Intra-abdominal drainage following pancreatic resection: A systematic review

Effect of passive versus active abdominal drainage on wound infection after pancreatectomy: A meta-analysis

Following pancreatic resection, there may be a variety of complications, including wound infection, haemorrhage, and abdominal infection. The placement of drainage channels during operation may decrease the chances of postoperative complications. However, what kind of drainage can decrease the rate of postoperative complications is still a matter of debate. The purpose of this research is to evaluate the efficacy of both active and passive drainage for post-operation wound complications. From the beginning of the database until November 2023, EMBASE, the Cochrane Library and the Pubmed database have been searched. The two authors collected 2524 related studies from 3 data bases for importation into Endnote software, and 8 finished trials were screened against the exclusion criteria. Passive drainage can decrease the incidence of superficial wound infection in postoperative patients with pancreas operation (Odds Ratio [OR], 1.30; 95% CI, 1.06-1.60 p = 0.01); No statistically significant difference was found in the incidence of deep infections among the two groups (OR, 1.51; 95% CI, 0.68-3.36 p = 0.31); No statistical significance was found for the rate of haemorrhage after active drainage on the pancreas compared with that of passive drainage (OR, 0.72; 95% CI, 0.29-1.77 p = 0.47); No statistically significant difference was found in the rate of death after operation for patients who had received a pancreas operation in active or passive drainage (OR, 0.90; 95% CI, 0.57-1.42 p = 0.65); On the basis of existing evidence, the use of passive abdominal drainage reduces postoperative surface wound infections in patients. But there were no statistically significant differences in the risk of severe complications, haemorrhage after surgery, or mortality. However, because of the limited sample size of this meta-analysis, it is necessary to have more high-quality research with a large sample size to confirm the findings.

Initial suction drainage decreases severe postoperative complications after pancreatic trauma: A cohort study

BACKGROUND

Few studies have addressed the question of which drain types are more beneficial for patients with pancreatic trauma (PT).

AIM

To investigate whether sustained low negative pressure irrigation (NPI) suction drainage is superior to closed passive gravity (PG) drainage in PT patients.

METHODS

PT patients who underwent pancreatic surgery were enrolled consecutively at a referral trauma center from January 2009 to October 2021. The primary outcome was defined as the occurrence of severe complications (Clavien-Dindo grade ≥ Ⅲb). Multivariable logistic regression was used to model the primary outcome, and propensity score matching (PSM) was included in the regression-based sensitivity analysis.

RESULTS

In this study, 146 patients underwent initial PG drainage, and 50 underwent initial NPI suction drainage. In the entire cohort, a multivariable logistic regression model showed that the adjusted risk for severe complications was decreased with NPI suction drainage [14/50 (28.0%) vs 66/146 (45.2%); odds ratio (OR), 0.437; 95% confidence interval (CI): 0.203-0.940]. After 1:1 PSM, 44 matched pairs were identified. The proportion of each operative procedure performed for pancreatic injury-related and other intra-abdominal organ injury-related cases was comparable in the matched cohort. NPI suction drainage still showed a lower risk for severe complications [11/44 (25.0%) vs 21/44 (47.7%); OR, 0.365; 95%CI: 0.148-0.901]. A forest plot revealed that NPI suction drainage was associated with a lower risk of Clavien-Dindo severity in most subgroups.

CONCLUSION

This study, based on one of the largest PT populations in a single high-volume center, revealed that initial NPI suction drainage could be recommended as a safe and effective alternative for managing complex PT patients.

Intraoperative radiation therapy induces immune response activity after pancreatic surgery

Background

Pancreatic cancer has highly aggressive features, such as local recurrence that leads to significantly high morbidity and mortality and recurrence after successful tumour resection. Intraoperative radiation therapy (IORT), which delivers targeted radiation to a tumour bed, is known to reduce local recurrence by directly killing tumour cells and modifying the tumour microenvironment.

Methods

Among 30 patients diagnosed with pancreatic cancer, 17 patients received IORT immediately after surgical resection. We investigated changes in the immune response induced by IORT by analysing the peritoneal fluid (PF) and blood of patients with and without IORT treatment after pancreatic cancer surgery. Further, we treated three pancreatic cell lines with PF to observe proliferation and activity changes.

Results

Levels of cytokines involved in the PI3K/SMAD pathway were increased in the PF of IORT-treated patients. Moreover, IORT-treated PF inhibited the growth, migration, and invasiveness of pancreatic cancer cells. Changes in lymphocyte populations in the blood of IORT-treated patients indicated an increased immune response.

