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Raza SS, Nutu OA, Powell-Brett S, Carvalheiro Boteon A, Hodson J, Abradelo M, Dasari B, Isaac J, Chatzizacharias N, Marudanayagam R, Mirza DF, Roberts JK, Sutcliffe RP. Impact of an enhanced recovery after surgery protocol on short-term outcomes in elderly patients undergoing pancreaticoduodenectomy. HPB (Oxford) 2022; 24:1720-1728. [PMID: 35643908 DOI: 10.1016/j.hpb.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/30/2022] [Accepted: 05/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND To determine whether the short-term benefits associated with an enhanced recovery after surgery programme (ERAS) following pancreaticoduodenectomy (PD) vary with age. METHODS 830 consecutive patients who underwent PD between January 2009 and March 2019 were divided according to age: elderly (≥75 years) vs. non-elderly patients (<75 years). Within each age group, cohort characteristics and outcomes were compared between patients treated pre- and post-ERAS (ERAS was systematically introduced in December 2012). Univariable and multivariable analysis were then performed, to assess whether ERAS was independently associated with length of hospital stay (LOS). RESULTS Of the entire cohort, 577 of 830 patients (69.5%) were managed according to an ERAS protocol, and 170 patients (20.5%) were aged ≥75 years old. Patients treated post-ERAS were significantly more comorbid than those pre-ERAS, with a mean Charlson Comorbidity Index of 4.6 vs. 4.1 (p < 0.001) and 6.0 vs. 5.7 (p = 0.039) for the non-elderly and elderly subgroups, respectively. There were significantly fewer medical complications in non-elderly patients treated post-ERAS compared to pre-ERAS (12.4% vs. 22.4%; p = 0.002), but not in elderly patients (23.6% vs. 14.0%; p = 0.203). On multivariable analysis, ERAS was independently associated with reduced LOS in both elderly (14.8% reduction, 95% CI: 0.7-27.0%, p = 0.041) and non-elderly patients (15.6% reduction, 95% CI: 9.2-21.6%, p < 0.001), with the effect size being similar in each group. CONCLUSION ERAS protocols can be safely applied to patients undergoing pancreaticoduodenectomy irrespective of age. Implementation of an ERAS protocol was associated with a significant reduction in postoperative LOS in both elderly and non-elderly patients, despite higher comorbidity in the post-ERAS period.
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Affiliation(s)
- Syed S Raza
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Oana A Nutu
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | - James Hodson
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Bobby Dasari
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - John Isaac
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
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Hackner D, Hobbs M, Merkel S, Siepmann T, Krautz C, Weber GF, Grützmann R, Brunner M. Impact of Patient Age on Postoperative Short-Term and Long-Term Outcome after Pancreatic Resection of Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2022; 14:cancers14163929. [PMID: 36010922 PMCID: PMC9406071 DOI: 10.3390/cancers14163929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 12/02/2022] Open
Abstract
(1) Purpose: to evaluate the impact of age on postoperative short-term and long-term outcomes in patients undergoing curative pancreatic resection for PDAC. (2) Methods: This retrospective single-center study comprised 213 patients who had undergone primary resection of PDAC from January 2000 to December 2018 at the University Hospital of Erlangen, Germany. Patients were stratified according the age into two groups: younger (≤70 years) and older (>70 years) patients. Postoperative outcome and long-term survival were compared between the groups. (3) Results: There were no significant differences regarding inhospital morbidity (58% vs. 67%, p = 0.255) or inhospital mortality (2% vs. 7%, p = 0.073) between the two groups. The median overall survival (OS) and disease-free survival (DFS) were significantly shorter in elderly patients (OS: 29.2 vs. 17.1 months, p < 0.001, respectively; DFS: 14.9 vs. 10.4 months, p = 0.034). Multivariate analysis revealed that age was a significant independent prognostic predictor for OS and DFS (HR 2.23, 95% CI 1.58−3.15; p < 0.001 for OS and HR 1.62, 95% CI 1.17−2.24; p = 0.004 for DFS). (4) Conclusion: patient age significantly influenced overall and disease-free survival in patients with PDAC undergoing primary resection in curative intent.
