title: Early Drain Removal--The Middle Ground Between the Drain Versus No Drain Debate in Patients Undergoing Pancreaticoduodenectomy: A Prospective Validation Study.
abstract: OBJECTIVE
  To perform an unbiased assessment of first postoperative day (POD 1) drain amylase level and pancreatic fistula (PF) after pancreaticoduodenectomy (PD).
  
  
  BACKGROUND
  Recent evidence demonstrated that drain abandonment in PD is unsafe. Early drain amylase levels have been proposed as predictors of PF after PD, allowing for selection of patients for early drain removal.
  
  
  METHODS
  Daily drain amylase levels were correlated with the development of PF in 2 independent cohorts of patients undergoing PD: training cohort (n = 126; year 2008) and validation cohort (n = 369; years 2009-2012).
  
  
  RESULTS
  POD 1 drain amylase level had the highest predictive ability (concordance index: 0.911) for PF in the training cohort. An amylase level of 612 U/L or higher showed the best accuracy (86%), sensitivity (93%), and specificity (79%). Thus, a cutoff value of 600 U/L was utilized. In the validation cohort, 229 (62.1%) patients had a POD 1 drain amylase level of lower than 600 U/L, and PF developed in only 2 (0.9%) cases; whereas in patients with POD 1 drain amylase level of 600 U/L or higher (n = 140) the PF rate was 31.4% (odds ratio [OR] = 52, P < 0.0001). On multivariate analysis, POD 1 drain amylase level of lower than 600 U/L (OR = 0.0192, P < 0.0001) was a stronger predictor of the absence of PF than pancreatic gland texture (OR = 0.193, P = 0.002) and duct diameter (OR = 0.861, P = 0.835).
  
  
  CONCLUSIONS
  After PD, the risk of PF is less than 1% if POD 1 drain amylase level is lower than 600 U/L. We propose that in this group, which comprise more than 60% of patients, drains should be removed on POD 1.
authors.affiliation: Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
authors.forename: Zhi
authors.initials: Z
authors.lastname: Ven Fong
authors.forename: Camilo
authors.initials: C
authors.lastname: Correa-Gallego
authors.forename: Cristina R
authors.initials: CR
authors.lastname: Ferrone
authors.forename: Gregory R
authors.initials: GR
authors.lastname: Veillette
authors.forename: Andrew L
authors.initials: AL
authors.lastname: Warshaw
authors.forename: Keith D
authors.initials: KD
authors.lastname: Lillemoe
authors.forename: Carlos
authors.initials: C
authors.lastname: Fernández-del Castillo
mesh_terms: D000368:Aged; D000681:Amylases / Q000378:metabolism*; D020878:Device Removal; D004322:Drainage; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010185:Pancreatic Fistula / Q000201:enzymology* / Q000209:etiology / Q000517:prevention & control*; D010190:Pancreatic Neoplasms / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D018579:Patient Selection; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D016896:Treatment Outcome
chemical_list: D000681:Amylases