Systematic review and meta-analysis of the impact of deviations from a clinical pathway on outcomes following pancreatoduodenectomy

Table 2 Summarising the morbidity, mortality and readmission rates along with length of stay and impact of deviations on these outcomes

Ref.	Length of stay1 (d)	Complications (%)		Mortality (%)	Readmissions (%)	Impact of deviations/non-compliance to clinical pathway
		Overall	≥ CD 3
Braga et al[16]	14.6 ± 9.8	60	20	3.5	12.2	Significantly lower deviations in patients with uneventful post-operative course; Lower compliance correlated with severity of postoperative complications; Low compliance to early oral feeding most likely to be associated with postoperative complications
Zouros et al[17]	9.7 ± 5.6	34.7	14.7	4	6.7	< 100% compliance associated with significantly higher rates of postoperative complications (72.7% vs 20.8%; P < 0.001)
Kagedan et al[18]	9 (7-14)	NA	NA	0.8	16	< 100% compliance associated with longer length of stay (13 vs 7 d, P < 0.001) and greater mean total cost of the index postoperative hospitalization ($20392.81 CAD vs $10562.28 CAD, P < 0.002)
Tremblay St-Germain et al[20]	8 (4-35)	67.5	29	0	222	Failure to remove urinary catheter by POD 3, and initiate solid diet ≤ POD 4 (P < 0.01 and P < 0.001, respectively), more likely to have prolonged length of stay (> 8 d)
Agarwal et al[23]	12 (4-78)	63.2	33.2	3.5	7.8	< 80% compliance associated with significantly increased major complications (44% vs 28.7%, P < 0.004), CR-POPF (32.7% vs 20.8%, P < 0.012), longer length of stay [15 (4-61) vs 11 (5-78), P < 0.001)], re-explorations (17.2% vs 6.8%, P < 0.002), escalation of antibiotics (24.1% vs 14.7%, P < 0.025) and mortality (6.8% vs 2.1%, P = 0.021)
Williamsson et al[24]	12 (6-97)	69.4	21.25	1.25	16.252	< 50% compliance associated with delayed discharge [10 (6-77) vs 23 (8-97) d] and higher incidence of CD ≥ 3A complications [21 (16%) vs 13 (50%)]; ≥ 90% (n = 13) compliance had a median discharge of POD 8 (7-9) and no complication ≥ CD3A
Karunakaran et al[6]	10.8 ± 5.8	71	23.5	6.2	23.72	< 50% compliance significantly higher risk of complications [DGE (79.7% vs 19.4%, P = 0.0001); POPF (22.2% vs 8.1%, P < 0.025); CD 3/4 complications (37.5% vs 6.1%, P < 0.0001)], longer length of stay (14 vs 10.8 d, P < 0.0001), 90-d readmissions (40.7% vs 14.3%, P = 0.0001) and mortality (14.1% vs 1%, P < 0.003)
Roulin et al[10]	14 (9-22)	83.7	36.9	3.1	11.3	< 70% compliance significantly increased length of stay [15 (10-23) vs 11 (7-16) d, P < 0.001], and overall (88.9% vs 78.8%, P < 0.029) and major (43.6 vs 28.2, P < 0.012) complications (especially respiratory and infectious)
Tankel et al[21]	14 (6-100)	NA	21.6	2.1	28.9	< 100% compliance had a longer length of stay ≥ 14 d
Capretti et al[22]	14.1 ± 8.6	54.6	15.6	1	3.4	Sum of failed ERP components/deviations significantly correlated with postoperative complications
St-Amour et al[19]	NA	NA	NA	NA	NA	No significant effect of ERAS® compliance on time to receipt of adjuvant chemotherapy from surgery, or disease-free survival

¹Expressed either as median (range) or mean (± SD).

²90-d readmissions (as opposed to others reporting 30-d readmissions). CD: Clavien-dindo; CAD: Canadian dollars; CR-POPF: Clinically-relevant post-pancreatectomy pancreatic fistula; DGE: Delayed gastric emptying; ERAS: Enhanced recovery after surgery; ERP: Enhanced recovery pathway; NA: Not available; POD: Post-operative day.