Using a 'no drain' policy in 342 laparoscopic hepatectomies: which factors predict failure?

Laparoscopic liver resection can be performed safely without intraoperative drain placement

BACKGROUND

Laparoscopic liver resection (LLR) has become a standardized procedure with advances in surgical techniques and perioperative management in the last decade; however, the necessity of routine drain placement in LLR has not been fully investigated. This study aimed to evaluate the need for intraoperative drain placement (IDP) in LLR.

METHODS

A total of 607 patients who underwent LLR for liver tumor at our institution between January 2015 and August 2021 were studied. Clinicopathological data, including intraoperative factors and postoperative outcomes, were compared between patients with and without IDP before and after propensity score matching. Variables shown to be different between the two groups were used for matching. Then, risk analysis for additional drainage procedure after surgery was performed in the original and matched cohorts.

RESULTS

Of the 607 patients, 4 (0.7%) and 14 (2.3%) developed incisional and organ/space surgical site infections, respectively, and 9 (1.5%) required additional drainage procedure after surgery. Ninety-three patients (15.3%) underwent IDP. The incidence and severity of postoperative complications were similar between patients with and without IDP in both the original and matched cohorts. In the matched cohort, simultaneous colectomy (odds ratio, 14.051, 95% confidence interval, 1.103-178.987; P = 0.042), rather than IDP (odds ratio, 1.836, 95% confidence interval, 0.157-21.509; P = 0.629), was independently associated with the risk of additional drainage procedure after surgery.

CONCLUSIONS

This study demonstrated that LLR could be performed safely without IDP.

Variation in Drain Management Among Patients Undergoing Major Hepatectomy

BACKGROUND

Although previous studies have suggested that drain management is highly variable, data on drain placement and timing of drain removal among patients undergoing hepatic resection remain scarce. The objective of the current study was to define the utilization of drain placement among patients undergoing major hepatic resection.

METHODS

The ACS NSQIP-targeted hepatectomy database was used to identify patients who underwent major hepatectomy between 2014 and 2017. Association between day of drain removal, timing of discharge, and drain fluid bilirubin on postoperative day (POD) 3 (DFB-3) was assessed. Propensity score matching (PSM) was used to compare outcomes of patients with a drain removed before and after POD 3.

RESULTS

Among 5330 patients, most patients had an abdominal drain placed at the time of hepatic resection (n = 3075, 57.7%). Of 2495 patients with data on timing of drain removal, only 380 patients (15.2%) had their drain removed by POD 3. Almost 1 in 6 patients (n = 441, 17.7%) were discharged home with the drain in place. DFB-3 values correlated poorly with POD of drain removal (R² = 0.0049). After PSM, early drain removal (≤ POD 3) was associated with lower rates of grade B or C bile leakage (2.1% vs. 7.1%, p = 0.008) and prolonged length of hospital stay (6.0% vs. 12.7%, p = 0.009) compared with delayed drain removal (> POD 3).

CONCLUSIONS

Roughly 3 in 5 patients had a drain placed at the time of major hepatectomy and only 1 in 7 patients had the drain removed early. This study demonstrated the potential benefits of early drain removal in an effort to improve the quality of care following major hepatectomy.

On-Site Monitoring of Postoperative Bile Leakage Using Bilirubin-Inducible Fluorescent Protein

Background

Bile leakage is the most common postoperative complication associated with hepatobiliary and pancreatic surgery. Until now, however, a rapid, accurate diagnostic method for monitoring intraoperative and postoperative bile leakage had not been established.

Method

Bilirubin levels in drained abdominal fluids collected from 23 patients who had undergone hepatectomy (n = 22) or liver transplantation (n = 1) were measured using a microplate reader with excitation/emission wavelengths of 497/527 nm after applying 5 µM of UnaG to the samples. UnaG was also sprayed directly on hepatic raw surfaces in swine hepatectomy models to identify bile leaks by fluorescence imaging.

Results

The bilirubin levels measured by UnaG fluorescence imaging showed favorable correlations with the results of the conventional light-absorptiometric methods (indirect bilirubin: rs = 0.939, p < 0.001; direct bilirubin: rs = 0.929, p < 0.001). Approximate time required for bilirubin measurements with UnaG was 15 min, whereas it took about 40 min with the conventional method at a hospital laboratory. Following administration of UnaG on hepatic surfaces, the fluorescence imaging identified bile leaks not only on the resected specimens but also in the abdominal cavity of the swine hepatectomy models.

Conclusion

Fluorescence imaging techniques using UnaG may enable real-time identification of bile leaks during hepatectomy and on-site rapid diagnosis of bile leaks after surgery.

Electronic supplementary material

The online version of this article (10.1007/s00268-020-05774-x) contains supplementary material, which is available to authorized users.

