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Hughes DLL, Hughes A, Gordon-Weeks AN, Silva MA. Continuous drain irrigation as a risk mitigation strategy for postoperative pancreatic fistula: a meta-analysis. Surgery 2024:S0039-6060(24)00192-2. [PMID: 38734504 DOI: 10.1016/j.surg.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 01/21/2024] [Accepted: 03/18/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Postoperative pancreatic fistula serves as the principle cause for the morbidity and mortality observed after pancreatectomy. Continuous drain irrigation as a treatment strategy for infected pancreatic necrosis has previously been described; however, its role adter pancreatectomy has yet to be determined. The aim of this study was to determine whether continuous drain irrigation reduces postoperative pancreatic fistula. METHODS A meta-analysis of the pre-existing literature was performed. The primary end point was whether continuous drain irrigation reduced postoperative pancreatic fistula after pancreatectomy. The secondary end point evaluated its impact on postoperative morbidity, mortality, and length of stay. RESULTS Nine articles involving 782 patients were included. Continuous drain irrigation use was associated with a statistically significant reduction in postoperative pancreatic fistula rates (odds ratio [95% confidence interval] 0.40 [0.19-0.82], P = .01). Upon subgroup analysis, a significant reduction in clinically relevant postoperative pancreatic fistula was also noted (odds ratio 0.37 [0.20-0.66], P = .0008). A reduction in postoperative complications was also observed-delayed gastric emptying (0.45 [0.24-0.84], P = .01) and the need for re-operation (0.33 [0.11-0.96], P = .04). This reduction in postoperative complications translated into a reduced length of stay (mean difference -2.62 [-4.97 to -0.26], P = .03). CONCLUSION Continuous drain irrigation after pancreatectomy is a novel treatment strategy with a limited body of published evidence. After acknowledging the limitations of the data, initial analysis would suggest that it may serve as an effective risk mitigation strategy against postoperative pancreatic fistula. Further research in a prospective context utilizing patient risk stratification for fistula development is, however, required to define its role within clinical practice.
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Affiliation(s)
- Daniel L L Hughes
- Department of Hepatopancreaticobiliary surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
| | - Aron Hughes
- Department of Acute Medicine, University Hospital of Wales, Cardiff, United Kingdom
| | - Alex N Gordon-Weeks
- Department of Hepatopancreaticobiliary surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Michael A Silva
- Department of Hepatopancreaticobiliary surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Zheng M, Niu T, Peng J, Shi L, Shao C. Active Intra-Abdominal Drainage Following Abdominal Digestive System Surgery: A Meta-Analysis and Systematic Review. J INVEST SURG 2023; 36:2180115. [PMID: 37733388 DOI: 10.1080/08941939.2023.2180115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 02/08/2023] [Indexed: 09/22/2023]
Abstract
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.
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Affiliation(s)
- Minghui Zheng
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Ting Niu
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Junfeng Peng
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Ligang Shi
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Chenghao Shao
- Department of Pancreatic-biliary Surgery, Second Affiliated Hospital of Naval Medical University, Shanghai, China
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Li KW, Wang K, Hu YP, Yang C, Deng YX, Wang XY, Liu YX, Li WQ, Ding WW. Initial suction drainage decreases severe postoperative complications after pancreatic trauma: A cohort study. World J Gastrointest Surg 2023; 15:1652-1662. [PMID: 37701705 PMCID: PMC10494579 DOI: 10.4240/wjgs.v15.i8.1652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 05/30/2023] [Accepted: 06/21/2023] [Indexed: 08/25/2023] Open
Abstract
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.
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Affiliation(s)
- Kai-Wei Li
- The First School of Clinical Medicine, Southern Medical University, Guangzhou 510515, Guangdong Province, China
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Kai Wang
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Yue-Peng Hu
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Chao Yang
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Yun-Xuan Deng
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Xin-Yu Wang
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Yu-Xiu Liu
- Division of Data and Statistics, Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Wei-Qin Li
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Wei-Wei Ding
- Division of Trauma and Surgical Intensive Care Unit, Research Institute of General Surgery, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210002, Jiangsu Province, China
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Xinyang Z, Taoying L, Xuli L, Jionghuang C, Framing Z. Comparison of the complications of passive drainage and active suction drainage after pancreatectomy: A meta-analysis. Front Surg 2023; 10:1122558. [PMID: 37151863 PMCID: PMC10157543 DOI: 10.3389/fsurg.2023.1122558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/13/2023] [Indexed: 05/09/2023] Open
Abstract
Objective This study aimed to compare the effect of passive drainage and active suction drainage on complications after pancreatectomy. Methods The databases were searched and covered in this study on the comparison of passive and active suction drainage after pancreatectomy from the database establishment to Feb. 2023. A meta-analysis was conducted with the RevMan5.3 software. Results On the whole, 1,903 cases were included in eight studies, including 994 cases in the passive drainage group, 909 in the active suction drainage group, 1,224 in the pancreaticoduodenectomy group, as well as 679 in the distal pancreatectomy group. No statistically significant difference was identified between the two groups in the incidence of total complications, the rate of abdominal hemorrhage, the rate of abdominal effusion, the death rate and the length of stay after pancreatectomy (all P > 0.05), whereas the difference in the incidence of pancreatic fistula after distal pancreatectomy between the two groups was of statistical significance (OR = 3.35, 95% CI = 1.12-10.07, P = 0.03). No significant difference was reported in pancreatic fistula between the two groups after pancreaticoduodenectomy. Conclusion After distal pancreatectomy, active suction drainage might down-regulate the incidence of postoperative pancreatic fistula.
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Affiliation(s)
- Zhou Xinyang
- Department of General Surgery, Wuyi First People's Hospital, Wuyi, China
| | - Lei Taoying
- Department of General Surgery, Wuyi First People's Hospital, Wuyi, China
| | - Lan Xuli
- Department of General Surgery, Wuyi First People's Hospital, Wuyi, China
| | - Chen Jionghuang
- Department of General Surgery, Sir Run Run Shaw Hospital, The Affiliated Hospital of the Medical College, ZheJiang University, Hangzhou, China
| | - Zhong Framing
- Department of General Surgery, Wuyi First People's Hospital, Wuyi, China
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Lin R, Liu Y, Lin X, Lu F, Yang Y, Wang C, Fang H, Chen Y, Huang H. A randomized controlled trial evaluating effects of prophylactic irrigation-suction near pancreaticojejunostomy on postoperative pancreatic fistula after pancreaticoduodenectomy. Langenbecks Arch Surg 2023; 408:137. [PMID: 37010643 DOI: 10.1007/s00423-023-02873-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 03/30/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common complication after pancreaticoduodenectomy (PD). However, whether irrigation-suction (IS) decreases the incidence and severity of CR-POPF has not yet been well elucidated. METHODS One hundred and twenty patients with planned PD were enrolled in the study at a high-volume pancreatic center in China from August 2018 to January 2020. A randomized controlled trial (RCT) was conducted to evaluate whether irrigation-suction (IS) decreases the incidence and severity of CR-POPF and other postoperative complications after PD. The primary endpoint was the incidence of CR-POPF, and the secondary endpoints were other postoperative complications. RESULTS Sixty patients were assigned to the control group and 60 patients to the IS group. The IS group had a comparable POPF rate (15.0% vs. 18.3%, p = 0.806) but a lower incidence of intra-abdominal infection (8.3% vs. 25.0%, p = 0.033) than the control group. The incidences of other postoperative complications were comparable in the two groups. The subgroup analysis for patients with intermediate/high risks for POPF also showed an equivalent POPF rate (17.0% vs. 20.4%, p = 0.800) and a significantly decreased incidence of intra-abdominal infection (8.5% vs. 27.8%, p = 0.020) in the IS group than that in the control group. The logistic regression models indicated that POPF was an independent risk factor for intra-abdominal infection (OR 0.049, 95% CI 0.013-0.182, p = 0.000). CONCLUSIONS Irrigation-suction near pancreaticojejunostomy does not reduce the incidence or severity of postoperative pancreatic fistula but decreases the incidence of intra-abdominal infection after pancreaticoduodenectomy.
