Impact of a fast-track surgery programme for pancreaticoduodenectomy

Adjunct mucin biomarkers MUC2+MUC5AC and MUC5AC+PSCA in a clinical setting identify and may improve correct selection of high-risk pancreatic lesions for surgery

BACKGROUND

Pancreatic cancer has dismal prognosis with a 5-year survival of 12 %. Cystic lesions have been identified as premalignant lesions. The challenge is to identify lesions with high risk of malignant progression, to offer patients prophylactic curative pancreatic surgery. Previous studies have identified mucin biomarker panels (MUCPs) as potential discriminators of pre- and malignant pancreatic cystic lesions. The present study assessed whether MUCPs contribute to more accurate identification of patients with high-risk pancreatic lesions and improve selection for surgery.

METHODS

This retrospective crossover study included 88 patients referred to endoscopic ultrasound because of unclear pancreatic cystic lesions. Clinical management and surgical decision-making with and without MUCP values were assessed by two expert teams with access to patient medical history, radiology, fine-needle aspirates, cytology, and cystic fluid carcinoembryonic antigen.

RESULTS

The adjunct of MUCPs improved decision-making in 2 of 21 cases with surgical pathology, identifying one cancer that otherwise would have been missed and sparing one patient from unnecessary surgery.

CONCLUSION

Access to MUCPs in a clinical setting improved correct selection of high-risk pancreatic lesions for surgery in single cases. A higher number of incorrect recommendations for surgery with the adjunct of MUCPs was also noted, which calls for caution.

Predictive effect of modified frailty index on postoperative nausea and vomiting in thyroid cancer patients

Postoperative nausea and vomiting (PONV) are common complications following thyroid cancer surgery, impacting patient well-being, prognosis, and potentially leading to severe complications. Frailty, a critical risk factor for postoperative complications, has not been thoroughly investigated concerning PONV in thyroid cancer patients. This study aimed to explore the correlation between frailty and PONV in thyroid cancer patients. A retrospective analysis was conducted on 908 patients who underwent radical thyroid cancer surgery at Jinan Central Hospital between January 2016 and September 2022. Patients were classified into the PONV group (626 patients) and the non-PONV group (282 patients). General and clinical data were collected for comparison. Independent risk factors for PONV were identified using univariate and multivariate logistic regression analyses. ROC curves evaluated the diagnostic efficiency of various indicators. A predictive model for PONV risk factors was developed, verified using ROC curves, and a scoring system was established. Age, Apfel score, modified frailty index (mFI) score, free fatty acids, uric acid, homocysteine (HCY), and fasting blood glucose were identified as independent risk factors for PONV through multivariable logistic regression analysis. The model achieved an area under the curve of 0.893 (0.871-0.915) in the ROC curve, with a sensitivity of 83.2%, specificity of 79.1%, and a maximum Youden index value of 0.623. mFI exhibited the strongest correlation with PONV post-radical thyroid cancer surgery, with a correlation coefficient of 0.523. The modified frailty index is a significant predictor of postoperative nausea and vomiting in patients undergoing thyroid cancer surgery.

Trends in pancreatic cancer mortality in the United States 1999-2020: a CDC database population-based study

INTRODUCTION

Pancreatic cancer is a significant public health concern and a leading cause of cancer-related deaths worldwide. This study aimed to investigate pancreatic cancer mortality trends and disparities in the United States (US) from 1999 to 2020.

METHODS

Data were obtained from the Centers for Disease Control (CDC) Wide-Ranging Online Data for Epidemiologic Research database. Mortality rates were age-adjusted and standardized to the year 2000 US population. Joinpoint regression was used to analyze temporal trends in age-adjusted mortality rates (AAMRs) by sociodemographic and geographic variables.

RESULTS

Between 1999 and 2020, pancreatic cancer led to a total of 810,628 deaths in the US, an average mortality of nearly 39,000 deaths per year. The AAMR slightly increased from 10.6 in 1999 to 11.1 in 2020, with an associated annual percent change (APC) of 0.2. Mortality rates were highest among individuals aged 65 and older. Black individuals experienced the highest overall pancreatic cancer-related AAMR at 13.8. Despite this, Black individuals experienced a decreasing mortality trend over time (APC -0.2) while White individuals experienced an increasing trend in mortality (APC 0.4). Additionally, individuals residing in rural areas experienced steeper rates of mortality increase than those living in urban areas (APC 0.6 for rural vs -0.2 for urban). White individuals in urban and rural populations experienced an increase in mortality, while Black individuals in urban environments experienced a decrease in mortality, and Black individuals in rural environments experienced stable mortality trends.

CONCLUSIONS

Mortality from pancreatic cancer continues to increase in the US, with racial and regional disparities identified in minorities and rural-dwelling individuals. These disparate findings highlight the importance of ongoing efforts to understand and address pancreatic cancer treatment and outcomes disparities in the US, and future studies should further investigate the underlying etiologies of these disparities and potential for novel therapies to reduce the mortality.

The Role of Enhanced Recovery after Surgery in Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis

INTRODUCTION

This study aimed to compare the safety and short-term outcomes of Enhanced Recovery After Surgery (ERAS) with standard care for patients undergoing pancreatoduodenectomy (PD) based on literature published following the first publication of ERAS guidelines for PD.

METHODS

Five medical databases were searched for studies that compared ERAS to standard care in adults undergoing PD. Data on postoperative complications, length of hospitalization, readmissions, and time to chemotherapy were analyzed using either a fixed- or random-effects model meta-analysis. Meta-regressions were conducted to investigate the role of operative technique, study origin, and study design.

RESULTS

Our analysis included 22 studies involving 4,043 patients. ERAS was associated with fewer complications (relative risk [RR]: 0.83; 0.75-0.91), particularly Clavien-Dindo (CD) grade 1 and 2 complications (RR: 0.82; 0.72-0.92), delayed gastric emptying (RR: 0.69; 0.52-0.93), and postoperative fistula (POPF) (RR: 0.76; 0.66-0.89), and a shorter time to chemotherapy (standardized mean difference [SMD]: -0.68; 95% CI: -0.88 to -0.48). ERAS did not affect the risk for CD grade 3 and 4 complications (RR: 1.00; 0.72-1.38), post-pancreatectomy hemorrhage (RR: 0.88; 0.67-1.14), length of stay (SMD: -0.56; 95% CI: -1.12 to 0.01), readmission (RR: 1.01; 0.84-1.21), and mortality (RR: 0.81; 0.54-1.22). The continent of origin was an effect moderator in the role of ERAS in CD grade 1 and 2 complications (p = 0.047) and POPF (p = 0.02).

CONCLUSION

Implementing ERAS principles in PD improves surgical outcomes without compromising safety. ERAS may also accelerate time to chemotherapy, an essential issue for future research.

Are enhanced recovery protocols after pancreatoduodenectomy still efficient when applied in elderly patients? A systematic review and individual patient data meta-analysis

BACKGROUND

This meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared to conventional care on postoperative outcomes in patients aged 70 years or older undergoing pancreatoduodenectomy (PD).

METHODS

Five databases were systematically searched. Comparative studies with available individual patient data (IPD) were included. The main outcomes were postoperative morbidity, length of stay, readmission and postoperative functional recovery elements. To assess an age-dependent effect, the group was divided in septuagenarians (70-79 years) and older patients (≥80 years).

RESULTS

IPD were obtained from 15 of 31 eligible studies comprising 1109 patients. The overall complication and major complication rates were comparable in both groups (OR 0.92 [95% CI: 0.65-1.29], p = .596 and OR 1.22 [95% CI: 0.61-2.46], p = .508). Length of hospital stay tended to be shorter in the ERAS group compared to the conventional care group (-0.14 days [95% CI: -0.29 to 0.01], p = .071) while readmission rates were comparable and the total length of stay including days in hospital after readmission tended to be shorter in the ERAS group (-0.28 days [95% CI: -0.62 to 0.05], p = .069). In the subgroups, the length of stay was shorter in octogenarians treated with ERAS (-0.36 days [95% CI: -0.71 to -0.004], p = .048). The readmission rate increased slightly but not significantly while the total length of stay was not longer in the ERAS group.

CONCLUSION

ERAS in the elderly is safe and its benefits are preserved in the care of even in patients older than 80 years. Standardized care protocol should be encouraged in all pancreatic centers.

Effect of accelerated rehabilitation nursing programmes on surgical site wound infection in patients undergoing laparoscopic cholecystectomy: A meta-analysis

This study aims to evaluate the effect of an accelerated rehabilitation nursing programme on the incidence of surgical site wound infections in patients undergoing laparoscopic cholecystectomy. Relevant studies regarding the use of an accelerated rehabilitation nursing programme in laparoscopic cholecystectomy were retrieved from databases, including PubMed, Web of Science, the Cochrane Library, EMBASE, CNKI and Wanfang Database. The search was conducted from the inception of each database until June 2023. Two independent researchers performed the literature screening, data collection and quality assessment of the included studies. Odds ratio (OR) and 95% confidence interval (CI) were used as the measures of effect. Statistical analysis was conducted using Stata 17.0, and a sensitivity analysis and publication bias evaluation were performed. A total of 21 studies involving 2480 patients (1179 in the intervention group and 1301 in the control group) were included. The meta-analysis revealed that the incidence of surgical site wound infections in the intervention group was significantly lower than in the control group (1.18% vs. 5.99%, OR: 0.322, 95% CI: 0.168-0.556, p < 0.001). Current evidence suggests that implementing accelerated rehabilitation nursing programmes for patients undergoing laparoscopic cholecystectomy has a clinically significant effect, leading to a substantial reduction in the incidence of surgical site wound infections. However, owing to the low quality of some of the included studies, further high-quality, multicentre, large-sample randomised controlled trials are required to validate the conclusions of this study.

