Peritoneal Drain Placement at Pancreatoduodenectomy

Abstract

Routine peritoneal drainage has traditionally accompanied pancreatoduodenectomy, yet its efficacy has been questioned in recent years. The first randomized, controlled trial to evaluate this practice reported an association between drainage and intra-abdominal abscess, fluid collection, and fistula following major pancreatic resections. Since that study, several retrospective works have also found little to no advantage from routine drainage. Conversely, a recent randomized, controlled trial suggested that eliminating drains increases the frequency and severity of complications. A deeper analysis of that trial demonstrated a benefit to selective drainage based on the degree of risk for developing clinically relevant pancreatic fistula, as assessed by the Fistula Risk Score. Drainage appeared to confer no benefit to patients with negligible and low fistula risk, while drain placement in moderate and high fistula risk patients was associated with significantly lower rates of intra-abdominal abscess, clinically relevant pancreatic fistula, and IR-guided percutaneous drainage. The Fistula Risk Score can identify patients who benefit from peritoneal drainage at pancreatoduodenectomy. The highest quality evidence on this topic suggests calculating the Fistula Risk Score intraoperatively, at the point of reconstruction, and placing drains in only patients with moderate or high clinically relevant pancreatic fistula risk.