TO THE EDITOR
We read with great interest the study by Liu et al. These authors analyzed the outcome of 125 patients undergoing totally laparoscopic gastrectomy for distal gastric cancer with or without prophylactic drain (PD) insertion. In this retrospective study, Liu et al demonstrated that in patients without placement of PDs there was no increased risk of postoperative complications. Furthermore, omitting a PD was associated with greater patient comfort. Of particular note, these interesting findings were confirmed by a propensity score matched analysis of 42 patients with and without PDs.
PDs facilitate the removal of postoperative fluid, which can potentially collect and become infected. In addition, PDs can help identify early postoperative complications such as anastomotic leakage and bleeding. In recent decades, the advances in surgical care have led to an overall decrease in postoperative complications. Therefore, the need for PDs has been debated and there is mounting evidence that they may even increase the risk of complications without preventing the need for reoperation. As an example, in major procedures such as liver resection, it has been shown that PDs increased the rate of biliary leak, length of hospital stay and total complications. The same outcomes were demonstrated in gastric surgery in a recent meta-analysis.
This is one of the few studies which highlight the issues of PDs in total laparoscopic distal gastrectomy and, interestingly, the authors identified body mass index (BMI) ≥ 29 kg/m2 to be associated with a higher risk of postoperative complications. The outcomes illustrated by the authors are in line with similar previously published articles[4,5]. Although the results by Liu et al are compelling, they need to be interpreted with caution. The data presented are prospectively maintained and retrospectively reviewed, but it is difficult to estimate the overall burden of postoperative morbidity as minor complications (Grade I), have not been included. Such examples are acute kidney injury treated with intravenous fluids, nausea treated with antiemetics, or electrolyte imbalances that responded to replacement therapy. This would add a more precise evaluation to the role of PDs in the postoperative setting, as minor complications could play an important role especially in the length of hospital stay. Secondly, the decision to insert a PD was made by the operating surgeon and the decision-making process which led to drain placement is unclear. This could bias the data, as it might be related to longer operative times and difficult surgery in high BMI patients. Thirdly, the cohort for this study was from a single-center, hence the generalizability to broader populations cannot be confirmed.
In summary, the authors should be commended for their work. They have demonstrated with a well-conducted analysis that PDs are not an independent risk factor for postoperative complications with the caveat that there appears to be a higher risk in patients with BMI ≥ 29 kg/m2; therefore, in this group PDs are recommended. Identifying pre-operative and intraoperative factors that can guide the decision-making in order to select low-risk patients with regard to the omission of PDs would be of great interest. Furthermore, randomized controlled trials on PDs vs non-PDs insertion, focusing on laparoscopic approaches for gastric surgery, would be useful to guide clinical decisions.
The authors express their gratitude to Dr. Hann A from University Hospitals Birmingham, United Kingdom, for his invaluable contribute to the English editing of this manuscript.