Thyroid Uncomplicated Surgery with Lack Placement of Drains. A Retrospective Analysis

Abstract

Background: Thyroid drains after thyroid surgery are often used despite evidence. The aim of this retrospective study was to determine the post-operative complication rates following thyroid uncomplicate surgery without drain. Material and methods: The medical records of two hundred and thirty-nine patients who undergone thyroid surgery without and with drain were reviewed. The rate of post-operative either complications and pain were evaluated. Results: The distribution of the operations performed were similar in two groups, in no-drain group (group A) there were total thyroidectomy 68.7% and lobectomy 31.3% while in drain group (group B) the total thyroidectomy were 70.8% and the lobectomy were 29.2%, this without statistical significant difference. Postoperative complications that occurred included seromas, hematoma and wound infections were without significantly differences. Postoperative pain was significantly lower in group A than in group B at two timepoint. The mean hospital stay was significantly shorter in the non-drained group. Conclusions: The no-drain uncomplicated thyroid surgery was safe and didn’t increase a rates of post-operative complications. In addition, we achieved significant reduction of postoperative pain, hospital stay and overall costs.

Introduction

Surgical drains in thyroid surgery have a long history as an integral concept to postoperative treatment, with the rationale to prevent a high degree of either fluid and blood collections. This accumulation may be hesitate in postoperative hematoma or seroma that may causing airway compressive effects or obstruction [1, 2].

Everyone of thyroid surgeons had encountered in his experience that patients whom hematoma developed after surgery often, the drains had been placed but were found to be nonfunctioning. Many studies have reported that the drains are ineffective to preventing hematoma [3, 4]. Recently, a large cohort study by Maorun et al., found that drains placement in thyroid surgery is not associated with decreased postoperative hematoma formation [4]. A review of the literature on this argumentation did not well established that the benefit of routine drainage after thyroid surgery, especially in uncomplicated cases [5]. While the presence of drains increases either discomfort and rate of infection as demonstrated in gastrointestinal surgery.

This report presents was a retrospective study performed in order to test the hypothesis that thyroid surgery without drains is associated with lower rates complication than the thyroid surgery with drain.

Materials and Methods

The study sample consisted of 239 consecutive patients undergone thyroid surgery for various indications performed by the same surgical team were identified from hospital database. Drains had been placed in all surgical procedures on the first 127 cases (group B) otherwise in the other 112 cases (group B) we didn’t use drains except in latero-cervical neck dissection, extensive tissue dissection and substernal goiter. We included patients who are undergone ad central neck dissection. The patients were to be treated without drains (Group A) or with drains (Group B).

The main observation of this study were fluid collections as seroma or bleeding after thyroid surgery without drains. Secondary outcomes were reoperations, wound infections and postoperative pain analysis.

In this retrospective analysis complications including wound infection, seroma, hematoma, bleeding, reoperation and postoperative pain were recorded. Surgical complications were gradate using Clavien-Dindo classification [6]. Visual Analogue Scale (VAS) was used to assess post-operative pain with 12, 24,48 h and 7 days after surgery by self-detection. The scale was standardized so that it ranged from 0 (any pain) and 10 (highest level). Informed consent was obtained in all cases. The retrospective review protocol was approved by the Institutional Review Board in our hospital.

Surgical Technique

Surgical technique did not differ from that standard described in most textbooks with uses of either energy device with a combination of pressure and continuous bipolar energy and intraoperative neurophysiological monitoring (IONM). The strap muscles were not divided. The recurrent laryngeal nerve was identified through a lateral approach and IONM. Parathyroid glands were identified and preserved as soon as possible or if they were removed, they were reimplanted in ipsilateral-sternocleidomastoid muscle.

Closed suctions drains were placed before wound closing in group A.

According to the protocols of our unit, drains were removed 24 and 48 h after surgery respectively in lobectomy a thyroidectomy procedure, when there were not evidence of bleeding. Patients with lobectomy were discharge 24 h after surgery and patients with thyroidectomy 48 h after surgery, when there were not evidence of bleeding too. Antibiotic prophylaxis was administered only in patients ASA III or with Type 2 diabetes.

