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Kuemmerli C, Balzano G, Bouwense SA, Braga M, Coolsen M, Daniel SK, Dervenis C, Falconi M, Hwang DW, Kagedan DJ, Kim SC, Lavu H, Nussbaum D, Partelli S, Passeri MJ, Pecorelli N, Pillarisetty VG, Pucci MJ, Sutcliffe RP, Tingstedt B, van der Kolk M, Vrochides D, Armstrong M, Wei A, Williamsson C, Yeo CJ, Zani S, Zouros E, Rozzini R, Abu Hilal M. Are enhanced recovery protocols after pancreatoduodenectomy still efficient when applied in elderly patients? A systematic review and individual patient data meta-analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2024; 31:308-317. [PMID: 38282543 DOI: 10.1002/jhbp.1417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/05/2023] [Accepted: 12/20/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND This meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared to conventional care on postoperative outcomes in patients aged 70 years or older undergoing pancreatoduodenectomy (PD). METHODS Five databases were systematically searched. Comparative studies with available individual patient data (IPD) were included. The main outcomes were postoperative morbidity, length of stay, readmission and postoperative functional recovery elements. To assess an age-dependent effect, the group was divided in septuagenarians (70-79 years) and older patients (≥80 years). RESULTS IPD were obtained from 15 of 31 eligible studies comprising 1109 patients. The overall complication and major complication rates were comparable in both groups (OR 0.92 [95% CI: 0.65-1.29], p = .596 and OR 1.22 [95% CI: 0.61-2.46], p = .508). Length of hospital stay tended to be shorter in the ERAS group compared to the conventional care group (-0.14 days [95% CI: -0.29 to 0.01], p = .071) while readmission rates were comparable and the total length of stay including days in hospital after readmission tended to be shorter in the ERAS group (-0.28 days [95% CI: -0.62 to 0.05], p = .069). In the subgroups, the length of stay was shorter in octogenarians treated with ERAS (-0.36 days [95% CI: -0.71 to -0.004], p = .048). The readmission rate increased slightly but not significantly while the total length of stay was not longer in the ERAS group. CONCLUSION ERAS in the elderly is safe and its benefits are preserved in the care of even in patients older than 80 years. Standardized care protocol should be encouraged in all pancreatic centers.
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Affiliation(s)
- Christoph Kuemmerli
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, Clarunis - University Centre for Gastrointestinal and Liver Diseases Basel, Basel, Switzerland
| | - Gianpaolo Balzano
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Stefan A Bouwense
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marco Braga
- Department of Surgery, Monza Hospital, University of Milano Bicocca, Monza, Italy
| | - Mariëlle Coolsen
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sara K Daniel
- HPB Surgery, University of Washington, Seattle, Washington, USA
| | | | - Massimo Falconi
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Harish Lavu
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniel Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Stefano Partelli
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | - Michael J Passeri
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Nicolò Pecorelli
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy
| | | | - Michael J Pucci
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert P Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Marion van der Kolk
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Misha Armstrong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alice Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Caroline Williamsson
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
| | - Charles J Yeo
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Efstratios Zouros
- Department of Surgery, Konstantopouleio General Hospital, Athens, Greece
| | - Renzo Rozzini
- Geriatrics Operating Units, Foundation Poliambulanza, Brescia, Italy
| | - Mohammed Abu Hilal
- Department of Surgery, Foundation Poliambulanza, Brescia, Italy
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Kapoor D, Perwaiz A, Singh A, Kumar AN, Chaudhary A. Factors predicting 30-day mortality after pancreaticoduodenectomy-the impact of elevated aspartate aminotransferase. Langenbecks Arch Surg 2023; 408:130. [PMID: 36991246 DOI: 10.1007/s00423-023-02865-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/19/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE High preoperative bilirubin levels and cholangitis are associated with poor peri-operative outcomes following pancreaticoduodenectomy (PD). However, the impact of deranged preoperative aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels on immediate postoperative outcomes is relatively unexplored. We hypothesized that deranged AST and ALT lead to worse postoperative outcomes after PD. The aim of this study was to assess the factors contributing to postoperative mortality (POM) following PD, and to study the impact of deranged aminotransferases. METHODS This is a retrospective analysis of 562 patients. Risk factors for POM were computed using a multivariate logistic regression model. RESULTS The rate of POM was 3.9%. On univariate analysis, the American Society of Anaesthesiologists grades, diabetes mellitus, cardiac comorbidity, preoperative biliary stenting, elevated serum bilirubin, AST, elevated serum creatinine, clinically relevant pancreatic fistula (CRPF), and grade B+C post-pancreatectomy hemorrhage (PPH) were associated with 30-day mortality. On multivariate analysis, preoperative elevated AST was independently predictive of 30-day POM (OR = 6.141, 95%CI 2.060-18.305, p = 0.001). Other factors independently predictive of POM were elevated serum creatinine, preoperative biliary stenting, CRPF and grade B and C PPH. The ratio of AST/ALT > 0.89 was associated with 8 times increased odds of POM. CONCLUSION Elevated preoperative AST emerged as a predictor of 30-day POM after PD, with an 8-times increased odds of death with an AST/ALT ratio > 0.89.
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Affiliation(s)
- Deeksha Kapoor
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India
| | - Azhar Perwaiz
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India
| | - Amanjeet Singh
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India
| | - Arun N Kumar
- Department of Data Science, Alke Research Private Limited, Bengaluru, Karnataka, India
| | - Adarsh Chaudhary
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
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Kapoor D, Barreto SG, Perwaiz A, Singh A, Chaudhary A. Can we predict the need for nutritional support following pancreatoduodenectomy? Pancreatology 2022; 22:160-167. [PMID: 34893447 DOI: 10.1016/j.pan.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/08/2021] [Accepted: 11/28/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The practice of routine placement of a tube jejunostomy at the time of pancreatoduodenectomy has given way to a more selective approach. However, the indications of establishing enteral access at the time of surgery remain poorly defined. This study aimed to assess the preoperative and intraoperative factors associated with the need for nutritional support after pancreatoduodenectomy, to guide decision-making for the establishment of intraoperative feeding access. METHODS Retrospective study, analyzing the data of 562 consecutive patients, who underwent pancreatoduodenectomy between March 2013 to December 2020. Univariate and multiple logistic regression analysis was carried out to ascertain the factors associated with the initiation of and need for nutritional support for more than 7 days postop. The utility of tube jejunostomy was studied in patients in whom it was performed. RESULTS Of 562 patients, 105 (18.7%) needed nutritional support. A tube jejunostomy was performed in 46 (8.2%) patients, parenteral nutrition was used in 83 (14.8%), and nasojejunal tube placed in 28 (4.9%) patients. On logistic regression analysis, age, serum albumin <3.0 gm/dl and operative blood loss were independently associated with the initiation of supportive nutrition, while preoperative gastric outlet obstruction (OR 3.105, 95% CI1.201-8.032, p = 0.019) and serum albumin <3.0 gm/dl (OR 2.669, 95% CI 1.131-6.300, p = 0.025) were associated with the need for prolonged nutritional support. The maximal benefit of tube jejunostomy was in patients with mental health disorders (83.3%). CONCLUSION Tube jejunostomy for nutritional support after pancreatoduodenectomy can be considered in patients with preoperative gastric outlet obstruction, serum albumin <3.0 gm/dl and mental health disorders.
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Affiliation(s)
- Deeksha Kapoor
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
| | - Savio George Barreto
- Division of Surgery & Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia.
| | - Azhar Perwaiz
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
| | - Amanjeet Singh
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
| | - Adarsh Chaudhary
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
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