Extended Experience with a Dynamic, Data-Driven Selective Drain Management Protocol in Pancreaticoduodenectomy: Progressive Risk Stratification for Better Practice

Trudeau, Maxwell T.; Maggino, Laura; Chen, Bofeng; McMillan, Matthew T.; Lee, Major K.; Roses, Robert E.; DeMatteo, Ronald P.; Drebin, Jeffrey A.; Vollmer, Charles M.

doi:10.1016/j.jamcollsurg.2020.01.028

Cited by 24 publications

(12 citation statements)

References 37 publications

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“…Drains would nonetheless remain in place after diagnosing a POPF in at least 20.4% of patients. A similar experience was reported by Trudeau et al [62]. Drains remained in place in 12.75% of patients, the overall CR-POPF rate was 8.7%, and the overall mortality rate was .8%, almost all in patients with CR-POPFs and surgical drains still in place.…”

Section: Discussionsupporting

confidence: 81%

Systematic review and meta-analysis of surgical drain management after the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy: draining-tract-targeted works better than standard management

Pedrazzoli

Brazzale

2020

Langenbecks Arch Surg

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Purpose Drains’ role after pancreaticoduodenectomy (PD) is debated by proponents of no drain, draining selected cases, and early drain removal. The aim of the study was to assess the effect of “standard” and “draining-tract-targeted” management of abdominal drains still in situ after diagnosing a postoperative pancreatic fistula (POPF). Methods PubMed and Scopus were searched for “pancreaticoduodenectomy or pancreatoduodenectomy or duodenopancreatectomy,” “Whipple,” “proximal pancreatectomy,” “pylorus-preserving pancreatectomy,” and “postoperative pancreatic fistula or POPF.”. Main outcomes included clinically relevant (CR) POPF, grade-C POPF, overall mortality, POPF-related mortality, and CR-POPF-related mortality. Secondary outcomes were incidence of radiological and/or endoscopic interventions, reoperations, and completion pancreatectomies. Results Overall, 12,089 studies were retrieved by the search of the English literature (01/01/1990–31/12/2018). Three hundred and twenty-six studies (90,321 patients) reporting ≥ 100 PDs and ≥ 10 PD/year were finally included into the study. Average incidences were obtained by averaging the incidence rates reported in the single articles. Pooled incidences were calculated by combining the number of events and the total number of patients considered in the various studies. These were then meta-analyzed using DerSimonian and Laird’s (1986) method. Pearson’s chi-squared test was used to compare pooled incidences between groups. Post hoc testing was used to see which groups differed. The meta-analyzed incidences were compared using a fixed effect for moderators. “Draining-tract-targeted” management showed a significant advantage over “standard” management in four clinically relevant outcomes out of eight according to pool analysis and in one of them according to meta-analysis. Conclusion Clinically, “draining-targeted” management of POPF should be preferred to “standard” management.

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Section: Discussionsupporting

confidence: 81%

Systematic review and meta-analysis of surgical drain management after the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy: draining-tract-targeted works better than standard management

Pedrazzoli

Brazzale

2020

Langenbecks Arch Surg

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“…Furthermore, the appropriate timing (POD1, POD3, or later) or optimal cutoff value (less than 500 14 , 1000 25 , or 5000 UI/l 24 ) varies widely based on the risk of fistula and type of anastomosis 26 , and these have not yet been determined specifically, with a wide range of AUC, from 0.574 26 to 0.911 12 . Moreover, everyday practice 27 may sometimes be far different from theory, as recent studies have highlighted that only a few surgeons (13–27 per cent) follow the recommendation for drain removal on POD3 in Korea 28 and the United States 29 , regardless of the ua-FRS 30 or DFA. One hypothesis for the low acceptance rate is the large discrepancy between guidelines and traditional experience-based management.…”

