Peritoneal drainage or no drainage after pancreaticoduodenectomy and/or distal pancreatectomy: a meta-analysis and systematic review

Prophylactic abdominal drainage for pancreatic surgery

RATIONALE

This is the fourth update of a Cochrane review first published in 2015 and last updated in 2021. The use of surgical drains is a very common practice after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications after pancreatic surgery is controversial.

OBJECTIVES

To assess the benefits and harms of routine abdominal drainage after pancreatic surgery; to compare the effects of different types of surgical drains; and to evaluate the optimal time for drain removal.

SEARCH METHODS

We searched CENTRAL, MEDLINE, three other databases, and five trials registers, together with reference checking and contact with study authors, to identify studies for inclusion in the review. The search dates were 20 April 2024 and 20 July 2024.

ELIGIBILITY CRITERIA

We included randomised controlled trials (RCTs) in participants undergoing pancreatic surgery comparing (1) drain use versus no drain use, (2) different types of drains, or (3) different schedules for drain removal. We excluded quasi-randomised and non-randomised studies.

OUTCOMES

Our critical outcomes were 30-day mortality, 90-day mortality, intra-abdominal infection, wound infection, and drain-related complications.

RISK OF BIAS

We used the Cochrane RoB 1 tool to assess the risk of bias in RCTs.

SYNTHESIS METHODS

We synthesised the results for each outcome using meta-analysis with the random-effects model where possible. We used GRADE to assess the certainty of evidence for each outcome.

INCLUDED STUDIES

We included 12 RCTs with a total of 2550 participants. The studies were conducted in North America, Europe, and Asia and were published between 2001 and 2024. All studies were at overall high risk of bias.

SYNTHESIS OF RESULTS

We considered the certainty of the evidence for intra-abdominal infection for the comparison of early versus late drain removal following pancreaticoduodenectomy to be moderate, downgraded due to indirectness. We considered the certainty of the evidence for the other outcomes to be low or very low, mainly downgraded due to high risk of bias, inconsistency, indirectness, and imprecision. Drain use versus no drain use following pancreaticoduodenectomy We included two RCTs with 532 participants randomised to the drainage group (N = 270) and the no drainage group (N = 262) after pancreaticoduodenectomy. The evidence is very uncertain about the effect of drain use on 30-day mortality (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.07 to 3.66; 2 studies, 532 participants), 90-day mortality (RR 0.25, 95% CI 0.06 to 1.15; 1 study, 137 participants), intra-abdominal infection rate (RR 0.85, 95% CI 0.21 to 3.51; 2 studies, 532 participants), and wound infection rate (RR 0.85, 95% CI 0.55 to 1.31; 2 studies, 532 participants) compared with no drain use. Neither study reported on drain-related complications. Drain use versus no drain use following distal pancreatectomy We included two RCTs with 626 participants randomised to the drainage group (N = 318) and the no drainage group (N = 308) after distal pancreatectomy. There were no deaths at 30 days in either group. The evidence is very uncertain about the effect of drain use on 90-day mortality (RR 0.16, 95% CI 0.02 to 1.35; 2 studies, 626 participants), intra-abdominal infection rate (RR 1.20, 95% CI 0.60 to 2.42; 1 study, 344 participants), and wound infection rate (RR 2.12, 95% CI 0.93 to 4.87; 2 studies, 626 participants) compared with no drain use. Neither study reported on drain-related complications. Active versus passive drain following pancreaticoduodenectomy We included three RCTs with 441 participants randomised to the active drain group (N = 222) and the passive drain group (N = 219) after pancreaticoduodenectomy. The evidence is very uncertain about the effect of an active drain on 30-day mortality (RR 1.24, 95% CI 0.30 to 5.07; 2 studies, 321 participants), intra-abdominal infection rate (RR 0.58, 95% CI 0.06 to 5.43; 3 studies, 441 participants), and wound infection rate (RR 0.92, 95% CI 0.44 to 1.90; 2 studies, 321 participants) compared with a passive drain. None of the studies reported on 90-day mortality. There were no drain-related complications in either group (1 study, 161 participants; very low-certainty evidence). Early versus late drain removal following pancreaticoduodenectomy We included three RCTs with 557 participants with a low risk of postoperative pancreatic fistula, randomised to the early drain removal group (N = 279) and the late drain removal group (N = 278) after pancreaticoduodenectomy. Low-certainty evidence suggests that early drain removal may result in little to no difference in 30-day mortality (RR 0.99, 95% CI 0.06 to 15.45; 3 studies, 557 participants) and wound infection rate (RR 1.07, 95% CI 0.47 to 2.46; 3 studies, 557 participants) compared with late drain removal. Moderate-certainty evidence shows that early drain removal probably results in a slight reduction in intra-abdominal infection rate compared with late drain removal (RR 0.45, 95% CI 0.26 to 0.79; 3 studies, 557 participants). Approximately 58 (34 to 102 participants) out of 1000 participants in the early removal group developed intra-abdominal infections compared with 129 out of 1000 participants in the late removal group. There were no deaths at 90 days in either study group (2 studies, 416 participants). None of the studies reported on drain-related complications.

