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(13): 3024-3037 [PMID: 33969088 DOI: 10.12998/wjcc.v9.i13.3024]
Corresponding Author of This Article
Savio George Barreto, FAIS, FRACS, PhD, Doctor, Senior Lecturer, College of Medicine and Public Health, Flinders University, Bedford Park 5042, South Australia, Australia. georgebarreto@yahoo.com
Research Domain of This Article
Surgery
Article-Type of This Article
Systematic Reviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Clin Cases. May 6, 2021; 9(13): 3024-3037 Published online May 6, 2021. doi: 10.12998/wjcc.v9.i13.3024
Systematic review and meta-analysis of the impact of deviations from a clinical pathway on outcomes following pancreatoduodenectomy
Monish Karunakaran, Pavan Kumar Jonnada, Savio George Barreto
Monish Karunakaran, Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Gurgaon 122001, Haryana, India
Monish Karunakaran, 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
Savio George Barreto, College of Medicine and Public Health, Flinders University, Bedford Park 5042, South Australia, Australia
Author contributions: Karunakaran M was responsible for the conceptualization of the study, selection of studies, interpretation of data and drafting of the manuscript; Jonnada PK was responsible for the selection of studies, statistical analysis and interpretation of data; Barreto SG was responsible for the conceptualization and design of the study, interpretation of data and critical review of the manuscript and final approval.
Conflict-of-interest statement: All the authors have no conflicts of Interest to declare.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Savio George Barreto, FAIS, FRACS, PhD, Doctor, Senior Lecturer, College of Medicine and Public Health, Flinders University, Bedford Park 5042, South Australia, Australia. georgebarreto@yahoo.com
Received: December 7, 2020 Peer-review started: December 7, 2020 First decision: December 31, 2020 Revised: January 6, 2021 Accepted: March 12, 2021 Article in press: March 12, 2021 Published online: May 6, 2021
ARTICLE HIGHLIGHTS
Research 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.
Research motivation
Appreciating the importance of deviations from a clinical pathway for pancreatic surgery will empower surgeons not only to identify patients at risk of complications but also to develop strategies to improve the pathway and, in turn, patient outcomes.
Research objectives
The objective of this systematic review was to assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes.
Research methods
A systematic review and meta-analysis of the literature gleaned from a search performed on MEDLINE, SCOPUS, EMBASE, and Google Scholar databases for the articles published between January 2000 and November 2020 relating to compliance with clinical pathways and its impact on outcomes in patients undergoing PD, was performed.
Research 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 4.32, 95%CI: -3.88 to -4.75; P < 0.0001). A 100% compliance 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 mean difference of 4.66, 95%CI: 2.81-6.51; P < 0.00001).
Research conclusions
Compliance to post-PD clinical pathways remains low. Deviations are associated with an increased risk of complications and length of hospital stay.
Research perspectives
Understanding the relevance of deviations to clinical pathways post-PD presents pancreatic surgeons with opportunities to scrutinize (and amend) their existing pathways with the ultimate goal of enhancing the recovery of their patients.
