title: The clinical role of critical pathway implementation for pancreaticoduodenectomy in 179 patients.
abstract: OBJECTIVE
  In June 2004, a critical pathway for patients undergoing pancreaticoduodenectomy (PD) was introduced. The objective of this study was to determine the clinical value of critical pathway implementation.
  
  
  METHODS
  256 consecutive patients who underwent PD between 2000 and 2010 were divided into 4 groups by date of operation as follows; group A (n = 77), the pre-pathway group; group B (n = 51), the CP implementation group who were managed according to departmental guidelines; group C (n = 78), the group who had no stenting in the reconstruction of PD; and group D (n = 50), the group who had reinforcement of the pancreaticojejunostomy. The success rates of clinical outcomes and post-operative morbidity were compared between each group, year by year and every 50 patients.
  
  
  RESULTS
  The success rates of clinical outcomes, including the timings of nasogastric tube removal, discontinuation of prophylactic anti-microbial agent, drain removal, starting oral intake, and patient discharge, were significantly improved in group B relative to group A, and in group C relative to group B. There were no significant differences in mortality and morbidity between any of the groups. All clinical outcomes reached a plateau at 2-3 years or 100-150 patients' operations after critical pathway implementation.
  
  
  CONCLUSIONS
  Long-term use of a critical pathway is associated with improved clinical outcomes. A certain period of time or volume of patients is needed for this improvement in clinical outcomes to reach a plateau, which indicates achieving standardization of peri-operative management.
authors.affiliation: Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan.
authors.forename: So
authors.initials: S
authors.lastname: Yamaki
authors.forename: Sohei
authors.initials: S
authors.lastname: Satoi
authors.forename: Hideyoshi
authors.initials: H
authors.lastname: Toyokawa
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Yanagimoto
authors.forename: Tomohisa
authors.initials: T
authors.lastname: Yamamoto
authors.forename: Satoshi
authors.initials: S
authors.lastname: Hirooka
authors.forename: Rintaro
authors.initials: R
authors.lastname: Yui
authors.forename: Kentaro
authors.initials: K
authors.lastname: Inoue
authors.forename: Yoichi
authors.initials: Y
authors.lastname: Matsui
authors.forename: A-Hon
authors.initials: AH
authors.lastname: Kwon
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D016009:Chi-Square Distribution; D019091:Critical Pathways; D004322:Drainage; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D061646:Operative Time; D016577:Pancreaticoduodenectomy / Q000379:methods*; D010193:Pancreaticojejunostomy; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control; D018709:Statistics, Nonparametric; D015607:Stents; D016896:Treatment Outcome