|
1
|
Ritter AS, Welsch T, Brodersen F, Auinger J, Moll-Khosrawi P, Goetz MR, Bardenhagen J, Nitschke C, Schneider T, Wellge B, Suling A, Uzunoglu FG, Heumann A, Nickel F, Hackert T, Izbicki JR. Impact of Enhanced Recovery After Surgery Protocol Compliance on Outcome After Pancreatic Surgery: Results From a Certified ERAS Center. ANNALS OF SURGERY OPEN 2024; 5:e501. [PMID: 39711657 PMCID: PMC11661770 DOI: 10.1097/as9.0000000000000501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2024] [Accepted: 09/12/2024] [Indexed: 12/24/2024] Open
Abstract
Objective The aim was to evaluate the sustainability of the pancreatic Enhanced Recovery After Surgery (ERAS) program and the effect of ERAS items on patient morbidity and hospital stay. Background The current ERAS guideline recommendations encompass 27 items to improve recovery after pancreatoduodenectomy (PD). Methods Patients who underwent pancreatic resection at the University Hospital Hamburg-Eppendorf between February 2016 and June 2023 were included. The datasets were retrospectively collected from a central database. The effects of individual ERAS items and compliance on morbidity and hospital stay were assessed by uni- and multivariable analyses. Results In total, 594 patients who underwent PD (44.8%), distal pancreatectomy (14.6%), total pancreatectomy (17.8%), or other pancreatic resections (22.7%) were included. Of these, 90 patients (15.2%) achieved a high overall ERAS compliance of ≥70%. High compliance was associated with significantly less complications (Clavien-Dindo ≥ 3a), reduced 30-day mortality, and a shorter hospital stay. Early mobilization on the first postoperative day (POD1), restrictive intravenous fluid administration, and timely removal of urinary catheters were significant multivariable predictors for lower morbidity. Early mobilization on POD1 also correlated with reduced morbidity in the subcohort of PD cases. Conclusions The pancreatic ERAS protocol can be sustainably implemented and applied to both, PD and non-PD cases. A high level of compliance with the ERAS protocol after pancreatic resections correlated with improved outcomes but was achieved by less than one-fifth of patients. Early mobilization on POD1 and restrictive fluid management were key indicators for optimized short-term outcomes.
Collapse
Affiliation(s)
- Alina S. Ritter
- From the Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thilo Welsch
- From the Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Freya Brodersen
- From the Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Auinger
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Parisa Moll-Khosrawi
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mara R. Goetz
- From the Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Bardenhagen
- From the Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Nitschke
- From the Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Schneider
- From the Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Björn Wellge
- From the Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Anna Suling
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Faik G. Uzunoglu
- From the Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Asmus Heumann
- From the Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Felix Nickel
- From the Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thilo Hackert
- From the Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R. Izbicki
- From the Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
|
2
|
Li Z, Zhou L, Li M, Wang W, Wang L, Dong W, Chen J, Gong S. Early mobilization after pancreatic surgery: A randomized controlled trial. Surgery 2024; 176:1179-1188. [PMID: 39054183 DOI: 10.1016/j.surg.2024.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 05/02/2024] [Accepted: 06/13/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Pancreatic surgery has long been burdened with high postoperative morbidity. Early mobilization has been advocated to prevent complications and improve functional capacity. However, there is a lack of high-quality evidence supporting how to implement early mobilization and its independent impact on postoperative outcomes. The aim of this study was to investigate the effectiveness of implementing early mobilization in reducing postoperative complications and enhancing recovery in patients undergoing pancreatic surgery. METHODS We conducted a single-blind, randomized trial in patients who underwent pancreatic surgery in a tertiary hospital in China. Eligible participants were randomly assigned to either the control group or the intervention group. Patients in the control group received usual care, whereas those in the intervention group received the early enforced mobilization protocol. The protocol consisted of 2 key components: professional assistance with the first ambulation on postoperative day 1 and family-involved supervision to achieve daily walking goals. The primary outcome was postoperative complications within 30 days, measured by the Comprehensive Complication Index. Secondary outcomes were postoperative mobilization, time to recovery of gastrointestinal function, postoperative pulmonary complications, pancreatic surgery-specific complications, patient-reported outcome measures, and 30-day readmission and mortality. RESULTS A total of 135 patients were enrolled: 67 in the intervention group and 68 in the control group. The median Comprehensive Complication Index was not statistically significant between groups (mean difference -1.7; 95% confidence interval -8.7 to 0). Patients in the intervention group had earlier first ambulation postoperatively, walked greater distances on postoperative days 1-7, and had earlier time to first defecation. Trends for improvement in patient-reported outcomes showed that scores of Quality of Recovery 15 at postoperative day 3, physical function of Quality of Life Questionnaire C30 at postoperative day 7, and global quality of life at postoperative day 30 were significantly greater in the intervention group. There was no between-group difference in other domains of the Quality of Life Questionnaire C30 or other secondary outcome measures. CONCLUSION Early enforced mobilization intervention did not reduce postoperative complications of patients undergoing pancreatic surgery, but it can enhance postoperative mobilization and improve the recovery of gastrointestinal function and patient-perceived quality of recovery.
Collapse
Affiliation(s)
- Zhi Li
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan Province, China
| | - Lili Zhou
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan Province, China
| | - Meixia Li
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan Province, China
| | - Wei Wang
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan Province, China
| | - Lisheng Wang
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Wenwen Dong
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan Province, China
| | - Juan Chen
- Mental Health Center, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Shu Gong
- Department of Nursing, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan Province, China.
| |
Collapse
|
|
3
|
Xu Y, Yang F, Fu D. Prognostic value of para-aortic lymph node metastasis and dissection for pancreatic head ductal adenocarcinoma: a retrospective cohort study. JOURNAL OF PANCREATOLOGY 2024; 7:199-206. [DOI: 10.1097/jp9.0000000000000159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2025] Open
Abstract
Background:
Para-aortic lymph node (PALN) metastasis affects approximately 20% of patients with pancreatic ductal adenocarcinoma (PDAC). However, the prognostic significance of PALN metastases and dissection remains unclear.
Methods:
This retrospective cohort study included patients with PDAC of the pancreatic head who had undergone pancreaticoduodenectomy (PD) at our center between January 2017 and December 2020.
Results:
A total of 234 patients were included in the study. PALN dissection improved the median overall survival (OS) without statistical significance (24.1 vs 18.1 months, P = .156). The median recurrence-free survival was significantly longer in the PALN-dissection group than the group without PALN dissection (18.2 vs 11.6 months, P = .040). Conversely, there were no significant differences in the long-term prognosis between the PALN-positive and PALN-negative subgroups in the PALN-dissection group. Multivariate analysis showed that PALN metastasis was not an independent risk factor for OS (hazard ratio: 0.831, 95% confidence interval: 0.538–1.285, P = .406).
Conclusions:
For patients with pancreatic head ductal adenocarcinoma, PD with PALN dissection may achieve survival prolongation and bridge the survival gap between patients with and without PALN metastasis without significantly increasing the perioperative risks.
