Background
In pancreatic cancer, multidisciplinary approach with adjuvant chemotherapy is one of the key elements to provide optimal long term and disease-free survival. Pancreatic resection is a major surgery with a risk of complications up to 40%, which may delay the first cycle of adjuvant chemotherapy. Enhanced Recovery after surgery (ERAS) is a multimodal strategy that aim to reduce the physiological stress induced by surgery. ERAS is evidence based and reduces morbidity, hospital stays, and consequently costs. It enhances recovery by reducing surgical stress, by optimal pain control, early oral diet, early mobilization and strict fluid balance.
Study aim
The aim of this study was to analyse whether patients with high compliance to ERAS protocol in pancreatic surgery for cancer have a reduction in the delay to first chemotherapy cycle after surgery.
Methods
This analysis is based on data from medical records of all consecutive ERAS patients hospitalized in CHUV (Centre Hospitalier Universitaire Vaudois) between 2012 and 2016, who underwent pancreatic surgery for cancer (pancreatic duct adenocarcinoma, malignant ampulloma, duodenal carcinoma) followed by adjuvant chemotherapy.
The primary end-point of the study was to assess the impact of perioperative compliance to ERAS on the delay between surgery and first cycle of adjuvant chemotherapy using Poisson regression model. The secondary end-point was to analyse overall and disease free survivals, surgical complications (according to the Comprehensive Complication Index (CCI) and Dindo- Clavien classification) and readmission rates.
Results
A total of 89 patients who underwent adjuvant chemotherapy were included. Overall, median compliance to ERAS was 63% (IQR 59-70) and median delay to adjuvant chemotherapy was 50 days (IQR 41-61). Median OS and DFS were 20 months (IQR 13-36) and 12 months (IQR 8-22). Readmission rate within 90 days after discharge is 22%. High compliance to ERAS protocol (367%) did not affect time to first cycle of adjuvant chemotherapy. However, high CCI, age over 65 years and ASA3 patients had a longer interval between surgery and first cycle of adjuvant chemotherapy. High CCI is associated with an earlier recurrence of the disease (median variation of 6 months).
Conclusion
While high compliance to ERAS protocol did not affect the time to first cycle of adjuvant chemotherapy, postoperative complications, age over 65 years and high ASA score increase the delay between surgery and adjuvant chemotherapy for patients with pancreatic malignancies. Postoperative complications are also correlated with earlier recurrence of the disease. More prospective studies using strict ERAS protocol are needed to confirm these results.