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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 27
| Issue : 2 | Page : 122-126 |
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Comparative study on outcome of thyroidectomy with and without placement of drain
D Thahzina Rahim, J Muhammed Salim
Department of General Surgery, Azeezia Institute of Medical Science and Research, Kollam, Kerala, India
| Date of Submission | 30-Jul-2021 |
| Date of Decision | 04-Sep-2021 |
| Date of Acceptance | 06-Sep-2021 |
| Date of Web Publication | 15-Nov-2021 |
Correspondence Address:
Dr. D Thahzina Rahim
Department of General Surgery, Azeezia Institute of Medical Science and Research, Kollam - 691 537, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ksj.ksj_40_21
Background: Many surgeons routinely use drains after thyroidectomy. The present study aimed to analyse and compare the immediate post-operative outcome in patients undergoing total thyroidectomy with and without placement of drain. Materials and Methods: A comparative observational study was conducted in 30 patients who underwent total thyroidectomy. They were randomly allocated to drain and no drain group post-operatively, with 15 subjects in each group, and the immediate post-operative outcome was assessed on day 0, day 1 and day 3 post-operatively, based on five parameters – post-operative pain, duration of hospital stay, haematoma formation, seroma formation and wound infection. The results were analysed statistically with Chi-square test and Mann–Whitney U test. Results and Discussion: Mean age of the participants was 36.07. All were females. There was association between post-operative pain and placement of drain, pain being less in participants without drain. Post-operative drain had no added advantage in preventing haematoma. None of the study subjects developed wound infection following thyroidectomy in any of the categories. There was a significant statistical association between the two groups based on hospital stay, and patients without drain were discharged earlier when compared to the patients with drain. Conclusion: Routine drain placement after thyroid surgery is not necessary, as thyroid surgery without the drain decreased the length of hospital stay without increasing patient morbidity. Placing of drain increased post-operative pain significantly.
Keywords: Placement of drain, post-operative outcome, thyroidectomy
How to cite this article:
Rahim D T, Salim J M. Comparative study on outcome of thyroidectomy with and without placement of drain. Kerala Surg J 2021;27:122-6 |
| Introduction | |  |
Thyroidectomy is one of the most commonly performed operative procedures in general surgery. The fear of potential haemorrhage from this highly vascular structure tempts the surgeon to place the drain.[1] The post-operative haemorrhage may compress the air passages and produce respiratory failure. Haemorrhage may be life threatening and require immediate reoperation. Most haematomas are clinically apparent within 2–4 h after surgery.[2],[3] 75% of life-threatening haematomas develop within the first 6 h after thyroid surgery with the rest mostly occurring in the following 24 h.[4],[5],[6],[7]
However, benefits attained out of the use of a drain are not yet pertinently proved. Some justifications for avoiding the drain include the negative pressure introduced through a suction drain system can potentially add to the lymphorrhoea volume of the operated site in addition to potential capillary leak possibility. There is also a criticism that an adequately sized drain may add to the scar. Furthermore, the use of drain was criticised to be not adequate in dimension so as to drain out completely a potential haemorrhage jeopardising airway.[4] There is also evidence to suggest that the use of drains increases the duration of hospital stay.[5] Due to the presence of foreign material, increased risk of surgical site infection was also suggested as a concern.
It is believed that many surgeons use a drain following thyroid surgery to obliterate the dead space and evacuate collected blood and serum. This is further reinforced by the fact that post-operative drains usually yield fluid.
