Systematic Review and Meta-analysis of Enhanced Recovery After Pancreatic Surgery with Particular Emphasis on Pancreaticoduodenectomies
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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.
KeywordsPancreatic Fistula Distal Pancreatectomy Pancreatic Resection Delay Gastric Emptying Total Pancreatectomy
This systematic review and meta-analysis was not funded.
Conflict of interest
The authors report no conflict of interest.
- 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
- 25.Bruns C, Wichmann MW et al (2007) Fast track pancreatic cancer surgery. Chirurgische Praxis 67(2):203–210 [in German]Google Scholar
- 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
- 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
- 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