surgical dissection. We also analyzed if the area value with significant change was related to the inflammatory response.

RESULTS

In gas chromatography, the area values after laparoscopic surgical dissection were significantly increased in 10 out of 37 kinds of fatty acids, compared to those before surgical dissection. The significant increase in area value of α-linoleic and eicosadienoic acids were positively correlated with the elevated level of C-reactive protein at postoperative day 2 (Spearman's ρ = 0.843, P < 0.001; Spearman's ρ = 0.785, P = 0.001).

CONCLUSIONS

The lipid droplets, generated after laparoscopic lymphadenectomy during gastric cancer surgery, contained various types of fatty acids, and some of them have been found to be associated with inflammatory response.

Feasibility of totally laparoscopic gastrectomy without prophylactic drains in gastric cancer patients

BACKGROUND

Prophylactic drains have been used to remove intraperitoneal collections and detect complications early in open surgery. In the last decades, minimally invasive gastric cancer surgery has been performed worldwide. However, reports on routine prophylactic abdominal drainage after totally laparoscopic distal gastrectomy are few.

AIM

To evaluate the feasibility performing totally laparoscopic distal gastrectomy without prophylactic drains in selected patients.

METHODS

Data of patients with distal gastric cancer who underwent totally laparoscopic distal gastrectomy with and without prophylactic drainage at China National Cancer Center/Cancer Hospital from February 2018 to August 2019 were reviewed. The outcomes between patients with and without prophylactic drainage were compared.

RESULTS

A total of 457 patients who underwent surgery for gastric cancer were identified. Of these, 125 patients who underwent totally laparoscopic distal gastrectomy were included. After propensity score matching, data of 42 pairs were extracted. The incidence of concurrent illness was higher in the drain group (42.9% vs 31.0%, P = 0.258). The overall postoperative complication rates were 19.5% and 10.6% in the drain (n = 76) and no-drain groups (n = 49), respectively; there were no significant differences between the two groups (P > 0.05). The difference between the two groups based on the need for percutaneous catheter drainage was also not significant (9.8% vs 6.4%, P = 0.700). However, patients with a larger body mass index (≥ 29 kg/m²) were prone to postoperative complications (P = 0.042). In addition, the number of days from surgery until the first flatus (4.33 ± 1.24 d vs 3.57 ± 1.85 d, P = 0.029) was greater in the drain group.

CONCLUSION

Omitting prophylactic drainage may reduce surgery time and result in faster recovery. Routine prophylactic drains are not necessary in selected patients. A prophylactic drain may be useful in high-risk patients.

Feasibility of totally laparoscopic gastrectomy without prophylactic drains in gastric cancer patients

BACKGROUND

Prophylactic drains have been used to remove intraperitoneal collections and detect complications early in open surgery. In the last decades, minimally invasive gastric cancer surgery has been performed worldwide. However, reports on routine prophylactic abdominal drainage after totally laparoscopic distal gastrectomy are few.

AIM

To evaluate the feasibility performing totally laparoscopic distal gastrectomy without prophylactic drains in selected patients.

METHODS

Data of patients with distal gastric cancer who underwent totally laparoscopic distal gastrectomy with and without prophylactic drainage at China National Cancer Center/Cancer Hospital from February 2018 to August 2019 were reviewed. The outcomes between patients with and without prophylactic drainage were compared.

RESULTS

A total of 457 patients who underwent surgery for gastric cancer were identified. Of these, 125 patients who underwent totally laparoscopic distal gastrectomy were included. After propensity score matching, data of 42 pairs were extracted. The incidence of concurrent illness was higher in the drain group (42.9% vs 31.0%, P = 0.258). The overall postoperative complication rates were 19.5% and 10.6% in the drain (n = 76) and no-drain groups (n = 49), respectively; there were no significant differences between the two groups (P > 0.05). The difference between the two groups based on the need for percutaneous catheter drainage was also not significant (9.8% vs 6.4%, P = 0.700). However, patients with a larger body mass index (≥ 29 kg/m2) were prone to postoperative complications (P = 0.042). In addition, the number of days from surgery until the first flatus (4.33 ± 1.24 d vs 3.57 ± 1.85 d, P = 0.029) was greater in the drain group.

