Effect of Surgery on Postoperative Levels of the Gut Homeostasis-Regulating Enzyme Intestinal Alkaline Phosphatase.

BACKGROUND: Intestinal homeostasis is a crucial factor for complication-free short- and long-term postoperative recovery. The brush border enzyme intestinal alkaline phosphatase (IAP) is an important regulator of gut barrier function and intestinal homeostasis and prevents endotoxemia by detoxifying lipopolysaccharides (LPSs). As IAP is predominantly secreted by enterocytes in the duodenum, we hypothesized that pancreaticoduodenectomy (PD) leads to a significantly stronger decrease in IAP than other major abdominal surgery. STUDY DESIGN: Pre- and postoperative blood, stool, and intestinal samples were collected from patients undergoing PD, as well as other major surgical procedures without duodenectomy. The samples were analyzed using enzyme histochemistry, the para -nitrophenyl phosphate method for IAP, and the limulus amebocyte lysate assay for LPS. RESULTS: Overall, 88 patients were prospectively enrolled in the study. Fecal IAP activity negatively correlated with serum LPS (r = -0.3603, p = 0.0006). PD led to a significant decline in IAP compared to preoperative baseline levels (p < 0.0001). The decline in IAP correlated with the length of proximal small intestinal resection (r = 0.4271, p = 0.0034). Compared to controls, PD was associated with a much more pronounced reduction in IAP-also after adjusting for surgical trauma (operative time, blood loss; r = 0.4598, p = 0.0086). Simultaneously, PD triggered a clearly more prominent increase in serum LPS compared to controls (p = 0.0001). Increased postoperative LPS was associated with an elongated hospitalization (r = 0.7534, p = 0.0062) and more prominent in pancreatic cancer (p = 0.0009). CONCLUSIONS: Based upon the functional roles for IAP, supplementation with exogenous IAP might be a new treatment option to improve short- and long-term outcome after PD.

Glucose Metabolism After Pancreatectomy: Opposite Extremes Between Pancreaticoduodenectomy and Distal Pancreatectomy.

CONTEXT: The rate of glucose metabolism changes drastically after partial pancreatectomy. OBJECTIVE: This work aims to analyze changes in patients' glucose metabolism and endocrine and exocrine function before and after partial pancreatectomy relative to different resection types (Kindai Prospective Study on Metabolism and Endocrinology after Pancreatectomy: KIP-MEP study). METHODS: A series of 278 consecutive patients with scheduled pancreatectomy were enrolled into our prospective study. Of them, 109 individuals without diabetes, who underwent partial pancreatectomy, were investigated. Data were compared between patients with pancreaticoduodenectomy (PD, n = 73) and those with distal pancreatectomy (DP, n = 36). RESULTS: Blood glucose levels during the 75-g oral glucose tolerance test (75gOGTT) significantly decreased after pancreatectomy in the PD group (area under the curve [AUC] -9.3%, P < .01), and significantly increased in the DP population (AUC + 16.8%, P < .01). Insulin secretion rate during the 75gOGTT and glucagon stimulation test significantly decreased after pancreatectomy both in the PD and DP groups (P < .001). Both groups showed similar homeostasis model assessment of insulin resistance (HOMA-IR) values after pancreatectomy. Decrease in exocrine function quality after pancreatectomy was more marked in association with PD than DP (P < .01). Multiple regression analysis indicated that resection type and preoperative HOMA-IR independently influenced glucose tolerance-related postoperative outcomes. CONCLUSIONS: Blood glucose levels after the OGTT differed markedly between PD and DP populations. The observed differences between PD and DP suggest the importance of individualization in the management of metabolism and nutrition after partial pancreatectomy.

Whipple's pancreaticoduodenectomy for cancer of the head of the pancreas in a patient with amyotrophic lateral sclerosis: perioperative challenges.

The association of amyotrophic lateral sclerosis and pancreatic cancer is rare. Amyotrophic lateral sclerosis is a neurodegenerative disease characterised by pure motor symptoms in the form of progressive muscle weakness and wasting, and can involve the bulbar and respiratory muscles, leading to significant morbidity. Successful surgery for patients with amyotrophic lateral sclerosis for pancreatic cancer has rarely been reported. Surgery in such patients is a dual-edged sword and is decided based on risk-benefit ratio. Patients are at high risk for general anaesthesia because of muscular weakness, increased sensitivity to muscle relaxants and certain anaesthetic drugs. There is a high chance of prolonged postoperative ventilatory support, aspiration pneumonia and pulmonary complications. We report a patient with cancer of the head of the pancreas who underwent successful elective pancreaticoduodenectomy.

