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Enhanced Perioperative Care in Liver and Pancreat Surgery

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Enhanced Perioperative Care in Liver and Pancreat Surgery Enhanced perioperative care in liver and pancreat surgery Citation for published version (APA): Coolsen, M. M. E. (2014). Enhanced perioperative care in liver and pancreat surgery. Maastricht University. https://doi.org/10.26481/dis.20141031mc Document status and date: Published: 01/01/2014 DOI: 10.26481/dis.20141031mc Document Version: Publisher's PDF, also known as Version of record Please check the document version of this publication: • A submitted manuscript is the version of the article upon submission and before peer-review. There can be important differences between the submitted version and the official published version of record. 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If the publication is distributed under the terms of Article 25fa of the Dutch Copyright Act, indicated by the “Taverne” license above, please follow below link for the End User Agreement: www.umlib.nl/taverne-license Take down policy If you believe that this document breaches copyright please contact us at: [email protected] providing details and we will investigate your claim. Download date: 06 Oct. 2021 Enhanced perioperative care in liver and pancreatic surgery 1 © Copyright Mariëlle Coolsen, Maastricht 2014 Layout: Tiny Wouters Cover: Kim Rauwerdink Printed by: Offpage ISBN: 978‐94‐6182‐497‐4 Enhanced perioperative care in liver and pancreatic surgery ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit Maastricht, op gezag van de Rector Magnificus, Prof dr. L.L.G. Soete volgens het besluit van het College van Decanen, in het openbaar te verdedigen op vrijdag 31 oktober 2014, om 12:00 uur. door Mariëlle Maria Etiën Coolsen Promotor Prof. dr. C.H.C. Dejong Co‐promotor Dr. S.W.M. Olde Damink Beoordelingscommissie Prof. dr. M.F. von Meyenfeldt (voorzitter) Prof. dr. W.F. Buhre Prof. dr. K.C. Conlon (University of Dublin, Trinity College) Dr. I.H.J.T. de Hingh Prof. dr. J.M.P. Kleijnen CONTENTS Chapter 1 Introduction and outline of the thesis 7 Part I Critical appraisal of literature: ERAS programs in HPB surgery 25 and endpoints in pancreatic surgery Chapter 2 Systematic review and meta‐analysis of enhanced recovery after 27 pancreatic surgery with particular emphasis on pancreaticoduodenectomies Chapter 3 A systematic review of outcomes in patients undergoing liver 47 surgery in an enhanced recovery after surgery pathway Chapter 4 To drain or not to drain: A cumulative meta‐analysis regarding the 61 use of routine abdominal drains after pancreaticoduodenectomy Chapter 5 Development of a composite endpoint for randomized controlled 77 trials in pancreaticoduodenectomy Part II Development of ERAS guidelines and a multicenter trial for 93 pancreaticoduodenectomy Chapter 6 Guidelines for perioperative care for pancreaticoduodenectomy: 95 Enhanced Recovery After Surgery (ERAS®) Society recommendations Chapter 7 Study protocol PANDA trial: PAncreaticoduodeNectomy and 129 Drainage After surgery: Multicenter randomized controlled trial of prophylactic abdominal drain versus no drain policy after pancreaticoduodenectomy, within an enhanced recovery after surgery pathway Part III Evaluation of implementing an ERAS program in liver and 143 pancreatic surgery Chapter 8 Initial experience with a multimodal enhanced recovery program 145 in patients undergoing liver resection Chapter 9 Improving outcome after pancreaticoduodenectomy‐ experiences 159 with implementing an enhanced recovery after surgery program Chapter 10 Implementing an enhanced recovery program after pancreatico‐ 173 duodenectomy in elderly patients ‐ is it feasible? Chapter 11 Attitudes of patients and care providers to enhanced recovery after 187 surgery programs following major abdominal surgery Chapter 12 General discussion and summary 203 Short summary 221 Summary in Dutch 225 Valorization 229 Appendices 237 List of publications 261 Dankwoord 265 Curriculum vitae 271 CHAPTER 1 Introduction and outline of the thesis 7 Chapter 1 8 General introduction 1.1 INTRODUCTION Liver and pancreatic resections are complex surgical procedures, which can cause considerable surgical stress and possible disruption of metabolic and pulmonary function. Improved operative techniques and insight into perioperative