Operative drainage following pancreatic resection: analysis of 1122 patients resected over 5 years at a single institution

Evidence-based approach for intraabdominal drainage in pancreatic surgery: A systematic review and meta-analysis

BACKGROUND

Historically intraoperative drains were employed after pancreatic surgery but over the last decade, there has been debate over the routine usage of drains.

AIM

To assess the necessity of intra-abdominal drain placement, identify the most effective drain type, and determine the optimal timing for drain removal.

METHODS

A systematic review of electronic databases, including PubMed, MEDLINE, PubMed Central, and Google Scholar, was conducted using Medical Subject Headings and keywords until December 2023. From an initial pool of 1910 articles, 48 were included after exclusion and screening. The primary outcomes analyzed were clinically relevant postoperative pancreatic fistula (CR-POPF), delayed gastric emptying (DGE), overall morbidity, and mortality. Subgroup analyses were performed for pancreaticoduodenectomy and distal pancreatectomy.

RESULTS

Routine use of drains is associated with a statistically significant increase in the risk of CR-POPF and DGE. Conversely, patients who did not have drains placed experienced a significant reduction in morbidity, readmission rates, and reoperations. No significant differences were observed between active and passive drain types. Early drain removal (< 3 days) yielded favorable outcomes compared to delayed removal.

CONCLUSION

Analysis of randomized controlled trials and cohort studies did not demonstrate an advantage of routine drain placement following pancreatic resection, potentially contributing to increased morbidity and mortality. The decision to use drains should be left to the discretion of the operating surgeon. However, early drain removal can substantially reduce morbidity.

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.

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".

A systematic review and meta-analysis of morbidity and pancreatic fistula after distal pancreatectomy with versus without prophylactic intra-abdominal drainage

BACKGROUND

The omission of a prophylactic intra-abdominal drainage has been under debate in pancreatic surgery due to the high-risk of complications and especially of postoperative pancreatic fistula (POPF). Recently, the second randomized controlled trial (RCT) and two propensity score-matched comparative studies assessing risks and benefits of a no-drainage policy versus prophylactic drainage after distal pancreatectomy (DP) have been published. This systematic review with meta-analysis provides an updated summary of the available evidence on this topic.

METHODS

RCTs and nonrandomized comparative studies (NCS) investigating outcomes of no drainage versus drainage after DP were searched systematically in MEDLINE, Embase, and CENTRAL. Random effects meta-analyses were performed, and the results presented as weighted odds ratios (OR) or mean differences with their corresponding 95% CI. Subgroup analyses were performed to account for interstudy heterogeneity between RCTs and NCS.

RESULTS

Two RCTs and six NCS with a total of 3610 patients undergoing DP were included of whom 1038 (28.8%) patients did not receive prophylactic drainage. A no-drainage policy was associated with significantly lower risks of POPF (OR 0.38, 95% CI: 0.25-0.56; P <0.00001), reduced major morbidity (OR 0.64, 95% CI: 0.47-0.89; P =0.008), less reinterventions (OR 0.70, 95% CI: 0.52-0.95; P =0.02), and fewer readmissions (OR 0.69, 95% CI: 0.54-0.88; P =0.003) as well as shorter length of hospital stay (mean differences -1.74, 95% CI: -2.70 to -0.78; P =0.0004). Subgroup analyses including only RCTs confirmed benefits of the no-drainage policy.

CONCLUSION

A no-drainage policy is associated with reduced POPF and morbidity and can therefore be recommended as standard procedure in patients undergoing DP.

Updates in the management of postoperative pancreatic fistula

Postoperative pancreatic fistula (POPF) remains a common and dreaded complication after pancreatic resections and is associated with increased morbidity and mortality. Over the years, several different strategies have been investigated to prevent and mitigate POPF. However, when a POPF occurs, a consensus on the optimal management strategy of grade B and grade C POPF is still lacking, and the current management strategy is often based on local expertise and driven by patient's condition. Nevertheless, whereas the incidence of POPF after pancreatic surgery has remained stable, the overall mortality related to this complication has decreased over the years. This reflects an improvement in the management of this complication, which has become increasingly conservative. The aim of this review is to provide an updated evidence-based overview on the management strategies of POPF for surgeons and physicians in the clinical practice.

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.

Predictors of non-home discharge after pancreatoduodenectomy in patients aged 80 years and above

BACKGROUND

Pancreatic cancer has the highest growth in incidence among patients aged ≥80 years. Discharge destination after hospitalization is increasingly recognized as a marker of return to baseline functional status. Our aim was to identify the preoperative and intraoperative predictors of non-home discharge in those aged 80 or older.

METHODS

The ACS-NSQIP pancreas-targeted database was queried to identify patients aged ≥80 years who underwent pancreatoduodenectomy (PD) from 2014 to 2020. Home discharge (HD) versus non-HD cohorts were compared using univariate logistic regression. Multivariable logistic regression was used to identify predictors of non-HD.

RESULTS

Non-HD was over twice as likely to occur in patients aged ≥80 years than in those aged 65-79 years (p < 0.01). Comorbidity factors significantly associated with non-HD in patients aged ≥80 years included COPD, hypertension, HF, lower preoperative albumin, but not obesity. Non-comorbidity factors included older age, female gender, ASA III-IV, preoperative dependent functional status, and transfer origin before PD.

CONCLUSION

Individuals ≥80 years have possibly delayed or lower rate of return to baseline functional status following PD compared to those aged 65-79 years. Predictors of non-HD can be identified to facilitate preoperative counseling and discharge planning, thus enhancing care workflow efficiency.

Effect of passive versus active abdominal drainage on wound infection after pancreatectomy: A meta-analysis

Following pancreatic resection, there may be a variety of complications, including wound infection, haemorrhage, and abdominal infection. The placement of drainage channels during operation may decrease the chances of postoperative complications. However, what kind of drainage can decrease the rate of postoperative complications is still a matter of debate. The purpose of this research is to evaluate the efficacy of both active and passive drainage for post-operation wound complications. From the beginning of the database until November 2023, EMBASE, the Cochrane Library and the Pubmed database have been searched. The two authors collected 2524 related studies from 3 data bases for importation into Endnote software, and 8 finished trials were screened against the exclusion criteria. Passive drainage can decrease the incidence of superficial wound infection in postoperative patients with pancreas operation (Odds Ratio [OR], 1.30; 95% CI, 1.06-1.60 p = 0.01); No statistically significant difference was found in the incidence of deep infections among the two groups (OR, 1.51; 95% CI, 0.68-3.36 p = 0.31); No statistical significance was found for the rate of haemorrhage after active drainage on the pancreas compared with that of passive drainage (OR, 0.72; 95% CI, 0.29-1.77 p = 0.47); No statistically significant difference was found in the rate of death after operation for patients who had received a pancreas operation in active or passive drainage (OR, 0.90; 95% CI, 0.57-1.42 p = 0.65); On the basis of existing evidence, the use of passive abdominal drainage reduces postoperative surface wound infections in patients. But there were no statistically significant differences in the risk of severe complications, haemorrhage after surgery, or mortality. However, because of the limited sample size of this meta-analysis, it is necessary to have more high-quality research with a large sample size to confirm the findings.

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.

Initial suction drainage decreases severe postoperative complications after pancreatic trauma: A cohort study

BACKGROUND

Few studies have addressed the question of which drain types are more beneficial for patients with pancreatic trauma (PT).