PERIOPERATIVE MULTIMODAL PROGRAM OF ENHANCED RECOVERY FOLLOWING PANCREATICODUODENECTOMY.

Mortality after pancreaticoduodenectomy (PD) decreased from 25% to 1-3% in the last decade. However, the number of early postoperative complications varies from 29.5% to 70%. Therefore, there is a need in new methods of perioperative management of patients after PD to improve the immediate results.  To analyze the effectiveness of perioperative treatment regimens, a prospective retrospective study of the results of 78 patients after PD with diseases of the head of the pancreas and the periampular zone for the period from 2003 to 2017 was conducted. For comparative analysis, the patients were divided into 2 groups: group I included 39 patients for the period from January 2015 to December 2017, the perioperative treatment of which was carried out in accordance with the enhanced recovery program, group II -39 patients from January 2003 to December 2014, which were conducted according to the traditional method. We studied the time of the restoration of oral nutrition, postoperative complications, the length of hospital stay (LoS).There were no mortality in groups. The overall incidence of Clavien-Dindo complications in I group was less than in II (10 (25.6%) vs. 18 (46.1%), p = 0.029). In I group, the incidence of delayed gastric emptying (DGE) was lower compared to II (15.4% (6 patients) versus 35.9% (14 patients), p=0.009). Pancreatic fistula (PF) in I and II groups did not differ significantly - 10.2% (4 patients) and 12.8% (5 patients), respectively (p=0.36). The incidence of surgical wound infections in I group was reduced in comparison with II (5.1% (2 patients) versus 17.9% (7 patients), (p=0.031).The LoS in I group was significantly less compared with II (14 days 95% CI: [13, 17] vs. 18 days 95% CI: [16, 18], p=0.012). The results of the ERAS program after PD shows the reducing number of postoperative complications and LoS, demonstrating the feasibility in clinical practice.

Meta-analysis of effect of routine enteral nutrition on postoperative outcomes after pancreatoduodenectomy.

BACKGROUND: The optimal nutritional treatment after pancreatoduodenectomy is still unclear. The aim of this meta-analysis was to investigate the impact of routine enteral nutrition following pancreatoduodenectomy on postoperative outcomes. METHODS: RCTs comparing enteral nutrition (regular oral intake with routine tube feeding) with non-enteral nutrition (regular oral intake with or without parenteral nutrition) after pancreatoduodenectomy were sought systematically in the MEDLINE, Cochrane Library and Web of Science databases. Postoperative data were extracted. Random-effects meta-analyses were performed to compare postoperative outcomes in the two arms, and pooled odds ratios (ORs) or mean differences (MDs) were calculated with 95 per cent confidence intervals. In subgroup analyses, the routes of nutrition were assessed. Percutaneous tube feeding and nasojejunal tube feeding were each compared with parenteral nutrition. RESULTS: Eight RCTs with a total of 955 patients were included. Enteral nutrition was associated with a lower incidence of infectious complications (OR 0·66, 95 per cent c.i. 0·43 to 0·99; P = 0·046) and a shorter length of hospital stay (MD -2·89 (95 per cent c.i. -4·99 to -0·80) days; P < 0·001) than non-enteral nutrition. Percutaneous tube feeding had a lower incidence of infectious complications (OR 0·47, 0·25 to 0·87; P = 0·017) and a shorter hospital stay (MD -1·56 (-2·13 to -0·98) days; P < 0·001) than parenteral nutrition (3 RCTs), whereas nasojejunal tube feeding was not associated with better postoperative outcomes (2 RCTs). CONCLUSION: As a supplement to regular oral diet, routine enteral nutrition, especially via a percutaneous enteral tube, may improve postoperative outcomes after pancreatoduodenectomy.

Effect of home enteral nutrition after pancreaticoduodenectomy.