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effect of drain use compared with no drain use on 90-day mortality, intra-abdominal infection rate, and wound infection rate in people undergoing either pancreaticoduodenectomy or distal pancreatectomy. The evidence is also very uncertain whether an active drain is superior, equivalent, or inferior to a passive drain following pancreaticoduodenectomy. Moderate-certainty evidence suggests that early drain removal is probably superior to late drain removal in terms of intra-abdominal infection rate following pancreaticoduodenectomy for people with low risk of postoperative pancreatic fistula.

FUNDING

None.

REGISTRATION

Registration: not available. Protocol and previous versions available via doi.org/10.1002/14651858.CD010583, doi.org/10.1002/14651858.CD010583.pub2, doi.org/10.1002/14651858.CD010583.pub3, doi.org/10.1002/14651858.CD010583.pub4, and doi.org/10.1002/14651858.CD010583.pub5.

Comparative Assessment of Outcomes: Abdominal Drain Versus No Abdominal Drain After Left Pancreatectomy-A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to compare outcomes between abdominal drain placement and no drain placement postpancreatectomy.

BACKGROUND

Left pancreatectomy (LP) is a surgical procedure commonly employed for various pancreatic conditions, often associated with postoperative complications like postoperative pancreatic fistula (POPF). While routine abdominal drainage following LP has been standard practice, recent evidence suggests potential benefits of omitting this approach.

METHODS

A comprehensive search was conducted on PubMed, Cochrane, and Embase from inception up to 15 March 2024, yielding nine studies comprising 15,817 patients. Data were extracted from randomized and nonrandomized studies reporting primary and secondary outcomes. The analysis was performed in Revman. Risk ratios were calculated with 95% CIs, and a P value of <0.05 was considered statistically significant.

RESULTS

A total of 13,081 patients underwent drain placement after left pancreatectomy, and 2736 patients were included in the no-drain group. Out of the total, 45.1% (n=7140) patients were male, with 45.9% (n=6012) males in the drain group and 41.2% (n=1128) males in the no-drain group. Major morbidity, defined as Clavien-Dindo grade ≥III complications, was significantly lower in the no-drain group [relative risk (RR): 0.77, 95% CI: 0.64-0.93, P =0.006]. Similarly, lower rates of postoperative pancreatic fistula (POPF) (RR: 0.51, 95% CI: 0.38-0.67, P <0.00001), readmission (RR: 0.75, 95% CI: 0.59-0.96, P =0.02), and surgical site infections (RR: 0.82, 95% CI: 0.70-0.95, P =0.009) were observed in the no-drain group. In addition, a shorter length of hospital stay was noted in this group [mean difference (MD): -1.65, 95% CI: -2.50 to -0.81, P =0.0001].

CONCLUSIONS

Omitting routine drainage after a left pancreatectomy is associated with reduced complications and shorter hospital stays, supporting its potential benefits in improving postoperative outcomes.

Dual-layer nanofibrous PCL/gelatin membrane as a sealant barrier to prevent postoperative pancreatic leakage

Post-operative pancreatic leakage is a severe surgical complication that can cause internal bleeding, infections, multiple organ damage, and even death. To prevent pancreatic leakage and enhance the protection of the suture lining and tissue regeneration, a dual-layer nanofibrous membrane composed of synthetic polymer polycaprolactone (PCL) and biopolymer gelatin was developed. The fabrication of this dual-layer (PGI-PGO) membrane was achieved through the electrospinning technique, with the inner layer (PGI) containing 2% PCL (w/v) and 10% gelatin (w/v), and the outer layer (PGO) containing 10% PCL (w/v) and 10% gelatin (w/v) in mixing ratios of 2:1 and 1:1, respectively. Experimental results indicated that a higher gelatin content reduced fiber diameter enhanced the hydrophilicity of the PGI layer compared to the PGO layer, improved the membrane's biodegradability, and increased its adhesive properties. In vitro biocompatibility assessments with L929 fibroblast cells showed enhanced cell proliferation in the PGI-PGO membrane. In vivo studies confirmed that the PGI-PGO membrane effectively protected the suture line without any instances of leakage and promoted wound healing within four weeks post-surgery. In conclusion, the nanofibrous PGI-PGO membrane demonstrates a promising therapeutic potential to prevent postoperative pancreatic leakage.

Meta-analysis of routine abdominal drainage versus no drainage following distal pancreatectomy: Does the best available evidence overcome "HPB surgeon's paranoia"?

AIMS

To evaluate comparative outcomes of routine abdominal drainage versus no drainage after distal pancreatectomy (DP).

