Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center: Value of tailored peri-pancreatectomy protocols

Table 2 Caribbean peri-pancreatic surgery protocols

Pre-operative	Multidisciplinary care	All patients presented at a weekly multidisciplinary team meeting to review images and consensus decision making
	Patient consultation	Patient evaluated by attending surgeon to relay multidisciplinary team decisions
	Pre-operative counseling	Verbal information during pre-operative consultation
		Ensure patient receives a written pamphlets with information
	Patient education	Refer to AHPBA Caribbean Chapter video resources
		Part one of informed consent process as outpatient
	Medical clearance	Pre-operative cardiopulmonary exercise testing
		Evaluation and clearance from cardiology/pulmonology teams
		Pre-operative consultations with anesthesia team in patients with borderline fitness as a condition for acceptance for surgery
	Prehabilitation	Patients encouraged to discontinue smoking
		Discuss exercise regime pre-operatively
		Pre-operative chest physiotherapy
		Supervised exercise regime with physical trainer
	Fasting guidelines	Discourage prolonged fasting
		Encourage a carbohydrate-rich drink on the morning of surgery
	Biliary decompression	Appropriate decompression, as decided by multidisciplinary team
		Ensure standard blood tests are available within 48 h of surgery
	Supportive care	Ensure ICU bed is reserved prior to surgery
		Ensure ≥ 2 units of packed cells are available in the operating room
Intra-operative	Pre-operative anesthesia	Avoid routine sedatives prior to surgery
		Regional block and/or rectal sheath blocks prior to surgery
	Surgical team	Two experienced HPB surgeons operate together
		Dedicated nursing team
		Dedicated anesthetic team
	Prevention of intra-operative hypothermia	Close monitoring to maintain normothermia
		Active warming devices
		Pneumatic compression device available
	Peri-operative fluid management	Patients receive intra-operative restricted goal directed fluid therapy
		Ensure warmed fluids
	Specialized equipment	Ensure specialty equipment is available: Omni-Tract®, staplers
	Peri-operative tasks	Administer thrombo-prophylaxis at induction
		Administer prophylactic antibiotics at induction
		Place central line, urinary catheter, arterial lines prior to surgery
Post-operative	Escalation	Follow rescue protocols and inform attending surgeon if there is any deviation from expected post-operative course
	Ambulation	Patients encouraged to ambulate on the same day post-operatively
	Post-operative review	Surgical team rostered to physically review patient on 4 hourly shifts for 1st 36 h
	Fluid balance	Ensure adequate urine output of 0.5-1 mL/kg/h
		Ensure appropriate intravenous fluid regime is being followed
	Respiratory	Encourage coughing
		Encourage use of incentive spirometer
		Ensure physiotherapist input
	Analgesia	Stepwise multimodal pain management to minimize opioid administration
	Tubes	Consider early removal of urinary catheter
		Consider early removal of nasogastric tubes
		Drain evaluation at post-operative day 3
	Post-operative diet	Consider early oral fluid intake, once clinically appropriate
	Thrombo-prophylaxis	Ensure pneumatic compression device is being used
		Ensure prophylactic low molecular weight heparin is being administered

AHPBA: Americas Hepato-Pancreato-Biliary Association; HPB: Hepato-pancreato-biliary; ICU: Intensive care unit.