Are Neck Drains a Contraindication to Day Case Surgery?

Julian Howard James,

Elinor Avalon Lesser*

C Ekambar E Reddy

Jaya Bhat

Tristram Hugh John Lesser

Department of ENT, Southport & Ormskirk Hospitals and *Department of Medicine, Wrexham Maelor Hospital.

Abstract

Aims: To assess the safety and patient acceptability of going home with neck drains after day case surgery.
Methods: Retrospective review of 18 day case surgery patients who were sent home same day with a closed suction drain after head & neck procedures. All patients had the drain removed the following day. Questionnaires were sent to all patients to assess their satisfaction and concerns of being discharged home with drains in situ. Non-responders were contacted by telephone. Outcome measures were drain related complications and patient satisfaction.
Results: None suffered from drain related ill effects and all patients were satisfied overall with being discharged home.
Conclusion: For patients that are suitable and motivated, discharge with drains in situ is not a contraindication for day case head & neck surgery.

Key words: day case surgery, head & neck surgery, drainage, patient satisfaction, length of stay

Introduction

According to the British Association of Day Surgery, patients overwhelmingly endorse day surgery as it provides timely treatment, less risk of cancellation, lower incidence of hospital acquired infections, and an earlier return to normal activities.1 The NHS plan is to perform 75% of elective procedures as day cases. Many ENT procedures can be performed as day surgery and has become the default option for patients who are suitable from a social and anaesthetic point of view.2, 3
Traditionally, procedures that required a surgical drain to be placed have been performed as in-patient procedures. A drain is used to guard against the formation of seromas or haematomas and in the neck, potential resultant airway distress from tracheal compression. Drains are generally used after procedures like parotidectomy, thyroidectomy and neck dissections. There have been numerous studies showing that it may not be necessary to place drains after some neck surgery, however, many surgeons still use them.4, 5
There is very little literature on patients being discharged home with neck drains in situ. However, in the UK patients having breast surgery are discharged home to have the drains removed by a specialist nurse, either in their homes or in a clinic.6, 7 Therefore, we assessed the safety and feasibility of discharging patients home with neck drains in situ after day case surgery.

Methods

A retrospective case notes review and questionnaire study was conducted at Southport and Ormskirk Hospitals Day Unit. Patients operated from January 2007 to December 2008 as day cases, who accepted the offer to be discharged home same day with neck drains in place were included. All of them had closed suction drain (mini vac set).8 The fixation of the drains was done using a similar to technique to that reported by Lim et al.9 Out of the 20 eligible patients who had drains placed 18 opted to be go home same day. Patients were not taught to empty their drains. Patients were instructed to do nothing, if the drain were to fall out, but turn up to their appointment the next day. They were told that they could return to the Day Unit the following day for drain removal or the specialist breast care nurses trained to remove drains would remove it at home. Drain related complications like slippage, blockage or non-functioning of drains were our outcome measures obtained from the records. Questionnaires were sent to these patients so that their satisfaction levels and concerns could be expressed. Their satisfaction was rated on a scale of 1 – 5. 1 represented ‘very unsatisfied’; 2 represented ‘unsatisfied’; 3 represented ‘satisfied’; 4 represented ‘moderately satisfied’ and 5 represented ‘very satisfied’. A section to write freely was included for patients to voice concerns.

Results

Median age of the patients was 42 years and age ranged between 16 and 73 years. There were 8 male and 10 female patients. Table 1 shows the details of the patients included in our study along with the procedures performed. Lymph node excision from level IV (n=4), Sistrunks procedure for thyroglossal duct cysts (n=4), hemithyroidectomy (n=3), branchial cyst or fistula excision (n=3), superficial or partial parotidectomy (n=2) and submandibular gland sialadenectomy (n=2) were the day case procedures performed.

Table1. Patient demographics, operations performed and patient satisfaction

S No.	Sex	Age	Operation	Satisfaction
1	M	61	Superficicla parotidectomy	4
2	F	16	Sistrunks procedure	5
3	F	42	Lymph node excision (lymphoma)	5
4	F	70	Parotid tail tumour	4
5	F	21	Sistrunks procedure	5
6	M	33	Branchial cyst excision	5
7	M	46	Branchial fistula excision	4
8	F	24	Lymph node excision	4
9	M	66	Lymph node excision	5
10	M	19	Sistrunks procedure	5
11	F	55	Submandibular gland excision	5
12	F	30	Submandibular gland excision	5
13	F	42	Hemithyroidectomy	5
14	F	40	Hemithyroidectomy	5
15	M	73	Lymph node excision	4
16	M	50	Branchial cyst excision	4
17	M	30	Sistrunks procedure	4
18	F	60	Hemithyroidectomy	3

M – Male; F – Female; Satisfaction: 1 = ‘very unsatisfied’; 2 = ‘unsatisfied’; 3 = ‘satisfied’; 4 = ‘moderately satisfied’ and 5 = ‘very satisfied’

The drain was emptied before discharge in 14(77.8%) patients and in 4 patients there was no record of it. The drain was removed the next day in all cases. This was done in 16 cases by the nurses in the day unit and in the other 2 cases, at home by the specialist breast care nurse. All drains were in place for approximately 24 hours. No complications were reported and none of the patients had any problems related of the drains. Questionnaires were returned by 11 (61.1%) and other 7 were telephoned to complete the questionnaire. Overall there were no patients who were unhappy with being discharged with the drains in place. Ten (55.6%) patients were ‘very satisfied’, 7 (38.9%) were ‘moderately satisfied’ and 1(5.6%) was just ‘satisfied’. Three (16.7%) patients thought the drain was an added stressor and 2(11.1%) thought the drain caused more pain.
The two patients that declined from being discharged home did so due to personal preference. These patients were transported 12 miles to the nearest wards in another hospital, University Hospital Aintree, as over-stays. These patients also had no postoperative complications.

