The impact of routine open nonsuction drainage on fluid accumulation after thyroid surgery: a prospective randomised clinical trial

Routine Use of Neck Drains Following Thyroid Operations to Prevent Complications Is No Longer Advisable

BACKGROUND

The use of cervical drains to prevent cervical hematoma or seroma after thyroidectomy remains a controversial issue.

OBJECTIVE

Identify clinical and surgical risk factors for hematoma or seroma and evaluate the usefulness of routine use of drains following thyroid surgery.

MATERIAL AND METHODS

The authors conducted a retrospective multicentric study related to consecutive patients submitted to thyroid surgery in seven Portuguese hospitals between January 2018 and December 2020 (n=945). The data collected included the following parameters: age and gender of the patients, anticoagulation or anti-aggregating therapy, histological diagnoses, type of surgery, the presence or absence of postoperative drains, thyroid weight, length of hospital stay, postoperative complications, and reinterventions. In this study, surgical complications evaluated were limited to the presence of hematoma or seroma. A total of 945 patients who underwent thyroid surgery were included in the study. Twenty-seven patients (2.9%, n=27) experienced complications classified as hematomas or seromas. In the series, significant differences were observed between the two groups according to hypocoagulation or anti-aggregation status (OR=3.62; 95% CI 1.14-11.4) (p=0.001) and the nature of histological diagnosis (toxic vs. non-toxic benign disease) (OR=6.59; 95% CI 1.83-23.7). Hypocoagulation or anti-aggregation status were independently associated with a higher risk of complications. The presence of drains was associated with longer hospitalization periods (p<0.001) and not a decreased need for reintervention.

CONCLUSION

Cervical hematoma or seroma are rare complications associated with both hypocoagulation and anti-aggregation therapy and with the presence of benign toxic pathology. The use of drains does not decrease the need for reintervention and is even associated with a longer length of hospital stay; therefore, their routine use should not be advised.

Effect of drainage versus no drainage after thyroid surgery on wound complications, a meta-analysis

A meta-analysis study was used to assess whether not placing a drain after thyroidectomy reduces postoperative wound complications. A critical review of the comprehensive literature up to May 2023 was conducted using four databases: PubMed, Embase, the Cochrane Library, and the web of science. Fourteen interrelated studies were reviewed after passing the inclusion and exclusion criteria established by the study and assessing the quality of the literature.95% confidence intervals (Cl) and odds ratios (OR) were calculated using fixed effects models. The data were meta-analysed using RevMan 5.3 software. The results showed that the use of drains during thyroid surgery did not have a favourable impact on patients. Intraoperative placement of drains did not reduce postoperative wound haematoma formation in patients, (OR, 0.86; 95% CI, 0.54, 1.36 p = 0.52). However, the incidence of postoperative wound infection was significantly higher in patients with drains used in intraoperative thyroid surgery, (OR, 0.22; 95% CI, 0.10, 0.45 p < 0.0001). As the sample size of the randomised controlled study used for this meta-analysis was limited, it is important to approach the findings with caution when interpreting the results.Conducting additional high-quality research with larger sample sizes is crucial in order to further confirm these results and reduce the likelihood of duplication.

A clinical comparative study of thyroid surgeries with and without drain

Most of the thyroid surgeries are accompanied by drain placement. The possibility of hematoma or seroma formation postoperatively is of concern to surgeons, as, thyroid is a highly vascular structure and a minor hemorrhage might also turn out to be life threatening, despite actual incidence of it being only 0.3-1%. Thus, drains are placed with an intention to obliterate dead space and clear the collecting blood or serum. Conversely, several studies have indicated chances of clots blocking the drainage tube and resulting in missing out of early detection of a massive bleed. Drains have also been known to add more discomfort to the patient, increase chances of infection, increase post operative pain, scar formation and longer duration of hospital stay. Thus, some surgeons believe in not placing a drain. To compare the outcomes of thyroid surgeries done with drain versus those thyroid surgeries done without drain. 40 patients, of either sex, between 18 and 70 years of age, who underwent thyroid surgeries for various thyroid disorders over a period of 6 months, were randomly allocated to either 'with drain' (group A) or 'without drain' (group B). The surgeon was made aware of drain status only intraoperatively. Patients were assessed for post-operative pain based on Visual Analogue Scale (VAS) at 6 and 24 h post-operatively. Post-operative complications including hematoma, seroma, and wound infection, if any, along with duration of hospitalization, were also documented. Patient was followed up one week post-operatively for wound check and suture removal. Both groups were homogenous according to age, sex, TIRADS, Bethesda, diagnosis and surgery performed. Postoperative pain at 6 and 24 h was significantly higher in group A than in group B [6.15 ± 1.31 vs 3.50 ± 0.88 (p = 0.001) (6 h), 4.45 ± 0.99 vs 1.20 ± 1.10 (p = 0.001) (24 h)]. Mean duration of hospitalization following thyroid surgery was significantly higher among group A than group B [3.80 ± 1.15 vs 2.15 ± 0.36 days (p = 0.001)]. Though not statistically significant, wound pain at 1 week and overall complications were higher in Group A than in Group B (p = 0.182, p = 0.127 respectively). Thyroid surgeries done without drain placement are likely to cause significantly lesser post-operative pain and shorter duration of hospitalization.

