A systematic review and meta-analysis of morbidity and pancreatic fistula after distal pancreatectomy with versus without prophylactic intra-abdominal drainage

Abstract

Background: The omission of a prophylactic intra-abdominal drainage has been under debate in pancreatic surgery due to the high-risk of complications and especially of postoperative pancreatic fistula (POPF). Recently, the second randomized controlled trial (RCT) and two propensity score-matched comparative studies assessing risks and benefits of a no-drainage policy versus prophylactic drainage after distal pancreatectomy (DP) have been published. This systematic review with meta-analysis provides an updated summary of the available evidence on this topic. Methods: RCTs and nonrandomized comparative studies (NCS) investigating outcomes of no drainage versus drainage after DP were searched systematically in MEDLINE, Embase, and CENTRAL. Random effects meta-analyses were performed, and the results presented as weighted odds ratios (OR) or mean differences with their corresponding 95% CI. Subgroup analyses were performed to account for interstudy heterogeneity between RCTs and NCS. Results: Two RCTs and six NCS with a total of 3610 patients undergoing DP were included of whom 1038 (28.8%) patients did not receive prophylactic drainage. A no-drainage policy was associated with significantly lower risks of POPF (OR 0.38, 95% CI: 0.25-0.56; P<0.00001), reduced major morbidity (OR 0.64, 95% CI: 0.47-0.89; P=0.008), less reinterventions (OR 0.70, 95% CI: 0.52-0.95; P=0.02), and fewer readmissions (OR 0.69, 95% CI: 0.54-0.88; P=0.003) as well as shorter length of hospital stay (mean differences -1.74, 95% CI: -2.70 to -0.78; P=0.0004). Subgroup analyses including only RCTs confirmed benefits of the no-drainage policy. Conclusion: A no-drainage policy is associated with reduced POPF and morbidity and can therefore be recommended as standard procedure in patients undergoing DP.