Passive Versus Active Intra‐Abdominal Drainage Following Pancreaticoduodenectomy: A Retrospective Study Using The American College of Surgeons NSQIP Database

Abstract

Background Prophylactic drainage following pancreaticoduodenectomy (PD) reduces morbidity and mortality. Little evidence exists to advise on whether passive gravity (PG) or active suction (AS) drainage systems result in superior outcomes. This study examines the relationship between drainage system and morbidity following PD. Methods All patients undergoing elective PD with an operatively placed drain in the 2016 ACS-NSQIP database were included. Pre-and intra-operative factors were examined. Multivariable logistic regression and coarsened exact matching (CEM) were used to assess for an association between drainage system (PG vs. AS) and morbidity. The primary outcome was postoperative pancreatic fistula (POPF). Results In total, 3430 patients were included: 563 (16.4%) with PG and 2867 (83.6%) with AS drainage system. On multivariable regression, 1787 patients were included. Drainage type was not associated with POPF, surgical site infection, delayed gastric emptying, or re-operation. AS drainage was protective against percutaneous drain insertion (OR 0.65, 95% CI 0.44-0.96, p = 0.033). In the CEM cohort (n = 268), superficial SSI was higher in the AS group (0.8% vs. 6.0%, p = 0.036). There was a trend toward higher rates of composite total SSI (PG 15.7%, AS 23.9%, p = 0.092) and organ space SSI (PG 14.2%, AS 20.2%, p = 0.195) in the AS group; this did not demonstrate statistical significance. Conclusions The findings of this study suggest that AS drainage is protective against percutaneous drain insertion, but may be associated with increased risk of SSI. There was no relation between drainage type and POPF. A prospective, randomized controlled trial is warranted to further explore these findings.

Association of gravity drainage and complications following Whipple: an analysis of the ACS-NSQIP targeted database

“…In the single-institution retrospective study by Schmidt and colleagues, gravity drainage was associated with lower rates of POPF (14% vs. 3%), but also correlated with higher volume surgeons, raising concerns about gravity drainage acting as a surrogate for procedure volume [ 13 ]. Though multiple recently published studies suggest no differences in outcomes between suction or gravity closed-drainage systems [ 15 , 16 , 23 ], each of these studies has significant limitations that warrant consideration. Previous randomized trials evaluating drainage type have been limited by small sample size or showed rates of CR-POPF higher than those typically seen in US hospitals [ 23 ].…”

“…Supporting this argument are institutional series associating higher leak rates with prolonged suction drainage and decreased leak rates associated with gravity drainage [ 12 , 13 ]. In contrast, recent publications have not demonstrated differences in POPF rates between closed-suction and gravity drains in mixed cohorts of pancreatectomy [ 15 ] or among a small cohort of pancreaticoduodenectomy (PD) alone [ 16 ].…”

Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review

“…They suggest that drain use might be associated with slightly reduced 90-day mortality. They suggest that active suction drainage systems might reduce LOS, but a more recent retrospective study of 3430 patients found an increased incidence of SSIs [211]. In pancreas transplantation, there is a single retrospective study showing the drain use is associated with reduced re-operation rates [211].…”

“…They suggest that active suction drainage systems might reduce LOS, but a more recent retrospective study of 3430 patients found an increased incidence of SSIs [211]. In pancreas transplantation, there is a single retrospective study showing the drain use is associated with reduced re-operation rates [211]. Due to the lack of research on prophylactic drainage in the pancreas transplant patient, we can neither recommend for or against their use nor a specific timeline for removal.…”

Letter to the Editor: Passive Versus Active Intra‐abdominal Drainage Following Pancreaticoduodenectomy: A Retrospective Study Using the American College of Surgeons NSQIP Database

“…The four articles collected data from different periods of the ACS-NSQIP: (2016) [1], (2016-2017) [2,3], (2016-2018) [4]. While drawing from the same source (ACS-NSQIP), the four articles reached different conclusions on the results of the postoperative outcome of the use of closed PG or AS drainage systems: no difference [2,3]; AS drainage is protective against percutaneous drain insertion but may be associated with increased risk of SSI [1]; PG drainage is independently associated with decreased rates of clinically relevant-POPF (CR-POPF), delayed gastric emptying (DGE), SSI and readmission following PD [4].…”