Background: Implementation of enhanced recovery after surgery (ERAS) program after pancreatic surgery was associated with decreased length of stay (LOS). However, there were only retrospective uncontrolled before-after study, and care protocols were heterogeneous. We aimed to evaluate the impact of ERAS program on postoperative outcomes after pancreatectomy through a prospective controlled study. Methods: A before/after study with a contemporary control group was undertaken in patients undergoing pancreatectomy. We compared 2 groups: the intervention hospital that implemented ERAS program and the control hospital that performed traditional care; and 2 periods: the preimplementation and the post-implementation period. A difference-in-differences approach was used to evaluate whether implementation of ERAS program was associated with improved LOS and postoperative morbidity. Results: About 97 and 75 patients were included in intervention and control hospital. In multivariate analysis, implementation of ERAS was associated with a significantly shorten LOS (hazard ratio 1.61; 95% CI 1.07–2.44) and higher compliance rate (OR 1.34; 95% CI 1.18–1.53). Difference-in-differences analysis revealed that LOS, morbidity, and readmission did not differ after ERAS implementation. Conclusion: Implementation of ERAS program was safe and effective after pancreatectomy with high compliance rate. LOS was significantly reduced without compromising morbidity

Keywords:
Enhanced recovery, Pancreatic surgery, Difference in differences analysis
1.
de Wilde RF, Besselink MG, van der Tweel I, de Hingh IH, van Eijck CH, Dejong CH, et al.; Dutch Pancreatic Cancer Group. Impact of nationwide centralization of pancreaticoduodenectomy on hospital mortality. Br J Surg. 2012 Mar; 99(3): 404–10.
2.
Balzano G, Zerbi A, Braga M, Rocchetti S, Beneduce AA, Di Carlo V. Fast-track recovery programme after pancreatico-duodenectomy reduces delayed gastric emptying. Br J Surg. 2008 Nov; 95(11): 1387–93.
3.
Yoshioka R, Yasunaga H, Hasegawa K, Horiguchi H, Fushimi K, Aoki T, et al. Impact of hospital volume on hospital mortality, length of stay and total costs after pancreaticoduodenectomy. Br J Surg. 2014 Apr; 101(5): 523–9.
4.
Gouma DJ, van Geenen RC, van Gulik TM, de Haan RJ, de Wit LT, Busch OR, et al. Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg. 2000 Dec; 232(6): 786–95.
5.
Balcom JH 4th, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg. 2001 Apr; 136(4): 391–8.
6.
Turrini O, Paye F, Bachellier P, Sauvanet A, Sa Cunha A, Le Treut YP, et al.; French Surgical Association (AFC). Pancreatectomy for adenocarcinoma in elderly patients: postoperative outcomes and long term results: a study of the French Surgical Association. Eur J Surg Oncol. 2013 Feb; 39(2): 171–8.
7.
Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997 May; 78(5): 606–17.
8.
Anderson AD, McNaught CE, MacFie J, Tring I, Barker P, Mitchell CJ. Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg. 2003 Dec; 90(12): 1497–504.
9.
Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr. 2010 Aug; 29(4): 434–40.
10.
Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev. 2011 Feb;(2):CD007635.
11.
Coolsen MM, van Dam RM, van der Wilt AA, Slim K, Lassen K, Dejong CH. Systematic review and meta-analysis of enhanced recovery after pancreatic surgery with particular emphasis on pancreaticoduodenectomies. World J Surg. 2013 Aug; 37(8): 1909–18.
12.
Kagedan DJ, Ahmed M, Devitt KS, Wei AC. Enhanced recovery after pancreatic surgery: a systematic review of the evidence. HPB (Oxford). 2015 Jan; 17(1): 11–6.
13.
Eccles M, Grimshaw J, Campbell M, Ramsay C. Research designs for studies evaluating the effectiveness of change and improvement strategies. Qual Saf Health Care. 2003 Feb; 12(1): 47–52.
14.
Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, et al.; Enhanced Recovery After Surgery (ERAS) Society, for Perioperative Care; European Society for Clinical Nutrition and Metabolism (ESPEN); International Association for Surgical Metabolism and Nutrition (IASMEN). Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg. 2013 Feb; 37(2): 240–58.
15.
Ryan AM, Burgess J, Dimic JB. Why we shouldn’t be indifferent to specification in difference-in-differences analysis. Health Serv Res. 2015; 50: 1211–35.
16.
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004 Aug; 240(2): 205–13.
17.
Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, et al.; International Study Group on Pancreatic Surgery (ISGPS). The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery. 2017 Mar; 161(3): 584–91.
18.
Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 2007 Jul; 142(1): 20–5.
19.
Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2007 Nov; 142(5): 761–8.
20.
Steventon A, Roberts A. Estimating length of stay in publicly-funded residential and nursing care homes: a retrospective analysis using linked administrative data sets. BMC Health Serv Res. 2012 Oct; 12(1): 377.
21.
