Guidelines for perioperative care for ...

1 Guidelines for perioperative care for pancreaticoduodenectomy: EnhancedRecovery After Surgery (ERAS ) Society recommendationsqKristoffer Lassena,b,*, Marielle Coolsenc, Karem Slimd, Francesco Carlie,Jos E. de Aguilar-Nascimentof, Markus Sch ferg, Rowan W. Parksb, Kenneth Fearonb,Dileep N. Loboh, Nicolas Demartinesg, Marco Bragai, Olle Ljungqvistj,k, Cornelis Dejongcon behalfof the ERAS Society, the European Society for Clinical Nutrition and Metabolism and the InternationalAssociation for Surgical Metabolism and NutritionaDepartment of GI and HPB Surgery, University Hospital Northern Norway, Troms and Institute of Clinical Medicine, University of Troms , NorwaybClinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, United KingdomcDepartment of Surgery, University Hospital Maastricht and NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht, The NetherlandsdDepartment of Digestive Surgery, Hospital CHU Estaing, Clermont-Ferrand, FranceeDepartment of Anesthesia, McGill University Health Centre, Montreal, Quebec, CanadafDepartment of Surgery.

2 Federal University of Mato Grosso, Cuiaba, BrazilgDepartment of Visceral Surgery, University Hospital of Lausanne (CHUV), SwitzerlandhDivision of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre National Institute for Health Research, Biomedical Research Unit, Nottingham University Hospitals,Queen s Medical Centre, Nottingham, United KingdomiSan Raffaele University, Milan, ItalyjDepartment of Surgery, rebro University Hospital, rebro, SwedenkDepartment of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Swedenarticle infoArticle history:Received 7 August 2012 Accepted 19 August 2012 Keywords: enhanced Recovery After Surgery (ERAS)PancreatoduodenectomyWhippleFast trackCritical pathwayGuidelinesPancreassummaryBackgrou nd & aims:Protocols for enhanced recovery provide comprehensive and evidence-basedguidelines for best perioperative care.

3 Protocol implementation may reduce complication rates andenhance functional recovery and, as a result of this, also reduce length-of-stay in hospital. There is nocomprehensive framework available for :An international working group constructed within the enhanced Recovery After Surgery(ERAS ) Society constructed a comprehensive and evidence-based framework for best perioperative carefor pancreaticoduodenectomy patients. Data were retrieved from standard databases and personalarchives. Evidence and recommendations were classified according to the GRADE system and reachedthrough consensus in the group. The quality of evidence was rated high , moderate , low or verylow . Recommendations were graded as strong or weak .Results:Comprehensive Guidelines are presented. Available evidence is summarised and recommenda-tions given for 27 care items.

4 The quality of evidence varies substantially and further research is neededfor many issues to improve the strength of evidence and grade of :The present evidence-based Guidelines provide the necessary platform upon which to basea unified protocol for perioperative care for pancreaticoduodenectomy. A unified protocol allows forcomparison between centres and across national borders. It facilitates multi-institutional prospectivecohort registries and adequately powered randomised trials. 2012 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights Guidelines are published as a joint effort between the enhanced Recovery After Surgery (ERAS) Society, for perioperative Care, The European Society for ClinicalNutrition and Metabolism (ESPEN) and The International Association for Surgical Metabolism and Nutrition (IASMEN) and copyrights for this publication is shared betweenthe three societies.

5 The Guidelines are published jointly in World Journal of Surgery (IASMEN) and Clinical Nutrition (ESPEN), and will also be available on the ESPEN ( ) and ERAS Society websites ( ).*Corresponding author. Department of GI and HPB Surgery, University Hospital Northern Norway, 9038 UNN-Troms , Norway. Tel.: 47 47616906; fax: 47 776 Lassen).Contents lists available atSciVerse ScienceDirectClinical Nutritionjournal homepage: $esee front matter 2012 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights Nutrition 31 (2012) 817e8301. IntroductionEnhanced Recovery After Surgery (ERAS), Fast-Track or ClinicalPathway programmes are multimodal strategies that aim toattenuate the loss of, and improve the restoration of, functionalcapacity after surgery. Morbidity is reduced1and recoveryenhanced by reducing surgical stress, by optimal control of pain,early oral diet and early mobilisation.