Impact of interventions to improve recovery of older adults following planned hospital admission on quality-of-life following discharge: linked-evidence synthesis

Objectives

To understand the impact of multicomponent interventions to improve recovery of older adults following planned hospital treatment, we conducted two systematic reviews, one of quantitative and one of qualitative evidence, and an overarching synthesis. These aimed to: • understand the effect of multicomponent interventions which aim to enhance recovery and/or reduce length of stay on patient-reported outcomes and health and social care utilisation • understand the experiences of patients, carers and staff involved in the delivery of interventions • understand how different aspects of the content and delivery of interventions may influence patient outcomes.

Review methods

We searched bibliographic databases including MEDLINE ALL, Embase and the Health Management Information Consortium, CENTRAL, and Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database, conducted forward and backward citation searching and examined reference lists of topically similar qualitative reviews. Bibliographic database searches were completed in May/June 2021 and updated in April 2022. We sought primary research from high-income countries regarding hospital inpatients with a mean/median age of minimum 60 years, undergoing planned surgery. Patients experienced any multicomponent hospital-based intervention to reduce length of stay or improve recovery. Quantitative outcomes included length of stay and any patient-reported outcome or experience or service utilisation measure. Qualitative research focused on the experiences of patients, carers/family and staff of interventions received. Quality appraisal was undertaken using the Effective Public Health Practice Project Quality Assessment Tool or an adapted version of the Wallace checklist. We used random-effects meta-analysis to synthesise quantitative data where appropriate, meta-ethnography for qualitative studies and qualitative comparative analysis for the overarching synthesis.

Results

Quantitative review: Included 125 papers. Forty-nine studies met criteria for further synthesis. Enhanced recovery protocols resulted in improvements to length of stay, without detriment to other outcomes, with minimal improvement in patient-reported outcome measures for patients admitted for lower-limb or colorectal surgery. Qualitative review: Included 43 papers, 35 of which were prioritised for synthesis. We identified six themes: 'Home as preferred environment for recovery', 'Feeling safe', 'Individualisation of structured programme', 'Taking responsibility', 'Essential care at home' and 'Outcomes'. Overarching synthesis: Intervention components which trigger successful interventions represent individualised approaches that allow patients to understand their treatment, ask questions and build supportive relationships and strategies to help patients monitor their progress and challenge themselves through early mobilisation.

Discussion

Interventions to reduce hospital length of stay for older adults following planned surgery are effective, without detriment to other patient outcomes. Findings highlight the need to reconsider how to evaluate patient recovery from the perspective of the patient. Trials did not routinely evaluate patient mid- to long-term outcomes. Furthermore, when they did evaluate patient outcomes, reporting is often incomplete or conducted using a narrow range of patient-reported outcome measures or limited through asking the wrong people the wrong questions, with lack of longer-term evaluation. Findings from the qualitative and overarching synthesis will inform policy-making regarding commissioning and delivering services to support patients, carers and families before, during and after planned admission to hospital.

Study registration

This trial is registered as PROSPERO registration number CRD42021230620.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 130576) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 23. See the NIHR Funding and Awards website for further award information.

Costs and clinical benefits of enhanced recovery after surgery (ERAS) in pancreaticoduodenectomy: an updated systematic review and meta-analysis

PURPOSE

ERAS is a holistic and multidisciplinary pathway that incorporates various evidence-based interventions to accelerate recovery and improve clinical outcomes. However, evidence on cost benefit of ERAS in pancreaticoduodenectomy remains scarce. This review aimed to investigate cost benefit, compliance, and clinical benefits of ERAS in pancreaticoduodenectomy.

METHODS

A comprehensive literature search was conducted on Medline, Embase, PubMed, CINAHL and the Cochrane library to identify studies conducted between 2000 and 2021, comparing effect of ERAS programmes and traditional care on hospital cost, length of stay (LOS), complications, delayed gastric emptying (DGE), readmission, reoperation, mortality, and compliance.

RESULTS

The search yielded 3 RCTs and 28 cohort studies. Hospital costs were significantly reduced in the ERAS group (SMD = - 1.41; CL, - 2.05 to - 0.77; P < 0.00001). LOS was shortened by 3.15 days (MD = - 3.15; CI, - 3.94 to - 2.36; P < 0.00001) in the ERAS group. Fewer patients in the ERAS group had complications (RR = 0.83; CI, 0.76-0.91; P < 0.0001). Incidences of DGE significantly decreased in the ERAS group (RR = 0.72; CI, 0.55-0.94; P = 0.01). The number of deaths was fewer in the ERAS group (RR = 0.76; CI, 0.58-1.00; P = 0.05).

CONCLUSION

This review demonstrated that ERAS is safe and feasible in pancreaticoduodenectomy, improves clinical outcome such as LOS, complications, DGE and mortality rates, without changing readmissions and reoperations, while delivering significant cost savings. Higher compliance is associated with better clinical outcomes, especially LOS and complications.

Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years.

DATA SOURCES

A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression.

RESULTS

A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I2 = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I2 = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I2= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I2 = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I2 = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class.

CONCLUSIONS

Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.

Pancreatic cancer - the past, the present, and the future

BACKGROUND

Pancreatic cancer has been and still is associated with a very poor prognosis. This is due to a lack of major breakthroughs with respect to early diagnosis, prognostication, prediction, as well as novel, targeted therapies. The benefits of surgery and chemotherapy are evident, but the fact that only some 10% of all patients have early, localized disease highlights the unmet need for new early detection methods. An improved understanding of tumor biology and the development of molecular markers detectable both in the circulation and in cancer tissues may underlie the development of new tools for optimizing both diagnosis and treatment.

MATERIAL AND METHODS

Review of the literature.

RESULTS AND CONCLUSION

If we do not improve precision oncology for pancreatic ductal adenocarcinoma, the prognosis will still remain dismal and the" burden" on society will increase substantially.

Complications and chemotherapy have little impact on postoperative quality of life after pancreaticoduodenectomy - a cohort study

BACKGROUND

With the poor prognosis of pancreatic cancer and the high rate of postoperative complications after pancreaticoduodenectomy, it is important to evaluate how the operation affects patients' quality of life.

METHODS

This single-centre study included all patients undergoing pancreaticoduodenectomy from 2006 to 2016. Quality of life was measured with two questionnaires preoperatively, and at 6 and 12 months postoperatively. Comparisons between groups were made using a linear mixed models analysis.

RESULTS

Of 279 patients planned for pancreaticoduodenectomy, 245 underwent the operation. The postoperative response rates were all 80% or more. Differences were found in one domain between the early and late time periods and three domains between patients receiving and not receiving adjuvant chemotherapy. No significant differences were found between patients with and without severe postoperative complications. However, the demographic variables of age group, sex, preoperative diabetes and smoking all exerted a significant impact on postoperative quality of life.

CONCLUSION

While little or no impact was shown for the factors of postoperative complications, time period and adjuvant chemotherapy, demographic data, such as age, sex, preoperative diabetes and smoking, had considerable impacts on postoperative quality of life after pancreaticoduodenectomy.

Iterative Changes in Risk-Stratified Pancreatectomy Clinical Pathways and Accelerated Discharge After Pancreaticoduodenectomy

BACKGROUND

Previous implementation of risk-stratified pancreatectomy clinical pathways (RSPCPs) decreased length of stay (LOS) following pancreaticoduodenectomy (PD). This study's primary aim was to measure the association of iterative RSPCP revisions with accelerated discharge and early postoperative outcomes.

METHODS

This is a retrospective cohort study of a prospectively maintained surgical database (10/2016-9/2020). In February 2019, revised RSPCPs were implemented with earlier nasogastric tube (NGT) removal (postoperative day [POD] 1 for low risk; POD 2 for high risk) and updated drain fluid amylase cutoffs for POD 1/POD 3 removal. Perioperative outcomes between original and revised pathways were compared. Predictors of accelerated discharge (defined as ≤ POD 5 for low risk; ≤ POD 6 for high risk) were identified.

RESULTS

There were 233 (36% high risk) patients in original and 131 (32% high risk) in revised RSPCPs. After revision, the rate of POD 1 NGT removal was higher while POD ≤ 3 drain removal was similar. Median LOS decreased for low risk (5 vs. 6 days, p = 0.011) and high risk (6 vs. 9 days, p = 0.005) with no increase in delayed gastric emptying, postoperative pancreatic fistula, or readmissions. With POD 1 NGT removal, diet tolerance was earlier without increased NGT reinsertions. In low-risk patients, younger age, POD 1 NGT removal, and POD ≤ 3 drain removal were independent predictors of accelerated discharge. In high-risk patients, POD 1 NGT removal and POD ≤ 3 drain removal were independent predictors of accelerated discharge.

