A Randomized Prospective Multicenter Trial Of Pancreaticoduodenectomy With And Without Routine Intraperitoneal Drainage?
Published 2016 · Medicine
To the Editor: I would like to congratulate George Van Buren and colleague for presenting level I evidence on the controversial topic of intraperitoneal drainage after pancreaticoduodenectomy (PD). With a randomized prospective multicenter trial they concluded that omission of intraperitoneal drainage in all cases of PD increases the frequency and severity of all complications. Omitting intraperitoneal drainage after PD is well described in retrospective studies and a single-center randomized controlled trial (RCT). Soft pancreas, small pancreatic duct diameter, prolonged operative time, blood loss more than 1000 mL, ampullary, duodenal, and bile duct pathology are known risk factors for the development of postoperative pancreatic fistula and other complications. The retrospective studies are prone to have selection bias and there is a high probability that the patients without these high-risk factors for pancreatic leak were the ones in whom the intraperitoneal drain was avoided. The only other prospective RCT had concluded that the trial failed to show a reduction in the number of death or complications with the addition of intraperitoneal closed suction drainage after pancreatic resection and therefore routine placement of drain is unnecessary. However, in the results there is no mention of the distribution of risk factors (texture of pancreas, pancreatic duct diameter) between 2 groups. My question to the authors is ‘‘how ethical is it to conduct an RCT and place the patients with known risk factors for postoperative complications at risk of developing postoperative morbidity and mortality?’’ The first step in management of pancreaticoenteric anastomosis leak is drainage. We all are aware that intraoperatively placed intraperitoneal drain does drain the high amylase containing fluid most of the time though drains fail sometimes. An experienced pancreatic surgeon would know during operation that this patient is likely to develop pancreatic leak and other complications. I am not