Comment on “Implementing a no‑drain policy for extraperitoneal colorectal anastomosis in a real‑life setting: analysis of outcomes and surgeons’ adherence”

With great interest, we read the informative article by Crippa et al. [1], and we would like to congratulate them for their informative article on a topic which has still got no consensus across the surgical fraternity.

Anastomotic leak (AL) is a known dreadful complication after colorectal resections which can prolong hospital stay and is often associated with increased hospital morbidity and mortality. In some cases, it can also result in delays in adjuvant treatment [2].

Incidence of AL post low anterior resection (LAR) for rectal cancer varies between 3 and 25% and a higher incidence of sub-clinical leaks [3].

The rational for using the abdominal drains after colorectal anastomosis was for early identification of AL, preventing formation of abdominal abscess and reducing the chances of intra-abdominal sepsis [4].

It has been argued over the years if the abdominal drains (AD) are really able to identify the AL at an early stage. GRECCAR 5 trial questioned the sensitivity of AD in detecting early AL and concluded no benefit in using routine AD for low rectal anastomosis [5].

Some authors in the past had endorsed AD as an early indicator for AL and as a prophylactic tool for reducing the risk of intra-abdominal abscess formation. However, with emphasis on early discharge and practicing ERAS (enhanced recovery after surgery) guidelines, doubts were casted on the routine use of AD post LAR [6].

There are certain risk factors including high body mass index (BMI), low rectal anastomosis, post neo-adjuvant chemo-radiotherapy, steroid use, prolonged surgery, restorative surgery without ileostomy, emergency surgery, and male patient, which may prompt the use of AD after LAR [7].

COMPASS study (prospective, multi-central) showed no clear advantage of AD in detecting AL early; instead, they concluded AD leads to prolonged hospital stay and increases incidence of SSI (surgical site infections) [8].

A survey by Willis et al. [9] showed the reluctance in adopting the recommendations from ERAS and other evidence which suggests against the routine use of AD post colonic resections.

A randomized trial showed the negative effects of AD in diet tolerance after intra-corporeal anastomosis with right hemicolectomy [10].

We feel use of AD after colorectal anastomosis is very variable, and it depends on the surgeons experience and should be based on the merit of the case.

Even after multiple studies which have been pro and against the use of AD, we still do not have a clear consensus. We think it will require multi-institutional prospective study to determine some meaningful results which can put this debate to rest. We in our clinical practice use Yeates drain after colonic resections; therefore, we feel choice of drains should also be considered when we formulate the outcomes while assessing the usefulness of AD.

We congratulate the authors for their valuable contribution on an interesting topic.

Author contribution

MB—prepared the manuscript, data analysis, concept TS- editing, supervising.

TS- editing, supervising.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.