CONCLUSIONS

Following iterative revisions in RSPCPs, LOS after PD decreased further without increasing readmissions, and NGTs were removed earlier without increased reinsertions. Early NGT and drain removal are modifiable practices within RSPCPs that are associated with accelerated discharge.

Implementation of an enhanced recovery after surgery program in the treatment of uterine fibroids with focused ultrasound ablation surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) can reduce the length of hospital stay, incidence of surgery-related complications, and postoperative pain. We aimed to demonstrate the implementation of an ERAS pathway in the treatment of uterine fibroids with focused ultrasound ablation surgery (FUAS).

MATERIALS AND METHODS

A retrospective data analysis was performed on clinical outcomes encompassing the following three phases: before ERAS (pre-ERAS), during adjustment of ERAS (interim-ERAS), and after the introduction of an ERAS program (post-ERAS). The purpose of describing the interim-ERAS was to provide references for the formulation of the program during the course of FUAS by describing the adjustment processes. Data from patients admitted to the hospital from September 2019 to December 2019 and April 2020 to November 2020 and who met the criteria for FUAS in the treatment of their uterine fibroids were examined. Length of stay, cost of surgery, postoperative pain score, utilization of postoperative analgesics, and incidence of postoperative adverse events were compared across the abovementioned three phases.

RESULTS

Compared with the pre-phase, the cost of treatment and length of stay were reduced after the implementation of ERAS. The use of analgesics before leaving the operating room, as well as the incidence of postoperative nausea and vomiting, were also reduced.

CONCLUSION

The implementation of an ERAS protocol might benefit patients with uterine fibroids treated with FUAS in terms of requiring a shorter hospitalization period, lower costs, and reduced opioid use.

Enhanced recovery protocols in patients undergoing pancreatic surgery: An umbrella review

AIM

To identify, synthesize and appraise the systematic reviews of ERAS for patients undergoing pancreatic surgery and facilitate ERAS implementation.

DESIGN

An umbrella review was used to identify systematic reviews.

METHODS

A systematic search following the PRISMA guidelines was used to search databases including PubMed, Embase, Cochrane Library, CINAHL, CNKI, WanFang and VJIP. AMSTAR 2 was used to appraise the quality of included reviews.

RESULTS

Ten systematic reviews were included. The quality of all included systematic reviews was rated as "critically low." The most frequently reported ERAS elements were epidurals analgesia/PCA (9/10), goal-directed mobilization (9/10) and early removal of drains (9/10). Only one review mentioned audit protocol compliance. None of the included reviews reported discharge standards. Ten reviews reported decreased length of stay, seven reviews reported lower hospital costs, and six reviews reported decreased total complications rate. There were no adverse effects reported.

Enhancing the cost-effectiveness of surgical care in pancreatic cancer: a systematic review and cost meta-analysis with trial sequential analysis

BACKGROUND

Clinical pathways (CP) based on Enhanced recovery after surgery (ERAS®) are increasingly utilised in patients undergoing pancreatoduodenectomy (PD). This systematic review aimed to compare the impact of CPs versus conventional care (CC) on peri-PD costs.

METHODS

A systematic review of major reference databases was undertaken. Quality assessment was performed using the CHEERS checklist. Incremental cost-effectiveness ratios were calculated as part of the cost-effectiveness analysis. A meta-analysis was performed using random-effects models and Trial sequential analysis (TSA) was used to assess the precision and conclusiveness of the results.

RESULTS

14 studies meeting inclusion criteria were included for full qualitative synthesis. All studies reported a reduction in overall costs, length of stay and overall complication rates for CPs when compared to CC. Meta-analysis performed on nine studies demonstrated significantly reduced costs in the CP group, with considerable heterogeneity (Pooled mean difference of $ 4.28 × 103, p < 0.01, I2 = 95%). Cost-effectiveness analysis in relation to complications demonstrated dominance of CPs over CC in being cheaper as well as more effective. TSA supported the cost benefit of enhanced-recovery CPs, displaying minimal type 1 error.

CONCLUSION

Peri-PD CPs result in significant cost-reduction in comparison to CC.

Impact of enhanced recovery protocols after pancreatoduodenectomy: meta-analysis

BACKGROUND

This individual-patient data meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared with conventional care on postoperative outcomes in patients undergoing pancreatoduodenectomy.

METHODS

The Cochrane Library, MEDLINE, Embase, Scopus, and Web of Science were searched systematically for articles reporting outcomes of ERAS after pancreatoduodenectomy published up to August 2020. Comparative studies were included. Main outcomes were postoperative functional recovery elements, postoperative morbidity, duration of hospital stay, and readmission.

RESULTS

Individual-patient data were obtained from 17 of 31 eligible studies comprising 3108 patients. Time to liquid (mean difference (MD) -3.23 (95 per cent c.i. -4.62 to -1.85) days; P < 0.001) and solid (-3.84 (-5.09 to -2.60) days; P < 0.001) intake, time to passage of first stool (MD -1.38 (-1.82 to -0.94) days; P < 0.001) and time to removal of the nasogastric tube (3.03 (-4.87 to -1.18) days; P = 0.001) were reduced with ERAS. ERAS was associated with lower overall morbidity (risk difference (RD) -0.04, 95 per cent c.i. -0.08 to -0.01; P = 0.015), less delayed gastric emptying (RD -0.11, -0.22 to -0.01; P = 0.039) and a shorter duration of hospital stay (MD -2.33 (-2.98 to -1.69) days; P < 0.001) without a higher readmission rate.

CONCLUSION

ERAS improved postoperative outcome after pancreatoduodenectomy. Implementation should be encouraged.

Perception and implementation status of enhanced recovery after surgery

Background: The enhanced recovery after surgery (ERAS) program that is being implemented in Korea is difficult to investigate because it is not a standardized protocol with a unified content, and it instead differs according to the details for each hospital. Herein, the author would like to introduce and analyze the results of a recently conducted large-scale survey on the current status and perception of the ERAS program in Korea among large domestic hospitals.Current Concepts: Surveys of domestic general surgeons in 2019 and hepatobiliary-pancreatic surgeons in 2020 both showed lower-than-expected response rates of less than 50% in questions related to perception and clinical implementation of the ERAS program. Thus, implementation of ERAS items related to the limited application of preoperative fasting and surgical drain insertion and active nutritional support before and after surgery remains low.Discussion and Conclusion: For surgeons in Korea, the implementation of ERAS programs and perception levels were low. In this regard, it is necessary to improve awareness through systematic education and promotion of the ERAS program, and supplementation of related multidisciplinary professional manpower and financial resources is essential to facilitate practical implementation of ERAS programs in clinical practice.

Routine Gastric Decompression after Pancreatoduodenectomy: Treating the Surgeon?

BACKGROUND

The decision to routinely leave a nasogastric tube after pancreatoduodenectomy remains controversial. We sought to determine the impact of immediate nasogastric tube removal versus early nasogastric tube removal (<24 h) on postoperative outcomes.

METHODS

A retrospective review of our institution's prospective ACS-NSQIP database identified patients that underwent pancreatoduodenectomy from 2015 to 2018. Outcomes were compared among patients with immediate nasogastric tube removal versus early nasogastric tube removal.

RESULTS

A total of 365 patients were included in primary analysis (no nasogastric tube, n = 99; nasogastric tube removed <24 h, n = 266). Thirty-day mortality and infectious, renal, cardiovascular, and pulmonary morbidity were similar in comparing those with no nasogastric tube versus early nasogastric tube removal on univariable and multivariable analyses (P > 0.05). Incidence of delayed gastric emptying (11.1 versus 13.2%) was similar between groups. Patients with no nasogastric tube less frequently required nasogastric tube reinsertion (n = 4, 4%) compared to patients with NGT <24 h (n = 39, 15%) (OR = 3.83, 95% CI [1.39-10.58]; P = 0.009).

CONCLUSION

Routine gastric decompression can be safely avoided after uneventful pancreaticoduodenectomy.

Single-port VATS combined with non-indwelling drain in ERAS: a retrospective study

Background

We investigated single-port video-assisted thoracoscopic surgery (VATS) combined with a postoperative non-indwelling drain in enhanced recovery after surgery (ERAS).

Methods

The clinical data of 127 patients who underwent double- and single-port VATS from January 2018 to December 2019 were analyzed retrospectively. The groups constituted 71 cases undergoing double-port and 56 cases undergoing single-port VATS (30 cases in the indwelling drain group and 26 cases in the non-indwelling drain group). The incidence of postoperative complications, pain scores, and postoperative hospital stay were compared between the two groups.

Results

Compared with the double-port group, the single-port group had shorter postoperative hospital stays and lower pain scores on the first and third postoperative days (P < 0.05). Pain scores on the first and third days were lower in the single-port non-indwelling drain group than in the single-port indwelling drain group (P < 0.05), and the postoperative hospitalization time was significantly shorter in the single-port group (P < 0.05). However, there was no significant difference between the two groups for operation time, incidence of complications, and pain scores 1 month after operation (P > 0.05).

Conclusions

The combination of single-port VATS with a non-indwelling drain can relieve postoperative pain, help patients recover quickly, and is in accordance with ERAS.

Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery: A Review

Importance

Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative now firmly entrenched within the field of perioperative care. Although ERAS is associated with significant clinical outcome improvements and cost savings in numerous surgical specialties, several opportunities and challenges deserve further discussion.

Observations

Uptake and implementation of ERAS Society guidelines, together with ERAS-related research, have increased exponentially since the inception of the ERAS movement. Opportunities to further improve patient outcomes include addressing frailty, optimizing nutrition, prehabilitation, correcting preoperative anemia, and improving uptake of ERAS worldwide, including in low- and middle-income countries. Challenges facing enhanced recovery today include implementation, carbohydrate loading, reversal of neuromuscular blockade, and bowel preparation. The COVID-19 pandemic poses both a challenge and an opportunity for ERAS.

Conclusions and Relevance

To date, ERAS has achieved significant benefit for patients and health systems; however, improvements are still needed, particularly in the areas of patient optimization and systematic implementation. During this time of global crisis, the ERAS method of delivering care is required to take surgery and anesthesia to the next level and bring improvements in outcomes to both patients and health systems.

Late postpancreatectomy hemorrhage from the gastroduodenal artery stump into an insufficient hepaticojejunostomy: a case report

Background

Mortality after elective pancreatic surgery in modern high-volume centers is very low. Morbidity remains high, affecting 20–40% of patients. Late postpancreatectomy hemorrhage is a rare but potentially lethal complication. The exceptionality in our case lies in the underlying mechanism of its clinical presentation. It is a demonstration of the difficulties associated with finding the source of bleeding in late postpancreatectomy hemorrhage.

Case presentation

An 82-year-old White female was diagnosed with a periampullary malignancy and underwent pancreatoduodenectomy. Postoperatively, the patient suffered from an anastomotic leak in the hepaticojejunostomy, which was treated with percutaneous pigtail drains in the abdomen and in the biliary tract. On the fourth postoperative week she presented blood in both drains and in her stool. Given our knowledge about the biliary anastomotic leak, this presentation led us to suspect an intraluminal source (biliary tract or gastrojejunostomy) with blood leaking through the insufficient hepaticojejunostomy into the abdominal cavity. Upper tract endoscopy and computed tomography angiography were, however, unremarkable. Further investigation with conventional angiography identified the bleeding source at the gastroduodenal artery stump, which was successfully coiled. Hence, the gastroduodenal artery stump was bleeding into the insufficient hepaticojejunostomy, filling up the biliary tree and the small intestine. After coiling of the artery, the remainder of the postoperative care was uneventful.

Conclusion

Postpancreatectomy hemorrhage presents a major clinical challenge after pancreatoduodenectomy, with significant morbidity and high risk for mortality. The treating physician must be alert and active in the investigation and treatment of the bleeding source to ensure a successful outcome.

Early Nasojejunal Nutrition Versus Early Oral Feeding in Patients After Pancreaticoduodenectomy: A Randomized Controlled Trial

Objective

The aim of this study was to test the hypothesis that early oral feeding (EOF) is superior to early nasojejunal nutrition (ENN) after pylorus-preserving pancreaticoduodenectomy (PPPD) in terms of delayed gastric emptying (DGE).

Background

DGE is a common complication after PPPD. Although EOF after PPPD is recommended by several international guidelines, there is no randomized trial to support this recommendation.

Methods

From September 2016 to December 2017, a total of 120 patients undergoing PPPD were randomized into the ENN, EOF, or saline groups at a 1:1:1 ratio (40 patients in each group). The primary endpoint was the rate of clinically relevant DGE. Secondary endpoints included overall morbidity, postoperative pancreatic fistula, post-pancreatectomy hemorrhage, abdominal infection, length of hospital stay, reoperation rate, and in-hospital mortality.

Results

The baseline characteristics and operative parameters were comparable between the groups. The incidence of clinically relevant DGE varied significantly among the three groups (ENN, 17.5%; EOF, 10.0%; saline, 32.5%; p =0.038). The saline group had a higher clinically relevant DGE rate than the EOF group (p = 0.014). The saline group also had greater overall morbidities than the ENN and EOF groups (p = 0.041 and p = 0.006, respectively). There were no significant differences in other surgical complication rates or postoperative hospital stay. No mortality was observed in any of the groups.

Conclusions

Nutritional support methods were not related to DGE after PPPD. EOF was feasible and safe after PPPD, and additional ENN should not be routinely administered to patients after PPPD.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT03150615.

Cost Analysis of Enhanced Recovery Programs in Colorectal, Pancreatic, and Hepatic Surgery: A Systematic Review

BACKGROUND

Enhanced recovery programs (ERPs) have been shown to improve postoperative outcomes after abdominal surgery. This study aimed to review the current literature to assess if ERPs in colorectal, pancreas, and liver surgery induce cost savings.

METHODS

A systematic review was performed including prospective and retrospective studies comparing conventional management versus ERP in terms of costs. All kinds of ERP were considered (fast-track, ERAS^®, or home-made protocols). Studies with no mention of a clear protocol and no reporting of protocol compliance were excluded.

RESULTS

Thirty-seven articles out of 144 identified records were scrutinized as full articles. Final analysis included 16 studies. In colorectal surgery, two studies were prospective (1 randomized controlled trial, RCT) and six retrospective, totaling 1277 non-ERP patients and 2078 ERP patients. Three of the eight studies showed no difference in cost savings between the two groups. The meta-analysis found a mean cost reduction of USD3010 (95% CI: 5370-650, p = 0.01) in favor of ERP. Among the five included studies in pancreas surgery (all retrospective, 552 non-ERP vs. 348 ERP patients), the mean cost reduction in favor of the ERP group was USD7020 (95% CI: 11,600-2430, p = 0.003). In liver surgery, only three studies (two retrospective and 1 RCT, 180 non-ERP vs. 197 ERP patients) were found, which precluded a sound cost analysis.

CONCLUSIONS

The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management. Cost data in liver surgery are scarce.

There Is No Increase in Perioperative Mortality After Pancreaticoduodenectomy in Octogenarians: Results From the Swedish National Registry for Tumors in the Pancreatic and Periampullary Region

Objective

The aim of this observational study was to compare postoperative mortality and complications between octogenarians and younger patients following pancreaticoduodenectomy (PD).

Summary Background Data

With the growing elderly population and improved operative and postoperative results, PD is performed more frequently in octogenarians. Despite recent studies, it is uncertain whether elderly patients experience worse postoperative outcomes than younger patients.

Methods

All patients registered in the Swedish National Registry for tumors in the pancreatic and periampullary region from 2010 to 2018 who underwent PD were included in the analysis.

Results

Out of 13,936 patients included in the registry, 2793 patients underwent PD and were divided into the following age groups: <70 (n = 1508), 70-79 (n = 1137), and ≥80 (n = 148) years old. There was no significant difference in in-hospital, 30- or 90-day mortality among groups. The 2 older groups had a higher rate of medical and some surgical complications but not a significantly higher rate of complications ≥IIIa according to the Clavien-Dindo classification system. The 2 older groups had lower body mass index, higher American Society of Anesthesiologists and Eastern Cooperative Oncology Group scores, lower smoking rates, and a higher rate of preoperative biliary drainage than the <70-year-old group (all P < 0.001). The operation time was shorter in the oldest group.

Conclusions

Despite the worse preoperative condition of octogenarians than younger patients, short-term mortality and serious complications were not increased. The shorter operation time, however, may indicate that patients in the oldest group were more strictly selected. With careful preoperative consideration, especially regarding cardiovascular morbidity, more octogenarians can potentially be safely offered PD.

National survey of Korean hepatobiliary-pancreatic surgeons on attitudes about the enhanced recovery after surgery protocol

Backgrounds/Aims

The purpose of this study was to investigate attitudes regarding the Enhanced Recovery After Surgery (ERAS) protocol of hepato-biliary-pancreatic (HBP) surgeons in Korea and the extent to which they use the protocol for perioperative management.

Methods

An online survey was conducted among members of the Korean Association of Hepato-Biliary-Pancreatic Surgery (KAHBPS) for eight weeks beginning on August 2019. The questionnaire, which was written in Korean, was based on the latest ERAS guidelines. Total responses were collected from 127 surgeons.

Results

Of the 127 total respondents, the largest proportion (44.9%) were working in Seoul. In terms of established in-hospital clinical pathways (CP), 19.7% of the participating surgeons had and followed a CP in pancreaticoduodenectomy (PD) and 21.3% in hepatectomy. Regarding the ERAS protocol for each surgery, four items (18.2%) regarding PD and seven items (35.0%) related to hepatectomy were followed by more than 50% of respondents.

Conclusions

ERAS guidelines are one of the consensuses for better recovery in perioperative management of patients undergoing major surgeries and encompass the overall process of patient recovery including patient education, pain control, physiologic balance, and perioperative nutrition. A novel project is needed to successfully implement an evidence-based enhanced recovery strategy.

Impact of enhanced recovery after surgery protocol on pancreaticoduodenectomy: a meta-analysis of non-randomized and randomized controlled trials

BACKGROUND

Enhanced recovery after surgery (ERAS) has been widely applied in many surgical specialties. However, with respect to the impact of ERAS on pancreaticoduodenectomy (PD), there still exist some controversies.

