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Liao R, Li JC, Chen J, Wei XF, Yan X. A clinical observational study on the application of enhanced recovery after laparoscopic pancreaticoduodenectomy. Front Surg 2022; 9:961161. [PMID: 36238863 PMCID: PMC9551302 DOI: 10.3389/fsurg.2022.961161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/25/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The safety and feasibility of enhanced recovery after surgery (ERAS) for laparoscopic pancreaticoduodenectomy (LPD) are unclear. The aim of this retrospective clinical study was to evaluate the impact of ERAS protocols for LPD. PATIENTS AND METHODS Between March 2016 and December 2018, a total of 34 consecutive patients with ERAS for LPD were prospectively enrolled and compared with 68 consecutive patients previously treated for non-ERAS after LPD during an equal time frame. The intraoperative and postoperative data were collected and comparatively analyzed. RESULTS The mean length of postoperative hospital stay (15.8 ± 3.4 and 23.1 ± 5.1 days, P < 0.001) was reduced significantly in ER group than those in non-ER group. The operation time (462.7 ± 117.0 vs. 450.9 ± 109.8 min, P = 0.627) and intraoperative blood loss (523.5 ± 270.0 vs. 537.5 ± 241.8 ml, P = 0.800) were similar in the two groups. The complications (ER: 32.4% vs. non-ER: 35.3%, P > 0.05) and their severities (Clavien-Dindo grade ≥3 complications, 2 vs. 5 patients; P = 0.783) of patients with ERAS protocols were not increased. No difference in mortality and readmission rates was found. Finally, the total medical costs ($2.1 ± 0.7 × 104 and $2.3 ± 0.7 × 104, P = 0.017) in ER group were lower than those in non-ER group. CONCLUSION the ERAS is safe and effective in the perioperative period of LPD. It could effectively reduce the length of postoperative stay and medical costs, and does not increase the incidence of postoperative complications.
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Affiliation(s)
- Rui Liao
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun-Cai Li
- Department of Thoracic Surgery, The People's Hospital of Yubei District of Chongqing City, Chongqing, China
| | - Jie Chen
- Department of Hepatobiliary Surgery, Zigong Fourth People's Hospital, Zigong, China
| | - Xu-Fu Wei
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiong Yan
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Arango NP, Prakash LR, Chiang YJ, Dewhurst WL, Bruno ML, Ikoma N, Kim MP, Lee JE, Katz MHG, Tzeng CWD. Risk-Stratified Pancreatectomy Clinical Pathway Implementation and Delayed Gastric Emptying. J Gastrointest Surg 2021; 25:2221-2230. [PMID: 33236322 DOI: 10.1007/s11605-020-04877-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/10/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a frequent complication after pancreaticoduodenectomy (PD) that impairs recovery and quality of life. The purpose of this study was to assess the impact risk-stratified pancreatectomy clinical pathways (RSPCPs) had on delayed gastric emptying (DGE) and identify factors associated with DGE in a contemporary period. METHODS A single-institution, prospective database was queried for consecutive PDs during July 2011-November 2019. Using international definitions, DGE rates were compared between periods before and after RSPCPs were implemented in 2016, classifying patients according to their postoperative pancreatic fistula (POPF) risk. Risk factors were analyzed to identify modifiable targets. RESULTS Among 724 elective PDs, 552 (76%) were for adenocarcinoma and 172 (24%) for other diagnoses. Of the 197 (27%) patients with DGE, 119 (16%) had type A, 41 (6%) type B, and 38 (5%) type C. In the overall cohort, DGE rates were higher with pylorus-preserving vs. classic hand-sewn reconstruction (odds ratio [OR] - 1.84; p < 0.001), postoperative abscess (OR - 2.54; p = 0.003), and non-white patients (p = 0.007), but lower after implementation of RSPCPs (OR - 0.34, p < 0.001). In the 374 patients treated with RSPCPs, only 17% (n = 65/374) developed DGE. Patients with protocol-compliant NGT removal ≤ 48 h were less likely to experience DGE (OR - 1.46, p = 0.042). CONCLUSION Our data suggest that implementation of preoperatively assigned RSPCPs as a care bundle was the most important factor in decreasing DGE. These gains were accentuated in patients who underwent early nasogastric tube removal and had a classic hand-sewn gastro-jejunostomy reconstruction. Application of these modifiable factors is generalizable with low implementation barriers.
