- Email: [email protected]
Cholecystectomy with and without surgical drainage
Cholecystectomy
with and without Surgical Drainage
Irwin M. Goldberg, MD, Denver, Colorado J. P. Goldberg, BA, Denver, Colorado R. D. Llechty, MD, Denver, Colorado Charles Buerk, MD, Denver, Colorado 6. Eiseman, MD, Denver, Colorado L. Norton, MD, Denver, Colorado
In 1913, thirty-one years after Langenbuch [I] performed the first cholecystectomy, another German surgeon introduced the technic of undrained “ideal cholecystectomy” [2]. Several subsequent investigators have advocated cholecystectomy without drainage under certain circumstances [39]. These reports describe a lower incidence of postoperative morbidity, decreased hospital stay, better cosmetic results, and less discomfort. However, most surgeons currently continue to drain the gallbladder bed [4]. This study was designed to determine whether surgical drainage after simple, uncomplicated cholecystectomy is necessary. Material and Methods From January 1972 through June 1974, a total of thirty-seven patients underwent cholecystectomy without drainage, performed by residents under the direction of five attending surgeons at the Colorado General Hospital and the Denver General Hospital. Nondrainage was elected when the following criteria were met: (1) absence of empyema, pericholecystic abscess, or other evidence of gross infection; (2) a dry gallbladder bed at the end of the operative procedure; and (3) elective operation that did not include exploration of the common duct. The thirty-seven patients without drainage were matched with thirty-seven patients with drainage in From the Department of Surgery, University of Colorado Medical Canter and Denver General Hospital, Denver, Colorado. Reprint requests should be addressed to Charles A. Buerk, MD. University of Colorado Medical Center, Department of Surgery, 4200 East Ninth Avenue, Denver, Colorado 80220.
Vdume 130, July 1975
whom the previously mentioned criteria were met. In addition, all thirty-seven patients without drainage had reperitonealization of the gallbladder bed, whereas only twenty-nine of the thirty-seven with drainage were so treated. All seventy-four patients in this study were managed by the same staff surgeons. Despite the retrospective nature of this study, these two groups were remarkably similar. (Figure 1.) No significant statistical difference was noted in incidence of clinical obesity or types of incision. The age differentials within each group were also comparable. The median age of the patients with drainage was twenty-nine years with a range of nineteen to seventy-five years, whereas the median age of those without drainage was twentyseven years with a range of sixteen to fifty-nine years. Twelve of the patients without drainage had simultaneous incidental appendectomy, compared with none of the patients who had drainage. The absence of postoperative morbidity and benefits of incidental appendectomy at laparotomy have been described well elsewhere [4,9-121. Cholecystectomy without drainage required 60 to 175 minutes, with a median duration of 90 minutes. Cholecystectomy with drainage, however, required 55 to 190 minutes, with a median duration of 121 minutes. This difference in operative time was statistically significant (p <0.005).
Results Table I summarizes mortality and postoperative complications. No deaths occurred in either group. Postoperative fever (38OC for forty-eight hours) was noted in 48.5 per cent of the patients with drainage, in comparison with only 26.5 per cent of
29
Goldberg et al
I
TABLE
Postoperative
Complications
With Drainage
Mortality Fever Wound infection Drain wound hemorrhage
Cent
Per Cent
0
o/37
0
Per
ber
o/37
17135 48.5 *3/37 8.1
* Two of these patients fever.
Without Drainage
.~ Number
Num-
l/37
and Mortality
2.7
x2
9134 26.5 0 0 0
are also included
0
p
...
...
3.58 3.12
...
