Enhanced recovery after surgery protocol in pancreatic surgery, critical factors for rapid patient recovery

Abstract

Background: Enhanced Recovery After Surgery (ERAS) is an evidence-based pathway with the purpose of optimizing recovery from surgery and potentially decreasing postoperative pain, reducing complications, and shortening hospital stay. With ERAS implementation multiple variables are changed simultaneously and identification of the factor(s) that drive improvement can be difficult. The aim of this study is to determine which ERAS factors are most impact on length of stay (LOS). Methods: All patients undergoing a pancreaticoduodenectomy (PD) at a quaternary referral center from Jan 2014 to Jun 2018 were identified. Patients were divided in two groups, pre-ERAS and ERAS. For the purposes of this analysis all patients who had minimally invasive surgery (MIS) and vascular reconstructions (VR) were excluded. Perioperative data was collected for clinicopathological features and ERAS adherence. Postoperative data was collected including, length of stay at the hospital (LOS), readmission rate 30 days after surgery, morbidity, and mortality. We used the ERAS guideline’s evidence levels and recommendation grades (Lassen et al) to assign a score for each factor from our institutional ERAS protocol. Factors with the highest scores were identified to form a core group with the most impact. (Table 1) Results: 191 patients underwent PD during this study period. We excluded 87 patients who had 22 MIS, 53 VR, and 12 having both, thus 104 patients were included in this study. Among these patients 56 (54%) were pre–ERAS and 48 (46%) were in the ERAS group. Patients’ median LOS was 10.5 days in pre-ERAS vs 7 days in the ERAS group (p < 0.001). The factors whose adherence was associated with favorable impact on LOS include: IV fluid balance during OR; starting a clear liquid diet POD#1; full liquid diet POD#2 and 3; early removal of urinary catheter (UC) POD#2; starting regular diet POD#4; and continuing regular diet on POD#5. In the ERAS group, the patients who adhered to these factors had a median LOS of 5 days compared to 7 days with statistical trend towards significance. (p = 0.1). Statistical analysis was performed utilizing Student’s T, Mann Whitney U, and Chi Square. Conclusion: The implementation of ERAS principles reduced LOS without harm to the postoperative recovery of patients. Strict fluid balance in the OR, early urinary catheter removal; early liquid intake; and a rapid progression to a regular diet were associated with a decreased LOS. This study showed that