S188 Comparative Assessment of Outcomes: Abdominal Drain vs No Abdominal Drain After Distal Pancreatectomy - A Systematic Review and Meta-Analysis

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Introduction: Distal pancreatectomy (DP) is a surgical procedure commonly employed for various pancreatic conditions, often associated with postoperative complications like post-operative pancreatic fistula (POPF). While routine abdominal drainage following DP has been standard practice, recent evidence suggests potential benefits of omitting this approach. This systematic review and meta-analysis aimed to compare outcomes between abdominal drain placement and no drain placement post-pancreatectomy. Methods: A comprehensive search was conducted on PubMed, Cochrane, and Embase from inception up to 15 March 2024, yielding 9 studies comprising 15,817 patients. Data were extracted from randomized and non-randomized studies reporting primary and secondary outcomes. The analysis was performed in Revman. Risk ratios and Mean Difference were calculated with 95% confidence intervals, and a P-value of < 0.05 was considered statistically significant. Results: A total of 13,081 patients underwent drain placement after distal pancreatectomy, and 2736 patients were included in the no-drain group. Out of the total, 45.1% (n= 7140) patients were male, with 45.9% (n= 6012) males in the drain group and 41.2% (n= 1128) males in the no-drain group. Major morbidity, defined as Clavien-Dindo grade ≥ III complications, was significantly lower in the no-drain group (RR: 0.77, 95% CI: 0.64 to 0.93, P = 0.006). Similarly, lower rates of POPF (RR: 0.51, 95% CI: 0.38 to 0.67, P< 0.00001), readmission (RR: 0.75, 95% CI: 0.59 to 0.96, P = 0.02), and surgical site infections (RR: 0.82, 95% CI: 0.70 to 0.95, P = 0.009) were observed in the no-drain group. Additionally, a shorter length of hospital stay was noted in this group (MD: -1.65, 95% CI: -2.50 to -0.81, P = 0.0001). There was no statistically significant association of post pancreatectomy hemorrhage, the need for radiological intervention, delayed gastric emptying, intra-abdominal abscess, re-operation, 30-day mortality, 90-day mortality, and Intensive Care Unit admission with any of the 2 groups. Conclusion: This study provides valuable insights into the debate surrounding postoperative drainage strategies in DP, suggesting the potential benefits of omitting routine abdominal drainage. However, further research is warranted to explore the impact of risk stratification, especially on various secondary outcomes, and validate our findings in diverse patient populations (see Figure 1, Table 1).Figure 1.: (A) Forest plot Major morbidity (Clavien–Dindo grade ≥ III) (B) Forest Plot Postoperative pancreatic fistula, grade B/C (C) Forest Plot Readmission (D) Forest Plot Surgical Site Infections (E) Forest Plot Length of Hospital Stay (F) Forest Plot Radiological Intervention. Table 1. - Study characteristics First Author Year Published Study Design Country Primary outcome Inclusion criteria Exclusion criteria Number of surgeons Nickel 2022 Retrospective Germany Complications and duration of hospital stay PD or DP with or withoutintraoperative intraperitoneal drain placement NR NR Van Bodegraven 2022 Retrospective USA, Netherlands and Italy Major morbidity DP with or without prophylactic drain placement Patients who had undergone pancreatoduodenectomyor if DP was performed for disconnectedpancreatic duct syndrome. NR Van Bodegraven 2024 RCT Netherlands and Italy Major morbidity Patients aged 18 years or older undergoing open or minimally invasive elective distal pancreatectomy for all indications Ppatients with an American Society of Anesthesiology (ASA)physical status of 4–5 or WHO performance status of 3–4, added by amendment following the death of a patient with ASA 4 due to a pre-existing cardiac condition NR Pollini 2022 Retrospective USA Associations between drain placement and surgical site infections (SSI). Pancreatic resections were identifiedin the database using current procedural terminology(CPT) codes. NR NR Paulus 2012 Retrospective USA Postoperative morbidity and the need for therapeutic intervention Elective distal pancreatectomy Concurrent extra-pancreatic organ removal exclusiveof the spleen 3 Correa 2013 Retrospective USA Morbidity, POPF Partial pancreatic resection NR 6 Behrman 2015 Retrospective USA Serious morbidity Elective distal pancreatectomy NR NR Van Buren 2017 RCT USA/Canada 60-day grade 2 orhigher grade complication rate Elective distal pancreatectomy Age< 18 years NR Mangieri 2020 retrospective USA Major morbidity Distal subtotal pancreatectomy, with or without splenectomy Preoperative jaundice, biliary stent or ASA grade 5; operations requiring pancreatic or enteric anastomosis, vascular resection, or biliary drain placement NR RCT: Randomized Controlled Trial, USA: United States of America, NR: Not Reported, POPF: Post-operative Pancreatic Fistula.

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