Drain Management after Pancreatoduodenectomy: Reappraisal of a Prospective Randomized Trial Using Risk Stratification.
BACKGROUND
A recent randomized trial used the Fistula Risk Score (FRS) to develop guidelines for selective drainage based on clinically relevant fistula (CR-POPF) risk. Additionally, postoperative day (POD) 1 drain and serum amylase have been identified as accurate postoperative predictors of CR-POPF. This study sought to identify patients who may benefit from selective drainage, as well as the optimal timing for drain removal after pancreatoduodenectomy.


METHODS
One hundred six pancreatoduodenectomies from a previously reported RCT were assessed using risk-adjustment. The incidence of CR-POPF was compared between FRS risk cohorts. Drain and serum amylase values from POD 1 were evaluated using receiver operating characteristic (ROC) analysis to establish cut-offs predictive of CR-POPF occurrence. A regression analysis compared drain removal randomizations (POD 3 vs POD 5).


RESULTS
Three-quarters of patients had moderate/high CR-POPF risk. This group had a CR-POPF rate of 36.3% vs 7.7% among negligible/low risk patients (p = 0.005). The areas under the ROC curve for CR-POPF prediction using POD 1 drain and serum amylase values were 0.800 (p = 0.000001; 95% CI 0.70-0.90) and 0.655 (p = 0.012; 95% CI 0.55-0.77), respectively. No significant serum amylase cut-offs were identified. Moderate/high risk patients with POD 1 drain amylase ≤ 5,000 U/L had significantly lower rates of CR-POPF when randomized to POD 3 drain removal (4.2% vs 38.5%; p = 0.003); moreover, these patients experienced fewer complications and shorter hospital stays.


CONCLUSIONS
A clinical care protocol is proposed whereby drains are recommended for moderate/high FRS risk patients, but may be omitted in patients with negligible/low risk. Drain amylase values in moderate/high risk patients should then be evaluated on POD 1 to determine the optimal timing for drain removal. Moderate/high risk patients with POD 1 drain amylase ≤ 5,000 U/L have lower rates of CR-POPF with POD 3 (vs POD ≥ 5) drain removal; early drain removal is recommended for these patients.
Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Matthew T
MT
McMillan
Departments of Surgery and Oncology, University of Verona, the Pancreas Institute, Verona, Italy.
Giuseppe
G
Malleo
Departments of Surgery and Oncology, University of Verona, the Pancreas Institute, Verona, Italy.
Claudio
C
Bassi
Departments of Surgery and Oncology, University of Verona, the Pancreas Institute, Verona, Italy.
Giovanni
G
Butturini
Departments of Surgery and Oncology, University of Verona, the Pancreas Institute, Verona, Italy.
Roberto
R
Salvia
Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Robert E
RE
Roses
Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Major K
MK
Lee
Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Douglas L
DL
Fraker
Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Jeffrey A
JA
Drebin
Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Electronic address: Charles.Vollmer@uphs.upenn.edu.
Charles M
CM
Vollmer
D020878:Device Removal / Q000379:methods*; D019468:Disease Management; D004322:Drainage / Q000295:instrumentation*; D005260:Female; D006801:Humans; D015994:Incidence; D007902:Length of Stay / Q000639:trends; D008297:Male; D008875:Middle Aged; D010182:Pancreatic Diseases / Q000601:surgery*; D010185:Pancreatic Fistula / Q000453:epidemiology / Q000209:etiology / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology / Q000601:surgery*; D011446:Prospective Studies; D012372:ROC Curve; D012307:Risk Factors