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Pancreaticoduodenectomy Can Almost Always Be Performed Safely Without Operative Drain Placement
*John W Kunstman, *Lee F Starker, James M. Healy, Ronald R Salem
Yale University, New Haven, CT
Objective: Examine the effects of forgoing operative drain placement on operative mortality and morbidity, need for re intervention, and length of stay following pancreaticoduodenectomy (PD).
Design: Prospective cohort study followed by a validation case series
Setting: High-volume tertiary center
Patients: Two consecutive cohorts each undergoing PD for any indication with the initial group having operative drains placed in cases subjectively concerning for POPF development; the second cohort did not undergo operative drainage whatsoever. A subsequent validation cohort was examined based on practice adjustments made following the initial study.
Interventions: None
Outcome Measures: Overall operative mortality and morbidity as defined by a standardized metric; incidence of POPF; need for procedural reintervention.
Results: 106 patients were evaluated in two consecutive cohorts of 53; in the first group, 30% had operative drains placed. 22.6% developed POPF versus 7.5% of patients in the no drainage group (p=0.06). Despite this, no significant difference in major morbidity (Clavien≥3, 20.8% versus 17.0%), median length of stay (days [IQR], 7 [6-11.25] versus 7 [6-9]), delayed gastric emptying (DGE, 22.6% versus 18.9%), or need for procedural reintervention (18.9% versus 15.1%) was observed.
Subsequently, 237 additional patients where drains were used only in exceptional circumstances were examined. Operative drains were placed in 3% of patients (n=7) and 90-day mortality was 1.3% (n=3). Incidence of POPF was 8.0%, DGE was 10.1%, median length of stay was 6 days (IQR, 5-7), and the overall major complication rate was 14.8%.
Conclusions: In most circumstances, drainage after PD appears unnecessary and can be avoided resulting in acceptable operative morbidity and mortality.
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