Original Article

Split Viewer

Journal of Minimally Invasive Surgery 2024; 27(2): 76-84

Published online June 15, 2024

https://doi.org/10.7602/jmis.2024.27.2.76

© The Korean Society of Endo-Laparoscopic & Robotic Surgery

Effect of prophylactic abdominal drainage on postoperative pain in laparoscopic hemicolectomy for colon cancer: a single-center observational study in Korea

Sung Seo Hwang1 , Heung-Kwon Oh1,2 , Hye-Rim Shin1 , Tae-Gyun Lee1 , Mi Jeong Choi1 , Min Hyeong Jo1 , Hong-min Ahn1 , Hyeonjeong Park1 , Hyun Hee Sim1 , Eunjeong Ji3 , Anuj Naresh Singhi1,4 , Duck-Woo Kim1,2 , Sung-Bum Kang1,2

1Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
2Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
3Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Korea
4Department of General Surgery, Saifee Hospital, Mumbai, India

Correspondence to : Heung-Kwon Oh
Department of Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea
E-mail: crsohk@gmail.com
https://orcid.org/0000-0002-8066-2367

Received: April 25, 2024; Revised: June 5, 2024; Accepted: June 8, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Purpose: This study aimed to evaluate the effect of prophylactic abdominal drainage (AD) in laparoscopic hemicolectomy, focusing on assessing postoperative pain outcomes.
Methods: Patients were categorized into two groups: those with and without AD (AD group vs. no-AD group). A numerical rating scale (NRS) was used to assess postoperative pain on each postoperative day (POD). Further, the inverse probability of treatment weighting (IPTW) method was used to reduce intergroup bias.
Results: In total, 204 patients who underwent laparoscopic hemicolectomies by a single surgeon between June 2013 and September 2022 at a single institution were retrospectively reviewed. After adjusting for IPTW, NRS scores on POD 2 were significantly lower in the no-AD group (3.2 ± 0.8 vs. 3.4 ± 0.8, p = 0.043). Further examination of postoperative outcomes showed no statistically significant differences in complications between the AD (17.3%) and no-AD (12.4%) groups (p = 0.170). The postoperative length of hospital stay was 7.3 ± 2.8 days in the AD group and 6.9 ± 3.0 days in the no-AD group, with no significant difference (p = 0.298). Time to first flatus was 3.0 ± 0.9 days in the AD group and 2.7 ± 0.9 days in the no-AD group, with no significant difference (p = 0.078). Regarding readmission within 1 month, there were four cases each in the AD (2.3%) and no-AD (1.7%) groups, with no significant difference (p = 0.733).
Conclusion: Laparoscopic hemicolectomy without AD resulted in no significant differences in postoperative clinical outcomes, except for postoperative pain. This finding suggests that prophylactic AD may exacerbate postoperative pain.

Keywords Drainage, Colectomy, Laparoscopy

The practice of draining body cavities has a long history in medical practice, extending back to antiquity. Draining chest empyema and ascites can be traced back to the time of Hippocrates in historical records [1]. Prophylactic abdominal drainage (ADs) have been used in colorectal surgery to remove intraperitoneal collections such as ascites, chyle, blood, and intestinal contents since the mid-1800s (notably reported by Billroth [2] in 1881). At that time, drainage was performed because these accumulations were believed to have the potential to cause infection. Further, ADs were also useful for early detection of postoperative bleeding or anastomotic leakage [3]. However, it has been widely recognized that there are no clear advantages to the use of prophylactic ADs in open colorectal surgery. Many studies have demonstrated little difference in postoperative complications, such as morbidity or mortality, regardless of AD placement [4-9]. Moreover, the Enhanced Recovery After Surgery (ERAS) guidelines recommend avoiding the routine use of ADs after colorectal surgery [10-12]. Despite these guidelines, a lot of surgeons routinely use this technique. According to an online survey on the adoption of ERAS guidelines among European Society of Coloproctology members in 2019 to 2020, it was found that the “no drainage” guideline was the least well-implemented [13]. This discrepancy underscores the ongoing debate and the lack of unanimous agreement in real-world clinical settings.

Research on ADs, particularly in minimally invasive surgeries, including laparoscopic procedures, has demonstrated a comparatively lower impact than well-established open surgery techniques. Owing to the varying practices implemented by hospitals and countries, more evidence is needed to support the decision not to use ADs in laparoscopic hemicolectomy. Given this clinical setting, to ensure generalizability and objectivity regarding the application of ADs in laparoscopic hemicolectomy, it is necessary to examine the differences in postoperative pain, recovery, complications, and other surgical outcomes between patients who have undergone the procedure with and without ADs (AD vs. no-AD groups). In this study, we attempted to challenge the conventional practice of prophylactic AD placement during laparoscopic hemicolectomy to uncover the potential effects associated with this approach.

Demographics

Data of all adult patients (aged ≥18 years) who underwent colorectal surgery at Seoul National University Bundang Hospital between April 2013 and September 2022 by a single surgeon were retrospectively reviewed using electronic medical records (EMRs). The exclusion criteria included surgeries other than hemicolectomies, presence of benign colonic diseases, requirement for simultaneous surgery for other conditions, and treatment with open hemicolectomies. Data on the baseline patient demographic characteristics, including age, sex, body mass index (BMI), smoking status, alcohol consumption status, presence of comorbidities, American Society of Anesthesiologists physical status (ASA PS) class, and history of abdominal surgery were collected. Information on blood tests, whether emergency surgery was conducted, operation time, estimated blood loss (EBL), type of operation, anastomotic configuration, time to gas passage after surgery, length of hospital stay after surgery, postoperative numerical rating scale (NRS) score for pain, postoperative complications, readmission rates within 30 days after surgery, operation year, and clinical stage of cancer were also reviewed. The final staging followed the American Joint Committee on Cancer 8th edition and is shown in Table 1. Readmissions within 30 days were included, regardless of whether they occurred in the emergency room or outpatient setting. The presence or absence of complications was objectively defined according to the Clavien-Dindo classification [14].

Table 1 . Summary of final staging

AJCC stage, 8th edNo-AD group (n = 112)AD group (n = 92)
O62
I3219
II3426
III3537
IV58

Most were adenocarcinomas.

AJCC, American Joint Committee on Cancer; AD, abdominal drainage.



Abdominal drainage

A Jackson-Pratt drain was used via the port site. There was no indication for inserting a drain, however, the decision to insert the drain was made by the colorectal surgeon after considering various factors, including the patient’s baseline information, bowel condition in the operating room, presence of severe inflammation, and high risk of anastomosis leakage. The drain was typically removed at least 5 days postoperatively, after the patient had consumed soft food and had a bowel movement. In some cases, the drain was kept in place for a longer period.

Outcomes measured

The primary outcome was postoperative NRS pain, specifically measured on the morning of the first, second, and fifth postoperative days (POD). In total, five ports (RUQ, LUQ, umbilicus, RLQ, and LLQ) were utilized. A standardized midline mini-laparotomy was performed with an incision length of 4 cm, ensuring no difference among the patient groups. Patient-controlled analgesia was uniformly used for all patients to control postoperative pain. Additionally, when patients reported severe pain, the nurses notified the physician, who then administered additional analgesics, such as acetaminophen, NSAIDs, or opioids. The time to flatus after surgery, length of hospital stay after surgery, readmission rates within 30 days after surgery, and postoperative complications were assessed as secondary outcomes.

Statistical analyses

Propensity scores were employed to estimate the probability of receiving a particular treatment conditional on baseline characteristics [15,16]. By incorporating these propensity scores into the analysis, the inverse probability of treatment weighting (IPTW) was used to reduce selection bias between the AD and no-AD groups. Weights were obtained by taking the inverse of the propensity scores, representing the probability of receiving an AD on the baseline covariates. A logistic regression model was applied to estimate the propensity scores for each participant, with the group variable as the dependent variable and the baseline covariates as the independent variables. A standardized mean difference (SMD) was calculated to evaluate covariate balance, with an absolute SMD greater than 0.2 indicating an imbalance. Potential confounding variables that could be considered before drain insertion into the operating room were included. Covariates for propensity scores in relation to the baseline characteristics of the patients were as follows: age, sex, BMI, smoking status, alcohol consumption status, presence of comorbidities, ASA PS class, history of abdominal surgery, blood tests, whether emergency surgery was conducted, type of operation, anastomotic configuration, year of operation, and clinical stage of cancer. All baseline characteristics described in Table 2 were used as covariates in regression modeling.

