Prophylactic intra-peritoneal drain placement following pancreaticoduodenectomy: A systematic review and meta-analysis

Table 1 Characteristics of the included studies

Ref.	Year	Country	Design	Drain	n	Sex (male/female)	Age (yr)	Type of surgery	Disease (M/B)	Score1
Heslin et al[30]	1998	United States	Retro	Yes	51	18/20	65 ± 2	PD	47/4	1
				No	38	19/32	65 ± 2	PPPD	31/7
Lim et al[33]	2013	France	Retro	Yes	27	8/19	62 (40-76)	PD	20/7	1
				No	27	8/19	62 (38-78)	PPPD	20/7
Mehta et al[36]	2013	United States	Retro	Yes	251	130/121	60.0	PD	162/89	1
				No	458	222/236	62.5	PPPD	289/169
Correa-Gallego et al[35]	2013	United States	PNR	Yes	386	NA	NA	NA	282/104	2
				No	353				257/96
Van Buren et al[37]	2014	United States	RCT	Yes	68	37/31	62.1 ± 11.7	PD	45/23	3
				No	69	38/31	64.3 ± 12.6		50/19

¹Scoring for RCT was according to Jadad scoring system, and the method of McKay et al[22] was used for non-randomized studies. B: Benign; M: Malignant; NA: Not available; PD: Pancreaticoduodenectomy; PNR: Prospective nonrandomized observational study; PPPD: Pylorus-preserving pancreaticoduodenectomy; RCT: Randomized controlled trial; Retro: Retrospective observational study.

Table 2 Definition of pancreatic fistula

Ref.	Definition of postoperative pancreatic fistula
Heslin et al[30]	> 30 mL/d pancreatic fluid drainage for more than 1 wk
Lim et al[33]	International study group on pancreatic fistula definition
Mehta et al[36]	International study group on pancreatic fistula definition
Correa-Gallego et al[35]	Clinical signs and symptoms with amylase-rich drainage > 50 mL/d after postoperative day 10
Van Buren et al[37]	International study group on pancreatic fistula definition

Table 3 Postoperative outcomes

Ref.	Drain	Complications		POPF	BF	DGE	IAA	POH	Mortality	Reoperation	Readmission	RGD
		Overall	Major
Heslin et al[30]	Yes	23	14	3	NA	NA	3	NA	NA	1	NA	2
	No	15	8	1	NA	NA	0	NA	NA	3	NA	1
Lim et al[33]	Yes	19	5	5	0	3	1	2	1	2	0	1
	No	15	2	0	0	4	1	2	1	1	1	1
Mehta et al[36]	Yes	171	62	41	NA	NA	NA	0	5	14	44	21
	No	248	75	35	NA	NA	NA	0	11	26	75	29
Correa-Gallego et al[35]	Yes	NA	139	104	NA	NA	NA	NA	3	2	107	68
	No	NA	105	59	NA	NA	NA	NA	11	2	73	49
Van Buren et al[37]	Yes	50/501	19/211	7/81	3/31	16/161	7/81	6/61	0/1/22	2	16	6
	No	52/551	28/281	14/141	1/21	26/291	17/181	10/131	4/6/82	6	12	16

¹After postoperative 30/60 d;

²after postoperative 30/60/90 d. BF: Biliary fistula; DGE: Delayed gastric emptying; IAA: Intra-abdominal abscess; NA: Not available; POPF: Postoperative pancreatic fistula; POH: Postoperative hemorrhage; RGD: Radiologic-guided drains.

Table 4 Summary results of drain vs no drain after pancreaticoduodenectomy

	Outcome	Studies (n)	Patients (n)	OR (95%CI)	P	Heterogeneity
						P	I2
All studies	Overall complications	4	989	0.62 (0.48-0.82)	< 0.01	0.39	1%
	Major complications	5	1728	0.75 (0.60-0.93)	0.01	0.11	47%
	Postoperative pancreatic fistula	5	1728	0.61 (0.33-1.12)	0.11	0.03	63%
	Biliary fistula	2	191	0.32 (0.03-3.14)	0.33	NA	NA
	Delayed gastric emptying	2	191	1.85 (0.94-3.62)	0.07	0.70	0%
	Intra-abdominal abscess formation	3	280	1.80 (0.82-3.97)	0.14	0.19	40%
	Post-pancreatectomy hemorrhage	2	191	1.55 (0.60-3.99)	0.36	0.63	0%
	Mortality	4	1639	2.32 (1.11-4.85)	0.02	0.33	12%
	Reoperation	5	1728	1.26 (0.73-2.17)	0.41	0.51	0%
	Readmission	4	1639	0.77 (0.60-0.98)	0.04	0.56	0%
	Radiologic-guided drains	5	1728	0.98 (0.57-1.66)	0.93	0.13	43%
ISGPF definition	Overall complications	3	900	0.61 (0.46-0.81)	< 0.01	0.26	26%
	Major complications	3	900	0.82 (0.34-1.98)	0.66	0.02	74%
	Postoperative pancreatic fistula (ISGPF B/C)	3	900	0.61 (0.14-2.66)	0.51	0.01	81%
	Intra-abdominal abscess formation	2	191	2.57 (1.05-6.29)	0.04	0.49	0%
	Mortality	3	900	1.68 (0.68-4.18)	0.26	0.40	0%
	Reoperation	3	900	1.16 (0.64-2.09)	0.63	0.36	3%
	Readmission	3	900	0.89 (0.62-1.27)	0.52	0.61	0%
	Radiologic-guided drains	3	900	1.34 (0.43-4.19)	0.61	0.05	66%
Quality score ≥ 2	Major complications	2	876	1.08 (0.47-2.46)	0.85	0.03	78%
	Postoperative pancreatic fistula (ISGPF B/C)	2	876	1.02 (0.26-4.00)	0.98	0.01	86%
	Mortality	2	876	4.88 (1.52-15.69)	0.01	0.61	0%
	Reoperation	2	876	2.10 (0.62-7.12)	0.23	0.42	0%
	Readmission	2	876	0.68 (0.50-0.93)	0.02	0.99	0%
	Radiologic-guided drains	2	876	1.42 (0.36-5.66)	0.62	0.01	85%

ISGPF: International Study Group on Pancreatic Fistula; OR: Odds ratio.