routine drainage after thyroid surgery—a meta-analysis

Journal of Surgical Oncology 2007;96:273–280

REVIEW

Routine Drainage After Thyroid Surgery—AMeta-Analysis

ALVARO SANABRIA, MD, MSc,1,2 ANDRE L. CARVALHO, MD, PhD,2 CARL E. SILVER, MD, FACS,3

ALESSANDRA RINALDO, MD, FACS,4 ASHOK R. SHAHA, MD, FACS,5 LUIZ P. KOWALSKI, MD, PhD,2

AND ALFIO FERLITO, MD, DLO, DPath, FRCS, FRCSEd, FRCSGlasg, FRCSI, FACS, FHKCORL, FDSRCS, FRCPath, FASCP, MCAP4*

1Department of Surgery, Universidad de La Sabana, Bogota, Colombia2Department of Head and Neck Surgery and Otorhinolaryngology, Hospital do Cancer AC Camargo, Sao Paulo,

Brazil3Department of Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York

4Department of Surgical Sciences, ENT Clinic, University of Udine, Udine, Italy5Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, New York

Thyroidectomy is a common surgical procedure. The results of some clinical trialssuggest that routine drainage does not offer advantages, but the evidence is not strongeither in favor of or against this intervention. The effect of routine drainage comparedto no drainage in patients subject to thyroidectomy was measured using a meta-analysis. After an extensive literature review, suitable randomized clinical trials wereselected for analysis. Outcome measures included the comparative incidence of neckhematoma or seroma and length of hospital stay. Eleven randomized clinical trialswere included. There were no statistically significant differences in the incidence ofneck hematoma/seroma (OR 1.03, 95% CI 0.59-1.81) between the groups. The meanlength of hospital stay was 1.53 days longer for the drainage group (95% CI 1.39–1.68). There was no difference found between routine drainage and no drainage withregard to the frequency of postoperative hematoma/seroma in patients followingthyroidectomy. In addition, the mean length of hospital stay was longer in the routinedrainage group.J. Surg. Oncol. 2007;96:273–280. � 2007 Wiley-Liss, Inc.

KEY WORDS: drainage; thyroidectomy; thyroid; complications; hematoma;seroma; meta-analysis

INTRODUCTION

Operations on the thyroid are the most commonsurgical procedures performed in the neck. In the pastmost surgeons employed wound drains routinely with thehope of decreasing the risk of acute airway obstruction byhematoma as well as postoperative hematoma or seroma[1–5]. Several authors, however, have suggested that useof drains could increase the risk of infection, the length ofhospital stay, treatment costs, and discomfort for thepatient. Moreover, the routine use of drains is not asubstitute for meticulous surgical technique with carefulhemostasis [6–11]. Therefore, the use of routine drainagein thyroid surgery has become controversial.

To solve this controversy, some randomized controlledtrials have been performed [12–24]. These trials couldnot identify a statistical difference in the rates of neckhematoma/seroma between groups using drains and those

*Correspondence to: Alfio Ferlito, MD, DLO, DPath, FRCS, FRCSEd,FRCSGlasg, FRCSI, FACS, FHKCORL, FDSRCS, FRCPath, FASCP,MCAP, Director of the Department of Surgical Sciences, Professor andChairman of the ENT Clinic, University of Udine, Policlinico Universitario,Piazzale S. Maria della Misericordia, I-33100 Udine, Italy. Fax: þ39 0432559339. E-mail: [email protected]

Received 2 November 2006; Accepted 5 March 2007

DOI 10.1002/jso.20821

Published online 27 April 2007 in Wiley InterScience(www.interscience.wiley.com).

� 2007 Wiley-Liss, Inc.

without drains. However, these trials had small samplesizes, and thus did not offer a conclusive response. Onewayto solve this problem is to perform a systematic review ofthe literature and meta-analysis of reported results.Recently, Pothier [25] performed a meta-analysis andconcluded that there are no differences in complicationrates between patients who underwent drainage incomparison with those who did not. However, the authordid not report other important outcomes such as length ofstay, did not assess the quality of the studies reviewed, anddid not present the type of surgical procedures and dia-gnosis, as recommended by the QUORUM statement [26].The objective of the present study is to measure the

beneficial or harmful effects of routine drainage on thefrequency of neck hematoma/seroma and length of stayin patients who have undergone thyroidectomy.

