Abdominal infectious complications associated with the dislocation of intraperitoneal part of drainage tube and poor drainage after major surgeries

Abstract

Abdominal drainage, serving as a diagnostic and therapeutic tool, has been widely applied to prevent complications after major abdominal surgical procedures. However, dislocation of intraperitoneal portion of drainage tube and poor drainage after major surgery has never been detailed. In this retrospective study, we determined whether postoperative abdominal infectious complications are attributed to dislocation of intraperitoneal portion of drainage tube. Patients were recruited from the Department of General Surgery at Beijing Shijitan Hospital, Capital Medical University, between June 2015 and June 2018. All of the enrolled patients had undergone different major abdominal surgical procedures with abdominal drainage. According to different fixation methods of the drainage tube, the patients were categorised as follows: group 1 as conventional extra‐abdominal fixation where the tubes were fixed on abdominal wall; group 2 as double fixation where the tubes were fixed by both extra‐abdominal and intra‐abdominal fixation. Among 60 patients (40 in group 1 and 20 in group 2) with suspected postoperative abdominal infection, abdominal computed tomography (CT) was performed to determine the presence of abnormality. Dislocation of drainage tubes, morbidity, treatment, and prognosis were compared between the two groups. None of the patients showed slip knot or drainage tube slipping from the abdomen based on physical examination and CT imaging. Drainage tube was fixed firmly on the abdominal wall. In group 1, 18 (45%) patients developed postoperative complications resulting from abdominal infection where severe dislocation of intraperitoneal portion of drainage tubes was confirmed by CT. Drainage tubes of six cases were significantly dislocated to the anterior abdominal wall from the target area; 7 upper abdominal drainage tubes dislocated to the lower abdomen; and 5 lower abdominal drainage tubes dislocated to the upper abdomen. Common complications included localised peritonitis (n = 4), abdominal abscess (n = 8), and anastomotic leakage (n = 6). Among them, 8 patients were cured by abdominal puncture catheter drainage; 5 underwent secondary operation and 5 were cured by conservative treatment. In group 2, no tube dislocation was identified by CT. Five patients (25%) developed complications, including localised peritonitis (n = 1), abdominal abscess (n = 1), and anastomotic leakage (n = 3). All the five patients were cured by conservative treatment. Postoperative abdominal infection complications can stem from dislocation of intraperitoneal portion of drainage tube and poor drainage after major abdominal surgery. Maintaining the intraperitoneal portion of drainage tube at the proper location, for example, by applying intraabdominal fixation, is paramount to decrease the incidence and severity of postoperative complications.

1. INTRODUCTION

Generally, one to two drainage tubes are placed close to abdominal surgical site according to patient's condition and requirement of surgery. This tube drains accumulated fluid of surgical area, such as inflammatory exudate or digestive fluid, out of abdominal cavity to enhance wound healing and prevent anastomotic leakage after major operation. ¹ Drainage tube also facilitates early diagnosis of postoperative intraabdominal haemorrhage, infection, or anastomotic leakage. ² , ³ More importantly, effective abdominal drainage plays a key role in the treatment of postoperative anastomotic leakage and abdominal infection. Clinically, although postoperative abdominal infectious complications are multifactorial, tube dislocation leads to poor drainage and postoperative abdominal complications. Unfortunately, patients had to undergo abdominal puncture catheter drainage (PCD) or secondary operation. Notably, dislocation of intraperitoneal portion of drainage tube can be confirmed by computed tomography (CT) imaging under complications such as abdominal infection or anastomotic leakage after abdominal surgery. How to effectively prevent dislocation of the intraperitoneal portion of drainage tube and poor abdominal drainage? At present, no relevant literature has reported on this critical topic. This retrospective study (same as a real‐world data study) aimed to explore potential causes and prevention of drainage tube dislocation.

2. PATIENTS AND METHODS

Patients were randomly recruited at the Department of General Surgery of Beijing Shijitan Hospital, Capital Medical University from June 2015 to June 2018. All the selected patients had undergone different major abdominal surgical procedures with abdominal drainage. Among 60 patients with suspected abdominal infectious complications, abdominal CT was performed to determine the presence of abnormality. Patients were divided into two groups according to different fixations of abdominal drainage tube: group 1 (n = 40), enrolled from June 2015 to June 2017, treated with extra‐abdominal fixation; and group 2 (n = 20), enrolled from June 2017 to June 2018, treated with both extra‐abdominal and newly developed intra‐abdominal fixation. As shown in Table 1, individual operation was successfully completed by the same team in two groups. Two silastic and/or latex tubes with a diameter of 10 mm or 12 mm were intraoperatively placed close to abdominal lesions or anastomotic sites (subphrenic, left/right paracolic sulcus, and/or pelvic cavity).

