Implementing an enhanced recovery program after pancreaticoduodenectomy in elderly patients: is it feasible?

BACKGROUND: An enhanced recovery after surgery (ERAS) program aims to reduce the stress response to surgery and thereby accelerate recovery. It is unclear whether these programs can be safely implemented for elderly patients, especially in highly complex surgery such as pancreaticoduodenectomy (PD). The objective of this study was to evaluate the feasibility of an ERAS program in elderly patients undergoing PD. METHODS: Implementation of the ERAS protocol was studied prospectively in a consecutive series of patients undergoing PD between January 2009 and August 2013. Patients were divided into two groups: /= 70 years. Endpoints were length of stay (LOS), readmissions, morbidity, mortality, and compliance with ERAS targets. RESULTS: Of a total of 110 patients, 55 were /= 70 years (median 77). Median LOS was 14 days in both groups. In patients without complications median LOS was 9 days. Both mortality and readmissions did not differ between groups (mortality n = 3 (5.5 %) in younger versus n = 6 (10.9 %) in older patients, p = 0.49, readmissions: n = 11 (20 %) versus n = 7 (12.7 %), p = 0.44). CT-drainage and relaparotomy-rates were not different between groups, nor was overall morbidity (n = 31 (56.3 %) in the older versus n = 35 (63.3 %) in the younger group, p = 0.44). There were no differences in compliance with elements of the ERAS protocol between groups. CONCLUSION: An ERAS program seems feasible and safe for patients >/= 70 years of age undergoing PD

Improving outcome after pancreaticoduodenectomy: experiences with implementing an enhanced recovery after surgery (ERAS) program

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 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

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

BACKGROUND: In the past decade, Enhanced Recovery after Surgery (ERAS) have been implemented in several fields of surgery. With these faster recovery and shorter hospital stay can be accomplished without an in morbidity or mortality. The purpose of this study was to review the evidence for implementation of an ERAS protocol in pancreatic with particular emphasis on pancreaticoduodenectomies (PDs). METHODS: A systematic search was performed in Medline, Embase, Pubmed, CINAHL, and Cochrane library for papers describing an ERAS program in adult patients undergoing elective pancreatic surgery published between January 1966 December 2012. The primary outcome measure was postoperative length of Secondary outcome measures were time to recovery of normal function, postoperative complication rates, readmissions, and mortality. meta-analysis of outcome measures focusing on PD was conducted. This review and meta-analysis was performed according to the PRISMA RESULTS: The literature search produced 248 potentially relevant papers. these, eight papers met the predefined inclusion criteria: five case- studies, two retrospective studies, and one prospective study, of 1,558 patients. Only three of the studies reported data on discharge and assessed time to recovery and return to normal function. ERAS protocol led in four of five comparative studies to a significant in length of stay (reduction of 2-6 days in different studies). Meta- four studies focusing on PDs showed that there was a significant complication rates in favor of the ERAS group (absolute risk difference % confidence interval (CI) 2.0-14.4, p = 0.008). Introduction of an ERAS did not result in an increase in mortality or readmissions. Delayed emptying and incidence of pancreatic fistula did not differ groups. All studies reporting on hospital costs showed a decrease after implementation of ERAS. CONCLUSIONS: This systematic review suggests an ERAS protocol in pancreatic resections may help to shorten hospital stay without compromising morbidity and mortality. This seemed to apply pancreatectomy, total pancreatectomy, and PD. Meta-analysis was those studies focusing on PD and showed that there were no differences readmission or mortality. Morbidity rates were significantly lower for managed according ERAS principles

Attitudes of patients and care providers to enhanced recovery after surgery programs after major abdominal surgery

BACKGROUND: Enhanced recovery after surgery (ERAS) is a well-established pathway of perioperative care in surgery in an increasing number of specialties. To implement protocols and maintain high levels of compliance, continued support from care providers and patients is vital. This survey aimed to assess the perceptions of care providers and patients of the relevance and importance of the ERAS targets and strategies. MATERIALS AND METHODS: Pre- and post-operative surveys were completed by patients who underwent major hepatic, colorectal, or oesophagogastric surgery in three major centers in Scotland, Norway, and The Netherlands. Anonymous web-based and article surveys were also sent to surgeons, anesthetists, and nurses experienced in delivering enhanced recovery protocols. Each questionnaire asked the responder to rate a selection of enhanced recovery targets and strategies in terms of perceived importance. RESULTS: One hundred nine patients and 57 care providers completed the preoperative survey. Overall, both patients and care providers rated the majority of items as important and supported ERAS principles. Freedom from nausea (median, 10; interquartile range [IQR], 8-10) and pain at rest (median, 10; IQR, 8-10) were the care components rated the highest by both patients and care providers. Early return of bowel function (median, 7; IQR, 5-8) and avoiding preanesthetic sedation (median, 6; IQR, 3.75-8) were scored the lowest by care providers. CONCLUSIONS: ERAS principles are supported by both patients and care providers. This is important when attempting to implement and maintain an ERAS program. Controversies still remain regarding the relative importance of individual ERAS components