Expanding the Whipple Accelerated Recovery Pathway (WARP) to All Patients Undergoing Pancreaticoduodenectomy (PD)

Introduction Enhanced recovery after surgery constitutes a multi-disciplinary approach to reduce length of stay (LOS), post-operative complications (POCs), and readmission rate (RR). This not only improves patient outcomes, but also reduces hospital costs. The Whipple Accelerated Recovery Pathway (WARP) trial successfully reduced LOS without increasing the rate of POCs and RR in patients undergoing pancreaticoduodenectomy (PD). However, the study was limited to a highly selective group of patients. This study aimed to determine if WARP could be expanded to all patients undergoing PD. Methods A single-institution retrospective review of 281 patients who underwent PD between 2017-2020 was conducted. Patients were divided into WARP-eligible (WEPs) and WARP-ineligible groups (WIPs) based on the WARP inclusion criteria to compare LOS, time to adjuvant therapy (TTAT), RR, POCs including delayed gastric emptying (DGE) and pancreatic fistula (POP), and 30-day and 90-day mortality using a univariate/multivariate logical regression analysis. Results In WEPs vs. WIPs, the mean LOS was 5 days vs. 6 days (p \u3c0.05), TTAT was 55 vs. 63 days (p \u3c0.05), RR was 12.6% vs. 23.5% (p \u3c0.05), DGE rate was 10.2% vs. 26.2% (p \u3c0.05), POP rate was 5.1% vs. 21.0% (p \u3c0.05), 30-day mortality was 2.5% vs 0.0% (p = 0.04), and 90-day mortality was 3.4 vs 1.2% (p = 0.22). Discussion Given low LOS, TTAT, and 30-day and 90-day mortality in both groups, WARP may be expanded to all patients undergoing PD. However, the differences in POCs and RR suggest that WIPs may require risk-reducing strategies during post-operative care