Prophylactic drain management after pancreaticoduodenectomy without focusing on the drain fluid amylase level: A prospective validation study regarding criteria for early drain removal that do not include the drain fluid amylase level

The latest guidelines from the Enhanced Recovery After Surgery (ERAS®) Society stated that early drain removal after pancreatoduodenectomy (PD) is beneficial in decreasing complications including postoperative pancreatic fistulas (POPFs). This study aimed to ascertain the actual benefits of early drain removal after PD. The data of 450 patients who underwent PD between 2018 and 2020 were retrospectively reviewed. The surgical outcomes were compared between patients whose drains were removed within 3 postoperative days (early removal group) and after 5 days (late removal group). Logistic regression analysis was performed to identify the risk factors for clinically relevant POPFs (CR-POPFs). Among the patients with drain fluid amylase < 5000 IU on the first postoperative day, the early removal group had fewer complications and shorter hospital stays than the late removal group (30.9% vs. 54.5%, p < 0.001; 9.8 vs. 12.5 days, p = 0.030, respectively). The incidences of specific complications including CR-POPFs were comparable between the two groups. Risk factor analysis showed that early drain removal did not increase CR-POPFs (p = 0.163). Although early drain removal has not been identified as apparently beneficial, this study showed that it may contribute to an early return to normal life without increasing complications.

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Kinetics of postoperative drain fluid amylase values after pancreatoduodenectomy: New insights to dynamic, data-driven drain management

Surgery ◽

10.1016/j.surg.2021.02.068 ◽

2021 ◽

Author(s):

Amer H. Zureikat ◽

Fabio Casciani ◽

Sarwat Ahmad ◽

Claudio Bassi ◽

Charles M. Vollmer

Keyword(s):

Data Driven ◽

Dynamic Data ◽

Drain Fluid ◽

Kinetics Of ◽

Drain Management

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Validation of day 1 drain fluid amylase level for prediction of clinically relevant fistula after distal pancreatectomy using the NSQIP database

Surgery ◽

10.1016/j.surg.2018.07.030 ◽

2019 ◽

Vol 165 (2) ◽

pp. 315-322 ◽

Cited By ~ 5

Author(s):

Fady Daniel ◽

Hani Tamim ◽

Mohammad Hosni ◽

Feras Ibrahim ◽

Aurelie Mailhac ◽

...

Keyword(s):

Distal Pancreatectomy ◽

Amylase Level ◽

Drain Fluid

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Redefining the Role of Drain Amylase Value for a Risk-Based Drain Management after Pancreaticoduodenectomy: Early Drain Removal Still Is Beneficial

Journal of Gastrointestinal Surgery ◽

10.1007/s11605-020-04658-8 ◽

2020 ◽

Cited By ~ 1

Author(s):

Roberto Salvia ◽

Giovanni Marchegiani ◽

Stefano Andrianello ◽

Alberto Balduzzi ◽

Gaia Masini ◽

...

Keyword(s):

Drain Removal ◽

Drain Amylase ◽

Drain Management

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Amylase level in cervical drain fluid and anastomotic leakage after cervical oesophagogastrostomy†

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezz008 ◽

2019 ◽

Vol 56 (2) ◽

pp. 301-306 ◽

Cited By ~ 2

Author(s):

Woo Sik Yu ◽

Joonho Jung ◽

Hyejung Shin ◽

Yunho Roh ◽

Go Eun Byun ◽

...

