2. First recorded use of drains is attributed to
Hippocrates (460-377 BC ) for Empyema
Lorenz Heister of Numberg (1683-1758 )
introduce the principle of capillary (action)
drainage .
Eugene Koeberle of Strasbourg(1865) used a
glass tube drain .
3. Heaton ( 1889 ) is credited with introducing
suction drainage .
Murphy ( 1947 ) introduced a technique for
intermittent suction .
Closed-system , continuous suction
introduced by Baron (1950 ) .
4. 1. Active Drains
Closed
JP(Jackson-Pratt Drain),
Redivac Suction Drain
Open
Sump Drain
FLUID
AIR
5. 1. Passive Drains
Closed
NGT, Foleys catheter,
T-Tube, Nelaton Drain etc.
Open
Penrose drains,
corrugated Drains
6. Active Drain Passive Drain
Function Works by negative
pressure created by
compressible drums or
mechanical evacuation
system
Depends upon
pressure differentials
& gravity
Pressure Gradient Negative Pressure Normal
Drain Exit site Dependent Position is
not necessary
Dependent position
for best function
Retrograde Infection Lower incidence Higher incidence
Fluid collection Decreased incidence
because negative
pressure improves
tissue apposition &
obliterates dead space
Increased incidence
because of limited
effect on dead space
Obstruction of Drain More common Less common
Pressure necrosis Greater incidence Less common
7. In 1905 Yates claimed “ drainage of General
Peritoneal cavity is physically and
physiologically impossible”.
Gravitz’s stated “ Peritoneum is able to
reabsorb secretions and combat bacteria.”
8. Review of
literature/Research work.
This is the most sophisticated way to get benefit
from the work and experiences of others in this era.
9. 1992
“the conscientious,explicit,judicious use of
current best evidence in making decisions
about the care of individual patients.”
( conscientious -------- attentive, Luborious,Pain taking)
( Explicit------------------ Obvious)
( Judicious--------------- Logical,Rational)
10. Its basic principles are that all practical
decisions made should
Be based on Research studies.
That the Research studies are selected and
interpreted according to some specific norms
characteristic for EBP.
The results should be analyzed and compared
with standards.
11. How to Review the literature/Research work?
Which Research work is Reliable and
practicable?
12. Anything present in support of an assertion
(statement).
Evidence is comprised of research findings
delivered from the systemic collection of Data
through observation & experiment and the
formulation of Question & testing of
Hypothesis.
There are certain scales to measure Evidence
(levels of Evidence )
Recommendations are made by different
Research Groups.
14. Grading of Recommendations Assessment, Development
and Evaluation (GRADE)
•Source: GRADE (Grading of Recommendations Assessment, Development and Evaluation) Working Group 2007(modified by EBM guideline editorial team)
Code
Quality of
Evidence
Definition
A High
Further research is very unlikely to change
our confidence in the estimate of effect.
•Several high-quality studies with consistent
results
•In special cases: one large, high-quality
multi-centre trial
B Moderate
Further research is likely to have an
important impact on our confidence in the
estimate of effect and may change the
estimate.
•One high-quality study
•Several studies with some limitations
C Low
Further research is very likely to have an
important impact on our confidence in the
estimate of effect and is likely to change the
estimate.
•One or more studies with severe limitations
D Very Low
Any estimate of effect is very uncertain.
•Expert opinion
No direct research evidence
15. University of Michigan Practice Guideline:
A: Randomized controlled trials.
B:
Controlled trials, no
randomization.
C: Observational trials.
D: Opinion of the expert panel
16. Cochrane collaboration: A worldwide
association of groups who create and
maintain systematic reviews of the literature
for specific topic areas.
Cochrane Review
USPSTF ( US Preventive Services Task Force)
AHRQ ( Agency of Health Care Research &
Quality)
17. A systematic Review & Meta-Analysis
Source. Ann Surg. Dec,2004; 240 (246)
Author from Switzerland, Department of
Visceral & Transplant Surgery, University
Hospital.
18. Review of Articles Comparing Prophylactic
Drainage Vs No Drainage in GI Surgery from
1966 to 2004.
17 RCTs for Hepato-pancreatico-biliary
Surgery.
None for upper GI Tract
13 for Lower GI Tract.
19. All studies were classified according to their
level of Evidence and then graded (A,B,C,D) as
suggested by Oxford Centre for EBM.
Studies were compared for the following end
points: mortality, overall complication rates,
leakage rates, infection rates (wound, intra-abdominal
collections, abscess), pulmonary
complication rates, reoperation rates, and
hospital stay.
