Prophylactic drain management after pancreaticoduodenectomy without focusing on the drain fluid amylase level: A prospective validation study regarding criteria for early drain removal that do not include the drain fluid amylase level

Abstract

Background/Purpose: Early drain removal (EDR) based on drain fluid amylase level (DFA) after pancreaticoduodenectomy excluded 15%-40% patients from EDR because of inappropriate DFA. Methods: Of 198 pancreatoduodenectomy cases, we used the first 105 cases as an exploration cohort to construct the optimal criteria for EDR on postoperative day (POD)4 that were applied to the subsequent 93 cases used as the validation cohort. After that, we examined another 142 patients to further assess the efficacy of the new EDR criteria. Results: Of the four independent predictors of clinically relevant postoperative pancreatic fistula (CR-POPF) ([1] soft pancreas, [2] positive drain fluid culture on POD1, and [3] serum C-reactive protein [CRP] ≥13 mg/dL on POD4) in the exploration cohort, EDR was applied to cases in the validation cohort meeting the [2] and/or [3], enabling 96% (89/93) applicability of EDR. Outcomes were improved in the validation cohort compared to the exploration cohort; CR-POPF: 8.6% vs 25.7%, P = .005; Dindo-Clavien grade ≥ 3 complications: 23.7% vs 41.9%, P = .007; and median hospital stay (day): 21 vs 27, P = .005. The subsequent 142 patients showed 92% (131/142) applicability of EDR and 5.6% (8/142) incidence of CR-POPF. Conclusions: Our new criteria for EDR, without DFA, enabled ≥ 90% applicability of EDR and reduced CR-POPF. K E Y W O R D S clinical outcomes, criteria, early drain removal, pancreaticoduodenectomy, postoperative pancreatic fistula | 951 TANIGUCHI eT Al. How to cite this article: TaniguchiK, Matsuyama R, Yabushita Y, et al. Prophylactic drain management after pancreaticoduodenectomy without focusing on the drain fluid amylase level: A prospective validation study regarding criteria for early drain removal that do not include the drain fluid amylase level.

Postoperative elevation of C‐reactive protein levels and high drain fluid amylase output are strong predictors of pancreatic fistulas after distal pancreatectomy

“…Recently, the clinical importance of the postoperative CRP value for predicting POPF after PD has been widely reported. 12,[17][18][19][20][21][22][23] On the other hand, to the best of our knowledge, there has been no study reporting the usefulness of postoperative CRP for predicting CR-POPF in patients after DP. Early elevation of the postoperative CRP value was found to be an independent risk factor for CR-POPF after DP in the present study.…”

“…The timing of evaluation of the postoperative CRP value differed in each report. Although several reports suggested that the CRP value on POD 4 was a useful predictor of POPF, 22,23 the CRP values on POD 1 and POD 3, but not on POD 2 or POD 4, were routinely examined in the present study. In our view, the POD 3 value may be suitable for predicting POPF, because POD 3 is the appropriate decision point in postoperative management, such as whether to continue the prophylactic antibiotics or remove drains, as Kanda et al reported.…”

“…15 Additionally, there is an increasing number of reports demonstrating the importance of postoperative CRP values as a useful predictor of POPF after pancreatectomy. 12,[16][17][18][19][20][21][22][23] Since these reports mainly involved patients who underwent pancreaticoduodenectomy (PD), little has been reported about the usefulness of postoperative CRP elevation as a predictor of POPF after DP. The aim of the present study was therefore to investigate the preoperative, intraoperative, and early postoperative factors that could be predictors of POPF after DP.…”

Validation of the triple‐checked criteria for drain management after pancreatectomy

“…16 Additionally, the most recent retrospective study from Japan also indicated that drain management after PD using their criteria without focusing on DFA for early drain removal reduced the incidence of CR-POPF and postoperative hospital stay. 17 The common concept of these reports and our study was that the standardization of drain management was important to secure the safety of the patients who underwent pancreatectomy.…”

“…In Japan, postoperative stay has been longer than those in other countries. 1,4,17,18 It was probably due to Japan's unique treatment policy of discharging patients only after they were completely well. This timeframe is going to get shorter due to improvements in surgical procedure and perioperative management in the future.…”