Early Drain Removal Versus Routine Drain Removal After Pancreaticoduodenectomy and/or Distal Pancreatectomy: A Meta-Analysis and Systematic Review.

BACKGROUND: Early drain removal (EDR) has been widely accepted, but not been routinely used in patients after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). This study aimed to evaluate the safety and benefits of EDR versus routine drain removal (RDR) after PD or DP. METHODS: A systematic search was conducted on medical search engines from January 1, 2008 to November 1, 2023, for articles that compared EDR versus RDR after PD or DP. The primary outcome was clinically relevant postoperative pancreatic fistula (CR-POPF). Further analysis of studies including patients with low-drain fluid amylase (low-DFA) on postoperative day 1 and defining EDR timing as within 3 days was also performed. RESULTS: Four randomized controlled trials (RCTs) and eleven non-RCTs with a total of 9465 patients were included in this analysis. For the primary outcome, the EDR group had a significantly lower rate of CR-POPF (OR 0.23; p < 0.001). For the secondary outcomes, a lower incidence was observed in delayed gastric emptying (OR 0.63, p = 0.02), Clavien-Dindo III-V complications (OR 0.48, p < 0.001), postoperative hemorrhage (OR 0.55, p = 0.02), reoperation (OR 0.57, p < 0.001), readmission (OR 0.70, p = 0.003) and length of stay (MD -2.04, p < 0.001) in EDR. Consistent outcomes were observed in the subgroup analysis of low-DFA patients and definite EDR timing, except for postoperative hemorrhage in EDR. CONCLUSION: EDR after PD or DP is beneficial and safe, reducing the incidence of CR-POPF and other postoperative complications. Further prospective studies and RCTs are required to validate this finding.

Clinical impact of various drain-fluid data for the postoperative complications after hepatectomy: criteria of prophylactic drain removal on postoperative day 1.

PURPOSE: Prophylactic drains reported to be useful to treat postoperative bile leakage (POBL) and reduce re-intervention after hepatectomy. However, prophylactic drains should remove in the early postoperative period. This study aimed to assess the association between postoperative complications and the drain-fluid data on postoperative day (POD) 1. METHODS: Medical records of 530 patients who underwent hepatectomy were retrospectively reviewed. We evaluated the drain-fluid data on POD 1, such as bilirubin (BIL), aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) and drain discharge volume. These variables were compared between patients with and without postoperative complications such as POBL and abdominal abscess not due to POBL. RESULTS: POBL was found in 44 patients (8.3%), PHLF was in 51 patients (9.6%), and abdominal abscess not due to POBL was in 21 patients (4.0%). Regarding POBL, drain-fluid BIL concentration and drain discharge volume was higher in the POBL group (p < 0.001 and p < 0.001, respectively). However, drain-fluid AST, ALT, and ALP concentrations were not different between two groups. As to the abdominal abscess not due to POBL, all drain-fluid data were not significantly different. Multivariate analysis for predicting POBL showed that the drain-fluid BIL concentration ≥ 2.68 mg/dL was an independent predictor (p < 0.001). In the subgroup analyses according to the type of hepatectomy, the drain-fluid BIL concentration was an independent predictor for POBL after both non-anatomical and anatomical hepatectomy. CONCLUSION: The drain-fluid BIL concentration on POD 1 is useful in predicting POBL after hepatectomy.

Postoperative computed tomography findings predict re-drainage cases after early drain removal in pancreaticoduodenectomy.

PURPOSE: This study aimed to investigate the risk factors for re-drainage in patients with early drain removal after pancreaticoduodenectomy (PD). METHODS: This study retrospectively analyzed 114 patients who underwent PD and prophylactic drain removal on postoperative day (POD) 4 between January 2012 and March 2021. We analyzed the risk factors for re-drainage according to various factors. Peri-pancreaticojejunostomic fluid collection (PFC) index and pancreatic cross-sectional area (CSA) were evaluated using computed tomography on POD 4. The PFC index was calculated by multiplying the length, width, and height at the maximum aspect. RESULTS: Among the 114 patients, 15 (13%) underwent re-drainage due to postoperative pancreatic fistula. Multivariate analysis identified a PFC index ≥ 8.16 cm3 on POD 4 (odds ratio [OR], 20.40, 95%CI 2.38-174.00; p = 0.006) and pancreatic CSA on POD 4 ≥ 3.65 cm2 (OR, 16.40, 95%CI 1.57-171.00; p = 0.020) as independent risk factors for re-drainage. CONCLUSION: A careful decision might be necessary for early drain removal in patients with a PFC index ≥ 8.16 cm3 and pancreatic CSA ≥ 3.65 cm2.

