Proposal of a Clinically Useful Criterion for Early Drain Removal After Pancreaticoduodenectomy
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Published on: March 15, 2024
Toshimitsu Iwasaki1, Satoshi Nara2, Yoji Kishi1
1Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
Insights
A new criterion using drain amylase and C-reactive protein on postoperative day 3 can safely predict no clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD), enabling early drain removal.
Area of Science:
- Gastroenterology
- Surgical Oncology
- Abdominal Surgery
Background:
- Postoperative pancreatic fistula (POPF) is a significant complication after pancreaticoduodenectomy (PD).
- Early and accurate identification of patients at low risk for CR-POPF is crucial for optimizing postoperative management, including timely drain removal.
Purpose of the Study:
- To establish a reliable criterion for early drain removal after PD.
- To identify predictive factors for CR-POPF available on postoperative day 3 (POD3).
Main Methods:
- Retrospective analysis of 300 patients undergoing PD with pancreaticojejunostomy.
- Identification of CR-POPF predictors available on or before POD3.
- Development and internal validation of a predictive criterion for no CR-POPF.
Main Results:
- The incidence of CR-POPF was 35%.
- Drain amylase (d-AMY) ≥ 350 IU/l and C-reactive protein (CRP) ≥ 14 mg/dl on POD3 were significant predictors of CR-POPF.
- A criterion of d-AMY < 350 IU/l and CRP < 14 mg/dl on POD3 predicted no CR-POPF with a positive predictive value of 89% in the validation cohort.
Conclusions:
- A simple two-factor criterion (d-AMY and CRP on POD3) reliably predicts the absence of CR-POPF after PD.
- Early drain removal is considered safe for patients meeting this criterion.
Purpose:
This study aimed to establish a reliable criterion for early drain removal after pancreaticoduodenectomy (PD) based on predictive factors of clinically relevant postoperative pancreatic fistula (CR-POPF) available on postoperative day 3 (POD3).
Methods:
A total of 300 consecutive patients who underwent PD with pancreaticojejunostomy at our hospital from 2011 to 2015 were analyzed retrospectively. CR-POPF was defined as POPF grade B or C according to the definition by ISGPF. Clinicopathological factors available on or before POD3 were analyzed to identify predictors of CR-POPF. Using obtained predictors, we developed a criterion for no CR-POPF and internally validated its relevance in 100 consecutive patients.
Results:
The incidence rates of CR-POPF, severe complications (Clavien-Dindo ≥ grade IIIa), and postoperative mortality were 35%, 9.6%, and 0.3%, respectively. Multivariate analysis showed that drain amylase (d-AMY) levels ≥ 350 IU/l on POD3, C-reactive protein (CRP) levels ≥ 14 mg/dl on POD3, preoperative endoscopic retrograde biliary drainage, and no portal vein resection were significant predictors of CR-POPF. Using the strongest predictors (i.e., d-AMY and CRP), we established a criterion for no CR-POPF: d-AMY levels < 350 IU/l and CRP levels < 14 mg/dl on POD3. The incidence rates of CR-POPF were 6%, 38%, and 88% in patients who fulfilled both of (n = 149), each of (n = 74), and none of (n = 77) the two factors, respectively. In the internal validation cohort, the positive predictive value of CR-POPF was 89%.
Conclusions:
A simple two-factor criterion available on POD3 after PD has a reliable predictive ability. In patients who fulfill this criterion, early drain removal is considered safe.
