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Kodali R, Parasar K, Anand U, Singh BN, Kant K, Arora A, Karthikeyan V, Anwar S, Saha B, Wadaskar S. Evidence-based approach for intraabdominal drainage in pancreatic surgery: A systematic review and meta-analysis. World J Methodol 2025; 15:99080. [DOI: 10.5662/wjm.v15.i3.99080] [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: 07/13/2024] [Revised: 11/09/2024] [Accepted: 12/05/2024] [Indexed: 03/06/2025] Open
Abstract
BACKGROUND Historically intraoperative drains were employed after pancreatic surgery but over the last decade, there has been debate over the routine usage of drains.
AIM To assess the necessity of intra-abdominal drain placement, identify the most effective drain type, and determine the optimal timing for drain removal.
METHODS A systematic review of electronic databases, including PubMed, MEDLINE, PubMed Central, and Google Scholar, was conducted using Medical Subject Headings and keywords until December 2023. From an initial pool of 1910 articles, 48 were included after exclusion and screening. The primary outcomes analyzed were clinically relevant postoperative pancreatic fistula (CR-POPF), delayed gastric emptying (DGE), overall morbidity, and mortality. Subgroup analyses were performed for pancreaticoduodenectomy and distal pancreatectomy.
RESULTS Routine use of drains is associated with a statistically significant increase in the risk of CR-POPF and DGE. Conversely, patients who did not have drains placed experienced a significant reduction in morbidity, readmission rates, and reoperations. No significant differences were observed between active and passive drain types. Early drain removal (< 3 days) yielded favorable outcomes compared to delayed removal.
CONCLUSION Analysis of randomized controlled trials and cohort studies did not demonstrate an advantage of routine drain placement following pancreatic resection, potentially contributing to increased morbidity and mortality. The decision to use drains should be left to the discretion of the operating surgeon. However, early drain removal can substantially reduce morbidity.
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Affiliation(s)
- Rohith Kodali
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Kunal Parasar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Basant Narayan Singh
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Kislay Kant
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Abhishek Arora
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Venkatesh Karthikeyan
- Department of Community Medicine, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Saad Anwar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Bijit Saha
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Siddhali Wadaskar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
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Miao C, Hu Y, Bai G, Cheng N, Cheng Y, Wang W. Prophylactic abdominal drainage for pancreatic surgery. Cochrane Database Syst Rev 2025; 5:CD010583. [PMID: 40377137 DOI: 10.1002/14651858.cd010583.pub6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2025]
Abstract
RATIONALE This is the fourth update of a Cochrane review first published in 2015 and last updated in 2021. The use of surgical drains is a very common practice after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications after pancreatic surgery is controversial. OBJECTIVES To assess the benefits and harms of routine abdominal drainage after pancreatic surgery; to compare the effects of different types of surgical drains; and to evaluate the optimal time for drain removal. SEARCH METHODS We searched CENTRAL, MEDLINE, three other databases, and five trials registers, together with reference checking and contact with study authors, to identify studies for inclusion in the review. The search dates were 20 April 2024 and 20 July 2024. ELIGIBILITY CRITERIA We included randomised controlled trials (RCTs) in participants undergoing pancreatic surgery comparing (1) drain use versus no drain use, (2) different types of drains, or (3) different schedules for drain removal. We excluded quasi-randomised and non-randomised studies. OUTCOMES Our critical outcomes were 30-day mortality, 90-day mortality, intra-abdominal infection, wound infection, and drain-related complications. RISK OF BIAS We used the Cochrane RoB 1 tool to assess the risk of bias in RCTs. SYNTHESIS METHODS We synthesised the results for each outcome using meta-analysis with the random-effects model where possible. We used GRADE to assess the certainty of evidence for each outcome. INCLUDED STUDIES We included 12 RCTs with a total of 2550 participants. The studies were conducted in North America, Europe, and Asia and were published between 2001 and 2024. All studies were at overall high risk of bias. SYNTHESIS OF RESULTS We considered the certainty of the evidence for intra-abdominal infection for the comparison of early versus late drain removal following pancreaticoduodenectomy to be moderate, downgraded due to indirectness. We considered the certainty of the evidence for the other outcomes to be low or very low, mainly downgraded due to high risk of bias, inconsistency, indirectness, and imprecision. Drain use versus no drain use following pancreaticoduodenectomy We included two RCTs with 532 participants randomised to the drainage group (N = 270) and the no drainage group (N = 262) after pancreaticoduodenectomy. The evidence is very uncertain about the effect of drain use on 30-day mortality (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.07 to 3.66; 2 studies, 532 participants), 90-day mortality (RR 0.25, 95% CI 0.06 to 1.15; 1 study, 137 participants), intra-abdominal infection rate (RR 0.85, 95% CI 0.21 to 3.51; 2 studies, 532 participants), and wound infection rate (RR 0.85, 95% CI 0.55 to 1.31; 2 studies, 532 participants) compared with no drain use. Neither study reported on drain-related complications. Drain use versus no drain use following distal pancreatectomy We included two RCTs with 626 participants randomised to the drainage group (N = 318) and the no drainage group (N = 308) after distal pancreatectomy. There were no deaths at 30 days in either group. The evidence is very uncertain about the effect of drain use on 90-day mortality (RR 0.16, 95% CI 0.02 to 1.35; 2 studies, 626 participants), intra-abdominal infection rate (RR 1.20, 95% CI 0.60 to 2.42; 1 study, 344 participants), and wound infection rate (RR 2.12, 95% CI 0.93 to 4.87; 2 studies, 626 participants) compared with no drain use. Neither study reported on drain-related complications. Active versus passive drain following pancreaticoduodenectomy We included three RCTs with 441 participants randomised to the active drain group (N = 222) and the passive drain group (N = 219) after pancreaticoduodenectomy. The evidence is very uncertain about the effect of an active drain on 30-day mortality (RR 1.24, 95% CI 0.30 to 5.07; 2 studies, 321 participants), intra-abdominal infection rate (RR 0.58, 95% CI 0.06 to 5.43; 3 studies, 441 participants), and wound infection rate (RR 0.92, 95% CI 0.44 to 1.90; 2 studies, 321 participants) compared with a passive drain. None of the studies reported on 90-day mortality. There were no drain-related complications in either group (1 study, 161 participants; very low-certainty evidence). Early versus late drain removal following pancreaticoduodenectomy We included three RCTs with 557 participants with a low risk of postoperative pancreatic fistula, randomised to the early drain removal group (N = 279) and the late drain removal group (N = 278) after pancreaticoduodenectomy. Low-certainty evidence suggests that early drain removal may result in little to no difference in 30-day mortality (RR 0.99, 95% CI 0.06 to 15.45; 3 studies, 557 participants) and wound infection rate (RR 1.07, 95% CI 0.47 to 2.46; 3 studies, 557 participants) compared with late drain removal. Moderate-certainty evidence shows that early drain removal probably results in a slight reduction in intra-abdominal infection rate compared with late drain removal (RR 0.45, 95% CI 0.26 to 0.79; 3 studies, 557 participants). Approximately 58 (34 to 102 participants) out of 1000 participants in the early removal group developed intra-abdominal infections compared with 129 out of 1000 participants in the late removal group. There were no deaths at 90 days in either study group (2 studies, 416 participants). None of the studies reported on drain-related complications. AUTHORS' CONCLUSIONS The evidence is very uncertain about the effect of drain use compared with no drain use on 90-day mortality, intra-abdominal infection rate, and wound infection rate in people undergoing either pancreaticoduodenectomy or distal pancreatectomy. The evidence is also very uncertain whether an active drain is superior, equivalent, or inferior to a passive drain following pancreaticoduodenectomy. Moderate-certainty evidence suggests that early drain removal is probably superior to late drain removal in terms of intra-abdominal infection rate following pancreaticoduodenectomy for people with low risk of postoperative pancreatic fistula. FUNDING None. REGISTRATION Registration: not available. Protocol and previous versions available via doi.org/10.1002/14651858.CD010583, doi.org/10.1002/14651858.CD010583.pub2, doi.org/10.1002/14651858.CD010583.pub3, doi.org/10.1002/14651858.CD010583.pub4, and doi.org/10.1002/14651858.CD010583.pub5.
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Affiliation(s)
- Chunmu Miao
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yali Hu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Guijuan Bai
- Department of Clinical Laboratory, Community Health Center of Dingshan Street Jiangjin District Chongqing City, Jiangjin, China
| | - Nansheng Cheng
- Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Weimin Wang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Nebbia M, Capretti G, Nappo G, Zerbi A. Updates in the management of postoperative pancreatic fistula. Int J Surg 2024; 110:6135-6144. [PMID: 38518082 PMCID: PMC11487019 DOI: 10.1097/js9.0000000000001395] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/11/2024] [Indexed: 03/24/2024]
Abstract
Postoperative pancreatic fistula (POPF) remains a common and dreaded complication after pancreatic resections and is associated with increased morbidity and mortality. Over the years, several different strategies have been investigated to prevent and mitigate POPF. However, when a POPF occurs, a consensus on the optimal management strategy of grade B and grade C POPF is still lacking, and the current management strategy is often based on local expertise and driven by patient's condition. Nevertheless, whereas the incidence of POPF after pancreatic surgery has remained stable, the overall mortality related to this complication has decreased over the years. This reflects an improvement in the management of this complication, which has become increasingly conservative. The aim of this review is to provide an updated evidence-based overview on the management strategies of POPF for surgeons and physicians in the clinical practice.
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Affiliation(s)
- Martina Nebbia
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni, Rozzano
| | - Giovanni Capretti
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni, Rozzano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
| | - Gennaro Nappo
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni, Rozzano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni, Rozzano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
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Zhu S, Yin M, Xu W, Lu C, Feng S, Xu C, Zhu J. Early Drain Removal Versus Routine Drain Removal After Pancreaticoduodenectomy and/or Distal Pancreatectomy: A Meta-Analysis and Systematic Review. Dig Dis Sci 2024; 69:3450-3465. [PMID: 39044014 DOI: 10.1007/s10620-024-08547-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/21/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Early drain removal (EDR) has been widely accepted, but not been routinely used in patients after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). This study aimed to evaluate the safety and benefits of EDR versus routine drain removal (RDR) after PD or DP. METHODS A systematic search was conducted on medical search engines from January 1, 2008 to November 1, 2023, for articles that compared EDR versus RDR after PD or DP. The primary outcome was clinically relevant postoperative pancreatic fistula (CR-POPF). Further analysis of studies including patients with low-drain fluid amylase (low-DFA) on postoperative day 1 and defining EDR timing as within 3 days was also performed. RESULTS Four randomized controlled trials (RCTs) and eleven non-RCTs with a total of 9465 patients were included in this analysis. For the primary outcome, the EDR group had a significantly lower rate of CR-POPF (OR 0.23; p < 0.001). For the secondary outcomes, a lower incidence was observed in delayed gastric emptying (OR 0.63, p = 0.02), Clavien-Dindo III-V complications (OR 0.48, p < 0.001), postoperative hemorrhage (OR 0.55, p = 0.02), reoperation (OR 0.57, p < 0.001), readmission (OR 0.70, p = 0.003) and length of stay (MD -2.04, p < 0.001) in EDR. Consistent outcomes were observed in the subgroup analysis of low-DFA patients and definite EDR timing, except for postoperative hemorrhage in EDR. CONCLUSION EDR after PD or DP is beneficial and safe, reducing the incidence of CR-POPF and other postoperative complications. Further prospective studies and RCTs are required to validate this finding.
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Affiliation(s)
- Shiqi Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
- Suzhou Clinical Centre of Digestive Diseases, Suzhou, 215006, Jiangsu, China
| | - Minyue Yin
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
- Suzhou Clinical Centre of Digestive Diseases, Suzhou, 215006, Jiangsu, China
| | - Wei Xu
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
- Suzhou Clinical Centre of Digestive Diseases, Suzhou, 215006, Jiangsu, China
| | - Chenghao Lu
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
- Suzhou Clinical Centre of Digestive Diseases, Suzhou, 215006, Jiangsu, China
| | - Shuo Feng
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
- Suzhou Clinical Centre of Digestive Diseases, Suzhou, 215006, Jiangsu, China
| | - Chunfang Xu
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China
- Suzhou Clinical Centre of Digestive Diseases, Suzhou, 215006, Jiangsu, China
| | - Jinzhou Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, 215006, Jiangsu, China.
