The Dilemma of Drains after Pancreatoduodenectomy: Still an Issue?

Background and Aims: Routine drainage after pancreatoduodenectomy is a controversial issue. In this article, we present and discuss the current evidence on abdominal drains in pancreatic surgery. Material and Methods: Review of the pertinent English-language literature. Results: There is a growing body of evidence showing a lack of benefit of prophylactic drainage after pancreatoduodenectomy. Randomized trials have reported similar outcomes with or without routine drains. If drains were used, early removal was found to be superior to late removal in patients with a low risk of postoperative pancreatic fistula. Consequently, criteria for early drain removal have been developed based on the measurement of drain amylase levels. On the contrary, there exists a subgroup of patients where drains may have a role. In patients with high risk of pancreatic fistula formation, such as those having a soft pancreatic texture, small pancreatic duct and high body mass index, the placement of drains may give sentinel information about future clinical deterioration. The drain may thus help reduce failure-to-rescue rates. Conclusion: Despite much research, there are many unanswered questions regarding drains in pancreatic surgery. It is evident that routine drainage should be abandoned for a more selective strategy. Furthermore, what is needed is a postoperative warning score that early on can identify patients at risk of a pancreatic fistula, without the routine placement of drains.