Keyword(s):

Anastomotic Leakage ◽

Mixed Model ◽

Linear Mixed Model ◽

Oral Feeding ◽

Drainage Tube ◽

Amylase Level ◽

Anastomotic Site ◽

Mixed Model Analysis ◽

Protein Levels ◽

Drain Fluid

Abstract OBJECTIVES Anastomotic leakage after oesophageal cancer surgery is a serious complication. The purpose of this study was to evaluate the possibility of anastomotic leakage by repeatedly measuring amylase levels in the fluid obtained from the drainage tube inserted at the cervical anastomotic site. METHODS Ninety-nine patients who underwent oesophagectomy and cervical oesophagogastrostomy between April 2014 and March 2017 were retrospectively reviewed. A drainage tube was placed at the anastomotic site, and amylase levels were measured daily from postoperative day (POD) 1 until oral feeding or confirmation of anastomotic leakage. The amylase levels were analysed with a linear mixed model. RESULTS The mean age of the patients was 64.9 ± 9.0 years, and there were 89 (89%) male patients. Almost all pathologies (92%) were squamous cell carcinomas. The anastomotic methods were as follows: 63 (63%) circular stapled, 33 (33%) hand-sewn and 3 (3%) semistapled. Anastomotic leakage was confirmed in 10 (10%) patients. The amylase levels increased until POD 2 in both the leakage and non-leakage groups, but the levels subsequently decreased in the non-leakage group, whereas the levels peaked on POD 3 in the leakage group. On performing the linear mixed model analysis, anastomotic leakage was significantly associated with the trends in postoperative amylase levels in the drainage tube (P < 0.001). Trends in the serum C-reactive protein levels and white blood cell count were not significantly associated with anastomotic leakage. CONCLUSIONS Amylase level trends measured in the cervical drain fluid can be a useful indicator of anastomotic leakage after cervical oesophagogastrostomy.

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A Simple Algorithm for Drain Management after Pancreaticoduodenectomy

The American Surgeon ◽

10.1177/000313481207801029 ◽

2012 ◽

Vol 78 (10) ◽

pp. 1143-1146 ◽

Cited By ~ 14

Author(s):

Nicholas N. Nissen ◽

Vijay G. Menon ◽

Vichin Puri ◽

Alagappan Annamalai ◽

Brendan Boland

Keyword(s):

Pancreatic Fistula ◽

Temporal Pattern ◽

Management Strategy ◽

Simple Algorithm ◽

International Study ◽

Study Group ◽

International Study Group ◽

Drain Removal ◽

Drain Amylase ◽

Drain Management

Pancreatic fistula (PF) continues to be the Achilles’ heel of pancreaticoduodenectomy (PD) with both morbidity and mortality linked to its occurrence. The optimal drain management strategy after PD remains unclear. We evaluated drain amylase (DA) levels on postoperative Day (POD) 0 to 5 in 76 consecutive patients undergoing PD to determine the patterns associated with PF. Of these 76 patients, eight patients (11%) developed Grade A, B, or C PF by International Study Group of Pancreatic Fistula criteria. POD 1 DA levels correlated closely with PF rates when high (greater than 5000 U/L, 100% PF rate) and low (less than 100 U/L, 2% PF rate). In patients with intermediate POD 1 DA (100 to 5000 U/L), 42 and 74 per cent had low DA levels on POD 3 and 5, respectively, and the PF rate was four of 31 (13%). Overall, the temporal pattern of decreasing DA levels after PD correlates closely with the risk of PF, and only two patients (5%) developed PF after early DA levels had normalized. Based on these data, we propose an algorithm of monitoring DA daily with drain removal when the level is less than 100 U/L. In our patient group drain removal would have occurred on a mean of 1.8 days and median 1 day after surgery.

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Early postoperative drain fluid amylase in risk-stratified patients: Implications for tailored post-pancreatectomy drain management

HPB ◽

10.1016/j.hpb.2019.03.071 ◽

2019 ◽

Vol 21 ◽

pp. S44-S45

Author(s):

T.E. Newhook ◽

E.A. Vega ◽

T.J. Vreeland ◽

L. Prakash ◽

W.L. Dewhurst ◽

...

