World Journal of Surgery

, Volume 37, Issue 8, pp 1909–1918 | Cite as

Systematic Review and Meta-analysis of Enhanced Recovery After Pancreatic Surgery with Particular Emphasis on Pancreaticoduodenectomies

  • M. M. E. Coolsen
  • R. M. van Dam
  • A. A. van der Wilt
  • K. Slim
  • K. Lassen
  • C. H. C. Dejong



In the past decade, Enhanced Recovery after Surgery (ERAS) protocols have been implemented in several fields of surgery. With these protocols, a faster recovery and shorter hospital stay can be accomplished without an increase in morbidity or mortality. The purpose of this study was to review systematically the evidence for implementation of an ERAS protocol in pancreatic resections, with particular emphasis on pancreaticoduodenectomies (PDs).


A systematic search was performed in Medline, Embase, Pubmed, CINAHL, and the Cochrane library for papers describing an ERAS program in adult patients undergoing elective pancreatic surgery published between January 1966 and December 2012. The primary outcome measure was postoperative length of stay. Secondary outcome measures were time to recovery of normal function, overall postoperative complication rates, readmissions, and mortality. Subsequently, a meta-analysis of outcome measures focusing on PD was conducted. This systematic review and meta-analysis was performed according to the PRISMA statement.


The literature search produced 248 potentially relevant papers. Of these, eight papers met the predefined inclusion criteria: five case-control studies, two retrospective studies, and one prospective study, describing a total of 1,558 patients. Only three of the studies reported data on discharge criteria and assessed time to recovery and return to normal function. Implementation of an ERAS protocol led in four of five comparative studies to a significant decrease in length of stay (reduction of 2–6 days in different studies). Meta-analysis of four studies focusing on PDs showed that there was a significant difference in complication rates in favor of the ERAS group (absolute risk difference 8.2 %, 95 % confidence interval (CI) 2.0–14.4, p = 0.008). Introduction of an ERAS protocol did not result in an increase in mortality or readmissions. Delayed gastric emptying and incidence of pancreatic fistula did not differ significantly between groups. All studies reporting on hospital costs showed a decrease after implementation of ERAS.


This systematic review suggests that using an ERAS protocol in pancreatic resections may help to shorten hospital length of stay without compromising morbidity and mortality. This seemed to apply to distal pancreatectomy, total pancreatectomy, and PD. Meta-analysis was performed for those studies focusing on PD and showed that there were no differences in readmission or mortality. Morbidity rates were significantly lower for patients managed according ERAS principles.


Pancreatic Fistula Distal Pancreatectomy Pancreatic Resection Delay Gastric Emptying Total Pancreatectomy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This systematic review and meta-analysis was not funded.

Conflict of interest

The authors report no conflict of interest.

Supplementary material

268_2013_2044_MOESM1_ESM.docx (16 kb)
Supplementary material 1 (DOCX 15 kb)