Table 2 . Demographic data of the study participants before and after IPTW

VariableBefore IPTW (n = 204)After IPTW (n = 402.8)
No-AD groupAD groupSMDNo-AD groupAD groupSMD
No. of participants11292227175.8
Age (yr)64.0 ± 13.366.8 ± 13.70.20766.5 ± 12.465.1 ± 13.80.107
Male sex53 (47.3)49 (53.3)0.059121.0 (53.3)86.9 (49.4)0.039
BMI (kg/m2)23.7 ± 3.224.7 ± 3.70.29123.9 ± 3.224.5 ± 3.40.161
Comorbidity81 (72.3)66 (71.7)0.006171.9 (75.7)122.3 (69.6)0.062
ASA PS grade0.1090.011
I, II95 (84.8)68 (73.9)174.7 (77.0)137.2 (78.1)
III, IV17 (15.2)24 (26.1)52.3 (23.0)38.6 (21.9)
Operation history30 (26.8)33 (35.9)0.09151.8 (22.8)55.1 (31.3)0.085
Smoking0.1780.061
Never82 (73.2)51 (55.4)132.2 (58.2)111.8 (63.6)
Ex21 (18.8)28 (30.4)56.6 (24.9)45.1 (25.6)
Current9 (8.0)13 (14.1)38.2 (16.8)18.9 (10.8)
Alcohol consumption0.0150.058
Never75 (67.0)63 (68.5)173.8 (76.6)124.4 (70.7)
Ex4 (3.6)3 (3.3)5.8 (2.6)4.8 (2.7)
Current33 (29.5)26 (28.3)47.3 (20.9)46.6 (26.5)
Clinical stage0.1170.071
1, 263 (56.2)41 (44.6)100.9 (44.4)90.7 (51.6)
3, 449 (43.8)51 (55.4)126.1 (55.6)85.1 (48.4)
Hemoglobin (g/dL)12.5 ± 2.111.1 ± 2.40.27212.0 ± 2.212.4 ± 2.60.189
WBC (×103/μL)6.8 ± 1.97.1 ± 2.50.1497.1 ± 1.97.2 ± 2.30.029
PLT (×103/μL)273.2 ± 82.1278.7±107.80.057282.2 ± 78.6289.0 ± 100.00.070
PT/INR1.0 ± 0.11.0 ± 0.10.0041.0 ± 0.11.0 ± 0.10.058
Albumin (g/dL)4.1 ± 0.53.9 ± 0.60.3774.0 ± 0.64.0 ± 0.60.133
Glucose (mg/dL)112.3 ± 28.0120.3 ± 33.80.259117.4 ± 28.4117.4 ± 30.10.001
Creatinine (mg/dL)0.8 ± 0.60.9 ± 0.60.0590.8 ± 0.50.9 ± 0.60.090
Operation year0.1670.070
2014–201847 (42.0)54 (58.7)128.4 (56.6)87.0 (49.5)
2019–202265 (58.0)38 (41.3)98.6 (43.4)88.8 (50.5)
Emergency operation4 (3.6)4 (4.3)0.00815.9 (7.0)18.3 (10.4)0.034
Radicality0.0470.001
R0110 (98.2)86 (93.5)216.6 (95.4)168.0 (95.5)
R22 (1.8)6 (6.5)10.4 (4.6)7.8 (4.5)
Operation time (min)134.7 ± 32.4164.4 ± 39.90.817152.5 ± 39.5155.2 ± 36.20.075
EBL (mL)56.3 ± 49.881.1 ± 84.80.35665.7 ± 63.471.4 ± 72.30.081
Operation type0.2050.093
LHC5 (4.5)23 (25.0)13.0 (5.7)26.4 (15.0)
RHC107 (95.5)69 (75.0)213.9 (94.3)149.4 (85.0)
Co-operationa)10 (8.9)9 (9.8)0.00925.2 (11.1)18.1 (10.3)0.008
Anastomosis type0.0230.009
Side-to-side107 (95.5)90 (97.8)221.5 (97.6)173.2 (98.5)
End-to-side5 (4.5)2 (2.2)5.5 (2.4)2.6 (1.5)

Values are presented as number only, mean ¡¾ standard deviation, or number (%).

IPTW, inverse probability of treatment weighting; AD, abdominal drainage; SMD, standardized mean difference; BMI, body mass index; ASA PS, American Society of Anesthesiologists physical status; WBC, white blood cell; PLT, platelet; PT, prothrombin ratio; INR, international normalized ratio; EBL, estimated blood loss; LHC, left hemicolectomy; RHC, right hemicolectomy.

a)Co-operation with other minor surgery.



Continuous variables are reported as the means or medians for normally distributed variables and compared using a two-sample t-test. The statistical significance of categorical variables was evaluated using the chi-square test or Fisher exact test. Statistical significance was considered at p-values of <0.05. Statistical analyses were performed using the R version 4.1.1 (R Foundation for Statistical Computing).

Study population

Fig. 1 presents the flowchart of patient selection. A total of 1,090 patients who underwent colectomies performed by a single surgeon at Seoul National University Bundang Hospital between April 2013 and September 2022 were retrospectively reviewed based on their EMRs. After excluding 632 patients who underwent other surgeries, such as cecectomy, ileocecectomy, anterior resection, Hartmann operation, and subtotal or total colectomy, only 404 patients who underwent right hemicolectomies and 54 patients who underwent left hemicolectomies (a total of 458 patients) were included. After excluding 131 patients with benign colonic diseases, nine patients who underwent simultaneous surgeries for other cancers, 111 patients who underwent open surgery, 179 patients who underwent laparoscopic right hemicolectomies, and 28 patients who underwent laparoscopic left hemicolectomies were included. Among them, three individuals had missing data, resulting in 204 patients being included in the review (AD group, 92 patients; no-AD group, 112 patients).

Fig. 1. Flow chart of patient selection. Three individuals were ruled out for inverse probability of treatment weighting adjustment due to insufficient data.
LHC, left hemicolectomy; RHC, right hemicolectomy.

Demographics

The baseline patient characteristics are shown in Table 2. Initially, variables such as age, BMI, hemoglobin level, albumin level, glucose level, operation time, EBL, and operation type between the two groups had a SMD exceeding 0.2. Therefore, IPTW was applied to adjust and align the SMD to <0.2, ensuring no significant differences in the variables between the two groups. A balanced plot of the potential confounding variables is shown in Fig. 2.

Fig. 2. Balance plot of potential confounding variables. Unadjusted means before adjustment with inverse probability of treatment weighting (IPTW) and adjusted means after adjustment with IPTW. Op, operation; EBL, estimated blood loss; BMI, body mass index; WBC, white blood cell; ASA, American Society of Anesthesiologists physical status classification; cStage, clinical stage; Em, emergency; Co-op, co-operation with other minor surgery.

Primary outcomes

The postoperative surgical outcomes are shown in Table 3. After adjustment with IPTW, the NRS on POD 1 was 3.4 ± 1.5 in the no-AD group and 3.3 ± 1.6 in the AD group, with no significant difference (p = 0.666). The NRS on POD 2 was significantly higher in the AD group than in the no-AD group (3.4 ± 0.8 vs. 3.2 ± 0.8, p = 0.043). On POD 5, the NRS was 2.5 ± 0.7 in the no-AD group and 2.4 ± 0.7 in the AD group, with no significant difference (p = 0.204). Postoperative NRS scores for pain on each day are shown in Fig. 3.