20. Open Cholecystectomy numerous RCTs and
Meta-analysis by Lewis et al, failed to
demonstrate a reduction of post-operative
complications by routine drainage. (Level 1a)
Lap. Cholecystectomy 2 RCTs, 4 of 34 (11.7%)
of drained had complications while in non
drained 2 of 33 (6.1%) had
complications.(Level 1a)
21. No RCT prospective study
One non Randomized Prospective Cohort
study (level 2b)
“The role of Prophylactic Drains after Surgery
for Perforated Duodenal Ulcer.”
22. Total pts. 119
Omental Patch Technique
75 pts. With Drain
44 pts. Without drain
23. Drainage neither reduced the incidence of
intra abdominal fluid collection including
abscess formation nor the duration of
Hospital stay.
But there were a significant number of Drain
related complications such as
Drain Tract infection (10.7%)
Acute Intestinal obstruction (2.7%)
24. Meta analysis
8 RCTs on Abdominal/Pelvic Drainage vs no
Drainage
3 RCTs has Level 1b
5 RCTs has Level 2b
717 pts. with Drain
673 pts. without Drain
Majority of studies on Elective Surgery
2 studies include Emergency cases
25. A slight advantage for non drained patients
in respect to clinical leakage (OR 1.38; CI
0.77–2.49) and wound infections (OR 1.41; CI
0.87–2.29) was documented, although this
advantage was not statistically significant.
Moreover, the meta-analysis by Urbach et al
showed that in only 1 of 20 clinical leakages
pus or feces emerged through the
drain,indicating that drains have a low
sensitivity (5%) to detect clinical leakage.
27. Open Appendectomy
Five RCTs on prophylactic drainage for
gangrenous and perforated appendicitis were
identified (level of evidence 2b).
The results showed higher wound infection rates
in drained patients (range 43–85%) than in non
drained patients (range 29–54%).
The pattern of intra-abdominal infections was
not uniform among the studies, as 2 studies
reported slightly higher intra-abdominal
infection rates in non drained patients,1 study a
higher rate in drained .
28. Meta-analysis including series with gangrenous
or perforated appendicitis only.
Four RCTs (all level 2b) were included in the
meta-analysis with the end point wound
infection, whereas data from 3 RCTs were
available for the end points intra-abdominal
infection and fecal fistula .
The analysis calculated an OR for wound
infections of 1.75 (CI 0.96–3.19). The OR for
fecal fistulas of 12.4 (CI 1.14–135) favors the no-drainage
group, whereas the OR for the end point
intra-abdominal infection of 1.43 (CI 0.39–5.29)
favors neither group.
29. Cochrane Review
Published on 3rd Sep. 2013
12 RCTs
1831 participants
915 pts with drain
916 pts without drain
9 RCTs include elective cholecystectomies
1 RCT include Acute cholecystitis
2 RCTs include both elective & emergency
cholecystectomies
30. There was no significant or clinically
important differences in the short-term
mortality, serious complications, quality of
life, length of hospital stay, operating time,
return to normal activity, or return to work in
the trials that reported these outcomes.
The proportion of patients who were
discharged as day-procedure laparoscopic
cholecystectomy seemed significantly lower
in the drain group than in the 'no drain' group
.
31. Journal of Minimal Access Surgery; 2012,Jul-
Sep
Suez Canal Hospital
RCT (Prospective)
Single Blind (Team Accessing Results)
Level of Evidence 1b
Group A with Drain ( closed Passive Drain)
Group B without Drain
Assessment. Post op Pain ,wound infection
& Hospital stay
32. Post op Pain VAS no difference at 24,48hrs &
1week.
Hospital Stay
Group A 1--3 days
Group B 1-- 2days
33. East & Centeral African Journal of Surgery
Vol.16,No 2,Jul/Aug 2011;62-71
Prospective RCT
90 pts.
Pts with generalized Peritonitis were excluded
45 pts. With drain (closed without suction)
45 pts. Without drain
34. Other complications included fecal fistula (2patients),
intraperitoneal abscess (3 patients) and paralytic ileus
(1 patient) all of them occurring in patients with
drains.
35. Many GI operations can be performed safely
without prophylactic drainage. Drains should
be omitted after colonic, or rectal resection
with primary anastomosis and appendectomy
for any stage of appendicitis
(recommendation grade A).
Currently, there is no evidence to support the
use of drain after laparoscopic
cholecystectomy (recommendation grade A).
Further well-designed randomised clinical
trials are required.
36. In any surgical procedure, good hemostasis,
appropriate antibiotics use and precise
surgical
technique with minimal tissue trauma limit
the need
for operative drain placement.