Conclusions

Based on the characterisation and quantification of immune cells in the blood and cytokine levels in the PF, we conclude that IORT induced an anti-tumour effect by activating the immune response, which may prevent pancreatic cancer recurrence.

Clinical trial registration

NCT03273374.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08807-3.

Active drain system with reticulated open-pore foam-surface dressing for postoperative pancreatic fistula in a rat model

Background

Postoperative pancreatic fistula (POPF) is one of the most harmful complications after pancreatic resection. Efficient drainage affects the clinical outcome of POPF. Inefficient drain of the fluid collection should contribute greatly to the need of additional interventional drainage, secondary morbid complications, and death.

Methods

A rat model of POPF was established by distal pancreatosplenectomy. A novel active drain system (ADS) for POPF was developed by wrapping polyvinyl alcohol sponges (PVA) to an end of the drainage tube. Passive drain system (PDS), ADS and ADS with PVA were used for POPF in rat models. The volume and amylase of ascites were measured. CT scan was applied to assess abdominal fluid collection. Rats pancreatic transection stumps were stained by hematoxylin and eosin (H&E).

Results

The volume of drainage of ADS with PVA group was less than that of PDS group and ADS group at late stage. CT scan showed obvious abdominal fluid collections in 2/8, 2/8 and 0/8 rats in PDS, ADS and ADS with PVA group separately. Macrofindings showed significant intra-abdominal adhesions and inflammation in PDS and ADS group but not in ADS with PVA group. H&E staining showed less inflammatory cells and destroyed pancreatic glands in ADS with PVA group.

Conclusion

ADS with PVA drained ascites effectively in the rat model of POPF. The effective drainage of pancreatic juice reduced the inflammation of abdominal organs and pancreatic resection stumps, and might promote the healing of POPF.

The diagnostic value of C-reactive protein for predicting pancreatic fistula following pancreatoduodenectomy

INTRODUCTION

Pancreaticoduodenectomy is the preferred treatment of neoplasms in the pancreas and duodenum. Postoperative pancreatic fistula is a critical complication. A potential predictive marker is C-reactive protein. This retrospective study examined the predictive value of C-reactive protein as a marker for development of postoperative pancreatic fistulas.

METHODS

All patients who had a pancreaticoduodenectomy from 1 January 2015 to 31 December 2019, were included. Levels of the biomarker and linear trajectory were determined for postoperative days one to four. Univariate analysis was used to identify predictive variables for a postoperative pancreatic fistula. Receiver operating characteristics curves, specificity, and sensitivity were calculated.

RESULTS

Five hundred and fifty-two patients underwent pancreaticoduodenectomy. C-reactive protein level greater than 121.5mg/L on the third postoperative day and an increase in C-reactive protein level between the first and fourth postoperative days, greater than 21.7mg/L, seemed to be reliable predictors. For Grade C postoperative pancreatic fistulas, increases in C-reactive protein, greater than 40.6ml/L the first four postoperative days, had a sensitivity of 100%. White blood cell count did not have similar reliability in predicting postoperative pancreatic fistulas.

CONCLUSION

Our findings indicate that small rises in C-reactive protein during the first postoperative days after pancreaticoduodenectomy are associated with an increased risk of developing postoperative pancreatic fistula.

Passive Versus Active Intra-Abdominal Drainage Following Pancreaticoduodenectomy: A Retrospective Study Using The American College of Surgeons NSQIP Database

BACKGROUND

Prophylactic drainage following pancreaticoduodenectomy (PD) reduces morbidity and mortality. Little evidence exists to advise on whether passive gravity (PG) or active suction (AS) drainage systems result in superior outcomes. This study examines the relationship between drainage system and morbidity following PD.

METHODS

All patients undergoing elective PD with an operatively placed drain in the 2016 ACS-NSQIP database were included. Pre- and intra-operative factors were examined. Multivariable logistic regression and coarsened exact matching (CEM) were used to assess for an association between drainage system (PG vs. AS) and morbidity. The primary outcome was postoperative pancreatic fistula (POPF).

RESULTS

In total, 3430 patients were included: 563 (16.4%) with PG and 2867 (83.6%) with AS drainage system. On multivariable regression, 1787 patients were included. Drainage type was not associated with POPF, surgical site infection, delayed gastric emptying, or re-operation. AS drainage was protective against percutaneous drain insertion (OR 0.65, 95% CI 0.44-0.96, p = 0.033). In the CEM cohort (n = 268), superficial SSI was higher in the AS group (0.8% vs. 6.0%, p = 0.036). There was a trend toward higher rates of composite total SSI (PG 15.7%, AS 23.9%, p = 0.092) and organ space SSI (PG 14.2%, AS 20.2%, p = 0.195) in the AS group; this did not demonstrate statistical significance.

