Standardization of perioperative care facilitates safe discharge by postoperative day five after pancreaticoduodenectomy

Abstract

IntroductionPancreaticoduodenectomy is a complex surgical procedure associated with high morbidity and prolonged length of stay. Enhanced recovery after surgery principles have reduced complications rate and length of stay for multiple types of operations. We hypothesized that implementation of a standardized perioperative care pathway would facilitate safe discharge by five days after pancreaticoduodenectomy.MethodsWe performed a retrospective cohort study of patients undergoing pancreaticoduodenectomy 18 months prior to and 18 months following implementation of a perioperative care pathway at a quaternary center performing high volume pancreatic surgery.ResultsA total of 145 patients underwent pancreaticoduodenectomy (mean age 63 ± 10 years, 52% female), 81 before and 64 following pathway implementation, and the groups were similar in terms of preoperative comorbidities. The percentage of patients discharged within 5 days of surgery increased from 36% to 64% following pathway implementation (p = 0.001), with no observed differences in post-operative serious adverse events (p = 0.34), pancreatic fistula grade B or C (p = 0.28 and p = 0.27 respectively), or delayed gastric emptying (p = 0.46). Multivariate regression analysis showed length of stay ≤5 days three times more likely after pathway implementation. Rates of readmission within 30 days (20% pre- vs. 22% post-pathway (p = 0.75)) and 90 days (27% pre- vs. 36% post-pathway (p = 0.27)) were unchanged after pathway implementation, and were no different between patients discharged before or after day 5 at both 30 days (19% ≤5 days vs. 23% ≥ 6 days (p = 0.68)) and 90 days (32% ≤5 days vs. 30% ≥ 6 days (p = 0.81)).ConclusionsStandardizing perioperative care via enhanced recovery protocols for patients undergoing pancreaticoduodenectomy facilitates safe discharge by post-operative day five.

A Modified Enhanced Recovery Pathway after Pancreaticoduodenectomy: Full Liquids on Discharge

“…Our pathway led to decrease in the LOS after PD from 7.1 to 5.2 days, and this is one of the lowest averages in hospital stay that we could find in the literature. All major enhanced pathways after a PD aimed to discharge patients in 5 days [5,16]. The percentages of patients who were discharged home on POD#5 in the literature ranges from 60 to 80% in general [5,16].…”

“…Guidelines were published by the ERAS society in 2012 to serve as roadmap for pancreatic surgeons to use [13]. In recent years, many variations of "fast track" recovery after PD have been published [5,[16][17][18][19][20]. A main target in the majority of these pathways is reduction of hospital LOS after a PD without increasing 30-day readmissions and complications [5].…”

Pancreatic paraganglioma mimicking pancreatic neuroendocrine tumor

“…Following surgery, the patient was managed according to our enhanced recovery after surgery (ERAS) pathway 6 and was discharged on postoperative day 5 without any complications. Serum metanephrine level was measured postoperatively as baseline for follow up.…”

Implementation of an accelerated recovery program for pancreatoduodenectomy

“…Панкреатодуоденектомія (ПД) залишається єдиним варіантом радикального лікування хворих із злоякісними пухлинами головки підшлункової залози і періампулярної зони і дає можливість довгострокової виживаності. В останні десятиліття відзначено значне зниження летальності після ПД (до 1-3%), однак частота ранніх післяопераційних ускладнень, які є основною перешкодою на шляху одужання пацієнтів, досягає 65% [4]. Існують і інші важливі незалежні фактори, які можуть затримувати процеси відновлення після операції.…”