“ Use of drains in gastrointestinal Surgery

Dr sumer yadav ms general surgery , mch plastic

and reconstructive surgery

A channel by which surplus liquid is drained or gradually carried out.

An appliance or piece of material that acts as a channel for the escape (exit) of gases, fluids and other material from a cavity, wound, infected area or focus of suppuration.

Drains inserted after surgery help the wound to heal faster and assist in preventing infection.

Hippocrates –drainage of empyema, ascitic fluid

200AD- Celsius devised means of draining ascites with conical tubes

1700AD –Johann Schltetus-1st person to use capillary drainage

1897AD Charles Penrose devised Penrose drain 1932AD Chaffin developed 1st commercially

available suction drain 1959AD silicone rubber discovered and

advantages were reported by Santos

Soft -Minimal damage to surrounding tissues

Smooth -Efficiently evacuate effluent and easy removal

Sterile- not potentiate infection or allow introduction of infection from external environment

Stable- Inert, non allergenic, not degraded by body

Simple to manage by both patient and staff

To remove unwanted fluid/ exudate /pus/gas

To allow monitoring of fluid volume & quality

To promote tissue apposition To allow diversion of body fluids To facilitate subsequent access to a body

space or cavity To diagnose about underlying cavity or

fistula

Haematoma

Other Fluids (serous, chyle, pus, etc)

Tissue adherence -- cosmesis

Greater tissue contact Inert material. Slides smoothly past any tissue Promotes ease of movement and deep

breathing Minimal pain on removal Comes in various sizes

Laminar flow through drain Poiseuille’s law

F =dP πr4 /8nL F = flow of fluid thru the drain lumen dP =pressure difference between the two ends n =viscosity L= length of drain

Flow directly prop to suction pressure, radius Indirectly prop to viscosity and length of drain

Double in drain diameter 16 fold increase in flow

Halving the length will double the flow

According to Poiseuille’s law the laminar flow rate of an incompressible fluid along a tube is proportional to the fourth power of radius of tube and suction pressure. Flow is inversely proportional to viscosity of the fluid and length of the tube.

It means that wider and small length tube have more flow rate.

Factors governing effluent movement Gravity Capillary action Tissue pressure Negative pressure

a. Prophylactic :-postoperatively to prevent accumulation of fluid or to detect early any leakage from anastomosis site.

b. Therapeutic :-to evacuate an existing collection.

i.e. lymph, pus, urine saliva, serum

c. Diagnostic :-MCUG,T-tube cholangiogram

a. Open:-drains directly to the exterior .e.g. Penrose and corrugated rubber drain. There are less chances of blockage, more comfortable to patient but more chances of infection.

b.Closed:-drains externally into a sealed container so having less chances of infection, better skin care, better care and accurate assessment of fluid drainage.

Internal drains Divert retain fluids form a body cavity to

another Useful in neurosurgery, ctvs ,G.I surgery and

urology E.g. Celestine, southar tubes, V-P shunt,

Pericardio-pleural tube External drains

Channel discharge from cavity to external environment

3.a.With suction :-where negative pressure is applied to facilitate drainage. It allow the drainage of fluid from areas where movement of fluid is against the natural pressure gradient, also helps apposition of tissue planes prevents fluid accumulation and blockage of tube less likely.

Disadvantage:-it also causes more tissue erosion and prevent healing of an established fistula by continued fluid drainage.

3.b.Non – Suction (passive ) drains

a. Sump suction :-in this double lumen tubes are there. Second tube act as a vent to allow air flow down to the tip of a drain. This prevent negative pressure at the tip and causes less tissue erosion and less blockage.

b. closed suction

Irritant drains composed of materials irritant to tissues excite fibrous tissue response leading to

fibrosis and tract formation E.g. latex, plastic and rubber drains

Inert drains Non irritant drains Provoke minimal tissue fibrosis E.g. polyvinyl chloride(PVC),polyurethane(PU) silicon elastomer (silastic)

Prior used red rubber or latex.(more chances fibrosis and allergic reactions)

Nowadays used polyurethane, silicone(silastic), silicone elastomer, siliconised latex or polytetrafluoroethylene(PTFE)

Material Example Properties

Latex rubber Penrose drain Soft, induces tract formation

Red rubber Red rubber tube catheter

Firm, induces tract formation

PVC Chest tube Firm ,induce some inflammation

Silastic Jackson-Pratt drain Soft, induces minimal inflammation

Heparin coated silastic Jackson Pratt drain Aims to inhibit clot formation and achieve greater patency

Hydrogel coating Some foley catheter,image guided percutaneous drain

Produce slippery surface resistant to encrustation

Polytetrafluoro-ethylene(PTFE)

Some foleys catheter Latex + teflon.

