Closed-suction versus Penrose drainage after cholecystectomy

Closed-Suction Versus Penrose Drainage After Cholecystectomy A Prospective, Randomized Evaluation

Michael G Sarr, MD, Kwan J Pankh, MD, Stanley L Mnken, MD, George D Zuidema, MD, and John L Cameron, MD, Baltimore, Maryland

Few topics will generate as heated a dlscusslon among general surgeons as whether or not to routinely dram all cholecystectomles, and if so, which type of dram to use Suffice It to say that the routme use of mtraperltoneal subhepatlc drams after cholecystectomy remains controversial There has been a recent resurgence of interest m nondramage of the uncomplicated cholecystectomy [l-12], however, many of the studies have been of a retrospective and thus uncontrolled design, or they have involved numbers of patients too small to adequately assess the effects of nondramage on the occurrence of bile perltomtls or mtraabdommal abscess Many surgeons remam unconvmced that nondramage of even uncomplrcated cholecystectomles 1s warranted Two years ago, we surveyed the surgeons at our mstltutlon concerning their use of drams after cholecystectomy The maJorlty routmely used drams and had strong opmlons about their use About half used a closed-suction dram, whereas the remainder used an open, passive dram (Penrose dram) Therefore, we undertook a prospective, randomized trial comparing closed-suction versus Penrose drainage after cholecystectomy without common duct exploration Material and Methods All patients undergomg cholecystectomy at The Johns Hopkins Medical Instltutlons from July 1983 through May 1985 and at the St Agnes Hospital from December 1984 through May 1985 were considered candldates for admlsslon mto the study This included patients with acute cholecystltls as well as chrome cholecystltls Most patients had mtraoperatlve cholanglography to exclude the presence of common duct stones Those without cholanglography had none of the mdlcatlons for common duct exploration All patients undergomg common bile duct exploration were excluded Patients gave informed consent according to the criteria established by the Joint Committee on Chmcal Investlgatlons of the Johns Hopkins Medical Instltutlons Randomlzatlon to either From the Departments of Surgery, The Johns Hopkins MedIcal lnsbtutlons and The St Agnes Hospital, Salbmore, Maryland Requests for reprints should be addressed to Michael Sarr MD, Department of Surgery, Mayo Cllntc and Foundabon Rochester, Minnesota 55901

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Group I, closed-suction drainage using a 6 mm diameter sllastlc Jackson-Pratt dram, or to Group II, open static dramage using two separate 1 mch Penrose drams, occurred m the operating room at the time of dram msertlon Randomlzatlon occurred by drawing a card from a box containing an equal number of cards labeled either closed-suction or Penrose In all cases, the drams were placed through a separate stab wound, extending mto the bed of the gallbladder and down near the cystic duct ligature Thereafter, the care of the dram was left to the dlscretlon of the attending surgeon A sterile colostomy bag was placed over the Penrose dram exit site m the first 14 patients m Group II to quantltate the amount of dramage Bile specimens were obtained mtraoperatlvely for culture Patients were evaluated dally until discharge by a physician Routine chnlcal and laboratory values were charted, including maximum dally temperature, volume of drainage, blood leukocyte count, serum blhrubm, and number of postoperative days m the hospital Patients were evaluated for the presence of wound or dram site infection and dram site tenderness Wounds were consldered infected if purulent material dramed from the wound or if erythema and mduratlon developed that required either antlblotlc treatment or open drainage and packing of the wound Dram site tenderness was categorized subJectlvely as absent if the dram exit site was no more tender than the mclslon, as moderate if the dram site was notlceably and focally more tender than anywhere else m the abdomen, and as severe if the patient complamed bitterly and spontaneously about pam at the dram site StatIstma analysis Where appropriate, patient groups were compared using Student’s t test for nonpaired data, chl-square analysis, or Fisher’s exact test

Results Study population: Of the 128 patients entered mto the study, 67 were randomized to Group I (closed-suction drainage) and 61 were randomized to Group II (open dramage) The two groups were similar with respect to age, sex, and the mdlcatlon for cholecystectomy (Table I) When Group I was compared with Group II, chronic cholecystltls was present m 67 percent and 64 percent of the patients, respectively, acute cholecystltls m 24 percent and 29

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Journal of Surgery

Drainage After Cholecystectomy

TABLE I

Cllnical Parameters of the Study Population’ Parameters

Age (mean f standard error of the mean) Sex Female Male lndrcatron for cholecystectomy Chronrc cholecyshtis Acute cholecysbhs Empyema of gallbladder Gallstone pancreatitis Acalculous cholecystrtrs Prophylactic antibiotics+

Group I (n = 67)

Group II (n = 61)

50f2yr

47 f

44 (72) 17 (26)

46 16 2 3 7 52

39 (64) 16 (29) 1 (2) 3 (5) 6 (13) 47 (77)