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Affiliation(s)
- Ronggui Lin
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Yuhuang Liu
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Xianchao Lin
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Fengchun Lu
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Yuanyuan Yang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Congfei Wang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Haizong Fang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Yanchang Chen
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Heguang Huang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China.
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Pergolini I, Schorn S, Goess R, Novotny AR, Ceyhan GO, Friess H, Demir IE. Drain use in pancreatic surgery: Results from an international survey among experts in the field. Surgery 2022; 172:265-272. [PMID: 34996604 DOI: 10.1016/j.surg.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Drain use in pancreatic surgery remains controversial. This survey sought to evaluate habits, experiences, and opinions of experts in the field on the use of drains to provide interesting insights for pancreatic surgeons worldwide. METHODS An online survey designed via Google Forms was sent in December 2020 to experienced surgeons of the International Study Group for Pancreatic Surgery. RESULTS Forty-two surgeons (42/63, 67%) completed the survey. During their career, 74% (31/42) performed personally >500 pancreatic resections; of these, 9 (21%) >1,500. Sixty-nine percent of the respondents (29/42) declared to always use drains during pancreatic resections and 17% (7/42) in >50% of the operations. For these participants, the use of drains does not increase but reduces the risk of pancreatic fistula and other complications, and more importantly, helps to detect them earlier and manage them better. By contrast, 2 surgeons (5%) declared to never apply drains, whereas other 4 (10%) use drains only in selective cases, deeming that drains increase the risk of infection and other complications. When applied, drains are managed very heterogeneously as for the type of drains, enzyme testing, and removal schedules. Four participants declared to practice continuous irrigation. Twenty-two surgeons (55%) remove drains routinely within the third postoperative day, other 11 (27.5%) only in selected cases, whereas 7 (17.5%) normally keep drains longer. CONCLUSION Despite plenty of publications on this topic, drain management in pancreatic surgery remains very heterogeneous. Safety and the surgeon´s personal experience seem to play a determining role.
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Affiliation(s)
- Ilaria Pergolini
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany; CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Stephan Schorn
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Rüdiger Goess
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Alexander R Novotny
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Güralp O Ceyhan
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany; Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey; German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany; CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany; Else Kröner Clinician Scientist Professor for Translational Pancreatic Surgery, Munich, Germany.
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Tan X, Zhang M, Li L, Wang H, Liu X, Jiang H. Retrospective study of active drainage in the management of anastomotic leakage after anterior resection for rectal cancer. J Int Med Res 2021; 49:3000605211065942. [PMID: 34918983 PMCID: PMC8721718 DOI: 10.1177/03000605211065942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective Anastomotic leakage (AL) is the most serious postoperative complication following anterior resection for rectal cancer. We aimed to investigate the efficacy of active drainage for the management of AL. Methods This was a retrospective study using information from a database of patients who underwent colorectal resection without a defunctioning ileostomy at our center between September 2013 and January 2021. We identified 122 cases with definitive AL who did not require revision emergent laparotomy. Among these patients, we evaluated those who received active drainage to replace the original passive drainage. Results There were 62 cases in the active drainage group and 60 cases in the passive drainage group. The active drainage group had a shorter mean AL spontaneous resolution time (26.9 ± 3.3 vs. 32.2 ± 4.8 days) and lower average hospitalization costs (82,680.6 vs. 92,299.3 renminbi (RMB)) compared with the passive drainage group, respectively. Moreover, seven patients in the passive drainage group subsequently underwent diverting stoma to resolve the Al, while all ALs resolved spontaneously after replacing the passive drainage with active drainage. Conclusions Our study suggests that active drainage may accelerate the spontaneous resolution of AL.
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Affiliation(s)
- Xiaojie Tan
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
| | - Mei Zhang
- Department of Gastrointestinal Surgery, the People's Hospital of Jimo District of Qingdao, Shandong Province, 266200, China
| | - Lai Li
- Department of General Surgery, the Second Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266042, China
| | - He Wang
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
| | - Xiaodong Liu
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
| | - Haitao Jiang
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
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He S, Xia J, Zhang W, Lai M, Cheng N, Liu Z, Cheng Y. Prophylactic abdominal drainage for pancreatic surgery. Cochrane Database Syst Rev 2021; 12:CD010583. [PMID: 34921395 PMCID: PMC8683710 DOI: 10.1002/14651858.cd010583.pub5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Sirong He
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jie Xia
- The Key Laboratory of Molecular Biology on Infectious Diseases, Chongqing Medical University, Chongqing, China
| | - Wei Zhang
- Department of Hepatopancreatobiliary Surgery, The People's Hospital of Jianyang City, Jianyang, China
| | - Mingliang Lai
- Department of Clinical Laboratory, Jiangjin Central Hospital, Chongqing, China
| | - Nansheng Cheng
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zuojin Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Li Y, Sun Y, Liu Z, Li Y, Gou S. Active drain system with reticulated open-pore foam-surface dressing for postoperative pancreatic fistula in a rat model. Ann Med Surg (Lond) 2021; 68:102559. [PMID: 34386219 PMCID: PMC8346361 DOI: 10.1016/j.amsu.2021.102559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/10/2021] [Indexed: 02/07/2023] Open
Abstract
Background Postoperative pancreatic fistula (POPF) is one of the most harmful complications after pancreatic resection. Efficient drainage affects the clinical outcome of POPF. Inefficient drain of the fluid collection should contribute greatly to the need of additional interventional drainage, secondary morbid complications, and death. Methods A rat model of POPF was established by distal pancreatosplenectomy. A novel active drain system (ADS) for POPF was developed by wrapping polyvinyl alcohol sponges (PVA) to an end of the drainage tube. Passive drain system (PDS), ADS and ADS with PVA were used for POPF in rat models. The volume and amylase of ascites were measured. CT scan was applied to assess abdominal fluid collection. Rats pancreatic transection stumps were stained by hematoxylin and eosin (H&E). Results The volume of drainage of ADS with PVA group was less than that of PDS group and ADS group at late stage. CT scan showed obvious abdominal fluid collections in 2/8, 2/8 and 0/8 rats in PDS, ADS and ADS with PVA group separately. Macrofindings showed significant intra-abdominal adhesions and inflammation in PDS and ADS group but not in ADS with PVA group. H&E staining showed less inflammatory cells and destroyed pancreatic glands in ADS with PVA group. Conclusion ADS with PVA drained ascites effectively in the rat model of POPF. The effective drainage of pancreatic juice reduced the inflammation of abdominal organs and pancreatic resection stumps, and might promote the healing of POPF.