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Affiliation(s)
- Natalia Paez Arango
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA.
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Fukushima T, Adachi T, Hanada M, Tanaka T, Oikawa M, Nagura H, Eguchi S, Kozu R. Role of Early Mobilization on the Clinical Course of Patients who Underwent Pancreaticoduodenectomy: A Retrospective Cohort Study. TOHOKU J EXP MED 2021; 254:287-294. [PMID: 34456202 DOI: 10.1620/tjem.254.287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The length of hospital stay is an important outcome measure in patients who have undergone pancreaticoduodenectomy. Although postoperative complications are known to adversely affect the length of hospital stay (LOS), the influence of early mobilization on LOS has not been clarified yet. This study aimed to examine the impact of the initial ambulation day, which is one of the components of early mobilization, on LOS after pancreaticoduodenectomy. We retrospectively enrolled patients who underwent pancreaticoduodenectomy between January 2013 and December 2017. Postoperative complications were evaluated using the Clavien-Dindo classification (CDC) system. Patients were divided into two groups based on the median LOS (early and late-discharge groups) and compared to determine their characteristics. Multivariate logistic regression analysis was performed with LOS as the dependent variable. Patients in the late-discharge group were significantly older, had an initial ambulation delay, and had higher rates of advanced disease stages and a CDC grade ≥ IIIa than those in the early discharge group. In the multivariate logistic regression analysis, CDC grade ≥ IIIa, initial ambulation day, and age were found to be significant independent factors associated with LOS. Our results demonstrated that not only postoperative complications, but also the initial ambulation day, could affect LOS after pancreaticoduodenectomy, emphasizing the importance of early ambulation for patients who undergo this surgery.
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Affiliation(s)
- Takuya Fukushima
- Department of Rehabilitation Medicine, Nagasaki University Hospital.,Department of Musculoskeletal Oncology and Rehabilitation, National Cancer Center
| | - Tomohiko Adachi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Masatoshi Hanada
- Department of Rehabilitation Medicine, Nagasaki University Hospital.,Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences
| | - Takayuki Tanaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Masato Oikawa
- Department of Rehabilitation Medicine, Nagasaki University Hospital.,Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences
| | - Hiroki Nagura
- Department of Rehabilitation Medicine, Nagasaki University Hospital.,Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Ryo Kozu
- Department of Rehabilitation Medicine, Nagasaki University Hospital.,Department of Cardiopulmonary Rehabilitation Science, Nagasaki University Graduate School of Biomedical Sciences
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Ergenc M, Karpuz S, Ergenc M, Yegen C. Enhanced recovery after pancreatic surgery: A prospective randomized controlled clinical trial. J Surg Oncol 2021; 124:1070-1076. [PMID: 34287900 DOI: 10.1002/jso.26614] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/08/2021] [Accepted: 07/10/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND OBJECTIVES The enhanced recovery after surgery (ERAS) protocol is a perioperative care bundle designed to achieve early healing after surgical procedures. This study aims to investigate the effect of the ERAS protocol on postoperative complications, length of hospital stay (LOS), and readmission rates in pancreatic surgery patients. METHODS The study was designed as a prospective and randomized controlled study between January 2016 and November 2018 on pancreatic surgery patients. A total of 38 patients were analyzed, 18 of whom were in the ERAS group and 20 in the control group. Patient demographics, intraoperative variables, and postoperative outcomes were recorded. RESULTS The groups were similar regarding age, sex, surgery type, American Society of Anesthesiologists scores, and laboratory results. There was no significant difference in the intraoperative variables. Early oral feeding was preferred, mostly in the ERAS group compared to the control group. Perioperative complication rates, including delayed gastric emptying and pancreatic fistula, LOS, and readmission rates, were similar between the two groups. CONCLUSIONS The ERAS protocol provided a minimal decrease in the total complication rates and had no effect on severe complications. Therefore, the ERAS protocol seems feasible and can be applied safely in pancreatic surgery patients.
