Operative drains after pancreatic resection – the Titanic is sinking

Abstract

The unsinkable ship of surgical dogma has been the mandatory placement of operative drains after a pancreatic resection. The hulls of smaller ships have more easily foundered when exposed to prospective clinical investigation. The routine use of pre-operative parenteral or enteral nutritional support, mechanical bowel preparation, post-operative nasogastric tubes and the delayed resumption of oral intake until the return of complete bowel function are examples of dogmatic approaches that have not withstood the test of prospective clinical assessment. The study by Dr Fisher and colleagues is an example of surgeons challenging surgical dogma, and implementing changes through the practice of evidence-based medicine.1 Importantly, Dr Fisher and colleagues carefully measured outcomes once these changes had been implemented, and then reported their results. Dr Fisher's study reports on two consecutive cohorts of patients who underwent a pancreatic resection between 2004 and 2010. In the first cohort (179 patients) operative drains were routinely placed and in the second cohort (47 patients) no operative drains were placed. There were no differences between the groups with regard to demographics or overall health status, and no other major changes in technique were reported. The overall complication rate (65% vs. 47%), and the median complication severity (1 vs. 0) was significantly lower in the group that did not have drains placed. Clinically significant pancreatic fistulae were similar between groups; however the number of patients requiring post-operative percutaneous drainage was higher in the group that did not have drains placed in the operating room. The mortality rate and reoperation rate were similar between the groups. Dr Fisher's report is encouraging as it describes a change in clinical practice based on careful assessment of previously published data. Jeekel and Heslin et al. published the initial series of pancreatic resection without the placement of operative drains.2,3 Both authors noted that improvements in image-guided percutaneous drainage techniques allowed for safe post-operative drainage in patients who developed significant abdominal collections, and that the potential risks of routine abdominal drain placement may no longer be warranted. Heslin's study prompted Conlon and Brennan (2001) to perform a prospective trial of 179 patients who were randomized to have no drains or closed suction drains placed at the time of resection.4 This randomized trial revealed no difference in overall mortality or complications between groups; however, in the group that had drains placed there was an increase in the overall number of pancreatic fistulae, collections and abscesses (perhaps because the drain allowed these events to be measured!). The conclusions of this previous study were that routine drainage should not be considered mandatory. More recent randomized trials have also suggested that abdominal drains may be associated with the infection of intra-abdominal fluid collections and that when placed should be removed as early as possible.5,6 The Titanic is slowly sinking, now 20 years after the first reports of non-drainage and 10 years after the first randomized trial. Dr Fisher's report will certainly contribute to its demise, and will hopefully contribute to other surgeons rethinking the dogma of mandatory surgical drainage of the operative bed after a pancreatectomy.