Do Drains Contribute to Pancreatic Fistulae? Analysis of over 5000 Pancreatectomy Patients

Active Intra-Abdominal Drainage Following Abdominal Digestive System Surgery: A Meta-Analysis and Systematic Review

BACKGROUND

Our objective is to compare the early outcomes associated with passive (gravity) drainage (PG) and active drainage (AD) after surgery.

METHODS

Studies published until April 28, 2022 were retrieved from the PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Web of Science databases.

RESULTS

Nine studies with 14,169 patients were identified. Two groups had the same intra-abdominal infection rate (RR: 0.55; P = 0.13); In subgroup analysis of pancreaticoduodenectomy, active drainage had no significant effect on postoperative pancreatic fistula (POPF) rate (RR: 1.21; P = 0.26) and clinically relevant POPF (CR-POPF) (RR: 1.05; P = 0.72); Active drainage was not associated with lower percutaneous drainage rate (RR: 1.00; P = 0.96), incidence of sepsis (RR: 1.00; P = 0.99) and overall morbidity (RR: 1.02; P = 0.73). Both groups had the same POPF rate (RR: 1.20; P = 0.18) and CR-POPF rate (RR: 1.20; P = 0.18) after distal pancreatectomy. There was no difference between two groups on the day of drain removal after pancreaticoduodenectomy (Mean difference: -0.16; P = 0.81) and liver surgery (Mean difference: 0.03; P = 0.99).

CONCLUSIONS

Active drainage is not superior to passive drainage and both drainage methods can be considered.

Drain Placement After Pancreatic Resection: Friend or Foe For Surgical Site Infections?

BACKGROUND

Despite multiple studies and randomized trials, there remains controversy over whether drains should be placed, and if so for how long, after pancreas resection. The aim was to determine if post-pancreatectomy drain placement and timing of drain removal were associated with differences in infectious outcomes and, if so, which specific procedures and infectious sites were most at risk.

METHODS

The ACS-NSQIP targeted pancreatectomy database was utilized to identify patients who underwent pancreatectomies between 2015 and 2020 with postoperative drain placement for retrospective cohort analysis. A propensity score matching analyses was conducted to determine associations between drain placement and surgical site infections (SSI).

RESULTS

Of 39,057 pancreatic resections, 66.4% were proximal pancreatectomies, and 33.6% were distal pancreatectomies. After propensity score matching, drain placement was not associated with significantly lower rates of superficial SSI (7% vs 9%, p = 0.755) or organ/space SSI (17% vs 16%, p = 0.647) after proximal pancreatectomy. After distal pancreatectomy, drain placement was associated with higher rates of organ/space SSI (12% vs 9%, p = 0.010). Drain removal on or after postoperative day 3 was significantly associated with higher rates of SSI in both proximal and distal pancreatectomy.

CONCLUSIONS

Drain placement is associated with an increased rate of organ/space SSI after distal pancreatectomy and not after pancreaticoduodenectomy. When drains are utilized, early removal is associated with a reduction of SSI after all types of pancreatectomy. In surgical units where post-pancreatectomy SSI is a concern, selective drain placement for high-risk glands or after distal pancreatectomy, combined with early drain removal, may be considered.

Prevention and Treatment of Grade C Postoperative Pancreatic Fistula

Postoperative pancreatic fistula (POPF) is a troublesome complication after pancreatic surgeries, and grade C POPF is the most serious situation among pancreatic fistulas. At present, the incidence of grade C POPF varies from less than 1% to greater than 9%, with an extremely high postoperative mortality rate of 25.7%. The patients with grade C POPF finally undergo surgery with a poor prognosis after various failed conservative treatments. Although various surgical and perioperative attempts have been made to reduce the incidence of grade C POPF, the rates of this costly complication have not been significantly diminished. Hearteningly, several related studies have found that intra-abdominal infection from intestinal flora could promote the development of grade C POPF, which would help physicians to better prevent this complication. In this review, we briefly introduced the definition and relevant risk factors for grade C POPF. Moreover, this review discusses the two main pathways, direct intestinal juice spillover and bacterial translocation, by which intestinal microbes enter the abdominal cavity. Based on the abovementioned theory, we summarize the operation techniques and perioperative management of grade C POPF and discuss novel methods and surgical treatments to reverse this dilemma.

