Evidence Vs. Practice in Early Drain Removal Following Pancreatectomy

Background: Early drain removal when postoperative day (POD) 1 drain fluid amylase (DFA) was ≤ 5000 U/L reduced complications in a previous randomized controlled trial. We hypothesized that most surgeons continue to remove drains late and this is associated with inferior outcomes. Methods: We assessed the practice of surgeons in a prospectively maintained pancreas surgery registry to determine the association between timing of drain removal with demographics, co-morbidities, and complications. We selected patients with POD1 DFA ≤ 5000 U/L and excluded those without drains, and subjects without data on POD1 DFA or timing of drain removal. Early drain removal was defined as ≤ POD5. Results: 244 patients met inclusion criteria. Only 90 (37%) had drains removed early. Estimated blood loss was greater in the late removal group (190 mL vs 100 mL, p = 0.005) and pathological findings associated with soft gland texture were more frequent (97(63%) vs 35(39%), p < 0.0001). Patients in the late drain removal group had more complications (84(55%) vs 30(33%), p = 0.001) including pancreatic fistula (55(36%) vs 4(4%), p < 0.0001), delayed gastric emptying (27(18%) vs 3(3%), p = 0.002), and longer length of stay (7 days vs 5 days, p < 0.0001). In subset analysis for procedure type, complications and pancreatic fistula remained significant for both pancreatoduodenectomy and distal pancreatectomy. Conclusion: Despite level 1 data suggesting improved outcomes with early removal when POD1 DFA is ≤ 5000 U/L, experienced pancreas surgeons more frequently removed drains late. This practice was associated with known risk factors (EBL, soft pancreas) and may be associated with inferior outcomes suggesting potential for improvement