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Feasibility of an Enhanced Recovery Protocol for Elective Pancreatoduodenectomy: A Multicenter International Cohort Study

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Abstract

Background

The first enhanced recovery after surgery (ERAS) guidelines for pancreatoduodenectomy (PD) were developed in 2012. The study aimed to assess compliance and outcomes of an ERAS protocol for PD, to study correlation between compliance and outcomes, and to identify risk factors for complications.

Methods

Retrospective cohort analysis is based on a prospective database, including all consecutive patients undergoing elective PD within an ERAS program in four centers: Lausanne University Hospital (Switzerland), Carolinas Medical Center (United States), Edouard Herriot Hospital (France), and University Medical Center Hamburg-Eppendorf (Germany). Patients’ characteristics, postoperative outcome and ERAS compliance were assessed. Logistic regression analysis was performed to assess predictors of postoperative complications.

Results

Between October 2012 and June 2017, 404 consecutive patients underwent PD. Median length of stay was 14 days with 11.3% readmission rate. Mean overall compliance was 62%, with pre-, intra- and postoperative compliance of 93%, 80% and 30%, respectively. Overall compliance ≥ 70% versus < 70% was significantly associated with a reduction in complications (p = 0.029) and length of stay (p < 0.001). Avoidance of postoperative nasogastric tube (OR = 0.31, p = 0.043), mobilization on day of surgery (OR = 0.28, p = 0.043), and mobilization more than 6 h on postoperative day 2 (OR = 0.45, p = 0.001) were independent predictors of reduced overall complications.

Conclusions

Implementation of enhanced recovery for PD is challenging, especially in the postoperative period. Overall compliance with ERAS protocol ≥ 70% was associated with decreased complications and length of stay. Specific ERAS elements, such as avoidance of postoperative nasogastric tube and early mobilization, independently improved outcomes.

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Acknowledgements

The authors would like to thank all members of their respective ERAS team. A special thanks to Valerie Addor, ERAS-dedicated clinical nurse at Lausanne University Hospital.

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Authors and Affiliations

  1. Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne UNIL, Rue du Bugnon 46, 1011, Lausanne, Switzerland

    Didier Roulin, Emmanuel Melloul, Martin Hübner & Nicolas Demartines

  2. Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    Björn Erik Wellg & Jakob Izbicki

  3. Division of HPB Surgery, Carolinas Medical Center, Charlotte, USA

    Dionisios Vrochides

  4. Department of Digestive, Hepato-Biliary and Pancreatic Surgery, Edouard Herriot Hospital, HCL, Lyon Sud Faculty of Medicine, UCBL1, Lyon, France

    Mustapha Adham

Authors
  1. Didier Roulin
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  2. Emmanuel Melloul
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  3. Björn Erik Wellg
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  4. Jakob Izbicki
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  5. Dionisios Vrochides
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  6. Mustapha Adham
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  7. Martin Hübner
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  8. Nicolas Demartines
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Correspondence to Nicolas Demartines.

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Roulin, D., Melloul, E., Wellg, B.E. et al. Feasibility of an Enhanced Recovery Protocol for Elective Pancreatoduodenectomy: A Multicenter International Cohort Study. World J Surg 44, 2761–2769 (2020). https://doi.org/10.1007/s00268-020-05499-x

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  • DOI: https://doi.org/10.1007/s00268-020-05499-x

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