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Research Article | Volume 14 Issue 5 (Sept - Oct, 2024) | Pages 543 - 550
A Meta-Analysis on Wound Drains After Thyroid Surgery in the Indian Subcontinent
 ,
 ,
 ,
1
HOD & Professor of General Surgery, Kanyakumari Government Medical College, India
2
Assistant Professor of General Surgery, Kanyakumari Government Medical College, India
3
Post Graduate in General Surgery, Kanyakumari Govt. Medical College, India
Under a Creative Commons license
Open Access
Received
Aug. 30, 2024
Revised
Sept. 15, 2024
Accepted
Sept. 20, 2024
Published
Oct. 15, 2024
Abstract

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.

Keywords
INTRODUCTION

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].

MATERIALS AND METHODS

Data Extraction and Eligibility Criteria:

The PRISMA guidelines identification search procedure approach was followed for the establishment of the inclusion criteria.

 

The following were the inclusion criteria:

  1. Individuals who had
  2. Contrasting the consequences of the surgical wound after drain placement and without it.
  3. Complications at the surgical
  4. Design: RCT

 

The following are the exclusion requirements:

  1. Patients undergoing lateral neck
  2. Research for which there was no full text

 

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.

 

STATISTICAL ANALYSIS:

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

TABLE 1: CHARACTERISTICS OF STUDIES INCLUDED IN META-ANALYSIS:

 

H-HEMATOMA; P-POST OPERATIVE PAIN; I-WOUND INFECTION; LOS -LENGTH OF STAYS

RESULTS

 

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.

 

FIGURE 4: FOREST PLOT FOR DRAIN VS NO DRAINS CAUSING PAIN BASED ON VISUAL ANALOGUE SCALE:

 

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

DISCUSSION

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.

 

LIMITATIONS OF THIS STUDY:

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.

CONCLUSION

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.

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