Abstract
Background
: Routine drainage of the operative bed following elective pancreatectomy remains controversial. Data specific to distal pancreatectomy (DP) have not been examined in a multi-institutional collaborative.
Methods
: Data from the American College of Surgeons-National Surgical Quality Improvement Program Pancreatectomy Demonstration Project were utilized. The impact of drain placement on development of pancreatectomy-related and overall morbidity were analyzed. Propensity scores for drain placement were calculated, and nearest neighbor matching was used to create a matched cohort. Groups were compared using bivariate and logistic regression analyses.
Results
: Over 14 months, 761 patients undergoing DP were accrued; 606 were drained. Propensity score matching was possible in 116 patients. Drain and no drain groups were not different with respect to multiple preoperative and operative variables. All pancreatic fistulas (p < 0.01) and overall morbidity (p < 0.05) were more common in patients who received a drain. The placement of a drain did not reduce the incidence of clinically relevant pancreatic fistula nor the need for postoperative procedures.
Conclusions
: Placement of drains following elective distal pancreatectomy was associated with a higher overall morbidity and pancreatic fistulas. Drains did not reduce intra-abdominal septic morbidity, clinically relevant pancreatic fistulas, nor the need for postoperative therapeutic intervention.
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References
Heider R, Meyer AA, Galanko JA, et al. Percutaneous drainage of pancreatic pseudocysts is associated with a higher failure rate than surgical treatment in unselected patients. Ann Surg 1999;229:781–7.
Conlon KC, Labow D, Leung D, et al. Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection. Ann Surg 2001;234:487–94.
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 of 104 consecutive patients. Ann Surg 2006;244:1–7.
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;252:207–14.
Correa-Gallego C, Brennan MF, D’Angelica M, et al. Operative drainage following pancreatic resection: analysis of 1122 patients resected over 5 years at a single institution. Ann Surg 2013;258:1051–8.
Grobmyer SR, Graham D, Brennan MF, et al. High-pressure gradients generated by closed-suction surgical drainage systems. Surg Infections 2002;3:245–9.
Jeekel J. No abdominal drainage after Whipple’s procedure. Br J Surg 1992;79:182–7.
Heslin MJ, Harrison LE, Brooks AD, et al. Is intra-abdominal drainage necessary after pancreaticoduodenectomy? J Gastrointest Surg 1998;2:373–8.
Fisher WE, Hodges SE, Silberfein EJ, et al. Pancreatic resection without routine intraperitoneal drainage. HPB 2011;13:503–10.
Paulus EM, Zarzaur BL, Behrman, SW. Routine drainage of the surgical bed after elective distal pancreatectomy: is it necessary? Am J Surg 2012;204:422–7.
Adham M, Chopin-Laly X, Lepilliez V, et al. Pancreatic resection: drain or no drain. Surgery 2013;154:1069–77.
Van der Wilt AA, Coolsen MM, de Hingh IH, et al. To drain or not to drain: a cumulative meta-analysis of the use of routine abdominal drains after pancreatic resection. HPB 2013;15:337–44.
Kaminsky PM, Mezhir JJ. Intraperitoneal drainage after pancreatic resection: a review of the evidence. J Surg Res 2013;184:925–30.
Mehta VV, Fisher SB, Maithel SK, et al. Is it time to abandon routine operative drain use? A single institution assessment of 709 consecutive pancreaticoduodenectomies. J Am Coll Surg 2013;216:635–42.
Van Buren G, Bloomston M, Hughes S, et al. A randomized prospective multicenter trial of pancreaticoduodenctomy with and without routine intraperitoneal drainage. Ann Surg 2014;4:605–12.
Available at: http://site.acsnsqip.org/wpcontent/uploads/2013/10/ACSNSQIP.PUF_.UserGuide.2012.pdf
Ball CG, Pitt HA, Kilbane ME, Dixon E, Sutherland FR, Lillemoe KD. Perioperative blood transfusions and operative time are quality indicators for pancreatoduodenectomy. HPB 2010;12:465–71.
Parikh P, Shiloach M, Cohen ME, Bilimoria KY, Ko CY, Hall BL, Pitt HA. Pancreatectomy risk calculator: an ACS-NSQIP resource. HPB 2010;12:488–97.
Pitt HA, Kilbane M, Strasberg SM, Pawlick TM, Dixon E, Zyromski NJ, Aloia TA, Henderson JM, Mulvihill SJ. ACS NSQIP has potential to create an HPB-NSQIP option. HPB 2009;11:405–13.
Parmar AD, Sheffiled KM, Vargas GM, et al. Factors associated with delayed gastric emptying after pancreaticoduedenectomy. HPB 2013;15:763–72.
