Is It Time to Abandon Routine Operative Drain Use? A Single Institution Assessment of 709 Consecutive Pancreaticoduodenectomies

Mehta, Vishes V.; Fisher, Sarah B.; Maithel, Shishir K.; Sarmiento, Juan M.; Staley, Charles A.; Kooby, David A.

doi:10.1016/j.jamcollsurg.2012.12.040

Cited by 84 publications

(40 citation statements)

References 29 publications

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“…In regard to early drain removal after DP, it should be emphasized that early drain removal (i.e., on POD1) and initial no drain management - which has been reported after PD (14,15) and after PD/DP (16,17) - are intrinsically different protocols for safe postoperative management. We have found that the operative drain is useful as both an informative tool for intraperitoneal bleeding immediately after surgery, and to identify patients at high risk of PF development by the evaluation of the drain amylase level.…”

Section: Discussionmentioning

confidence: 99%

Safety and efficacy of early drain removal and triple-drug therapy to prevent pancreatic fistula after distal pancreatectomy

et al. 2015

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Objective: Prior studies suggested that early drain removal prevented the development of pancreatic fistula (PF) after pancreaticoduodenectomy (PD), but there has been no corresponding prospective trial for distal pancreatectomy (DP). The purpose of this study was to determine the safety and efficacy of early drain removal and triple-drug therapy (TDT) with gabexate mesilate, octreotide and carbapenem antibiotics to prevent PF after DP in patients at high-risk of developing PF. Methods:A total 71 patients who underwent a DP were enrolled. We prospectively divided them into two groups: the late-removal group, in which the drain remained in place for at least for 5 days postoperatively (n=30) and the early-removal group in which the drain was removed on postoperative day1 (POD1) (n=41). For the patients with a high drain amylase level (≥ 10,000 IU/L) and patients with symptomatic intraperitoneal fluid collection, our original TDT was introduced. The primary endpoint was the safety and efficacy of this management, and the secondary endpoint was the incidence of PF. Results:The incidence of clinical PF was significantly lower in the early-removal group (0% vs. the late removal 16%; p<0.001). In the early-removal group, TDT was administered to 12 patients (29%) and none of the patients needed additional treatment after TDT. Conclusions:Postoperative management after DP with early drain removal and TDT was safe and effective for preventing PF.

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Section: Discussionmentioning

confidence: 99%

Safety and efficacy of early drain removal and triple-drug therapy to prevent pancreatic fistula after distal pancreatectomy

et al. 2015

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“…Some studies have suggested abandoning the routine placement of drains without being at risk of higher morbidity and mortality [37,48]. However, a recent randomized prospective multicentre trial reported a higher risk of complications and mortality in patients without intra-peritoneal drainage [49].…”

Section: Discussionmentioning

confidence: 99%

Negative predictive value of drain amylase concentration for development of pancreatic fistula after pancreaticoduodenectomy

et al. 2015

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“…Contrary to this dogma, a growing body of evidence has failed to demonstrate a decrease in the frequency and severity of postoperative complications or the necessity for intervention and that the use of intraperitoneal drains after PD should not be mandatory. [34][35][36][37] However, a randomized controlled trial was recently stopped early by the Data Safety Monitoring Board because mortality increased from 3% to 12% in patients undergoing PD without intraperitoneal drainage; these patients also had increased frequency and severity of complications. 38 The authors cautioned against abandoning the use of intraperitoneal drains in all patients undergoing PD, explicitly stating that this would not be safe.…”

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confidence: 99%

Canadian practice patterns for pancreaticoduodenectomy

Cyr

Truong

Lam-McCulloch

et al. 2015

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Background: Discordant practice patterns may be a consequence of evidence-practice gaps or deficiencies in knowledge translation. We examined the current strategies used by hepato-pancreatico-biliary (HPB) surgeons in Canada for the perioperative management of pancreaticoduodenectomy (PD). Methods:We generated a web-based survey that focused on the perioperative measures surrounding PD. The survey was distributed to all members of the Canadian Hepato-Pancreatico-Biliary Association. Results:The survey was distributed to 74 surgeons and received a response rate of 50%. Many similarities in surgical techniques were reported; for example, most surgeons (86.5%) reconstruct the pancreas with pancreaticojejunostomy rather than pancreaticogastrostomy. In contrast, variable techniques regarding the use of peritoneal drainage tubes, anastomotic stents, octreotide and other intraoperative modalities were reported. Most surgeons (75.7%) reported that their patients frequently required preoperative biliary drainage, yet there was minimal agreement with the designated criteria. There was variability in postoperative care, including the use of epidural analgesia and timing of postoperative oral nutrition. Conclusion:We identified heterogeneity among Canadian HPB surgeons, suggesting a number of evidence-practice gaps within specific domains of pancreatic resections. Focused research in these areas may facilitate technical agreement and improve patient outcomes following PD.Contexte : La discordance entre les modes de pratique pourrait être due à des lacunes au plan des pratiques fondées sur des preuves ou à une déficience du transfert des connaissances. Nous avons étudié les stratégies actuellement utilisées par les chirurgiens hépato-pancréato-biliaires (HPB) au Canada pour la prise en charge périopératoire de la pancréatoduodénectomie (PD). Méthodes :Nous avons préparé un questionnaire électronique sur les mesures péri-opératoires entourant la PD. Le questionnaire a été distribué à tous les membres de l'Association hépato-pancréato-biliaire canadienne.Résultats : Le questionnaire a été distribué à 74 chirurgiens et a généré un taux de réponse de 50 %. De nombreuses similitudes dans les techniques chirurgicales ont été signalées : par exemple, la majorité des chirurgiens (86,5 %) reconstruisent le pancréas par pancréatojéjunostomie plutôt que par pancréatogastrostomie. En revanche, on a observé une variabilité dans les techniques d'utilisation des drains péritonéaux, des endoprothèses anastomotiques, des octréotides et autres modalités peropératoires. La majorité des chirurgiens (75,7 %) ont signalé que leurs patients avaient souvent besoin de drains biliaires préopératoires et pourtant, les critères désignés ne semblaient pas faire l'unanimité. On a aussi noté des différences dans les soins postopératoires, y compris en ce qui concerne le recours à l'analgésie péridurale et le moment de la reprise de l'alimentation orale après la chirurgie. Conclusion :Nous avons observé une hétérogénéité dans la pratique des chirurgiens HP...

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Is It Time to Abandon Routine Operative Drain Use? A Single Institution Assessment of 709 Consecutive Pancreaticoduodenectomies

Cited by 84 publications

References 29 publications

Safety and efficacy of early drain removal and triple-drug therapy to prevent pancreatic fistula after distal pancreatectomy

Safety and efficacy of early drain removal and triple-drug therapy to prevent pancreatic fistula after distal pancreatectomy

Negative predictive value of drain amylase concentration for development of pancreatic fistula after pancreaticoduodenectomy

Canadian practice patterns for pancreaticoduodenectomy

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