Fast Track—Different Implications in Pancreatic Surgery

Abstract

Concepts in "fast-track" surgery, which provide optimal perioperative care, have been proven to significantly reduce complication rates and decrease hospital stay. This study explores whether fast-track concepts can also be safely applied and improve the outcomes of major pancreatic resections. Perioperative data from 255 consecutive patients, who underwent pancreatic resection by means of fast-track surgery in a high-volume medical center, were analyzed using univariate and multivariate models. Of the 255 patients, 180 received a pancreatic head resection and 51 received distal, 15 received total, and 9 received segmental pancreatectomies. The patients were discharged on median day 10 with a 30-day readmission rate of 3.5%. The in-hospital mortality was 2%, whereas medical and surgical morbidities were 17 and 25%, respectively. Fast-track parameters, such as first stools, normal food, complete mobilization, and return to normal ward, correlated significantly with early discharge (p < 0.05). Patients' age, operation time, and early extubation proved to be independent factors of early discharge, shown through multivariate analysis (odds ratio: 4.0, 2.0, and 2.8, respectively; p < 0.05). Low readmission, mortality, and morbidity rates demonstrate that fast-track surgery is in fact feasible and safe and promotes earlier discharge without compromising patient outcomes.

Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations

“…Suprapubic catheterisation is superior to transurethral catheterisation if used for DGE is a specific problem after PD occurring in &10-25 % of patients [6,7,9,170]. It may be necessary to insert a nasojejunal feeding tube in a minority of patients.…”

“…Chewing gum has been shown to be safe and beneficial in restoring gut activity after colorectal surgery [176][177][178] Postoperative artificial nutrition Most patients tolerate normal oral intake soon after elective PD. Early oral intake in this patient group has been shown to be feasible and safe [6,144]. A recent large multicentre RCT in patients undergoing only major upper gastrointestinal and hepatopancreaticobiliary surgery (including [80 patients undergoing PD) investigated this issue and concluded that allowing early diet is safe for these patients and that enteral tube feeding did not confer benefit [144].…”

Fifty consecutive pancreatectomies without mortality

“…In general, mortality rates found in national publications by the year 2012 ranged between 4.3% and 21.9% [8][9][10][11][12][13][14] , being superior to those described in the international literature 3 .…”

“…Thus, Berberat et al 8 , Balzano et al 23 and di Sebastiano et al 24 found an average hospital stay of 10, 13 and 10 days, respectively, in series of patients undergoing pancreatectomy. Postoperative fluid restriction, early oral intake and mobilization, effective analgesia and early removal of drains and catheters form, in general, the main recommendations suggested by these and other authors 8,[23][24][25] . While we agree with most of these measures, we do not practice fluid restriction, neither the early removal of abdominal drains.…”

Perioperative fast track program in intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery in advanced ovarian cancer

“…The introduction of Fast-track programs achieves good results in postoperative outcomes in many surgical pathologies (34)(35)(36)(37)(38)(39)(40)(41). For instance, nephrectomy (42); radical prostatectomy (43); knee and hip prosthesis (44); abdominal aortic aneurysm (36); bariatric surgery (45,46) and lung resections (47) can all be carried out with a mean hospital admittance of less than 4 days and others such as antireflux surgery; suprarenalectomy; cholecystectomy; thyroidectomy; etc, are already carried out in many hospitals in ambulatory care (48,49).…”