MATERIALS AND METHODS

All randomized controlled trials comparing the use ofpostoperative drainage versus no drainage in patients whounderwent elective partial or total thyroidectomy due tobenign or malignant disease were evaluated, irrespectiveof the number of patients randomized, database registry,and language of the article. The studies included adultpatients (older than 18 years) with a preoperative clinicaldiagnosis of benign (goiter, thyroiditis), indeterminate(follicular neoplasm) or malignant (papillary or follicularcarcinoma) disease of the thyroid, scheduled for partial ortotal thyroidectomy. Studies that included patients whoneeded radical or modified radical neck dissection as apart of surgical treatment and cases with giant goiters,were excluded.Interventions assessed were ‘‘active’’ (closed wound

suction) postoperative drainage versus no drainage andoutcomes measured were neck hematoma/seroma,detected clinically or by an imaging exam, recorded asyes or no (primary outcome) and length of hospital stay(secondary outcome). All outcome measures wereconfined to the period of hospitalization and the 30 daysafter discharge.

Search Strategy

We searched The Cochrane Central Register of Cont-rolled Trials (CENTRAL) on The Cochrane Library(Issue 4, 2005), The National Library of Medicine(PubMed) (1966 to February 2006), The IntelligentGateway to Biomedical and Pharmacological Informa-tion (EMBASE) (1980 to February 2006), The LatinA-merican and Caribbean Health Sciences Library(LILACS) (1980 to February 2006), and Science CitationIndex Expanded (SCI-EXPANDED) (1980 to February2006). The search strategy identified studies in all langu-ages. When necessary, non-English language papers were

translated for a full assessment. The search strategy forthe review was constructed by using a combination ofMESH subject headings and text words (thyroid diseases,thyroid neoplasms, parathyroid, thyroidectomy, surgery,drainage), relating to the use of drains in partial or totalthyroidectomy. Authors of included trials were contactedto seek further information on any published, unpub-lished, and ongoing trials. We also checked the referencelists of all the identified trials for more relevant reports.If inclusion criteria were not fulfilled, trials were

excluded and reasons for exclusion were listed. Metho-dological quality assessment was performed includingevaluation of randomization, allocation concealment,blinding, lost to follow-up and intention to treat analysis,and each criterion was classified as adequate, inadequateor unclear, as stated by the Cochrane Reviewers’Handbook [27].Inclusion and exclusion criteria were recorded for each

trial. Details regarding the use of drains in the post-operative period, disease that indicated surgery (benignor malignant), type of surgical resection, length ofhospital stay, presence or absence of neck hematoma/seroma and necessity for procedures to manage theselocal complications were recorded. Data regarding themethodological quality as number of randomized patients,number of patients not randomized, and reasons for non-randomization, ‘‘drop-outs,’’ blinding of patient and ob-server and intention-to-treat analysis were also recorded.Parathyroid surgery was included in the search

strategy, and some of the studies reviewed reportedsome parathyroidectomies, Kristoffersson et al. [12]included 26 patients who underwent parathyroidectomy,representing 26% of the study population and Ayyashet al. [15] included 7 patients, representing 7% of thatpopulation. Only these 33 patients, constituting 2.6% ofthe total population analyzed, had been submitted toparathyroidectomy. Consequently, these individuals wereeliminated from the study, and conclusions of this studycannot be applied to this subgroup of patients.

Statistics

The statistical package STATA 8.0 was used. Fordichotomous outcomes, the impact of the interventionwas expressed as an odds ratio (OR) with 95% confidenceinterval; and for continuous outcomes, a mean differencewith 95% confidence interval was used. A random effectsmodel was used. The Chi-square test for heterogeneitywas used to provide an indication of between-studyheterogeneity, and the degree of heterogeneity observedwas quantified using the I-squared statistic. Sensitivityanalysis was performed using trials with high methodo-logical quality. Causes of heterogeneity, where hetero-geneity was found, (Chi-squared test P< 0.10) were

Journal of Surgical Oncology DOI 10.1002/jso

274 Sanabria et al.

explained subjectively. Funnel plot [28] and Begg test[29] were used to assess publication bias.

