Advertisement

Journal of Gastrointestinal Surgery

, Volume 23, Issue 1, pp 135–144 | Cite as

Evolving the Paradigm of Early Drain Removal Following Pancreatoduodenectomy

  • Thomas F. Seykora
  • Laura Maggino
  • Giuseppe Malleo
  • Major K. LeeIV
  • Robert Roses
  • Roberto Salvia
  • Claudio Bassi
  • Charles M. VollmerJrEmail author
2018 SSAT Plenary Presentation

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.

Keywords

Pancreatoduodenectomy Early removal Fistula CR-POPF Amylase Drain 

Supplementary material

11605_2018_3959_MOESM1_ESM.docx (16 kb)
ESM 1 (DOCX 15 kb)
11605_2018_3959_MOESM2_ESM.docx (14 kb)
ESM 2 (DOCX 14 kb)
11605_2018_3959_MOESM3_ESM.docx (24 kb)
ESM 3 (DOCX 24 kb)

References

  1. 1.
    Kawai M, Tani M, Terasawa H, et al. Early removal of Prophylactic Drains Reduces the Risk of Intra-abdominal Infections in Patients With Pancreatic Head Resection: Prospective Study for 104 Consecutive Patients. Ann Surg. 2006;244(1):1.  https://doi.org/10.1097/01.sla.0000218077.14035.a6 CrossRefGoogle Scholar
  2. 2.
    Molinari E, Bassi C, Salvia R, et al. Amylase Value in Drains After Pancreatic Resection as Predictive Factor of Postoperative Pancreatic Fistula: Results of a Prospective Study in 137 Patients. Ann Surg. 2007;246(2):281.  https://doi.org/10.1097/sla.0b013e3180caa42f CrossRefGoogle Scholar
  3. 3.
    Bassi C, Molinari E, Malleo G, et al. Early Versus Late Drain Removal After Standard Pancreatic Resections: Results of a Prospective Randomized Trial. Ann Surg. 2010;252(2):207.  https://doi.org/10.1097/sla.0b013e3181e61e88 CrossRefGoogle Scholar
  4. 4.
    Fong ZV, Correa-Gallego C, Ferrone CR, et al. Early Drain Removal—The Middle Ground Between the Drain Versus No Drain Debate in Patients Undergoing Pancreaticoduodenectomy: A Prospective Validation Study. Ann Surg. 2015;262(2):378.  https://doi.org/10.1097/sla.0000000000001038 CrossRefGoogle Scholar
  5. 5.
    McMillan MT, Fisher WE, Van Buren G, et al. The Value of Drains as a Fistula Mitigation Strategy for Pancreatoduodenectomy: Something for Everyone? Results of a Randomized Prospective Multi-institutional Study. J Gastrointest Surg. 2015;19(1):21–31.  https://doi.org/10.1007/s11605-014-2640-z CrossRefGoogle Scholar
  6. 6.
    McMillan MT, Malleo G, Bassi C, et al. Multicenter, Prospective Trial of Selective Drain Management for Pancreatoduodenectomy Using Risk Stratification. Ann Surg. 2017;265(6):1209.  https://doi.org/10.1097/sla.0000000000001832 CrossRefGoogle Scholar
  7. 7.
    Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM. A Prospectively Validated Clinical Risk Score Accurately Predicts Pancreatic Fistula after Pancreatoduodenectomy. J Am Coll Surg. 2013;216(1):1–14.  https://doi.org/10.1016/j.jamcollsurg.2012.09.002 CrossRefGoogle Scholar
  8. 8.
    Villafane-Ferriol N, Buren G Van, Mendez-Reyes JE, et al. Sequential drain amylase to guide drain removal following pancreatectomy. HPB (Oxford). 2018.  https://doi.org/10.1016/j.hpb.2017.11.008
  9. 9.
    McMillan MT, Malleo G, Bassi C, et al. Pancreatic fistula risk for pancreatoduodenectomy: an international survey of surgeon perception. HPB. 2017;19(6):515–524.  https://doi.org/10.1016/j.hpb.2017.01.022 CrossRefGoogle Scholar
  10. 10.
    McMillan MT, Malleo G, Bassi C, Sprys MH, Vollmer CM. Defining the practice of pancreatoduodenectomy around the world. HPB. 2015;17(12):1145–1154.  https://doi.org/10.1111/hpb.12475 CrossRefGoogle Scholar
  11. 11.
