<clinical_study>
  <!-- This xml conforms to an XML Schema at:
    https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
  <required_header>
    <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
    <link_text>Link to the current ClinicalTrials.gov record.</link_text>
    <url>https://clinicaltrials.gov/ct2/show/NCT03757455</url>
  </required_header>
  <id_info>
    <org_study_id>R18125</org_study_id>
    <nct_id>NCT03757455</nct_id>
  </id_info>
  <brief_title>ERAS Protocol in Pancreaticoduodenectomy and Total Pancreatectomy</brief_title>
  <official_title>Enhanced Recovery Versus Standard Recovery After Low-risk Pancreatoduodenectomy Identified With Acinar Cell Count or Total Pancreatectomy: a Randomized Controlled Trial</official_title>
  <sponsors>
    <lead_sponsor>
      <agency>Tampere University Hospital</agency>
      <agency_class>Other</agency_class>
    </lead_sponsor>
  </sponsors>
  <source>Tampere University Hospital</source>
  <oversight_info>
    <has_dmc>No</has_dmc>
    <is_fda_regulated_drug>No</is_fda_regulated_drug>
    <is_fda_regulated_device>No</is_fda_regulated_device>
  </oversight_info>
  <brief_summary>
    <textblock>
      In the study, the enhanced recovery after surgery (ERAS) program is applied to total&#xD;
      pancreatectomy (TP) and low-risk pancreaticoduodenectomy (PD) patients identified by a small&#xD;
      number of acinar cells in the cut edge of the pancreas. The research setting is randomized&#xD;
      and controlled. All patients arriving at the Tampere University Hospital (TAUH) for PD or TP&#xD;
      surgery are recruited into the study. Recruited patients are randomized to the ERAS protocol&#xD;
      and to the standard protocol recovery program. The ERAS program differs from the normal care&#xD;
      protocol preoperatively, intraoperatively and postoperatively as explained in the following&#xD;
      section.&#xD;
&#xD;
      In the ERAS protocol, both on the previous day of the surgery and on the following days, the&#xD;
      patient is discussed with the patient about the benefits of the protocol used and the&#xD;
      recovery program objectives. The purpose is to motivate and encourage the patient. On the day&#xD;
      of surgery, the patient's intake of food and fluids is allowed to be closer to the surgery&#xD;
      and the patient is also given a carbohydrate drink two hours before surgery. The nasogastric&#xD;
      tube set at the beginning of surgery is removed at the end of the surgery and peripancreatic&#xD;
      or perihepatic drains are not routinely placed. After surgery, drinking is allowed after four&#xD;
      hours and the patient is encouraged to move as actively as possible in the bed. On the first&#xD;
      and second postoperative day, the patient is allowed to enjoy normal food and drink according&#xD;
      to his or her ability, and pancreatic capsules are given in the course of food. Additionally,&#xD;
      the analgesic to be administered through the epidural cannula is dosed as far as possible to&#xD;
      allow mobilization of the patient. The discussion on the benefits and recovery targets of the&#xD;
      ERAS protocol are continued. On the third postoperative day, the epidural infusion is&#xD;
      discontinued and the pain medication is moved to opioid-based pain management. This is&#xD;
      continued until specific criteria for passing to the follow-up care are met.&#xD;
&#xD;
      Typical complications (pancreatic fistula, delayed gastric emptying, postpancreatectomy&#xD;
      hemorrhage) are registered during hospitalization and their severity ratings according to&#xD;
      ISGPS, ISPGF and Clavien-Dindo classifications are also determined. Other variables&#xD;
      registered are the number of intensive care days, situations requiring new surgeries, 30 and&#xD;
      90 day mortality, the completion time of the criteria for passing to follow up care, and the&#xD;
      total length of hospitalization. In addition, the need for readmissions is registered. The&#xD;
      implementation of the ERAS protocol is followed by a separate tracking template, in which the&#xD;
      nurses record the progress of the goals specified in the protocol on a daily basis. The&#xD;
      results of the study are analyzed with the intention-to-treat principle.&#xD;
    </textblock>
  </brief_summary>
  <detailed_description>
    <textblock>
      In the study, the enhanced recovery after surgery (ERAS) program is applied to total&#xD;
      pancreatectomy (TP) and low-risk pancreaticoduodenectomy (PD) patients identified by a small&#xD;
      number of acinar cells in the cut edge of the pancreas. The research setting is randomized&#xD;
      and controlled. All patients arriving at the Tampere University Hospital (TAUH) for PD or TP&#xD;
      surgery are recruited into the study. Patients will be sent a handout of the study along with&#xD;
      the letter of invitation for the surgery itself. Recruitment takes place at the first&#xD;
      appointment of the surgery where the surgeon presents the study to the patient. If the&#xD;
      patient wishes to participate in the study, the patient issues a signature on the consent&#xD;
      form. They are randomized to this ERAS program for shortened recovery period and a standard&#xD;
