Implementation of an Enhanced Recovery Pathway After Pancreaticoduodenectomy in Patients with Low Drain Fluid Amylase.

Robert P Sutcliffe, Majd Hamoui, John Isaac, Ravi Marudanayagam, Darius F Mirza, Paolo Muiesan, John K Roberts

Journal: World journal of surgery 2016;39(8):2023-30

PMID: 25809067

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Abstract

INTRODUCTION

The safety and feasibility of an enhanced recovery pathway (ERP) after pancreatic surgery is largely unknown. Our aim was to prospectively evaluate a targeted ERP after pancreaticoduodenectomy (PD), using first postoperative day (POD) drain fluid amylase (DFA1) values to identify patients at low risk of pancreatic fistula (PF).

PATIENTS AND METHODS

Non-randomized cohort study of 130 consecutive patients. Perioperative outcomes were compared before (pre-ERP; N=65) and after (post-ERP; N=65) implementation of an ERP. Patients in each group were stratified according to the risk of PF using DFA1<350 IU/l. Low-risk patients in the post-ERP group were selected for early oral intake and early drain removal.

RESULTS

81/130 patients had a DFA1<350. Incidence of PF was significantly lower in low-risk patients (9 vs. 45%, P=0.0001). In low-risk patients, morbidity (43 vs. 36%) and mortality (2.7 vs. 4.5%) were similar for both pre- and post-ERP patients. Hospital stay (median 9 vs. 7 days, P=0.03) and 30-day readmissions (17 vs. 2%, P=0.04) were lower in low-risk patients in the post-ERP group. In high-risk patients, there was no difference in outcomes between pre- and post-ERP.

CONCLUSION

Patients at low risk of PF after PD can be identified by first POD DFA1. Enhanced recovery after PD is safe and leads to improved short-term outcomes in low-risk patients.

Address: Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Third Floor Nuffield House, Birmingham, B15 2TH, UK, [email protected].

DOI: 10.1007/s00268-015-3051-3

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MeSH Terms: Adult, Aged, Aged, 80 and over, Amylases, Anastomosis, Surgical, Body Fluids, Clinical Protocols, Cohort Studies, Device Removal, Drainage, Enteral Nutrition, Female, Humans, Incidence, Length of Stay, Male, Middle Aged, Pancreas, Pancreatic Diseases, Pancreatic Fistula, Pancreatic Neoplasms, Pancreaticoduodenectomy, Pancreaticojejunostomy, Postoperative Care, Risk Assessment, Stomach