TABLE 1.

Characteristics of two groups

Characteristics	Group 1 (n = 40) extra‐abdominal fixation	Group 2 (n = 20) extra‐abdominal + intra‐abdominal fixation	P value
Sex (M/F)	23/17	15/5	.185
Age (years, mean ± SD)	61.08 ± 9.39	61.66 ± 12.68	.362
Over 65 years	12	9	.251
Disease types
Colon cancer	11	4	.753
Rectal cancer	6	3	.990
Liver cancer	10	1	.081
Intestinal perforation	1	0	.990
Cholangiocarcinoma	3	3	.390
Gastric cancer	2	3	.322
Pancreatic cancer	6	4	.718
Benign biliary tumour	1	0	.990
Duodenal cancer	0	1	.344
Pancreatic cystadenoma	0	1	.344
Surgical methods
Radical resection of colon cancer	11	4	.753
Radical resection of rectal cancer	6	3	.990
Whipple	8	7	.206
Microwave ablation of liver cancer	5	0	.159
Partial hepatectomy	5	1	.653
Radical gastrectomy plus Roux‐en‐Y anastomosis	2	3	.322
Gastrojejunostomy	2	0	.548
Radical resection of cholangiocarcinoma	1	1	.990
Microwave ablation of pancreatic carcinoma	0	1	.344
Drainage tube dislocation	18	0	.001
Complications associated with drainage	18	5	.133
Localised peritonitis	4	1	.656
Anastomotic leakage	6	3	.990
Intestinal	5	2
pancreatic	1	1
Abdominal abscess	8	1	.249
Treatment of complications
Puncture catheter drainage	8	0	.043
Secondary operation	5	0	.159
Conservative treatment	5	5	.221

In group 1, abdominal skin around drainage tube was sutured with a No. 4 silk thread. Then, thread was knotted to ensure the tube being fixed firmly on the abdominal wall. In group 2, external fixation was the same as that in group 1. One of the following two techniques for intraabdominal fixation was used: (a) the head of tube was sutured to the edge of tissue close to the target area, such as mesentery, ligament, or fixed omentum to limit tube dislocation in the abdominal cavity as shown in Figure 1A. After Whipple operation, a drainage tube was placed close to anastomosis of cholangioenterostomy, and the head of tube was sutured; (b) a hole in proportion to the diameter of the tube was punched on mesentery, omentum, or lateral peritoneum. Prior to access to abdominal wall, the tube passed through the hole to limit dislocation in abdominal cavity. As shown in Figure 1B, after Whipple operation, a drainage tube was placed adjacent to the pancreaticojejunal and bilioenteric anastomosis passing through mesentery prior to abdominal wall. In principle, the first fixation could be used for all patients. If there was no suitable place for suturing, the second fixation would be selected. The incidence of dislocation of abdominal drainage tubes, morbidity, treatment, and prognosis were compared between the two groups.

FIGURE 1.

(A) In new technique 1, the drainage tube was sutured to mesentery. Drainage tube was placed near anastomosis of cholangioenterostomy. The head of the tube was sutured to mesentery (arrow). (B) In new technique 2, the drainage tube passed through peritoneal channel. The tube placed near pancreaticojejunal anastomosis passed through mesentery (arrow) prior to abdominal wall

Statistical analysis was performed by using the SPSS software (version 25, IBM Corp; Armonk, NY). Continuous data were compared using the Student t test. Categorical data were evaluated by Pearson χ2 test, if any cell had expected count less than 5, Fisher's exact test was analysed. Results were expressed as mean ± SD (⁻ X ± s) for normalised data and median (M) and interquartile range (IQR) for non‐normalised data. P < .05 was considered statistically significant.