Early drain removal after live liver donor hepatectomy is safe - a randomized controlled pilot study.

INTRODUCTION: The current study aimed to assess the safety of early drain removal after live donor hepatectomy (LDH). METHODS: One hundred eight consecutive donors who met the inclusion criteria were randomized to early drain removal (EDR - postoperative day (POD) 3 - if serous and the drain bilirubin level was less than 3 mg/dl - "3 × 3" rule) and routine drain removal (RDR - drain output serous and less than 100 ml). The primary outcome was to compare the safety. The secondary outcome was to compare the postoperative morbidity. RESULTS: Preoperative, intraoperative, and postoperative parameters except for the timing of drain removal were comparable. EDR was feasible in 46 out of 54 donors (85.14%) and none required re-intervention after EDR. There was significantly better pain relief with EDR (p = 0.00). Overall complications, pulmonary complications, and hospital stay were comparable on intention-to-treat analysis. However, pulmonary complications (EDR - 1.9% vs RDR - 16.3% P = 0.030), overall complications (18.8% vs 36.3%, P = 0.043), and hospital stay (8 vs 9, P = 0.014) were more in the RDR group on per treatment analysis. Bile leaks were seen in three donors (3.7% in the EDR group vs 1.9% in RDR, P = 0.558), and none of them required endo-biliary interventions. Re-exploration for intestinal obstruction was required for 3 donors in RDR (0% vs 5.7%; p = 0.079). CONCLUSION: EDR by the "3 × 3" rule after LDH is safe and associated with better pain relief. On per treatment analysis, EDR was associated with significantly less hospital stay and lower pulmonary and overall complications. CLINICAL TRIAL REGISTRY: Clinical Trials.gov - NCT04504487.

Evidence Versus Practice in Early Drain Removal After Pancreatectomy.

BACKGROUND: Early drain removal when postoperative day (POD) one drain fluid amylase (DFA) was ≤5000 U/L reduced complications in a previous randomized controlled trial. We hypothesized that most surgeons continue to remove drains late and this is associated with inferior outcomes. METHODS: We assessed the practice of surgeons in a prospectively maintained pancreas surgery registry to determine the association between timing of drain removal with demographics, comorbidities, and complications. We selected patients with POD1 DFA ≤5000 U/L and excluded those without drains, and subjects without data on POD1 DFA or timing of drain removal. Early drain removal was defined as ≤ POD5. RESULTS: Two hundred and forty four patients met inclusion criteria. Only 90 (37%) had drains removed early. Estimated blood loss was greater in the late removal group (190 mL versus 100 mL, P = 0.005) and pathological findings associated with soft gland texture were more frequent (97 [63%] versus 35 [39%], P < 0.0001). Patients in the late drain removal group had more complications (84 [55%] versus 30 [33%], P = 0.001) including pancreatic fistula (55 [36%] versus 4 [4%], P < 0.0001), delayed gastric emptying (27 [18%] versus 3 [3%], P = 0.002), and longer length of stay (7 d versus 5 d, P < 0.0001). In subset analysis for procedure type, complications and pancreatic fistula remained significant for both pancreatoduodenectomy and distal pancreatectomy. CONCLUSIONS: Despite level one data suggesting improved outcomes with early removal when POD1 DFA is ≤ 5000 U/L, experienced pancreas surgeons more frequently removed drains late. This practice was associated with known risk factors (estimated blood loss, soft pancreas) and may be associated with inferior outcomes suggesting potential for improvement.

Safety and efficacy of early drain removal and triple-drug therapy to prevent pancreatic fistula after distal pancreatectomy.

OBJECTIVE: Prior studies suggested that early drain removal prevented the development of pancreatic fistula (PF) after pancreaticoduodenectomy (PD), but there has been no corresponding prospective trial for distal pancreatectomy (DP). The purpose of this study was to determine the safety and efficacy of early drain removal and triple-drug therapy (TDT) with gabexate mesilate, octreotide and carbapenem antibiotics to prevent PF after DP in patients at high-risk of developing PF. METHODS: A total 71 patients who underwent a DP were enrolled. We prospectively divided them into two groups: the late-removal group, in which the drain remained in place for at least for 5 days postoperatively (n = 30) and the early-removal group in which the drain was removed on postoperative day 1 (POD1) (n = 41). For the patients with a high drain amylase level (≥10,000 IU/L) and patients with symptomatic intraperitoneal fluid collection, our original TDT was introduced. The primary endpoint was the safety and efficacy of this management, and the secondary endpoint was the incidence of PF. RESULTS: The incidence of clinical PF was significantly lower in the early-removal group (0% vs. the late removal 16%; p < 0.001). In the early-removal group, TDT was administered to 12 patients (29%) and none of the patients needed additional treatment after TDT. CONCLUSIONS: Postoperative management after DP with early drain removal and TDT was safe and effective for preventing PF.

