ASSOCIATIONS BETWEEN PATIENT CHARACTERISTICS AND WHIPPLE PROCEDURE OUTCOMES BEFORE AND AFTER IMPLEMENTATION OF AN ENHANCED RECOVERY AFTER SURGERY PROTOCOL
Anna S. Koerner*1, Alexander S. Thomas2, John A. Chabot2, Michael D. Kluger2, Kazuki Sugahara2, Beth Schrope2
1Columbia University Vagelos College of Physicians and Surgeons, New York, NY; 2Columbia University Irving Medical Center, New York, NY
Background: The Enhanced Recovery After Surgery (ERAS) protocol is a multimodal perioperative care bundle that has been shown to improve pancreatic surgery outcomes. Prior work has suggested ERAS can reduce length of stay (LOS) without increasing readmission risk. This work evaluates whether a Whipple ERAS protocol can be implemented at a quaternary care center without increasing complication, mortality, or readmission rates. We also aimed to assess if patient characteristics, especially insurance status (proxy for socioeconomic status), are associated with disparities in outcomes in patients undergoing a Whipple ERAS protocol.
Methods: A retrospective review identified demographic and clinical data for 458 patients undergoing Whipple operations at a single institution from October 2017 to May 2022. ERAS was implemented at this institution on October 1, 2019. All patients undergoing Whipple operations were managed with an ERAS protocol after this date. Patients were split into two cohorts: pre-ERAS (treated before implementation) and post-ERAS (treated after). Outcomes included LOS, 30-day readmission and mortality rates, and rate of major complications. Chi-square and Mann-Whitney U tests were performed to assess for differences in group composition and outcomes between cohorts. Univariate analyses and multiple regressions were performed to assess for associations between patient characteristics and outcomes. P-values <0.05 were considered significant.
Results: 213 patients underwent Whipple operations prior to ERAS implementation and 245 were managed with an ERAS protocol. More post-ERAS patients had a BMI >30 (15.5% vs. 8.0%; p=0.01) and received neoadjuvant chemotherapy (15.5% vs. 4.2%; p<0.001). Patients treated post-ERAS had a higher rate of major complications (57.6% vs. 37.6%; p<0.001). LOS and 30-day mortality and readmission rates were not different between the two cohorts (all p>0.2). A univariate analysis found that Medicaid patients did not have significantly higher rates of major complications or 8-day or longer LOS compared to non-Medicaid patients (both p>0.7). Multiple regression found that no factors predicted major complications in the pre-ERAS cohort (all p>0.1). Presence of a soft pancreas was independently associated with a higher rate of major complications (OR=2.06, 95% CI:1.09-3.92) in the post-ERAS cohort.
Conclusion: Our data indicate that a Whipple ERAS protocol did not significantly shorten LOS, increase re-admissions, or impact 30-day mortality. Rate of overall complications did not significantly change after implementation, but rate of major complications increased. These outcomes were not significantly impacted by characteristics including race/ethnicity, gender, or insurance status. Further analysis is warranted to examine if other pre-operative factors, like cancer staging, account for increased major complications.
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