Collapse
Affiliation(s)
- Yecheng Xu
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Feng Yang
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Huashan Hospital, Fudan University, Shanghai 200040, China
| |
Collapse
|
|
4
|
Doussot B, Doussot A, Ayav A, Santucci N, Deguelte S, Sow AK, El Amrani M, Duvillard L, Piessen G, Girard E, Mabrut JY, Garnier J, Ortega-Deballon P, Fournel I, Facy O. Diagnostic Accuracy of Lipase as Early Predictor of Postoperative Pancreatic Fistula: Results from the LIPADRAIN study. ANNALS OF SURGERY OPEN 2024; 5:e492. [PMID: 39310332 PMCID: PMC11415086 DOI: 10.1097/as9.0000000000000492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 08/07/2024] [Indexed: 09/25/2024] Open
Abstract
Objective To evaluate the diagnostic accuracy of drain fluid lipase as an early predictor of postoperative pancreatic fistula and establish the most appropriate day for their measure. Background Clinically relevant postoperative pancreatic fistula remains a potentially life-threatening complication after pancreatic surgery. Early detection strategies remain key to reduce both the incidence and the burden of pancreatic fistula. Methods The LIPAse DRAIN (LIPADRAIN) study is a multicenter, prospective diagnostic study conducted in 7 tertiary university hospitals. Drain fluid values to detect clinically relevant postoperative pancreatic fistula from postoperative day 1 to postoperative day 6 were evaluated using receiver operating characteristic curve analysis. A biomarker was considered to be relevant for clinical use if its area under the curve (AUC) was greater than 0.75. Results Of the 625 patients included in the analysis, clinically relevant postoperative pancreatic fistula occurred in 203 (32%) patients. On postoperative days 3 and 4, drain fluid lipase was a reliable biomarker to detect clinically relevant postoperative pancreatic fistula (AUC: 0.761; 95% confidence interval [CI]: 0.761-0.799 and AUC: 0.784; 95% CI: 0.743-0.821, respectively). On postoperative day 3, with a threshold of 299 units/L, drain fluid lipase yielded a negative predictive value of 51%, sensitivity of 78%, and specificity of 63% for the detection of clinically relevant postoperative pancreatic fistula. Conclusions In this multicenter prospective study, drain fluid lipase is a reliable biomarker at postoperative days 3 and 4 for the diagnosis of clinically relevant postoperative pancreatic fistula after pancreatic surgery and should be systematically measured on postoperative day 3.
Collapse
Affiliation(s)
- Béranger Doussot
- From the Department of Digestive and Surgical Oncology, University Hospital Dijon, Dijon, France
| | - Alexandre Doussot
- Department of Digestive Surgical Oncology, Liver Transplantation Unit, CHU Besancon, Besancon, France
| | - Ahmet Ayav
- Department of Hepatobiliary, Colorectal and Digestive Surgery, University of Nancy, CHU Nancy-Brabois, Nancy, France
| | - Nicolas Santucci
- From the Department of Digestive and Surgical Oncology, University Hospital Dijon, Dijon, France
| | - Sophie Deguelte
- Department of Endocrine, Digestive and Oncological Surgery, Robert-Debré University Hospital, Reims, France
| | - Amadou Khalilou Sow
- INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
| | - Mehdi El Amrani
- Department of Digestive Surgery and Liver Transplantation, Claude Huriez University Hospital, Lille, France
| | - Laurence Duvillard
- Université de Bourgogne, INSERM Research Center U1231- PADYS team, Department of Biochemistry, University Hospital Dijon, Dijon, France
- Department of Biochemistry, University Hospital Dijon, Dijon, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - Edouard Girard
- Colorectal Unit, Department of Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean-Yves Mabrut
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, Hospital Croix Rousse, Lyon, France
| | - Jonathan Garnier
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Pablo Ortega-Deballon
- From the Department of Digestive and Surgical Oncology, University Hospital Dijon, Dijon, France
| | - Isabelle Fournel
- INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
| | - Olivier Facy
- From the Department of Digestive and Surgical Oncology, University Hospital Dijon, Dijon, France
| |
Collapse
|
|
5
|
Theja S, Mishra S, Bhoriwal S, Garg R, Bharati SJ, Kumar V, Gupta N, Vig S, Kumar S, Deo SVS, Bhatnagar S. Feasibility of the ERAS (Enhanced Recovery After Surgery) Protocol in Patients Undergoing Gastrointestinal Cancer Surgeries in a Tertiary Care Hospital-A Prospective Interventional Study. Indian J Surg Oncol 2024; 15:304-311. [PMID: 38741624 PMCID: PMC11088603 DOI: 10.1007/s13193-024-01897-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/02/2024] [Indexed: 05/16/2024] Open
Abstract
Enhanced Recovery After Surgery (ERAS) protocols have emerged as a promising approach to optimize perioperative care and improve outcomes in various surgical specialties. Despite feasibility studies on ERAS in various surgeries, there remains a paucity of research focusing on gastrointestinal cancer surgeries in the Indian context. The primary objective is to evaluate the compliance rate of the ERAS protocol and secondary objectives include the compliance rate of individual components of the protocol, the complications, the length of hospital stay, and the challenges faced during implementation in patients undergoing gastrointestinal cancer surgeries in our tertiary care cancer center. In this prospective interventional study (CTRI/2022/04/041657; registered on 05/04/2022), we evaluated 50 patients aged 18 to 70 years undergoing surgery for gastrointestinal malignancies and implemented a refined ERAS protocol tailored to our institutional resources and conditions based on standard ERAS society recommendations for gastrointestinal surgeries and specific recommendations for colorectal, pancreatic, and esophageal surgeries.Our study's mean overall compliance rate with the ERAS protocol was 88.54%. We achieved a compliance rate of 91.98%, 81.66%, and 92.00% for pre-operative, intraoperative, and post-operative components respectively. Fourteen (28%) patients experienced complications during the study. The median length of stay was 6.5 days (5.25-8). Challenges were encountered during the preoperative, intraoperative, and postoperative phases. The study highlighted the feasibility of implementing the ERAS protocol in a cancer institute, but specific challenges need to be addressed for its optimal success in gastrointestinal cancer surgeries. Supplementary Information The online version contains supplementary material available at 10.1007/s13193-024-01897-y.
Collapse
Affiliation(s)
- Surya Theja
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Seema Mishra
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, Room No. 249, Second Floor, New Delhi, Delhi India
| | - Sandeep Bhoriwal
- Department of Surgical Oncology, Dr. BRAIRCH, AIIMS, New Delhi, Delhi India
| | - Rakesh Garg
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Sachidanand Jee Bharati
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Vinod Kumar
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Nishkarsh Gupta
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Saurabh Vig
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Sunil Kumar
- Department of Surgical Oncology, Dr. BRAIRCH, AIIMS, New Delhi, Delhi India
| | - S. V. S. Deo
- Department of Surgical Oncology, Dr. BRAIRCH, AIIMS, New Delhi, Delhi India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| |
Collapse
|
|
6
|
Ni YX, Li Z, Zhou LL, Gong S. Factors influencing early mobilisation for patients undergoing pancreatic surgery from multiple perspectives: a qualitative descriptive study. BMJ Open 2023; 13:e077419. [PMID: 38056941 PMCID: PMC10711852 DOI: 10.1136/bmjopen-2023-077419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/09/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVES Despite early mobilisation as a key component of enhanced recovery after surgery pathways for pancreatic surgery, the implementation of early mobilisation remains unsatisfactory. What factors influence the implementation of early mobilisation from the lens of all stakeholders is unclear. The aim of this study was to identify the influencing factors of early mobilisation in pancreatic surgery from the perspective of patients, family members and health professionals. DESIGN A qualitative descriptive design using individual interviews and focus groups. SETTING AND PARTICIPANTS Twenty-two patients undergoing pancreatic surgery, 10 family members and 10 healthcare professionals from a large university teaching hospital in China. METHODS We collected data on participants' views on factors influencing early mobilisation after pancreatic surgery. Two researchers independently reviewed the transcripts and emergent coding. The data were analysed using qualitative content analysis. RESULTS Three main categories that influenced the implementation of early mobilisation in pancreatic surgery were identified: (1) attitude towards early postoperative mobilisation (eg, perceived advantages or disadvantages of early mobilisation), (2) subjective norm (eg, impact from health professionals, family members and fellow patients) and (3) perceived behavioural control (eg, knowledge, abilities, resources and environment). CONCLUSION Factors influencing early mobilisation are diverse and multidimensional. The successful implementation of early mobilisation requires the dedication of both patients and healthcare professionals.
