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Meta-Analysis
. 2016 Oct 21;10(10):CD010583.
doi: 10.1002/14651858.CD010583.pub3.

Prophylactic abdominal drainage for pancreatic surgery

Yao Cheng  1 , Jie Xia, Mingliang Lai, Nansheng Cheng, Sirong He
Affiliations
Meta-Analysis

Prophylactic abdominal drainage for pancreatic surgery

Yao Cheng et al. Cochrane Database Syst Rev. .

Update in

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 methods: For the initial version of this review, we searched the Cochrane Library (2015, Issue 3), MEDLINE (1946 to 9 April 2015), Embase (1980 to 9 April 2015), Science Citation Index Expanded (1900 to 9 April 2015), and Chinese Biomedical Literature Database (CBM) (1978 to 9 April 2015). For this updated review, we searched the Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, and CBM from 2015 to 28 August 2016.

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

Data collection and analysis: We identified five trials (of 985 participants) which met our inclusion criteria. Two review authors independently identified the trials 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 employed the random-effects model.

Main results: Drain use versus no drain useWe included three trials involving 711 participants who were randomized to the drainage group (N = 358) and the no drainage group (N = 353) after pancreatic surgery. There was inadequate evidence to establish the effect of drains on mortality at 30 days (2.2% with drains versus 3.4% no drains; RR 0.78, 95% CI 0.31 to 1.99; three studies; low-quality evidence), mortality at 90 days (2.9% versus 11.6%; RR 0.24, 95% CI 0.05 to 1.10; one study; low-quality evidence), intra-abdominal infection (7.3% versus 8.5%; RR 0.89, 95% CI 0.36 to 2.20; three studies; very low-quality evidence), wound infection (12.3% versus 13.3%; RR 0.92, 95% CI 0.63 to 1.36; three studies; low-quality evidence), morbidity (64.8% versus 62.0%; RR 1.04, 95% CI 0.93 to 1.16; three studies; moderate-quality evidence), length of hospital stay (MD -0.66 days, 95% CI -1.60 to 0.29; three studies; moderate-quality evidence), or additional open procedures for postoperative complications (11.5% versus 9.1%; RR 1.18, 95% CI 0.55 to 2.52; three studies). There was one drain-related complication in the drainage group (0.6%). Type of drainWe 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. There was no evidence of differences between the two groups in mortality at 30 days (1.2% with active drain versus 0% with passive drain), intra-abdominal infection (0% versus 2.6%), wound infection (6.1% versus 9.0%; RR 0.68, 95% CI 0.23 to 2.05), morbidity (22.0% versus 32.1%; RR 0.68, 95% CI 0.41 to 1.15), or additional open procedures for postoperative complications (1.2% versus 7.7%; RR 0.16, 95% CI 0.02 to 1.29). The active drain group was associated with shorter length of hospital stay (MD -1.90 days, 95% CI -3.67 to -0.13; 14.1% decrease of an 'average' length of hospital stay) than in the passive drain group. The quality of evidence was low, or very low. Early versus late drain removalWe 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 evidence of differences between the two groups in mortality at 30 days (0% for both groups) or additional open procedures for postoperative complications (0% with early drain removal versus 1.8% with late drain removal; RR 0.33, 95% CI 0.01 to 8.01). The early drain removal group was associated with lower rates of postoperative complications (38.5% versus 61.4%; RR 0.63, 95% CI 0.43 to 0.93), shorter length of hospital stay (MD -2.10 days, 95% CI -4.17 to -0.03; 21.5% decrease of an 'average' length of hospital stay), and hospital costs (17.0% decrease of 'average' hospital costs) than in the late drain removal group. The quality of evidence for each of the outcomes was low.

Authors' conclusions: It is unclear whether routine abdominal drainage has any effect on the reduction of mortality and postoperative complications after pancreatic surgery. In case of drain insertion, low-quality evidence suggests that active drainage may reduce hospital stay after pancreatic surgery, and early removal may be superior to late removal for people with low risk of postoperative pancreatic fistula.

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Conflict of interest statement

YC: none known.

JX: none known.

ML: none known.

NC: none known.

SH: none known.

