Selective use of drains in thyroid surgery. Is the routine drainage after surgery for thyroid necessary? A prospective randomized clinical study [ISRCTN63623153]. To drain or not to drain in thyroid surgery. A controlled clinical study. Is lack of placement of drains after thyroidectomy with central neck dissection safe? A prospective, randomized study. [Assessment of drain insertion in thyroid surgery?]. Does draining the neck affect morbidity following thyroid surgery? Drainage after thyroid surgery: a prospective randomized study. Drainage after thyroidectomy: a randomized clinical trial. Is the insertion of drains after uncomplicated thyroid surgery always necessary?
To identify whether there are differences in the use of drains and, if used, which would be the best for thyroid surgery.
                Prospective, longitudinal, comparative, randomized study.
                General Hospital Mexico City, Mexico.
                One hundred fifty patients were studied, divided into three groups: group A, without drain; group B, with a Penrose drain; and group C, with a semirigid suction drain. On the basis of the preoperative diagnosis, subtotal or total thyroidectomy or hemithyroidectomy was performed. Analyzed variables were thyroid volume (TV), transoperative bleeding (TOB), flow of postoperative drain (PD), length of hospital stay (HS), and complications, such as seromas, hematomas, and hemorrhages. Statistical Analysis. Multiple variant analysis, using Scheffe's procedure and chi2.
                Group A had an average TOB of 107 mL, HS of 2 days, and TV of 153.24 mL with two complications (seromas). Group B had an average TOB of 149.8 mL, HS of 2.6 days, TV of 175.4 mL, PD of 29.6 mL, and three complications (2 seromas and 1 hematoma). Group C had an average TOB of 161.5 mL, HS of 3.11 days, TV of 173.5 mL, PD of 25.84 mL, and two seromas. No differences existed regardless of the type of drain used between groups B and C.
                Statistical analysis showed that the size of the gland, diagnosis, type of surgery, transoperative bleeding, and complications are not valid arguments to leave an external drain in thyroid surgery. No advantages were found between the Penrose or the semirigid suction drains. Hospital stay was longer in patients with the suction drain. These results support the notion that the use of wound drainage cannot substitute for meticulous dissection and transoperative hemostasis. Drains are usually left after thyroid surgery to prevent formation of hematoma and seroma in the thyroid bed. This is done to reduce complications and hospital stay. Objective evaluation of the amount collected in the thyroid bed by ultrasonography (USG) can help in assessing the role of drains.
                A randomized prospective control study was conducted on 94 patients undergoing 102 thyroid surgeries, over a period of fifteen months. Patients included in the study were randomly allocated to drain and non-drain group on the basis of computer generated random number table. The surgeon was informed of the group just before the closure of the wound Postoperatively USG neck was done on first and seventh postoperative day by the same ultrasonologist each time. Any swelling, change in voice, tetany and tingling sensation were also recorded. The data was analyzed using two-sample t-test for calculating unequal variance.
                Both groups were evenly balanced according to age, sex, and size of tumor, type of procedure performed and histopathological diagnosis. There was no significant difference in collection of thyroid bed assessed by USG on D1 & D7 in the two groups (p = 0.313) but the hospital stay was significantly reduced in the non-drain group (p = 0.007). One patient in the drain group required needle aspiration for collection in thyroid bed. No patient in either group required re-operation for bleeding or haematoma.
                Routine drainage of thyroid bed following thyroid surgery may not be necessary. Not draining the wound results in lesser morbidity and decreased hospital stay. Drainage after thyroid surgery is widely used to prevent postoperative complications by evacuation of blood and fluids. However, to our knowledge no study has shown the benefit of drainage. Therefore, we performed a prospective, randomized study on the rate of complications after drainage or no drainage in thyroid surgery. One hundred fifty patients were allocated to drainage or no drainage. No difference was seen between the two groups according to the experience of the surgeon, type of operation, diagnosis, weight of thyroid specimens, operation time, and hospital stay. All complications were recorded and resulted in two patients receiving reoperation because of bleeding, two permanent laryngeal nerve palsies, one case of permanent hypocalcemia, ten minor hematomas, one wound infection, and one lymphatic leakage. No difference was seen between the groups. This study does not support prophylactic routine drainage after uncomplicated thyroid surgery. Selective use of drains after thyroidectomy has been suggested in the literature. Although the safety of thyroidectomy without drains has been reviewed, there is little specific data available to identify the safety of thyroidectomy combined with central neck dissection (CND) without drains. This study aims to determine the feasibility and safety of thyroidectomy without drains, especially in cases of combined CND.
                Prospective, randomized study.
                One hundred ninety-eight consecutive thyroidectomized patients were enrolled in this study. Drain group (n = 101) consisted of 41 hemithyroidectomies (HT), 28 total thyroidectomies (TT), and 32 total TT with CND. No-drain group (n = 97) consisted of 42 HT, 18 TT, and 37 TT with CND. The following variables were examined: perioperative complications (hemorrhage, hematoma, seroma), intraoperative bleeding, operation time, volume of resected thyroid gland, time of hospital discharge after operation, duration of drain placement, and total amount of drainage (drain group).
