Feasibility and Effectiveness of Three-day Discharge After Distal Pancreatectomy

1. BACKGROUND AND RATIONALE Over the years, improvements in the management of patients undergoing pancreatic surgery have contributed to enhancing postoperative outcomes and patient recovery. This progress is largely attributed to the centralization of care in high-volume centers. The integration of minimally invasive techniques (such as laparoscopic and robotic surgery), and the adoption of Enhanced Recovery After Surgery (ERAS) protocols. Despite these advancements, the average length of stay (LOS) after distal pancreatectomy (DP) remains around 5 to 7 days. Extended hospital stays often arise from postoperative complications, which occur in approximately 40% of cases following DP. Among these complications, clinically relevant pancreatic fistula (CR-POPF) is the most frequent, affecting up to one-third of patients. However, in most cases, POPF following DP is managed conservatively by simply maintaining the abdominal drain placed intraoperatively. POPF can eventually lead to intra-abdominal fluid collections but rarely to more severe complications such as delayed gastric emptying (DGE), and post-pancrectomy hemorrhage (PPH). Delays in hospital discharge often occur in patients who have already achieved functional recovery, but stay in the hospital due to nonclinical factors such as healthcare system culture or concerns from both surgeons and patients about early discharge.

An early discharge program in selected patients has been successfully demonstrated in colorectal and bariatric surgery. Studies indicate that performing these procedures in an outpatient setting is both feasible and safe, provided upon careful patient selection, patient education, strict adherence to ERAS protocols, and effective follow-up via phone or app-based systems. The advantages of outpatient surgery have been shown to reduce healthcare costs and decrease the wait times for surgery while maintaining equivalent care quality and readmission risk. Although outpatient surgery would be unrealistic for pancreatic surgery, an early discharge program (i.e., before POD5) to patients undergoing DP could yield similar benefits as observed after colorectal surgery. However, the feasibility of an early discharge program has yet to be evaluated in this specific population. The hypothesis is that an early discharge protocol could be effective and feasible in patients undergoing minimally invasive DP, within a preoperative educational program and an adequate telephone follow-up after discharge, without increasing access to ED visits or hospital readmission.

Previous experience and ongoing studies The Division of Pancreatic Surgery at San Raffaele Hospital is among the leading centers for pancreatic surgery in Italy, performing over 300 pancreatic resections annually for the past five years. A prospective quality-improvement registry has been maintained since 2015, encompassing perioperative data from over 2000 patients. In 2023 alone, our division conducted 340 pancreatic resections, including 205 pancreatoduodenectomies, 106 distal pancreatectomies, and 23 total pancreatectomies.

For DP, a minimally invasive approach is preferred for patients with benign or selected malignant lesions, based on factors such as lesion location, vascular involvement, and extent of parenchymal resection required. In our experience, approximately two-thirds of DPs are performed laparoscopically, with a conversion rate to open surgery lower than 10%. Postoperative discharge typically occurs around 7 days after surgery (IQR 6-10), with functional recovery achieved by day 5 (IQR 4-6). Discharge criteria include the ability to tolerate solid food, independence from intravenous fluids, restored gastrointestinal function, sufficient pain management with oral analgesics, independent mobilization, the absence of clinical complications, and the patient's willingness to leave the hospital. In our previous experience, 30% of patients achieved discharge criteria within three days after surgery and underwent an early discharge without 30-day emergency department (ED) visits or hospital readmission, underling the safety of an early discharge protocol. Similar results were found in a different study by the University Hospital Southampton researchers, where they have shown that implementation of ERP (enhanced recovery programme) optimizes outcomes for laparoscopic distal pancreatectomy, with significant earlier return to normal gut function and reduced length of stay, with a median length of stay of 3 days after surgery, without increasing the readmission rate.

For patients with pancreatic fistula, discharge often involves an abdominal drain, with follow-up outpatient visits on POD 7 and POD 15.