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"NO DRAIN" FOLLOWING RADICAL GYNAECOLOGIC OPERATIONS - A Study of 75 Cases

Shubhada P Neel, TS Shylasree,Hemant B Tongaonkar, Jagdeesh N Kulkarni
Genitourinary service, Department of Surgical Oncology, Tata Memorial Hospital, Parel, Mumbai 400 012, India.

Objectives : To evaluate the clinical safety of omitting retroperitoneal drainage in radical gynaecologic operations.Design : Prospective study.

Methods : Stage IB and IIA cancer cervix undergoing radical hysterectomy with pelvic lymphadenectomy and stage I cancer endometrium undergoing total hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy. Posterior peritoneum was not closed and abdominal drain was not kept in these patients.

Result : There was no significant increase in the postoperative morbidity. Six patients had pelvic lymphoceles, out of which only one was symptomatic giving incidence of 1.3%, which did not require active intervention.

Conclusion : Facilitating drainage of lymph into the peritoneal cavity by keeping the retroperitoneum open dispenses the routine use of drains without increase in postoperative morbidity.

INTRODUCTION

Routine use of drains has been in vogue since preantibiotic era to reduce ensuing morbidity due to postoperative infections, ureteric fistulae and lymphocele formation. [1] Recently with the advent of effective antibiotic therapy, newer surgical techniques, better imaging modalities to detect morbid complications and the understanding of peritoneal physiology, many clinicians are questioning the role of routine use of drains.

Contrary to the popular belief that drains decrease lymphocele formation, it has been found that they act as a source of infection and epithelialise the drain tract and thereby increase lymphocele formation. [2] Moreover experimental studies in animals [3] have shown the ability of the peritoneal surface to resorb secretions and combat bacteria. This concept led several experts to conduct prospective randomised controlled trials on drain Vs no drain in radical gynaecologic surgeries [2,4] and concluded that drains rather than preventing contribute to the postoperative morbidity.

In keeping with the above trend, we designed a study of using "No Drain" in radical gynaecological surgeries in 75 patients, which forms the basis of this report.

MATERIAL AND METHODS

Seventy-five patients underwent radical surgery with pelvic lymphadenectomy without drain for cancer cervix stage IB and IIA and Stage I endometrial cancer between March 1997 and Feb. 1999 at Tata Memorial Hospital, Mumbai, India.

Cervical cancer patients underwent Rutledge type III radical hysterectomy [5] with bilateral PLND* while endometrial cancer patients were subjected to standard TAH-BSO** with limited pelvic lymphadenectomy. The PLND template in the former group included removal of lymphnodes, lymphatics and areolar tissue from bifurcation ofcommon iliac artery proximally to the circumflex iliac vein distally. Laterally dissection encompassed tissue upto artery including the intervascular compartment. Inferiorly contents of obturator fossa above obturator nerve were removed. In the endometrial cancer group, dissection was limited to external iliac and obturator fossa only. During PLND, visible lymphatics were clipped, ligated or cauterised.

The raw area was later washed with saline to remove clots, debris and protein rich coagulum and covered with absorbable gelatin sponge (Gelfoam) and absorbable haemostat (surgical) at the end of surgery to avoid clot formation. Posterior peritoneum was left open in contrast to the watertight closure followed in the past. All the patients received 1 gm IV cephalosporin one hour before surgery as per the protocol. Bladder was drained by 16 F-foley catheter, which was removed on the 5th postoperative day. Blood loss during surgery was corrected on the operating table and in the immediate postoperative period. Diuretics were not used in any of the patients.

Features related to surgery and subsequent morbidity were recorded (Tables 1-3).

Postoperative ileus was defined as the time period till the return of bowel sounds. Abdominal and pelvic sonography was done on day 5. All nonecogenic cysts in the pelvis were considered as lymphoceles. Any symptoms presumably considered to be due to lymphoceles were noted. Patients with lymphoceles were followed up with serial sonograms at weekly intervals till their complete resolution.

*PLND : pelvic lymphnode dissection.

**TAH-BSO : Total abdominal hysterectomy and bilateral salpingo-oophorectomy.

RESULTS

Results of the study are summarised in Tables 1-3.

TABLE 1
Patient characteristics and surgical details (n=75)
1.
Mean age
41.8 yr.
2.
Diagnosis
Ca Cervix 67 (89%)
Ca Endometrium 8 (11%)
3.
Histology
Squamous 56 (74%)
Adeno 19 (26%)
4.
Mean operative time
128 mins.
5. Type of lymphadenectomy
Ilio-obturator 67 (89%)
Obturator 8 (11%)
6.
Mean no. of nodes removed
12
7.
Lymph node metastasis
2

TABLE 2
Surgical morbidity (n=75)
1. Blood loss

< 500 ml

67 (89%)

> 500 ml

8 (11%)
2.
Mean Postoperative Ileus
3 days
3. Lymphocele 6 (8%)
Symptomatic 1 (1.3%)
Asymptomatic 5 (6.6%)
4.
Leg oedema
1 (1.3%)
5.
Flank pain
0
6.
Febrile morbidity
0
7.
Ascites
0
8.
Mean hospital stay
6.9 days
9.
Readmission
0

Six patients (8%) developed lymphocele in our study, of which only one was symptomatic (1.3%). There was no increased incidence of flank pain, febrile morbidity, ascites, postoperative ileus, urinary fistulae and readmissions in the lymphocele group. Characteristics of the patients with lymphocele are given in Table 3.