RESULTS

Sixteen studies were identified by the primary search[12–24,30–32]. One was excluded because it hadduplicated data [17], three because they compared twotypes of drains [19,20,30] and one more because it used asoft drain [14]. Fifteen studies were identified in MED-LINE and one in LILACS. Those from MEDLINE werein English and German and those from LILACS inSpanish. Inclusion criteria were similar for selected trials:adult patients admitted for elective thyroidectomy, withpreoperative diagnosis of benign or malignant condition.Peix et al. [16] admitted only patients with a diagnosis ofcold nodule and Tubergen et al. [31] admitted onlypatients with euthyroid goiter. Exclusion criteria alsowere similar for included studies: (a) associated neckdissection, (b) extension to thoracic cavity, (c) previousneck surgery, (d) hematologic disorders, and (e) para-thyroid surgery. Nonetheless, the Khanna et al. [24] studyreported 102 procedures corresponding to 94 patients,including eight partial thyroidectomies performed in asecond operative time on the same patients.

With the exception of one study, primary trials did notreport differences in age, gender, type of surgery, anddiagnosis between groups. The Ayyash et al. [15] andDebry et al. [21] studies reported no differences indiagnosis, but did not report the actual numbers. Pezzulloet al. [23] reported statistically significant differences inage and weight of the surgical specimen, which suggeststhe introduction of bias in the randomization andassigning process.

The Hurtado-Lopez et al. [22] study randomizedpatients to three groups: a control group, a soft draingroup, and a suction drain group. We decided to excludepatients from the soft drain group, because there was aclear clinical difference between it and the suction group.

All the included procedures reported by Peix et al. [16]and Kristoffersson et al. [12] were unilateral lobectomy.Schoretsanitis et al. [18] and Tubergen et al. [31] includedonly near total and unilateral thyroidectomy. The otherstudies included all types of thyroid operations. Debryet al. [21] included four patients with central compartmentdissection, without complications in any of them. Hurtado-Lopez et al. [22], Debry et al. [21], Wihlborg et al. [13],Pezzullo et al. [23], Kristoffersson et al. [12], and Susluet al. [32] studies did not report criteria for drain removal.Peix et al. [16] removed drains after ‘‘24–48 hr’’ andTubergen et al. [31] at the second postoperative day.Ayyash et al. [15] and Khanna et al. [24] removed thedrain when drainage was less than 30 ml/24 hr and

Schoretsanitis et al. [18] when drainage was less than25 ml/24 hr.

Hematoma/seroma was defined clinically by physi-cians, but criteria used were not stated. Debry et al. [21]used ultrasonography in case of doubt and Khannaet al. [24] and Tubergen et al. [31] used postoperativelyultrasonography in all cases.

Methodological Quality

Studies included were parallel randomized controlledtrials. Randomization was considered adequate in theDebry et al. [21], Schoretsanitis et al. [18], and Khannaet al. [24] studies, and unclear in the others because theydidn’t specify the method used. Allocation concealmentwas adequate in the Peix et al. [16], Ayyash et al. [15], andKristoffersson et al. [12] studies, which used sealedenvelopes, inadequate in Debry et al. [21] and unclear inthe others because they didn’t specify the method used.The Pezzullo et al. [23] study describes a procedure ofrandomization and allocation concealment, but their datareveal statistical differences in patient age and specimenweight that could be related to some bias in these qualitycharacteristics. Double blinding was not performed in thestudies, for the obvious reason of the impossibility ofblinding the intervention. However, only the Peixet al. [16] study used a mechanism to decrease thepossibility of bias, using an independent evaluator ofoutcome. Follow-up was adequate in all studies and noneof them reported dropouts. Intention to treat analysis forprimary outcomes was made in all studies.

Outcomes

The eleven studies recruited a total of 1244 patients:617 in the drainage group and 627 in the no drainagegroup. Distribution of type of thyroidectomy, diagnosisand length of hospital stay are shown in Table I. For theDebry et al. [21] study, we found an inconsistency in thenumber and group with hematoma/seroma reported in thetext and in table IV. However the text clearly stated thatall hematoma/seroma occurred in the drainage group, sonumbers were registered in this way.

Thirty-three of 617 (5.35%) patients in the drainagegroup and 30 of 627 (4.78%) in the no drainage groupdeveloped a postoperative neck hematoma/seroma,respectively. The OR was 1.06 (95% CI 0.62–1.82). Nostatistically significant differences or heterogeneity wereobserved (P¼ 0.570) (Fig. 1).