Should Drains Suck? A Propensity Score Analysis of Closed-Suction Versus Closed-Gravity Drainage After Pancreatectomy

BACKGROUND

Post-operative pancreatic fistula (POPF) remains one of the most common complications after pancreatic surgery. We previously reported that the majority of US surgeons leave drains after pancreatectomy. However, there remains controversy and surgeon bias on the use of gravity compared with suction drainage with limited data on patient outcomes to guide management.

METHODS

Demographics, comorbidities, perioperative, and outcome data were captured from the most recent ACS National Surgical Quality Improvement Program (NSQIP)-targeted pancreatectomy databases. This is a retrospective cohort analysis comparing closed-suction to closed-gravity drains with multivariate analysis and propensity score matching (PSM).

RESULTS

Of 9232 patients that underwent a pancreatectomy with closed drain placement, 1345 (15%) were to gravity and 7887 (85%) were to suction. On multivariate and PSM, stratified by surgery-type, there was no difference in biochemical leak (Whipple, 4 vs. 4%; distal, 8 vs. 6%) or clinically relevant (CR)-POPF (Whipple, 13 vs. 15%; distal, 12 vs. 15%). On multivariate analysis, there was an increase in organ-space surgical site infections with suction drains for patients undergoing Whipple procedure (12 vs. 16%, p = 0.004), which did not persist on PSM (p = 0.088). Finally, there were no significant differences in amylase level, time to drain removal, or superficial surgical site infections for patients undergoing either procedure based on drain type.

CONCLUSION

The majority of drains utilized after pancreatectomy in the USA are placed to suction, though a significant proportion are kept to gravity. Neither type of drain is associated with increased CR-POPF or other post-operative outcomes compared with the other; therefore, both types remain reasonable options if drains are to be placed.

Association of gravity drainage and complications following Whipple: an analysis of the ACS-NSQIP targeted database

Background

The optimal type of operative drainage following pancreaticoduodenectomy (PD) remains unclear. Our objective is to investigate risk associated with closed drainage techniques (passive [gravity] vs. suction) after PD.

Methods

We assessed operative drainage techniques utilized in patients undergoing PD in the ACS-NSQIP pancreas-targeted database from 2016 to 2018. Using multivariable logistic regression to adjust for characteristics of the patient, procedure, and pancreas, we examined the association between use of gravity drainage and postoperative outcomes.

Results

We identified 9665 patients with drains following PD from 2016 to 2018, of which 12.7% received gravity drainage. 61.0% had a diagnosis of adenocarcinoma or pancreatitis, 26.5% had a duct <3 mm, and 43.5% had a soft or intermediate gland. After multivariable adjustment, gravity drainage was associated with decreased rates of postoperative pancreatic fistula (odds ratio [OR] 0.779, 95% confidence interval [CI] 0.653–0.930, p=0.006), delayed gastric emptying (OR 0.830, 95% CI 0.693–0.988, p=0.036), superficial SSI (OR 0.741, 95% CI 0.572–0.959, p=0.023), organ space SSI (OR 0.791, 95% CI 0.658–0.951, p=0.012), and readmission (OR 0.807, 95% CI 0.679–0.958, p=0.014) following PD.

Conclusions

Gravity drainage is independently associated with decreased rates of CR-POPF, DGE, SSI, and readmission following PD. Additional prospective research is necessary to better understand the preferred drainage technique following PD.

Drain Contamination after Distal Pancreatectomy: Incidence, Risk Factors, and Association with Postoperative Pancreatic Fistula

OBJECTIVE

Distal pancreatectomy (DP) remains associated with significant morbidity, but little data is available about the clinical significance of drain contamination. We explored the incidence, risk factors, and association with surgical outcomes of positive drainage culture (PDC) after DP. In addition, the predictive capacity of early PDC for postoperative pancreatic fistula (POPF) was evaluated.

METHODS

We retrospectively analyzed our prospectively collected database of patients who underwent DP between January 2005 and December 2015. Surveillance drainage cultures for microorganisms were conducted until drain removal or positive culture. The relationships between clinical variables and PDC were examined.

RESULTS

Of 480 consecutive cases who underwent DP, 176 (36.7%) had PDC. One hundred twelve patients (23.3%) developed POPF according to the 2016 ISGPS definition, with the 90-day mortality rate of 0.2%. Staphylococcus spp. was the most frequent isolate. Thirty-eight (21.6%) patients had PDC within 3 days after surgery, and 129 (73.3%) within the first 7 days of operation. Body mass index (BMI) ≥ 25 kg/m² and massive intraoperative blood loss were independent predictors for PDC. PDC had a negative impact on surgical outcomes, including POPF. Early PDC was identified as a newly independent risk factor for POPF. Compared with other microorganisms, those contaminated with Staphylococcus and Klebsiella had higher incidences of POPF.