Collapse
Affiliation(s)
- Yun-Xia Ni
- Department of Cardiology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Zhi Li
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Li-Li Zhou
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| | - Shu Gong
- Department of Nursing, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
|
7
|
Olsén MF, Andersson T, Nouh MA, Johnson E, Block L, Vakk M, Wennerblom J. Development of and adherence to an ERAS ® and prehabilitation protocol for patients undergoing pancreatic surgery: An observational study. Scand J Surg 2023; 112:235-245. [PMID: 37461804 DOI: 10.1177/14574969231186274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND AND OBJECTIVE There are still gaps in knowledge concerning the adherence to different multimodal pathways in pancreatic surgery. The aim of this trial was to explore and evaluate an Enhanced Recovery After Surgery (ERAS®) and prehabilitation protocol in patients undergoing open pancreatic surgery. METHODS Three groups of patients were included: two prospective series of 75 patients undergoing open pancreatic surgery following an ERAS® protocol with or without prehabilitation, and one group of 55 historical controls. Variables regarding adherence to, and effects of the protocols, were collected from the local database and the patients' hospital records. Patients' adherence to advice given pre-operatively was followed up using a study-specific questionnaire. RESULTS The patients reported high adherence to remembered advice given. The health care professionals' adherence to the various parts of the concepts varied. ERAS® implementation resulted in more frequent gut motility stimulation (p < 0.001) and shorter duration of epidural anesthesia, site drains, and urinary catheter (p = 0.001). With prehabilitation, more patients were screened concerning nutritional status and prescribed preoperative training (p < 001). There was a significant change in weight before surgery, a shorter time to first flatus and a shorter length of stay after implementation of the concepts (p < 0.05). Complications were rare in all three groups and there were no significant differences between the groups. CONCLUSION The implementation of an ERAS® and a prehabilitation protocol increased adherence to the protocols by both patients and healthcare professionals. An implementation of an ERAS® protocol with and without prehabilitation decreases length of stay and may decrease preoperative weight loss and time to bowel movement.
Collapse
Affiliation(s)
- Monika Fagevik Olsén
- Department of Physical Therapy, Sahlgrenska University Hospital S-413 45 Gothenburg Sweden
| | - Thomas Andersson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Micheline Al Nouh
- Department of Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Erik Johnson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Linda Block
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Anaesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - My Vakk
- Department of Clinical Nutrition, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johanna Wennerblom
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
|
8
|
Sun BJ, Yue TM, Xu N, Fowler C, Lee B. Impact of Successful Implementation of an Enhanced Recovery After Surgery Protocol for Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2023; 30:8156-8165. [PMID: 37684372 DOI: 10.1245/s10434-023-14222-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/13/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) are complex operations for the treatment of peritoneal metastases. Enhanced recovery after surgery (ERAS) protocols are intended to standardize preoperative, intraoperative, and postoperative pathways, with the goal of improving patient care. This study describes feasibility and outcomes after implementing an ERAS protocol for CRS/HIPEC at a tertiary academic center. METHODS A single-institution experience of CRS/HIPEC was reviewed from January 2020 to March 2023. Patients were categorized according to whether they underwent CRS/HIPEC before or after ERAS initiation. Outcomes and protocol adherence were evaluated. RESULTS A total of 115 CRS/HIPEC operations were included-74 before and 41 after ERAS implementation. Median age was younger in the post-ERAS group, whereas sex, comorbidities, peritoneal carcinomatosis index, operation performed, and operative time were similar between groups. The most common primary cancer sites were gynecologic (40%), appendiceal (24%), and colorectal (22%). Adherence to all postoperative ERAS components was 76%. More post-ERAS patients ambulated by postoperative day (POD) 1 (90% vs. 54%; p < 0.001), tolerated liquid diet by POD 2 (88% vs. 32%; p < 0.001), and had foley removed by POD 3 (86% vs. 43%; p < 0.001). There was a trend toward decreased length of stay in the post-ERAS cohort (7 vs. 8 days; p = 0.092), with no difference in major complications, intensive care unit admission, or 30-day readmission. CONCLUSIONS Despite the heterogeneity of CRS/HIPEC operations, implementing an ERAS protocol for our patients was feasible and resulted in postoperative outcomes and adherence comparable with that of other major abdominal surgeries. This supports the potential for success in ERAS programs for CRS/HIPEC patients.
Collapse
Affiliation(s)
- Beatrice J Sun
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Tiffany M Yue
- Stanford University School of Medicine, Stanford, CA, USA
| | - Nova Xu
- Stanford University School of Medicine, Stanford, CA, USA
| | - Cedar Fowler
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Byrne Lee
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, Stanford, CA, USA.
| |
Collapse
|
|
9
|
Grosh KM, Folkert KN, Chou J, Shebrain SA, Munene GM. A Cohort Study of an Enhanced Recovery Pathway for Pancreatic Surgery at a Community Hospital. Am Surg 2023; 89:2350-2356. [PMID: 35491837 DOI: 10.1177/00031348221093806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathways have been shown to improve pancreatic surgery outcomes, though feasibility in a community hospital remain unclear. We hypothesized that an ERAS protocol would reduce hospital length of stay (LOS) without increased morbidity. METHODS An ERAS pathway was initiated for patients undergoing pancreatic surgery at a community cancer center and compared to a historical cohort. The primary outcome was hospital LOS. Secondary outcomes included 30-day readmission rates, comprehensive complication index (CCI®), textbook outcomes (TO), and mortality. RESULTS A total of 144 patients were included, with 63 patients in the ERAS group and 81 in the control group. The mean LOS decreased significantly in the ERAS group (6.85 [± 4.8]) vs 9.96 [±6.8] days, P = .001), without an increase in 30-day admission rates or CCI. CONCLUSIONS Implementation of an ERAS protocol in a community setting reduced LOS without a corresponding increase in readmission rates or morbidity.
Collapse
Affiliation(s)
- Kent M Grosh
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Kyra N Folkert
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Jesse Chou
- Department of Plastic and Maxillofacial Surgery, University of Virginia, Charlottesville, VA, USA
| | - Saad A Shebrain
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Gitonga M Munene
- Department of General Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
- Western Michigan Cancer Center, Kalamazoo, MI, USA
| |
Collapse
|
|
10
|
De Luca R, Gianotti L, Pedrazzoli P, Brunetti O, Rizzo A, Sandini M, Paiella S, Pecorelli N, Pugliese L, Pietrabissa A, Zerbi A, Salvia R, Boggi U, Casirati A, Falconi M, Caccialanza R. Immunonutrition and prehabilitation in pancreatic cancer surgery: A new concept in the era of ERAS® and neoadjuvant treatment. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:542-549. [PMID: 36577556 DOI: 10.1016/j.ejso.2022.12.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/21/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
Pancreatic cancer (PC) is an aggressive disease, with a growing incidence, and a poor prognosis. Neoadjuvant treatments in PC are highly recommended in borderline resectable and recently in upfront resectable PC. PC is characterized by exocrine insufficiency and nutritional imbalance, leading to malnutrition/sarcopenia. The concept of malnutrition in PC is multifaceted, as the cancer-related alterations create an interplay with adverse effects of anticancer treatments. All these critical factors have a negative impact on the postoperative and oncological outcomes. A series of actions and programs can be implemented to improve resectable and borderline resectable PC in terms of postoperative complications, oncological outcomes and patients' quality of life. A timely nutritional evaluation and the implementation of appropriate evidence-based nutritional interventions in onco-surgical patients should be considered of importance to improve preoperative physical fitness. Unfortunately, nutritional care and its optimization are often neglected in real-world clinical practice. Currently available studies and ERAS® guidelines mostly support the use of pre- or perioperative medical nutrition, including immunonutrition, in order to decrease the rate of postoperative infections and length of hospital stay. Further data also suggest that medical nutrition should be considered proactively in PC patients, to possibly prevent severe malnutrition and its consequences on disease and treatment outcomes. This narrative review summarizes the most recent data related to the role of prehabilitation, ERAS® program, medical nutrition, and the timing of intervention on clinical outcomes of upfront resectable and borderline PC, and their potential implementation within the timeframe of neoadjuvant treatments.
