Enhancing perioperative evaluation and abdominal drain in patients undergoing distal pancreatectomy

We read with great interest the article titled “Prophylactic abdominal drainage after distal pancreatectomy (PANDORINA): an international, multicentre, open-label, randomised controlled, non-inferiority trial” published in The Lancet Gastroenterology & Hepatology (1). This high-quality trial sheds light on the non-inferiority of the no-drain policy in managing patients undergoing distal pancreatectomy (DP) and presents a valuable selection of postoperative intervention strategies. The results revealed that the no-drain approach was safe with regard to major morbidity [21 (15%) vs. 29 (20%)] and effectively lowered the incidence of grade B or C postoperative pancreatic fistulas [POPF; 16 (12%) vs. 39 (27%)] compared with the drain approach. Given the significant implications for clinical practice, it is imperative to emphasize the importance of this outcome. Based on the above, we provide insightful recommendations for additional improvements.

First, the Distal Pancreatectomy Fistula Risk Score (D-FRS) score was used in this trial to stratify the patients in the high-risk and low-risk POPF groups by combining pancreatic thickness and main pancreatic duct diameter. However, the assessment of the risk of POPF based solely on preoperative measurements of pancreatic duct diameter and thickness is insufficient. Various studies have demonstrated that a soft pancreatic texture is significantly associated with the development of clinically relevant (CR)-POPF (2), and different pathological types of pancreatic tumours have different pancreatic textures. Therefore, experienced ultrasound physicians comprehensively evaluate pancreatic texture, pancreatic duct diameter, and pancreatic thickness intraoperatively, which can more effectively distinguish patients into high- and low-risk groups and facilitate decision-making for abdominal drainage placement. When adequate preoperative and intraoperative evaluations were performed, the results were more convincing.

Second, recognizing the role of abdominal drainage strategies after DP is meaningful. In the drain group, the incidence of B or C POPF has reached 27%, which may be due to insufficient drainage. All patients in the drain group received an abdominal drain placed beyond the former splenic bed with the tip next to the pancreatic transection margin, while avoiding direct contact with the artery or vein stumps after DP combined with splenectomy. However, in clinical practice, the drainage effect of this strategy is often insufficient, which may further increase the incidence of B or C POPF. In addition, simple and sole drain placement may be inadequate in selected patients among experienced pancreatic surgeons. In our large-volume minimally invasive pancreatic surgery centre, we recommended placement of two abdominal drainage tubes, one of which, negative pressure drainage, was placed under the left caudate lobe with the tip next to the pancreatic transection margin, where fluid accumulation often occurs, and the other drainage tube was placed in the same position as in the article. This strategy can significantly reduce the incidence of B or C POPF (3).

Third, addressing potential confounding factors is essential, different centres used different drain types and drain sizes, which may have led to sample bias in the drainage effect. Furthermore, as a reminder, co-intervention for pancreatic stump closures is essential, especially in low-volume centres, as they may have just passed the learning curve or not (4). Implementing co-intervention for pancreatic stump closure can effectively reduce the incidence of POPF and postpancreatectomy haemorrhage (PPH), thereby further improving patient economic benefits, and promoting early recovery.

Last, the authors considered several subgroup analyses based on different variables influencing the risk of complications and notably POPF, but they did not mention conducting subgroup analyses and interaction tests for some significantly important characteristics. Our last recommendation suggests conducting analyses across pathological type, spleen preservation, learning curve (centre volume) and minimally invasive surgery, which was demonstrated to be associated with a reduction in the risk of POPF after DP (5). It would have been interesting and significant to have data on the impact of omitting drainage in the subgroups of patients undergoing DP.

In conclusion, the research published in The Lancet Gastroenterology & Hepatology represents a substantial contribution to our understanding of decision-making for prophylactic abdominal drainage after DP. This article demonstrated that the non-inferiority of omitting drainage compared to routine drainage after DP and the no-drain policy even reduced the detection of grade B or C POPF. This study introduced a new standard approach for eligible patients undergoing DP. Our suggestions only serve to improve an already excellent work of research. We believe that these results will contribute to the practice-changing and implementation of a no-drain policy in patients undergoing DP.

Acknowledgments

Funding: This study was supported by Guilin Science and Technology Plan Project (Grant number: 20220139-5-3), The Technology Project within the No. 924 Hospital of PLA Joint Logistic Support Force (Grant number: S2022FH01), Guangxi Healthcare Science and Technology Plan Project (Grant number: Z-C20241574), The Fundamental Research Funds for the Central Universities of HIT.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-24-599/coif). The authors have no conflicts of interest to declare.

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References

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