A 45-year-old woman was admitted with choledocholithiasis. Two days prior, following endoscopic retrograde cholangiopancreatography (ERCP), she had gone to the OR for cholecystectomy. The procedure was completed laparoscopically, though the surgeon reported a difficult dissection. The surgeon left a Blake drain in the gallbladder fossa, which initially contained punch-colored fluid. Today, there is bilious fluid in the drain.
Surgical drains are used to monitor for postoperative leaks or abscesses, to collect normal physiologic fluid, or to minimize dead space. A hospitalist caring for surgical patients may be the first provider to note when something changes in the color or volume of surgical drains. Table 1 lists various types of drains with their indications for use.
Surgical Tubes and Drains
Chest tubes. Chest tubes are placed in the pleural space to evacuate air or fluid. They can be as thin as 20 French or as thick as 40 French (for adults). Chest tubes are typically placed between the fourth and fifth intercostal spaces in the anterior axillary or mid-axillary line; however, the location may vary according to the indication for placement. The tubes can be straight or angled.
The tubes are connected to a collecting system with a three-way chamber. The water chamber holds a column of water, which prevents air from being sucked into the pleural space with inhalation. The suction chamber can be attached to continuous wall suction to remove air or fluid, or it can be placed on “water seal” with no active suction mechanism. The third chamber is the collection chamber for fluid drainage.
Indications for a chest tube include pneumothorax, hemothorax, or a persistent or large pleural effusion. Pneumothorax and hemothorax usually require immediate chest tube placement. Chest tubes are also commonly placed at the end of thoracic surgeries to allow for appropriate re-expansion of the lung tissue.
A chest X-ray should be obtained after any chest tube insertion to ensure appropriate placement. Chest tubes are equipped with a radiopaque line along the longitudinal axis, which should be visible on X-ray. Respiratory variation in the fluid in the collecting tube, called “tidling,” should also be seen in a correctly placed chest tube, and should be monitored at the bedside to reassure continued appropriate location. The interventional radiologist or surgeon who placed the tube should determine the subsequent frequency of serial chest X-rays required to monitor the location of the chest tube.
If the patient has a pneumothorax, air bubbles will be visible in the water chamber; called an air leak, these are often more apparent when the patient coughs. The chest tube should initially be set to continuous suction at -20 mmHg to evacuate the air. Once the air leak has stopped, the chest tube should be placed on water seal to confirm resolution of the pneumothorax (water seal mimics normal physiology). If, after the transition from suction to water seal, resumption of the air leak is noted, it may indicate recurrence of the patient’s pneumothorax. A stat chest X-ray should be obtained, and the chest tube should be placed back on continuous suction. In general, a chest X-ray should be obtained any time the chest tube is changed from suction to water seal or vice versa.
If the patient experiences ongoing or worsening pain, fever, or inadequate drainage, a chest computed tomographic (CT) scan may be warranted to identify inappropriate positioning or other complications, such as occlusion or effusion of the tube. Blood or other debris might clog chest tubes; the surgical team may be able to evacuate the tube with suction tubing at the bedside. If unsuccessful, the tube may need to be removed and reinserted.
The team that placed the tube should help the hospitalist determine the timing of the chest tube removal. If the patient has a pleural effusion, the chest tube can usually be removed when the output is less than 100-200 mL per day and the lung is expanded. The tube should usually be taken off suction and placed on water seal to rule out pneumothorax prior to tube removal.
Penrose drains. Penrose drains are often used to drain fluid or to keep a space open for drainage. Surgeons may use sutures to anchor Penrose drains to skin. Common indications include:
- Ventral hernia repair;
- Debridement of infected pancreatitis; and
- Drainage of superficial abscess cavities.
Penrose drains are simple, flexible tubes that are open at both ends; in contrast to closed drains, they permit ingress as well as egress, facilitating colonization.
Closed suction drains. Closed suction drains with a plastic bulb attachment (i.e., Jackson-Pratt, Blake, Hemovac) are used to collect fluid from a postoperative cavity. Common indications include:
- Post-mastectomy to drain subcutaneous fluid;
- Abdominal surgery;
- Plastic surgery to prevent seroma formation and promote tissue apposition;
- Cholecystectomy if there is concern for damage to ducts of Luschka or other source of bile leak;
- Inadvertent postoperative leakage following a difficult rectal anastomosis; and
- Post-pancreatic surgery.
The quality and quantity of fluid drained should always be carefully noted and recorded. Changes in the fluid can imply development of bleed, leak, or other complications. The surgical team should be contacted immediately if changes are noted.
Typically, closed suction drains will be left in place until the drainage is less than 20 mL per day. These drains can be left in for weeks if necessary and will often be removed during the patient’s scheduled surgical follow-up. Rare complications include erosion into surrounding tissues and inadvertent suturing of the drain in place, such that reexploration is required to remove it. If a closed suction drain becomes occluded, contact the team that placed the drain for further recommendations on adjustment, replacement, or removal.
