Implementation Of Enhanced Recovery After Surgery (ERAS) In Patients Undergoing Total Laparoscopic Pancreaticoduodenectomy (TLPD)

Background: Total laparoscopic pancreaticoduodenectomy(TLPD)was first described by Ganger and Pomp in 1994,whereas Danish surgeon Kehletin 2001 was the first to propose enhanced recovery after surgery(ERAS).It can reduce stress and trauma as well as postoperative complications and accelerate rehabitation of patients with preoperative,intraoperative and postoperative outcomes.As laparoscopic surgeries are often considered to be an important part for patients treated under ERAS but its implementation specifically for patients taking TLPD is still has not been recognized widely.Benefits of ERAS protocol have been well documented;however,it is unclear whether the improvements come from the protocol or shifts in expectations.Although postoperative outcomes have improved in last few decades,patients still experience significant postoperative morbidity and full recovery after surgery takes longer than we think.In recent years,enhanced recovery after surgery with large number of evidence-based perioperative interventions have proved to be beneficial in terms of improved postoperative outcomes,and accelerated patient recovery in the context of gastrointestinal,genitourinary and orthopedic surgery.But the concept of ERAS still has great controversy in surgical fields because of complicated operation,great trauma,various complications such as liver surgery or pancreatic operation has not been widely recognized.Methods: This retrospective study was done to investigate the implementation of ERAS with 101 patients following TLPD in the 2nd department of Hepatobiliaric Surgery of The 1st hospital of Jilin University,Changchun,China during April 2015 to January 2018.All the patients were divided in to two groups,where 1st group was managed with conservative treatment and 2nd was managed with ERAS protocol which included: Preoperative counseling,Preoperative biliary drainage,Preoperative fasting,Antibiotic prophylaxis,Avoiding hypothermia,Early removal of nasogastric intubation,Preventive analgesia,Two abdominal drainages,Somatostain analogues,Remove urinary catheter,Delayed gastric emptying,Postoperative nutrition and Early mobilization.Mortality,morbidity,post-operative complications,length of stay,reoperations and readmission rate,of early removal of nasogastric tube(NGT),removal of abdominal tubes,resumption of oral fluids,early mobilization and shorter hospital stay were set as main statistical parameters.Results: In total 101 patients data was collected who TLPD(39 patients in Control group and 62 patients in the ERAS group).Mean age was 57 years in the control group and 55 years in the ERAS group,ratio of female/male was 48.7/51.3% in the control group and 50/50% in the ERAS group.No significant differences were recorded in the ASA between the two groups as P value(0.867)was greater than 0.05.For ASA II/III the distribution was 97.4/2.4% and 90.3/6.5% respectively.A higher incident of peroperative biliary drainage was recorded in ERAS group(17.9% compared to 27.4%),although there was no significant difference.Mean surgical time for control group was 288.51 min and for ERAS group 301.61min(P=0.169),no significance was found in the duration of three anastomoses between these two groups.There were no significant differences in average intraoperative transfusion between both groups.However,the ERAS required a greater number of packed blood cells than the control group(9 Compared to 1;P= 0.106).Shorter time of NG tube placement was observed in the ERAS group(6.13 days Compared to 8.28 days;P=0.010),which was statistically significant as P<o.o5.Mean time needed for mobilization was 3.90 days in the control group and 3.19 days in the ERAS group(P=0.028).Early start of oral feeding was achieved in ERAS group(6.38 days to compare with 8.36 days)and it was statistically significant(P=0.018).Mortality was 0.99% which corresponds to 2 patients in the ERAS group,no death records in the control group.Mortality rate in the control group was 0% and 3.23% in the ERAS group(P=0.69).The most frequent complications in the control group were pancreatic fistula(28.2%),biliary fistula(7.7%),gastroparesis(12.8%),and abdominal infection(15.4%).The most frequent complications in the ERAS group were pancreatic fistula(29.1%),biliary fistula(4.8%),gastrointestinal fistula(4.8%),lung infection(8.1%).Removal of Choledochojejunostomy drainage was early in ERAS group(4.76 days in ERAS group and 6.16 days in control group)and was also statistically significant(P=0.019).Removal of Pancreaticojejunostomy drainage was also early in ERAS group (5.11 days in ERAS group and 6.76 days in Control group)and was statistically significant too(P=0.012).The reoperation rate was higher in the control group(5.1%)compared to ERAS group(1.6%)where P=0.681 and it was not significant.The length of stay in hospital was also less in ERAS group(23.23 days)than the control group(18.38 days)and was statistically significant(P=0.012).ICU stay was shorter in ERAS group(2.55 days)than Control group(3.03 days)and was also statistically significant(P=0.045).Conclusions: Not all the parameters were statistically significant in our study but early oral feeding,mobilisaion,LOS,indwelling period of NGT,postoperative LOS and for perianastomotic drainages outcomes were significant.Even though TLPD is one of the most complex and risky procedure in the field of HPB surgery,it is of no doubt that implementation of ERAS for patients undergoing TLPD is safe and feasible.Further evidence-based studies should be performed to determine a better outcome.