(67) (24) (3) (4) (10) (76)

Comparlsonof Dralnage Techniques’

Parameter

Group I

p Value

Duration of drainage (d) 3 3 f 0 2 p
2 yr

45 (67) 22 (33)

TABLE II

Group II 41f02 132 f lO+

39161 32161

13f06 56ztO3

All values except those indicating temperature elevatron, are expressed as the mean f standard error of the mean + Measured in 14 patients NS = not slgnlfrcant l

Values in parentheses are percentages + Includes all patients with acute cholecystrhs, gallbladder, and age of 65 years or older l

empyema

of

percent, respectively, empyema of the gallbladder m 3 percent and 2 percent, respectively; and gallstone pancreatltls m 4 percent and 5 percent, respectively Acalculous cholecystltls was found m 10 percent of the patients m Group I and m 13 percent of the patients m Group II Preoperative prophylactic antlblotlcs were used m 78 percent of the patients m Group I and m 77 percent of the patients m Group II according to the discretion of the attendmg surgeon However, all patients considered to be at high risk for the development of mfectlous comphcatlons were given prophylactic antlblotlcs High-risk patients were those with acute cholecystltls, those with empyema of the gallbladder, and those over 65 years of age Comparison of drainage techniques: Closedsuction drams (Group I) were removed earlier than the Penrose drams (Group II) (Table II), and thus the duration of drainage was shorter m Group I, 3 3 f 0 2 days, than m Group II, 4 1 f 0 2 days (mean f standard error of the mean, p
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TABLE Ill

Compllcatlons of Drainage Techniques

Complication Positive lntraoperative bile culture Wound infection Drain site infection Drain site tenderness Moderate Severe

Group I (n)

p Value

15158 l/67 l/67 8167 6167 2167

Group II (n) 8143

005
5/61 0161 24161 22161 2161

respectively, 0 05 < p
This prospective, randomized study has demonstrated that closed-suction drainage 1s superior to open, passive drainage with Penrose drams after cholecystectomy without common bile duct exploration Closed-suction drams were associated with a decrease m postoperative fever during the first 2

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postoperative days, a decreased incidence of dram site tenderness, and a trend toward a decreased incidence of wound mfectlon Retrospective studies by Polk [14], Chllton and Mann [15], and Farha et al [16] arrived at similar conclusions Two previous studies have prospectively compared closed-suction versus open, passive dramage after cholecystectomy Gupta and colleagues [17] found an increased incidence of wound mfectlon and mtraabdommal abscess with Penrose drams, however, the number of patients studied was small Rlvas et al [18] compared 100 patients with closed-suction drainage with 100 patients with Penrose drams and also found a somewhat higher incidence of wound mfectlon with Penrose drams The use of routme drainage after cholecystectomy, however, remains controversial Several retrospective studies found a higher incidence of wound infection and postoperative fever m patients with postoperative drainage after routme cholecystectomy compared with patients m whom a dram was not used [2,4,5] These studies were repeated by others m a prospective, and thus more meaningful manner [1,3,8,10-121 Although postoperative fever was consistently more common m patients with drams, the incidence of wound infection was not increased by wound drainage, especially d the dram was removed wrthm 48 hours These mvestlgators concluded that drainage was not required after most cholecystectomles Many surgeons, however, remam reluctant to omit dramage after cholecystectomy Drams are employed primarily to prevent either subhepatlc abscess or bile perltomtls from an undrained bile leak These serious complications after cholecystectomy are very unusual and occur m less than 1 percent of patients [19] Thus, to demonstrate the efficacy of postoperative drainage after cholecystectomy m preventing these complications, a study would have to include many hundreds of patients Several studies have examined the occurrence of subhepatlc fluid collections after routme cholecystectomy [8,20] Subhepatlc fluid collections developed m about 20 percent of patients undergoing cholecystectomy without dramage as documented by ultrasonography, whereas similar collections developed m only 5 percent when a dram was used Other investigators have evaluated the fluid from a subhepatlc dram after cholecystectomy to determme if leakage of bile was common postoperatively Truedson [21] analyzed dramage fluid for comugated blhrubm Although the dramage fluid from most patients had the equivalent of only several mllhhters of hepatlc bile, about 10percent of patients had significantly greater amounts of conJugated blhrubm, thus suggesting a more significant bile leak Van der Linden and colleagues [22] found that a slgmficant amount of the radlonuchde Tc-HIDA,

