Analyse factuelle du drainage abdominal prophylactique

Should surgical drainage after lateral transperitoneal laparoscopic adrenalectomy be routine?-A retrospective comparative study

Background

Whether to use surgical drains after abdominal surgery or not has received much attention since a hundred years ago. Nowadays, lateral transperitoneal laparoscopic adrenalectomy (LTLA) is a widely used technique to treat adrenal tumors worldwide. However, the placement of drains after LTLA remains controversial.

Methods

Data of 150 patients, who underwent LTLA between October 2014 and September 2020 by the same lead surgeon, were collected, including demographic, pathology, preoperative, operative variables and postoperative complications. The patients were divided into two groups, with and without drainage. The postoperative recovery of the two groups was compared.

Results

Among 150 patients (65 men and 85 women, median age 48 years, median BMI 23.53), 89 patients had no drainage and 61 patients had drainage after surgery. Variables of the two groups were analyzed. Placement of drains correlated with long operative time (P<0.01). Patients with drain had longer hospital stays (P<0.001) and a higher incidence of postoperative complications (P=0.022). Other factors, including tumor size (P=0.61), tumor location (P=0.387), ASA score (P=0.687), pathology (P=0.55), VAS pain score (P=0.41), intraoperative blood loss (P=0.11), were not found to be significantly associated with drain placement. There was no conversion to open surgery in both groups. Moreover, no mortality was observed in either group.

Conclusions

This study revealed that it is feasible and safe not to leave a drain in selective and uncomplicated patients and that surgical drainage should not be routine after LTLA.

Multicenter phase III randomized trial comparing laparoscopy and laparotomy for colon cancer surgery in patients older than 75 years: the CELL study, a Fédération de Recherche en Chirurgie (FRENCH) trial

Background

Several multicenter randomized controlled trials comparing laparoscopy and conventional open surgery for colon cancer have demonstrated that laparoscopic approach achieved the same oncological results while improving significantly early postoperative outcomes. These trials included few elderly patients, with a median age not exceeding 71 years. However, colon cancer is a disease of the elderly. More than 65% of patients operated on for colon cancer belong to this age group, and this proportion may become more pronounced in the coming years. In current practice, laparoscopy is underused in this population.

Methods

The CELL (Colectomy for cancer in the Elderly by Laparoscopy or Laparotomy) trial is a multicenter, open-label randomized, 2-arm phase III superiority trial. Patients aged 75 years or older with uncomplicated colonic adenocarcinoma or endoscopically unresectable colonic polyp will be randomized to either colectomy by laparoscopy or laparotomy. The primary endpoint of the study is overall postoperative morbidity, defined as any complication classification occurring up to 30 days after surgery. The secondary endpoints are: 30-day and 90-day postoperative mortality, 30-day readmission rate, quality of surgical resection, health-related quality of life and evolution of geriatric assessment. A 35 to 20% overall postoperative morbidity rate reduction is expected for patients operated on by laparoscopy compared with those who underwent surgery by laparotomy. With a two-sided α risk of 5% and a power of 80% (β = 0.20), 276 patients will be required in total.

Discussion

To date, no dedicated randomized controlled trial has been conducted to evaluate morbidity after colon cancer surgery by laparoscopy or laparotomy in the elderly and the benefits of laparoscopy is still debated in this context. Thus, a prospective multicenter randomized trial evaluating postoperative outcomes specifically in elderly patients operated on for colon cancer by laparoscopy or laparotomy with curative intent is warranted. If significant, such a study might change the current surgical practices and allow a significant improvement in the surgical management of this population, which will be the vast majority of patients treated for colon cancer in the coming years.

Trial registration

ClinicalTrials.gov NCT03033719 (January 27, 2017).

Drainage versus No Drainage after Laparoscopic Cholecystectomy for Acute Cholecystitis: A Meta-Analysis

To conduct a randomized controlled trial (RCT), meta-analysis to assess the effectiveness of drains in reducing complications after laparoscopic cholecystectomy (LC) for acute cholecystitis needs to be carried out. An electronic search of PubMed, Embase, Science Citation Index, and the Cochrane Library from January 1990 to January 2018 was performed to identify randomized clinical trials that compare prophylactic drainage with no drainage in LC for acute cholecystitis. The outcomes were calculated as odds ratios (ORs) with 95 per cent confidence intervals (CIs) using RevMan 5.2. Four RCTs, which included 796 patients, were identified for analysis in our study. There was no statistically significant difference in the rate of morbidities (OR = 1.23, 95% CI 0.55-2.76, P = 0.61). Abdominal pain was more severe in the drain group 24 hours after surgery (mean difference = 0.80, 95% CI 0.47-1.14; P < 0.00001). No significant difference was present with respect to wound infection rate and hospital stay. The use of abdominal drainage does not appear to be of any benefit in patients having undergone early LC for acute cholecystitis.

