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
Maxwell T. Trudeau4
Estimated H-index: 4
(UPenn: University of Pennsylvania),
Laura Maggino12
Estimated H-index: 12
(UPenn: University of Pennsylvania)
+ 6 AuthorsCharles M. Vollmer67
Estimated H-index: 67
(UPenn: University of Pennsylvania)
Sources
Abstract
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.
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References37
Newest
#1Brett L. Ecker (UPenn: University of Pennsylvania)H-Index: 19
#2Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 25
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
view all 4 authors...
Background Improvements in surgical outcomes are predicated on recognizing effective practices with subsequent adaptation. It is unknown whether risk assessment for pancreatic fistula (clinically relevant postoperative pancreatic fistula [CR-POPF]) after pancreaticoduodenectomy (PD) translates to improved patient outcomes at the practice level. Study design A prospectively collected, single-surgeon career experience (2003 to 2018) of 455 consecutive pancreatectomies (303 PDs and 152 distal pancr...
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#1Brett L. Ecker (UPenn: University of Pennsylvania)H-Index: 19
#2Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 25
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
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Objective:The aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy.Background:The utility of technical strategies to prevent clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatoduodenectomy (PD) may vary by the circ
Source
#1Priya M. Puri (UPenn: University of Pennsylvania)H-Index: 7
#2Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
Postoperative pancreatic fistula (POPF) is the most common complication after major pancreatic resections and is the greatest contributor to postoperative morbidity and mortality following pancreatoduodenectomy (PD). The relatively recent establishment of a standardized definition of POPF by the International Study Group of Pancreatic Fistula (ISGPF) allowed for the delineation between innocuous biochemical POPF (grade A) and clinically relevant (CR) POPF (grades B and C). This classification sy...
Source
#1Brett L. Ecker (UPenn: University of Pennsylvania)H-Index: 19
#2Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 25
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
view all 35 authors...
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#1Gregory T. Kennedy (UPenn: University of Pennsylvania)H-Index: 9
#2Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 25
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
view all 5 authors...
Background Experienced surgeons demonstrate improved pancreatoduodenectomy outcomes, but little is known about what distinguishes their practice. Furthermore, the concept of experience has been variably interpreted in the surgical literature. We investigated how 4 interpretations of experience influence pancreatoduodenectomy management decisions. Methods A survey assessing pancreatoduodenectomy practice patterns was distributed by 6 surgical societies. Regression analysis identified behaviors as...
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#1Joal D. Beane (IU: Indiana University)H-Index: 23
#2Michael G. House (IU: Indiana University)H-Index: 27
Last. Henry A. Pitt (TU: Temple University)H-Index: 61
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Objective:The objectives are to report practice patterns and management of operatively placed drains and to compare outcomes in patients with early versus delayed drain removal after pancreatoduodenectomy.Background:Early drain removal after pancreatoduodenectomy, when guided by postoperative day (P
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#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 25
#2Giuseppe MalleoH-Index: 46
Last. Charles M. VollmerH-Index: 67
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Objective:This multicenter study sought to prospectively evaluate a drain management protocol for pancreatoduodenectomy (PD).Background:Recent evidence suggests value for both selective drain placement and early drain removal for PD. Both strategies have been associated with reduced rates of clinica
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#1Claudio BassiH-Index: 111
Last. M.W. Büchler (Heidelberg University)H-Index: 79
view all 33 authors...
Background In 2005, the International Study Group of Pancreatic Fistula developed a definition and grading of postoperative pancreatic fistula that has been accepted universally. Eleven years later, because postoperative pancreatic fistula remains one of the most relevant and harmful complications of pancreatic operation, the International Study Group of Pancreatic Fistula classification has become the gold standard in defining postoperative pancreatic fistula in clinical practice. The aim of th...
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#1Helmut Witzigmann (Heidelberg University)H-Index: 34
#2Markus K. DienerH-Index: 51
Last. Markus W. BüchlerH-Index: 177
view all 14 authors...
OBJECTIVE This dual-center, randomized, controlled, noninferiority trial aimed to prove that omission of drains does not increase reintervention rates after pancreatic surgery. BACKGROUND There is considerable uncertainty regarding intra-abdominal drainage after pancreatoduodenectomy. METHODS Patients undergoing pancreatic head resection with pancreaticojejunal anastomosis were randomized to intra-abdominal drainage versus no drainage. Primary endpoint was overall reintervention rate (relaparoto...