The safety of omitting prophylactic abdominal drainage after laparoscopic liver resection: Retrospective analysis of 100 consecutive cases

Introduction

Whether prophylactic abdominal drainage after laparoscopic liver resection (LLR) is necessary remains unclear. This study aimed to evaluate the safety of omitting prophylactic abdominal drainage after LLR.

Methods

A retrospective analysis of 100 consecutive patients who underwent LLR at Osaka Rosai Hospital from April 2011 to November 2018 was performed. During this period, prophylactic abdominal drainage was routinely omitted during LLR without biliary anastomosis. The primary endpoint was the frequency of additional abdominal drainage. The secondary endpoint was the rate of postoperative complications.

Results

Ninety-six patients (96%) underwent partial resection or lateral segmentectomy, and 89 patients (89%) were Child-Pugh grade A. The median operative time was 102 (range, 31-274) minutes. The median blood loss was minimal (range, 0-280 ml), and blood transfusion was performed for one patient (1%). One case (1%) was converted to open surgery. Additional abdominal drainage was required for one patient (1%) with an intraabdominal abscess. Postoperative complications were seen in 5 patients (5%). High-grade complications (≥grade III according to the Clavien-Dindo classification) were seen in two patients (2%). There were no cases of reoperation or perioperative death. The median postoperative hospital stay was 8 (range, 4-65) days.

Conclusions

Prophylactic abdominal drainage could be safely omitted for selected patients and operative procedures.

Abandoning Prophylactic Abdominal Drainage after Hepatic Surgery: 10 Years of No-Drain Policy in an Enhanced Recovery after Surgery Environment

BACKGROUND

Routine prophylactic abdominal drainage after hepatic surgery is still being debated, as it may be unnecessary, possibly harmful, and uncomfortable for patients. This study evaluated the safety of a no-drain policy after liver resection within an Enhanced Recovery after Surgery (ERAS) programme.

METHODS

All hepatectomies performed without prophylactic drainage during 2005-2014 were included. Primary end points were resection-surface-related (RSR) morbidity, defined as the presence of postoperative biloma, hemorrhage or abscess, and reinterventions. Secondary end points were length of stay, total postoperative morbidity, the composite end point of liver surgery-specific complications, readmissions, and 90-day mortality. Uni- and multivariate analyses were performed to identify independent risk factors for RSR morbidity. A systematic search was performed to compare the results of this study to literature.

RESULTS

A total of 538 resections were included in the study. The RSR complication and reintervention rate was 15 and 12%, respectively. Major liver resection (≥3 segments) was an independent risk factor for the development of RSR morbidity (OR 3.01, 95% CI 1.61-5.62; p = 0.001) and need for RSR reintervention (OR 3.02, 95% CI 1.59-5.73; p = 0.001).

CONCLUSION

RSR morbidity, mortality, and reintervention rates after liver surgery without prophylactic drainage in patients, treated within an ERAS programme, were comparable to previously published data. A no-drain policy after partial hepatectomy seems safe and feasible.

Role of Drain Placement in Major Hepatectomy: A NSQIP Analysis of Procedure-Targeted Hepatectomy Cases

BACKGROUND

The value of drain placement in hepatic surgery has not been conclusive. The aim of this study was to determine whether drain placement during major hepatectomy was associated with negative postoperative outcomes and whether its placement reduced the need for secondary procedures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Hepatectomy Database was used to identify patients who underwent major hepatectomy. Patients were divided into two groups based on the placement of a drain during the procedure. Propensity score-matched cohorts of patients who underwent major hepatic resection with or without drain placement were created accounting for patient characteristics. The primary outcomes were 30-day postoperative complications including bile leak, post-hepatectomy liver failure, and invasive intervention as well as mortality and readmission.

RESULTS

A total of 1005 patients underwent major hepatectomy; 500 patients (49.8 %) had prophylactic drains placed at the conclusion of the procedure. Drain placement was associated with any complication (p < 0.001), blood transfusion (p < 0.001), renal insufficiency (p = 0.02), bile leak (p < 0.001), invasive intervention (p = 0.02), length of stay (p = 0.001), and readmission (p < 0.001). In the matched cohort, drain placement was associated with any complication (p < 0.001), blood transfusion (p < 0.001), superficial surgical site infection (SSI) (p = 0.028), bile leak (p < 0.001), and longer length of stay (0.03). In addition, placement of a prophylactic drain did not decrease the rate of postoperative bile leaks requiring therapeutic intervention (p = 0.21) (Table 2). In multivariate analysis, drain placement was independently associated with any complication (p < 0.001), blood transfusion (p = 0.02), bile leak (p < 0.001), invasive intervention (p = 0.011), superficial surgical site infection (SSI) (p = 0.039), and hospital readmission (p = 0.005) (Table 3). Placement of a prophylactic drain did not decrease the rate of postoperative bile leaks requiring therapeutic intervention (p = 0.15).