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Affiliation(s)
- Yang Li
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ying Sun
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zhiqiang Liu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yongfeng Li
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shanmiao Gou
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
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10
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Park LJ, Baker L, Smith H, Lemke M, Davis A, Abou-Khalil J, Martel G, Balaa FK, Bertens KA. Passive Versus Active Intra-Abdominal Drainage Following Pancreatic Resection: Does A Superior Drainage System Exist? A Systematic Review and Meta-Analysis. World J Surg 2021; 45:2895-2910. [PMID: 34046692 DOI: 10.1007/s00268-021-06158-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 12/14/2022]
Abstract
Postoperative pancreatic fistula (POPF) is a major source of morbidity following pancreatic resection. Surgically placed drains under suction or gravity are routinely used to help mitigate the complications associated with POPF. Controversy exists as to whether one of these drain management strategies is superior. The objective was to identify and compare the incidence of POPF, adverse events, and resource utilization associated with passive gravity (PG) versus active suction (AS) drainage following pancreatic resection. MEDLINE, EMBASE, CINAHL, and Cochrane Library databases were searched from inception to May 18, 2020. Outcomes of interest included POPF, post-pancreatectomy hemorrhage (PPH), surgical site infection (SSI), other major morbidity, and resource utilization. Descriptive qualitative and pooled quantitative meta-analyses were performed. One randomized control trial and five cohort studies involving 10 663 patients were included. Meta-analysis found no difference in the odds of developing POPF between AS and PG (p = 0.78). There were no differences in other endpoints including PPH (p = 0.58), SSI (wound p = 0.21, organ space p = 0.05), major morbidity (p = 0.71), or resource utilization (p = 0.72). The risk of POPF or other adverse outcomes is not impacted by drain management following pancreatic resection. Based on current evidence, a suggestion cannot be made to support the use of one drain over another at this time. There is a trend toward increased intra-abdominal wound infections with AS drains (p = 0.05) that merits further investigation.
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Affiliation(s)
- Lily J Park
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Laura Baker
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Heather Smith
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Madeline Lemke
- Division of General Surgery, Department of Surgery, Western University, London, Canada
| | - Alexandra Davis
- Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital, CCW1667b, 501 Smyth Road, Ottawa, K1H 8L6, Canada
| | - Jad Abou-Khalil
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada.,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital, CCW1667b, 501 Smyth Road, Ottawa, K1H 8L6, Canada
| | - Guillaume Martel
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada.,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital, CCW1667b, 501 Smyth Road, Ottawa, K1H 8L6, Canada
| | - Fady K Balaa
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada.,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital, CCW1667b, 501 Smyth Road, Ottawa, K1H 8L6, Canada
| | - Kimberly A Bertens
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada. .,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital, CCW1667b, 501 Smyth Road, Ottawa, K1H 8L6, Canada.
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11
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Kone LB, Maker VK, Banulescu M, Maker AV. Should Drains Suck? A Propensity Score Analysis of Closed-Suction Versus Closed-Gravity Drainage After Pancreatectomy. J Gastrointest Surg 2021; 25:1224-1232. [PMID: 32394123 DOI: 10.1007/s11605-020-04613-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/11/2020] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Lyonell B Kone
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, IL, USA.,Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Vijay K Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, IL, USA.,Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Mihaela Banulescu
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Ajay V Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, Chicago, IL, USA. .,Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
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12
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Veziant J, Selvy M, Buc E, Slim K. Evidence-based evaluation of abdominal drainage in pancreatic surgery. J Visc Surg 2021; 158:220-230. [PMID: 33358121 DOI: 10.1016/j.jviscsurg.2020.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- J Veziant
- Department of digestive and hepato-biliary surgery, university hospital center of Clermont-Ferrand, Clermont-Ferrand, France.
| | - M Selvy
- Department of digestive and hepato-biliary surgery, university hospital center of Clermont-Ferrand, Clermont-Ferrand, France
| | - E Buc
- Department of digestive and hepato-biliary surgery, university hospital center of Clermont-Ferrand, Clermont-Ferrand, France
| | - K Slim
- Department of digestive and hepato-biliary surgery, university hospital center of Clermont-Ferrand, Clermont-Ferrand, France; Groupe francophone de réhabilitation améliorée après chirurgie (GRACE), Beaumont, France
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13
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Chao J, Zhu C, Jia Z, Zhang X, Qin X. Prophylactic active irrigation drainage reduces the risk of post-operative pancreatic fistula-related complications in patients undergoing limited pancreatic resection. J Minim Access Surg 2021; 17:197-201. [PMID: 33047685 PMCID: PMC8083757 DOI: 10.4103/jmas.jmas_290_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective: The objective of this study is to evaluate the efficacy of prophylactic active irrigation drainage in preventing post-operative pancreatic fistula (POPF) and POPF-related complications in patients undergoing limited pancreatic resection (LPR). Materials and Methods: Patients who underwent LPR for benign or borderline pancreatic lesions between February 2014 and March 2019 were enroled in this retrospective study. Patients were divided into two groups according to the type of intraperitoneal drainage used: closed-suction drainage (CSD) or continuous active irrigation drainage (CAID). Data regarding the outcomes and complications of surgery were collected and analysed. Results: A total of 50 patients (33 women; age, 50.1 ± 10.8 years) were included in this study. Twenty-nine patients were treated with CSD, and 21 patients were treated with CAID. Clinically relevant POPF and POPF-related complications occurred in 11 patients in the CSD group and in two patients in the CAID group (P = 0.024). Patients in the CSD group demonstrated a longer tube indwelling time than those in the CAID group (17.1 ± 10.2 days vs. 13.7 ± 7.5 days; P = 0.044). Mean post-operative hospital stay was also longer in the CSD group than in the CAID group (20.6 ± 7.9 days vs. 16.1 ± 6.3 days; P = 0.039). Conclusions: Prophylactic CAID appears to be an effective alternative for the management of POPF and POPF-related complications in patients undergoing LPR.
