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01-10-2018 | Original Article

Improved Outcomes in 394 Pancreatic Cancer Resections: the Impact of Enhanced Recovery Pathway

Authors: Vandana Agarwal, Martin Jose Thomas, Riddhi Joshi, Vikram Chaudhari, Manish Bhandare, Abhishek Mitra, Ashwin deSouza, Reshma Ambulkar, Shailesh V. Shrikhande

Published in: Journal of Gastrointestinal Surgery | Issue 10/2018

Abstract

Background

Enhanced recovery (ER) pathway reduces morbidity and accelerates recovery. It is associated with reduced postoperative stay, morbidity, and costs. Feasibility and safety of ER programme has not been studied in developing countries. The objectives were to assess compliance with Enhanced Recovery After Surgery (ERAS) elements and to assess outcomes in pancreatic surgery.

Methods

Prospective study conducted from February 2014 to December 2016, following elective pancreatic cancer surgery. Team was educated prior to implementation of ERAS. Patients were followed up until 30 days postoperatively or discharge. Data was recorded regarding the compliance with the protocol, functional GI recovery, mobilisation, and postoperative morbidity and mortality.

Results

A total of 394 patients underwent surgery. Compliance with ER elements implemented was 84% (23–100%). Compliance > 80% with ER elements was observed in 278 patients (70.5%) and < 80% in 116 patients (29.5%). Patients with > 80% compliance have significantly lower major complications (28.7 vs. 44%, p = 0.001), mortality (2.1 vs. 6.8%, p = 0.021), and postoperative stay (11 (5–78) days vs. 15 (4–61) days, p < 0.001).

Conclusion

ER programme is feasible and safe in resource and infrastructure limited lower middle-income country. Improved compliance was associated with reduced major complications, mortality, and shorter stay in patients undergoing pancreatic cancer surgery in high-volume centre.

Trial Registration

CTRI/2015/01/005393 (www.ctri.nic.in)

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Basse L, Hjort Jakobsen D, Billesbolle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann Surg. 2000;232(1):51–7.CrossRefPubMedPubMedCentral

Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630–41.CrossRefPubMed

Dai J, Jiang Y, Fu D. Reducing postoperative complications and improving clinical outcome: Enhanced recovery after surgery in pancreaticoduodenectomy - A retrospective cohort study. Int J Surg. 2017;39:176–81. https://doi.org/10.1016/j.ijsu.2017.01.089.CrossRefPubMed

Bai X, Zhang X, Lu F, Li G, Gao S, Lou J, Zhang Y, Ma T, Wang J, Chen W, Huang B, Liang T. The implementation of an enhanced recovery after surgery (ERAS) program following pancreatic surgery in an academic medical center of China. Pancreatology. 2016;16(4):665–70. https://doi.org/10.1016/j.pan.2016.03.018.CrossRefPubMed

Shrikhande SV, Barreto G, Shukla PJ. Pancreatic fistula after pancreaticoduodenectomy: the impact of a standardized technique of pancreaticojejunostomy. Langenbecks Arch Surg. 2008;393(1):87–91. https://doi.org/10.1007/s00423-007-0221-2.CrossRefPubMed

Shrikhande SV, Sivasanker M, Vollmer CM, Friess H, Besselink MG, Fingerhut A, Yeo CJ, Fernandez-del Castillo C, Dervenis C, Halloran C, Gouma DJ, Radenkovic D, Asbun HJ, Neoptolemos JP, Izbicki JR, Lillemoe KD, Conlon KC, Fernandez-Cruz L, Montorsi M, Bockhorn M, Adham M, Charnley R, Carter R, Hackert T, Hartwig W, Miao Y, Sarr M, Bassi C, Buchler MW, International Study Group of Pancreatic S. Pancreatic anastomosis after pancreatoduodenectomy: A position statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2017;161(5):1221–34. https://doi.org/10.1016/j.surg.2016.11.021.CrossRefPubMed

Pillai SA, Palaniappan R, Pichaimuthu A, Rajendran KK, Sathyanesan J, Govindhan M. Feasibility of implementing fast-track surgery in pancreaticoduodenectomy with pancreaticogastrostomy for reconstruction--a prospective cohort study with historical control. Int J Surg. 2014;12(9):1005–9. https://doi.org/10.1016/j.ijsu.2014.07.002.CrossRefPubMed

Shirodkar M, Mohandas KM. Subjective global assessment: a simple and reliable screening tool for malnutrition among Indians. Indian J Gastroenterol. 2005;24(6):246–50.PubMed

Keith JN. Bedside nutrition assessment past, present, and future: a review of the Subjective Global Assessment. Nutr Clin Pract. 2008;23(4):410–6. https://doi.org/10.1177/0884533608321215.CrossRefPubMed

10.

Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibanes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187–96. https://doi.org/10.1097/SLA.0b013e3181b13ca2.CrossRefPubMed

11.

Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-Del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Buchler M, International Study Group on Pancreatic S. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery. 2017;161(3):584–91. https://doi.org/10.1016/j.surg.2016.11.014.CrossRefPubMed

12.

Shrikhande SV, Barreto SG, Somashekar BA, Suradkar K, Shetty GS, Talole S, Sirohi B, Goel M, Shukla PJ. Evolution of pancreatoduodenectomy in a tertiary cancer center in India: improved results from service reconfiguration. Pancreatology. 2013;13(1):63–71. https://doi.org/10.1016/j.pan.2012.11.302.CrossRefPubMed

13.

Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Buchler MW. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2007;142(5):761–8. https://doi.org/10.1016/j.surg.2007.05.005.CrossRefPubMed

14.

Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Buchler MW. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 2007;142(1):20–5. https://doi.org/10.1016/j.surg.2007.02.001.CrossRefPubMed

15.

Miller BC, Christein JD, Behrman SW, Callery MP, Drebin JA, Kent TS, Pratt WB, Lewis RS, Jr., Vollmer CM, Jr. Assessing the impact of a fistula after a pancreaticoduodenectomy using the Post-operative Morbidity Index. HPB (Oxford). 2013;15(10):781–8. https://doi.org/10.1111/hpb.12131.CrossRefPubMedPubMedCentral

16.

Berberat PO, Ingold H, Gulbinas A, Kleeff J, Muller MW, Gutt C, Weigand M, Friess H, Buchler MW. Fast track--different implications in pancreatic surgery. J Gastrointest Surg. 2007;11(7):880–7. https://doi.org/10.1007/s11605-007-0167-2.CrossRefPubMed

17.

Kennedy EP, Rosato EL, Sauter PK, Rosenberg LM, Doria C, Marino IR, Chojnacki KA, Berger AC, Yeo CJ. Initiation of a critical pathway for pancreaticoduodenectomy at an academic institution--the first step in multidisciplinary team building. J Am Coll Surg. 2007;204(5):917–23; discussion 23-4. https://doi.org/10.1016/j.jamcollsurg.2007.01.057.CrossRefPubMed

18.

Balzano G, Zerbi A, Braga M, Rocchetti S, Beneduce AA, Di Carlo V. Fast-track recovery programme after pancreatico- duodenectomy reduces delayed gastric emptying. Br J Surg. 2008;95(11):1387–93. https://doi.org/10.1002/bjs.6324.CrossRefPubMed

19.

Montiel Casado MC, Pardo Sanchez F, Rotellar Sastre F, Marti Cruchaga P, Alvarez Cienfuegos FJ. [Experience of a cephalic pancreatoduodenectomy fast-track program]. Cir Esp. 2010;87(6):378–84. https://doi.org/10.1016/j.ciresp.2010.03.007.CrossRefPubMed

20.

di Sebastiano P, Festa L, De Bonis A, Ciuffreda A, Valvano MR, Andriulli A, di Mola FF. A modified fast-track program for pancreatic surgery: a prospective single-center experience. Langenbecks Arch Surg. 2011;396(3):345–51. https://doi.org/10.1007/s00423-010-0707-1.CrossRefPubMed

21.

Robertson N, Gallacher PJ, Peel N, Garden OJ, Duxbury M, Lassen K, Parks RW. Implementation of an enhanced recovery programme following pancreaticoduodenectomy. HPB (Oxford). 2012;14(10):700–8. https://doi.org/10.1111/j.1477-2574.2012.00521.x.CrossRefPubMedPubMedCentral

22.