AIM

To investigate whether sustained low negative pressure irrigation (NPI) suction drainage is superior to closed passive gravity (PG) drainage in PT patients.

METHODS

PT patients who underwent pancreatic surgery were enrolled consecutively at a referral trauma center from January 2009 to October 2021. The primary outcome was defined as the occurrence of severe complications (Clavien-Dindo grade ≥ Ⅲb). Multivariable logistic regression was used to model the primary outcome, and propensity score matching (PSM) was included in the regression-based sensitivity analysis.

RESULTS

In this study, 146 patients underwent initial PG drainage, and 50 underwent initial NPI suction drainage. In the entire cohort, a multivariable logistic regression model showed that the adjusted risk for severe complications was decreased with NPI suction drainage [14/50 (28.0%) vs 66/146 (45.2%); odds ratio (OR), 0.437; 95% confidence interval (CI): 0.203-0.940]. After 1:1 PSM, 44 matched pairs were identified. The proportion of each operative procedure performed for pancreatic injury-related and other intra-abdominal organ injury-related cases was comparable in the matched cohort. NPI suction drainage still showed a lower risk for severe complications [11/44 (25.0%) vs 21/44 (47.7%); OR, 0.365; 95%CI: 0.148-0.901]. A forest plot revealed that NPI suction drainage was associated with a lower risk of Clavien-Dindo severity in most subgroups.

CONCLUSION

This study, based on one of the largest PT populations in a single high-volume center, revealed that initial NPI suction drainage could be recommended as a safe and effective alternative for managing complex PT patients.

Serum amylase on postoperative day one is a strong predictor of pancreatic fistula after pancreaticoduodenectomy: a retrospective cohort

Background/aim

Early identification of patients at risk for developing postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) may facilitate drain management. In this context, it was aimed to examine the efficiency of the serum amylase (SA) value on postoperative day (PoD) 1 in predicting the occurrence of POPF.

Materials and methods

A total of 132 patients who underwent PD were studied. Occurrences of POPF were classified according to the International Study Group on Pancreatic Fistula classification as a biochemical leak (BL) or clinically relevant grade b/c POPF (CR-POPF). Receiver operating characteristic analysis identified a threshold value of SA on PoD 1 associated with POPF formation.

Results

Overall, 66 (50%) patients had POPF, including 51 (38.7%) with BL and 15 with CR-POPF (11.3%). The threshold value of SA associated with the development of POPF was 120 IU/L (odds ratio [OR]: 3.20; p = 0.002). In the multivariate analysis, independent POPF risk factors were SA ≥120 IU/L, soft pancreatic texture, and high-risk pathology (i.e., duodenal, biliary, ampullary, islet cell, and benign tumors); SA ≥120 IU/L outperformed soft pancreatic texture and high-risk pathology in predicting POPF, respectively (OR: 2.22; p = 0.004 vs. OR: 1.37; p = 0.012 vs. OR: 1.35; p = 0.018). In a subset analysis according to gland texture (soft vs. hard), patients with soft pancreatic texture exhibited a significantly higher incidence of POPF (63.4% vs. 34.4%) and SA ≥120 IU/L (52.1% vs. 27.9%); SA <120 IU/L had a negative predictive value of 82.5% for developing POPF in patients with hard pancreatic texture (OR: 4.28, p = 0.028).

Conclusion

A SA value ≥120 IU/L on the day after PD, which is the strongest predictor for POPF, can be used as a biomarker of the occurrence of POPF. The advantage of SA measurement is that it can contribute to identifying suitable patients for early drain removal.

Evaluation of the Value of Intraoperative Peri-Pancreatic Fluid Amylase Concentration in Predicting a Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is a common complication after pancreaticoduodenectomy (PD) and is a cause of significant morbidity and mortality. This study aimed to assess the predictive value of the amylase concentration of fluid accumulating in the peri-pancreatic region intraoperatively or intraoperative amylase concentration (IOAC) for the development of a clinically relevant POPF after PD.

METHODS

All consecutive patients who underwent PD between April 2018 and May 2021 were prospectively included in the study. IOAC and postoperative day-three drain fluid amylase values were measured, and the incidence of clinically relevant POPF (CR-POPF) was noted. Receiver operating characteristic analysis was used to evaluate the predictive capacity of the IOAC for a CR-POPF.

RESULTS

The study included 64 patients. A clinically relevant POPF was seen in 12 (18.8%) patients. On ROC analysis, the area under the curve (AUC) was 0.912 (with 95% CI of 0.822-1.001, p<0.001), which is highly significant. A cut-off IOAC value of 236 IU/L was derived, and an IOAC above this value was shown to predict the development of a CR-POPF in the postoperative period with a sensitivity of 91.7%. The highest positive predictive value (87.5%) was obtained with a cut-off of 772 IU/L.

CONCLUSION

An IOAC is an early, simple, and sensitive predictor for the development of a clinically relevant POPF after PD and can potentially aid in managing the resulting morbidity with intraoperative and postoperative measures.

Differential Gains in Surgical Outcomes for High-Risk vs Low-Risk Pancreaticoduodenectomy with Successive Refinements of Risk-Stratified Care Pathways

BACKGROUND

The use of risk-stratified pancreatectomy care pathways (RSPCPs) is associated with reduced length of stay (LOS). This study sought to evaluate the impact of successive pathway revisions with the hypothesis that high-risk patients require iterative pathway revisions to optimize outcomes.

STUDY DESIGN

A prospectively maintained database (October 2016 to December 2021) was evaluated for pancreaticoduodenectomy patients managed with RSPCPs preoperatively assigned based on postoperative pancreatic fistula (POPF) risk. Launched in October 2016 (version [V] 1), RSPCPs were optimized in February 2019 (V2) and November 2020 (V3). Targeted pathway components included earlier nasogastric tube removal, diet advancement, reduced intravenous fluids and opioids, institution-specific drain fluid amylase cutoffs for early day 3 removal, and patient education. Primary outcome was LOS. Secondary outcomes included major complication (Accordion grade 3+), POPF (International Study Group for Pancreatic Surgery Grade B/C), and delayed gastric emptying (DGE).

RESULTS

Of 481 patients, 234 were managed by V1 (83 high-risk), 141 by V2 (43 high-risk), and 106 by V3 (43 high-risk). Median LOS reduction was greatest in high-risk patients with a 7-day reduction (pre-RSPCP, 12 days; V1, 9 days; V2, 7 days; V3, 5 days), compared with low-risk patients (pre-pathway, 10 days; V1, 6 days; V2, 5 days; V3, 4 days). Complications decreased significantly among high-risk patients (V1, 45%; V2, 33%; V3, 19%; p < 0.001), approaching rates in low-risk patients (V1, 21%; V2, 20%; V3, 14%). POPF (V1, 33%; V2, 23%; V3, 16%; p < 0.001) and DGE (V1, 23%; V2, 22%; V3, 14%; p < 0.001) improved among high-risk patients.

CONCLUSIONS

Risk-stratified pancreatectomy care pathways are associated with reduced LOS, major complication, Grade B/C fistula, and DGE. The easiest gains in surgical outcomes are generated from the immediate improvement in the patients most likely to be fast-tracked, but high-risk patients benefit from successive application of the learning health system model.

