A Drain Amylase ≪ 1000 U/L On the First Post-Operative Day Effectively Predicts the Absence of a High-Impact Fistula Following Pancreatic Resection
Gregory R. Veillette*, Camilo Correa-Gallego, Cristina R. Ferrone, Sarah P. Thayer, Jennifer a. Wargo, Andrew L. Warshaw, Carlos Fernandez Del-Castillo
Surgery, Massachusetts General Hospital, Boston, MA
Introduction: The use and management of drains following pancreatic resection remains controversial. Recent data suggests that an elevated drain amylase level on the first post-operative day is the strongest predictive factor for pancreatic fistula development. We sought to confirm these observations, and to determine if this measurement could specifically predict the absence of clinically-significant fistulae. Methods: A prospective study of all patients undergoing pancreatic resection during calendar year 2008 was performed. Patients had drain amylase levels measured daily, and a pancreatic fistula was defined according to the ISGPF; grades B and C fistulae were considered as clinically-significant.Results: A total of 202 pancreatic resections were performed, including 125 pancreaticoduodenectomies (PD) and 61 distal pancreatectomies (DP). Using the ISGPF definition, the fistula rate was 50% following PD and 56% after DP, with rates of clinically-significant fistula of 13% and 15%, respectively. A drain amylase level greater than 1000 U/L on the first post-operative day following PD had a sensitivity of 80% for detection of a fistula (grades A, B and C) and 93% for a clinically-significant one (grades B and C). Furthermore, the negative predictive value of a drain amylase level less than 1000 U/L was 98% for clinically significant fistulas (p = 0.0003). Following DP, a drain amylase level greater than 1000 U/L on the first post-operative day had a sensitivity of 87% for development of a fistula and 89% for a high-impact fistula, with a negative predictive value of 94% in the latter group.Conclusion: Quantification of drain amylase levels on the first post-operative day after pancreatic resection can indeed predict development of pancreatic fistula. Patients with a drain amylase value less than 1000 U/L on the first post-operative day are very unlikely to develop a clinically- significant, high- impact pancreatic fistula following proximal or distal resection, and perhaps should have the drains removed early in their course.
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