Table 3 . Postoperative surgical outcomes before and after IPTW

OutcomesBefore IPTW (n = 204)After IPTW (n = 402.8)
No-AD group (n = 112)AD group (n = 92)p-valueNo-AD group (n = 227)AD group (n = 175.8)p-value
NRS
POD 13.7 ± 1.43.1 ± 1.60.0023.4 ± 1.53.3 ± 1.60.666
POD 23.3 ± 0.83.3 ± 0.90.9813.2 ± 0.83.4 ± 0.80.043
POD 52.4 ± 0.72.4 ± 0.80.8612.5 ± 0.72.4 ± 0.70.204
Postoperative complications17 (15.2)13 (14.1)0.83328.2 (12.4)30.4 (17.3)0.170
Hospital stay (day)6.9 ± 3.87.3 ± 2.90.4796.9 ± 3.07.3 ± 2.80.298
First time to flatus (day)2.9 ± 1.02.9 ± 1.00.5662.7 ± 0.92.9 ± 0.90.078
Readmission (%)2.72.21.0001.72.30.733

Values are presented as mean ± standard deviation, number (%), or percentage only.

IPTW, inverse probability of treatment weighting; AD, abdominal drainage; NRS, numerical rating scale; POD, postoperative day.



Fig. 3. Postoperative NRS pain score on each day in the unadjusted (A) and adjusted (B) patient groups. Unadjusted means before adjustment with inverse probability of treatment weighting (IPTW) and adjusted means after adjustment with IPTW.
AD, abdominal drainage.

Secondary outcomes

After adjustment with IPTW, no statistically significant differences in complications were found between the no-AD (28.2 cases, 12.4%) and AD (30.4 cases, 17.3%) groups (p = 0.170). Surgical complications were classified according to the Clavien-Dindo grade, as summarized in Table 4. Grade 1 complications were observed in eight cases in both groups. Grade 2 complications were present in six cases in the no-AD group and three cases in the AD group. Grade 3 complications occurred in two cases in each group. Additionally, one case of a Grade 4 complication was reported in the no-AD group. Notably, in the no-AD group, there were two cases of anastomotic leakage, both of which required reoperation. The length of postoperative hospital stay was 6.8 ± 3.0 days and 7.3 ± 2.8 days in the no-AD and AD groups, respectively, with no statistically significant difference (p = 0.298). The time to flatus was 2.7 ± 0.9 days in the no-AD group and 2.9 ± 0.9 days in the AD group, with no statistically significant difference (p = 0.078). Finally, regarding readmission to the outpatient or emergency departments within 1 month, four cases (1.7%) in the no-AD group and four cases (2.3%) in the AD group were noted, with no significant difference (p = 0.733).

Table 4 . Clavien-Dindo classification of surgical complica­tions

Clavien-Dindo classificationNo AD group (n = 17)AD group (n = 13)
Grade I88
Grade II63
Grade III22
Grade IV10

AD, abdominal drainage.


To the best of our knowledge, this is the first study to determine the effect of prophylactic AD on postoperative pain in patients with colon cancer undergoing laparoscopic surgery.

The primary objective of this study was to evaluate the effect of prophylactic AD during laparoscopic hemicolectomy. The results showed that the absence of AD did not result in any statistically significant differences in postoperative surgical outcomes, except for postoperative pain, providing crucial evidence for clinical decision-making regarding the use of AD in laparoscopic hemicolectomy. Thus, this provides new insights into the role of AD in laparoscopic hemicolectomy, especially in the context of postoperative pain management.

The placement of surgical drains has long been considered an important aspect of the postoperative management of patients [17]. As mentioned above, AD is commonly performed with the rationale that it may prevent complicated intraabdominal fluid collection, reduce anastomotic leakage, and allow early detection of bleeding, anastomotic leakage, or other complications [18,19]. However, conflicting results have been reported regarding the efficacy and safety of AD. In a meta-analysis by Urbach et al. [6], drains did not effectively detect anastomotic leakage at an early stage. Among the 20 patients with drains who experienced anastomotic leakage, the diagnosis relied on the identification of intestinal content in the effluent in only one case, constituting a 5% detection rate. Drain placement has also been associated with additional adverse events such as increased production of serous fluid, wound infection, and mobility discomfort [20,21]. In addition, AD has been shown to affect the well-being of patients, while indwelling drains have been associated with increased discomfort, which can increase postoperative anxiety [22]. Moreover, many studies do not support the routine use of prophylactic AD after colorectal surgery because of the lack of clinical benefits [23,24]. However, these studies were conducted before the era of minimally invasive surgery, and there is a relative scarcity of research on AD in the context of laparoscopic surgery.

This study found that AD could exacerbate postoperative pain after laparoscopic hemicolectomy. Patients are expected to experience severe pain immediately after surgery, regardless of the presence of AD, which should gradually decrease daily starting from POD 1. In our study, NRS on POD 2 was significantly higher in the AD group than in the no-AD group after IPTW, suggesting that AD had an effect on the degree of postoperative pain. Thus, this study contributes to the limited research on prophylactic AD in hemicolectomy patients.

In our study, we did not observe significant differences between the two groups in terms of length of hospital stay. However, other studies have reported a significantly shorter duration of this parameter. Studies conducted by Hagmüller et al. [25] (with a mean hospital stay of 14.9 days in the AD group vs. 13.3 days in the no-AD group) and Sagar et al. [26] (with a median hospital stay of 12 days in the AD group vs. 13 days in the no-AD group), both published before the implementation of advanced recovery protocols, reported a shorter duration of hospital stay in the no-AD group. Some studies have proposed that refraining from AD implementation could result in improved functional outcomes and a reduced hospital period [27]. This effect may be influenced by differences in postoperative care protocols; however, further research is needed to confirm this hypothesis.

Our study has some limitations. Firstly, it is important to note that although the NRS is a reliable and valid measure of pain intensity and distress, it captures only part of the pain experienced by patients [28]. In addition, the retrospective review of these scores and the small sample size in this study may introduce limitations in terms of reliability. It should be noted that this study was conducted by a single surgeon at a single center. Additionally, given the complexity and difficulty of surgeries, surgeons may have preferred to use AD, which could introduce a potential bias.

In conclusion, the results of this single-center retrospective study suggest that AD can exacerbate postoperative pain in patients without increasing the risk of complications. This study could serve as crucial evidence to support the decision not to insert prophylactic AD in actual clinical practice.

Ethical statements

This study was approved by the Institutional Review Board (IRB) of Seoul National University Bundang Hospital (IRB No. B-2308-844-101). In accordance with the policy of the IRB, the need for informed consent was waived due to the retrospective design and minimal risk to the patients.

Authors’ contributions

Conceptualization: HKO

Data curation: SSH, HP, HHS

Formal analysis: SSH, HKO, EJ

Investigation: SSH, HHS

Methodology: SSH, HKO, EJ, HA, ANS DWK, SBK

Supervision: HKO

Writing–original draft: SSH, HKO

Writing–review & editing: SSH, HKO, HRS, TGL, MJC, MHJ, HA, ANS, DWK, SBK

All authors read and approved the final manuscript.

Conflict of interest

Heung Kwon Oh, serving as the editorial board of Journal of Minimally Invasive Surgery, did not participate in the review process of this article. No other potential conflicts of interest pertinent to this article were reported.

Funding/support

None.

Acknowledgments

The authors would like to acknowledge the presentation of this research at the ACKSS 2023 where it received valuable feedback.

Data availability

The data presented in this study are available upon reasonable request to the corresponding author.