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Affiliation(s)
- Danilo Hackner
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
- Division of Health Care Sciences, Dresden International University, 01067 Dresden, Germany
| | - Mirianna Hobbs
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Susanne Merkel
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Timo Siepmann
- Division of Health Care Sciences, Dresden International University, 01067 Dresden, Germany
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01069 Dresden, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Georg F. Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
- Correspondence: ; Tel.: +49-09131-85-33296
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Wang Q, Chen C, Li H. Laparoscopic Pancreaticoduodenectomy in Elderly Patients: Systematic Review and Meta-Analysis. Front Surg 2022; 9:807940. [PMID: 35310445 PMCID: PMC8931034 DOI: 10.3389/fsurg.2022.807940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 02/02/2022] [Indexed: 01/08/2023] Open
Abstract
Background The safety and efficacy of laparoscopic pancreaticoduodenectomy (LPD) in elderly patients who often suffer from pre-existing conditions (e.g., cardiovascular diseases) and poor functional reserve remain unclear. This meta-analysis aimed to evaluate the safety and efficacy of LPD in elderly patients. Methods A systematic literature search was conducted using the PubMed, Embase, Web of Science, and Cochrane Library databases. All studies published from their inception to January 2022 reporting perioperative outcomes after LPD in elderly patients were included in the search (Group 1, comparing the perioperative outcomes of LPD and OPD in elderly patients; Group 2, comparing the perioperative outcomes after LPD between elderly and non-elderly patients). The evaluated outcomes included perioperative mortality, postoperative complications, conversion, operative time, estimated blood loss (EBL), postoperative hospital stay (POHS), and readmission. Results In total 8 studies were included in the meta-analysis. Pooled analysis of Group 1 showed that EBL, 90-day mortality, major morbidity, bile leak, POH, abdominal infection, reoperation, POP, POCE, and readmission were not significantly different between the LPD and the OPD group. LPD was associated with longer operative time, lower POPF rate, lower DEG rate, and shorter POHS. Pooled analysis of Group 2 showed that mortality, major morbidity, POPF, DEG, bile leak, POH, abdominal infection, reoperation, conversion, operative time, EBL, and readmission were not significantly different between the elderly and the non-elderly group. The POHS of elderly group was significantly longer than non-elderly group. Conclusion LPD may be a safe and feasible procedure for elderly patients and is associated with short POHS.
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Affiliation(s)
- Qiang Wang
- School of Clinical Medicine, Guizhou Medical University, Guiyang, China
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Chengxin Chen
- School of Clinical Medicine, Guizhou Medical University, Guiyang, China
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Haiyang Li
- School of Clinical Medicine, Guizhou Medical University, Guiyang, China
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
- *Correspondence: Haiyang Li
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Ayala CI, Li AY, Lu A, Wilson A, Bergquist JR, Poultsides GA, Norton JA, Visser BC, Dua MM. More Than an ERAS Pathway is Needed to Meet Target Length of Stay After Pancreaticoduodenectomy. J Surg Res 2021; 270:195-202. [PMID: 34688991 DOI: 10.1016/j.jss.2021.08.034] [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: 03/01/2021] [Revised: 08/01/2021] [Accepted: 08/24/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocols have been successfully instituted for pancreaticoduodenectomy (PD). This study evaluates reasons patients fail to meet length of stay (LOS) and areas for pathway improvement. MATERIALS AND METHODS A multidisciplinary team developed and implemented an ERAS protocol for open PD in 2017. The study includes a medical record review of all patients who were perioperatively managed with the ERAS protocol and failed to meet LOS after PD procedures. Target LOS was defined as 7 d. RESULTS From 2017 to 2020, 44% (93 of 213) of patients using ERAS protocol after PD procedures failed to meet target LOS. The most common reason to fail target LOS was ileus or delayed gastric emptying (47 of 93, LOS 11). Additional reasons included work-up of leukocytosis or pancreatic leak (17 of 93, LOS 14), additional "night" of observation (14 of 93, LOS 8), and orthostatic hypotension (3 of 93, LOS 10). Of these additional 46 patients, 19 patients underwent computed tomography (on or after POD 7) and only four patients received additional inpatient intervention. CONCLUSIONS The most common reason for PD pathway failure included slow return of gastrointestinal function, a known complication after PD. The remaining patients were often kept for observation without additional intervention. This group represents an actionable cohort to target for improving LOS through surgeon awareness rather than protocol modification.
