Background: This meta-analysis study was to evaluate the effectiveness of drain usage after thyroidectomy in preventing wound hematoma, post-operative pain, length of hospital stays, and wound infection. Objectives: Post-operative wound complications following thyroid surgery are not decreased by the use of drains. Materials AND METHODS: Following PRISMA guidelines, a systematic review and meta-analysis were carried out. After a search of the literature, RCTs comparing the use of drains versus not using any drains in patients undergoing thyroid surgery were found. Excluded from consideration were trials involving patients who had lateral neck dissections. Data extraction and methodological quality grading were carried out by impartial reviewers. Heterogeneity was evaluated and the risk ratio (RR) or mean difference (MD) with a 95% confidence interval was computed. Results: A total of 13 RCTs with 1100 patients were included in the meta-analysis. The rates of hematoma were found to be higher in the drain group (P value=0.24) as compared to no drain group (P value=0.015). The wound infection rates (P value=0.21), the length of hospital stay (P value=0.33), and the pain score (P value=0.37) on the first week of the postoperative day were all higher in the drain group as compared to no drain group. Conclusion: Overall, there was a higher incidence of hematoma, pain, length of hospital stays, and infection in the drain group. It indicates that patients do not benefit from using a drain following a thyroidectomy.
Among the most prevalent surgical procedures performed globally for both benign and malignant thyroid gland diseases is thyroid surgery. It is closely related to numerous important organs; the thyroid gland presents a special surgical challenge. Both Kocher and Billroth altered the concept of treating thyroid disease and established the approach to the thyroid gland. Understanding changed physiology, developing minimally invasive diagnostic and surgical methods, and improving imaging technology have all happened quickly in succession. There is no scientific proof to support the usefulness of drainage in thyroid surgeries. In all thyroid surgeries, many surgeons utilize drains regularly and have done so for years according to recommendations [3]. Since the thyroid is a profusely vascularized endocrine organ, any haemorrhage inside the confined paratracheal space has the potential to impede lymphatic and venous drainage, which might result in tracheal obstruction and laryngopharyngeal edema.[1,2] Surgeons routinely perform postoperative drain insertion for thyroid gland in the surgical field. The goal is to prohibit fluid from building up in the surgical wound site because this could compress the patient's trachea and put their life in peril.[5]
Patients who have hematoma formation after surgery are more likely to develop postoperative infections. Recent research has revealed no Desirable variation in the consequences following surgery for wounds among patients having thyroid surgery with intraoperative placements of drains[6,7]. Nonetheless, it has been suggested in certain research that the usage of drains ought to be minimized. Previous reports suggested that the use of drains following thyroid surgery is not very beneficial[8,9]. This has caused some researchers to consider whether drains should be inserted or not after thyroid surgery. The rate of wound hemorrhage following thyroid surgery is not that high, according to some researchers who oppose the insertion of intraoperative drains. Other research indicates that there is no difference in the two groups' incidence of postoperative problems with and without drainage[4,11]. Furthermore, research has shown a correlation between the occurrence of wound complications and the usage of thyroid drains[10].
The PRISMA guidelines identification search procedure approach was followed for the establishment of the inclusion criteria.
The following were the inclusion criteria:
The following are the exclusion requirements:
The patients underwent pre-operative workup evaluations according to surgical guidelines. Patients with comorbidities were excluded from the research. Every case underwent the standard examinations, which included blood investigations (thyroid profile - T3, T4, TSH), radiographic workup (ultrasonography neck, X- ray chest, X-ray neck anteroposterior and lateral view), pathological workup (fine needle aspiration cytology). For every patient, a pre- operative indirect laryngoscopy was performed to evaluate the status of vocal cords. Additionally, the subjects were divided into two groups at randomly allocated into the drain and no-drain groups.
SEARCH STRATEGY:
We used PubMed, Embase, the Cochrane Library, and Google Scholar for research on the use of drains in thyroidectomy from the time the database was created until March 2024. For further analysis, all pertinent data from the literature was input into Excel software during the study. Additionally, a critical evaluation was done to find pertinent research.
Data analyzed using the software program RevMan 5.2. For dichotomous variables, risk ratios (RRs) and 95% confidence intervals (c.i.) were utilized; for continuous data, mean differences (MDs) and 95% c.i. were employed. When information for an outcome was available from four or more trials, a meta-analysis was carried out. Following the classification of the studies based on the assessment criteria, there was a potential for bias in each of the chosen studies. If the study satisfied all quality requirements, it was categorized as the study was categorized as having minimal risk of bias if it satisfied all quality standards. There is a medium chance of bias if one or more studies are left out. There was a substantial danger of bias in the study if one or more of the quality standards were not adequately addressed.
