Criteria for drain removal following liver resection

Background: Abdominal drains have been placed prophylactically and removed in liver resection without robust evidence. The present study was designed to establish the optimal time for removal of such drains. Methods: Data on abdominal prophylactic drains were analysed in a consecutive series of patients who underwent liver resection for malignancy between 2006 and 2009. Bilirubin levels in drain fluid were measured and bacteriological cultures were taken on days 1, 3, 5 and 7 after surgery. Drains were removed on day 3 if the drain-fluid bilirubin level was less than 5 mg/dl and bacteriological cultures were negative. Drains remained in situ until these conditions were met. Results: A total of 514 abdominal drains were placed in 316 patients operated on in the study period. Fifty-eight patients (18.4 per cent) had positive drain-fluid cultures and 14 (4.4 per cent) had bile leakage (drain-fluid bilirubin level 5 mg/dl or more). Only one patient required ultrasound-guided abdominal drainage. On multivariable analysis, drain-fluid bilirubin level on day 3 after surgery was the strongest predictor of infection (odds ratio 15.11, 95 per cent confidence interval 3.04 to 92.11; P < 0.001). The area under the receiver operating characteristic curve on day 3 had the highest predictive value: 83.6 per cent accuracy and 3.9 per cent false-positive rate for a drain-fluid bilirubin level of 3.01 mg/dl (51.5 mu mol/l). Conclusion: The 3 x 3 rule (drain-fluid bilirubin level below 3 mg/dl on day 3 after operation) is an accurate criterion for removal of prophylactically placed abdominal drains in liver resection. Copyright (c) 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.