Section: Discussionmentioning

confidence: 99%

Establishment and external validation of neutrophil-to-lymphocyte ratio in excluding postoperative pancreatic fistula after pancreatoduodenectomy

et al. 2023

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Background Factors excluding postoperative pancreatic fistula (POPF), facilitating early drain removal and hospital discharge represent a novel approach in patients undergoing enhanced recovery after pancreatic surgery. This study aimed to establish the relevance of neutrophil-to-lymphocyte ratio (NLR) in excluding POPF after pancreatoduodenectomy (PD). Methods A prospectively maintained database of patients who underwent PD at two high-volume centres was used. Patients were divided into three cohorts (training, internal, and external validation). The primary endpoints of this study were accuracy, optimal timing, and cutoff values of NLR for excluding POPF after PD. Results From 2012 to 2020, in a 2:1 ratio, 451 consecutive patients were randomly sampled as training (n = 301) and validation (n = 150) cohorts. Additionally, the external validation cohort included 197 patients between 2018 and 2020. POPF was diagnosed in 135 (20.8 per cent) patients. The 90-day mortality rate was 4.1 per cent. NLR less than 8.5 on postoperative day 3 (OR, 95 per cent c.i.) was significantly associated with the absence of POPF in the training (2.41, 1.19 to 4.88; P = 0.015), internal validation (5.59, 2.02 to 15.43; P = 0.001), and external validation (5.13, 1.67 to 15.76; P = 0.004) cohorts when adjusted for relevant clinical factors. Postoperative outcomes significantly differed using this threshold. Conclusion NLR less than 8.5 on postoperative day 3 may be a simple, independent, cost-effective, and easy-to-use criterion for excluding POPF.

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“…This approach leads to a significant shift from the standard assessment strategy for drain fluid amylase to a stratified and titrated approach that in turn promotes individualized data-driven drain management and facilitates accelerated management in a significant proportion of patients (133). Post-operatively drain management should be algorithmic and supported by the data from the high-volume centers (133)(134)(135)(136)(137)(138). Since all high-risk patients are likely to have drains, drain removal should be guided by drain fluid amylase, drainage volume, the character of the effluent, and the clinical condition of the patient.…”

Section: Post-operative Mitigation Strategies: Proactive Preemptive A...mentioning

confidence: 99%

“…These extra days may aid in the identification of a selective group of patients with the high-risk pancreas that may manifest CR-POPF later in the hospital course (133). In these high-risk patients raised serum amylase levels and C-reactive protein levels may also act as predictors of POPF development (133)(134)(135)(136)(137)(138).…”

Section: Post-operative Mitigation Strategies: Proactive Preemptive A...mentioning

confidence: 99%

“Mitigation strategies for post-operative pancreatic fistula after pancreaticoduodenectomy in high-risk pancreas: an evidence-based algorithmic approach”—a narrative review

Parray¹,

Chaudhari²,

Shrikhande³

et al. 2022

Chin Clin Oncol

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Background and Objective: Postoperative pancreatic fistula (POPF) is associated with a mortality of up to 25% apart from significant morbid sequelae related to abdominal sepsis and post pancreatectomy hemorrhage. Numerous strategies to curtail the risk of POPF and associated morbidity have been largely unsuccessful. The pancreaticoenteric anastomosis post pancreaticoduodenectomy in a high-risk pancreas represents a significant surgical and clinical challenge. In this narrative review, we present the strategies for early identification and comprehensive management of the high-risk pancreas as per the available literature and present a stepwise algorithmic approach of different fistula mitigation strategies in patients undergoing pancreaticoduodenectomy.Methods: Medline, PubMed, Embase, Cochrane Library, and various center-specific guidelines were searched for the pancreas, pancreatic cancer, pancreatectomy, pancreatoduodenectomy, Whipple's operation, postoperative, complications, fistula, High-risk pancreas, risk assessment, different predictors, and scoring systems for the high-risk pancreas, current and emerging concepts in the development of POPF and mitigation strategies management and treatment in various combinations.

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Extended Experience with a Dynamic, Data-Driven Selective Drain Management Protocol in Pancreaticoduodenectomy: Progressive Risk Stratification for Better Practice

Cited by 24 publications

References 37 publications

Systematic review and meta-analysis of surgical drain management after the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy: draining-tract-targeted works better than standard management

Systematic review and meta-analysis of surgical drain management after the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy: draining-tract-targeted works better than standard management

Establishment and external validation of neutrophil-to-lymphocyte ratio in excluding postoperative pancreatic fistula after pancreatoduodenectomy

“Mitigation strategies for post-operative pancreatic fistula after pancreaticoduodenectomy in high-risk pancreas: an evidence-based algorithmic approach”—a narrative review

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