Readmission following pancreatectomy: what can be improved?

Discharge C-reactive protein predicts 90-day readmission after pancreatoduodenectomy: a conditional inference tree analysis

BACKGROUND

The aim of this study was to assess the predictive value of discharge C-reactive protein (CRP) and white blood cell (WBC) levels for 90-day readmission after pancreatoduodenectomy (PD).

METHODS

A two-centre, retrospective study was performed between 2008 and 2022. Receiver operating characteristic (ROC) curve analysis was used to determine the predictive value of CRP level and WBC count at discharge. A conditional inference tree (CTREE) was constructed to identify combined risks within subgroups using variables associated with readmission.

RESULTS

Of 438 patients, 54 (12%) were readmitted. The median WBC count at discharge was comparable between the readmitted and not readmitted groups (9.1 vs. 8.5 G/l). The CRP levels at discharge were predictive of 90-day readmission, with an area under the ROC curve (AUC) of 0.63 (95% CI: 0.55-0.63). A CRP concentration below 105 mg/l ruled out 90-day readmission, with a negative predictive value (NPV) of 90% (95% CI: 81%-95%). CTREE confirmed the diagnostic value of CRP at discharge (AUC = 0.68, 95% CI 0.60-0.68). CTREE additionally identified previous wound infection as a second risk factor for readmission in patients with CRP levels less than 101 mg/l (P = 0.003).

CONCLUSION

CRP levels below 105 mg/l at discharge allow for a safe discharge with a low 90-day readmission rate. Wound infection, but not WBC count, was a positive predictor of 90-day readmission with moderate accuracy, suggesting the need for predischarge imaging for undetected complications in this patient cohort.

TRIAL REGISTRATION

Our retrospective analysis did not require registration with a publicly accessible registry.

Classification of Post-pancreatectomy Readmissions and Opportunities for Targeted Mitigation Strategies

OBJECTIVE

Within a learning health system paradigm, this study sought to evaluate reasons for readmission to identify opportunities for improvement.

BACKGROUND

Post-pancreatectomy readmission rates have remained constant despite improved index hospitalization metrics.

METHODS

We performed a single-institution case-control study of consecutive patients with pancreatectomy (October 2016 to April 2022). Complications were prospectively graded in biweekly faculty and advanced practice provider meetings. We analyzed risk factors during index hospitalization and categorized indications for 90-day readmissions.

RESULTS

A total of 835 patients, median age 65 years and 51% (427/835) males, underwent 64% (534/835) pancreatoduodenectomies, 34% (280/835) distal pancreatectomies, and 3% (21/835) other resections. Twenty-four percent (204/835) of patients were readmitted. The primary indication for readmission was technical in 51% (105/204), infectious in 17% (35/204), and medical/metabolic in 31% (64/204) of patients. Procedures were required in 77% (81/105) and 60% (21/35) of technical and infectious readmissions, respectively, while 66% (42/64) of medical/metabolic readmissions were managed noninvasively. During the index hospitalization, benign pathology [odds ratio (OR): 1.8, P =0.049], biochemical pancreatic leak (OR: 2.3, P =0.001), bile/gastric/chyle leak (OR: 6.4, P =0.001), organ-space infection (OR: 3.4, P =0.007), undrained fluid on imaging (OR: 2.4, P =0.045), and increasing white blood cell count (OR: 1.7, P =0.045) were independently associated with odds of readmission.

CONCLUSIONS

Most readmissions following pancreatectomy were technical in origin. Patients with complications during the index hospitalization, increasing white blood cell count, or undrained fluid before discharge were at the highest risk for readmission. Predischarge risk stratification of readmission risk factors and augmentation of in-clinic resources may be strategies to reduce readmission rates.

The Implications of Readmission on Cost and Patient Outcomes Following Distal Pancreatectomy and Splenectomy

BACKGROUND

Robotic platform usage for distal pancreatectomy and splenectomy has grown exponentially in recent years. This study aims to identify the impact of readmission following robotic distal pancreatectomy and splenectomy and to analyze the financial implications of these readmissions.

METHODS

We prospectively followed 137 patients after robotic distal pancreatectomy and splenectomy. Readmission was defined as rehospitalization within 30 days post-discharge. Total cost incorporated initial and readmission hospital costs, when applicable. Outcomes were analyzed using chi-square/Fisher's exact test and Student's t test. Data are presented as median (mean ± SD).