METHODS

Literature search was performed in PubMed, Web of Science and the Cochrane Library from January, 1990 to July, 2019. A meta-analysis was performed using fixed-effects or random-effects models.

RESULTS

Twenty-two studies containing 4147 patients were identified. The entire pooled data showed that ERAS significantly reduced overall and minor morbidity (RR: 0.80, 95% CI: 0.72-0.88, p < 0.001; RR: 0.78, 95% CI: 0.69-0.88, p < 0.001, respectively), but didn't affect major morbidity (RR: 0.97, 95% CI: 0.84-1.13, p = 0.72). ERAS markedly reduced the incidences of delayed gastric emptying (DGE) (RR: 0.69, 95% CI: 0.55-0.88, p = 0.002), incisional infection (RR: 0.75, 95% CI: 0.60-0.94, p = 0.01) and intra-abdominal infection (RR: 0.79, 95% CI: 0.63-1.00, p = 0.05), but didn't influence clinically-relevant postoperative pancreatic fistula (CR-POPF) (RR: 0.86, 95% CI: 0.73-1.01, p = 0.07). Shorter length of stay (LOS) (WMD: -5.07, 95% CI: -6.71 to -3.43, p < 0.001) was noted in ERAS group, without increasing 30-day readmission (RR: 1.03, 95% CI: 0.86-1.24, p = 0.71) and mortality (RR: 0.70, 95% CI: 0.41-1.21, p = 0.20).

CONCLUSION

ERAS significantly reduced overall and minor morbidity, incidences of DGE, incisional and intra-abdominal infections, and shortened LOS in PD, without increasing 30-day readmission and mortality. However, more large-scale randomized controlled trials are still needed to confirm the findings.

Nasogastric Decompression vs No Decompression After Pancreaticoduodenectomy: The Randomized Clinical IPOD Trial

Importance

Although standardization of pancreaticoduodenectomy (PD) has improved postoperative outcomes, morbidity remains high. Fast-track surgery programs appear to improve morbidity, and avoiding nasogastric tube decompression (NGTD), already outdated in most major abdominal surgery, is strongly suggested after PD by fast-track surgery programs but lacks high-level evidence, especially regarding safety.

Objective

To assess in a randomized clinical trial whether the absence of systematic NGTD after PD reduces postoperative complications.

Design, Setting, and Participants

The IPOD study (Impact of the Absence of Nasogastric Decompression After Pancreaticoduodenectomy) was an open-label, prospective, single-center, randomized clinical trial conducted at a high-volume pancreatic surgery university hospital in France. In total, 155 patients who were 18 to 75 years of age and required PD for benign or malignant disease were screened for study eligibility. Key exclusion criteria were previous gastric or esophageal surgery and severe comorbidities. Patients were randomly assigned (1:1) to systematic NGTD or to no nasogastric decompression and were followed up until 90 days after surgery.

Interventions

For patients without NGTD, the NGT was removed immediately after surgery, whereas for patients with NGTD, the NGT was removed 3 to 5 days after surgery.

Main Outcomes and Measures

The primary end point was the occurrence of postoperative complications grade II or higher using the Clavien-Dindo classification. The primary end point and safety were evaluated in the intent-to-treat population.

Results

From January 2016 to August 2018, 125 screened patients were considered eligible for the study, and 111 were randomized to no NGTD (n = 52) or to NGTD (n = 59). No patient was lost to follow-up. The 2 groups had similar patient demographic and clinical characteristics at baseline. The median (interquartile range) age was 63.0 (57.0-66.5) years in the group with NGTD (38 [64.4%] were males) and 64.0 (58.0-68.0) years in the group without NGTD (31 [59.6%] were males). The postoperative complication rates grade II or higher were similar between the 2 groups (risk ratio, 0.99; 95% CI, 0.66-1.47; P > .99). Pulmonary complication rates (risk ratio, 0.59; 95% CI, 0.18-1.95; P = .44) and delayed gastric emptying rates (risk ratio, 1.07; 95% CI, 0.52-2.21; P > .99) were not significantly different between the groups. Median (interquartile) length of hospital stay for patients without NGTD was not significantly different compared with those with NGTD (10.0 [9.0-16.3] vs 12.0 [10.0-16.0] days; P = .14).

Conclusions and Relevance

The present study found no significant difference in postoperative complication occurrence of Clavien-Dindo classification grade II or higher between systematic NGTD and no NGTD after PD, suggesting that avoiding systematic nasogastric decompression is safe for this indication.

Trial Registration

ClinicalTrials.gov Identifier: NCT02594956.

Early Versus Late Oral Refeeding After Pancreaticoduodenectomy for Malignancy: a Comparative Belgian-French Study in Two Tertiary Centers

BACKGROUND

In the era of fast-track surgery, because pancreaticoduodenectomy (PD) carries a significant morbidity, surgeons hesitate to begin early oral feeding and achieve early discharge. We compared the outcome of two different approaches to the postoperative management of PD in two tertiary centers.

METHODS

Of patients having undergone PD for malignancy from 2008 to 2017, 100 patients who received early postoperative oral feeding (group A) were compared to 100 patients from another center who received early enteral feeding and a delayed oral diet (group B). Surgical indication and approach and type of pancreatic anastomosis were similar between both groups. Postoperative outcomes were retrospectively reviewed.

RESULTS

Patient characteristics were similar between both groups, except significantly more neoadjuvant treatment in group A (A = 20% vs. B = 9%, p < 0.01). Mortality rates were 3% and 4% in groups A and B, respectively (p = 0.71). The rate of severe postoperative morbidity was significantly lower in group A (13% vs. 26%, p = 0.02), resulting in a lower reoperation rate (p < 0.01). Delayed gastric emptying and clinically relevant pancreatic fistula were similar between both groups but chyle leaks were more frequent in group A (10% vs. 3%, p = 0.04). The median hospital stay was shorter in group A (16 vs. 20 days, p < 0.01).

CONCLUSION

In the present study, early postoperative oral feeding after PD was associated with a shorter hospital stay and did not increase severe postoperative morbidity or the rate of pancreatic fistula. However, it resulted in more chyle leaks and did not prevent delayed gastric emptying.

Chinese Survey on Enhanced Recovery after Surgery and Thromboprophylaxis Following Arthroplasty

Objective

To examine the current perspectives of enhanced recovery after surgery (ERAS) and the clinical practice applications of important ERAS principles among Chinese orthopaedic surgeons.

Methods

This was a cross‐sectional study using an online survey that was completed between November and December 2018. A 16‐item online questionnaire regarding the experiences of ERAS, perceptions of methods, and durations and concerns of venous thromboembolism (VTE) prophylaxis was sent to 2000 orthopaedic surgeons nationwide, and 1720 (86%) surgeons responded. Statistical analyses were conducted to assess all respondents' results and to compare differences among subgroups that were stratified according to city and hospital level, as well as their professional title.

Results

According to the results of the survey, ERAS awareness was high (65.1%) and most surgeons recognized the importance of thromboprophylaxis. However, the timing of ERAS was not consistent, with 22.8%, 31.9%, and 37.7% of surgeons choosing to initiate pharmaceutical prophylaxis within <6 h, 6–12 h, and 12–24 h after surgery, respectively. Low‐molecular‐weight heparin was mainly selected during hospitalization, and new oral anticoagulants (NOACs) were the first choice after discharge. Regarding postoperative antithrombotic therapy, particularly when combined with analgesics, the potential bleeding risk was mostly considered (80.0%)Tranexamic acid was believed to have no effect on the timing of NOAC therapy initiation (56.2%). Most of the above outcomes were influenced by the hospital level and professional title of the surgeon. Surgeons who had higher awareness on ERAS and better adhered to the guidelines were from higher‐level hospitals as well as had more advanced professional titles. City level partly might influence their practice but not impact surgeons' awareness.

Conclusions

The awareness and perception of the concept of ERAS and prophylactic antithrombotic regimens remain different among Chinese orthopaedic surgeons in different level cities and with various professional titles. Continuing medical educations (CME) on VTE prophylaxis is needed for improving the quality of health care in China.

The Safety and Feasibility of Enhanced Recovery after Surgery in Patients Undergoing Pancreaticoduodenectomy: An Updated Meta-Analysis

Background

Enhanced recovery after surgery (ERAS) is a multimodal, multidisciplinary, evidence-based approach to care for surgical patients and aims at optimizing the perioperative management and outcomes. The ERAS approach was first implemented in colorectal surgery patients; however, the reported applications in pancreatoduodenectomy patients are limited. In recent years, studies on ERAS for patients undergoing pancreaticoduodenectomy have been published. The accumulation of new randomized controlled trials and high-quality case-control studies stimulated us to update the analysis. Our study comprehensively collected data to provide the best evidence summary for the clinic.

Aim

To evaluate the safety and feasibility of enhanced recovery after surgery in the perioperative management of pancreatoduodenectomy patients.

