Key messages
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It is unclear if use of a drain (tube) affects postoperative complications after pancreaticoduodenectomy (Whipple's procedure, a major surgical operation involving the pancreas, duodenum, and other organs) or distal pancreatectomy (surgical removal of the body and tail of the pancreas).
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We do not know if an active (suction) drain after pancreaticoduodenectomy is better, worse, or the same as a passive (no suction) drain.
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Early drain removal is probably better than late drain removal with regard to abdominal infection rate for people undergoing pancreaticoduodenectomy with a low risk of postoperative complications.
What is pancreatic surgery?
Pancreatic surgery is performed to treat various diseases, including pancreatic cancers, chronic pancreatitis (a condition where repeated inflammation permanently damages the pancreas), and biliary and duodenal cancers. The rate of postoperative complications after pancreatic surgery is high, ranging from 30% to 60%.
How is this managed?
The use of surgical drains is a very common practice after pancreatic surgery. However, the routine placement of a surgical drain to prevent postoperative complications after pancreatic surgery has been questioned.
What did we want to find out?
We wanted to compare (1) use of drain versus no drain, (2) different types of drains, and (3) different schedules for drain removal, by looking at:
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number of deaths at 30 days;
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number of deaths at 90 days;
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abdominal infection rate;
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wound infection rate;
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drain-related complication rate.
What did we do?
We searched for studies that compared:
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use of drain versus no drain;
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different types of drains; or
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different schedules for drain removal.
There were no restrictions on language, date of publication, or study setting. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes.
What did we find?
We found 12 studies involving a total of 2550 people. The studies were conducted in North America, Europe, and Asia and were published between 2001 and 2024. Eight studies were funded by non-commercial grants. One study was funded by a commercial company.
Main results
Use of drain (270 people) versus no drain (262 people) following pancreaticoduodenectomy (2 studies)
It is unclear if the use of a drain affects the number of deaths at 30 days, number of deaths at 90 days, wound infection rate, or abdominal infection rate after pancreaticoduodenectomy compared with no drain. Neither study reported drain-related complications.
Use of drain (318 people) versus no drain (308 people) following distal pancreatectomy (2 studies)
There were no deaths at 30 days in either group. It is unclear if the use of a drain affects the number of deaths at 90 days, wound infection rate, or abdominal infection rate after distal pancreatectomy compared with no drain. Neither study reported drain-related complications.
Active drain (222 people) versus passive drain (219 people) following pancreaticoduodenectomy (3 studies)
It is unclear if an active drain affects the number of deaths at 30 days, abdominal infection rate, or wound infection rate after pancreaticoduodenectomy compared with a passive drain. None of the studies reported the number of deaths at 90 days. There were no drain-related complications in either group.
Early drain removal (279 people) versus late drain removal (278 people) following pancreaticoduodenectomy (3 studies)
Early drain removal may make little to no difference to the number of deaths at 30 days or wound infection rate following pancreaticoduodenectomy compared with late drain removal. There were no deaths at 90 days in either group. Early drain removal probably results in a slight reduction in the abdominal infection rate (71 fewer abdominal infections per 1000 participants). None of the studies reported drain-related complications.
What are the limitations of the evidence?
We are not confident in the evidence because it is possible that people in the studies were aware of what treatment they were getting, and not all the studies provided information on everything we were interested in. In addition, some studies did not clearly report how they were conducted, and there were not enough studies to be certain about the results of our outcomes.
How up-to-date is this evidence?
This review updates our previous review. The evidence is current to July 2024.
The evidence is very uncertain about the effect of drain use compared with no drain use on 90-day mortality, intra-abdominal infection rate, and wound infection rate in people undergoing either pancreaticoduodenectomy or distal pancreatectomy. The evidence is also very uncertain whether an active drain is superior, equivalent, or inferior to a passive drain following pancreaticoduodenectomy. Moderate-certainty evidence suggests that early drain removal is probably superior to late drain removal in terms of intra-abdominal infection rate following pancreaticoduodenectomy for people with low risk of postoperative pancreatic fistula.
The use of surgical drains is a very common practice after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications after pancreatic surgery is controversial. This is the third update of a previously published Cochrane Review to address the uncertain benifits of prophylactic abdominal drainage in pancreatic surgery.
To assess the benefits and harms of routine abdominal drainage after pancreatic surgery; to compare the effects of different types of surgical drains; and to evaluate the optimal time for drain removal.
We searched CENTRAL, MEDLINE, three other databases, and five trials registers, together with reference checking and contact with study authors, to identify studies for inclusion in the review. The search dates were 20 April 2024 and 20 July 2024.
We included all randomised controlled trials (RCTs) that compared abdominal drainage versus no drainage in people undergoing pancreatic surgery. We also included RCTs that compared different types of drains and different schedules for drain removal in people undergoing pancreatic surgery.
Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We conducted the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) or standardized mean difference (SMD) for continuous outcomes with 95% confidence intervals (CI). For all analyses, we used the random-effects model. We used GRADE to assess the certainty of the evidence for important outcomes.
We identified a total of nine RCTs with 1892 participants.
Drain use versus no drain use
We included four RCTs with 1110 participants, randomised to the drainage group (N = 560) and the no drainage group (N = 550) after pancreatic surgery. Low-certainty evidence suggests that drain use may reduce 90-day mortality (RR 0.23, 95% CI 0.06 to 0.90; two studies, 478 participants). Compared with no drain use, low-certainty evidence suggests that drain use may result in little to no difference in 30-day mortality (RR 0.78, 95% CI 0.31 to 1.99; four studies, 1055 participants), wound infection rate (RR 0.98, 95% CI 0.68 to 1.41; four studies, 1055 participants), length of hospital stay (MD -0.14 days, 95% CI -0.79 to 0.51; three studies, 876 participants), the need for additional open procedures for postoperative complications (RR 1.33, 95% CI 0.79 to 2.23; four studies, 1055 participants), and quality of life (105 points versus 104 points; measured with the pancreas-specific quality of life questionnaire (scale 0 to 144, higher values indicating a better quality of life); one study, 399 participants). There was one drain-related complication in the drainage group (0.2%). Moderate-certainty evidence suggests that drain use probably resulted in little to no difference in morbidity (RR 1.03, 95% CI 0.94 to 1.13; four studies, 1055 participants). The evidence was very uncertain about the effect of drain use on intra-abdominal infection rate (RR 0.97, 95% CI 0.52 to 1.80; four studies, 1055 participants; very low-certainty evidence), and the need for additional radiological interventions for postoperative complications (RR 0.87, 95% CI 0.40 to 1.87; three studies, 660 participants; very low-certainty evidence).
Active versus passive drain
We included two RCTs involving 383 participants, randomised to the active drain group (N = 194) and the passive drain group (N = 189) after pancreatic surgery. Compared with a passive drain, the evidence was very uncertain about the effect of an active drain on 30-day mortality (RR 1.23, 95% CI 0.30 to 5.06; two studies, 382 participants; very low-certainty evidence), intra-abdominal infection rate (RR 0.87, 95% CI 0.21 to 3.66; two studies, 321 participants; very low-certainty evidence), wound infection rate (RR 0.92, 95% CI 0.44 to 1.90; two studies, 321 participants; very low-certainty evidence), morbidity (RR 0.97, 95% CI 0.53 to 1.77; two studies, 382 participants; very low-certainty evidence), length of hospital stay (MD -0.79 days, 95% CI -2.63 to 1.04; two studies, 321 participants; very low-certainty evidence), and the need for additional open procedures for postoperative complications (RR 0.44, 95% CI 0.11 to 1.83; two studies, 321 participants; very low-certainty evidence). There was no drain-related complication in either group.
Early versus late drain removal
We included three RCTs involving 399 participants with a low risk of postoperative pancreatic fistula, randomised to the early drain removal group (N = 200) and the late drain removal group (N = 199) after pancreatic surgery. Compared to late drain removal, the evidence was very uncertain about the effect of early drain removal on 30-day mortality (RR 0.99, 95% CI 0.06 to 15.45; three studies, 399 participants; very low-certainty evidence), wound infection rate (RR 1.32, 95% CI 0.45 to 3.85; two studies, 285 participants; very low-certainty evidence), hospital costs (SMD -0.22, 95% CI -0.59 to 0.14; two studies, 258 participants; very low-certainty evidence), the need for additional open procedures for postoperative complications (RR 0.77, 95% CI 0.28 to 2.10; three studies, 399 participants; very low-certainty evidence), and the need for additional radiological procedures for postoperative complications (RR 1.00, 95% CI 0.21 to 4.79; one study, 144 participants; very low-certainty evidence). We found that early drain removal may reduce intra-abdominal infection rate (RR 0.44, 95% CI 0.22 to 0.89; two studies, 285 participants; very low-certainty evidence), morbidity (RR 0.49, 95% CI 0.30 to 0.81; two studies, 258 participants; very low-certainty evidence), and length of hospital stay (MD -2.20 days, 95% CI -3.52 to -0.87; three studies, 399 participants; very low-certainty evidence), but the evidence was very uncertain. None of the studies reported on drain-related complications.
None.
Registration: not available.
Protocol and previous versions available via doi.org/10.1002/14651858.CD010583, doi.org/10.1002/14651858.CD010583.pub2, doi.org/10.1002/14651858.CD010583.pub3, doi.org/10.1002/14651858.CD010583.pub4, and doi.org/10.1002/14651858.CD010583.pub5.