To drain or not to drain, that is the question. The role of the placement of abdominal drainage in pancreatic surgery

Current evidence for routine abdominal drainage after pancreatic surgery is still unclear.

Although mortality after pancreatic resections has decreased in recent years due to advances in surgical technique and perioperative management, morbidity has not followed the same trend. For many years, prophylactic drains have been used to facilitate the detection of intra-abdominal complications including postoperative pancreatic fistula (POPF) and haemorrhage, to prevent fluid collections and their infection. Randomized controlled trials and meta-analyses that compared abdominal drainage versus no drainage after pancreatic surgery were inconclusive^{1, 2}.

The role of drain to reduce postoperative complications is still controversial.

On the other hand, drain placement may lead to retrograde infection by the drain route, patient discomfort, or direct damage to vascular structures. Some studies have reported that the use of abdominal drains may result in a longer hospital stay, and even increase the occurrence of complications such as POPF^{3, 4}.

Despite this, most pancreatic surgeons around the world use prophylactic abdominal drainage after this kind of surgery. POPF is one of the most common complications after pancreatic surgery and the placement of abdominal drainage aims to protect against its possible severe consequences.

An important point to consider when reading the scientific literature on this subject is that most studies and systematic reviews of drain management combined distal pancreatectomy (DP) with pancreatoduodenectomy (PD), although POPF after PD has a different etiopathogenesis and should not be compared with the situation after DP.

Van Bodegraven et al.³ present the first systematic review and meta-analysis to compare no drain placement versus routine abdominal drainage in patients undergoing DP specifically. Five studies were included in the meta-analysis, involving 2153 patients. No drain placement was associated with a lower rate of major complications (Clavien–Dindo grade ≥ III), POPF, and readmissions. No difference was found on the rates of radiological intervention and reoperation between the two groups. Non-randomized studies could have been exposed to different bias. There was heterogeneity between studies. Different stump closure methods could have affected the POPF rates. As the authors underline, future larger randomized trials are needed before final conclusions can be drawn. Risk-stratification should also be considered.

To drain or not to drain? This hamletic dilemma still remains without an answer.

When evaluating whether to place an abdominal drainage in pancreatic surgery, many factors should be considered. There is little evidence in medical literature and further studies are needed.