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Study flow diagram: 2018 review update
Figuras y tablas -
Figure 1

Study flow diagram: 2018 review update

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Comparison 1 Drain use versus no drain use, Outcome 1 Mortality (30 days).
Figuras y tablas -
Analysis 1.1

Comparison 1 Drain use versus no drain use, Outcome 1 Mortality (30 days).

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Comparison 1 Drain use versus no drain use, Outcome 2 Mortality (90 days).
Figuras y tablas -
Analysis 1.2

Comparison 1 Drain use versus no drain use, Outcome 2 Mortality (90 days).

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Comparison 1 Drain use versus no drain use, Outcome 3 Intra‐abdominal infection.
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Analysis 1.3

Comparison 1 Drain use versus no drain use, Outcome 3 Intra‐abdominal infection.

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Comparison 1 Drain use versus no drain use, Outcome 4 Wound infection.
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Analysis 1.4

Comparison 1 Drain use versus no drain use, Outcome 4 Wound infection.

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Comparison 1 Drain use versus no drain use, Outcome 5 Morbidity.
Figuras y tablas -
Analysis 1.5

Comparison 1 Drain use versus no drain use, Outcome 5 Morbidity.

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Comparison 1 Drain use versus no drain use, Outcome 6 Length of hospital stay (days).
Figuras y tablas -
Analysis 1.6

Comparison 1 Drain use versus no drain use, Outcome 6 Length of hospital stay (days).

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Comparison 1 Drain use versus no drain use, Outcome 7 Additional open procedures for postoperative complications.
Figuras y tablas -
Analysis 1.7

Comparison 1 Drain use versus no drain use, Outcome 7 Additional open procedures for postoperative complications.

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Comparison 1 Drain use versus no drain use, Outcome 8 Additional radiological interventions for postoperative complications.
Figuras y tablas -
Analysis 1.8

Comparison 1 Drain use versus no drain use, Outcome 8 Additional radiological interventions for postoperative complications.

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Comparison 2 Active drain versus passive drain, Outcome 1 Mortality (30 days).
Figuras y tablas -
Analysis 2.1

Comparison 2 Active drain versus passive drain, Outcome 1 Mortality (30 days).

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Comparison 2 Active drain versus passive drain, Outcome 2 Intra‐abdominal infection.
Figuras y tablas -
Analysis 2.2

Comparison 2 Active drain versus passive drain, Outcome 2 Intra‐abdominal infection.

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Comparison 2 Active drain versus passive drain, Outcome 3 Wound infection.
Figuras y tablas -
Analysis 2.3

Comparison 2 Active drain versus passive drain, Outcome 3 Wound infection.

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Comparison 2 Active drain versus passive drain, Outcome 4 Morbidity.
Figuras y tablas -
Analysis 2.4

Comparison 2 Active drain versus passive drain, Outcome 4 Morbidity.

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Comparison 2 Active drain versus passive drain, Outcome 5 Length of hospital stay (days).
Figuras y tablas -
Analysis 2.5

Comparison 2 Active drain versus passive drain, Outcome 5 Length of hospital stay (days).

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Comparison 2 Active drain versus passive drain, Outcome 6 Additional open procedures for postoperative complications.
Figuras y tablas -
Analysis 2.6

Comparison 2 Active drain versus passive drain, Outcome 6 Additional open procedures for postoperative complications.

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Comparison 3 Early versus late drain removal, Outcome 1 Morbidity.
Figuras y tablas -
Analysis 3.1

Comparison 3 Early versus late drain removal, Outcome 1 Morbidity.

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Comparison 3 Early versus late drain removal, Outcome 2 Length of hospital stay (days).
Figuras y tablas -
Analysis 3.2

Comparison 3 Early versus late drain removal, Outcome 2 Length of hospital stay (days).

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Comparison 3 Early versus late drain removal, Outcome 3 Hospital costs (EUR).
Figuras y tablas -
Analysis 3.3

Comparison 3 Early versus late drain removal, Outcome 3 Hospital costs (EUR).

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Comparison 3 Early versus late drain removal, Outcome 4 Additional open procedures for postoperative complications.
Figuras y tablas -
Analysis 3.4

Comparison 3 Early versus late drain removal, Outcome 4 Additional open procedures for postoperative complications.