CONCLUSION

Omitting prophylactic drainage may reduce surgery time and result in faster recovery. Routine prophylactic drains are not necessary in selected patients. A prophylactic drain may be useful in high-risk patients.

Should we still use prophylactic drain in gastrectomy for cancer? A systematic review and meta-analysis

Prophylactic drain in gastrectomy for cancer is still widely used, although some evidence has disputed this practice and spreading enhanced recovery protocol has been pushing towards surgical simplification. This study aimed at assessing the impact of drain placement on important clinical outcomes, evaluating the results of randomised controlled trials (RCTs), or cohort studies whenever information provided by the former was scarce. PubMed, PMC, Cochrane Library, CNKI and Wanfang databases were searched from January 1990 to February 2019, both for RCTs and cohort studies comparing use or avoidance of prophylactic drain in gastric cancer patients undergoing gastrectomy. All RCTs and cohort studies were rated according to Jadad score and Newcastle-Ottawa-Scale, respectively. Meta-analysis was separately performed on RCTs and cohort studies. The following clinical outcomes were considered: anastomotic leak, reoperation rate, additional drain procedure, length of stay, postoperative morbidity, postoperative mortality, readmission rate and drain related complications. Overall, 3 RCTs (330 patients) and 7 cohort studies (2897 patients) were included. Seven studies came from Eastern Countries. Meta-analysis on RCTs evidenced that drain avoidance halves overall morbidity (RR = 0.47, 95%CI 0.26-0.86, p = 0.014) and slightly reduces length of stay (SMD -0.24, 95%CI -0.51-0.03, p = 0.083). Only one postoperative death occurred in the drain group. The other outcomes were either not reported or reported just by one RCT each. Meta-analysis on cohort studies, despite higher statistical power, did not highlight any significant difference. This meta-analysis showed that prophylactic drain avoidance can reduce morbidity and length of stay, while not significantly affecting other major surgical outcomes.

Laparoscopic gastrectomy with and without prophylactic drains in gastric cancer: a propensity score-matched analysis

BACKGROUND

The number of patients who are undergoing laparoscopic gastrectomy for treating gastric cancer is increasing. Although prophylactic drains have been widely employed following the procedure, there are few studies reporting the efficacy of prophylactic drainage. Therefore, this study assessed the efficacy of prophylactic drains following laparoscopic gastrectomy for gastric cancer.

METHODS

Data of patients who received laparoscopic gastrectomy for treating gastric cancer in our institution between April 2011 and March 2017 were reviewed, and the outcomes of patients with and without a prophylactic drainage were compared. Propensity score matching was used to minimize potential selection bias.

RESULTS

A total of 779 patients who underwent surgery for gastric cancer were reviewed; of these, 628 patients who received elective laparoscopic gastrectomy were included in this study. After propensity score matching, data of 145 pairs of patients were extracted. No significant differences were noted in the incidence of postoperative complications between the drain and no-drain groups (19.3% vs 11.0%, P = 0.071). The days after the surgery until the initiation of soft diet (6.3 ± 7.4 vs 4.9 ± 2.9 days, P = 0.036) and the length of postoperative hospital stay (15.7 ± 12.9 vs 13.0 ± 6.3 days, P = 0.023) were greater in the drain group than those in the no-drain group.

CONCLUSIONS

This study suggests that routinely using prophylactic drainage following laparoscopic gastrectomy for treating gastric cancer is not obligatory.

