Enhanced recovery after pancreatic surgery: a systematic review of the evidence

Implementation of an enhanced recovery after surgery (ERAS) program following hepato- pancreato-biliary (HPB) surgeries – Our experience

396 Background: Enhanced Recovery After Surgery (ERAS) protocols have been shown to have positive effects on lengths of stay (LOHS) and resource utilisation without a rise in readmission and post-operative morbidity rates in colorectal, hepatic and oesophago-gastric surgery. This study aimed to investigate the effects of an ERAS protocol on postoperative morbidity and readmission rates following pancreatic surgery in a tertiary referral centre. Methods: The perioperative care of patients undergoing pancreatic surgery was guided by a locally developed ERAS protocol incorporating pre-operative counselling and carbohydrate loading. Intra-thecal opiate and Patient Controlled Analgesia devices were utilised for postoperative analgesia. Supplemental intravenous fluid prescription was protocolised. Oral intake was restarted from post-operative day (PoD) 1 and escalated on an on-demand basis. Patients were mobilised from PoD 1 and escalated daily. Drain removal and step down care decisions were guided by serum markers and clinical progress. Results: 212 consecutive patients from 2010 to 2014 were included (conventional, N = 108, ERAS protocol, N = 104). 134 (63.2%) patients underwent pancreaticoduodenectomy, 41 (19.3%) patients underwent distal pancreatectomy, 11 (5.2%) patients underwent total pancreatectomy and the rest underwent palliative bypass or other procedures. There was a statistically significant reduction in the volume of supplemental intravenous fluids received with no significant renal impairment noted. Median LOHS was reduced to 10 days (Inter-quartile range [IQR] 7 – 19) from 16 days (IQR 12 – 26) (P < 0.001). Median critical care stay was reduced from 7 days (IQR 5 – 10) to 6 (IQR 4 -7) (P = 0.020). There was a statistically significant reduction in clinically significant wound complications (P = 0.019). There were no statistically significant increases in readmission rates, pancreas-specific or other generic post-operative morbidity rates. Conclusions: ERAS protocols are a viable peri-operative management strategy after major pancreatic surgery, and data suggests that LOHS can be reduced without an associated increase in readmission or post-operative morbidity rates.

Effectiveness of Enhanced Recovery After Surgery protocol in pancreatic surgery: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Knee replacement surgery was traditionally associated with prolonged recovery and rehabilitation programmes in hospital. Enhanced recovery after surgery (ERAS) protocols have been shown to be cost effective while not compromising patient safety or functional outcome. Despite this proven efficacy, ERAS has not been widely adopted in South African orthopaedic practices. The aim of this study is to determine if it is possible to practise these guidelines in South Africa so as to decrease the length of stay (LOS) without an increase in complication rate or compromise in functional outcome. METHODS: Included in the study were 119 patients undergoing elective total knee arthroplasty between 2013 and 2017. They were divided into two cohorts. The first group was treated with a traditional protocol and included 59 patients. The second group was treated with ERAS and included 60 patients, following implementation of the ERAS protocol in 2015. The functional outcome was assessed using the Oxford Knee Score (OKS). The 30-day readmission rate was used to assess safety of early discharge. LOS and patient demographics were also collected to compare the cohorts. RESULTS: There was no clinically significant difference between the cohorts with regards to OKS or readmission rate. Two sample t-tests were used to compare these parameters. The mean OKS for the traditional group was 59.1 (SD 2.4), and for the ERAS group, 58.7 (SD 5.0) (p = 0.73). The readmission rate was 8.5% in the traditional group and 10% in the ERAS group (p = 1.00). The LOS was significantly decreased in the ERAS group, with a mean of 2.3 days (SD 1.8) compared to 5.0 (SD 2.2) in the traditional group (p < 0.001). CONCLUSION: ERAS protocols used in the South African context in elective total knee arthroplasty significantly decrease the LOS without compromising patient safety or functional outcome. Level of evidence: Level 3.

Abstract: BACKGROUND: In total knee arthroplasty (TKA), fast-track or enhanced recovery after surgery (ERAS) programs are proven to be cost-effective without compromising patient safety or functional outcomes. The aim of this study is to determine if these promising results could be reproduced in Indian practice. METHODS: This retrospective study compared patients who underwent simultaneous bilateral TKA through ERAS protocol (n = 100) from January 2021 to June 2022 with a propensity-matched historical group operated through conventional protocol (n = 100) from July 2019 to June 2020. The time for straight leg raise (SLR), time to discharge, Visual Analog Score (VAS) for pain, range of motion (ROM), the Knee Society Score (KSS), complication rate, and readmission rate were compared between the groups in the early postoperative and follow-up periods up to 1 year. RESULTS: The mean length of stay (LOS) was significantly shorter in the ERAS group (2.3 days vs. 5.1 days, P < 0.001). The time to SLR was also significantly earlier in the ERAS group. The VAS score was significantly low on days 1, 2, 7, and 14 postsurgery. The KSS and ROM were significantly better in the ERAS group till 14 days. The VAS, KSS, and ROM were comparable between the groups at 1 month and later follow-up periods. There was no significant difference with regard to the rate of complications and readmissions. CONCLUSION: ERAS protocols used in bilateral TKA significantly reduced the LOS without compromising patient safety or functional outcomes. Standardized ERAS practices for all TKAs could benefit patients as well as health-care systems.

