DO DRAINS HELP OR HURT IN HPB SURGERY? Henry A. Pitt, M.D. Chief Quality Officer Temple University Health System July 23, 217
DISCLOSURES Henry A. Pitt has nothing to disclose Leader of the ACS-NSQIP HPB Collaborative Hepatectomy Pancreatectomy Major Partial Whipple Distal
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
Institutions HPB Collaborative PROCEDURE TARGETED 16 14 12 1 8 6 4 Hepatectomy Pancreatectomy USA 14 Canada 9 Australia 2 Lebanon 1 2 213 214 215 216 217 Singapore 1
Percent 7 6 5 4 3 2 1 OPERATIONS 216 Hepatectomy N=3,539 Major Partial 7 6 5 4 3 2 1 Pancreatectomy N=5,362 Whipple Distal
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
Percent 4 3 2 1 MORBIDITY 216 Hepatectomy 4 3 2 1 Pancreatectomy Major Partial Whipple Distal
Percent 4 3 2 1 OVERALL SSI 216 Hepatectomy 4 3 2 1 Pancreatectomy Major Partial Whipple Distal
Percent 2 15 1 5 SSI TYPES 216 Major Hepatectomy 2 15 1 5 Whipple Procedure Superficial Organ Space Superficial Organ Space
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
Percent 1 8 6 4 2 DRAIN USAGE 216 Hepatectomy 1 Pancreatectomy 8 6 4 2 Major Partial Whipple Distal
DRAIN REMOVAL 216 5 4 Major Hepatectomy Whipple Procedure Percent 3 2 1 1 3 4 7 8 14 15 3 >3 Postoperative Day
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
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;223:774-83 *Schwartz et al World J Surg 217;41:11-18 *Karachristos et al 216 SSAT, ACS NSQIP
Percent HPB Collaborative ORGAN SPACE & ANY SSI 2 15 1 5 No Drain Drain *p<.1 NS * 2 15 1 5 Organ Space SSI // Any SSI
BILE LEAK INTERVENTION 2 15 No Drain * Drain *p<.1 Percent 1 5 * Bile Leak // Leak Intervention
2 15 HPB Collaborative LOS READMISSIONS No Drain Drain *p<.1 * 2 15 Percent 1 NS 1 5 5 LOS // Readmissions
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
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
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
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
8 6 HPB Collaborative DFA-1 MEASUREMENT *p<.1 vs POD 1-3 %Patients 4 2 * * * * 1 3 4 7 8 14 15 3 >3 Postoperative Day
%Patients 8 6 4 2 HPB Collaborative OVERALL MORBIDITY *p<.5 vs POD 1-3 and POD 4-7 * * * 1 3 4 7 8 14 15 3 >3 Postoperative Day
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
5 4 HPB Collaborative PROPENSITY MORBIDITY Early Delayed *p<.1 vs Early * %Patients 3 2 1 Serious Morbidity // Overall Morbidity
%Patients HPB Collaborative PANCREATIC FISTULA & LOS 12 1 8 6 4 Early Delayed *p<.2 vs Early * * 12 1 8 6 4 Days 2 2 CR-POPF // Length of Stay
DFA-1 & DRAIN RMOVAL DFA-1 measured in 58 patients Drain removed early 27 pts DFA-1 <1, 56% pts eligible for early removal
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