Evidence Versus Practice in Early Drain Removal After Pancreatectomy

Villafañe-Ferriol, Nicole; Baugh, Katherine A.; McElhany, Amy L.; Buren, George Van; Fang, Andrew; Tashakori, E.K.; Reyes, Jose E. Mendez; Cao, Hop S. Tran; Silberfein, Eric J.; Massarweh, Nader N.; Hsu, Cary; Barakat, Omar; Schmidt, Carl; Zyromski, Nicholas J.; Dillhoff, Mary; Villarreal, Joshua A.; Fisher, William E.

doi:10.1016/j.jss.2018.11.048

Cited by 16 publications

(13 citation statements)

References 18 publications

(22 reference statements)

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“…6,21 The accuracy and feasibility of the DFA1 value have recently been validated in an increasing number of studies, propounding controversy about its optimal cut-off point. 22,23 Not only a common value for DFA1 but also the individual PF risk of each patient should be considered for the safe management of drains, 24 as LPF develops in low-risk patients with an initially low DFA value. The present study proposed a DFA1 cut-off value of 650 U/L to predict LPF in the ROC analysis (AUC of 0.852).…”

Section: F I G U R Ementioning

confidence: 99%

The clinical impact and risk factors of latent pancreatic fistula after pancreatoduodenectomy

Ohgi

Yamamoto

Sugiura

et al. 2020

J Hepato Biliary Pancreat

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Background: Latent pancreatic fistula (LPF) is difficult to diagnose during the early postoperative phase because of initially normal drain fluid amylase (DFA) levels. The present study investigated the clinical significance and risk factors of LPF after pancreatoduodenectomy. Methods: A total of 662 patients who underwent pancreatoduodenectomy between 2010 and 2018 were retrospectively analyzed. LPF was defined as pancreatic fistula that developed later regardless of initially low DFA levels. Results: Among the 372 patients with DFA ≤375 U/L (three times the upper limit for serum) on postoperative day (POD) 3, LPF occurred in 37 (10%). The rates of postoperative hemorrhaging (11% vs 1.5%), intraabdominal abscess (57% vs 7.2%) and reintervention (46% vs 2.7%) were significantly higher in the patients with LPF than in those without LPF. A multivariate analysis revealed that a body mass index ≥25 kg/m 2 , a non-combined portal vein resection, a DFA on POD 1 ≥650 U/L and a C-reactive protein level on POD 3 ≥11 mg/dL were independent risk factors for LPF. Conclusions: Latent pancreatic fistula was significantly associated with severe complications and worse outcomes after pancreatoduodenectomy. Early drain removal may be unfavorable for patients with some of these risk factors.

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Section: F I G U R Ementioning

confidence: 99%

The clinical impact and risk factors of latent pancreatic fistula after pancreatoduodenectomy

Ohgi

Yamamoto

Sugiura

et al. 2020

J Hepato Biliary Pancreat

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“…Adachi et al discussed the possibility of a close relationship between intraperitoneal infection via the drain and subsequent pancreatic fistula, and concluded that early drain removal after DP provided favorable postoperative outcomes (26). Another study reported that late drain removal was significantly associated with complications after DP (15). Furthermore, Yang F et al reported a close relationship between pancreatic fistula following DP and positive bacterial culture in the drainage fluid, and demonstrated that Staphylococcus spp.…”

Section: Discussionmentioning

confidence: 99%

Surgical Outcomes Following Early Drain Removal After Distal Pancreatectomy in Elderly Patients