  1. Robinson JO. Surgical drainage: an historical perspective. Br J Surg 1986;73:422-426.
    Pubmed CrossRef
  2. Billroth T. Clinical surgery. The New Sydenham Society; 1881:307-308.
  3. Manz CW, LaTendresse C, Sako Y. The detrimental effects of drains on colonic anastomoses: an experimental study. Dis Colon Rectum 1970;13:17-25.
    Pubmed CrossRef
  4. Petrowsky H, Demartines N, Rousson V, Clavien PA. Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-analyses. Ann Surg 2004;240:1074-1085.
    Pubmed KoreaMed CrossRef
  5. Merad F, Yahchouchi E, Hay JM, Fingerhut A, Laborde Y, Langlois-Zantain O. Prophylactic abdominal drainage after elective colonic resection and suprapromontory anastomosis: a multicenter study controlled by randomization. French Associations for Surgical Research. Arch Surg 1998;133:309-314.
    Pubmed CrossRef
  6. Urbach DR, Kennedy ED, Cohen MM. Colon and rectal anastomoses do not require routine drainage: a systematic review and meta-analysis. Ann Surg 1999;229:174-180.
    CrossRef
  7. Merad F, Hay JM, Fingerhut A, et al. Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis?: a multicenter controlled randomized trial. French Association for Surgical Research. Surgery 1999;125:529-535.
    Pubmed CrossRef
  8. 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;31:951-960.
    Pubmed KoreaMed CrossRef
  9. Denost Q, Rouanet P, Faucheron JL, et al. To drain or not to drain infraperitoneal anastomosis after rectal excision for cancer: the GRECCAR 5 Randomized Trial. Ann Surg 2017;265:474-480.
    Pubmed CrossRef
  10. Carmichael JC, Keller DS, Baldini G, et al. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2017;60:761-784.
    Pubmed CrossRef
  11. 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 2019;43:659-695.
    Pubmed CrossRef
  12. Cavallaro P, Bordeianou L. Implementation of an ERAS pathway in colorectal surgery. Clin Colon Rectal Surg 2019;32:102-108.
    Pubmed KoreaMed CrossRef
  13. ESCP Enhanced Recovery Collaborating Group. An international assessment of the adoption of enhanced recovery after surgery (ERAS®) principles across colorectal units in 2019-2020. Colorectal Dis 2021;23:2980-2987.
    Pubmed CrossRef
  14. 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;240:205-213.
    Pubmed KoreaMed CrossRef
  15. Heinze G, Jüni P. An overview of the objectives of and the approaches to propensity score analyses. Eur Heart J 2011;32:1704-1708.
    Pubmed CrossRef
  16. Cole SR, Hernán MA. Adjusted survival curves with inverse probability weights. Comput Methods Programs Biomed 2004;75:45-49.
    Pubmed CrossRef
  17. Makama JG, Ameh EA. Surgical drains: what the resident needs to know. Niger J Med 2008;17:244-250.
    Pubmed CrossRef
  18. Puleo FJ, Mishra N, Hall JF. Use of intra-abdominal drains. Clin Colon Rectal Surg 2013;26:174-177.
    Pubmed KoreaMed CrossRef
  19. Frouws MA, van de Velde CJ. Routine prophylactic drainage in rectal surgery: closing the chapter? Transl Cancer Res 2016;5(Suppl 7):S1345-S1348.
    CrossRef
  20. Tsujinaka S, Konishi F. Drain vs no drain after colorectal surgery. Indian J Surg Oncol 2011;2:3-8.
    Pubmed KoreaMed CrossRef
  21. Mujagic E, Zeindler J, Coslovsky M, et al. The association of surgical drains with surgical site infections: a prospective observational study. Am J Surg 2019;217:17-23.
    Pubmed CrossRef
  22. Findik UY, Topcu SY, Vatansever O. Effects of drains on pain, comfort and anxiety in patients undergone surgery. Int J Caring Sci 2013;6:412-419.
  23. Cavaliere D, Popivanov G, Cassini D, et al. Is a drain necessary after anterior resection of the rectum?: a systematic review and meta-analysis. Int J Colorectal Dis 2019;34:973-981.
    Pubmed CrossRef
  24. Karliczek A, Jesus EC, Matos D, Castro AA, Atallah AN, Wiggers T. Drainage or nondrainage in elective colorectal anastomosis: a systematic review and meta-analysis. Colorectal Dis 2006;8:259-265.
    Pubmed CrossRef
  25. Hagmüller E, Lorenz D, Werthmann K, Trede M. Uses and risks of drainage following elective colon resection: a prospective, randomized and controlled clinical study. Chirurg 1990;61:266-271.
    Pubmed
  26. Sagar PM, Couse N, Kerin M, May J, MacFie J. Randomized trial of drainage of colorectal anastomosis. Br J Surg 1993;80:769-771.
    Pubmed CrossRef
  27. Greer NL, Gunnar WP, Dahm P, et al. Enhanced recovery protocols for adults undergoing colorectal surgery: a systematic review and meta-analysis. Dis Colon Rectum 2018;61:1108-1118.
    Pubmed CrossRef
  28. Wood BM, Nicholas MK, Blyth F, Asghari A, Gibson S. Assessing pain in older people with persistent pain: the NRS is valid but only provides part of the picture. J Pain 2010;11:1259-1266.
    Pubmed CrossRef

Article

Original Article

Journal of Minimally Invasive Surgery 2024; 27(2): 76-84

Published online June 15, 2024 https://doi.org/10.7602/jmis.2024.27.2.76

Copyright © The Korean Society of Endo-Laparoscopic & Robotic Surgery.

Effect of prophylactic abdominal drainage on postoperative pain in laparoscopic hemicolectomy for colon cancer: a single-center observational study in Korea

Sung Seo Hwang1 , Heung-Kwon Oh1,2 , Hye-Rim Shin1 , Tae-Gyun Lee1 , Mi Jeong Choi1 , Min Hyeong Jo1 , Hong-min Ahn1 , Hyeonjeong Park1 , Hyun Hee Sim1 , Eunjeong Ji3 , Anuj Naresh Singhi1,4 , Duck-Woo Kim1,2 , Sung-Bum Kang1,2

1Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
2Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
3Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Korea
4Department of General Surgery, Saifee Hospital, Mumbai, India

Correspondence to:Heung-Kwon Oh
Department of Surgery, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea
E-mail: crsohk@gmail.com
https://orcid.org/0000-0002-8066-2367

Received: April 25, 2024; Revised: June 5, 2024; Accepted: June 8, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose: This study aimed to evaluate the effect of prophylactic abdominal drainage (AD) in laparoscopic hemicolectomy, focusing on assessing postoperative pain outcomes.
Methods: Patients were categorized into two groups: those with and without AD (AD group vs. no-AD group). A numerical rating scale (NRS) was used to assess postoperative pain on each postoperative day (POD). Further, the inverse probability of treatment weighting (IPTW) method was used to reduce intergroup bias.
Results: In total, 204 patients who underwent laparoscopic hemicolectomies by a single surgeon between June 2013 and September 2022 at a single institution were retrospectively reviewed. After adjusting for IPTW, NRS scores on POD 2 were significantly lower in the no-AD group (3.2 ± 0.8 vs. 3.4 ± 0.8, p = 0.043). Further examination of postoperative outcomes showed no statistically significant differences in complications between the AD (17.3%) and no-AD (12.4%) groups (p = 0.170). The postoperative length of hospital stay was 7.3 ± 2.8 days in the AD group and 6.9 ± 3.0 days in the no-AD group, with no significant difference (p = 0.298). Time to first flatus was 3.0 ± 0.9 days in the AD group and 2.7 ± 0.9 days in the no-AD group, with no significant difference (p = 0.078). Regarding readmission within 1 month, there were four cases each in the AD (2.3%) and no-AD (1.7%) groups, with no significant difference (p = 0.733).
Conclusion: Laparoscopic hemicolectomy without AD resulted in no significant differences in postoperative clinical outcomes, except for postoperative pain. This finding suggests that prophylactic AD may exacerbate postoperative pain.

Keywords: Drainage, Colectomy, Laparoscopy

INTRODUCTION

The practice of draining body cavities has a long history in medical practice, extending back to antiquity. Draining chest empyema and ascites can be traced back to the time of Hippocrates in historical records [1]. Prophylactic abdominal drainage (ADs) have been used in colorectal surgery to remove intraperitoneal collections such as ascites, chyle, blood, and intestinal contents since the mid-1800s (notably reported by Billroth [2] in 1881). At that time, drainage was performed because these accumulations were believed to have the potential to cause infection. Further, ADs were also useful for early detection of postoperative bleeding or anastomotic leakage [3]. However, it has been widely recognized that there are no clear advantages to the use of prophylactic ADs in open colorectal surgery. Many studies have demonstrated little difference in postoperative complications, such as morbidity or mortality, regardless of AD placement [4-9]. Moreover, the Enhanced Recovery After Surgery (ERAS) guidelines recommend avoiding the routine use of ADs after colorectal surgery [10-12]. Despite these guidelines, a lot of surgeons routinely use this technique. According to an online survey on the adoption of ERAS guidelines among European Society of Coloproctology members in 2019 to 2020, it was found that the “no drainage” guideline was the least well-implemented [13]. This discrepancy underscores the ongoing debate and the lack of unanimous agreement in real-world clinical settings.