- Suzhou Clinical Centre of Digestive Diseases, Suzhou, 215006, Jiangsu, China.
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Sok C, Shah MM. ASO Author Reflections: Preoperative Imaging Findings to Predict Postoperative Pancreatic Fistula: Adding Another Tool to the Surgeon's Toolbox. Ann Surg Oncol 2024; 31:2660-2661. [PMID: 38123731 DOI: 10.1245/s10434-023-14821-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Caitlin Sok
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mihir M Shah
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.
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Ahmad SB, Hodges JC, Nassour I, Casciani F, Lee KK, Paniccia A, Vollmer CM, Zureikat AH. The risk of clinically-relevant pancreatic fistula after pancreaticoduodenectomy is better predicted by a postoperative trend in drain fluid amylase compared to day 1 values in isolation. Surgery 2023; 174:916-923. [PMID: 37468367 DOI: 10.1016/j.surg.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 05/23/2023] [Accepted: 06/18/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Recent studies support early drain removal after pancreaticoduodenectomy in patients with a drain fluid amylase on postoperative day 1 (DFA1) level of ≤5,000. The use of DFA1 to guide drain management is increasingly common among pancreatic surgeons; however, the benefit of checking additional drain fluid amylases beyond DFA1 is less known. We sought to determine whether a change in drain fluid amylase (ΔDFA) is a more reliable predictor of clinically relevant postoperative fistula than DFA1 alone. METHODS Using the American College of Surgeons National Surgical Quality Improvement Plan, pancreaticoduodenectomy patients with intraoperative drain placement, known DFA1, highest recorded drain fluid amylase value on postoperative day 2 to 5 (DFA2nd), day of drain removal, and clinically relevant postoperative fistula status were reviewed. Logistic models compared the predictive performance of DFA1 alone versus DFA1 + ΔDFA. RESULTS A total of 2,417 patients with an overall clinically relevant postoperative fistula rate of 12.6% were analyzed. On multivariable regression, clinical predictors for clinically relevant postoperative fistula included body mass index, steroid use, operative time, and gland texture. These variables were used to develop model 1 (DFA1 alone) and model 2 (DFA1 + ΔDFA). Model 2 outperformed model 1 in predicting the risk of clinically relevant postoperative fistula. According to model 2 predictions, the risk of clinically relevant postoperative fistula increased with any rise in drain fluid amylase, regardless of whether the DFA1 was above or below 5,000 U/L. The risk of clinically relevant postoperative fistula significantly decreased with any drop in drain fluid amylase, with an odds reduction of approximately 50% corresponding with a 70% decrease in drain fluid amylase (P < .001). A risk calculator was developed using DFA1 and a secondary DFA value in conjunction with other clinical predictors for clinically relevant postoperative fistula. CONCLUSION Clinically relevant postoperative fistula after pancreaticoduodenectomy is more accurately predicted by DFA1 and ΔDFA versus DFA1 in isolation. We developed a novel risk calculator to provide an individualized approach to drain management after pancreaticoduodenectomy.
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Affiliation(s)
- Sarwat B Ahmad
- Department of Surgery, University of Pittsburgh Medical Center, PA
| | - Jacob C Hodges
- Wolff Center at University of Pittsburgh Medical Center, PA
| | - Ibrahim Nassour
- Department of Surgery, University of Pittsburgh Medical Center, PA
| | - Fabio Casciani
- Department of Surgery, University of Verona, Italy; Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kenneth K Lee
- Department of Surgery, University of Pittsburgh Medical Center, PA
| | | | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, PA.
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Longo KS, Bassaneze T, Peres MCDT, Palma RT, Waisberg J. ALTERNATIVE FISTULA RISK SCORE AND FIRST POSTOPERATIVE DAY DRAIN FLUID AMYLASE AS PREDICTORS OF PANCREATIC FISTULA AFTER PANCREATICODUODENECTOMY. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1728. [PMID: 37222385 DOI: 10.1590/0102-672020230002e1728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 01/30/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND The high morbidity and mortality rates of pancreaticoduodenectomy are mainly associated with pancreaticojejunal anastomosis, the most fragile and susceptible to complications such as clinically relevant postoperative pancreatic fistula. AIMS The alternative fistula risk score and the first postoperative day drain fluid amylase are predictors of the occurrence of clinically relevant postoperative pancreatic fistula. No consensus has been reached on which of the scores is a better predictor; moreover, their combined predictive power remains unclear. To the best of our knowledge, this association had not yet been studied. METHODS This study assessed the predictive effect of alternative fistula risk score and/or drain fluid amylase on clinically relevant postoperative pancreatic fistula in a retrospective cohort of 58 patients following pancreaticoduodenectomy. The Shapiro-Wilk and Mann-Whitney tests were applied for assessing the distribution of the samples and for comparing the medians, respectively. The receiver operating characteristics curve and the confusion matrix were used to analyze the predictive models. RESULTS The alternative fistula risk score values were not statistically different between patients in the clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 59.5, p=0.12). The drain fluid amylase values were statistically different between clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 27, p=0.004). The alternative fistula risk score and drain fluid amylase were independently less predictive for clinically relevant postoperative pancreatic fistula, compared to combined alternative fistula risk score + drain fluid amylase. CONCLUSION The combined model involving alternative fistula risk score >20% + drain fluid amylase=5,000 U/L was the most effective predictor of clinically relevant postoperative pancreatic fistula occurrence following pancreaticoduodenectomy.
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Affiliation(s)
- Karina Scalabrin Longo
- Centro Universitário Faculdade de Medicina do ABC, Department of Gastrointestinal Surgery - Santo André (SP), Brazil
| | - Thiago Bassaneze
- Centro Universitário Faculdade de Medicina do ABC, Department of Gastrointestinal Surgery - Santo André (SP), Brazil
| | | | - Rogério Tadeu Palma
- Centro Universitário Faculdade de Medicina do ABC, Department of Gastrointestinal Surgery - Santo André (SP), Brazil
| | - Jaques Waisberg
- Centro Universitário Faculdade de Medicina do ABC, Department of Gastrointestinal Surgery - Santo André (SP), Brazil
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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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Blunck CK, Vickers SM, Wang TN, Dudeja V, Reddy S, Rose JB. Adjusting Drain Fluid Amylase for Drain Volume Does Not Improve Pancreatic Fistula Prediction. J Surg Res 2023; 284:312-317. [PMID: 36634411 DOI: 10.1016/j.jss.2022.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 09/22/2022] [Accepted: 11/16/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Drain fluid amylase (DFA) levels have been used to predict clinically relevant postoperative pancreatic fistula (CR-POPF) and guide postoperative drain management. Optimal DFA cutoff thresholds vary between studies, thereby prompting investigation of an alternative assessment technique. As DFA measurements could, in theory, be distorted by variations in ascites fluid production, we hypothesized that adjusting DFA for volume corrected drain fluid amylase (vDFA) would improve CR-POPF predictive models. METHODS A single-institution retrospective cohort study of patients, who underwent pancreatoduodenectomies (PD) and distal pancreatectomies (DP) between 2013 and 2019, was performed. DFAs and vDFAs were measured on postoperative day (POD) 3. Clinicopathologic variables were compared between cohorts by univariable and multivariable analyses and Receiver operating characteristic (ROC) curves. RESULTS Patients developing a CR-POPF were more likely to be male and have elevated DFA, vDFA, and body mass index (BMI). vDFA use did not contribute to a superior CR-POPF predictive model compared to DFA-a finding consistent on subanalysis of surgery type PD versus DP. In CR-POPF predictive models, DFA, vDFA, and male sex significantly improved CR-POPF predictive models when considering both surgery subtypes, while only DFA and vDFA significantly improved models when cohorts were segregated by surgery type. CONCLUSIONS Postoperative DFA remains a preferred method of predicting CR-POPF as the proposed vDFA assessment technique only adds complexity without increased discriminability.
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Affiliation(s)
| | - Selwyn M Vickers
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Thomas N Wang
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Vikas Dudeja
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Sushanth Reddy
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - J Bart Rose
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama.
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Sahara K, Ruff SM, Miyake K, Toyoda J, Yabushita Y, Homma Y, Kumamoto T, Matsuyama R, Endo I, Pawlik TM. Trends and Variations in Drain Use Following Pancreatoduodenectomy: Is Early Drain Removal Becoming More Common? World J Surg 2023; 47:1772-1779. [PMID: 37000199 DOI: 10.1007/s00268-023-06966-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Although previous studies have noted the potential benefit of early drain removal (EDR) after pancreatoduodenectomy (PD), there is a paucity of data on the timing of drain removal utilizing a national database that reflect the "real world" setting. Given the ongoing controversy related to PD drain use and management, we sought to define trends in drain use among a large national cohort, as well as identify factors associated with EDR following PD. METHODS The ACS NSQIP targeted pancreatectomy database was used to identify patients who underwent PD between 2014 and 2020. The trend in proportion of patients with EDR (removal ≤ POD3) as well as predictors of EDR were assessed. Risk-adjusted postoperative outcomes were evaluated by multivariable regression analysis. RESULTS Among 14,356 patients, 16.2% of patients (N = 2324) experienced EDR, and the proportion of patients with EDR increased by 68% over the study period (2014: 10.9% vs. 2020: 18.3%, p < 0.001). Higher drain fluid amylase on POD1-3 [LogWorth (LW) = 44.3], operative time (LW = 33.2), and use of minimally invasive surgery (LW = 14.0) were associated with EDR. Additionally, EDR was associated with decreased risk of overall and serious morbidity, PD-related morbidity (e.g., pancreatic fistula), reoperation, prolonged length of stay and readmission (all p < 0.05). CONCLUSIONS Routine drain placement remains a common practice among most surgeons. EDR following PD increased over time was associated with lower post-operative complications and shorter LOS. Despite evidence that EDR was safe and may even be associated with lower complications, only 1 in 6 patients were managed with EDR.
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Affiliation(s)
- Kota Sahara
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
- Department of Surgery, Saiseikai Yokohamashi Nanbu Hospital, 3 Chome-2-10 Konandai, Konan Ward, Yokohama, Kanagawa, 234-0054, Japan
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave, Columbus, OH, 43210, USA
| | - Samantha M Ruff
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave, Columbus, OH, 43210, USA
| | - Kentaro Miyake
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
| | - Junya Toyoda
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
| | - Yasuhiro Yabushita
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
| | - Yuki Homma
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
| | - Takafumi Kumamoto
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
| | - Ryusei Matsuyama
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery Division, Yokohama City University School of Medicine, 3 Chome-9 Fukuura, Kanazawa Ward, Yokohama, Kanazawa, 236-0004, Japan
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, 395 W. 12th Ave, Columbus, OH, 43210, USA.
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Chen K, Liu Z, Yang B, Ma Y, Zhang S, Shao Z, Yang Y, Tian X. Efficacy and safety of early drain removal following pancreatic resections: a meta-analysis. HPB (Oxford) 2023; 25:485-496. [PMID: 36822926 DOI: 10.1016/j.hpb.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 01/29/2023] [Accepted: 02/07/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND No consensus was reached with regard to the effect of EDR on postoperative outcomes after pancreatic surgery. The meta-analysis was designed to explore the efficacy and safety of early drain removal (EDR). METHODS Systematic literature search was performed. Data extraction and correction were performed by three researchers. For dichotomous and continuous outcomes, we calculated the pooled risk difference and mean difference with 95% confidence intervals, respectively. The heterogeneity of included studies was evaluated using Cochran's Q and I2 test. The stratified analyses of pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) were performed. RESULTS A total of 10 studies including 3 RCTs and 7 non RCTs were included for meta-analysis, among which 1780 patients with EDR and 5613 patients with late drain removal (LDR) were enrolled. The meta-analysis of both all the available studies and studies only with selected low risk patients indicated that EDR group had significantly lower incidences of Grade B/C postoperative pancreatic fistula (POPF) and total complications for both PD and DP. However, no advantages of EDR were observed in the meta-analysis of the 3 RCTs. In addition, EDR was associated with a lower incidence of intra-abdominal infection after PD. While for DP, EDR group had decreased risk of delayed gastric emptying and re-operation, and shorter postoperative in-hospital stay. CONCLUSIONS The meta-analysis demonstrates that EDR is effective and safe for both PD and DP considering POPF and total complications, especially for patients with low concentration of postoperative drain fluid amylase.