...
in the group with
the patients without drainage (p
OF PATIENTS 50 60 70
80
90
100
Wound infection occurred in 8.1 per cent of the patients with drains, whereas none of the patients without drains, including those having incidental appendectomy, had wound infection (p = 0.120). None of the patients with wound infection was malnourished, obese, or diabetic. The patients with wound infection were forty-five, sixty-three, and seventy-five years old. The respective operation times were 90, 95, and 140 minutes. Hemorrhage from the drain wound occurred in one patient. Neither group of patients included any case of bile peritonitis or postoperative pericholecystic abscess. Considering all postoperative complications as a single category, the group with drainage had a statistically greater incidence of postoperative complications (nineteen of thirty-five) than did the group without drainage (nine of thirty-four) (p <0.025). (Table I.) A combined total of twenty-one postoperative complications occurred in our patients with drains. However, only nineteen are listed because two patients each had two complications. Therefore, only one complication per patient has been considered in our data. Postoperative hospitalization in the patients without drainage ranged from two to ten days, with a median of three days. The postoperative hospital stay of the patients with drainage ranged from three to nine days, with a median of five days. (Figure 2.) This difference is statistically significant (p <0.005). Two patients with drainage who had exceptionally long hospital stays were deleted from this comparison. One of the patients had a complicated urinary tract infection and the other had extended bile leakage from the drain site. This latter patient had operative trauma to the gallbladder bed and probably should have been deleted from the study. Comments
Reper,toneal~rat,on of Gall Bladder Bed o=-
----I
05
Figure 1. Clinical variables in pati&ts tive cholecystectomy.
30
undergoing elec-
The majority of surgeons continue to use drainage in all patients undergoing cholecystectomy. Tradition, not completely derived from scientific data, presumably dictates such practice [4,6,13151. We began this study with two basic assumptions: first, that no controlled study to date shows a statistical advantage of drainage over nondrainage after uncomplicated cholecystectomy [4,6,8, 14-161; and second, that a drain, like any other foreign material, carries an inherent morbidity of its own. Our experience so far, although limited, supports both of these assumptions. In this study,
The American Journal of Surgery
Cholecystectomy and Drainage
patients with drains had longer periods of hospitalization and more postoperative complications than did those without drains. Fever, the most commonly encountered complication, occurred almost twice as frequently in the patients with drains. Two factors may have added to the increased incidence of fever in those with drainage: more cholangiograms were taken and the median operative time was longer. However, a simultaneous adjustment for these two factors is possible using both direct and indirect statistical methods. The resulting data (Table II) are still consistent with a higher incidence of fever in the group of patients with drainage (p
Volume 130, July 1975
NUMBER
OF POST-OPERATIVE
DAYS
Figure 2. Postoperative hospital stay in patients ing elective chotecystectomy.
undergo-
[10,23-271. Several surgeons have reported cases of bile peritonitis that occurred without warning hours to weeks after cholecystectomy with drainage [10,25,26]. Therefore, the lack of bile leakage from a drain cannot be interpreted as indicating the absence of bile leakage or the absence of impending bile peritonitis [24]. Doctor Frederick Coller remarked that “bile is not educated to climb drains” [16]. McLauchlin [14] stated that “a drain should not be used to substitute for good surgical technique.” We believe that our data, in agreement with other studies [3-91, suggest that cholecystectomy without drainage, in comparison with cholecystectomy and drainage, has an equivalent incidence of mortality and a decreased incidence of morbidity. Results of neither this study nor others contradict the use of drains in the presence of bacterial sepsis or gross bile leakage. However, we believe that in uncomplicated cases with a dry gallbladder bed, drainage is unnecessary. TABLE II
Adjustment for Difference in Frequency Cholangiography and Operative Time Distribution Related toTheir Influence on the Incidence of Fever
Direct adjustment* Indirect adjustment Overall per cent with fever ._. _~_ * p < 0.1 for this comparison.
Patients with Fever with Drainage (per cent)
Patients with Fever without Drainage (per cent)
59 46 49
29 28 26
of
31
Goldberg et al
Summary
Thirty-seven patients who met specific criteria had cholecystectomy without drainage, and thirtyseven matched control patients had cholecystectomy with drainage. This study suggests that surgical drainage after every uncomplicated cholecystectomy is unnecessary and may be unwise. Such drainage may result in an increased incidence of postoperative morbidity and prolonged hospital stay. Acknowledgment: We gratefully acknowledge the statistical guidance of Philip G. Archer, ScD, Department of Biometrics, University of Colorado Medical Center.
