Does intraoperative closed-suction drainage influence the rate of pancreatic fistula after pancreaticoduodenectomy?

Abstract

BackgroundAlthough drainage of pancreatic anastomoses after pancreaticoduodenectomy (PD) is still debated, it remains recommended, especially in patients with a high risk of post-operative pancreatic fistula (POPF). Modalities of drainage of pancreatic anastomoses, especially the use of passive (PAD) or closed-suction (CSD) drains, and their impact on surgical outcomes, have been poorly studied. The aim was to compare CSD versus PAD on surgical outcomes after PD.MethodsRetrospective analysis of 197 consecutive patients who underwent a standardized PD at two tertiary centers between March 2012 and April 2015. Patients with PAD (n = 132) or CSD (n = 65) were compared.ResultsThere was no significant difference in terms of 30-day overall and severe post-operative morbidity, post-operative hemorrhage, post-operative intra-abdominal fluid collections, 90-day post-operative mortality and mean length of hospital stay. The rate of POPF was significantly increased in the CSD group (47.7% vs. 32.6%; p = 0.04). CSD was associated with an increase of grade A POPF (21.5% vs. 8.3%; p = 0.03), while clinically relevant POPF were not impacted. In patients with grade A POPF, the rate of undrained intra-abdominal fluid collections was increased in the PAD group (46.1% vs. 21.4%; p = 0.18). After multivariate analysis, CSD was an independent factor associated with an increased rate of POPF (OR = 2.43; p = 0.012).ConclusionsThere was no strongly relevant difference in terms of surgical outcomes between PAD or CSD of pancreatic anastomoses after PD, but CSD may help to decrease the rate of undrained post-operative intra-abdominal collections in some patients. Further randomized, multi-institutional studies are needed.

Suction or Gravity: Impact of Closed-System Drain Type on the Postoperative Outcomes of Pancreatoduodenectomy

“…Previous studies on the modality of intraoperative drainage after PD have predominately examined the influence of open versus closed drainage systems and found no differences in terms of clinically relevant (CR-) POPF or other important postoperative complications. [1][2][3] As open systems are typically more cumbersome to manage, closed-system drains (CSDs) are more commonly used in clinical practice. Although surgeon preference typically dictates whether CSDs are placed to active suction (e.g., via a Jackson-Pratt bulb) or passive gravity (e.g., via a bile bag or "unclenched" Jackson-Pratt bulb), few studies have investigated the optimal method of closed-system drainage after PD.…”

“…Although surgeon preference typically dictates whether CSDs are placed to active suction (e.g., via a Jackson-Pratt bulb) or passive gravity (e.g., via a bile bag or "unclenched" Jackson-Pratt bulb), few studies have investigated the optimal method of closed-system drainage after PD. [1][2][3][4] Given the relatively high morbidity rates observed after PD, further information on the optimal method of drainage would have a significant clinical impact. Therefore, we used a nationwide cohort of patients undergoing PD to investigate the impact of CSD type (suction vs gravity) on CR-POPF and other relevant perioperative outcomes.…”

“…The optimal method of drainage after PD remains controversial as small randomized controlled trials conducted on this topic have produced conflicting results. [1][2][3][4] Jiang et al 4 randomized 160 patients to either prophylactic active or conventional passive drainage after PD. The authors found a decreased incidence of grade C POPF among patients in the active drain group.…”

Pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy to prevent post-operative pancreatic fistula, a dissonance between evidence and practice

“…Leakage of pancreatic enzymes leading to either formation of abdominal collection or pancreatic fi stula is one the most feared complications. Incidence of post-operative pancreatic fi stula (POPF) after PD is reported to be from 11% to 47.7% in various reports [2,3]. This wide variation in occurrence of POPF is partly due to variability in defi nition of fi stula particularly in older studies.…”

Pancreatoyeyunoanastomosis con técnica de Blumgart modificada para reconstrucción post-pancreatoduodenectomía. Estudio de serie de casos con seguimiento

“…La mortalidad en los últimos años se ha acercado a cifras por debajo del 5%. La morbilidad continúa alrededor del 35% y está asociada principalmente a la filtración de la anastomosis pancreática [1][2][3][4][5][6][7][8][9][10] . Nuestro equipo publicó la experiencia con reconstrucción pancreática en PD utilizando pancreato-gastro-anastomosis ducto mucosa (PGADM), con una morbilidad global del 35% y mortalidad de 5%…”