Research on ADs, particularly in minimally invasive surgeries, including laparoscopic procedures, has demonstrated a comparatively lower impact than well-established open surgery techniques. Owing to the varying practices implemented by hospitals and countries, more evidence is needed to support the decision not to use ADs in laparoscopic hemicolectomy. Given this clinical setting, to ensure generalizability and objectivity regarding the application of ADs in laparoscopic hemicolectomy, it is necessary to examine the differences in postoperative pain, recovery, complications, and other surgical outcomes between patients who have undergone the procedure with and without ADs (AD vs. no-AD groups). In this study, we attempted to challenge the conventional practice of prophylactic AD placement during laparoscopic hemicolectomy to uncover the potential effects associated with this approach.

METHODS

Demographics

Data of all adult patients (aged ≥18 years) who underwent colorectal surgery at Seoul National University Bundang Hospital between April 2013 and September 2022 by a single surgeon were retrospectively reviewed using electronic medical records (EMRs). The exclusion criteria included surgeries other than hemicolectomies, presence of benign colonic diseases, requirement for simultaneous surgery for other conditions, and treatment with open hemicolectomies. Data on the baseline patient demographic characteristics, including age, sex, body mass index (BMI), smoking status, alcohol consumption status, presence of comorbidities, American Society of Anesthesiologists physical status (ASA PS) class, and history of abdominal surgery were collected. Information on blood tests, whether emergency surgery was conducted, operation time, estimated blood loss (EBL), type of operation, anastomotic configuration, time to gas passage after surgery, length of hospital stay after surgery, postoperative numerical rating scale (NRS) score for pain, postoperative complications, readmission rates within 30 days after surgery, operation year, and clinical stage of cancer were also reviewed. The final staging followed the American Joint Committee on Cancer 8th edition and is shown in Table 1. Readmissions within 30 days were included, regardless of whether they occurred in the emergency room or outpatient setting. The presence or absence of complications was objectively defined according to the Clavien-Dindo classification [14].

Table 1 . Summary of final staging.

AJCC stage, 8th edNo-AD group (n = 112)AD group (n = 92)
O62
I3219
II3426
III3537
IV58

Most were adenocarcinomas..

AJCC, American Joint Committee on Cancer; AD, abdominal drainage..



Abdominal drainage

A Jackson-Pratt drain was used via the port site. There was no indication for inserting a drain, however, the decision to insert the drain was made by the colorectal surgeon after considering various factors, including the patient’s baseline information, bowel condition in the operating room, presence of severe inflammation, and high risk of anastomosis leakage. The drain was typically removed at least 5 days postoperatively, after the patient had consumed soft food and had a bowel movement. In some cases, the drain was kept in place for a longer period.

Outcomes measured

The primary outcome was postoperative NRS pain, specifically measured on the morning of the first, second, and fifth postoperative days (POD). In total, five ports (RUQ, LUQ, umbilicus, RLQ, and LLQ) were utilized. A standardized midline mini-laparotomy was performed with an incision length of 4 cm, ensuring no difference among the patient groups. Patient-controlled analgesia was uniformly used for all patients to control postoperative pain. Additionally, when patients reported severe pain, the nurses notified the physician, who then administered additional analgesics, such as acetaminophen, NSAIDs, or opioids. The time to flatus after surgery, length of hospital stay after surgery, readmission rates within 30 days after surgery, and postoperative complications were assessed as secondary outcomes.

Statistical analyses

Propensity scores were employed to estimate the probability of receiving a particular treatment conditional on baseline characteristics [15,16]. By incorporating these propensity scores into the analysis, the inverse probability of treatment weighting (IPTW) was used to reduce selection bias between the AD and no-AD groups. Weights were obtained by taking the inverse of the propensity scores, representing the probability of receiving an AD on the baseline covariates. A logistic regression model was applied to estimate the propensity scores for each participant, with the group variable as the dependent variable and the baseline covariates as the independent variables. A standardized mean difference (SMD) was calculated to evaluate covariate balance, with an absolute SMD greater than 0.2 indicating an imbalance. Potential confounding variables that could be considered before drain insertion into the operating room were included. Covariates for propensity scores in relation to the baseline characteristics of the patients were as follows: age, sex, BMI, smoking status, alcohol consumption status, presence of comorbidities, ASA PS class, history of abdominal surgery, blood tests, whether emergency surgery was conducted, type of operation, anastomotic configuration, year of operation, and clinical stage of cancer. All baseline characteristics described in Table 2 were used as covariates in regression modeling.

Table 2 . Demographic data of the study participants before and after IPTW.

VariableBefore IPTW (n = 204)After IPTW (n = 402.8)
No-AD groupAD groupSMDNo-AD groupAD groupSMD
No. of participants11292227175.8
Age (yr)64.0 ± 13.366.8 ± 13.70.20766.5 ± 12.465.1 ± 13.80.107
Male sex53 (47.3)49 (53.3)0.059121.0 (53.3)86.9 (49.4)0.039
BMI (kg/m2)23.7 ± 3.224.7 ± 3.70.29123.9 ± 3.224.5 ± 3.40.161
Comorbidity81 (72.3)66 (71.7)0.006171.9 (75.7)122.3 (69.6)0.062
ASA PS grade0.1090.011
I, II95 (84.8)68 (73.9)174.7 (77.0)137.2 (78.1)
III, IV17 (15.2)24 (26.1)52.3 (23.0)38.6 (21.9)
Operation history30 (26.8)33 (35.9)0.09151.8 (22.8)55.1 (31.3)0.085
Smoking0.1780.061
Never82 (73.2)51 (55.4)132.2 (58.2)111.8 (63.6)
Ex21 (18.8)28 (30.4)56.6 (24.9)45.1 (25.6)
Current9 (8.0)13 (14.1)38.2 (16.8)18.9 (10.8)
Alcohol consumption0.0150.058
Never75 (67.0)63 (68.5)173.8 (76.6)124.4 (70.7)
Ex4 (3.6)3 (3.3)5.8 (2.6)4.8 (2.7)
Current33 (29.5)26 (28.3)47.3 (20.9)46.6 (26.5)
Clinical stage0.1170.071
1, 263 (56.2)41 (44.6)100.9 (44.4)90.7 (51.6)
3, 449 (43.8)51 (55.4)126.1 (55.6)85.1 (48.4)
Hemoglobin (g/dL)12.5 ± 2.111.1 ± 2.40.27212.0 ± 2.212.4 ± 2.60.189
WBC (×103/μL)6.8 ± 1.97.1 ± 2.50.1497.1 ± 1.97.2 ± 2.30.029
PLT (×103/μL)273.2 ± 82.1278.7±107.80.057282.2 ± 78.6289.0 ± 100.00.070
PT/INR1.0 ± 0.11.0 ± 0.10.0041.0 ± 0.11.0 ± 0.10.058
Albumin (g/dL)4.1 ± 0.53.9 ± 0.60.3774.0 ± 0.64.0 ± 0.60.133
Glucose (mg/dL)112.3 ± 28.0120.3 ± 33.80.259117.4 ± 28.4117.4 ± 30.10.001
Creatinine (mg/dL)0.8 ± 0.60.9 ± 0.60.0590.8 ± 0.50.9 ± 0.60.090
Operation year0.1670.070
2014–201847 (42.0)54 (58.7)128.4 (56.6)87.0 (49.5)
2019–202265 (58.0)38 (41.3)98.6 (43.4)88.8 (50.5)
Emergency operation4 (3.6)4 (4.3)0.00815.9 (7.0)18.3 (10.4)0.034
Radicality0.0470.001
R0110 (98.2)86 (93.5)216.6 (95.4)168.0 (95.5)
R22 (1.8)6 (6.5)10.4 (4.6)7.8 (4.5)
Operation time (min)134.7 ± 32.4164.4 ± 39.90.817152.5 ± 39.5155.2 ± 36.20.075
EBL (mL)56.3 ± 49.881.1 ± 84.80.35665.7 ± 63.471.4 ± 72.30.081
Operation type0.2050.093
LHC5 (4.5)23 (25.0)13.0 (5.7)26.4 (15.0)
RHC107 (95.5)69 (75.0)213.9 (94.3)149.4 (85.0)
Co-operationa)10 (8.9)9 (9.8)0.00925.2 (11.1)18.1 (10.3)0.008
Anastomosis type0.0230.009
Side-to-side107 (95.5)90 (97.8)221.5 (97.6)173.2 (98.5)
End-to-side5 (4.5)2 (2.2)5.5 (2.4)2.6 (1.5)

Values are presented as number only, mean ¡¾ standard deviation, or number (%)..

