Value of primary operative drain placement after major hepatectomy: a multi-institutional analysis of 1,041 patients.
BACKGROUND
The value of routine primary (intraoperative) drain placement after major hepatectomy remains unclear. We sought to determine if primary drainage led to decreased rates of complications, specifically, intra-abdominal biloma or infection requiring a secondary (postoperative) drainage procedure.


METHODS
All patients who underwent major hepatectomy (≥3 hepatic segments) at 3 institutions, from 2000 to 2012, were identified. Patients with biliary anastomoses were excluded. Primary outcomes were any complication, rate of secondary drainage procedures, bile leak, and 30-day readmission.


RESULTS
There were 1,041 patients who underwent major hepatectomy without biliary anastomosis; 564 (54%) had primary drains placed at the surgeon's discretion. Primary drain placement was associated with increased complications (56% vs 44%; p < 0.001), bile leaks (7.3% vs 4.2%; p = 0.048), and 30-day readmissions (16.4% vs 8.0%; p < 0.001), but was not associated with a decrease in secondary drainage procedures (8.0% vs 5.9%; p = 0.23). Patients with primary drains demonstrated higher American Society of Anesthesioloigsts (ASA) class, greater blood loss, more transfusions, and larger resections. After accounting for these significant clinicopathologic variables on multivariate analysis, primary drain placement was not associated with increased risk of any complications. Primary drainage was, however, independently associated with increased risk of bile leak (hazard ratio [HR] 2.04; 95% CI1.02 to 4.09; p = 0.044) and 30-day readmission (HR 1.79; 95% CI1.14 to 2.80; p = 0.011). There still was no reduction in the need for secondary drainage procedures (HR 0.98; p = 0.96).


CONCLUSIONS
Primary intraoperative drain placement after major hepatectomy does not decrease the need for secondary drainage procedures and may be associated with increased bile leaks and 30-day readmissions. Routine drain placement is not warranted.
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA.
Malcolm H
MH
Squires
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA.
Neha L
NL
Lad
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA.
Sarah B
SB
Fisher
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA.
David A
DA
Kooby
Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
Sharon M
SM
Weber
Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
Adam
A
Brinkman
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA.
Juan M
JM
Sarmiento
Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY.
Charles R
CR
Scoggins
Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY.
Michael E
ME
Egger
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA.
Kenneth
K
Cardona
Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
Clifford S
CS
Cho
Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, KY.
Robert C G
RC
Martin
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA.
Maria C
MC
Russell
Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
Emily
E
Winslow
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA.
Charles A
CA
Staley
Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA. Electronic address: smaithe@emory.edu.
Shishir K
SK
Maithel
D004322:Drainage / Q000295:instrumentation*; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000639:trends; D011182:Postoperative Care / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology / Q000601:surgery*; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology