Predictive value of post-operative drain amylase levels for post-operative pancreatic fistula

Abstract

Backgrounds/AimsTraditionally, surgically placed pancreatic drains are removed, at the discretion of the operating surgeon. Moving towards enhanced recovery after surgery (ERAS), we looked for predictors for early drain removal. The purpose of this paper was to establish which postoperative days' (POD) drain amylase is most predictive against post-operative pancreatic fistula (POPF).MethodsWe conducted a retrospective study of 196 patients who underwent pancreatic resection at our institute from January 2006 to October 2013. Drain amylase levels were routinely measured. The International Study Group of Pancreatic Fistula (ISGPF) definition of POPF, and clinical severity grading were used.Results5.1% (10 of 196) patients developed ISGPF Grades B and C POPF. Negative predictive value of developing significant POPF, if drain amylase values were low on PODs 1 and 3 was 98.7% (95% CI: 0.93–1.00). This translated to confidence in removing surgically placed pancreatic drains, at POD 1 and 3 when drain amylase values are low.ConclusionsPatients with low drain amylase values on POD 1 and 3, are unlikely to develop POPF and may have pancreatic drains removed earlier.

Impact of continuous local lavage on pancreatic juice-related postoperative complications: Three case reports

“…A recovery rate of injected fluid > 80% should be guaranteed; and (3) Toxic amylase levels should decrease dramatically after CLL. Amylase levels in the drainage discharge are extremely important to evaluate pancreatic leakage after surgery[22]. Amylase levels in the draining discharge within the lower triple-digits ( i.e ., approximately 100–500 U/L) are ideal after CLL induction.…”

Lymphopenia following pancreaticoduodenectomy is associated with pancreatic fistula formation

“…POD #3 was selected given prior reports in which drain amylase was used as an indicator of safety for drain removal at this time point . 2 , 8 …”

“…Reported rates of POPF range from 3-45%, with a 0-5% mortality rate. 1 - 4 A systematic review of 60,000 patients demonstrated that 3.5% of all pancreaticoduodenectomy patients had a POPF that lead to organ failure, the need for re-operation, or death. An additional 8.9% of patients required antibiotic therapy or additional procedures such as percutaneous, endoscopic, or angiographic interventions as part of their POPF treatment.…”

“… 9 , 10 Decisions regarding leaving drains, and also managing them, remain extremely variable amongst surgeons. 2 , 8 , 11 , 12 …”

“… 13 Based on these data and similar reports, efforts have turned to early drain removal when a drain is left in place, with a variety of groups reporting various drain amylase values predictive of safe drain removal at post-operative day (POD) 1 or 3. 2 , 7 , 8 , 11 While useful, drain amylase lacks specificity for clinically relevant POPF and is limited in identifying POPF only in patients with surgical drains in place. As POPF can lead to infection, sepsis, and septic shock, the aim of this study is to investigate the known immunologic alternations in response to sepsis, specifically lymphopenia, to identify an additional early readily available marker to improve specificity for only clinically relevant POPF.…”