A risk-adjusted analysis of drain use in pancreaticoduodenectomy: some is good, but more may not be better

Abstract

Presenter: Lisa Brubaker MD | Baylor College of Medicine Background: Intraperitoneal drain placement is presumed to decrease morbidity and mortality in patients who develop a clinically relevant post-operative 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, particularly in cases at greater risk for CR-POPF. Methods: The Fistula Risk Score (FRS), mitigation strategies (including number of drains placed), and clinical outcomes were obtained from a multi-institutional database of PDs performed from 2003-2020. Outcomes were compared between patients receiving 0, 1, or 2 intraperitoneal drains. A risk-adjusted multivariable regression analysis was used to evaluate the optimal drainage approach. Results: A total of 4292 PDs utilized 0 (7.3%), 1 (45.2%), or 2 (47.5%) drains with an observed overall CR-POPF rate of 9.6%, which was higher in intermediate/high FRS zone (FRS 3-10) cases compared to negligible/low FRS zone (FRS 0-2) cases (13% vs. 2.4%, p<0.001). The number of drains placed correlated with FRS zone (median of 2 in intermediate/high vs. 1 in negligible/low risk cases). Obviation of drains was associated with increases in mortality regardless of the FRS zone (mortality rate 3% vs. 1.1% vs. 0.4%, p = 0.017 for negligible/low risk cases and 14.4% vs. 2.0% vs. 2.1%, p<0.001 for intermediate/high risk cases with 0, 1, or 2 drains, respectively), as well as significant increases in morbidity for the intermediate/high risk cases (Figure 1). In contrast, the use of 1 drain instead of 2 had comparable rates of mortality, CR-POPF, average complication burden attributed to a CR-POPF and reoperations for the intermediate/high risk cases (Figure 1). Further, in a logistic regression model accounting for patient factors, operative details, and alternative risk-reducing strategies, the placement of 1 drain compared to 2 was associated with a lower incidence of CR-POPF (OR 0.59, 95% CI 0.415-0.839, p = 0.003) in the intermediate/high risk cases. Conclusion: For pancreaticoduodenectomy, drain omission is associated with inferior outcomes. In intermediate/high risk zone cases, placement of a single drain appears to mitigate the complication frequency and burden just as well as multiple drains, and perhaps even better.