Skip to main content

Enhanced Recovery Program After Pancreatectomy

  • Chapter
  • First Online:
Book cover Pancreatic Cancer
  • 1722 Accesses

Abstract

ERAS (enhanced recovery after surgery) was initially developed by Henrik Kehlet in 2001, which was first to describe and implement such a multimodal care protocol successfully in colonic surgery [1]. Subsequently, many studies have been published on this topic, not only in colonic surgery but also in many other fields of surgery (e.g., musculoskeletal [2], breast [3], aortic [4, 5], bariatric [6, 7], and prostate surgery [8]). ERAS has been used with other terms like “fast track” or “critical or clinical pathway.” The purpose of ERAS is not a simple early discharge but with supplying the most appropriate perioperative management by evidence-based medicine, to reduce surgical stress and maintain patient homeostasis therefore to reduce surgical morbidity and hospital stay and cost, and to improve quality of life. With an ERAS program, the patients can reduce the unnecessary stressful routines such as nasogastric tube insertion, preoperative bowel preparation, long perioperative nil by mouth, long prophylactic antibiotics, etc. and can quickly restore the homeostasis with pain control, early ambulation, enhancement of gut function, perioperative nutritional support, psychological support, etc. To maintain ERAS, multidiscipline approach is mandatory including surgeon, physician, anesthesiologist, nurse, dietician, etc.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 99.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 129.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 199.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183:630–41.

    Article  PubMed  Google Scholar 

  2. Barbieri A, Vanhaecht K, Van Herck P, et al. Effects of clinical pathways in the joint replacement: a meta-analysis. BMC Med. 2009;7:32.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Arsalani-Zadeh R, ElFadl D, Yassin N, MacFie J. Evidence-based review of enhancing postoperative recovery after breast surgery. Br J Surg. 2011;98:181–96.

    Article  CAS  PubMed  Google Scholar 

  4. Podore PC, Throop EB. Infrarenal aortic surgery with a 3-day hospital stay: a report on success with a clinical pathway. J Vasc Surg. 1999;29:787–92.

    Article  CAS  PubMed  Google Scholar 

  5. Brustia P, Renghi A, Gramaglia L, et al. Mini-invasive abdominal aortic surgery. Early recovery and reduced hospitalization after multidisciplinary approach. J Cardiovasc Surg. 2003;44:629–35.

    CAS  Google Scholar 

  6. Wasowicz-Kemps DK, Bliemer B, Boom FA, de Zwaan NM, van Ramshorst B. Laparoscopic gastric banding for morbid obesity: outpatient procedure versus overnight stay. Surg Endosc. 2006;20:1233–7.

    Article  CAS  PubMed  Google Scholar 

  7. McCarty TM, Arnold DT, Lamont JP, Fisher TL, Kuhn JA. Optimizing outcomes in bariatric surgery: outpatient laparoscopic gastric bypass. Ann Surg. 2005;242:494–8.. discussion 498–501

    PubMed  PubMed Central  Google Scholar 

  8. Kirsh EJ, Worwaq EM, Sinner M, Ghodak GW. Using outcome data and patient satisfaction surveys to develop policies regarding minimum length of hospitalization after radical prostatectomy. Urology. 2000;56:101–6.. discussion 106–7

    Article  CAS  PubMed  Google Scholar 

  9. de Oliveira ML, Winter JM, Schafer M, et al. Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg. 2006;244:931–9.

    Article  Google Scholar 

  10. de Wilde RF, Besselink MG, van der Tweel I, et al. Impact of nationwide centralization of pancreaticoduodenectomy on hospital mortality. Br J Surg. 2012;99:404–10.

    Article  PubMed  Google Scholar 

  11. Gouma DJ, van Geenen RC, van Gulik TM, et al. Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg. 2000;232:786–95.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Yeo CJ, Cameron JL, Sohn TA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg. 1997;226:248–57.. discussion 257–60

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Richter A, Niedergethmann M, Sturm JW, Lorenz D, Post S, Trede M. Long-term results of partial pancreaticoduodenectomy for ductal adenocarcinoma of the pancreatic head: 25-year experience. World J Surg. 2003;27:324–9.

    Article  PubMed  Google Scholar 

  14. Coolsen MME, van Dam RM, van der Wilt AA, Slim K, Lassen K, Dejong CHC. Systematic review and meta-analysis of enhanced recovery after pancreatic surgery with particular emphasis on pancreaticoduodenectomies. World J Surg. 2013;37:1909–18.

    Article  CAS  PubMed  Google Scholar 

  15. Kagedan DJ, Ahmed M, Katharine S, Devitt S, Wel AC. Evidenced recovery after pancreatic surgery; a systemic review of the evidence. HPB. 2015;17:11–6.