OBJECTIVES: Providing home enteral nutrition (HEN) might prevent further deterioration of nutritional status and reduce complication risk after very invasive abdominal surgery. The aim of this study was to assess the effect of HEN after pancreaticoduodenectomy (PD). METHODS: Between January 2013 and July 2016, 150 consecutive patients underwent PD. All patients received postoperative enteral nutrition until discharge. HEN (400 or 800 kcal/d) was introduced in March 2015 for patients with reduced food intake (daily, <15 kcal/kg ideal body weight) at discharge (HEN group). Patients with low intake at discharge treated before March 2015 were considered historical controls (non-HEN group). All patients received postoperative enteral nutrition until discharge. Primary outcomes measures included morbidity rate and nutritional status including body weight and blood examination from discharge until postoperative day (POD) 90. RESULTS: The HEN and non-HEN groups included 24 and 39 patients, respectively. HEN was provided for a median of 68 d (range, 21-90 d) and two patients (8.4%) developed tube obstruction during HEN. The HEN group showed significantly lower rate of morbidity of Clavien-Dindo grade II from discharge to POD 90 or higher (4 of 24, 16.7% versus 17 of 39, 46.1%; P = 0.031) and significantly higher rate of increase in body weight (median: 4.9% versus -4%; P = 0.003), serum albumin levels on POD 90 (median: 3.8 versus 3.5 g/dL; P = 0.020), and prognostic nutritional index (median: 48.5 versus 42.5; P = 0.012). Multivariate logistic analysis demonstrated that body weight at discharge (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.53-0.97) and not receiving HEN (OR, 3.86; 95% CI, 1.81-15.2) were prognostic factors for morbidity after discharge. CONCLUSION: HEN is safe and may reduce postdischarge morbidity and improve nutritional status after PD.

Development and Feasibility of an Interactive Smartphone App for Early Assessment and Management of Symptoms Following Pancreaticoduodenectomy.

BACKGROUND: Patients who have undergone pancreaticoduodenectomy because of pancreatic cancer experience distressing symptoms and unmet supportive care needs after discharge. To meet these needs, we have developed a mobile health app (Interaktor) for daily assessment of symptoms and access to self-care advice that includes a risk assessment model for alerts with real-time interactions with professionals. OBJECTIVE: The study aim was to develop and test a version of the Interaktor app adapted for patients who have undergone pancreaticoduodenectomy. METHODS: The app was developed and tested for feasibility in 6 patients during 4 weeks. One nurse monitored and responded to alerts. Logged data from the app were collected, and all participants were interviewed about their experiences. RESULTS: Adherence to reporting daily was 84%. Alerts were generated in 41% of the reports. The patients felt reassured and cared for and received support for symptom management. The app was easy to use, had relevant content, and had few technical problems, although suggestions for improvement were given. CONCLUSIONS: The daily reporting of symptoms and having access to a nurse in real time in the case of an alarming symptom seem to enhance symptom management and render a feeling of security in patients. Some modifications of the app are needed before use in a larger sample. IMPLICATIONS FOR PRACTICE: Daily reporting of symptoms after pancreaticoduodenectomy enhances symptom management, self-care, and participation without being a burden to patients, indicating that mobile health can be used in clinical practice by patients with poor prognosis who experience severe symptoms.

Enhanced recovery after surgery protocol enhances early postoperative recovery after pancreaticoduodenectomy.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocol is a multimodal, multidisciplinary and evidence-based approach to reduce surgical stress and enhance recovery in the postoperative period. This study aimed to analyze the outcome of ERAS protocol in patients after pancreaticoduodenectomy (PD). METHODS: A total of 50 consecutive patients with pancreatic/periampullary cancer who underwent PD between January 2016 to August 2017 were included in the study. As per the institute ERAS protocol, nasogastric tube (NGT) was removed on postoperative day (POD) 1 if output was less than 200 mL and oral sips were allowed; oral liquids were allowed on POD2; semisolid diet by POD3; abdominal drain was removed on POD 4 if output was less than 100 mL with no evidence of postoperative pancreatic fistula (POPF); normal diet was allowed on POD5. Discharge criteria on POD6 were afebrile, tolerating oral normal diet, pain free and no surgery related complications (defined as per the ISGPS definitions). RESULTS: NGT was removed on POD1 in 45 (90%) patients, abdominal drain removed by POD4 in 41 (82%) and 43 (86%) patients were discharged on POD6. There was no 30-day postoperative mortality. Three (6%) patients had delayed gastric emptying (DGE). None had postoperative hemorrhage and POPF. Readmission rate was 8%. A significant relation was found between the length of hospital stay (LOS) with age (P < 0.05) and a marginal relation between LOS and postoperative albumin (P = 0.05). CONCLUSIONS: ERAS protocol can be safely followed in the perioperative care of patients who undergo PD. Early removal of NGT and allowing oral diet restore bowel function early. ERAS decreases the LOS and postoperative complications.

