Drain Management After Pancreatoduodenectomy: BJS Open | June 2026

Introduction:

Optimal drain management after pancreatoduodenectomy (PD) remains critical for preventing postoperative pancreatic fistula (POPF) while supporting enhanced recovery. This study proposes a dynamic, risk-adapted algorithm based on intraoperative risk and postoperative biochemical markers.

Why was this study needed?

Current drain removal protocols largely rely on early drain fluid amylase (DFA) levels using a one-size-fits-all approach. However, these strategies may not be reliable in patients at high intrinsic risk of POPF, particularly those with a soft pancreas and small pancreatic duct.

What did the study show?

• High-risk PD (soft pancreas and duct ≤3 mm) had significantly higher POPF rates than non-high-risk PD.
• Early DFA was highly predictive in low-risk patients but was considerably less reliable in high-risk patients.
• For non-high-risk PD, safe drain removal on POD 3 was guided by low POD 1 and POD 3 DFA along with normal serum amylase/lipase.
• For high-risk PD, delaying drain removal until POD 5 improved safety.
• In high-risk patients, combining POD 5 DFA with C-reactive protein provided better prediction of clinically relevant POPF than DFA alone.
• The proposed algorithm individualizes drain management according to each patient's fistula risk rather than applying a uniform protocol.

Clinical Impact:

Drain management after pancreatoduodenectomy should be individualized. Early drain removal remains appropriate for low-risk patients, whereas high-risk patients benefit from delayed removal guided by serial biochemical assessment, potentially reducing POPF-related complications.

Take-Home Message:

A risk-stratified, dynamic drain management strategy is superior to a one-size-fits-all approach after pancreatoduodenectomy. Tailoring drain removal according to intraoperative risk and postoperative biomarkers can improve patient safety while supporting enhanced recovery.