Selective post-hepatectomy surgical drain placement and liver-related complications

Abstract

Presenter: Cameron Gaskill MD, MPH | The University of Texas MD Anderson Cancer Center Background: Many surgeons selectively place surgical drains for the putative purpose of diagnosing clinically significant bile leaks and organ space infections and mitigating their sequelae including reducing secondary percutaneous drains. No consensus guidelines exist for when it is appropriate for a surgical drain to be selectively placed. Within this context, we sought to analyze both predictors and outcomes associated with surgical drain placement to measure their effectiveness in diagnosing or reducing liver-related complications. Methods: We studied consecutive patients undergoing hepatectomy from January 2017 to December 2018, using a single-institution database maintained prospectively with biweekly review by a faculty surgeon and two advanced practice providers. Patient health information, perioperative details, and outcomes were recorded for a period of 90 postoperative day. Complications were defined in accordance with the Accordion grading system with major complications defined as ≥3. Clinically significant bile leaks were defined by meeting International Study Group of Liver Surgery Grade B or C criteria and combined with organ space infections (OSI) to make a composite endpoint. Statistical analysis was completed using logistic regressions and linear regressions for categorical and continuous variables, respectively, reported as odds ratio (OR) and median values, after controlling for patient ASA, BMI, age, and Kawaguchi-Gayet classification (surgical difficulty and extent). Results: A total of 466 patients (median age 57 years, interquartile range [IQR 49–66]; 54% female) were analyzed. One hundred (21.5%) patients had surgical drains placed near the liver resection margin, while 366 (78.5%) did not. Clinically significant bile leaks and/or OSI were noted in 22% (n=22) of patients with surgical drains and 5.7% (n=21) of patients without surgical drains (p<0.001). Of 100 drains, 78% did not identify or prevent clinically signficant bile leaks and/or OSI. Of the 22 patients with primary drains and clinically significant bile leaks and/or OSI, 10 (45.5%) required additional percutaneous drainage while 12 (54.5%) did not. The presence of a surgical drain was associated with increased median length of stay (LOS) (5 days [IQR 4-6] with drain vs. 4 days [IQR 3-5] without drain, p<0.001). After controlling for surgical drain placement, Kawaguchi-Gayet classification was not associated with major complication (OR 1.2 95% CI 0.90 – 1.79, p=0.175), clinically significant bile leak (OR 0.70 95%CI 0.39 – 1.26, p=0.234), OSI (OR 1.27 95%CI 0.84 – 1.92, p=0.254), need for percutaneous drain (OR 0.76 95%CI0.41 – 1.40, p=0.377), or readmission within 90 days (OR 1.05 95%CI 0.76 – 1.45, p=0.770). Conclusion: Almost 4 of 5 surgical drains did not diagnose or drain a clinically significant bile leak and/or OSI. The placement of a surgical drain is associated with increased LOS and may not mitigate the risk of clinically significant bile leaks and/or OSI, but may reduce the need for additional percutaneous drains in high-risk patients who fail a post-resection leak test or inspection.