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Evolving the Paradigm of Early Drain Removal Following Pancreatoduodenectomy

  • 2018 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

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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Authors and Affiliations

  1. Department of Surgery, University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St., Philadelphia, PA, 19104, USA

    Thomas F. Seykora, Laura Maggino, Major K. Lee IV, Robert Roses, Claudio Bassi & Charles M. Vollmer Jr

  2. 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

    Laura Maggino, Giuseppe Malleo & Roberto Salvia

Authors
  1. Thomas F. Seykora
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  2. Laura Maggino
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  3. Giuseppe Malleo
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  4. Major K. Lee IV
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  5. Robert Roses
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  6. Roberto Salvia
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  7. Claudio Bassi
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  8. Charles M. Vollmer Jr
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Corresponding author

Correspondence to Charles M. Vollmer Jr.

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All authors listed in this manuscript have fulfilled the four ICMJE criteria for authorship.

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Seykora, T.F., Maggino, L., Malleo, G. et al. Evolving the Paradigm of Early Drain Removal Following Pancreatoduodenectomy. J Gastrointest Surg 23, 135–144 (2019). https://doi.org/10.1007/s11605-018-3959-7

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  • DOI: https://doi.org/10.1007/s11605-018-3959-7

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