RESULTS

Of 137 patients, 20 (14%) were readmitted. Readmitted patients were 67 (66 ± 10.3) years old and had a BMI of 30 (30 ± 7.0) kg/m2; 9 (45%) had previous abdominal operations. Non-readmitted patients were 67 (62 ± 14.7) years old and had a BMI of 28 (28 ± 5.7) kg/m2; 37 (32%) had previous abdominal operations (P = NS, for all). Readmitted patients vs non-readmitted patients had operative durations of 327 (363 ± 179.1) vs 251 (293 ± 176.4) minutes (P = .10), estimated blood loss (EBL) of 90 (159 ± 214.6) vs 100 (244 ± 559.4) mL (P = .50), and tumor diameter of 3 (4 ± 2.0) vs 3 (4 ± 2.9) cm (P = 1.00). Initial length of stay (LOS) for readmitted patients vs patients who were not readmitted was 5 (5 ± 2.7) vs 4 (5 ± 3.0) days (P = 1.00); total hospital cost of those readmitted, including both admissions, was $29,095 (32,324 ± 20,227.38) vs $24,663 (25,075 ± 10,786.45) (P = .018) for those not readmitted.

DISCUSSION

Despite a similar perioperative course, readmissions were associated with increased costs. We propose thorough consideration before readmission and increased patient education initiatives will reduce readmissions after robotic distal pancreatectomy and splenectomy.

Use of Perioperative Advanced Practice Providers to Reduce Cost and Readmission in the Postoperative Hepatopancreatobiliary Population: Results of a Simulation Study

BACKGROUND

Postoperative healthcare use and readmissions are common among the hepatopancreatobiliary (HPB) population. We evaluated the surgical volume required to sustain advanced practice providers (APPs) in the perioperative setting for cost reduction.

STUDY DESIGN

Using decision analysis modeling, we evaluated costs of employing dedicated perioperative APP navigators compared with no APPs navigators. Simulated subjects could: (1) present to an emergency department, with or without readmission, (2) present for direct readmission, (3) require additional office visits, or (4) require no additional care. We informed our model using the most current available published data and performed sensitivity analyses to evaluate thresholds under which dedicated perioperative APP navigators are beneficial.

RESULTS

Subjects within the APP navigator cohort accumulated $1,270 and a readmission rate of 6.9%, compared with $2,170 and 13.5% with no APP navigators, yielding a cost savings of $905 and 48% relative reduction in readmission. Based on these estimated cost savings and national salary ranges, a perioperative APPs become financially self-sustaining with 113 to 139 annual HPB cases, equating to 2 to 3 HPB cases weekly. Sensitivity analyses revealed that perioperative APP navigators were no longer cost saving when direct readmission rates exceeded 8.9% (base case 3.7%).

CONCLUSIONS

We show that readmissions are reduced by nearly 50% with an associated cost savings of $900 when employing dedicated perioperative APPs. This position becomes financially self-sufficient with an annual HPB case load of 113 to 139 cases. High-volume HPB centers could benefit from postdischarge APP navigators to optimize outcomes, minimize high-value resource use, and ultimately save costs.

Disparate potential for readmission prevention exists among inpatient and outpatient procedures in a minimally invasive surgery practice

BACKGROUND

Administrators have focused on decreasing postoperative readmissions for cost reduction without fully understanding their preventability. This study describes the development and implementation of a surgeon-led readmission review process that assessed preventability.

METHODS

A gastrointestinal surgical group at a tertiary referral hospital developed and implemented a template to analyze inpatient and outpatient readmissions. Monthly stakeholder assessments reviewed and categorized readmissions as potentially preventable or not preventable. Continuous variables were examined by the Student's t test and reported as means and standard deviations. Categorical variables were examined by the Pearson χ2 statistic and Fisher's exact test.

