Original Paper Received: February 13, 2014 Accepted after revision: May 13, 2014 Published online: July 30, 2014
Dig Surg 2014;31:177–184 DOI: 10.1159/000363583
Improving Outcome after Pancreaticoduodenectomy: Experiences with Implementing an Enhanced Recovery After Surgery (ERAS) Program Marielle M.E. Coolsen a Ronald M. van Dam a Arwind Chigharoe a Steven W.M. Olde Damink a, b Cornelis H.C. Dejong a, b a
Department of Surgery, University Hospital Maastricht, and b NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre, Maastricht, The Netherlands
Key Words Perioperative care · Fast track · Enhanced recovery · Pancreaticoduodenectomy
Abstract Background: Pancreaticoduodenectomies (PDs) are complex surgical procedures that require high-standard perioperative care. The objective of this study was to evaluate the effects of implementing an Enhanced Recovery After Surgery (ERAS) program for PD on patient outcome. Methods: 230 patients undergoing PD in the Maastricht University Medical Centre between January 1995 and January 2012 were included. Group 1 (no ERAS; 1995–2005) received traditional care. From January 2006, several elements of an ERAS pathway for pancreatic surgery were implemented (group 2: ‘ERAS-like’). From 2009 onwards the ERAS pathway was fully implemented (group 3: ERAS). Mortality, complications, readmissions and length of hospital stay (LOS) were evaluated in the subgroups and compared. Results: Median LOS was significantly reduced from 20 days in group 1 to 13 days in group 2 and 14 days in group 3 (p = 0.001). Median LOS of patients without complications was 16, 10 and 9 days in groups 1, 2 and 3, respectively (p < 0.0001). Over time, the
© 2014 S. Karger AG, Basel 0253–4886/14/0313–0177$39.50/0 E-Mail [email protected] www.karger.com/dsu
average age of patients undergoing PD increased significantly. Complication rates as well as mortality and readmission rates did not change over time. Conclusion: Implementing an ERAS program contributed to a decrease of LOS without compromising other outcomes. Mortality, morbidity and readmission rates stayed unchanged and more complications were managed non-operatively. © 2014 S. Karger AG, Basel
Introduction
Pancreaticoduodenectomy (PD) is a technically challenging surgical procedure and is currently the only curative treatment for malignancy in the periampullary region. In the original report by Whipple et al. [1] on 41 PDs, a mortality rate of 29% was recorded. Nowadays, centralization of PD patients in specialized centers and advances in perioperative care have resulted in mortality rates of less than 5% [2]. Morbidity rates, however, have remained as high as 40–60% [3, 4]. Presented at the Tenth World Congress of the European-African Hepato-Pancreato-Biliary Association, Belgrade, Serbia, May 2013.
M.M.E. Coolsen Department of Surgery University Hospital Maastricht, PO Box 5800 NL–6202 AZ Maastricht (The Netherlands) E-Mail marielle.coolsen @ maastrichtuniversity.nl
Table 1. Protocol for the ERAS program for PD
Preoperative outpatient visit Pre-admission counselling Give consent form and patient information Day before surgery/admission Normal oral nutrition until midnight No pre-anesthetic medication Day of surgery Carbohydrate drinks up to 2 h prior to surgery Start antithrombotic prophylaxis Preoperative antimicrobial prophylaxis Mid-thoracic epidural anesthesia Short-acting i.v. anesthetic agent Preferably no nasogastric drainage or removal of NG tube after surgery Warm i.v. fluids and upper and lower body bear hugger Jugular catheter (till resumption of oral intake) Avoidance of excessive i.v. fluids Patient sent to recovery ward (ICU setting) Restart oral intake of water or iced-chips POD 1: Patient sent to surgical ward Patient mobilizes out of bed Free drinking up to 1.5 liters Continue portable epidural analgesia Antiemetics if based on nausea score 1,000 mg paracetamol every 6 h 1,000 mg magnesium oxide twice daily POD 2: If patient is capable, resumption of regular diet Continue mobilization Remove urinary catheter Continuation epidural analgesia Stop low-dose opioids POD 3: Stop epidural analgesia Discontinue i.v. fluids Start NSAIDs based on pain score Continue mobilization Regular diet POD 4: Drain removal if amylase is