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Affiliation(s)
- Jiadeng Chao
- Department of General Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
| | - Chunfu Zhu
- Department of General Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
| | - Zhongzhi Jia
- Department of General Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
| | - Xudong Zhang
- Department of General Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
| | - Xihu Qin
- Department of General Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou 213003, Jiangsu Province, China
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14
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Tarvainen T, Sirén J, Kokkola A, Sallinen V. Effect of Hydrocortisone vs Pasireotide on Pancreatic Surgery Complications in Patients With High Risk of Pancreatic Fistula: A Randomized Clinical Trial. JAMA Surg 2020; 155:291-298. [PMID: 32022887 PMCID: PMC7042940 DOI: 10.1001/jamasurg.2019.6019] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Question Is hydrocortisone noninferior compared with pasireotide in reducing pancreatic surgery complications? Findings In this randomized clinical trial that included 126 patients undergoing partial pancreatectomy, the mean Comprehensive Complication Index score (a measurement of overall postoperative morbidity) was –6.16 points lower in patients receiving pasireotide and the lower limit of the 90% CI crossed the prespecified noninferiority margin (–9). In subgroup analyses of patients undergoing distal pancreatectomy, the mean Comprehensive Complication Index score was significantly lower (10.3 points) in the pasireotide vs hydrocortisone group. Meaning In this study, hydrocortisone is not noninferior compared with pasireotide, and pasireotide may be more effective in reducing postoperative complications in patients undergoing distal pancreatectomy. Importance Both hydrocortisone and pasireotide have been shown in randomized clinical trials to be effective in reducing postoperative complications of pancreatic surgery, but to date no randomized clinical trial has evaluated the effectiveness of pasireotide compared with hydrocortisone. Objective To assess the noninferiority of hydrocortisone compared with pasireotide in reducing complications after partial pancreatectomy. Design, Setting, and Participants A noninferiority, parallel-group, individually randomized clinical trial was conducted at a single academic center between May 19, 2016, and December 17, 2018. Outcome collectors and analyzers were blinded. A total of 281 patients undergoing partial pancreatectomy were assessed for inclusion. Patients younger than 18 years, those allergic to hydrocortisone or pasireotide, patients undergoing pancreaticoduodenectomy with hard pancreas or dilated pancreatic duct, and patients not eventually undergoing partial pancreatectomy were excluded. Modified intention-to-treat analysis was used in determination of the results. Interventions Treatment included pasireotide, 900 μg, subcutaneously twice a day for 7 days or hydrocortisone, 100 mg, intravenously 3 times a day for 3 days. Main Outcomes and Measures The primary outcome was the Comprehensive Complication Index (CCI) score within 30 days. The noninferiority limit was set to 9 CCI points. Results Of the 281 patients (mean [SD] age, 63.8 years) assessed for eligibility, 168 patients (mean [SD] age, 63.6 years) were randomized and 126 were included in the modified intention-to-treat analyses. Sixty-three patients received pasireotide (35 men [56%]; median [interquartile range] age, 64 [56-70] years) and 63 patients received hydrocortisone (25 men [40%]; median [interquartile range] age, 67 [56-73] years). The mean (SD) CCI score was 23.94 (17.06) in the pasireotide group and 30.11 (20.47) in the hydrocortisone group (mean difference, –6.16; 2-sided 90% CI, –11.73 to –0.60), indicating that hydrocortisone was not noninferior. Postoperative pancreatic fistula was detected in 34 patients (54%) in the pasireotide group and 39 patients (62%) in the hydrocortisone group (odds ratio, 1.39; 95% CI, 0.68-2.82; P = .37). One patient in the pasireotide group and 2 patients in the hydrocortisone group died within 30 days. In subgroup analyses of patients undergoing distal pancreatectomy, the CCI score was a mean of 10.3 points lower (mean [SD], 16.03 [11.94] vs 26.28 [21.76]; 2-sided 95% CI, −19.34 to −2.12; P = .03) and postoperative pancreatic fistula rate was lower (37% vs 67%; P = .02) in the pasireotide group compared with the hydrocortisone group. Conclusions and Relevance In this study, hydrocortisone was not noninferior compared with pasireotide in patients undergoing partial pancreatectomy. Pasireotide may be more effective than hydrocortisone in patients undergoing distal pancreatectomy. Trial Registration ClinicalTrials.gov identifier: NCT02775227; EudraCT identifier: 2016-000212-16
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Affiliation(s)
- Timo Tarvainen
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jukka Sirén
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Arto Kokkola
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Sallinen
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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15
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Xourafas D, Ejaz A, Tsung A, Dillhoff M, Pawlik TM, Cloyd JM. Suction or Gravity: Impact of Closed-System Drain Type on the Postoperative Outcomes of Pancreatoduodenectomy. Am Surg 2020. [DOI: 10.1177/000313482008600208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Dimitrios Xourafas
- Department of Surgery Brigham and Women's Hospital Boston, Massachusetts Department of Surgery The Ohio State University Wexner Medical Center Columbus, Ohio
| | - Aslam Ejaz
- Department of Surgery The Ohio State University Wexner Medical Center Columbus, Ohio
| | - Allan Tsung
- Department of Surgery The Ohio State University Wexner Medical Center Columbus, Ohio
| | - Mary Dillhoff
- Department of Surgery The Ohio State University Wexner Medical Center Columbus, Ohio
| | - Timothy M. Pawlik
- Department of Surgery The Ohio State University Wexner Medical Center Columbus, Ohio
| | - Jordan M. Cloyd
- Department of Surgery The Ohio State University Wexner Medical Center Columbus, Ohio
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16
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Park L, Baker L, Smith H, Davies A, Abou Khalil J, Martel G, Balaa F, Bertens KA. Passive versus active intra-abdominal drainage following pancreatic resection: does a superior drainage system exist? A protocol for systematic review. BMJ Open 2019; 9:e031319. [PMID: 31530619 PMCID: PMC6756355 DOI: 10.1136/bmjopen-2019-031319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most common cause of major morbidity following pancreatic resection. Intra-abdominal drains are frequently positioned adjacent to the pancreatic anastomosis or transection margin at the time of surgery to aid in detection and management of CR-POPF. Drains can either evacuate fluid by passive gravity (PG) or be attached to a closed suction (CS) system using negative pressure. There is controversy as to whether one of these two systems is superior. The objective of this review is to identify and compare the incidence of adverse events (AEs) and resource utilisation associated with PG and CS drainage following pancreatic resections. METHODS AND ANALYSIS MEDLINE, EMBASE, CINAHL and Cochrane Central Registry of Controlled Trials will be searched from inception to April 2019, to identify interventional and observational studies comparing PG and CS drains following pancreatic resection. The primary outcome is POPF as defined by the International Study Group for Pancreatic Fistula in 2017. Secondary outcomes include postoperative AE, resource utilisation (length of stay, return to emergency department, readmission and reintervention), time to drain removal and quality of life. Study selection, data extraction and risk of bias assessment will be performed independently, by two reviewers. A meta-analysis will be conducted if deemed statistically appropriate. Subgroup analysis by study design will be performed. Study heterogeneity will be calculated with the χ2 test and reported as I2 statistics. Statistical analyses will be conducted and displayed using RevMan V.5.3 ETHICS AND DISSEMINATION: Ethics approval is not required. The results of this study will be submitted to relevant conferences for presentation and peer-reviewed journals for publication. PROSPERO REGISTRATION NUMBER CRD42019123647.
