use of drains in gastrointestinal surgery
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“ 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.
Thanking youThanking you
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