Meta-analysis of prophylactic abdominal drainage in pancreatic surgery

Hüttner, Felix J; Probst, Pascal; Knebel, Phillip; Strobel, Oliver; Hackert, Thilo; Ulrich, Alexis; Büchler, Markus W.; Diener, MK

doi:10.1002/bjs.10505

Cited by 42 publications

(25 citation statements)

References 36 publications

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“…In 2017, Huettner et al published a meta-analysis of studies comparing abdominal drainage with no drainage after pancreatic surgery. They included the randomized controlled trials of Conlon et al [29], Van Buren et al [30], and Witzigmann et al [32] and showed that pancreatic resection with or without abdominal drainage resulted in similar rates of mortality, morbidity, and reintervention [33].…”

Section: Discussionmentioning

confidence: 99%

Abdominal drainage versus no drainage after distal pancreatectomy: study protocol for a randomized controlled trial

Kaiser

Niesen

Probst

et al. 2019

Trials

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Background The placement of prophylactic intra-abdominal drains has been common practice in abdominal operations including pancreatic surgery. The PANDRA trial showed that the omission of drains following pancreatic head resection was non-inferior to intra-abdominal drainage in terms of postoperative reinterventions and superior in terms of clinically relevant pancreatic fistula rate and fistula-associated complications. The aim of the present PANDRA II trial is to evaluate the clinical outcome with versus without prophylactic drain placement after distal pancreatectomy. Methods The PANDRA II trial is a mono-center, randomized controlled, non-inferiority trial with two parallel study groups. In the control group at least one passive intra-abdominal drain is placed at the pancreatic resection margin. In the experimental group no drains are placed. The primary endpoint of this trial will be the Comprehensive Complication Index (CCI) measuring all postoperative complications within 90 days. Secondary endpoints are in-hospital mortality and morbidity, including the rates of postoperative pancreatic fistula, chyle leak, postpancreatectomy hemorrhage, delayed gastric emptying, reinterventions and reoperations, surgical site infection, and abdominal fascia dehiscence. Moreover, length of hospital stay, duration of intensive care unit stay, and the rate of readmission after discharge from hospital (up to day 90 after surgery) are assessed. We will need to analyze 252 patients to test the hypothesis that no drainage is non-inferior to drain placement in terms of the CCI (δ 7.5 points) in a one-sided t test with a one-sided level of significance of 2.5% and a power of 80%. Discussion The results of the PANDRA II trial will help to evaluate the effect of an omission of prophylactic intraperitoneal drainage on the rate of complications after open or minimally invasive distal pancreatectomy. Trial registration German Clinical Trials Register (DRKS), DRKS00013763 . Registered on 6 March 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3442-0) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Abdominal drainage versus no drainage after distal pancreatectomy: study protocol for a randomized controlled trial

Kaiser

Niesen

Probst

et al. 2019

Trials

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“…Drains were removed on POD 3–4 if the fluid amylase was <3 times the higher of the serum amylase or the upper limit of normal and there was no concern for leak based on appearance of the output. Using the ISGPS definition of pancreatic leak, which has been found to predict LoS > 10 days in previous studies, we did find a significant association with grade B or C leak and LoS within goal of 5 days or readmission; many of these leaks were diagnosed upon readmission regardless of initial LOS, however[21,47,48]. Patients with higher drain amylases on POD 3 may not have been discharged as readily for fear of development of a leak or need for additional teaching to go home with a drain, but there is the possibility that the drain was not appropriately functioning and readings could have been misleadingly low.…”

Section: Discussionmentioning

confidence: 69%

Standardization of perioperative care facilitates safe discharge by postoperative day five after pancreaticoduodenectomy

et al. 2018

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IntroductionPancreaticoduodenectomy is a complex surgical procedure associated with high morbidity and prolonged length of stay. Enhanced recovery after surgery principles have reduced complications rate and length of stay for multiple types of operations. We hypothesized that implementation of a standardized perioperative care pathway would facilitate safe discharge by five days after pancreaticoduodenectomy.MethodsWe performed a retrospective cohort study of patients undergoing pancreaticoduodenectomy 18 months prior to and 18 months following implementation of a perioperative care pathway at a quaternary center performing high volume pancreatic surgery.ResultsA total of 145 patients underwent pancreaticoduodenectomy (mean age 63 ± 10 years, 52% female), 81 before and 64 following pathway implementation, and the groups were similar in terms of preoperative comorbidities. The percentage of patients discharged within 5 days of surgery increased from 36% to 64% following pathway implementation (p = 0.001), with no observed differences in post-operative serious adverse events (p = 0.34), pancreatic fistula grade B or C (p = 0.28 and p = 0.27 respectively), or delayed gastric emptying (p = 0.46). Multivariate regression analysis showed length of stay ≤5 days three times more likely after pathway implementation. Rates of readmission within 30 days (20% pre- vs. 22% post-pathway (p = 0.75)) and 90 days (27% pre- vs. 36% post-pathway (p = 0.27)) were unchanged after pathway implementation, and were no different between patients discharged before or after day 5 at both 30 days (19% ≤5 days vs. 23% ≥ 6 days (p = 0.68)) and 90 days (32% ≤5 days vs. 30% ≥ 6 days (p = 0.81)).ConclusionsStandardizing perioperative care via enhanced recovery protocols for patients undergoing pancreaticoduodenectomy facilitates safe discharge by post-operative day five.

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“…After the actual usefulness of abdominal drains was called into question for other abdominal surgeries [53][54][55] and for pancreatic surgery [18], there has been a great debate among the drainers [20] non-drainers [19,56], selective drainers according to the Fistula Risk Score [57][58][59], the early drain removers [16,60], and selective drainers and early removers [61]. Several systematic reviews and meta-analyses that variously included both RCTs and non-RCTs, both on PD and distal pancreatectomy [21][22][23][24][25][26][27][28][29][30], led to different opinions regarding the usefulness of drains after PD. Some judged them demonstrably useful [23,27,30], while others found no evidence to confirm as much [28,29].…”

Section: Discussionmentioning

confidence: 99%

“…Some said they are only useful in selected patients (such as those at high risk of POPF) [25]. Other findings were neutral (drains neither increased nor reduced PO complications and mortality) [21,22,24,26]. When drains were used, their early removal seemed a good idea [21,24,29,30].…”

Section: Discussionmentioning

confidence: 99%

“…Subsequent prospective randomized trials designed to compare patients with and without drains after pancreatic surgery produced contradictory findings [19,20]. Several systematic reviews and meta-analyses have since been performed on this issue [21][22][23][24][25][26][27][28][29][30]. Unfortunately, the level of evidence for all the above-mentioned studies was moderate, low, or very low [29,30].…”

Section: Introductionmentioning

confidence: 99%

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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

Pedrazzoli

Brazzale

2020

Langenbecks Arch Surg

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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.

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Meta-analysis of prophylactic abdominal drainage in pancreatic surgery

Abstract: Pancreatic resection with, or without abdominal drainage results in similar rates of mortality, morbidity and reintervention.

Cited by 42 publications

References 36 publications

Abdominal drainage versus no drainage after distal pancreatectomy: study protocol for a randomized controlled trial

Abdominal drainage versus no drainage after distal pancreatectomy: study protocol for a randomized controlled trial

Standardization of perioperative care facilitates safe discharge by postoperative day five after pancreaticoduodenectomy

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

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