Collapse
Affiliation(s)
- Raffaele De Luca
- Department of Surgical Oncology, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca, HPB Unit, San Gerardo Hospital, Monza, Italy.
| | - Paolo Pedrazzoli
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo and Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Oronzo Brunetti
- Medical Oncology Unit, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | - Alessandro Rizzo
- Medical Oncology Unit, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | - Marta Sandini
- Surgical Oncology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Salvatore Paiella
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Luigi Pugliese
- Department of Surgery, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Pietrabissa
- Department of Surgery, University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center - IRCCS and Humanitas University - Department of Biomedical Sciences Rozzano, Milan, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, Pisa University Hospital, Pisa, Italy
| | - Amanda Casirati
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Riccardo Caccialanza
- Clinical Nutrition and Dietetics Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| |
Collapse
|
|
11
|
Impact of Variations in the Nursing Care Supply-Demand Ratio on Postoperative Outcomes and Costs. J Patient Saf 2023; 19:86-92. [PMID: 36696585 DOI: 10.1097/pts.0000000000001094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Improving surgical outcomes is a priority during the last decades because of the rising economic health care burden. The adoption of enhanced recovery programs has been proven to be part of the solution. In this context, the impact of variations in the nursing care supply-demand ratio on postoperative complications and its economic consequences is still not well elucidated. Because patients require different amounts of care, the present study focused on the more accurate relationship between demand and supply of nursing care rather than the nurse-to-patient ratio. METHODS Through a 3-year period, 838 patients undergoing elective and emergent colorectal and pancreatic surgery within the institutional enhanced recovery after surgery (ERAS) protocol were retrospectively investigated. Nursing demand and supply estimations were calculated using a validated program called the Projet de Recherche en Nursing (PRN), which assigns points to each patient according to the nursing care they need ( estimated PRN) and the actual care they received ( real PRN), respectively. The real/estimated PRN ratio was used to create 2 patient groups: one with a PRN ratio higher than the mean (PRN+) and a second with a PRN ratio below the mean (PRN-). These 2 groups were compared regarding their postoperative complication rates and cost-revenue characteristics. RESULTS The mean PRN ratio was 0.81. A total of 710 patients (84.7%) had a PRN+ ratio, and 128 (15.3%) had a PRN- ratio. Multivariable analysis focusing on overall complications, severe complications, and prolonged length of stay revealed no significant impact of the PRN ratio for all outcomes ( P > 0.2). The group PRN- had a mean margin per patient of U.S. dollars 1426 (95% confidence interval, 3 to 2903) compared with a margin of U.S. dollars 676 (95% confidence interval, -2213 to 3550) in the PRN+ group ( P = 0.633). CONCLUSIONS A PRN ratio of 0.8 may be sufficient for patients treated following enhanced recovery after surgery guidelines, pending the adoption of an accurate nursing planning system. This may contribute to better allocation of nursing resources and optimization of expenses on the long run.
Collapse
|
|
12
|
Intraoperative conditions of patients undergoing pancreatoduodenectomy. Surg Oncol 2023; 46:101897. [PMID: 36630813 DOI: 10.1016/j.suronc.2022.101897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/18/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a severe complication following pancreatoduodenectomy (PD). Previous research in colorectal surgery demonstrated suboptimal intraoperative conditions to be related with an increased risk of anastomotic leakage. Aim of this study was to evaluate the intraoperative condition of patients undergoing PD by both assessing whether these known intraoperative modifiable risk factors in colorectal surgery are also present during PD and by measuring compliance to intraoperative ERAS guidelines. Secondly, to determine the relation of these factors with POPF. MATERIALS AND METHODS This prospective single center study included patients undergoing PD from 2016 to 2020. Parameters regarding the patient's general condition, local perfusion, oxygenation, surgical factors and ERAS elements were measured with a checklist intraoperatively, before the creation of the pancreatojejunal anastomosis. Uni- and multivariable logistic regression analyses were performed. RESULTS 83 patients were included. POPF occurred in 27.7% (9.0% grade B, 10.0% grade C). Patients with POPF significantly had more other postoperative complications compared to patients without POPF (100% vs. 76.2%, p = 0.017). A suboptimal intraoperative condition was observed in 89.2%. Overall compliance to the intraoperative ERAS guideline was 0%. In univariable analysis, soft pancreatic tissue, pancreatic duct <3 mm, tumor location and intraoperative vasopressor administration were significantly associated with POPF. In multivariable analysis, only soft pancreatic tissue was independently associated with POPF (OR 13.627; 95% CI 1.656-112.157, p = 0.015). CONCLUSION Awareness amongst surgeons and anesthesiologists should be created. The influence of these intraoperative factors on POPF should be further evaluated in future, larger studies.
Collapse
|
|
13
|
Kobayashi K, Inoue Y, Omiya K, Sato S, Kato T, Oba A, Ono Y, Sato T, Ito H, Matsueda K, Saiura A, Takahashi Y. Diagnosis and management of postpancreatectomy hemorrhage: A single-center experience of consecutive 1,096 pancreatoduodenectomies. Pancreatology 2023; 23:235-244. [PMID: 36764874 DOI: 10.1016/j.pan.2023.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 12/19/2022] [Accepted: 01/10/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND/OBJECTIVES This study aimed to assess the outcomes and characteristics of post-pancreatectomy hemorrhage (PPH) in over 1000 patients who underwent pancreatoduodenectomy (PD) at a high-volume hepatopancreaticobiliary center. METHODS This retrospective study analyzed consecutive patients who underwent PD from 2010 through 2021. PPH was diagnosed and managed using our algorithm based on timing of onset and location of hemorrhage. RESULTS Of 1096 patients who underwent PD, 33 patients (3.0%) had PPH; incidence of in-hospital and 90-day mortality relevant to PPH were one patient (3.0%) and zero patients, respectively. Early (≤24 h after surgery) and late (>24 h) PPH affected 9 patients and 24 patients, respectively; 16 patients experienced late-extraluminal PPH. The incidence of postoperative pancreatic fistula (p < 0.001), abdominal infection (p < 0.001), highest values of drain fluid amylase (DFA) within 3 days, and highest value of C-reactive protein (CRP) within 3 days after surgery (DFA: p < 0.001) (CRP: p = 0.010) were significantly higher in the late-extraluminal-PPH group. The highest values of DFA≥10000U/l (p = 0.022), CRP≥15 mg/dl (p < 0.001), and incidence of abdominal infection (p = 0.004) were identified as independent risk factors for PPH in the multivariate analysis. Although the hospital stay was significantly longer in the late-extraluminal-PPH group (p < 0.001), discharge to patient's home (p = 0.751) and readmission rate within 30-day (p = 0.765) and 90-day (p = 0.062) did not differ between groups. CONCLUSIONS Standardized management of PPH according to the onset and source of hemorrhage minimizes the incidence of serious deterioration and mortality. High-risk patients with PPH can be predicted based on the DFA values, CRP levels, and incidence of abdominal infections.
