174

Use of Intra-Abdominal Drains

Frances J. Puleo, MD1 Nitin Mishra, MD1 Jason F. Hall, MD, MPH, FACS2

1 Department of Surgery, Robert Wood Johnson Medical School, University Address for correspondence Jason F. Hall, MD, MPH, FACS,
of Medicine and Dentistry of New Jersey, Edison, New Jersey Department of Colon and Rectal Surgery, Lahey Clinic, 41 Mall Road,
2 Department of Colon and Rectal Surgery, Lahey Clinic, Burlington, Burlington, MA 01805 (e-mail: Jason.F.Hall@Lahey.org).
Massachusetts

Clin Colon Rectal Surg 2013;26:174–177.

Abstract The use of drains in colorectal surgery has been a subject of debate for several decades.

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Keywords Prophylactic drainage of the peritoneal cavity has become less popular in recent years.
► colon and rectal This change is due to several studies demonstrating that intraperitoneal drains do not
surgery adequately drain the peritoneal cavity and do not prevent or contain anastomotic leaks.
► drains Percutaneous drain placement has become the standard of care for patients with intra-
► drainage abdominal abscesses. Selected anastomotic leaks in the stable patient can also be
► anastomosis managed with percutaneous drains. In this article, the authors review in detail the use of
► anastomotic leak drains and the literature to support their use in our everyday practice.

Objectives: On completion of this article, the reader should the fifth postoperative day. Patients were followed for at least
understand the role of prophylactic and therapeutic drainage 30 days postoperatively. Two patients in the drainage group
in colorectal surgery, and be familiar with recent studies had clinical signs of an anastomotic leak. The quantity or
related to the use of drains in colorectal surgery. character of the intraperitoneal drainage had not alerted the
clinicians to the presence of an anastomotic leak.4
The concept of using drains during surgical procedures has Several randomized studies were subsequently conducted
been documented for centuries. Hippocrates described the examining anastomotic healing rates and other outcomes with
use of tubes to remove ascitic fluid from the abdominal or without drain placement. The results of a limited number of
cavity.1 In the 19th century, Theodore Billroth believed that these studies are summarized in ►Table 1. Drain placement
drainage of the peritoneal cavity was essential for saving the did not have a significant effect on the rate of anastomotic leak
lives of patients after gastrointestinal surgery.1,2 In 1964, or other outcomes. These studies however had poor randomi-
Berliner studied dogs who underwent two colonic anasto- zation and assessment of outcomes was subjective.5
moses, one of which had a rubber drain placed at the suture In 2004, a meta-analysis was performed to review the use
line. The dogs were sacrificed and 11 out of 20 dogs were of drains as early indicators of leak and as treatment.1,6 The
found to have an anastomotic leak at autopsy at drain site. The authors performed a meta-analysis of 717 drained and 673
authors of this study concluded that drain placement pre- nondrained patients and assessed for anastomotic leak,
vented omentum, visceral peritoneum, or small bowel from wound infection, and respiratory complications. The authors
adhering to and therefore sealing colonic anastomosis.3 concluded that there was no significant benefit of drainage in
reducing risk of leak or other surgical complications.1,6 The
authors found that only 1 in 20 of the drains contained pus or
Use of Drains in Colonic Anastomosis
enteric contents, which represented only a 5% sensitivity for
In 1986, Hoffman et al performed the first human prospective the detection of anastomotic leaks.1,6
study of prophylactic drainage of colonic anastomoses. Sixty In 2004, the Cochrane Collaboration performed a system-
patients were randomized to drainage or no drainage groups. atic review of the literature on prophylactic use of drains in
The drainage group had the drain placed near but not colorectal surgery. The review included six randomized con-
touching the anastomosis. The drain was affixed to the skin trolled studies with 1,140 patients, comparing drainage and
and drained into a colostomy bag. All drains were removed on no drainage protocols after anastomosis in elective colorectal

Issue Theme Perioperative Copyright © 2013 by Thieme Medical DOI http://dx.doi.org/

Management; Guest Editor, Sharon L. Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0033-1351134.
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 Use of Intra-Abdominal Drains Puleo et al. 175