RESULTS

There were 61 readmission events after 849 inpatient operations (7.2%) and 16 after 856 outpatient operations (1.9%), the latter of which were all classified as potentially preventable. Colorectal procedures represented 65.6% of readmissions despite being only 37.2% of all cases. The majority (67.2%) of readmission events were not preventable. Compared to the not-preventable group, the potentially preventable group experienced more dehydration (30.0% vs 9.8%, P = .045) and ileostomy creation (78.6% vs 33.3%, P = .017). The potential for outpatient management to prevent readmission was significantly higher in the potentially preventable group (40.0% vs 0.0%, P < .001), as was premature discharge prevention (35.0% vs 0.0%, P < .001).

CONCLUSION

The use of the standardized template developed for analyzing readmission events after inpatient and outpatient procedures identified a disparate potential for readmission prevention. This finding suggests that a singular focus on readmission reduction is misguided, with further work needed to evaluate and implement appropriate quality-based strategies.

Reducing unplanned general surgical readmissions: a review of the Australian and New Zealand National Surgical Quality Improvement Program Database

BACKGROUND

Unplanned surgical readmissions are an important indicator of quality care and are a key focus of improvement programs. The aims of this study were to evaluate the factors that lead to unplanned hospital readmissions in patients undergoing general surgical procedures and to identify preventable readmissions.

METHODS

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database from 2016 to 2020 at a tertiary hospital was conducted to identify patients undergoing a general surgical procedure. Various perioperative parameters were studied to identify risk factors and reasons for unplanned readmission. Preventable readmissions were identified.

RESULTS

A total of 3069 patients underwent a general surgical procedure. Of these, the overall unplanned readmission rate was 8.8% (n = 247). The most common reason for readmission was associated with surgical site infections (n = 112, 44.3%) followed by pain (n = 50, 20.2%), with over 45% deemed as preventable readmissions. Factors associated with increased risk of readmission included older age, longer index length of stay, prolonged operative time, elective procedures, higher ASA score and contaminated procedures.

CONCLUSION

Unplanned readmissions are more likely to occur in patients who develop postoperative complications. Understanding factors associated with readmissions may facilitate targeted quality improvement projects that reduce hospital readmission after surgery.

Hepatopancreatobiliary readmission score out performs administrative LACE+ index as a predictive tool of readmission

BACKGROUND

This study aims to compare the LACE + readmission index to a novel hepatopancreatobiliary readmission risk score (HRRS) in predicting post-operative hepatopancreatobiliary (HPB) cancer patient readmissions.

METHODS

A retrospective review of 104 postoperative HPB cancer patients from January 2017 to July of 2019 was performed. Univariable and multivariable analyses were utilized.

RESULTS

The LACE + index did not predict 30-day (OR 1.01, 95% CI, 0.97-1.05, p = 0.81, c-statistic = 0.52) or 90-day (OR 1.02, 95% CI, 0.98-1.05, p = 0.43) readmission. Patients readmitted within 30 days had significantly increased HRRS scores compared to those who were not (0 vs 34, p < 0.001). A single unit increase in HRRS corresponded to a 6.5% increased risk of readmission; (OR 1.065, 95% CI, 1.038-1.094, p < 0.0001). HRRS independently predicted 30-day (OR 1.07, 95% CI, 1.04-1.11, p < 0.0001) and 90-day postoperative readmission (OR 1.05, 95% CI 1.03-1.08, p < 0.0001).

CONCLUSIONS

HRRS better predicts postoperative readmissions for HPB surgical patients compared to LACE+. Accurate assessment of postoperative readmission must include readmission scores focused on clinically relevant perioperative parameters.

Risk Factors Associated With Readmission After Pancreatectomy: A Single-Institution Retrospective Cohort Study

BACKGROUND

Pancreatectomy has a significant rate of procedure-specific morbidity which can result in readmission. Readmission has been proposed as a measure of quality. The goal of this study is to determine what factors are associated with readmission after pancreatectomy and whether readmission can be prevented.

METHODS

A retrospective review of a single institution's pancreatectomies between January 2011 and April 2015 was performed. Demographic, perioperative, and outpatient data were collected from the medical record. Primary outcome was 90-day readmission. Univariate and multivariable analyses were performed to determine which factors were associated with increased risk for readmission.

