Top

Published in:

01-08-2015 | Original Scientific Report

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

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

Published in: World Journal of Surgery | Issue 8/2015

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.

Winter JM, Cameron JL, Campbell KA, Arnold MA, Chang DC, Coleman J et al (2006) 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg 10(9):1199–1210PubMedCrossRef

Assifi MM, Lindenmeyer J, Leiby BE, Grunwald Z, Rosato EL, Kennedy EP et al (2012) Surgical Apgar score predicts perioperative morbidity in patients undergoing pancreaticoduodenectomy at a high-volume center. J Gastrointest Surg 16(2):275–281PubMedCrossRef

De Oliveira ML, Winter JM, Schafer M, Cunningham SC, Cameron JL, Yeo CJ et al (2006) Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 244(6):931–937CrossRef

Yang YM, Tian XD, Zhuang Y, Wang WM, Wan YL, Huang YT (2005) Risk factors of pancreatic leakage after pancreaticoduodenectomy. World J Gastroenterol 11(16):2456–2461PubMedCentralPubMedCrossRef

Kawai M, Tani M, Hirono S, Ina S, Miyazawa M, Yamaue H (2009) How do we predict the clinically relevant pancreatic fistula after pancreaticoduodenectomy? An analysis in 244 consecutive patients. World J Surg 33(12):2670–2678. doi:10.1007/s00268-009-0220-2 PubMedCrossRef

Fuks D, Piessen G, Huet E, Tavernier M, Zerbib P, Michot F et al (2009) Life-threatening postoperative pancreatic fistula (grade C) after pancreaticoduodenectomy: incidence, prognosis, and risk factors. Am J Surg 197(6):702–709PubMedCrossRef

Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J et al (2005) International study group on pancreatic fistula definition. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138(1):8–13PubMedCrossRef

Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M (2014) Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 38(6):1531–1541. doi:10.1007/s00268-013-2416-8 PubMedCrossRef

Coolsen MM, Wong-Lun-Hing EM, van Dam RM, van der Wilt AA, Slim K, Lassen K et al (2013) A systematic review of outcomes in patients undergoing liver surgery in an enhanced recovery after surgery pathways. HPB 15(4):245–251PubMedCentralPubMedCrossRef

10.

Yu Z, Zhuang CL, Ye XZ, Zhang CJ, Dong QT, Chen BC (2014) Fast-track surgery in gastrectomy for gastric cancer: a systematic review and meta-analysis. Langenbecks Arch Surg 399(1):85–92PubMedCrossRef

11.

Lemanu DP, Singh PP, Berridge K, Burr M, Birch C, Babor R et al (2013) Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy. Br J Surg 100(4):482–489PubMedCrossRef

12.

Petrowsky H, Demartines N, Rousson V, Clavien PA (2004) Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-analyses. Ann Surg 240(6):1074–1084PubMedCentralPubMedCrossRef

13.

Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, Enhanced Recovery After Surgery (ERAS^®) Group et al (2009) Consensus review of optimal perioperative care in colorectal surgery: enhanced recovery after surgery (ERAS^®) group recommendations. Arch Surg 144(10):961–969PubMedCrossRef

14.

Findlay JM, Gillies RS, Millo J, Sgromo B, Marshall RE, Maynard ND (2014) Enhanced recovery for esophagectomy: a systematic review and evidence-based guidelines. Ann Surg 259(3):413–431PubMedCrossRef

15.

Cerantola Y, Valerio M, Persson B, Jichlinski P, Ljungqvist O, Hubner M et al (2013) Guidelines for perioperative care after radical cystectomy for bladder cancer: enhanced recovery after surgery (ERAS^®) society recommendations. Clin Nutr 32(6):879–887PubMedCrossRef

16.

Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN, Enhanced Recovery After Surgery (ERAS^®) Society, for Perioperative Care, European Society for Clinical Nutrition and Metabolism (ESPEN), International Association for Surgical Metabolism and Nutrition (IASMEN) et al (2013) Guidelines for perioperative care in elective rectal/pelvic surgery: enhanced recovery after surgery (ERAS^®) society recommendations. World J Surg 37(2):285–305. doi:10.1007/s00268-012-1787-6 PubMedCrossRef

17.

Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, Enhanced Recovery After Surgery (ERAS^®) Society, for Perioperative Care, European Society for Clinical Nutrition and Metabolism (ESPEN), International Association for Surgical Metabolism and Nutrition (IASMEN) et al (2013) Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS^®) society recommendations. World J Surg 37(2):259–284. doi:10.1007/s00268-012-1772-0 PubMedCrossRef

18.

Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Enhanced Recovery After Surgery (ERAS^®) Society, for Perioperative Care, European Society for Clinical Nutrition and Metabolism (ESPEN), International Association for Surgical Metabolism and Nutrition (IASMEN) et al (2013) Guidelines for perioperative care for pancreaticoduodenectomy: enhanced recovery after surgery (ERAS^®) society recommendations. World J Surg 37(2):240–258. doi:10.1007/s00268-012-1771-1 PubMedCrossRef

19.

Van Buren G, Bloomston M, Hughes SJ, Winter J, Behrman SW, Zyromski NJ et al (2014) A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage. Ann Surg 259(4):605–612PubMedCrossRef

20.

