Is Prophylactic Abdominal Drainage Necessary after Laparoscopic Colectomy for Colon Cancer? A Propensity Score-matched Analysis

INTRODUCTION

In 2018, the Enhanced Recovery after Surgery (ERAS) Society’s guidelines recommended that pelvic and peritoneal drains should not be used routinely in perioperative care in colorectal surgery.¹ However, with routine practices of many surgeons in a long period, prophylactic drainage after colectomy is not easily abandoned, particularly in low-to-middle income country (LMIC) setting. Prophylactic abdominal drains after colectomy have been used to early detect potential complications including bleeding and anastomotic leakage, and prevent fluid accumulation. On the contrary, routine drainage can cause some disadvantages such as increased serous secretion, increased risk of intra-abdominal infection, bowel obstruction, and prolonged hospital length of stay.^2–5 There were a number of studies on the safety and effectiveness of prophylactic drainage after elective colorectal surgery and most of them showed similar complication rate between groups with and without routine drainage.^2,3,5–7 Most authors agreed that prophylactic drains had no effect on clinical outcomes in elective colorectal surgery. Nevertheless, the majority of these studies were performed in upper-middle- or high-income countries, which healthcare facilities are better than in LMICs. Whether no prophylactic drainage after colectomy is safe in LMIC setting is still questioned. Also, the ERAS Society’s recommendation was based on relatively old evidences, which most of the studies were performed around 20 years ago.^2,7 Meanwhile, there have been changes in colectomy, for example, the wide application of minimally invasive surgery, more radical surgery such as complete mesocolic excision and extended lymph node dissection (D3 lymphadenectomy), stapled anastomosis, and the use of new instruments in the surgery. Updated studies on whether the use of routine drainage is necessary after colorectal anastomosis are needed.

In our hospital, we started to apply the ERAS guidelines without routine drainage for colectomy since 2018 and the results are promising. Hence, this study aimed to compare outcomes of patients who underwent laparoscopic colectomy with and without prophylactic abdominal drainage in the treatment of colon cancer.

METHODS

RESULTS

A total of 143 patients with colon cancer underwent laparoscopic colectomy from January 2018 to June 2021 were included in the study: 59 patients with prophylactic drainage and 84 patients without prophylactic drainage after the surgery. The PSM strategy resulted in 94 patients (47 patients in each group). The characteristics of the patients and tumors were more balanced between the two groups after matching (Tables 1 and 2).

Median age was 62 years in both groups before matching and 62 and 64 years in the drain and no-drain groups after matching, respectively. Female was predominant in both groups after matching. Before matching, the most frequent comorbidities were hypertension (54.2 and 46.4% in the drain and no-drain groups before matching), followed by diabetes (20.3 and 20.2%) and coronary artery disease (22 and 16.7%); there were 13 patients (22%) in the drain group and 17 patients (20.2%) in the no-drain group with previous laparotomy or laparoscopic surgery. Comorbidities were balanced between groups after matching (Table 1).

In our study, the tumors located in all sections of the colon. Before matching, the most frequent were the sigmoid colon (25.4 and 20.2% in the drain and no-drain groups, respectively), followed by the descending colon (22 and 17.9%) and left colic flexure (15.3 and 7.1%). According to the TNM staging system, most of the patients were graded as stage III postoperatively (57.6 and 71.4% in the drain and no-drain groups before matching). After matching, tumor’s location and stage were balanced between groups (Table 2).

Preoperative bowel preparation was performed in 18.6 and 10.7% of the patients in the drain and no-drain groups before matching. The operating time was similar in the two groups (median was 210 and 198 minutes before matching and 205 and 198 minutes after matching in the drain and no-drain groups, respectively). Before matching, the most frequent types of colectomy were right hemicolectomy (48 patients, 33.6%), followed by left hemicolectomy (46 patients, 32.2%). Median intraoperative blood loss was 50 mL in both groups and 11 patients (five in the drain group and six in the no-drain group) required blood transfusion. Most operative characteristics were balanced between groups after matching (Table 3). The median (IQR) time of drainage in the drain group was 5 (4.2; 6) days.

There were no significant differences in time to oral feeding, time of analgesics use, and time to flatus between the two groups in both the analyses before and after matching. Postoperative hospital length of stay, however, was significantly shorter in the no-drain group compared to the drain group in both the unmatched and matched cohorts (median of 5 vs 6 days). The drain group had higher rate of postoperative complications and more severe complications based on Clavien-Dindo classification in both the analyses before and after matching; however, the difference did not reach statistical significance. The most frequent complication was fluid accumulation but all required medical treatment only. Other complications were uncommon (Table 4).

