Discussion
The aim of the current study was to evaluate the feasibility of drainless parotid surgery following the application of FS to the surgical bed. Our results suggest that drainless parotidectomy following application of FS is safe, reduces LOS and may reduce seromas. The inclusion of deep lobe tumors, parapharyngeal tumors and revision surgeries with no significant change in outcome suggests that the same manner of drainless surgery may also be applied in these patients. In agreement with previous studies supporting the role of FS following parotid surgery, we suggest that it should be considered as an alternative to the conservative use of drains following parotid surgery.
The use of FS has increased in recent years, including in the head and neck region [1,2,3,4,5, 6, 7]. Yet, articles describing this procedure should be divided into those that examine the impact of FS use on drain output [2,13,14], and those that refer to drainless surgery using FS [4,6,5,9]. Regarding the former, a randomized controlled trial by Maharaj et al. has shown that the use of FS significantly reduced wound drainage by 30% and post-operative seroma from 22.7% to 3.6% [2]. Previous studies have found that FS may reduce wound complications such as salivary fistula and hematoma [14]. The aforementioned publications have encouraged the principal surgeon (A.K) to start using FS in head and neck surgeries, including parotidectomies.
The first to question the necessity of drains in parotid surgery was Patel in 2006 [13], yet this was employed on a selective group of patients. Concerns of leaving the parotid bed undrained are probably based on the rich blood supply and secretive nature of the gland. Interestingly, use of FS was feasible and safe in drainless mastectomy, which also involves a secretive gland rich in fat tissue [15]. Our study’s result support the report by Congilio et al. [16] on successful drainless outpatient parotidectomy in a selected group of patients. Conboy et al. described their experience in 20 patients who underwent drainless parotidectomy using FS [6]. Two patients required aspirations due to post-operative seroma, and no other complications were noted. Chorney et al. investigated the impact of FS on wound complications in 100 patients [3]. While no suction drain was used in the FS group, a passive drain was used in 8.7% of patients in the FS group. Although there were no differences in wound complications between the groups, both groups had exceedingly higher rates of infection - 23.9% in the FS group and 16.7% in the drain group – compared to the rates of infection reported by other studies, including the current one. Chudek et al. reported that the use of FS has allowed for a drainless surgery, and resulted in an absolute risk reduction for seroma/salivary leak, as well as shortening the LOS [5]. However, as all patients underwent partial parotidectomies, while revision surgeries and deep lobe tumors were excluded, no conclusion could be drawn on FS use in these patients. The FS group in our study had a higher prevalence of deep lobe tumors compared to the control group (borderline significance), yet no difference was found in post-operative complications between the two groups. Furthermore, our cohort also included tumors involving parapharyngeal space as well as revision surgeries. Therefore, the current study further strengthens the findings by Chudek et al., suggesting that FS should be considered as an alternative for traditional suction drains even in complex parotid surgeries.
In recent years, the investigation of surgical outcome has shifted from safety-focused reports (i.e. complications, etc.) to safety and quality of life [17]. In the head and neck field this shift has been mostly prominent in thyroid and parathyroid surgery, encouraging reports on drainless surgery and minimally invasive approaches or on remote access approaches eliminating the cervical scar [1, 18, 19]. This rational was supported by recent studies that have emphasized the role of such scars on the quality of life of patients [20]. In parotid surgery this progress has been mild at best. Parotidectomy via a modified Blair incision and insertion of a suction drain is still considered the gold standard for treatment. The greatest change in the evolution of parotid surgery was the introduction of a modified/partial superficial parotidectomy, which leaves as much normal parotid tissue as possible and removes the tumor with a cuff of normal parotid tissue around it [17,21]. Other modifications for incisions, including minimal skin incisions [11] or cosmetic incisions [22] have seldom been suggested. Studies using self-assessment scores have shown that surgical drains are associated with a significant increase in patients’ anxiety and pain as well as reduced comfort [23]. Similar to the aforementioned studies on the impact of surgical neck scars [20], studies on the impact of drains on patients’ quality of life and post-operative recovery should be undertaken, which may further encourage a change in the surgical paradigm, as experienced by our group and others [4,5].
Finally, the decrease in post-operative LOS is also an important consideration when implementing drainless surgery. Most importantly, it reduces the exposure of patients and their families to nosocomial infections and improves patient satisfaction. While the mean LOS in our control group was 1.5 days, a US nationwide study (n=66,914) has reported a mean LOS of 2.5 days [24]. Another recent US nationwide study has found that a LOS ≥2 days was an independent risk factor for readmission within 30 days following parotidectomy [25]. Considering that the cost of a hospitalization day is USD ≥9000 [24,25] compared with the cost of FS (~300$), this cost difference should also be taken as a major factor for implementing drainless FS parotid surgery.
Our study has several limitations. As a retrospective study it is based on the quality of documentation of post-operative complications and patient adherence to follow-up. This has also prevented us from prospectively evaluating the impact of drain on patient post-operative satisfaction and quality of life. Although ours is one of the largest studies to report drainless parotidectomies, it is possible that a larger cohort would have had an impact on the statistical significance of the observed trends in post-operative outcomes. As our series included all consecutive patients operated on before and after the implementation of FS, selection bias based on case selection was not relevant, yet inherent selection bias of retrospective design remains. A minor limitation relates to generalizability of the findings given that it is a single surgeon experience. Drain device usage maybe country-specific, as well as hospital admission policy, observation practices and costing which may differ by geographies.