Two-drain versus three-train strategy in robotic-assisted pancreaticoduodenectomy: impact on complications

Background: Surgeons have placed different number of intraperitoneal drains (IDs) in the absence of a harmonized reference or rationale. This study aims to evaluate whether robotic-assisted pancreaticoduodenectomy (RPD) with a 2-drain and an additional inferior pancreaticojejunostomy (PJ) drain strategy reduces the frequency or severity of complications, particularly the rate of postoperative percutaneous drainage. Methods: We collected data from 235 patients of RPD performed by 1 single surgeon with and without the use of extra ID inferior to PJ site and compared the complications between the 2 groups after propensity score matching. Results: RPD with 3 drains showed a lower incidence of postoperative percutaneous drainage (31 [35.2%] vs 5 [5.7%], P < .001], surgical site infection (SSI) or intra-abdominal fluid collection (46 [52.2%] vs 31 [35.2%], P = .003), and clinically relevant postoperative pancreatic fistula (CR-POPF; 27 [30.7%] vs 11 [12.5%], P = .006). More than half (48 [54.5%]) of the patients in 3-drain group had a drainage volume of inferior PJ drainage that consistently exceeded the superior PJ drainage or intermittently exceeded the superior PJ drainage. For those at high risk of pancreatic fistula (International Study Group for Pancreatic Surgery [ISGPS-C] and [ISGPS-D]), 3 drains significantly reduced the postoperative percutaneous drainage rate and incidence of SSI or intra-abdominal fluid collection compared to 2 drains. Conclusions: This study suggested that prophylactic placement of additional inferior PJ drain during RPD, in contrast to 2 drains only, significantly reduces the incidence of CR-POPF, SSI or intra-abdominal fluid collection, and postoperative percutaneous drainage.