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Evolving the Paradigm of Early Drain Removal Following Pancreatoduodenectomy.

Published on Jan 1, 2019in Journal of Gastrointestinal Surgery2.686
· DOI :10.1007/S11605-018-3959-7
Thomas F. Seykora2
Estimated H-index: 2
(UPenn: University of Pennsylvania),
Laura Maggino10
Estimated H-index: 10
(UPenn: University of Pennsylvania)
+ 5 AuthorsCharles M. Vollmer40
Estimated H-index: 40
(UPenn: University of Pennsylvania)
Abstract
Recent data illustrates improved outcomes when adhering to early drain removal following pancreatoduodenectomy (PD). This study aims to explore the potential benefits of expanding the timeframe for early drain removal. Six hundred forty PDs were originally managed by selective drain placement and early removal. Outcomes were reappraised in the framework of a novel proposal; intraoperative drains were omitted based on a low-risk profile (Fistula Risk Score 0–2), followed by drain removal at PODs 1, 3, and 5 if drain fluid amylase (DFA) fell below specific cutoffs based on optimized negative predictive values (NPV) for clinically relevant postoperative pancreatic fistula (CR-POPF). Characteristics of the remaining cohort with drains in situ on POD5 were examined using multivariable analysis (MVA). Intraoperative FRS would preclude drains from 230 (35.9%) negligible/low-risk cases with a cohort CR-POPF rate of 1.7%. Of the remaining patients, 30.5% would have drains removed on POD1 based on a DFA threshold of 300 IU/L (NPV = 98.4%), demonstrating a 1.6% CR-POPF rate. On POD3, drains could be removed in the residual cohort from 21.1% of patients with DFA ≤ 150 IU/L (NPV = 96.6%), reflecting a 3.4% CR-POPF rate. On POD5, a DFA threshold of 50 IU/L (NPV = 84%) identified 16.3% more patients whose drains could be removed. The remaining cohort (POD5 DFA > 50 IU/L), “enriched” for fistula development and reflecting just 18.4% of the original patients, displays a 61% CR-POPF rate. Among these patients on POD5, a DFA threshold > 2000 IU/L best predicted subsequent CR-POPF (PPV = 89.5%), and MVA revealed a positive association between pancreatic cancer/pancreatitis (OR = 4.37, p = 0.022) and longer operations (OR = 3.74, p = 0.014) with CR-POPF development. Early drain removal is a dynamic concept and can be employed throughout the postoperative time course using conditional thresholds to better identify patients at risk for CR-POPF.
  • References (22)
  • Citations (1)
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References22
Newest
#1Laura MagginoH-Index: 10
#2Giuseppe MalleoH-Index: 29
Last. Charles M. VollmerH-Index: 40
view all 15 authors...
Objective:The aim of this study was to describe characteristics and management approaches for grade B pancreatic fistula (B-POPF) and investigate whether it segregates into distinct subclasses.Background:The 2016 ISGPS refined definition of B-POPF is predicated on various postoperative management ap
6 CitationsSource
#1Laura Maggino (UPenn: University of Pennsylvania)H-Index: 10
#2Jason B. Liu (U of C: University of Chicago)H-Index: 6
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
view all 5 authors...
Background Longer operative time (OT) has been associated with negative outcomes in various surgical procedures, but its role in pancreatic resection, a complex, high-acuity endeavor, is not yet well defined. The aim of this study was to analyze the relationship between OT and pancreatectomy outcomes in a risk-adjusted fashion. Study Design This retrospective cohort study analyzed patients undergoing pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) between 2014 and 2015 using the proce...
7 CitationsSource
#1Joal D. BeaneH-Index: 14
#2Michael G. HouseH-Index: 29
Last. Henry A. PittH-Index: 61
view all 5 authors...
10 CitationsSource
#1Brett L. Ecker (UPenn: University of Pennsylvania)H-Index: 12
#2Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 17
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
view all 26 authors...
Objective:To identify a clinical fistula risk score following distal pancreatectomy.Background:Clinically relevant pancreatic fistula (CR-POPF) following distal pancreatectomy (DP) is a dominant contributor to procedural morbidity, yet risk factors attributable to CR-POPF and effective practices to
19 CitationsSource
#1Matthew T. McMillanH-Index: 17
#2Giuseppe MalleoH-Index: 29
Last. Charles M. VollmerH-Index: 40
view all 13 authors...
Objective:This multicenter study sought to prospectively evaluate a drain management protocol for pancreatoduodenectomy (PD).Background:Recent evidence suggests value for both selective drain placement and early drain removal for PD. Both strategies have been associated with reduced rates of clinica
54 CitationsSource
#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 17
#2Giuseppe Malleo (University of Verona)H-Index: 29
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
view all 7 authors...
Abstract Introduction Clinically relevant postoperative pancreatic fistula (CR-POPF) is a morbid complication following pancreatoduodenectomy (PD). It is unclear how pancreatic surgeons perceive risk for this complication, and the implications thereof. Methods A web-based survey was distributed to members of 22 international GI surgical societies. CR-POPF risk factors were categorized as follows: (i) patient factors, (ii) pancreatic gland characteristics, (iii) intraoperative variables, (iv) per...
7 CitationsSource
#1Nicole Villafane-Ferriol (BCM: Baylor College of Medicine)H-Index: 4
#2George Van Buren (BCM: Baylor College of Medicine)H-Index: 18
Last. William E. Fisher (BCM: Baylor College of Medicine)H-Index: 42
view all 16 authors...
2 CitationsSource
#1Claudio BassiH-Index: 80
Last. Markus W. Büchler (Heidelberg University)H-Index: 127
view all 33 authors...
Background In 2005, the International Study Group of Pancreatic Fistula developed a definition and grading of postoperative pancreatic fistula that has been accepted universally. Eleven years later, because postoperative pancreatic fistula remains one of the most relevant and harmful complications of pancreatic operation, the International Study Group of Pancreatic Fistula classification has become the gold standard in defining postoperative pancreatic fistula in clinical practice. The aim of th...
421 CitationsSource
#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 17
#2Brett L. Ecker (UPenn: University of Pennsylvania)H-Index: 12
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
view all 12 authors...
Background Evidence suggests externalized trans-anastomotic stents may be beneficial as a fistula mitigation strategy for pancreatoduodenectomy (PD); however, previous studies have not been rigorously risk-adjusted.
10 CitationsSource
#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 17
#2John D. Christein (UA: University of Alabama)H-Index: 29
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
view all 12 authors...
Background Differences in the behavior of postoperative pancreatic fistulas (POPF) have been described after various pancreatic resections. Here, we compare POPFs after pancreatoduodenectomy (PD) and distal pancreatectomy (DP) using the average complication burden (ACB), a quantitative measure of complication burden. Methods From 2001 to 2014, 837 DPs and 1,533 PDs were performed by 14 surgeons at 4 institutions. POPFs were categorized by International Study Group on Pancreatic Fistula standards...
32 CitationsSource
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