Selective Policy of No Drain after Pancreaticoduodenectomy Is a Valid Option in Patients at Low Risk of Pancreatic Fistula: A Case-Control Analysis
Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, Assistance Publique Hôpitaux de Paris (AP-HP), Beaujon Hospital, Université Paris 7, 100 Boulevard du Général Leclerc, 92118, Clichy, France. World Journal of Surgery
(Impact Factor: 2.64).
02/2013; 37(5). DOI: 10.1007/s00268-013-1947-3
Abdominal drainage is routinely performed after pancreaticoduodenectomy (PD), but this policy has recently been challenged. The aim of the present study was to assess whether abdominal drainage could be omitted after PD in patients at low risk of pancreatic fistula (PF).
From 2009 to 2011, 27 consecutive patients underwent PD without abdominal drainage. Their preoperative characteristics and postoperative outcomes were compared to those of 27 matched patients undergoing PD with prophylactic drainage. Patients were matched 1:1 in terms of demographic data, preoperative weight loss, preoperative biliary drainage, surgical indication, and main risk factors of PF (pancreatic texture, main duct size, and body mass index).
Overall morbidity rates (no drainage, 56 % vs. drainage, 70 %; p < 0.4) and operative mortality (1 patient in each group) were similar in both groups. The two groups did not differ significantly in terms of delayed gastric emptying (15 vs. 11 %; p = 0.68), and chylous ascites (4 vs. 15 %; p = 0.35). Radiological or surgical interventions for surgical complications were required in 2 patients (1 in each group). Pancreatic fistula rate (0 vs. 22 %; p = 0.009) and hospital stay (10 vs. 15 days; p = 0.004) were significantly reduced in the no drainage group as compared to the drainage group. The hospital readmission rate was similar in the two groups (no drainage, 3.7 vs. 0 %; p = 0.31).
This study suggests that abdominal drainage should not be considered routinely after PD in patients at low risk of PF. A no drain policy may reduce hospital stay after PD.
Available from: Kenichiro Uemura
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ABSTRACT: The indicators for proper drain management following pancreaticoduodenectomy (PD) remain unclear. Our aim was to identify appropriate timing and proper indicators for safe drain management after PD.
Prospectively collected data from 200 patients who underwent PD were evaluated. Postoperative clinical factors for clinically relevant pancreatic fistulas (CR-POPFs) and management of surgically placed drains were analyzed retrospectively.
CR-POPFs occurred in 8% of patients. By logistic regression analysis, one factor (non-serous fluid in the drain) on postoperative day (POD) 1 and two factors (non-serous fluid in the drain and serum CRP levels) on POD 3 and 4 were significantly associated with CR-POPFs. Receiver operating characteristic analysis demonstrated that combined predictive factors on POD 4 were the most accurate. Of 163 patients with serous fluid in the drain and CRP <15.6 mg/dl on POD 4, 1% had CR-POPFs, but no patient required POPF-related re-drainage. In contrast, among 37 patients with non-serous fluid in the drain or CRP levels ≥15.6 mg/dl, 35% had CR-POPFs, and 8% required POPF-related re-drainage.
A combination of CRP levels and the color of surgical drain fluid, not POD1 or 3, but on POD 4, may be the most accurate indicators for safe drain management following PD. J. Surg. Oncol. © 2014 Wiley Periodicals, Inc.
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ABSTRACT: Background and objective
Prophylactic intraperitoneal drainage is usually indwelled after abdominal operation. This study assessed whether prophylactic intraperitoneal drainage was of value after pancreatic resection.
A systematic literature search was performed to identify relevant articles. Data aggregation and analysis were performed using RevMan 5.0 software package.
A randomized controlled trial and seven observational cohort studies including a total of 2690 patients were eligible. The overall and major complication rates and the occurrence of pancreatic fistula in patients with drainage were higher than those without drainage. Prophylactic intraperitoneal drainage was not associated with a statistically significant reduction in the need for percutaneous drainage, reoperation and readmission, nor with an increase in mortality.
The present meta-analysis demonstrated that prophylactic intraperitoneal drainage after pancreatic resection appears to be unable to improve the postoperative course, and may be associated with more severe and higher rate of complication and increased pancreatic fistula occurrence. There is a serious bias in the criteria to insert drain or not in these retrospective studies. Therefore these results should be confirmed by randomized controlled trial.
Available from: wjgnet.com
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ABSTRACT: With the development of imaging technology and surgical techniques, pancreatic resections to treat pancreatic tumors, ampulla tumors, and other pancreatic diseases have increased. Pancreaticoduodenectomy, one type of pancreatic resection, is a complex surgery with the loss of pancreatic integrity and various anastomoses. Complications after pancreaticoduodenectomy such as pancreatic fistulas and anastomosis leakage are common and significantly associated with patient outcomes. Pancreatic fistula is one of the most important postoperative complications; this condition can cause intraperitoneal hemorrhage, septic shock, or even death. An effective way has not yet been found to avoid the occurrence of pancreatic fistula. In most medical centers, the frequency of pancreatic fistula has remained between 9% and 13%. The early detection and routine drainage of anastomotic fistulas, pancreatic fistulas, bleeding, or other intra-abdominal fluid collections after pancreatic resections are considered as important and effective ways to reduce postoperative complications and the mortality rate. However, many recent studies have argued that routine drainage after abdominal operations, including pancreaticoduodenectomies, does not affect the incidence of postoperative complications. Although inserting drains after pancreatic resections continues to be a routine procedure, its necessity remains controversial. This article reviews studies of the advantages and disadvantages of routine drainage after pancreaticoduodenectomy and discusses the necessity of this procedure.
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