Pancreatic surgery 101: drain, no drain, early drain removal, or late drain removal. What are the data? Where do we go from here?

Congratulations to the group at the University of Verona, led by Professors Paolo Pederzoli and Claudio Bassi! Their group has made tremendous contributions to our understanding of pancreatic surgical diseases over the last several decades. In the current issue of Annals of Surgery, we are again treated to a thoughtful, well-done study of great importance to pancreatophiles and others who manage patients requiring pancreatic surgery. This study focuses on drain management after standard pancreatic resection (either pancreaticoduodenectomy or distal pancreatectomy DP ). Make no mistake about it, whereas pancreatic surgery has become safer, it is not without significant risks. Overall, mortality rates have declined, hospital length of stay has been reduced, there is less use of blood transfusions, we are better able to manage complications and we are better able to identify patients with premalignant lesions who benefit from intervention. Furthermore, through the use of multidisciplinary teams (including gastroenterologists, anesthesiologists, intensivists, genetic counselors, oncologists, nutritionists, surgeons, experienced nurse practitioners, and many others) we are seeing improvements in long-term survival in our cancer patients. However, pancreatic surgery is not without risk. The “Achilles heel” of pancreaticoduodenectomy remains the pancreatic anastomosis. Failure of healing of the pancreatic anastomosis may lead to intra-abdominal abscess, likely contributes to postpancreatectomy hemorrhage and delayed gastric emptying, often requires the skills of our interventional radiologists, and, albeit infrequently currently, may lead to the need for reoperation. Various techniques have been modified, proposed, challenged, and studied in an effort to reduce failure of healing of the pancreatic anastomosis, and the development of a pancreatic fistula. Randomized studies have looked at pancreaticojejunostomy (PJ) versus pancreaticogastrostomy, stents versus no stents, duct-to-mucosa versus invagination PJ, the use of prophylactic octreotide, or fibrin glue, the use of an isolated Roux-en-Y limb for the pancreatic anastomosis, and many other techniques . with variable results. Here the authors approach the issue of early versus late drain removal. In this study, performed over a 13-month period at their pancreatic center in Italy, the authors analyzed 184 “standard” pancreatic resections (pylorus preserving pancreaticoduodenectomy PPPD with PJ and DP with or without splenectomy). Drains were used in all patients, so this study does not address the “drain versus no drain” controversy. Of the 184 patients, 50 were excluded from randomization because the amylase value in their drains on postoperative day 1 was found to be in excess of 5000 U/L. An additional 20 patients were excluded because they developed either a biliary fistula, postpancreatectomy hemorrhage, or the material exiting the abdomen through the drain appeared “sinister” within 3 days of surgery. Thus, after excluding those 70 patients, the remaining 114 patients (66% PPPD vs. 34% DP) were randomly allocated to either early (day 3) or late (day 5 or after) drain removal. Notably, each of the 114 patients randomized had a transabdominal ultrasound before randomization, to exclude the presence of a 5 cm or larger peripancreatic fluid collection. Standard definitions for pancreatic complications were used. The primary end point of the study was the incidence of pancreatic fistula, although secondary end points included other complications, postoperative hospital length of stay, readmission, and hospital cost differences. As with any well-done, randomized study, one can carefully dissect the trial, and find areas of concern or question. Although their method of gastrointestinal reconstruction appears close to our standard technique, a careful read of their Methods indicates that the end-to-side hepaticojejunostomy (HJ) was performed 20-cm distal to the upstream PJ (some individuals do the HJ closer to the PJ) and the end-to-side duodenojejunostomy was carried out fully 50-cm below the HJ. This distance puts additional loops in the reconstructive limb above the mesocolon, between the DJ and the HJ. The authors used flat Penrose drains (Redax: silicone; available 6–16 mm in width and