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Affiliation(s)
- Carlos I Ayala
- Department of Surgery, Stanford University, Stanford, California
| | - Amy Y Li
- Department of Surgery, Stanford University, Stanford, California
| | - Amy Lu
- Departemnt of Anesthesia, Stanford University, Stanford, California
| | - Alicia Wilson
- Departemnt of Anesthesia, Stanford University, Stanford, California
| | - John R Bergquist
- Department of Surgery, Stanford University, Stanford, California
| | | | - Jeffrey A Norton
- Department of Surgery, Stanford University, Stanford, California
| | - Brendan C Visser
- Department of Surgery, Stanford University, Stanford, California
| | - Monica M Dua
- Department of Surgery, Stanford University, Stanford, California.
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Abstract
ABSTRACT Pancreaticoduodenectomy is considered to be the most complicated operation in abdominal surgery. The purpose of this study was to evaluate the safety and efficacy of laparoscopic pancreaticoduodenectomy (LPD) in elderly patients. We searched PubMed, Embase, and Cochrane Library databases for relevant studies that were published before June 2020. Seven cohort studies were eligible with 3200 patients. The result of meta-analysis showed that, for the elderly, severe complications, clinical pancreas fistula, and delayed gastric emptying in the LPD group were significantly lower than those in the open pancreaticoduodenectomy (OPD) group. There was no significant difference in postoperative bleeding, reoperation, and readmission between the 2 groups. For the LPD, the mortality, delayed gastric emptying, and severe complication in elder patients were significantly higher than those in young patients. There was no significant difference in postoperative bleeding, R0 rate, reoperation rate, and readmission rate between the aged and the young. Therefore, LPD can reduce postoperative complications in elderly patients compared with OPD, which can be used as a potential alternative to OPD in elderly patients. However, laparoscopic approach cannot eliminate the high risk of postoperative death and severe complications caused by age. More high-quality studies need to be done for further verification.
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Affiliation(s)
- Wei Zhang
- From the Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - Zhangkan Huang
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Jianwei Zhang
- From the Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
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Enhanced recovery after pancreatoduodenectomy-does age have a bearing? Langenbecks Arch Surg 2021; 406:1093-1101. [PMID: 33774746 DOI: 10.1007/s00423-021-02108-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 01/25/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION With the proven benefits of enhanced recovery protocols (ERP) after pancreatoduodenectomy (PD), their implementation has become a well-accepted clinical practice across the major pancreatic surgery centres of the world. The impact of age on the execution of ERP has remained an area of ambiguity. The aim of this study was to assess the impact of age on the feasibility of various postoperative elements of ERP after PD. METHODS A retrospective study was conducted which included 548 patients undergoing PD, managed using ERP, from March 2013 to September 2020. Patients were divided into two groups: < 70 years and ≥ 70 years. Compliance to recovery parameters and postoperative outcomes, including, the incidence of major complications, length of stay (LOS), mortality rates and re-admissions, were compared between the two groups. The impact of age, as a continuous variable, was also studied on the feasibility of each postoperative element. RESULTS One-fifth (113/548) of the cohort comprised of patients aged 70 years and above. The 'elderly' patients had a significantly higher prevalence of diabetes, hypertension, and cardiac disease. They were also more likely to get admitted to the intensive care unit for postoperative monitoring (p < 0.001). The median LOS was 8.0 days in the young and 9.0 days in the elderly (p = 0.253). Rate of major complications (age < 70, n = 37 (8.5%) vs age ≥ 70, n = 7 (6.2%), p = 0.421) and 30-day mortality (age < 70, n = 15 (3.4%) vs age ≥ 70, n = 7 (6.2%), p = 0.185) was not statistically different between the two groups. Compliance of various postoperative elements was similar between the two groups. When studied as a continuous variable, age did not seem to be associated with higher non-compliance of any of the postoperative recovery elements. CONCLUSION Age is not a barrier in the safe implementation of postoperative element of ERPs after PD. Enhanced recovery protocols do not need to be modified for the aged.