IPTW, inverse probability of treatment weighting; AD, abdominal drainage; SMD, standardized mean difference; BMI, body mass index; ASA PS, American Society of Anesthesiologists physical status; WBC, white blood cell; PLT, platelet; PT, prothrombin ratio; INR, international normalized ratio; EBL, estimated blood loss; LHC, left hemicolectomy; RHC, right hemicolectomy..

a)Co-operation with other minor surgery..



Continuous variables are reported as the means or medians for normally distributed variables and compared using a two-sample t-test. The statistical significance of categorical variables was evaluated using the chi-square test or Fisher exact test. Statistical significance was considered at p-values of <0.05. Statistical analyses were performed using the R version 4.1.1 (R Foundation for Statistical Computing).

RESULTS

Study population

Fig. 1 presents the flowchart of patient selection. A total of 1,090 patients who underwent colectomies performed by a single surgeon at Seoul National University Bundang Hospital between April 2013 and September 2022 were retrospectively reviewed based on their EMRs. After excluding 632 patients who underwent other surgeries, such as cecectomy, ileocecectomy, anterior resection, Hartmann operation, and subtotal or total colectomy, only 404 patients who underwent right hemicolectomies and 54 patients who underwent left hemicolectomies (a total of 458 patients) were included. After excluding 131 patients with benign colonic diseases, nine patients who underwent simultaneous surgeries for other cancers, 111 patients who underwent open surgery, 179 patients who underwent laparoscopic right hemicolectomies, and 28 patients who underwent laparoscopic left hemicolectomies were included. Among them, three individuals had missing data, resulting in 204 patients being included in the review (AD group, 92 patients; no-AD group, 112 patients).

Figure 1. Flow chart of patient selection. Three individuals were ruled out for inverse probability of treatment weighting adjustment due to insufficient data.
LHC, left hemicolectomy; RHC, right hemicolectomy.

Demographics

The baseline patient characteristics are shown in Table 2. Initially, variables such as age, BMI, hemoglobin level, albumin level, glucose level, operation time, EBL, and operation type between the two groups had a SMD exceeding 0.2. Therefore, IPTW was applied to adjust and align the SMD to <0.2, ensuring no significant differences in the variables between the two groups. A balanced plot of the potential confounding variables is shown in Fig. 2.

Figure 2. Balance plot of potential confounding variables. Unadjusted means before adjustment with inverse probability of treatment weighting (IPTW) and adjusted means after adjustment with IPTW. Op, operation; EBL, estimated blood loss; BMI, body mass index; WBC, white blood cell; ASA, American Society of Anesthesiologists physical status classification; cStage, clinical stage; Em, emergency; Co-op, co-operation with other minor surgery.

Primary outcomes

The postoperative surgical outcomes are shown in Table 3. After adjustment with IPTW, the NRS on POD 1 was 3.4 ± 1.5 in the no-AD group and 3.3 ± 1.6 in the AD group, with no significant difference (p = 0.666). The NRS on POD 2 was significantly higher in the AD group than in the no-AD group (3.4 ± 0.8 vs. 3.2 ± 0.8, p = 0.043). On POD 5, the NRS was 2.5 ± 0.7 in the no-AD group and 2.4 ± 0.7 in the AD group, with no significant difference (p = 0.204). Postoperative NRS scores for pain on each day are shown in Fig. 3.

Table 3 . Postoperative surgical outcomes before and after IPTW.

OutcomesBefore IPTW (n = 204)After IPTW (n = 402.8)
No-AD group (n = 112)AD group (n = 92)p-valueNo-AD group (n = 227)AD group (n = 175.8)p-value
NRS
POD 13.7 ± 1.43.1 ± 1.60.0023.4 ± 1.53.3 ± 1.60.666
POD 23.3 ± 0.83.3 ± 0.90.9813.2 ± 0.83.4 ± 0.80.043
POD 52.4 ± 0.72.4 ± 0.80.8612.5 ± 0.72.4 ± 0.70.204
Postoperative complications17 (15.2)13 (14.1)0.83328.2 (12.4)30.4 (17.3)0.170
Hospital stay (day)6.9 ± 3.87.3 ± 2.90.4796.9 ± 3.07.3 ± 2.80.298
First time to flatus (day)2.9 ± 1.02.9 ± 1.00.5662.7 ± 0.92.9 ± 0.90.078
Readmission (%)2.72.21.0001.72.30.733

Values are presented as mean ± standard deviation, number (%), or percentage only..

IPTW, inverse probability of treatment weighting; AD, abdominal drainage; NRS, numerical rating scale; POD, postoperative day..



Figure 3. Postoperative NRS pain score on each day in the unadjusted (A) and adjusted (B) patient groups. Unadjusted means before adjustment with inverse probability of treatment weighting (IPTW) and adjusted means after adjustment with IPTW.
AD, abdominal drainage.

Secondary outcomes

After adjustment with IPTW, no statistically significant differences in complications were found between the no-AD (28.2 cases, 12.4%) and AD (30.4 cases, 17.3%) groups (p = 0.170). Surgical complications were classified according to the Clavien-Dindo grade, as summarized in Table 4. Grade 1 complications were observed in eight cases in both groups. Grade 2 complications were present in six cases in the no-AD group and three cases in the AD group. Grade 3 complications occurred in two cases in each group. Additionally, one case of a Grade 4 complication was reported in the no-AD group. Notably, in the no-AD group, there were two cases of anastomotic leakage, both of which required reoperation. The length of postoperative hospital stay was 6.8 ± 3.0 days and 7.3 ± 2.8 days in the no-AD and AD groups, respectively, with no statistically significant difference (p = 0.298). The time to flatus was 2.7 ± 0.9 days in the no-AD group and 2.9 ± 0.9 days in the AD group, with no statistically significant difference (p = 0.078). Finally, regarding readmission to the outpatient or emergency departments within 1 month, four cases (1.7%) in the no-AD group and four cases (2.3%) in the AD group were noted, with no significant difference (p = 0.733).

Table 4 . Clavien-Dindo classification of surgical complica­tions.

Clavien-Dindo classificationNo AD group (n = 17)AD group (n = 13)
Grade I88
Grade II63
Grade III22
Grade IV10

AD, abdominal drainage..


DISCUSSION

To the best of our knowledge, this is the first study to determine the effect of prophylactic AD on postoperative pain in patients with colon cancer undergoing laparoscopic surgery.

The primary objective of this study was to evaluate the effect of prophylactic AD during laparoscopic hemicolectomy. The results showed that the absence of AD did not result in any statistically significant differences in postoperative surgical outcomes, except for postoperative pain, providing crucial evidence for clinical decision-making regarding the use of AD in laparoscopic hemicolectomy. Thus, this provides new insights into the role of AD in laparoscopic hemicolectomy, especially in the context of postoperative pain management.

The placement of surgical drains has long been considered an important aspect of the postoperative management of patients [17]. As mentioned above, AD is commonly performed with the rationale that it may prevent complicated intraabdominal fluid collection, reduce anastomotic leakage, and allow early detection of bleeding, anastomotic leakage, or other complications [18,19]. However, conflicting results have been reported regarding the efficacy and safety of AD. In a meta-analysis by Urbach et al. [6], drains did not effectively detect anastomotic leakage at an early stage. Among the 20 patients with drains who experienced anastomotic leakage, the diagnosis relied on the identification of intestinal content in the effluent in only one case, constituting a 5% detection rate. Drain placement has also been associated with additional adverse events such as increased production of serous fluid, wound infection, and mobility discomfort [20,21]. In addition, AD has been shown to affect the well-being of patients, while indwelling drains have been associated with increased discomfort, which can increase postoperative anxiety [22]. Moreover, many studies do not support the routine use of prophylactic AD after colorectal surgery because of the lack of clinical benefits [23,24]. However, these studies were conducted before the era of minimally invasive surgery, and there is a relative scarcity of research on AD in the context of laparoscopic surgery.