    Article  PubMed  Google Scholar 

  16. Porter GA, Pisters PWT, Mansyur C, Bisanz A, Reyna K, Stanford P. Cost and utilization impact of a clinical pathway for patients undergoing pancreaticoduodenectomy. Ann Surg Oncol. 2000;7:484–9.

    Article  CAS  PubMed  Google Scholar 

  17. Vanounou T, Pratt W, Fischer JE, Vollmer JCM, Callery MP. Deviation-based cost modelling: a novel model to evaluate the clinical and economic impact of clinical pathways. J Am Coll Surg. 2007;204:570–9.

    Article  PubMed  Google Scholar 

  18. Kennedy EP, Rosato EL, Sauter PK, et al. Initiation of a critical pathway for pancreaticoduodenectomy at an academic institution – the first step in multidisciplinary team building. J Am Coll Surg. 2007;204:917–23.

    Article  PubMed  Google Scholar 

  19. Berberat P, Ingold H, Gulbinas A, et al. Fast track – different implications in pancreatic surgery. J Gastrointest Surg. 2007;11:880–7.

    Article  CAS  PubMed  Google Scholar 

  20. Balzano G, Zerbi A, Braga M, Rocchetti S, Beneduce AA, Di Carlo V. Fast-track recovery programme after pancreatico-duodenectomy reduces delayed gastric emptying. Br J Surg. 2008;95:1387–93.

    Article  CAS  PubMed  Google Scholar 

  21. Kennedy E, Grenda T, Sauter P, et al. Implementation of a critical pathway for distal pancreatectomy at an academic institution. J Gastrointest Surg. 2009;13:938–44.

    Article  PubMed  Google Scholar 

  22. di Sebastiano P, Festa L, De Bonis A, et al. A modified fast-track programme for pancreatic surgery: a prospective single-centre experience. Langenbeck’s Arch Surg. 2011;396:345–51.

    Article  Google Scholar 

  23. Robertson N, Gallacher PJ, Peel N, et al. Implementation of an enhanced recovery programme following pancreaticoduodenectomy. HPB. 2012;14:700–8.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Nikfarjam M, Weinberg L, Low N, et al. A fast track recovery programme significantly reduces hospital length of stay following uncomplicated pancreaticoduodenectomy. JOP. 2013;4:63–70.

    Google Scholar 

  25. Abu HM, Di Fabio F, Badran A, et al. Implementation of enhanced recovery programme after pancreatoduodenectomy: a single-centre UK pilot study. Pancreatology. 2013;13:58–62.

    Article  Google Scholar 

  26. Lassen K, Coolsen MM, Slim K, et al. Guidelines for perioperative care for pancreaticoduodenectomy: enhanced recovery after surgery (ERAS®) Society recommendation. World J Surg. 2013;37:240–58.

    Article  PubMed  Google Scholar 

  27. Fearon KCH, Ljungqvist O, von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24:466–77.

    Article  CAS  PubMed  Google Scholar 

  28. Gustafsson UO, Scott MJ, Schwent W, et al. Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS R) Society recommendation. Clin Nutr. 2012;31:783–800.

    Article  CAS  PubMed  Google Scholar 

  29. Nygren J, Thacker J, Carli F, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: enhanced recovery after surgery (ERAS R) society recommendations. World J Surg. 2013;37:285–305.

    Article  CAS  PubMed  Google Scholar 

  30. Mortensen K, Nilsson M, Slim K, et al. Consensus guidelines for enhanced recovery after gastrectomy. Br J Surg. 2014;101:1209–29.

    Article  CAS  PubMed  Google Scholar 

  31. Scott MJ, Baldini G, Fearon KCH, et al. Enhanced recovery after surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand. 2015;59:1212–31.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Veradhan KK, Lobo DN, Ljungqvist O. Enhanced recovery after surgery: the future of improving surgical care. Crit Care Clin. 2010;26:527–47.

    Article  Google Scholar 

  33. Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ. Participants in the VANSQIP. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. 2005;242:326–41.. discussion 41–3

    PubMed  PubMed Central  Google Scholar 

  34. Chowdhury AH, Lobo DN. Fluids and gastrointestinal function. Curr Opin Clin Nutr Metab Care. 2011;14:469–76.

    Article  PubMed  Google Scholar 

  35. Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet. 2002;359:1812–8.

    Article  PubMed  Google Scholar 

  36. Varadhan KK, Lobo DN. A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right. Proc Nutr Soc. 2010;69:488–98.

    Article  PubMed  Google Scholar 

  37. Bragg D, El-Sharkawy AM, Psaltis E, Maxwell-Armstrong CA, Lobo DN. Postoperative ileus: recent developments in pathophysiology and management. Clin Nutr. 2015;34:367–76.

    Article  PubMed  Google Scholar 

  38. Chen Y, Ou G, Lian G, et al. Effect of preoperative biliary drainage on complications following pancreatectomy. Medicine. 2015;94:e 1199.