Sutcliffe RP, Battula N, Haque A, Ali A, Srinivasan P, Atkinson SW et al (2012) Utility of drain fluid amylase measurement on the first postoperative day after pancreaticoduodenectomy. World J Surg 36(4):879–883. doi:10.1007/s00268-012-1460-0 PubMedCrossRef

21.

Tsujie M, Nakamori S, Miyamoto A, Yasui M, Ikenaga M, Hirao M et al (2012) Risk factors of pancreatic fistula after pancreaticoduodenectomy: patients with low drain amylase level on postoperative day 1 are safe from developing pancreatic fistula. Hepatogastroenterology 59(120):2657–2660PubMed

22.

Molinari E, Bassi C, Salvia R, Butturini G, Crippa S, Talamini G et al (2007) Amylase value in drains after pancreatic resection as predictive factor of postoperative pancreatic fistula: results of a prospective study in 137 patients. Ann Surg 246(2):281–287PubMedCentralPubMedCrossRef

23.

Kehlet H (1997) Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78(5):606–617PubMedCrossRef

24.

Coolsen MM, van Dam RM, van der Wilt AA, Slim K, Lassen K, Dejong CH (2013) Systematic review and meta-analysis of enhanced recovery after pancreatic surgery with particular emphasis on pancreaticoduodenectomies. World J Surg 37(8):1909–1918. doi:10.1007/s00268-013-2044-3 PubMedCrossRef

25.

Abu Hilal M, Di Fabio F, Badran A, Alsaati H, Clarke H, Fecher I et al (2013) Implementation of enhanced recovery programme after pancreatoduodenectomy: a single-centre UK pilot study. Pancreatology 13(1):58–62PubMedCrossRef

26.

Balzano G, Zerbi A, Braga M, Rocchetti S, Beneduce AA, Di Carlo V (2008) Fast-track recovery programme after pancreatico-duodenectomy reduces delayed gastric emptying. Br J Surg 95(11):1387–1393PubMedCrossRef

27.

Robertson N, Gallacher PJ, Peel N, Garden OJ, Duxbury M, Lassen K et al (2012) Implementation of an enhanced recovery programme following pancreaticoduodenectomy. HPB 14(10):700–708PubMedCentralPubMedCrossRef

28.

Lassen K, Kjaeve J, Fetveit T, Tranø G, Sigurdsson HK, Horn A et al (2008) Allowing normal food at will after major upper gastrointestinal surgery does not increase morbidity: a randomized multicenter trial. Ann Surg 247(5):721–729PubMedCrossRef

29.

Gerritsen A, Wennink RA, Besselink MG, van Santvoort HC, Tseng DS, Steenhagen E et al (2014) Early oral feeding after pancreatoduodenectomy enhances recovery without increasing morbidity. HPB 16(7):656–664PubMedCentralPubMedCrossRef

30.

Bassi C, Molinari E, Malleo G, Crippa S, Butturini G, Salvia R et al (2010) Early versus late drain removal after standard pancreatic resections: results of a prospective randomized trial. Ann Surg 252(2):207–214PubMedCrossRef

31.

Kawai M, Tani M, Terasawa H, Ina S, Hirono S, Nishioka R et al (2006) Early removal of prophylactic drains reduces the risk of intra-abdominal infections in patients with pancreatic head resection: prospective study for 104 consecutive patients. Ann Surg 244(1):1–7PubMedCentralPubMedCrossRef

32.

Conlon KC, Labow D, Leung D, Smith A, Jarnagin W, Coit DG et al (2001) Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection. Ann Surg 234(4):487–493PubMedCentralPubMedCrossRef

33.

Israel JS, Rettammel RJ, Leverson GE, Hanks LR, Cho CS, Winslow ER et al (2014) Does postoperative drain amylase predict pancreatic fistula after pancreatectomy? J Am Coll Surg 218(5):978–987PubMedCrossRef

34.

Roberts KJ, Hodson J, Mehrzad H, Marudanayagam R, Sutcliffe RP, Muiesan P et al (2014) A preoperative predictive score of pancreatic fistula following pancreatoduodenectomy. HPB 16(7):620–628PubMedCentralPubMedCrossRef

Title: Implementation of an Enhanced Recovery Pathway After Pancreaticoduodenectomy in Patients with Low Drain Fluid Amylase
Authors: Robert P. Sutcliffe
Majd Hamoui
John Isaac
Ravi Marudanayagam
Darius F. Mirza
Paolo Muiesan
John K. Roberts
Publication date: 01-08-2015
Publisher: Springer International Publishing
Published in: World Journal of Surgery / Issue 8/2015
Print ISSN: 0364-2313
Electronic ISSN: 1432-2323
DOI: https://doi.org/10.1007/s00268-015-3051-3

At a glance: The STEP trials

Springer Medicine

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

Abstract

Introduction

Patients and methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Introduction

Patients and methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 8/2015

One Example of a Model Humanitarian Mission

Patient Selection for Oesophagectomy: Impact of Age and Comorbidities on Outcome

Patterns of Use and Short-Term Outcomes of Minimally Invasive Surgery for Malignant Pheochromocytoma: A Population-Level Study

Laparoscopic Colorectal Cancer Resection in High-Volume Surgical Centers: Long-Term Outcomes from the LAPCOLON Group Trial

Hypertrophy of the Left Liver in Patients with Large Tumors in the Right Liver

Posterosuperior Lesion has a High Risk of Lateral and Central Nodal Metastasis in Solitary Papillary Thyroid Cancer