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DRAINAGE AFTER DISTAL PANCREATECTOMY: STILL AN UNSOLVED PROBLEM
Marcel C C. Machado*1, Marcel C C. Machado2
1clinical emergency, University of Sao Paulo, Sao Paulo, sao Paulo, Brazil; 2Surgery, Hospital Sirio Libanes, Sao Paulo, Sao Paulo, Brazil
Background
Routine drainage of the operative bed following elective pancreatectomy remains controversial. Some authors suggest that drainage is not helpful after elective pancreatectomy and may be detrimental.
Our hypothesis is that in patients with distal pancreatectomy with splenectomy that develops pancreatic fistula, no drainage or insufficient drainage may cause clinically relevant pancreatic fistula. Fluid collection with high amylase content may run towards the left subphrenic space. In this setting, a single drain left at the surgical field may not be enough. Indeed, a recent multicentric study showed that concomitant splenectomy is an independent risk fact for clinically relevant pancreatic fistula. Moreover intraoperative drainage was associated with a greater fistula rate but reduced fistula severity. Therefore, we have used double drainage for all spleno-pancreatectomy in the last 5 years. This study shows the initial results of this policy.
Methods
164 patients submitted to distal pancreatic resection with splenectomy for benign or malignant diseases by open or laparoscopic approach are reviewed. 85 underwent open spleno-pancreatectomy and 79 laparoscopic approach. There were 96 men and 68 women with mean age of 57.3 years. In this study all procedures were done as a part of standard patient care as directed by the Hospital and not to a research protocol. Data collection was performed as part of our ongoing quality monitoring. In accordance with our Ethical Committee guidelines formal ethical review was not required. Two drains were used in every patient. One drain was located on the left sub phrenic space and one drain near to pancreatic stump. The first drain was removed by 5-7 days after surgery if fluid amylase content was below 2x plasma level. The second drain was removed after 9 days if amylase content is also below 2x plasma amylase level. If amylase content is higher drain is left in place and removed when volume is below 10 ml or amylase is below 2x plasma level or after 30 days after the procedure with any volume and amylase content.
Results
Postoperative pancreatic fistula occurred in 38 patients (23.1%). In every case no additional procedure was necessary. No postoperative abscess or fluid collection needing further intervention other than late removal of the drain was observed.
Conclusion
If drains are used in distal pancreatectomy they must be located in order to direct pancreatic fluid far from the subphrenic space. This can be accomplished by using two drains. This policy reduced postoperative pancreatic fistula severity, main cause of morbidity or mortality of this procedure.
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