Compliance with ERAS protocols improves overall and disease free survival after pancreaticoduodenectomy

Abstract

Background: Compliance with Enhanced Recovery After Surgery (ERAS) protocols has yielded improved oncologic outcomes in the colorectal literature. There is little data to illustrate the effect of ERAS compliance on oncologic outcomes after pancreaticoduodenectomy (PD) for adenocarcinoma. This study seeks to evaluate whether ERAS compliance at our institution has had a positive impact on overall and disease-free survival after PD. Methods: We used the ERAS Interactive Audit System (EIAS) to compile a list of all patients who underwent PD at our institution since September of 2015, at which point an ERAS pathway was implemented. We then case-matched those patients to others who underwent PD prior to ERAS introduction. We analyzed differences between these two cohorts in postoperative and oncologic outcomes, with a focus on overall and disease-free survival. We then subcategorized the ERAS patients into two tiers of protocol item compliance (>85% and 65%–85%), and subjected them to similar analysis. Results: The median follow-up for the ERAS cohort was 19 months. Overall survival at 19 months was significantly higher for ERAS patients when compared to pre-ERAS patients (65% versus 39.8%; p 0.003). Disease-free survival was also significantly higher at 19 months (50% versus 21.4%; p 0.017). Among ERAS patients, the high-compliance group had an overall survival of 80% (versus 60% in the low-compliance group) and disease free survival of 70% (versus 43%). Conclusion: Adherence to ERAS protocols has resulted in a significant improvement in oncologic outcomes after PD. These benefits seem to correspond to the degree of ERAS compliance.Table 1Demographics, perioperative data, and outcomes for FD patientsCharacteristicPre-ERAS®ERAS®p-ValueTotal, no.4040 Male, no. (%)22 (55%)25 (62.5%) Female, no. (%)18 (45%)15 (37.5%)Age in years, median (range)64.5 (32–86)63.5 (32–83)Perioperative data EBL in mL, median (range)625 (75–2500)600 (200–2400) Length of stay in days, median (range)9.5 (6–81)8 (5–27)0.065 30-day mortality, no. (%)2 (5%)1 (2.5%)0.556Oncologic factors Tumor size in mm, median (range)32 (15–68)35 (13–71) R0 resection27 (67.5%)12 (30%) R1 resection13 (32.5%)28 (70%) Lymphovascular invasion25 (62.5%)27 (67.5%) Positive lymph nodes, no. (%)30 (75%)30 (75%) Number of positive nodes, median (range)3 (0–23)3 (0–15) Neoadjuvant chemotherapy used, no. (%)12 (30%)12 (30%)19 month Overall survival39.8%65%0.00319 month disease free survival21.4%50%0.017Relationship between ERAS® item compliance and oncologie outcomesCharacteristicCompliance 65–85%Compliance >85%p-Value19 month overall survival60%80%0.2519 month disease free survival43%70%0.14Abbreviations; ERAS, enhanced recovery after surgery; PD, pancreaticoduodenectomy; EBL, estimated blued loss Open table in a new tab Abbreviations; ERAS, enhanced recovery after surgery; PD, pancreaticoduodenectomy; EBL, estimated blued loss