ALTERNATIVE FISTULA RISK SCORE AND FIRST POSTOPERATIVE DAY DRAIN FLUID AMYLASE AS PREDICTORS OF PANCREATIC FISTULA AFTER PANCREATICODUODENECTOMY

BACKGROUND

The high morbidity and mortality rates of pancreaticoduodenectomy are mainly associated with pancreaticojejunal anastomosis, the most fragile and susceptible to complications such as clinically relevant postoperative pancreatic fistula.

AIMS

The alternative fistula risk score and the first postoperative day drain fluid amylase are predictors of the occurrence of clinically relevant postoperative pancreatic fistula. No consensus has been reached on which of the scores is a better predictor; moreover, their combined predictive power remains unclear. To the best of our knowledge, this association had not yet been studied.

METHODS

This study assessed the predictive effect of alternative fistula risk score and/or drain fluid amylase on clinically relevant postoperative pancreatic fistula in a retrospective cohort of 58 patients following pancreaticoduodenectomy. The Shapiro-Wilk and Mann-Whitney tests were applied for assessing the distribution of the samples and for comparing the medians, respectively. The receiver operating characteristics curve and the confusion matrix were used to analyze the predictive models.

RESULTS

The alternative fistula risk score values were not statistically different between patients in the clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 59.5, p=0.12). The drain fluid amylase values were statistically different between clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 27, p=0.004). The alternative fistula risk score and drain fluid amylase were independently less predictive for clinically relevant postoperative pancreatic fistula, compared to combined alternative fistula risk score + drain fluid amylase.

CONCLUSION

The combined model involving alternative fistula risk score >20% + drain fluid amylase=5,000 U/L was the most effective predictor of clinically relevant postoperative pancreatic fistula occurrence following pancreaticoduodenectomy.

Adjusting Drain Fluid Amylase for Drain Volume Does Not Improve Pancreatic Fistula Prediction

INTRODUCTION

Drain fluid amylase (DFA) levels have been used to predict clinically relevant postoperative pancreatic fistula (CR-POPF) and guide postoperative drain management. Optimal DFA cutoff thresholds vary between studies, thereby prompting investigation of an alternative assessment technique. As DFA measurements could, in theory, be distorted by variations in ascites fluid production, we hypothesized that adjusting DFA for volume corrected drain fluid amylase (vDFA) would improve CR-POPF predictive models.

METHODS

A single-institution retrospective cohort study of patients, who underwent pancreatoduodenectomies (PD) and distal pancreatectomies (DP) between 2013 and 2019, was performed. DFAs and vDFAs were measured on postoperative day (POD) 3. Clinicopathologic variables were compared between cohorts by univariable and multivariable analyses and Receiver operating characteristic (ROC) curves.

RESULTS

Patients developing a CR-POPF were more likely to be male and have elevated DFA, vDFA, and body mass index (BMI). vDFA use did not contribute to a superior CR-POPF predictive model compared to DFA-a finding consistent on subanalysis of surgery type PD versus DP. In CR-POPF predictive models, DFA, vDFA, and male sex significantly improved CR-POPF predictive models when considering both surgery subtypes, while only DFA and vDFA significantly improved models when cohorts were segregated by surgery type.

CONCLUSIONS

Postoperative DFA remains a preferred method of predicting CR-POPF as the proposed vDFA assessment technique only adds complexity without increased discriminability.

Prophylactic abdominal drainage or no drainage after distal pancreatectomy (PANDORINA): a binational multicenter randomized controlled trial

BACKGROUND

Prophylactic abdominal drainage is current standard practice after distal pancreatectomy (DP), with the aim to divert pancreatic fluid in case of a postoperative pancreatic fistula (POPF) aimed to prevent further complications as bleeding. Whereas POPF after pancreatoduodenectomy, by definition, involves infection due to anastomotic dehiscence, a POPF after DP is essentially sterile since the bowel is not opened and no anastomoses are created. Routine drainage after DP could potentially be omitted and this could even be beneficial because of the hypothetical prevention of drain-induced infections (Fisher, Surgery 52:205-22, 2018). Abdominal drainage, moreover, should only be performed if it provides additional safety or comfort to the patient. In clinical practice, drains cause clear discomfort. One multicenter randomized controlled trial confirmed the safety of omitting abdominal drainage but did not stratify patients according to their risk of POPF and did not describe a standardized strategy for pancreatic transection. Therefore, a large pragmatic multicenter randomized controlled trial is required, with prespecified POPF risk groups and a homogeneous method of stump closure. The objective of the PANDORINA trial is to evaluate the non-inferiority of omitting routine intra-abdominal drainage after DP on postoperative morbidity (Clavien-Dindo score ≥ 3), and, secondarily, POPF grade B/C.

METHODS/DESIGN

Binational multicenter randomized controlled non-inferiority trial, stratifying patients to high and low risk for POPF grade B/C and incorporating a standardized strategy for pancreatic transection. Two groups of 141 patients (282 in total) undergoing elective DP (either open or minimally invasive, with or without splenectomy). Primary outcome is postoperative rate of morbidity (Clavien-Dindo score ≥ 3), and the most relevant secondary outcome is grade B/C POPF. Other secondary outcomes include surgical reintervention, percutaneous catheter drainage, endoscopic catheter drainage, abdominal collections (not requiring drainage), wound infection, delayed gastric emptying, postpancreatectomy hemorrhage as defined by the international study group for pancreatic surgery (ISGPS) (Wente et al., Surgery 142:20-5, 2007), length of stay (LOS), readmission within 90 days, in-hospital mortality, and 90-day mortality.

DISCUSSION

PANDORINA is the first binational, multicenter, randomized controlled non-inferiority trial with the primary objective to evaluate the hypothesis that omitting prophylactic abdominal drainage after DP does not worsen the risk of postoperative severe complications (Wente etal., Surgery 142:20-5, 2007; Bassi et al., Surgery 161:584-91, 2017). Most of the published studies on drain placement after pancreatectomy focus on both pancreatoduodenectomy and DP, but these two entities present are associated with different complications and therefore deserve separate evaluation (McMillan et al., Surgery 159:1013-22, 2016; Pratt et al., J Gastrointest Surg 10:1264-78, 2006). The PANDORINA trial is innovative since it takes the preoperative risk on POPF into account based on the D-FRS and it warrants homogenous stump closing by using the same graded compression technique and same stapling device (de Pastena et al., Ann Surg 2022; Asbun and Stauffer, Surg Endosc 25:2643-9, 2011).

Routine prophylactic abdominal drainage versus no-drain strategy after distal pancreatectomy: A multicenter propensity score matched analysis

BACKGROUND

/Objectives Postoperative pancreatic fistula (POPF) remains the most common complication after distal pancreatectomy (DP). Traditionally, surgical drains are placed routinely after DP, but some question its efficacy and postulate that the use of drains may convert a self-limiting postoperative collection into a POPF. This study aimed to compare outcomes between three institutions with varying drainage strategies.

METHODS

The study is a retrospective propensity score-matched analysis of intraoperative prophylactic drain placement during DP (2010-2019). The primary outcome is major morbidity. Propensity score matching was used to obtain comparable groups.

RESULTS

Overall, 963 patients after DP were included. One center did not place a surgical drain routinely, but decided to place a drain when unsatisfactory pancreatic closure occurred. Prophylactic abdominal drains were placed in 805 patients (84%) of which 74 could be matched to 74 patients without a drain. The rate of major morbidity (8% vs 19%, p = 0.054) and radiological interventions (5% vs 12%, p = 0.147) were non-significantly lower in the no-drain group as compared to the prophylactic drain group, respectively. The rates of POPF (4% vs 16%, p = 0.014) were lower in the no-drain group.