Acknowledgments
The authors would like to acknowledge the Surgical Clinical Reviewers, Surgeon Champions, and pancreatic surgeons who participated in the Pancreatectomy Demonstration Project at the institutions listed below. We also wish to thank the leadership of the American College of Surgeons and of ACS-NSQIP for the opportunity to conduct the demonstration project.
• Albany Medical Center
• Baptist Memphis
• Baylor University
• Baystate Medical Center
• Beth Israel Deaconess
• Boston Medical Center
• Brigham & Women’s
• California Pacific Medical Center
• Cleveland Clinic
• Emory University
• Hospital University Pennsylvania
• Intermountain
• IU University
• IU Methodist
• Johns Hopkins
• Kaiser Permanente SF
• Kaiser Walnut
• Leigh Valley
• Massachusetts General
• Mayo-Methodist
• Mayo-St Mary’s
• Northwestern University
• Ohio State University
• Oregon Health Sciences Center
• Penn State University
• Providence Portland
• Sacred Heart
• Stanford University
• Tampa General
• Thomas Jefferson University
• University Alabama
• UC Irvine
• UC San Diego
• University Iowa
• University Kentucky
• University Minnesota
• University Texas Medical Branch
• University Virginia
• University Wisconsin
• Vanderbilt University
• Wake Forest University
• Wash University St. Louis
• Winthrop University
Conflict of Interest
The American College of Surgeons-National Surgical Quality Improvement Program and the hospitals participating in the ACS-NSQIP are the source of that data used herein; they have not verified and are not responsible for the statistical validity of that data or the conclusions derived by the authors
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Dr. Peter J Allen (New York, NY):
I would like to congratulate Dr. Behrman and colleagues on a very well-designed study that I believe demonstrates the benefit of prospective data collection, multi-institutional collaboration, and careful statistical study design.
I have two questions:
1. Your data demonstrate a clear increase in operative morbidity and pancreatic fistula associated with the use of drains. Changing surgical practice is difficult, particularly—it seems—when it comes to this small plastic tube that we were all told is necessary after pancreatic resection. I imagine, that many will now argue that we should instead—rather than routint use- use drains selectively, although I would suggest this study was on selective drainage as 116 of 761 patients did not have drains placed. Given the very careful, and nicely done, propensity score matching. Matched to age, gender, body weight, gland texture and duct size, vascular resection, and even postoperative pathology. How would you counsel surgeons who would now use drains selectively? If you were to place a drain, in whom would you do so?
2. It was interesting to see that there was no difference between groups with respect to the need for postoperative interventional drainage or reoperation, which suggests that drains did not improve the ability to treat postoperative fistula, leak, or abscess. Do you have any additional data to suggest whether placing an operative drain could make pancreatic fistula harder or easier to treat? Data such as number of I.R. or operative procedures, total length of drainage, readmission rates, or any other outcome data regarding management of the these complications?
Thank you again for allowing me to comment, I look forward to seeing this in publication.
Closing Discussant
Dr. Behrman:
Thank you Dr. Allen. Our study suggests that drains do not mitigate serious morbidity including clinically relevant pancreatic fistulae following distal pancreatectomy regardless of remnant consistency, duct size or pathology. Over one half of our patients had a soft remnant, and a small duct yet drains did not add a protective effect relative to procedure related morbidity or the need for post-operative therapeutic intervention. This suggests to me that operatively placed drains are often sequestered from pancreatic leaks when they do occur and thus can be avoided without an increase in untoward consequences. Studies from the Whipple population suggest a benefit to early drain removal if there is no evidence of a leak implying that prolonged drainage may lead toward an increase in post-operative complications. We had incomplete data to analyze in this regard but agree this would be important to assess going forward.
Data from the ACS-NSQIP Pancreatectomy Demonstration Project did not allow for a deeper inspection of post-operative therapeutic intervention and outcome such as number and duration of percutaneous drains and readmission. If a patient develops a clinically relevant pancreatic fistula with an operatively placed drain in place I am not clear how that would enhance its management other than potentially avoid a post-operative therapeutic intervention. However, our data demonstrates that the need for percutaneous drainage or reoperation is not reduced in those with an operatively placed drain.
This paper was presented at the Society for Surgery of the Alimentary Tract, May 4, 2014, Chicago, IL, as a long oral presentation.
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Behrman, S.W., Zarzaur, B.L., Parmar, A. et al. Routine Drainage of the Operative Bed Following Elective Distal Pancreatectomy Does Not Reduce the Occurrence of Complications. J Gastrointest Surg 19, 72–79 (2015). https://doi.org/10.1007/s11605-014-2608-z
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DOI: https://doi.org/10.1007/s11605-014-2608-z