[Surgery for pancreatic cancer: Evidence-based surgical strategies]

Pancreatic cancer surgery represents a challenge for surgeons due to its technical complexity, the potential complications that may appear, and ultimately because of its poor survival. The aim of this article is to summarize the scientific evidence regarding the surgical treatment of pancreatic cancer in order to help surgeons in the decision making process in the management of these patients .Here we will review such fundamental issues as the need for a biopsy before surgery, the type of pancreatic anastomosis leading to better results, and the need for placement of drains after pancreatic surgery will be discussed.

Meta-analysis of drainage versus no drainage after laparoscopic cholecystectomy

BACKGROUND AND OBJECTIVES

Routine drainage after laparoscopic cholecystectomy is still controversial. This meta-analysis was performed to assess the role of drains in reducing complications in laparoscopic cholecystectomy.

METHODS

An electronic search of Medline, Science Citation Index Expanded, Scopus, and the Cochrane Library database from January 1990 to June 2013 was performed to identify randomized clinical trials that compare prophylactic drainage with no drainage in laparoscopic cholecystectomy. The odds ratio for qualitative variables and standardized mean difference for continuous variables were calculated.

RESULTS

Twelve randomized controlled trials were included in the meta-analysis, involving 1939 patients randomized to a drain (960) versus no drain (979). The morbidity rate was lower in the no drain group (odds ratio, 1.97; 95% confidence interval, 1.26 to 3.10; P = .003). The wound infection rate was lower in the no drain group (odds ratio, 2.35; 95% confidence interval, 1.22 to 4.51; P = .01). Abdominal pain 24 hours after surgery was less severe in the no drain group (standardized mean difference, 2.30; 95% confidence interval, 1.27 to 3.34; P < .0001). No significant difference was present with respect to the presence and quantity of subhepatic fluid collection, shoulder tip pain, parenteral ketorolac consumption, nausea, vomiting, and hospital stay.

CONCLUSION

This study was unable to prove that drains were useful in reducing complications in laparoscopic cholecystectomy.

Drainage vs. non-drainage after cholecystectomy for acute cholecystitis: a retrospective study

Many surgeons practice prophylactic drainage after cholecystectomy without reliable evidence. This study was conducted to answer the question whether to drain or not to drain after cholecystectomy for acute calculous cholecystitis. A retrospective review of all patients who had cholecystectomy for acute cholecystitis in Aseer Central Hospital, Abha, Saudi Arabia, was conducted from April 2010 to April 2012. Data were extracted from hospital case files. Preoperative data included clinical presentation, routine investigations and liver function tests. Operative data included excessive adhesions, bleeding, bile leak, and drain insertion. Complicated cases such as pericholecystic collections, mucocele and empyema were also reported. Patients who needed therapeutic drainage were excluded. Postoperative data included hospital stay, volume of drained fluid, time of drain removal, and drain site problems. The study included 103 patients allocated into two groups; group A (n  =  38) for patients with operative drain insertion and group B (n  =  65) for patients without drain insertion. The number of patients with preoperative diagnosis of acute non-complicated cholecystitis was significantly greater in group B (80%) than group A (36.8%) (P < 0.001). Operative time was significantly longer in group A. All patients who were converted from laparoscopic to open cholecystectomy were in group A. Multivariate analysis revealed that hospital stay was significantly (P < 0.001) longer in patients with preoperative complications. There was no added benefit for prophylactic drain insertion after cholecystectomy for acute calculous cholecystitis in non-complicated or in complicated cases.

Peritonitis from an abdominal wall biloma: a unique reason to avoid prophylactic surgical drainage

Prophylactic drainage of the peritoneal space after major surgery is widely practised despite evidence against its efficacy. We describe the case of a 56-year-old woman who underwent a converted cholecystectomy and whose correctly sited abdominal drain resulted in the formation of a biloma between the external and internal oblique musculature. Subsequent leakage from the biloma into the abdominal cavity presented as peritonitis days after surgery, necessitating an emergency laparotomy. This case represents the first reported description of an abdominal wall biloma as a complication of post-cholecystectomy abdominal drainage. The evidence surrounding prophylactic drainage is discussed.