CONCLUSION

Drain placement after major hepatectomy may lead to increased postoperative complications including bile leak, superficial surgical site infection, and hospital length of stay and does not decrease the need for secondary procedures in patients with bile leaks.

The safety of the early removal of prophylactic drainage after liver resection based solely on predetermined criteria: a propensity score analysis

BACKGROUND

Prophylactic drainage after liver resection remains a common practice amongst hepatic surgeons. However, there is little information about the optimal timing of drain removal.

METHODS

From April 2008 to December 2012 (conventional group), the drains were removed based on the treating surgeon's view. From January 2013 to April 2016 (ERP group), the drains were removed on POD 3 if the bile concentration of the drain discharge was less than three times the serum bilirubin on POD 3, and the amount of drain discharge was <500 ml on POD 3. The postoperative outcomes of the two groups were compared using one-to-one propensity score-matching analysis.

RESULTS

One hundred nine patients were extracted from ERP group (n = 226) and conventional group (n = 246). The time to drain removal was significantly shorter in the ERP group than in the conventional group (3 days vs. 5 days, P < 0.001). The frequency of delayed bile leakage or the appearance of symptomatic abdominal fluid collection after drain removal did not differ between the two groups (3% vs. 4%, P = 0.791).

CONCLUSION

Drain removal on POD 3 based on the volume and bile concentration is safe.

Predictors of the Effectiveness of Prophylactic Drains After Hepatic Resection

BACKGROUND

Randomized clinical trials have demonstrated the limited efficacy of prophylactic drains following hepatic resection. However, many surgeons still insist on using prophylactic drains. This study was designed to identify patients who require prophylactic drains to manage or monitor postoperative complications after hepatic resection.

METHODS

Data were retrospectively collected from 316 patients who underwent hepatic resection and received a prophylactic drain. The patients were divided into two groups according to whether the drain was used to manage or monitor the following postoperative complications: bile leakage (prophylactic drains were used to monitor and treat bile leakage) and postoperative hemorrhage (the drainage fluid was macroscopically bloody and required drain fluid blood counts and monitoring to assess the need for transfusion or reoperation). The results were then validated in a separate cohort of 101 patients.

RESULTS

In 25/316 patients (7.9 %), the prophylactic drains were clinically effective, being used to manage bile leakage in 18 patients and hemorrhage in 8. Intraoperative bile leakage (P = 0.021) and long operation time (≥ 360 min) (P = 0.017) were independent predictors of bile leakage. Intraoperative blood loss (≥ 650 ml) (P = 0.0009) was an independent predictor of hemorrhage. In the subsequent 101 patients, prophylactic drains were clinically effective in patients with one of these predictors with sensitivity, specificity, and false-negative rates of 88.9, 62.0, and 1.7 %, respectively.

CONCLUSION

A prophylactic drain should be considered following hepatic resection for patients with intraoperative bile leakage, operation time of ≥ 360 min, or blood loss of ≥ 650 ml.

The role of peri-hepatic drain placement in liver surgery: a prospective analysis

BACKGROUND

The standard use of an intra-operative perihepatic drain (IPD) in liver surgery is controversial and mainly supported by retrospective data. The aim of this study was to evaluate the role of IPD in liver surgery.

METHODS

All patients included in a previous, randomized trial were analysed to determine the association between IPD placement, post-operative complications (PC) and treatment. A multivariate analysis identified predictive factors of PC.

RESULTS

One hundred and ninety-nine patients were included in the final analysis of which 114 (57%) had colorectal liver metastases. IPD (n = 87, 44%) was associated with pre-operative biliary instrumentation (P = 0.023), intra-operative bleeding (P < 0.011), Pringle's manoeuver(P < 0.001) and extent of resection (P = 0.001). Seventy-seven (39%) patients had a PC, which was associated with pre-operative biliary instrumentation (P = 0.048), extent of resection (P = 0.002) and a blood transfusion (P = 0.001). Patients with IPD had a higher rate of high-grade PC (25% versus 12%, P = 0.008). Nineteen patients (9.5%) developed a post-operative collection [IPD (n = 10, 11.5%) vs. no drains (n = 9, 8%), P = 0.470]. Seven (8%) patients treated with and 9(8%) without a IPD needed a second drain after surgery, P = 1. Resection of ≥3 segments was the only independent factor associated with PC [odds ratio (OR) = 2, P = 0.025, 95% confidence interval (CI) 1.1-3.7].

DISCUSSION

In spite of preferential IPD use in patients with more complex tumours/resections, IPD did not decrease the rate of PC, collections and the need for a percutaneous post-operative drain. IPD should be reserved for exceptional circumstances in liver surgery.