      protocol recovery program. Allocation to the groups takes place using opaque envelope-coded&#xD;
      randomization codes. The research nurse prepares the envelopes in twelve patient&#xD;
      randomization blocs.&#xD;
&#xD;
      To determine the low risk PD-patients recruited, the pathologial sample of the cut-edge of&#xD;
      the pancreas is analyzed by pathologist during the surgery. If the pancreatic cut-edge&#xD;
      contains less than 40% acinar cells, the patients is considered low risk patient. This method&#xD;
      is based on earlier studies in our pancreatic research group. All TP patients are per se in&#xD;
      the small complication risk group. Only those patients with a low risk of complications&#xD;
      continue to be involved in the study in standardized or ERAS protocol groups according to the&#xD;
      original allocation.&#xD;
&#xD;
      ERAS protocol consist of following actions in comparison to standard protocol:&#xD;
&#xD;
      First appointment:&#xD;
&#xD;
      - Enlightenment on the benefits and objectives of the ERAS protocol&#xD;
&#xD;
      Call to the patient day before the surgery:&#xD;
&#xD;
        -  Discussing the course, benefits and goals of care in ERAS&#xD;
&#xD;
        -  4 dl PreOp drink before bedtime&#xD;
&#xD;
      Operation day:&#xD;
&#xD;
        -  Fluid intake allowed 2 hours before surgery&#xD;
&#xD;
        -  2 dl PreOP drink 2 h before cutting&#xD;
&#xD;
      Intraoperative:&#xD;
&#xD;
        -  Drains in the peripancreatic or perihepatic regions are not set unless the surgeon sees&#xD;
           this particular reason&#xD;
&#xD;
        -  The nasogastric tube is removed at the end of the surgery&#xD;
&#xD;
      Postoperative:&#xD;
&#xD;
        -  Mobilization with nurses assisted, possibly sitting on the edge of the bed if possible&#xD;
&#xD;
        -  Drinks allowed after 4h surgery&#xD;
&#xD;
      Postoperative day 1:&#xD;
&#xD;
        -  Drinking and normal food by mouth according to the patient's capabilities&#xD;
&#xD;
        -  Removal of urinary catheter&#xD;
&#xD;
        -  Intravenous liquids only if needed&#xD;
&#xD;
        -  Mobilization physiotherapist and nurse guided as actively as possible&#xD;
&#xD;
        -  Pain management by epidural cannula at the level to make mobilization possible&#xD;
&#xD;
        -  Discussion of the ERAS protocol (objectives, benefits, time of passing to follow up&#xD;
           care) (also continues on the following days) and encouragement&#xD;
&#xD;
        -  If drains are set: amylase tests&#xD;
&#xD;
        -  Pancreatin capsules per os before eating, 25,000 IU 1-2 capsules on big meals and 1 on&#xD;
           snack (continued on the following days)&#xD;
&#xD;
      Postoperative day 2:&#xD;
&#xD;
      - Mobilization: As much as possible, autonomous movement&#xD;
&#xD;
      Postoperative day 3:&#xD;
&#xD;
        -  Ending epidural infusion, cannula removal later if p.o. medication is sufficient&#xD;
&#xD;
        -  As independent as possible&#xD;
&#xD;
      Pain relief: oxycodone / naloxone p.o. to keep mobilization possible:&#xD;
&#xD;
        1. 2x 5 / 2.5 mg ≤ 60 kg&#xD;
&#xD;
        2. 2x 10/5 mg&gt; 60 kg&#xD;
&#xD;
        3. 2x 15 / 7.5&gt; 100kg. In addition, paracetamol 1g three times a day p.o.&#xD;
&#xD;
      Postoperative day 4:&#xD;
&#xD;
        -  Support and encouragement continues&#xD;
&#xD;
        -  Pain management at a level that allows mobility&#xD;
&#xD;
        -  Passing to follow up care when following criteria are met:&#xD;
&#xD;
             1. The patient should be able to enjoy at least two meals without significant nausea&#xD;
&#xD;
             2. Bowel movements returned&#xD;
&#xD;
             3. The patient should be able to move, urinate, and perform daily operations at&#xD;
                pre-operative level&#xD;
&#xD;
             4. The patient does not need strong analgesics when moving&#xD;
&#xD;
             5. The temperature, pulse rate, blood pressure and respiratory rate should be in the&#xD;
                reference range or pre-cut level.&#xD;
&#xD;
             6. The patient has no signs of bleeding.&#xD;
&#xD;
        -  Pain medication changes to tramadol 100 mg three times a day when discharged&#xD;
&#xD;
      For all those involved in the study, PD's surgery technique is standardized to classic&#xD;
      Whipple surgery, submersion bowel-pancreatic seam, antecholic gastro-jejunostomy and&#xD;
      entero-entero anastomosis.&#xD;
&#xD;
      The patient is left out of the study if a patient is undergoing another surgery than PD, TP&#xD;
      or does not undergo surgery at all. Likewise, the study is suspended from the consideration&#xD;
      of the surgeon if, for any other reason, the patient may be expected to be a high&#xD;
      complication risk patient.&#xD;
&#xD;
      Typical complications (pancreatic fistula, delayed gastric emptying, postpancreatectomy&#xD;
      hemorrhage) are registered during hospitalization and their severity ratings according to&#xD;
      ISGPS, ISPGF and Clavien-Dindo classifications are also determined. Other variables&#xD;
      registered are the number of intensive care days, situations requiring new surgeries, 30 and&#xD;
      90 day mortality, the completion time of the criteria for passing to follow up care, and the&#xD;
      total length of hospitalization. In addition, the need for readmissions is registered. The&#xD;