Complications of Neck Drains in Thyroidectomies: A Systematic Review and Meta-Analysis

OBJECTIVES

Intraoperative placement of neck drains in thyroidectomy patients remains a widespread practice, despite prevailing evidence discouraging this practice. This systematic review and meta-analysis was conducted to update the currently available evidence base.

METHODS

Two independent investigators performed a comprehensive literature search to identify randomized control trials that evaluated postoperative complications associated with neck drains. This was conducted using four databases: Medline, Web of Science, EMBASE, and Cochrane. Identified articles were then screened using a strict eligibility criterion. Sixteen studies were included in the final quantitative analysis and assessed for risk of bias. All methods were in accordance with recommendations from the Cochrane Review Group, U.K. National Health Service Centre for Reviews and Dissemination, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Our initial search yielded 743 articles. Of those, 16 were included for final quantitative synthesis. The overall analysis demonstrated that postoperative hematomas [pooled odds ratio (OR) = 2.09 (1.04, 4.21); P = .04] and surgical site infections [pooled OR = 3.85 (2.04, 7.28); P < .01] were significantly more likely in the drained group. Furthermore, hospital stays were longer in the drained group [pooled mean difference = 0.88 days (0.56, 1.20); P < .01]. There were no significant differences in fluid volumes within the thyroid bed between study groups [pooled mean difference = -2.30 mL (-4.82, 0.21); P = .07].

CONCLUSION

The drained patient group had overall higher odds of hematomas, surgical site infections, and longer hospital stays. Therefore, we recommend against this practice of neck drain insertions in patients who have undergone thyroidectomies. Laryngoscope, 131:690-700, 2021.

Efficacy of Drainless Total Thyroidectomy in Intrathyroidal Lesions of Thyroid

Introduction  There is difference of opinion about the placement of the drain in thyroid surgeries, and, to the best of our knowledge, the efficacy of drainless total thyroidectomy regarding various parameters of thyroid lesions has not been well-established.

Objective  To report our experience with drainless total thyroidectomy, and to define an appropriate patient population for its performance.

Methods  This is a retrospective case analysis of the patients who underwent total thyroidectomy for intrathyroidal lesions with or without central neck dissection in a tertiary referral hospital (number = 74). The patients, who had undergone total thyroidectomy without any drain insertion, were analyzed, and the relationships among various parameters of thyroid lesions were noted in relation to seroma and hematoma formation.

Results  Seroma formation was noted only in 5 out of 74 patents (6.75%). All of the seromas that occurred were observed in patients with thyroid lesions < 4 cm, and 4 out of 5 seromas were observed in patients with a malignant pathology. There was no statistically significant difference in seroma formation between patients younger or older than 50 years of age.

The nature of the lesion, whether benign or malignant, did not affect the formation of seroma. Of interest is the fact that none of the 10 patients who had central neck dissection performed as part of their treatment developed seroma.

Conclusions  Drainless total thyroidectomy is safe across all age groups for patients harboring either benign or malignant thyroid pathologies. However, caution is to be observed in opting for drainless total thyroidectomy in patients with large lesions (> 5 cm)

Ultrasound Identifies Broken Drainage Tube Postthyroidectomy

Drains are routinely used after thyroidectomy and lateral neck dissection. In rare cases, the drainage tube is broken and retained in the neck. It is difficult to identify the sonographic features of the remnant tube due to variable reasons. However, through comparative and phantom observations, we noticed the double-tract sign of the tube wall and drainage holes as the key points to solving this problem. We report such a case of the ultrasound-guided localization of a broken drainage tube that was retained in the patient.

The application of drains in thyroid surgery

It has been shown that the use of drain in thyroid surgery does not reduce the reoperation rate for hemorrhage. The aim of this systematic review was to update the knowledge of the role of drain in thyroid surgery in term of postoperative complications, pain and hospital length of stay (LOS). A systematic search was performed in the PubMed and Embase database to identify all randomized controlled trials (RCTs) comparing clinical outcomes in patients who underwent thyroidectomy or lobectomy with or without drainage. The primary outcome was reoperation rate for bleeding; the secondary outcomes were development of hematoma, seroma, and wound infection; postoperative pain evaluated by Visual Analogue Scale (VAS) at the postoperative day (POD) 1, and hospital LOS. Risk ratios (RRs) and 95% confident intervals (95% CI) were used for dichotomous variables; mean differences (MDs) and 95% CI for continuous variables. Statistical heterogeneity was evaluated and its degree was quantified by the I2 statistic. Twenty RCTs were included, with 2,204 patients enrolled. No difference was found between the two groups in term of reoperation [RR 1.13 (0.43, 2.95); I2 =0%], hematoma [RR 1.18 (0.71, 1.95); I2 =0%], and seroma [RR 0.82 (0.44, 1.53); I2 =0%]. Patients with drain had higher postoperative pain [MD 1.91 (1.30, 2.53); I2 =97%], prolonged hospital LOS [MD 1.34 (0.91, 1.76) days; I2 =98%], and increased wound infection rate [RR 2.82 (1.36, 5.86); I2 =0%], even though the latter was not confirmed in the sensitivity analysis including only studies with ≥100 patients per trial. The use of drain after thyroid surgery increase postoperative pain and hospital LOS, with no decrease of reoperation rate, hematoma and seroma formation. An increased wound infection rate in patients with drain is suggested, but a large RCT should be performed to confirm this correlation.