Keyword(s):

Drain Fluid ◽

Drain Management

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Innovations in pancreatic anastomosis technique during pancreatoduodenectomies

Langenbeck s Archives of Surgery ◽

10.1007/s00423-020-01942-8 ◽

2020 ◽

Vol 405 (7) ◽

pp. 1039-1044

Author(s):

S. Ferencz ◽

Zs. Bíró ◽

A. Vereczkei ◽

D. Kelemen

Keyword(s):

Pancreatic Fistula ◽

Reoperation Rate ◽

Whipple Procedure ◽

Morbidity Rate ◽

Amylase Level ◽

Pancreatic Anastomosis ◽

Drain Removal ◽

Pancreatic Resections ◽

Drain Amylase

Abstract Purpose Pancreatic fistula following pancreatic resections is still a relevant complication. The present work shows the efforts of a single institute to decrease this problem. Methods A total of 130 patients (63 men, 67 women) with a mean age of 60 (range: 23–81) years were operated on between January 2013 and March 2020. The most frequent type of pancreatic resection was a Whipple procedure with partial antrectomy. During all operations, an innovative method was used, namely a modification of the purse-string suture pancreatojejunostomy. Moreover, an early drain removal policy was applied, based on the drain amylase level on the first and subsequent postoperative days. Results Mean postoperative hospital stay was 13 days (range: 7–75). The overall morbidity rate was 43.8%; the clinically relevant (grade B/C) pancreatic fistula (CR-POPF) rate was 6.9%. Delayed gastric emptying (DGE) was observed in 4% of the patients. The ratio of operative mortality was 0.7%; the reoperation rate was 5.3%. Based on the drain amylase level on the first postoperative day, two groups could be established. In the first one, the drain was removed early, on the fourth day in average (range: 2–6). In the other group, the drain was left in situ protractedly or reinserted later on. Conclusion A single center’s experience proves that the refinement of the technique can improve the results of pancreatic surgery.

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Standardization of early drain removal following pancreatic resection: proposal of the “Ottawa pancreatic drain algorithm”

Patient Safety in Surgery ◽

10.1186/s13037-019-0219-z ◽

2019 ◽

Vol 13 (1) ◽

Cited By ~ 1

Author(s):

Heather Smith ◽

Fady K. Balaa ◽

Guillaume Martel ◽

Jad Abou Khalil ◽

Kimberly A. Bertens

Keyword(s):

Length Of Stay ◽

Pancreatic Resection ◽

Statistical Significance ◽

Cohort Analysis ◽

Standardized Protocol ◽

Drain Removal ◽

Retrospective Cohort Analysis ◽

Before And After ◽

Drain Amylase ◽

Drain Management

Abstract Background Early drain removal after pancreatic resection is encouraged for individuals with low postoperative day 1 drain amylase levels (POD1 DA) to mitigate associated morbidity. Although various protocols for drain management have been published, there is a need to assess the implementation of a standardized protocol. Methods The Ottawa pancreatic drain algorithm (OPDA), based on POD1 DA and effluent volume, was developed and implemented at our institution. A retrospective cohort analysis was conducted of all patients undergoing pancreatic resection January 1, 2016-October 30, 2017, excluding November and December 2016 (one month before and after OPDA implementation). Results 42 patients pre-implementation and 53 patients post-implementation were included in the analysis. The median day of drain removal was significantly reduced after implementation of the OPDA (8 vs. 5 days; p = 0.01). Early drain removal appeared safe with no difference in reoperation or readmission rate after protocol implementation (p = 0.39; p = 0.76). On subgroup analysis, median length of stay was significantly shorter following OPDA implementation for patients who underwent DP and did not develop a postoperative pancreatic fistula (POPF) (6 vs 10 days, p = 0.03). Although the incidence of both surgical site infection and POPF were reduced following the intervention, neither reached statistical significance (38.1 to 28.3%, p = 0.31; and 38.1 to 28.3%, p = 0.31 respectively). Conclusions Implementing the OPDA was associated with earlier drain removal and decreased length of stay in patients undergoing distal pancreatectomy who did not develop POPF, without increased morbidity. Standardizing drain removal may help facilitate early drain removal after pancreatic resection at other institutions.

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