Enhanced Recovery Deviation and Failure After Pancreaticoduodenectomy: Causative  Factors and Impact.

Tankel J et al. Enhanced Recovery Deviation and Failure After Pancreaticoduodenectomy: Causative
Factors and Impact. Surg Res. 2020 Jan;245:569-576.

What is already known:

ERAS for pancreaticoduodenectomy has been around for a while. The ERAS society first published guidelines in 2012 and then updated in 2019 [they can be found here]. However, these procedures still have a high morbidity and despite the best efforts of both clinicians and patients, there will be some patients who will either deviate from the ERAS protocol or fail ERAS’ key goals. The key is to predict which ones.

What this paper adds:

Interestingly there was no discernible relationship between
ERAS protocol deviation and failure. There was also no relationship noted between protocol deviation and serious complications or pancreatic fistula. Univariate and multivariate analyses identified variables associated with protocol deviation and failure. On univariate analysis: protocol deviation was associated with male gender, prolonged surgery time (>270 min) and prolonged Length of Stay. On multivariate analysis only prolonged LoS remained significant. Perhaps this is obvious? It stands to reason that if there are deviations from protocol then this would be associated with prolonged LoS. It suggests that perhaps deviation does not alter the course of those destined to ultimately fail to achieve the ERAS protocol goals. The next step is to accurately predict complications. The holy grail?

Chris Jones, Guildford.


Continuous wound infiltration versus epidural analgesia after hepato-pancreato-biliary surgery (POP-UP): a randomised controlled, open-label, non-inferiority trial

Mungroop TH, Veelo DP, Busch OR, van Dieren S, van Gulik TM, Karsten TM, de Castro SM, Godfried MB, Thiel B, Hollmann MW, Lirk P, Besselink MG. Lancet Gastroenterol Hepatol. 2016 Oct;1(2):105-113

What is already known:

Epidural analgesia has always been considered the “gold-standard” but slowly that is being questioned. Also the majority of studies with pain as their main outcome, use simple visual analogue scores (VAS)to differentiate the modalities. Importantly however, this is one of the first to include patient reported outcomes as well as VAS.

What this paper adds:

The authors used a validated scoring system called the OBAS score (Overall Benefit of Analgesia Score). It is a validated composite score including analgesia side-effects and patient satisfaction, as well as VAS scores.

They compared epidural analgesia with continuous infusions of local anaesthetic via a wound catheter in patients undergoing various different types of open hepato-pancreato-biliary surgery (mostly pancreatoduodenectomy (35% followed by liver resection (18%)). The authors set out to show that it the wound catheter was not inferior to epidural which they duly did. Vasopressor use was much lower in the wound catheter group. Adding to the growing body of evidence that an epidural is not the only option for major open abdominal surgery.

Chris Jones, Guildford. @chrisnjones


The economics of recovery after pancreatic surgery: detailed cost minimization analysis of an enhanced recovery program.

HPB (Oxford). 2017 Nov;19(11):1026-1033. 

What is already known:

There have been quite a few successful published programmes for pancreatic surgery as well as published ERAS guidelines. But less is known about the economic benefits of these programmes.

What this paper adds:

This was a Canadian retrospective cost minimization analysis of patients undergoing pancreaticoduodenectomy with an ERAS programme versus standard care. Despite only a small reduction in total length of stay (10 vs 11 days, p=0.003), there was a pretty impressive cost saving of over 13,000 Canadian dollars per patient (including readmissions, $16,627 vs $29,872, p=0.016). The main areas of cost savings were through reducing unnecessary laboratory tests and imaging investigations. Showing nicely that it is not just reducing bed-days that saves money.

Chris Jones, Guildford. @chrisnjones


Enhanced Recovery Pathways in Pancreatic Surgery

Barton JG. Enhanced Recovery Pathways in Pancreatic Surgery. Surg Clin North Am. 2016 Dec;96(6):1301-1312.

What is already known: Mortality in pancreatic surgery has improved dramatically over the past number of years, from 25% in the 1970’s to only 2% in high-volume centres. Morbidity however remains in excess of 40%. The ERAS society has produced guidelines for pancreatic surgery in 2012, which can be found here.

What this paper adds: This is a really good overview of ERAS for pancreatic surgery, with both a literature review and a more detailed look at some of the specific pancreatic elements. These include: pre-operative biliary drainage, use of intra-abdominal drains post-op, somatostatin analogues and different analgesic regimens. The author also gives a detailed day to day run through of his own institutional ERAS programme.

Chris Jones, Guildford.


ERAS for elderly patients undergoing pancreaticoduodenectomy

Partelli S, Crippa S, Castagnani R, Ruffo G, Marmorale C, Franconi AM, De Angelis C, Falconi M. Evaluation of an enhanced recovery protocol after pancreaticoduodenectomy in elderly patients. HPB (Oxford). 2016 Feb;18(2):153-8.

What is already known:

ERAS society guidelines exist for major pancreatic resections (link), and this study aims to study the effects of an ERAS program on elderly patients (>75 years) undergoing pancreaticoduodenectomy, compared to a historical cohort.

What this paper adds:

A retrospective study demonstrating that ERAS is feasible and safe for elderly patients undergoing pancreaticoduodenectomy. In this small study (88 patients, of which 22 patients underwent an ERAS programme and 66 were historical controls) there was no overall difference in postoperative outcomes, but found a reduced length of stay in patients who had no complications (4 versus 8 days).

Adherence to ERAS elements was mixed. Only 9% had their abdominal drains removed early and 32% tolerated starting an oral diet before postoperative day 4. Whilst 95% had epidural analgesia and 90% had early NG tube removal and tolerated early mobilisation.

Chris Jones, Guildford.