DISCUSSION

Currently radical gynaecologic surgery has reached paramount safety. Due to negligible mortality the focus is shifting reduction of morbidity. Understandably PLND is expected to render significant morbidity which could be a menace in a

TABLE 3
Characteristics of the lymphocele group
Sr.
Day of detection*
Size in cm.
Symptoms
Treatment
Disappearance
No.of lymphocele*
1.
Day 5
3.5
Nil
Observation
Day 10
2.
Day 5
5
Nil
Observation
Day 10
3.
Day 5
6.5
Limb oedema**
Bed rest and limb elevation
Day 15
4.
Day 5
3.1
Nil
Observation
Day 10
5.
Day 5
5
Nil
Observation
Day 10
6.
Day 5
4
Nil
Observation
Day 20

*Counted from the day of surgery. **Deep vein thrombosis was ruled out by Doppler studies.

few patients. Although dreaded complications like permanent lymphoedema and deep vein thrombosis are events of the past, lymphocele in the immediate postoperative period could be troublesome.

Incidence of lymphocele quoted in the literature is 1-3% in the drain group [6] and nil in the no drain group. [2] Incidence of symptomatic lymphoceles in our earlier cases studied during January 1996 to December 1996 was 4.5%, where retroperitoneal drainage was provided, as opposed to only 1.3% in the current study wherein retroperitoneal drainage was omitted. However this is not a prospective or randomised comparison and not all patients treated prior to this study underwent routine postoperative sonography in order to document presence of postoperative lymphocele. Lymphoceles in the immediate postoperative period have been associated with extensive dissections and anticoagulant usage. Experimental studies have shown that anticoagulants delay [7] the closure of severed lymphatics which otherwise normally seal within 24-48 hours of surgery. [8] Persistent and delayed lymphoceles have been associated with residual [9] or recurrent [10] disease respectively. None of the above mentioned factors contributed to lymphocele formation in our study.

Lymphoceles are less common with transperitoneal approach presumably because extravasated lymph is resorbed through the peritoneal surface. [11] Transperitoneal approach with nonclosure of the peritoneum aids in internal drainage of the lymph, which is akin to peritoneal dialysis. This also prevents the loss of plasma proteins through the drain fluid [12] and unnecessary infusion of colloids in the postoperative period. We found no significant difference in the pre and post operative plasma protein levels in our patients. There was no increased incidence of transfusion of plasma products based on plasma protein levels.

In our opinion, other added advantages of not keeping a drain are,

1.Early ambulation, which decreases the incidence of co-morbid, conditions like embolism and hypostatic pneumonia in the postoperative period. Our patients were ambulatory within 12 hours postoperative and required fewer analgesics.

2.Reduction in the time spent by the nursing staff in measuring and charting the drain fluid.

3.The cost of the drain tube can be dispensed.

In conclusion, our study confirms the safety of the procedure with added benefits. The concept of draining the lymph internally into the peritoneum by keeping the posterior peritoneum open appears logical and scientific and confirms the studies concluded by other experts.

REFERENCES

    1. Symmonds RE. Morbidity and complications of radical hysterectomy with pelvic lymph node dissection. Am J Obstet Gynecol 1966; 94 : 663-78.
    2. Patsner B. Closed suction drainage versus no drainage following radical abdominal hysterectomy with pelvic lymphadenectomy for stage IB cervical cancer. Gynaecologic oncology 1995; 57 : 232-34.
    3. Yates JL. An experimental study of the local effects of peritoneal drainage. Surg Gynecol Obstet 1905; 1 : 473.
    4. Pierluigi BP, Francesco M, Giuseppe C, et al, A randomised study comparing retroperitoneal drainage with no drainage after lymphadenectomy in gynaecologic malignancies. Gynaecologic oncology 1997; 65 : 478-82.
    5. Piver MS, Rutledge F, Smith JP. Five classes of extended hysterectomy for women with cervical cancer. Am J Obstet Gynecol1974; 44 : 265-72.
    6. Petru E, Tamussino K, Lahousen M, Winter R, Pickel H, Haas J. Pelvic and paraaortic lymphocysts after radical surgery because of cervical and ovarian cancer. Am J Obstet Gynecol 1989; 161 : 937-41.
    7. Braun WE, Banowsky LH, Straffon RA, Nakamoto S, et al. Lymphoceles associated with renal transplantation. Report of 15 cases and review of the literature. Amer J Med 1974; 57 : 714.
    8. Chrobak L, Bartos V, Brzek V, Hnizdora D. Coagulation properties of human thoracic duct lymph. Amer J Med Sci 1967; 253 : 69.
    9. Mori N. Clinical and experimental studies on so called lymphocyst, which develops after radical hysterectomy in cancer of the uterine cervix. J Jap Obst Gynec Soc 1955; 2 : 178.
    10. Cantrell CJ, Wilkinson EJ. Recurrent squamous cell carcinoma of the cervix within  pelvic- abdominal lymphocysts. Obstet Gynecol 1983; 62 : 530-34.
    11. Basinger GT, Gittes RF. Lymphocyst : ultrasound diagnosis and urologic management. J Urol  1975; 114 : 740.
    12. Orr JW Jr, Barter JF, Kilgore LC, et al. Closed suction pelvic drainage after radical pelvic  surgical procedures. Am J Obstet Gynecol 1986; 155 : 867-71.

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