Efficacy of Prophylactic Drain Placement in Laparoscopic Total Gastrectomy: A Retrospective Study

The aim of this study was to assess the efficacy of prophylactic drain placement in laparoscopic total gastrectomy (LTG). Ninety-four patients with gastric cancer who underwent LTG between December 2007 and December 2014 were enrolled in this study. A tube drain was placed in 29 patients after considering it necessary by operators, whereas no tube drain was placed in remaining patients. All patients were classified into either the drain or the no-drain group and were investigated for clinical characteristics and surgical outcomes. Overall, complications occurred in 15 patients and were not significantly different between the drain and no-drain groups [5 (17.2%) versus 10 (15.4%) patients]. No significant difference was observed in median duration of postoperative hospital stay between the drain and no-drain groups (12 versus 12 days). There was no significant difference in the duration of hospital stay regardless of the presence of drains in both groups of patients who developed complications (with drain: 27 days versus without drain: 21.5 days) and those who did not develop complications (with drain: 12 days versus without drain: 12 days). In conclusion, on the basis of the results of this study, routine prophylactic drain placement in LTG may not be necessary because it does not offer any additional benefits for patients.

Novel management of postoperative pain using only oral analgesics after LADG

PURPOSE

Managing postoperative pain is important to ensure a good quality of life and fast recovery after surgery. We examined the feasibility of peroral management for the postoperative pain after laparoscopic-assisted distal gastrectomy (LADG).

METHODS

Between June 2012 and September 2013, we enrolled 34 patients prospectively to receive peroral tramadol/acetaminophen combination tablets, celecoxib and prochlorperazine maleate after LADG through postoperative day 3 (ORAL group). The postoperative pain was assessed using a visual analogue scale. Postoperative outcomes related to the analgesic methods were compared with those of patients who used epidural anesthesia between January 2010 and December 2011 (EPI group).

RESULTS

The ORAL group pain scale scores on postoperative days 1-3 were 3.96, 3.06 and 2.40, respectively. The frequency of additional analgesic use in the ORAL group was significantly lower than in the EPI group (P = 0.006). The rate of urethral catheter reinsertion was 20.6 % in the EPI group (P = 0.054). A multivariate analysis revealed that only epidural anesthesia was a significant risk factor for the need for additional medication four times or more for breakthrough pain (P = 0.048).

CONCLUSION

Postoperative pain management using oral analgesics after LADG is feasible and safe, and is an ideal pain treatment associated with few adverse events while providing pain relief not inferior to epidural anesthesia.

Significance of prophylactic intra-abdominal drain placement after laparoscopic distal gastrectomy for gastric cancer

BACKGROUND

Unnecessary intra-abdominal drain insertion must be avoided, but little is known about the value of prophylactic drainage following laparoscopic distal gastrectomy (LDG). In this study, we investigated the significance of prophylactic drain placement after LDG for gastric cancer.

METHODS

Seventy-eight consecutive patients with gastric cancer who underwent LDG in our department were retrospectively analyzed. The patients were divided into two groups according to the insertion of a prophylactic intra-abdominal drain following LDG. The 'drain group' comprised 45 patients with routine use of a prophylactic intra-abdominal drain, and the 'no-drain group' comprised 33 patients who did not undergo placement of an intra-abdominal drain.

RESULTS

There were no significant differences in terms of the mean age of the patients, male/female ratio, body mass index, and concurrent diseases between the drain group and the no-drain group. In addition, there were no significant differences in the tumor location, tumor diameter, depth of the tumor, nodal metastasis, and tumor stage between the two groups. All patients in each group were successfully treated with R0 surgery, and no patient required conversion to open surgery. Surgery-related factors, including lymph node dissection and operative time, were similar in the drain group and the no-drain group. A comparison of the amount of intraoperative blood loss between patients with and without postoperative complications revealed that patients who experienced postoperative complications had a significantly larger amount of blood loss than those without postoperative complications. A comparison of operative times between patients with and without surgery-related postoperative local complications revealed that patients who experienced surgery-related postoperative local complications had a significantly longer operative time than those without surgery-related postoperative local complications. Analysis of operative times in each group revealed that patients with surgery-related postoperative local complications had a significantly longer operative time than those without surgery-related postoperative local complications in the no-drain group.