Nasogastric and duodenal tubes. Nasogastric tubes (NGTs) are often used in the nonoperative management of small bowel obstruction or ileus. They should be placed in the most dependent portion of the gastric lumen and confirmed by chest or abdominal X-ray. NGTs are sump pumps and have a double lumen, which includes an air port to assure flow. The air port should be patent for optimal functioning. The tube may be connected to continuous wall suction or intermittent suction, set to low (less than 60 mmHg) to avoid mucosal avulsion.
NGT output should decrease during the resolution of obstruction or ileus, and symptoms of nausea, vomiting, and abdominal distention should concomitantly improve. Persistently high output in a patient with other indicators of bowel function (flatus, for example) may suggest postpyloric placement (and placement should be checked by X-ray). The timing of NGT removal depends on resumption of bowel function.
Gastrostomy and jejunostomy tubes. Gastrostomy tubes are most commonly used for feeding but may also be used for decompression of functional or anatomic gastric outlet obstruction. They are indicated when patients need prolonged enteral access, such as those with prolonged mechanical ventilation or head and neck pathology that prohibits oral feeding. They are also rarely used for gastropexy to tack an atonic or patulous stomach to the abdominal wall or to prevent recurrence of paraesophageal hernias. These tubes can be placed percutaneously by interventional radiologists, endoscopically by surgeons and gastroenterologists, or laparoscopically or laparotomally by surgeons. This last option is often reserved for patients with difficult anatomy or those who are having laparotomy for another reason.
Because of the stomach’s generous lumen, gastrostomy tubes rarely clog. In the event that they do get clogged, carbonated liquids, meat tenderizer, or enzymes can help dissolve the obstruction. If a gastrostomy tube is left to drain, the patient may experience significant fluid and electrolyte losses, so these need to be carefully monitored.
Jejunostomy tubes are used exclusively for feeding and are usually placed 10-20 cm distal to the ligament of Treitz. These tubes are indicated in patients who require distal feedings due to gastric dysfunction or in those who have undergone a surgery in which a proximal anastomosis requires time to heal. These tubes are more apt to clog and can be more difficult to manage because the lumen of the small bowel is smaller than the stomach. Some prefer not to put pills down the tube to mitigate this risk. Routine flushes with water or saline (30 mL every four to six hours) are also helpful in mitigating the risk of clogging. In the event that they do get clogged, they may be treated like gastrostomy tubes, using carbonated liquids, meat tenderizer, or enzymes to help dissolve the obstruction.
Percutaneous tube sites should be examined frequently for signs of infection. Though gastrostomy and jejunostomy tubes are typically well secured intraabdominally, they can become dislodged. If a gastrostomy or jejunostomy tube has been in place for more than two weeks, it can easily be replaced at the bedside with a tube of comparable caliber by a member of the surgical team or by an experienced hospitalist. If the tube has been in place less than two weeks, it requires replacement with radiographic guidance, as the risk of creating a false lumen is high. Over time, tubes can become loose and fall out. If they need replacement, the preceding guidelines apply.
Back to the Case
A potential major complication of cholecystectomy is severance of the common bile duct, which necessitates significant further surgery. Less severe complications include injuries to the cholecystohepatic ducts (otherwise known as the ducts of Luschka), which can result in leakage of bile into the peritoneal cavity. A bile leak can lead to abscess and systemic infection if left undrained.
Surgeons who are concerned for such a complication intraoperatively may opt to leave a closed suction drain in the gallbladder fossa, such as a Blake drain, for monitoring and subsequent drainage. The drain will remain in place at least until the patient’s diet has been advanced fully, because digestion promotes the secretion of bile and may elucidate a leak. Bilious fluid in the Blake drain is suspicious for a leak.
The surgeon should be notified, and imaging should be obtained to find the nature of the injury to the biliary tree (CT scan with IV contrast, hepatobiliary iminodiacetic acid scan, or endoscopic retrograde cholangiopancreatography). If injury to major biliary structures (the cystic duct stump, the hepatic ducts, or the common bile duct) is diagnosed, a stent may be placed in order to restore ductile continuity.
Minor leaks, with damage to the cystic duct stump, hepatic ducts, and common bile duct ruled out, more often resolve on their own over time, and thus the patient’s closed suction drain will be left in place until biliary drainage ceases, without further initial intervention.
Surgical tubes and drains have several placement indications. Alterations in quality and quantity of output can indicate changes in clinical status, and hospitalists should be able to handle initial troubleshooting. TH
Dr. Columbus is a general surgery resident at Brigham and Women’s Hospital in Boston. Dr. Havens is an instructor for the department of surgery at Brigham and Women’s Hospital. Dr. Peetz is an instructor for the department of surgery at University Hospital Case Medical Center in Cleveland.