Implementation of enhanced recovery after surgery for pancreatoduodenectomy increases the proportion of patients achieving textbook outcome: A retrospective cohort study.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) for patients undergoing pancreatoduodenectomy is associated with reduced length of stay (LOS) and morbidity. However, external validating of the impact is difficult due to the multimodal aspects of ERAS. This study aimed to assess implementation of ERAS for pancreatoduodenectomy with a composite measure of multiple ideal outcome indicators defined as 'textbook outcome' (TBO). METHODS: In a tertiary referral center, 250 patients undergoing pancreatoduodenectomy were included in ERAS (May 2012-January 2017) and compared to a cohort of 125 patients undergoing traditional perioperative management (November 2009-April 2012). TBO was defined as proportion of patients without prolonged LOS, Clavien-Dindo ≥ III complications, postoperative pancreatic fistula, postpancreatectomy hemorrhage, bile leakage, readmissions or 30-day/in-hospital mortality. Additionally, overall treatment costs were calculated and compared using bootstrap independent t-test. RESULTS: The two cohorts were comparable in terms of demographic and surgical details. Implementation of ERAS was associated with reduced median LOS (10 days vs 13 days, p < 0.001) and comparable overall complication rate (62.0% vs 61.6%, p = 0.940) when compared to the traditional management group. In addition, a higher proportion of patients achieved TBO (56.4% vs 44.0%, p = 0.023) when treated according to ERAS principles. Furthermore, ERAS was associated with reduced mean total costs (£18132 vs £19385, p < 0.005). CONCLUSION: Implementation of ERAS for patients undergoing pancreatoduodenectomy is beneficial for both patients and hospitals. ERAS increased the proportion of patients achieving TBO and reduced overall costs. TBO is a potential measure for the evaluation of ERAS.

Early and long-term outcomes of re-sternotomy for aortic valve replacement with patent coronary artery grafts.

OBJECTIVE: The aim was to evaluate early and long-term outcomes of re-sternotomy for aortic valve replacement (AVR) with previous patent coronary artery grafts. METHODS: Data for re-sternotomy for AVRs (group 1 isolated AVR, group 2 AVR with concomitant procedure) were collected (2000-2019). Logistic regression analysis was performed to identify predictors of in-hospital mortality and postoperative composite outcome (in-hospital death, transient ischemic attack/stroke, renal failure requiring new hemofiltration, deep sternal wound infection, re-exploration for bleeding/tamponade and length of stay >30 days). Survival curves were compared using log-rank test Cox proportion hazards model was used for predictors of long-term survival. RESULTS: Total 178 patients were included (groups 1-90 patients, group 2-88 patients). Mean age was 75 ± 4 years and mean log EuroSCORE was 17 ± 12% (15 ± 8% - group 1 vs. 19 ± 14% - group 2, p = 0.06). Mean follow-up was 6.3 ± 4.4 years. Cardiovascular injury occurred in 12%. Left internal mammary artery was most commonly injured. In-hospital mortality was 7.8% (5% - group 1 vs. 10.2% - group 2, p = 0.247). NYHA class III-IV, perioperative intra-aortic balloon pump and cardiovascular injury were independent predictors of in-hospital mortality (hazard ratio: 13.33, 95% confidence interval: 2.04-83.33, p = 0.007). Survival was significantly worse with cardiovascular injury at re-sternotomy up to 5 years (46% vs. 67%, p = 0.025) and postoperative complications (p = 0.023). Survival was significantly lower than age-matched first-time AVR and UK population. CONCLUSIONS: Long-term survival is significantly impaired by cardiovascular injury and perioperative complications of re-sternotomy.