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Affiliation(s)
- Kai Chen
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China
| | - Zonghao Liu
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China
| | - Bohan Yang
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China
| | - Yongsu Ma
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China
| | - Shupeng Zhang
- Department of General Surgery, Tianjin Fifth Centre Hospital, Tianjin 300450, China
| | - Zhijiang Shao
- Department of General Surgery, Tianjin Fifth Centre Hospital, Tianjin 300450, China
| | - Yinmo Yang
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China.
| | - Xiaodong Tian
- Department of General Surgery, Peking University First Hospital, Beijing, 100034, China.
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He C, Zhang Y, Li L, Zhao M, Wang C, Tang Y. Risk factor analysis and prediction of postoperative clinically relevant pancreatic fistula after distal pancreatectomy. BMC Surg 2023; 23:5. [PMID: 36631791 PMCID: PMC9835372 DOI: 10.1186/s12893-023-01907-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/06/2023] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Postoperative pancreatic fistula (POPF) following distal pancreatectomy (DP) is a serious complication. In the present study, we aimed to identify the risk factors associated with clinically relevant postoperative pancreatic fistula (CR-POPF) and establish a nomogram model for predicting CR-POPF after DP. METHODS In total, 115 patients who underwent DP at the General Hospital of Northern Theater Command between January 2005 and December 2020 were retrospectively studied. Univariate and multivariable logistic regression analyses were used to identify the independent risk factors associated with CR-POPF. Then, a nomogram was formulated based on the results of multivariable logistic regression analysis. The predictive performance was evaluated with receiver operating characteristic (ROC) curves. Decision curve and clinical impact curve analyses were used to validate the clinical application value of the model. RESULTS The incidence of CR-POPF was 33.0% (38/115) in the present study. Multivariate logistic regression analysis identified the following variables as independent risk factors for POPF: body mass index (BMI) (OR 4.658, P = 0.004), preoperative albumin level (OR 7.934, P = 0.001), pancreatic thickness (OR 1.256, P = 0.003) and pancreatic texture (OR 3.143, P = 0.021). We created a nomogram by incorporating the above mentioned risk factors. The nomogram model showed better predictive value, with a concordance index of 0.842, sensitivity of 0.710, and specificity of 0.870 when compared to each risk factor. Decision curve and clinical impact curve analyses also indicated that the nomogram conferred a high clinical net benefit. CONCLUSION Our nomogram could accurately and objectively predict the risk of postoperative CR-POPF in individuals who underwent DP, which could help clinicians with early identification of patients who might develop CR-POPF and early development of a suitable fistula mitigation strategy and postoperative management.
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Affiliation(s)
- Chenchen He
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, 110000 China ,grid.412449.e0000 0000 9678 1884China Medical University, Shenyang, 110122 China
| | - Yibing Zhang
- Department of Medical Affairs, The General Hospital of Northern Theater Command, Shenyang, China
| | - Longfei Li
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, 110000 China
| | - Mingda Zhao
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, 110000 China
| | - Chunhui Wang
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, 110000 China
| | - Yufu Tang
- Department of Hepatobiliary and Thyroid Surgery, General Hospital of Northern Theater Command, Shenyang, 110000 China
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Xie X, Chen K, Liu Z, Wang F, Ma Y, Zhang S, Shao Z, Yang Y, Tian X. Safety evaluation of early drain removal following pancreaticoduodenectomy: A single-center retrospective cohort study. Front Oncol 2022; 12:993901. [PMID: 36249020 PMCID: PMC9554647 DOI: 10.3389/fonc.2022.993901] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/15/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives The effects of early drain removal (EDR) on postoperative complications after pancreaticoduodenectomy (PD) remains to be investigated. This single-center retrospective cohort study was designed to explore the safety of EDR after PD. Methods A total of 112 patients undergoing PD with drain fluid amylase (DFA) on postoperative day (POD) 1 and 3 <= 5000 were divided into EDR and late drain removal (LDR). Propensity Score Matching (PSM) was used. We compared postoperative outcomes between two groups and explore the risk factors of total complications using univariate and multiple logistic regression analyses. Results No statistical differences were found in primary outcomes, including Grade B/C postoperative pancreatic fistula (POPF) (Original cohort: 5.71% vs. 3.90%; P = 1.000; PSM cohort: 3.33% vs. 6.67%; P = 1.000), and total complications (Original cohort: 17.14% vs. 32.47%; P = 0.093; PSM cohort: 13.33% vs. 33.33%; P = 0.067). The EDR was associated with shorter in-hospital stay (Original cohort: 11 days vs. 15 days; P < 0.0001; PSM cohort: 11 days vs. 15 days; P < 0.0001). Conclusions EDR on POD 3 is safe for patients undergoing PD with low risk of POPF.
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Affiliation(s)
- Xuehai Xie
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Kai Chen
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Zonghao Liu
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Feng Wang
- Department of Endoscopy Center, Peking University First Hospital, Beijing, China
| | - Yongsu Ma
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Shupeng Zhang
- Department of General Surgery, Tianjin Fifth Centre Hospital, Tianjin, China
| | - Zhijiang Shao
- Department of General Surgery, Tianjin Fifth Centre Hospital, Tianjin, China
| | - Yinmo Yang
- Department of General Surgery, Peking University First Hospital, Beijing, China
- *Correspondence: Yinmo Yang, ; Xiaodong Tian,
| | - Xiaodong Tian
- Department of General Surgery, Peking University First Hospital, Beijing, China
- *Correspondence: Yinmo Yang, ; Xiaodong Tian,
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Trudeau MT, Casciani F, Ecker BL, Maggino L, Seykora TF, Puri P, McMillan MT, Miller B, Pratt WB, Asbun HJ, Ball CG, Bassi C, Behrman SW, Berger AC, Bloomston MP, Callery MP, Castillo CFD, Christein JD, Dillhoff ME, Dickson EJ, Dixon E, Fisher WE, House MG, Hughes SJ, Kent TS, Malleo G, Salem RR, Wolfgang CL, Zureikat AH, Vollmer CM. The Fistula Risk Score Catalog: Toward Precision Medicine for Pancreatic Fistula After Pancreatoduodenectomy. Ann Surg 2022; 275:e463-e472. [PMID: 32541227 DOI: 10.1097/sla.0000000000004068] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE This study aims to present a full spectrum of individual patient presentations of pancreatic fistula risk, and to define the utility of mitigation strategies amongst some of the most prevalent, and vulnerable scenarios surgeons encounter. BACKGROUND The FRS has been utilized to identify technical strategies associated with reduced CR-POPF incidence across various risk strata. However, risk-stratification using the FRS has never been investigated with greater granularity. By deriving all possible combinations of FRS elements, individualized risk assessment could be utilized for precision medicine purposes. METHODS FRS profiles and outcomes of 5533 PDs were accrued from 17 international institutions (2003-2019). The FRS was used to derive 80 unique combinations of patient "scenarios." Risk-matched analyses were conducted using a Bonferroni adjustment to identify scenarios with increased vulnerability for CR-POPF occurrence. Subsequently, these scenarios were analyzed using multivariable regression to explore optimal mitigation approaches. RESULTS The overall CR-POPF rate was 13.6%. All 80 possible scenarios were encountered, with the most frequent being scenario #1 (8.1%) - the only negligible-risk scenario (CR-POPF rate = 0.7%). The moderate-risk zone had the most scenarios (50), patients (N = 3246), CR-POPFs (65.2%), and greatest non-zero discrepancy in CR-POPF rates between scenarios (18-fold). In the risk-matched analysis, 2 scenarios (#59 and 60) displayed increased vulnerability for CR-POPF relative to the moderate-risk zone (both P < 0.001). Multivariable analysis revealed factors associated with CR-POPF in these scenarios: pancreaticogastrostomy reconstruction [odds ratio (OR) 4.67], omission of drain placement (OR 5.51), and prophylactic octreotide (OR 3.09). When comparing the utilization of best practice strategies to patients who did not have these conjointly utilized, there was a significant decrease in CR-POPF (10.7% vs 35.5%, P < 0.001; OR 0.20, 95% confidence interval 0.12-0.33). CONCLUSION Through this data, a comprehensive fistula risk catalog has been created and the most clinically-impactful scenarios have been discerned. Focusing on individual scenarios provides a practical way to approach precision medicine, allowing for more directed and efficient management of CR-POPF.
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Affiliation(s)
- Maxwell T Trudeau
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Fabio Casciani
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | - Brett L Ecker
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Laura Maggino
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | - Thomas F Seykora
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Priya Puri
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Matthew T McMillan
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Benjamin Miller
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Wande B Pratt
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | | | - Claudio Bassi
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | | | - Adam C Berger
- Jefferson Medical College, Philadelphia, Pennsylvania
| | | | - Mark P Callery
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - John D Christein
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Mary E Dillhoff
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Euan J Dickson
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | | | | | - Michael G House
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Steven J Hughes
- University of Florida College of Medicine, Jacksonville, Florida
| | - Tara S Kent
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | | | | | - Amer H Zureikat
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Charles M Vollmer
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Yin J, Zhu Q, Zhang K, Gao W, Wu J, Lu Z, Jiang K, Miao Y. Development and validation of risk prediction nomogram for pancreatic fistula and risk-stratified strategy for drainage management after pancreaticoduodenectomy. Gland Surg 2022; 11:42-55. [PMID: 35242668 PMCID: PMC8825517 DOI: 10.21037/gs-21-550] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/18/2021] [Indexed: 08/10/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is the major complication following pancreaticoduodenectomy (PD). We sought to develop and validate a risk prediction model for POPF after PD with the aim of determining personal risk probability and proposing a novel strategy for intraoperative placement and/or early-removal of prophylactic drainage. METHODS Data from 993 patients undergoing PD from January 2012 to December 2016 were retrospectively analyzed. Patients were randomly assigned to either training cohort or validation cohort. A nomogram was formulated based on the results from multivariable regression model for prediction of POPF. Internal and external validation were carried out with calibration plot respectively. RESULTS POPF occurred in 162 (16.3%) patients. The final pre-/intra-operative prediction model included alanine transaminase level [odds ratio (OR) 1.00, 95% confidence interval (CI): 1.00-1.00, P=0.023], combined portal-superior mesenteric vein resection (OR 0.22, 95% CI: 0.05-0.95, P=0.043), pancreatic duct diameter (OR 1.48, 95% CI: 1.11-1.96, P=0.007), intraoperative colloid infusion (OR 1.00, 95% CI: 1.00-1.00, P=0.001), pathology (OR 1.71, 95% CI: 1.09-2.66, P=0.018). The area under the curve (AUC) was 0.667 in the training cohort and 0.621 in the validation cohort. The final postoperative prediction model included pancreatic duct diameter (OR 1.58, 95% CI: 1.14-2.19, P=0.006), intraoperative colloid infusion (OR 2.52, 95% CI: 1.26-5.06, P=0.009), drainage fluid amylase on postoperative day 3 (POD3) (OR 4.70, 95% CI: 3.30-6.70, P<0.001), and neutrophil count on POD3 (OR 2.83, 95% CI: 1.63-4.93, P<0.001). The AUC was 0.809 in the training cohort and 0.797 in the validation cohort. Based on these variables, two nomogram prediction models were developed respectively. The calibration plot of the two models showed a good correlation between the expected risk and the actual risk in the low-risk range. Our risk-stratified strategy for drain management according to nomograms may be beneficial for 34.5% of patients. CONCLUSIONS Our study formulated and validated two nomogram models for predicting POPF that performed particularly well in the low-risk range. This tool may allow surgeons to propose a risk stratified strategy for intraoperative drain placement and early drain removal, which may be beneficial for a substantial proportion of patients.