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Comparison 4 Drain use versus no drain use sensitivity analysis for missing data, Outcome 1 Mortality (90 days) ‐ worst‐case scenario.
Figuras y tablas -
Analysis 4.1

Comparison 4 Drain use versus no drain use sensitivity analysis for missing data, Outcome 1 Mortality (90 days) ‐ worst‐case scenario.

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Comparison 4 Drain use versus no drain use sensitivity analysis for missing data, Outcome 2 Mortality (90 days) ‐ best‐case scenario.
Figuras y tablas -
Analysis 4.2

Comparison 4 Drain use versus no drain use sensitivity analysis for missing data, Outcome 2 Mortality (90 days) ‐ best‐case scenario.

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Summary of findings for the main comparison. Drain use versus no drain use for pancreatic surgery

Drain use versus no drain use for pancreatic surgery

Patient or population: people undergoing elective open pancreatic resections
Setting: hospital
Intervention: drain use
Comparison: no drain use

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Risk with no drain use

Risk with drain use

Mortality

Follow‐up: 30 days

23 per 1000

18 per 1000

(7 to 46)

RR 0.78
(0.31 to 1.99)

1055
(4 studies)

⊕⊕⊕⊝
Moderate1,2

Mortality

Follow‐up: 90 days

42 per 1000

10 per 1000

(3 to 38)

RR 0.23
(0.06 to 0.90)

478
(2 studies)

⊕⊕⊕⊝
Moderate1,2

Intra‐abdominal infection

Follow‐up: 30 days

82 per 1000

80 per 1000

(43 to 148)

RR 0.97
(0.52 to 1.80)

1055
(4 studies)

⊕⊝⊝⊝
Very low1,2,3,4

Wound infection

Follow‐up: 30 days

99 per 1000

97 per 1000

(68 to 140)

RR 0.98
(0.68 to 1.41)

1055
(4 studies)

⊕⊕⊝⊝
Low1,2,3

Drain‐related complications

Follow‐up: 30 days

See comment

See comment

Not estimable

179
(1 study)

⊕⊕⊝⊝
Low1,2,3

There was 1 drain‐related complication in the drainage group. The drainage tube was broken.

Morbidity

Follow‐up: 30 days

597 per 1000

614 per 1000

(561 to 674)

RR 1.03
(0.94 to 1.13)

1055
(4 studies)

⊕⊕⊕⊝
Moderate2,3

Length of hospital stay

Follow‐up: 30 days

The mean length of hospital stay in the no drain groups was 13.8 days

The mean length of hospital stay in the drain groups was
0.66 days lower
(1.6 lower to 0.29 higher)

MD ‐0.66 (‐1.60 to 0.29)

711
(3 studies)

⊕⊕⊕⊝
Moderate2,3

Hospital costs

Follow‐up: 30 days

Not reported

Additional open procedures for postoperative complications

Follow‐up: 30 days

71 per 1000

94 per 1000

(56 to 158)

RR 1.33
(0.79 to 2.23)

1055
(4 studies)

⊕⊕⊝⊝
Low1,2,3

Additional radiological interventions for postoperative complications

Follow‐up: 30 days

121 per 1000

105 per 1000

(48 to 227)

RR 0.87
(0.40 to 1.87)

660
(3 studies)

⊕⊝⊝⊝
Very low1,2,3,4

Pain

Follow‐up: 30 days

Not reported

Quality of life

Follow‐up: 30 days

FACT‐PA questionnaire: scale 0 to 144, where higher values indicate better quality of life

The mean quality of life score in the no drain group was 104 points

The mean quality of life score in the drain groups was
105 points

Not estimable (see comment)

399
(1 study)

⊕⊕⊝⊝
Low2,3,5

The study reported the mean quality of life score, without mentioning the standard deviation.

* The basis for the assumed risk was the control group proportion in the study. The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the control group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; RR: Risk ratio; MD: mean difference.

