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

Effects of seamless care in the perioperative management of laparoscopic pancreatoduodenectomy on patients' quality of life and postoperative complications

This study investigates the efficacy of the seamless care model in operative management for patients who have undergone laparoscopic Pancreatoduodenectomy, evaluating its potential effects on postoperative quality of life (QOL) and complications. This study encompassed patients who underwent LPD at our institution between February 2022 and May 2023. Patients were randomly allocated to either the standard care group(control group) or the seamless care group(intervention group) using a random number table method. QOL was assessed both preoperatively and postoperatively. The incidence of adverse events before to discharge was evaluated. No significant changes in preoperative QOL measures were seen between the two groups (P > 0.05). Postoperatively, the intervention group exhibited markedly superior physiological function scores and overall quality of life (P < 0.05), as well as a considerably reduced frequency of adverse events (P < 0.05). The intervention group exhibited significantly shorter times to first postoperative flatus and shortened hospital stays relative to the control group (P < 0.05), times to ambulation demonstrated no significant difference (P > 0.05). Seamless care significantly enhances quality of life and reduces adverse events following LPD, warranting its broader clinical implementation.

Reduction of Postoperative Complications in Pancreatic Surgery by Standardizing Perioperative Management: An Observational Cohort Study

Introduction

Resection for pancreatic malignancy remains the gold standard for cure. Postoperative morbidity continues to be high even after technical innovations. This study evaluates the effectiveness of a standard perioperative pancreatic oncological surgery step-by-step protocol in reducing organ-specific complications.

Methods

In this observational cohort study, we analyzed the outcomes of oncologic pancreatic head resections from 2015 to 2022 after the implementation of a standard perioperative fail-safe protocol and compared these data with a historical cohort (2013-2014). In the study group, all patients were treated with preoperative limited mechanical bowel preparation, administration of a somatostatin analog, and a "pancreatic duct tube" in pancreatoduodenectomy. The primary outcome measure was the occurrence of postoperative organ-specific complications.

Results

A total of 151 patients were included in this study. The rate of postoperative pancreatic fistula (grade B and C) in the fail-safe group was 4.2%. Other organ-specific complications as postoperative hemorrhage (2.5%) and delayed gastric emptying (9.2%) also occurred less frequent than before implementation of the fail-safe protocol.

Conclusion

The use of this standardized fail-safe protocol for oncologic pancreatoduodenectomy can lead to a low postoperative morbidity with improved surgical outcomes.

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.

Obesity and Pancreatic Cancer: A Matched-Pair Survival Analysis

BACKGROUND

Morbid obesity is a risk factor for pancreatic ductal adenocarcinoma (PDAC). However, the impact of obesity on postoperative outcomes and overall survival in patients with PDAC remains a controversial topic.

METHODS

Patients who underwent pancreatic surgery for PDAC between 1997 and 2018 were included in this study. Matched pairs (1:1) were generated according to age, gender and American Society of Anesthesiologists status. Obesity was defined according to the WHO definition as BMI ≥ 30 kg/m². The primary endpoint was the difference in overall survival between patients with and without obesity.

RESULTS

Out of 553 patients, a total of 76 fully matched pairs were generated. Obese patients had a mean BMI-level of 33 compared to 25 kg/m² in patients without obesity (p = 0.001). The frequency of arterial hypertension (p = 0.002), intraoperative blood loss (p = 0.039), and perineural invasion (p = 0.033) were also higher in obese patients. Clinically relevant postoperative complications (p = 0.163) and overall survival rates (p = 0.885) were comparable in both study groups. Grade II and III obesity resulted in an impaired overall survival, although this was not statistically significant. Subgroup survival analyses revealed no significant differences for completion of adjuvant chemotherapy and curative-intent surgery.

CONCLUSIONS

Obesity did not affect overall survival and postoperative complications in these patients with PDAC. Therefore, pancreatic surgery should not be withheld from obese patients.

Clinical Pathways for Oncological Gastrectomy: Are They a Suitable Instrument for Process Standardization to Improve Process and Outcome Quality for Patients Undergoing Gastrectomy? A Retrospective Cohort Study

(1) Background: Oncological gastrectomy requires complex multidisciplinary management. Clinical pathways (CPs) can potentially facilitate this task, but evidence related to their use in managing oncological gastrectomy is limited. This study evaluated the effect of a CP for oncological gastrectomy on process and outcome quality. (2) Methods: Consecutive patients undergoing oncological gastrectomy before (n = 64) or after (n = 62) the introduction of a CP were evaluated. Assessed parameters included catheter and drain management, postoperative mobilization, resumption of diet and length of stay. Morbidity, mortality, reoperation and readmission rates were used as indicators of outcome quality. (3) Results: Enteral nutrition was initiated significantly earlier after CP implementation (5.0 vs. 7.0 days, p < 0.0001). Readmission was more frequent before CP implementation (7.8% vs. 0.0%, p = 0.05). Incentive spirometer usage increased following CP implementation (100% vs. 90.6%, p = 0.11). Mortality, morbidity and reoperation rates remained unchanged. (4) Conclusions: After implementation of an oncological gastrectomy CP, process quality improved, while indicators of outcome quality such as mortality and reoperation rates remained unchanged. CPs are a promising tool to standardize perioperative care for oncological gastrectomy.