Evaluation of an enhanced recovery after surgery protocol for pancreaticoduodenectomy in a tertiary referral hospital: a retrospective cohort study

Abstract

Purpose: The implementation of an enhanced recovery after surgery (ERAS) protocol results in accelerated perioperative recovery, reduced length of hospital stay (LOS) and in-hospital costs. The primary endpoint of this study is to evaluate the different targets of the ERAS protocol separately. The secondary endpoints are the 30-day reoperation rate, readmission rate and mortality. Method: This single centre retrospective analysis reviews the data of 154 patients who underwent a pancreaticoduodenectomy between August 2016 and December 2019. As per ERAS protocol, the epidural analgesia was stopped on postoperative day (POD)2, the nasogastric tube (NGT) removed on POD3 and regular food tolerated by POD5. Drains were removed on POD2, POD3 and the soft drain along the pancreatic anastomosis between POD3-10. Results: Epidural analgesia was discontinued on POD2 in 26 patients (17.7%), the NGT removed on POD3 in 74 patients (49.0%), and regular food started by POD5 in 52 patients (34.9%). The lateral drain was removed in 81 patients (52.9%) on POD2, the medial drain in 39 patients (26.2%) at POD3, the soft drain in 95 patients (61.7%) between POD3 and POD10. Nine patients (5.8%) had post-pancreatectomy haemorrhage (PPH), 14 (9.1%) had a postoperative pancreatic fistula grade B or C (POPF), 5 (3.3%) had a bile leakage, and 44 (28.6%) experienced delayed gastric emptying (DGE). The 30-day readmission rate was 8.4%, the reoperation rate was 10.4%, and the in-hospital mortality 1.3%. Conclusion: Efficient implementation requires strict follow-up of all included ERAS elements, but should not be restricted to low-risk patients. Delayed gastric emptying and POPF are predictors for a prolonged LOS. Length of hospital stay is influenced by multiple factors and therefore not a good parameter to evaluate implementation of an ERAS protocol.