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Affiliation(s)
- Lily Park
- School of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Laura Baker
- General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Heather Smith
- General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Jad Abou Khalil
- Hepatopancreaticobiliary Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Hepatopancreaticobiliary Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Fady Balaa
- Hepatopancreaticobiliary Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Kimberly A Bertens
- Hepatopancreaticobiliary Surgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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17
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Passive drainage to gravity and closed-suction drainage following pancreatoduodenectomy lead to similar grade B and C postoperative pancreatic fistula rates. A meta-analysis. Int J Surg 2019; 67:24-31. [DOI: 10.1016/j.ijsu.2019.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/12/2019] [Accepted: 05/03/2019] [Indexed: 12/17/2022]
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18
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Marchegiani G, Ramera M, Viviani E, Lombardo F, Cybulski A, Chincarini M, Malleo G, Bassi C, Zamboni GA, Salvia R. Dislocation of intra-abdominal drains after pancreatic surgery: results of a prospective observational study. Langenbecks Arch Surg 2019; 404:213-222. [PMID: 30771076 DOI: 10.1007/s00423-019-01760-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 02/05/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE The use of intra-abdominal drains after major surgical procedures represents a well-established but controversial practice. No data are available regarding both the occurrence and the potential impact of their postoperative accidental dislocation. The aim of this study is to assess the actual rate of dislocation of intra-abdominal drains postoperatively and to evaluate its clinical impact. METHODS This is a prospective observational study using major pancreatic surgery as a model. Ninety-one consecutive patients undergoing pancreatoduodenectomy (PD) or distal pancreatectomy (DP) underwent low-dose, non-enhanced computed tomography (LDCT) on postoperative days (POD) 1 and 3 in a blinded fashion to assess the position of drains. We compared the outcomes of patients with dislocated and correctly placed drains. RESULTS Overall, drains were dislocated in 30 patients (33%), without differences between PD and DP. Most of dislocations were already present on POD 1 (77%). Postoperative complications occurred in 57% of patients, and the rate of postoperative pancreatic fistula (POPF) was 27%. The dislocated cohort had lesser morbidity (40% vs. 66%; relative risk (RR), 0.35; 95% CI, 0.14-0.86; P = 0.020), and the rate of POPF (3% vs. 39%, respectively; RR, 0.05; 95% CI, 0.01-0.42; P < 0.001). After PD, patients with dislocated drains had a shorter hospital stay (12 vs. 20 days; P = 0.015). No significant differences in terms of need for percutaneous drainage procedures, abdominal collections, or grade C POPFs were found between the groups. CONCLUSIONS Dislocation of intra-abdominal drains is an early and frequent event after major pancreatic resection. Its occurrence might protect against the negative effects of maintaining drainage, eventually leading to better postoperative outcomes. This data reinforces the knowledge that surgical drains might be detrimental in selected cases.
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Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Marco Ramera
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Elena Viviani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Fabio Lombardo
- Department of Radiology, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Adam Cybulski
- Department of Radiology, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Marco Chincarini
- Department of Radiology, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy. .,Department of General and Pancreatic Surgery, "GB Rossi" Hospital, University of Verona, Piazzale L.A. Scuro, 10, 37134, Verona, Italy.
| | - Giulia A Zamboni
- Department of Radiology, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
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19
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Zhang W, He S, Cheng Y, Xia J, Lai M, Cheng N, Liu Z. Prophylactic abdominal drainage for pancreatic surgery. Cochrane Database Syst Rev 2018; 6:CD010583. [PMID: 29928755 PMCID: PMC6513487 DOI: 10.1002/14651858.cd010583.pub4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The use of surgical drains has been considered mandatory 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, compare the effects of different types of surgical drains, and evaluate the optimal time for drain removal. SEARCH METHODS For the last version of this review, we searched CENTRAL (2016, Issue 8), and MEDLINE, Embase, Science Citation Index Expanded, and Chinese Biomedical Literature Database (CBM) to 28 August 2016). For this updated review, we searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, and CBM from 2016 to 15 November 2017. SELECTION CRITERIA We included all randomized controlled trials that compared abdominal drainage versus no drainage in people undergoing pancreatic surgery. We also included randomized controlled studies that compared different types of drains and different schedules for drain removal in people undergoing pancreatic surgery. DATA COLLECTION AND ANALYSIS We identified six studies (1384 participants). Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). For all analyses, we used the random-effects model. MAIN RESULTS Drain use versus no drain useWe included four studies with 1110 participants, who were randomized to the drainage group (N = 560) and the no drainage group (N = 550) after pancreatic surgery. There was little or no difference in mortality at 30 days between groups (1.5% with drains versus 2.3% with no drains; RR 0.78, 95% CI 0.31 to 1.99; four studies, 1055 participants; moderate-quality evidence). Drain use probably slightly reduced mortality at 90 days (0.8% versus 4.2%; RR 0.23, 95% CI 0.06 to 0.90; two studies, 478 participants; moderate-quality evidence). We were uncertain whether drain use reduced intra-abdominal infection (7.9% versus 8.2%; RR 0.97, 95% CI 0.52 to 1.80; four studies, 1055 participants; very low-quality evidence), or additional radiological interventions for postoperative complications (10.9% versus 12.1%; RR 0.87, 95% CI 0.79 to 2.23; three studies, 660 participants; very low-quality evidence). Drain