Do drains contribute to pancreatic fistula? Analysis of over 5,000 pancreatectomy patients in a single year

Abstract

Objective: Conflicting evidence exists from randomized controlled trials supporting both increased complications/fistulae and improved outcomes with drain placement after pancreatectomy. The objective was to determine drain practice patterns in the U.S.A., and to identify if drain placement was a risk for fistula formation. Methods: Demographic, perioperative, and outcomes data were captured from the NSQIP 2014 database, including components of the fistula risk score. Fistulas were classified based on International Study Group definition. P < 0.05 was used for statistical significance in univariate analysis and entry criteria to adjusted logistic regression models. Results: Of 5013 pancreatectomy patients, 4343 (87%) underwent drain placement. When controlled for other factors, drain placement was associated with ducts <3 mm, soft glands, and blood transfusion within 72 h of surgery. Age, obesity, neoadjuvant radiation, INR, and malignant histology lost significance in the adjusted model. Drained patients experienced higher readmission rates (17 vs. 14%, p < 0.05); and experienced increased (20 vs. 8%, p < 0.01) and type A/B/C fistulae. Fistula was associated with obesity, no neoadjuvant chemotherapy, drain placement, <3 mm duct, soft gland, and longer operative times. Drain placement remained independently associated with fistula after both distal pancreatectomy (OR = 2.84 [1.70–4.75], p < 0.01) and pancreaticoduodenectomy (OR = 2.29 [1.28–4.11], p < 0.01). Conclusion: Drains are placed in the vast majority (87%) of pancreatectomy patients from >100 institutions; particularly those with soft glands, small ducts, and associated blood transfusions. When these factors are controlled for, drain placement is independently associated with clinically relevant fistulae in both distal and proximal pancreatectomy, raising questions regarding the utility of drain placement.