BackgroundClinical evidence has proved that enhanced recovery after surgery (ERAS) can improve short-term clinical outcomes after various types of surgeries, but the long-term benefits have not yet been examined, especially with respect to cancer surgeries. Therefore, a systematic review of the current evidence was conducted.MethodsThe Pubmed, Cochrane Library, Embase, and Web of Science databases were searched using the following key words as search terms: “ERAS” or “enhanced recovery” or “fast track”, “oncologic outcome”, “recurrence”, “metastasis”, “long-term outcomes”, “survival”, and “cancer surgery”. The articles were screened using the inclusion and exclusion criteria, and the data from the included studies were extracted and analyzed.ResultsA total of twenty-six articles were included in this review. Eighteen articles compared ERAS and conventional care, of which, 12 studies reported long-term overall survival (OS), and only 4 found the improvement by ERAS. Four studies reported disease-free survival (DFS), and only 1 found the improvement by ERAS. Five studies reported the outcomes of return to intended oncologic treatment after surgery (RIOT), and 4 found improvements in the ERAS group. Seven studies compared high adherence to ERAS with low adherence, of which, 6 reported the long-term OS, and 3 showed improvements by high adherence. One study reported high adherence could reduce the interval from surgery to RIOT. Four studies reported the effect of altering one single item within the ERAS protocol, but the results of 2 studies were controversial regarding the long-term OS between laparoscopic and open surgery, and 1 study showed improvements in OS with restrictive fluid therapy.ConclusionsThe use of ERAS in cancer surgeries can improve the on-time initiation and completion of adjuvant chemotherapy after surgery, and the high adherence to ERAS can lead to better outcomes than low adherence. Based on the current evidence, it is difficult to determine whether the ERAS protocol is associated with long-term overall survival or cancer-specific survival.

Enhanced Recovery After Lung Resection Surgery: Knowing What We Can Do… and Doing It

Enhanced recovery: joining the dots

Enhanced recovery after surgery (ERAS) pathways have been shown to improve pancreatic surgery outcomes, though feasibility in a community hospital remain unclear. We hypothesized that an ERAS protocol would reduce hospital length of stay (LOS) without increased morbidity. An ERAS pathway was initiated for patients undergoing pancreatic surgery at a community cancer center and compared to a historical cohort. The primary outcome was hospital LOS. Secondary outcomes included 30-day readmission rates, comprehensive complication index (CCI®), textbook outcomes (TO), and mortality. A total of 144 patients were included, with 63 patients in the ERAS group and 81 in the control group. The mean LOS decreased significantly in the ERAS group (6.85 [± 4.8]) vs 9.96 [±6.8] days, P = .001), without an increase in 30-day admission rates or CCI. Implementation of an ERAS protocol in a community setting reduced LOS without a corresponding increase in readmission rates or morbidity.

Communicating Value: Use of a Novel Framework in the Assessment of an Enhanced Recovery Initiative.

Background Enhanced Recovery After Surgery (ERAS) has been established in various surgical specialties. This prospective controlled randomized study was intended to assess the efficacy of implementing intravenous lidocaine infusion with enhanced recovery after pancreatic surgery (ERAPS) program on postoperative patients’ outcomes. Methods Thirty patients aged 30 to 70 years, of ASA class II who underwent elective pancreatic cancer surgery under general anesthesia were divided into two equal groups, Group L received IV lidocaine infusion, and Group S received IV saline. Postoperative pain intensity was our primary outcome, total postoperative epidural bupivacaine consumption, hospital stay, gastro-intestinal recovery, time to first ambulation, hospital stay duration, effect on immune response and perioperative complications were secondary outcomes. Results The visual analog scale (VAS) scores for pain were significantly lower in Group L compared with those in Groups S (p < 0.05). Post-operative epidural bupivacaine consumption, time to first patient ambulation, food intake and return of bowel movement were significantly less in Group L (p < 0.05%). There were no significant differences between groups in times to pass first flatus, first defecation, length of hospital stay (p > 0.05). Natural killer cell isolation and cytotoxic lymphocytes count decreased in both studied groups postoperatively in comparison to preoperative value and this reduction was significantly detected in Group S when compared with Group L (p = 0.001). The function of natural killer cell and cytotoxic lymphocytes with or without stimulation enhanced in Group L while it suppressed in Group S postoperatively in comparison to preoperative reading and significant difference was recorded between the two groups (p = 0.001). Conclusion Implementation of lidocaine in ERAS protocol in patients with cancer pancreas undergoing pancreatic surgery decreased pain score, reduced post-operative epidural bupivacaine consumption, shortened time to return of bowel sound, and enhanced patient ambulation and the patient’s immunity.

Single institution outcomes of enhanced recovery after surgery protocol implementation in pancreatoduodenectomy

Implementation of an Enhanced Recovery After Surgery program in elective colorectal surgery: a prospective cohort study

The enhanced recovery after surgery (ERAS) protocol is a perioperative care bundle designed to achieve early healing after surgical procedures. This study aims to investigate the effect of the ERAS protocol on postoperative complications, length of hospital stay (LOS), and readmission rates in pancreatic surgery patients. The study was designed as a prospective and randomized controlled study between January 2016 and November 2018 on pancreatic surgery patients. A total of 38 patients were analyzed, 18 of whom were in the ERAS group and 20 in the control group. Patient demographics, intraoperative variables, and postoperative outcomes were recorded. The groups were similar regarding age, sex, surgery type, American Society of Anesthesiologists scores, and laboratory results. There was no significant difference in the intraoperative variables. Early oral feeding was preferred, mostly in the ERAS group compared to the control group. Perioperative complication rates, including delayed gastric emptying and pancreatic fistula, LOS, and readmission rates, were similar between the two groups. The ERAS protocol provided a minimal decrease in the total complication rates and had no effect on severe complications. Therefore, the ERAS protocol seems feasible and can be applied safely in pancreatic surgery patients.

ASGE guideline on screening for pancreatic cancer in individuals with genetic susceptibility: summary and recommendations