      implementation of the ERAS protocol is followed by a separate tracking template, in which the&#xD;
      nurses record the progress of the goals specified in the protocol on a daily basis. The&#xD;
      results of the study are analyzed with the intention-to-treat principle.&#xD;
&#xD;
      The main variable of the study is the treatment period at the university hospital. The side&#xD;
      variables are the total treatment time, the total amount of complications, and the number of&#xD;
      readmissions. The hypothesis is that recovery is faster in the ERAS group, but the occurrence&#xD;
      of complications and readmissions are the same in both groups.&#xD;
&#xD;
      A statistical power calculation, assuming 80% statistical power (1-β) and 5% significance&#xD;
      level (α), was carried out with a continuous outcome superiority trial. The sample size was&#xD;
      calculated using the main coefficient of variation assuming that in the standard protocolled&#xD;
      patients the median of the discharge time is nine days and in the ERAS program for seven&#xD;
      days, i.e. a presumption of approximately 20% decrease in treatment days. Three days were&#xD;
      assumed to be the standard deviation. The sample size thus obtained is 36 per group, which is&#xD;
      rounded up to approximately 80 patients in total.&#xD;
&#xD;
      When evaluating the time spent collecting the data, it is assumed that 20% of the patients&#xD;
      will drop out of the study for various reasons. In TAUH, approximately 100 PDs and 15 TP&#xD;
      patients are operated in two years and approximately 70% of patients of PD are in a low risk&#xD;
      of complications. Consequently, the number of patients to be collected in two years would be&#xD;
      approximately 0.7 ∙ 0.8 ∙ 100 + 0.8 ∙ 15 ≈ 68, which is almost sufficient for the purpose of&#xD;
      this study to achieve statistical significance. The estimated duration of the study is&#xD;
      therefore little more than two years. However, the study will be continued as long as&#xD;
      necessary to collect the required number of patients. When half of the final number of&#xD;
      patients has been collected, an interim analysis is made of the differences in the groups. If&#xD;
      the results of the ERAS protocol are at least as good as the standard group, the study will&#xD;
      be continued.&#xD;
&#xD;
      All recruited patients are asked for written consent for participation in the study. The&#xD;
      research file is stored in the TAUH research register. Patient information and research&#xD;
      results are treated confidentially in the manner required by the Finnish Personal Data Act.&#xD;
      The final research results are reported at group level and the identification of individual&#xD;
      investigators is not possible. The research funding is provided by the Tampereen Pancreatic&#xD;
      Research Group the largest funders being the State Research Fund and Sigrid Jusélius&#xD;
      Foundation. Also Finnish Medicine Foundation in providing personal funding.&#xD;
&#xD;
      The research has been approved by the Ethics Committee of the Tampere University Hospital.&#xD;
      The earlier ERAS studies have shown that their use is safe and in most cases beneficial to&#xD;
      the patient. In this study, it is novel that only small complication risk patients are&#xD;
      included in the study. In addition, halfway between the research is performed an interim&#xD;
      analysis to ensure the safety of the ERAS protocol. Patient's own consent is asked before&#xD;
      surgery, and information on the research is provided within the limits of the success of the&#xD;
      study. Patient's refusal or suspension of study does not affect the patient's treatment in&#xD;
      any way.&#xD;
    </textblock>
  </detailed_description>
  <overall_status>Terminated</overall_status>
  <why_stopped>
    Not enought participants&#xD;
  </why_stopped>
  <start_date type="Actual">September 1, 2020</start_date>
  <completion_date type="Actual">October 1, 2021</completion_date>
  <primary_completion_date type="Actual">October 1, 2021</primary_completion_date>
  <phase>N/A</phase>
  <study_type>Interventional</study_type>
  <has_expanded_access>No</has_expanded_access>
  <study_design_info>
    <allocation>Randomized</allocation>
    <intervention_model>Parallel Assignment</intervention_model>
    <intervention_model_description>Randomized controlled trial</intervention_model_description>
    <primary_purpose>Treatment</primary_purpose>
    <masking>Single (Participant)</masking>
  </study_design_info>
  <primary_outcome>
    <measure>Days until discharge from university hospital</measure>
    <time_frame>Up to 24 weeks</time_frame>
    <description>Time in days since the entry to hospital on the surgery day to the discharge day to follow up care or home</description>
  </primary_outcome>
  <secondary_outcome>
    <measure>Days until discharge from follow up care</measure>
    <time_frame>Up to 24 weeks</time_frame>
    <description>Time in days since the entry to hospital on the surgery day to the discharge day from the follow up care</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>Total number of complications</measure>
    <time_frame>Postoperatively up to 24 weeks</time_frame>