Statistical Analysis

All statistical analysis were performed using Statistics Kingdom® online-free edition .

Categorical data are presented as number of cases with percentages and continuous variables as median add standard deviation.

Continuous variable was compared by independent two-sample t test. Differences in VAS scale score between patients with and without drain were tested using the non-parametric Mann-Whitney U test, and a two-sided P-value was reported. No corrections for multiple tests were performed. The results are reported with 95% confidence intervals, and p value < 0.05 was considered to be significant.

The costs data were retrieved from our Finance Department. Analysis includes total costs care services, healthcare services and those for primary procedure.

The economic dependent variable of this report were costs of recovery add to theatre running costs, that include either differences hospital stay and in operative time.

Results

There were 82 women and 30 men in group A with mean age 50.2 (range 21–75) years and 89 women and 38 men in group B with mean age 57 (range 27–77) .

No significant differences in term of gender and ASA score (Table 1). The distribution of the operations performed were similar in two groups, in group A there were total thyroidectomy 68.7% and lobectomy 31.3% while in group B the total thyroidectomy were 70.8% and the lobectomy were 29.2%, this without statistical significant difference.

Table 1.

Clinical features of patients

	Group A (No drain)	Group B (drain)	p value
No. patients	112	127
Age mean (range)	50.2 (21–75)	57,51 (27–77)	ns
Sex (F/M), n	82/30	89/38	ns
ASA (percentage)
I	18.4%	14.7%	ns
II	74.8%	75.9%	ns
III	6.8%	9.4%	ns

Value in percentage on single group; ns none significant. Age was evaluated as mean and range

The postoperative complications that occurred in group A vs. group B were seromas in 3 vs. 1 cases, hematoma in 2 vs. 4 cases and 3 wound infections only in group B without significantly differences. Two patients in drained group requiring reoperation within 24 after surgery from postoperative bleeding and 3 weeks after surgery for abscess on surgery field. (Table 2) Drains production did exceed 30 mL daily and were removed on the first postoperative day in lobectomy and second postoperative days for thyroidectomy except the 3 cases of hematoma that they were removed in fourth postoperative days.

Table 2.

postoperative complications

	Group A (No.112)	Group B (No.127)	total	P* value
Seroma	3 (2.6%)	1 (0.7%)	4	ns
Hematoma	2 (1.8%)	4 (3.1%)	6	ns
Wound infection	0	3 (2.6%)	3	ns
requiring operation	-	1 (0.7%)	1	ns
requiring antibiotics	-	2 (1.8%)	2	ns
Bleeding requiring reoperation	0	1 (2.6%)	1	ns

* p value are calculated with Student’s t test

The postoperative pain was significantly lower in group A than in group B at two timepoint respectively at 24 h and 48 h after surgery (3.9±1.6 and 5.6 ±1.5, p < 0.01; 3.3±1.7 and 4.7±1.4, p < 0.01). There were no differences in postoperative pain between groups at other timepoints.

The mean hospital stay was significantly shorter in the non-drained group (2.1 ±0.58 and 2.8 ±0.73, p < 0.001). Importantly, overall costs were significant lower in no-drain group then in drain group (2590±715.33 vs. 3144±819, p < 0.001) (Table 3).

Table 3.

postoperative patients result

	Group A (No.112)	Group B (No.127)	P value
Type of surgery % (No.cases)
Total thyroidectomy	68.7%(77)	70.8% (90)	ns
Hemi-thyroidectomy	31.3%(35)	29.2% (37)	ns
Operating time, min (mean±SD)
Total thyroidectomy	82.2 ± 11.6	84.6±14.1	0.15
Hemi-thyroidectomy	43.2±9.3	41.6±8.8	0.17
VAS (mean±SD)*
12 h	3.9 ±1.6	5.6 ±1.5	< 0.01
24 h	3.3 ±1.7	4.7 ±1.4	< 0.01
48 h	2.6 ±1.6	3.1 ±1.2	ns
7 days	1.89 ±1.1	1.9 ±1.2	ns
Hospital stay, days (mean±SD)	2.1 ±0.58	2.8 ±0.73	< 0.001
Total hospital costs € (mean±SD)	2590±715.33	3144±819	< 0.001

p value are calculated with Student’s t test, * p value are calculated with Mann Whitney U;

Discussion

Extensive use of drain in thyroid surgery is controversial argumentation. Some authors recommended the routine use of drainage to prevent hematoma and detected early bleeding. Generally, the incidence of postoperative bleeding is only 0.3-1% and most of hematoma occur within first 6 h following surgery [1, 7–11].