Only Peix et al. [16], Schoretsanitis et al. [18],Hurtado-Lopez et al. [22], Pezzullo et al. [23], Tubergenet al. [31] and Suslu et al. [32] reported standard deviationfigures with respect to length of hospital stay. Debryet al. [21] and Ayyash et al. [15] reported length ofhospital stay but without a standard deviation and others


Routine Drainage After Thyroid Surgery 275

didn’t reported length of hospital stay, so their data wereimpossible to use in the meta-analysis. Among the groupswith useable data, the mean difference was 1.48 days(95% CI 1.35–1.62), greater for the drain group, but theheterogeneity test was statistically significant (P< 0.01;I2 ¼ 88% (Fig. 2).In the Hurtado-Lopez et al. [22], Peix et al. [16]

Schoretsanitis et al. [18] Tubergen et al. [31] and Susluet al. [32] studies, lengths of stay had statisticallysignificant longer stays for the drainage group. In thePezzullo et al. [23], Debry et al. [21] and Ayyashet al. [15] studies, stays were longer for drainage groupbut the differences were not statistically significant.In the Hurtado-Lopez et al. [22] study, four patients

developed postoperative neck hematoma/seroma. Twopatients in the no drainage group were managed withaspiration. There was no report of management of the twopatients with hematoma/seroma in the drainage group. Inthe Ayyash et al. [15] study, two of the seven patients withhematoma/seroma in the no drainage group requiredintervention, but neither of the two patients withhematoma/seroma in the drainage group needed it. Inthe Kristoffersson et al. [12] study, the single patient withhematoma/seroma from the drainage group requiredevacuation. In the Wihlborg et al. [13] study, onepatient in each group needed reoperation, while in theSchoretsanitis et al. [18] study two patients from the nodrainage group and one from the drainage group werereoperated. In the Tubergen et al. [31] study two patientsfrom the drainage group needed intervention and in theSuslu et al. [32] study two patients from the drainagegroup needed reintervention and one patient in the non-drainage group was treated with multiple needle aspira-tions. None of the patients in the Peix et al. [16], Debryet al. [21], and Pezzullo et al. [23] studies neededintervention of the hematoma/seroma. In total, 10patients in the drainage group and 5 in the no drainagegroup needed an intervention.Although cosmetic results and discomfort were not

subjects of the meta-analysis, it is of interest that Ayyashet al. [15] stated that cosmetic results were equal at4 weeks follow-up, and Kristoffersson et al. [12] did notfind statistical differences in subjective or objective signsof discomfort at 1 and 3 months postoperatively.A funnel plot for selected studies is shown in Figure 3.

The adjusted rank correlation test and the regressionasymmetry test were not statistically significant (inter-cept P-value¼ 0.259) which does not support a publica-tion bias.We performed a sensitivity analysis by methodological

quality, excluding the Debry et al. [21] and Pezzulloet al. [23] studies, because of the inadequate randomiza-tion and allocation concealment. The OR for neckcollections (OR 0.98, IC 95% 0.55–1.72) and length of


TABLEI.

ClinicalCharacteristics

ofIncluded

Studies

Study

Year

Typeofthyroidectomy

Diagnosis

Total

Partial

Benign

Malignanta

Length

ofstay

(days)

(mean�SD)

Drain

Nodrain

Total

Drain

Nodrain

Total

Drain

Nodrain

Total

Drain

Nodrain

Total

Drain

Nodrain

Total

Kristofferssonet

al.[12]

1986

050

50

100

40

31

71

10

19

29

100

Wihlborg

etal.[13]

1988

10

11

21

65

64

129

51

50

101

25

24

49

150

Ayyashet

al.[15]

1991

63

944

47

91

00

4.4

4.15

100

Peixet

al.[16]

1992

048

49

97

36

39

75

12

10

22

3.81�1.06

3.26�1.33

97

Schoretsanitiset

al.[18]

1998

0100

100

200

85

88

173

15

12

27

3.4�0.65

1.6�0.58

200

Debry

etal.[21]

1999

21

19

40

22

38

60

00

2.09

1.72

100

Hurtado-Lopez

etal.[22]

2001

59

14

45

41

86

41

37

78

913

22

3.11�2.7

2�0.94

100

Pezzulloet

al.[23]

2001

76

13

23

24

47

22

24

46

86

14

5.9�2.4

4.7�1.9

60

Tubergen

etal.[31]

2001

52

48

100

52

48

100

4.56�1.09

3.88�1.3

100

Khannaet

al.[24]

2005

3.71

3.07

102

Susluet

al.[32]

2006

31

29

60

37

38

75

68

67

135

2.6�1.0

1.3�0.7

135

Total

80

77

157

486

499

985

395

384

779

79

84

163

1,244

aIncludingundetermined

nodules.