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Affiliation(s)
- Jie Yin
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Qicong Zhu
- Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, China
| | - Kai Zhang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Wentao Gao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Junli Wu
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Zipeng Lu
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Kuirong Jiang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
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OUP accepted manuscript. Br J Surg 2022; 109:739-745. [DOI: 10.1093/bjs/znac123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 01/20/2022] [Accepted: 03/31/2022] [Indexed: 11/13/2022]
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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: 12] [Impact Index Per Article: 3.0] [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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18
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Brubaker LS, Casciani F, Fisher WE, Wood AL, Cagigas MN, Trudeau MT, Parikh VJ, Baugh KA, Asbun HJ, Ball CG, Behrman SW, Berger AC, Bloomston MP, Callery MP, Christein JD, Fernandez-Del Castillo C, Dillhoff ME, Dixon E, House MG, Hughes SJ, Kent TS, Kunstman JW, Wolfgang CL, Zureikat AH, Vollmer CM, Van Buren G. A risk-adjusted analysis of drain use in pancreaticoduodenectomy: Some is good, but more may not be better. Surgery 2021; 171:1058-1066. [PMID: 34433515 DOI: 10.1016/j.surg.2021.07.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/16/2021] [Accepted: 07/16/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Intraperitoneal drain placement decreases morbidity and mortality in patients who develop a clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD). It is unknown whether multiple drains mitigate CR-POPF better than a single drain. We hypothesize that multiple drains decrease the complication burden more than a single drain in cases at greater risk for CR-POPF. METHODS The Fistula Risk Score (FRS), mitigation strategies (including number of drains placed), and clinical outcomes were obtained from a multi-institutional database of PDs performed from 2003 to 2020. Outcomes were compared between cases utilizing 0, 1, or 2 intraperitoneal drains. Multivariable regression analysis was used to evaluate the optimal drainage approach. RESULTS A total of 4,292 PDs used 0 (7.3%), 1 (45.2%), or 2 (47.5%) drains with an observed CR-POPF rate of 9.6%, which was higher in intermediate/high FRS zone cases compared with negligible/low FRS zone cases (13% vs 2.4%, P < .001). The number of drains placed also correlated with FRS zone (median of 2 in intermediate/high vs 1 in negligible/low risk cases). In intermediate/high risk cases, the use of 2 drains instead of 1 was not associated with a reduced rate of CR-POPF, average complication burden attributed to a CR-POPF, reoperations, or mortality. Obviation of drains was associated with significant increases in complication burden and mortality - regardless of the FRS zone. CONCLUSION In intermediate/high risk zone cases, placement of a single drain or multiple drains appears to mitigate the complication burden while use of no drains is associated with inferior outcomes.
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Affiliation(s)
- Lisa S Brubaker
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Fabio Casciani
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | - William E Fisher
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - Amy L Wood
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - Martha Navarro Cagigas
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - Maxwell T Trudeau
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Viraj J Parikh
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Katherine A Baugh
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | | | | | | | | | | | - Mark P Callery
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - John D Christein
- University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | | | - Mary E Dillhoff
- The Ohio State University Wexner Medical Center, Columbus, OH
| | | | | | | | - Tara S Kent
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | | | | | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - George Van Buren
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX. https://twitter.com/GeorgeVanBuren
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19
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Jiménez Romero C, Alonso Murillo L, Rioja Conde P, Marcacuzco Quinto A, Caso Maestro Ó, Nutu A, Pérez Moreiras I, Justo Alonso I. Pancreaticoduodenectomy and external Wirsung stenting: Our outcomes in 80 cases. Cir Esp 2021; 99:440-449. [PMID: 34103272 DOI: 10.1016/j.cireng.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 07/12/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION There is controversy regarding the ideal pancreaticojejunostomy technique after pancreaticoduodenectomy. Many authors consider the external Wirsung stenting technique to be associated with a low incidence of fistula, morbidity and mortality. We analyse our experience with this technique. PATIENTS AND METHODS A retrospective analysis of the morbidity and mortality of a series of 80 consecutive patients who had been treated surgically over a 6.5-year period for pancreatic head or periampullary tumors, performing pancreaticoduodenectomy and pancreaticojejunostomy with external Wirsung duct stenting. RESULTS Mean patient age was 68.3 ± 9 years, and the resectability rate was 78%. The texture of the pancreas was soft in 51.2% of patients and hard in 48.8%. Pylorus-preserving resection was performed in 43.8%. Adenocarcinoma was the most frequent tumor (68.8%), and R0 was confirmed in 70% of patients. Biochemical fistula was observed in 11.2%, pancreatic fistula grade B in 12.5% and C in 2.5%, whereas the abdominal reoperation rate was 10%. Median postoperative hospital stay was 16 days, and postoperative and 90-day mortality was 2.5%. Delayed gastric emptying was observed in 36.3% of patients, de novo diabetes in 12.5%, and exocrine insufficiency in 3. Patient survival rates after 1, 3 and 5 years were 80.2%, 53.6% and 19.2%, respectively. CONCLUSIONS Although our low rates of postoperative complications and mortality using external Wirsung duct stenting coincides with other more numerous recent series, it is necessary to perform a comparative analysis with other techniques, including more cases, to choose the best reconstruction technique after pancreaticoduodenectomy.
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Affiliation(s)
- Carlos Jiménez Romero
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - Laura Alonso Murillo
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Paula Rioja Conde
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Alberto Marcacuzco Quinto
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Óscar Caso Maestro
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Anisa Nutu
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Iago Justo Alonso
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
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Liu X, Chen K, Chu X, Liu G, Yang Y, Tian X. Prophylactic Intra-Peritoneal Drainage After Pancreatic Resection: An Updated Meta-Analysis. Front Oncol 2021; 11:658829. [PMID: 34094952 PMCID: PMC8172774 DOI: 10.3389/fonc.2021.658829] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/28/2021] [Indexed: 12/19/2022] Open
Abstract
Introduction Prophylactic intra-peritoneal drainage has been considered to be an effective measure to reduce postoperative complications after pancreatectomy. However, routinely placed drainage during abdominal surgery may be unnecessary or even harmful to some patients, due to the possibility of increasing complications. And there is still controversy about the prophylactic intra-peritoneal drainage after pancreatectomy. This meta-analysis aimed to analyze the incidence of complications after either pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) in the drain group and no-drain group. Methods Data were retrieved from four electronic databases PubMed, EMBASE, the Cochrane Library and Web of Science up to December 2020, including the outcomes of individual treatment after PD and DP, mortality, morbidity, clinically relevant postoperative pancreatic fistula (CR-POPF), bile leak, wound infection, postoperative hemorrhage, delayed gastric emptying (DGE), intra-abdominal abscess, reoperation, intervened radiology (IR), and readmission. Cochrane Collaboration Handbook and the criteria of the Newcastle-Ottawa scale were used to assess the quality of studies included. Results We included 15 studies after strict screening. 13 studies with 16,648 patients were analyzed to assess the effect of drain placement on patients with different surgery procedures, and 4 studies with 6,990 patients were analyzed to assess the effect of drain placement on patients with different fistula risk. For patients undergoing PD, the drain group had lower mortality but higher rate of CR-POPF than the no-drain group. For patients undergoing DP, the drain group had higher rates of CR-POPF, wound infection and readmission. There were no significant differences in bile leak, hemorrhage, DGE, intra-abdominal abscess, and IR in either overall or each subgroup. For Low-risk subgroup, the rates of hemorrhage, DGE and morbidity were higher after drainage. For High-risk subgroup, the rate of hemorrhage was higher while the rates of reoperation and morbidity were lower in the drain group. Conclusions Intraperitoneal drainage may benefit some patients undergoing PD, especially those with high pancreatic fistula risk. For DP, current evidences suggest that routine drainage might not benefit patients, but no clear conclusions can be drawn because of the study limitations.
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Affiliation(s)
- Xinxin Liu
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Kai Chen
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Xiangyu Chu
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Guangnian Liu
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Yinmo Yang
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Xiaodong Tian
- Department of General Surgery, Peking University First Hospital, Beijing, China
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21
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Casciani F, Bassi C, Vollmer CM. Decision points in pancreatoduodenectomy: Insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula. Surgery 2021; 170:889-909. [PMID: 33892952 DOI: 10.1016/j.surg.2021.02.064] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/25/2021] [Accepted: 02/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indicate avenues for future research to reduce the burden of clinically relevant pancreatic fistula. METHODS A 109-item questionnaire was sent to a panel of international pancreatic surgery experts, recognized for their clinical and scientific authority. Their practice habits and thought processes regarding clinically relevant pancreatic fistula risk assessment, anastomotic construction, application of technical adjuncts, and mitigation strategies, as well as postoperative management, was explored. Sixteen clinical vignettes were presented to reveal their certain approaches to unique situations-both common and uncommon. RESULTS Sixty experts, with a cumulative 48,860 pancreatoduodenectomies, completed the questionnaire. Their median pancreatectomy/pancreatoduodenectomy case volume was 1,200 and 705 procedures, respectively, with a median career duration of 22 years and 200 indexed publications. Although pancreatico-jejunostomy reconstruction with transperitoneal drainage is the standard operative approach for most authorities, uncertainty emerges regarding the employment of objective risk stratification and adaptation of practice to risk. Concrete suggestions are offered to inform decision-making in intimidating circumstances. Early drain removal is frequently embraced, while a step-up approach is unanimously invoked to treat severe clinically relevant pancreatic fistula. CONCLUSION A comprehensive conceptual framework of 4 sequential phases of decision-making is proposed-risk assessment, anastomotic technique, mitigation strategy employment, and postoperative management. Basic science studies and outcome analyses are proposed for improvement.
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Affiliation(s)
- Fabio Casciani
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Surgery, University of Verona, Italy. https://twitter.com/F_Casciani
| | - Claudio Bassi
- Department of Surgery, University of Verona, Italy. https://twitter.com/pennsurgery
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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22
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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: 6] [Impact Index Per Article: 1.5] [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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23
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Systematic review and meta-analysis of surgical drain management after the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy: draining-tract-targeted works better than standard management. Langenbecks Arch Surg 2020; 405:1219-1231. [PMID: 33104886 PMCID: PMC7686010 DOI: 10.1007/s00423-020-02005-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/29/2020] [Indexed: 01/04/2023]
Abstract
Purpose Drains’ role after pancreaticoduodenectomy (PD) is debated by proponents of no drain, draining selected cases, and early drain removal. The aim of the study was to assess the effect of “standard” and “draining-tract-targeted” management of abdominal drains still in situ after diagnosing a postoperative pancreatic fistula (POPF). Methods PubMed and Scopus were searched for “pancreaticoduodenectomy or pancreatoduodenectomy or duodenopancreatectomy,” “Whipple,” “proximal pancreatectomy,” “pylorus-preserving pancreatectomy,” and “postoperative pancreatic fistula or POPF.”. Main outcomes included clinically relevant (CR) POPF, grade-C POPF, overall mortality, POPF-related mortality, and CR-POPF-related mortality. Secondary outcomes were incidence of radiological and/or endoscopic interventions, reoperations, and completion pancreatectomies. Results Overall, 12,089 studies were retrieved by the search of the English literature (01/01/1990–31/12/2018). Three hundred and twenty-six studies (90,321 patients) reporting ≥ 100 PDs and ≥ 10 PD/year were finally included into the study. Average incidences were obtained by averaging the incidence rates reported in the single articles. Pooled incidences were calculated by combining the number of events and the total number of patients considered in the various studies. These were then meta-analyzed using DerSimonian and Laird’s (1986) method. Pearson’s chi-squared test was used to compare pooled incidences between groups. Post hoc testing was used to see which groups differed. The meta-analyzed incidences were compared using a fixed effect for moderators. “Draining-tract-targeted” management showed a significant advantage over “standard” management in four clinically relevant outcomes out of eight according to pool analysis and in one of them according to meta-analysis. Conclusion Clinically, “draining-targeted” management of POPF should be preferred to “standard” management. Electronic supplementary material The online version of this article (10.1007/s00423-020-02005-8) contains supplementary material, which is available to authorized users.
