Drain use after pancreatic surgery

Review question

Is drain use able to reduce postoperative complications after pancreatic surgery?

Background

The use of surgical drains has been considered mandatory after pancreatic surgery. The role of drain use to reduce complications after pancreatic surgery (called postoperative complications) is controversial.

Study characteristics

We searched for all relevant, well-conducted studies up to August 2016. We included five randomized controlled trials (an experiment in which participants are randomly allocated to two or more interventions, possibly including a control intervention or no intervention, and the results are compared). The five studies included 985 participants. Three of the five trials randomized 711 participants to drain use (number of participants (N) = 358) or no drain use (N = 353). One trial randomized 170 participants to active drain (suction drains under low or high pressure, N = 82) and passive drain (drains without suction, N = 78). One trial randomized 114 participants with low risk of postoperative pancreatic fistula (a complication during which the pancreas is disconnected from the nearby gut, and then reconnected to allow pancreatic juice containing digestive enzymes to enter the digestive system) to early drain removal (N = 57) and late drain removal (N = 57).

Key results

There was insufficient evidence to determine the effect on death (2.2% with drain use versus 3.4% with no drain use), infections in the abdomen (7.3% versus 8.5%), wound infections (12.3% versus 13.3%), overall complications (64.8% versus 62.0%), duration of hospital stay (14.3 days versus 13.8 days), or additional open procedures for postoperative complications (11.5% versus 9.1%) between drain use and no drain use. There was one drain-related complication (the drainage tube was broken) in the drain use group (0.6%).

There was insufficient evidence to determine the effect on death (1.2% with active drain versus 0% with passive drain), infections in the abdomen (0% versus 2.6%), wound infections (6.1% versus 9.0%), overall complications (22.0% versus 32.1%), or additional open procedures for postoperative complications (1.2% versus 7.7%) between active drain and passive drain. Active drain was associated with shorter length of hospital stay (14.1% decrease of an 'average' duration of hospitalization) than passive drain.

Information on deaths following early or late removal of drains was available from one small study in which there were no deaths in either group. Rates of additional open procedures for postoperative complications were low (0% with early removal versus 1.8% with late removal). Early drain removal was associated with a lower complication rate (38.5% versus 61.4%), shorter duration of hospitalization (21.5% decrease of an 'average' duration of hospitalization), and lower hospital costs (17.0% decrease of 'average' hospital costs) than in the late drain removal.

It is not clear whether routine drain use has any effect on the reduction of death and postoperative complications after pancreatic surgery. In case of drain insertion, active drain appears to be associated with earlier discharge from hospital than passive drain after pancreatic surgery, and early removal appears to be better than late removal for people with a low risk of postoperative pancreatic fistula.

Quality of the evidence

All trials were at high risk of bias (suggesting the possibility of overestimating the benefits or underestimating the harms). Overall, the quality of the evidence varied from very low to moderate.

Authors' conclusions: 

It is unclear whether routine abdominal drainage has any effect on the reduction of mortality and postoperative complications after pancreatic surgery. In case of drain insertion, low-quality evidence suggests that active drainage may reduce hospital stay after pancreatic surgery, and early removal may be superior to late removal for people with low risk of postoperative pancreatic fistula.

Read the full abstract...
Background: 

The use of surgical drains has been considered mandatory after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications after pancreatic surgery is controversial.

Objectives: 

To assess the benefits and harms of routine abdominal drainage after pancreatic surgery, compare the effects of different types of surgical drains, and evaluate the optimal time for drain removal.

Search strategy: 

For the initial version of this review, we searched the Cochrane Library (2015, Issue 3), MEDLINE (1946 to 9 April 2015), Embase (1980 to 9 April 2015), Science Citation Index Expanded (1900 to 9 April 2015), and Chinese Biomedical Literature Database (CBM) (1978 to 9 April 2015). For this updated review, we searched the Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, and CBM from 2015 to 28 August 2016.

Selection criteria: 

We included all randomized controlled trials that compared abdominal drainage versus no drainage in people undergoing pancreatic surgery. We also included randomized controlled trials that compared different types of drains and different schedules for drain removal in people undergoing pancreatic surgery.

Data collection and analysis: 

We identified five trials (of 985 participants) which met our inclusion criteria. Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). For all analyses, we employed the random-effects model.

Main results: 

Drain use versus no drain use

We included three trials involving 711 participants who were randomized to the drainage group (N = 358) and the no drainage group (N = 353) after pancreatic surgery. There was inadequate evidence to establish the effect of drains on mortality at 30 days (2.2% with drains versus 3.4% no drains; RR 0.78, 95% CI 0.31 to 1.99; three studies; low-quality evidence), mortality at 90 days (2.9% versus 11.6%; RR 0.24, 95% CI 0.05 to 1.10; one study; low-quality evidence), intra-abdominal infection (7.3% versus 8.5%; RR 0.89, 95% CI 0.36 to 2.20; three studies; very low-quality evidence), wound infection (12.3% versus 13.3%; RR 0.92, 95% CI 0.63 to 1.36; three studies; low-quality evidence), morbidity (64.8% versus 62.0%; RR 1.04, 95% CI 0.93 to 1.16; three studies; moderate-quality evidence), length of hospital stay (MD -0.66 days, 95% CI -1.60 to 0.29; three studies; moderate-quality evidence), or additional open procedures for postoperative complications (11.5% versus 9.1%; RR 1.18, 95% CI 0.55 to 2.52; three studies). There was one drain-related complication in the drainage group (0.6%).

Type of drain

We included one trial involving 160 participants who were randomized to the active drain group (N = 82) and the passive drain group (N = 78) after pancreatic surgery. There was no evidence of differences between the two groups in mortality at 30 days (1.2% with active drain versus 0% with passive drain), intra-abdominal infection (0% versus 2.6%), wound infection (6.1% versus 9.0%; RR 0.68, 95% CI 0.23 to 2.05), morbidity (22.0% versus 32.1%; RR 0.68, 95% CI 0.41 to 1.15), or additional open procedures for postoperative complications (1.2% versus 7.7%; RR 0.16, 95% CI 0.02 to 1.29). The active drain group was associated with shorter length of hospital stay (MD -1.90 days, 95% CI -3.67 to -0.13; 14.1% decrease of an 'average' length of hospital stay) than in the passive drain group. The quality of evidence was low, or very low.

Early versus late drain removal

We included one trial involving 114 participants with a low risk of postoperative pancreatic fistula who were randomized to the early drain removal group (N = 57) and the late drain removal group (N = 57) after pancreatic surgery. There was no evidence of differences between the two groups in mortality at 30 days (0% for both groups) or additional open procedures for postoperative complications (0% with early drain removal versus 1.8% with late drain removal; RR 0.33, 95% CI 0.01 to 8.01). The early drain removal group was associated with lower rates of postoperative complications (38.5% versus 61.4%; RR 0.63, 95% CI 0.43 to 0.93), shorter length of hospital stay (MD -2.10 days, 95% CI -4.17 to -0.03; 21.5% decrease of an 'average' length of hospital stay), and hospital costs (17.0% decrease of 'average' hospital costs) than in the late drain removal group. The quality of evidence for each of the outcomes was low.

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