276 Sanabria et al.

hospital stay (mean difference 1.49, IC 95% 1.36–1.62)was not different from those globally reported.

DISCUSSION

Basis of the Analysis

Routine drainage for thyroid surgery is a controversialsubject. The use of passive drains, which was ineffectivefor its purpose of prevention of tracheal compression byhematoma has been supplanted by the availability and useof ‘‘active’’ simple portable closed wound suction drains,which serve mainly to prevent hematoma and seromabeneath the skin flaps. Thus the study was confined to use

of active suction drains and the outcomes included onlythe factors stated above.

While some authors have recommended the routineuse of drainage after thyroidectomy for the above statedreasons [1–5], this recommendation has been debatedextensively in the literature [6–11]. Ruark and Abdel-Misih [6] reviewed retrospectively 110 thyroid operationswithout drainage, without encountering a single instanceof acute hematoma, nor did Ariyanayagam et al. [7] in aretrospective review of 260 thyroid procedures performedwithout drainage. The latter series included toxic goitersand reoperations. Daou [9] studied prospectively 150thyroid procedures without drainage, and found only two


Fig. 1. Forrest plot for the frequency of neck hematoma/seroma.

Fig. 2. Forrest plot for the length of stay in thyroidectomy. Fig. 3. Funnel plot of included studies.


late hematomas. Defechereux et al. [10] with 1,789 andTabaqchali et al. [11] reviewed 606 thyroidectomies inretrospective comparative studies, and found no statisti-cally significant differences between drainage and nodrainage groups. These studies, however, are prone tobias because of their retrospective or non-randomizedcomparative design.Some randomized controlled trials were performed to

solve this difficulty [12–24]. None of them were able todemonstrate statistically significant differences in thefrequency of acute or late neck hematoma/seroma.However, some studies included groups with soft drains,which have a drainage mechanism different fromnegative pressure suction drains, or compared differenttypes of drains, variables that could introduce significantheterogeneity. Each individual study was unable toaccrue a large enough sample size and had insufficientpower to definitively answer the question of the utility ofthyroid surgery drainage. As the complication of seroma/hematoma occurs in only about 5% of cases, a cohort ofapproximately 1,000 patients would be necessary in orderto find a 50% reduction in incidence attributable to anyintervention. Thus, systematic review with meta-analysiscould help to overcome this difficulty because it canincrease the power of individual studies if they areclinically and statistically homogeneous.

Quality of Studies Evaluated

In this study, it was possible to find 11 randomizedcontrolled trials [12,13,15,16,18,21–24,31,32], clinicallyand statistically homogeneous that were appropriate for ameta-analysis. In general terms, the quality of studiesincluded was acceptable. Unfortunately, most studies donot report broadly each step in the trial design, assuggested by the CONSORT statement [33], whichclassifies many quality criteria as unclear. This makes itdifficult to assess methodological quality. Only the Debryet al. [21] study had a clear violation of assignationconcealment and the Pezzullo et al. [23] study had astatistically significant difference in the groups at thebeginning, which suggests a bias in randomization andassignation process. A subgroup analysis excluding thesestudies did not show any difference compared withthe global summary OR, which support the results of themeta-analysis adjusted by methodological quality. Inaddition, study conclusions are not at risk because ofpublication bias, which makes the results stronger.

Conclusions of the Analysis

Results of this systematic review confirm that routinedrainage in thyroid surgery does not offer any advantagein decreasing the frequency of acute or late neckhematoma/seroma compared with no drainage. With the

number of patients included, this study has a posterioripower calculation of 80% to find an absolute 3%difference between groups. Moreover, when neck hema-toma/seroma was analyzed, there had been no differencein management between the two groups.As a secondary outcome, this study evaluated length of