CONCLUSIONS

The findings of this study suggest that AS drainage is protective against percutaneous drain insertion, but may be associated with increased risk of SSI. There was no relation between drainage type and POPF. A prospective, randomized controlled trial is warranted to further explore these findings.

Meta-analysis of modified Blumgart anastomosis and interrupted transpancreatic suture in pancreaticojejunostomy after pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) remains the main cause of surgery related mortality after pancreaticoduodenectomy. Various pancreatoenteric anastomosis methods have been developed to reduce the POPF rate. However, the optimum choice has not been clarified. A literature search is performed in electronic databases, including PubMed, Medline, Embase, CNKI and the Cochrane Library. Studies comparing modified Blumgart anastomosis with interrupted transpancreatic suture are included in this meta-analysis. Grade B/C POPF, overall POPF rate and overall sever complication rate (Clavien-Dindo classification IIIa or more) are measured as primary outcomes. Revman 5.3 was used to perform the analysis. Five retrospective comparative studies and 1 randomized controlled trial with a total number of 1409 patients are included in our analysis. Meta-analysis revealed that modified Blumgart anastomosis is associated with lower rate of grade B/C POPF [Odds Ratio (OR) 95% confidence interval (CI),0.32 (0.12-0.84); P = 0.02] and intra-abdominal abscess [OR 95%CI, 0.43 (0.29-0.65); P < 0.01] comparing with interrupted transpancreatic suture. However, this procedure could not reduce overall POPF [OR 95%CI,0.70 (0.34-1.44); P = 0.34] and overall sever complication rate [OR 95%CI,0.91 (0.48-1.72); P = 0.77]. At current level of evidence, modified Blumgart anastomosis is superior to interrupted transpancreatic suture in terms of grade B/C POPF and intra-abdominal abscess. However, high-grade evidence will be necessary to confirm these results.

Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery

Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgeries. POPF develops as a consequence of pancreatic juice leakage from a surgically exfoliated surface and/or anastomotic stump, which sometimes cause intraperitoneal abscesses and subsequent lethal hemorrhage. In recent years, various surgical and perioperative attempts have been examined to reduce the incidence of POPF. We reviewed several well-designed studies addressing POPF-related factors, such as reconstruction methods, anastomotic techniques, stent usage, prophylactic intra-abdominal drainage, and somatostatin analogs, after pancreaticoduodenectomy and distal pancreatectomy, and we assessed the current status of POPF. In addition, we also discussed the current status of POPF in minimally invasive surgeries, laparoscopic surgeries, and robotic surgeries.

Non-inferiority of open passive drains compared with closed suction drains in pancreatic surgery outcomes: A prospective observational study

BACKGROUND

Policies concerning the management of operatively placed drains after pancreatic surgery are still under debate. Open passive drains and closed-suction drains are both used currently in clinical practice worldwide, but there are no reliable data regarding potential differences in the postoperative outcomes associated with each drain type. The aim of the present study was to compare open passive drains and closed-suction drains with regard to postoperative contamination of the drainage fluid and overall morbidity and mortality.

METHODS

This study was a prospective, observational analysis of 320 consecutive, standard, partial resections (pancreaticoduodenectomy and distal pancreatectomy at a single institution from April 2016 to April 2017. Either open passive drains (n = 189, 51%) or closed-suction drains (n = 131) were used according to the operating surgeon's choice. Postoperative outcomes, including samples of drainage fluid collected on postoperative day V and sent for microbiologic analysis, were registered.

RESULTS

The open passive drain and closed-suction drain cohorts did not differ in terms of their clinical features, use of neoadjuvant chemotherapy or preoperative biliary drainage, fistula risk zone, and type of operative procedure. The overall rate of postoperative day V drainage fluid contamination (27.5% vs. 20.6%, P = .1) was similar between the groups. The same results were obtained for each specific procedure. The postoperative outcomes, namely, overall 30-day morbidity, postoperative pancreatic fistula, intra-abdominal fluid collections, percutaneous drainage, wound infections, reintervention, mean duration of hospital stay, and mortality did not differ between the 2 groups. Qualitative microbiologic analysis revealed that after pancreaticoduodenectomy, 61.5% of the bacteria contaminating the drainage fluid were attributable to human gut flora, while after distal pancreatectomy, 84.8% of the bacteria belonged to skin and mucous flora (P < .01), however, the spectrum of bacterial contamination did not significantly differ between the open passive drain and closed-suction drain cohorts.