10. 1 I.
12.
13. 14. 15. 16.
17. 18.
References 19. I. Langenbuch C: Ein Fall von Extirpation der Gallenblase wegen Chronischer Cholelithiasis. Heilung. Bed K/in Wochenschr 19: 725, 1882. 2. Spivack JL: The Surgical Technique of Abdominal Operations, 5th ed. Springfield, Illinois. Thomas, 1955, p 618. 3. Dreese WC: Cholecystectomy without drains. J Inf Co// Surg 40: 433, 1963. 4. Kambouris AA, Carpenter WS, Allaben RD: Cholecystectomy without drainage. Surg Gynecol Obsfet 137: 613, 1973. 5. Kole W: Erfahrungen mit der Drainagelosen, ldealen Cholecystecktomie. Langenbecks Arch Chir 324: 307. 1969. 6. Myers MB: Drain fever, a complication of drainage after cholecystectomy. Surgery 52: 314, 1962. 7. Newmann S: Zue Drainage and Nichtdrainage in der Gallen Chirurgie. Chirurg9: 414, 1961. 8. Haldbo K: Drainage in operations on the bile passages. Acta Chir Stand 95: 265, 1947. 9. Verbrycke JR Jr: Cholecystectomy without drainage; report
32
20. 21.
22.
23. 24.
25. 26. 27.
of 86 consecutiv’e cases without mortality. M J & Ret 126: 705, 1927. Williams CB. Halpin IX, Knox JS: Drainage following cholecystectomy. Br J Surg 59: 293, 1972. Bogart JN, Sebesta DG: Incidental aDDendeCtOmY and its effeet on the incidence of wound in&tion in cholecystectomy. Am Surg 28: 650, 1969. Eiseman B, Robinson RM, Brown JH: Simultaneous appendectomy and herniorrhaphy without prophylactic antibiotic therapy. Surgery51: 578, 1962. Nora PF, Vanecko RM, Bransfield JJ: Prophylactic abdominal drains. Arch Surg 105: 173, 1972. McLauchlin R, Schilling JA: Abdominal drainage, present concepts. J Okla State Med Assoc 50: 143, 1957. Yates JL: An experimental study of the local effects of peritoneal drainage. Surg Gynecol Obstet 1: 473, 1905. Holm JC, Edmunds LH, Baker JW: Life threatening complications after operations upon the biliary tract. Surg Gynecol Obstet 127: 241, 1968. Glenn F: Complications of biliary tract surgery. Surg Gynecol Obstet 110: 141, 1960. Glenn F: Surgical treatment of biliary tract disease. NY State J Med62: 203, 1962. Reynolds JT: lntraperitoneal drainage, when and how. Surg GynecolObstet 101: 242, 1955. Cruse P, Foold R: A five-year prospective study of 23,649 surgical wounds. Arch Surg 107: ‘206, 1973. US Department of Health, Education, and Welfare, National Center of Health Statistics: Surgical operations in shortstay hospitals. Vita/Health Stat 13(11): 4, 1968. Strohl EL, Diffenbaugh WG. Azderson RE: The role of drainage following biliary tract surgery. Surg C/in North Am 44: 281, 1964. McKenzie G: Extravasation of bile after operations on the biliary tract. Aust NZ J Surg 24: 181, 1955. MacVicar FT, McNair TJ, Wilken BJ. Bruce J: Death following gall bladder surgery. J R Co// Surg Edinb 12: 139, 1967. Douglas DM, Turner GG: Rapid death in bile peritonitis. Er Med J 2: 280, 1940. James KL: Bile peritonitis of unusual causation. Lancet 2: 311, 1938. Mean RL: Bile peritonitis. Am Surg 30: 583, 1964.