Methods

A systematic literature search of PubMed, Embase, and the Cochrane Library was performed up to July 2019. All randomized controlled trials and case-control studies that applied ERAS for patients undergoing pancreaticoduodenectomy were considered for inclusion in this study. The patients were divided into two groups: patients who received the ERAS perioperative management approach were defined as the ERAS group and patients who received the traditional perioperative management approach were defined as the control group. All statistical analyses were conducted using the Revman5.3 software, and the outcomes were calculated as odds ratios or weighted mean differences with their corresponding 95% confidence intervals. A funnel plot was created to assess publication bias. Subgroup and sensitivity analyses were performed to explore the sources of heterogeneity.

Results

A total of 20 studies involving 3613 patients (1914 patients in the ERAS group vs. 1699 patients in the control group) were included in this study. Among the 20 studies, 4 were randomized controlled trials, and 16 were case-control studies. The overall postoperative complication rate was significantly lower in the ERAS group (OR = 0.62, 95% CI: 0.53-0.74, P < 0.00001) than in the control group. In addition, the minor complication rate (Clavien-Dindo I-II) was also lower in the ERAS group (OR = 0.70, 95% CI: 0.58-0.86, P = 0.0005). The patients in the ERAS group had a lower incidence of delayed gastric emptying (OR = 0.51, 95% CI: 0.42-0.63, P < 0.00001) and shorter length of hospital stay (WMD = -4.27, 95% CI: -4.81~-3.73, P < 0.00001) than in the control group. The rates of pancreatic fistula (regardless of Grade A/B/C), wound infections, abdominal abscesses, readmission, reoperation, and morbidity were not significantly different between the two groups.

Conclusion

The ERAS approach is safe and effective in the perioperative management of patients undergoing pancreaticoduodenectomy and helps to accelerate the postoperative recovery and improve prognosis.

Development and Feasibility of an Interactive Smartphone App for Early Assessment and Management of Symptoms Following Pancreaticoduodenectomy

BACKGROUND

Patients who have undergone pancreaticoduodenectomy because of pancreatic cancer experience distressing symptoms and unmet supportive care needs after discharge. To meet these needs, we have developed a mobile health app (Interaktor) for daily assessment of symptoms and access to self-care advice that includes a risk assessment model for alerts with real-time interactions with professionals.

OBJECTIVE

The study aim was to develop and test a version of the Interaktor app adapted for patients who have undergone pancreaticoduodenectomy.

METHODS

The app was developed and tested for feasibility in 6 patients during 4 weeks. One nurse monitored and responded to alerts. Logged data from the app were collected, and all participants were interviewed about their experiences.

RESULTS

Adherence to reporting daily was 84%. Alerts were generated in 41% of the reports. The patients felt reassured and cared for and received support for symptom management. The app was easy to use, had relevant content, and had few technical problems, although suggestions for improvement were given.

CONCLUSIONS

The daily reporting of symptoms and having access to a nurse in real time in the case of an alarming symptom seem to enhance symptom management and render a feeling of security in patients. Some modifications of the app are needed before use in a larger sample.

IMPLICATIONS FOR PRACTICE

Daily reporting of symptoms after pancreaticoduodenectomy enhances symptom management, self-care, and participation without being a burden to patients, indicating that mobile health can be used in clinical practice by patients with poor prognosis who experience severe symptoms.

Perioperative nutritional management of patients undergoing pancreatoduodenectomy: an international survey among surgeons

BACKGROUND

There is still a lack of good evidence regarding the optimal perioperative nutritional management for patients undergoing pancreatoduodenectomy (PD). The aim of this international survey was to assess the current practice among pancreatic surgeons.

METHODS

A web survey of 30 questions was sent to the members of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA). All members were invited by email to answer the online survey. A reminder was sent after 4 weeks.

RESULTS

In total 420 out of 2500 surgeons (17%) answered the survey. Almost half of the surgeons (44%) did not organize a preoperative nutritional consultation for their patients. Seventy-seven percent of the participants did not have specific nutritional thresholds before the operation. A majority (66%) routinely used biological parameters to detect or follow malnutrition. Regarding intraoperative details, 69% of the respondents routinely leaved a nasogastric tube at the end of PD for gastric drainage. Sixty-six percent of the participants reported a postoperative nutritional follow-up consultation during hospitalization, and 58% of them had established local standardized protocols for postoperative nutritional support.

CONCLUSION

Management of perioperative nutrition in patients undergoing PD was very disparate internationally. No specific preoperative nutritional thresholds were used, and postoperative feeding routes and timing were diverse.

Effects of the Enhanced Recovery Program on the Recovery and Stress Response in Patients With Cancer Undergoing Pancreatoduodenectomy

Aim the study was the comparison of enhanced recovery after surgery (ERAS) versus conventional care (CON) protocols in patients undergoing pancreatoduodenectomy with regard to pain intensity, emotional response (optimism/sadness/stress), and stress biomarker levels (adrenocorticotropopic hormone, cortisol). We conducted a prospective two-group randomized controlled study with repeated measures in 85 patients with cancer pancreatoduodenectomy. In the ERAS group (N = 44), the ERAS protocol was followed, compared with the CON group (N = 41). We assessed pain with the numeric rating scale and a behavioral scale (Critical Care Pain Observation Tool), emotional responses (numeric rating scale), and serum adrenocorticotropopic hormone and cortisol levels at three time points: T1, admission day; T2, day of surgery; and T3, discharge day (ERAS) or the fifth day of stay (CON). Data were analyzed by linear mixed modeling to account for repeated measurements. We observed decreased postoperative pain in ERAS patients after adjusting for confounders (p = .002) and a trend for less complications. No significant associations with stress/emotional responses were noted. Only age, but not protocol, appeared to have a significant effect on adrenocorticotropopic hormone levels despite a significant interaction with time toward increased adrenocorticotropopic hormone levels in the ERAS group. In conclusion, despite its fast track nature, ERAS is not associated with increased stress in patients undergoing pancreatoduodenectomy and is associated with decreased pain.

Early postoperative fluid retention is a strong predictor for complications after pancreatoduodenectomy

BACKGROUND

Perioperative fluid overload has been reported to increase complications after a variety of operative procedures. This study was conducted to investigate the incidence of fluid retention after pancreatic resection and its association with postoperative complications.

METHODS

Data from 1174 patients undergoing pancreatoduodenectomy between 2010 and 2016 were collected from the Swedish National Pancreatic and Periampullary Cancer Registry. Early postoperative fluid retention was defined as a weight gain ≥2 kg on postoperative day 1. Outcome measures were overall complications, as well as procedure-specific complications.

RESULTS

The weight change on postoperative day 1 ranged from -1 kg to +9 kg. A total of 782 patients (66.6%) were considered to have early fluid retention. Patients with fluid retention had significantly higher rates of total complications (p = 0.002), surgical complications (p = 0.001), pancreatic anastomotic leakage (p = 0.018) and wound infection (p = 0.023). Multivariable logistic regression confirmed early fluid retention as an independent risk factor for total complications (OR 1.46; p = 0.003), surgical complications (OR 1.49; p = 0.002), pancreatic anastomotic leakage (OR 1.48; p = 0.027) and wound infection (OR 1.84; p = 0.023).

CONCLUSIONS

Fluid retention is common after elective pancreatic resection, and its associated with an increased rate of postoperative complications.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Influence of Clinical pathways on treatment and outcome quality for patients undergoing pancreatoduodenectomy? A retrospective cohort study

BACKGROUND

Pancreatic surgery demands complex multidisciplinary management. Clinical pathways (CPs) are a tool to facilitate this task, but evidence for their utility in pancreatic surgery is scarce. This study evaluated the effect of CPs on quality of care for pancreatoduodenectomy.

METHODS

Data of all consecutive patients who underwent pancreatoduodenectomy before (n = 147) or after (n = 148) CP introduction were evaluated regarding catheter and drain management, postoperative mobilization, pancreatic enzyme substitution, resumption of diet and length of stay. Outcome quality was assessed using glycaemia management, morbidity, mortality, reoperation and readmission rates.

RESULTS

Catheters and abdominal drainages were removed significantly earlier in patients treated with CP (p < 0.0001). First intake of liquids, nutritional supplement and solids was significantly earlier in the CP group (p < 0.0001). Exocrine insufficiency was significantly less common after CP implementation (47.3% vs. 69.7%, p < 0.0001). The number of patients receiving intraoperative transfusion dropped significantly after CP implementation (p = 0.0005) and transfusion rate was more frequent in the pre-CP group (p = 0.05). The median number of days with maximum pain level >3 was significantly higher in the CP group (p < 0.0001). There was no significant difference in mortality, morbidity, reoperation and readmission rates.

CONCLUSIONS

Following implementation of a CP for pancreatoduodenectomy, several indicators of process and outcome quality improved, while others such as mortality and reoperation rates remained unchanged. CPs are a promising tool to improve quality of care in pancreatic surgery.

Nasogastric Tube on Demand is Rarely Necessary After Pancreatoduodenectomy Within an Enhanced Recovery Pathway

BACKGROUND

Evidence-based guidelines for enhanced recovery (ERAS) pathways after pancreatoduodenectomy (PD) are available. Routine use of nasogatric tube (NGT) after PD is not recommended. This study aims to evaluate the need for NGT reinsertion after PD performed within an ERAS setting.