Early chest drain removal on the day of uniportal thoracoscopic segmentectomy.

OBJECTIVE: Although early removal of postoperative chest drains can facilitate recovery, it can be difficult to achieve in segmentectomy due to the management of air leakage in intersegmental planes. This study prospectively examined the feasibility of drain removal on the same day of uniportal thoracoscopic segmentectomy. METHODS: Twenty patients who underwent uniportal thoracoscopic segmentectomy between July 2021 and May 2022 were enrolled in this prospective study. The indications for drain removal on the day of surgery were absence of air leakage in an intraoperative sealing test, radiographic evidence of lung expansion, and continuous absence of air leakage via a drainage bottle for 4 h after the operation. The primary endpoint was rate of the patients who required re-drainage after the postoperative drainage tube was removed on the day of surgery. The secondary end points were postoperative pain evaluated using a numerical rating scale on postoperative days 1, 7, and 28; morbidity; and postoperative hospitalization period. RESULTS: Fifteen patients successfully underwent drain removal on the day of surgery. None required re-drainage. The mean postoperative hospitalization period was 2.3 ± 1.7 days. Overall, 12 of the 15 (80%) patients were discharged on postoperative day 1 or 2. The mean numerical rating scale scores were 1.2 ± 1.6, 0.4 ± 0.7, and 0.4 ± 1.5 on postoperative days 1, 7, and 28, respectively. CONCLUSION: In uniportal thoracoscopic segmentectomy, drain removal on the day of surgery is feasible and may reduce pain on postoperative day 1.

Early versus late drain removal in patients after pancreatoduodenectomy: A systematic review and meta-analysis.

Whether early or late drain removal (EDR/LDR) is better for patients after pancreatic resection remains controversial. We aim to systematically evaluate the safety and efficacy of early or late drain removal in patients who undergo pancreatic resection. We searched seven databases from January 1, 2000, through September 2021, and included randomized controlled trials (RCTs) or observational studies comparing EDR vs. LDR in patients after pancreatic resection. We separately pooled effect estimates across RCTs and observational studies. Finally, we included 4 RCTs with 711 patients and 8 nonRCTs with 7207 patients. Based on the pooled RCT data, compared to LDR, EDR reduced hospital length of stay (LOS) (RR: -2.59, 95% CI: -4.13 to -1.06) and hospital cost (RR: -1022.27, 95% CI: -1990.39 to -54.19). Based on the pooled nonRCT data, EDR may reduce the incidence of all complications (OR: 0.45, 95% CI: 0.32 to 0.63), pancreatic fistula (OR: 0.26, 95% CI: 0.15 to 0.45), wound infection (RR: 0.59, 95% CI: 0.06 to 5.45)), reoperation (OR: 0.62, 95% CI: 0.40 to 0.96) and hospital readmission (OR: 0.57, 95% CI: 0.47 to 0.69). There was an uncertain effect on mortality (OR from pooled nonRCTs: 1.02, 95% CI: 0.41 to 2.53) and delayed gastric emptying (RR from pooled RCTs: 0.76, 95% CI: 0.41 to 1.41). The findings of this meta-analysis suggest that early drain removal is associated with lower hospital cost, is safe and may reduce the incidence of complications compared to late drain removal in patients after pancreaticoduodenectomy.

Safety evaluation of early drain removal following pancreaticoduodenectomy: A single-center retrospective cohort study.

Objectives: The effects of early drain removal (EDR) on postoperative complications after pancreaticoduodenectomy (PD) remains to be investigated. This single-center retrospective cohort study was designed to explore the safety of EDR after PD. Methods: A total of 112 patients undergoing PD with drain fluid amylase (DFA) on postoperative day (POD) 1 and 3 <= 5000 were divided into EDR and late drain removal (LDR). Propensity Score Matching (PSM) was used. We compared postoperative outcomes between two groups and explore the risk factors of total complications using univariate and multiple logistic regression analyses. Results: No statistical differences were found in primary outcomes, including Grade B/C postoperative pancreatic fistula (POPF) (Original cohort: 5.71% vs. 3.90%; P = 1.000; PSM cohort: 3.33% vs. 6.67%; P = 1.000), and total complications (Original cohort: 17.14% vs. 32.47%; P = 0.093; PSM cohort: 13.33% vs. 33.33%; P = 0.067). The EDR was associated with shorter in-hospital stay (Original cohort: 11 days vs. 15 days; P < 0.0001; PSM cohort: 11 days vs. 15 days; P < 0.0001). Conclusions: EDR on POD 3 is safe for patients undergoing PD with low risk of POPF.