Dig Surg 2014;31:177–184 DOI: 10.1159/000363583
Improving Outcome after Pancreaticoduodenectomy: Experiences with Implementing an Enhanced Recovery After Surgery (ERAS) Program Marielle M.E. Coolsen a Ronald M. van Dam a Arwind Chigharoe a Steven W.M. Olde Damink a, b Cornelis H.C. Dejong a, b a
Department of Surgery, University Hospital Maastricht, and b NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre, Maastricht, The Netherlands
Key Words Perioperative care · Fast track · Enhanced recovery · Pancreaticoduodenectomy
Abstract Background: Pancreaticoduodenectomies (PDs) are complex surgical procedures that require high-standard perioperative care. The objective of this study was to evaluate the effects of implementing an Enhanced Recovery After Surgery (ERAS) program for PD on patient outcome. Methods: 230 patients undergoing PD in the Maastricht University Medical Centre between January 1995 and January 2012 were included. Group 1 (no ERAS; 1995–2005) received traditional care. From January 2006, several elements of an ERAS pathway for pancreatic surgery were implemented (group 2: ‘ERAS-like’). From 2009 onwards the ERAS pathway was fully implemented (group 3: ERAS). Mortality, complications, readmissions and length of hospital stay (LOS) were evaluated in the subgroups and compared. Results: Median LOS was significantly reduced from 20 days in group 1 to 13 days in group 2 and 14 days in group 3 (p = 0.001). Median LOS of patients without complications was 16, 10 and 9 days in groups 1, 2 and 3, respectively (p < 0.0001). Over time, the
© 2014 S. Karger AG, Basel 0253–4886/14/0313–0177$39.50/0 E-Mail [email protected] www.karger.com/dsu
average age of patients undergoing PD increased significantly. Complication rates as well as mortality and readmission rates did not change over time. Conclusion: Implementing an ERAS program contributed to a decrease of LOS without compromising other outcomes. Mortality, morbidity and readmission rates stayed unchanged and more complications were managed non-operatively. © 2014 S. Karger AG, Basel
Introduction
Pancreaticoduodenectomy (PD) is a technically challenging surgical procedure and is currently the only curative treatment for malignancy in the periampullary region. In the original report by Whipple et al. [1] on 41 PDs, a mortality rate of 29% was recorded. Nowadays, centralization of PD patients in specialized centers and advances in perioperative care have resulted in mortality rates of less than 5% [2]. Morbidity rates, however, have remained as high as 40–60% [3, 4]. Presented at the Tenth World Congress of the European-African Hepato-Pancreato-Biliary Association, Belgrade, Serbia, May 2013.
M.M.E. Coolsen Department of Surgery University Hospital Maastricht, PO Box 5800 NL–6202 AZ Maastricht (The Netherlands) E-Mail marielle.coolsen @ maastrichtuniversity.nl
Table 1. Protocol for the ERAS program for PD
Preoperative outpatient visit Pre-admission counselling Give consent form and patient information Day before surgery/admission Normal oral nutrition until midnight No pre-anesthetic medication Day of surgery Carbohydrate drinks up to 2 h prior to surgery Start antithrombotic prophylaxis Preoperative antimicrobial prophylaxis Mid-thoracic epidural anesthesia Short-acting i.v. anesthetic agent Preferably no nasogastric drainage or removal of NG tube after surgery Warm i.v. fluids and upper and lower body bear hugger Jugular catheter (till resumption of oral intake) Avoidance of excessive i.v. fluids Patient sent to recovery ward (ICU setting) Restart oral intake of water or iced-chips POD 1: Patient sent to surgical ward Patient mobilizes out of bed Free drinking up to 1.5 liters Continue portable epidural analgesia Antiemetics if based on nausea score 1,000 mg paracetamol every 6 h 1,000 mg magnesium oxide twice daily POD 2: If patient is capable, resumption of regular diet Continue mobilization Remove urinary catheter Continuation epidural analgesia Stop low-dose opioids POD 3: Stop epidural analgesia Discontinue i.v. fluids Start NSAIDs based on pain score Continue mobilization Regular diet POD 4: Drain removal if amylase is