CONCLUSION

In this international retrospective multicenter study, a selective no-drain strategy after DP was not associated with higher rates major morbidity or radiological interventions as compared to routine prophylactic abdominal drainage. Although the rate of POPF was lower in the no-drain group, randomized trials should confirm the safety and outcome of a no-drain strategy after DP.

C-reactive protein identifies patients at risk of postpancreatectomy hemorrhage

Background

Postpancreatectomy hemorrhage grade C (PPH C) is a dreaded complication after pancreaticoduodenectomy (PD) with high mortality rate. Concurrent risk factors for PPH C have been difficult to recognize. Connection between postoperative pancreatic fistulas (POPF) and PPH C is well known, but POPF is often unknown prior to the PPH. The aim of this retrospective study was to define potential predictive factors for PPH C.

Methods

Retrospectively, 517 patients who underwent PD between 2003 and 2018 were included in the study. Twenty-three patients with PPH C were identified, and a matched control group of 92 patients was randomly selected. Preoperative data (body mass index, cardiovascular disease, history of abdominal surgery, biliary stent, C-reactive protein (CRP), ASA-score), perioperative data (bleeding, pancreatic anastomosis, operation time), and postoperative data (CRP, drain amylase, POPF, biliary fistula) were analyzed as potential predictors of PPH C.

Results

High postoperative CRP (median 140 mg/L on day 5 or 6) correlated with the development of PPH C (p < 0.05). Postoperative drain amylase levels were not clinically relevant for occurrence of PPH C. Grade C POPF or biliary leak was observed in the majority of the PPH C patients, but the leaking anastomoses were not detected before the bleeding started.

Discussion

High postoperative CRP levels are related to an increased risk of PPH C.

Development and validation of risk prediction nomogram for pancreatic fistula and risk-stratified strategy for drainage management after pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is the major complication following pancreaticoduodenectomy (PD). We sought to develop and validate a risk prediction model for POPF after PD with the aim of determining personal risk probability and proposing a novel strategy for intraoperative placement and/or early-removal of prophylactic drainage.

METHODS

Data from 993 patients undergoing PD from January 2012 to December 2016 were retrospectively analyzed. Patients were randomly assigned to either training cohort or validation cohort. A nomogram was formulated based on the results from multivariable regression model for prediction of POPF. Internal and external validation were carried out with calibration plot respectively.

RESULTS

POPF occurred in 162 (16.3%) patients. The final pre-/intra-operative prediction model included alanine transaminase level [odds ratio (OR) 1.00, 95% confidence interval (CI): 1.00-1.00, P=0.023], combined portal-superior mesenteric vein resection (OR 0.22, 95% CI: 0.05-0.95, P=0.043), pancreatic duct diameter (OR 1.48, 95% CI: 1.11-1.96, P=0.007), intraoperative colloid infusion (OR 1.00, 95% CI: 1.00-1.00, P=0.001), pathology (OR 1.71, 95% CI: 1.09-2.66, P=0.018). The area under the curve (AUC) was 0.667 in the training cohort and 0.621 in the validation cohort. The final postoperative prediction model included pancreatic duct diameter (OR 1.58, 95% CI: 1.14-2.19, P=0.006), intraoperative colloid infusion (OR 2.52, 95% CI: 1.26-5.06, P=0.009), drainage fluid amylase on postoperative day 3 (POD3) (OR 4.70, 95% CI: 3.30-6.70, P<0.001), and neutrophil count on POD3 (OR 2.83, 95% CI: 1.63-4.93, P<0.001). The AUC was 0.809 in the training cohort and 0.797 in the validation cohort. Based on these variables, two nomogram prediction models were developed respectively. The calibration plot of the two models showed a good correlation between the expected risk and the actual risk in the low-risk range. Our risk-stratified strategy for drain management according to nomograms may be beneficial for 34.5% of patients.

CONCLUSIONS

Our study formulated and validated two nomogram models for predicting POPF that performed particularly well in the low-risk range. This tool may allow surgeons to propose a risk stratified strategy for intraoperative drain placement and early drain removal, which may be beneficial for a substantial proportion of patients.

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.

Distal Pancreatic Resection with Splenectomy in the Rat: A Pancreatic Fistula Model to Investigate Postsurgical Damage?

BACKGROUND

Postoperative pancreatic fistula (POPF) is a major complication in pancreatic surgery and can cause considerable postoperative morbidity. Advanced surgical-technical approaches to prevent POPF did not yield a substantial improvement. To investigate innovative treatments, experimental animal models of distal pancreatic resection and pancreaticoduodenectomy are of fundamental importance. After a failed attempt to replicate a previously described rat model for pancreatic fistula induction, we proceeded to distal pancreatic resection with splenectomy to provoke pancreatic leakage and generate a suitable animal model.

METHODS

Distal pancreatic resection with splenectomy was performed in 40 rats. The rats were sacrificed on postoperative day (POD) 1, 2, 4, 6, 8, or 10, and the abdominal cavity was explored. Ascites probes were collected pre- and postoperatively for the detection of pancreas amylase and lipase. Tissue samples from the naïve pancreas (POD 0) and the postoperatively harvested remnant were evaluated histologically. The extent of necrosis was determined, and samples were examined for neutrophil infiltration. TUNEL staining served for the verification of necrosis in distinct cases. Immunohistochemistry of Ki67, von Willebrand factor, and CD68 was performed to evaluate proliferation, blood-vessel sprouting, and macrophage invasion.

RESULTS

The rats showed no clinical symptoms or severe complications in the postoperative course up to 10 days. Abdominal exploration revealed adhesions in the upper abdomen, but no intra-abdominal fluid accumulations were found. Signs of inflammation and tissue damage were evident at the pancreatic resection margin on histological examination whereas the naïve pancreatic tissue was widely unaffected. Statistically significant differences were seen between the preoperative and postoperative extent of necrosis, the presence of neutrophil infiltrate, and levels of ascitic amylase and lipase. Immunohistochemical staining on Ki67, von Willebrand factor, and CD68 did not reveal any workable results on nonstatistical examination, and it was therefore not considered for further analyses.

CONCLUSION

Creating a functional animal model of pancreatic fistula that reflects the clinical and pathophysiological impact of pancreatic leakage in humans has not been achieved. Our approach of left pancreatic resection recapitulated inflammation and tissue damage, early events in the development of fistulas, and it could be suitable for the experimental testing of novel targeting methods.

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.

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.

Proposal of a Clinically Useful Criterion for Early Drain Removal After Pancreaticoduodenectomy

PURPOSE

This study aimed to establish a reliable criterion for early drain removal after pancreaticoduodenectomy (PD) based on predictive factors of clinically relevant postoperative pancreatic fistula (CR-POPF) available on postoperative day 3 (POD3).

METHODS

A total of 300 consecutive patients who underwent PD with pancreaticojejunostomy at our hospital from 2011 to 2015 were analyzed retrospectively. CR-POPF was defined as POPF grade B or C according to the definition by ISGPF. Clinicopathological factors available on or before POD3 were analyzed to identify predictors of CR-POPF. Using obtained predictors, we developed a criterion for no CR-POPF and internally validated its relevance in 100 consecutive patients.

