Drain Management after Pancreatoduodenectomy: Reappraisal of a Prospective Randomized Trial Using Risk Stratification

作者：McMillan Matthew T; Malleo Giuseppe; Bassi Claudio; Butturini Giovanni; Salvia Roberto; Roses Robert E; Lee Major K; Fraker Douglas L; Drebin Jeffrey A; Vollmer Charles M Jr^*

来源：Journal of the American College of Surgeons, 2015, 221(4): 798-809.

DOI：10.1016/j.jamcollsurg.2015.07.005

BACKGROUND: A recent randomized trial used the Fistula Risk Score (FRS) to develop guidelines for selective drainage based on clinically relevant fistula (CR-POPF) risk. Additionally, postoperative day (POD) 1 drain and serum amylase have been identified as accurate postoperative predictors of CR-POPF. This study sought to identify patients who may benefit from selective drainage, as well as the optimal timing for drain removal after pancreatoduodenectomy.
STUDY DESIGN: One hundred six pancreatoduodenectomies from a previously reported RCT were assessed using risk-adjustment. The incidence of CR-POPF was compared between FRS risk cohorts. Drain and serum amylase values from POD 1 were evaluated using receiver operating characteristic (ROC) analysis to establish cut-offs predictive of CR-POPF occurrence. A regression analysis compared drain removal randomizations (POD 3 vs POD 5).
RESULTS: Three-quarters of patients had moderate/high CR-POPF risk. This group had a CR-POPF rate of 36.3% vs 7.7% among negligible/low risk patients (p = 0.005). The areas under the ROC curve for CR-POPF prediction using POD 1 drain and serum amylase values were 0.800 (p = 0.000001; 95% CI 0.70-0.90) and 0.655 (p = 0.012; 95% CI 0.55-0.77), respectively. No significant serum amylase cut-offs were identified. Moderate/high risk patients with POD 1 drain amylase <= 5,000 U/L had significantly lower rates of CR-POPF when randomized to POD 3 drain removal (4.2% vs 38.5%; p = 0.003); moreover, these patients experienced fewer complications and shorter hospital stays.
CONCLUSIONS: A clinical care protocol is proposed whereby drains are recommended formoderate/high FRS risk patients, but may be omitted in patients with negligible/low risk. Drain amylase values in moderate/high risk patients should then be evaluated on POD1 to determine the optimal timing for drain removal. Moderate/high risk patients with POD 1 drain amylase <= 5,000 U/L have lower rates of CR-POPF with POD 3 (vs POD >= 5) drain removal; early drain removal is recommended for these patients.

• 出版日期2015-10