    Beane JD, House MG, Ceppa EP, Dolejs SC, Pitt HA. Variation in Drain Management After Pancreatoduodenectomy: Early Versus Delayed Removal. Ann Surg. 2017:1.  https://doi.org/10.1097/sla.0000000000002570
  12. 12.
    McMillan MT, Christein JD, Callery MP, et al. Prophylactic octreotide for pancreatoduodenectomy: more harm than good? HPB. 2014;16(10):954–962.  https://doi.org/10.1111/hpb.12314 CrossRefGoogle Scholar
  13. 13.
    Sachs TE, Pratt WB, Kent TS, Callery MP, Vollmer CM. The pancreaticojejunal anastomotic stent: Friend or foe? Surgery. 2013;153(5):651–662.  https://doi.org/10.1016/j.surg.2012.11.007 CrossRefGoogle Scholar
  14. 14.
    McMillan MT, Ecker BL, Behrman SW, et al. Externalized Stents for Pancreatoduodenectomy Provide Value Only in High-Risk Scenarios. J Gastrointest Surg. 2016;20(12):2052–2062.  https://doi.org/10.1007/s11605-016-3289-6 CrossRefGoogle Scholar
  15. 15.
    Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery. 2017;161(3):584–591.  https://doi.org/10.1016/j.surg.2016.11.014 CrossRefGoogle Scholar
  16. 16.
    Maggino L, Malleo G, Bassi C, et al. Decoding Grade B Pancreatic Fistula: A Clinical and Economical Analysis and Subclassification Proposal. Ann Surg. 2018:1.  https://doi.org/10.1097/sla.0000000000002673
  17. 17.
    Strasberg SM, Linehan DC, Hawkins WG. The Accordion Severity Grading System of Surgical Complications. Ann Surg. 2009;250(2):177.  https://doi.org/10.1097/sla.0b013e3181afde41 CrossRefGoogle Scholar
  18. 18.
    McMillan MT, Christein JD, Callery MP, et al. Comparing the burden of pancreatic fistulas after pancreatoduodenectomy and distal pancreatectomy. Surgery. 2016;159(4):1013–1022.  https://doi.org/10.1016/j.surg.2015.10.028 CrossRefGoogle Scholar
  19. 19.
    Giglio MC, Spalding DRC, Giakoustidis A, et al. Meta-analysis of drain amylase content on postoperative day 1 as a predictor of pancreatic fistula following pancreatic resection. Br J Surg. 2016;103(4):328–336.  https://doi.org/10.1002/bjs.10090 CrossRefGoogle Scholar
  20. 20.
    Ecker BL, McMillan MT, Allegrini V, et al. Risk Factors and Mitigation Strategies for Pancreatic Fistula After Distal Pancreatectomy: Analysis of 2026 Resections From the International, Multi-institutional Distal Pancreatectomy Study Group. Ann Surg. 2017:1.  https://doi.org/10.1097/sla.0000000000002491
  21. 21.
    Maggino L, Liu JB, Ecker BL, Pitt HA, Vollmer CM. Impact of Operative Time on Outcomes after Pancreatic Resection: A Risk-Adjusted Analysis Using the American College of Surgeons NSQIP Database. J Am Coll Surg. 2018.  https://doi.org/10.1016/j.jamcollsurg.2018.01.004
  22. 22.
    McMillan MT, Vollmer CM, Asbun HJ, et al. The Characterization and Prediction of ISGPF Grade C Fistulas Following Pancreatoduodenectomy. J Gastrointest Surg. 2016;20(2):262–276.  https://doi.org/10.1007/s11605-015-2884-2 CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2018

Authors and Affiliations

  • Thomas F. Seykora
    • 1
  • Laura Maggino
    • 1
    • 2
  • Giuseppe Malleo
    • 2
  • Major K. LeeIV
    • 1
  • Robert Roses
    • 1
  • Roberto Salvia
    • 2
  • Claudio Bassi
    • 1
  • Charles M. VollmerJr
    • 1
    Email author
  1. 1.Department of SurgeryUniversity of Pennsylvania, University of Pennsylvania Perelman School of MedicinePhiladelphiaUSA
  2. 2.Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, the Pancreas InstituteUniversity of Verona Hospital TrustVeronaItaly

Personalised recommendations