A hospital-to-home evaluation of an enhanced recovery protocol for elective pancreaticoduodenectomy in China: A cohort study

Costs and clinical benefits of enhanced recovery after surgery (ERAS) in pancreaticoduodenectomy: an updated systematic review and meta-analysis

PURPOSE

ERAS is a holistic and multidisciplinary pathway that incorporates various evidence-based interventions to accelerate recovery and improve clinical outcomes. However, evidence on cost benefit of ERAS in pancreaticoduodenectomy remains scarce. This review aimed to investigate cost benefit, compliance, and clinical benefits of ERAS in pancreaticoduodenectomy.

METHODS

A comprehensive literature search was conducted on Medline, Embase, PubMed, CINAHL and the Cochrane library to identify studies conducted between 2000 and 2021, comparing effect of ERAS programmes and traditional care on hospital cost, length of stay (LOS), complications, delayed gastric emptying (DGE), readmission, reoperation, mortality, and compliance.

RESULTS

The search yielded 3 RCTs and 28 cohort studies. Hospital costs were significantly reduced in the ERAS group (SMD = - 1.41; CL, - 2.05 to - 0.77; P < 0.00001). LOS was shortened by 3.15 days (MD = - 3.15; CI, - 3.94 to - 2.36; P < 0.00001) in the ERAS group. Fewer patients in the ERAS group had complications (RR = 0.83; CI, 0.76-0.91; P < 0.0001). Incidences of DGE significantly decreased in the ERAS group (RR = 0.72; CI, 0.55-0.94; P = 0.01). The number of deaths was fewer in the ERAS group (RR = 0.76; CI, 0.58-1.00; P = 0.05).

CONCLUSION

This review demonstrated that ERAS is safe and feasible in pancreaticoduodenectomy, improves clinical outcome such as LOS, complications, DGE and mortality rates, without changing readmissions and reoperations, while delivering significant cost savings. Higher compliance is associated with better clinical outcomes, especially LOS and complications.

Impact of enhanced recovery protocols after pancreatoduodenectomy: meta-analysis

BACKGROUND

This individual-patient data meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared with conventional care on postoperative outcomes in patients undergoing pancreatoduodenectomy.

METHODS

The Cochrane Library, MEDLINE, Embase, Scopus, and Web of Science were searched systematically for articles reporting outcomes of ERAS after pancreatoduodenectomy published up to August 2020. Comparative studies were included. Main outcomes were postoperative functional recovery elements, postoperative morbidity, duration of hospital stay, and readmission.

RESULTS

Individual-patient data were obtained from 17 of 31 eligible studies comprising 3108 patients. Time to liquid (mean difference (MD) -3.23 (95 per cent c.i. -4.62 to -1.85) days; P < 0.001) and solid (-3.84 (-5.09 to -2.60) days; P < 0.001) intake, time to passage of first stool (MD -1.38 (-1.82 to -0.94) days; P < 0.001) and time to removal of the nasogastric tube (3.03 (-4.87 to -1.18) days; P = 0.001) were reduced with ERAS. ERAS was associated with lower overall morbidity (risk difference (RD) -0.04, 95 per cent c.i. -0.08 to -0.01; P = 0.015), less delayed gastric emptying (RD -0.11, -0.22 to -0.01; P = 0.039) and a shorter duration of hospital stay (MD -2.33 (-2.98 to -1.69) days; P < 0.001) without a higher readmission rate.

CONCLUSION

ERAS improved postoperative outcome after pancreatoduodenectomy. Implementation should be encouraged.

Impact of enhanced recovery after surgery protocol on pancreaticoduodenectomy: a meta-analysis of non-randomized and randomized controlled trials

BACKGROUND

Enhanced recovery after surgery (ERAS) has been widely applied in many surgical specialties. However, with respect to the impact of ERAS on pancreaticoduodenectomy (PD), there still exist some controversies.

METHODS

Literature search was performed in PubMed, Web of Science and the Cochrane Library from January, 1990 to July, 2019. A meta-analysis was performed using fixed-effects or random-effects models.

RESULTS

Twenty-two studies containing 4147 patients were identified. The entire pooled data showed that ERAS significantly reduced overall and minor morbidity (RR: 0.80, 95% CI: 0.72-0.88, p < 0.001; RR: 0.78, 95% CI: 0.69-0.88, p < 0.001, respectively), but didn't affect major morbidity (RR: 0.97, 95% CI: 0.84-1.13, p = 0.72). ERAS markedly reduced the incidences of delayed gastric emptying (DGE) (RR: 0.69, 95% CI: 0.55-0.88, p = 0.002), incisional infection (RR: 0.75, 95% CI: 0.60-0.94, p = 0.01) and intra-abdominal infection (RR: 0.79, 95% CI: 0.63-1.00, p = 0.05), but didn't influence clinically-relevant postoperative pancreatic fistula (CR-POPF) (RR: 0.86, 95% CI: 0.73-1.01, p = 0.07). Shorter length of stay (LOS) (WMD: -5.07, 95% CI: -6.71 to -3.43, p < 0.001) was noted in ERAS group, without increasing 30-day readmission (RR: 1.03, 95% CI: 0.86-1.24, p = 0.71) and mortality (RR: 0.70, 95% CI: 0.41-1.21, p = 0.20).