Sakamoto

Yagyu

Uchinaka

et al. 2020

In Vivo

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Background/Aim: The efficacy and safety of early drain removal following distal pancreatectomy in elderly patients are unclear. We aimed to investigate the short-term surgical outcomes following early drain removal after distal pancreatectomy in elderly patients. Patients and Methods: Fifty-seven patients aged ≥70 years who underwent distal pancreatectomy at our Hospital were enrolled in the study. Data were retrospectively analyzed to evaluate the short-term surgical outcomes following early drain removal after distal pancreatectomy in elderly patients. Results: The incidence of pancreatic fistula following distal pancreatectomy in the early-removal group was significantly lower vs. the conventional group (p=0.022). Multivariate analysis revealed that early drain removal was an independent factor for reducing the risk of pancreatic fistula after distal pancreatectomy in elderly patients (p=0.042). Conclusion: Early drain removal following distal pancreatectomy is an effective and safe surgical perioperative management procedure to prevent pancreatic fistula in elderly patients. General surgery for elderly patients has been increasing with aging populations, worldwide (1). Additionally, pancreatic resection for elderly patients has been gradually accepted because the surgical outcomes after pancreatectomy were not inferior compared to younger patients (2-5). Distal pancreatectomy (DP) for benign or malignant disease located in the left pancreas is considered a safe surgical procedure, with low mortality of 0-0.3% with recent advances in surgical techniques and management; however, morbidity associated with DP remains high (6). Pancreatic fistula is one of the main complications after DP, occurring in 18-39% of patients undergoing DP, and can lead to intra-abdominal abscess or postoperative hemorrhage, which prolong the length of postoperative hospital stay and increase medical costs (6-9). Regarding elderly patients with organ functional impairment or frailty, even if not fatal, pancreatic fistula is a more serious complication compared to younger patients because of the possibility of postoperative loss of independence caused by pancreatic fistula. Therefore, safer surgical procedures or perioperative management are needed to minimize the incidence of pancreatic fistula after DP in elderly patients. Although several randomized control trials closed the stump of remnant pancreas to attempt to decrease pancreatic fistula after DP, no definitive methods exist to prevent or decrease postoperative pancreatic fistula after DP (10-13). Recently, early drain removal has been reported to effectively reduce the incidence of postoperative pancreatic fistula after DP (14, 15). However, the surgical outcomes of early drain removal after DP in elderly patients are uncertain. Considering population aging (16), studies involving only elderly patients are needed. Therefore, we aimed to assess the short-term surgical outcomes following early drain removal after DP compared with conventional drain removal in a cohort of only elder...

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“…The optimal time point for drain removal after PD is still subject to debate, and surgical practice varies substantially. 2 We wish to comment on the randomized controlled trials (RCT) cited by the authors. Kawai et al 3 published a prospective series conducted over consecutive periods, rather than a RCT.…”

Section: To the Editormentioning

confidence: 99%

“…

To the editor,We read with interest the report by Xourafas et al 1 on early vs. late drain removal after pancreatoduodenectomy (PD) in 1825 patients with a POD1 amylase levels 5000 U/L.The optimal time point for drain removal after PD is still subject to debate, and surgical practice varies substantially. 2 We wish to comment on the randomized controlled trials (RCT) cited by the authors. Kawai et al 3 published a prospective series conducted over consecutive periods, rather than a RCT.

…”

mentioning

confidence: 99%

Validation of early drain removal after pancreatoduodenectomy based on modified fistula risk score stratification: a population-based assessment

Dembinski¹,

Régimbeau²

2020

HPB

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To the editor,We read with interest the report by Xourafas et al. 1 on early vs. late drain removal after pancreatoduodenectomy (PD) in 1825 patients with a POD1 amylase levels 5000 U/L.The optimal time point for drain removal after PD is still subject to debate, and surgical practice varies substantially. 2 We wish to comment on the randomized controlled trials (RCT) cited by the authors. Kawai et al. 3 published a prospective series conducted over consecutive periods, rather than a RCT. Bassi et al. 4 conducted the first RCT on this topic although the study population was heterogeneous (e.g. cases of distal pancreatectomy). They respectively found that early drain removal was associated with lower morbidity and pancreatic fistula (PF) rates. Surprisingly, the only RCT to have evaluated early drain removal after PD in a population without early PF was not cited. It was conducted by our team, 5 we failed to prove that early drain removal was associated with a significantly lower surgical site infection (SSI) rate; this may explain this omission. However, we found that early drain removal was associated with a lower incidence of deep-SSI, a shorter length-of-stay and did not appear to worsen the morbidity, reoperation and mortality rates. Furthermore, our study highlighted some important secondary outcomes: an early routine CT-scan was poorly predictive of PF, and bilateral drainage or mobilization of the drain prior to removal was not associated with an elevated POD30-SSI rate.Nevertheless, we fully endorse Xourafas et al.'s message: early drain removal is safe in selected patients undergoing PD.

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Evidence Versus Practice in Early Drain Removal After Pancreatectomy

Cited by 16 publications

References 18 publications

The clinical impact and risk factors of latent pancreatic fistula after pancreatoduodenectomy

The clinical impact and risk factors of latent pancreatic fistula after pancreatoduodenectomy

Surgical Outcomes Following Early Drain Removal After Distal Pancreatectomy in Elderly Patients

Validation of early drain removal after pancreatoduodenectomy based on modified fistula risk score stratification: a population-based assessment

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