3. RESULTS

None of the patients exhibited knot slipping or drainage tube slipping from the abdomen by physical examination and CT imaging after operations. The tube was fixed to the skin firmly by extra‐abdominal fixation. Among 40 patients in group 1, 18 (45%) were confirmed to have intraperitoneal portion dislocation of drainage tube by CT. This patient population consisted of 8 males and 10 females, aged 45 to 80 years (mean ± SD: 61.33 ± 9.15 years; with 5 cases over 65 years old). Four cases had liver cancer, 4 with colon cancer, 3 with rectal cancer, 2 with cholangiocarcinoma, 2 with gastric cancer, 1 with intestinal perforation, pancreatic cancer, and benign biliary tumour. Surgical procedures included radical resection for colon cancer in 4 cases and for rectal cancer in 3 cases, Whipple in 4 cases, microwave ablation of liver cancer in 2 cases, partial hepatectomy in 2 cases, radical gastrectomy plus Roux‐en‐Y anastomosis in 2 cases, and gastrojejunostomy in 1 case. Drainage tubes in 3 cases with Whipple and 3 cases with radical operation on low rectal cancer were significantly dislocated to the anterior abdominal wall from the original target area. Seven upper tubes were dislocated to the lower abdomen and 5 lower tubes to the upper abdomen. As shown in Figure 2, the patient underwent radical gastrectomy plus Roux‐en‐Y anastomosis. The CT showed that the head of drainage tube placed close to gastrointestinal anastomosis had shifted to the left diaphragm on the fourth day after operation. The intra‐abdominal dislocation of drainage tube resulted in poor drainage of abdominal cavity or loss of drainage. All 18 (100%) patients with the intraperitoneal portion dislocation had developed abdominal infectious complications. Eight cases underwent abdominal PCD, 5 underwent secondary operation and 5 were cured by conservative treatment. In group 2, no (0/20) intraperitoneal portion dislocation of drainage tube was identified by CT. Five cases (25%) developed abdominal complications associated with poor drainage and were cured by conservative treatment (Table 1).

FIGURE 2.

The drainage tube shift after traditional method. Computed tomography examination showed that the head of the left drainage tube placed near gastrointestinal anastomosis shifted to the left diaphragm (arrow) on the fourth day after radical gastrectomy plus Roux‐en‐Y anastomosis operation

4. DISCUSSION

Since the first application of abdominal drainage tube for patients who underwent gynaecological surgery by Dr Sims in 1870s, it has been widely applied by surgeons in clinic. Placement of drainage tubes after abdominal surgery can prevent postoperative abdominal abscess from anastomotic leakage, and even save patients' lives, especially for those undergoing gastrointestinal surgery. ⁴ Drainage tube placed effectively in abdominal cavity can not only discharge accumulated fluid around lesions and promote wound healing, but can also limit abdominal infection and enhance healing of anastomotic leakage. Effective drainage significantly reduces the risk of abdominal PCD and even secondary surgery due to abdominal abscess. ² , ⁵ This is very important for patients undergoing major abdominal surgery including pancreaticoduodenectomy (Whipple operation), which is extremely traumatic with a much higher incidence of postoperative complications, such as anastomotic leakage and abdominal infection. If a drainage tube is dislocated, away from the target area, poor drainage or loss of drainage would occur in abdominal cavity. Reoperation often aggravates the patient's condition, prolongs hospital stay, and even leads to death. When intra‐abdominal part of the tube dislocates, the head of the tube may poke into abdominal viscera or peritoneal wall, causing discomfort or severe complications, such as abdominal viscera haemorrhage, intestinal obstruction, or perforation. ⁶ , ⁷ In extra‐abdominal fixation group, dislocation of intra‐abdominal part of the tube resulted in poor drainage of abdominal cavity. Some cases required abdominal PCD or secondary operation. It is controversial that abdominal drainage tubes shall be applied to what kinds of operations. The drainage tubes themselves can cause problems. Drains must not be considered a substitute for meticulous technique.

Several factors may contribute to dislocation of abdominal drainage tube. Firstly, extra‐abdominal fixation is not firm enough. The ligation of suture at the puncture hole was not tight enough, so that the tube moved in the coil of the suture. In the current study, the tube was firmly fixed at the abdominal wall, with no slippage or dislocation due to loosen ligation of extra‐abdominal fixation. Secondly, the tube was not subjected to intra‐abdominal fixation. Generally, surgeons place the head of the tube to either paracolic sulcus, subhepatic space, pelvic cavity, adjacent to lesion site, or anastomosis. Although extra‐abdominal fixation on abdominal wall can prevent dislocation to some extent, intra‐abdominal part, especially the head of the tube, is free and has not been effectively fixed in peritoneal cavity. The intra‐abdominal part of the tube may be dislocated with changes in the position of patients or of extra‐abdominal part, even when extra‐abdominal fixation is firm. ⁸ In group 1, the intraabdominal part dislocation was identified by CT, although drainage tube was sutured to the skin firmly, knot did not slip, and the tube did not slip from the abdomen. Thirdly, dislocation of intra‐abdominal part may be related to the nature of the tube. In this research, we did not investigate the texture of drainage tube. Fourthly, dislocation is related to specific conditions of patients. Postoperative movement and changes in position such as turning over and changing beds can frequently cause slip of the tube or dislocation of the intra‐abdominal part. After major surgery, patients unconsciously and uneasily turned over positions, causing dislocation of drainage tube. Among cases in group 1, dislocation of the intra‐abdominal part may be related to bed change between ICU and ordinary ward after operation. In addition, tube dislocation may be associated with patient's age, respiratory, and digestive diseases after operation. In elderly patients, due to muscle relaxation of abdominal wall, increased space in abdominal cavity enlarges the range of movement for drainage tube correspondingly, which increases the chance of dislocation. Symptoms of respiratory and digestive diseases, such as heavy cough, intractable hiccups, and violent vomiting, can also cause abrupt changes in intra‐abdominal pressure, leading to dislocation of drainage tube.