Rothman KJ, Greenland S, Lash TL. Modern Epidemiology. 3rd ed. Philadelphia (PA): Lippincott, Williams & willkins; 2008.
22.
Ai CR, Norton EC. Interaction terms in logit and probit models. Econ Lett. 2003; 80(1): 123–9.
23.
Porter GA, Pisters PW, Mansyur C, Bisanz A, Reyna K, Stanford P, et al. Cost and utilization impact of a clinical pathway for patients undergoing pancreaticoduodenectomy. Ann Surg Oncol. 2000 Aug; 7(7): 484–9.
24.
Vanounou T, Pratt W, Fischer JE, Vollmer CM Jr, Callery MP. Deviation-based cost modeling: a novel model to evaluate the clinical and economic impact of clinical pathways. J Am Coll Surg. 2007 Apr; 204(4): 570–9.
25.
Kennedy EP, Rosato EL, Sauter PK, Rosenberg LM, Doria C, Marino IR, et al. Initiation of a critical pathway for pancreaticoduodenectomy at an academic institution—the first step in multidisciplinary team building. J Am Coll Surg. 2007 May; 204(5): 917–23.
26.
Kennedy EP, Grenda TR, Sauter PK, Rosato EL, Chojnacki KA, Rosato FE Jr, et al. Implementation of a critical pathway for distal pancreatectomy at an academic institution. J Gastrointest Surg. 2009 May; 13(5): 938–44.
27.
Nikfarjam M, Weinberg L, Low N, Fink MA, Muralidharan V, Houli N, et al. A fast track recovery program significantly reduces hospital length of stay following uncomplicated pancreaticoduodenectomy. JOP. 2013 Jan; 14(1): 63–70.
28.
Abu Hilal M, Di Fabio F, Badran A, Alsaati H, Clarke H, Fecher I, et al. Implementation of enhanced recovery programme after pancreatoduodenectomy: a single-centre UK pilot study. Pancreatology. 2013 Jan-Feb; 13(1): 58–62.
29.
Coolsen MM, van Dam RM, Chigharoe A, Olde Damink SW, Dejong CH. Improving outcome after pancreaticoduodenectomy: experiences with implementing an enhanced recovery after surgery (ERAS) program. Dig Surg. 2014; 31(3): 177–84.
30.
Robertson N, Gallacher PJ, Peel N, Garden OJ, Duxbury M, Lassen K, et al. Implementation of an enhanced recovery programme following pancreaticoduodenectomy. HPB (Oxford). 2012 Oct; 14(10): 700–8.
31.
Reid-Lombardo KM, Farnell MB, Crippa S, Barnett M, Maupin G, Bassi C, et al.; Pancreatic Anastomotic Leak Study Group. Pancreatic anastomotic leakage after pancreaticoduodenectomy in 1,507 patients: a report from the Pancreatic Anastomotic Leak Study Group. J Gastrointest Surg. 2007 Nov; 11(11): 1451–8.
32.
Braga M, Capretti G, Pecorelli N, Balzano G, Doglioni C, Ariotti R, et al. A prognostic score to predict major complications after pancreaticoduodenectomy. Ann Surg. 2011 Nov; 254(5): 702–7.
33.
Gaujoux S, Cortes A, Couvelard A, Noullet S, Clavel L, Rebours V, et al. Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy. Surgery. 2010 Jul; 148(1): 15–23.
34.
Wellner UF, Kayser G, Lapshyn H, Sick O, Makowiec F, Höppner J, et al. A simple scoring system based on clinical factors related to pancreatic texture predicts postoperative pancreatic fistula preoperatively. HPB (Oxford). 2010 Dec; 12(10): 696–702.
35.
Shubert CR, Wagie AE, Farnell MB, Nagorney DM, Que FG, Reid Lombardo KM, et al. Clinical Risk Score to Predict Pancreatic Fistula after Pancreatoduodenectomy: Independent External Validation for Open and Laparoscopic Approaches. J Am Coll Surg. 2015 Sep; 221(3): 689–98.
36.
Johnston MJ, Arora S, King D, Bouras G, Almoudaris AM, Davis R, et al. A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery. Surgery. 2015 Apr; 157(4): 752–63.
37.
ERAS Compliance Group. The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry. Ann Surg. 2015 Jun; 261(6): 1153–9.
38.
Braga M, Pecorelli N, Ariotti R, Capretti G, Greco M, Balzano G, et al. Enhanced recovery after surgery pathway in patients undergoing pancreaticoduodenectomy. World J Surg. 2014 Nov; 38(11): 2960–6.
39.
Maessen J, Dejong CH, Hausel J, Nygren J, Lassen K, Andersen J, et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg. 2007 Feb; 94(2): 224–31.
40.
Goodney PP, Stukel TA, Lucas FL, Finlayson EV, Birkmeyer JD. Hospital volume, length of stay, and readmission rates in high-risk surgery. Ann Surg. 2003 Aug; 238(2): 161–7.
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2019
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