GRADE Working Group grades of evidence
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1 Downgraded one level for serious imprecision (very few events, confidence interval of risk ratio overlapped 0.75 and 1.25).
2 Publication bias could not be assessed because of the few number of studies.
3 Downgraded one level for serious risk of bias.
4 Downgraded one level for serious heterogeneity.
5 Downgraded one level due to serious imprecision (total population size was less than 400).

Figuras y tablas -
Summary of findings for the main comparison. Drain use versus no drain use for pancreatic surgery
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Summary of findings 2. Active drain versus passive drain for pancreatic surgery

Active drain versus passive drain for pancreatic surgery

Patient or population: people undergoing elective open pancreatic resections
Setting: hospital
Intervention: active drain
Comparison: passive drain

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with passive drain

Risk with active drain

Mortality

Follow‐up: 30 days

1 per 1000

3 per 1000

(0 to 69)

RR 2.86
(0.12 to 69.06)

160
(1 study)

⊕⊕⊝⊝
Low1,2

There were no events in the control arm. A risk of "1 per 1000" was chosen for illustration. RR was calculated using a correction factor and should be interpreted with caution.

Mortality

Follow‐up: 90 days

Not reported

Intra‐abdominal infection

Follow‐up: 30 days

26 per 1000

5 per 1000

(0 to 100)

RR 0.19
(0.01 to 3.90)

160
(1 study)

⊕⊝⊝⊝
Very low1,2,3

Wound infection

Follow‐up: 30 days

90 per 1000

61 per 1000

(21 to 184)

RR 0.68
(0.23 to 2.05)

160
(1 study)

⊕⊝⊝⊝
Very low1,2,3

Drain‐related complications

Follow‐up: 30 days

Not reported

Morbidity

Follow‐up: 30 days

321 per 1000

218 per 1000

(131 to 369)

RR 0.68
(0.41 to 1.15)

160
(1 study)

⊕⊕⊝⊝
Low2,3,4

Length of hospital stay

Follow‐up: 30 days

The mean length of hospital stay in the passive drain group was 14.5 days

The mean length of hospital stay in the active drain group was
1.90 days lower
(3.67 days to 0.13 days lower)

MD ‐1.90 (‐3.67 to ‐0.13)

160
(1 study)

⊕⊕⊝⊝
Low2,3,5

Hospital costs

Follow‐up: 30 days

Not reported

Additional open procedures for postoperative complications

Follow‐up: 30 days

77 per 1000

12 per 1000

(2 to 99)

RR 0.16
(0.02 to 1.29)

160
(1 study)

⊕⊝⊝⊝
Very low1,2,3

Additional radiological interventions for postoperative complications

Follow‐up: 30 days

Not reported

Pain

Follow‐up: 30 days

Not reported

Quality of life

Follow‐up: 30 days

Not reported

* The basis for the assumed risk was the control group proportion in the study. The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the control group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; MD: mean difference; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded two levels for very serious imprecision (small sample sizes, very few events, confidence intervals of risk ratios overlapped 0.75 and 1.25).
2 Publication bias could not be assessed because of the few number of studies.
3 Downgraded one level for serious risk of bias.
4 Downgraded one level for serious imprecision (small sample sizes, very few events).
5 Downgraded one level due to serious imprecision (total population size was less than 400).

Figuras y tablas -
Summary of findings 2. Active drain versus passive drain for pancreatic surgery
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Summary of findings 3. Early versus late drain removal for pancreatic surgery

Early versus late drain removal for pancreatic surgery

Patient or population: people undergoing elective open pancreatic resections

Setting: hospital
Intervention: early drain removal
Comparison: late drain removal

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with late drain removal

Risk with early drain removal

Mortality

Follow‐up: 30 days

There was no mortality in either group.

