title: A simple algorithm for drain management after pancreaticoduodenectomy.
abstract: Pancreatic fistula (PF) continues to be the Achilles' heel of pancreaticoduodenectomy (PD) with both morbidity and mortality linked to its occurrence. The optimal drain management strategy after PD remains unclear. We evaluated drain amylase (DA) levels on postoperative Day (POD)  0 to 5 in 76 consecutive patients undergoing PD to determine the patterns associated with PF. Of these 76 patients, eight patients (11%) developed Grade A, B, or C PF by International Study Group of Pancreatic Fistula criteria. POD 1 DA levels correlated closely with PF rates when high (greater  than 5000 U/L, 100% PF rate) and low (less than 100 U/L, 2% PF rate). In patients with intermediate POD 1 DA (100 to 5000 U/L), 42 and 74 per cent had low DA levels on POD 3 and 5, respectively, and the PF rate was four of 31 (13%). Overall, the temporal pattern of decreasing DA levels after  PD correlates closely with the risk of PF, and only two patients (5%) developed PF after early DA levels had normalized. Based on these data, we propose an algorithm of monitoring DA daily with drain removal when the level is less than 100 U/L. In our patient group drain removal would have  occurred on a mean of 1.8 days and median 1 day after surgery.
authors.affiliation: Department of Surgery, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA. Nicholas.nissen@cshs.org
authors.forename: Nicholas N
authors.initials: NN
authors.lastname: Nissen
authors.forename: Vijay G
authors.initials: VG
authors.lastname: Menon
authors.forename: Vichin
authors.initials: V
authors.lastname: Puri
authors.forename: Alagappan
authors.initials: A
authors.lastname: Annamalai
authors.forename: Brendan
authors.initials: B
authors.lastname: Boland
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000681:Amylases; D004322:Drainage; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010185:Pancreatic Fistula / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D011182:Postoperative Care / Q000379:methods*
chemical_list: D000681:Amylases