RESULTS

A total of 257 patients met inclusion criteria; the 90-day readmission rate was 32.7%. The median time to readmission was 13 days. Readmitted patients were more likely to have a postoperative pancreatic fistula (POPF) on univariate analysis. Surgical site infections were more common in readmitted patients (18% vs 6.4%, P = .0138). Upon multivariable adjustment, only POPF (P = .0005) remained significant. A positive dose-response relationship was noted between POPF grade and the odds of readmission with odds ratios (ORs) ranging from 1.6 (95% Confidence Interval (CI): .6-4.1) for grade A to 16.7 (95% CI: 1.8-156.8) for grade C, albeit with limited precision.

CONCLUSIONS

Readmission after pancreatectomy is a common occurrence despite the many advancements in perioperative care. Our data suggest that POPF is a risk factor for readmission after pancreatectomy. Presently, this factor is not clearly preventable. This suggests that readmission may not be the best measure of quality to utilize in the evaluation of pancreatic surgery.

Factors affecting readmission rates after pancreatectomy

BACKGROUND

Pancreatectomy is a complex operation with a historic readmission rate of approximately 20%. Hospital readmissions lead to increased patient and health system costs, morbidity, and mortality making them a topic of great interest. The objective of this study was to identify factors associated with readmission after pancreatectomy in order to target areas for improvement.

METHODS

Pancreatectomy procedures for malignancy in adults from 2005 to 2011 were identified in the California State Inpatient Database. Descriptive analysis was conducted to evaluate the association between baseline variables and readmission status. Logistic regression models were developed to determine whether the bivariate associations identified persisted after adjusting for patient characteristics.

RESULTS

Of the 4262 patients who underwent a pancreatectomy, 843 (19.8%) were readmitted within 30 days. Readmission rates by year did not vary over the study period. Results from multivariable analysis showed that males, Hispanics, Medicare recipients, patients with an initial length of stay >11 days, patients who were discharged to a skilled nursing facility, and those with chronic anemia were more likely to be readmitted compared to those without these characteristics. The majority of readmissions occurred within 15 days after discharge.

CONCLUSIONS

Readmissions after pancreatectomy are multifactorial. Preoperative optimization, minimizing postoperative complications, and assuring patients have been evaluated by a multidisciplinary team may reduce the readmission rate.

Towards a patient journey perspective on causes of unplanned readmissions using a classification framework: results of a systematic review with narrative synthesis

BACKGROUND

Several literature reviews have been published focusing on the prevalence and/or preventability of hospital readmissions. To our knowledge, none focused on the different causes which have been used to evaluate the preventability of readmissions. Insight into the range of causes is crucial to understand the complex nature of readmissions. We conducted a systematic review to: (1) evaluate the range of causes of unplanned readmissions in a patient journey, and (2) present a cause classification framework that can support future readmission studies.

METHODS

A literature search was conducted in PUBMED and EMBASE using "readmission" and "avoidability" or "preventability" as key terms. Studies that specified causes of unplanned readmissions were included. The causes were classified into eight preliminary root causes: Technical, Organization (integrated care), Organization (hospital department level), Human (care provider), Human (informal caregiver), Patient (self-management), Patient (disease), and Other. The root causes were based on expert opinions and the root cause analysis tool of PRISMA (Prevention and Recovery Information System for Monitoring and Analysis). The range of different causes were analyzed using Microsoft Excel.

RESULTS

Forty-five studies that reported 381 causes of readmissions were included. All studies reported causes related to organization of care at the hospital department level. These causes were often reported as preventable. Twenty-two studies included causes related to patient's self-management and 19 studies reported causes related to patient's disease. Studies differed in which causes were seen as preventable or unpreventable. None reported causes related to technical failures and causes due to integrated care issues were reported in 18 studies.

CONCLUSIONS

This review showed that causes for readmissions were mainly evaluated from a hospital perspective. However, causes beyond the scope of the hospital can also play a major role in unplanned readmissions. Opinions regarding preventability seem to depend on contextual factors of the readmission. This study presents a cause classification framework that could help future readmission studies to gain insight into a broad range of causes for readmissions in a patient journey.

Travel distance affects rates and reasons for inpatient visits after pancreatectomy

BACKGROUND

Centralization of complex surgical care leads to increased travel distances for patients. We sought to determine if increased travel distance to the index hospital altered inpatient Visit rates following pancreatectomy.