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Hufkens AS, van Cleven S, Abreu de Carvalho L, Vanlander A, Berrevoet F. Evaluation of an enhanced recovery program for outcome improvement after pancreaticoduodenectomy: A retrospective cohort study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2020.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Cui Z, Li N, Gao C, Fan Y, Zhuang X, Liu J, Zhang J, Tan Q. Precision implementation of early ambulation in elderly patients undergoing off-pump coronary artery bypass graft surgery: a randomized-controlled clinical trial. BMC Geriatr 2020; 20:404. [PMID: 33054724 PMCID: PMC7560239 DOI: 10.1186/s12877-020-01823-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 10/07/2020] [Indexed: 01/17/2023] Open
Abstract
Background Although early ambulation (EA) is associated with improved outcomes in post-operative patients, implementation of EA in elderly patients is still a challenge. In this study, we aimed to design and assess a precision early ambulation program for cardiac rehabilitation. Methods We conducted a single-center, randomized and controlled clinical trial in elderly patients aged over 60 years after off-pump coronary artery bypass graft (OPCABG) surgery. Patients were randomly assigned to a precision early ambulation (PEA) group or a routine ambulation (Control) group. Age-predicted maximal heart rate (APMHR) and maximal oxygen uptake (VO2max) were used as a reference to formulate and monitor the PEA regimen. The primary end-point was the postoperative length of stay in hospital (PLOS). The secondary end-points included 90-day mortality, incidence of early discharge, laboratory tests, length of ICU stay, the incidence of multiple organ complications and post-traumatic stress disorder (PTSD). Ambulation outcomes were also recorded. Results In total, 178 patients were enrolled (n = 89 per group). In the intent-to-treat analysis, PLOS in the PEA group was shorter than that in the Control group (9.04 ± 3.08 versus 10.09 ± 3.32 days, respectively. Mean difference 1.045 days; 95% confidence interval [CI] 0.098–1.992; P = 0.031 in the unadjusted model; mean difference 0.957 days; CI 0.007–1.907; P = 0.048 in adjusted model). The incidence of early discharge differed significantly between the PEA and control groups (41[46.1%] versus 24[27.0%] patients, respectively. Odds ratio [OR] 0.432; CI 0.231–0.809; P = 0.009 in unadjusted model; OR 0.466; CI 0.244–0.889, P = 0.02 in adjusted model). The time of first bowel movement, partial pressure O2 and post-traumatic stress disorder score in the PEA group were better than those in the Control group. Participants walked much longer distances on day 3 in the PEA group than those in the Control group (76.12 ± 29.02 versus 56.80 ± 24.40 m, respectively, P < 0.001). Conclusion APMHR and VO2max are valuable for implementation of PEA according to an established security threshold. PEA after OPCAPG surgery is safe and reliable for elderly patients, not only reducing the hospital stay, but also improving their physiological and psychological symptoms. Trial registration This study is a component of a protocol retrospectively registered: Application of ERAS in cardiovascular surgery. Trial registration number: ChiCTR1800018167. Date of registration: 3rd September, 2018. URL of trial registry record: http://www.chictr.org.cn/index.aspx
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Affiliation(s)
- Zhaomei Cui
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Na Li
- Department of Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Chaonan Gao
- Department of Biostatistics, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, Shandong, China
| | - Yiou Fan
- Department of Toxicological and Functional Test, Centers for Disease Control and Prevention of Shandong, Jinan, 250014, China
| | - Xin Zhuang
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Jing Liu
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Jie Zhang
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China
| | - Qi Tan
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China. .,Intensive Care Unit (ICU), Department of Cardiac Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, Shandong, China.
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Abstract
Enhanced Recovery after Surgery (ERAS) is a multicentric program that includes the fields of nursing and anesthesia, nutrition and fluid management, and minimally invasive surgery. ERAS protocols focus on reducing the postoperative complications and stress response, optimizing the postoperative recovery. They have been implemented in many surgical fields, such as cardiac, gastric, and urologic, as they were shown to be effective in reducing morbidity and the overall health costs and in improving patient satisfaction. The aim of this minireview was to investigate the impact of ERAS programs on patients' postoperative outcome after hepato-pancreato-biliary surgery.
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Affiliation(s)
- Maria Kapritsou
- Anesthesiology Department, Hellenic Anticancer Institute "Saint Savvas" Hospital, Day Care Surgery N. Kourkoulos, Athens, Greece
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