6 As a consequence, length-of-stay in hospital (LOSH) and costs are also reduced. The ERAS grouphas published evidence-based consensus recommendations forcolorectal ,3 Beneficial experiences with clinical pathwayprogrammes after pancreaticoduodenectomy (PD, Whipple sprocedure) have been published,4e9but the reported seriesemployed different protocols, or no prospective protocol at comprehensive consensus framework is presented on which tobase a future protocol for optimal perioperative care after PD. Sucha recommendation will allow for a unified protocol to be developedand validated prospectively across different institutions andhealthcare systems. This guideline framework has been formulatedand endorsed by the ERAS Society, European Society for ClinicalNutrition and Metabolism (ESPEN) and the International Associa-tion for Surgical Metabolism and Nutrition (IASMEN).

7 2. Literature searchThe authors met in April 2011 and the topics to be included wereagreed and allocated. A principal literature search up to June 2011was undertaken. Comprehensive drafts were circulated for discus-sion and reviewed in a group conference in November 2011. Addi-tionalrelevantliterature publishedafterJune2011 wasconsideredbymembers of the group at meetings in November 2011 and May Study selectionAll co-authors screened web-based databases and personalarchives for relevant articles. Non-systematic emphasis was givento more recent publications and publications of better quality(moderate- and high-quality randomised controlled trials andhigh-quality, large cohort studies; and systematic reviews andmeta-analyses of these). Retrospective series were considered onlyif data of better quality could not be Quality assessment and gradingThe strength of evidence and conclusive recommendations wereassessed and agreed by all authors in May 2012.

8 Quality of evidenceand recommendations were evaluated according to the Grading ofRecommendations, Assessment, Development and Evaluation(GRADE) from the GRADE Guidelines ,12therecommendations are: Strong recommendations indicate that thepanel is confident that the desirable effects of adherence toa recommendation outweigh the undesirable effects . Weakrecommendations indicate that the desirable effects of adherenceto a recommendation probably outweigh the undesirable effects,but the panel is less confident . Recommendations are based onquality of evidence (high, moderate, low, very low) but also on thebalance between desirable and undesirable effects; and on valuesand latter implies that, in some cases, strongrecommendations may be reached from low-quality data andviceversa. A summary of the Guidelines is shown inTable Evidence and Preoperative counsellingPreoperative counselling targeting expectations about surgicaland anaesthetic procedures may diminish fear and anxiety andenhance postoperative recovery and , leaflets or multimedia information containing expla-nations of the procedure along with tasks that the patient should beencouraged to fulfil may improve perioperative feeding, earlypostoperative mobilisation, pain control, and respiratory physio-therapy.

9 And hence reduce the risk of ,the patient should meet with the surgeon, anaesthetist and and recommendation: Patients should receive dedi-cated preoperative counselling level: grade: Preoperative biliary drainageFive meta-analyses,19e23and two articles from a randomizedcontrolled trial (RCT) not included in the meta-analyses,24,25assessed the role of biliary drainage before PD. Thefirst meta-analysis from 2002,19included randomized (n 5) and non-randomized trials (n 18). A Cochrane review21included 5randomized trials, but considered all 5 trials to have a risk of bias,thereby weakening the conclusions reached. Of the trials included, 4evaluated percutaneous drainage and 1 evaluated endoscopicdrainage. The Cochrane review concluded that preoperative biliarydrainage did not decrease mortality in patients with obstructivejaundice.

10 Although there was a trend towards decreased post-operative morbidity, the increased risk of procedure-relatedcomplications counterbalanced this possible benefit (especially forpercutaneous drainage). Thefindings of the Cochrane review werein accordance with those of the other meta-analyses, suggestingthat preoperative drainage confers neither benefit nor harm. Onerecent RCT not included in the meta-analyses24(and which includedpatients with serum bilirubin concentrations<250mmol/l) showedincreased morbidity in patients undergoing preoperative biliarydrainage (endoscopic primarily; percutaneous as rescue option), butthe delay in surgery did not affect overall and recommendation: Preoperative endoscopicbiliary drainage should not be carried out routinely in patientswith a serum bilirubin concentration<250 level: grade: Preoperative smoking and alcohol consumptionOverall postoperative morbidity is increased by two- to three-fold in alcohol , 1 month of preoperative abstinencehas been shown to significantly improve outcome in a group whotook five or more drinks (60 g of ethanol) a day without clinical orhistorical evidence of alcohol related illness.