METHODS

A systematic search of MEDLINE, CENTRAL and Web of Science and bibliographic reference lists were conducted (last search: 20th April 2024). All comparative studies reporting outcomes of DP with routine abdominal drainage and no drainage were included and their risk of bias were assessed. Overall perioperative complications, clinically-relevant postoperative pancreatic fistula (CR-POPF), delayed gastric emptying (DGE), postoperative haemorrhage, surgical site infections (SSIs), need for radiological intervention, reoperation, re-admission, and postoperative mortality were the evaluated outcome parameters.

RESULTS

Eight comparative studies (2 randomised and 6 observational) reporting 8164 patients who underwent DP with (n = 6394) or without (n = 1770) routine abdominal drainage were included. Routine abdominal drainage was associated with significantly higher rates of CR-POPF (OR 2.87; 95 % CI 2.34-3.52, p < 0.00001), radiological intervention (OR 1.33; 95 % CI 1.10-1.61, p = 0.0003), SSIs (OR 2.47; 95 % CI 1.29-4.72, p = 0.006) or re-admission (OR 1.54; 95 % CI 1.30-1.82, P < 0.00001) compared to no use of drain. However, there was no significant difference in C-D III or higher postoperative morbidities (OR 1.25; 95 % CI 0.98-1.60, p = 0.08), DGE (OR 1.17; 95 % CI 0.81-1.67, p = 0.41), reoperation (OR 1.11; 95 % CI 0.80-1.54, P = 0.53), postoperative haemorrhage (OR 0.59; 95 % CI 0.18-2.00, P = 0.40), or mortality (RD 0.0; 95 % CI -0.01-0.01, p = 0.76) between two groups.

CONCLUSIONS

The meta-analysis of best available evidence indicates safety of "no drain policy" in distal pancreatectomy considering its lower risk of CR-POPF, re-intervention and hospital re-admission. More randomised evidence is required to overcome the "HPB surgeon's paranoia".

Early Drain Removal Versus Routine Drain Removal After Pancreaticoduodenectomy and/or Distal Pancreatectomy: A Meta-Analysis and Systematic Review

BACKGROUND

Early drain removal (EDR) has been widely accepted, but not been routinely used in patients after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). This study aimed to evaluate the safety and benefits of EDR versus routine drain removal (RDR) after PD or DP.

METHODS

A systematic search was conducted on medical search engines from January 1, 2008 to November 1, 2023, for articles that compared EDR versus RDR after PD or DP. The primary outcome was clinically relevant postoperative pancreatic fistula (CR-POPF). Further analysis of studies including patients with low-drain fluid amylase (low-DFA) on postoperative day 1 and defining EDR timing as within 3 days was also performed.

RESULTS

Four randomized controlled trials (RCTs) and eleven non-RCTs with a total of 9465 patients were included in this analysis. For the primary outcome, the EDR group had a significantly lower rate of CR-POPF (OR 0.23; p < 0.001). For the secondary outcomes, a lower incidence was observed in delayed gastric emptying (OR 0.63, p = 0.02), Clavien-Dindo III-V complications (OR 0.48, p < 0.001), postoperative hemorrhage (OR 0.55, p = 0.02), reoperation (OR 0.57, p < 0.001), readmission (OR 0.70, p = 0.003) and length of stay (MD -2.04, p < 0.001) in EDR. Consistent outcomes were observed in the subgroup analysis of low-DFA patients and definite EDR timing, except for postoperative hemorrhage in EDR.

CONCLUSION

EDR after PD or DP is beneficial and safe, reducing the incidence of CR-POPF and other postoperative complications. Further prospective studies and RCTs are required to validate this finding.

Safety and effectiveness of minimally invasive central pancreatectomy versus open central pancreatectomy: a systematic review and meta-analysis

BACKGROUND

Central pancreatectomy is a surgical procedure for benign and low-grade malignant tumors which located in the neck and proximal body of the pancreas that facilitates the preservation of pancreatic endocrine and exocrine functions but has a high morbidity rate, especially postoperative pancreatic fistula (POPF). The aim of this systematic review and meta-analysis was to evaluate the safety and effectiveness between minimally invasive central pancreatectomy (MICP) and open central pancreatectomy (OCP) basing on perioperative outcomes.

METHODS

An extensive literature search to compare MICP and OCP was conducted from October 2003 to October 2023 on PubMed, Medline, Embase, Web of Science, and the Cochrane Library. Fixed-effect models or random effects were selected based on heterogeneity, and pooled odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 10 studies with a total of 510 patients were included. There was no significant difference in POPF between MICP and OCP (OR = 0.95; 95% CI [0.64, 1.43]; P = 0.82), whereas intraoperative blood loss (MD = - 125.13; 95% CI [- 194.77, -55.49]; P < 0.001) and length of hospital stay (MD = - 2.86; 95% CI [- 5.00, - 0.72]; P = 0.009) were in favor of MICP compared to OCP, and there was a strong trend toward a lower intraoperative transfusion rate in MICP than in OCP (MD = 0.34; 95% CI [0.11, 1.00]; P = 0.05). There was no significant difference in other outcomes between the two groups.

