Early vs late drain removal after pancreatectomy

One discussion this week included early vs late drain removal in pancreatectomy.

References: Beane JD, et al. Variation of drain management after pancreatoduodenectomy: early versus delayed removal. Annals of Surgery. 2017 Oct. doi: 10.1097/SLA.0000000000002570

Deminski J, et al. Early removal of intraperitoneal drainage after pancreatoduodenectomy in patients without postoperative fistula at POD3: results of a randomized clinical trial. Journal of Visceral Surgery. 2019 Jan 31. pii: S1878-7886(18)30084-5. doi: 10.1016/j.jviscsurg.2018.06.006

Summary:  Early drain removal after pancreatoduodenectomy, when guided by postoperative day (POD) 1 drain fluid amylase (DFA-1), is associated with reduced rates of clinically relevant postoperative pancreatic fistula (CR-POPF).

To measure if surgeons have altered their management based on this strategy, Beane et al (2017) analyzed the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) 2014 Participant Use File to identify patients having undergone pancreatoduodenectomy (n = 3093). Patients with intraoperatively placed drains were stratified according to measurement of DFA-1 and day of drain removal. Patients with POD 1 DFA-1 of ≤5000 U/L whose drains were removed by POD 3 were propensity score-matched with patients whose drains were removed after POD 3.

Beane et al (2017) found that measurement of DFA-1 was associated with earlier time to drain removal and shorter postoperative length of stay. Propensity score matching revealed that early drain removal when DFA-1 was ≤5000 U/L was associated with significant reductions in overall morbidity (35.3% vs 52.3%), CR-POPF (0.9% vs 7.9%), and length of stay (6 vs 8 days). In conclusion, clinical outcomes are best when drain fluid amylase is low and operatively placed drains are removed by POD 3 (Beane et al, 2017).

In investigating the relationship between early removal of abdominal drain and surgical site infections (SSI), Dembinski et al (2019) randomized 141 patients. They conclude that the timing of AD removal was not associated with an increase of 30-day SSI.

More specifically, early removal of drains was not associated with a significant decrease of 30-day SSI (14.1% vs. 24.3%, P=0.12). A lower rate of deep SSI was observed in the early arm (2.8% vs. 17.1%, P=0.03), leading to a shorter length of stay (17.8±6.8 vs. 21.0±6.1, P=0.01). Grade BC PF rate (5.6%), severe morbidity (17.7%), reoperation rate (7.8%), 30-day mortality (1.4%) and wound-SSI rate (7.8%) were similar between arms (Dembinski et al, 2019).

Additional Reading: Villafane-Ferriol N, et al. Evidence versus practice in early drain removal after pancreatectomy. Journal of Surgical Research. 2019 Jan 4;236:332-339.  doi: 10.1016/j.jss.2018.11.048.

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