Collapse
Affiliation(s)
- Kosuke Kobayashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Kojiro Omiya
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shoki Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomotaka Kato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kiyoshi Matsueda
- Department of Diagnostic Ultrasound, Interventional Radiology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akio Saiura
- Department of Hepatobiliary and Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| |
Collapse
|
|
14
|
Enhanced recovery after surgery is feasible and safe in liver transplantation: a cohort study. HPB (Oxford) 2022; 24:2022-2028. [PMID: 35973930 DOI: 10.1016/j.hpb.2022.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/22/2022] [Accepted: 07/13/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The principles of enhanced recovery after surgery (ERAS) are being applied to still more advanced procedures. Liver transplantation offers a unique opportunity for a multimodal approach including donor care as well. Our objective was to determine if ERAS was applicable and safe in orthotopic liver transplantation (OLT). METHODS A national single centre retrospective study showing the implementation of ERAS from 2013 to 2019 with the proceeding 2 years serving as baseline. The primary endpoints were mortality, length of stay (LOS) in the ward and intensive care unit stay. Secondary endpoints were complications estimated by Dindo-Clavien classification, comprehensive complication index (CCI®) and re-admissions. RESULTS A total of 334 patients were included. LOS was significantly reduced from a median of 22.5 days at introduction to 14 days at 2019. Cold ischaemia time was reduced from a mean of 10.7 to 6.0 h and the use of blood products (erythrocytes, plasma and thrombocytes) from a median of 28 to 6 units. Complications were reduced in severity. Mortality and readmission rates were not affected. CONCLUSION ERAS principles are safe and recommended in patients undergoing OLT resulting in reduced severity of complications and LOS without affecting re-admissions or mortality.
Collapse
|
|
15
|
Majid-Jarrar G, Labgaa I, Halkic N, Demartines N, Hübner M, Roulin D. Application of an enhanced recovery after surgery pathway for distal pancreatectomy. BJS Open 2022; 6:6758524. [PMID: 36221188 PMCID: PMC9553863 DOI: 10.1093/bjsopen/zrac119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/15/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ghada Majid-Jarrar
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Ismail Labgaa
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Nermin Halkic
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Nicolas Demartines
- Correspondence to: Nicolas Demartines, Department of Visceral Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland (e-mail: )
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | | |
Collapse
|
|
16
|
Raza SS, Nutu OA, Powell-Brett S, Carvalheiro Boteon A, Hodson J, Abradelo M, Dasari B, Isaac J, Chatzizacharias N, Marudanayagam R, Mirza DF, Roberts JK, Sutcliffe RP. Impact of an enhanced recovery after surgery protocol on short-term outcomes in elderly patients undergoing pancreaticoduodenectomy. HPB (Oxford) 2022; 24:1720-1728. [PMID: 35643908 DOI: 10.1016/j.hpb.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/30/2022] [Accepted: 05/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND To determine whether the short-term benefits associated with an enhanced recovery after surgery programme (ERAS) following pancreaticoduodenectomy (PD) vary with age. METHODS 830 consecutive patients who underwent PD between January 2009 and March 2019 were divided according to age: elderly (≥75 years) vs. non-elderly patients (<75 years). Within each age group, cohort characteristics and outcomes were compared between patients treated pre- and post-ERAS (ERAS was systematically introduced in December 2012). Univariable and multivariable analysis were then performed, to assess whether ERAS was independently associated with length of hospital stay (LOS). RESULTS Of the entire cohort, 577 of 830 patients (69.5%) were managed according to an ERAS protocol, and 170 patients (20.5%) were aged ≥75 years old. Patients treated post-ERAS were significantly more comorbid than those pre-ERAS, with a mean Charlson Comorbidity Index of 4.6 vs. 4.1 (p < 0.001) and 6.0 vs. 5.7 (p = 0.039) for the non-elderly and elderly subgroups, respectively. There were significantly fewer medical complications in non-elderly patients treated post-ERAS compared to pre-ERAS (12.4% vs. 22.4%; p = 0.002), but not in elderly patients (23.6% vs. 14.0%; p = 0.203). On multivariable analysis, ERAS was independently associated with reduced LOS in both elderly (14.8% reduction, 95% CI: 0.7-27.0%, p = 0.041) and non-elderly patients (15.6% reduction, 95% CI: 9.2-21.6%, p < 0.001), with the effect size being similar in each group. CONCLUSION ERAS protocols can be safely applied to patients undergoing pancreaticoduodenectomy irrespective of age. Implementation of an ERAS protocol was associated with a significant reduction in postoperative LOS in both elderly and non-elderly patients, despite higher comorbidity in the post-ERAS period.
Collapse
Affiliation(s)
- Syed S Raza
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Oana A Nutu
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | - James Hodson
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Bobby Dasari
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - John Isaac
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | | | | | | |
Collapse
|
|
17
|
Chen H, Wang W, Zou S, Wang X, Ying X, Cheng D, Weng Y, Deng X, Shen B. Serum lipase on postoperative day one is a strong predictor of clinically relevant pancreatic fistula after pancreaticoduodenectomy: A retrospective cohort. Pancreatology 2022; 22:810-816. [PMID: 35717304 DOI: 10.1016/j.pan.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/07/2022] [Accepted: 06/01/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Increased postoperative serum amylase has been recently reported to be associated with increased postoperative morbidity, but studies on postoperative serum lipase are limited. The aim of this study was to evaluate the value of postoperative serum lipase in predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). METHOD A retrospective analysis was performed on 212 patients who underwent PD from September 2018 and March 2021, focusing on the association between postoperative day (POD) 1 serum lipase and CR-POPF. RESULTS Overall, 108 (50.9%) patients had elevated serum lipase levels (>68 U/L) on POD 1. Patients with elevated serum lipase exhibited a significantly higher incidence of CR-POPF (37.0% vs. 6.7%, p < 0.001). Receiver operating characteristic (ROC) analyses showed improved diagnostic accuracy for POD 1 serum lipase compared with POD 1 serum amylase in predicting CR-POPF (AUC: 0.801 vs. 0.745, p = 0.029). Elevated serum lipase on POD 1 and elevated serum CRP on POD 3 were identified as independent predictors of CR-POPF. A simple early postoperative model, consisting of POD 1 serum lipase levels and POD 3 serum CRP levels, showed good discrimination (AUC 0.76, 95% CI 0.69-0.83) to identify the onset of CR-POPF. CONCLUSION Serum lipase on POD 1 outperformed serum amylase on POD 1 in predicting CR-POPF after PD. The combination of POD 1 serum lipase and POD 3 serum CRP provides a reliable predicting model for CR-POPF.
Collapse
Affiliation(s)
- Haoda Chen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weishen Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Siyi Zou
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinjing Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiayang Ying
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dongfeng Cheng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanchi Weng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Xiaxing Deng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| |
Collapse
|
|
18
|
Principles of enhanced recovery in gastrointestinal surgery. Langenbecks Arch Surg 2022; 407:2619-2627. [PMID: 35861873 DOI: 10.1007/s00423-022-02602-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 06/28/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND To reduce the impact of surgery-related stress, enhanced recovery after surgery (ERAS) pathways have been developed since over 15 years with subsequent improved postoperative outcome. This multimodal and evidence-based perioperative approach has spread to all fields of gastrointestinal surgery, from esophagus, stomach, duodenum and pancreas, liver, small intestine and colon, and rectum, as well as for other specialties like vascular and cardia surgeries or neurosurgery, among others. PURPOSE The aim of this state-of-the-art article is to assess current state of evidence on perioperative management specifically in gastrointestinal surgery, with a focus on surgery-related aspects, outcome benefit, and future directions. CONCLUSION The surgical team must promote continuous improvement of the patient's ERAS compliance to ensure optimal perioperative care. Everyday clinical practice should be performed according to latest evidence-based medicine and challenging surgical dogma. Moreover, the surgeon must lead and support a multidisciplinary and collaborative teamwork tailored to patient's need especially with anesthetists and nursing staff.