CONCLUSION

MICP was as safe and effective as OCP and had less intraoperative blood loss and a shorter length of hospital stay. However, further studies are needed to confirm the results.

Prophylactic abdominal drainage after distal pancreatectomy (PANDORINA): an international, multicentre, open-label, randomised controlled, non-inferiority trial

BACKGROUND

Prophylactic passive abdominal drainage is standard practice after distal pancreatectomy. This approach aims to mitigate the consequences of postoperative pancreatic fistula (POPF) but its added value, especially in patients at low risk of POPF, is currently being debated. We aimed to assess the non-inferiority of a no-drain policy in patients after distal pancreatectomy.

METHODS

In this international, multicentre, open-label, randomised controlled, non-inferiority trial, we recruited patients aged 18 years or older undergoing open or minimally invasive elective distal pancreatectomy for all indications in 12 centres in the Netherlands and Italy. We excluded patients with an American Society of Anesthesiology (ASA) physical status of 4-5 or WHO performance status of 3-4, added by amendment following the death of a patient with ASA 4 due to a pre-existing cardiac condition. Patients were randomly assigned (1:1) intraoperatively by permuted blocks (size four to eight) to either no drain or prophylactic passive drain placement, stratified by annual centre volume (<40 or ≥40 distal pancreatectomies) and low risk or high risk of grade B or C POPF. High-risk was defined as a pancreatic duct of more than 3 mm in diameter, a pancreatic thickness at the neck of more than 19 mm, or both, based on the Distal Pancreatectomy Fistula Risk Score. Other patients were considered low-risk. The primary outcome was the rate of major morbidity (Clavien-Dindo score ≥III), and the most relevant secondary outcome was grade B or C POPF, grading per the International Study Group for Pancreatic Surgery. Outcomes were assessed up to 90 days postoperatively and analysed in the intention-to-treat population and per-protocol population, which only included patients who received the allocated treatment. A prespecified non-inferiority margin of 8% was compared with the upper limit of the two-sided 95% CI (Wald) of unadjusted risk difference to assess non-inferiority. This trial is closed and registered in the Netherlands Trial Registry, NL9116.

FINDINGS

Between Oct 3, 2020, and April 28, 2023, 376 patients were screened for eligibility and 282 patients were randomly assigned to the no-drain group (n=138; 75 [54%] women and 63 [46%] men) or the drain group (n=144; 73 [51%] women and 71 [49%] men). Seven patients in the no-drain group received a drain intraoperatively; consequently, the per-protocol population included 131 patients in the no-drain group and 144 patients in the drain group. The rate of major morbidity was non-inferior in the no-drain group compared with the drain group in the intention-to-treat analysis (21 [15%] vs 29 [20%]; risk difference -4·9 percentage points [95% CI -13·8 to 4·0]; pnon-inferiority=0·0022) and the per-protocol analysis (21 [16%] vs 29 [20%]; risk difference -4·1 percentage points [-13·2 to 5·0]; pnon-inferiority=0·0045). Grade B or C POPF was observed in 16 (12%) patients in the no-drain group and in 39 (27%) patients in the drain group (risk difference -15·5 percentage points [95% CI -24·5 to -6·5]; pnon-inferiority<0·0001) in the intention-to-treat analysis. Three patients in the no-drain group died within 90 days; the cause of death in two was not considered related to the trial. The third death was a patient with an ASA score of 4 who died after sepsis and a watershed cerebral infarction at second admission, leading to multiple organ failure. No patients in the drain group died within 90 days.

INTERPRETATION

A no-drain policy is safe in terms of major morbidity and reduced the detection of grade B or C POPF, and should be the new standard approach in eligible patients undergoing distal pancreatectomy.

FUNDING

Ethicon UK (Johnson & Johnson Medical, Edinburgh, UK).

Early vs late drain removal after pancreatic resection-a systematic review and meta-analysis

BACKGROUND

Reducing clinically relevant post-operative pancreatic fistula (CR-POPF) incidence after pancreatic resections has been a topic of great academic interest. Optimizing post-operative drain management is a potential strategy in reducing this major complication.

METHODS

Studies involving pancreatic resections, including both pancreaticoduodenectomy (PD) and distal pancreatic resections (DP), with intra-operative drain placement were screened. Early drain removal was defined as removal before or on the 3rd post-operative day (POD) while late drain removal was defined as after the 3rd POD. The primary outcome was CR-POPF, International Study Group of Pancreatic Surgery (ISGPS) Grade B and above. Secondary outcomes were all complications, severe complications, post-operative haemorrhage, intra-abdominal infections, delayed gastric emptying, reoperation, length of stay, readmission, and mortality.

