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Use of primary surgical drains in synchronous resection for colorectal liver metastases: a NSQIP analysis of current practice paradigm

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Abstract

Background

There are no studies examining the use of subhepatic drains after simultaneous resection of synchronous colorectal liver metastases (sCRLM). This study aimed to (1) describe the current practices regarding primary drain placement, (2) evaluate drain efficacy in mitigating postoperative complications, and (3) determine impact of drain maintenance duration on patient outcomes.

Methods

The ACS-NSQIP targeted data from 2014 to 2017 were analyzed. Propensity score of surgical drain versus no drain cohorts was performed. Main study outcomes were mortality, major morbidity, organ/space surgical site infection (SSI), secondary drain/aspiration procedure, and any septic events. Additional univariate/multivariate logistic analyses were performed to identify associations with drain placement and duration. Major hepatectomy was defined as formal right hepatectomy and any trisectionectomy.

Results

584 combined liver and colorectal resection (CRR) cases were identified. Open partial hepatectomy with colectomy was the most common procedure (70%, n = 407). Nearly 40% of patients received surgical drains (n = 226). Major hepatectomy, lower serum albumin, and no intraoperative portal vein occlusion (Pringle maneuver) were significantly associated with drain placement (p < 0.05). In the matched cohort (n = 190 in each arm), patients with surgical drains experienced higher rates of major morbidity (30% vs 12%), organ/space SSI (16% vs 6%), postoperative drain/aspiration procedures (9% vs 3%), and sepsis/septic shock (12% vs 4%) (all p < 0.05). Patients with severely prolonged drain removal, defined as after postoperative day 13 (POD13), had higher risk of postoperative morbidity compared to those with earlier drain removal (p < 0.01). 30-day mortality rate was not significantly different between the two groups.

Conclusion

Primary surgical drains were placed in a substantial percentage of patients undergoing combined resection for sCRLM. This case-matched analysis suggested that surgical drains are associated with an increase in postoperative morbidity. Postoperative drain maintenance past 13 days is associated with worse outcomes compared to earlier removal.

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Acknowledgements

The authors would like to thank Rodica Muraru and the Center for Outcomes Research in Surgery (CORES) department at the Indiana University School of Medicine for their contribution in providing statistical advice.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Division of Surgical Oncology, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA

    Elliott J. Yee, Mohammed H. Al-Temimi, Katelyn F. Flick, Trang K. Nguyen, Nicholas J. Zyromski, C. Max Schmidt, Attila Nakeeb, Michael G. House & Eugene P. Ceppa

  2. Indiana University Health, Indianapolis, IN, USA

    E. Molly Kilbane

  3. Indiana University School of Medicine, 545 Barnhill Dr., Emerson Hall 541, Indianapolis, IN, 46202, USA

    Eugene P. Ceppa

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  1. Elliott J. Yee
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Correspondence to Eugene P. Ceppa.

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Drs. Yee, Al-Temimi, Flick, Nguyen, Zyromski, Schmidt, Nakeeb, House, Ceppa, and Mrs. Kilbane have no conflicts of interest or financial ties to disclose.

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Appendix

Appendix

Hepatectomy CPT codes:

47120, 47122, 47125, 47130

Colectomy CPT codes:

44140, 44141, 44143, 44144, 44145, 44146, 44147, 44150, 44151, 44160, 44204, 44205, 44206, 44207, 44208, 44210

Proctectomy CPT codes:

44155, 44156, 44157, 44158, 44211, 44212, 45110, 45111, 45112, 45113, 45114, 45116, 45119, 45120, 45121, 45123, 45126, 45130, 45135, 45160, 45395, 45397, 45402, 45550

Secondary liver metastases ICD-9/10 codes:

C78.7, 197.

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Yee, E.J., Al-Temimi, M.H., Flick, K.F. et al. Use of primary surgical drains in synchronous resection for colorectal liver metastases: a NSQIP analysis of current practice paradigm. Surg Endosc 35, 4275–4284 (2021). https://doi.org/10.1007/s00464-020-07917-6

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