Merits of Enhanced Recovery after Surgery Protocol following Whipple Pancreaticoduodenectomy: A Pilot Study

Abstract

Introduction: While Enhanced Recovery After Surgery (ERAS) has been widely implemented in upper and lower gastrointestinal operations, its application after whipple pancreaticoduodenectomy remains at an experimental level and has not been accepted as a standard of care in most centers including ours. Aim: To assess the merits and safety of ERAS after Whipple pancreaticoduodenectomy. Materials and Methods: This was a pilot study (prospective cohort study design) conducted at Christian Medical College Vellore, Tamil Nadu, India. Total 30 consecutive patients who underwent whipple procedure between September 2016 and May 2017 were managed using the ERAS protocol in the postoperative period. The operations were performed by one of the three senior surgeons and a standard method of reconstruction was followed. All patients underwent a feeding jejunostomy as part of the operation. The primary end point was duration of hospital stay and secondary end points were number of days required for urinary catheter removal, ambulation, cessation of intravenous fluids, discontinuation of infusional analgesia, removal of nasogastric tube, normal oral intake and drain removal. The rates of complications including Postoperative Pancreatic Fistula (POPF), Delayed Gastric Emptying (DGE), intra abdominal collection, post pancreatectomy haemorrhage and death were also calculated and compared with previous year data to assess the safety of ERAS protocol. Results: Mean age of patients was 53.9 years. There were 26 males and four females in this study. Total 21 out of the 30 patients had ampullary adenocarcinoma. More than 80% of the patients achieved milestones like urinary catheter removal, ambulation, cessation of i.v. fluids and infusional analgesia. Total 14 out of 30 (46.6%) patients tolerated normal diet by day 6 and 17 patients were managed without utilising the feeding jejunostomy. Drains were removed only in seven patients as per protocol. The mean hospital stay was 20.1 in comparison to the mean stay of the previous year which was 22.8 days. However, 15 patients were fit for discharge by day 15 based on discharge criteria, but were not discharged as the patients wanted to stay longer. There was no increase in morbidity or mortality in comparison to the previous year. Conclusion: The implementation of ERAS protocol appears to have no negative impact in the postoperative recovery in the patients with a potential for shortening hospital stay without added postoperative morbidity.

Keywords

• critical pathway surgery
• delayed gastric emptying
• fast track surgery
• postoperative pancreatic fistula