title: Implementation of an Enhanced Recovery Pathway After Pancreaticoduodenectomy in Patients with Low Drain Fluid Amylase.
abstract: BACKGROUND
  The safety and feasibility of an enhanced recovery pathway (ERP) after pancreatic surgery is largely unknown. Our aim was to prospectively evaluate a targeted ERP after pancreaticoduodenectomy (PD), using first postoperative day (POD) drain fluid amylase (DFA1) values to identify patients at low risk of pancreatic fistula (PF).
  
  
  METHODS
  Non-randomized cohort study of 130 consecutive patients. Perioperative outcomes were compared before (pre-ERP; N=65) and after (post-ERP; N=65) implementation of an ERP. Patients in each group were stratified according to the risk of PF using DFA1<350 IU/l. Low-risk patients in the post-ERP group were selected for early oral intake and early drain removal.
  
  
  RESULTS
  81/130 patients had a DFA1<350. Incidence of PF was significantly lower in low-risk patients (9 vs. 45%, P=0.0001). In low-risk patients, morbidity (43 vs. 36%) and mortality (2.7 vs. 4.5%) were similar for both pre- and post-ERP patients. Hospital stay (median 9 vs. 7 days, P=0.03) and 30-day readmissions (17 vs. 2%, P=0.04) were lower in low-risk patients in the post-ERP group. In high-risk patients, there was no difference in outcomes between pre- and post-ERP.
  
  
  CONCLUSIONS
  Patients at low risk of PF after PD can be identified by first POD DFA1. Enhanced recovery after PD is safe and leads to improved short-term outcomes in low-risk patients.
authors: Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Third Floor Nuffield House, Birmingham, B15 2TH, UK, robert.sutcliffe@uhb.nhs.uk.
authors: Robert P
authors: RP
authors: Sutcliffe
authors: Majd
authors: M
authors: Hamoui
authors: John
authors: J
authors: Isaac
authors: Ravi
authors: R
authors: Marudanayagam
authors: Darius F
authors: DF
authors: Mirza
authors: Paolo
authors: P
authors: Muiesan
authors: John K
authors: JK
authors: Roberts
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000681:Amylases / Q000378:metabolism; D000714:Anastomosis, Surgical / Q000009:adverse effects; D001826:Body Fluids / Q000737:chemistry; D002985:Clinical Protocols; D015331:Cohort Studies; D020878:Device Removal; D004322:Drainage; D004750:Enteral Nutrition / Q000379:methods*; D005260:Female; D006801:Humans; D015994:Incidence; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010179:Pancreas / Q000601:surgery; D010182:Pancreatic Diseases / Q000601:surgery; D010185:Pancreatic Fistula / Q000175:diagnosis / Q000453:epidemiology* / Q000378:metabolism; D010190:Pancreatic Neoplasms / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000379:methods*; D010193:Pancreaticojejunostomy; D011182:Postoperative Care / Q000379:methods*; D018570:Risk Assessment; D013270:Stomach / Q000601:surgery
chemical_list: D000681:Amylases