Implementation of an Enhanced Recovery Pathway After Pancreaticoduodenectomy in Patients with Low Drain Fluid Amylase

Abstract Introduction: 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). Patients and 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. Conclusion: 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.