Drain use after pancreatic surgery

Review question

Can the use of a drain reduce postoperative complications after pancreatic surgery?

Background

The use of surgical drains has been considered mandatory after pancreatic surgery. However, the role of a drain in reducing complications after pancreatic surgery (called postoperative complications) is controversial.

Study characteristics

We searched for all relevant, well-conducted studies up to November 2017. We included six randomized controlled studies (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 six studies included 1384 participants who underwent pancreatic surgery. Four of the six studies randomized 1110 participants to drain use (number of participants = 560) or no drain use (N = 550). One trial randomized 170 participants to an active drain (drains with low or high pressure suction, N = 82) and passive drain (drains without suction, N = 78). One trial randomized 114 participants with a 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) or late drain removal (N = 57).

Key results

There was probably little or no difference in death at 30 days (1.5% with drains versus 2.3% with no drains), overall complications (61.7% versus 59.7%), or duration of hospitalization (14.3 days versus 13.8 days) between the drain use and no drain use groups. Drain use probably slightly reduced death at 90 days (0.8% versus 4.2%). We were uncertain whether drain use reduced infections in the abdomen (7.9% versus 8.2%), or the need for additional radiological interventions for postoperative complications (10.9%% versus 12.1%). Drain use may lead to similar wound infections (9.8% versus 9.9%), need for additional open procedures for postoperative complications (9.4% versus 7.1%), and quality of life scores (105 points versus 104 points) when compared with no drain use. There was one drain-related complication (the drainage tube was broken) in the drain use group (0.2%).

Active drains may lead to similar rates of death at 30 days (1.2% with active drain versus 0% with passive drain), and overall complications (22.0% versus 32.1%) when compared with no passive drain. We were uncertain whether active drains reduced intra-abdominal infections (0% versus 2.6%), wound infections (6.1% versus 9.0%), or the need for additional open procedures for postoperative complications (1.2% versus 7.7%). Active drains may slightly reduce duration of hospitalization (14.1% decrease of an 'average' duration of hospitalization).

There were no deaths in either group in one small study that examimed early versus late removal of drains. Early drain removal may reduce overall complications (38.6% with early drain removal versus 61.4% with late drain removal), duration of hospitalization (21.5% decrease of an 'average' duration of hospitalization), and hospital costs (17.0% decrease of 'average' hospital costs). We were uncertain whether early drain removal reduced the need for additional open procedures for postoperative complications (0% versus 1.8%).

It was unclear whether routine drain use had any effect on the reduction of death 30 days, or postoperative complications. Routine abdominal drainage probably slightly reduced death at 90 days. Active drains appeared to be associated with earlier discharges from hospital than passive drains, and early removal appeared to be better than late removal for people with a low risk of postoperative pancreatic fistula.

Quality of the evidence

All studies 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 was unclear whether routine abdominal drainage had any effect on the reduction of mortality at 30 days, or postoperative complications after pancreatic surgery. Moderate-quality evidence suggested that routine abdominal drainage probably slightly reduced mortality at 90 days. Low-quality evidence suggested that use of an active drain compared to the use of a passive drain may slightly reduce the length of 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 last version of this review, we searched CENTRAL (2016, Issue 8), and MEDLINE, Embase, Science Citation Index Expanded, and Chinese Biomedical Literature Database (CBM) to 28 August 2016). For this updated review, we searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, and CBM from 2016 to 15 November 2017.

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 studies that compared different types of drains and different schedules for drain removal in people undergoing pancreatic surgery.

Data collection and analysis: 

We identified six studies (1384 participants). Two review authors independently identified the studies 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 used the random-effects model.

Main results: 

Drain use versus no drain use

We included four studies with 1110 participants, who were randomized to the drainage group (N = 560) and the no drainage group (N = 550) after pancreatic surgery. There was little or no difference in mortality at 30 days between groups (1.5% with drains versus 2.3% with no drains; RR 0.78, 95% CI 0.31 to 1.99; four studies, 1055 participants; moderate-quality evidence). Drain use probably slightly reduced mortality at 90 days (0.8% versus 4.2%; RR 0.23, 95% CI 0.06 to 0.90; two studies, 478 participants; moderate-quality evidence). We were uncertain whether drain use reduced intra-abdominal infection (7.9% versus 8.2%; RR 0.97, 95% CI 0.52 to 1.80; four studies, 1055 participants; very low-quality evidence), or additional radiological interventions for postoperative complications (10.9% versus 12.1%; RR 0.87, 95% CI 0.79 to 2.23; three studies, 660 participants; very low-quality evidence). Drain use may lead to similar amount of wound infection (9.8% versus 9.9%; RR 0.98 , 95% CI 0.68 to 1.41; four studies, 1055 participants; low-quality evidence), and additional open procedures for postoperative complications (9.4% versus 7.1%; RR 1.33, 95% CI 0.79 to 2.23; four studies, 1055 participants; low-quality evidence) when compared with no drain use. There was little or no difference in morbidity (61.7% versus 59.7%; RR 1.03, 95% CI 0.94 to 1.13; four studies, 1055 participants; moderate-quality evidence), or length of hospital stay (MD -0.66 days, 95% CI -1.60 to 0.29; three studies, 711 participants; moderate-quality evidence) between groups. There was one drain-related complication in the drainage group (0.2%). Health-related quality of life was measured with the pancreas-specific quality-of-life questionnaire (FACT-PA; a scale of 0 to 144 with higher values indicating a better quality of life). Drain use may lead to similar quality of life scores, measured at 30 days after pancreatic surgery, when compared with no drain use (105 points versus 104 points; one study, 399 participants; low-quality evidence). Hospital costs and pain were not reported in any of the studies.

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. An active drain may lead to similar mortality at 30 days (1.2% with active drain versus 0% with passive drain; low-quality evidence), and morbidity (22.0% versus 32.1%; RR 0.68, 95% CI 0.41 to 1.15; low-quality evidence) when compared with a passive drain. We were uncertain whether an active drain decreased intra-abdominal infection (0% versus 2.6%; very low-quality evidence), wound infection (6.1% versus 9.0%; RR 0.68, 95% CI 0.23 to 2.05; very low-quality evidence), or the number of additional open procedures for postoperative complications (1.2% versus 7.7%; RR 0.16, 95% CI 0.02 to 1.29; very low-quality evidence). Active drain may reduce length of hospital stay slightly (MD -1.90 days, 95% CI -3.67 to -0.13; one study; low-quality evidence; 14.1% decrease of an 'average' length of hospital stay). Additional radiological interventions, pain, and quality of life were not reported in the study.

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 mortality in either group. Early drain removal may slightly reduce morbidity (38.6% with early drain removal versus 61.4% with late drain removal; RR 0.63, 95% CI 0.43 to 0.93; low-quality evidence), length of hospital stay (MD -2.10 days, 95% CI -4.17 to -0.03; low-quality evidence; 21.5% decrease of an 'average' length of hospital stay), and hospital costs (MD -EUR 2069.00, 95% CI -3872.26 to -265.74; low-quality evidence; 17.0% decrease of 'average' hospital costs). We were uncertain whether early drain removal reduced additional open procedures for postoperative complications (0% versus 1.8%; RR 0.33, 95% CI 0.01 to 8.01; one study; very low-quality evidence). Intra-abdominal infection, wound infection, additional radiological interventions, pain, and quality of life were not reported in the study.

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