Collapse
|
|
19
|
Scarsi S, Martin D, Halkic N, Demartines N, Roulin D. Enhanced recovery in elderly patients undergoing pancreatic resection: A retrospective monocentric study. Medicine (Baltimore) 2022; 101:e29494. [PMID: 35687782 PMCID: PMC9276327 DOI: 10.1097/md.0000000000029494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 05/05/2022] [Indexed: 01/04/2023] Open
Abstract
Enhanced recovery after surgery (ERAS) pathway for pancreas has demonstrated its value in clinical practice. However, there is a lack of specific evidence about its application in elderly patients. The aim of the present study was to assess the impact of age on compliance and postoperative outcomes. Patients ≥70 years old that underwent pancreatic resection within an ERAS pathway between 2012 and 2018 were included, and divided into three groups: 70-74, 75-79, and ≥80 years old. Compliance with ERAS items, length of stay, mortality, and complications were analyzed. 114 patients were included: 49, 37, and 28 patients aged 70-74, 75-79, and ≥80 years, respectively. Overall compliance to ERAS items between groups was not different (66%, 66%, and 62%, P = .201). No significant difference was observed in terms of median length of stay (14, 17, and 17 days, P = .717), overall complications (67%, 78%, and 71%, P = .529), major complications (26%, 32%, and 39%, P = .507), or mortality (0%, 3%, and 4%, P = .448) with increasing age. Application of an ERAS pathway is feasible in elderly patients with pancreatic resection. Increasing age was neither associated with poorer compliance nor worse postoperative outcomes.
Collapse
|
|
20
|
Iterative Changes in Risk-Stratified Pancreatectomy Clinical Pathways and Accelerated Discharge After Pancreaticoduodenectomy. J Gastrointest Surg 2022; 26:1054-1062. [PMID: 35023033 DOI: 10.1007/s11605-021-05235-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/08/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous implementation of risk-stratified pancreatectomy clinical pathways (RSPCPs) decreased length of stay (LOS) following pancreaticoduodenectomy (PD). This study's primary aim was to measure the association of iterative RSPCP revisions with accelerated discharge and early postoperative outcomes. METHODS This is a retrospective cohort study of a prospectively maintained surgical database (10/2016-9/2020). In February 2019, revised RSPCPs were implemented with earlier nasogastric tube (NGT) removal (postoperative day [POD] 1 for low risk; POD 2 for high risk) and updated drain fluid amylase cutoffs for POD 1/POD 3 removal. Perioperative outcomes between original and revised pathways were compared. Predictors of accelerated discharge (defined as ≤ POD 5 for low risk; ≤ POD 6 for high risk) were identified. RESULTS There were 233 (36% high risk) patients in original and 131 (32% high risk) in revised RSPCPs. After revision, the rate of POD 1 NGT removal was higher while POD ≤ 3 drain removal was similar. Median LOS decreased for low risk (5 vs. 6 days, p = 0.011) and high risk (6 vs. 9 days, p = 0.005) with no increase in delayed gastric emptying, postoperative pancreatic fistula, or readmissions. With POD 1 NGT removal, diet tolerance was earlier without increased NGT reinsertions. In low-risk patients, younger age, POD 1 NGT removal, and POD ≤ 3 drain removal were independent predictors of accelerated discharge. In high-risk patients, POD 1 NGT removal and POD ≤ 3 drain removal were independent predictors of accelerated discharge. CONCLUSIONS Following iterative revisions in RSPCPs, LOS after PD decreased further without increasing readmissions, and NGTs were removed earlier without increased reinsertions. Early NGT and drain removal are modifiable practices within RSPCPs that are associated with accelerated discharge.
Collapse
|
|
21
|
Pain management, fluid therapy and thromboprophylaxis after pancreatoduodenectomy: a worldwide survey among surgeons. HPB (Oxford) 2022; 24:558-567. [PMID: 34629261 DOI: 10.1016/j.hpb.2021.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/15/2021] [Accepted: 09/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this survey was to assess practices regarding pain management, fluid therapy and thromboprophylaxis in patients undergoing pancreatoduodenectomy on a global basis. METHODS This survey study among surgeons from eight (inter)national scientific societies was performed according to the CHERRIES guideline. RESULTS Overall, 236 surgeons completed the survey. ERAS protocols are used by 61% of surgeons and respectively 82%, 93%, 57% believed there is a relationship between pain management, fluid therapy, and thromboprophylaxis and clinical outcomes. Epidural analgesia (50%) was most popular followed by intravenous morphine (24%). A restrictive fluid therapy was used by 58% of surgeons. Chemical thromboprophylaxis was used by 88% of surgeons. Variations were observed between continents, most interesting being the choice for analgesic technique (transversus abdominis plane block was popular in North America), restrictive fluid therapy (little use in Asia and Oceania) and duration of chemical thromboprophylaxis (large variation). CONCLUSION The results of this international survey showed that only 61% of surgeons practice ERAS protocols. Although the majority of surgeons presume a relationship between pain management, fluid therapy and thromboprophylaxis and clinical outcomes, variations in practices were observed. Additional studies are needed to further optimize, standardize and implement ERAS protocols after pancreatic surgery.
Collapse
|
|
22
|
Pecorelli N, Mazza M, Guarneri G, Delpini R, Partelli S, Balzano G, Turi S, Meani R, Beretta L, Falconi M. Impact of care pathway adherence on recovery following distal pancreatectomy within an enhanced recovery program. HPB (Oxford) 2021; 23:1815-1823. [PMID: 33975798 DOI: 10.1016/j.hpb.2021.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 03/22/2021] [Accepted: 04/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND In bowel surgery, adherence to enhanced recovery program (ERP) has been associated with improved recovery. The objective of this study was to evaluate the impact of adherence to ERP elements on outcomes, and identify factors associated with successful recovery following distal pancreatectomy (DP). METHODS Data for 376 patients who underwent DP managed within an ERP including 16 perioperative elements were reviewed. Primary endpoint was successful recovery, a composite outcome defined as length of hospital stay≤7 days, no severe complications nor readmissions. RESULTS Patients had a mean (SD) overall adherence of 76 (14)%. Overall, 166 (44%) patients had a successful recovery. There was a positive association between overall adherence and successful recovery (OR 1.19, 95%CI 1.08-1.31 for every additional element, p = 0.001), while an inverse relationship was found with comprehensive complication index (8% reduction, 95%CI -15 to -2%, p = 0.011). Adherence to postoperative phase interventions had the greatest impact on recovery (OR 1.29, 95%CI 1.13-1.47 for every additional postoperative element; p < 0.001). At multivariable regression, early termination of IV fluids was the only ERP element associated with successful recovery (OR 2.80, 95%CI 1.73-4.54; p < 0.001). CONCLUSION Increased adherence to ERP elements was associated with successful early recovery and reduction of postoperative complication severity.
Collapse
Affiliation(s)
- Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | | | - Giovanni Guarneri
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | | | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Turi
- Department of Anesthesia, San Raffaele Scientific Institute, Milan, Italy
| | - Renato Meani
- Department of Anesthesia, San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Beretta
- Department of Anesthesia, San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| |
Collapse
|
|
23
|
Koh FH, Chua JMW, Tan JLJ, Foo FJ, Tan WJ, Sivarajah SS, Ho LML, Teh BT, Chew MH. Paradigm shift in gastrointestinal surgery − combating sarcopenia with prehabilitation: Multimodal review of clinical and scientific data. World J Gastrointest Surg 2021; 13:734-755. [PMID: 34512898 PMCID: PMC8394378 DOI: 10.4240/wjgs.v13.i8.734] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/08/2021] [Accepted: 07/12/2021] [Indexed: 02/06/2023] Open
Abstract
A growing body of evidence has demonstrated the prognostic significance of sarcopenia in surgical patients as an independent predictor of postoperative complications and outcomes. These included an increased risk of total complications, major complications, re-admissions, infections, severe infections, 30 d mortality, longer hospital stay and increased hospitalization expenditures. A program to enhance recovery after surgery was meant to address these complications; however, compliance to the program since its introduction has been less than ideal. Over the last decade, the concept of prehabilitation, or “pre-surgery rehabilitation”, has been discussed. The presurgical period represents a window of opportunity to boost and optimize the health of an individual, providing a compensatory “buffer” for the imminent reduction in physiological reserve post-surgery. Initial results have been promising. We review the literature to critically review the utility of prehabilitation, not just in the clinical realm, but also in the scientific realm, with a resource management point-of-view.