use may lead to similar amount of wound infection (9.8% versus 9.9%; RR 0.98 , 95% CI 0.68 to 1.41; four studies, 1055 participants; low-quality evidence), and additional open procedures for postoperative complications (9.4% versus 7.1%; RR 1.33, 95% CI 0.79 to 2.23; four studies, 1055 participants; low-quality evidence) when compared with no drain use. There was little or no difference in morbidity (61.7% versus 59.7%; RR 1.03, 95% CI 0.94 to 1.13; four studies, 1055 participants; moderate-quality evidence), or length of hospital stay (MD -0.66 days, 95% CI -1.60 to 0.29; three studies, 711 participants; moderate-quality evidence) between groups. There was one drain-related complication in the drainage group (0.2%). Health-related quality of life was measured with the pancreas-specific quality-of-life questionnaire (FACT-PA; a scale of 0 to 144 with higher values indicating a better quality of life). Drain use may lead to similar quality of life scores, measured at 30 days after pancreatic surgery, when compared with no drain use (105 points versus 104 points; one study, 399 participants; low-quality evidence). Hospital costs and pain were not reported in any of the studies.Type of drainWe included one trial involving 160 participants, who were randomized to the active drain group (N = 82) and the passive drain group (N = 78) after pancreatic surgery. An active drain may lead to similar mortality at 30 days (1.2% with active drain versus 0% with passive drain; low-quality evidence), and morbidity (22.0% versus 32.1%; RR 0.68, 95% CI 0.41 to 1.15; low-quality evidence) when compared with a passive drain. We were uncertain whether an active drain decreased intra-abdominal infection (0% versus 2.6%; very low-quality evidence), wound infection (6.1% versus 9.0%; RR 0.68, 95% CI 0.23 to 2.05; very low-quality evidence), or the number of additional open procedures for postoperative complications (1.2% versus 7.7%; RR 0.16, 95% CI 0.02 to 1.29; very low-quality evidence). Active drain may reduce length of hospital stay slightly (MD -1.90 days, 95% CI -3.67 to -0.13; one study; low-quality evidence; 14.1% decrease of an 'average' length of hospital stay). Additional radiological interventions, pain, and quality of life were not reported in the study.Early versus late drain removalWe included one trial involving 114 participants with a low risk of postoperative pancreatic fistula, who were randomized to the early drain removal group (N = 57) and the late drain removal group (N = 57) after pancreatic surgery. There was no mortality in either group. Early drain removal may slightly reduce morbidity (38.6% with early drain removal versus 61.4% with late drain removal; RR 0.63, 95% CI 0.43 to 0.93; low-quality evidence), length of hospital stay (MD -2.10 days, 95% CI -4.17 to -0.03; low-quality evidence; 21.5% decrease of an 'average' length of hospital stay), and hospital costs (MD -EUR 2069.00, 95% CI -3872.26 to -265.74; low-quality evidence; 17.0% decrease of 'average' hospital costs). We were uncertain whether early drain removal reduced additional open procedures for postoperative complications (0% versus 1.8%; RR 0.33, 95% CI 0.01 to 8.01; one study; very low-quality evidence). Intra-abdominal infection, wound infection, additional radiological interventions, pain, and quality of life were not reported in the study. AUTHORS' CONCLUSIONS It was unclear whether routine abdominal drainage had any effect on the reduction of mortality at 30 days, or postoperative complications after pancreatic surgery. Moderate-quality evidence suggested that routine abdominal drainage probably slightly reduced mortality at 90 days. Low-quality evidence suggested that use of an active drain compared to the use of a passive drain may slightly reduce the length of hospital stay after pancreatic surgery, and early removal may be superior to late removal for people with low risk of postoperative pancreatic fistula.
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Affiliation(s)
- Wei Zhang
- The People's Hospital of Jianyang CityDepartment of Hepatopancreatobiliary SurgeryNo. 180, Hospital RoadJianyangSichuanChina641499
| | - Sirong He
- Chongqing Medical UniversityDepartment of Immunology, College of Basic MedicineNo. 1 Yixue RoadChongqingChina450000
| | - Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Jie Xia
- Chongqing Medical UniversityThe Key Laboratory of Molecular Biology on Infectious DiseasesChongqingChina450000
| | - Mingliang Lai
- Jiangjin Central HospitalDepartment of Clinical LaboratoryNo. 65, Jiang Zhou RoadChongqingChina402260
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Zuojin Liu
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
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Sallinen VJ, Le Large TYS, Tieftrunk E, Galeev S, Kovalenko Z, Haugvik SP, Antila A, Franklin O, Martinez-Moneo E, Robinson SM, Panzuto F, Regenet N, Muffatti F, Partelli S, Wiese D, Ruszniewski P, Dousset B, Edwin B, Bartsch DK, Sauvanet A, Falconi M, Ceyhan GO, Gaujoux S. Prognosis of sporadic resected small (≤2 cm) nonfunctional pancreatic neuroendocrine tumors - a multi-institutional study. HPB (Oxford) 2018; 20:251-259. [PMID: 28988702 DOI: 10.1016/j.hpb.2017.08.034] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 07/30/2017] [Accepted: 08/30/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Malignant potential of small (≤20 mm) nonfunctional pancreatic neuroendocrine tumors (sNF-PNET) is difficult to predict and management remain controversial. The aim of this study was to assess the prognosis of sporadic nonmetastatic sNF-PNETs. METHODS Patients were identified from databases of 16 centers. Outcomes and risk factors for recurrence were identified by uni- and multivariate analyses. RESULTS sNF-PNET was resected in 210 patients, and 66% (n = 138) were asymptomatic. Median age was 60 years, median tumor size was 15 mm, parenchyma-sparing surgery was performed in 42%. Postoperative mortality was 0.5% (n = 1), severe morbidity rate was 14.3% (n = 30), and 14 of 132 patients (10.6%) with harvested lymph nodes had metastatic lymph nodes. Tumor size, presence of biliary or pancreatic duct dilatation, and WHO grade 2-3 were independently associated with recurrence. Patients with tumors sized ≤10 mm were disease free at last follow-up. The 1-, 3- and 5-year disease-free survival rates for patients with tumors sized 11-20 mm on preoperative imaging were 95.1%, 91.0%, and 87.3%, respectively. CONCLUSIONS In sNF-PNETs, the presence of biliary or pancreatic duct dilatation or WHO grade 2-3 advocate for surgical treatment. In the remaining patients, a wait-and-see policy might be considered.