Table 1 Summarizes data from early randomized trials

# Patients Type of Anastomotic Anastomotic Wound infection Wound infection

anastomosis leak (drain) leak (no drain) (drain) (no drain)
(%) (%) (%) (%)
Sagar et al2 148 Colorectal 11.0 6.0 15.0 6.0
Johnson et al26 106 Colonic 12.2 10.5 20.4 17.5
4
Hoffman at el 70 Colonic 3.5 3.3 14.2 6.6

surgery.7 The primary objective was to determine if prophy- between the two groups: 6.8% for the drainage group and 6%
lactic drainage prevented clinical anastomotic leakage. The for the no-drainage group. There were 18 deaths, 8 (3.2%) in
review also measured overall mortality, anastomotic leak, those with drainage and 10 (4%) in those without drainage.

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wound infection, reoperation, and extra-abdominal compli- Pelvic drainage did not prevent anastomotic leakage or
cations in the two groups.7 A review of these six trials showed prevent complications in this study.11
an overall mortality of 3% in the patients who had drains Brown et al focused solely on drain usage in anastomosis
placed compared with 4% in the nondrainage group. This below the peritoneal reflection. In 8 months, the authors
difference was not statistically significant.7 randomized 60 patients undergoing pelvic anastomosis to a
Anastomotic leak was defined as the presence of a radio- drain or no drain group. They found no significant difference
logic dehiscence on postoperative enema. The rate of radio- in postoperative complications in the drainage group com-
logic leak was 3% for drainage group versus 4% in the pared with the nondrainage group. The overall leak rate in
nondrainage group. Operative placement of a drain did not both groups was 7%, and there was no difference in the
appear to be associated with the anastomotic leak rate. On incidence of pulmonary complications or wound infections.
further analysis of the data, based on the level of the anasto- The overall 30-day mortality for both groups was 1%.8 Al-
mosis, there was no benefit to drainage of pelvic anastomosis; though this study had a small sample size, the authors
however, this was only reviewed in two of the six studies.7 concluded that prophylactic drainage does not improve the
In addition to their postulated effect on anastomotic outcomes of patients undergoing low rectal anastomosis.8
healing, drains have been thought to increase pain, leading In 2004, Peters et al reviewed the database of the Dutch
to possible pulmonary complications. There is a theoretical TME trial to determine risk factors for anastomotic leakage.
benefit in preventing wound infection. In the Cochrane On review of the 924 patients enrolled, the presence of one or
Review, extra-abdominal complications were found to be at more pelvic drains after surgery was associated with a lower
7% for the drainage group compared with 6% for the non- leakage rate: 9.6% of the patients with pelvic drainage had
drainage group. Drainage did not protect the wounds from leakage, compared with 23.5% without a drain; which was
infection or increase the rate of infection. Wound infection statistically significant.12 These authors also found that the
rates were the same in the two groups among all the studies. need for reoperation after detection of anastomotic leak was
The authors concluded that there was insufficient evidence to significantly lower for patients with pelvic drainage than for
support use of prophylactic drains in colorectal surgery.7 those without a drain.12 These results appear to favor the use
of prophylactic drains in rectal surgery; however, some care is
necessary in interpreting these results. There is a large
Use of Drains after Low Pelvic Anastomosis
element of selection bias in interpreting the differences in
Although the aforementioned data does not appear to suggest anastomotic leak rates in the two groups. The use of drains
that routine drainage of the peritoneal cavity is useful, there is was not randomized, but rather left to the discretion of the
some evidence for the use of prophylactic drainage in rectal operating surgeon. One could safely assume that patients who
surgery. Pelvic anastomosis has a higher rate of anastomotic had difficult pelvic dissections were more likely to have a
leak when compared with colonic anastomosis.8–11 After a drain placed. It is also a safe assumption that patients with
total mesorectal resection, typically there is a large raw difficult dissections are also more likely to suffer from anas-
surface which typically secretes a large amount of serous tomotic leak. In addition, this study was also not designed or
and sometimes hemorrhagic fluid. The pelvis represents a powered to study the effects of drains on anastomotic leaks,
fixed, dependent, cavity. These anatomic constraints make but rather the effect of radiation on local recurrence and
accumulation of a fluid collection more likely and it is mortality.12
postulated that drain placement can prevent formation of In 2005, Yeh at al published a prospective study of 978
an abscess or seroma.8 patients undergoing a low anterior resection in a single
Merad et al studied 494 patients who were randomized to institution. Their objective was to investigate prophylactic
a drain or no drain while undergoing rectal or anal anasto- pelvic drainage and risk factors associated with anastomotic
mosis for a variety of different conditions. They examined the leakage. In their study, surgeons picked the type of drain used
rates of anastomotic leakage in both groups as well as other during the operation. The authors studied multiple factors to
postoperative complications. The leakage rate was similar determine risk factors for anastomotic leak. They concluded

