Risk-Stratified Pancreatectomy Clinical Pathway Implementation and Delayed Gastric Emptying

Surgical treatment and survival analysis of primary duodenal malignant tumor: a retrospective cohort study

“…Third, LR damages or cuts off vagus nerves distributed in duodenum and jejunum, causing gastrointestinal motor dysfunction and delaying gastric emptying. Our findings are similar to the previous research (20,21). Thus, intraoperative jejunal nutrition tube placement may not only effectively prevent DGE but also provide adequate enteral nutrition for patients with DGE.…”

Risk-stratified posthepatectomy pathways based upon the Kawaguchi–Gayet complexity classification and impact on length of stay

“…We have reported prior enhanced recovery efforts from our institution for hepato-pancreato-biliary surgery patient care and demonstrated continued iterative changes to these within a learning health care system model [ [13] , [14] , [15] , 24 ]. Specifically, a traditional enhanced recovery pathway was suggested within our group and resulted in a reduction in LOS after implementation within one surgeon's practice [ 24 ].…”

“…Although 100% consensus across all elements was not realistic in the first iteration, basic tenets of enhanced recovery included the following: early and aggressive ambulation, universal bowel regimens with or without use of promotility agents, low intravenous fluid rates (initially 75 mL/h postoperatively and 50 mL/h postoperatively 8 hours later) with saline lock when 600 mL oral intake was documented ( Table 1 ) [ 22 ]. Liver-specific goals were based on previously identified obstacles to patient recovery and early discharge, as well as evidence from our group's efforts with pancreatectomy care pathways that early enteral nutrition after major gastrointestinal operations is feasible [ [13] , [14] , [15] ]. These included requiring solid food on day 1 for low–intermediate-risk patients and on day 2 for high-risk patients, limiting peak opioid use by standardizing intravenous patient-controlled anesthesia settings, weaning opioids through required nonopioid bundles, and earlier intravenous-to-oral opioid medication use (linked to sooner diets) to promote the progress of low–intermediate-risk patients who were previously treated similarly to high-risk counterparts.…”

“…Many enhanced recovery programs have yet to be personalized via a priori stratification based on surgical complexity. We have created, implemented, validated, and twice revised preoperatively determined risk-stratified pancreatectomy clinical pathways, resulting in median LOS reduction from 12 to 6 days in high-risk and 10 to 5 days in low-risk pancreatoduodenectomy patients from 2016 to 2020 [ [13] , [14] , [15] ]. The foundation of this success was preoperative patient education on expected outcomes stratified by risks associated with their anticipated risk of postoperative pancreatic fistula.…”

Hospital costs of delayed gastric emptying following pancreatoduodenectomy and the financial headroom for novel prophylactic treatment strategies

“…3 Several studies found positive results of prophylactic treatment strategies for DGE, including use of Erythromycin, application of a different surgical technique and implementation of clinical pathways. [12][13][14] However, a standard and widely accepted prophylactic treatment for DGE is currently lacking. Currently, treatment of DGE is solely based on nutritional support, nasogastric tube placement, and sometimes prokinetic drugs.…”