Figures

Figure 1
Figure 1
Study flow diagram.
Figure 2
Figure 2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figure 3
Figure 3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Analysis 1.1
Analysis 1.1
Comparison 1 Drain use versus no drain use, Outcome 1 Mortality (30 days).
Analysis 1.2
Analysis 1.2
Comparison 1 Drain use versus no drain use, Outcome 2 Mortality (90 days).
Analysis 1.3
Analysis 1.3
Comparison 1 Drain use versus no drain use, Outcome 3 Intra‐abdominal infection.
Analysis 1.4
Analysis 1.4
Comparison 1 Drain use versus no drain use, Outcome 4 Wound infection.
Analysis 1.5
Analysis 1.5
Comparison 1 Drain use versus no drain use, Outcome 5 Drain‐related complications.
Analysis 1.6
Analysis 1.6
Comparison 1 Drain use versus no drain use, Outcome 6 Morbidity.
Analysis 1.7
Analysis 1.7
Comparison 1 Drain use versus no drain use, Outcome 7 Length of hospital stay (days).
Analysis 1.8
Analysis 1.8
Comparison 1 Drain use versus no drain use, Outcome 8 Additional open procedures for postoperative complications.
Analysis 1.9
Analysis 1.9
Comparison 1 Drain use versus no drain use, Outcome 9 Additional radiological interventions for postoperative complications.
Analysis 2.1
Analysis 2.1
Comparison 2 Active drain versus passive drain, Outcome 1 Mortality (30 days).
Analysis 2.2
Analysis 2.2
Comparison 2 Active drain versus passive drain, Outcome 2 Intra‐abdominal infection.
Analysis 2.3
Analysis 2.3
Comparison 2 Active drain versus passive drain, Outcome 3 Wound infection.
Analysis 2.4
Analysis 2.4
Comparison 2 Active drain versus passive drain, Outcome 4 Morbidity.
Analysis 2.5
Analysis 2.5
Comparison 2 Active drain versus passive drain, Outcome 5 Length of hospital stay (days).
Analysis 2.6
Analysis 2.6
Comparison 2 Active drain versus passive drain, Outcome 6 Additional open procedures for postoperative complications.
Analysis 3.1
Analysis 3.1
Comparison 3 Early versus late drain removal, Outcome 1 Mortality (30 days).
Analysis 3.2
Analysis 3.2
Comparison 3 Early versus late drain removal, Outcome 2 Morbidity.
Analysis 3.3
Analysis 3.3
Comparison 3 Early versus late drain removal, Outcome 3 Length of hospital stay (days).
Analysis 3.4
Analysis 3.4
Comparison 3 Early versus late drain removal, Outcome 4 Hospital costs (EUR).
Analysis 3.5
Analysis 3.5
Comparison 3 Early versus late drain removal, Outcome 5 Additional open procedures for postoperative complications.
Analysis 4.1
Analysis 4.1
Comparison 4 Drain use versus no drain use (sensitivity analysis by changing between worst‐case scenario analysis and best‐case scenario analysis for missing data), Outcome 1 Mortality (90 days) (worst‐case scenario).
Analysis 4.2
Analysis 4.2
Comparison 4 Drain use versus no drain use (sensitivity analysis by changing between worst‐case scenario analysis and best‐case scenario analysis for missing data), Outcome 2 Mortality (90 days) (best‐case scenario).
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Update of

References

References to studies included in this review

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    1. Jiang H, Liu N, Zhang M, Lu L, Dou R, Qu L. A randomized trial on the efficacy of prophylactic active drainage in prevention of complications after pancreaticoduodenectomy. Scandinavian Journal of Surgery 2016;1(1):1457496916665543. [] - PubMed

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Additional references

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References to other published versions of this review

    1. Cheng Y, Yang C, Lin Y, Lu J, Wu S, Zhou R, et al. Prophylactic abdominal drainage for pancreatic surgery. Cochrane Database of Systematic Reviews 2013, Issue 6. [DOI: 10.1002/14651858.CD010583] - DOI - PubMed
    1. Peng S, Cheng Y, Yang C, Lu J, Wu S, Zhou R, et al. Prophylactic abdominal drainage for pancreatic surgery. Cochrane Database of Systematic Reviews 2015, Issue 8. [DOI: 10.1002/14651858.CD010583.pub2] - DOI - PubMed

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