DISCUSSION

Our study revealed the safety and effectiveness of laparoscopic colectomy without prophylactic drainage after surgery for colon cancer in a LMIC setting. Compared to laparoscopic colectomy with prophylactic drainage, the approach without prophylactic drainage yielded similar safety results when considering the prevention of postoperative complications. The rate of anastomotic leak, bleeding, abdominal abscess, and reoperation due to complications was low and balanced between the two groups. With respect to the effectiveness, the two groups were not significantly different in the time to flatus, time to oral feeding and time of analgesics use, but the approach without prophylactic drainage significantly shortened the length of postoperative hospital stay.

Prophylactic drainage is expected to provide some benefits. The first is to remove collected fluid after surgery, which is thought to reduce the risk of intra-abdominal infection.^11,12 The second is to early detect postoperative complications such as intra-abdominal bleeding or anastomotic leakage. Another potential benefit is to minimize the severity of leakage when occurring and possibly avoid reoperation.^13,14 Our study showed that there was no difference in fluid accumulation and intra-abdominal infection between the two groups. Thus, similar to other studies,^1,15 our results suggest that prophylactic drainage for the prevention of intraperitoneal fluid accumulation is not necessary.

Abdominal drainage might have a role in the diagnosis and treatment of anastomotic leakage. In our study, one patient in the drain group was diagnosed with anastomotic leakage at day 6 postoperatively without clinical signs of peritonitis except that there was fecal fluid in the drain’s output. Conservative treatment was successful for that patient. Whereas two patients in the no-drain group with anastomotic leakage required reoperation, one with a misdiagnosis of postoperative paralytic ileus and the other with a diagnosis of localized peritonitis in the right upper quadrant. Prophylactic drainage in these two patients might help to early diagnose anastomotic leakage or prevent reoperation. Therefore, routine drainage may still play a role in the diagnosis and treatment of anastomotic leakage. Nevertheless, it should be highlighted that with the application of the ERAS protocol and the advancement of surgical techniques and instruments, anastomotic leakage is very rare. Thus, routine drainage for all patients should be considered and further studied in terms of the diagnosis and prevention of anastomotic leakage.

On the other hand, routine drainage may cause some problems. In our study, three patients in the drain group had intestinal obstruction; one patient resolved after drain removal and two patients required reoperation. Whether the drainage tube causes intestinal obstruction is still unclear, but this complication was mentioned before.^4,16 In addition, routine drainage can cause other problems such as pain, discomfort, and limitation of returning to normal activities of the patients.

Routine abdominal drainage is still under debate in colectomy for colon cancer. Some studies showed no significant difference between the groups with and without prophylactic drainage in terms of postoperative complications such as anastomotic leakage, mortality, wound infection, pelvic sepsis, postoperative bowel obstruction, and reintervention for abdominal complication.^{5,7,13,17–20} Several other studies favored routine drainage after colorectal surgery because a prophylactic drain could reduce the incidence of colorectal anastomotic leakage and the rate of reintervention due to complications.^21–23 However, since most level-1 evidence studies (well-designed randomized controlled trial and systematic review and meta-analysis) recommended against the use of prophylactic drainage, we agree with the ERAS guidelines that routine drainage should not be used after colorectal anastomosis. Since most of the studies were performed in the upper-middle- or high-income countries, our study supports this recommendation in the LMIC setting.

There are several limitations in this study. First, the sample size of the study is relatively small. Second, there was potential selection bias in the comparison between the two groups, which is a nature of a non-randomized comparative study. We tried to overcome this issue by using the PSM analysis, but potential bias might not be ruled out completely. Third, this study came from a single center with a single surgical team. This might limit the generalizability of the results to other settings.

CONCLUSION

In conclusion, laparoscopic colectomy without prophylactic drainage is safe in the treatment of colon cancer. This approach does not increase postoperative complications but shortens the length of postoperative hospital stay when compared to the surgery with routine prophylactic drainage. We suggest against the use of prophylactic drainage after laparoscopic colectomy for colon cancer even in the LMIC setting.

AUTHORS’ CONTRIBUTIONS

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Le Huy Luu, Tran Van Hoi, and Nguyen Lam Vuong. The first draft of the manuscript was written by Le Huy Luu and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

ORCID

Nguyen Lam Vuong http://orcid.org/0000-0003-2684-3041

REFERENCES

1. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced recovery after surgery (ERAS(®)) society recommendations: 2018. World J Surg 2018;43(3):659–695. DOI: 10.1007/s00268-018-4844-y.

2. Jesus EC, Karliczek A, Matos D, et al. Prophylactic anastomotic drainage for colorectal surgery. Cochrane Database Syst Rev 2004;2004(4):Cd002100. DOI: 10.1002/14651858.CD002100.pub2.

3. Guerra F, Giuliani G, Coletta D, et al. A meta-analysis of randomized controlled trials on the use of suction drains following rectal surgery. Dig Surg 2018;35(6):482–490. DOI: 10.1159/000485139.

