Operative drainage after pancreatic resection ‘should be abandoned’

By Eleanor McDermid, Senior medwireNews Reporter

Routine prophylactic drainage offers no benefits to patients undergoing pancreatic resection, say researchers.

In fact, patients given the drains have more postoperative morbidity and longer hospital stays, and are more likely to be readmitted, report Peter Allen and team from the Memorial Sloan-Kettering Cancer Center in New York, USA.

"In addition, the placement of operative drains in patients who did develop pancreatic leak/fistula did not appear to improve the ability to resolve the leak," they say, noting that 85% of patients with versus 70% of those without drains eventually needed percutaneous computed tomography-guided drainage.

The study was a retrospective analysis, but it backs the findings of a randomized, controlled trial conducted at the same institution about 10 years ago, which concluded that drainage after pancreatic resection was not necessary.

"These recommendations have not met widespread acceptance even at our own institution, and routine drainage is still practiced by the majority of pancreatic surgeons around the world," say Allen et al in the Annals of Surgery.

Although retrospective, the latest study benefited from the habitual practices of the six highest-volume surgeons at the center, who between them carried out 1122 pancreatic resections during 2006-2011. Two of the surgeons were habitual drainers, placing drains in more than 95% of patients; while two were selective drainers (about 50% of patients); and two were routine nondrainers (about 15% of patients). So patients were effectively partially randomized according to which surgeon treated them.

Postoperative fistulae of at least grade 3 were slightly but significantly more common in patients with than without drains, at 20% versus 16%. Also, infected intra-abdominal collections, or leaks with positive cultures, were more frequent in patients with than without drains, at 13% versus 9%.

In all, 33% of patients with drains versus 26% of those without had a grade 3-4 complication. The median length of hospital stay was 8 days in patients with versus 7 days in those without drains, and 27% versus 20% needed to be readmitted.

"Ultimately, perhaps the most compelling argument that can be offered to support abandoning routine drainage after pancreatic resections is that the devastating complications that are feared to be associated with uncontrolled leaks (sepsis, postpancreatectomy hemorrhage, death) have not been found to be more easily managed in patients who have had drains placed at operation," says the team.

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