RESULTS

The incidence rates of CR-POPF, severe complications (Clavien-Dindo ≥ grade IIIa), and postoperative mortality were 35%, 9.6%, and 0.3%, respectively. Multivariate analysis showed that drain amylase (d-AMY) levels ≥ 350 IU/l on POD3, C-reactive protein (CRP) levels ≥ 14 mg/dl on POD3, preoperative endoscopic retrograde biliary drainage, and no portal vein resection were significant predictors of CR-POPF. Using the strongest predictors (i.e., d-AMY and CRP), we established a criterion for no CR-POPF: d-AMY levels < 350 IU/l and CRP levels < 14 mg/dl on POD3. The incidence rates of CR-POPF were 6%, 38%, and 88% in patients who fulfilled both of (n = 149), each of (n = 74), and none of (n = 77) the two factors, respectively. In the internal validation cohort, the positive predictive value of CR-POPF was 89%.

CONCLUSIONS

A simple two-factor criterion available on POD3 after PD has a reliable predictive ability. In patients who fulfill this criterion, early drain removal is considered safe.

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.

Conservative drain management increases the incidence of grade B postoperative pancreatic fistula without increasing serious complications: Does persistent drainage reflect the quality of pancreatic surgery or institutional policy?

BACKGROUND

Among grade B/C postoperative pancreatic fistula (POPF), the clinical burden of patients treated with persistent drainage alone was reported to be less. As the clinical difference might depend on drain management, we evaluated their clinical burden under conservative drain management.

METHODS

We included 292 patients who underwent pancreaticoduodenectomy or distal pancreatectomy between 2013 and 2015. Patients with grade B POPF were categorized into those receiving persistent drainage alone (B-drain) and those receiving other treatments (B-other). The clinical burden of these groups and patients with biochemical leakage (BL) was compared.

RESULTS

BL, grade B POPF, and grade C POPF occurred in 42 (14%), 93 (32%), and 4 (1.4%) patients, respectively. The B-drain group comprised 61% of grade B POPF. The overall major morbidity (Clavien-Dindo grade ≥ 3) in the B-drain group was significantly lower than in the B-other group (18% vs 50%, P = .001) but was comparable to that of the BL group (19%, P = .848). The POPF-related major morbidity in the B-drain and B-other group were 0% and 25%, respectively (P < .001).

CONCLUSIONS

Under conservative drain management, patients with grade B POPF frequently experienced persistent drainage alone and the clinical burden of B-drain group and BL group was comparable.

Systematic review and meta-analysis of surgical drain management after the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy: draining-tract-targeted works better than standard management

Purpose

Drains’ role after pancreaticoduodenectomy (PD) is debated by proponents of no drain, draining selected cases, and early drain removal. The aim of the study was to assess the effect of “standard” and “draining-tract-targeted” management of abdominal drains still in situ after diagnosing a postoperative pancreatic fistula (POPF).

Methods

PubMed and Scopus were searched for “pancreaticoduodenectomy or pancreatoduodenectomy or duodenopancreatectomy,” “Whipple,” “proximal pancreatectomy,” “pylorus-preserving pancreatectomy,” and “postoperative pancreatic fistula or POPF.”. Main outcomes included clinically relevant (CR) POPF, grade-C POPF, overall mortality, POPF-related mortality, and CR-POPF-related mortality. Secondary outcomes were incidence of radiological and/or endoscopic interventions, reoperations, and completion pancreatectomies.

Results

Overall, 12,089 studies were retrieved by the search of the English literature (01/01/1990–31/12/2018). Three hundred and twenty-six studies (90,321 patients) reporting ≥ 100 PDs and ≥ 10 PD/year were finally included into the study. Average incidences were obtained by averaging the incidence rates reported in the single articles. Pooled incidences were calculated by combining the number of events and the total number of patients considered in the various studies. These were then meta-analyzed using DerSimonian and Laird’s (1986) method. Pearson’s chi-squared test was used to compare pooled incidences between groups. Post hoc testing was used to see which groups differed. The meta-analyzed incidences were compared using a fixed effect for moderators. “Draining-tract-targeted” management showed a significant advantage over “standard” management in four clinically relevant outcomes out of eight according to pool analysis and in one of them according to meta-analysis.

Conclusion

Clinically, “draining-targeted” management of POPF should be preferred to “standard” management.

Electronic supplementary material

The online version of this article (10.1007/s00423-020-02005-8) contains supplementary material, which is available to authorized users.

Passive Versus Active Intra-Abdominal Drainage Following Pancreaticoduodenectomy: A Retrospective Study Using The American College of Surgeons NSQIP Database

BACKGROUND

Prophylactic drainage following pancreaticoduodenectomy (PD) reduces morbidity and mortality. Little evidence exists to advise on whether passive gravity (PG) or active suction (AS) drainage systems result in superior outcomes. This study examines the relationship between drainage system and morbidity following PD.

METHODS

All patients undergoing elective PD with an operatively placed drain in the 2016 ACS-NSQIP database were included. Pre- and intra-operative factors were examined. Multivariable logistic regression and coarsened exact matching (CEM) were used to assess for an association between drainage system (PG vs. AS) and morbidity. The primary outcome was postoperative pancreatic fistula (POPF).

RESULTS

In total, 3430 patients were included: 563 (16.4%) with PG and 2867 (83.6%) with AS drainage system. On multivariable regression, 1787 patients were included. Drainage type was not associated with POPF, surgical site infection, delayed gastric emptying, or re-operation. AS drainage was protective against percutaneous drain insertion (OR 0.65, 95% CI 0.44-0.96, p = 0.033). In the CEM cohort (n = 268), superficial SSI was higher in the AS group (0.8% vs. 6.0%, p = 0.036). There was a trend toward higher rates of composite total SSI (PG 15.7%, AS 23.9%, p = 0.092) and organ space SSI (PG 14.2%, AS 20.2%, p = 0.195) in the AS group; this did not demonstrate statistical significance.

CONCLUSIONS

The findings of this study suggest that AS drainage is protective against percutaneous drain insertion, but may be associated with increased risk of SSI. There was no relation between drainage type and POPF. A prospective, randomized controlled trial is warranted to further explore these findings.

Blame it on the injury: Trauma is a risk factor for pancreatic fistula following distal pancreatectomy compared with elective resection

BACKGROUND

Postoperative pancreatic fistula (POPF) remains a significant source of morbidity following distal pancreatectomy (DP). There is a lack of information regarding the impact of trauma on POPF rates when compared with elective resection. We hypothesize that trauma will be a significant risk factor for the development of POPF following DP.

METHODS

A retrospective, single-institution review of all patients undergoing DP from 1999 to 2017 was performed. Outcomes were compared between patients undergoing DP for traumatic injury to those undergoing elective resection. Univariate and multivariable analyses were performed using SAS (version 9.4).