Collapse
Affiliation(s)
- Frederick H Koh
- Division of Surgery, Sengkang General Hospital, Singapore 544886, Singapore
| | - Jason MW Chua
- Institute of Molecular and Cell Biology, Agency for Science Technology and Research, Singapore 138673, Singapore
| | - Joselyn LJ Tan
- Institute of Molecular and Cell Biology, Agency for Science Technology and Research, Singapore 138673, Singapore
| | - Fung-Joon Foo
- Division of Surgery, Sengkang General Hospital, Singapore 544886, Singapore
| | - Winson J Tan
- Division of Surgery, Sengkang General Hospital, Singapore 544886, Singapore
| | | | - Leonard Ming Li Ho
- Division of Surgery, Sengkang General Hospital, Singapore 544886, Singapore
| | - Bin-Tean Teh
- Duke-NUS Graduate Medical School, National Cancer Centre Singapore, Singapore 169610, Singapore
| | - Min-Hoe Chew
- Division of Surgery, Sengkang General Hospital, Singapore 544886, Singapore
| |
Collapse
|
|
24
|
Nelson G, Wang X, Nelson A, Faris P, Lagendyk L, Wasylak T, Bathe OF, Bigam D, Bruce E, Buie WD, Chong M, Fairey A, Hyndman ME, MacLean A, McCall M, Pin S, Wang H, Gramlich L. Evaluation of the Implementation of Multiple Enhanced Recovery After Surgery Pathways Across a Provincial Health Care System in Alberta, Canada. JAMA Netw Open 2021; 4:e2119769. [PMID: 34357394 PMCID: PMC8346943 DOI: 10.1001/jamanetworkopen.2021.19769] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Engaging multidisciplinary care teams in surgical practice is important for the improvement of surgical outcomes. OBJECTIVE To evaluate the association of multiple Enhanced Recovery After Surgery (ERAS) pathways with ERAS guideline adherence and outcomes. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study compared a pre-ERAS cohort (2013-2017) with a post-ERAS cohort (2014-2018). All patients were from Alberta Health Services in Alberta, Canada, and had available ERAS and up to 1-year postsurgery administrative data. Data collected included age, sex, body mass index, tobacco and alcohol use, diabetes, comorbidity index, and surgical characteristics. Data analysis was performed from May 7, 2020, to February 1, 2021. INTERVENTIONS Implementation of 5 ERAS pathways (colorectal, liver, pancreas, gynecologic oncology, and radical cystectomy) across 9 sites. MAIN OUTCOMES AND MEASURES Adherence to ERAS guidelines was measured by the percentage of patients whose care met the common ERAS pathway care element criteria. Surgical procedures were grouped by complexity; complications were classified by severity. Outcome measures for the pre-post-ERAS cohorts included length of stay (LOS), readmission, complications, and mortality. RESULTS A total of 7757 patients participated in the study, including 984 in the pre-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 526 [53.5%] female) and 6773 in the post-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 3470 [51.2%] male). In the total cohort, care-element adherence improved from 52% to 76% (P < .001), no significant differences were found in serious complications (from 6.2% to 4.9%; P = .08) or 30-day mortality (from 0.71% to 0.93%; P = .50), 1-year mortality decreased from 7.1% to 4.6% (P < .001), mean (SD) LOS decreased from 9.4 (7.0) to 7.8 (5.0) days (P < .001), and 30-day readmission rates were unchanged (from 13.4% to 11.7%; P = .12). After adjustment for patient characteristics, the LOS mean difference decreased 0.71 days (95% CI, -1.13 to -0.29 days; P < .001), with no significant differences in adjusted 30-day readmission (-3.5%; 95% CI, -22.7% to 20.4%; P = .75), serious complications (1.3%; 95% CI, -26.2% to 39.0%; P = .94), or mortality (30-day mortality: 42% [95% CI, -35.4% to 212.3%]; P = .38; 1-year mortality: 8% [95% CI, -20.5% to 46.8%]; P = .62). The adjusted 1-year readmission rate was -15.6% (95% CI, -27.7% to -1.5%; P = .03) in favor of ERAS, and readmission LOS was shorter by 1.7 days (95% CI, -3.3 to -0.1 days; P = .04). CONCLUSIONS AND RELEVANCE The results of this quality improvement study suggest that implementation of ERAS across multiple pathways may improve health care practitioner adherence to ERAS guidelines, LOS, and readmission rates at a system level.
Collapse
Affiliation(s)
- Gregg Nelson
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Xiaoming Wang
- Analytics, Data Integration, Measurement, and Reporting, Alberta Health Services, Calgary, Alberta, Canada
| | - Alison Nelson
- Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
| | - Peter Faris
- Analytics, Data Integration, Measurement, and Reporting, Alberta Health Services, Calgary, Alberta, Canada
| | | | - Tracy Wasylak
- Strategic Clinical Networks, Alberta Health Services, Calgary, Alberta, Canada
| | - Oliver F. Bathe
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - David Bigam
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Erin Bruce
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, Alberta, Canada
| | - W. Donald Buie
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Michael Chong
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Adrian Fairey
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - M. Eric Hyndman
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Anthony MacLean
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Michael McCall
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Sophia Pin
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Haili Wang
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
|
25
|
Probability of Postoperative Complication after Liver Resection: Stratification of Patient Factors,Operative Complexity, and Use of Enhanced Recovery after Surgery. J Am Coll Surg 2021; 233:357-368.e2. [PMID: 34111534 DOI: 10.1016/j.jamcollsurg.2021.05.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/10/2021] [Accepted: 05/10/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The current study aimed to assess the performance of the 3-level complexity classification that stratified liver resection procedures into 3 complexity grades (grade I, low; grade II, intermediate; and grade III, high complexity) and to evaluate whether the Enhanced Recovery after Surgery (ERAS) protocol improves postoperative outcomes for each complexity grade. STUDY DESIGN Consecutive patients undergoing open liver resection and laparoscopic liver resection at Lausanne University Hospital during 2010 to 2020 were assessed. RESULTS A total of 437 patients were included. Operative time, estimated blood loss, and length of hospital stay increased significantly, with a stepwise increase of the grades from I to III in open liver resection and laparoscopic liver resection (all, p < 0.05). The same trend for Comprehensive Complication Index was found in open liver resection (p < 0.005). Age (p = 0.004), 3-level complexity classification (grade II vs I; p = 0.001; grade III vs I; p < 0.001), no use of the ERAS protocol (p = 0.016), and biliary reconstruction (p < 0.001) were significant predictors for postoperative complication, defined as Comprehensive Complication Index ≥ 26.2 in a multivariable logistic regression analysis. The prediction model incorporating the 4 factors had a calculated Concordance Index of 0.735 and 0.742 based on the bootstrapping method. The use of ERAS protocol was associated with lower probability of postoperative complication for each complexity grade and age. CONCLUSIONS The use of ERAS protocol can decrease the probability of postoperative complication for each surgical complexity of liver resection and patient age. This finding emphasized the importance of tailoring perioperative management according to surgical complexity and patient age to improve outcomes after liver resection.
Collapse
|
|
26
|
Karunakaran M, Jonnada PK, Barreto SG. Systematic review and meta-analysis of the impact of deviations from a clinical pathway on outcomes following pancreatoduodenectomy. World J Clin Cases 2021; 9:3024-3037. [PMID: 33969088 PMCID: PMC8080740 DOI: 10.12998/wjcc.v9.i13.3024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/06/2021] [Accepted: 03/12/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery is steadily gaining importance in patients undergoing pancreatic surgery, including pancreatoduodenectomy (PD). While clinical pathways targeting enhanced-recovery can achieve their intended outcome in reducing length of stay, compliance to these pathways, and their relevance is poorly understood. The aim of this systematic review was to assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes.
