• Annals of surgery · Jun 2017

    Multicenter Study

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

    • Matthew T McMillan, Giuseppe Malleo, Claudio Bassi, Valentina Allegrini, Luca Casetti, Jeffrey A Drebin, Alessandro Esposito, Luca Landoni, Major K Lee, Alessandra Pulvirenti, Robert E Roses, Roberto Salvia, and Charles M Vollmer.
    • *Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA †University of Verona, Verona, Italy.
    • Ann. Surg. 2017 Jun 1; 265 (6): 1209-1218.

    ObjectiveThis multicenter study sought to prospectively evaluate a drain management protocol for pancreatoduodenectomy (PD).BackgroundRecent evidence suggests value for both selective drain placement and early drain removal for PD. Both strategies have been associated with reduced rates of clinically relevant pancreatic fistula (CR-POPF)-the most common and morbid complication after PD.MethodsThe protocol was applied to 260 consecutive PDs performed at two institutions over 17 months. Risk for ISGPF CR-POPF was determined intraoperatively using the Fistula Risk Score (FRS); drains were omitted in negligible/low risk patients and drain fluid amylase (DFA) was measured on postoperative day 1 (POD 1) for moderate/high risk patients. Drains were removed early (POD 3) in patients with POD 1 DFA ≤5,000 U/L, whereas patients with POD 1 DFA >5,000 U/L were managed by clinical discretion. Outcomes were compared with a historical cohort (N = 557; 2011-2014).ResultsFistula risk did not differ between cohorts (median FRS: 4 vs 4; P = 0.933). No CR-POPFs developed in the 70 (26.9%) negligible/low risk patients. Overall CR-POPF rates were significantly lower after protocol implementation (11.2 vs 20.6%, P = 0.001). The protocol cohort also demonstrated lower rates of severe complication, any complication, reoperation, and percutaneous drainage (all P < 0.05). These patients also experienced reduced hospital stay (median: 8 days vs 9 days, P = 0.001). There were no differences between cohorts in the frequency of bile or chyle leaks.ConclusionsDrains can be safely omitted for one-quarter of PDs. Drain amylase analysis identifies which moderate/high risk patients benefit from early drain removal. This data-driven, risk-stratified approach significantly decreases the occurrence of clinically relevant pancreatic fistula.

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