RESULTS

Nine studies met the inclusion criteria and were included for analysis. The studies had a total of 8574 patients, comprising 1946 in the early removal group and 6628 in the late removal group. Early drain removal was associated with a significantly lower risk of CR-POPF (OR: 0.24, p < 0.01). Significant reduction in risk of post-operative haemorrhage (OR: 0.55, p < 0.01), intra-abdominal infection (OR: 0.35, p < 0.01), re-admission (OR: 0.63, p < 0.01), re-operation (OR: 0.70, p = 0.03), presence of any complications (OR: 0.46, p < 0.01), and reduced length of stay (SMD: -0.75, p < 0.01) in the early removal group was also observed.

CONCLUSION

Early drain removal is associated with significant reductions in incidence of CR-POPF and other post-operative complications. Further prospective randomised trials in this area are recommended to validate these findings.

Pancreatic Fistulas: Current Evidence and Strategy-A Narrative Review

Pancreatic fistulas are highly feared complications following surgery on or near the pancreas, abdominal trauma, or severe inflammation. These fistulas arise from leaks in the pancreatic ductal system, leading to various complications such as abscesses, delayed gastric emptying, and hemorrhage. Severe cases present with sepsis or organ failure, dramatically increasing mortality and morbidity. Risk factors include smoking, high BMI, male gender, age, and surgery-related factors like prolonged operation time and non-ligation of the main pancreatic duct. Therefore, treatment options and preventive measurements have become a hot topic in recent years. Studies have investigated the use of fibrin sealants, different closure methods, and less invasive surgical techniques. Treatment options consist of conservative measurements and the use of percutaneous drainage, prophylactic transpapillary stenting, and surgery in severe cases. As EUS has become widely available, transmural stenting started to influence the management of pancreatic fluid collections (PFCs). However, studies on its use for the management of pancreatic fistulas are lacking. Medical treatment options like somatostatin analogs and pasireotide have been investigated but yielded mixed results.

Efficacy and safety of early drain removal following pancreatic resections: a meta-analysis

BACKGROUND

No consensus was reached with regard to the effect of EDR on postoperative outcomes after pancreatic surgery. The meta-analysis was designed to explore the efficacy and safety of early drain removal (EDR).

METHODS

Systematic literature search was performed. Data extraction and correction were performed by three researchers. For dichotomous and continuous outcomes, we calculated the pooled risk difference and mean difference with 95% confidence intervals, respectively. The heterogeneity of included studies was evaluated using Cochran's Q and I² test. The stratified analyses of pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) were performed.

RESULTS

A total of 10 studies including 3 RCTs and 7 non RCTs were included for meta-analysis, among which 1780 patients with EDR and 5613 patients with late drain removal (LDR) were enrolled. The meta-analysis of both all the available studies and studies only with selected low risk patients indicated that EDR group had significantly lower incidences of Grade B/C postoperative pancreatic fistula (POPF) and total complications for both PD and DP. However, no advantages of EDR were observed in the meta-analysis of the 3 RCTs. In addition, EDR was associated with a lower incidence of intra-abdominal infection after PD. While for DP, EDR group had decreased risk of delayed gastric emptying and re-operation, and shorter postoperative in-hospital stay.

CONCLUSIONS

The meta-analysis demonstrates that EDR is effective and safe for both PD and DP considering POPF and total complications, especially for patients with low concentration of postoperative drain fluid amylase.

Prospective cohort study on short-term outcomes of 3D-laparoscopic pancreaticoduodenectomy with stented pancreaticogastrostomy

BACKGROUND

Minimally invasive pancreaticoduodenectomy, either laparoscopic or robotic, is a high-risk procedure with demanding learning curve. The aim of this prospective cohort study was to evaluate short-term clinical and oncologic outcomes of 3D-laparoscopic pancreaticoduodenectomy (3dLPD) with stented pancreaticogastrostomy (sPG) and Roux-en-Y gastroenterostomy (ryGES).

METHODS

Between March 2016 and July 2021, 347 consecutive patients underwent 3dLPD for confirmed or suspected pancreatic or periampullary tumors. Pancreatic duct diameter measured 3 mm or less in 221 (64%) and pancreatic texture was soft in 191 (55%) patients. Simultaneous resection of the superior mesenteric or portal vein was performed in 52 (15%) patients.