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Affiliation(s)
- Ville J Sallinen
- Department of Abdominal Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Transplantation and Liver Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
| | - Tessa Y S Le Large
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Elke Tieftrunk
- Department of Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Shamil Galeev
- General Surgery Department, Saint Luke's Clinical Hospital, Saint Petersburg, Russia
| | - Zahar Kovalenko
- Federal Medical and Rehabilitation Center, Department of Surgical Oncology, Moscow, Russia
| | - Sven-Petter Haugvik
- The Intervention Center, Oslo University Hospital, Oslo, Norway; Department of Surgery, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Anne Antila
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Oskar Franklin
- Department of Surgical and Perioperative Sciences, Umea University, Umea, Sweden
| | - Emma Martinez-Moneo
- Gastroenterology Department, Hospital Universitario Cruces, Barakaldo, Bizkaia, Spain
| | - Stuart M Robinson
- Department of HPB Surgery, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Francesco Panzuto
- Digestive and Liver Disease Unit, Sant'Andrea Hospital - Sapienza University of Rome, Italy
| | - Nicolas Regenet
- Department of Digestive and Endocrine Surgery, Institut des Maladies Digestives (IMAD), Nantes 44093, France
| | - Francesca Muffatti
- Chirurgia Del Pancreas, Chirurgia Del Pancreas, Pancreas Translational & Clinical Research Center, Università Vita e Salute, Ospedale San Raffaele IRCC, Milano, Italy
| | - Stefano Partelli
- Chirurgia Del Pancreas, Chirurgia Del Pancreas, Pancreas Translational & Clinical Research Center, Università Vita e Salute, Ospedale San Raffaele IRCC, Milano, Italy
| | - Dominik Wiese
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Philippe Ruszniewski
- Department of Gastroenterology, Pôle des Maladies de L'Appareil Digestif (PMAD), DHU Unity, Clichy 92110, France; Université Paris Diderot, Paris, France
| | - Bertrand Dousset
- Department of Digestive, Pancreatic and Endocrine Surgery, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Bjørn Edwin
- The Intervention Center, Oslo University Hospital, Oslo, Norway; Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Detlef K Bartsch
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Marburg, Germany
| | - Alain Sauvanet
- Université Paris Diderot, Paris, France; AP-HP, Hôpital Beaujon, Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de L'Appareil Digestif (PMAD), DHU Unity, University Paris VII, AP-HP, Hôpital Beaujon, Clichy 92110, France
| | - Massimo Falconi
- Chirurgia Del Pancreas, Chirurgia Del Pancreas, Pancreas Translational & Clinical Research Center, Università Vita e Salute, Ospedale San Raffaele IRCC, Milano, Italy
| | - Güralp O Ceyhan
- Department of Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sebastien Gaujoux
- Department of Digestive, Pancreatic and Endocrine Surgery, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
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21
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Ikeshima R, Mizushima T, Takahashi H, Haraguchi N, Nishimura J, Hata T, Matsuda C, Ikenaga M, Nakajima K, Yamamoto H, Murata K, Doki Y, Mori M. The efficacy of active drainage for preventing postoperative organ/space surgical site infections in patients with Crohn's disease. Surg Today 2017; 48:25-32. [PMID: 28608250 DOI: 10.1007/s00595-017-1549-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 05/11/2017] [Indexed: 11/11/2022]
Abstract
PURPOSE Patients with Crohn's disease (CD) show a higher incidence of surgical site infections (SSIs) after bowel resection in comparison to other patient populations because CD patients commonly suffer from anemia, malnutrition, and immunosuppression. In comparison to conventional passive drainage, active drainage using a closed-suction drain reportedly reduces postoperative wound-related complications in several diseases. In the present study, we aimed to investigate the incidence of SSI and to identify the risk factors for SSI in patients with CD. METHODS We retrospectively analyzed the patient characteristics and perioperative data of 106 CD patients who underwent bowel resection at our institution between January 2000 and June 2016. We statistically analyzed the incidence of different types of SSI (overall, incisional, and organ/space) in relation to patient-related and surgery-related risk factors. RESULTS Overall postoperative SSIs were diagnosed in 19 patients (17.9%), including incisional SSI (n = 16; 15.1%), organ/space SSI (n = 7; 6.6%), and both (n = 4; 3.8%). A long operative time (p = 0.036) and colonic involvement (p = 0.011) were significantly associated with the overall risk of developing an SSI. Active drainage significantly reduced the incidence of organ/space SSI (p = 0.037). CONCLUSION Intraabdominal active drainage was more useful than passive drainage for preventing organ/space SSI development.
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Affiliation(s)
- Ryo Ikeshima
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Tsunekazu Mizushima
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan. .,Department of Therapeutics for Inflammatory Bowel Diseases, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan.
| | - Hidekazu Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Naotsugu Haraguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Junichi Nishimura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Taishi Hata
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Chu Matsuda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Masakazu Ikenaga
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan.,Department of Gastroenterological Surgery, Higashiosaka City Medical Center, Osaka, Japan.,Japan Department of Surgery, Higashiosaka City General Hospital, Osaka, Japan
| | - Kiyokazu Nakajima
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Hirofumi Yamamoto
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Kohei Murata
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan.,Department of Surgery, Suita Municipal Hospital, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
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22
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Aumont O, Dupré A, Abjean A, Pereira B, Veziant J, Le Roy B, Pezet D, Buc E, Gagnière J. Does intraoperative closed-suction drainage influence the rate of pancreatic fistula after pancreaticoduodenectomy? BMC Surg 2017; 17:58. [PMID: 28511699 PMCID: PMC5434540 DOI: 10.1186/s12893-017-0257-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/10/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Although drainage of pancreatic anastomoses after pancreaticoduodenectomy (PD) is still debated, it remains recommended, especially in patients with a high risk of post-operative pancreatic fistula (POPF). Modalities of drainage of pancreatic anastomoses, especially the use of passive (PAD) or closed-suction (CSD) drains, and their impact on surgical outcomes, have been poorly studied. The aim was to compare CSD versus PAD on surgical outcomes after PD. METHODS Retrospective analysis of 197 consecutive patients who underwent a standardized PD at two tertiary centers between March 2012 and April 2015. Patients with PAD (n = 132) or CSD (n = 65) were compared. RESULTS There was no significant difference in terms of 30-day overall and severe post-operative morbidity, post-operative hemorrhage, post-operative intra-abdominal fluid collections, 90-day post-operative mortality and mean length of hospital stay. The rate of POPF was significantly increased in the CSD group (47.7% vs. 32.6%; p = 0.04). CSD was associated with an increase of grade A POPF (21.5% vs. 8.3%; p = 0.03), while clinically relevant POPF were not impacted. In patients with grade A POPF, the rate of undrained intra-abdominal fluid collections was increased in the PAD group (46.1% vs. 21.4%; p = 0.18). After multivariate analysis, CSD was an independent factor associated with an increased rate of POPF (OR = 2.43; p = 0.012). CONCLUSIONS There was no strongly relevant difference in terms of surgical outcomes between PAD or CSD of pancreatic anastomoses after PD, but CSD may help to decrease the rate of undrained post-operative intra-abdominal collections in some patients. Further randomized, multi-institutional studies are needed.
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Affiliation(s)
- Ophélie Aumont
- Department of Digestive and Hepatobiliary Surgery, Estaing University Hospital, 1, place Lucie et Raymond Aubrac, 63000, Clermont-Ferrand, France
| | - Aurélien Dupré
- Department of Surgical Oncology, Léon Bérard Cancer Center, Lyon, France
| | - Adeline Abjean
- Department of Digestive and Hepatobiliary Surgery, Estaing University Hospital, 1, place Lucie et Raymond Aubrac, 63000, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics, Délégation à la Recherche Clinique et à l'Innovation, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Julie Veziant
- Department of Digestive and Hepatobiliary Surgery, Estaing University Hospital, 1, place Lucie et Raymond Aubrac, 63000, Clermont-Ferrand, France
| | - Bertrand Le Roy
- Department of Digestive and Hepatobiliary Surgery, Estaing University Hospital, 1, place Lucie et Raymond Aubrac, 63000, Clermont-Ferrand, France
| | - Denis Pezet
- Department of Digestive and Hepatobiliary Surgery, Estaing University Hospital, 1, place Lucie et Raymond Aubrac, 63000, Clermont-Ferrand, France.,UMR 1071 INSERM / Clermont Auvergne University, Clermont-Ferrand, France
| | - Emmanuel Buc
- Department of Digestive and Hepatobiliary Surgery, Estaing University Hospital, 1, place Lucie et Raymond Aubrac, 63000, Clermont-Ferrand, France.,UMR 1071 INSERM / Clermont Auvergne University, Clermont-Ferrand, France
| | - Johan Gagnière
- Department of Digestive and Hepatobiliary Surgery, Estaing University Hospital, 1, place Lucie et Raymond Aubrac, 63000, Clermont-Ferrand, France. .,UMR 1071 INSERM / Clermont Auvergne University, Clermont-Ferrand, France.
