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ENHANCED RECOVERY PATHWAYS FOR PANCREATODUODENECTOMY MAY NOT PROVIDE SIMILAR BENEFITS TO OTHER OPERATIONS
Victor Perim
*, Annabelle L. Fonseca, Vikas Dudeja, Martin Heslin, Daniel I. Chu, John Bart B. Rose, Sushanth Reddy
Department of Surgery, University of Alabama at Birmingham (UAB), Birmingham, AL
INTRODUCTION: Enhanced Recovery Pathways (ERPs) have demonstrated improved postoperative outcomes across various surgical populations. However, the impact of ERP on patients undergoing complex hepatopancreatobiliary (HPB) resections remains a topic of debate, largely due to limited data on the outcomes of modern ERP approaches. Thus, this study aims to assess the impact of ERP implementation on patients undergoing pancreatoduodenectomies (PD) at a major academic center in the deep south of the United States.
METHODS: Patients undergoing PD at a tertiary center were prospectively followed from 2013 to 2023. An institutional ERP protocol was introduced in 2018, dividing cases into ERP (2019–2023) and pre-ERP (2013–2017) based on the surgery date. The year 2018, considered a transition period, was excluded from the analysis.
RESULTS: A total of 458 patients who underwent pancreatoduodenectomy (PD) were analyzed, with 178 in the ERP group and 280 in the pre-ERP group. The groups were comparable in age (66 [57–71] vs. 65 [57–72] years; p = 0.7), BMI (27.1 [24.4–31.3] vs. 27.9 [23.4–31.6]; p = 0.9), median income ($61,887 [50,707–82,188] vs. ($67,664 [48,968–88,747]; p = 0.4), and distance from the hospital (79 [45–116] vs. 86 [48–147] miles; p = 0.12). However, the ERP group had a higher proportion of African American patients (26% vs. 20%; p = 0.003) and use of neoadjuvant therapy (39% vs. 0%; p < 0.001). Clinically, ERP patients were more complex, with higher proportions of ASA III/IV status (96.4% vs. 97.9%; p = 0.009), malignant diagnoses (83% vs. 45%; p < 0.001) and heart failure (2.8% vs. 0.4%; p = 0.035). ERP implementation was associated with a reduced median length of stay (LOS) (8 [7–13] vs. 6 [5–9] days; p < 0.001) while maintaining comparable mortality (2.4% vs. 2.5%; p > 0.9) and 30-day reoperation (7.9% vs. 7.1%; p = 0.8) rates between the groups. However, ERP was also associated with higher rates of 30-day readmission (26 vs. 19%; p = 0.047), postoperative complications (49% vs. 40%; p = 0.047), and acute kidney injury (AKI) (12% vs. 0.7%; p < 0.001). In the multivariable analysis, the use of ERP was significantly associated with a reduced LOS (? = -0.16, p < 0.001). Conversely, having a malignant diagnosis (? = 0.8, p < 0.001), higher creatinine levels (? = 0.21, p = 0.003), and the occurrence of postoperative complications (? = 0.37, p < 0.001) were all linked to an increased LOS.
CONCLUSIONS: ERP implementation for PD is associated with a reduced early LOS but also linked to higher rates of 30-day readmissions, postoperative complications, AKI. The overall benefit of ERP in this patient population remains uncertain. Future research should focus on evaluating individual ERP components and their specific impact on the HPB population.
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