Enhanced Recovery After Pancreatic Surgery Does One Size Really Fit All? A Clinical Score to Predict the Failure of an E
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ORIGINAL SCIENTIFIC REPORT
Enhanced Recovery After Pancreatic Surgery Does One Size Really Fit All? A Clinical Score to Predict the Failure of an Enhanced Recovery Protocol After Pancreaticoduodenectomy Giovanni Capretti1,3 • Marco Cereda1,2 • Francesca Gavazzi1 • Fara Uccelli1 Cristina Ridolfi1 • Gennaro Nappo1 • Greta Donisi1 • Andrea Evangelista4 • Alessandro Zerbi1,3
•
Accepted: 28 June 2020 Ó The Author(s) 2020
Abstract Background The inability to comply with enhanced recovery protocols (ERp) after pancreaticoduodenectomy (PD) is a real but understated issue. Our goal is to report our experience and a potential tool to predict ERp failure in order to better characterize this problem. Methods From January 1, 2014, to January 31, 2016, 205 consecutive patients underwent PD in our center and were managed according to an ERp. Failure to comply with postoperative protocol items was defined as any of: no active ambulation on postoperative day 1 (POD1); less than 4 h out of bed on POD2; removal of nasogastric tube and bladder catheter after POD1 and POD3, respectively; reintroduction of oral feeding after POD4; and continuation of intravenous infusions after POD4. Data were collected in a prospective database. Results Taking in consideration the number of failed items and the length of stay, we defined failure of the ERp as no compliance to two or more items. A total of 116 patients (56.6%) met this definition of failure. We created a predictive model consisting of age, BMI, operative time, and pancreatic stump consistency. These variables were independent predictors of failure (OR 1.03 [1.001–1.06] p = 0.01; OR 1.11 [1.01–1.22] p = 0.03; OR 1.004 [1.001–1.009] p = 0.02 and OR 2.89 [1.48–5.67] p = 0.002, respectively). Patient final score predicted the failure of the ERp with an area under the ROC curve of 0.747. Conclusions It seems to be possible to predict ERp failure after PD. Patients at high risk of failure may benefit more from a specific ERp.
Introduction & Marco Cereda [email protected] 1
Pancreatic Surgery Unit, Humanitas Clinical and Research Center – IRCCS, via Manzoni 56, 20089 Rozzano, Milan, Italy
2
School of Medicine and Surgery, University of MilanoBicocca, San Gerardo Hospital via Pergolesi 33, 20900 Monza, Italy
3
Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
4
Department of Economy and Statistic, University of Torino, Torino, Italy
Pancreaticoduodenectomy (PD) is one of the most challenging operations with a high rate of complications and a measurable mortality risk even in high-volume hospitals [1–3]. Over the last 10 years, enhanced recovery programs such as fast track and enhanced recovery after surgery (ERAS) have been developed and applied to different branches of surgery. These programs involve a multimodal, evidence-based approach aimed at reducing surgical and anesthesiological stress and maintaining postoperative physiological function [4, 5]. Such approaches rely on a multidisciplinary team an
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