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23
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Surveillance strategy for small asymptomatic non-functional pancreatic neuroendocrine tumors - a systematic review and meta-analysis. HPB (Oxford) 2017; 19:310-320. [PMID: 28254159 DOI: 10.1016/j.hpb.2016.12.010] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/11/2016] [Accepted: 12/22/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Non-functional pancreatic neuroendocrine tumors (NF-PNET) are rare neoplasms being increasingly diagnosed. Surgical treatment or expectant management are both suggested for small NF-PNETs. The aim of this study was to evaluate the outcome of surveillance strategy for small NF-PNETs. METHODS A systematic search was performed up to March 2016 in MEDLINE, EMBASE and the Cochrane Library according to the PRISMA guidelines. Data was pooled using the random-effects model. RESULTS Nine articles including 344 patients with sporadic and 64 patients with MEN1 related NF-PNET were selected. Tumor growth was observed in 22% and 52%, development of metastases were reported on 0% and 9%, and rate of secondary surgical resection was 12% and 25% in patients with sporadic or MEN1 related NF-PNETs, respectively. All metastases (1 distant, 4 nodal) were reported by a single study in patients with MEN1. Reason for secondary surgery was tumor growth in half of patients undergoing surgery. DISCUSSION Expectant management of small asymptomatic, sporadic, NF-PNETs could be a reasonable option in highly selected patients. However, the level of evidence is low and longer follow-up is needed to identify patients could benefit from upfront surgery instead of expectant treatment.
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24
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Globke B, Schmelzle M, Bahra M, Pratschke J, Neudecker J. Drainagen in der Viszeralchirurgie: (un)verzichtbar? Chirurg 2017; 88:395-400. [DOI: 10.1007/s00104-017-0404-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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25
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Sallinen V. Recent Advances in Pancreatic Surgery. Scand J Surg 2016; 105:213-214. [PMID: 30208792 DOI: 10.1177/1457496916673801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Ville Sallinen
- Departments of Transplantation and Liver Surgery and Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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26
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Abstract
BACKGROUND The use of surgical drains has been considered mandatory 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, compare the effects of different types of surgical drains, and evaluate the optimal time for drain removal. SEARCH METHODS For the initial version of this review, we searched the Cochrane Library (2015, Issue 3), MEDLINE (1946 to 9 April 2015), Embase (1980 to 9 April 2015), Science Citation Index Expanded (1900 to 9 April 2015), and Chinese Biomedical Literature Database (CBM) (1978 to 9 April 2015). For this updated review, we searched the Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, and CBM from 2015 to 28 August 2016. SELECTION CRITERIA We included all randomized controlled trials that compared abdominal drainage versus no drainage in people undergoing pancreatic surgery. We also included randomized controlled trials that compared different types of drains and different schedules for drain removal in people undergoing pancreatic surgery. DATA COLLECTION AND ANALYSIS We identified five trials (of 985 participants) which met our inclusion criteria. Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). For all analyses, we employed the random-effects model. MAIN RESULTS Drain use versus no drain useWe included three trials involving 711 participants who were randomized to the drainage group (N = 358) and the no drainage group (N = 353) after pancreatic surgery. There was inadequate evidence to establish the effect of drains on mortality at 30 days (2.2% with drains versus 3.4% no drains; RR 0.78, 95% CI 0.31 to 1.99; three studies; low-quality evidence), mortality at 90 days (2.9% versus 11.6%; RR 0.24, 95% CI 0.05 to 1.10; one study; low-quality evidence), intra-abdominal infection (7.3% versus 8.5%; RR 0.89, 95% CI 0.36 to 2.20; three studies; very low-quality evidence), wound infection (12.3% versus 13.3%; RR 0.92, 95% CI 0.63 to 1.36; three studies; low-quality evidence), morbidity (64.8% versus 62.0%; RR 1.04, 95% CI 0.93 to 1.16; three studies; moderate-quality evidence), length of hospital stay (MD -0.66 days, 95% CI -1.60 to 0.29; three studies; moderate-quality evidence), or additional open procedures for postoperative complications (11.5% versus 9.1%; RR 1.18, 95% CI 0.55 to 2.52; three studies). There was one drain-related complication in the drainage group (0.6%). Type of drainWe included one trial involving 160 participants who were randomized to the active drain group (N = 82) and the passive drain group (N = 78) after pancreatic surgery. There was no evidence of differences between the two groups in mortality at 30 days (1.2% with active drain versus 0% with passive drain), intra-abdominal infection (0% versus 2.6%), wound infection (6.1% versus 9.0%; RR 0.68, 95% CI 0.23 to 2.05), morbidity (22.0% versus 32.1%; RR 0.68, 95% CI 0.41 to 1.15), or additional open procedures for postoperative complications (1.2% versus 7.7%; RR 0.16, 95% CI 0.02 to 1.29). The active drain group was associated with shorter length of hospital stay (MD -1.90 days, 95% CI -3.67 to -0.13; 14.1% decrease of an 'average' length of hospital stay) than in the passive drain group. The quality of evidence was low, or very low. Early versus late drain removalWe included one trial involving 114 participants with a low risk of postoperative pancreatic fistula who were randomized to the early drain removal group (N = 57) and the late drain removal group (N = 57) after pancreatic surgery. There was no evidence of differences between the two groups in mortality at 30 days (0% for both groups) or additional open procedures for postoperative complications (0% with early drain removal versus 1.8% with late drain removal; RR 0.33, 95% CI 0.01 to 8.01). The early drain removal group was associated with lower rates of postoperative complications (38.5% versus 61.4%; RR 0.63, 95% CI 0.43 to 0.93), shorter length of hospital stay (MD -2.10 days, 95% CI -4.17 to -0.03; 21.5% decrease of an 'average' length of hospital stay), and hospital costs (17.0% decrease of 'average' hospital costs) than in the late drain removal group. The quality of evidence for each of the outcomes was low. AUTHORS' CONCLUSIONS It is unclear whether routine abdominal drainage has any effect on the reduction of mortality and postoperative complications after pancreatic surgery. In case of drain insertion, low-quality evidence suggests that active drainage may reduce hospital stay after pancreatic surgery, and early removal may be superior to late removal for people with low risk of postoperative pancreatic fistula.
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Affiliation(s)
| | - Jie Xia
- Chongqing Medical UniversityThe Key Laboratory of Molecular Biology on Infectious DiseasesChongqingChina450000
| | - Mingliang Lai
- Jiangjin Central HospitalDepartment of Clinical LaboratoryNo. 65, Jiang Zhou RoadChongqingChina402260
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduChina610041
| | - Sirong He
- Chongqing Medical UniversityDepartment of Immunology, College of Basic MedicineNo.1 Yixue RoadChongqingChina450000
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