Letter to the Editor: A commentary on “Routine abdominal drainage after pancreatectomy: a Bayesian meta-analysis”

Dear Editor,

We read with great interest the recent article by Hou et al^[1] titled “Routine abdominal drainage after pancreatectomy: A Bayesian meta-analysis.” The authors systematically evaluated the necessity of routine intra-abdominal drainage after pancreatectomy and assessed its impact on postoperative complications using a Bayesian statistical model. The study addresses a highly relevant and ongoing clinical question and presents a well-structured methodological approach, offering valuable insights for optimizing perioperative drainage strategies in pancreatic surgery.

The use of a Bayesian hierarchical model to synthesize data from both randomized controlled trials and non-randomized studies represents a significant strength. This approach effectively accounts for the low incidence of adverse outcomes and enhances the robustness of the analysis. Furthermore, the authors performed subgroup analyses for pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), revealing that routine drainage significantly increased the risk of postoperative pancreatic fistula (POPF) and clinically relevant POPF. These findings highlight the potential risks of non-selective drainage, particularly among patients with low intraoperative risk profiles. This conclusion is well-aligned with the emerging trend favoring “selective drainage” and provides strong guidance for clinical practice.

Notably, the study also found that routine drainage after PD might be associated with reduced postoperative mortality. This suggests that in high-risk or technically complex procedures, drainage could still play a valuable role in early detection and timely management of complications. Such findings support the notion of an “individualized drainage” strategy and resonate with current trends in risk-stratified perioperative care.

While we commend the authors for their thoughtful contribution, we also believe that there are several details worthy of further consideration:

First, intraoperative variables such as pancreatic texture, duct diameter, type of anastomosis, vascular resection and reconstruction, and the use of reinforcement materials were not quantitatively assessed. These factors are known to influence both the decision to place a drain and the likelihood of developing POPF^[2]. Future studies incorporating intraoperative scoring systems such as the Fistula Risk Score (FRS) could improve the interpretability and applicability of the findings.

Second, the included studies lacked standardization regarding drainage techniques, including the type, location, and removal timing of drains. Additionally, perioperative management protocols – such as antibiotic use, frequency of drain fluid analysis, and postoperative feeding strategies – were not uniformly reported or analyzed^[3]. Since these variables may significantly impact postoperative outcomes and readmission rates, incorporating them into future models would enhance the clinical relevance of the evidence.

Third, despite the adoption of advanced statistical modeling, most included studies were observational in nature. This inherently limits the quality of the evidence and may introduce potential biases. We recommend that future research efforts include well-designed, prospective, multicenter randomized controlled trials with strict stratification to validate and expand upon these findings.

Moreover, although subgroup analyses were performed for PD and DP, high-risk populations – such as elderly patients, individuals with diabetes, malnutrition, or immunosuppression – were not separately analyzed^[4,5]. Identifying subpopulations that may still benefit from routine drainage would help refine the concept of “selective drainage” and support more personalized perioperative strategies.

In conclusion, this study provides a scientifically rigorous and timely response to a long-standing debate in pancreatic surgery. The authors’ advocacy for “selective rather than routine drainage” is consistent with contemporary surgical principles of precision, minimally invasiveness, and individualization. Their findings merit further confirmation through high-quality prospective studies and may significantly contribute to future guidelines on drainage strategies in pancreatic resections^[6].

Ethical approval

This correspondence did not require ethical approval.

Consent

Not applicable.

Sources of funding

This work did not receive any funding related to its research, authorship, or publication.

Author contributions

P.Y., W.H., and X.C. found the question and wrote the draft. H.L. and J.W. revised the manuscript. P.Y., W.H., and X.C. contributed equally to this work and share first authorship. H.L. and J.W. contributed equally to this work and share corresponding authorship. All authors have approved the letter.

Conflicts of interest disclosure

The authors declare that they have no competing interests related to this work.

Guarantor

Jianjun Wang.

Research registration unique identifying number (UIN)

Not applicable.

Provenance and peer review

This paper was no invited.

Data availability statement

All data analyzed or generated during this study are included in the article.

Declaration and use of AI

No artificial intelligence tools were used in the design, execution, or writing of this study, and our article is compliant with the TITAN Guidelines 2025.