Clinics in Colon and Rectal Surgery Vol. 26 No. 3/2013

176 Use of Intra-Abdominal Drains Puleo et al.

that pelvic drainage was not associated with decreased leak Anastomotic leak is a dreaded complication of colorectal
rate.9 surgery. The mortality of anastomotic leaks can be as high as
Tsujinaka et al studied 196 patients who underwent low 12%.22 There is also significant associated morbidity with
anterior resection with TME to determine if drain placement reoperation for an anastomotic leak. Nonoperative manage-
had any effect on anastomotic leakage and its management. ment of anastomotic leaks with percutaneous drainage has
Anastomotic leak occurred in 21 (10.7%) of the 196 patients in been proven to be successful in selected patients. The success
the study. A change in the character of the drainage fluid was rate of CT-guided percutaneous drainage for colonic anasto-
noted in 15 (71.4%) of the patients with an anastomotic leak. mosis leaks has been reported at roughly 80% although
These patients were subsequently treated by nonoperative significant selection bias is inherent in this statistic.7 For
management, which consisted of nothing per mouth, hyper- rectal anastomoses, treatment of anastomotic leaks with
alimentation, and leaving the drain in place. The authors percutaneous drainage is less successful (roughly 48% in
suggest that based upon their results, pelvic drainage may act one study).6
as an early indicator of anastomotic leak and that placement Intra-abdominal abscess is a common occurrence after
of a drain may decrease the need for surgical intervention for colon and rectal surgery. Often, these abscesses can be

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an anastomotic leak.13 managed nonoperatively with placement of a percutaneous
drain.23 In 2002, Khurrum Baig et al performed a retrospec-
tive study that examined 40 patients who underwent com-
Use of Percutaneous Drainage as Therapy
puted tomography- (CT-) guided drainage of intra-abdominal
Although the use of operatively placed drains is controversial, abscess that occurred after a variety of colorectal surgical
percutaneous drainage can be used in certain clinical scenar- procedures. Among the 40 patients, 65% had a complete
ios to avoid emergency surgery. Complicated diverticulitis resolution of their abscess with one attempt at drainage.
can be treated with nonoperative management in 70 to 100% Another 35% required repeat drainage with another catheter.
of cases. Percutaneous drain placement has a major role in Of the 40 patients, only 6 ultimately required laparotomy for
this nonoperative management. Roughly 15% of patients with treatment of the postop abscess.23 This study suggests that
acute diverticulitis will develop an abscess.14 In 2006, the postoperative abscesses can be safely treated with percuta-
practice parameters published by the American Society of neous drainage in patients who are hemodynamically stable
Colon and Rectal surgeons suggested that patients with and do not have peritonitis.
abscesses greater than 2 cm are candidates for percutaneous
drain placement.14 This treatment paradigm can sometimes
Drains as a Risk Factor for Infection
prevent urgent surgery and a resultant stoma.14,15 There are
several studies that suggest that patients with diverticular Surgical-site infections (SSIs) are a major cause of increased
abscesses treated with antibiotics alone have similar out- length of stays and health care cost. Drains have been
comes to those treated with antibiotics and percutaneous implicated as being a risk factor for the development of a
drainage. Durmishi et al examined 34 patients with divertic- surgical site infection. In 2001, a prospective single center
ular abscesses. The authors defined treatment failure as study from Taiwan reviewed the cause of surgical site in-
recurrence of the abscess, need for colostomy, or emergency fections in 2,809 patients. Although they reviewed a large
surgery within 4 weeks. The average abscess size was 6 cm. Of number of factors, they did conclude that the presence of a
the 11 patients who were treatment failures, 10 (88%) re- drain after elective surgery for colon or rectal resection was a
quired a colostomy. There was also a 33% mortality associated risk factor for developing a surgical site infection. The study
with treatment failure.16 A similar case-control study com- found that 3.8% of patients with a drain had an infection of
pared treatment failure of patients treated with percutaneous their surgical incision. The authors concluded that a drain
drainage
antibiotics and antibiotics alone. The matching acted like a foreign body and increased the risk of surgical site
process was not described. Treatment failure was defined as infection and potentially anastomotic leak.24 This study is
recurrence of the abscess within 4 weeks, need for colostomy, subject to selection bias because patients with at high risk for
or need for emergency surgery. The rates of emergency SSIs are more likely to have a drain placed intraoperatively.
surgery (30 vs. 16%) or mortality (9 vs. 3%) were not different Other studies have established that surgical drains can
(p > 0.05).17 harbor significant pathogens including methicillin-resistant
Abdominopelvic abscess occurs in 7 to 28% of patients with Staphylococcus aureus (MRSA). One study documented a
Crohn disease.18,19 Historically, these abscesses would have decrease in the percentage of drains with a positive culture
been treated with an operation resulting in bowel resection when patients were treated with prophylactic first-genera-
and possible stoma creation.18 Percutaneous drainage has tion cephalosporins. However, the authors did not demon-
become a first-line treatment for intra-abdominal abscess in strate a difference in SSIs.25
patients with Crohn disease.20 Drain placement is a tempo-
rizing measure to allow improvement of patient’s nutritional
Conclusions
status, and control local sepsis, which ultimately may de-
crease surgical complications.20 The success rate for treat- The use of drains after colorectal surgery has evolved over the
ment of patients with a percutaneous drain ranges from 50 to last several decades. The use of prophylactic drains in intra-
65%.18,19,21 peritoneal colonic surgery is not supported by data

