Drainage was found to be unnecessary after removal of part of the pancreas
A clinical study by Dutch scientists has shown that the absence of drainage after surgical removal of the left side of the pancreas improves patient recovery outcomes compared to the current routine practice of leaving a surgical drain in the wound. As reported in The Lancet Gastroenterology & Hepatology, this approach reduces the risk of developing postoperative pancreatic fistulas and the length of hospital stay.
Distal pancreatectomy, in which the body and tail of the pancreas are removed (sometimes along with the spleen), is considered the standard surgical procedure for symptomatic benign, precancerous and malignant disease of the left side of the pancreas. Twelve to 25 percent of patients after such surgery may develop a postoperative pancreatic fistula, in which pancreatic fluid high in proteolytic enzymes leaks into the abdominal cavity. Such a fistula is considered a serious complication because it can lead to bleeding, intraperitoneal infection, and sepsis.
To prevent this complication, surgeons routinely provide passive drainage of the abdominal cavity. However, there is a consensus that drain placement after distal pancreatectomy is not mandatory, especially in low-risk patients. Moreover, a no-drainage policy would relieve patients of the burden of surgical drainage and reduce the risk of postoperative infection. In one multicenter randomized trial, surgeons found similar rates of postoperative morbidity in patients with and without abdominal drainage. However, this was not enough to change the routine practice of drain placement after this surgery.
A team of abdominal surgeons led by Marc Besselink of the University of Amsterdam evaluated the efficacy and safety of a no-drain policy after distal pancreatectomy in a clinical trial. The study included 282 patients who were randomized into two groups: no drainage and with drainage. After exclusion of seven patients, 144 patients were in the group with drainage and 131 in the group without drainage. The rationale for drain placement in the patients was based on the surgeon's decision during surgery, who categorized the patients as high risk for pancreatic fistula development due to rupture of the glandular parenchyma during stapling and comorbidities.
The primary analysis showed that patients without drainage were less likely to develop a postoperative pancreatic fistula than patients with drainage (risk difference 15.5 percentage points, p less than 0.0001). Other statistical models also showed the superiority of the absence of drainage over its presence (p = 0.0045). However, a subsequent analysis of patients with pancreatic fistula who required reintervention showed no significant difference between groups in mean time to diagnosis.
No differences were found in the rates of delayed gastric emptying, bleeding after pancreatectomy, wound infection, blood transfusion, radiologic and endoscopic interventions, re-hospitalization within 90 days, and reoperations. The surgeons calculated that the mean length of hospital stay was significantly shorter in the group without drainage, although the median days of stay were similar. Mortality at 90 days was not significantly different between the groups without and with drainage. Subgroup analysis also showed a greater effectiveness of no drainage in reducing the risk of fistula and other postoperative complications.
With ever-increasing health care costs, a policy of no-drainage after distal pancreatectomy may reduce these costs while benefiting the effectiveness and safety of postoperative care, according to the researchers.
Surgeons are looking for ways to make various surgeries safer, and sometimes robots help them do so. However, as American scientists have discovered, robot-assisted gallbladder removal is associated with more frequent damage to the bile ducts.