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.