hospital stay, because randomized studies, as well ascommon logic suggests a delay in hospital discharge forthe drainage group. Meta-analysis showed an increase oflength of hospital stay in drainage group of 1.49 days, butthis result should be analyzed carefully, because the testfor heterogeneity was statistically significant. With theexception of the Ayyash et al. [15] study, all the studiesfound an increase in length of hospital stay in drainagegroups; statistically significant in three. Therefore, thesummary result probably represents a real difference. Onthe other hand, a bias against the no drainage group inlength of hospital stay measures must be recognized,because trials included did not report an early dischargestrategy for patients without drainage, and length ofhospital stay found for the no drainage groups couldrepresent the clinical routine that was applied to drainedpatients. Thus, it is expected that no drainage couldproduce a more significant decrease in length of stay if anearly hospital discharge policy is considered. Moreover,as only randomized controlled trials were included,influence of other variables that could modify the lengthof stay such as particular health care reimbursements andlocal practices, was counterbalanced in each individualtrial. The results of this systematic review indicate thatlength of hospital stay could be unnecessarily prolongedwhen routine drainage is used.It is important to realize that conclusions of this study

can only be applied to patients who undergo total orsubtotal thyroidectomy for benign or malignant diseasebut without previous neck surgery, hemostasis disorders,extension to the thoracic cavity or those who require neckdissection. It is possible that this concept can beextended. A recent report by Lee et al. [34] concludedthat thyroidectomy without drains is safe and effectiveeven in combination with central neck dissection withseveral advantages to the patients compared to routinedrainage and with significant reduction of hospital stay.Nevertheless, central neck dissection as defined by thisgroup consisted only of dissection of level VI lymphnodes and did not include dissection of the lateral neck(levels III and IV) which is considered ‘‘central neckdissection’’ by many other surgeons.

Practical Considerations

Despite many prospective randomized studies andmeta-analyses, the issue of routine use of drains inthyroid surgery remains controversial. The reasons


278 Sanabria et al.

include attitudes of individual surgeons, the size andextent of the operative field, and fear of trachealcompression from major postoperative bleeding. Manysenior surgeons, who have used drains successfullythroughout their careers will continue to use drains inthyroid surgery. Surgeons generally will use drains ifthere is a large dead space, a concern for bleeding, an‘‘oozing’’ thyroid bed, or if any other unusual concernabout postoperative accumulation of blood or fluidbeneath the skin flaps. Though the drains do not preventhematoma, observation of blood issuing from the drainsin the immediate postoperative period may expedite earlydiagnosis of significant hemorrhage. Such hemorrhage,confined to a closed space around the trachea maycompromise the airway. Drains alone cannot decompressan expanding hematoma from major arterial bleeding,and the complication must be treated by immediatelyreopening the wound. Fortunately, this occurrence isquite rare, but may be encountered once or twice duringthe career of an experienced surgeon, and its possibilityshould always be considered.

In a series by Shaha and Jaffe [1], the majority of thehematomas occurred in patients with drains in place, butthis may represent preselection of cases at greater risk.The meta-analysis presented here did confirm that theincidence of hematoma and seroma remain unchangedwith or without drains.

This meta-analysis also offers important clinicalinformation related to the length of hospitalization withthe drains. The presence of drains will usually commit thepatient to, at least, an overnight stay. Although patientscould be discharged with drains in place, most are quitereluctant to go home under such circumstances.

Another issue is the type of drain. The majority ofsurgeons today use a portable closed suction drainagesystem. The fear of retrograde contamination has beenexpressed, but is generally not accepted as a significantcause of postoperative infection. In general, the overalluse of drains in thyroid surgery appears to be veryselective and almost 80% of the thyroid surgeries, at thepresent time, are performed without the use of drains.

CONCLUSIONS

While drains have been employed routinely for manyyears in order to prevent postoperative hematoma orseroma formation after thyroid or parathyroid surgery, ameta-analysis of 11 prospective randomized studiestotaling 1,244 patients revealed no significant differencein the incidence of postoperative hematoma or seroma inpatients in whom postoperative drains were or were notplaced. In addition, there was an increase in length ofhospital stay for the patients with drains, found to be

statistically significant in three of 11 studies. Patientswith giant goiters, mediastinal dissection or neckdissection were not included in the analysis, nor werepatients in whom soft ‘‘passive’’ drains had been used.The meta-analysis demonstrates no advantage withregard to prevention of hematoma or seroma by theroutine placement of postoperative closed wound suctiondrains beneath the skin flaps after uncomplicated thyroidsurgery.

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