114
(1 study)

⊕⊕⊕⊝
Moderate1,2

Mortality

Follow‐up: 90 days

Not reported

Intra‐abdominal infection

Follow‐up: 30 days

Not reported

Wound infection

Follow‐up: 30 days

Not reported

Drain‐related complications

Follow‐up: 30 days

Not reported

Morbidity

Follow‐up: 30 days

614 per 1000

387 per 1000

(264 to 571)

RR 0.63
(0.43 to 0.93)

114
(1 study)

⊕⊕⊝⊝
Low1,2,3

Length of hospital stay

Follow‐up: 30 days

The mean length of hospital stay in the late removal group was 10.8 days

The mean length of hospital stay in the early removal group was
2.1 days lower
(4.17 days to 0.03 days lower)

MD ‐2.10 (‐4.17 to ‐0.03)

114
(1 study)

⊕⊕⊝⊝
Low1,3,4

Hospital costs

Follow‐up: 30 days

The mean hospital costs in the late removal group was EUR 12140.00

The mean hospital costs in the early removal group was EUR 2069 lower
(EUR 3872.26 lower to EUR 265.74 lower)

MD ‐2069.00 (‐3872.26 to ‐265.74)

114
(1 study)

⊕⊕⊝⊝
Low1,3,4

Additional open procedures for postoperative complications

Follow‐up: 30 days

18 per 1000

6 per 1000
(0 to 141)

RR 0.33
(0.01 to 8.01)

114
(1 study)

⊕⊝⊝⊝
Very low1,3,5

Additional radiological interventions for postoperative complications

Follow‐up: 30 days

Not reported

Pain

Follow‐up: 30 days

Not reported

Quality of life

Follow‐up: 30 days

Not reported

* The basis for the assumed risk was the control group proportion in the study. The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the control group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; MD: mean difference; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Publication bias could not be assessed because of the few number of studies.
2 Downgraded one level for serious imprecision (small sample sizes, very few events).
3 Downgraded one level due to serious risk of bias.
4 Downgraded one level due to serious imprecision (total population size was fewer than 400).
5 Downgraded two levels for very serious imprecision (small sample sizes, very few events, confidence intervals of risk ratios overlapped 0.75 and 1.25).

Figuras y tablas -
Summary of findings 3. Early versus late drain removal for pancreatic surgery
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Comparison 1. Drain use versus no drain use

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Mortality (30 days) Show forest plot

3

711

Risk Ratio (M‐H, Random, 95% CI)

0.78 [0.31, 1.99]

2 Mortality (90 days) Show forest plot

2

478

Risk Ratio (M‐H, Random, 95% CI)

0.23 [0.06, 0.90]

3 Intra‐abdominal infection Show forest plot

4

1055

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.52, 1.80]

4 Wound infection Show forest plot

4

1055

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.68, 1.41]

5 Morbidity Show forest plot

4

1055

Risk Ratio (M‐H, Random, 95% CI)

1.03 [0.94, 1.13]

6 Length of hospital stay (days) Show forest plot

3

711

Mean Difference (IV, Random, 95% CI)

‐0.66 [‐1.60, 0.29]

7 Additional open procedures for postoperative complications Show forest plot

4

1055

Risk Ratio (M‐H, Random, 95% CI)

1.33 [0.79, 2.23]

8 Additional radiological interventions for postoperative complications Show forest plot

3

660

Risk Ratio (M‐H, Random, 95% CI)

0.87 [0.40, 1.87]
Figuras y tablas -
Comparison 1. Drain use versus no drain use
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Comparison 2. Active drain versus passive drain

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Mortality (30 days) Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

2 Intra‐abdominal infection Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

3 Wound infection Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

4 Morbidity Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

5 Length of hospital stay (days) Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

6 Additional open procedures for postoperative complications Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected
Figuras y tablas -
Comparison 2. Active drain versus passive drain
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Comparison 3. Early versus late drain removal

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Morbidity Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

2 Length of hospital stay (days) Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

3 Hospital costs (EUR) Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

4 Additional open procedures for postoperative complications Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected
Figuras y tablas -
Comparison 3. Early versus late drain removal
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Comparison 4. Drain use versus no drain use sensitivity analysis for missing data

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Mortality (90 days) ‐ worst‐case scenario Show forest plot

2

536

Risk Ratio (M‐H, Random, 95% CI)

2.15 [0.05, 89.11]

2 Mortality (90 days) ‐ best‐case scenario Show forest plot

2

536

Risk Ratio (M‐H, Random, 95% CI)

0.07 [0.00, 1.01]
Figuras y tablas -
Comparison 4. Drain use versus no drain use sensitivity analysis for missing data
Ir a la tabla de la revisión