Drain or No Drain Following Pancreaticoduodenectomy: The Unsolved Dilemma

BACKGROUND AND AIMS

There is no consensus regarding the routine placement of intra-abdominal drains after pancreaticoduodenectomy. We aim to determine the effects of intraperitoneal drain placement during pancreaticoduodenectomy on 30-day postoperative morbidity and mortality.

METHODS

Patients who underwent pancreaticoduodenectomy for pancreatic tumors were identified from the 2014-2015 American College of Surgeons-National Surgical Quality Improvement Program Database. Univariate and multivariate analyses adjusting for known prognostic variables were performed. A subgroup analysis was performed based on the risk for development of postoperative pancreatic leak determined by the pancreatic duct caliber, parenchymal texture, and body mass index.

RESULTS

A total of 6858 patients with pancreatic tumors who underwent pancreaticoduodenectomy were identified in the 2014-2015 American College of Surgeons-National Surgical Quality Improvement Program Database dataset. In all, 87.4% of patients had intraperitoneal drains placed. A 30-day mortality rate was higher in the no-drain group (2.9% vs. 1.7%, P = 0.003). Patients in the drain group had a higher incidence of overall morbidity (49.5% vs. 41.2%, P = 0.0008), delayed gastric emptying (18.1% vs. 13.7%, P = 0.004), pancreatic fistulae (19.4% vs. 9.9%, P ⩽ 0.0001), and prolonged length of hospital stay over 10 days (43.7% vs. 34.9%, P < 0.0001). Subgroup analysis based on risk categories revealed a higher 30-day mortality rate in the no-drain group among patients with high-risk features (3.1% vs. 1.6%, P = 0.02). Delayed gastric emptying and pancreatic fistula development remained significantly higher in the drain group only in the high-risk category. Prolonged length of hospital stay and composite morbidity remained higher in the drain group regardless of the risk category.

CONCLUSION

To our knowledge, this is the largest study to date that aims at clarifying the pros and cons of the intraperitoneal drain placement during pancreaticoduodenectomy for pancreatic tumors. We showed a higher 30-day mortality rate if drain insertion was omitted during pancreaticoduodenectomy in patients with softer pancreatic textures, smaller pancreatic duct caliber, and body mass index over 25. Postoperative 30-day morbidity rate was higher if a drain was inserted regardless of the risk category. Further randomized controlled trials with prospective evaluation of stratification factors for fistula risk are needed to establish a clear recommendation.

Solitary cavernous lymphangioma of the duodenum: a case report

Duodenal lymphangioma is an extremely rare benign tumor of the gastrointestinal tract. In this case report, we describe the case of a 39-year-old Lebanese female with cystic lymphangioma of the duodenum diagnosed by exploratory laparotomy and immunohistochemical analysis. Herein our findings are described.

Portomesenteric venous gas: A late complication of pneumatosis intestinalis

BACKGROUND

The pneumatosis intestinalis is an entity with multiple aetiologies and may be associated with a fatal outcome when present on plain radiographs. When associated with the presence of portomesenteric venous gas (PMVG) it is typically the result of bowel ischaemia.

METHODS AND RESULTS

We are presenting a case of a 43 year old male who presented with a two days history of haematemesis, generalised abdominal pain and distension. Computed tomography (CT) scan revealed a gross amount of air within the portal venous system and small bowel dilatation to the level of distal ileum was also seen with associated pneumatosis intestinalis. Emergency laparotomy was conducted which demonstrated a simple band adhesion resulting in bowel ischaemia. The patient was making a good post-operative recovery complicated only by sub-therapeutic treatment of schizophrenia.

CONCLUSION

The presence of gas within the portal venous system and PI in adults can indicate severe life-threatening disease. This requires early surgical intervention in those patients with a clinical suspicion of bowel ischaemia, and with radiological signs. This may avoid significant mortality.

Living related liver transplantation in children

Background

Living related liver transplantation (LRLT) has become established for treating children with end-stage liver disease. The aim of this study was to review a single-centre experience of left lateral segment liver transplants from living donors in children.

Methods

Fifty left lateral segment LRLT procedures have been performed since 1993. There were 17 girls and 33 boys, of median age 1·5 years (range 0·5 to 13 years), with a median weight of 10 (range 0·7–44) kg. Donors included 23 mothers, 26 fathers and one uncle, with a median age of 33 (range 19–46) years.

Results

At a median follow-up of 86 months, there was no donor mortality and low morbidity. Patient and graft survival rates were 98, 96 and 96 per cent, and 98, 96 and 93 per cent at 1, 3 and 5 years respectively. Three children had a second transplant at a median of 9 years after the first. The incidence of hepatic artery thrombosis, portal vein thrombosis and biliary complications was 6, 4 and 14 per cent respectively.

Conclusion

Living related liver transplantation has good long-term results in children.

Solid pseudopapillary neoplasm of the pancreas in a 12-year-old female: case report and review of the literature

Solid pseudopapillary neoplasms of the pancreas (SPNP) are rare pancreatic tumors that occur predominantly in young women, with very few cases reported in men. While the origin of the tumor may be unclear, it is characterized by a distinct histological appearance and a clinical course highlighting its low malignant potential. SPNP have an excellent prognosis and are potentially curable provided they are managed appropriately by complete surgical resection. In the rare instances where metastatic disease is encountered, surgical debulking has been shown to prolong survival. The role of chemotherapy and radiation therapy in the management of SPNP is still controversial. We report here on an unusual occurrence of SPNP in the area of the head of the pancreas in a 12-year-old female treated by pancreatico-duodenectomy, together with a review of the literature.