Discussion

In order to comply with the NHS plan’s aim to perform 75% of elective cases as day surgery, most hospitals have seen an increasing drive to convert more and more elective inpatient procedures to day cases. This desire to increase the number of patients treated as day cases has prompted us to assess the safety and patient desirability of discharging patients with neck drains.
The use of a neck drain for some procedures has precluded patients from being discharged home the same day leading to a longer hospital stay and greater hospital expense. Many have argued against the routine use of drains to perform some of these procedures as day cases. The use of a fibrin sealant in parotidectomy has been shown to reduce the amount of drainage fluid produced and has also been used in day surgery without the use of a drain resulting in no postoperative complications.10, 11 Studies comparing the use of drains versus no drains relating to ENT surgery are mostly concentrated on thyroid surgery. The overall consensus in these studies shows that there is no significant difference in the formation of seromas and haematomas with or without a drain.4, 5 We were not comfortable with the idea of not using a neck drain considering the amount of dissection and potential dead space that would be there at the end of the procedure. Hence, we wanted to use neck drains but still perform these procedures as day cases. Therefore, we had to answer the question as to whether patients can be discharged home with neck drains in situ.
Ha et al reviewed those patients that had undergone neck dissection with an overnight stay in hospital that were subsequently discharged with neck drains in situ. They were kept in one night as the authors believed that many of the common complications of neck dissection occur at the time of surgery or by postoperative day one. Each patient had been taught to strip, empty and record the drain output before being discharged.12 There is established evidence and practice in the UK for breast surgery patients being sent home with drains in situ and return to clinic or have the breast care nurse remove them at home.6, 7 This is also currently the practice of the Southport and Ormskirk Trust. The above studies show patients can be discharged with drains in situ after a short hospital stay in those are well motivated and are able to care for themselves. The difference in our study was that patients were discharged on day of the operation as true day case surgery. Our study takes this one step further to show that this can also be done with day case patients. Many surgeons in the UK are not happy to avoid use of a drain, when they feel it is needed. They can still use them and perform these procedures as day cases safely.
The results from our study show a high satisfaction in those patients willing to be discharged home. The fact that 18 out 20 (90%) opted to be discharged home, shows that most people would prefer to recover at home and not in hospital. Despite no complications in our study; it is not to say that they will never occur. Patients should be well-informed of potential complications and should know when to and when not to present to Accident & Emergency for potential worst case scenarios. Only 3 patients thought that drain was an added stress factor. The two patients that opted for over-stays required transport by ambulance and as such is a difficulty associated with the use of drains in day surgery for this particular trust.13 This clearly indicates that if it is possible and safe to discharge with neck drains it avoids further unnecessary expenditure.

Conclusion

There were no complications in patients sent home with neck drains in situ and patients were also satisfied with this approach. This study demonstrates that neck drains are not a contraindication to day case surgery in suitable patients.

References

1. British Association of Day Surgery. Day Surgery: A Guide for Primary Care Trusts. www.daysurgeryuk.net/bads/joomla/files/handbooks/Commissioning.pdf [Accessed 17/12/09]
2. Lesser, TH, Al-Jassim, AH. (1994) Day case surgery in otolaryngology: the setting up and first year of a freestanding unit. J Laryngol Otol 108, 406-9.
3. Máchalová, M, Slapák, I. (2008) One-day surgery in pediatric otolaryngology--10 years' experience. Int J Pediatr Otorhinolaryngol 72, 1747-50.
4. Khanna, J, Mohil, RS, Chintamani, Bhatnagar, D, Mittal, MK, Sahoo, M, Mehrotra, M. (2005) Is the routine drainage after surgery for thyroid necessary? A prospective randomized clinical study. BMC Surg 5, 11.
5. Hopkins, C, Mansuri, S, Terry, RM. (2006) How we do it: Dispensing with drains in hemithyroidectomy--a feasibility study. Clin Otolaryngol 31, 452-5.
6. Chadha, NK, Cumming, S, O'Connor, R, Burke, M. (2004) Is discharge home with drains after breast surgery producing satisfactory outcomes? Ann R Coll Surg Engl 86, 353-7.
7. Chapman, D, Purushotham, AD. (2001) Acceptability of early discharge with drain in situ after breast surgery. Br J Nurs 10, 1447-50.
8. Day Surgery: Operational guide. Waiting, booking and choice. Department of Health August 2002. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4060341.pdf [Accessed 17/12/09]
9. Lim, M, Pitkin, L, Spraggs, P. (2005) A New Head and Neck Surgical Drain Fixation Technique. J Laryngol Otol 119, 396-7.
10. Conboy, P, Brown, DH. (2008) Use of tissue sealant for day surgery parotidectomy. J Otolaryngol Head Neck Surg 37, 208-11.
11. Maharaj, M, Diamond, C, Williams, D, Seikaly, H, Harris, J. (2006) Tisseel to reduce postparotidectomy wound drainage: randomized, prospective, controlled trial. J Otolaryngol 35, 36-9.
12. Ha, PK, Couch, ME, Tufano, RP, Koch, WM, Califano, JA. (2005) Short hospital stay after neck dissection. J Otolaryngol Head Neck Surg 133, 677-80.
13. Lesser, TH, Al-Jassim, AH. (1994) Day case surgery in otolaryngology: the setting up and first year of a freestanding unit. J Laryngol Otol 108, 406-9.

Address for Correspondence:
Mr C Ekambar E Reddy
SpR ENT & Skull base surgery
University Hospital Aintree
Lower Lane, Liverpool L7 9AE

First Published August 2010

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