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

Abstract

Purpose

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

Methods

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

Results

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

Conclusions

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

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Acknowledgments

The authors thank Dr. Aya Kuchiba for support of statistical analysis. We thank Ellen Knapp, PhD, from Edanz Group (www.edanzediting.com/ac) for editing a draft of this manuscript.

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All authors have made substantial contributions to the manuscript; have participated in the acquisition, analysis, and interpretation of data; and have participated in the drafting and revision of the work.

Corresponding author

Correspondence to Satoshi Nara.

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This study received institutional review board approval and conformed to the ethical standards of the World Medical Association (principles of the Declaration of Helsinki).

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The authors declare that they have no conflict of interest.

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Iwasaki, T., Nara, S., Kishi, Y. et al. Proposal of a Clinically Useful Criterion for Early Drain Removal After Pancreaticoduodenectomy. J Gastrointest Surg 25, 737–746 (2021). https://doi.org/10.1007/s11605-020-04565-y

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  • DOI: https://doi.org/10.1007/s11605-020-04565-y

Keywords

  • Pancreaticoduodenectomy
  • Postoperative pancreatic fistula
  • C-reactive protein
  • Drain