Hepatobiliary Surgery: Preventing Infections With Drainage Tubes
Overview
The utilization of prophylactic abdominal drainage tubes following hepatobiliary surgery remains a subject of debate within the medical community. This study aimed to assess the impact of prophylactic abdominal drainage tube placement post-hepatobiliary surgery on postoperative infections. Thirteen randomized controlled trials, involving 3620 patients, were analyzed via a comprehensive search of databases including PubMed, Embase, Cochrane Library, and Web of Science up to August 2023.
The results revealed no significant disparity in postoperative infection rates between patients with drainage tubes (1840 patients) and those without (1783 patients) (relative risk [RR] = 1.17, 95% confidence interval [CI]: 0.94–1.47, p = 0.16). However, the non-drainage group exhibited lower incidences of infectious abdominal fluid (RR = 2.09, 95% CI: 1.57–2.80, p < 0.00001) and postoperative bile leakage (RR = 1.77, 95% CI: 1.27–2.47, p < 0.001), along with shorter hospital stays post-surgery (mean difference = 1.27, 95% CI: 0.32–2.22, p = 0.009).
In conclusion, the placement of prophylactic abdominal drainage tubes post-hepatobiliary surgery does not demonstrate a reduction in postoperative infection rates when compared to not utilizing drainage. Moreover, there was no significant discrepancy in the risk of postoperative wound infection between patients with and without abdominal drainage tubes.
This study’s findings are strengthened by the exclusion of lower-quality literature during the literature quality assessment, enhancing the credibility of the conclusions drawn from the meta-analysis.
Introduction
Hepatobiliary surgery stands as a paramount treatment modality for hepatobiliary tumors in China, showcasing benefits in both enhancing patients’ quality of life and extending their survival duration. However, postoperative infections pose a significant concern, with occurrence rates ranging from 4.29% to 12.3%. These infections, if severe, can lead to multi-organ dysfunction and jeopardize patient well-being. Abdominal drainage, a fundamental technique in abdominal surgery, plays a pivotal role in managing postoperative complications by draining secretions from the abdominal cavity.
Traditionally, abdominal drainage tubes have been routinely employed for preventive drainage after hepatobiliary surgery to monitor and prevent complications like fistula formation, bleeding, or infection. However, the advent of enhanced recovery after surgery (ERAS) protocols has brought into question the necessity and efficacy of prophylactic drainage tubes. Some experts argue that these tubes may serve as conduits for bacterial proliferation, potentially exacerbating infection risks. Moreover, accumulated postoperative fluid, even if initially uninfected, could escalate into abscesses or infectious fistulas. Consequently, there has been a trend among some surgeons to forgo drainage tubes following conventional surgical procedures.
Nevertheless, controversy persists regarding the placement of abdominal drainage tubes after hepatobiliary surgery due to factors such as wound size, operation duration, and the propensity for liver bleeding and bile leakage. To address this issue and provide evidence-based guidance, this study conducted a meta-analysis of randomized controlled trials (RCTs) to assess the impact of preventive peritoneal drainage on postoperative infections following hepatobiliary surgery. By synthesizing data from high-quality RCTs, the study aims to offer valuable insights for informed clinical decision-making in the management of patients undergoing hepatobiliary surgery.
Method
A comprehensive literature search was conducted from establishment to August 2023 across multiple databases, including Embase, PubMed, Web of Science, and Cochrane Library, focusing on English-language studies. Search terms encompassed various phrases related to liver resection, hepatic surgery, and abdominal drainage. Additional searches were performed for relevant reviews and references cited in included articles.
Selection criteria for literature included studies involving patients who underwent hepatobiliary surgical procedures, with interventions categorized into postoperative placement of prophylactic abdominal drains (RAD group) versus no prophylactic drains (NRAD group) in randomized controlled trials (RCTs). Exclusion criteria comprised duplicate publications, non-RCTs, incomplete data, study protocols, reviews, case reports, conference abstracts, and animal experiments.
Data extraction and quality assessment were conducted using Notexpress 3.6 software, with irrelevant and duplicate articles removed initially. Remaining literature underwent screening based on titles and abstracts, followed by secondary screening of full texts.
Literature quality assessment and evaluation of publication bias were performed independently by two researchers using bias tools recommended by the Cochrane Handbook for Systematic Evaluation. Six criteria were evaluated, including random allocation sequence generation, concealment of allocation scheme, blinding, completeness of information, freedom from selective reporting bias, and other controls for bias. Disagreements were resolved through discussion and agreement between researchers.
Overall, this systematic approach ensures the inclusion of relevant RCTs and rigorous evaluation of literature quality, enhancing the reliability and validity of the findings synthesized from the selected studies.