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Affiliation(s)
- Muhammer Ergenc
- Department of General Surgery, School of Medicine, Marmara University, Istanbul, Turkey
| | - Sakir Karpuz
- Department of General Surgery, School of Medicine, Marmara University, Istanbul, Turkey
| | - Merve Ergenc
- Department of Anesthesiology and Reanimation, School of Medicine, Marmara University, Istanbul, Turkey
| | - Cumhur Yegen
- Department of General Surgery, School of Medicine, Marmara University, Istanbul, Turkey
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Dalgatov KD, Kozodaeva MV, Titkova SM, Smirnova OA, Sazhin AV. [Safety of enhanced recovery after surgery (ERAS) protocol in the treatment of patients undergoing pancreatoduodenectomy]. Khirurgiia (Mosk) 2021:19-26. [PMID: 34786912 DOI: 10.17116/hirurgia202111119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To study the effectiveness of enhanced recovery after surgery (ERAS) protocol versus traditional perioperative management in patients with hepatopancreatobiliary tumors undergoing pancreatoduodenectomy. MATERIAL AND METHODS The study included 111 patients who have undergone pancreatoduodenectomy between January 2014 and December 2019. Patients were divided into 2 groups: perioperative ERAS protocol (85 patients) and traditional treatment (26 patients). Postoperative complications, length of hospital-stay and incidence of readmissions were analyzed. RESULTS Mean length of hospital-stay for ERAS protocol was 13.4±7.6 days, conventional management - 16.5±7.5 days (p=0.004). Postoperative 30-day mortality was 8.24 and 7.7% in both groups, respectively (p=1.0). Intraoperative blood loss was significantly less in the ERAS group (248.24±214.0 vs. 321.15±155.0 ml, p=0.004). Overall incidence of postoperative complications was 56.5% and 65.4%, respectively (p=0.420). However, incidence of Clavien-Dindo grade IV complications was significantly higher in case of traditional treatment (19.2 vs. 4.7%, p=0.015). Readmission rate within 30 days was slightly less in the ERAS group (6.4 vs. 20.8%, p=0.052). CONCLUSION Enhanced recovery after surgery protocol is safe, reduces the number of postoperative complications, length of hospital-stay and rate of readmissions.
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Affiliation(s)
- K D Dalgatov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - M V Kozodaeva
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - S M Titkova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - O A Smirnova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia
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Eriksson K, Wikström L, Broström A, Pakpour AH. Predictors for Early Physical Recovery for General and Orthopedic Patients after Major Surgery: Structural Equational Model Analyses. Pain Manag Nurs 2019; 21:371-378. [PMID: 31712064 DOI: 10.1016/j.pmn.2019.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 10/07/2019] [Accepted: 10/07/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Attention to factors that may affect patients' ability to experience enhanced recovery after surgery is essential in planning for postoperative care. AIMS To create models of predefined pre,- peri-, and postoperative variables in order to analyze their impact on patients' physical recovery on postoperative days 1 and 2 after major orthopedic and general surgery. DESIGN An exploratory design with repeated measures was used, including 479 patients who had undergone orthopedic (289) or general surgery (190) at three hospitals. METHODS Pain, nausea, and level of physical ability were measured preoperatively and on postoperative days 1 and 2 by using the Numerical Rating Scale and items from the Postoperative Recovery Profile. Structural equation modeling was used to explore the impact of the predefined variables on patients' physical recovery. RESULTS The orthopedic group contained significantly more women and significantly more patients with pain and opioid use. Although the models showed good fit, "traditional" preoperative (pain, nausea, physical abilities, chronic pain, opioid use) and perioperative variables (anesthesia, length of surgery) constituted few (orthopedic) or no (general surgery) predictive properties for physical recovery. Postoperative average pain intensity, average nausea intensity, and physical ability explained physical recovery on day 1, and physical recovery on day 1 predicted physical recovery on day 2. CONCLUSIONS "Traditional" predictors had little effect on patients' postoperative physical recovery, while associations with common postoperative symptoms were shown. Further research is needed to explore additional variables affecting early physical recovery and to understand how soon patients are physically ready to return home.