RESULTS

Postoperative complications were observed in 189 (54%) patients, with severe complications (Clavien-Dindo grade > 2) in 68 (20%) including 4 (1.2%) deaths. Clinically relevant pancreatic fistula (cPOPF) occurred in 88 (25%), hemorrhage in 25 (7%), and bile leakage in 10 (3%) patients. Clinical pancreatic fistula was strongly associated with soft pancreatic texture and small pancreatic duct diameter (p < 0.001) and managed by endoscopic trans-gastric drainage in 34 (38.6%) patients, reoperation in 12 (13.6%), and ICU admission in 11 (12.5%). The remaining 31 (35%) patients with cPOPF were managed without invasive intervention. Median length of hospital stay after surgery was 13 (range 5-112; IQR 8-18) days. In pancreatic adenocarcinoma (PDAC) the R0-resection rate was 66/186 (36%), R1-indirect 95/186 (51%), and R1-direct 25 (13%). Median number of locoregional lymph nodes retrieved in PDAC was 21 (IQR 15-28). R0-resection rate for malignancy other than PDAC was 78/86 (91%) with a median of 16 (IQR 12-22) locoregional lymph nodes retrieved.

CONCLUSION

3dLPD with sPG and ryGES is associated with 1.2% mortality and 25% cPOPF. About two-third of patients with cPOPF were managed with some type of invasive intervention, whereas the intraoperatively placed drains sufficed in one-third of patients.

CLINICAL TRIAL REGISTRY

Clinicaltrials.gov NCT02671357.

Safety evaluation of early drain removal following pancreaticoduodenectomy: A single-center retrospective cohort study

Objectives

The effects of early drain removal (EDR) on postoperative complications after pancreaticoduodenectomy (PD) remains to be investigated. This single-center retrospective cohort study was designed to explore the safety of EDR after PD.

Methods

A total of 112 patients undergoing PD with drain fluid amylase (DFA) on postoperative day (POD) 1 and 3 <= 5000 were divided into EDR and late drain removal (LDR). Propensity Score Matching (PSM) was used. We compared postoperative outcomes between two groups and explore the risk factors of total complications using univariate and multiple logistic regression analyses.

Results

No statistical differences were found in primary outcomes, including Grade B/C postoperative pancreatic fistula (POPF) (Original cohort: 5.71% vs. 3.90%; P = 1.000; PSM cohort: 3.33% vs. 6.67%; P = 1.000), and total complications (Original cohort: 17.14% vs. 32.47%; P = 0.093; PSM cohort: 13.33% vs. 33.33%; P = 0.067). The EDR was associated with shorter in-hospital stay (Original cohort: 11 days vs. 15 days; P < 0.0001; PSM cohort: 11 days vs. 15 days; P < 0.0001).

Conclusions

EDR on POD 3 is safe for patients undergoing PD with low risk of POPF.

Optimal drain management following complicated laparoscopic cholecystectomy for acute cholecystitis: a propensity-matched comparative study

PURPOSE

This study was performed to investigate the effect of drain placement on complicated laparoscopic cholecystectomy (cLC) for acute cholecystitis (AC).

METHODS

This single-center retrospective study reviewed patients with AC who underwent cLC between January 2010 and December 2020. cLC was defined as open conversion, subtotal cholecystectomy, adjacent organ injury during surgery, operation time of ≥90 minutes, or estimated blood loss of ≥100 mL. One-to-one propensity score matching was performed to compare the surgical outcomes between patients with and without drain on cLC.

RESULTS

A total of 216 patients (mean age, 65.8 years; 75 female patients [34.7%]) underwent cLC, and 126 (58.3%) underwent intraoperative abdominal drainage. In the propensity score-matched cohort (61 patients in each group), early drain removal (≤postoperative day 3) was performed in 42 patients (68.9%). The overall rate of surgical site infection (SSI) was 10.7%. Late drain removal demonstrated significantly worse surgical outcomes than no drain placement and early drain removal for overall complications (13.1% vs. 21.4% vs. 47.4%, p = 0.006), postoperative hospital stay (3.8 days vs. 4.4 days vs. 12.7 days, p < 0.001), and SSI (4.9% vs. 11.9% vs. 31.6%, p = 0.006). In the multivariate analysis, late drain removal was the most significant risk factor for organ space SSI.

CONCLUSION

This study demonstrated that drain placement is not routinely recommended, even after cLC for AC. When placing a drain, early drain removal is recommended because late drain removal is associated with a higher risk of organ space SSI.

The Severity of Postoperative Pancreatic Fistula Predicts 30-Day Unplanned Hospital Visit and Readmission after Pancreaticoduodenectomy: A Single-Center Retrospective Cohort Study

BACKGROUND

Unplanned hospital visits (UHV) and readmissions after pancreaticoduodenectomy (PD) impact patients' postoperative recovery and are associated with increased financial burden and morbidity. The aim of this study is to identify predictive factors related to these events and target the potentially preventable UHV and readmissions.

METHODS

We enrolled 518 patients in this study. Characteristics were compared between patients with or without UHV and readmissions.

RESULTS

The unplanned visit and readmission rate was 23.4% and 15.8%, respectively. Postoperative pancreatic fistula (POPF) grade B or C, the presence of postoperative biliary drainage, and reoperation were found to be predictive factors for UHV, whereas POPF grade B or C and the presence of postoperative biliary drainage were independently associated with hospital readmission. The most common reason for readmission was an infection, followed by failure to thrive. The overall mortality rate in the readmission group was 4.9%.