Haemorrhage can be life threatening, thus necessitating an immediate reoperation. This fear prompts surgeons to use a routine drain after any type of thyroid surgery. Post-operative bleeding is actually quite rare and occurs in only 0.3%–1% of patients after a thyroidectomy.[4],[8]
Many studies have suggested that drains may be blocked with clotted blood. Thus, the surgeon is not alerted even if major bleeding occurs.[2],[4],[8],[9]
Arterial bleeding near the trachea leads to decreased space, which subsequently compresses the airway and produces significant oedema in the soft tissues of the larynx and pharynx. All this will lead to suffocating haematoma, necessitating immediate re-exploration, evacuation with haemostasis in the operating theatre. This is, however, a very infrequent complication, with figures ranging from 0.3% to 2.5%; when it does exist, it presents a big challenge for both the surgeon and the anaesthesiologist.[10],[11] The risk is greater in patients with intrathoracic goitre and those with Graves' disease.[11] Suffocating haematoma tends to appear between two and 6 h after surgery, and most patients report coughing, vomiting or nausea before the haemorrhage. Possible causes for this complication include displacement of an improperly applied suture, the opening of a vessel in which inadequate diathermic method of coagulation was used or 'drooling' of an area that has been improperly cauterised without identifying the exact bleeding source.[11]
Surgical drains neither prevent the formation of haematoma nor can identify it is earlier sometimes. In fact, haemorrhage can appear, and the container may be empty because the blood has clotted inside the drain. Bandages do not reduce the risk of haemorrhage either. They prevent blood from collecting in the subcutaneous plane, but the blood may dissect the deep plane to the pre-thyroid musculature in the paratracheal region, leading to compression of the airway at that level.[11]
Sometimes, the suction tip itself will account for a foreign body reaction and the inflammation caused by them can increase the amount of fluid collected there. In addition, the vacuum created by the negative suction of the drain may prevent the lymphatics from sealing off, thus causing an increase in seroma formation and drainage.[2],[12] Furthermore, a possible relationship between drain insertion and infective complications is also there. Meticulous haemostasis and an adequate surgical technique are the keys for avoiding haemorrhage and haematoma formation.
With this background, the present study aimed to analyse and compare the immediate post-operative outcome in patients undergoing total thyroidectomy with and without placement of drain.
| Materials and Methods | | |
The research question was-does negative pressure suction drain have any role in immediate post-operative outcome in patients undergoing thyroidectomy for pre-operatively proven benign thyroid diseases. A comparative observational study was conducted at a tertiary care hospital. The study population included patients who underwent total thyroidectomy with pre-operatively proven benign thyroid diseases necessitating total thyroidectomy and with no comorbidities between November 2018 and May 2020. Patients undergoing total thyroidectomy and near-total thyroidectomy without any specific comorbidities and with normal vocal cords pre-operatively were included. Those patients who required simultaneous neck dissection or had known coagulation disorder, patients who underwent previous thyroid surgeries and those with thyroid malignancy were excluded. Random sampling was done and the size was calculated as 30 using the formula
n = 15.029 in each group
After obtaining ethical committee clearance and written informed consent, the patients received 24 h prophylactic antibiotic coverage using parenteral amoxicillin + clavulanic acid combination (1.2 g 12 hourly – 2 doses). They were randomly allocated to drain [Figure 1] and [Figure 2] and no drain [Figure 3] group post-operatively, with 15 subjects in each group, and the immediate post-operative outcome was assessed on day 0, day 1 and day 3 post-operatively, based on post-operative pain [Figure 4], duration of hospital stay, haematoma formation, seroma formation and wound infection. The results were analysed statistically with Chi-square test and Mann–Whitney U test.
The patients were evaluated as per surgical guidelines for pre-operative workup. Patients with any comorbidities were excluded from the study. All standard investigations including blood investigations (thyroid profile), radiological investigations (ultrasonography neck, X-ray chest, X-ray neck), pathological (fine needle aspiration cytology) investigations as required were done for each case. Pre-operative indirect laryngoscopy to assess the vocal cords was also done for all patients. Moreover, the subjects were randomly allocated to drain and non-drain group.
Data were collected using pro forma and entered in Microsoft office excel 2007. Statistical analysis was done using R software (R Software version 4.0.5 (Shake and Throw), R Foundation, 2021). Percentages were calculated and Chi-square test was used to find the association between the variables. Significance was assessed as 5% level of significance.
| Results | | |
Age
Mean age of the study participants was 36.07 years with standard deviation 8.08 years. 50% of the study subjects were in 31–40 years of age group [Figure 5].
All the study participants were females. Post-operative drain was put for 15 study subjects following thyroidectomy, and no drain was put for the rest. Post-operative pain was assessed using visual analogue scale (VAS). 15 (50%) patients reported post-operative pain more than five in VAS, and 15 (50%) patients reported post-operative pain <5 in VAS [Figure 6].
Chi-square test was done between post-operative pain and placement of drain. It was found that there was a significant statistical association between the two variables, post-operative pain was reported less in participants without drain (P < 0.001). Two (6.7%) participants developed haematoma following thyroidectomy. This was similar in both groups. Two (6.7%) participants developed seroma following thyroidectomy equally in both groups.
Chi-square test was done to test the association between the development of seroma and placement of drain. It was found that there was no significant statistical association between the two variables. Post-operative drain had no added advantage in preventing seroma [Figure 7] and [Figure 8]. | Figure 8: Seroma developed in drain group on post-operative day 3 after removal of drain on post-operative day 1
Click here to view |
None of the study subjects developed wound infection following thyroidectomy in any of the categories. 15 (50%) of the participants got discharged on post-operative day 3, whereas 4 (13.3%), 11 (36.7%) participants got discharged on post-operative days 4 and 5, respectively [Figure 9]. Chi-square test found that there was a significant statistical association between the two variables, and participants without drain were discharged on an earlier day compared to the participants with drain (P < 0.001).
| Discussion | | |
Drains have been traditionally used in most of the surgical procedures involving the thyroid. Our study failed to show any advantage in the routine use of the drain after thyroid surgery. Arterial bleeding near the trachea leads to decreased space, which subsequently compresses the airway and produces significant oedema in the soft tissues of the larynx and pharynx. All this causes suffocating haematoma, and immediate treatment and surgical revision in the operating theatre are required. This complication appears very infrequently, with figures ranging from 0.3% and 2.5%; however, when it does exist, it presents a big challenge for both the surgeon and the anaesthesiologist.[2],[4],[11] The risk is greater in patients with intra-thoracic goitre and those with Graves' disease.[11] Suffocating haematoma tends to appear between two and 6 h after surgery, and most patients report coughing, vomiting or nausea before the haemorrhage. Possible causes for this complication include displacement of an improperly applied suture, the opening of a vessel in which diathermia was used for coagulation or 'drooling' of an area that has been improperly cauterised.[11] In this study, haematoma occurred in two patients, one from each group. Thus, post-operative drain placement had no added advantage in preventing haematoma. Surgical drains neither prevent this complication from occurring nor contribute to early detection.[4],[11] In fact, haemorrhage can appear, and the container may be empty because the blood has clotted inside the drain. Bandages do not reduce the risk of haemorrhage either. They keep blood from collecting in the subcutaneous plane, but the blood may dissect the deep plane to the pre-thyroid musculature in the paratracheal region, leading to compression of the airway at that level.[11] It was reported in literature that the suction drain itself causes fluid collection by virtue of its inflammation. In addition, the vacuum created by the negative suction of the drain may prevent the lymphatics from sealing off, thus causing an increase in seroma formation and drainage.[2],[11] Here, in this study, we got an equal incidence of seroma in both groups. Furthermore, a possible relationship between drain insertion and infective complications has been observed in some studies.[8],[13],[14] However, we found no relationship between wound infections and drain usage in our study. Studies investigating the relationship between drain insertion and post-operative pain are noted,[8],[15] and its authors noted an approximate 50% reduction in the VAS score in the group in which no drains were used. We obtained similar results in our study. These results indicate that drain insertion might be directly associated with higher levels of post-operative discomfort due to increased pain. This would be reflected by patient satisfaction and early discharge independent of any complications. Harris et al. demonstrated that thyroid surgery without the use of a drain decreases the length of hospital stay while adding no increase in patient morbidity.[5] We also observed that performing a thyroidectomy without the use of drain decreased the length of hospital stay.
| Conclusion | | |
A comparative observational analysis was done for 30 patients who underwent total thyroidectomy for benign thyroid disorders with no comorbidities based on the placement of drain or not. Their post-operative outcome analysed on post-operative day 0, day 1 and day 3 based on post-operative pain (assessed by VAS score), duration of hospital stay, haematoma formation, seroma formation and wound infection revealed that post-operative pain was more in drained group compared to non-drained group. The incidence of haematoma and seroma was equal in both groups, and post-operative drain placement had no added advantage in preventing both. None of the study subjects developed infection during the post-operative period. Duration of hospital stay was significantly less for non-drained group compared to the drained ones. This study concludes that non-placement of drain improves patient outcome post-operatively.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 13. | Ariyanayagam DC, Naraynsingh V, Busby D, Sieunarine K, Raju G, Jankey N, et al. Thyroid surgery without drainage; 15 years of clinical experience. J R Coll Surg Edinburgh 1993;38:69-70. |
| 14. | Kristoffersson A, Sandzén B, Järhult J. Drainage in uncomplicated thyroid and parathyroid surgery. Br J Surg 1986;73:121-2. |
| 15. | Schoretsanitis G, Melissas J, Sanidas E, Christodoulakis M, Vlachonikolis JG, Tsiftsis DD. Does draining the neck affect morbidity following thyroid surgery? Am Surg 1998;64:778-80. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
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