Systematic review and meta-analysis of the impact of deviations from a clinical pathway on outcomes following pancreatoduodenectomy

BACKGROUND Enhanced recovery after surgery is steadily gaining importance in patients undergoing pancreatic surgery,including pancreatoduodenectomy(PD).While clinical pathways targeting enhanced-recovery can achieve their intended outcome in reducing length of stay,compliance to these pathways,and their relevance is poorly understood.The aim of this systematic review was to assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes.AIM To assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes.METHODS A systematic review of major reference databases was undertaken,according to preferred reporting items for systematic reviews and meta-analysis guidelines,between January 2000 and November 2020 relating to compliance with clinical pathways and its impact on outcomes in patients undergoing PD.A meta-analysis was performed using fixed-effects or random-effects models.RESULTS Eleven studies including 1852 patients were identified.Median overall compliance to all components of the clinical pathway was 65.7%[interquartile range(IQR):62.7%-72.3%]with median compliance to post-operative parameters of the clinical pathway being 44%(IQR:34.5%-52.25%).Meta-analysis using a fixed-effects model showed that≥50%compliance to a clinical pathway predicted significantly fewer post-operative complications[pooled odds ratio(OR):9.46,95%confidence interval(CI):5.00-17.90;P<0.00001]and a significantly shorter length of hospital stay[pooled mean difference(MD):4.32,95%CI:-3.88 to-4.75;P<0.0001].At 100%compliance which was associated with significantly fewer post-operative complications(pooled OR:11.25,95%CI:4.71-26.84;P<0.00001)and shorter hospital stay(pooled MD of 4.66,95%CI:2.81-6.51;P<0.00001).CONCLUSION Compliance to post-PD clinical pathways remains low.Deviations are associated with an increased risk of complications and length of hospital stay.Understanding the relevance of deviations to clinical pathways post-PD presents pancreatic surgeons with opportunities to actively pursue an enhanced-recovery of their patients.

Borderline resectable pancreatic tumors:Is there a need for further refinement of this stage?

BACKGROUND:The ideal treatment of patients with 'borderline resectable pancreatic tumors (BRTs)' needs to be established.Current protocols advise neoadjuvant chemo(radio)therapy,although some patients may appear to have BRT on preoperative imaging and a complete resection may be achieved without the need for vascular resection.The aim of the present study was to identify specific findings on preoperative imaging that could help predict in which patients with BRT a complete resection,with or without vascular resection (VR),could be achieved.METHODS:Twelve patients with BRTs were identified.Tumor location,maximum degree of circumferential contact (CC),length of contact of the tumor with major vessels (LC),and luminal narrowing of vessels at the point of contact with the tumor (venous deformity,VD) were graded on preoperatively acquired multidetector computed tomography (MDCT) images and then compared with the intraoperative findings and need for VR.RESULTS:A complete resection (R0) was achieved in 10 patients with 2 having microscopic positive margins (R1) on histopathology at the uncinate margin.Four of the 10 patients required VR (40%).In 3 of the 4 patients whose tumors required VRs,CC was ≥grade III and VD was grade 2.LC did not influence the need for VR.CONCLUSIONS:It is possible to achieve a complete resection at the first instance in patients found to have BRTs on preoperative imaging.Preoperative MDCT-based grading systems and our proposed criteria may help identify such patients,thus avoiding any delay in curative resections in such patients.