    Article  Google Scholar 

  39. van der Gaag NA, Kloek JJ, de Castro SM, et al. Preoperative biliary drainage in patients with obstructive jaundice: history and current status. J Gastrointest Surg. 2009;13:814–20.

    Article  PubMed  Google Scholar 

  40. Klinkenbijl JH, Jeekel J, Schmitz PI, et al. Carcinoma of the pancreas and periampullary region: palliation versus cure. Br J Surg. 1993;80:1575–8.

    Article  CAS  PubMed  Google Scholar 

  41. Povoski SP, Karpeh Jr MS, Conlon KC, et al. Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy. Ann Surg. 1999;230:131–42.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Pisters PW, Hudec WA, Hess KR, et al. Effect of preoperative biliary decompression on pancreaticoduodenectomy-associated morbidity in 300 consecutive patients. Ann Surg. 2001;234:47–55.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Sohn TA, Yeo CJ, Cameron JL, Pitt HA, Lillemoe KD. Do preoperative biliary stents increase postpancreaticoduodenectomy complication? J Gastrointest Surg. 2000;4:258–67.

    Article  CAS  PubMed  Google Scholar 

  44. Velanovich V, Kheibek T, Khan M. Relationship of postoperative complications from preoperative biliary stents after pancreaticoduodenectomy. A new cohort analysis and meta-analysis of modern studies. JOP. 2009;10:24–9.

    PubMed  Google Scholar 

  45. Fang Y, Gurusamy KS, Wang Q, et al. Meta-analysis of randomized clinical trials on safety and efficacy of biliary drainage before surgery for obstructive jaundice. Br J Surg. 2013;100:1589–96.

    Article  CAS  PubMed  Google Scholar 

  46. Garcea G, Chee W, Ong SL, et al. Preoperative biliary drainage for distal obstruction: the case against revisited. Pancreas. 2010;39:119–26.

    Article  PubMed  Google Scholar 

  47. van der Gaag NA, Rauws EA, van Eijck CH, et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med. 2010;362:129–37.

    Article  PubMed  Google Scholar 

  48. Takahashi Y, Nagino M, Nishio H, Ebata T, Igami T, Nimura Y. Percutaneous transhepatic drainage catheter tract recurrence in cholangiocarcinoma. Br J Surg. 2010;97:1860–6.

    Article  CAS  PubMed  Google Scholar 

  49. Miller M, Wishart HY, Nimmo WS. Gastric contents at induction of anaesthesia. Is a 4-hour fast necessary? Br J Anaesth. 1983;55:1185–8.

    Article  CAS  PubMed  Google Scholar 

  50. Smith I, Kranke P, Murat I, et al. Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2011;28:556–69.

    Article  PubMed  Google Scholar 

  51. Svanfeldt M, Thorell A, Brismar K, et al. Effects of 3 days of “postoperative” low caloric feeding with or without bed rest on insulin sensitivity in healthy subjects. Clin Nutr. 2003;22:31–8.

    Article  CAS  PubMed  Google Scholar 

  52. Ljungqvist O, Nygren J, Thorell A. Modulation of postoperative insulin resistance by pre-operative carbohydrate loading. Proc Nutr Soc. 2002;61:329–36.

    Article  CAS  PubMed  Google Scholar 

  53. Hausel J, Nygren J, Lagerkranser M, et al. A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients. Anesth Analg. 2001;93:1344–50.

    Article  CAS  PubMed  Google Scholar 

  54. Helminen H, Viitanen H, Sajanti J. Effect of preoperative intravenous carbohydrate loading on preoperative discomfort in elective surgery patients. Eur J Anaesthesiol. 2009;26:123–7.

    Article  CAS  PubMed  Google Scholar 

  55. American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2011;114:495–511.

    Article  Google Scholar 

  56. Noblett SE, Watson DS, Huong H, et al. Pre-operative oral carbohydrate loading in colorectal surgery: a randomized controlled trial. Color Dis. 2006;8:563–9.

    Article  CAS  Google Scholar 

  57. Yuill KA, Richardson RA, Davidson HIM, et al. The administration of an oral carbohydrate-containing fluid prior to major elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperatively – a randomised clinical trial. Clin Nutr. 2005;24:32–7.

    Article  CAS  PubMed  Google Scholar 

  58. Weimann A, Braga M, Harsanyi A, et al. ESPEN Guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr. 2006;25:224–44.

    Article  CAS  PubMed  Google Scholar 

  59. Lassen K, Kjaeve J, Fetveit T, et al. Allowing normal food at will after major upper gastrointestinal surgery does not increase morbidity: a randomized multicenter trial. Ann Surg. 2008;247:721–9.