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Abstract
INTRODUCTION There is controversy regarding the ideal pancreaticojejunostomy technique after pancreaticoduodenectomy. Many authors consider the external Wirsung stenting technique to be associated with a low incidence of fistula, morbidity and mortality. We analyse our experience with this technique. PATIENTS AND METHODS A retrospective analysis of the morbidity and mortality of a series of 80 consecutive patients who had been treated surgically over a 6.5-year period for pancreatic head or periampullary tumors, performing pancreaticoduodenectomy and pancreaticojejunostomy with external Wirsung duct stenting. RESULTS Mean patient age was 68.3 ± 9 years, and the resectability rate was 78%. The texture of the pancreas was soft in 51.2% of patients and hard in 48.8%. Pylorus-preserving resection was performed in 43.8%. Adenocarcinoma was the most frequent tumor (68.8%), and R0 was confirmed in 70% of patients. Biochemical fistula was observed in 11.2%, pancreatic fistula grade B in 12.5% and C in 2.5%, whereas the abdominal reoperation rate was 10%. Median postoperative hospital stay was 16 days, and postoperative and 90-day mortality was 2.5%. Delayed gastric emptying was observed in 36.3% of patients, de novo diabetes in 12.5%, and exocrine insufficiency in 3. Patient survival rates after 1, 3 and 5 years were 80.2, 53.6 and 19.2%, respectively. CONCLUSIONS Although our low rates of postoperative complications and mortality using external Wirsung duct stenting coincides with other more numerous recent series, it is necessary to perform a comparative analysis with other techniques, including more cases, to choose the best reconstruction technique after pancreaticoduodenectomy.
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Mangieri CW, Kuncewitch M, Fowler B, Erali RA, Moaven O, Shen P, Clark CJ. Surgical drain placement in distal pancreatectomy is associated with an increased incidence of postoperative pancreatic fistula and higher readmission rates. J Surg Oncol 2020; 122:723-728. [PMID: 32614999 PMCID: PMC7775868 DOI: 10.1002/jso.26072] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/08/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) can result in significant morbidity after distal pancreatectomy (DP). It is common practice to place prophylactic surgical drains during DP to monitor and minimize POPF complications; however, their use is controversial. OBJECTIVE The aim of this study is to determine if drainage helps to prevent adverse outcomes and decrease the need for additional interventions after DP. METHODS All patients who underwent DP without vascular resection were identified in the 2014 Targeted Pancreatectomy American College of Surgeons National Surgery Quality Improvement Program Participant Use File. Patients undergoing emergency procedures, American Society of Anesthesiology (ASA) 5, or diagnosed with preoperative sepsis were excluded. Univariate and multiple variable analyses were performed to evaluate postoperative outcomes based on use of surgical drain. RESULTS A total of 1158 patients (age median: 62; interquartile range: 16; female 58.6%) underwent elective DP with 85.1% (n = 985) having drain placed at time of operation. Laparoscopic technique was used in the majority of patients (54.1%, n = 619). POPF occurred in 201 patients (17.5%). Additional percutaneous drain was required in 106 patients (9.2%). POPF was higher in surgical drain group, 19.4% vs 6.9% (P < .001). Need for percutaneous drain was similar between drain and no drain groups, 9.3% vs 8.1% (P = .600). Postoperative sepsis, shock, major complication, reoperation, and 30-day mortality was similar between drain and no drain groups (all P > .05). However, readmission was higher in the surgical drain group, 17.8% vs 10.4% (odds ratio [OR]: 1.9; 95% confidence interval [CI]: 1.1-3.1; P = .018). After adjusting for age, ASA, and operative time, readmission remained higher in the surgical drain group (OR: 1.9; 95% CI: 1.1-3.2; P = .016). CONCLUSION The use of surgical drainage during DP was associated with increased incidence of readmission and POPF. Drainage showed no effect on outcomes of postoperative sepsis, shock, major complications, reoperation, and 30-day mortality. Based on these results, routine prophylactic drainage should be reconsidered for patients undergoing DP.
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Affiliation(s)
| | - Michael Kuncewitch
- Wake Forest Baptist Medical Center, Division of Surgical Oncology Winston-Salem, NC
| | - Brett Fowler
- Wake Forest Baptist Medical Center, Division of Surgical Oncology Winston-Salem, NC
| | - Richard A. Erali
- Wake Forest Baptist Medical Center, Division of Surgical Oncology Winston-Salem, NC
| | - Omeed Moaven
- Wake Forest Baptist Medical Center, Division of Surgical Oncology Winston-Salem, NC
| | - Perry Shen
- Wake Forest Baptist Medical Center, Division of Surgical Oncology Winston-Salem, NC
| | - Clancy J. Clark
- Wake Forest Baptist Medical Center, Division of Surgical Oncology Winston-Salem, NC
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Liao CH, Wu YT, Cheng CT, Ooyang CH, Kang SC, Fu CY, Hsu YP, Hsieh CH, Chen CC. An Image-Based Mobile Health App for Postdrainage Monitoring: Usability Study. J Med Internet Res 2020; 22:e17686. [PMID: 32857060 PMCID: PMC7486677 DOI: 10.2196/17686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 07/16/2020] [Accepted: 07/19/2020] [Indexed: 01/16/2023] Open
Abstract
Background The application of mobile health (mHealth) platforms to monitor recovery in the postdischarge period has increased in recent years. Despite widespread enthusiasm for mHealth, few studies have evaluated the usability and user experience of mHealth in patients with surgical drainage. Objective Our objectives were to (1) develop an image-based smartphone app, SurgCare, for postdrainage monitoring and (2) determine the feasibility and clinical value of the use of SurgCare by patients with drainage. Methods We enrolled 80 patients with biliary or peritoneal drainage in this study. A total of 50 patients were assigned to the SurgCare group, who recorded drainage monitoring data with the smartphone app; and 30 patients who manually recorded the data were assigned to the conventional group. The patients continued to record data until drain removal. The primary aim was to validate feasibility for the user, which was defined as the proportion of patients using each element of the system. Moreover, the secondary aim was to evaluate the association of compliance with SurgCare and the occurrence of unexpected events. Results The average submission duration was 14.98 days, and the overall daily submission rate was 84.2%. The average system usability scale was 83.7 (SD 3.5). This system met the definition of “definitely feasible” in 34 patients, “possibly feasible” in 10 patients, and “not feasible” in 3 patients. We found that the occurrence rates of complications in the SurgCare group and the conventional group were 6% and 26%, respectively, with statistically significant differences P=.03. The rate of unexpected hospital return was lower in the SurgCare group (6%) than in the conventional groups (26%) (P=.03). Conclusions Patients can learn to use a smartphone app for postdischarge drainage monitoring with high levels of user satisfaction. We also identified a high degree of compliance with app-based drainage-recording design features, which is an aspect of mHealth that can improve surgical care.
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Affiliation(s)
- Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gang University, Taoyaun, Taiwan
| | - Yu-Tung Wu
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gang University, Taoyaun, Taiwan
| | - Chi-Tung Cheng
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gang University, Taoyaun, Taiwan
| | - Chun-Hsiang Ooyang
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gang University, Taoyaun, Taiwan
| | - Shih-Ching Kang
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gang University, Taoyaun, Taiwan
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gang University, Taoyaun, Taiwan
| | - Yu-Pao Hsu
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gang University, Taoyaun, Taiwan
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Linkou Chang Gung Memorial Hospital, Chang Gang University, Taoyaun, Taiwan
| | - Chih-Chi Chen
- Department of Physical Medicine and Rehabilitation, Linkou Chang Gung Memorial Hospital, Chang Gang University, Taoyaun, Taiwan
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27
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Early drain removal after major pancreatectomy reduces postoperative complications: a single-center, randomized, controlled trial. JOURNAL OF PANCREATOLOGY 2020. [DOI: 10.1097/jp9.0000000000000049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Trudeau MT, Maggino L, Chen B, McMillan MT, Lee MK, Roses R, DeMatteo R, Drebin JA, Vollmer CM. Extended Experience with a Dynamic, Data-Driven Selective Drain Management Protocol in Pancreaticoduodenectomy: Progressive Risk Stratification for Better Practice. J Am Coll Surg 2020; 230:809-818e1. [PMID: 32081751 DOI: 10.1016/j.jamcollsurg.2020.01.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 01/31/2020] [Accepted: 01/31/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Intraoperative drain use for pancreaticoduodenectomy has been practiced in an unconditional, binary manner (placement/no placement). Alternatively, dynamic drain management has been introduced, incorporating the Fistula Risk Score (FRS) and drain fluid amylase (DFA) analysis, to mitigate clinically relevant postoperative pancreatic fistula (CR-POPF). STUDY DESIGN An extended experience with dynamic drain management was used at a single institution for 400 consecutive pancreaticoduodenectomies (2014 to 2019). This protocol consists of the following: drains omitted for negligible/low-risk FRS (0 to 2) and drains placed for moderate/high-risk FRS (3 to 10) with early (postoperative day [POD] 3) removal if POD1 DFA ≤5,000 U/L. Adherence to this protocol was prospectively annotated and outcomes were retrospectively analyzed. RESULTS The overall CR-POPF rate was 8.7%, with none occurring in the negligible/low-risk cases. Moderate/high-risk patients manifested an 11.9% CR-POPF rate (n = 35 of 293), which was lower on-protocol (9.5% vs 21%; p = 0.014). After drain placement, POD1 DFA ≥5,000 U/L was a better predictor of CR-POPF than FRS (odds ratio 14.7; 95% CI, 4.3 to 50.3). For POD1 DFA ≤5,000 U/L, early drain removal was associated with fewer CR-POPFs (2.8% vs 23.5%; p < 0.001), and substantiated by multivariable analysis (odds ratio 0.09; 95% CI, 0.03 to 0.28). Surgeon adherence was inversely related to CR-POPF rate (R = 0.846). CONCLUSIONS This extended experience validates a dynamic drain management protocol, providing a model for better drain management and individualized patient care after pancreaticoduodenectomy. This study confirms that drains can be safely omitted from negligible/low-risk patients, and moderate/high-risk patients benefit from early drain removal.
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Affiliation(s)
- Maxwell T Trudeau
- From the Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA; Department of Surgery, Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy; Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. World J Surg 2020; 44:2056-2084. [DOI: 10.1007/s00268-020-05462-w] [Citation(s) in RCA: 286] [Impact Index Per Article: 57.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Howe JR, Merchant NB, Conrad C, Keutgen XM, Hallet J, Drebin JA, Minter RM, Lairmore TC, Tseng JF, Zeh HJ, Libutti SK, Singh G, Lee JE, Hope TA, Kim MK, Menda Y, Halfdanarson TR, Chan JA, Pommier RF. The North American Neuroendocrine Tumor Society Consensus Paper on the Surgical Management of Pancreatic Neuroendocrine Tumors. Pancreas 2020; 49:1-33. [PMID: 31856076 PMCID: PMC7029300 DOI: 10.1097/mpa.0000000000001454] [Citation(s) in RCA: 259] [Impact Index Per Article: 51.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This manuscript is the result of the North American Neuroendocrine Tumor Society consensus conference on the surgical management of pancreatic neuroendocrine tumors from July 19 to 20, 2018. The group reviewed a series of questions of specific interest to surgeons taking care of patients with pancreatic neuroendocrine tumors, and for each, the available literature was reviewed. What follows are these reviews for each question followed by recommendations of the panel.