CONCLUSION

ERAS significantly reduced overall and minor morbidity, incidences of DGE, incisional and intra-abdominal infections, and shortened LOS in PD, without increasing 30-day readmission and mortality. However, more large-scale randomized controlled trials are still needed to confirm the findings.

The Safety and Feasibility of Enhanced Recovery after Surgery in Patients Undergoing Pancreaticoduodenectomy: An Updated Meta-Analysis

Background

Enhanced recovery after surgery (ERAS) is a multimodal, multidisciplinary, evidence-based approach to care for surgical patients and aims at optimizing the perioperative management and outcomes. The ERAS approach was first implemented in colorectal surgery patients; however, the reported applications in pancreatoduodenectomy patients are limited. In recent years, studies on ERAS for patients undergoing pancreaticoduodenectomy have been published. The accumulation of new randomized controlled trials and high-quality case-control studies stimulated us to update the analysis. Our study comprehensively collected data to provide the best evidence summary for the clinic.

Aim

To evaluate the safety and feasibility of enhanced recovery after surgery in the perioperative management of pancreatoduodenectomy patients.

Methods

A systematic literature search of PubMed, Embase, and the Cochrane Library was performed up to July 2019. All randomized controlled trials and case-control studies that applied ERAS for patients undergoing pancreaticoduodenectomy were considered for inclusion in this study. The patients were divided into two groups: patients who received the ERAS perioperative management approach were defined as the ERAS group and patients who received the traditional perioperative management approach were defined as the control group. All statistical analyses were conducted using the Revman5.3 software, and the outcomes were calculated as odds ratios or weighted mean differences with their corresponding 95% confidence intervals. A funnel plot was created to assess publication bias. Subgroup and sensitivity analyses were performed to explore the sources of heterogeneity.

Results

A total of 20 studies involving 3613 patients (1914 patients in the ERAS group vs. 1699 patients in the control group) were included in this study. Among the 20 studies, 4 were randomized controlled trials, and 16 were case-control studies. The overall postoperative complication rate was significantly lower in the ERAS group (OR = 0.62, 95% CI: 0.53-0.74, P < 0.00001) than in the control group. In addition, the minor complication rate (Clavien-Dindo I-II) was also lower in the ERAS group (OR = 0.70, 95% CI: 0.58-0.86, P = 0.0005). The patients in the ERAS group had a lower incidence of delayed gastric emptying (OR = 0.51, 95% CI: 0.42-0.63, P < 0.00001) and shorter length of hospital stay (WMD = -4.27, 95% CI: -4.81~-3.73, P < 0.00001) than in the control group. The rates of pancreatic fistula (regardless of Grade A/B/C), wound infections, abdominal abscesses, readmission, reoperation, and morbidity were not significantly different between the two groups.

Conclusion

The ERAS approach is safe and effective in the perioperative management of patients undergoing pancreaticoduodenectomy and helps to accelerate the postoperative recovery and improve prognosis.

Enhanced recovery care versus traditional care following laminoplasty: A retrospective case-cohort study

Enhanced recovery after surgery (ERAS) has been shown to shorten length of hospital stay and reduce perioperative complications in many types of surgeries. However, there has been a paucity of research examining the application of ERAS to major spinal surgery. The current study was performed to compare complications and hospital stay after laminoplasty between an ERAS group and a traditional care group.The ERAS group included 114 patients who underwent laminoplasty managed with an ERAS protocol between January 2016 and June 2017. The traditional care group included 110 patients, who received traditional perioperative care between November 2014 and December 2015. Postoperative hospital stay (POPH), physiological function, postoperative visual analogue scale (VAS) pain score, and postoperative complications were compared between the 2 groups.The mean POPH was significantly shorter in the ERAS group than traditional care group (5.75 ± 2.46 vs. 7.67 ± 3.45 d, P < .001). ERAS protocol significantly promoted postoperative early food-taking (8.45 ± 2.94 h vs 21.64 ± 2.66 h, P < .001), reduced the first time of assisted walking (30.79 ± 14.45 vs. 65.24 ± 25.34 h, P < .001), postoperative time of indwelling urinary catheters (24.76 ± 12.34 vs. 53.61 ± 18.16 h, P < .001), and wound drainage catheters (43.92 ± 7.14 vs. 48.85 ± 10.10 h, P < .001), as compared with the traditional care group. Pain control was better in the ERAS group than traditional care group in terms of mean VAS score (2.72 ± 0.46 vs. 3.35 ± 0.46, P < .001) and mean maximum VAS score (3.76 ± 1.12 vs. 4.35 ± 1.15, P < .001) in 3 days after surgery. The morbidity rate was 21.05% (24 of 114 patients) in the ERAS group and 20.90% (23 of 110 patients) in the control group (P = .75).The ERAS protocol is both safe and feasible for patients undergoing laminoplasty, and can decrease the length of postoperative hospitalization without increasing the risk of complications.