This retrospective study showed that uncomplicated thyroid surgery without drain don’t increase complication rates.

Many surgeons use still insert drains to prevent any fluid collection for all procedures on thyroid surgery, this is a particularly important data which confirm that were saw in other reports.

It is known, as some authors recommended, the risk of postoperative fluid collection as seroma or bleeding is higher for some disease when being a large dead space like retrosternal goiter, Grave’s disease and when it is necessary extensive dissection or latero-cervical nodes dissection for some cancer. In our experiences, as indicated in some studies on the safety of thyroidectomy without drains the central neck dissection didn’t an indication to use a drainage [8].

There are number of reports indicates that the use of drains after thyroid surgery didn’t decrease the risk of reoperation for hematoma or severe bleeding, but may be increase wound infection rates and consequentially hospital stay [1, 7–12].

Wound infection is uncommon postoperative complication after thyroid surgery and occurs often in patients with drains [7, 14]. In our report, there were a total of 2 wound infections. This complication was only in drain group, but not statistically significant. In one case wound infection was treated with re-operations 3 weeks after surgery, while the other case was treated with antibiotics oral administration without recovery. Severe postoperative hemorrhage occurred in drained patients too, the day after surgery. The patient underwent reoperation within 24 h after surgery and the drains were obstructed by clots. Thus, drainage did not prevent hemorrhage in this case, and the decision to reoperate was made when respiratory noise developed.

Conversely, none of the patients without drains required reoperation.

Several studies found no significant differences between group with or without drains on hematomas development after thyroid surgery with regard to drain use [7–14].

There were differences in postoperative pain score in two timepoint, peculiarly when the drains were inside. According to previous reports drain itself could induce inflammatory response, and its presence may increase both pain and fluid collection. Some authors reported significantly reduction in VAS score in patients not drained following thyroid surgery, especially on first postoperative day [13]. In this report, we found differences statistically significant in postoperative pain score in two timepoint, peculiarly when the drains were inside (Fig. 1). These results indicate that drains in place might be directly associated with postoperative discomfort without differences between group after their removal. According to previous reports drain itself could induce inflammatory response, and its presence may increase both pain and fluid collection.

Fig. 1.

Visual analogue Scale (VAS): the mean VAS score for Group A and group B in early pos-operative time

In this study, we demonstrated that the no-drain for thyroid surgery was no effective for increasing the rate of complications.

In the present study the average of operating time was low in either groups. This may due to uses of advanced vessel sealing devices. This according to the previous reports, it was report that the advanced vessel sealing devices application significantly decreases either operative time and intraoperative bleeding comparted to conventional technique on thyroid surgery [14, 15].

In our study, we found a significant difference between the groups with drain versus no drain with regard to length of hospital stay, this difference leading to a reduction significantly in healthy costs in no-drain group.

Therefore, on the basis of the results we believe that may be avoiding the use of drains in uncomplicated thyroidectomy; this does not increase the surgical complication rates and overall hospital stay.

Conclusions

We have shown in our retrospectively reports that the no-drain method is safe and effective even in uncomplicated thyroid surgery and appears no increased incidence of post-operative complications. In addition, without drain placement there were improvement in post-operative pain, hospital stay and then in total hospital costs. We think is not possible to control every cofounding factor and surgeon preference and intraoperative evaluation should be taken in account. However, on the basis of the literature report and including our single center’s experience, we make us confident that drain placement should be avoid in some cases of thyroid surgery especially when the procedure is uncomplicated and intraoperative hemostasis is ensured.

Funding

No funding was received for this article.

Declarations

Conflict of interest

The authors have no conflicts of interest to declare.

Ethics approval and consent to participate

The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.