management has lowered mortality after liver resection to its current level of 5% but morbidity rates remain high, ranging between 30% and 50%1‐3. In large series morbidity rates for pancreatic resections can be as high as 40 to 60%4‐6. In order to improve postoperative outcome it is now recommended to centralize these major abdominal procedures in specialized, high‐volume clinics. Because of this, mortality rates for pancreatico‐ duodenectomy (PD), which is the most common form of pancreatic resection, have decreased from 9.8 to 5.1% in the Netherlands7. Postoperative length‐of‐stay (LOS) after PD varies from 14 to 20 days in different studies8‐10. In many hospitals current perioperative care for liver and pancreatic surgery is still conservative. Nasogastric tubes are left in place for days after surgery with the patient either receiving no food at all or only through a needle jejunostomy8. Even though this delivers artificial nutrients it is an intervention that bypasses the cephalic‐vagal digestive reflex and appears to be associated with considerable risk11,12. Other conservative practices are late postoperative mobilization and placement of drains at the end of the surgical procedure5,8,13,14. It has been shown that in liver surgery the placement of abdominal drains is not effective and may even increase the risk of intra‐ abdominal infections15‐17. Similarly, in pancreatic surgery the use of abdominal drains is supported by little evidence. In a randomized controlled trial (RTC) comparing routine drainage versus no drainage after pancreatic surgery, the incidence of intra‐abdominal collections of fistulas turned out to be higher after drainage18. Fasting from midnight also remains common practice in elective (liver and pancreatic) surgery even though this is not supported by evidence19. It has been shown that patients should be allowed to drink clear fluids up to 2 hours and ingest solid food up to 6 hours before surgery20. Enhanced Recovery After Surgery (ERAS) programs, also referred to as fast track, clinical or critical pathway programs, are multimodal, standardized care protocols implemented for a specific surgical field. An ERAS program addresses a variety of evidence‐based perioperative interventions and demands a multidisciplinary approach in which surgeons, anesthesiologists, intensive care staff, and nurses work together as a team. The purpose of an ERAS program is to accelerate postoperative recovery and shorten postoperative length of stay (LOS) without increasing or even lowering morbidity and readmission rates. ERAS programs have been successfully implemented in colonic surgery and appear to reduce the length of stay and complication rates without compromising patient safety21,22. The LAFA trial compared open colonic resection with laparoscopic resection using either an ERAS protocol or a standard care 9 Chapter 1 protocol. This trial showed that laparoscopy combined with an ERAS protocol resulted in the optimal perioperative treatment of patients undergoing colonic resections23. Numerous other studies have been published on the implementation of ERAS programs in many other surgical fields (e.g. musculoskeletal24, breast25, aortic26,27, bariatric28, and prostate surgery29). All of these studies showed a decrease in LOS without increasing postoperative morbidity or mortality. Apart from a reduction in postoperative LOS the implementation of an ERAS program may also reduce complication rates after liver and pancreatic surgery. Concerns have been raised, however, regarding the safety of ERAS programs for these upper gastrointestinal (GI) procedures since they are still associated with relatively high morbidity rates and excite a considerable stress response. A nil‐by‐mouth regimen is still widely practiced because of fear for gastric distention and anastomotic leakage30‐32. Especially in PD, where complications as delayed gastric emptying (DGE) regularly occur, there is a reluctance to allow volitional intake of normal food during the immediate postoperative period33. This reluctance, however, is not justified by evidence obtained from randomized trials and may even be considered "obsolete" care34,35. Even so, liver and pancreatic procedures are relatively infrequent procedures for which it may be difficult to implement an ERAS program that requires close collaboration between all caregivers.
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