RESULTS

Of the 372 patients who underwent DP during the study period, 298 met inclusion criteria: 38 DPs for trauma (TDP), 260 elective DPs (EDP). Clinically significant grade B or C POPFs occurred in 17 (44.7%) of 38 TDPs compared with 41 (15.8%) of 260 EDPs (p < 0.0001). On multivariable analysis, traumatic injury was found to be independently predictive of developing a grade B or C POPF (odds ratio, 4.3; 95% confidence interval, 2.10-8.89). Age, sex, and wound infection were highly correlated with traumatic etiology and therefore were not retained in the multivariable model. When analyzing risk factors for each group (trauma vs. elective) separately, we found that TDP patients who developed POPFs had less sutured closure of their duct, higher infectious complications, and longer hospital stays, while EDP patients that suffered POPFs were more likely to be male, younger in age, and at a greater risk for infectious complications. Lastly, in a subgroup analysis involving only patients with drains left postoperatively, trauma was an independent predictor of any grade of fistula (A, B, or C) compared with elective DP (odds ratio, 8.6; 95% confidence interval, 3.09-24.15), suggesting that traumatic injury is risk factor for pancreatic stump closure disruption following DP.

CONCLUSION

To our knowledge, this study represents the largest cohort of patients comparing pancreatic leak rates in traumatic versus elective DP, and demonstrates that traumatic injury is an independent risk factor for developing an ISGPF grade B or C pancreatic fistula following DP.

LEVEL OF EVIDENCE

Prognostic study, Therapeutic, level III.

Extended Experience with a Dynamic, Data-Driven Selective Drain Management Protocol in Pancreaticoduodenectomy: Progressive Risk Stratification for Better Practice

BACKGROUND

Intraoperative drain use for pancreaticoduodenectomy has been practiced in an unconditional, binary manner (placement/no placement). Alternatively, dynamic drain management has been introduced, incorporating the Fistula Risk Score (FRS) and drain fluid amylase (DFA) analysis, to mitigate clinically relevant postoperative pancreatic fistula (CR-POPF).

STUDY DESIGN

An extended experience with dynamic drain management was used at a single institution for 400 consecutive pancreaticoduodenectomies (2014 to 2019). This protocol consists of the following: drains omitted for negligible/low-risk FRS (0 to 2) and drains placed for moderate/high-risk FRS (3 to 10) with early (postoperative day [POD] 3) removal if POD1 DFA ≤5,000 U/L. Adherence to this protocol was prospectively annotated and outcomes were retrospectively analyzed.

RESULTS

The overall CR-POPF rate was 8.7%, with none occurring in the negligible/low-risk cases. Moderate/high-risk patients manifested an 11.9% CR-POPF rate (n = 35 of 293), which was lower on-protocol (9.5% vs 21%; p = 0.014). After drain placement, POD1 DFA ≥5,000 U/L was a better predictor of CR-POPF than FRS (odds ratio 14.7; 95% CI, 4.3 to 50.3). For POD1 DFA ≤5,000 U/L, early drain removal was associated with fewer CR-POPFs (2.8% vs 23.5%; p < 0.001), and substantiated by multivariable analysis (odds ratio 0.09; 95% CI, 0.03 to 0.28). Surgeon adherence was inversely related to CR-POPF rate (R = 0.846).

CONCLUSIONS

This extended experience validates a dynamic drain management protocol, providing a model for better drain management and individualized patient care after pancreaticoduodenectomy. This study confirms that drains can be safely omitted from negligible/low-risk patients, and moderate/high-risk patients benefit from early drain removal.

Meta-analysis of modified Blumgart anastomosis and interrupted transpancreatic suture in pancreaticojejunostomy after pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) remains the main cause of surgery related mortality after pancreaticoduodenectomy. Various pancreatoenteric anastomosis methods have been developed to reduce the POPF rate. However, the optimum choice has not been clarified. A literature search is performed in electronic databases, including PubMed, Medline, Embase, CNKI and the Cochrane Library. Studies comparing modified Blumgart anastomosis with interrupted transpancreatic suture are included in this meta-analysis. Grade B/C POPF, overall POPF rate and overall sever complication rate (Clavien-Dindo classification IIIa or more) are measured as primary outcomes. Revman 5.3 was used to perform the analysis. Five retrospective comparative studies and 1 randomized controlled trial with a total number of 1409 patients are included in our analysis. Meta-analysis revealed that modified Blumgart anastomosis is associated with lower rate of grade B/C POPF [Odds Ratio (OR) 95% confidence interval (CI),0.32 (0.12-0.84); P = 0.02] and intra-abdominal abscess [OR 95%CI, 0.43 (0.29-0.65); P < 0.01] comparing with interrupted transpancreatic suture. However, this procedure could not reduce overall POPF [OR 95%CI,0.70 (0.34-1.44); P = 0.34] and overall sever complication rate [OR 95%CI,0.91 (0.48-1.72); P = 0.77]. At current level of evidence, modified Blumgart anastomosis is superior to interrupted transpancreatic suture in terms of grade B/C POPF and intra-abdominal abscess. However, high-grade evidence will be necessary to confirm these results.

Outcomes After Minimally-invasive Versus Open Pancreatoduodenectomy: A Pan-European Propensity Score Matched Study

OBJECTIVE

To assess short-term outcomes after minimally invasive (laparoscopic, robot-assisted, and hybrid) pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) among European centers.

BACKGROUND

Current evidence on MIPD is based on national registries or single expert centers. International, matched studies comparing outcomes for MIPD and OPD are lacking.

METHODS

Retrospective propensity score matched study comparing MIPD in 14 centers (7 countries) performing ≥10 MIPDs annually (2012-2017) versus OPD in 53 German/Dutch surgical registry centers performing ≥10 OPDs annually (2014-2017). Primary outcome was 30-day major morbidity (Clavien-Dindo ≥3).

RESULTS

Of 4220 patients, 729/730 MIPDs (412 laparoscopic, 184 robot-assisted, and 130 hybrid) were matched to 729 OPDs. Median annual case-volume was 19 MIPDs (interquartile range, IQR 13-22), including the first MIPDs performed in 10/14 centers, and 31 OPDs (IQR 21-38). Major morbidity (28% vs 30%, P = 0.526), mortality (4.0% vs 3.3%, P = 0.576), percutaneous drainage (12% vs 12%, P = 0.809), reoperation (11% vs 13%, P = 0.329), and hospital stay (mean 17 vs 17 days, P > 0.99) were comparable between MIPD and OPD. Grade-B/C postoperative pancreatic fistula (POPF) (23% vs 13%, P < 0.001) occurred more frequently after MIPD. Single-row pancreatojejunostomy was associated with POPF in MIPD (odds ratio, OR 2.95, P < 0.001), but not in OPD. Laparoscopic, robot-assisted, and hybrid MIPD had comparable major morbidity (27% vs 27% vs 35%), POPF (24% vs 19% vs 25%), and mortality (2.9% vs 5.2% vs 5.4%), with a fewer conversions in robot-assisted- versus laparoscopic MIPD (5% vs 26%, P < 0.001).

CONCLUSIONS

In the early experience of 14 European centers performing ≥10 MIPDs annually, no differences were found in major morbidity, mortality, and hospital stay between MIPD and OPD. The high rates of POPF and conversion, and the lack of superior outcomes (ie, hospital stay, morbidity) could indicate that more experience and higher annual MIPD volumes are needed.

Standardization of early drain removal following pancreatic resection: proposal of the "Ottawa pancreatic drain algorithm"

Background

Early drain removal after pancreatic resection is encouraged for individuals with low postoperative day 1 drain amylase levels (POD1 DA) to mitigate associated morbidity. Although various protocols for drain management have been published, there is a need to assess the implementation of a standardized protocol.