METHODS

It is a prospective observational study of all patients undergoing PD in a tertiary referral hospital within the study period from 2015 throughout 2016. Pre- and postoperative variables were collected. Patients requiring NGT reinsertion were identified. Comparative analysis of patients with and without a NGT reinsertion was performed, as well as multivariate analysis for risk factors for on-demand NGT reinsertion.

RESULTS

Two-hundred and one patients were included. In total, 45 (22.4%) patients required NGT reinsertion after PD. A total of 32 (15.9%) patients underwent a relaparotomy. Reinsertion of NGT in patients not undergoing a relaparotomy occurred in 26 (15.4%) patients. The presence of a major postoperative complication was a risk factor for reinsertion of NGT, OR 5.27 (2.54-10.94, p = 0.001). Patients with the need for a NGT reinsertion had a higher frequency of major postoperative complications and relaparotomy compared to patients without the need of a NGT reinsertion, 26 (57.8%) versus 32 (20.5%), p < 0.001 and 19 (42.2%) versus 13 (8.3%), p < 0.001, respectively.

CONCLUSION

Routine use of NGT after PD is not justified within an ERAS setting. Immediate removal of the NGT after the procedure can be performed safely, and reinsertion on demand is rarely necessary in uncomplicated courses.

Effect of Enhanced Recovery After Surgery program on pancreaticoduodenectomy: a randomized controlled trial

BACKGROUND

This study aims to investigate the noninferiority of Enhanced Recovery After Surgery (ERAS) for pancreaticoduodenectomy (PD).

METHODS

In this single-center trial, we randomly assigned 276 adult patients who underwent open PD into ERAS and conventional groups with 138 patients in each, from 2015 through 2017. The primary endpoint was the incidence of overall morbidity until postoperative 3 months. The secondary endpoints were in-hospital or 30-day mortality, postoperative length of stay (LOS), nutritional status and overall hospital costs.

RESULTS

Overall morbidity was reported in 64 patients (52.0%, ERAS group) and in 68 patients (54.8%, conventional group) (risk difference [RD] -2.81 percentage points (pp); 90% two-sided confidence interval -13.24 to 7.63). Mortality did not occur in any patients. The two groups did not differ significantly in median postoperative LOS (both 11 days; RD -8.46 pp), body mass index (22.4 ± 2.75 vs. 22.4 ± 2.65 kg/m2 ; RD -3.48 pp), Patient-Generated Subjective Global Assessment score over 4 (45 [40.5%] vs. 50 [43.1%] patients; RD -2.56 pp), and median overall hospital cost (15.61 vs. 16.04, ×106 KRW; RD -6.08 pp).

CONCLUSIONS

Even in PD, modified ERAS protocol was not inferior to conventional protocol, while reducing treatment burden.

Impact of Enhanced Recovery After Surgery on Postoperative Recovery for Pancreaticoduodenectomy: Pooled Analysis of Observational Study

Purpose: To assess the impact of enhanced recovery after surgery (ERAS) protocols in pancreaticoduodenectomy. Methods: Four databases were searched for studies describing ERAS program in patients undergoing pancreatic surgery published up to May 01, 2018. Primary outcomes were mortality, readmission, reoperation and postoperative complications. Secondary outcomes were the length of stay and cost. Results: A total of 19 studies met inclusion and exclusion criteria and included 3,387 patients. Meta-analysis showed a decrease in pancreatic fistula (OR = 0.79, 95% CI: 0.67 to 0.95; I 2 = 0%), infection (OR = 0.63, 95% CI: 0.50 to 0.78; I 2 = 0%), especially incision infection (OR = 0.62, 95% CI: 0.42 to 0.91; I 2 = 0%), and pulmonary infection (OR = 0.28, 95% CI: 0.12 to 0.66; I 2 = 0%). Length-of-stay (MD: -3.89 days, 95% CI: -4.98 to -2.81; I 2 = 78%) and cost were also significantly reduced. There was no significant increase in mortality, readmission, reoperation, or delayed gastric emptying. Conclusion: This analysis revealed that using ERAS protocols in pancreatic resections may help decrease the incidence of pancreatic fistula and infections. Furthermore, ERAS also reduces length of stay and cost of care. This study provides evidence for the benefit of ERAS protocols.

A Combination of Robotic Approach and ERAS Pathway Optimizes Outcomes and Cost for Pancreatoduodenectomy

OBJECTIVE

To determine the impact of enhanced recovery after surgery (ERAS) pathway implementation on outcomes, and cost of robotic and open pancreatoduodenectomy.

BACKGROUND

ERAS pathways have shown benefit in open pancreatoduodenectomy (OPD). The impact of ERAS on robotic pancreatoduodenectomy (RPD) is unknown.

METHODS

Retrospective review of consecutive RPD and OPDs in the pre-ERAS (July, 2014-July, 2015) and ERAS (July, 2015-July, 2016) period. Univariate and multivariate logistic regression was used to determine impact of ERAS and operative approach alone, or in combination (pre-ERAS + OPD, pre-ERAS + RPD, ERAS + OPD, ERAS + RPD) on length of hospital stay (LOS) and overall cost.

RESULTS

In all, 254 consecutive pancreatoduodenectomies (RPD 62%, OPD 38%) were analyzed (median age 67, 47% female). ERAS patients had shorter LOS (6 vs 8 days; P = 0.004) and decreased overall cost (USD 20,362 vs 24,277; P = 0.001) compared with non-ERAS patients, whereas RPD was associated with decreased LOS (7 vs 8 days; P = 0.0001) and similar cost compared with OPD. On multivariable analysis (MVA), RPD was predictive of shorter LOS [odds ratio (OR) 0.33, confidence interval (CI) 0.16-0.67, P = 0.002), whereas ERAS was protective against high cost (OR 0.57, CI 0.33-0.97, P = 0.037). On MVA, when combining operative approach with ERAS pathway use, a combined ERAS + RPD approach was associated with reduced LOS and optimal cost compared with other combinations (pre-ERAS + OPD, pre-ERAS + RPD, ERAS + OPD).

CONCLUSION

ERAS implementation is independently associated with cost savings for pancreatoduodenectomy. A combination of ERAS and robotic approach synergistically decreases hospital stay and overall cost compared with other strategies.

Integrating perioperative medicine with anaesthesia in India: Can the best be achieved? A review

Integrating perioperative medicine with anaesthesia is the need of the hour. Evolution of a new superspeciality called perioperative anaesthesia can improve surgical outcomes by quality perioperative care and guarantee imminent escalation of influence and power for anaesthesiologists. All original peer-reviewed manuscripts pertaining to surgery-specific perioperative surgical home models involving preoperative, intraoperative and postoperative initiatives spanning the past 5 years have been reviewed using PubMed and Google Scholar. Whether the perioperative surgical home model is feasible or still a distant dream in the Indian perspective has been analysed.

Sustainability of an Enhanced Recovery Program for Pancreaticoduodenectomy with Pancreaticogastrostomy

BACKGROUND:

Enhanced recovery program for pancreaticoduodenectomy have become standard care. Little is known about adherence rates and sustainability of the program, especially when pancreaticogastrostomy is used in reconstruction. The aim of this study was, therefore, to evaluate adherence rates and continued outcome, after implementation of an enhanced recovery program.

METHODS:

Consecutive patients undergoing pancreaticoduodenectomy at the Department of Surgery, Skåne University Hospital, Lund, Sweden were followed, after implementation of enhanced recovery program, October 2012. In April 2015, some items in the enhanced recovery program were modified, namely earlier removal of nasogastric tubes and abdominal drain. The patients were analyzed in three groups, the implementation group (control) and two post-implementation groups; intermediate and modified group. Sustainability was assessed according to length of stay and adherence rate.

RESULTS:

In total, 160 patients were identified. The overall protocol adherence rate increased from 65% to 72%, p = 0.035. While the pre- and intraoperative protocol items were fulfilled to more than >90%, the postoperative were lower, but increasing over time; 48%, 50%, and 58%, p = 0.033. Postoperative complications and hospital length of stay did not change significantly.

CONCLUSION:

The positive outcome of an enhanced recovery program for pancreaticoduodenectomy was reasonably well sustained. Compliance with the protocol has increased, but strict adherence remains a challenge, especially with the postoperative items.

First results from the Swedish National Pancreatic and Periampullary Cancer Registry

BACKGROUND

Despite improvements in therapy regimens over the past decades, overall survival rates for pancreatic and periampullary cancer are poor. Specific cancer registries are set up in various nations to regional differences and to enable larger prospective trials. The aim of this study was to describe the Swedish register, including possibilities to improve diagnostic work-ups, treatment, and follow-up by means of the register.

METHODS

Since 2010, all patients with pancreatic and periampullary cancer (including also patients who have undergone pancreatic surgery due to premalignant or benign lesions) have been registered in the Swedish National Periampullary and Pancreatic Cancer registry.

RESULTS

In total 9887 patients are listed in the registry; 8207 of those have malignant periampullary cancer. Approximately one-third (3282 patients) have had resections performed, including benign/premalignant resections. 30-day and 90-day mortality after pancreatoduodenectomy is 1.5% and 3.5%, respectively. The overall 3-year survival for resected pancreatic ductal adenocarcinoma is 35%. Regional variations decreased over the studied period, but still exist.

