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

Abstract

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.

The Choice of the Most Appropriate Suture Threads for Pancreatic Anastomoses on the Basis of Their Mechanical Characteristics

“…The incidence of POPF primarily influences the postoperative course of patients undergoing pancreatoduodenectomy in terms of morbidity and mortality [ 42 ], access to oncological treatments [ 43 ], and the level of healthcare costs [ 3 ]. POPF is a complex process influenced by a wide number of different factors such as the pancreatic texture, the diameter of the main pancreatic duct, the type of pancreatic pathology requiring resection, and the amount of intraoperative blood loss [ 44 ].…”

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

“…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.…”

“…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).…”