CONCLUSIONS

PDC occurs commonly after DP and plays a critical role in the development of surgical morbidities including POPF. Extreme caution is warranted in patients involving contamination with specific types of microorganisms.

Magnetic compression anastomosis for biliojejunostomy and pancreaticojejunostomy in Whipple's procedure: An initial clinical study

BACKGROUND AND AIM

Magnetic anastomosis has been attempted in biliary and intestinal reconstruction. The objective of the current study was to introduce an initial clinical use of magnetic compression anastomosis for pancreaticojejunostomy and biliojejunostomy in Whipple's procedure.

METHODS

Patients with peri-ampullary carcinoma and dilated bile and pancreatic ducts were prospectively enrolled from 2016 to 2017. After pancreaticoduodenectomy, an appropriate mother magnet and drainage tube was placed in the proximal bile duct and pancreatic duct. The daughter magnets were introduced to mate with the mother magnets at the anastomotic sites. A close postoperative surveillance and routine cholangiopancreaticography via the drainage tube were performed.

RESULTS

One female and three male patients with a median age of 69 years (range, 57-77) were included. The diameter of the common bile ducts and pancreatic ducts ranged from 8 to 15 mm, and 7 to 10 mm, respectively. The median time duration for biliojejunostomy and pancreaticojejunostomy was 7 (range, 5-8 min) min and 9 (range, 8-10 min) min, respectively. The median time of biliojejunostomy and pancreaticojejunostomy formation was 17 (range, 15-21 days) days and 11 (range, 10-18 days), respectively. With a median follow up of 313 days, one patient developed biliary anastomotic stricture at 11 months after surgery, and underwent stent placement via percutaneous transhepatic drainage sinus, and recovered well.

CONCLUSIONS

Magnetic anastomosis is safe, effective, and simple for both biliojejunostomy and pancreaticojejunostomy in Whipple's procedure.

Population-Based Assessment of Selective Drain Placement During Pancreatoduodenectomy Using the Modified Fistula Risk Score

BACKGROUND

Recent studies on postoperative pancreatic fistula (POPF) prevention suggest that omission of perioperative drains is safe for negligible- or low-risk patients undergoing pancreatoduodenectomy (PD). However, this proposed pathway has not been validated in a nationwide cohort.

STUDY DESIGN

The ACS-NSQIP-targeted pancreatectomy database from 2014 to 2016 was queried to identify patients who underwent PD. Using a previously validated modified Fistula Risk Score (mFRS), patients were stratified as negligible/low- or intermediate/high-risk. Multivariate regression models were used to analyze the effect of intraoperative drain placement on relevant perioperative outcomes in both high- and low-risk patients.

RESULTS

Among 6,730 patients undergoing PD, 3,375 (50%) were high-risk; 3,355 (50%) were low-risk. Among high-risk patients, drain placement (n = 3,093, 92%) was associated with a higher rate of POPF (26% vs 16%, p = 0.0003), clinically relevant (CR) POPF (20% vs 12%, p = 0.0015), and extended hospital length of stay (LOS, 9 vs 7 days, p < 0.0001), but decreased serious morbidity (29% vs 35%, p = 0.0330). Similarly, drain placement in low-risk patients (n = 2,785, 83%) was associated with a higher rate of POPF (11% vs 6%, p = 0.0006) and extended LOS (8 vs 7 days, p < 0.0001), yet lower serious morbidity (18% vs 23%, p = 0.0037). On multivariate logistic regression, drain placement was associated with significantly increased odds of CR-POPF and a significantly reduced incidence of serious morbidity among both high-risk (odds ratio [OR] 0.72, 95% CI 0.55 to 0.94, p = 0.0155) and low-risk patients (OR 0.71, 95% CI 0.57 to 0.89, p = 0.0027).

CONCLUSIONS

In this population-based cohort, the mFRS was unable to stratify patients relative to the need for selective drain placement during PD. For both high- and low-risk patients, perioperative drain placement was associated with increased rates of POPF, CR-POPF, and extended LOS, but decreased incidence of serious morbidity.