Novel use of REDCap to develop an advanced platform to display predictive analytics and track compliance with Enhanced Recovery After Surgery for pancreaticoduodenectomy.

BACKGROUND: Prediction models are increasingly being used with clinical practice guidelines to inform decision making. Enhanced Recovery After Surgery (ERAS®) protocols are standardized care pathways that incorporate evidence-based practices to improve patient outcomes. Predictive analytics incorporated within a data management system, such as Research Electronic Data Capture (REDCap), may help clinicians estimate risk probabilities and track compliance with standardized care practices. METHODS: Predictive models were developed from retrospective data on 400 patients who underwent pancreaticoduodenectomy from 2008 through 2014. The REDCap was programmed to display predictive analytics and create a data tracking system that met ERAS guidelines. Based on predictive scores for serious complication, 30-day readmission, and 30-day mortality, we developed targeted interventions to decrease readmissions and postoperative laboratory tests. RESULTS: Predictive models demonstrated a receiver-operating characteristic area (ROC) ranges of 641-856. After implementing the REDCap platform, the readmission rate for high-risk patients decreased 15.8% during the initial three months following ERAS implementation. Based on predictive outputs, patients with a low-risk score received a limited set of postoperative laboratory tests. Targeted interventions to decrease hospital readmission for high-risk patients included home care orders and post-discharge instructions. CONCLUSIONS: The REDCap platform offers hospitals a practical option to display predictive analytics and create a data tracking program that meets ERAS guidelines. Prediction models programmed into REDCap offer clinicians a support tool to assess the probability of patient outcomes. Risk calculations based on predictive scores enabled clinicians to titrate postoperative laboratory tests and develop post-discharge home care orders.

Intensive perioperative rehabilitation improves surgical outcomes after pancreaticoduodenectomy.

PURPOSE: Although the mortality rate for pancreaticoduodenectomy (PD) has decreased to around 2.8-5% in high-volume centers, postoperative complications are still common in 30-50% of cases. Preoperative exercise, called "prehabilitation," has been recently reported to reduce the frequency of complications after surgery. This study aims to evaluate the impact of the intensive perioperative rehabilitation on improvement of surgical outcomes for patients undergoing PD. METHODS: Between 2003 and 2014, 576 consecutive patients underwent PD in Wakayama Medical University Hospital. Of these, 331 patients received perioperative rehabilitation combined with prehabilitation and postoperative rehabilitation between 2009 and 2014. Previously, 245 patients underwent PD without perioperative rehabilitation between 2003 and 2008. We compared surgical outcomes between the patients undergoing PD with and without perioperative rehabilitation to evaluate the efficacy of our rehabilitation program. RESULTS: The frequency of pulmonary complications was significantly lower in patients undergoing PD with perioperative rehabilitation than those without (0.9% vs. 4.3%, P = 0.011). There were no significant differences in other complication or mortality rates. Length of hospital stay was also shorter in patients receiving perioperative rehabilitation than that of those not receiving it (16 vs. 24 days, P < 0.001). CONCLUSIONS: Intensive perioperative rehabilitation might reduce postoperative pulmonary complications and shorten postoperative hospital stay after PD. Therefore, we suggest that perioperative rehabilitation should be included as part of enhanced recovery after surgery for patients undergoing PD, although further large-scale studies are necessary to confirm our results.

Comparison of patient outcomes with and without stenting tube in pancreaticoduodenectomy.