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Affiliation(s)
- James R. Howe
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Claudius Conrad
- Department of Surgery, St. Elizabeth Medical Center, Tufts University School of Medicine, Boston, MA
| | | | - Julie Hallet
- Department of Surgery, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jeffrey A. Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rebecca M. Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Herbert J. Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Steven K. Libutti
- §§ Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Gagandeep Singh
- Department of Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Jeffrey E. Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A. Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Michelle K. Kim
- Department of Medicine, Mt. Sinai Medical Center, New York, NY
| | - Yusuf Menda
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Jennifer A. Chan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Rodney F. Pommier
- Department of Surgery, Oregon Health & Sciences University, Portland, OR
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Peritoneal drainage or no drainage after pancreaticoduodenectomy and/or distal pancreatectomy: a meta-analysis and systematic review. Surg Endosc 2019; 34:4991-5005. [DOI: 10.1007/s00464-019-07293-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 11/28/2019] [Indexed: 12/11/2022]
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Newhook TE, Vega EA, Vreeland TJ, Prakash L, Dewhurst WL, Bruno ML, Kim MP, Ikoma N, Vauthey JN, Katz MH, Lee JE, Tzeng CWD. Early postoperative drain fluid amylase in risk-stratified patients promotes tailored post-pancreatectomy drain management and potential for accelerated discharge. Surgery 2019; 167:442-447. [PMID: 31727324 DOI: 10.1016/j.surg.2019.09.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/03/2019] [Accepted: 09/20/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND First postoperative day drain fluid amylase (DFA1) <5000 U/L is commonly used for early drain removal. We manage patients with risk-stratified pancreatectomy care pathways determined preoperatively by risk for postoperative pancreatic fistula. We hypothesized that preoperative risk stratification would yield unique DFA1/DFA3 cutoffs for safe early drain removal. METHODS Patients with DFA1/DFA3 values after pancreaticoduodenectomy or distal pancreatectomy were identified. Patients were risk stratified as "low-risk pancreaticoduodenectomy," "high-risk pancreaticoduodenectomy," or "distal pancreatectomy." Receiver operator characteristic analyses yielded clinically relevant sensitivity thresholds for International Study Group on Pancreatic Surgery grade B/C postoperative pancreatic fistulas. RESULTS From October 2016 to April 2018, 174 patients were preoperatively stratified as low-risk pancreaticoduodenectomy (n = 78, 45%), high-risk pancreaticoduodenectomy (n = 51, 29%), and distal pancreatectomy (n = 45, 26%). B/C postoperative pancreatic fistulas developed in 3% (n = 2) of low-risk pancreaticoduodenectomies, 37% (n = 19) of high-risk pancreaticoduodenectomies, and 24% (n = 11) of distal pancreatectomies (low- vs high-risk pancreaticoduodenectomy P < .001, low-risk pancreaticoduodenectomy versus distal pancreatectomy P = .004, high-risk pancreaticoduodenectomy versus distal pancreatectomy P = .25). B/C postoperative pancreatic fistulas occurred in 16% (n = 21) pancreaticoduodenectomy patients (high- + low-risk pancreaticoduodenectomy), and B/C postoperative pancreatic fistulas were excluded in pancreaticoduodenectomy with 100% sensitivity if DFA1 ≤ 136 or DFA3 ≤ 93. DFA1 < 5000 excluded B/C postoperative pancreatic fistulas with only 57% sensitivity after pancreaticoduodenectomy. Exclusion of B/C postoperative pancreatic fistulas occurred with 100% sensitivity if DFA1 ≤ 661 or DFA3 ≤ 141 in low-risk pancreaticoduodenectomy patients, DFA1 ≤ 136 or DFA3 ≤ 93 in high-risk pancreaticoduodenectomy patients, and DFA1 < 49 or DFA3 < 26 in distal pancreatectomy patients. CONCLUSION Preoperative risk stratification results in unique DFA1/DFA3 thresholds to exclude B/C postoperative pancreatic fistulas, thus allowing for safe drain removal and potential for accelerated discharge. Rather than applying generic DFA cutoffs based on national databases, we propose institution-specific DFA1 and DFA3 values tailored to 3 replicable postoperative pancreatic fistula-risk pathways.
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Affiliation(s)
- Timothy E Newhook
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo A Vega
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Timothy J Vreeland
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Laura Prakash
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Whitney L Dewhurst
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Morgan L Bruno
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael P Kim
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naruhiko Ikoma
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew Hg Katz
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey E Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.
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You Y, Han IW, Choi DW, Heo JS, Ryu Y, Park DJ, Choi SH, Han S. Nomogram for predicting postoperative pancreatic fistula. HPB (Oxford) 2019; 21:1436-1445. [PMID: 30982739 DOI: 10.1016/j.hpb.2019.03.351] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/26/2019] [Accepted: 03/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous studies analyzed risk factors for postoperative pancreatic fistula (POPF) and developed risk prediction tool using scoring system. However, no study has built a nomogram based on individual risk factors. This study aimed to evaluate individual risks of POPF and propose a nomogram for predicting POPF. METHODS From 2007 to 2016, medical records of 1771 patients undergoing pancreaticoduodenctomy were reviewed retrospectively. Variables with p < 0.05 in multivariate logistic regression analysis were included in the nomogram. Internal performance validation was executed using a repeated cross validation method. RESULTS Of 1771 patients, 222 (12.5%) experienced POPF. In multivariable analysis, sex (p = 0.004), body mass index (BMI) (p < 0.001), ASA score (p = 0.039), preoperative albumin (p = 0.035), pancreatic duct diameter (p = 0.002), and location of tumor (p < 0.001) were identified as independent predictors for POPF. Based on these six variables, a POPF nomogram was developed. The area under the curve (AUC) estimated from the receiver operating characteristic (ROC) graph was 0.709 in the train set and 0.652 in the test set. CONCLUSIONS A POPF nomogram was developed. This nomogram may be useful for selecting patients who need more intensified therapy and establishing customized treatment strategy.
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Affiliation(s)
- Yunghun You
- Department of Surgery, Konkuk University Choongju Hospital, Konkuk University School of Medicine, 6, Gwangmyeong 1-gil, Chungju-si, Chungcheongbuk-do, 27376, South Korea
| | - In W Han
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
| | - Dong W Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Jin S Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Youngju Ryu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Dae J Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Seong H Choi
- Department of Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 158, Paryong-ro, Masanhoewon-gu, Changwon-si, Gyeongsangnam-do, 51353, South Korea
| | - Sunjong Han
- Department of Surgery, Seoul National University College of Medicine, Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
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Xourafas D, Ejaz A, Tsung A, Dillhoff M, Pawlik TM, Cloyd JM. Validation of early drain removal after pancreatoduodenectomy based on modified fistula risk score stratification: a population-based assessment. HPB (Oxford) 2019; 21:1303-1311. [PMID: 30898434 DOI: 10.1016/j.hpb.2019.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 01/30/2019] [Accepted: 02/04/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent studies on postoperative pancreatic fistula (POPF) prevention following pancreatoduodenectomy (PD) have proposed omission of perioperative drains for negligible/low-risk patients and early drain removal (≤POD3) for intermediate/high-risk patients with POD1 drain amylase levels of ≤5000 U/L, though this has not been validated using a nationwide cohort. METHODS The ACS-NSQIP targeted pancreatectomy database from 2014 to 2016 was queried to identify patients who underwent PD. Patients with POD1 drain amylase levels of ≤5000 U/L were initially stratified as negligible/low- or intermediate/high-risk based on a previously validated modified fistula risk score (mFRS). Differences in relevant postoperative outcomes were then compared among patients who underwent early (≤POD3) vs. late (≥POD4) drain removal. RESULTS Among 1825 patients who underwent PD, 1540 (84%) had POD1 drain amylase of ≤5000 U/L: 719 (47%) high-risk and 821 (53%) low-risk. Among high-risk patients, early drain removal (n = 205, 29%) was associated with lower rates of POPF (3% vs. 18%, p < 0.001), clinically relevant (CR)-POPF (2% vs. 15%, p < 0.001), overall morbidity (27% vs. 47%, p < 0.001), serious morbidity (15% vs. 24%, p = 0.007) and hospital length of stay (LOS, 7 vs. 8 days, p < 0.001). Similarly, early drain removal in low-risk patients (n = 273, 33%) was associated with decreased rates of POPF (1% vs. 6%, p = 0.003), CR-POPF (1% vs. 5%, p = 0.014), overall morbidity (28% vs. 41%, p = 0.0003), serious morbidity (8% vs. 14%, p = 0.015) and LOS (6 vs. 8 days, p < 0.001). On multivariate logistic regression analysis, early drain removal remained associated with significantly decreased odds of POPF, CR-POPF, overall and serious morbidity as well as LOS among both high- and low-risk patients (all p < 0.05). CONCLUSIONS Among patients with POD1 drain amylase ≤5000 U/L following PD, early drain removal (≤POD3) is associated with improved postoperative outcomes among both high- and low-risk patients. Early drain removal based on POD1 drain amylase is indicated regardless of mFRS.
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Affiliation(s)
- Dimitrios Xourafas
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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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: 1.0] [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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Characterization and Optimal Management of High-risk Pancreatic Anastomoses During Pancreatoduodenectomy. Ann Surg 2019; 267:608-616. [PMID: 28594741 DOI: 10.1097/sla.0000000000002327] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy. BACKGROUND The utility of technical strategies to prevent clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatoduodenectomy (PD) may vary by the circumstances of the anastomosis. The Fistula Risk Score (FRS) identifies a distinct high-risk cohort (FRS 7 to 10) that demonstrates substantially worse clinical outcomes. The value of various fistula mitigation strategies in these particular high-stakes cases has not been previously explored. METHODS This multinational study included 5323 PDs performed by 62 surgeons at 17 institutions. Mitigation strategies, including both technique related (ie, pancreatogastrostomy reconstruction; dunking; tissue patches) and the use of adjuvant strategies (ie, intraperitoneal drains; anastomotic stents; prophylactic octreotide; tissue sealants), were evaluated using multivariable regression analysis and propensity score matching. RESULTS A total of 522 (9.8%) PDs met high-risk FRS criteria, with an observed CR-POPF rate of 29.1%. Pancreatogastrostomy, prophylactic octreotide, and omission of externalized stents were each associated with an increased rate of CR-POPF (all P < 0.001). In a multivariable model accounting for patient, surgeon, and institutional characteristics, the use of external stents [odds ratio (OR) 0.45, 95% confidence interval (95% CI) 0.25-0.81] and the omission of prophylactic octreotide (OR 0.49, 95% CI 0.30-0.78) were independently associated with decreased CR-POPF occurrence. In the propensity score matched cohort, an "optimal" mitigation strategy (ie, externalized stent and no prophylactic octreotide) was associated with a reduced rate of CR-POPF (13.2% vs 33.5%, P < 0.001). CONCLUSIONS The scenarios identified by the high-risk FRS zone represent challenging anastomoses associated with markedly elevated rates of fistula. Externalized stents and omission of prophylactic octreotide, in the setting of intraperitoneal drainage and pancreaticojejunostomy reconstruction, provides optimal outcomes.
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Zaghal A, Tamim H, Habib S, Jaafar R, Mukherji D, Khalife M, Mailhac A, Faraj W. Drain or No Drain Following Pancreaticoduodenectomy: The Unsolved Dilemma. Scand J Surg 2019; 109:228-237. [PMID: 30931801 DOI: 10.1177/1457496919840960] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS There is no consensus regarding the routine placement of intra-abdominal drains after pancreaticoduodenectomy. We aim to determine the effects of intraperitoneal drain placement during pancreaticoduodenectomy on 30-day postoperative morbidity and mortality. METHODS Patients who underwent pancreaticoduodenectomy for pancreatic tumors were identified from the 2014-2015 American College of Surgeons-National Surgical Quality Improvement Program Database. Univariate and multivariate analyses adjusting for known prognostic variables were performed. A subgroup analysis was performed based on the risk for development of postoperative pancreatic leak determined by the pancreatic duct caliber, parenchymal texture, and body mass index. RESULTS A total of 6858 patients with pancreatic tumors who underwent pancreaticoduodenectomy were identified in the 2014-2015 American College of Surgeons-National Surgical Quality Improvement Program Database dataset. In all, 87.4% of patients had intraperitoneal drains placed. A 30-day mortality rate was higher in the no-drain group (2.9% vs. 1.7%, P = 0.003). Patients in the drain group had a higher incidence of overall morbidity (49.5% vs. 41.2%, P = 0.0008), delayed gastric emptying (18.1% vs. 13.7%, P = 0.004), pancreatic fistulae (19.4% vs. 9.9%, P ⩽ 0.0001), and prolonged length of hospital stay over 10 days (43.7% vs. 34.9%, P < 0.0001). Subgroup analysis based on risk categories revealed a higher 30-day mortality rate in the no-drain group among patients with high-risk features (3.1% vs. 1.6%, P = 0.02). Delayed gastric emptying and pancreatic fistula development remained significantly higher in the drain group only in the high-risk category. Prolonged length of hospital stay and composite morbidity remained higher in the drain group regardless of the risk category. CONCLUSION To our knowledge, this is the largest study to date that aims at clarifying the pros and cons of the intraperitoneal drain placement during pancreaticoduodenectomy for pancreatic tumors. We showed a higher 30-day mortality rate if drain insertion was omitted during pancreaticoduodenectomy in patients with softer pancreatic textures, smaller pancreatic duct caliber, and body mass index over 25. Postoperative 30-day morbidity rate was higher if a drain was inserted regardless of the risk category. Further randomized controlled trials with prospective evaluation of stratification factors for fistula risk are needed to establish a clear recommendation.
