First-day Versus Early Drain Removal Following Pancreaticoduodenectomy: a Randomized Controlled Trial

Introduction Pancreatic surgery is a complex discipline with a high risk of post-operative morbidity such as pancreatic fistula (POPF) with variable impact on clinical outcome, fluid collection and hemorrhage. For such reason the intraoperative placement of intra-abdominal drains (ID) to early detect, mitigate, and manage post-operative complications is still considered to be a routine practice.

Controversies on ID placement have emerged from both randomized and non-randomized clinical studies investigating its possible role in increasing POPF and postoperative morbidity as well as prolonged hospital stay. According to Conlon et al the presence of drains failed to reduce either the need for interventional radiologic drainage or surgical exploration for intraabdominal sepsis and was associated with the development of more intra-abdominal abscesses, collections, or fistulas. Some authors report significantly higher postoperative abdominal complications after late removal of ID. A prolonged period of drain insertion is associated with a higher rate of postoperative complications with increased hospital stay and costs, not to mention that dislocation of intra-abdominal drains is an early and frequent event after major pancreatic resection.

The optimal timing for drain removal after PD is still a subject of debate: most studies have shown that outcomes are best when ID are removed in postoperative day (POD) 3 when POPF is excluded (given a specific cut off for drain fluid amylase, DFA).

Even though many authors advocate early ID removal to prevent intra-abdominal infection or fistula, in clinical practice many surgeons may feel more comfortable to maintain IDs for a prolonged period (more than 3 days) even when criteria for POPF or other abdominal complications are not met.

In some studies correlation between drain fluid amylase (DFA) in POD1 after pancreatic resections and development of POPF has been examined, defining ideal cut-off points ranging between 5.000U/L and 90 U/l3-17-20-21 (depending on intraoperative risk stratification) that can be used to achieve the best timing for drain removal.