Objective To evaluate the clinical effect of different pancreaticojejunostomy techniques in the treatment of pancreaticoduodenectomy and investigate the applicability of pancreaticojejunostomy without pancreatic duct stenting. Methods From January 2012 to December 2015, 87 patients who underwent pancreaticoduodenectomy were randomly assigned to either Group A (duct-to-mucosa anastomosis with pancreatic duct stenting, n = 43) or Group B (pancreas-jejunum end-to-side anastomosis without stenting (n = 44). The operative duration of pancreaticojejunostomy, postoperative hospital stay, and incidence of postoperative complications were compared between the two methods. Results The operative duration of pancreaticojejunostomy without use of the pancreatic duct stent was significantly shorter in Group B than in Group A (t = 7.137). The postoperative hospital stay was significantly shorter in Group B than in Group A (t = 2.408). The differences in the incidence of postoperative complications such as pancreatic fistula, abdominal bleeding, abdominal infection and delayed gastric emptying were not significantly different between the two groups (χ2 = 0.181, 0.322, 0.603, and 0.001, respectively). Conclusion Pancreaticoduodenectomy without pancreatic duct stenting is safe and reliable and can reduce the operative time and hospital stay. No significant differences were observed in the incidence of postoperative complications.

A hospital-to-home evaluation of an enhanced recovery protocol for elective pancreaticoduodenectomy in China: A cohort study.

Enhanced recovery after surgery (ERAS) programs have been shown to decrease postoperative complications and hospital stay in pancreaticoduodenectomy. However, no studies concerned recovery after discharge except readmission. This study evaluated an ERAS program for pancreaticoduodenectomy from hospital to home.A prospective ERAS cohort undergoing elective pancreaticoduodenectomy was compared with a retrospective control group in terms of postoperative complications and hospital stay, and home recovery after discharge. Propensity-score matching was used to balance their baselines.Two groups of 31 patients with similar propensity scores were established. Postoperative morbidities were 18 of 31 and 26 of 31 in the ERAS and control groups, respectively (P = .06). Patients in the ERAS group suffered from fewer cardiovascular complications (3/31 vs 11/31; P = .04) and intestinal dysbacteriosis (4/31 vs 13/31; P = .04). Median postoperative hospital stay was shorter in the ERAS group (8 vs 16 days; P < .001). Although the 2 groups were similar in terms of sleep, defecation, vigor, performance status, and pain control in first month after discharge, patients in the ERAS group enjoyed better food intake recovery (18/31 vs 5/31 in first week, P = .002; 22/31 vs 9/31 in second week, P = .008; 23/31 vs 13/31 in fourth week, P = .01) and fewer weight loss (10/31 vs 19/31; P = .05). Multivariate analyses showed that both improvements were associated with no bowel preparation.ERAS implementation in selected patients undergoing pancreaticoduodenectomy could promise better outcomes, not only in the hospital but also at home in the short term.

Manejo nutricional en la rehabilitación multimodal precoz en cirugía pancreática / Nutrition management in enhanced recovery after abdominal pancreatic surgery

Los programas de rehabilitación multimodal precoz son estrategias estandarizadas perioperatorias con el objetivo de mejorar la recuperación del paciente, disminuir las complicaciones, la estancia hospitalaria y el coste sanitario. El aspecto nutricional es un componente esencial de la rehabilitación multimodal precoz, recomendándose realizar un cribado nutricional previo al ingreso hospitalario, evitar el ayuno prequirúrgico mediante una sobrecarga oral de hidratos de carbono, e iniciar de manera precoz la ingesta oral posquirúrgica. Sin embargo, no existen protocolos estandarizados de progresión de dieta en cirugía pancreática. Se realiza una revisión de las diferentes estrategias nutricionales publicadas desde 2006 hasta 2016 en la rehabilitación multimodal precoz de este tipo de cirugía y sus posibles implicaciones en la evolución postoperatoria. Los estudios evaluados son muy heterogéneos por lo que no se pueden extraer resultados concluyentes sobre el protocolo de dieta a implementar, su influencia en variables clínicas ni la necesidad o no de nutrición artificial concomitante (AU)

Multimodal rehabilitation programs are perioperative standardized strategies with the objective of improving patient recovery, and decreasing morbidity, hospital stay and health cost. The nutritional aspect is an essential component of multimodal rehabilitation programs and therefore nutritional screening is recommended prior to hospital admission, avoiding pre-surgical fasting, with oral carbohydrate overload and early initiation of oral intake after surgery. However, there are no standardized protocols of diet progression after pancreatic surgery. A systematic review was been performed of papers published between 2006 and 2016, describing different nutritional strategies after pancreatic surgery and its possible implications in postoperative outcome. The studies evaluated are very heterogeneous, so conclusive results could not be drawn on the diet protocol to be implemented, its influence on clinical variables, or the need for concomitant artificial nutrition (AU)

[Accelerated postoperative rehabilitation in patients undergoing pancreatoduodenectomy]. / Uskorennaia posleoperatsionnaia reabilitatsiia patsientov, perenesshikh pankreatoduodenal'nuiu rezektsiiu.