The American Journal of Surgery
with and without Surgical Drainage
Irwin M. Goldberg, MD, Denver, Colorado J. P. Goldberg, BA, Denver, Colorado R. D. Llechty, MD, Denver, Colorado Charles Buerk, MD, Denver, Colorado 6. Eiseman, MD, Denver, Colorado L. Norton, MD, Denver, Colorado
In 1913, thirty-one years after Langenbuch [I] performed the first cholecystectomy, another German surgeon introduced the technic of undrained “ideal cholecystectomy” [2]. Several subsequent investigators have advocated cholecystectomy without drainage under certain circumstances [39]. These reports describe a lower incidence of postoperative morbidity, decreased hospital stay, better cosmetic results, and less discomfort. However, most surgeons currently continue to drain the gallbladder bed [4]. This study was designed to determine whether surgical drainage after simple, uncomplicated cholecystectomy is necessary. Material and Methods From January 1972 through June 1974, a total of thirty-seven patients underwent cholecystectomy without drainage, performed by residents under the direction of five attending surgeons at the Colorado General Hospital and the Denver General Hospital. Nondrainage was elected when the following criteria were met: (1) absence of empyema, pericholecystic abscess, or other evidence of gross infection; (2) a dry gallbladder bed at the end of the operative procedure; and (3) elective operation that did not include exploration of the common duct. The thirty-seven patients without drainage were matched with thirty-seven patients with drainage in From the Department of Surgery, University of Colorado Medical Canter and Denver General Hospital, Denver, Colorado. Reprint requests should be addressed to Charles A. Buerk, MD. University of Colorado Medical Center, Department of Surgery, 4200 East Ninth Avenue, Denver, Colorado 80220.
Vdume 130, July 1975
whom the previously mentioned criteria were met. In addition, all thirty-seven patients without drainage had reperitonealization of the gallbladder bed, whereas only twenty-nine of the thirty-seven with drainage were so treated. All seventy-four patients in this study were managed by the same staff surgeons. Despite the retrospective nature of this study, these two groups were remarkably similar. (Figure 1.) No significant statistical difference was noted in incidence of clinical obesity or types of incision. The age differentials within each group were also comparable. The median age of the patients with drainage was twenty-nine years with a range of nineteen to seventy-five years, whereas the median age of those without drainage was twentyseven years with a range of sixteen to fifty-nine years. Twelve of the patients without drainage had simultaneous incidental appendectomy, compared with none of the patients who had drainage. The absence of postoperative morbidity and benefits of incidental appendectomy at laparotomy have been described well elsewhere [4,9-121. Cholecystectomy without drainage required 60 to 175 minutes, with a median duration of 90 minutes. Cholecystectomy with drainage, however, required 55 to 190 minutes, with a median duration of 121 minutes. This difference in operative time was statistically significant (p <0.005).
Results Table I summarizes mortality and postoperative complications. No deaths occurred in either group. Postoperative fever (38OC for forty-eight hours) was noted in 48.5 per cent of the patients with drainage, in comparison with only 26.5 per cent of
29
Goldberg et al
I
TABLE
Postoperative
Complications
With Drainage
Mortality Fever Wound infection Drain wound hemorrhage
Cent
Per Cent
0
o/37
0
Per
ber
o/37
17135 48.5 *3/37 8.1
* Two of these patients fever.
Without Drainage
.~ Number
Num-
l/37
and Mortality
2.7
x2
9134 26.5 0 0 0
are also included
0
p
...
...
3.58 3.12
...