METHODS

Pancreatectomies from 2013-2016 were reviewed retrospectively from a single high-volume institution. Travel distance for 936 patients was determined, and patients were grouped by 50-mile increments. Visits (Observations or Readmissions) and corresponding reasons were gathered.

RESULTS

222 patients (23.7%) had a Visit to any hospital (AH) within 90 days postoperative; 195 (87.8%) were to the index hospital (IH). The <50 miles group had the highest Visit rate to AH (28.6% vs. 17.8% vs. 24.6%; P = 0.008) and the IH (26.9% vs. 15.2% vs. 20.6%; P = 0.002) compared to 50-100 and > 100 miles. This trend was statistically significant for Observations, but not Readmissions. Gastrointestinal (GI) complaints alone led to 20.7% patients requiring Visits to AH at 90-days, mostly in <50miles group for Visits and Observations at AH and IH.

CONCLUSIONS

Patients closest to the IH had the highest Visit and Observation rate following pancreatectomy without affecting Readmission rate, with GI complaints as a driving factor. Inpatient education and outpatient symptom management may reduce repeat hospitalization.

How do studies assess the preventability of readmissions? A systematic review with narrative synthesis

Background

A large number of articles examined the preventability rate of readmissions, but comparison and interpretability of these preventability rates is complicated due to the large heterogeneity of methods that were used.

To compare (the implications of) the different methods used to assess the preventability of readmissions by means of medical record review.

Methods

A literature search was conducted in PUBMED and EMBASE using “readmission” and “avoidability” or “preventability” as key terms. A consensus-based narrative data synthesis was performed to compare and discuss the different methods.

Results

Abstracts of 2504 unique citations were screened resulting in 48 full text articles which were included in the final analysis. Synthesis led to the identification of a set of important variables on which the studies differed considerably (type of readmissions, sources of information, definition of preventability, cause classification and reviewer process). In 69% of the studies the cause classification and preventability assessment were integrated; meaning specific causes were predefined as preventable or not preventable. The reviewers were most often medical specialist (67%), and 27% of the studies added interview as a source of information.

Conclusion

A consensus-based standardised approach to assess preventability of readmission is warranted to reduce the unwanted bias in preventability rates. Patient-related and integrated care related factors are potentially underreported in readmission studies.

Electronic supplementary material

The online version of this article (10.1186/s12874-019-0766-0) contains supplementary material, which is available to authorized users.

Investigating Transitional Care to Decrease Post-pancreatectomy 30-Day Hospital Readmissions for Dehydration or Failure to Thrive

BACKGROUND

Current literature emphasizes post-operative complications as a leading cause of post-pancreatectomy readmissions. Transitional care factors associated with potentially preventable conditions such as dehydration and failure to thrive (FTT) may play a significant role in readmission after pancreatectomy and have not been studied.

METHODS

Thirty-one post-pancreatectomy patients, who were readmitted for dehydration or FTT between 2009 and 2014, were compared to 141 nonreadmitted patients. Medical record review and a questionnaire-based survey, specifically designed to assess transitional care, were used to identify predictors of readmissions for dehydration or FTT. Logistic regression models were used to evaluate outcomes.

RESULTS

On multivariable analysis, the strongest predictors of readmission for dehydration and FTT were the patient's lower educational level (P = 0.0233), the absence of family during the delivery of discharge instructions (P = 0.0098), episodic intermittent nausea at discharge (P = 0.0019), uncertainty about quantity, quality, or frequency of fluid intake (P = 0.0137), and the inability or failure to adhere to the clinician's instructions in the outpatient setting (P = 0.0048).

CONCLUSION

Transitional-care-related factors are found to be associated with post-pancreatectomy readmission for dehydration and FTT. Using these results to identify high-risk patients and implement focused preventive measures combining efficient communication and optimal inpatient and outpatient management could potentially decrease readmission rates.

After Pancreatectomy, the “90 Days from Surgery” Definition Is Superior to the “30 Days from Discharge” Definition for Capture of Clinically Relevant Readmissions

BACKGROUND

Previous studies by different authors have reported their readmission rates after pancreatectomy as either “30 days from discharge” or “90 days from surgery.” The objective of this study was to determine which of these definitions captures the most surgery-related complications.

