Abstract
Objective
The objective of this study is to evaluate the impact of a fast-track protocol in a high-volume center for patients with pancreatic disorders.
Background
The concept of fast-track surgery allowing accelerated postoperative recovery is accepted in colorectal surgery, but efficacy data are only preliminary for patients undergoing major pancreatic surgery. We aimed to evaluate the impact of a modified fast-track protocol in a high-volume center for patients with pancreatic disorders.
Methods
Between February 2005 and January 2010, 145 subjects had resective pancreatic surgery and were enrolled in the program. Essential features of the program were no preanaesthetic medication, upper and lower air-warming device, avoidance of excessive i.v. fluids perioperatively, effective control of pain, early reinstitution of oral feeding, and immediate mobilization and restoration of bowel function following surgery. Outcome measures were postoperative complications such as pancreatic fistula, delayed gastric emptying, biliary leak, intra-abdominal abscess, post-pancreatectomy hemorrhage, acute pancreatitis, wound infection, 30-day mortality, postoperative hospital stay, and readmission rates.
Results
On average, patients were discharged on postoperative day 10 (range 6–69), with a 30-day readmission rate of 6.2%. Percentage of patients with at least one complication was 38.6%. Pancreatic anastomotic leakage occurred in seven of 101 pancreatico-jejunostomies, and biliary leak in three of 109 biliary jejunostomies. Postoperative hemorrhage occurred in ten (6.9%) patients and wound infection in nine (6.2%) cases. In-hospital mortality was 2.7%. Fast-track parameters, such as normal food and first stool, correlated significantly with early discharge (<0.05). At multivariate analysis, lack of jaundice, and resumption of normal diet by the 5th postoperative day were independent factors of early discharge.
Conclusion
Fast-track programs are feasible, easy, and also applicable for patients undergoing a major surgery such as pancreatic resection.
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Abbreviations
- NSAID:
-
Non-steroidal anti-inflammatory drug
- ISGPS:
-
International Study Group on Pancreatic Surgery
References
Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database Syst Rev 2006 Oct 18; (4): CD004080
Karliczek A, Jesus EC, Matos D, Castro AA, Atallah AN, Wiggers T (2006) Drainage or nondrainage in elective colorectal anastomosis: a systematic review and meta-analysis. Colorectal Dis 8:259–265
Kehlet H, Dahal JB (2003) Anaesthesia, surgery and challenges in postoperative recovery. Lancet 362:1921–1928
Minowada G, Welch WJ (1995) Clinical implication of the stress response. J Clin Invest 95:3–12
Kehlet H (1991) The surgical stress response: should it be prevented? Can J Surg 34:565–567
Kehlet H, Wilmore DW (2002) Multimodal strategies to improve surgical outcome. Am J Surg 183:630–641
Bessey PQ (1995) Metabolic response to critical illness. In: Wilmore DW, Cheung LY, Harken AH, Holcroft JW, Meakins JL (eds) Scientific American surgery. Scientific American INC, New York, pp 1–31
Hill GL, Douglas RG, Schroeder D (1993) Metabolic basis for the management of patients undergoing major surgery. World J Surg 17:144–153
Kehlet H (2008) Fast-track colorectal surgery. Lancet 371:791–793
Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, Nygren J, Hausel J, Soop M, Andersen J, Kehlet H (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24:466–477
Büchler MW, Wagner M, Schmied BM, Uhl W, Friess H, Z’Graggen K (2003) Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg 138:1310–1314
Neoptolemos JP, Russel RC, Bramhall S, Theis B (1997) Low mortality following resection for pancreatic and periampullary tumours in 1,026 patients: UK survey of specialist pancreatic units. UK Pancreatic Cancer Group. Br J Surg 84:1370–1376
Balcom JHT, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C (2001) Ten-year experience with 733 pancreatic resection: changing indications, older patients, and decreasing length of hospitalization. Arch Surg 136:391–398
Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, Hruban RH, Ord SE, Sauter PK, Coleman J, Zahurak ML, Grochow LB, Abrams RA (1997) Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 226:248–257
Gouma DJ, van Geenen RC, van Gulik TM, de Haan RJ, de Wit LT, Busch OR, Obertop H (2000) Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg 232:786–795
Berberat PO, Ingold H, Gulbinas A, Kleeff J, Müller MW, Gutt C, Weigand M, Friess H, Büchler MW (2007) Fast track—different implications in pancreatic surgery. J Gastrointest Surg 11:880–887
Balzano G, Zerbi A, Braga M, Rocchetti S, Beneduce AA, Di Carlo V (2008) Fast- track recovery programme after pancreatico-duodenectomy reduces delayed gastric emptying. Br J Surg 95:1387–1393
Bullingham A, Strunin L (1995) Prevention of postoperative venous thromboembolism. Br J Anaesth 75:622–630
Sagar PM, Kruegener G, MacFie J (1992) Nasogastric intubation and elective abdominal surgery. Br J Surg 79:1127–1131
Cheatham ML, Chapman WC, Key SP, Sawyers JL (1995) A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg 221:469–476
Rowbotham DJ, Smith G (1992) Postoperative nausea and vomiting. Br J Anaesth 69(suppl1):1–68
Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Büchler M, For the International Study Group on Pancreatic Fistula (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138:8–13
Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW (2007) Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 142:761–768
Wente MN, Veit JA, Bassi C, Dervenis C, Fungerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Buchler MW (2007) Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 142:20–25
Z’graggen K, Uhl W, Friess H, Büchler MW (2002) How to do a safe pancreatic anastomosis. J Hepatobiliary Pancreat Surg 9:733–737
Diener MK, Knaebel HP, Heukaufer C, Antes G, Büchler MW, Seiler CM (2007) A systematic review and meta-analysis of pylorus-preserving versus classical pancreaticoduodenectomy for surgical treatment of periampullary and pancreatic carcinoma. Ann Surg 245:187–200
Hartel M, Wente MN, Hinz U, Kleeff J, Wagner M, Müller MW, Friess H, Büchler MW (2005) Effect of antecolic reconstruction on delayed gastric emptying after the pylorus-preserving Whipple procedure. Arch Surg 140:1094–1099
Muller MW, Friess H, Beger HG, Kleeff J, Lauterburg B, Glasbrenner B, Riepl RL, Büchler MW (1997) Gastric emptying following pylorus-preserving Whipple and duodenum-preserving pancreatic head resection in patients with chronic pancreatitis. Am J Surg 173:257–263
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di Sebastiano, P., Festa, L., De Bonis, A. et al. A modified fast-track program for pancreatic surgery: a prospective single-center experience. Langenbecks Arch Surg 396, 345–351 (2011). https://doi.org/10.1007/s00423-010-0707-1
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DOI: https://doi.org/10.1007/s00423-010-0707-1