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Affiliation(s)
- A Zaghal
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - H Tamim
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - S Habib
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - R Jaafar
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - D Mukherji
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - M Khalife
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - A Mailhac
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - W Faraj
- Liver Transplantation and HPB Unit, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
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Seykora TF, Maggino L, Malleo G, Lee MK, Roses R, Salvia R, Bassi C, Vollmer CM. Evolving the Paradigm of Early Drain Removal Following Pancreatoduodenectomy. J Gastrointest Surg 2019; 23:135-144. [PMID: 30406578 DOI: 10.1007/s11605-018-3959-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/29/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent data illustrates improved outcomes when adhering to early drain removal following pancreatoduodenectomy (PD). This study aims to explore the potential benefits of expanding the timeframe for early drain removal. METHODS Six hundred forty PDs were originally managed by selective drain placement and early removal. Outcomes were reappraised in the framework of a novel proposal; intraoperative drains were omitted based on a low-risk profile (Fistula Risk Score 0-2), followed by drain removal at PODs 1, 3, and 5 if drain fluid amylase (DFA) fell below specific cutoffs based on optimized negative predictive values (NPV) for clinically relevant postoperative pancreatic fistula (CR-POPF). Characteristics of the remaining cohort with drains in situ on POD5 were examined using multivariable analysis (MVA). RESULTS Intraoperative FRS would preclude drains from 230 (35.9%) negligible/low-risk cases with a cohort CR-POPF rate of 1.7%. Of the remaining patients, 30.5% would have drains removed on POD1 based on a DFA threshold of 300 IU/L (NPV = 98.4%), demonstrating a 1.6% CR-POPF rate. On POD3, drains could be removed in the residual cohort from 21.1% of patients with DFA ≤ 150 IU/L (NPV = 96.6%), reflecting a 3.4% CR-POPF rate. On POD5, a DFA threshold of 50 IU/L (NPV = 84%) identified 16.3% more patients whose drains could be removed. The remaining cohort (POD5 DFA > 50 IU/L), "enriched" for fistula development and reflecting just 18.4% of the original patients, displays a 61% CR-POPF rate. Among these patients on POD5, a DFA threshold > 2000 IU/L best predicted subsequent CR-POPF (PPV = 89.5%), and MVA revealed a positive association between pancreatic cancer/pancreatitis (OR = 4.37, p = 0.022) and longer operations (OR = 3.74, p = 0.014) with CR-POPF development. CONCLUSION Early drain removal is a dynamic concept and can be employed throughout the postoperative time course using conditional thresholds to better identify patients at risk for CR-POPF.
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Affiliation(s)
- Thomas F Seykora
- Department of Surgery, University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Laura Maggino
- Department of Surgery, University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St., Philadelphia, PA, 19104, USA.,Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, the Pancreas Institute, University of Verona Hospital Trust, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, the Pancreas Institute, University of Verona Hospital Trust, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Major K Lee
- Department of Surgery, University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Robert Roses
- Department of Surgery, University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, the Pancreas Institute, University of Verona Hospital Trust, P.le L.A. Scuro 10, 37134, Verona, Italy
| | - Claudio Bassi
- Department of Surgery, University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St., Philadelphia, PA, 19104, USA
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St., Philadelphia, PA, 19104, USA.
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Xourafas D, Ejaz A, Tsung A, Dillhoff M, Pawlik TM, Cloyd JM. Population-Based Assessment of Selective Drain Placement During Pancreatoduodenectomy Using the Modified Fistula Risk Score. J Am Coll Surg 2018; 228:583-591. [PMID: 30586644 DOI: 10.1016/j.jamcollsurg.2018.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND Recent studies on postoperative pancreatic fistula (POPF) prevention suggest that omission of perioperative drains is safe for negligible- or low-risk patients undergoing pancreatoduodenectomy (PD). However, this proposed pathway has not been validated in a nationwide cohort. STUDY DESIGN The ACS-NSQIP-targeted pancreatectomy database from 2014 to 2016 was queried to identify patients who underwent PD. Using a previously validated modified Fistula Risk Score (mFRS), patients were stratified as negligible/low- or intermediate/high-risk. Multivariate regression models were used to analyze the effect of intraoperative drain placement on relevant perioperative outcomes in both high- and low-risk patients. RESULTS Among 6,730 patients undergoing PD, 3,375 (50%) were high-risk; 3,355 (50%) were low-risk. Among high-risk patients, drain placement (n = 3,093, 92%) was associated with a higher rate of POPF (26% vs 16%, p = 0.0003), clinically relevant (CR) POPF (20% vs 12%, p = 0.0015), and extended hospital length of stay (LOS, 9 vs 7 days, p < 0.0001), but decreased serious morbidity (29% vs 35%, p = 0.0330). Similarly, drain placement in low-risk patients (n = 2,785, 83%) was associated with a higher rate of POPF (11% vs 6%, p = 0.0006) and extended LOS (8 vs 7 days, p < 0.0001), yet lower serious morbidity (18% vs 23%, p = 0.0037). On multivariate logistic regression, drain placement was associated with significantly increased odds of CR-POPF and a significantly reduced incidence of serious morbidity among both high-risk (odds ratio [OR] 0.72, 95% CI 0.55 to 0.94, p = 0.0155) and low-risk patients (OR 0.71, 95% CI 0.57 to 0.89, p = 0.0027). CONCLUSIONS In this population-based cohort, the mFRS was unable to stratify patients relative to the need for selective drain placement during PD. For both high- and low-risk patients, perioperative drain placement was associated with increased rates of POPF, CR-POPF, and extended LOS, but decreased incidence of serious morbidity.
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Affiliation(s)
- Dimitrios Xourafas
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Allan Tsung
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jordan M Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
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Ecker BL, McMillan MT, Maggino L, Vollmer CM. Taking Theory to Practice: Quality Improvement for Pancreaticoduodenectomy and Development and Integration of the Fistula Risk Score. J Am Coll Surg 2018; 227:430-438.e1. [DOI: 10.1016/j.jamcollsurg.2018.06.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 06/25/2018] [Accepted: 06/25/2018] [Indexed: 12/19/2022]
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Martin AN, Narayanan S, Turrentine FE, Bauer TW, Adams RB, Zaydfudim VM. Pancreatic duct size and gland texture are associated with pancreatic fistula after pancreaticoduodenectomy but not after distal pancreatectomy. PLoS One 2018; 13:e0203841. [PMID: 30212577 PMCID: PMC6136772 DOI: 10.1371/journal.pone.0203841] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/28/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Pancreatic fistula remains a morbid complication after pancreatectomy. Since the proposed mechanism of pancreatic fistula is different between pancreaticoduodenectomy and distal pancreatectomy, we hypothesized that pancreatic gland texture and duct size are not associated with pancreatic fistula after distal pancreatectomy. METHODS All patients ≥18 years in the 2014-15 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) targeted pancreatectomy dataset were linked with the ACS NSQIP Public Use File (PUF). Pancreatic duct size (<3 mm, 3-6 mm, >6 mm) and pancreatic gland texture (hard, intermediate, soft) were categorized. Separate multivariable analyses were performed to evaluate associations between pancreatic duct size and gland texture after pancreaticoduodenectomy and distal pancreatectomy. RESULTS A total of 9366 patients underwent pancreaticoduodenectomy or distal pancreatectomy during the study period. Proportion of pancreatic fistula was similar after distal pancreatectomy (606 of 3132, 19.4%) and pancreaticoduodenectomy (1163 of 6335, 18.4%, p = 0.245). Both pancreatic gland texture and duct size were significantly associated with pancreatic fistula after pancreaticoduodenectomy (p<0.001). However, there was no association between pancreatic fistula and gland texture or duct size (all p≥0.169) after distal pancreatectomy. Operative approach (minimally invasive versus open) was not associated with pancreatic fistula after distal pancreatectomy (p = 0.626). Patients with pancreatic fistula after distal pancreatectomy had increased rate of postoperative complications including longer length of stay, higher rates of readmission and reoperation compared to patients who did not have a pancreatic fistula (all p<0.001). CONCLUSIONS Unlike among patients who had pancreaticoduodenectomy, pancreatic gland texture and duct size are not associated with development of pancreatic fistula following distal pancreatectomy. Other clinical factors should be considered in this patient population.
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Affiliation(s)
- Allison N. Martin
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Sowmya Narayanan
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Florence E. Turrentine
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, United States of America
| | - Todd W. Bauer
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Reid B. Adams
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, United States of America
- Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, United States of America
- * E-mail:
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Torres OJM, Fernandes EDSM, Vasques RR, Waechter FL, Amaral PCG, Rezende MBD, Costa RM, Montagnini AL. PANCREATODUODENECTOMY: BRAZILIAN PRACTICE PATTERNS. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2018; 30:190-196. [PMID: 29019560 PMCID: PMC5630212 DOI: 10.1590/0102-6720201700030007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/04/2017] [Indexed: 12/19/2022]
Abstract
Background: Pancreatoduodenectomy is a technically challenging surgical procedure with an incidence of postoperative complications ranging from 30% to 61%. The procedure requires a high level of experience, and to minimize surgery-related complications and mortality, a high-quality standard surgery is imperative. Aim: To understand the Brazilian practice patterns for pancreatoduodenectomy. Method: A questionnaire was designed to obtain an overview of the surgical practice in pancreatic cancer, specific training, and experience in pancreatoduodenectomy. The survey was sent to members who declared an interest in pancreatic surgery. Results: A total of 60 questionnaires were sent, and 52 have returned (86.7%). The Southeast had the most survey respondents, with 25 surgeons (48.0%). Only two surgeons (3.9%) performed more than 50% of their pancreatoduodenectomies by laparoscopy. A classic Whipple procedure was performed by 24 surgeons (46.2%) and a standard International Study Group on Pancreatic Surgery lymphadenectomy by 43 surgeons (82.7%). For reconstruction, pancreaticojejunostomy was performed by 49 surgeons (94.2%), single limb technique by 41(78.9%), duct-to-mucosa anastomosis by 38 (73.1%), internal trans-anastomotic stenting by 26 (50.0%), antecolic route of gastric reconstruction by 39 (75.0%), and Braun enteroenterostomy was performed by only six surgeons (11.5%). Prophylactic abdominal drainage was performed by all surgeons, and somatostatin analogues were utilized by six surgeons (11.5%). Early postoperative enteral nutrition was routine for 22 surgeons (42.3%), and 34 surgeons (65.4%) reported routine use of a nasogastric suction tube. Conclusion: Heterogeneity was observed in the pancreatoduodenectomy practice patterns of surgeons in Brazil, some of them in contrast with established evidence in the literature.
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Zhang W, He S, Cheng Y, Xia J, Lai M, Cheng N, Liu Z, Cochrane Upper GI and Pancreatic Diseases Group. 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: 24] [Impact Index Per Article: 3.4] [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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Affiliation(s)
- William E Fisher
- Division of General Surgery, Michael E. DeBakey Department of Surgery, Elkins Pancreas Center, Baylor College of Medicine, 6620 Main Street, Suite 1425, Houston, TX 77030, USA.