  1. 1.
    Kehlet H (1997) Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78(5):606–617PubMedCrossRefGoogle Scholar
  2. 2.
    Kehlet H, Wilmore DW (2002) Multimodal strategies to improve surgical outcome. Am J Surg 183(6):630–641PubMedCrossRefGoogle Scholar
  3. 3.
    Barbieri A et al (2009) Effects of clinical pathways in the joint replacement: a meta-analysis. BMC Med 7:32PubMedCrossRefGoogle Scholar
  4. 4.
    Arsalani-Zadeh R et al (2011) Evidence-based review of enhancing postoperative recovery after breast surgery. Br J Surg 98(2):181–196PubMedCrossRefGoogle Scholar
  5. 5.
    Podore PC, Throop EB (1999) Infrarenal aortic surgery with a 3-day hospital stay: a report on success with a clinical pathway. J Vasc Surg 29(5):787–792PubMedCrossRefGoogle Scholar
  6. 6.
    Brustia P et al (2003) Mini-invasive abdominal aortic surgery. Early recovery and reduced hospitalization after multidisciplinary approach. J Cardiovasc Surg 44(5):629–635Google Scholar
  7. 7.
    Wasowicz-Kemps DK et al (2006) Laparoscopic gastric banding for morbid obesity: outpatient procedure versus overnight stay. Surg Endosc 20(8):1233–1237PubMedCrossRefGoogle Scholar
  8. 8.
    McCarty TM et al (2005) Optimizing outcomes in bariatric surgery: outpatient laparoscopic gastric bypass. Ann Surg 242(4):494–498 discussion 498–501PubMedGoogle Scholar
  9. 9.
    Kirsh EJ et al (2000) Using outcome data and patient satisfaction surveys to develop policies regarding minimum length of hospitalization after radical prostatectomy. Urology 56(1):101–106 discussion 106–107PubMedCrossRefGoogle Scholar
  10. 10.
    DeOliveira ML et al (2006) Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 244(6):931–939PubMedCrossRefGoogle Scholar
  11. 11.
    Wilde RF et al (2012) Impact of nationwide centralization of pancreaticoduodenectomy on hospital mortality. Br J Surg 99:404–410PubMedCrossRefGoogle Scholar
  12. 12.
    Gouma DJ et al (2000) Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg 232(6):786–795PubMedCrossRefGoogle Scholar
  13. 13.
    Yeo CJ et al (1997) Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 226(3):248–257 discussion 257–260PubMedCrossRefGoogle Scholar
  14. 14.
    Richter A et al (2003) Long-term results of partial pancreaticoduodenectomy for ductal adenocarcinoma of the pancreatic head: 25-year experience. World J Surg 27(3):324–329. doi: 10.1007/s00268-002-6659-z PubMedCrossRefGoogle Scholar
  15. 15.
    Varadhan KK et al (2010) The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 29(4):434–440PubMedCrossRefGoogle Scholar
  16. 16.
    Wind J et al (2006) Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 93:800–809PubMedCrossRefGoogle Scholar
  17. 17.
    Wente MN et al (2007) Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the international study group of pancreatic surgery (ISGPS). Surgery 142(5):761–768PubMedCrossRefGoogle Scholar
  18. 18.
    Bassi C et al (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138(1):8–13PubMedCrossRefGoogle Scholar
  19. 19.
    Slim K et al (2003) Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 73(9):712–716PubMedCrossRefGoogle Scholar
  20. 20.
    Stroup DF et al (2000) Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA 283(15):2008–2012PubMedCrossRefGoogle Scholar
  21. 21.
    Freemantle N (2000) StatsDirect—statistical software for medical research in the 21st century. BMJ 321(16):1536CrossRefGoogle Scholar
  22. 22.
    Egger M (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 13(315):629–634CrossRefGoogle Scholar
  23. 23.
    Chaudhary A, Parvez A, Singh AP (2008) Early discharge after pancreaticoduodenectomy—fair or foul? Conference: 39th annual meeting of the American pancreatic association Chicago, IL. November 7–8, 2008. Pancreas 37(4):464CrossRefGoogle Scholar
  24. 24.
    Wichmann MW et al (2006) A prospective clinical feasibility study for multimodal “fast track” rehabilitation in elective pancreatic cancer surgery. Rozhl Chir 85(4):169–175PubMedGoogle Scholar
  25. 25.
    Bruns C, Wichmann MW et al (2007) Fast track pancreatic cancer surgery. Chirurgische Praxis 67(2):203–210 [in German]Google Scholar
  26. 26.
    Vanounou T et al (2007) Deviation-based cost modeling: a novel model to evaluate the clinical and economic impact of clinical pathways. J Am Coll Surg 204(4):570–579PubMedCrossRefGoogle Scholar
  27. 27.
    Vollmer CM Jr et al (2007) Quality assessment in high-acuity surgery: volume and mortality are not enough. Arch Surg 142(4):371–380PubMedCrossRefGoogle Scholar
  28. 28.
    Balcom JH et al (2001) Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg 136(4):391–398PubMedCrossRefGoogle Scholar
  29. 29.
    French JJ et al (2009) Fast-track management of patients undergoing proximal pancreatic resection. Ann R Coll Surg Engl 91(3):201–204PubMedCrossRefGoogle Scholar
  30. 30.
    Kow AW et al (2008) Striving for a better operative outcome: 101 pancreaticoduodenectomies. HPB (Oxford) 10(6):464–471CrossRefGoogle Scholar
  31. 31.
    Pratt WB et al (2008) Epidural analgesia for pancreatoduodenectomy: a critical appraisal. J Gastrointest Surg 12(7):1207–1220PubMedCrossRefGoogle Scholar
  32. 32.
