Early discharge after Whipple safe for low-risk patients

Last Updated: 2019-02-05

By Will Boggs MD

NEW YORK (Reuters Health) - Low-risk patients can be safely discharged five days after pancreaticoduodenectomy (PD, i.e., a Whipple operation), according to results from a randomized controlled trial.

"The premise for the study is that once the medical aspects are taken care of after a major surgery, such as the Whipple operation, patients actually recover better (improved sleep, food, activity) at home (and) are much less at risk for infectious complications that can occur in hospitals," Dr. Harish Lavu from Thomas Jefferson University in Philadelphia told Reuters Health by email.

Dr. Lavu and colleagues developed the Whipple Accelerated Recovery Pathway (WARP) for patients at low to moderate risk of perioperative complications and evaluated whether it could reduce hospital length of stay without increasing readmissions or PD-associated complications, compared with their standard post-PD pathway targeting hospital discharge on postoperative day (POD) 7.

WARP, which targeted hospital discharge on POD day 5, included the establishment of early discharge goals with patients and families, shortened ICU stay, a modified postoperative dietary and drain management algorithm, rigorous physical therapy with an in-hospital gym visit, standardized rectal suppository administration, and close telehealth follow-up after hospital discharge.

In the primary endpoint interim analysis, the rate of POD 5 discharge was 74.3% (26/35) in the WARP group versus only 14.3% (5/35) in the control group, which prompted early halting of the trial.

In the final analysis, 75.7% (28/37) of WARP patients were discharged by POD 5, compared with 12.8% (5/39) of control patients, with no significant difference in hospital readmission rates between the groups (8.1% versus 10.3%, respectively), the authors reported January 17th online in the Journal of the American College of Surgeons.

There were nominally fewer postoperative complications in the WARP group (29.7%) than in the control group (43.6%) (p=0.24), and significantly fewer patients randomized to WARP (13.5% vs 41.0%) required nasogastric tube reinsertion. Other postoperative interventions occurred with similar frequency in both treatment groups.

There were no deaths in either group in the first 60 postoperative days.

Among patients with periampullary malignancy, the median time to initiation of adjuvant therapy was significantly shorter in the WARP group (51 days) than in the control group (66 days).

"One of the really pleasant surprises in the findings was the dramatic reduction in time to commencement of adjuvant therapy, which has been shown to increase long-term survival in pancreas cancer patients," Dr. Lavu said.

Median hospital charges were significantly lower in the WARP group ($139,735) than in the control group ($155,542).

"With the success of this study in low-to-moderate risk patients, we opened it up to all-comers, including those with substantial comorbidities," Dr. Lavu said. "What we found was that in the next 134 patients who underwent the Whipple operation at our institution after the study closed, but implementing the WARP protocol, 42% of patients went home in 5 days and 67% by 6 days, with a median length of stay of 6 days. The average length of stay currently in high-volume centers in the U.S. for Whipple patients is 9 days."

"Using the latest surgical techniques and perioperative science, it is possible today to recover patients from major surgery faster and with better outcomes than at any time in history," he said.

Dr. Venu G. Pillarisetty and Dr. Sara K. Daniel from University of Washington School of Medicine in Seattle, who recently reported results of their enhanced recovery protocol for PD patients, told Reuters Health by email, "From the presented data, it's not clear if the described WARP protocol would benefit patients with more comorbidities, but our recently published data using an Enhanced Recovery After Surgery (ERAS) pathway for the Whipple procedure demonstrate that early discharge is possible for a broad array of patients. Our study had a 64% rate of five-day or earlier discharge, despite the inclusion of 41% of patients with a soft pancreas and 30% who had a vascular resection. Additionally, we found a less than 15% ICU admission rate in our series, which included many high-risk patients."

"Carefully studying potential ways to improve already high-quality care is critically important to advancing clinical care," they said. "Ideally, pathways are created that can be used for the average patient, rather than just the exceptional ones."

SOURCE: http://bit.ly/2SArPm4

J Am Coll Surg 2019.