4. Poon CM, Leong HT. Abdominal drain causing early small bowel obstruction after laparoscopic colectomy. Jsls 2009;13(4):625–627. PMID: 20202408.

5. Menahem B, Vallois A, Alves A, et al. Prophylactic pelvic drainage after rectal resection with extraperitoneal anastomosis: Is it worthwhile? A meta-analysis of randomized controlled trials. Int J Colorectal Dis 2017;32(11):1531–1538. DOI: 10.1007/s00384-017-2891-8.

6. Bretagnol F, Slim K, Faucheron JL. [Anterior resection with low colorectal anastomosis. To drain or not?]. Ann Chir 2005;130(5):336–339. DOI: 10.1016/j.anchir.2005.03.007.

7. Zhang HY, Zhao CL, Xie J, et al. To drain or not to drain in colorectal anastomosis: A meta-analysis. Int J Colorectal Dis 2016;31(5):951–960. DOI: 10.1007/s00384-016-2509-6.

8. Hashiguchi Y, Muro K, Saito Y, et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer. Int J Clin Oncol 2020;25(1):1–42. DOI: 10.1007/s10147-019-01485-z.

9. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240(2):205–213. DOI: 10.1097/01.sla.0000133083.54934.ae.

10. Ho DE, Imai K, King G, et al. ‘MatchIt’: Nonparametric preprocessing forparametric causal inference. J Stat Softw 2011;42(8):1–28. DOI: https://doi.org/10.18637/jss.v042.i08.

11. Dougherty SH, Simmons RL. The biology and practice of surgical drains. Part II. Curr Probl Surg 1992;29(9):633–730. DOI: 10.1016/0011-3840(92)90028-2.

12. Lennox MS. Prophylactic drainage of colonic anastomoses. Br J Surg 1984;71(1):10–11. DOI: 10.1002/bjs.1800710103.

13. Solaini L, Cavaliere D, Pecchini F, et al. The use of intra-abdominal drain in minimally invasive right colectomy: A propensity score matched analysis on postoperative outcomes. Int J Colorectal Dis 2019;34(12):2137–2141. DOI: 10.1007/s00384-019-03440-w.

14. Taflampas P, Christodoulakis M, Tsiftsis DD. Anastomotic leakage after low anterior resection for rectal cancer: Facts, obscurity, and fiction. Surg Today 2009;39(3):183–188. DOI: 10.1007/s00595-008-3835-2.

15. Puleo FJ, Mishra N, Hall JF. Use of intra-abdominal drains. Clin Colon Rectal Surg 2013;26(3):174–177. DOI: 10.1055/s-0033-1351134.

16. Yang M, Kidane B, Saettler E. Delayed small bowel obstruction due to intra-abdominal drain: Case report and literature review. Int Surg 2018;103(3–4):149–153. DOI: 10.9738/intsurg-d-14-00297.1.

17. Podda M, Di Saverio S, Davies RJ, et al. Prophylactic intra-abdominal drainage following colorectal anastomoses. A systematic review and meta-analysis of randomized controlled trials. Am J Surg 2020;219(1):164–174. DOI: 10.1016/j.amjsurg.2019.05.006.

18. Urbach DR, Kennedy ED, Cohen MM. Colon and rectal anastomoses do not require routine drainage: A systematic review and meta-analysis. Ann Surg 1999;229(2):174–180. DOI: 10.1097/00000658-199902000-00003.

19. Petrowsky H, Demartines N, Rousson V, et al. Evidence-based value of prophylactic drainage in gastrointestinal surgery: A systematic review and meta-analyses. Ann Surg 2004;240(6):1074–1084; discussion 1084–1075. DOI: 10.1097/01.sla.0000146149.17411.c5.

20. Karliczek A, Jesus EC, Matos D, et al. Drainage or nondrainage in elective colorectal anastomosis: A systematic review and meta-analysis. Colorectal Dis 2006;8(4):259–265. DOI: 10.1111/j.1463-1318.2006.00999.x.

21. Akiyoshi T, Ueno M, Fukunaga Y, et al. Incidence of and risk factors for anastomotic leakage after laparoscopic anterior resection with intracorporeal rectal transection and double-stapling technique anastomosis for rectal cancer. Am J Surg 2011;202(3):259–264. DOI: 10.1016/j.amjsurg.2010.11.014.

22. Qu H, Liu Y, Bi DS. Clinical risk factors for anastomotic leakage after laparoscopic anterior resection for rectal cancer: A systematic review and meta-analysis. Surg Endosc 2015;29(12):3608–3617. DOI: 10.1007/s00464-015-4117-x.

23. Rondelli F, Bugiantella W, Vedovati MC, et al. To drain or not to drain extraperitoneal colorectal anastomosis? A systematic review and meta-analysis. Colorectal Dis 2014;16(2):O35–O42. DOI: 10.1111/codi.12491.