...
in the group with
the patients without drainage (p
OF PATIENTS 50 60 70
80
90
100
Wound infection occurred in 8.1 per cent of the patients with drains, whereas none of the patients without drains, including those having incidental appendectomy, had wound infection (p = 0.120). None of the patients with wound infection was malnourished, obese, or diabetic. The patients with wound infection were forty-five, sixty-three, and seventy-five years old. The respective operation times were 90, 95, and 140 minutes. Hemorrhage from the drain wound occurred in one patient. Neither group of patients included any case of bile peritonitis or postoperative pericholecystic abscess. Considering all postoperative complications as a single category, the group with drainage had a statistically greater incidence of postoperative complications (nineteen of thirty-five) than did the group without drainage (nine of thirty-four) (p <0.025). (Table I.) A combined total of twenty-one postoperative complications occurred in our patients with drains. However, only nineteen are listed because two patients each had two complications. Therefore, only one complication per patient has been considered in our data. Postoperative hospitalization in the patients without drainage ranged from two to ten days, with a median of three days. The postoperative hospital stay of the patients with drainage ranged from three to nine days, with a median of five days. (Figure 2.) This difference is statistically significant (p <0.005). Two patients with drainage who had exceptionally long hospital stays were deleted from this comparison. One of the patients had a complicated urinary tract infection and the other had extended bile leakage from the drain site. This latter patient had operative trauma to the gallbladder bed and probably should have been deleted from the study. Comments
Reper,toneal~rat,on of Gall Bladder Bed o=-
----I
05
Figure 1. Clinical variables in pati&ts tive cholecystectomy.
30
undergoing elec-
The majority of surgeons continue to use drainage in all patients undergoing cholecystectomy. Tradition, not completely derived from scientific data, presumably dictates such practice [4,6,13151. We began this study with two basic assumptions: first, that no controlled study to date shows a statistical advantage of drainage over nondrainage after uncomplicated cholecystectomy [4,6,8, 14-161; and second, that a drain, like any other foreign material, carries an inherent morbidity of its own. Our experience so far, although limited, supports both of these assumptions. In this study,
The American Journal of Surgery
Cholecystectomy and Drainage
patients with drains had longer periods of hospitalization and more postoperative complications than did those without drains. Fever, the most commonly encountered complication, occurred almost twice as frequently in the patients with drains. Two factors may have added to the increased incidence of fever in those with drainage: more cholangiograms were taken and the median operative time was longer. However, a simultaneous adjustment for these two factors is possible using both direct and indirect statistical methods. The resulting data (Table II) are still consistent with a higher incidence of fever in the group of patients with drainage (p
Volume 130, July 1975
NUMBER
OF POST-OPERATIVE
DAYS
Figure 2. Postoperative hospital stay in patients ing elective chotecystectomy.
undergo-
[10,23-271. Several surgeons have reported cases of bile peritonitis that occurred without warning hours to weeks after cholecystectomy with drainage [10,25,26]. Therefore, the lack of bile leakage from a drain cannot be interpreted as indicating the absence of bile leakage or the absence of impending bile peritonitis [24]. Doctor Frederick Coller remarked that “bile is not educated to climb drains” [16]. McLauchlin [14] stated that “a drain should not be used to substitute for good surgical technique.” We believe that our data, in agreement with other studies [3-91, suggest that cholecystectomy without drainage, in comparison with cholecystectomy and drainage, has an equivalent incidence of mortality and a decreased incidence of morbidity. Results of neither this study nor others contradict the use of drains in the presence of bacterial sepsis or gross bile leakage. However, we believe that in uncomplicated cases with a dry gallbladder bed, drainage is unnecessary. TABLE II
Adjustment for Difference in Frequency Cholangiography and Operative Time Distribution Related toTheir Influence on the Incidence of Fever
Direct adjustment* Indirect adjustment Overall per cent with fever ._. _~_ * p < 0.1 for this comparison.
Patients with Fever with Drainage (per cent)
Patients with Fever without Drainage (per cent)
59 46 49
29 28 26
of
31
Goldberg et al
Summary
Thirty-seven patients who met specific criteria had cholecystectomy without drainage, and thirtyseven matched control patients had cholecystectomy with drainage. This study suggests that surgical drainage after every uncomplicated cholecystectomy is unnecessary and may be unwise. Such drainage may result in an increased incidence of postoperative morbidity and prolonged hospital stay. Acknowledgment: We gratefully acknowledge the statistical guidance of Philip G. Archer, ScD, Department of Biometrics, University of Colorado Medical Center.