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Affiliation(s)
- Kerstin Eriksson
- School of Health and Welfare, Jönköping University, Jönköping, Sweden; Department of Anesthesia and Intensive Care, Ryhov County Hospital, Jönköping, Sweden.
| | - Lotta Wikström
- School of Health and Welfare, Jönköping University, Jönköping, Sweden; Department of Anesthesia and Intensive Care, Ryhov County Hospital, Jönköping, Sweden
| | - Anders Broström
- School of Health and Welfare, Jönköping University, Jönköping, Sweden; Department of Clinical Neurophysiology, University Hospital, Linköping, Sweden
| | - Amir H Pakpour
- School of Health and Welfare, Jönköping University, Jönköping, Sweden; Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
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Ji HB, Zhu WT, Wei Q, Wang XX, Wang HB, Chen QP. Impact of enhanced recovery after surgery programs on pancreatic surgery: A meta-analysis. World J Gastroenterol 2018; 24:1666-1678. [PMID: 29686474 PMCID: PMC5910550 DOI: 10.3748/wjg.v24.i15.1666] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/08/2018] [Accepted: 03/18/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the impact of enhanced recovery after surgery (ERAS) programs on postoperative complications of pancreatic surgery.
METHODS Computer searches were performed in databases (including PubMed, Cochrane Library and Embase) for randomized controlled trials or case-control studies describing ERAS programs in patients undergoing pancreatic surgery published between January 1995 and August 2017. Two researchers independently evaluated the quality of the studies’ extracted data that met the inclusion criteria and performed a meta-analysis using RevMan5.3.5 software. Forest plots, demonstrating the outcomes of the ERAS group vs the control group after pancreatic surgery, and funnel plots were used to evaluate potential publication bias.
RESULTS Twenty case-control studies including 3694 patients, published between January 1995 and August 2017, were selected for the meta-analysis. This study included the ERAS group (n = 1886) and the control group (n = 1808), which adopted the traditional perioperative management. Compared to the control group, the ERAS group had lower delayed gastric emptying rates [odds ratio (OR) = 0.58, 95% confidence interval (CI): 0.48-0.72, P < 0.00001], lower postoperative complication rates (OR = 0.57, 95%CI: 0.45-0.72, P < 0.00001), particularly for the mild postoperative complications (Clavien-Dindo I-II) (OR = 0.71, 95%CI: 0.58-0.88, P = 0.002), lower abdominal infection rates (OR = 0.70, 95%CI: 0.54-0.90, P = 0.006), and shorter postoperative length of hospital stay (PLOS) (WMD = -4.45, 95%CI: -5.99 to -2.91, P < 0.00001). However, there were no significant differences in complications, such as, postoperative pancreatic fistulas, moderate to severe complications (Clavien-Dindo III- V), mortality, readmission and unintended reoperation, in both groups.
CONCLUSION The perioperative implementation of ERAS programs in pancreatic surgery is safe and effective, can decrease postoperative complication rates, and can promote recovery for patients.
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Affiliation(s)
- Hai-Bin Ji
- Department of Hepatobiliary Surgery, Affiliated Hospital of Binzhou Medical University, Binzhou 256603, Shandong Province, China
| | - Wen-Tao Zhu
- Department of Hepatobiliary Surgery, Affiliated Hospital of Binzhou Medical University, Binzhou 256603, Shandong Province, China
| | - Qiang Wei
- Department of Hepatobiliary Surgery, Affiliated Hospital of Binzhou Medical University, Binzhou 256603, Shandong Province, China
| | - Xiao-Xiao Wang
- Department of Hepatobiliary Surgery, Affiliated Hospital of Binzhou Medical University, Binzhou 256603, Shandong Province, China
| | - Hai-Bin Wang
- Department of Hepatobiliary Surgery, Affiliated Hospital of Binzhou Medical University, Binzhou 256603, Shandong Province, China
| | - Qiang-Pu Chen
- Department of Hepatobiliary Surgery, Clinical Nutrition Support Center, Affiliated Hospital of Binzhou Medical University; Clinical Nutrition and Metabolism Key Laboratory of Shandong Province, Binzhou 256603, Shandong Province, China
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