It is the practice of most pancreatic surgeons, including ourselves, to place one or two drains after pancreatic resection. During our residency, we were taught that the theoretical (never proven) advantage of drainage was to identify an early bile, pancreatic or enteric leak, or postoperative hemorrhage and thereby treat earlier by reoperation, transfusion, or modern interventional treatment; or in some cases, the drain would control the leak and remove the need for intervention. Indeed, the drainage issue after any kind of abdominal surgery is a classic example of surgical dogma over modern evidence-based medicine. There are numerous examples of randomized controlled trials,1–5 and more recently systematic reviews and meta-analyses,6 that have clearly demonstrated that drainage after appendicectomy,1 cholecystectomy,2 hepatectomy,3 colectomy,4 and lately also gastrectomy5 is useless in preventing complications and is even harmful for the patients by increasing the risk of intra-abdominal infection.
Still We Ignore and Drain
In the current issue of the Annals of Surgery (Kawai et al), we find another study from a high-volume academic surgical center in Japan that has analyzed the important question of drainage after pancreatic resection. The specific question of this trial was to find the better day of drain removal (day 8 or day 4) after pancreaticoduodenectomy. In 2001, the Memorial Sloan Kettering surgical group had published a randomized controlled trial,7 the first one in pancreatic surgery, investigating the drainage issue after pancreatic head and left pancreatic resection. The conclusion of the New York study was that drainage after pancreatic resection is not superior to no drainage and is not helpful to the regular pancreas resection patient.
In a prospective consecutive design recruiting two cohorts of 52 patients, respectively, Kawai et al provide several important messages:
Pancreatic fistulae, abdominal abscesses, and collections developed more frequently when the drains were removed at day 8 as opposed to day 4.
Drainage cultures were colonized/infected in 31% of patients at day 7 versus 4% at day 4.
Clinical signs of systemic infection developed more often in patients that had drains for 8 days, resulting in a longer hospital stay of such patients.
In multivariate analysis, the only independent prognostic factor for abdominal infection was longer-term drainage.
Still We Will Ignore and Drain?
Unfortunately, the study by Kawai et al did not address the question of whether no drainage at all is equal or better than short- or long-term placement of drains after pancreatic head resection. However, this does not diminish the important lesson; long-term (8 days) drainage after pancreaticoduodenectomy is dangerous and carries a considerable (30%) risk of newly acquired (via drainage) infection and consequent morbidity for the patient.
The time has come for us as pancreatic surgeons to accept that long-term drainage is not beneficial and probably harmful.
The next step is to repeat the pioneer New York trial, preferably in a multicentric, multicontinental controlled setting, of short-term versus no drainage—why don't we start soon? In recruiting a sufficient number of patients after a Whipple procedure, this proposed trial will then support or refute the New York trial conclusion that no drainage at all is the new standard for the routine pancreatic resection patient and might possibly also answer the question whether we are left with some specific situations (for example, the patient after neoadjuvant chemoradiation where large amounts of drainage fluids are to be expected), when it is still better to drain.
Undoubtedly, these data from a fine Japanese trial are moving us forward. Unfortunately, there is yet not enough evidence to totally abandon drainage after pancreatic resection, but the roadmap is there and we can now remove the abdominal drains by postoperative day 4. In our department, we routinely remove abdominal drains after pancreatic resection at postoperative day 1 or 2.8
Footnotes
Reprints: Markus W. Büchler, MD, Department of Surgery, University of Heidelberg, Im Neuenheimer Feld 110, D-69120 Heidelberg, Germany. E-mail: Markus_Buechler@med.uni-heidelberg.de.
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