This study found that AD could exacerbate postoperative pain after laparoscopic hemicolectomy. Patients are expected to experience severe pain immediately after surgery, regardless of the presence of AD, which should gradually decrease daily starting from POD 1. In our study, NRS on POD 2 was significantly higher in the AD group than in the no-AD group after IPTW, suggesting that AD had an effect on the degree of postoperative pain. Thus, this study contributes to the limited research on prophylactic AD in hemicolectomy patients.

In our study, we did not observe significant differences between the two groups in terms of length of hospital stay. However, other studies have reported a significantly shorter duration of this parameter. Studies conducted by Hagmüller et al. [25] (with a mean hospital stay of 14.9 days in the AD group vs. 13.3 days in the no-AD group) and Sagar et al. [26] (with a median hospital stay of 12 days in the AD group vs. 13 days in the no-AD group), both published before the implementation of advanced recovery protocols, reported a shorter duration of hospital stay in the no-AD group. Some studies have proposed that refraining from AD implementation could result in improved functional outcomes and a reduced hospital period [27]. This effect may be influenced by differences in postoperative care protocols; however, further research is needed to confirm this hypothesis.

Our study has some limitations. Firstly, it is important to note that although the NRS is a reliable and valid measure of pain intensity and distress, it captures only part of the pain experienced by patients [28]. In addition, the retrospective review of these scores and the small sample size in this study may introduce limitations in terms of reliability. It should be noted that this study was conducted by a single surgeon at a single center. Additionally, given the complexity and difficulty of surgeries, surgeons may have preferred to use AD, which could introduce a potential bias.

In conclusion, the results of this single-center retrospective study suggest that AD can exacerbate postoperative pain in patients without increasing the risk of complications. This study could serve as crucial evidence to support the decision not to insert prophylactic AD in actual clinical practice.

Notes

Ethical statements

This study was approved by the Institutional Review Board (IRB) of Seoul National University Bundang Hospital (IRB No. B-2308-844-101). In accordance with the policy of the IRB, the need for informed consent was waived due to the retrospective design and minimal risk to the patients.

Authors’ contributions

Conceptualization: HKO

Data curation: SSH, HP, HHS

Formal analysis: SSH, HKO, EJ

Investigation: SSH, HHS

Methodology: SSH, HKO, EJ, HA, ANS DWK, SBK

Supervision: HKO

Writing–original draft: SSH, HKO

Writing–review & editing: SSH, HKO, HRS, TGL, MJC, MHJ, HA, ANS, DWK, SBK

All authors read and approved the final manuscript.

Conflict of interest

Heung Kwon Oh, serving as the editorial board of Journal of Minimally Invasive Surgery, did not participate in the review process of this article. No other potential conflicts of interest pertinent to this article were reported.

Funding/support

None.

Acknowledgments

The authors would like to acknowledge the presentation of this research at the ACKSS 2023 where it received valuable feedback.

Data availability

The data presented in this study are available upon reasonable request to the corresponding author.

Fig 1.

Figure 1.Flow chart of patient selection. Three individuals were ruled out for inverse probability of treatment weighting adjustment due to insufficient data.
LHC, left hemicolectomy; RHC, right hemicolectomy.
Journal of Minimally Invasive Surgery 2024; 27: 76-84https://doi.org/10.7602/jmis.2024.27.2.76

Fig 2.

Figure 2.Balance plot of potential confounding variables. Unadjusted means before adjustment with inverse probability of treatment weighting (IPTW) and adjusted means after adjustment with IPTW. Op, operation; EBL, estimated blood loss; BMI, body mass index; WBC, white blood cell; ASA, American Society of Anesthesiologists physical status classification; cStage, clinical stage; Em, emergency; Co-op, co-operation with other minor surgery.
Journal of Minimally Invasive Surgery 2024; 27: 76-84https://doi.org/10.7602/jmis.2024.27.2.76

Fig 3.

Figure 3.Postoperative NRS pain score on each day in the unadjusted (A) and adjusted (B) patient groups. Unadjusted means before adjustment with inverse probability of treatment weighting (IPTW) and adjusted means after adjustment with IPTW.
AD, abdominal drainage.
Journal of Minimally Invasive Surgery 2024; 27: 76-84https://doi.org/10.7602/jmis.2024.27.2.76

Table 1 . Summary of final staging.

AJCC stage, 8th edNo-AD group (n = 112)AD group (n = 92)
O62
I3219
II3426
III3537
IV58

Most were adenocarcinomas..

AJCC, American Joint Committee on Cancer; AD, abdominal drainage..


Table 2 . Demographic data of the study participants before and after IPTW.

VariableBefore IPTW (n = 204)After IPTW (n = 402.8)
No-AD groupAD groupSMDNo-AD groupAD groupSMD
No. of participants11292227175.8
Age (yr)64.0 ± 13.366.8 ± 13.70.20766.5 ± 12.465.1 ± 13.80.107
Male sex53 (47.3)49 (53.3)0.059121.0 (53.3)86.9 (49.4)0.039
BMI (kg/m2)23.7 ± 3.224.7 ± 3.70.29123.9 ± 3.224.5 ± 3.40.161
Comorbidity81 (72.3)66 (71.7)0.006171.9 (75.7)122.3 (69.6)0.062
ASA PS grade0.1090.011
I, II95 (84.8)68 (73.9)174.7 (77.0)137.2 (78.1)
III, IV17 (15.2)24 (26.1)52.3 (23.0)38.6 (21.9)
Operation history30 (26.8)33 (35.9)0.09151.8 (22.8)55.1 (31.3)0.085
Smoking0.1780.061
Never82 (73.2)51 (55.4)132.2 (58.2)111.8 (63.6)
Ex21 (18.8)28 (30.4)56.6 (24.9)45.1 (25.6)
Current9 (8.0)13 (14.1)38.2 (16.8)18.9 (10.8)
Alcohol consumption0.0150.058
Never75 (67.0)63 (68.5)173.8 (76.6)124.4 (70.7)
Ex4 (3.6)3 (3.3)5.8 (2.6)4.8 (2.7)
Current33 (29.5)26 (28.3)47.3 (20.9)46.6 (26.5)
Clinical stage0.1170.071
1, 263 (56.2)41 (44.6)100.9 (44.4)90.7 (51.6)
3, 449 (43.8)51 (55.4)126.1 (55.6)85.1 (48.4)
Hemoglobin (g/dL)12.5 ± 2.111.1 ± 2.40.27212.0 ± 2.212.4 ± 2.60.189
WBC (×103/μL)6.8 ± 1.97.1 ± 2.50.1497.1 ± 1.97.2 ± 2.30.029
PLT (×103/μL)273.2 ± 82.1278.7±107.80.057282.2 ± 78.6289.0 ± 100.00.070
PT/INR1.0 ± 0.11.0 ± 0.10.0041.0 ± 0.11.0 ± 0.10.058
Albumin (g/dL)4.1 ± 0.53.9 ± 0.60.3774.0 ± 0.64.0 ± 0.60.133
Glucose (mg/dL)112.3 ± 28.0120.3 ± 33.80.259117.4 ± 28.4117.4 ± 30.10.001
Creatinine (mg/dL)0.8 ± 0.60.9 ± 0.60.0590.8 ± 0.50.9 ± 0.60.090
Operation year0.1670.070
2014–201847 (42.0)54 (58.7)128.4 (56.6)87.0 (49.5)
2019–202265 (58.0)38 (41.3)98.6 (43.4)88.8 (50.5)
Emergency operation4 (3.6)4 (4.3)0.00815.9 (7.0)18.3 (10.4)0.034
Radicality0.0470.001
R0110 (98.2)86 (93.5)216.6 (95.4)168.0 (95.5)
R22 (1.8)6 (6.5)10.4 (4.6)7.8 (4.5)
Operation time (min)134.7 ± 32.4164.4 ± 39.90.817152.5 ± 39.5155.2 ± 36.20.075
EBL (mL)56.3 ± 49.881.1 ± 84.80.35665.7 ± 63.471.4 ± 72.30.081
Operation type0.2050.093
LHC5 (4.5)23 (25.0)13.0 (5.7)26.4 (15.0)
RHC107 (95.5)69 (75.0)213.9 (94.3)149.4 (85.0)
Co-operationa)10 (8.9)9 (9.8)0.00925.2 (11.1)18.1 (10.3)0.008
Anastomosis type0.0230.009
Side-to-side107 (95.5)90 (97.8)221.5 (97.6)173.2 (98.5)
End-to-side5 (4.5)2 (2.2)5.5 (2.4)2.6 (1.5)

Values are presented as number only, mean ¡¾ standard deviation, or number (%)..