Morales Soriano R, Esteve Perez N, Tejada Gavela S, Cuadrado Garcia A, Rodriguez Pino JC, Moron Canis JM, Molina Romero X, Munoz Perez J, Gonzalez Argente X. Outcomes of an enhanced recovery after surgery programme for pancreaticoduodenectomy. Cir Esp. 2015;93(8):509–15. https://doi.org/10.1016/j.ciresp.2015.04.009.CrossRefPubMed

23.

Abu Hilal M, Di Fabio F, Badran A, Alsaati H, Clarke H, Fecher I, Armstrong TH, Johnson CD, Pearce NW. Implementation of enhanced recovery programme after pancreatoduodenectomy: a single-centre UK pilot study. Pancreatology. 2013;13(1):58–62. https://doi.org/10.1016/j.pan.2012.11.312.CrossRefPubMed

24.

Partelli S, Crippa S, Castagnani R, Ruffo G, Marmorale C, Franconi AM, De Angelis C, Falconi M. Evaluation of an enhanced recovery protocol after pancreaticoduodenectomy in elderly patients. HPB (Oxford). 2016;18(2):153–8. https://doi.org/10.1016/j.hpb.2015.09.009.CrossRefPubMed

25.

Nikfarjam M, Weinberg L, Low N, Fink MA, Muralidharan V, Houli N, Starkey G, Jones R, Christophi C. A fast track recovery program significantly reduces hospital length of stay following uncomplicated pancreaticoduodenectomy. JOP. 2013;14(1):63–70. https://doi.org/10.6092/1590-8577/1223.CrossRefPubMed

26.

Braga M, Pecorelli N, Ariotti R, Capretti G, Greco M, Balzano G, Castoldi R, Beretta L. Enhanced recovery after surgery pathway in patients undergoing pancreaticoduodenectomy. World J Surg. 2014;38(11):2960–6. https://doi.org/10.1007/s00268-014-2653-5.CrossRefPubMed

27.

Coolsen MM, van Dam RM, Chigharoe A, Olde Damink SW, Dejong CH. Improving outcome after pancreaticoduodenectomy: experiences with implementing an enhanced recovery after surgery (ERAS) program. Dig Surg. 2014;31(3):177–84. https://doi.org/10.1159/000363583.CrossRefPubMed

28.

Morgan KA, Lancaster WP, Walters ML, Owczarski SM, Clark CA, McSwain JR, Adams DB. Enhanced Recovery After Surgery Protocols Are Valuable in Pancreas Surgery Patients. J Am Coll Surg. 2016;222(4):658–64. https://doi.org/10.1016/j.jamcollsurg.2015.12.036.CrossRefPubMed

29.

Zouros E, Liakakos T, Machairas A, Patapis P, Agalianos C, Dervenis C. Improvement of gastric emptying by enhanced recovery after pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int. 2016;15(2):198–208.CrossRefPubMed

30.

Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schafer M, Parks RW, Fearon KC, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CH, Society E, European Society for Clinical N, Metabolism, International Association for Surgical M, Nutrition. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations. Clin Nutr. 2012;31(6):817–30. https://doi.org/10.1016/j.clnu.2012.08.011.CrossRefPubMed

31.

Xiong J, Szatmary P, Huang W, de la Iglesia-Garcia D, Nunes QM, Xia Q, Hu W, Sutton R, Liu X, Raraty MG. Enhanced Recovery After Surgery Program in Patients Undergoing Pancreaticoduodenectomy: A PRISMA-Compliant Systematic Review and Meta-Analysis. Medicine (Baltimore). 2016;95(18):e3497. https://doi.org/10.1097/MD.0000000000003497.CrossRefPubMedPubMedCentral

Title: Improved Outcomes in 394 Pancreatic Cancer Resections: the Impact of Enhanced Recovery Pathway
Authors: Vandana Agarwal
Martin Jose Thomas
Riddhi Joshi
Vikram Chaudhari
Manish Bhandare
Abhishek Mitra
Ashwin deSouza
Reshma Ambulkar
Shailesh V. Shrikhande
Publication date: 01-10-2018
Publisher: Springer US
Published in: Journal of Gastrointestinal Surgery / Issue 10/2018
Print ISSN: 1091-255X
Electronic ISSN: 1873-4626
DOI: https://doi.org/10.1007/s11605-018-3809-7

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Improved Outcomes in 394 Pancreatic Cancer Resections: the Impact of Enhanced Recovery Pathway

Abstract

Background

Methods

Results

Conclusion

Trial Registration

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Trial Registration

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