How to prevent dislocation of drainage tube? First of all, pay close attention to intra‐abdominal fixation. To some extent, intra‐abdominal fixation reduces dislocation of intra‐abdominal part of drainage tube. However, intra‐abdominal part should be sutured to tissue in avascular region at the edge of resection site so that drainage tube can be pulled out easily without bleeding. Drainage tube passing through a split hole is key for fixing intraabdominal part, without affecting its removal. The two techniques of internal fixation can be used separately or combinatorically. We performed intra‐abdominal fixation in addition to conventional external fixation. Intra‐abdominal fixation helps to prevent dislocation of intra‐abdominal part of the tube as demonstrated by CT imaging. Even with mild intestinal leakage, bile leakage, or pancreatic leakage after surgery, the position of drainage tube adjacent to anastomosis is not shifted so that the contents of leakage can be completely drained out. This reduces irritating effects of leaking fluid on the surgical site, adjacent organs, nerves, and blood vessels as well as promotes wound healing. ⁸ Therefore, abdominal PCD or reoperation is reduced, secondary injury avoided, hospital stay shortened, and hospitalisation costs decreased. ⁹ In group 2, patients with anastomotic leakage and abdominal infection underwent conservative treatment and discharged. No secondary surgery or abdominal PCD was performed. Secondly, extra‐abdominal fixation on abdominal wall should be fixed firmly. In general, the skin should be sutured with No. 4 or No. 7 silk thread; and the thread knotted at the site where drainage tube goes through abdominal wall. Then the suture is wrapped around drainage tube for two to three times and the thread is knotted firmly to prevent slipping. Finally, appropriately selecting drainage tube, perfectly grasping principles of abdominal drainage tube placement, and timely guiding patients to carry out normal activities are also important. A tube with moderate texture, large curvature, small tissue irritation, and X‐ray impermeability should be selected to reduce dislocation of drainage tube caused by patient's activities or changes in position of extra‐abdominal part, as well as to determine tube's position and drainage efficacy when CT is performed after operation. ¹⁰ The size of drainage incision in abdominal wall should be matched with the diameter of a tube. A large drainage port is susceptible to drainage tube slippage and incisional hernia. ² , ¹⁰ Patients with abdominal tube, especially those at advanced age and with chronic diseases, should be given proper guidance on postoperative activities. When transporting patients such as changing beds, drainage tube should be properly protected to avoid dislocation and accidental pullout.

Recent scientific evidence suggests that drains are unnecessary after most abdominal operations. Drains should be used only in certain specific operation types such as pancreatic surgery. ¹¹ But, drains cannot be omitted if clear risk factors are present. In this real‐world data study, a small number of patients undergoing various abdominal operation will significantly affect the robustness of statistical analysis. Although the two groups in the current study are not very similar, they are close and comparable. When performed abdominal CT on patients suspected of abdominal complications, we unexpectedly identified dislocation of intraperitoneal portion of drainage tube, leading to abdominal drainage failure, although drainage tube was sutured to the skin firmly, knot did not slip and the tube did not slip from the abdomen. At present, dislocation of intraperitoneal portion of drainage tube may occur in various abdominal operation, leading to poor drainage.

In summary, to our best knowledge, for the first time, we have reported that postoperative abdominal complications can result from dislocation of intraperitoneal portion of drainage tubes and poor drainage after major abdominal surgery. Maintaining the intraperitoneal portion at the proper location by applying improvement of fixation may decrease the incidence and severity of postoperative complications.

CONFLICT OF INTEREST

The authors have no potential conflict of interest.

AUTHOR CONTRIBUTIONS

Y.G. contributed to experimental design, draft manuscript, and data analysis. X.G., J.W., Z.H., W.W., S.L., and J.Z. contributed to data interpretation, figure preparation, and critically revise the manuscript. K.L., G.X., W.Y., D.L., Q.F., B.A., K.G., N.Z., J.P., and M.S. contributed to methodology, data acquisition, and critically revise the manuscript. B.Z. and B.Z. contributed to conceptualisation, experimental design, resources, supervision, draft, and critically revise the manuscript.

Guo Y, Guo X, Wang J, et al. Abdominal infectious complications associated with the dislocation of intraperitoneal part of drainage tube and poor drainage after major surgeries. Int Wound J. 2020;17:1331–1336. 10.1111/iwj.13371