Surgical Outcomes Following Early Drain Removal After Distal Pancreatectomy in Elderly Patients.

BACKGROUND/AIM: The efficacy and safety of early drain removal following distal pancreatectomy in elderly patients are unclear. We aimed to investigate the short-term surgical outcomes following early drain removal after distal pancreatectomy in elderly patients. PATIENTS AND METHODS: Fifty-seven patients aged ≥70 years who underwent distal pancreatectomy at our Hospital were enrolled in the study. Data were retrospectively analyzed to evaluate the short-term surgical outcomes following early drain removal after distal pancreatectomy in elderly patients. RESULTS: The incidence of pancreatic fistula following distal pancreatectomy in the early-removal group was significantly lower vs. the conventional group (p=0.022). Multivariate analysis revealed that early drain removal was an independent factor for reducing the risk of pancreatic fistula after distal pancreatectomy in elderly patients (p=0.042). CONCLUSION: Early drain removal following distal pancreatectomy is an effective and safe surgical perioperative management procedure to prevent pancreatic fistula in elderly patients.

Prophylactic drain management after pancreaticoduodenectomy without focusing on the drain fluid amylase level: A prospective validation study regarding criteria for early drain removal that do not include the drain fluid amylase level.

BACKGROUND/PURPOSE: Early drain removal (EDR) based on drain fluid amylase level (DFA) after pancreaticoduodenectomy excluded 15%-40% patients from EDR because of inappropriate DFA. METHODS: Of 198 pancreatoduodenectomy cases, we used the first 105 cases as an exploration cohort to construct the optimal criteria for EDR on postoperative day (POD)4 that were applied to the subsequent 93 cases used as the validation cohort. After that, we examined another 142 patients to further assess the efficacy of the new EDR criteria. RESULTS: Of the four independent predictors of clinically relevant postoperative pancreatic fistula (CR-POPF) ([1] soft pancreas, [2] positive drain fluid culture on POD1, and [3] serum C-reactive protein [CRP] ≥13 mg/dL on POD4) in the exploration cohort, EDR was applied to cases in the validation cohort meeting the [2] and/or [3], enabling 96% (89/93) applicability of EDR. Outcomes were improved in the validation cohort compared to the exploration cohort; CR-POPF: 8.6% vs 25.7%, P = .005; Dindo-Clavien grade ≥ 3 complications: 23.7% vs 41.9%, P = .007; and median hospital stay (day): 21 vs 27, P = .005. The subsequent 142 patients showed 92% (131/142) applicability of EDR and 5.6% (8/142) incidence of CR-POPF. CONCLUSIONS: Our new criteria for EDR, without DFA, enabled ≥ 90% applicability of EDR and reduced CR-POPF.

Early drain removal improves quality of life and clinical outcomes in patients with breast cancer - Results from a randomised controlled trial.

PURPOSE: The use of suction drains after breast cancer surgery (BCS) is common practice. However, the optimal time to remove drains is not clear yet and limited research has been conducted so far to assess the impact of their use on patient comfort. The goal of this study was to investigate the effect of early drain removal after BCS on quality of life (QoL) and clinical outcome. METHOD: A randomised controlled trial was conducted in 99 patients scheduled for BCS including placement of suction drains. Patients were randomised into either group 1: drains removed output-based, i.e., flow less than 30 ml/day or group 2: drains removed at hospital discharge, i.e., 4-5 days after surgery. A questionnaire on QoL was completed by the patients both pre- and postoperatively. RESULTS: Early drain removal was associated with a significant improvement in QoL. Additionally, total duration of home care nursing was considerably lower in the early-removal group (19 versus 1 day on average). No differences were observed in wound healing or the rate of wound infections, the latter being slightly lower in the early-removal group (13% versus 6%). Total volumes of fluid drained and/or aspirated were significantly lower in the early-removal group (median 1745 ml versus 752 ml), but more aspirations were needed (median 1 versus 3). The new policy of early drain removal was preferred by 94% of the patients in the early removal group. CONCLUSIONS: Early removal of suction drains improves QoL and has no negative effect on clinical outcomes after BCS.