Enhanced Recovery Pathways in Hepato-pancreato-biliary Surgery

Abstract

In the last two decades enhanced recovery pathways (ERP) have been successfully implemented in various fields of surgery, notably in colorectal surgery where numerous meta-analyses have shown lower complication rates associated with reduced postoperative stay and diminished hospital costs [ 1 , 2 ]. Following these encouraging results, ERP have been progressively implemented to hepato-pancreato-biliary (HPB) surgery, which is traditionally considered as high-risk surgery. Review of the Current LiteratureAlthough pancreatic surgery has become safer in high-volume specialized centers with a significant reduction of perioperative mortality to 5 %, reported morbidity rates still remain considerably high, ranging from 40 to 60 % with a postoperative length of stay ranging from 14 to 20 days after pancreaticoduodenectomy [ 3 ]. Delayed recovery is mainly due to pancreatic fistula and delayed gastric emptying. A recently published systematic review in pancreatic surgery found that ERPs were associated with both a significant decrease in length of stay of 2-6 days and a reduction in complications without increased mortality or readmission rate [ 3 ]. However, the occurrence of pancreatic fistula or delayed gastric emptying did not differ [ 3 ]. On the other hand, the pathways were heterogeneous and important data like time to functional recovery and compliance to the ERP elements were scarcely described. Therefore, future prospective studies based on the published guidelines for perioperative care for pancreaticoduodenectomy by the ERAS ® Society are required in order to assess the proper impact of ERP on functional postoperative recovery [ 4 ].