                There were no significant differences in age, sex, volume of resected thyroid gland, types of operation, operation time, and histopathlologic diagnosis between two groups. In the drain group, overall perioperative complications occurred in seven (7/101, 6.9%) patients. In the no-drain group, overall perioperative complications occurred in nine (10/97, 10.3%) patients. There was no significant difference in overall perioperative complications between the drain and no-drain groups, even in cases of performing CND. Time of hospital discharge after operation was significantly shorter in the no-drain group than the drain group (P < .05).
                We conclude that thyroidectomy without drains is safe and effective even in combination with CND and appears to confer several advantages over the routine drainage method. In addition, we achieved significant reduction of hospital stay, which led to a reduction in costs for the patients. Although generally recommended the benefit of suction drains in thyroid surgery is not proven.
                Therefore, we started a prospective randomized trial including all patients who were referred to our institution for resection of an euthyroid goiter (n = 52 with drains and 48 without). On the third postoperative day as well as four weeks later the patients were questioned and physically examined, including an ultrasound of the neck and, if present, the measurement of a hematoma.
                Two patients had to be reoperated due to a hemorrhage detected by the drains. Further the study revealed that patients without drains left the hospital significantly earlier (3.9 vs 4.6 days, p = 0.006). On the other hand the hematoma size in this group was larger than in the group with drains (1.9 ml vs. 0.9 ml, p = 0.016). The other clinical parameters were comparable in both groups. Four weeks postoperatively no differences were detected.
                So far neither our results nor those in the literature could prove that severe postoperative hemorrhage can be recognized or treated faster with the use of drains. Although drains reduce the size of hematomas significantly, the quantity is too small for any clinical relevance. Based on these results a general insertion of drains after resection of an euthyroid goiter is not recommended. A prospective randomized study questioning the benefit of neck drainage in thyroid surgery is presented. Two hundred consecutive patients, candidates for elective thyroid surgery, were randomized into Group A (no drain) and Group B (drain). Reoperation for bleeding was necessary for two patients of Group A and for one patient in Group B. Minor hematomas occurred in seven patients from Group A and five patients from Group B; wound infection occurred in two and four patients in Groups A and B, respectively; and lymphatic discharge occurred in two patients from Group B. These differences were not statistically different. The present study failed to demonstrate any protective value from the use of drains. However, the hospital stay was shorter and pain scores were smaller in the non-drain Group A. Between November, 1996 and May, 1997 a series of 100 consecutive unselected patients undergoing all types of thyroid surgery--including even those inducing large dead space e.g. substernal goitre and carcinoma thyroid with recurrent nerve dissection--were randomly allotted to either receive drainage (n = 43) or not (n = 57). Patients with cervical dissection for lymph node metastasis were not included. Severe intra-operative haemorrhage was not a reason for exclusion. No complications such as haematoma or seroma were found in the undrained group whereas only minor complications such as haematoma (n = 4) were noted in the drained group. Whatever the group, none of the patients required re-exploration. The difference in overall hospital stay (1.72 days in the group of undrained patients versus 2.09 days in the drained group) was not statistically significant. A randomized clinical trial of surgical drainage in thyroid surgery was performed on 97 patients. Morbidity was not significantly different between both groups. The length of hospital stay was shorter in the undrained group. However, this RCT is not an indication of the value of drainage after thyroid surgery because the series is too small. Using a meta-analysis of the RCTs reported it is possible to show that to drain is not useful. We conducted a prospective, randomized study to evaluate the necessity of drainage after uncomplicated thyroid surgery.
                The subjects were 135 patients who underwent thyroid surgery between September 2002 and February 2004. The patients were randomized into two groups according to whether drains were inserted at the time of surgery. Group 1 consisted of 68 patients with drains and group 2 consisted of 67 patients without drains. The indications for surgery, procedures performed, local complications (such as infection, seroma, and bleeding or hematoma), necessity for reoperation, and hospital stay were recorded.
                There were 110 (81.5%) women and 25 (18.5%) men, with a median age of 46.9 +/- 12.5 years. The mean hospital stay was 2.6 +/- 1.0 days in group 1 and 1.3 +/- 0.7 days in group 2 (P = 0.001). Local complications developed in five (7.3%) patients from group 1, as wound infections in two (2.9%), seroma in one (1.5%), and hemorrhage in two (2.9%); and in two (3%) patients from group 2, as seroma in one (1.5%) and hematoma in one (1.5%). Both of the group 1 patients with postoperative hemorrhage required reoperation within 8 h after initial surgery. The hematoma in the group 2 patient was treated successfully with needle aspiration.
                These findings suggest that the routine use of drains may be abandoned in uncomplicated thyroid surgery, since serious postoperative bleeding rarely occurs and hematomas can be treated by needle aspiration if drains have not been placed. Furthermore, the use of drains prolongs hospital stay and increases the risk of infection.
There is no clear evidence that using drains in patients undergoing thyroid operations significantly improves patient outcomes and drains may be associated with an increased length of hospital stay. The existing evidence is from trials involving patients having goitres without mediastinal extension, normal coagulation indices and the operation not involving any lateral neck dissection for lymphadenectomy.