Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-analyses

Abstract

Objective: To determine the evidence-based value of prophylactic drainage in gastrointestinal (GI) surgery.

Methods: An electronic search of the Medline database from 1966 to 2004 was performed to identify articles comparing prophylactic drainage with no drainage in GI surgery. The studies were reviewed and classified according to their quality of evidence using the grading system proposed by the Oxford Centre for Evidence-based Medicine. Seventeen randomized controlled trials (RCTs) were found for hepato-pancreatico-biliary surgery, none for upper GI tract, and 13 for lower GI tract surgery. If sufficient RCTs were identified, we performed a meta-analysis to characterize the drain effect using the random-effects model.

Results: There is evidence of level 1a that drains do not reduce complications after hepatic, colonic, or rectal resection with primary anastomosis and appendectomy for any stage of appendicitis. Drains were even harmful after hepatic resection in chronic liver disease and appendectomy. In the absence of RCTs, there is a consensus (evidence level 5) about the necessity of prophylactic drainage after esophageal resection and total gastrectomy due to the potential fatal outcome in case of anastomotic and gastric leakage.

Conclusion: Many GI operations can be performed safely without prophylactic drainage. Drains should be omitted after hepatic, colonic, or rectal resection with primary anastomosis and appendectomy for any stage of appendicitis (recommendation grade A), whereas prophylactic drainage remains indicated after esophageal resection and total gastrectomy (recommendation grade D). For many other GI procedures, especially involving the upper GI tract, there is a further demand for well-designed RCTs to clarify the value of prophylactic drainage.

FIGURE 1. Meta-analysis of RCTs comparing prophylactic drain versus no drain after liver resection. Estimates of drain effects of each study are presented on a log scale along with the 95% CI. The weight of each study is reflected by the size of square. Studies were analyzed according to the complication end points bile collections (A), infected collections (B), and pulmonary complications (C). The open diamond represents the global estimate of the drain effect along with the 95% CI (random-effects model). Test of heterogeneity is provided by the χ²-based Q statistic.

FIGURE 2. Meta-analysis of RCTs comparing prophylactic drain versus no drain after colorectal resection. Estimates of drain effects of each study are presented on a log scale along with the 95% CI. The weight of each study is reflected by the size of square. Studies were analyzed according to the complication end points clinical leakage (A), wound infections (B), and pulmonary complications (C). The open diamond represents the global estimate of the drain effect along with the 95% CI (random-effects model). Test of heterogeneity is provided by χ²-based Q statistic.

FIGURE 3. Meta-analysis of RCTs comparing prophylactic drain versus no drain after appendectomy for gangrenous or perforated appendicitis. Estimates of drain effects of each study are presented on a log scale along with the 95% CI. The weight of each study is reflected by the size of square. Studies were analyzed according to the complication end points intra-abdominal infections (A), wound infections (B), and fecal fistulas (C). The open diamond represents the global estimate of the drain effect along with the 95% CI (random-effects model). Test of heterogeneity is provided by χ²-based Q statistic.