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an agent selectively excreted mto the bile, could be recovered from the subhepatlc drainage fluid m the early postoperative period followmg cholecystectomy Edlund and others [7] found a transient mcrease m total serum blhrubm m patients undergomg cholecystectomy without drainage A similar increase was not seen m patients with a dram These fmdmgs suggested that a certain amount of brhrubm (bile) m the nondramage group leaked mto the subhepatlc space and was reabsorbed mto the circulation, m contrast, m the drainage group, this bile was evacuated by the dram These studies showed that bile leaks do occur after cholecystectomy and that drams appear to allow the egress of these fluids Indeed, Truedson et al [23] also cultured the dramage fluid and compared the results to the mtraoperatlve bile culture They found that m patients with bacterobdla at the time of cholecystectomy, the identical organism could be recovered from the drainage fluid postoperatively m about a third of patients Obviously, the maJorlty of subhepatlc fluid collections remam asymptomatic and do not lead to mfectlous comphcatlons However, it has been well documented that about 15percent of patients with chronic cholecystltls will have bacteroblha Possibly of more importance, however, are patients with acute cholecystltrs and patients over age 65, they have an incidence of bacteroblha of greater than 50 percent [24] Subhepatlc bile leaks m these patients may have different imphcatlons, and routme dramage m these patients seems indicated Further support for postoperative dramage comes from a study by Alexander et al [25] These mvestlgators found that the fluid collectmg m surgical wounds progressively lost the ability to opsomze bacteria and thereby inhibited eventual phagocytosls by normal leukocytes Although the routine use of a dram after cholecystectomy will remain controversial, a number of studies have addressed the topic of which type of dram is best Salam et al [20] found that 6 mm diameter closed suction drams were superior to 2 5 mm drams m preventing subhepatlc fluid collections after cholecystectomy Hanna [26] found that a sump suction dram was more efficient m evacuatmg fluid than the static Penrose dram In contrast, van der Linden et al [27] found that sump suction drams evacuated less fluid after cholecystectomy than passive tube drams left to closed gravity dramage Our findings were srmllar with less dramage fluid recovered from the group of patients wrth closed-suction drams compared with the group with Penrose drams One potential explanation is that tissue was drawn mto the holes within the dram by the applied suction and thereby prevented further drainage of wound fluid However, another potential explanation is that by maxlmlzmg tissue oppoa-

The American Journal of Surgery

Drainage After Chclecystectomy

tlon and obhteratmg any dead space, total tissue fluid exudation was mnnmrzed Our experimental design did not allow us to dlstmgulsh between the two possible explanations Another consideration is the potential for mfectlous comphcatlons related directly to the dram Penrose drams, when left m place for prolonged periods, can serve as a two-way street Nora et al [28] found a 34 percent incidence of positive bacterial cultures from the inside of a Penrose dram They also found a much greater mcldence of mtraabdommal mfectlon m dogs after splenectomy when dramed with a Penrose dram. Similar experimental observations were made in rabbits subjected to splenectomy with a Penrose dram [29] Passive drams, such as the Penrose dram, can never be rendered a closed system, and thus the potential for supermfectlon from skm contammants remains a dlstmct posslblhty Thus, with all factors considered, a closedsuction dram appears to be the best alternative Our prospective, randomized study and others [17,18] support the use of a closed-suction dram as being superior to an open, passive dram (Penrose dram) after cholecystectomy In fact, there appears to be little Justlficatlon for using a Penrose dram Although our study did not address the role of nondrainage after cholecystectomy, we believe that postoperative, subhepatlc dramage after cholecystectomy is mdlcated Possible exceptions, however, might include straightforward elective cholecystectomlea m patients known not to have bacteroblha However, even m these instances, it is hard to argue agamst the use of a closed-suction dram postoperatively for less than 48 hours to allow one to determme whether a slgmficant bile leak has occurred Summary Closed-suction dramage was compared prospectively to open, passive dramage (Penrose drams) m 128 patients undergoing cholecystectomy Patients were randomized at the time of operation to receive either closed-suction drams (Group I, 67 patients) or Penrose drams (Group II, 61 patients) The preoperative clinical parameters of the two groups were slmllar The patients in Group I when compared with those m Group II had a shorter duration of dramage (3 3 days and 4 1 days, respectively, p
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sus 5 of 61 patients m Group II, 0 05 < p
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Chetlln SH. Ellrott DW Preoperative anttblotlcs In biliaty surgery Arch Surg 1973. 107 319-23 Alexander JW, Korelitz J, Alexander NS PreventIon of wound infections a case for closed suction drainage to remove would fluids deftctent tn opsomic protetns Am J Surg 1976, 132 59-63 Hanna EA Efftclency of peritoneal dramage Surg Gynecol Obstet 1970, 131 963-5

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van der Linden W, Gedda S, Edlund G Sump dramage versus static drainage after cholecystectomy Surg Gynecol Obstet 1961, 152, 629-30 Nora PF, Vanecko RM, Bransfleld JJ Prophylactic abdominal drains Arch Surg 1972, 105 173-6 Cerise EJ, Pierce WA, Diamond DL Abdominal drains their role as a source of tnfectton followlng cholecystectomy Ann Surg 1970, 171 764-Q

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