METHODS

A prospectively maintained database at a high volume center was queried to identify all individuals who underwent pancreatectomy between 2000 and 2012 for any diagnosis. The data was analyzed at 30 days after discharge and 90 days after operation. The optimal timing for complication reporting was defined as the time point that maximized the capture of surgery-related readmissions and direct major surgical complications while minimizing the capture of disease (cancer)-related readmissions.

RESULTS

There were 1123 patients included during the study time period. The median age was 63 years old, and 55.6% were male. Operations included 833 (74.2%) pancreaticoduodenectomies, 257 (22.9%) distal pancreatectomies, 18 (1.6%) total pancreatectomies, and 15 (1.3%) central pancreatectomies. Surgery-related readmissions occurred in 248 (22%) individuals, while readmission related to malignant disease progression occurred in 25 (2%) individuals. The 30 days from discharge definition captured 184 surgery-related readmissions and 1 disease-related readmission (sensitivity 0.74, specificity 0.96). The 90 days from surgery definition captured 215 surgery-related readmissions and 1 disease-related readmission (sensitivity 0.87, specificity 0.96). Major surgical complication was the only independent factor associated with readmission not captured by the 30 days from discharge definition (p = 0.002, HR 3.94, 95% CI 1.44–12.22).

CONCLUSION

The 90 days from surgery definition was superior to the 30 days from discharge definition, especially with regards to readmission related to major surgical complications.

Cost-Effectiveness Analysis in Cancer Care

With the increasing complexity of modern medical therapies, it is becoming imperative to recognize the marginal cost and gains of increasingly sophisticated (and expensive) interventions. By understanding the incremental cost of a given intervention, investigators must help answer questions about healthcare resource utilization that are not answered by randomized clinical trials. The continued funding of biomedical research and pharmaceuticals will require more objective study of the return on investment for any given treatment modality, and cost-effectiveness analyses will be instrumental in providing solutions to the inequalities in healthcare delivery.

Nomogram to Predict Postoperative Readmission in Patients Who Undergo General Surgery

IMPORTANCE

The Centers for Medicare and Medicaid Services have implemented penalties for hospitals with above-average readmission rates under the Hospital Readmissions Reductions Program. These changes will likely be extended to affect postoperative readmissions in the future.

OBJECTIVES

To identify variables that place patients at risk for readmission, develop a predictive nomogram, and validate this nomogram.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective review and prospective validation of a predictive nomogram. A predictive nomogram was developed with the linear predictor method using the American College of Surgeons National Surgical Quality Improvement Program database paired with institutional billing data for patients who underwent nonemergent inpatient general surgery procedures. The nomogram was developed from August 1, 2006, through December 31, 2011, in 2799 patients and prospectively validated from November 1, 2013, through December 19, 2013, in 255 patients at a single academic institution. Area under the curve and positive and negative predictive values were calculated.

MAIN OUTCOMES AND MEASURES

The outcome of interest was readmission within 30 days of discharge following an index hospitalization for a surgical procedure.

RESULTS

Bleeding disorder (odds ratio, 2.549; 95% CI, 1.464-4.440), long operative time (odds ratio, 1.601; 95% CI, 1.186-2.160), in-hospital complications (odds ratio, 16.273; 95% CI, 12.028-22.016), dependent functional status, and the need for a higher level of care at discharge (odds ratio, 1.937; 95% CI, 1.176-3.190) were independently associated with readmission. The nomogram accurately predicted readmission (C statistic = 0.756) in a prospective evaluation. The negative predictive value was 97.9% in the prospective validation, while the positive predictive value was 11.1%.

CONCLUSIONS AND RELEVANCE

Development of an online calculator using this predictive model will allow us to identify patients who are at high risk for readmission at the time of discharge. Patients with increased risk may benefit from more intensive postoperative follow-up in the outpatient setting.

Enhanced recovery after pancreatic surgery: a systematic review of the evidence

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols have been shown to reduce hospital stay without compromising outcomes. Attempts to apply ERAS principles in the context of pancreatic surgery have generated encouraging results. A systematic review of the current evidence for ERAS following pancreatic surgery was conducted.

METHODS

A literature search of MEDLINE, CINAHL, EMBASE and the Cochrane Library was performed for articles describing postoperative clinical pathways in pancreatic surgery during the years 2000-2013. The keywords 'clinical pathway', 'critical pathway', 'fast-track', 'pancreas' and 'surgery' and their synonyms were used as search terms. Articles were selected for inclusion based on predefined criteria and ranked for quality. Details of the ERAS protocols and relevant outcomes were extracted and analysed.