10. 1 I.
12.
13. 14. 15. 16.
17. 18.
References 19. I. Langenbuch C: Ein Fall von Extirpation der Gallenblase wegen Chronischer Cholelithiasis. Heilung. Bed K/in Wochenschr 19: 725, 1882. 2. Spivack JL: The Surgical Technique of Abdominal Operations, 5th ed. Springfield, Illinois. Thomas, 1955, p 618. 3. Dreese WC: Cholecystectomy without drains. J Inf Co// Surg 40: 433, 1963. 4. Kambouris AA, Carpenter WS, Allaben RD: Cholecystectomy without drainage. Surg Gynecol Obsfet 137: 613, 1973. 5. Kole W: Erfahrungen mit der Drainagelosen, ldealen Cholecystecktomie. Langenbecks Arch Chir 324: 307. 1969. 6. Myers MB: Drain fever, a complication of drainage after cholecystectomy. Surgery 52: 314, 1962. 7. Newmann S: Zue Drainage and Nichtdrainage in der Gallen Chirurgie. Chirurg9: 414, 1961. 8. Haldbo K: Drainage in operations on the bile passages. Acta Chir Stand 95: 265, 1947. 9. Verbrycke JR Jr: Cholecystectomy without drainage; report
32
20. 21.
22.
23. 24.
25. 26. 27.
of 86 consecutiv’e cases without mortality. M J & Ret 126: 705, 1927. Williams CB. Halpin IX, Knox JS: Drainage following cholecystectomy. Br J Surg 59: 293, 1972. Bogart JN, Sebesta DG: Incidental aDDendeCtOmY and its effeet on the incidence of wound in&tion in cholecystectomy. Am Surg 28: 650, 1969. Eiseman B, Robinson RM, Brown JH: Simultaneous appendectomy and herniorrhaphy without prophylactic antibiotic therapy. Surgery51: 578, 1962. Nora PF, Vanecko RM, Bransfield JJ: Prophylactic abdominal drains. Arch Surg 105: 173, 1972. McLauchlin R, Schilling JA: Abdominal drainage, present concepts. J Okla State Med Assoc 50: 143, 1957. Yates JL: An experimental study of the local effects of peritoneal drainage. Surg Gynecol Obstet 1: 473, 1905. Holm JC, Edmunds LH, Baker JW: Life threatening complications after operations upon the biliary tract. Surg Gynecol Obstet 127: 241, 1968. Glenn F: Complications of biliary tract surgery. Surg Gynecol Obstet 110: 141, 1960. Glenn F: Surgical treatment of biliary tract disease. NY State J Med62: 203, 1962. Reynolds JT: lntraperitoneal drainage, when and how. Surg GynecolObstet 101: 242, 1955. Cruse P, Foold R: A five-year prospective study of 23,649 surgical wounds. Arch Surg 107: ‘206, 1973. US Department of Health, Education, and Welfare, National Center of Health Statistics: Surgical operations in shortstay hospitals. Vita/Health Stat 13(11): 4, 1968. Strohl EL, Diffenbaugh WG. Azderson RE: The role of drainage following biliary tract surgery. Surg C/in North Am 44: 281, 1964. McKenzie G: Extravasation of bile after operations on the biliary tract. Aust NZ J Surg 24: 181, 1955. MacVicar FT, McNair TJ, Wilken BJ. Bruce J: Death following gall bladder surgery. J R Co// Surg Edinb 12: 139, 1967. Douglas DM, Turner GG: Rapid death in bile peritonitis. Er Med J 2: 280, 1940. James KL: Bile peritonitis of unusual causation. Lancet 2: 311, 1938. Mean RL: Bile peritonitis. Am Surg 30: 583, 1964.
The American Journal of Surgery