Extended Experience with a Dynamic, Data-Driven Selective Drain Management Protocol in Pancreaticoduodenectomy: Progressive Risk Stratification for Better Practice.
Published on May 1, 2020in Journal of The American College of Surgeons6.113
· DOI :10.1016/J.JAMCOLLSURG.2020.01.028
Abstract Background Intraoperative drain use for pancreatoduodenectomy (PD) has been practiced in an unconditional, binary manner (placement/no-placement). Alternatively, dynamic drain management has been introduced, incorporating the Fistula Risk Score (FRS) and drain fluid amylase (DFA) analysis, to mitigate clinically-relevant pancreatic fistula (CR-POPF). Study Design An extended experience with dynamic drain management was employed at a single institution for 400 consecutive PDs (2014-2019). This protocol consists of two-parts; (1) drains omitted for negligible/low risk FRS (0-2); (2) drains placed for moderate/high FRS (3-10) with early (POD3) removal if POD1 DFA≤5,000 U/L. Adherence to this protocol was prospectively annotated and outcomes were retrospectively analyzed. Results The overall CR-POPF rate was 8.7% with none occurring in the negligible/low risk cases. Moderate/high risk patients manifested a 11.9% CR-POPF rate (N=35/293), which was lower on-protocol (9.5 vs. 21%, p=0.014). After drain placement, POD1 DFA≥5,000 U/L was a better predictor of CR-POPF than FRS (OR 14.7, 95% CI 4.3-50.3). For POD1 DFA≤5,000 U/L, early drain removal was associated with fewer CR-POPFs (2.8 vs. 23.5%, p Conclusion This extended experience validates a dynamic drain management protocol, providing a model for better drain management and individualized patient care after PD. This study confirms that drains can be safely omitted from negligible/low risk patients, and moderate/high risk patients benefit from early drain removal.