Impact of Fast-Track Rehabilitation protocol following Pancreaticoduodenectomy.

INTRODUCTION : Malignancies of the head of pancreas and the periampullary region are managed surgically by pancreaticoduodenectomy (PD). Few decades back PD was associated with a very high morbidity and mortality. Recent advancements in surgical and anaesthetic techniques and the improvement in peri-operative care have evolved PD into a procedure with acceptable morbidity and mortality. Today PD is associated with a mortality of less than 5% in high volume tertiary care centres1 – 7. But the morbidity rate almost remains the same (between 30% and 60%), requiring high level peri-operative care and prolonged hospital stay. Fast-track surgery (or enhanced recovery after surgery) is an interdisciplinary, multimodal concept designed to accelerate postoperative recovery. The objectives of fast-track surgery are to reduce postoperative morbidity and reduce hospital stay time leading to an earlier return to normal life. The multimodal concept was first introduced in colonic surgery. Several studies have demonstrated the effectiveness of this programme in colonic resection. Most centres have implemented fast-track protocol in colorectal surgeries and these are now being extrapolated to other abdominal surgeries. Recently, fast track surgery has been proposed in pancreatic surgery with encouraging results, but such data are sparse. There has been no previous attempt at implementing fast-track surgery in PD with pancreaticogastrostomy as part of reconstruction. There has been hesitation in implementing fast-track programme after pancreatico-gastric anastomosis following PD, the reason being the fear of precipitating a leak. Fast-track programme combines various techniques used in the care of patients undergoing elective surgery like epidural or regional anaesthesia, minimally invasive techniques, optimal pain control and aggressive postoperative rehabilitation, including early enteral/oral feeding and ambulation. Most of the randomised trials on fast track surgery did not demonstrate any significant difference in terms of quality of life, patient satisfaction, nutritional recovery or postoperative lean body mass deterioration10. However a safe early discharge from the hospital by itself is a favourable outcome. Recent published studies have confirmed no increase in morbidity and mortality by adhering to these principles. But there are very few such studies and further studies are warranted. AIM : 1. To evaluate the feasibility and safety of implementing fast track rehabilitation protocol following pancreaticoduodenectomy with pancreaticogastrostomy. 2. To evaluate whether fast track rehabilitation principles following pancreaticoduodenectomy is associated with faster recovery, reduced morbidity and reduced length of hospital stay. CONCLUSION : Implementation of fast-track programme is associated with early recovery, early feeding, early passage of stools, early removal of drains and early discharge. Despite earlier concerns with fast-track surgery, it did not increase the complication rate, morbidity and mortality. Fast-track programme appears to be feasible and safe after pancreaticoduodenectomy, even with pancreatico-gastric anastomosis. This protocol is practical and can be easily introduced with no increase in cost. The reduced incidence of DGE might contribute to shorter hospital stay and eventually to a reduced treatment cost. Further studies are needed to evaluate the impact of fast-track approach and optimize the protocol. Experience in implementing the protocol might contribute to further enhancing recovery and reducing hospital stay, in high volume centres