    Article  PubMed  Google Scholar 

  60. Gianotti L, Meier R, Lobo DN, et al.. 2009ESPEN guidelines on parenteral nutrition: pancreas. Clin Nutr. 2009;28:428–35.

    Article  CAS  PubMed  Google Scholar 

  61. Gerritsen A, Besselink MGH, Gouma DJ, Steenhagen E, Borel Rinkes IHM, Molenaar IQ. Systematic review of five feeding routes after pancreatoduodenectomy. Br J Surg. 2013;100:589–98.

    Article  CAS  PubMed  Google Scholar 

  62. Lobo DN, Bostock KA, Neal KR, et al. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet. 2002;359:1812–8.

    Article  PubMed  Google Scholar 

  63. Lobo DN. Fluid overload and surgical outcome: another piece in the jigsaw. Ann Surg. 2009;249:186–8.

    Article  PubMed  Google Scholar 

  64. Brandstrup B, Tonnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg. 2003;238:641–8.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Kudsk KA. Evidence for conservative fluid administration following elective surgery. Ann Surg. 2003;238:649–50.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Kita T, Mammoto T, Kishi Y. Fluid management and postoperative respiratory disturbances in patients with transthoracic esophagectomy for carcinoma. J Clin Anesth. 2002;14:252–6.

    Article  PubMed  Google Scholar 

  67. Boland MR, Noorani A, Varty K, Coffey JC, Agha R, Walsh SR. Perioperative fluid restriction in major abdominal surgery: systematic review and meta-analysis of randomized, clinical trials. World J Surg. 2013;37:1193–202.

    Article  PubMed  Google Scholar 

  68. MacKay G, Fearon K, McConnachie A, Serpell MG, Molloy RG, O’Dwyer PJ. Randomized clinical trial of the effect of postoperative intravenous fluid restriction on recovery after elective colorectal surgery. Br J Surg. 2006;93:1469–74.

    Article  CAS  PubMed  Google Scholar 

  69. Vermeulen H, Hofland J, Legemate DA, Ubbink DT. Intravenous fluid restriction after major abdominal surgery: a randomized blinded clinical trial. Trials. 2009;10:50.

    Article  PubMed  PubMed Central  Google Scholar 

  70. van Samkar G, Eshuis WJ, Bennink RJ, et al. Intraoperative fluid restriction in pancreatic surgery: a double blinded randomised controlled trial. PLoS ONE. 2015;10:e0140294.

    Article  PubMed  PubMed Central  Google Scholar 

  71. Buvanendran A, Kroin JS, Della Valle CJ, Kari M, Moric M, Tuman KJ. Perioperative oral pregabalin reduces chronic pain after total knee arthroplasty: a prospective, randomized, controlled trial. Anesth Analg. 2010;110:199–207.

    Article  CAS  PubMed  Google Scholar 

  72. Samad TA, Moore KA, Sapirstein A, et al. Interleukin-1beta-mediated induction of Cox-2 in the CNS contributes to inflammatory pain hypersensitivity. Nature. 2001;410:471–5.

    Article  CAS  PubMed  Google Scholar 

  73. Joshi GP. Multimodal analgesia techniques and postoperative rehabilitation. Anesthesiol Clin North Am. 2005;23:185–202.

    Article  CAS  Google Scholar 

  74. Werawatganon T, Charuluxanun S. Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev. 2005;1:CD004088.

    Google Scholar 

  75. Block BM, Liu SS, Rowlingson AJ, et al. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA. 2003;290:2455–63.

    Article  CAS  PubMed  Google Scholar 

  76. Jørgensen H, Wetterslev J, Møiniche S, Dahl JB. Epidural local anaesthetics versus opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery. Cochrane Database Syst Rev. 2000;4:CD001893.

    Google Scholar 

  77. Bruns H, Rahbari NN, Loffler T, et al. Perioperative management in distal pancreatectomy: results of a survey in 23 European participating centres of the DISPACT trial and a review of literature. Trials. 2009;10:58.

    Article  PubMed  PubMed Central  Google Scholar 

  78. Pratt WB, Steinbrook RA, Maithel SK, et al. Epidural analgesia for pancreatoduodenectomy: a critical appraisal. J Gastrointest Surg. 2008;12:1207–20.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Sang-Jae Park .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer-Verlag Berlin Heidelberg

About this chapter

Cite this chapter

Park, SJ. (2017). Enhanced Recovery Program After Pancreatectomy. In: Kim, SW., Yamaue, H. (eds) Pancreatic Cancer. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-47181-4_35

Download citation

  • DOI: https://doi.org/10.1007/978-3-662-47181-4_35

  • Published:

  • Publisher Name: Springer, Berlin, Heidelberg

  • Print ISBN: 978-3-662-47180-7

  • Online ISBN: 978-3-662-47181-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics