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Use of drains in gastrointestinal surgery

drains

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Use of drains in gastrointestinal surgery

  1. 1. “ Use of drains in gastrointestinal Surgery Dr sumer yadav ms general surgery , mch plastic and reconstructive surgery
  2. 2.  A channel by which surplus liquid is drained or gradually carried out.  An appliance or piece of material that acts as a channel for the escape (exit) of gases, fluids and other material from a cavity, wound, infected area or focus of suppuration.  Drains inserted after surgery help the wound to heal faster and assist in preventing infection.
  3. 3.  Hippocrates –drainage of empyema, ascitic fluid  200AD- Celsius devised means of draining ascites with conical tubes  1700AD –Johann Schltetus-1st person to use capillary drainage  1897AD Charles Penrose devised Penrose drain  1932AD Chaffin developed 1st commercially available suction drain  1959AD silicone rubber discovered and advantages were reported by Santos
  4. 4.  Soft -Minimal damage to surrounding tissues  Smooth -Efficiently evacuate effluent and easy removal  Sterile- not potentiate infection or allow introduction of infection from external environment  Stable- Inert, non allergenic, not degraded by body  Simple to manage by both patient and staff
  5. 5.  To remove unwanted fluid/ exudate /pus/gas  To allow monitoring of fluid volume & quality  To promote tissue apposition  To allow diversion of body fluids  To facilitate subsequent access to a body space or cavity  To diagnose about underlying cavity or fistula
  6. 6.  Haematoma  Other Fluids (serous, chyle, pus, etc)  Tissue adherence -- cosmesis
  7. 7.  Greater tissue contact  Inert material.  Slides smoothly past any tissue  Promotes ease of movement and deep breathing  Minimal pain on removal  Comes in various sizes
  8. 8.  Laminar flow through drain  Poiseuille’s law F =dP πr4 /8nL  F = flow of fluid thru the drain lumen  dP =pressure difference between the two ends  n =viscosity  L= length of drain  Flow directly prop to suction pressure, radius  Indirectly prop to viscosity and length of drain  Double in drain diameter 16 fold increase in flow  Halving the length will double the flow
  9. 9.  According to Poiseuille’s law the laminar flow rate of an incompressible fluid along a tube is proportional to the fourth power of radius of tube and suction pressure. Flow is inversely proportional to viscosity of the fluid and length of the tube.  It means that wider and small length tube have more flow rate.
  10. 10.  Factors governing effluent movement  Gravity  Capillary action  Tissue pressure  Negative pressure
  11. 11. a. Prophylactic :-postoperatively to prevent accumulation of fluid or to detect early any leakage from anastomosis site. b. Therapeutic :-to evacuate an existing collection. i.e. lymph, pus, urine saliva, serum c. Diagnostic :-MCUG,T-tube cholangiogram
  12. 12. a. Open:-drains directly to the exterior .e.g. Penrose and corrugated rubber drain. There are less chances of blockage, more comfortable to patient but more chances of infection. b.Closed:-drains externally into a sealed container so having less chances of infection, better skin care, better care and accurate assessment of fluid drainage.
  13. 13.  Internal drains  Divert retain fluids form a body cavity to another  Useful in neurosurgery, ctvs ,G.I surgery and urology  E.g. Celestine, southar tubes, V-P shunt, Pericardio- pleural tube  External drains  Channel discharge from cavity to external environment
  14. 14. 3.a.With suction :-where negative pressure is applied to facilitate drainage. It allow the drainage of fluid from areas where movement of fluid is against the natural pressure gradient, also helps apposition of tissue planes prevents fluid accumulation and blockage of tube less likely. Disadvantage:-it also causes more tissue erosion and prevent healing of an established fistula by continued fluid drainage. 3.b.Non – Suction (passive ) drains
  15. 15.  a. Sump suction :-in this double lumen tubes are there. Second tube act as a vent to allow air flow down to the tip of a drain. This prevent negative pressure at the tip and causes less tissue erosion and less blockage.  b. closed suction
  16. 16.  Irritant drains  composed of materials irritant to tissues  excite fibrous tissue response leading to fibrosis and tract formation  E.g. latex, plastic and rubber drains  Inert drains  Non irritant drains  Provoke minimal tissue fibrosis  E.g. polyvinyl chloride(PVC),polyurethane(PU) silicon elastomer (silastic)
  17. 17.  Prior used red rubber or latex.(more chances fibrosis and allergic reactions)  Nowadays used polyurethane, silicone(silastic), silicone elastomer, siliconised latex or polytetrafluoroethylene(PTFE)
  18. 18. Material Example Properties Latex rubber Penrose drain Soft, induces tract formation Red rubber Red rubber tube catheter Firm, induces tract formation PVC Chest tube Firm ,induce some inflammation Silastic Jackson-Pratt drain Soft, induces minimal inflammation Heparin coated silastic Jackson Pratt drain Aims to inhibit clot formation and achieve greater patency Hydrogel coating Some foley catheter,image guided percutaneous drain Produce slippery surface resistant to encrustation Polytetrafluoro- ethylene(PTFE) Some foleys catheter Latex + teflon. Smoother than latex Silicone elastomer Some foleys catheter latex +silicone –more resistant to encrustation Polymer hydromer Some foleys catheter Latex bounded with .smoother than latex
  19. 19.  Should not exit cavity through same surgical incision.  Reach skin by safest shortest route  Appropriate size and length  A gravity drain must be placed in the safest and most dependent recess in cavity  Must be inserted away from delicate structures  Firmly secured at exit wound  Appropriate care-dressing,emptying.  Must be removed when no longer useful-at once or by progressive shortening
  20. 20.  What is being drained  Consistency,-larger lumen, suction drain  Why is the drain needed  Latex, red rubber for tract formation  Where is the drain located  Related to delicate structures,  Sterile sites-closed drain  Negative pressure zones-underwater seal
  21. 21.  Trauma to tissues during insertion and removal  Fistula formation/perforation –erosion of adjacent tissues  Visceral herniation through tract  Anastomotic leak  Flap necrosis  Bacterial colonization and sepsis
  22. 22.  Fluid and electrolyte loss  Pain  Restricted mobility  Drain malfunction-migration,blockage,vacuum failure  Prolonged healing-delayed foreign body
  23. 23.  A substitute for poor surgical technique or inadequate hemostasis  Wrong indication  Delayed removal  Untimely removal  Wrong selection of appropriate drain  Inadequate care of drain  Insertion in main surgical wound
  24. 24.  Abscess cavity  Infected wound  Must not adhere to healing tissue  Must contain an anti septic  must be replaced frequently.
  25. 25.  Fistulae.  Discharging sinuses.  Same principles of packs.
  26. 26.  Sheet drain wrapped around a wick or pack  Keep tract opened and drain the inflammatory exudates.  Require less replacement
  27. 27.  Sheet drainage  Simple insertion, care and removal .  Not expensive.  Tissue irritant.
  28. 28.  Parallel tubes .  Side and end holes.  Thick fluid can block drainage.
  29. 29.  When air tight seal could not be obtained.  Suction machines can be connected intermittently.
  30. 30. Yeates drain Rubber corrugated drain Penrose drain
  31. 31. Hemovac drain Jackson–Pratt drain Foleys catheter Pigtail catheter
  32. 32.  Most effective method of drainage.  Require air tight seal.  Closed drainage.  Allow better tissue coaptation.
  33. 33. Intercostal catheter Mediastinal catheter
  34. 34. Vacuum assisted closure (VAC) drain
  35. 35. 3-way Coude catheter Foleys catheter
  36. 36. Ryle tube Fine bore NG tube
  37. 37. T-tube(Khers) Salem sump tube
  38. 38. Celestine tube
  39. 39.  To allow decompression of gastric contents  To reduce postoperative nausea and vomiting  To reduce abdominal distension  To lower risk of aspiration and subsequent pneumonia formation.  Study by Cheatam et al1995 shows slight postoperative reduction of nausea & vomiting and more patient discomfort.  Study by Nelson et al2005 shows with non insertion of tube showed less respiratory complications and early return of gastrointestinal functions by early passage of flatus.
  40. 40.  Acute gastric dilatation  Duodenal fistula  Gastric outlet obstruction  Small bowel obstruction  Nasogastric feeding
  41. 41.  Once anastomotic leak occurred drainage is accepted as the treatment of choice  In Cochrane review Karliczek et al2006 showed drainage after routine colorectal surgery rate of mortality, wound dehiscence, wound infection, reintervention and extra abdominal complications is quite similar in both drain or without drain (573/1140).
  42. 42.  Petrowsky et al2004 showed both wound infection rate subsequent fistula formation is lower if no drain left irrespective of severity of appendicitis.
  43. 43.  Lewis et al1990 showed no postoperative reduction in complication.  Cochrane review showed that postoperative drainage increase wound infection rates following open cholecystectomy also increases incidence of respiratory complications.  Same review showed increased rates of wound infection and delayed postoperative discharge in patients in which drain was used.
  44. 44.  Prophylactic drainage is generally recommended for subphrenic collections and biliomas after liver resection.  But Cochrane review showed more chances of infection of collection if drain is present and recommends percutaneous drain placement postoperatively.
  45. 45.  Used for decompression of oedematous CBD.  To prevent biliary leakage.  To provide access for postoperative visualization and retrieval of retained stones.  Trial by De-Roover et al, Sheen-Chen et al and williams et al showed longer postoperative stay in T- tube placement.
  46. 46.  Study done in perforated duodenal ulcer cases (75/119) showed more chances of complication as intestinal obstruction with drain placement.  Study done in subtotal and total gastrectomy cases (108) showed no difference in complication rate.
  47. 47.  In pancreaticoduodenectomy for a lesion of head of pancreas one drain is put near to the pancreaticojejunostomy site and another near the hepaticojejunostomy site.  Study by Conlon et al in patient after pancreatic resection rate of complication and number of intervention for collection were greater with drain.
  48. 48.  Used for reducing blood and fluid accumulation.  Study fails to clarify situation.  Currently the placement of drain following incisional hernia repair has to be at the discretion of the operating surgeon.
  49. 49. Thanking youThanking you

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