Drain Management After Pancreatectomy


Authors

Year

Study design

Procedure

Variable

Sample size

Morbiditya (%)

Pancreatic fistulab (%)

Re-drainage (%)

Reoperation (%)

Readmission (%)

Mortality (%)

Conlon et al. [11]

2001

RCT

PD and DP

Drain

88

22

12.5

13

9

NA

2

No drain

91

12

0

8

4

NA

2

Fisher et al. [12]

2011

Retrospective study

PD and DP

Drain

179

21

12

2*

4

9*

1

No drain

47

15

11

11

0

17

2

Mehta et al. [13]

2013

Retrospective study

PD

Drain

251

36.3

16.3

8.4

5.6

17.5

2.0

No drain

458

30.2

7.6*

6.3

5.7

16.8

2.5

Correa-Gallego et al. [14]

2013

Retrospective study

PD and DP

Drain

553

33

20

19

<1

27

1

No drain

569

26*

16*

15

<1

20*

2

Adham et al. [15]

2013

Retrospective study

PD and DP

Drain

130

29.4

9.2

14.6

NA

NA

5.4

No drain

112

42.9

11.4

20.5

NA

NA

4.5

van Buren et al. [16]

2014

RCT

PD

Drain

68

28

10

9*

3

16

3

No drain

69

41

20

23

9

12

12


PD pancreaticoduodenectomy, DP distal pancreatectomy, RCT randomized controlled trial, NA not available

*A significant reduction was observed (P < 0.05)

aMorbidity was identified as Clavien IIIa or more

bPancreatic fistula was identified as clinically relevant pancreatic fistula



It had remained still controversial whether routine intraperitoneal drains decrease the postoperative complications after pancreatectomy. In 2014, a multicenter randomized controlled trial in the USA has evaluated whether pancreaticoduodenectomy without routine intraperitoneal drains does not increase the incidence of severe postoperative complications [16]. One hundred thirty-seven patients who underwent pancreaticoduodenectomy were enrolled in this study; 68 patients were randomized to drain group, and 69 patients were randomized to no drain group. The primary endpoint for this a multicenter randomized controlled trial was the 60-day grade II or greater complication rate. This study has demonstrated that pancreaticoduodenectomy without intraperitoneal drainage was associated with increased 60-day grade II or greater complication rate, which was the primary endpoint for this a multicenter randomized controlled trial (drain group 52% vs. no drain group 68%, P = 0.047). Moreover, no drain in this study significantly increased gastroparesis (drain group 24% vs. no drain group 42%, P = 0.021), intra-abdominal abscess (drain group 12% vs. no drain group 26%, P = 0.033), diarrhea more than grade II (drain group 3% vs. no drain group 17%, P = 0.005), abdominal fluid collection (drain group 2% vs. no drain group 12%, P = 0.033). The most important point was that the study was stopped early by the Data Safety Monitoring Board although this study were planned to require a total of 752 patients for the two groups at first. Because mortality in no drain group was 12% which was a fourfold increase compared to 3% in drain group after 90-day follow-up. This study concluded that pancreaticoduodenectomy without intraperitoneal drainage significantly increased the incidence of severe complications and contributed to increased mortality.



36.3 The Impact of Early Removal Drain After Pancreatectomy


What is appropriate drain management after pancreatectomy? The period of drain insertion is the most important point regarding drain management after pancreatectomy. Table 36.2 summarized two studies which have reported the association between early drain removal and pancreatic fistula. One prospective study and one randomized controlled trial have been designed to clarify whether the intended period of drain insertion influenced postoperative complication rates after pancreatectomy. The study by Kawai et al. prospectively assigned the patients who underwent PD into two groups: group I (n = 52, drain to be removed on postoperative day (POD) 8) and group II (n = 52, drain to be removed on POD 4). The incidence of pancreatic fistula was significantly lower in POD 4 (3.6%) than in POD 8 (23%) (P = 0.0038) [17]. The incidences of intra-abdominal infections, including intra-abdominal abscess and infected intra-abdominal collections, were significantly reduced in POD 4 (7.7%) compared with POD 8 (38%) (P = 0.0003). Moreover, drain removal on POD8 was the only independent risk factor for intra-abdominal infections by multivariate analysis (odds ratio: 6.7). This study has concluded that postoperative complications rates including pancreatic fistula and intra-abdominal infections were significantly lower when the prophylactic drains were to be removed on POD 4.


Table 36.2
Studies to evaluate the association between early removal drain and pancreatic fistula













































Authors

Year

Study design

Procedure

Variable

Sample size

Pancreatic fistulaa (%)

Intra-abdominal infection (%)

Reoperation (%)

Readmission (%)

Mortality (%)

Kawai et al. [17]

2006

Prospective study

PD

Early drain removal on POD4

52

3.6*

7.7*

0

0

0

Late drain removal on POD8

52

23

38

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Jun 26, 2017 | Posted by in ONCOLOGY | Comments Off on Drain Management After Pancreatectomy

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