AIM: To assess safety and clinical-economic effectiveness of complex postoperative rehabilitation after pancreatoduodenectomy. MATERIAL AND METHODS: 73 patients were included in the study. Main group consisted of 39 patients who underwent accelerated postoperative rehabilitation that was developed in our clinic. In the control group of 34 patients this protocol was not applied. The main components of rehabilitation were multicomponent analgesia, early enteral nutrition, physical rehabilitation by using of exercise therapy and physiotherapy. RESULTS: There were no significant differences in the incidence of postoperative complications and mortality (58.8% and 74.3%; p=0.213, 5.8% and 7.7%; p=0.678, respectively). Median of postoperative hospital-stay in the study group was 13 days (9; 16), in the control group - 15 days (9; 24). An estimated economic effect in the study group was 558 764, 84 rubles. CONCLUSION: Accelerated postoperative rehabilitation after pancreatoduodenectomy is safe and does not lead to increased number of postoperative complications and mortality. Developed protocol has clinical advantages and is cost-effective.

The impact of a clinical pathway on patient postoperative recovery following pancreaticoduodenectomy.

BACKGROUND: Pancreaticoduodenectomies (PD) are complex surgical procedures. Clinical pathways (CPW) are surgical process improvement tools that guide postoperative recovery and are associated with high quality care. Our objective was to report the quality of surgical care following implementation of a CPW. METHODS: We developed and implemented a CPW for patients undergoing PD at a single high volume hepato-pancreato-biliary (HPB) centre. Patient outcomes were collected prospectively during the implementation period. A comparator cohort was selected by identifying patients that underwent a PD prior to CPW development. RESULTS: 122 patients underwent a PD during the CPW implementation period; 83 patients were initiated on the CPW. 74 patients underwent PD during the 12-month period prior to the CPW. The median hospital stay decreased after the implementation of the CPW (11 vs 8 days, p < 0.01) with no significant changes to mortality, morbidity, reoperation, or readmission rates. In-hospital complications were significantly higher in patients that were not initiated on the CPW (54% vs 74%, p = 0.03). CONCLUSION: Results suggest the CPW reduced variability and allowed a greater proportion of patients to receive all elements of care, resulting in improved quality and efficiency of care based on current best evidence recommendations.

Reducing postoperative complications and improving clinical outcome: Enhanced recovery after surgery in pancreaticoduodenectomy - A retrospective cohort study.

BACKGROUND: An enhanced recovery after surgery (ERAS) programme aims to reduce the stress response to surgery and thereby accelerate recovery. The experience of implementing the ERAS programmes in pancreatoduodenectomy (PD) is relatively limited. The aim of this study was to evaluate the feasibility, safety and clinical outcomes of the ERAS programme after PD at a high-volume Chinese university referral centre. METHODS: Between September 2014 and July 2016, a retrospective analysis of 166 consecutive patients who underwent PD at a tertiary referral care center was carried out. Ninety-eight patients who received conventional perioperative management (the conventional group) were compared with 68 patients who received ERAS programme (the ERAS group). The incidences of postoperative complications, length of stay, expenses, postoperative readmissions, and reoperation rates were compared. RESULTS: A total of 166 patients who underwent PD were analysed (68 patients in the ERAS group, and 98 patients in the conventional group). There were no significant differences in mortality, reoperation, and readmission rates. The ERAS group had a lower morbidity rate than the conventional group (50% vs. 90.8%; P = 0.00), as well as a shorter length of hospital stay (7.5 vs 12 days; P = 0.00). Delayed gastric emptying was significantly reduced in the ERAS group (0 vs. 11.2%; P = 0.011). Pancreatic fistula (grade B,C) was significantly reduced in the ERAS group (14.7 vs 30.6%; P = 0.018). The median total hospital cost was also significantly reduced in the ERAS group (¥79790.40 vs ¥102982.81; P = 0.000). CONCLUSION: The ERAS programme is feasible and safe in patients who underwent PD, and it can reduce postoperative complications and improve clinical outcomes.