CONCLUSIONS

Intraoperative factors such as the operative time and the amount of intraoperative blood loss affected the occurrence of postoperative complications following LDG. A prophylactic drain may thus be useful in patients at higher risk and in those with a longer operative time or massive intraoperative bleeding.

Is routine drainage necessary after pancreaticoduodenectomy?

With the development of imaging technology and surgical techniques, pancreatic resections to treat pancreatic tumors, ampulla tumors, and other pancreatic diseases have increased. Pancreaticoduodenectomy, one type of pancreatic resection, is a complex surgery with the loss of pancreatic integrity and various anastomoses. Complications after pancreaticoduodenectomy such as pancreatic fistulas and anastomosis leakage are common and significantly associated with patient outcomes. Pancreatic fistula is one of the most important postoperative complications; this condition can cause intraperitoneal hemorrhage, septic shock, or even death. An effective way has not yet been found to avoid the occurrence of pancreatic fistula. In most medical centers, the frequency of pancreatic fistula has remained between 9% and 13%. The early detection and routine drainage of anastomotic fistulas, pancreatic fistulas, bleeding, or other intra-abdominal fluid collections after pancreatic resections are considered as important and effective ways to reduce postoperative complications and the mortality rate. However, many recent studies have argued that routine drainage after abdominal operations, including pancreaticoduodenectomies, does not affect the incidence of postoperative complications. Although inserting drains after pancreatic resections continues to be a routine procedure, its necessity remains controversial. This article reviews studies of the advantages and disadvantages of routine drainage after pancreaticoduodenectomy and discusses the necessity of this procedure.

Use of fibrin glue sealant with polyglycolic acid sheets to prevent pancreatic fistula formation after laparoscopic-assisted gastrectomy

PURPOSE

A pancreatic fistula is a serious postoperative complication that can occur after gastrectomy with lymphadenectomy for gastric cancer. The aim of this prospective study was to analyze the usefulness of the local application of fibrin glue sealant (FG) and polyglycolic acid sheets (PAS) in preventing pancreatic fistula formation after gastrectomy.

PATIENTS AND METHODS

The surface of the pancreas was covered with FG and PAS after peri-pancreatic lymph node dissection in 34 patients (F/P group). The postoperative outcome was compared with historical control subjects who did not receive the same application (control group, 64 patients).

RESULTS

A pancreatic fistula occurred in three patients in the control group but in none the F/P group (P = 0.049). The volume of drainage fluid on postoperative day (POD) 1 and 3 was smaller in the F/P group than in the control group (POD1: F/P group, 80 ml; control: 150 ml, P < 0.001; POD3: 60 vs. 120 ml, P < 0.001). The amylase levels in the drainage fluid on POD1 and 3 were also significantly lower in the F/P group than in the control group (POD1: F/P group, 660 U/L; control: 1220 U/L, P = 0.030; POD2: 270 vs. 830 U/L, P = 0.038; POD3, 160 vs. 630 U/L, P = 0.041).

CONCLUSION

The application of FG and PAS after LAG helps to prevent pancreatic fistula formation.

[Significance of drains in surgery]

Placing drains is one the most common procedures following operations in surgical disciplines. The indication for placing a drain is, however, usually based on a traditional belief rather than being evidence-based. This paper presents an overview of the literature regarding the indications and the evidence level for placing drains following operations in visceral, vascular, thoracic and orthopeedic surgery as well as traumatology. In visceral surgery the indications for placing drains could be clarified over the past decades but in other surgical fields the level of evidence needs further investigation and clarification through future studies. The available data suggest that in most cases a prophylactic drainage can be avoided. In addition, drains may lead to increased morbidity and higher treatment costs.