    <description>Total number of postoperative complications</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>Readmission frequency</measure>
    <time_frame>From the discharge up to 24 weeks for any cause related to surgery</time_frame>
    <description>Number of readmissions in contrast to total patient number</description>
  </secondary_outcome>
  <number_of_arms>2</number_of_arms>
  <enrollment type="Actual">35</enrollment>
  <condition>Pancreatic Cancer</condition>
  <condition>Surgery--Complications</condition>
  <condition>Pancreatic Fistula</condition>
  <condition>Delayed Gastric Emptying</condition>
  <condition>Pancreatic Hemorrhage</condition>
  <arm_group>
    <arm_group_label>Enchanced recovery after surgery protocol</arm_group_label>
    <arm_group_type>Experimental</arm_group_type>
    <description>ERAS-protocol as described in low risk patients after pancreaticoduodenectomy or total pancreatectomy</description>
  </arm_group>
  <arm_group>
    <arm_group_label>Standard protocol</arm_group_label>
    <arm_group_type>No Intervention</arm_group_type>
    <description>Standard recovery protocol after pancreaticoduodenectomy or total pancreatectomy</description>
  </arm_group>
  <intervention>
    <intervention_type>Procedure</intervention_type>
    <intervention_name>ERAS protocol preoperative actions</intervention_name>
    <description>First appointment:&#xD;
- Enlightenment on the benefits and objectives of the ERAS protocol&#xD;
Call to the patient day before the surgery:&#xD;
Discussing the course, benefits and goals of care in ERAS 4 dl PreOp drink before bedtime&#xD;
Operation day:&#xD;
Fluid intake allowed 2 hours before surgery 2 dl PreOP drink 2 h before cutting</description>
    <arm_group_label>Enchanced recovery after surgery protocol</arm_group_label>
  </intervention>
  <intervention>
    <intervention_type>Procedure</intervention_type>
    <intervention_name>ERAS protocol intraoperative actions</intervention_name>
    <description>Intraoperative:&#xD;
Drains in the peripancreatic or perihepatic regions are not set unless the surgeon sees this particular reason The nasogastric tube is removed at the end of the surgery</description>
    <arm_group_label>Enchanced recovery after surgery protocol</arm_group_label>
  </intervention>
  <intervention>
    <intervention_type>Procedure</intervention_type>
    <intervention_name>ERAS protocol postoperative actions</intervention_name>
    <description>Postoperatively:&#xD;
Mobilization with nurses assisted Drinks allowed after 4h surgery&#xD;
POP 1:&#xD;
Drinking and normal food Removal of urinary catheter Intravenous liquids only if needed Mobilization Pain management by epidural cannula Discussion of the ERAS protocol Pancreatin capsules per os before eating&#xD;
Postoperative day 2:&#xD;
- Mobilization: As much as possible, autonomous movement&#xD;
Postoperative day 3:&#xD;
Ending epidural infusion cannula removal Mobilization as independently as possible&#xD;
Pain relief: oxycodone/naloxone p.o. to keep mobilization possible:&#xD;
Postoperative day 4:&#xD;
Support and encouragement continues Pain management at a level that allows mobility</description>
    <arm_group_label>Enchanced recovery after surgery protocol</arm_group_label>
  </intervention>
  <eligibility>
    <criteria>
      <textblock>
        Inclusion Criteria:&#xD;
&#xD;
          -  All PD or TP patients 18-99 years old&#xD;
&#xD;
        Exclusion Criteria:&#xD;
&#xD;
          -  Any other surgery than PD or TP&#xD;
&#xD;
          -  High risk patients&#xD;
&#xD;
          -  Refusal for the study&#xD;
      </textblock>
    </criteria>
    <gender>All</gender>
    <minimum_age>18 Years</minimum_age>
    <maximum_age>99 Years</maximum_age>
    <healthy_volunteers>No</healthy_volunteers>
  </eligibility>
  <overall_official>
    <last_name>Johanna Laukkarinen, MD-PhD</last_name>
    <role>Study Director</role>
    <affiliation>Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland</affiliation>
  </overall_official>
  <location>
    <facility>
      <name>Tampere University Hospital Deparment of Gastroenterologic Surgery</name>
      <address>
        <city>Tampere</city>
        <zip>33521</zip>
        <country>Finland</country>
      </address>
    </facility>
  </location>
  <location_countries>
    <country>Finland</country>
  </location_countries>
  <verification_date>November 2021</verification_date>
  <study_first_submitted>November 13, 2018</study_first_submitted>
  <study_first_submitted_qc>November 27, 2018</study_first_submitted_qc>
  <study_first_posted type="Actual">November 29, 2018</study_first_posted>
  <last_update_submitted>November 27, 2021</last_update_submitted>
  <last_update_submitted_qc>November 27, 2021</last_update_submitted_qc>
  <last_update_posted type="Actual">December 9, 2021</last_update_posted>
  <responsible_party>
    <responsible_party_type>Sponsor</responsible_party_type>
  </responsible_party>
  <condition_browse>
    <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
    <mesh_term>Pancreatic Fistula</mesh_term>
    <mesh_term>Gastroparesis</mesh_term>
    <mesh_term>Hemorrhage</mesh_term>
    <mesh_term>Fistula</mesh_term>
  </condition_browse>
  <!-- Results have not yet been posted for this study                                          -->
</clinical_study>


