Feasibility On The Implementation Of Enhanced Recovery After Surgery In Pancreatoduodenectomy (PD) And The Early-warning Value Of Urine Neutrophil Gelatinase-Associated Lipocalin For Acute Kidney Injury In PD

Enhanced Recovery After Surgery (ERAS) is the use of having a series of perioperative optimization strategy of evidence based medicine, block or reduce the stress response, and ultimately achieve the purpose of rapid recovery. ERAS has been widely applied and has achieved good clinical benefit in many surgical disciplines, but the implementation in pancreatoduodenectomy (PD) is lagging. We are the first in China to carry out clinical research applied the concept of ERAS to PD and the preliminary results show that the implementation of ERAS in PD is safe and efficient.Perioperative fluid management is an important part of Enhanced Recovery After Surgery. Restrictive fluid therapy can not meet the actual capacity requirements in some patients, easily lead to the occurrence of postoperative acute kidney injury (AKI). Neutrophil gelatinase-associated lipocalin (NGAL) is considered a diagnostic marker for early-warning of acute kidney injury, but its early-warning role in acute kidney injury after PD needs further investigation.Part One:Feasibility on the implementation of Enhanced Recovery After Surgery in pancreatoduodenectomy.Objective:To study the safety and efficacy of ERAS implemented to PD.Methods:Retrospectively analyzed the clinical data of 357 patients underwent PD and treated in Department of General Surgery, Nanjing General Hospital of Nanjing Military Command in July 2008 to December 2015. All patients were divided into the conventional group (191 cases) and ERAS group (166 cases). The demographic profile, preoperative and intraoperative parameters, postoperative recovery, morbidity and mortality of the patients in two groups were compared.Results:In two groups, preoperative and intraoperative parameters were similar except for preoperative biliary drainage. There were no significant difference between the ERAS and conventional groups in morbidity, mortality, and readmission. The ERAS group had an earlier recovery of gut motility, mobilization, and oral feeding. The hospital length of stay (LOS) and postoperative LOS in ERAS group were significant shorter than which in conventional group(P<0.05).Conclusion:ERAS program is applied to PD patients may facilitate postoperative recovery of gut motility, reduce the burden of health care without increasing the risk of complications, readmission and mortality. ERAS program is safe and efficient in the patients undergoing PD.Part Two:Early-warning value of urine neutrophil gelatinase-associated lipocalin for acute kidney injury in pancreatoduodenectomy.Objective:To study the early-warning role of urine neutrophil gelatinase-associated lipocalin (uNGAL) in acute kidney injury after PD.Methods:Detected uNGAL within preoperative 24h and postoperative Oh,2h,4h,6h, 12h,24h,48h of 70 patients underwent PD and treated in Department of General Surgery, Nanjing General Hospital of Nanjing Military Command in April 2015 to April 2016. Using receiver operating characteristic curve (ROC curve) evaluate the diagnostic value of uNGAL for AKI.Results:Using ROC curve evaluate the diagnostic value of uNGAL in postoperative 4h,6h and 12h for AKI, the area under curve (AUC) were respectively 0.852 [95%CI(0.758～0.946), P<0.05]、0.891 [95%CI(0.818～0.964), P<.05]、0.865 [95%CI(0.780～0.950), P<0.05]. When respectively 150.200,170ng/mL as the cutoff value, the sensitivity and specificity were 83.9% and 79.5%,80.6% and 84.6%,80.6 and 79.5%.Conclusion:The uNGAL had an early-warning value for AKI after PD. The uNGAL in postoperative 6h had the highest diagnostic value for AKI after PD, it was an ideal diagnostic marker.