IPTW, inverse probability of treatment weighting; AD, abdominal drainage; SMD, standardized mean difference; BMI, body mass index; ASA PS, American Society of Anesthesiologists physical status; WBC, white blood cell; PLT, platelet; PT, prothrombin ratio; INR, international normalized ratio; EBL, estimated blood loss; LHC, left hemicolectomy; RHC, right hemicolectomy..

a)Co-operation with other minor surgery..


Table 3 . Postoperative surgical outcomes before and after IPTW.

OutcomesBefore IPTW (n = 204)After IPTW (n = 402.8)
No-AD group (n = 112)AD group (n = 92)p-valueNo-AD group (n = 227)AD group (n = 175.8)p-value
NRS
POD 13.7 ± 1.43.1 ± 1.60.0023.4 ± 1.53.3 ± 1.60.666
POD 23.3 ± 0.83.3 ± 0.90.9813.2 ± 0.83.4 ± 0.80.043
POD 52.4 ± 0.72.4 ± 0.80.8612.5 ± 0.72.4 ± 0.70.204
Postoperative complications17 (15.2)13 (14.1)0.83328.2 (12.4)30.4 (17.3)0.170
Hospital stay (day)6.9 ± 3.87.3 ± 2.90.4796.9 ± 3.07.3 ± 2.80.298
First time to flatus (day)2.9 ± 1.02.9 ± 1.00.5662.7 ± 0.92.9 ± 0.90.078
Readmission (%)2.72.21.0001.72.30.733

Values are presented as mean ± standard deviation, number (%), or percentage only..

IPTW, inverse probability of treatment weighting; AD, abdominal drainage; NRS, numerical rating scale; POD, postoperative day..


Table 4 . Clavien-Dindo classification of surgical complica­tions.

Clavien-Dindo classificationNo AD group (n = 17)AD group (n = 13)
Grade I88
Grade II63
Grade III22
Grade IV10

AD, abdominal drainage..


References

  1. Robinson JO. Surgical drainage: an historical perspective. Br J Surg 1986;73:422-426.
    Pubmed CrossRef
  2. Billroth T. Clinical surgery. The New Sydenham Society; 1881:307-308.
  3. Manz CW, LaTendresse C, Sako Y. The detrimental effects of drains on colonic anastomoses: an experimental study. Dis Colon Rectum 1970;13:17-25.
    Pubmed CrossRef
  4. Petrowsky H, Demartines N, Rousson V, Clavien PA. Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-analyses. Ann Surg 2004;240:1074-1085.
    Pubmed KoreaMed CrossRef
  5. Merad F, Yahchouchi E, Hay JM, Fingerhut A, Laborde Y, Langlois-Zantain O. Prophylactic abdominal drainage after elective colonic resection and suprapromontory anastomosis: a multicenter study controlled by randomization. French Associations for Surgical Research. Arch Surg 1998;133:309-314.
    Pubmed CrossRef
  6. Urbach DR, Kennedy ED, Cohen MM. Colon and rectal anastomoses do not require routine drainage: a systematic review and meta-analysis. Ann Surg 1999;229:174-180.
    CrossRef
  7. Merad F, Hay JM, Fingerhut A, et al. Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis?: a multicenter controlled randomized trial. French Association for Surgical Research. Surgery 1999;125:529-535.
    Pubmed CrossRef
  8. 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;31:951-960.
    Pubmed KoreaMed CrossRef
  9. Denost Q, Rouanet P, Faucheron JL, et al. To drain or not to drain infraperitoneal anastomosis after rectal excision for cancer: the GRECCAR 5 Randomized Trial. Ann Surg 2017;265:474-480.
    Pubmed CrossRef
  10. Carmichael JC, Keller DS, Baldini G, et al. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2017;60:761-784.
    Pubmed CrossRef
  11. 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 2019;43:659-695.
    Pubmed CrossRef
  12. Cavallaro P, Bordeianou L. Implementation of an ERAS pathway in colorectal surgery. Clin Colon Rectal Surg 2019;32:102-108.
    Pubmed KoreaMed CrossRef
  13. ESCP Enhanced Recovery Collaborating Group. An international assessment of the adoption of enhanced recovery after surgery (ERAS®) principles across colorectal units in 2019-2020. Colorectal Dis 2021;23:2980-2987.
    Pubmed CrossRef
  14. 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;240:205-213.
    Pubmed KoreaMed CrossRef
  15. Heinze G, Jüni P. An overview of the objectives of and the approaches to propensity score analyses. Eur Heart J 2011;32:1704-1708.
    Pubmed CrossRef
  16. Cole SR, Hernán MA. Adjusted survival curves with inverse probability weights. Comput Methods Programs Biomed 2004;75:45-49.
    Pubmed CrossRef
  17. Makama JG, Ameh EA. Surgical drains: what the resident needs to know. Niger J Med 2008;17:244-250.
    Pubmed CrossRef
  18. Puleo FJ, Mishra N, Hall JF. Use of intra-abdominal drains. Clin Colon Rectal Surg 2013;26:174-177.
    Pubmed KoreaMed CrossRef
  19. Frouws MA, van de Velde CJ. Routine prophylactic drainage in rectal surgery: closing the chapter? Transl Cancer Res 2016;5(Suppl 7):S1345-S1348.
    CrossRef
  20. Tsujinaka S, Konishi F. Drain vs no drain after colorectal surgery. Indian J Surg Oncol 2011;2:3-8.
    Pubmed KoreaMed CrossRef
  21. Mujagic E, Zeindler J, Coslovsky M, et al. The association of surgical drains with surgical site infections: a prospective observational study. Am J Surg 2019;217:17-23.
    Pubmed CrossRef
  22. Findik UY, Topcu SY, Vatansever O. Effects of drains on pain, comfort and anxiety in patients undergone surgery. Int J Caring Sci 2013;6:412-419.
  23. Cavaliere D, Popivanov G, Cassini D, et al. Is a drain necessary after anterior resection of the rectum?: a systematic review and meta-analysis. Int J Colorectal Dis 2019;34:973-981.
    Pubmed CrossRef
  24. Karliczek A, Jesus EC, Matos D, Castro AA, Atallah AN, Wiggers T. Drainage or nondrainage in elective colorectal anastomosis: a systematic review and meta-analysis. Colorectal Dis 2006;8:259-265.
    Pubmed CrossRef
  25. Hagmüller E, Lorenz D, Werthmann K, Trede M. Uses and risks of drainage following elective colon resection: a prospective, randomized and controlled clinical study. Chirurg 1990;61:266-271.
    Pubmed
  26. Sagar PM, Couse N, Kerin M, May J, MacFie J. Randomized trial of drainage of colorectal anastomosis. Br J Surg 1993;80:769-771.
    Pubmed CrossRef
  27. Greer NL, Gunnar WP, Dahm P, et al. Enhanced recovery protocols for adults undergoing colorectal surgery: a systematic review and meta-analysis. Dis Colon Rectum 2018;61:1108-1118.
    Pubmed CrossRef
  28. Wood BM, Nicholas MK, Blyth F, Asghari A, Gibson S. Assessing pain in older people with persistent pain: the NRS is valid but only provides part of the picture. J Pain 2010;11:1259-1266.
    Pubmed CrossRef

Share this article on

  • kakao talk
  • line

Related articles in JMIS

Journal of Minimally Invasive Surgery

pISSN 2234-778X
eISSN 2234-5248