Smoother than latex

Silicone elastomer Some foleys catheter latex +silicone –more resistant to encrustation

Polymer hydromer Some foleys catheter Latex bounded with .smoother than latex

Should not exit cavity through same surgical incision.

Reach skin by safest shortest route Appropriate size and length A gravity drain must be placed in the safest

and most dependent recess in cavity Must be inserted away from delicate

structures Firmly secured at exit wound Appropriate care-dressing,emptying. Must be removed when no longer useful-at

once or by progressive shortening

What is being drained Consistency,-larger lumen, suction drain

Why is the drain needed Latex, red rubber for tract formation

Where is the drain located Related to delicate structures, Sterile sites-closed drain Negative pressure zones-underwater seal

Trauma to tissues during insertion and removal

Fistula formation/perforation –erosion of adjacent tissues

Visceral herniation through tract Anastomotic leak Flap necrosis Bacterial colonization and sepsis

Fluid and electrolyte loss Pain Restricted mobility Drain malfunction-

migration,blockage,vacuum failure Prolonged healing-delayed foreign body

A substitute for poor surgical technique or inadequate hemostasis

Wrong indication Delayed removal Untimely removal Wrong selection of appropriate drain Inadequate care of drain Insertion in main surgical wound

Abscess cavity Infected wound Must not adhere

to healing tissue Must contain an

anti septic must be replaced

frequently.

Fistulae. Discharging

sinuses. Same principles of

packs.

Sheet drain wrapped around a wick or pack

Keep tract opened and drain the inflammatory exudates.

Require less replacement

Sheet drainage Simple insertion,

care and removal .

Not expensive. Tissue irritant.

Parallel tubes . Side and end

holes. Thick fluid can

block drainage.

When air tight seal could not be obtained.

Suction machines can be connected intermittently.

Yeates drain

Rubber corrugated drain

Penrose drain

Hemovac drain Jackson–Pratt drain

Foleys catheter Pigtail catheter

Most effective method of drainage.

Require air tight seal.

Closed drainage. Allow better

tissue coaptation.

Intercostal catheter

Mediastinal catheter

Vacuum assisted closure (VAC) drain

3-way Coude catheterFoleys catheter

Ryle tubeFine bore NG tube

T-tube(Khers)Salem sump tube

Celestine tube

To allow decompression of gastric contents To reduce postoperative nausea and vomiting To reduce abdominal distension To lower risk of aspiration and subsequent

pneumonia formation. Study by Cheatam et al1995 shows slight

postoperative reduction of nausea & vomiting and more patient discomfort.

Study by Nelson et al2005 shows with non insertion of tube showed less respiratory complications and early return of gastrointestinal functions by early passage of flatus.

Acute gastric dilatation Duodenal fistula Gastric outlet obstruction Small bowel obstruction Nasogastric feeding

Once anastomotic leak occurred drainage is accepted as the treatment of choice

In Cochrane review Karliczek et al2006 showed drainage after routine colorectal surgery rate of mortality, wound dehiscence, wound infection, reintervention and extra abdominal complications is quite similar in both drain or without drain (573/1140).

Petrowsky et al2004 showed both wound infection rate subsequent fistula formation is lower if no drain left irrespective of severity of appendicitis.

Lewis et al1990 showed no postoperative reduction in complication.

Cochrane review showed that postoperative drainage increase wound infection rates following open cholecystectomy also increases incidence of respiratory complications.

Same review showed increased rates of wound infection and delayed postoperative discharge in patients in which drain was used.

Prophylactic drainage is generally recommended for subphrenic collections and biliomas after liver resection.

But Cochrane review showed more chances of infection of collection if drain is present and recommends percutaneous drain placement postoperatively.

Used for decompression of oedematous CBD.

To prevent biliary leakage. To provide access for postoperative

visualization and retrieval of retained stones.

Trial by De-Roover et al, Sheen-Chen et al and williams et al showed longer postoperative stay in T- tube placement.

Study done in perforated duodenal ulcer cases (75/119) showed more chances of complication as intestinal obstruction with drain placement.

Study done in subtotal and total gastrectomy cases (108) showed no difference in complication rate.

In pancreaticoduodenectomy for a lesion of head of pancreas one drain is put near to the pancreaticojejunostomy site and another near the hepaticojejunostomy site.

Study by Conlon et al in patient after pancreatic resection rate of complication and number of intervention for collection were greater with drain.

Used for reducing blood and fluid accumulation.

Study fails to clarify situation. Currently the placement of drain

following incisional hernia repair has to be at the discretion of the operating surgeon.

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