RESULTS

Ten articles describing an ERAS protocol in pancreatic surgery were identified. The level of evidence was graded as low to moderate. No articles reported an adverse effect of an ERAS protocol for pancreatic surgery on perioperative morbidity or mortality. Length of stay (LoS) was decreased and readmission rates were found to be unchanged in six of seven studies that compared these outcomes.

CONCLUSIONS

Evidence indicates that ERAS protocols may be implemented in pancreatic surgery without compromising patient safety or increasing LoS. Enhanced recovery after surgery programmes in the context of pancreatic surgery should be standardized based upon the best available evidence, and trials of ERAS programmes involving multiple centres should be performed.

Feeding jejunostomy tube placement in patients undergoing pancreaticoduodenectomy: an ongoing dilemma

BACKGROUND

Concomitant placement of feeding jejunostomy tubes (FJT) during pancreaticoduodenectomy is common, yet there are limited data regarding catheter-specific morbidity and associated outcomes. This information is crucial to appropriately select patients for feeding tube placement and to optimize perioperative nutrition strategies.

METHODS

A review of all patients undergoing pancreaticoduodenectomy with FJT placement was completed. Patients were grouped by the occurrence of FJT-related morbidity. Multivariable logistic regression was performed to identify predictors of FJT morbidity; these complications were then further defined. Finally, associated postoperative outcomes were compared between groups.

RESULTS

In total, 126 patients were included, of which 18 (14 %) had complications directly related to their FJT, including pericatheter infection (n = 6), pneumatosis intestinalis (n = 4), severe tube feed intolerance (n = 3), and primary catheter malfunction (n = 7). Following adjustment with logistic regression, preoperative hypoalbuminemia was identified as the only independent predictor of FJT complications (OR 2.23, p = 0.035). Patients with FJT complications were more likely to be initiated on total parenteral nutrition (TPN; 55.6 vs. 7.4 %, p -0.035) and to require TPN at discharge (16.7 vs. 0%, p = 0.003). Correspondingly, these patients resumed an oral diet later (14 vs. 8 days, p = 0.06). Both reoperation (50.0 vs. 6.5%, p < 0.001) and readmission (50.0 vs. 22.4%, p = 0.041) rates were higher among patients with FJT complications.

CONCLUSIONS

FJT-related morbidity is common among patients undergoing pancreaticoduodenectomy and is associated with inferior outcomes and other performance metrics. Preoperative malnutrition appears to predict FJT complications, creating an ongoing dilemma regarding FJT placement. In the future, it will be important to better define criteria for FJT placement during pancreaticoduodenectomy.

A standardized care plan is associated with shorter hospital length of stay in patients undergoing pancreaticoduodenectomy

BACKGROUND

In this retrospective review, we evaluate a standardized care plan (SCP) for patients undergoing pancreaticoduodenectomy, which included selective placement of feeding jejunostomy tubes (FJTs) and a perioperative fast-track recovery pathway (FTRP).

METHODS

A review of 242 patients undergoing pancreaticoduodenectomy was completed. Patients treated pre- and post-SCP implementation were compared. Univariate comparison followed by multivariable linear regression were performed to identify predictors of hospital length of stay (HLOS).

RESULTS

SCP patients (n = 100) were slightly older but otherwise similar to pre-SCP patients (n = 142). FJT placement occurred less frequently in SCP patients (38 versus 94%, P < 0.001). All SCP patients were initiated on the FTRP. Among SCP patients, an oral diet was introduced earlier (5 versus 8.5 d, P < 0.001) and HLOS was shorter (11 versus 13 d, P = 0.015). Readmission rates were similar. Following adjustment with linear regression, we confirmed SCP status as a predictor of HLOS. To assess SCP components, HLOS was evaluated separately based on FTRP status and FJT placement. Although both were highly associated with HLOS, neither was independently predictive in multivariable analysis.

CONCLUSIONS

Implementation of an SCP resulted in shorter HLOS without an increase in readmissions. Future studies are necessary to identify specific components of SCPs that most influence outcomes.