    Fukase M, Shimamura H, Takeda K (2009) Introduction of the critical path for pancreaticoduodenectomy taking in the concept of probiotics. Conference: joint 40th anniversary meeting of American pancreatic association and Japan pancreas society Honolulu, HI United States. November 4–11, 2009. Pancreas 38(8):997Google Scholar
  33. 33.
    Little AB, Whipple TW (1996) Clinical pathway implementation in the acute care hospital setting. J Nurs Care Qual 11(2):54–61PubMedCrossRefGoogle Scholar
  34. 34.
    Pratt WB, Vollmer CM, Callery MP (2009) Outcomes in pancreatic resection are negatively influenced by pre-operative hospitalization. HPB 11(1):57–65PubMedCrossRefGoogle Scholar
  35. 35.
    Burden S et al (2010) Study protocol: preoperative nutrition in patients undergoing gastrointestinal surgery. Cochrane Database Syst Rev. doi: 10.1002/14651858.CD008879.pub2 Google Scholar
  36. 36.
    Ypsilantis E et al (2009) Current status of fast-track recovery pathways in pancreatic surgery. J Pancreas 10(6):646–650 [Electronic Resource]Google Scholar
  37. 37.
    Spelt L et al (2011) Fast-track programmes for hepatopancreatic resections: where do we stand? HPB 13(12):833–838PubMedCrossRefGoogle Scholar
  38. 38.
    Hall TC et al (2012) Enhanced recovery programmes in hepatobiliary and pancreatic surgery: a systematic review. Ann R Coll Surg Engl 94(5):318–326PubMedCrossRefGoogle Scholar
  39. 39.
    Balzano G et al (2008) Fast-track recovery programme after pancreatico-duodenectomy reduces delayed gastric emptying. Br J Surg 95(11):1387–1393PubMedCrossRefGoogle Scholar
  40. 40.
    Porter GA et al (2000) Cost and utilization impact of a clinical pathway for patients undergoing pancreaticoduodenectomy. Ann Surg Oncol 7(7):484–489PubMedCrossRefGoogle Scholar
  41. 41.
    Kennedy EP et al (2007) Initiation of a critical pathway for pancreaticoduodenectomy at an academic institution–the first step in multidisciplinary team building. J Am Coll Surg 204(5):917–923 discussion 923–924PubMedCrossRefGoogle Scholar
  42. 42.
    Robertson N et al (2012) Implementation of an enhanced recovery programme following pancreaticoduodenectomy. HPB 14(10):700–708PubMedCrossRefGoogle Scholar
  43. 43.
    Kennedy EP et al (2009) Implementation of a critical pathway for distal pancreatectomy at an academic institution. J Gastrointest Surg 13(5):938–944PubMedCrossRefGoogle Scholar
  44. 44.
    di Sebastiano P et al (2011) A modified fast-track program for pancreatic surgery: a prospective single-center experience. Langenbecks Arch Surg 396(3):345–351PubMedCrossRefGoogle Scholar
  45. 45.
    Berberat PO et al (2007) Fast track—different implications in pancreatic surgery. J Gastrointest Surg 11(7):880–887PubMedCrossRefGoogle Scholar
  46. 46.
    Vlug MS et al (2011) Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 254(6):868–875PubMedCrossRefGoogle Scholar
  47. 47.
    Gillissen F et al (2013) Structured synchronous implementation of an enhanced recovery program in elective colonic surgery in 33 hospitals in the Netherlands. World J Surg. doi: 10.1007/s00268-013-1938-4
  48. 48.
    Bassi C et al (2005) Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study. Ann Surg 242(6):767–771 discussion 771–773PubMedCrossRefGoogle Scholar
  49. 49.
    Miedema BW et al (1992) Complications following pancreaticoduodenectomy. Current management. Arch Surg 127(8):945–949 discussion 949–950PubMedCrossRefGoogle Scholar
  50. 50.
    Buchler MW et al (2000) Pancreatic fistula after pancreatic head resection. Br J Surg 87(7):883–889PubMedCrossRefGoogle Scholar
  51. 51.
    Buchler MW et al (2003) Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg 138(12):1310–1314 discussion 1315PubMedCrossRefGoogle Scholar
  52. 52.
    Halloran CM et al (2002) Complications of pancreatic cancer resection. Dig Surg 19(2):138–146PubMedCrossRefGoogle Scholar
  53. 53.
    Maessen J et al (2007) A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 94(2):224–231PubMedCrossRefGoogle Scholar
  54. 54.
    Ahmed J et al (2010) Compliance with enhanced recovery programmes in elective colorectal surgery. Br J Surg 97:754–758PubMedCrossRefGoogle Scholar
  55. 55.
    van den Broek MA et al (2011) Development of a composite endpoint for randomized controlled trials in liver surgery. Br J Surg. doi: 10.1002/bjs.7503 Google Scholar
  56. 56.
    Lassen K et al (2012) Guidelines for perioperative care for pancreaticoduodenectomy: enhanced recovery after surgery (ERAS®) society recommendations. World J Surg. doi: 10.1016/j.clnu.2012.08.011 Google Scholar

Copyright information

© Société Internationale de Chirurgie 2013

Authors and Affiliations

  • M. M. E. Coolsen
    • 1
  • R. M. van Dam
    • 1
  • A. A. van der Wilt
    • 1
  • K. Slim
    • 3
  • K. Lassen
    • 4
    • 5
    • 6
  • C. H. C. Dejong
    • 1
    • 2
  1. 1.Department of SurgeryUniversity Hospital MaastrichtMaastrichtThe Netherlands
  2. 2.NUTRIM School for Nutrition, Toxicology and MetabolismMaastricht University Medical CentreMaastrichtThe Netherlands
  3. 3.Department of General and Digestive SurgeryCHU EstaingClermont-FerrandFrance
  4. 4.Department of Gastrointestinal SurgeryUniversity Hospital Northern NorwayTromsøNorway
  5. 5.Institute of Clinical MedicineUniversity of TromsøTromsøNorway
  6. 6.Clinical and Surgical Sciences (Surgery)Royal InfirmaryEdinburghUK

Personalised recommendations