Enhanced Recovery After Minimally Invasive Pancreaticoduodenectomy
Condition: Pancreatic Neoplasms; Periampullary Neoplasms
MeSH terms: Neoplasms; Pancreatic Neoplasms
Study type: Observational

Summary: 
      This prospective observational cohort study aims to improve the postoperative course after
      minimally invasive pancreaticoduodenectomy (MIP) with stented pancreaticogastrostomy (sPG)
      for pancreatic head or peri-ampullary neoplasms. Patients are submitted to an enhanced
      recovery after surgery (ERAS) program with early enteral nutrition (EEN).
    

Detailed description: 
      Pancreaticoduodenectomy (PD) is the standard of care for patients with malignant or benign
      disease of the pancreatic head or peri-ampullary region. The postoperative course after PD is
      strongly dependent of the occurrence of pancreatic fistula (POPF) and/or delayed gastric
      emptying (DGE). In a recent multicentre randomized controlled trial, the investigators have
      shown pancreaticogastrostomy (PG; without a stent in the pancreatic duct) to be associated
      with 8% POPF rate, significantly lower than pancreaticojejunostomy (20%) (1). Since then, PG
      reconstruction is considered the standard of care in PD, which is also underlined in more
      recent systematic reviews.

      In patients without POPF after PD, the length of hospital stay is determined by the
      occurrence of DGE, which is poorly understood and currently lacks any effective treatment.
      Patients who developed DGE after PD with PG anastomosis (n=18; 20%) had a significantly
      (p=0.014) longer (mean + sem) length of hospital stay (LOS) of 26.3 + 1.58 days, as compared
      to 22.4 + 1.27 days for patients without DGE (n=69). These figures are observed in the
      investigators' center as part of the multicentre RCT.

      Enhanced recovery after surgery (ERAS) or fast-track (FT) programs are able to reduce
      postoperative length of hospital stay (LOS). Indeed recently, ERAS or FT programs have been
      implemented successfully in PD (2). Patients were discharged 4 days earlier in the ERAS
      group, without a negative effect on the clinical outcome. Still, many surgeons are reluctant
      to implement ERAS programs because they fear compromising patient safety.

      In efforts to improve the outcomes of PD, many surgical techniques have been evaluated to
      restore the pancreatic digestive continuity after PD. However, the best way to ensure this
      and whether or not to perform the procedure via standard open or minimally invasive, i.e. 2-
      or 3-dimensional laparoscopic (3D-LPD) or 3-dimensional robotic surgery (RPD), is still under
      debate. The investigators have passed the learning curve of 50 3D-LPD and hypothesize the
      implementation of ERAS and EEN in 3D-LPD can improve short-term outcomes.
    

Intervention name(s): ERAMIP
Intervention type(s): Procedure
Intervention description(s): 3D-LPD with stented umbrella-pancreaticogastrostomy & Roux-en-Y reconstruction of the biliary limb of the hepatico-jejunostomy onto the efferent limb of the gastro-enterostomy (RY-GES)
Observational model: Cohort
Time perspective: Prospective
Sampling method: Probability Sample
Study population: 
        Patients with pancreatic or peri-ampullarf neoplasms to undergo minimally invasive
        pancreaticoduodenectomy
      
Keywords: pancreatic surgery; neoplasms