Full CH 1 _Lillemoe-9781496385574

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PART I Pancreas and Biliary Tract

TABLE 1.1  Critical (Enhanced Recovery) Pathway for Pancreaticoduodenectomy  (Continued) Postoperative day 1 Remove nasogastric tube, if present Start sips of water and ice chips @ 30 mL/h Out of bed ambulating Liberal gum chewing until discharge Discontinue sequential compression devices, continue TED stockings and

heparin subcutaneously Discontinue antibiotics Discontinue arterial catheter Drain amylase level Continue intravenous beta-blockade (if indicated), octreotide (if gland soft), and PPI Transfer from ICU to floor Clear liquid diet, ad lib or limited @ 30–60 mL/h Remove Foley catheter Minimize all IV fluids Begin diuresis and continue until discharge or patient reaches preoperative weight Drain amylase level Start azithromycin, 500 mg IV daily for motility Ambulate TID Clear liquid diet, ad lib or limited @ 30 to 60 mL/h Early drain removal if no postoperative pancreatic fistula Continue TEDs, subcutaneous heparin, blockade, and PPI until hospital discharge Ambulate QID Diabetic teaching and endocrine consult (if appropriate) Discontinue IV fluids Regular diet with pancreatic enzymes (if appropriate) Switch all medications to oral route including analgesics Remove Jackson–Pratt drain with lowest volume (if appropriate) Discuss pathology; Medical oncology and radiation oncology consults (if appropriate) Distribute preprinted discharge instructions Discharge home Arrange follow-up appointment for 4 weeks after discharge Discharge medications: PPI, pancreatic enzymes, analgesics, stool softeners

Postoperative day 2

Postoperative day 3

Postoperative Day 4

Postoperative day 5

Postoperative day 6 or 7

Modified from Kennedy EP, Rosato EL, Sauter PK, et al. Initiation of a critical pathway for pancreaticoduodenectomy at an academic institution-the first step in multidisciplinary team building. J Am Coll Surg . 2007;204(5):917-923. Copyright © 2007 American College of Surgeons. With permission. a Given an increasing trend toward neoadjuvant therapy for not only borderline-resectable but also resectable patients, preoper- ative stenting has, must needs, become more routine, despite mildly increased risk of surgical-site infections.

DEVIATIONS FROM THE PATHWAY (COMPLICATIONS) Any deviation from the ideal postoperative course as delineated by the critical pathway constitutes a complication. Defining and grading complications is an essential part of the care of pancreatico- biliary surgical patients. Defining and Grading of Complications The definition and grading of postoperative complications has been greatly facilitated by several recent publications. Clavien and colleagues, for instance, have, over the course of the last several decades, developed and refined a useful complication grading system. As this system, unlike other systems, is based on the intervention required to treat the complication (Table 1.2), it is highly repro- ducible and therefore more useful for comparing outcomes. Specific to pancreaticobiliary patients, the International Study Group of Pancreatic Surgery (ISGPS) has provided consensus definitions for common complications seen in a busy pan- creaticobiliary practice, including delayed gastric emptying (DGE) and POPF. Demonstration of the importance of universally accepted definitions is provided by these two common

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