CONCLUSION

The use of open passive drains and closed-suction drains for major pancreatic resection does not significantly impact the postoperative outcome. The spectrum of drain contamination depends on the specific operative procedure rather than on the type of drain used.

Evaluation of Drain Amylase Level after Pancreaticoduodenectomy with Special Reference to Delayed Pancreatic Fistula

Postoperative pancreatic fistula (PF) is a relatively frequent and occasionally fatal complication of pancreatoduodenectomy (PD). Several risk factors for PF have been reported, including high drain amylase level (D-AMY). Among the 140 consecutive patients who underwent PD, we analyzed 110 cases with D-AMY measurements over time after PD. According to the D-AMY change, we divided patients into five patterns and defined delayed PF cases. We analyzed clinical characteristics, including serum amylase and D-AMY, and examined the correlation between the period of drain insertion and PF grade. In 15 delayed PF cases, 12 cases were grade B or C, pancreatic cancer was less frequent, pancreatic ducts were smaller, and soft pancreas texture was more commonly observed. The D-AMYon postoperative day (POD) 1 was higher in cases of delayed PF compared with non-PF cases ( P < 0.0001). In 28 cases with drain removal before POD 7, grade B or C PF was not observed afterward. The average D-AMYon POD 1 in cases with drain removal before POD 1 was significantly lower than in delayed PF cases. Although further studies are required to determine the most appropriate timing of drain removal, it is thought that intra-abdominal drains should be removed within seven days of PD in cases without signs of PF. On the other hand, delayed PF should be considered in cases of soft pancreas texture and/or high D-AMY on POD 1, even if D-AMY levels are low on POD 3 or decreasing on POD 5.

Risk factors and preventive strategies for post-operative pancreatic fistula after pancreatic surgery: a comprehensive review

BACKGROUND

Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded complications are the development of a post-operative pancreatic fistula (POPF). The prediction and prevention of POPF remains an area of debate with several questions yet to be firmly addressed with solid answers.

METHODS

A systematic review of systematic reviews/meta-analyses and randomized trials in the English literature (PubMed/MEDLINE, Cochrane library, EMBASE) covering January 2005 to December 2015 on risk factors and preventive strategies for POPF.

RESULTS

A total of 49 systematic reviews and meta-analyses over the past decade discussed patient, surgeon, pancreatic disease and intraoperative related factors of POPF. Non-modifiable factors (age, BMI, comorbidity) and pathology (histotype, gland texture, duct size) that indicates surgery are associated with POPF risk. Consideration of anastomotic technique and use of somatostatin-analogs may slightly modify the risk of fistula. Sealant products appear to have no effect. Perioperative bleeding and transfusion enhance risk, but is modifiable by focus on technique and training. Drains may not prevent fistulae, but may help in early detection. Early drain-amylase may aid in detection. Predictive scores lack uniform validation, but may have a role in patient information if reliable pre-operative risk factors can be obtained.

CONCLUSIONS

Development of POPF occurs through several demonstrated risk factors. Anastomotic technique and use of somatostatin-analogs may slightly decrease risk. Drains may aid in early detection of leaks, but do not prevent POPF.

A Randomized Trial on the Efficacy of Prophylactic Active Drainage in Prevention of Complications after Pancreaticoduodenectomy

BACKGROUND AND AIMS

This randomized controlled trial was conducted to examine whether prophylactic active drainage decreases morbidity associated with pancreati-coduodenectomy.

MATERIAL AND METHODS

A prospective, randomized controlled trial was conducted between April 2010 and May 2015 when 160 consecutive patients following elective pancreaticoduodenectomy were randomized intraoperatively to either prophylactic active drainage group or conventional passive drainage group. The main objectives were the incidence of postoperative pancreatic fistula and the associated clinical outcomes.

RESULTS

There were 82 patients in the active drain group and 78 patients in the passive drain group. The overall pancreatic fistula rate occurred similarly in the two groups (11.0% (9/82) vs 14.1% (11/78), p = 0.360). Grade C pancreatic fistula in active drain group was significantly less than that in passive drain group (0% (0/82) vs 6.4% (5/78), p = 0.026). The mean postoperative hospital stay and parenteral nutrition support time in active drainage group were shorter than those in passive drainage group (12.6 days vs 14.5 days, p = 0.037; 6.9 days vs 8.6 days, p = 0.047, respectively).

CONCLUSION

Prophylactic active drainage reveals significant reduction in severity of complications associated with pancreatic fistula and might be recommended as an alternative for patients with high risk of developing serious pancreatic fistula after pancreaticoduodenectomy.