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Marchegiani G, Perri G, Pulvirenti A, Sereni E, Azzini AM, Malleo G, Salvia R, Bassi C. Non-inferiority of open passive drains compared with closed suction drains in pancreatic surgery outcomes: A prospective observational study. Surgery 2018; 164:443-449. [PMID: 29903511 DOI: 10.1016/j.surg.2018.04.025] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/07/2018] [Accepted: 04/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Policies concerning the management of operatively placed drains after pancreatic surgery are still under debate. Open passive drains and closed-suction drains are both used currently in clinical practice worldwide, but there are no reliable data regarding potential differences in the postoperative outcomes associated with each drain type. The aim of the present study was to compare open passive drains and closed-suction drains with regard to postoperative contamination of the drainage fluid and overall morbidity and mortality. METHODS This study was a prospective, observational analysis of 320 consecutive, standard, partial resections (pancreaticoduodenectomy and distal pancreatectomy at a single institution from April 2016 to April 2017. Either open passive drains (n = 189, 51%) or closed-suction drains (n = 131) were used according to the operating surgeon's choice. Postoperative outcomes, including samples of drainage fluid collected on postoperative day V and sent for microbiologic analysis, were registered. RESULTS The open passive drain and closed-suction drain cohorts did not differ in terms of their clinical features, use of neoadjuvant chemotherapy or preoperative biliary drainage, fistula risk zone, and type of operative procedure. The overall rate of postoperative day V drainage fluid contamination (27.5% vs. 20.6%, P = .1) was similar between the groups. The same results were obtained for each specific procedure. The postoperative outcomes, namely, overall 30-day morbidity, postoperative pancreatic fistula, intra-abdominal fluid collections, percutaneous drainage, wound infections, reintervention, mean duration of hospital stay, and mortality did not differ between the 2 groups. Qualitative microbiologic analysis revealed that after pancreaticoduodenectomy, 61.5% of the bacteria contaminating the drainage fluid were attributable to human gut flora, while after distal pancreatectomy, 84.8% of the bacteria belonged to skin and mucous flora (P < .01), however, the spectrum of bacterial contamination did not significantly differ between the open passive drain and closed-suction drain cohorts. CONCLUSION The use of open passive drains and closed-suction drains for major pancreatic resection does not significantly impact the postoperative outcome. The spectrum of drain contamination depends on the specific operative procedure rather than on the type of drain used.
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Affiliation(s)
- Giovanni Marchegiani
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giampaolo Perri
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Alessandra Pulvirenti
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Elisabetta Sereni
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Anna Maria Azzini
- Microbiology and Virology Unit, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy.
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Villafane-Ferriol N, Van Buren G, Mendez-Reyes JE, McElhany AL, Massarweh NN, Silberfein E, Hsu C, Tran Cao HS, Schmidt C, Zyromski N, Dillhoff M, Roch A, Oliva E, Smith AC, Zhang Q, Fisher WE. Sequential drain amylase to guide drain removal following pancreatectomy. HPB (Oxford) 2018; 20:514-520. [PMID: 29478737 PMCID: PMC5995628 DOI: 10.1016/j.hpb.2017.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 11/09/2017] [Accepted: 11/22/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although used as criterion for early drain removal, postoperative day (POD) 1 drain fluid amylase (DFA) ≤ 5000 U/L has low negative predictive value for clinically relevant postoperative pancreatic fistula (CR-POPF). It was hypothesized that POD3 DFA ≤ 350 could provide further information to guide early drain removal. METHODS Data from a pancreas surgery consortium database for pancreatoduodenectomy and distal pancreatectomy patients were analyzed retrospectively. Those patients without drains or POD 1 and 3 DFA data were excluded. Patients with POD1 DFA ≤ 5000 were divided into groups based on POD3 DFA: Group A (≤350) and Group B (>350). Operative characteristics and 60-day outcomes were compared using chi-square test. RESULTS Among 687 patients in the database, all data were available for 380. Fifty-five (14.5%) had a POD1 DFA > 5000. Among 325 with POD1 DFA ≤ 5000, 254 (78.2%) were in Group A and 71 (21.8%) in Group B. Complications (35 (49.3%) vs 87 (34.4%); p = 0.021) and CR-POPF (13 (18.3%) vs 10 (3.9%); p < 0.001) were more frequent in Group B. CONCLUSIONS In patients with POD1 DFA ≤ 5000, POD3 DFA ≤ 350 may be a practical test to guide safe early drain removal. Further prospective testing may be useful.
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Affiliation(s)
- N Villafane-Ferriol
- Baylor College of Medicine Michael E. DeBakey Department of Surgery, One Baylor Plaza Suite 404D, Houston, TX 77030
| | - G Van Buren
- Baylor College of Medicine Michael E. DeBakey Department of Surgery, One Baylor Plaza Suite 404D, Houston, TX 77030
| | - JE Mendez-Reyes
- Baylor College of Medicine Michael E. DeBakey Department of Surgery, One Baylor Plaza Suite 404D, Houston, TX 77030
| | | | - NN Massarweh
- Baylor College of Medicine Michael E. DeBakey Department of Surgery, One Baylor Plaza Suite 404D, Houston, TX 77030
| | - E Silberfein
- Baylor College of Medicine Michael E. DeBakey Department of Surgery, One Baylor Plaza Suite 404D, Houston, TX 77030
| | - C Hsu
- Baylor College of Medicine Michael E. DeBakey Department of Surgery, One Baylor Plaza Suite 404D, Houston, TX 77030
| | - HS Tran Cao
- Baylor College of Medicine Michael E. DeBakey Department of Surgery, One Baylor Plaza Suite 404D, Houston, TX 77030
| | - C Schmidt
- The Ohio State University Department of Surgery, M256 Starling Loving Hall, 320W 10th Avenue, Columbus, Ohio 43210
| | - N Zyromski
- Indiana University School of Medicine Department of Surgery, 545 Barhill Drive EH 519, Indianapolis, IN 46202
| | - M Dillhoff
- The Ohio State University Department of Surgery, M256 Starling Loving Hall, 320W 10th Avenue, Columbus, Ohio 43210
| | - A Roch
- Baylor College of Medicine Michael E. DeBakey Department of Surgery, One Baylor Plaza Suite 404D, Houston, TX 77030,Indiana University School of Medicine Department of Surgery, 545 Barhill Drive EH 519, Indianapolis, IN 46202
| | - E Oliva
- Baylor College of Medicine Michael E. DeBakey Department of Surgery, One Baylor Plaza Suite 404D, Houston, TX 77030
| | - AC Smith
- Baylor College of Medicine Michael E. DeBakey Department of Surgery, One Baylor Plaza Suite 404D, Houston, TX 77030
| | - Q Zhang
- Baylor College of Medicine Michael E. DeBakey Department of Surgery, One Baylor Plaza Suite 404D, Houston, TX 77030
| | - WE Fisher
- Baylor College of Medicine Michael E. DeBakey Department of Surgery, One Baylor Plaza Suite 404D, Houston, TX 77030
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El Khoury R, Kabir C, Maker VK, Banulescu M, Wasserman M, Maker AV. Do Drains Contribute to Pancreatic Fistulae? Analysis of over 5000 Pancreatectomy Patients. J Gastrointest Surg 2018; 22:1007-1015. [PMID: 29435899 DOI: 10.1007/s11605-018-3702-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 01/25/2018] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Conflicting evidence exists from randomized controlled trials supporting both increased complications/fistulae and improved outcomes with drain placement after pancreatectomy. The objective was to determine drain practice patterns in the USA, and to identify if drain placement was associated with fistula formation. METHODS Demographic, perioperative, and patient outcome data were captured from the most recent annual NSQIP pancreatic demonstration project database, including components of the fistula risk score. Significant variables in univariate analysis were entered into adjusted logistic regression models. RESULTS Of 5013 pancreatectomy patients, 4343 (87%) underwent drain placement and 18% of patients experienced a pancreatic fistula. When controlled for other factors, drain placement was associated with ducts < 3 mm, soft glands, and blood transfusion within 72 h of surgery. Age, obesity, neoadjuvant radiation, preoperative INR level, and malignant histology lost significance in the adjusted model. Drained patients experienced higher readmission rates (17 vs. 14%; p < 0.05) and increased (20 vs. 8%; p < 0.01) pancreatic fistulae. Fistula was associated with obesity, no neoadjuvant chemotherapy, drain placement, < 3 mm duct diameter, soft gland, and longer operative times. Drain placement remained independently associated with fistula after both distal pancreatectomy (OR = 2.84 (1.70, 4.75); p < 0.01) and pancreatoduodenectomy (OR = 2.29 (1.28, 4.11); p < 0.01). CONCLUSIONS Despite randomized controlled clinical trial data supporting no drain placement, drains are currently placed in the vast majority (87%) of pancreatectomy patients from > 100 institutions in the USA, particularly those with soft glands, small ducts, and perioperative blood transfusions. When these factors are controlled for, drain placement remains independently associated with fistulae after both distal and proximal pancreatectomy.
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Affiliation(s)
- R El Khoury
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, 835 S. Wolcott St. MC790, Chicago, IL, USA.,Departments of Surgery and Research, Creticos Cancer Center and the Advocate Health Research Institute, Chicago, IL, USA
| | - C Kabir
- Departments of Surgery and Research, Creticos Cancer Center and the Advocate Health Research Institute, Chicago, IL, USA
| | - V K Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, 835 S. Wolcott St. MC790, Chicago, IL, USA.,Departments of Surgery and Research, Creticos Cancer Center and the Advocate Health Research Institute, Chicago, IL, USA
| | - M Banulescu
- Departments of Surgery and Research, Creticos Cancer Center and the Advocate Health Research Institute, Chicago, IL, USA
| | - M Wasserman
- Departments of Surgery and Research, Creticos Cancer Center and the Advocate Health Research Institute, Chicago, IL, USA
| | - A V Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, 835 S. Wolcott St. MC790, Chicago, IL, USA. .,Departments of Surgery and Research, Creticos Cancer Center and the Advocate Health Research Institute, Chicago, IL, USA.
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Abstract
BACKGROUND Pancreatic anastomosis is the Achilles heel of pancreatic surgery. Despite substantial progress in surgical techniques the rate of postoperative pancreatic fistulas remains very high. For this reason various supportive measures to secure pancreatic anastomoses are of continuing interest. OBJECTIVE This review presents the newest evidence-based data on supportive measures designed to secure a pancreatic anastomosis. MATERIAL AND METHODS The most recent meta-analyses, randomized controlled trials and the largest retrospective studies on the role of pancreatic duct stenting, double loop reconstruction, autologous patches and drainage in pancreaticoduodenectomy were taken into account. The value of somatostatin analogues, perioperative nutrition and fluid management is critically discussed. RESULTS The existing body of evidence on supportive measures is insufficient and remains controversial. The use of somatostatin analogues, drainages and restrictive perioperative fluid management has proven effective. In contrast, routine stenting of the pancreatic duct cannot be recommended. Other approaches, such as double loop reconstruction and use of autologous patches lack sufficient evidence. CONCLUSION Meticulous surgical technique and surgeon experience remain the cornerstones of performing a safe pancreatic anastomosis; however, some additional supportive measures seem to have significant potential and should be further investigated in large and well-designed prospective clinical trials.
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Affiliation(s)
- O Belyaev
- Klinik für Allgemein- und Viszeralchirurgie, St. Josef-Hospital, Ruhr-Universiät Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland.
| | - W Uhl
- Klinik für Allgemein- und Viszeralchirurgie, St. Josef-Hospital, Ruhr-Universiät Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland
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Pancreatogastrostomy Vs. Pancreatojejunostomy: a Risk-Stratified Analysis of 5316 Pancreatoduodenectomies. J Gastrointest Surg 2018; 22:68-76. [PMID: 28840459 DOI: 10.1007/s11605-017-3547-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 08/14/2017] [Indexed: 01/31/2023]
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Abstract
Many pancreatic surgeons continue to use intraperitoneal drains, but others have limited or avoided their use, believing this improves outcomes. We conducted a systematic review and meta-analysis of the literature assessing outcomes in pancreatectomy without drains, selective drainage, and early drain removal. We searched PubMed, Embase, and the Cochrane Library databases and conducted a systematic review of randomized and nonrandomized studies comparing routine intra-abdominal drainage versus no drainage, selective drain use, and early versus late drain removal after pancreatectomy, with major complications as the primary outcome. A meta-analysis of the literature assessing routine use of drains was conducted using the random-effects model. A total of 461 articles met search criteria from PubMed (168 articles), Embase (263 articles), and the Cochrane Library (30 articles). After case reports and articles without primary data on complications were excluded, 14 studies were identified for systematic review. Definitive evidence-based recommendations cannot be made regarding the management of drains following pancreatectomy because of limitations in the available literature. Based on available evidence, the most conservative approach, pending further data, is routine placement of a drain and early removal unless the patient's clinical course or drain fluid amylase concentration suggests a developing fistula.
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