Postoperative management after pancreatic resections; controversies and recommendations for a fast-track protocol

Background: Despite the availability of the scientific evidence for the pancreatic fast-track surgery concept its translation into clinical practice, by most institutions, remains slow. Reasons being lack of awareness of evidence-based fast-track data; a lack of agreement with the data (difficult to accept); lack of belief that their own institution can actually perform fast-track surgery, time-limitation and insufficient expertise or staff support. However recent findings within specific perioperative care components of pancreatic postoperative management could help further validate pancreatic fast-track surgery and enhance its adaptation. Methods: Between January 2011 and August 2013, patients who underwent pancreatic resection were enrolled into the study at either of the two institutions. The Verona University arm subjected to the Verona enhanced recovery postoperative protocol while the National Cancer Institute, Cairo University group were subjected to conventional postoperative management. Both groups were followed up for effective control of pain, early reinstitution of oral feeding, effective immediate mobilization and restoration of bowel function following surgery. Outcome measures for each patient group were assessed in terms of postoperative complications such as pancreatic fistula (PF), delayed gastric emptying, biliary leak, intra-abdominal abscess, post-pancreatectomy hemorrhage, acute pancreatitis, wound infection, 30-day mortality, postoperative hospital stay, and readmission rates. Results: Overall morbidity for Verona (n= 101) and Cairo (n= 98) was 35% and 44.6%, respectively; and 30-day mortality was 5.9% versus 8.2%. In both groups postoperative PF was the most frequent associated complication. We observed 10 fistulae in the Verona group (9.9%), and 32 in Cairo group (32.7%). Delayed gastric emptying occurred in 5% of Verona patients and 10.2% of Cairo. Readmission rate was 4% (Verona) and 2.8% (Cairo). The overall length of stay, taking into consideration readmissions, remained significantly shorter in the fast track group (median 9 days, range: 7-16 days versus 14 days, range: 8-29 days; p<0.001). The primary discharge destination was home in both groups. Conclusions: The available evidence and data when compared to the results, provide a set of recommendations to suggest some items for a standardized protocol. Data on length of stay for both pathways are encouraging towards implementing a standardized postoperative management pathway.