World Journal of Surgery

, Volume 39, Issue 8, pp 2023–2030 | Cite as

Implementation of an Enhanced Recovery Pathway After Pancreaticoduodenectomy in Patients with Low Drain Fluid Amylase

  • Robert P. SutcliffeEmail author
  • Majd Hamoui
  • John Isaac
  • Ravi Marudanayagam
  • Darius F. Mirza
  • Paolo Muiesan
  • John K. Roberts
Original Scientific Report



The safety and feasibility of an enhanced recovery pathway (ERP) after pancreatic surgery is largely unknown. Our aim was to prospectively evaluate a targeted ERP after pancreaticoduodenectomy (PD), using first postoperative day (POD) drain fluid amylase (DFA1) values to identify patients at low risk of pancreatic fistula (PF).

Patients and methods

Non-randomized cohort study of 130 consecutive patients. Perioperative outcomes were compared before (pre-ERP; N = 65) and after (post-ERP; N = 65) implementation of an ERP. Patients in each group were stratified according to the risk of PF using DFA1 <350 IU/l. Low-risk patients in the post-ERP group were selected for early oral intake and early drain removal.


81/130 patients had a DFA1 <350. Incidence of PF was significantly lower in low-risk patients (9 vs. 45 %, P = 0.0001). In low-risk patients, morbidity (43 vs. 36 %) and mortality (2.7 vs. 4.5 %) were similar for both pre- and post-ERP patients. Hospital stay (median 9 vs. 7 days, P = 0.03) and 30-day readmissions (17 vs. 2 %, P = 0.04) were lower in low-risk patients in the post-ERP group. In high-risk patients, there was no difference in outcomes between pre- and post-ERP.


Patients at low risk of PF after PD can be identified by first POD DFA1. Enhanced recovery after PD is safe and leads to improved short-term outcomes in low-risk patients.


Pancreatic Fistula Postoperative Pancreatic Fistula Pancreatic Anastomosis Early Oral Feeding Pancreatic Duct Diameter 
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.


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Copyright information

© Société Internationale de Chirurgie 2015

Authors and Affiliations

  • Robert P. Sutcliffe
    • 1
    Email author
  • Majd Hamoui
    • 1
  • John Isaac
    • 1
  • Ravi Marudanayagam
    • 1
  • Darius F. Mirza
    • 1
  • Paolo Muiesan
    • 1
  • John K. Roberts
    • 1
  1. 1.Liver UnitUniversity Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth HospitalBirminghamUK

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