CONCLUSIONS

UHV and readmissions remain common among patients undergoing PD. Patients with grade B or C POPF assessed during index hospitalization harbor an approximately two-fold increased risk of subsequent unplanned visits or readmissions compared to those with no POPF or biochemical leak. Proper preventive strategies should be adopted for high-risk patients in this population to maintain the continuum of healthcare and improve quality.

Prophylactic abdominal drainage for pancreatic surgery

BACKGROUND

The use of surgical drains is a very common practice after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications after pancreatic surgery is controversial. This is the third update of a previously published Cochrane Review to address the uncertain benifits of prophylactic abdominal drainage in pancreatic surgery.

OBJECTIVES

To assess the benefits and harms of routine abdominal drainage after pancreatic surgery, compare the effects of different types of surgical drains, and evaluate the optimal time for drain removal.

SEARCH METHODS

In this updated review, we re-searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, and the Chinese Biomedical Literature Database (CBM) on 08 February 2021.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared abdominal drainage versus no drainage in people undergoing pancreatic surgery. We also included RCTs that compared different types of drains and different schedules for drain removal in people undergoing pancreatic surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We conducted the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) or standardized mean difference (SMD) for continuous outcomes with 95% confidence intervals (CI). For all analyses, we used the random-effects model. We used GRADE to assess the certainty of the evidence for important outcomes.

MAIN RESULTS

We identified a total of nine RCTs with 1892 participants. Drain use versus no drain use We included four RCTs with 1110 participants, randomised to the drainage group (N = 560) and the no drainage group (N = 550) after pancreatic surgery. Low-certainty evidence suggests that drain use may reduce 90-day mortality (RR 0.23, 95% CI 0.06 to 0.90; two studies, 478 participants). Compared with no drain use, low-certainty evidence suggests that drain use may result in little to no difference in 30-day mortality (RR 0.78, 95% CI 0.31 to 1.99; four studies, 1055 participants), wound infection rate (RR 0.98, 95% CI 0.68 to 1.41; four studies, 1055 participants), length of hospital stay (MD -0.14 days, 95% CI -0.79 to 0.51; three studies, 876 participants), the need for additional open procedures for postoperative complications (RR 1.33, 95% CI 0.79 to 2.23; four studies, 1055 participants), and quality of life (105 points versus 104 points; measured with the pancreas-specific quality of life questionnaire (scale 0 to 144, higher values indicating a better quality of life); one study, 399 participants). There was one drain-related complication in the drainage group (0.2%). Moderate-certainty evidence suggests that drain use probably resulted in little to no difference in morbidity (RR 1.03, 95% CI 0.94 to 1.13; four studies, 1055 participants). The evidence was very uncertain about the effect of drain use on intra-abdominal infection rate (RR 0.97, 95% CI 0.52 to 1.80; four studies, 1055 participants; very low-certainty evidence), and the need for additional radiological interventions for postoperative complications (RR 0.87, 95% CI 0.40 to 1.87; three studies, 660 participants; very low-certainty evidence). Active versus passive drain We included two RCTs involving 383 participants, randomised to the active drain group (N = 194) and the passive drain group (N = 189) after pancreatic surgery. Compared with a passive drain, the evidence was very uncertain about the effect of an active drain on 30-day mortality (RR 1.23, 95% CI 0.30 to 5.06; two studies, 382 participants; very low-certainty evidence), intra-abdominal infection rate (RR 0.87, 95% CI 0.21 to 3.66; two studies, 321 participants; very low-certainty evidence), wound infection rate (RR 0.92, 95% CI 0.44 to 1.90; two studies, 321 participants; very low-certainty evidence), morbidity (RR 0.97, 95% CI 0.53 to 1.77; two studies, 382 participants; very low-certainty evidence), length of hospital stay (MD -0.79 days, 95% CI -2.63 to 1.04; two studies, 321 participants; very low-certainty evidence), and the need for additional open procedures for postoperative complications (RR 0.44, 95% CI 0.11 to 1.83; two studies, 321 participants; very low-certainty evidence). There was no drain-related complication in either group. Early versus late drain removal We included three RCTs involving 399 participants with a low risk of postoperative pancreatic fistula, randomised to the early drain removal group (N = 200) and the late drain removal group (N = 199) after pancreatic surgery. Compared to late drain removal, the evidence was very uncertain about the effect of early drain removal on 30-day mortality (RR 0.99, 95% CI 0.06 to 15.45; three studies, 399 participants; very low-certainty evidence), wound infection rate (RR 1.32, 95% CI 0.45 to 3.85; two studies, 285 participants; very low-certainty evidence), hospital costs (SMD -0.22, 95% CI -0.59 to 0.14; two studies, 258 participants; very low-certainty evidence), the need for additional open procedures for postoperative complications (RR 0.77, 95% CI 0.28 to 2.10; three studies, 399 participants; very low-certainty evidence), and the need for additional radiological procedures for postoperative complications (RR 1.00, 95% CI 0.21 to 4.79; one study, 144 participants; very low-certainty evidence). We found that early drain removal may reduce intra-abdominal infection rate (RR 0.44, 95% CI 0.22 to 0.89; two studies, 285 participants; very low-certainty evidence), morbidity (RR 0.49, 95% CI 0.30 to 0.81; two studies, 258 participants; very low-certainty evidence), and length of hospital stay (MD -2.20 days, 95% CI -3.52 to -0.87; three studies, 399 participants; very low-certainty evidence), but the evidence was very uncertain. None of the studies reported on drain-related complications.