CONCLUSION

Results from the Swedish National Registry are satisfactory and comparable to international standards. Trends over time show increasing resection rates and some improved results. Better collaboration and openness within pancreatic surgeons is an important side effect.

Afferent Loop Decompression Technique is Associated with a Reduction in Pancreatic Fistula Following Pancreaticoduodenectomy

OBJECTIVES

Postoperative pancreatic fistula (POPF) is a major complication and main cause of mortality after pancreaticoduodenectomy (PD). Afferent loop decompression technique (ALDT) has theoretical feasibility to reduce the rate of POPF. The aim of this study is to determine whether ALDT is a protective factor for POPF.

METHODS

A total of 492 consecutive patients who underwent PD between January 2012 and December 2014 were identified from a prospective database. All data were extracted and events were judged based on medical records. Propensity score matching was conducted to balance several variables. Univariate and multivariate analyses were performed, respectively, to investigate the independent risk factors for pancreatic fistula. ALDT required a nasogastric tube with multiple side holes to be placed deep into the afferent jejunal limb. The rationale for this technique was to prevent pancreatic fistula by decreasing intraluminal pressure in the afferent jejunal loop by placement of the nasogastric tube and the application of continuous low-pressure suction after surgery.

RESULTS

The total rate of POPF for the entire cohort was 30.7%, and ISGPS grade-A/B/C POPF rates were 18.1, 10.6 and 2.0%, respectively. In-hospital mortality was 1.6%. Among the 331 patients who received ALDT, 89 developed pancreatic leakage (26.9 vs. 38.5% for non-ALDT; P = 0.009) and eight developed biliary leakage (2.4 vs. 6.2% for non-ALDT; P = 0.035). Apart from ALDT, decreased preoperative ALT, soft pancreas, long operative time and tumour presence in the lower common bile duct (as opposed to the pancreas) were identified as other independent risk factors for POPF following multivariate logistic regression analysis.

CONCLUSIONS

ALDT may reduce the incidence of POPF after PD.

Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS)

BACKGROUND

The optimal nutritional therapy in the field of pancreatic surgery is still debated.

METHODS

An international panel of recognized pancreatic surgeons and pancreatologists decided that the topic of nutritional support was of importance in pancreatic surgery. Thus, they reviewed the best contemporary literature and worked to develop a position paper to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection. Strength of recommendation and quality of evidence were based on the approach of the grading of recommendations assessment, development and evaluation Working Group.

RESULTS

The measurement of nutritional status should be part of routine preoperative assessment because malnutrition is a recognized risk factor for surgery-related complications. In addition to patient's weight loss and body mass index, measurement of sarcopenia and sarcopenic obesity should be considered in the preoperative evaluation because they are strong predictors of poor short-term and long-term outcomes. The available data do not show any definitive nutritional advantages for one specific type of gastrointestinal reconstruction technique after pancreatoduodenectomy over the others. Postoperative early resumption of oral intake is safe and should be encouraged within enhanced recovery protocols, but in the case of severe postoperative complications or poor tolerance of oral food after the operation, supplementary artificial nutrition should be started at once. At present, there is not enough evidence to show the benefit of avoiding oral intake in clinically stable patients who are complicated by a clinically irrelevant postoperative pancreatic fistula (a so-called biochemical leak), while special caution should be given to feeding patients with clinically relevant postoperative pancreatic fistula orally. When an artificial nutritional support is needed, enteral nutrition is preferred whenever possible over parenteral nutrition. After the operation, regardless of the type of pancreatic resection or technique of reconstruction, patients should be monitored carefully to assess for the presence of endocrine and exocrine pancreatic insufficiency. Although fecal elastase-1 is the most readily available clinical test for detection of pancreatic exocrine insufficiency, its sensitivity and specificity are low. Pancreatic enzyme replacement therapy should be initiated routinely after pancreatoduodenectomy and in patients with locally advanced disease and continued for at least 6 months after surgery, because untreated pancreatic exocrine insufficiency may result in severe nutritional derangement.

CONCLUSION

The importance of this position paper is the consensus reached on the topic. Concentrating on nutritional support and therapy is of utmost value in pancreatic surgery for both short- and long-term outcomes.

Perioperative Optimization With Nutritional Supplements in Patients Undergoing Gastrointestinal Surgery for Cancer (PROGRESS): Protocol for a Feasibility Randomized Controlled Trial

Background

Postoperative morbidity following gastrointestinal tract major surgery ranges between 40% and 60%. Malnutrition, poor protein intake, and surgery-related impairment of the immune system and its function have been associated with postoperative infections. Supplemental perioperative nutrition may improve nutrition by increasing protein intake to influence cell-mediated immunity, thereby reducing the rate of postoperative infectious complications.

Objective

The primary objective of our trial is to determine the proportion of eligible patients randomized in an 18-month period. The primary feasibility outcome will be to (1) stop, main study not feasible: estimated proportion of randomized patients <40.0% (40/100); (2) continue with protocol modifications: estimated proportion of randomized patients 40.0% (40/100) to 59.0% (50/100); or (3) continue without modification: estimated proportion of randomized patients ≥60.0% (60/100). The secondary objectives are to evaluate compliance with the nutritional supplements and to estimate differences in postoperative complications, global health-related quality of life (QoL), and median length of hospital stay between the groups.

Methods

This is a double-blind randomized placebo-controlled feasibility trial. The intervention comprises three nutritional supplements: a protein isolate powder (ISOlution); immunomodulation (INergy-FLD), formulated liquid diet; and carbohydrate loading (PreCovery). Patients will consume 1 serving of the protein supplement per day from the randomization time up to 6 days before surgery (30 days in total). The immunomodulation, a solution that contains arginine, protein isolate, omega-6 fatty acids, and RNA, aims to attenuate excessive inflammatory responses and to replenish nutrients. This solution will be consumed as 3 doses per day for 5 days before and after surgery. Carbohydrate loading helps to reduce the stress from surgery by decreasing insulin resistance. Patients will have 2 servings the evening before surgery and 1 serving 2-3 hours before surgery. To be eligible, patients must have a resectable gastrointestinal cancer for which an elective operation is planned. Patients will be stratified according to nutritional status. The operation should occur within 4 weeks from enrollment.

Results

We expect to screen 165 eligible patients; 60.6% (100/165) of them will be randomized to either intervention or placebo. Assuming a two-sided alpha of .05, this will give us a 95% CI around the estimate of 53%-68%. A sample size of 50 per group will enable us to estimate the treatment effect and corresponding variance of the complication rate and QoL measures with adequate precision. The success is defined as the proportion of eligible patients randomized as ≥60.0% (60/100). Patients’ compliance is defined as an intake of at least 70% (41/58) sachets of the intervention volume.

Conclusions

The results will help to determine the feasibility of a larger randomized controlled trial to implement a perioperative nutritional supplement program for patients undergoing gastrointestinal surgery for cancer.

Trial Registration

ClinicalTrials.gov NCT03445260; https://clinicaltrials.gov/ct2/show/NCT03445260 (Archived by WebCite at http://www.webcitation.org/72CAmMzgP)

International Registered Report Identifier (IRRID)

PRR1-10.2196/10491

C-Reactive Protein on Postoperative Day 1 Is a Reliable Predictor of Pancreas-Specific Complications After Pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula and pancreas-specific complications have a significant influence on patient management and outcomes after pancreatoduodenectomy. The aim of the study was to assess the value of serum C-reactive protein on the postoperative day 1 as early predictor of pancreatic fistula and pancreas-specific complications.

METHODS

Between 2013 and 2016, 110 patients underwent pancreaticoduodenectomy. Clinical, biological, intraoperative, and pathological characteristics were prospectively recorded. Pancreatic fistula was graded according to the International Study Group on Pancreatic Fistula classification. A composite endpoint was defined as pancreas-specific complications including pancreatic fistula, intra-abdominal abscess, postoperative hemorrhage, and bile leak. The diagnostic accuracy of serum C-reactive protein on postoperative day 1 in predicting adverse postoperative outcomes was assessed by ROC curve analysis.

RESULTS

Six patients (5%) died and 87 (79%) experienced postoperative complications (pancreatic-specific complications: n = 58 (53%); pancreatic fistula: n = 48 (44%)). A soft pancreatic gland texture, a main pancreatic duct diameter < 3 mm and serum C-reactive protein ≥ 100 mg/L on postoperative day 1 were independent predictors of pancreas-specific complications (p < 0.01) and pancreatic fistula (p < 0.01). ROC analysis showed that serum C-reactive protein ≥ 100 mg/L on postoperative day 1 was a significant predictor of pancreatic fistula (AUC: 0.70; 95%CI: 0.60-0.79, p < 0.01) and pancreas-specific complications (AUC: 0.72; 95%CI: 0.62-0.82, p < 0.01). ROC analysis showed that serum C-reactive protein ≥ 50 mg/L at discharge was a significant predictor of 90-day hospital readmission (AUC: 0.70; 95%CI: 0.60-0.79, p < 0.01).

CONCLUSIONS

C-reactive protein levels reliably predict risks of pancreatic fistula, pancreas-specific complications, and hospital readmission, and should be inserted in risk-stratified management algorithms after pancreaticoduodenectomy.