DO DRAINS HELP OR HURT IN HPB SURGERY? Henry A. Pitt, M.D. Chief Quality Officer Temple University Health System July 23, 2017

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1 DO DRAINS HELP OR HURT IN HPB SURGERY? Henry A. Pitt, M.D. Chief Quality Officer Temple University Health System July 23, 217

2 DISCLOSURES Henry A. Pitt has nothing to disclose Leader of the ACS-NSQIP HPB Collaborative Hepatectomy Pancreatectomy Major Partial Whipple Distal

3 GOALS Encourage quality improvement initiatives with engagement of HPB Surgeons, Surgeon Champions and SCRs Reduce variation among hospitals and surgeons ACS Provide a forum to share and disseminate best practices AHPBA

4 Institutions HPB Collaborative PROCEDURE TARGETED Hepatectomy Pancreatectomy USA 14 Canada 9 Australia 2 Lebanon Singapore 1

5 Percent OPERATIONS 216 Hepatectomy N=3,539 Major Partial Pancreatectomy N=5,362 Whipple Distal

6 216 HEPATECTOMY 216 PANCREATECTOMY 8 hospitals 82% cases Hepatectomy 12 Outcomes Bile leak Liver failure 86 hospitals 84% cases Whipple-deciles 15 Outcomes Panc fistula DGE Distal-deciles 14 Outcomes Panc fistula DGE

7 Percent MORBIDITY 216 Hepatectomy Pancreatectomy Major Partial Whipple Distal

8 Percent OVERALL SSI 216 Hepatectomy Pancreatectomy Major Partial Whipple Distal

9 Percent SSI TYPES 216 Major Hepatectomy Whipple Procedure Superficial Organ Space Superficial Organ Space

10 LEAKS & FISTULAS 216 Bile Leaks International Study group Grades A, B, C Major 13% Partial 5% Pancreatic fistulas International Study Group Grades A, B, C Whipple 18% Distal 19% Bile leak Pancreatic fistula

11 Percent DRAIN USAGE 216 Hepatectomy 1 Pancreatectomy Major Partial Whipple Distal

12 DRAIN REMOVAL Major Hepatectomy Whipple Procedure Percent >3 Postoperative Day

13 HEPATECTOMY DRAINS Five randomized trials and a Chochrane Systematic Review do not support the routine use of drains in hepatic surgery Numbers were small and had few major hepatectomies Liver surgeons continue to routinely insert drains in uncomplicated hepatectomies Hepatectomy Drains

14 TARGETED HEPATECTOMY 214 ACS-NSQIP Hepatectomy database* 3,84 hepatectomies, 787 major Excluded partial (<3 segments) and concomitant operations (colon, Hepatico-Jej) Multivariable regression models bile leak *Brauer et al J Am Coll Surg 216;223: *Schwartz et al World J Surg 217;41:11-18 *Karachristos et al 216 SSAT, ACS NSQIP

15 Percent HPB Collaborative ORGAN SPACE & ANY SSI No Drain Drain *p<.1 NS * Organ Space SSI // Any SSI

16 BILE LEAK INTERVENTION 2 15 No Drain * Drain *p<.1 Percent 1 5 * Bile Leak // Leak Intervention

17 2 15 HPB Collaborative LOS READMISSIONS No Drain Drain *p<.1 * 2 15 Percent 1 NS LOS // Readmissions

18 CONCLUSIONS Drain placement after major hepatectomy results in more surgical site infections, bile leaks, interventions for leaks, and readmissions Bile leaks are associated with multiple post hepatectomy adverse outcomes Routine drain placement is not warranted after major hepatectomy

19 PANCREATECTOMY DRAINS 28 POD#1 Drain fluid amylase (DFA-1) <5, low risk pancreatic fistula 21 Randomized trial of early vs late drain removal panc fistula 2% vs 26% 212 Panc Demo Project only 7% pts early removal Drain amylase * * p <.1 vs > POD 5 POD 3 > POD 5

20 PANCREATECTOMY DRAINS Soft gland texture and small pancreatic duct predict pancreatic fistula 214 Drain fluid amylase POD #1 predicts risk of pancreatic fistula 216 Systematic review recommends drain removal by POD #3 c low DFA-1 Whipple Drain amylase

21 DRAIN MANAGEMENT 214 ACS-NSQIP Participant Use File 3,69 patients pancreatoduodenectomy 2,698 operative drains placed (88%) 626 DFA never measured (23%) 58 DFA-1 measured (22%) 27 Drains removed by POD #3 (8%) 116 Propensity matched to POD #4-7

22 8 6 HPB Collaborative DFA-1 MEASUREMENT *p<.1 vs POD 1-3 %Patients 4 2 * * * * >3 Postoperative Day

23 %Patients HPB Collaborative OVERALL MORBIDITY *p<.5 vs POD 1-3 and POD 4-7 * * * >3 Postoperative Day

24 PROPENSITY MATCHING Age Weight loss Gland texture Gender ASA Class Duct size Race Jaundice Blood transf BMI Biliary stent Operative time Diabetes Neoadjuvant rx Pathology

25 5 4 HPB Collaborative PROPENSITY MORBIDITY Early Delayed *p<.1 vs Early * %Patients Serious Morbidity // Overall Morbidity

26 %Patients HPB Collaborative PANCREATIC FISTULA & LOS Early Delayed *p<.2 vs Early * * Days 2 2 CR-POPF // Length of Stay

27 DFA-1 & DRAIN RMOVAL DFA-1 measured in 58 patients Drain removed early 27 pts DFA-1 <1, 56% pts eligible for early removal

28 CONCLUSIONS Significant variation exists in the use of drain fluid amylase and timing of drain removal after pancreatoduodenectomy If drain fluid amylase on POD #1 is <5, U/L, outcomes are best when drains are removed by POD #3 Using an evidence based approach to the management of drains has the potential to improve postoperative outcomes