Comparison of Postoperative Drain Insertion versus No Drain Insertion in Thyroidectomies: Retrospective case-control study from the Sultan Qaboos University Hospital, Muscat, Oman

OBJECTIVES

A thyroidectomy is a frequently performed surgical procedure which can result in life-threatening complications. The insertion of a drain after a thyroidectomy has been suggested to prevent such complications. This study aimed to evaluate the use of surgical drains following thyroidectomies in relation to postoperative complications and mass sizes.

METHODS

This retrospective case-control study included all thyroidectomies conducted at the Sultan Qaboos University Hospital, Muscat, Oman, from January 2011 to December 2013. Length of hospital stay, readmission, postoperative complications and mass size were evaluated.

RESULTS

During the study period, 250 surgeries were carried out on 241 patients. The majority of patients were female (87.2%). Drains were inserted postoperatively after 202 surgeries (80.8%) compared to 48 surgeries (19.2%) without drains. A total of 32 surgeries (12.8%) were conducted on patients with thyroid masses <1 cm, 138 (55.2%) on those with masses between 1-4 cm and 80 (32.0%) on those with masses >4 cm. The association between drain use and mass size was not significant (P = 0.439). Although postoperative complications were more prevalent in patients with drains, the relationship between these factors was not significant (P >0.050). Length of hospital stay was significantly longer among patients with postoperative drains (P <0.010).

CONCLUSION

The routine insertion of drains after thyroid surgeries was found to result in longer hospital stays and did not reduce rates of post-thyroidectomy complications. Thyroid mass size should not be used as an indicator for the insertion of a drain after thyroidectomy.

Clinical Pathway for Thyroidectomy

Clinical pathways are care plans applicable to patient care procedures that present variations in practice and a predictable clinical course. They are designed not as a substitute for clinical judgment, but rather as a means to improve the effectiveness and efficiency of the procedures. This clinical pathway is the result of a collaborative work of the Sections of Endocrine Surgery and Quality Management of the Spanish Association of Surgeons. It attempts to provide a framework for standardizing the performance of thyroidectomy, the most frequently performed operation in endocrine surgery. Along with the usual documents of clinical pathways (temporary matrix, variance tracking and information sheets, assessment indicators and a satisfaction questionnaire) it includes a review of the scientific evidence around different aspects of pre, intra and postoperative management. Among others, antibiotic and antithrombotic prophylaxis, preoperative preparation in hyperthyroidism, intraoperative neuromonitoring and systems for obtaining hemostasis are included, along with management of postoperative hypocalcemia.

Systematic review and meta-analysis of wound drains after thyroid surgery

BACKGROUND

Drainage after routine thyroid and parathyroid surgery remains controversial. However, there is increasing evidence from a number of randomized clinical trials (RCTs) suggesting no benefit from the use of drains.

METHODS

A systematic review and meta-analysis was performed according to PRISMA guidelines. A literature search was carried out, and RCTs comparing the use of drains versus no drains in patients who underwent thyroid or parathyroid surgery were included. Trials including patients who underwent lateral neck dissection were excluded. Methodological quality was graded and data were extracted by independent reviewers. Risk ratio (RR) or mean difference (MD) with 95 per cent confidence interval (c.i.) was calculated and heterogeneity was assessed.

RESULTS

Twenty-five RCTs were included in the meta-analysis comprising 2939 patients. There was no significant difference between the two groups in rate of reoperation for neck haematoma (RR 1·90, 95 per cent c.i. 0·87 to 4·14), ultrasound-assessed fluid volume on day 1 after surgery (MD 2·30 (95 per cent c.i. -0·73 to 5·34) ml), wound collection requiring intervention (RR 0·64, 0·38 to 1·09) or not (RR 0·93, 0·66 to 1·30), transient voice change (RR 2·33, 0·91 to 5·96) and persistent recurrent laryngeal nerve palsy (RR 1·67, 0·22 to 12·51). Length of hospital stay was significantly greater in the drain group (MD 1·25 (0·83 to 1·68) days), as were wound infection rates (RR 2·53, 1·23 to 5·21) and pain score measure using a visual analogue scale from 1 to 10 on day 1 after surgery (MD 1·46 (0·67 to 2·26) units).

CONCLUSION

The results indicate that drain use after routine thyroid surgery does not confer a benefit to patients.