Evidence vs practice in early drain removal following pancreatectomy

Abstract

Objective: Early drain removal when POD1 drain fluid amylase (DFA) was ≤5000 IU/L reduced complications in a previous randomized controlled trial. We hypothesized that most surgeons continue to remove drains late and that this is associated with inferior outcomes. Methods: We assessed the practice of pancreas surgeons in a prospectively maintained pancreas surgery consortium database to determine the association between timing of drain removal with demographics, co-morbidities, and all complications including clinically relevant post-operative pancreatic fistula (CR-POPF). We excluded patients without drains or POD1 DFA >5000, and if POD1 DFA values or timing of drain removal was unknown. Early drain removal was defined as ≤POD5. Early and late removal groups were compared using Chi square. Results: 213 patients met all inclusion criteria. Only 74 (35%) had drains removed early. There was no difference between groups in demographics or co-morbidities. EBL was greater in the late group (early 146 mL, late 325 mL; p=0.008). All other intra-operative characteristics were similar. Complications were significantly increased in the late group (Table 1). There were no CR-POPF or major complications in patients with early removal. When subset analysis was performed for type of resection, complications remained significant for distal pancreatectomy (early (4/29 (14%) vs late 24/35 (69%), p <0.0001). Conclusion: Despite level 1 data suggesting improved outcomes with early removal when POD1 DFA is ≤5000, experienced pancreas surgeons more frequently removed drains late. This practice was not explained by known risk factors (except EBL) and may be associated with inferior outcomes suggesting potential for improvement, particularly in distal pancreatectomy.Table 1Comparison of Early and Late Drain Removal GroupsEarly (n=74)Late (n=139)p-valuePatients with any complication21 (28%)114 (82%)<0.0001Patients with major complications(Accordion grade ≥3)016 (11%)0.04Pancreatic fistula (Grade B/C)010 (7%)0.03 Open table in a new tab