AUTHORS' CONCLUSIONS

Compared with no drain use, it is unclear whether routine drain use has any effect on mortality at 30 days or postoperative complications after pancreatic surgery. Compared with no drain use, low-certainty evidence suggests that routine drain use may reduce mortality at 90 days. Compared with a passive drain, the evidence is very uncertain about the effect of an active drain on mortality at 30 days or postoperative complications. Compared with late drain removal, early drain removal may reduce intra-abdominal infection rate, morbidity, and length of hospital stay for people with low risk of postoperative pancreatic fistula, but the evidence is very uncertain.

Prophylactic Intra-Peritoneal Drainage After Pancreatic Resection: An Updated Meta-Analysis

Introduction

Prophylactic intra-peritoneal drainage has been considered to be an effective measure to reduce postoperative complications after pancreatectomy. However, routinely placed drainage during abdominal surgery may be unnecessary or even harmful to some patients, due to the possibility of increasing complications. And there is still controversy about the prophylactic intra-peritoneal drainage after pancreatectomy. This meta-analysis aimed to analyze the incidence of complications after either pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) in the drain group and no-drain group.

Methods

Data were retrieved from four electronic databases PubMed, EMBASE, the Cochrane Library and Web of Science up to December 2020, including the outcomes of individual treatment after PD and DP, mortality, morbidity, clinically relevant postoperative pancreatic fistula (CR-POPF), bile leak, wound infection, postoperative hemorrhage, delayed gastric emptying (DGE), intra-abdominal abscess, reoperation, intervened radiology (IR), and readmission. Cochrane Collaboration Handbook and the criteria of the Newcastle-Ottawa scale were used to assess the quality of studies included.

Results

We included 15 studies after strict screening. 13 studies with 16,648 patients were analyzed to assess the effect of drain placement on patients with different surgery procedures, and 4 studies with 6,990 patients were analyzed to assess the effect of drain placement on patients with different fistula risk. For patients undergoing PD, the drain group had lower mortality but higher rate of CR-POPF than the no-drain group. For patients undergoing DP, the drain group had higher rates of CR-POPF, wound infection and readmission. There were no significant differences in bile leak, hemorrhage, DGE, intra-abdominal abscess, and IR in either overall or each subgroup. For Low-risk subgroup, the rates of hemorrhage, DGE and morbidity were higher after drainage. For High-risk subgroup, the rate of hemorrhage was higher while the rates of reoperation and morbidity were lower in the drain group.

Conclusions

Intraperitoneal drainage may benefit some patients undergoing PD, especially those with high pancreatic fistula risk. For DP, current evidences suggest that routine drainage might not benefit patients, but no clear conclusions can be drawn because of the study limitations.

Evidence-based evaluation of abdominal drainage in pancreatic surgery

Pancreatic fistula is the most common and dreaded complication after pancreatic resection, responsible for high morbidity and mortality (2 to 30%). Prophylactic drainage of the operative site is usually put in place to decrease and/or detect postoperative pancreatic fistula (POPF) early. However, this policy is currently debated and the data from the literature are unclear. The goal of this update is to analyze the most recent evidence-based data with regard to prophylactic abdominal drainage after pancreatic resection (pancreatoduodenectomy [PD] or distal pancreatectomy [PD]). This systematic review of the literature between 1990 and 2020 sought to answer the following questions: should drainage of the operative site after pancreatectomy be routine or adapted to the risk of POPF? If a drainage is used, how long should it remain in the abdomen, what criteria should be used to decide to remove it, and what type of drainage should be preferred? Has the introduction of laparoscopy changed our practice? The literature seems to indicate that it is not possible to recommend the omission of routine drainage after pancreatic resection. By contrast, an approach based on the risk of POPF using the fistula risk score seems beneficial. When a drain is placed, early removal (within 5 days) seems feasible based on clinical, laboratory (C-reactive protein, leukocyte count, neutrophile/lymphocyte ratio, dosage and dynamic of amylase in the drains on D1, D3±D5) and radiological findings. This is in line with the development of enhanced recovery programs after pancreatic surgery. Finally, this literature review did not find any specific data relative to mini-invasive pancreatic surgery.