Published online May 6, 2021. doi: 10.12998/wjcc.v9.i13.3024
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
Processing time: 136 Days and 7.3 Hours
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.
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.
The objective of this systematic review was to assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes.
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.
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).
Compliance to post-PD clinical pathways remains low. Deviations are associated with an increased risk of complications and length of hospital stay.
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.