Prophylactic intra-peritoneal drain placement following pancreaticoduodenectomy: a systematic review and meta-analysis

Abstract

Aim: To conduct a meta-analysis comparing outcomes after pancreaticoduodenectomy (PD) with or without prophylactic drainage.

Methods: Relevant comparative randomized and non-randomized studies were systemically searched based on specific inclusion and exclusion criteria. Postoperative outcomes were compared between patients with and those without routine drainage. Pooled odds ratios (OR) with 95%CI were calculated using either fixed effects or random effects models.

Results: One randomized controlled trial and four non-randomized comparative studies recruiting 1728 patients were analyzed. Patients without prophylactic drainage after PD had significantly higher mortality (OR=2.32, 95%CI: 1.11-4.85; P=0.02), despite the fact that they were associated with fewer overall complications (OR=0.62, 95%CI: 0.48-0.82; P=0.00), major complications (OR=0.75, 95%CI: 0.60-0.93; P=0.01) and readmissions (OR=0.77, 95%CI: 0.60-0.98; P=0.04). There were no significant differences in the rates of pancreatic fistula, intra-abdominal abscesses, postpancreatectomy hemorrhage, biliary fistula, delayed gastric emptying, reoperation or radiologic-guided drains between the two groups.

Conclusion: Indiscriminate abandonment of intra-abdominal drainage following PD is associated with greater mortality, but lower complication rates. Future randomized trials should compare routine vs selective drainage.

Keywords: Drain; Meta-analysis; Morbidity; Pancreaticoduodenectomy; Postoperative pancreatic fistula.

Figure 1

Flow diagram depicting the study selection. CP: Central pancreatectomy; DP: Distal pancreatectomy; PD: Pancreaticoduodenectomy.

Figure 2

Forest plots illustrating meta-analysis of primary outcomes comparing drain with no drain after pancreaticoduodenectomy. Pooled odds ratios (ORs) with 95%CIs were calculated using the fixed effects models to analyze outcomes at A: 30 d; B: 60 d; and C: 90 d.

Figure 3

Forest plots illustrating meta-analysis of secondary outcomes comparing drain with no drain after pancreaticoduodenectomy. Pooled odds ratios (ORs) with 95%CIs were calculated using fixed or random effects models to analyze outcomes at 30 d. A: Pancreatic fistula; B: Overall complications; C: Major complications; D: Intra-abdominal abscess; E: Postoperative hemorrhage; F: Delayed gastric emptying; G: Reoperation; H: Readmission; I: Biliary fistula; J: Radiologic-guided drain.

Figure 4

Forest plots illustrating meta-analysis of secondary outcomes comparing drain with no drain after pancreaticoduodenectomy. Pooled odds ratios (ORs) with 95%CIs were calculated using fixed or random effects models to analyze outcomes at 60 d. A: Pancreatic fistula; B: Overall complications; C: Major complications; D: Delayed gastric emptying; E: Intra-abdominal abscess; F: Biliary fistula; G: Postoperative hemorrhage.

Figure 5

Funnel plot to investigate publication bias.