Enhanced Recovery After Surgery Program in Patients Undergoing Pancreaticoduodenectomy: A PRISMA-Compliant Systematic Review and Meta-Analysis.

Enhanced recovery after surgery (ERAS) pathways are multimodal, evidence-based approaches to optimize patient outcome after surgery. However, the use of ERAS protocols to improve morbidity and recovery time without compromising safety following pancreaticoduodenectomy (PD) remains to be elucidated.We conducted a systemic review and meta-analysis to assess the safety and efficacy of ERAS protocols compared with conventional perioperative care (CPC) in patients following PD.PubMed, Medline, Embase, and Science Citation Index Expanded and Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library were searched between January 2000 and June 2015.The patients who underwent PD with ERAS protocols or CPC were eligible. The studies that compared postoperative length of hospital stay (PLOS), postoperative complications, or in-hospital costs in the 2 groups were included.A meta-analysis, meta-regression, sensitivity analysis, and subgroup analysis were performed to estimate the postoperative outcomes between the 2 groups and identified the potential confounders. We used the methodological index for nonrandomized studies checklist to assess methodological qualities. Weighted mean differences (WMD) or odds ratios (OR) were calculated with their corresponding 95% confidence intervals (CI). The publication bias tests were also performed through the funnel plots.In total, 14 nonrandomized comparative studies with 1409 ERAS cases and 1310 controls were analyzed. Implementation of an ERAS protocol significantly reduced PLOS (WMD: -4.17 days; 95%CI: -5.72 to -2.61), delayed gastric emptying (OR: 0.56; 95%CI: 0.44-0.71), overall morbidity (OR: 0.63; 95% CI: 0.54-0.74), and in-hospital costs compared to CPC (all P < 0.001). There were no statistically significant differences in other postoperative outcomes. Age, gender, and ERAS component implementation did not significantly contribute to heterogeneity for PLOS as shown by meta-regression analysis.Our study suggested that ERAS was as safe as CPC and improved recovery of patients undergoing PD, thus reducing in-hospital costs. General adoption of ERAS protocols during PD should be recommended.

Evaluation of an enhanced recovery protocol after pancreaticoduodenectomy in elderly patients.

BACKGROUND: Recent evidence has shown that enhanced recovery after surgery (ERAS) protocols decrease hospital stay following pancreaticoduodenectomy (PD). The aims of this study were to assess the feasibility and to evaluate the effect of introducing ERAS principles after PD in elderly patients. METHODS: Patients ≥75 years were defined as elderly. Comparison of postoperative outcome was performed between 22 elderly patients who underwent ERAS (elderly ERAS + patients) and a historical cohort of 66 elderly patients who underwent standard protocols (elderly ERAS-patients). RESULTS: The lowest adherence with ERAS among elderly patients was observed for starting a solid food diet within POD 4 (n = 7) and early drains removal (n = 2). The highest adherence was observed for post-operative glycemic control (n = 21), epidural analgesia (n = 21), mobilization (n = 20) and naso-gastric removal in POD 0 (n = 20). Post-operative outcomes did not differ between elderly ERAS+ and elderly ERAS- patients. In patients with an uneventful postoperative course, the median intention to discharge was earlier in elderly ERAS + patients as compared to the elderly ERAS- patients (4 days versus 8 days, P < 0.001). CONCLUSION: An ERAS protocol following PD seems to be feasible and safe among elderly although it is not associated with improved postoperative outcomes.

Is age a barrier to pancreaticoduodenectomy? An Italian dual-institution study.