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 Use of Intra-Abdominal Drains Puleo et al. 177

demonstrating improvement in outcomes related to anasto- 11 Merad F, Hay JM, Fingerhut A, et al; French Association for Surgical
motic leak or other common surgical complications. Prophy- Research. Is prophylactic pelvic drainage useful after elective
lactic drainage of the pelvis after complex pelvic surgery may rectal or anal anastomosis? A multicenter controlled randomized
trial. Surgery 1999;125(5):529–535
decrease the development of pelvic collections; however, it is
12 Peeters KC, Tollenaar RA, Marijnen CA, et al; Dutch Colorectal
not clear whether drains influence the rates of anastomotic Cancer Group. Risk factors for anastomotic failure after total
leak. mesorectal excision of rectal cancer. Br J Surg 2005;92(2):211–216
The technical feasibility and safety of postoperative per- 13 Tsujinaka S, Kawamura YJ, Konishi F, Maeda T, Mizokami K. Pelvic
cutaneous drainage of pelvic or abdominal collections has drainage for anterior resection revisited: use of drains in anasto-
motic leaks. ANZ J Surg 2008;78(6):461–465
been demonstrated. Percutaneous drainage plays an impor-
14 Rafferty J, Shellito P, Hyman NH, Buie WD; Standards Committee of
tant role in the management of several disease processes such
American Society of Colon and Rectal Surgeons. Practice param-
as diverticulitis or Crohn disease. Management of selected eters for sigmoid diverticulitis. Dis Colon Rectum 2006;49(7):
patients with anastomotic leaks with percutaneous drainage 939–944
is also possible. As in any field of inquiry with multiple 15 Wolff BG. The ASCRS Textbook of Colon and Rectal Surgery. 1st ed.
conflicting data sources, the decision to drain or not to drain New York, NY: Springer Science þ Business Media; 2007:274

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
16 Durmishi Y, Gervaz P, Brandt D, et al. Results from percutaneous
will largely be an individualized choice based on surgeon
drainage of Hinchey stage II diverticulitis guided by computed
preferences and patient factors. tomography scan. Surg Endosc 2006;20(7):1129–1133
17 Brandt D, Gervaz P, Durmishi Y, Platon A, Morel P, Poletti PA.
Percutaneous CT scan-guided drainage vs. antibiotherapy alone for
Hinchey II diverticulitis: a case-control study. Dis Colon Rectum
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