DISTRIBUTION CHARACTERISTICS OF STUDIES USED FOR META- ANALYSIS:
STUDY |
YEAR |
DRAIN |
NO DRAIN |
GEORGE ET AL |
2023 |
27 |
27 |
IQBAL ET AL |
2015 |
30 |
30 |
ZAHID ALI ET AL |
2012 |
30 |
30 |
AFZAL ET AL |
2015 |
30 |
30 |
MUTHAMMAL ET AL |
2018 |
50 |
50 |
ISHAQ ET AL |
2008 |
30 |
30 |
SHAHID MEMOON ET AL |
2020 |
49 |
49 |
NAWAZ ET AL |
2015 |
32 |
36 |
RAMULA DURAI ET AL |
2021 |
50 |
50 |
RAHIM ET AL |
2021 |
15 |
15 |
KHANNA ET AL |
2005 |
50 |
44 |
MABOOD ET AL |
2022 |
108 |
108 |
DHANARAJ ET AL |
2022 |
50 |
50 |
H-HEMATOMA; P-POST OPERATIVE PAIN; I-WOUND INFECTION; LOS -LENGTH OF STAYS
|
AUTHOR |
YEAR |
DESIGN |
COUNTRY |
SAMPLE SIZE (DRAIN/ NO DRAIN) |
DRAIN - H/P/I/LOS |
NO DRAIN - H/P/I/LOS |
1 |
GEORGE ET AL [22] |
2023 |
RCT |
INDIA |
54 [27/27] |
1/6/2/3.5 |
1/3.6/1/2 |
2 |
IQBAL ET AL [26] |
2015 |
RCT |
PAKISTAN |
60 [30/30] |
0/2/0/2 |
0/1/0/1 |
3 |
ZAHID ALI MEMOM ET AL[27] |
2012 |
RCT |
PAKISTAN |
60 [30/30] |
0/6/0/4 |
0/3/0/3 |
4 |
AFZAL ET AL[32] |
2015 |
RCT |
PAKISTAN |
60 [30/30] |
1/3.01/NR/2.5 |
0/2.47/NR/2 |
5 |
MUTHAMMAL ET AL[25] |
2018 |
RCT |
INDIA |
100 [50/50] |
2/2.82/1/3 |
1/3.86/1/2 |
6 |
ISHAQ ET AL [21] |
2008 |
RCT |
PAKISTAN |
60 [30/30] |
2/4.2/0/3 |
1/3.1/0/0 |
7 |
NAWAZ ET AL [28] |
2015 |
RCT |
PAKISTAN |
68 [32/36] |
0/3.63/1/4.33 |
1/1.19/0/3.33 |
8 |
SHAHID MEMON ET AL [20] |
2020 |
RCT |
PAKISTAN |
98 [49/49] |
1/6.86/3/3.97 |
1/4.25/1/1.96 |
9 |
RAMULA DURAI ET AL [29] |
2021 |
RCT |
INDIA |
100 [50/50] |
1/NR/2/2 |
0/NR/1/4 |
10 |
RAHIM ET AL [23] |
2021 |
RCT |
INDIA |
30 [15/15] |
2/6/1/5 |
2/2/0/3 |
11 |
KHANNA ET AL [19] |
2005 |
RCT |
INDIA |
94 [50/44] |
1/NR/1/4.35 |
0/NR/1/3.07 |
12 |
MABOOD ET AL [30] |
2022 |
RCT |
PAKISTAN |
216 [108/108] |
NR/5.52/1/7.6 |
NR/3.61/0/3.50 |
13 |
DHANARAJ ET AL[31] |
2022 |
PROSPECT IVE |
INDIA |
100 [50/50] |
NR/5.52/1/7.6 |
NR/3.61/0/3.50 |
Out of 159 eligible studies, 13 were found and included after meeting the inclusion criteria and being published between 2005 and March 2024. At the beginning of this trial, approximately 1100 thyroidectomy subjects were divided into two groups with 551 patients who had drains placed after surgery and 549 patients who did not have the drain placed. The range of individuals in the study was 30 to 216. 13 RCT studies had their bias risk evaluated.
HEMATOMA:
Twelve studies reported on hematoma formation between two groups. This study revealed hematoma formation in the drained group is slightly higher compared to the no drained group. (95% CI: 0.47,1.21)
POSTOPERATIVE PAIN:
The pain score calculated in this study was based on VAS ( visual analog scale ). Most of the studies show that the pain during the first week of the postoperative period is less in no drain compared to the drained group.so, significantly less pain in no drain group. (95% CI:0.77,1.63)
WOUND INFECTION:
Twelve studies reported wound infection between the drain and no drain group. These studies revealed significant differences between the two groups. The wound infection rate is higher in a drained group compared to no drain group. (95%CI: 0.53,1.63)
LENGTH OF HOSPITAL STAY:
Length of hospital stay is higher in all the studies in a drained group compared to no drained group. (95%CI:0.94,1.46)
FIGURE 2: FOREST PLOT FOR DRAIN VS NO DRAINS CAUSING HEMATOMA:
FIGURE 3: FOREST PLOT FOR DRAIN VS NO DRAINS CAUSING WOUND INFECTION:
The wound infection rate was higher in the drain group as compared to no drain group.