Statistical Analysis
In this meta-analysis, conducted using RevMan 5.3, the official software of the Cochrane Collaboration, statistical techniques were employed to synthesize data from multiple studies. Mean difference (MD) was utilized as the effect size for measurement data, while relative risk (RR) served as the effect size for counting data. Each effect size was accompanied by its point estimate and a 95% confidence interval (CI) to quantify the precision of the estimate. To assess heterogeneity among the included studies, Cochran’s Q statistic (χ2 test) and Higgins I^2 test were employed. A significant I^2 value (>50%) indicated substantial heterogeneity among the studies.
The random effects model was applied for meta-analysis to account for variability between studies, and efforts were made to mitigate obvious heterogeneity through subgroup analysis or sensitivity analysis. In instances where heterogeneity was not statistically significant (I^2 ≤ 50%), the fixed-effect model was utilized for meta-analysis to provide a more conservative estimate.
To evaluate publication bias, funnel plots were utilized, which graphically depict the distribution of study results. A p-value of ≤0.05 was considered statistically significant, guiding the determination of the significance of the findings. This rigorous approach ensured robust analysis and interpretation of the pooled data while adhering to established standards in meta-analysis methodology.
Result
A comprehensive literature review was conducted, resulting in the identification of 13 randomized controlled trials (RCTs) comprising a total of 3,620 patients, with 1,840 patients in the peritoneal drainage group and 1,783 in the non-peritoneal drainage group. The quality assessment of the included studies demonstrated high quality, with all studies employing randomization methods and scoring 4 on the improved JADAD scale. The analysis focused on various postoperative outcomes, including wound infection rate, incidence of infective abdominal effusion, postoperative biliary leakage, and length of postoperative hospital stay.
Regarding the incidence of postoperative wound infection, no significant difference was observed between the peritoneal drainage and non-peritoneal drainage groups. However, the non-peritoneal drainage group exhibited a significantly lower incidence of infective abdominal effusion compared to the peritoneal drainage group. Similarly, the incidence of postoperative biliary leakage was lower in the non-peritoneal drainage group. Furthermore, the length of postoperative hospital stay was significantly shorter in the non-peritoneal drainage group.
Publication bias analysis indicated minimal impact on the results of the meta-analysis, with funnel plots demonstrating good symmetry for most outcomes. However, certain publication bias was observed in the analysis of the length of hospital stay, although it was not deemed severe.
Overall, the findings suggest that non-peritoneal drainage may be associated with favorable postoperative outcomes, including reduced incidence of infective abdominal effusion, biliary leakage, and shorter hospital stays compared to peritoneal drainage. These results provide valuable insights for clinicians and policymakers in optimizing postoperative management strategies for patients undergoing hepatobiliary surgery.
Conclusion
Patients undergoing hepatobiliary surgery often face various challenges, including advanced age, compromised immunity, complex comorbidities, extensive procedures, and prolonged hospitalization, leading to a heightened risk of postoperative infections. Although short-term indwelling drainage tubes are commonly used in hepatobiliary surgery to manage fluid drainage and monitor recovery, they also carry the risk of complications, such as organ damage, bleeding, tube dislodgement, and infection.
Studies have identified several independent risk factors for postoperative drainage tube complications, including inadequate drainage, tube detachment, improper positioning, and self-removal. A meta-analysis comparing patients with routine abdominal drainage (RAD) versus non-RAD (NRAD) after hepatobiliary surgery found no significant difference in the incidence of postoperative wound infections, suggesting that prolonged intra-abdominal drainage may increase the risk of infection.
While traditional practice advocates for routine drainage tube placement to monitor postoperative conditions, the Enhanced Recovery After Surgery (ERAS) approach challenges this notion, suggesting that drainage tubes may be unnecessary if the surgeon is proficient in liver anatomy, performs meticulous surgery, and conducts thorough intraoperative examinations. Moreover, in cases of severe bleeding, vital signs monitoring and imaging techniques can guide timely intervention without relying solely on drainage tubes.
The meta-analysis indicated that patients in the NRAD group experienced lower rates of intra-abdominal infections, bile leakage, and shorter hospital stays compared to those with RAD, highlighting the potential benefits of avoiding routine drainage tube placement. However, the decision to use prophylactic drainage tubes should consider factors such as operative complexity, bleeding risk, surgeon expertise, hospital resources, and backup systems in case of complications.
In conclusion, while prophylactic abdominal drainage tubes may be beneficial for high-risk patients, especially those with longer procedures or significant bleeding, their routine use after hepatobiliary surgery may not significantly impact infection rates. Future large-scale prospective studies are warranted to further evaluate the necessity of prophylactic drainage in hepatobiliary surgery and inform clinical practice guidelines.
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