Is there a role for drain use in elective laparoscopic cholecystectomy? A controlled randomized trial
George Tzovaras, M.D.*, Paraskevi Liakou, M.D., Frank Fafoulakis, M.D., Ioannis Baloyiannis, M.D., Dimitris Zacharoulis, M.D., Constantine Hatzitheoﬁlou, M.D.
Department of Surgery, University Hospital ofLarissa, Larissa, Greece KEYWORDS:
Drain; Laparoscopic cholecystectomy Abstract BACKGROUND: Although the issue of drain use in open cholecystectomy has been adequately addressed by prospective randomized trials, there is lack of evidence on the usefulness of drains in elective laparoscopic cholecystectomy, and the surgeons follow their beliefs and bias on this debate. Therefore, a controlledrandomized trial was designed to assess the value of drains in elective laparoscopic cholecystectomy. METHODS: During a 5-year period (January 2002 to December 2006), 284 patients were randomized to have a drain placed (group A), whereas 281 patients were randomized not to have a drain (group B) placed in the subhepatic space. End points of this trial were to detect any differences in morbidity,postoperative pain, and hospital stay between the 2 groups. RESULTS: There was no mortality in either group and no statistically signiﬁcant difference in morbidity or hospital stay between the 2 groups. However, postoperative pain was signiﬁcantly increased in patients who had a drain placed; median visual analog scale (VAS) score was 5 (range 1 to 8) versus 3 (range 1 to 8), in the non-drained group (P.0001). Interestingly, in 2 of 3 patients in whom a drain was placed against randomization because of bile leak suspicion, a bile leak occurred. CONCLUSIONS: The routine use of a drain in elective laparoscopic cholecystectomy has nothing to offer; in contrast, it is associated with increased pain. It would be reasonable, however, to leave a drain if there is a worry about an unsolved or potentialbile leak, bearing in mind that drain placement, although sometimes providing a false sense of security, does not guarantee either prevention or treatment of postoperative bile collections, bleeding, or bile peritonitis. © 2009 Elsevier Inc. All rights reserved.
Despite the fact that cholecystectomy is one of the most commonly performed procedures and the issue of drainage would be considereda relatively simple one, surgeons have persistently failed to solve this ongoing controversy. There have been many reports, with conﬂicting results,
* Corresponding author. Tel.: 011-30-2410-682730; fax: 1-302410-611097. E-mail address: email@example.com Manuscript received March 30, 2008; revised manuscript May 30, 2008
on this topic during the era of open cholecystectomy. However, mostof these well-designed controlled randomized trials failed to demonstrate any beneﬁt from drainage in open cholecystectomy.1,2 In fact, some of them suggested that drainage in cholecystectomy patients might be harmful.1 After the introduction of laparoscopy and during its early years, the majority of surgeons used to drain the subhepatic space during laparoscopic cholecystectomy, mainly for fearof bile peritonitis. After the general acceptance of laparo-
0002-9610/$ - see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.05.011
760 scopic cholecystectomy as the treatment of choice for the management of symptomatic gallstone disease, and as experience is increasingly accumulated, several surgeons have accepted a kind of extrapolation of the resultsof randomized trials in open cholecystectomy to the laparoscopic approach. However, again surgeons keep being divided among those who routinely place a drain, those who place a drain selectively, and those who never place a drain, based rather on their personal experience, belief, or bias. In a recent Australian survey, one third of the responding surgeons in Queensland reported using drains...