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#1Matthew T. McMillanH-Index: 25
#2Sameer Soi (Mayo Clinic)H-Index: 6
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
view all 27 authors...
Objective:To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative pancreatic fistula (CR-POPF) occurrence as a quality indicator.Background:Accurate assessment of surgeon and institutional performance requires (1) standardized definitions for the outcome of
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Cited By8
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#1Mu-xing Li (PKU: Peking University)H-Index: 1
#2Hangyan Wang (PKU: Peking University)H-Index: 5
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Abstract null null Background null A novel procedure called shark mouth pancreaticojejunostomy (SMP) was developed, for the reconstruction of the pancreatic stump which has a theoretical advantage for anastomosis healing and wide applicability. null null null Methods null A comparative study of the patients who underwent SMP (SMP cohort) and those who underwent end-to-end dunking pancreaticojejunostomy (historic cohort) at Peking University Third Hospital was conducted. Each group was analyzed f...
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#1Lisa Suzanne Brubaker (BCM: Baylor College of Medicine)H-Index: 3
#2Fabio Casciani (University of Verona)H-Index: 3
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Abstract null null Background null Intraperitoneal drain placement decreases morbidity and mortality in patients who develop a clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD). It is unknown whether multiple drains mitigate CR-POPF better than a single drain. We hypothesize that multiple drains decrease the complication burden more than a single drain in cases at greater risk for CR-POPF. null null null Methods null The Fistula Risk Score (FRS...
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#1Roberto Salvia (University of Verona)H-Index: 57
#2Giovanni Marchegiani (University of Verona)H-Index: 32
Last. Claudio Bassi (University of Verona)H-Index: 111
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BACKGROUND The application of postoperative pancreatic fistula (POPF) risk stratification and mitigation strategies requires an update of the protocol for an early drain removal after pancreaticoduodenectomy (PD). The aim of the study is to highlight the unreliability of a single drain fluid amylase (DFA) cutoff-based protocol in the setting of a risk-based drain management. METHODS The role of postoperative day one (POD1) DFA in predicting POPF was explored in the setting of both selective drai...
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#1Stefano Partelli (UniSR: Vita-Salute San Raffaele University)H-Index: 45
#2Valentina Andreasi (UniSR: Vita-Salute San Raffaele University)H-Index: 11
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Abstract Background A fatty infiltration of the pancreas has been traditionally regarded as the main histological risk factor for postoperative pancreatic fistula, whereas the role of the secreting acinar compartment has been poorly investigated. The aim of this study was to evaluate the role of acinar content at pancreatic resection margin in the development of clinically relevant postoperative pancreatic fistula and clinically relevant postoperative acute pancreatitis after pancreaticoduodenec...
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#1Fabio Casciani (UPenn: University of Pennsylvania)H-Index: 3
#2Claudio Bassi (University of Verona)H-Index: 111
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
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Abstract Background Despite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indica...
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#1Amer H. Zureikat (University of Pittsburgh)H-Index: 44
#2Fabio Casciani (UPenn: University of Pennsylvania)H-Index: 3
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#1George Van Buren (BCM: Baylor College of Medicine)H-Index: 19
#2Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
Pancreatic fistula has been the defining complication and challenge of pancreatic surgery. Better awareness and mitigation of postoperative pancreatic fistulas has led to significant improvements in morbidity and mortality of pancreatic surgery. The definition and management of pancreatic fistulas has sequentially progressed over the last three decades; the literature ranges from retrospective, observational studies to prospective multicenter randomized controlled trials. The landmark literature...
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#1Takeo ToshimaH-Index: 24
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#1Sergio Pedrazzoli (UNIPD: University of Padua)H-Index: 42
#2Alessandra Rosalba Brazzale (UNIPD: University of Padua)H-Index: 13
PURPOSE Drains' role after pancreaticoduodenectomy (PD) is debated by proponents of no drain, draining selected cases, and early drain removal. The aim of the study was to assess the effect of "standard" and "draining-tract-targeted" management of abdominal drains still in situ after diagnosing a postoperative pancreatic fistula (POPF). METHODS PubMed and Scopus were searched for "pancreaticoduodenectomy or pancreatoduodenectomy or duodenopancreatectomy," "Whipple," "proximal pancreatectomy," "p...
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