Post-operative pain was higher in the drain group as compared to no drain group.
FIGURE 5: FOREST PLOT FOR DRAIN VS NO DRAINS INFLUENCING LENGTH OF HOSPITAL STAY:
The length of hospital stay was noted to be prolonged in the drain group as compared to the no-drain group.
TABLE 2 P-VALUE INTERPRETATION OF DRAINS AND NO DRAINS ON HEMATOMA, PAIN, INFECTION, AND LENGTH OF HOSPITAL STAYS:
COMPLICATIONS WIH DRAIN |
P- VALUE |
COMPLICATIONS WITH NO DRAIN |
P- VALUE |
HEMATOMA |
0.24 |
HEMATOMA |
0.015 |
PAIN SCORE |
0.37 |
PAIN SCORE |
0.037 |
INFECTION |
0.21 |
INFECTION |
0.023 |
LENGTH OF STAYS |
0.33 |
LENGTH OF STAYS |
0.051 |
Regarding the benefits of placing a drainage tube during thyroid surgery, there is no reliable research. It's still debatable if drains are necessary during thyroid surgery. The majority of drain applications are built more on custom than on empirical data[15]. In thyroid surgery, the use of drains is intended to avoid hematoma formation or other complications following the operation[16]. There was once a belief that draining the fluid that collects following thyroid surgery, reduces the risk of infection by keeping the fluid from creating a culture media for germs[17]. Many surgeons still regularly placed drains during thyroid surgery, despite an increasing body of literature highlighting the drawbacks of doing so[5,18]. Surgical methods for treating benign thyroid illness have significantly improved over the past ten years, leading to a reduction in both postoperative complications and mortality. It does not seem necessary to employ drains following thyroid surgery as a result. The purpose of this study was to obtainfurther data from a substantial body of
COMPLICATIONS |
DRAIN GROUP |
NO DRAIN GROU P |
Hematoma |
11 (1.9%) |
7 (1.27%) |
Postoperative pain |
48 (8.86%) |
29 (5.33%) |
Infection |
14 (2.54%) |
6 (1.09%) |
Length of hospital stay |
48 (8.86%) |
31 (5.80%) |
excellent literature to establish the necessity of intraoperative placement of drains in the thyroid gland. Totally 1100 thyroidectomy patients were chosen as the beginning point for the current meta-analysis investigation; 551 of these patients had intraoperative drains, and 549 did not[7,12,14]. The study's findings showed that the drain group had considerably longer hospital stays than the non-drain group. We found that the drain group experienced postoperative pain more frequently, and analyzed it by VAS(visual analogue scale).
VISUAL ANALOGUE SCALE FOR PAIN INTENSITY:
SCALE |
PAIN INTENSITY |
0 |
No pain |
1-3 |
Mild pain |
4-5 |
Moderate pain |
6-7 |
Severe pain |
8-9 |
Very severe pain |
10 |
Worst pain possible |
After thyroid surgery, the drain group's average duration of stay in the hospital was much longer than the no-drain group. Those in the drain group spent an average of 3.15 days in the hospital, while those in the no-drain group spent 2.51 days there. On the initial day following surgery, pain in the drain group was significantly greater than non-drain group. Patients using drains reported
higher levels of wound infection as compared to the no-drain group. Patients without drains had a considerably shorter hospital stay and less discomfort following surgery. Without drainage, thyroidectomy is feasible, less painful, and leads to a faster recovery. This study examines and shows that in patients having thyroidectomies, the placement of an intraoperative drain did not lower the risk of complications from the wounds after surgery.
The purpose of the study was to identify the impact of drain insertion on surgical wound complications in individuals having established thyroidectomies. Previous research' use of inaccurate or incomplete data may have exacerbated bias. Individuals with racial, age, and gender identities as well as their nutritional health are potential sources of prejudice. Furthermore, the value of the research being done might have been impacted by some unpublished work and incomplete data.
According to this meta-analysis and comprehensive evaluation of 13 RCTs was done based on the drain insertion or not. An analysis of their post-operative outcome based on wound infection, length of hospital stays, hematoma formation, and post-operative pain (measured by VAS score) showed that the drained group had more postoperative pain than the non-drained group. Intraoperative drain insertion increases the risk of wound infection, and hematoma formation in the drain group as compared to no drain group. The no-drained group's hospital stay was far shorter than that of the drained group. Patients do not benefit from the intraoperative insertion of drains, as a result. The results of this study show that patients postoperative outcomes are better when a drain is not inserted.
Funding: No particular grant from a governmental, private, or nonprofit organization has been disclosed by the authors for this research.
Conflicting interests: none were mentioned. Publication permission from patients: not necessary.
Data availability statement: All study-related data are uploaded as supplemental material or are provided in the publication.