Department of Surgery, Division of Surgical Oncology, University of Illinois at Chicago, 835 S. Wolcott St. MC790, Chicago, IL, USA.
Departments of Surgery and Research, Creticos Cancer Center and the Advocate Health Research Institute, Chicago, IL, USA.
J Gastrointest Surg. 2018 Jun;22(6):1007-1015. doi: 10.1007/s11605-018-3702-4. Epub 2018 Feb 12.
Conflicting evidence exists from randomized controlled trials supporting both increased complications/fistulae and improved outcomes with drain placement after pancreatectomy. The objective was to determine drain practice patterns in the USA, and to identify if drain placement was associated with fistula formation.
Demographic, perioperative, and patient outcome data were captured from the most recent annual NSQIP pancreatic demonstration project database, including components of the fistula risk score. Significant variables in univariate analysis were entered into adjusted logistic regression models.
Of 5013 pancreatectomy patients, 4343 (87%) underwent drain placement and 18% of patients experienced a pancreatic fistula. When controlled for other factors, drain placement was associated with ducts < 3 mm, soft glands, and blood transfusion within 72 h of surgery. Age, obesity, neoadjuvant radiation, preoperative INR level, and malignant histology lost significance in the adjusted model. Drained patients experienced higher readmission rates (17 vs. 14%; p < 0.05) and increased (20 vs. 8%; p < 0.01) pancreatic fistulae. Fistula was associated with obesity, no neoadjuvant chemotherapy, drain placement, < 3 mm duct diameter, soft gland, and longer operative times. Drain placement remained independently associated with fistula after both distal pancreatectomy (OR = 2.84 (1.70, 4.75); p < 0.01) and pancreatoduodenectomy (OR = 2.29 (1.28, 4.11); p < 0.01).
Despite randomized controlled clinical trial data supporting no drain placement, drains are currently placed in the vast majority (87%) of pancreatectomy patients from > 100 institutions in the USA, particularly those with soft glands, small ducts, and perioperative blood transfusions. When these factors are controlled for, drain placement remains independently associated with fistulae after both distal and proximal pancreatectomy.
有随机对照试验的证据相互矛盾，支持在胰腺切除术后放置引流管会增加并发症/瘘管的风险，但也会改善结果。目的是确定美国的引流实践模式，并确定引流是否与瘘管形成有关。
从最新的年度 NSQIP 胰腺示范项目数据库中获取人口统计学、围手术期和患者结局数据，包括瘘管风险评分的组成部分。单因素分析中的显著变量被纳入调整后的逻辑回归模型。
在 5013 例胰腺切除术患者中，4343 例（87%）进行了引流放置，18%的患者发生了胰腺瘘。在控制其他因素后，引流放置与胆管<3mm、软胰腺和手术 72 小时内输血有关。年龄、肥胖、新辅助放疗、术前 INR 水平和恶性组织学在调整后的模型中失去了意义。引流患者的再入院率更高（17% vs. 14%；p<0.05），胰腺瘘的发生率也更高（20% vs. 8%；p<0.01）。瘘与肥胖、无新辅助化疗、引流放置、胆管<3mm 直径、软胰腺和手术时间较长有关。在远端胰腺切除术（OR=2.84（1.70，4.75）；p<0.01）和胰十二指肠切除术（OR=2.29（1.28，4.11）；p<0.01）后，引流放置仍然与瘘独立相关。
尽管有随机对照临床试验数据支持不放置引流管，但目前在美国的 100 多家机构中，绝大多数（87%）胰腺切除术患者都放置了引流管，特别是那些有软胰腺、小胆管和围手术期输血的患者。当控制这些因素时，引流放置仍然与远端和近端胰腺切除术后的瘘独立相关。
