Early Versus Late Drainage Removal in Patients Who Underwent Pancreaticoduodenectomy: A Comprehensive Systematic Review and Meta-analysis of Randomized Controlled Trials Using Trial Sequential Analysis

Abstract

Background The superiority of early drain removal (EDR) versus late (LDR) after pancreaticoduodenectomy (PD) has been demonstrated only in RCTs. Methods A meta-analysis was conducted using a random-effects model and trial sequential analysis. The critical endpoints were morbidity, redrainage, relaparotomy, and postoperative pancreatic fistula (CR-POPF). Hemorrhage (PPH), delayed gastric emptying (DGE), length of stay (LOS), and readmission rates were also evaluated. Risk ratios (RRs) and mean differences (MDs) with a 95% confidence interval (CI) were calculated. Type I and type II errors were excluded, comparing the accrued sample size (ASS) with the required sample size (RIS). When RIS is superior to ASS, type I or II errors can be hypothesized. Results ASS was 632 for all endpoints except DGE and PPH (557 patients). The major morbidity (RR 0.55; 95% CI 0.32–0.97) was lower in the EDR group. The CR-POPF rate was lower in the EDR than in the LDR group (RR 0.50), but this difference is not statistically significant (95% CI 0.24–1.03). The RIS to confirm or exclude these results can be reached by randomizing 5959 patients. The need for percutaneous drainage, relaparotomy, PPH, DGE, and readmission rates was similar. The related RISs were higher than ASS, and type II errors cannot be excluded. LOS was shorter in the EDR than the LDR group (MD − 2.25; 95% CI − 3.23 to − 1.28). The RIS was 567, and type I errors can be excluded. Conclusions EDR, compared with LDR, is associated with lower major morbidity and shorter LOS.

Intraperitoneal prophylactic drain after pancreaticoduodenectomy: an Italian survey

“…This reluctance appears related to multiple factors: (i) the shortcomings of available risk prediction tools for CR-POPF; (ii) the uncertainty of outcomes from a minimally invasive approach in PD; (iii) the concern about an increase in the re-laparotomy rate. Generally, an interesting observation was that, despite the amount of literature available encouraging early removal [ 5 ] or drainage omission [ 8 ] in low-risk patients, the customs of Italian pancreatic surgeons remain very conservative. Nonetheless, evaluating emotional intelligence, which depends on experience and knowledge, can help surgeons understand that selective IPD omission could be the least regrettable choice when the risk of CR-POPF is low.…”

“…However, several issues about IPD use and management remain under debate. Indeed, the dogma of routine IPD use was challenged, especially in low-risk pancreatic remnants, and several randomized studies reported similar complication rates when IPD was omitted [ 5 – 8 ]. Second, the timing of removal was recently investigated, hypothesizing that early removal could be safe [ 9 – 13 ].…”