Pecorelli Nicolò, Ricci Claudio, Esposito Alessandro, Capretti Giovanni, Partelli Stefano, Butturini Giovanni, Boggi Ugo, Cucchetti Alessandro, Zerbi Alessandro, Salvia Roberto, Falconi Massimo
Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy.
Vita-Salute" San Raffaele University, Milan, Italy.
Updates Surg. 2025 Jan;77(1):9-17. doi: 10.1007/s13304-024-01987-0. Epub 2024 Oct 13.
Intraperitoneal prophylactic drain (IPD) use in distal pancreatectomy (DP) is still controversial. A survey was carried out through the Italian community of pancreatic surgeons using institutional emails, Twitter, and Facebook accounts of the Italian Association for the Study of the Pancreas (AISP) and the Italian Association of Hepato-biliary-pancreatic Surgery (AICEP). The survey was structured to learn surgeons' practice in using IPD through questions and one clinical vignette. Respondents were asked to report their regrets for omission and commission regarding the IPD use for the clinical scenario, eliciting a scale between 0 (no regret) and 100 (maximum regret). The threshold model and a multilevel mixed regression were built to identify respondents' attitudes. One hundred six surgeons completed the survey. Sixty-three (59.4%) respondents confirmed using at least 1 drain, while 43 (40.6%) placed 2 IPDs. Only 13 respondents (12.3%) declared a change in IPD strategy in patients at high risk of clinically relevant postoperative pancreatic fistula (CR-POPF), while 9 (9.4%) respondents changed their strategy in low-risk POPF situations. Thirty-five (35.5%) respondents declared they would remove the IPD within the third postoperative day (POD) in the absence of CR-POPF suspicion. The median omission regret, which proved to be the wrong decision, was 80 (50-100, IQR). The median regret due to the commission of IPD, which turned out to be useless, was 2.5 (1-20, IQR). The CR-POPF probability threshold at which drainage omission was the less regrettable choice was 7% (1-35, IQR). The threshold to perceive drain omission as the least regrettable choice was higher in female surgeons (P < 0.001), in surgeons who modulated the strategies based on the risk of CR-POPF, and in high volume centers (p = 0.039). The threshold was lower in surgeons who performed minimally invasive distal pancreatectomy (P < 0.001), adopted a closed system (P < 0.001), placed two IPDs (P < 0.001), or perceived the IPD as important to prevent reintervention (p = 0.047). Drain management after DP remains very heterogeneous among surgeons. The regret model suggested that IPD omission could be performed in low-risk patients (7% of CR-POPF), leading to low regret in the case of the wrong decision, making it an acceptable clinical decision.
在胰体尾切除术（DP）中使用腹腔预防性引流管（IPD）仍存在争议。通过意大利胰腺外科医生群体，利用意大利胰腺研究协会（AISP）和意大利肝胆胰外科协会（AICEP）的机构电子邮件、推特和脸书账户开展了一项调查。该调查通过问题和一个临床病例 vignette 进行构建，以了解外科医生使用 IPD 的实践情况。要求受访者报告他们对于在该临床病例中使用 IPD 的遗漏和实施方面的遗憾程度，得出一个介于 0（无遗憾）和 100（最大遗憾）之间的量表。构建了阈值模型和多级混合回归以确定受访者的态度。106 名外科医生完成了调查。63 名（59.4%）受访者确认至少使用了 1 根引流管，而 43 名（40.6%）放置了 2 根 IPD。只有 13 名受访者（12.3%）宣称在具有临床相关术后胰瘘（CR-POPF）高风险的患者中改变了 IPD 策略，而 9 名（9.4%）受访者在低风险 POPF 情况下改变了他们的策略。35 名（35.5%）受访者宣称在没有 CR-POPF 怀疑的情况下，他们会在术后第三天（POD）内移除 IPD。被证明是错误决定的遗漏遗憾中位数为 80（50 - 100，四分位距）。因实施了后来被证明无用的 IPD 而产生的遗憾中位数为 2.5（1 - 20，四分位距）。引流遗漏是最不可惜选择时的 CR-POPF 概率阈值为 7%（1 - 35，四分位距）。在女外科医生中（P < 0.001）、在根据 CR-POPF 风险调整策略的外科医生中以及在高容量中心（p = 0.039），将引流遗漏视为最不可惜选择的阈值更高。在进行微创胰体尾切除术的外科医生中（P < 0.001）、采用封闭系统的外科医生中（P < 0.001）、放置 2 根 IPD 的外科医生中（P < 0.001）或认为 IPD 对预防再次干预很重要的外科医生中（p = 0.047），该阈值较低。DP 后的引流管理在外科医生中仍然非常不一致。遗憾模型表明，在低风险患者（CR-POPF 发生率为 7%）中可以省略 IPD，在做出错误决定的情况下遗憾程度较低，使其成为一个可接受的临床决策。
