The Value of Drains as a Fistula Mitigation Strategy for Pancreatoduodenectomy: Something for Everyone? Results of a Randomized Prospective Multi-institutional Study

McMillan, Matthew T.; Fisher, William E.; Buren, George Van; McElhany, Amy L.; Bloomston, Mark; Hughes, Steven J.; Winter, Jordan M.; Behrman, Stephen W.; Zyromski, Nicholas J.; Velanovich, Vic; Brown, Kimberly M.; Morgan, Katherine A.; Vollmer, Charles M.

doi:10.1007/s11605-014-2640-z

Cited by 83 publications

(51 citation statements)

References 47 publications

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“…The median years of experience as an attending surgeon was 14 (IQR [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19], and the median career PD volume as an attending surgeon was 265.5 (IQR 98.3-734.8). Soft pancreatic parenchyma was encountered 58.8% of the time.…”

Section: Operative Characteristics Of the Protocol Cohortmentioning

confidence: 99%

“…[1][2][3][4][5][6][7][8][9][10][11] Proponents for routine drainage cite its ability to evacuate bile, chyle, blood, pus, or degradative pancreatic juice that may occur postoperatively. [1][2][3][4][5][6][7][8][9][10][11] Proponents for routine drainage cite its ability to evacuate bile, chyle, blood, pus, or degradative pancreatic juice that may occur postoperatively.…”

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confidence: 99%

“…Conversely, others have argued that drainage can be detrimental-potentially serving as a nidus for infection 4,7 or for allowing prolonged high-pressure closedsuction drainage to erode the anastomotic site. 11 A secondary analysis of the Van Buren study 9 focused specifically on CR-POPF using risk stratification and identified the potential for a middle-ground approach to drain management. 8,11 The first study by Van Buren et al 8 demonstrated reduced morbidity and mortality with routine drainage; conversely, the most recent randomized trial reported higher rates of reintervention and clinically relevant pancreatic fistula (CR-POPF) after drainage.…”

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confidence: 99%

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Multicenter, Prospective Trial of Selective Drain Management for Pancreatoduodenectomy Using Risk Stratification

et al. 2017

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Section: Operative Characteristics Of the Protocol Cohortmentioning

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Multicenter, Prospective Trial of Selective Drain Management for Pancreatoduodenectomy Using Risk Stratification

et al. 2017

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“…25 A secondary endpoint of that study sought to identify subsets of patients who experience significantly lower rates of CR-POPF with drainage. 26 Using a risk-stratified approach, they demonstrated a benefit to drainage in patients with moderate/high (per Fistula Risk Score calculation 9 ) CR-POPF risk. In the present study, approximately 95 % of the grade C POPF patients who did not receive drainage at their index operation demonstrated moderate/high FRS risk.…”

Section: Management Of Grade C Popfs and Other Postoperative Considermentioning

confidence: 99%

The Characterization and Prediction of ISGPF Grade C Fistulas Following Pancreatoduodenectomy

McMillan

Vollmer

Asbun

et al. 2016

Journal of Gastrointestinal Surgery

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This global study represents the largest analysis of grade C POPFs following PD. It describes the severe burden that grade C POPFs incur on patients, with high rates of reoperation and infection, while also potentially worsening overall survival by causing death and delay/omission of adjuvant therapy. Additionally, aggressive clinical management for these POPFs did not improve or worsen 90-day mortality. Predictive tools developed through these data may provide value in managing this difficult complication.

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“…Rather more, drains could diminish the rate and severity of POPF in patients with high risk of POPF. Drains could possibly be avoided in patients with low risk of POPF [46]. However, the majority of pancreatic surgeons still consider routine placement of intraabdominal drains mandatory [15-17].…”

Section: Discussionmentioning

confidence: 99%

DRAPA trial – closed-suction drains versus closed gravity drains in pancreatic surgery: study protocol for a randomized controlled trial

Čečka

Loveček

Jon

et al. 2015

Trials

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BackgroundThe morbidity of pancreatic resection remains high, with pancreatic fistula being the most common cause. The important question is whether any postoperative treatment adjustment may prevent the development of clinically significant postoperative pancreatic fistulae. Recent studies have shown that intraabdominal drains and manipulation using them are of great importance. Although authors of a few retrospective reports have described good results of pancreatic resection without the use of intraabdominal drains, a recent prospective randomized trial showed that routine elimination of drains in pancreaticoduodenectomy is associated with poor outcome. An important issue arises as to which type of drain is most suitable for pancreatic resection. Two types of surgical drains exist: open drains and closed drains. Open drains are considered obsolete nowadays because of frequent retrograde infection. Closed drains include two types: passive gravity drains and closed-suction drains. Closed-suction drains are more effective, as they remove fluid from the abdominal cavity under light pressure. However, some surgeons believe that closed-suction drains represent a potential hazard to patients and that negative pressure might increase the risk of pancreatic fistulae. Nobody has yet specifically dealt with the question of which kind of drainage is most appropriate in pancreatic surgery.Methods/DesignThe aim of the DRAins in PAncreatic surgery (DRAPA) trial is to compare the closed-suction drain versus the closed passive gravity drain in pancreatic resection. DRAPA is a dual-centre, prospective, randomized controlled trial. The primary endpoint is the rate of postoperative pancreatic fistula; the secondary endpoint is postoperative morbidity with follow-up of 3 months.DiscussionNo study to date has compared different types of drains in pancreatic surgery. This study is designed to answer the question whether any particular type of drain might lower the rate of postoperative pancreatic fistula or other complications.Trial registrationClinicalTrials.gov Identifier: NCT01988519. Registered 13 November 2013.

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The Value of Drains as a Fistula Mitigation Strategy for Pancreatoduodenectomy: Something for Everyone? Results of a Randomized Prospective Multi-institutional Study

Abstract: The results of this analysis suggest that drains diminish the rate and severity of CR-POPF in patients with moderate/high risk, but they could possibly be avoided in the roughly one third of patients with negligible/low risk.

Cited by 83 publications

References 47 publications

Multicenter, Prospective Trial of Selective Drain Management for Pancreatoduodenectomy Using Risk Stratification

Multicenter, Prospective Trial of Selective Drain Management for Pancreatoduodenectomy Using Risk Stratification

The Characterization and Prediction of ISGPF Grade C Fistulas Following Pancreatoduodenectomy

DRAPA trial – closed-suction drains versus closed gravity drains in pancreatic surgery: study protocol for a randomized controlled trial

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