download date: ClinicalTrials.gov processed this data on September 20, 2023
link text: Link to the current ClinicalTrials.gov record.
url: https://clinicaltrials.gov/ct2/show/NCT03757455
org study id: R18125
nct id: NCT03757455
lead sponsor: 
has dmc: No
is fda regulated drug: No
is fda regulated device: No
In the study, the enhanced recovery after surgery (ERAS) program is applied to total
      pancreatectomy (TP) and low-risk pancreaticoduodenectomy (PD) patients identified by a small
      number of acinar cells in the cut edge of the pancreas. The research setting is randomized
      and controlled. All patients arriving at the Tampere University Hospital (TAUH) for PD or TP
      surgery are recruited into the study. Recruited patients are randomized to the ERAS protocol
      and to the standard protocol recovery program. The ERAS program differs from the normal care
      protocol preoperatively, intraoperatively and postoperatively as explained in the following
      section.

      In the ERAS protocol, both on the previous day of the surgery and on the following days, the
      patient is discussed with the patient about the benefits of the protocol used and the
      recovery program objectives. The purpose is to motivate and encourage the patient. On the day
      of surgery, the patient's intake of food and fluids is allowed to be closer to the surgery
      and the patient is also given a carbohydrate drink two hours before surgery. The nasogastric
      tube set at the beginning of surgery is removed at the end of the surgery and peripancreatic
      or perihepatic drains are not routinely placed. After surgery, drinking is allowed after four
      hours and the patient is encouraged to move as actively as possible in the bed. On the first
      and second postoperative day, the patient is allowed to enjoy normal food and drink according
      to his or her ability, and pancreatic capsules are given in the course of food. Additionally,
      the analgesic to be administered through the epidural cannula is dosed as far as possible to
      allow mobilization of the patient. The discussion on the benefits and recovery targets of the
      ERAS protocol are continued. On the third postoperative day, the epidural infusion is
      discontinued and the pain medication is moved to opioid-based pain management. This is
      continued until specific criteria for passing to the follow-up care are met.

