Analysis of complications after Whipple's procedure using ERAS protocols
The administration of perioperative fluids is a controversial issue that can be associated with the development of postoperative pancreatic fistula (POPF) after Whipple procedure.
To evaluate whether intraoperative fluid management along with Enhanced Recovery after Surgery (ERAS) protocols affect outcomes following major pancreatic resection.
A retrospective cohort study was conducted from January 2012 to January 2017, collecting all patients scheduled for duodenopancreatectomy (DP). Patients were divided into 2 groups according to the use of ERAS protocols and the use of a fluid therapy algorithm.
A total of 67 patients were analyzed, 49.3% of which were females. The most frequent diagnoses were Pancreatic Cancer n:48 (71.6%), followed by intraductal papillary mucinous neoplasm n:6 (9%). The majority of patients were in the ERAS group n:46 (68.7%); 80.4% and 95.7% of them did not develop pancreatic fistula or delayed gastric emptying (DGE) respectively, and the incidence for both was 11.94%. Fluid therapy was below 5000 mL (P=0.001) with blood loss less 300 mL (P = 0.001) in the ERAS group. The length of stay was shorter in the ERAS group (7 days, interquartilel range 5-12, P < 0.001). No differences in 30 days mortality were found.
The implementation of ERAS protocols in DP did show a decrease in intraoperative blood loss, intravenous fluids therapy, need for transfusion, DGE, or total hospital stay. However, intraoperative fluid restriction in DP did not show a reduction in the development of POPF.
2. Ahmad SA, Edwards MJ, Sutton JM, et al. Factors influencing readmission after pancreaticoduodenectomy: a multi-institution-al study of 1302 patients. Ann Surg 2012;256:529-537.
3. Callery MP, Pratt WB, Kent TS, et al. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg 2013;216:1-14.
4. Lassen K, Coolsen MME, Slim K, et al. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery after Surgery (ERAS(r)) Society recommendations. World J Surg 2013;37: 240-258.
5. Sikora SS, Posner MC. Management of the pancreatic stump following pancreaticoduodenectomy. Br J Surg 1995;82: 1590-1597.
6. Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 2017; 161:584-591.
7. Wente MN, Bassi C, Dervenis C, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007;142:761-768.
11. Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology 2002;97:820-826.
12. Voldby AW, Brandstrup B. Fluid therapy in the perioperative setting-a clinical review. J Intensive Care 2016;4:27.
13. Mythen MG, Swart M, Acheson N, et al. Perioperative fluid management: consensus statement from the enhanced recovery partnership. Perioper Med (Lond) 2012;1:2.
14. Cannesson M, Ramsingh D, Rinehart J, et al. Perioperative goal-directed therapy and postoperative outcomes in patients under-going high-risk abdominal surgery: a historical-prospective, comparative effectiveness study. Crit Care 2015;19:261.
15. Navarro LHC, Bloomstone JA, Auler JOC, et al. Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioper Med (Lond) 2015;4:3.
16. Benes J, Giglio M, Brienza N, et al. The effects of goal-directed fluid therapy based on dynamic parameters on post-surgical outcome: a meta-analysis of randomized controlled trials. Crit Care 2014;18:584.
17. Visioni A, Shah R, Gabriel E, et al. Enhanced recovery after surgery for non-colorectal surgery?: a systematic review and meta-analysis of major abdominal surgery. Ann Surg 2018;267:57-65.
18. Scott MJ, Miller TE. Pathophysiology of major surgery and the role of enhanced recovery pathways and the anesthesiologist to improve outcomes. Anesthesiol Clin 2015;33:79-91.
19. Jones C, Kelliher L, Dickinson M, et al. Randomized clinical trial on enhanced recovery versus standard care following open liver resection: enhanced recovery following open liver resection. Br J Surg 2013;100:1015-1024.
20. Joliat GR, Labgaa I, Hübner M, et al. Cost-benefit analysis of the implementation of an enhanced recovery program in liver surgery. World J Surg 2016;40:2441-2450.
21. Han IW, Kim H, Heo J, et al. Excess intraoperative fluid volume administration is associated with pancreatic fistula after pancreaticoduodenectomy: a retrospective multicenter study. Medicine (Baltimore) 2017;96:e6893.
22. Pedrazzoli S. Pancreatoduodenectomy (PD) and postoperative pancreatic fistula (POPF): a systematic review and analysis of the POPF-related mortality rate in 60,739 patients retrieved from the English literature published between 1990 and 2015. Medicine (Baltimore) 2017;96:e6858.
23. Fischer M, Matsuo K, Gonen M, et al. Relationship between intraoperative fluid administration and perioperative outcome after pancreaticoduodenectomy: results of a prospective randomized trial of acute normovolemic hemodilution compared with standard intraoperative management. Ann Surg 2010;252:952-958.
24. Khalil JA, Mayo N, Dumitra S, et al. Pancreatic fistulae after a pancreatico-duodenectomy: are pancreatico-gastrostomies safer than pancreatico-jejunostomies? An expertise-based trial and propensity-score adjusted analysis. HPB (Oxford) 2014;16:1062-1067.
25. Chen BP, Chen M, Bennett S, et al. Systematic review and meta-analysis of restrictive perioperative fluid management in pancreaticoduodenectomy. World J Surg 2018;42:2938-2950.
26. Wang S, Wang X, Dai H, et al. The effect of intraoperative fluid volume administration on pancreatic fistulas after pancreaticoduodenectomy. J Invest Surg 2014;27:88-94.
27. Berger AC, Howard TJ, Kennedy EP, et al. Does type of pancreaticojejunostomy after pancreaticoduodenectomy de-crease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. J Am Coll Surg 2009;208:738-747.
28. Tran K, Van Eijck C, Di Carlo V, et al. Occlusion of the pancreatic duct versus pancreaticojejunostomy: a prospective randomized trial. Ann Surg 2002;236:422-428. discussion 428.
29. Z’graggen K, Uhl W, Friess H, et al. How to do a safe pancreatic anastomosis. J Hepatobiliary Pancreat Surg 2002;9:733-737.
30. Dong Z, Xu J, Wang Z, et al. Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev 2013;CD008914.
31. Yang SH, Dou KF, Sharma N, et al. The methods of reconstruction of pancreatic digestive continuity after pancreaticoduodenectomy: a meta-analysis of randomized controlled trials. World J Surg 2011;35:2290-2297.
32. Melis M, Marcon F, Masi A, et al. Effect of intra-operative fluid volume on peri-operative outcomes after pancreaticoduodenectomy for pancreatic adenocarcinoma: intra-operative fluids and pancreatectomy. J Surg Oncol 2012;105:81-84.