Methods

The Ottawa pancreatic drain algorithm (OPDA), based on POD1 DA and effluent volume, was developed and implemented at our institution. A retrospective cohort analysis was conducted of all patients undergoing pancreatic resection January 1, 2016-October 30, 2017, excluding November and December 2016 (one month before and after OPDA implementation).

Results

42 patients pre-implementation and 53 patients post-implementation were included in the analysis. The median day of drain removal was significantly reduced after implementation of the OPDA (8 vs. 5 days; p = 0.01). Early drain removal appeared safe with no difference in reoperation or readmission rate after protocol implementation (p = 0.39; p = 0.76). On subgroup analysis, median length of stay was significantly shorter following OPDA implementation for patients who underwent DP and did not develop a postoperative pancreatic fistula (POPF) (6 vs 10 days, p = 0.03). Although the incidence of both surgical site infection and POPF were reduced following the intervention, neither reached statistical significance (38.1 to 28.3%, p = 0.31; and 38.1 to 28.3%, p = 0.31 respectively).

Conclusions

Implementing the OPDA was associated with earlier drain removal and decreased length of stay in patients undergoing distal pancreatectomy who did not develop POPF, without increased morbidity. Standardizing drain removal may help facilitate early drain removal after pancreatic resection at other institutions.

Validation of early drain removal after pancreatoduodenectomy based on modified fistula risk score stratification: a population-based assessment

BACKGROUND

Recent studies on postoperative pancreatic fistula (POPF) prevention following pancreatoduodenectomy (PD) have proposed omission of perioperative drains for negligible/low-risk patients and early drain removal (≤POD3) for intermediate/high-risk patients with POD1 drain amylase levels of ≤5000 U/L, though this has not been validated using a nationwide cohort.

METHODS

The ACS-NSQIP targeted pancreatectomy database from 2014 to 2016 was queried to identify patients who underwent PD. Patients with POD1 drain amylase levels of ≤5000 U/L were initially stratified as negligible/low- or intermediate/high-risk based on a previously validated modified fistula risk score (mFRS). Differences in relevant postoperative outcomes were then compared among patients who underwent early (≤POD3) vs. late (≥POD4) drain removal.

RESULTS

Among 1825 patients who underwent PD, 1540 (84%) had POD1 drain amylase of ≤5000 U/L: 719 (47%) high-risk and 821 (53%) low-risk. Among high-risk patients, early drain removal (n = 205, 29%) was associated with lower rates of POPF (3% vs. 18%, p < 0.001), clinically relevant (CR)-POPF (2% vs. 15%, p < 0.001), overall morbidity (27% vs. 47%, p < 0.001), serious morbidity (15% vs. 24%, p = 0.007) and hospital length of stay (LOS, 7 vs. 8 days, p < 0.001). Similarly, early drain removal in low-risk patients (n = 273, 33%) was associated with decreased rates of POPF (1% vs. 6%, p = 0.003), CR-POPF (1% vs. 5%, p = 0.014), overall morbidity (28% vs. 41%, p = 0.0003), serious morbidity (8% vs. 14%, p = 0.015) and LOS (6 vs. 8 days, p < 0.001). On multivariate logistic regression analysis, early drain removal remained associated with significantly decreased odds of POPF, CR-POPF, overall and serious morbidity as well as LOS among both high- and low-risk patients (all p < 0.05).

CONCLUSIONS

Among patients with POD1 drain amylase ≤5000 U/L following PD, early drain removal (≤POD3) is associated with improved postoperative outcomes among both high- and low-risk patients. Early drain removal based on POD1 drain amylase is indicated regardless of mFRS.

An update on treatment options for pancreatic adenocarcinoma

Pancreatic cancer is one of the most lethal solid organ tumors. Due to the rising incidence, late diagnosis, and limited treatment options, it is expected to be the second leading cause of cancer deaths in high income countries in the next decade. The multidisciplinary treatment of this disease depends on the stage of cancer at diagnosis (resectable, borderline, locally advanced, and metastatic disease), and combines surgery, chemotherapy, chemoradiotherapy, and supportive care. The landscape of multidisciplinary pancreatic cancer treatment is changing rapidly, especially in locally advanced disease, and the number of treatment options in metastatic disease, including personalized medicine, innovative targets, immunotherapy, therapeutic vaccines, adoptive T-cell transfer, or stemness inhibitors, will probably expand in the near future. This review summarizes the current literature and provides an overview of how new therapies or new therapeutic strategies (neoadjuvant therapies, conversion surgery) will guide multidisciplinary disease management, future clinical trials, and, hopefully, will increase overall survival.

Open and minimally invasive pancreatic neoplasms enucleation: a systematic review

BACKGROUND

Pancreatic enucleation (pEN) as parenchyma-sparing procedure for small pancreatic neoplasms is quickly becoming the most common surgical option in such setting. Nowadays, pEN is frequently carried out through a minimally invasive approach either laparoscopic or robotic. Its impact on overall perioperative complications and pancreatic fistula (POPF) is still under evaluation. The scope of our systematic review is to assess pEN's perioperative outcomes and to evaluate the effect of the minimally invasive techniques over POPF and other surgical complications.

METHODS

We performed a systematic literature search (time-frame January 1999-September 2018), considering exclusively those studies which included at least 5 cases of either open or minimally invasive pEN. Data regarding postoperative outcome and POPF were extracted and analyzed. We defined postoperative morbidities by the Clavien-Dindo classification while POPF according to the International Study Group of Pancreatic Fistula (ISGPF) definition.

RESULTS

Sixty-three studies met the criteria selected, accounting for a study population of 2485 patients. 27.7% had a minimally invasive pEN. The overall postoperative morbidity rate was 46.1% with 11.9% rated as severe (Clavien-Dindo ≥ 3). Mortality rate was 0.69%. The minimally invasive approach to pEN led to a statistically significant reduction of both the overall POPF rate (28.7% vs. 45.9%, p < 0.001), and clinically significant B-C POPF (p < 0.027). The postoperative overall morbidity rate was clearly in favor of the minimally invasive approach (27.6% vs. 55.2%, p < 0.001).

CONCLUSIONS

Our review confirms that pEN is a safe and feasible technique for the treatment of small benign or low-grade pancreatic neoplasms and it can be implemented with an acceptable morbidity rate along with low mortality. The minimally invasive approach is gaining widespread acceptance due to its supposed non-inferiority compared with the traditional open approach. In our review, it showed to be even better in terms of POPF incidence rate and short-term postoperative outcome. Still, such data need to be corroborated by randomized clinical trials.

Impact of expanding indications on surgical and oncological outcome in 1434 consecutive pancreatoduodenectomies

BACKGROUND

Over the years, high-volume pancreatic centers expanded their indications for pancreatoduodenectomy (PD) but with unknown impact on surgical and oncological outcome.

METHODS

All consecutive PDs performed between 1992-2017 in a single pancreatic center were identified from a prospectively maintained database and analyzed according to three time periods.

RESULTS

In total, 1434 patients underwent PD. Over time, more elderly patients underwent PD (P < 0.001) with increased use of vascular resection (10.4 to 16.0%, P < 0.001). In patients with cancer (n = 1049, 74.8%), the proportion pT3/T4 tumors increased from 54.3% to 70.6% over time (P < 0.001). The postoperative pancreatic fistula (16.0%), postpancreatectomy hemorrhage (8.0%) and delayed gastric emptying (31.0%) rate did not reduce over time, whereas median length of stay decreased from 16 to 12 days (P < 0.001). The overall failure-to-rescue rate (6.9%) and in-hospital mortality (2.2%) remained stable (P = 0.89 and P = 0.45). In 523 patients with pancreatic cancer (36.5%), the use of both adjuvant and neoadjuvant chemotherapy increased over time (both p<0.001), and the five-year overall survival improved from 11.0% to 17.4% (P < 0.001).