      Typical complications (pancreatic fistula, delayed gastric emptying, postpancreatectomy
      hemorrhage) are registered during hospitalization and their severity ratings according to
      ISGPS, ISPGF and Clavien-Dindo classifications are also determined. Other variables
      registered are the number of intensive care days, situations requiring new surgeries, 30 and
      90 day mortality, the completion time of the criteria for passing to follow up care, and the
      total length of hospitalization. In addition, the need for readmissions is registered. The
      implementation of the ERAS protocol is followed by a separate tracking template, in which the
      nurses record the progress of the goals specified in the protocol on a daily basis. The
      results of the study are analyzed with the intention-to-treat principle.
In the study, the enhanced recovery after surgery (ERAS) program is applied to total
      pancreatectomy (TP) and low-risk pancreaticoduodenectomy (PD) patients identified by a small
      number of acinar cells in the cut edge of the pancreas. The research setting is randomized
      and controlled. All patients arriving at the Tampere University Hospital (TAUH) for PD or TP
      surgery are recruited into the study. Patients will be sent a handout of the study along with
      the letter of invitation for the surgery itself. Recruitment takes place at the first
      appointment of the surgery where the surgeon presents the study to the patient. If the
      patient wishes to participate in the study, the patient issues a signature on the consent
      form. They are randomized to this ERAS program for shortened recovery period and a standard
      protocol recovery program. Allocation to the groups takes place using opaque envelope-coded
      randomization codes. The research nurse prepares the envelopes in twelve patient
      randomization blocs.