AIM To assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes.
METHODS A systematic review of major reference databases was undertaken, according to preferred reporting items for systematic reviews and meta-analysis guidelines, between January 2000 and November 2020 relating to compliance with clinical pathways and its impact on outcomes in patients undergoing PD. A meta-analysis was performed using fixed-effects or random-effects models.
RESULTS Eleven studies including 1852 patients were identified. Median overall compliance to all components of the clinical pathway was 65.7% [interquartile range (IQR): 62.7%-72.3%] with median compliance to post-operative parameters of the clinical pathway being 44% (IQR: 34.5%-52.25%). Meta-analysis using a fixed-effects model showed that ≥ 50% compliance to a clinical pathway predicted significantly fewer post-operative complications [pooled odds ratio (OR): 9.46, 95% confidence interval (CI): 5.00-17.90; P < 0.00001] and a significantly shorter length of hospital stay [pooled mean difference (MD): 4.32, 95%CI: -3.88 to -4.75; P < 0.0001]. At 100% compliance which was associated with significantly fewer post-operative complications (pooled OR: 11.25, 95%CI: 4.71-26.84; P < 0.00001) and shorter hospital stay (pooled MD of 4.66, 95%CI: 2.81-6.51; P < 0.00001).
CONCLUSION Compliance to post-PD clinical pathways remains low. Deviations are associated with an increased risk of complications and length of hospital stay. Under-standing the relevance of deviations to clinical pathways post-PD presents pancreatic surgeons with opportunities to actively pursue an enhanced-recovery of their patients.
Collapse
Affiliation(s)
- Monish Karunakaran
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Gurgaon 122001, Haryana, India
- Department of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurgaon 122001, Haryana, India
| | - Pavan Kumar Jonnada
- Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru 560029, Karnataka, India
| | - Savio George Barreto
- Division of Surgery and Perioperative Medicine, Flinders Medical Center, Bedford Park 5042, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park 5042, South Australia, Australia
| |
Collapse
|
|
27
|
Achieving 'Marginal Gains' to Optimise Outcomes in Resectable Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13071669. [PMID: 33916294 PMCID: PMC8037133 DOI: 10.3390/cancers13071669] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary Improving outcomes in pancreatic cancer is achievable through the accumulation of marginal gains. There exists evidence of variation and undertreatment in many areas of the care pathway. By fully realising the existing opportunities, there is the potential for immediate improvements in outcomes and quality of life. Abstract Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.
Collapse
|
|
28
|
Karunakaran M, Barreto SG. ERAS® following pancreatoduodenectomy - more than just reducing hospital stay. HPB (Oxford) 2021; 23:321. [PMID: 33246800 DOI: 10.1016/j.hpb.2020.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Monish Karunakaran
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India; Department of Liver Transplantation & Regenerative Medicine, Medanta-The Medicity, India
| | - Savio G Barreto
- College of Medicine and Public Health, Flinders University, South Australia, Australia; Division of Surgery and Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia.
| |
Collapse
|
|
29
|
Gilgien J, Hübner M, Halkic N, Demartines N, Roulin D. Perioperative fluids and complications after pancreatoduodenectomy within an enhanced recovery pathway. Sci Rep 2020; 10:17898. [PMID: 33087844 PMCID: PMC7578041 DOI: 10.1038/s41598-020-74907-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/05/2020] [Indexed: 01/04/2023] Open
Abstract
Optimized fluid management is a key component of enhanced recovery (ERAS) pathways. Implementation is challenging for pancreatoduodenectomy (PD) and clear guidance is missing in the respective protocol. The aim of this retrospective study was to evaluate the influence of perioperative intravenous (IV) fluid administration on postoperative complications. 164 consecutive patients undergoing PD within ERAS between October 2012 and June 2017 were included. Perioperative IV fluid and morbidity (Clavien classification and comprehensive complication index (CCI)) were assessed. A threshold of more than 4400 ml IV fluid during the first 24 h could be identified to predict occurrence of complications (area under ROC curve 0.71), with a positive and negative predictive value of 93 and 23% respectively. More than 4400 ml intravenous fluids during the first 24 h was an independent predictor of overall postoperative complications (adjusted odds ratio 4.40, 95% CI 1.47–13.19; p value = 0.008). Patients receiving ≥ 4400 ml were associated with increased overall complications (94 vs 77%; p value < 0.001), especially pulmonary complications (31 vs 16%; p value = 0.037), as well as a higher median CCI (33.7 vs 26.2; p value 0.041). This threshold of 4400 ml intravenous fluid might be a useful indicator for the management following pancreatoduodenectomy.
Collapse
Affiliation(s)
- Jérôme Gilgien
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), 1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), 1011, Lausanne, Switzerland
| | - Nermin Halkic
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), 1011, Lausanne, Switzerland.
| | - Didier Roulin
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), 1011, Lausanne, Switzerland
| |
Collapse
|
|
30
|
St-Amour P, St-Amour P, Joliat GR, Eckert A, Labgaa I, Roulin D, Demartines N, Melloul E. Impact of ERAS compliance on the delay between surgery and adjuvant chemotherapy in hepatobiliary and pancreatic malignancies. Langenbecks Arch Surg 2020; 405:959-966. [PMID: 32918147 PMCID: PMC7541355 DOI: 10.1007/s00423-020-01981-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/01/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Multidisciplinary approach with adjuvant chemotherapy is the key element to provide optimal outcomes in pancreas and liver malignancies. However, post-operative complications may increase the interval between surgery and chemotherapy with negative oncologic effects. HYPOTHESIS AND STUDY AIM The aim of the study was to analyse whether compliance to Enhanced Recovery After Surgery (ERAS) pathway was associated with decreased interval to adjuvant chemotherapy. METHODS Retrospective analysis of all consecutive ERAS patients with surgery for hepatobiliary or pancreatic malignancies at the University Hospital of Lausanne between 2012 and 2016. Multivariate analysis was performed to assess the impact of ERAS compliance on time to chemotherapy. RESULTS A total of 133 patients with adjuvant chemotherapy were included (n = 44 liver and n = 89 pancreatic cancer). Median compliance to ERAS was 61% (IQR 55-67) for the study population, and median delay to chemotherapy was 49 days (IQR 39-61). Overall, compliance ≥ 67% to ERAS induced a significant reduction in the interval between surgery and chemotherapy for young patients (< 65 years old) with or without severe comorbidities (reduction of 22 and 10 days, respectively). High compliance in young ASA3 patients with liver colorectal metastases was associated with an increase of 481 days of DFS. CONCLUSIONS ERAS compliance ≥ 67% tends to be associated with a reduction in the delay to adjuvant chemotherapy for young patients with hepatobiliary and pancreatic malignancies. More prospective studies with strict adhesion to the ERAS protocol are needed to confirm these results.
Collapse
Affiliation(s)
- Pénélope St-Amour
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Pascal St-Amour
- Department of Economics, HEC Lausanne, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Aude Eckert
- Department of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Ismail Labgaa
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Didier Roulin
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Emmanuel Melloul
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| |
Collapse
|
|
31
|
Roulin D, Demartines N. Evidence for enhanced recovery in pancreatic cancer surgery. Langenbecks Arch Surg 2020; 405:595-602. [DOI: 10.1007/s00423-020-01921-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 06/24/2020] [Indexed: 12/18/2022]
|
|
32
|
Hu Q, Wu JF. Comment on: Comparison of the duration of hospital stay after laparoscopic or open distal pancreatectomy: randomized controlled trial. Br J Surg 2020; 107:e278. [PMID: 32432356 DOI: 10.1002/bjs.11680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 04/16/2020] [Indexed: 12/07/2022]
Affiliation(s)
- Q Hu
- Department of General Surgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - J F Wu
- Department of General Surgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| |
Collapse
|