CONCLUSIONS

In a period where indications for PD expanded, with more elderly patients, more advanced cancers and increased use of vascular resections, surgical outcome remained favorable and five-year survival for pancreatic cancer improved.

Hypophosphatemia as a Predictor of Organ-Specific Complications Following Gastrointestinal Surgery: Analysis of 8034 Patients

BACKGROUND

Organ-specific complications (OSC) remain serious potential sequela of gastrointestinal surgery. Hypophosphatemia correlates with poor outcomes and may be a harbinger of OSC after gastrointestinal surgery. Our goal was to describe and evaluate the relationship between postoperative phosphate levels and OSC.

METHODS

Consecutive patients who underwent pancreatic, colorectal, or gastric resections were analyzed. OSC were defined as those resulting from the failure of at least one anastomosis performed during the primary resection, manifesting as an anastomotic leak, fistula, and/or intra-abdominal abscess. Postoperative serum phosphate levels and other recognized OSC risk factors were compared among patients who did and did not develop OSC.

RESULTS

A total of 8034 patients who underwent pancreatic (n = 397), colorectal (n = 5808), or gastric (n = 1829) resections were included in the study. In each resection group, the majority of patients experienced hypophosphatemia postresection with the nadir on postoperative day (POD) 2, and the subgroups that developed OSC exhibited lower phosphate levels on POD3-7. On multivariate analysis, lower phosphate level on POD3 remained significantly associated with OSC following pancreatic resection [median (interquartile range) mmol/L, 0.65 (0.53-0.76) vs. 0.71 (0.61-0.84), p = 0.045] and colorectal resection [0.71 (0.61-0.87) vs. 0.77 (0.65-0.94), p = 0.006], and lower phosphate level on POD4 remained associated with OSC following gastric resection [0.87 (0.74-1.03) vs. 0.96 (0.81-1.13), p = 0.049].

CONCLUSION

This study identified a consistent trajectory of serum phosphate levels following 3 different gastrointestinal operations and association between early postoperative phosphate levels and OSC. Persistent lower phosphate levels should raise the level of concern for evolving postoperative leak and may lead to earlier radiographic evaluation and treatment.

Abdominal drainage versus no drainage after distal pancreatectomy: study protocol for a randomized controlled trial

Background

The placement of prophylactic intra-abdominal drains has been common practice in abdominal operations including pancreatic surgery. The PANDRA trial showed that the omission of drains following pancreatic head resection was non-inferior to intra-abdominal drainage in terms of postoperative reinterventions and superior in terms of clinically relevant pancreatic fistula rate and fistula-associated complications. The aim of the present PANDRA II trial is to evaluate the clinical outcome with versus without prophylactic drain placement after distal pancreatectomy.

Methods

The PANDRA II trial is a mono-center, randomized controlled, non-inferiority trial with two parallel study groups. In the control group at least one passive intra-abdominal drain is placed at the pancreatic resection margin. In the experimental group no drains are placed. The primary endpoint of this trial will be the Comprehensive Complication Index (CCI) measuring all postoperative complications within 90 days. Secondary endpoints are in-hospital mortality and morbidity, including the rates of postoperative pancreatic fistula, chyle leak, postpancreatectomy hemorrhage, delayed gastric emptying, reinterventions and reoperations, surgical site infection, and abdominal fascia dehiscence. Moreover, length of hospital stay, duration of intensive care unit stay, and the rate of readmission after discharge from hospital (up to day 90 after surgery) are assessed. We will need to analyze 252 patients to test the hypothesis that no drainage is non-inferior to drain placement in terms of the CCI (δ 7.5 points) in a one-sided t test with a one-sided level of significance of 2.5% and a power of 80%.

Discussion

The results of the PANDRA II trial will help to evaluate the effect of an omission of prophylactic intraperitoneal drainage on the rate of complications after open or minimally invasive distal pancreatectomy.

Trial registration

German Clinical Trials Register (DRKS), DRKS00013763. Registered on 6 March 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3442-0) contains supplementary material, which is available to authorized users.

Impact of Drain Placement and Duration on Outcomes After Pancreaticoduodenectomy: A National Surgical Quality Improvement Program Analysis

BACKGROUND

The decisions to routinely place a drain after pancreaticoduodenectomy and how long to leave the drain remain controversial due to conflicting evidence and significant variations in clinical practice. This study aims to address those questions by using a large national database and a rigorous analytical model.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program 2015-2016 Pancreatectomy Participant Use Data Files were used to identify patients who had undergone pancreaticoduodenectomy (n = 7583). Univariable and multivariable binomial regression analyses were performed to control for potential confounders and various preoperative risk factors. Cox regression with drain as a time-dependent covariate, conditional on having a drain placed, was used to examine the association between the drain remaining in place and morbidities.

RESULTS

Of 7583 patients, drains were placed in 6666 (87.9%). Drain placement decreased the risk of developing serious morbidity (relative risk [RR] 0.73, 95% confidence interval [CI] 0.65-0.82), overall morbidity (RR 0.79, 95% CI 0.72-0.87), and organ space surgical site infection (RR 0.72, 95% CI 0.61-0.85). Drain placement did not change the risk of developing a clinically relevant postoperative pancreatic fistula (RR 0.96, 95% CI 0.78-1.19). However, for those with drains placed, length of drainage was independently associated with serious morbidity (hazard ratio [HR] 3.06, 95% CI 2.65-3.53), overall morbidity (HR 2.48, 95% CI 2.20-2.80), and organ space surgical site infection (HR 1.47, 95% CI 1.23-1.74).

CONCLUSIONS

Routine drain placement following pancreaticoduodenectomy may decrease postoperative complications, including serious morbidity, overall morbidity, and organ space surgical site infections; however, length of drainage was associated with increased risk of the previously-named complications. These results support the routine placement and early removal of intraoperative surgical drains in pancreaticoduodenectomy.

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.

Discharge destination following pancreaticoduodenectomy: A NSQIP analysis of predictive factors and post-discharge outcomes

INTRODUCTION

Pancreaticoduodenectomy is a complex surgical procedure. The purpose of this study was to identify factors associated non-home discharge destination and to characterize outcomes after non-home discharge.

METHODS

10,719 pancreaticoduodenectomy cases contained in the National Surgical Quality Improvement Program (NSQIP) Targeted Pancreatectomy dataset (years 2014-2016) were examined with univariate and multivariate logistic regression.

RESULTS

1336 patients (12.5%) were discharged to rehabilitation, skilled care, or acute care facilities. Preoperative factors significantly associated with non-home discharge on multivariate analysis were female gender, older age, elevated BMI, poor functional status or dyspnea, smoking, low albumin, COPD, and ascites. Intraoperative factors significantly associated with non-home discharge destination on multivariate analysis were longer operative time, open surgery, softer pancreatic texture, drain placement, and jejunostomy tube placement. A nomogram was generated for estimating probability of non-home discharge immediately after surgery.

CONCLUSION

Preoperative and intraoperative factors can be used to predict probability of non-home discharge immediately after completion of pancreaticoduodenectomy.