The aim of this study is to evaluate the role of age after pancreaticoduodenectomy. This is a retrospective study of 223 patients who underwent pancreaticoduodenectomy for periampullary diseases. Three age groups of patients were compared: ≤70 years of age (group A); between 71 and 79 years of age (group B) and 80 years of age or older (group C). The primary endpoint was the postoperative mortality rate. Secondary endpoints were the overall postoperative morbidity, postoperative pancreatic fistula, postoperative pancreatic haemorrhage, bile leakage, delayed gastric emptying rates, the length of hospital stay, intensive care unit stay, the type of discharge from hospital, reoperation rate and overall survival. Uni-multivariate analyses and Kaplan-Meier curve were carried out. At univariate analysis, only the type of discharge from hospital showed that group B and C patients required a period of rehabilitation more frequently than group A (P = 0.047 and P < 0.001, respectively). Multivariate analysis confirmed that age was not related to postoperative mortality (P = 0.258), morbidity (P = 0.912) and overall survival (P = 0.658), but it was related to type of discharge (P < 0.001). The present study seems to suggest that a pancreaticoduodenectomy is a feasible and safe procedure, even in elderly and very elderly patients even if the latter require a longer period of rehabilitation.

Resultados de la rehabilitación multimodal en la duodenopancreatectomía cefálica / Outcomes of an enhanced recovery after surgery programme for pancreaticoduodenectomy

INTRODUCCIÓN: La rehabilitación multimodal precoz (RMP) ha demostrado en la cirugía colorrectal una reducción de la morbilidad y de la hospitalización sin comprometer la seguridad de los pacientes. La experiencia de la RMP en la duodenopancreatectomía cefálica (DPC) es más limitada. Los objetivos de este estudio fueron analizar la aplicabilidad de un programa RMP en los pacientes intervenidos mediante una DPC en nuestro medio y evaluar los resultados postoperatorios. MÉTODOS: Estudio retrospectivo utilizando una base de datos prospectiva de 41 pacientes a los que se realizó DPC y fueron incluidos en un programa de RMP. Se evaluaron 3 elementos clave: retirada precoz de sondas y drenajes, ingesta oral y movilización precoz. Las variables analizadas fueron la mortalidad, morbilidad, datos perioperatorios, estancia hospitalaria, reintervenciones y reingresos. Este grupo de pacientes fue comparado con un grupo control de 44 pacientes consecutivos, en los que se realizó una DPC con manejo postoperatorio estándar. RESULTADOS: Se estudió a 85 pacientes intervenidos con DPC (41 pacientes en el grupo RMP y 44 pacientes en el grupo control). La mortalidad global fue del 2,4%: 2 pacientes pertenecientes al grupo control. No encontramos diferencias significativas en la mortalidad, ingreso en Reanimación, reintervenciones ni reingresos. El grupo RMP presentó una morbilidad menor que el grupo control (32 vs. 48%; p = 0,072), y una estancia hospitalaria menor (14,2 vs. 18,7 días; p = 0,014). Todos los elementos clave propuestos fueron conseguidos. CONCLUSIONES: La RMP en la DPC puede implantarse con seguridad en nuestro medio. Permite unificar los cuidados perioperatorios, disminuir la variabilidad clínica y la estancia media y como consecuencia, el coste hospitalario

BACKGROUND: Enhanced recovery after surgery (ERAS) has demonstrated in colorectal surgery a reduction in morbidity and length of stay without compromising security. Experience with ERAS programs in pancreatoduodenectomy (PD) is still limited. The aims of this study were first to evaluate the applicability of an ERAS program for PD patients in our hospital, and second to analyze the postoperative results. METHODS: A retrospective study using a prospectively maintained database identified 41 consecutive PD included in an ERAS program. Key elements studied were early removal of tubes and drainages, early oral feeding and early mobilization. Variables studied were mortality, morbidity, perioperative data, length of stay, re-interventions and inpatient readmission. This group of patients was compared with an historic control group of 44 PD patients with a standard postoperative management. RESULTS: A total of 85 pancreatoduodenectomies were analyzed (41 patients in the ERAS group, and 44 patients in the control group. General mortality was 2.4% (2 patients) belonging to the control group. There were no statistical differences in mortality, length of stay in intensive care, reoperationss, and readmissions. ERAS group had a lower morbidity rate than the control group (32 vs. 48%; P=.072), as well as a lower length of stay (14.2 vs. 18.7 days). All the key ERAS proposed elements were achieved. CONCLUSIONS: ERAS programs may be implemented safely in pancreaticoduodenectomy. They may reduce the length of stay, unifying perioperative care and diminishing clinical variability and hospital costs