Evidence for enhanced recovery in pancreatic cancer surgery
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REVIEW ARTICLE
Evidence for enhanced recovery in pancreatic cancer surgery Didier Roulin 1
&
Nicolas Demartines 1
Received: 19 June 2020 / Accepted: 24 June 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract Background Enhanced recovery is a multimodal and evidence-based perioperative approach with the aim to improve postoperative outcome. Following successful results in colorectal surgery, the implementation of enhanced recovery has spread to many surgical disciplines including pancreatic surgery. Purpose The aim of this study is to review current evidence on enhanced recovery focusing on pancreatic cancer surgery and to discuss potential areas of further development. Conclusion In pancreatic cancer surgery, enhanced recovery is associated with better clinical outcome, especially reduced overall postoperative complications, and reduced length of stay without any increase in readmission rate. The occurrence of delayed gastric emptying, but not pancreatic fistula, seems to be reduced with enhanced recovery. The improved postoperative outcome correlates with net costs savings. The improvement of clinical outcome was mainly described for short-term complications. The extension to long-term outcome and survival benefits, as well as the impact on quality of life, remains to be determined. Keywords Pancreatic cancer . Pancreatoduodenectomy, distal pancreatectomy . Enhanced recovery
Introduction The concept of enhanced recovery after surgery (ERAS) was developed in order to apply evidence-based medicine to the entire perioperative patient’s journey with the involvement of a multidisciplinary team [1]. The aim of enhanced recovery is not only to shorten patient’s length of stay, which is also called “fast-track,” but mainly to sustain patient’s recovery and to avoid complications. Following encouraging results in colorectal surgery, enhanced recovery protocols, which include several evidence-based items, were further expanded to most surgical procedures. The common objective of these protocols is to reduce the surgical stress and to support the return to preoperative state in terms of mobilization and gastro-intestinal function, allowing the patient to get back to his baseline condition early [2]. Interestingly, a major impact of surgery is the * Nicolas Demartines [email protected] 1
Department of Visceral Surgery, Lausanne University Hospital CHUV and University of Lausanne UNIL, 1011 Lausanne, Switzerland
induction of a stress response mechanism inducing a state of insulin resistance [3]. The magnitude of this insulin resistance is increased with the extent of surgery, being much higher for open colorectal resection compared with laparoscopic cholecystectomy [4]. As pancreatic surgery, especially pancreatoduodenectomy (PD), is one of the most extensive and demanding gastro-intestinal procedure, the expected surgical stress is major. While the mortality of pancreas surgery is low, with an in-hospital mortality after PD ≤ 1.6% in high-volume centers, the morbidity still remains high, with
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