Early drain removal after hepatectomy: an underutilized management strategy

Abstract

Background: Randomized controlled trials and a Cochrane Review suggest that routine drainage is not necessary in patients undergoing hepatectomy. Contemporary ACS-NSQIP data suggest that 50% of patients undergoing hepatectomy in North America receive abdominal drains, and early drain removal is not widely practiced. Recent single center analyses from Japan demonstrates that drain removal by POD 2 or 3 is safe and may result in fewer organ space infections as well as shorter length of stay. Thus, the aim of this analysis is to compare the outcomes of North American patients who have early (POD 0-3) versus routine (POD 4-7) drain removal. Methods: Patients undergoing major hepatectomy (≥ 3 segments) or partial hepatectomy (≤ 2 segments) were identified in the 2014–16 ACS-NSQIP Procedure Targeted Participant Use File. Patients undergoing concomitant biliary reconstruction or colon resection were excluded. Only patients who had one or more drains placed at surgery were analyzed. Patients who had drains in place for more than 7 days also were excluded so that early drain removal (POD 0-3) could be compared to routine drain removal (POD 4-7) in patients without early bile leaks or other complications. Patients were stratified by extent of hepatectomy and propensity score matched for multiple demographic, comorbidity, laboratory, procedure and pathologic variables. Outcomes of early and routine drain removal patients were compared by Mann-Whiting U and chi-square test. Results: Of 2,599 patients, 1,654 (64%) underwent a partial (PH) and 945 (36%) had a major hepatectomy (MH). Early drain removal was performed in 661 (40%) of PH and 211 (22%) of MH patients. Multiple outcomes were significantly (p < 0.01) better in the early drain removal patients, but these patients were less likely (p < 0.01) to have hepatitis, a prior biliary stent, neoadjuvant therapy, a major hepatectomy, a Pringle maneuver, a concurrent ablation, perioperative transfusions, or malignant pathology. Therefore, 779 early drain removal patients were matched to 779 routine drain removal patients (Table). Early drain removal patients had significantly less (p < 0.02) overall and serious morbidity, fewer pneumonias and required fewer postoperative biliary drainage procedures. Length of stay was 2 days shorter, (p<0.001) and readmissions were 3% lower (p < .01) in early drain removal patients. Conclusion: Early drain removal (POD 0-3) is performed in only one-third of hepatectomy patients who receive drains. Routine drain removal (POD 4-7) is practiced in a variety of patients some of whom are perceived to be at higher risk for complications. After controlling for these factors, early drain removal is associated with lower overall and serious morbidity as well as shorter length of stay and fewer readmissions. Early drain removal after hepatecomy is an underutilized management strategy.