      To determine the low risk PD-patients recruited, the pathologial sample of the cut-edge of
      the pancreas is analyzed by pathologist during the surgery. If the pancreatic cut-edge
      contains less than 40% acinar cells, the patients is considered low risk patient. This method
      is based on earlier studies in our pancreatic research group. All TP patients are per se in
      the small complication risk group. Only those patients with a low risk of complications
      continue to be involved in the study in standardized or ERAS protocol groups according to the
      original allocation.

      ERAS protocol consist of following actions in comparison to standard protocol:

      First appointment:

      - Enlightenment on the benefits and objectives of the ERAS protocol

      Call to the patient day before the surgery:

        -  Discussing the course, benefits and goals of care in ERAS

        -  4 dl PreOp drink before bedtime

      Operation day:

        -  Fluid intake allowed 2 hours before surgery

        -  2 dl PreOP drink 2 h before cutting

      Intraoperative:

        -  Drains in the peripancreatic or perihepatic regions are not set unless the surgeon sees
           this particular reason

        -  The nasogastric tube is removed at the end of the surgery

      Postoperative:

        -  Mobilization with nurses assisted, possibly sitting on the edge of the bed if possible

        -  Drinks allowed after 4h surgery

      Postoperative day 1:

        -  Drinking and normal food by mouth according to the patient's capabilities

        -  Removal of urinary catheter

        -  Intravenous liquids only if needed

        -  Mobilization physiotherapist and nurse guided as actively as possible

        -  Pain management by epidural cannula at the level to make mobilization possible

        -  Discussion of the ERAS protocol (objectives, benefits, time of passing to follow up
           care) (also continues on the following days) and encouragement

        -  If drains are set: amylase tests

        -  Pancreatin capsules per os before eating, 25,000 IU 1-2 capsules on big meals and 1 on
           snack (continued on the following days)

      Postoperative day 2:

      - Mobilization: As much as possible, autonomous movement

      Postoperative day 3:

        -  Ending epidural infusion, cannula removal later if p.o. medication is sufficient

        -  As independent as possible

      Pain relief: oxycodone / naloxone p.o. to keep mobilization possible:

        1. 2x 5 / 2.5 mg ≤ 60 kg

        2. 2x 10/5 mg> 60 kg

        3. 2x 15 / 7.5> 100kg. In addition, paracetamol 1g three times a day p.o.

      Postoperative day 4:

        -  Support and encouragement continues

        -  Pain management at a level that allows mobility

        -  Passing to follow up care when following criteria are met:

             1. The patient should be able to enjoy at least two meals without significant nausea

             2. Bowel movements returned

             3. The patient should be able to move, urinate, and perform daily operations at
                pre-operative level

             4. The patient does not need strong analgesics when moving

             5. The temperature, pulse rate, blood pressure and respiratory rate should be in the
                reference range or pre-cut level.

             6. The patient has no signs of bleeding.

        -  Pain medication changes to tramadol 100 mg three times a day when discharged

      For all those involved in the study, PD's surgery technique is standardized to classic
      Whipple surgery, submersion bowel-pancreatic seam, antecholic gastro-jejunostomy and
      entero-entero anastomosis.

      The patient is left out of the study if a patient is undergoing another surgery than PD, TP
      or does not undergo surgery at all. Likewise, the study is suspended from the consideration
      of the surgeon if, for any other reason, the patient may be expected to be a high
      complication risk patient.

      Typical complications (pancreatic fistula, delayed gastric emptying, postpancreatectomy
      hemorrhage) are registered during hospitalization and their severity ratings according to
      ISGPS, ISPGF and Clavien-Dindo classifications are also determined. Other variables
      registered are the number of intensive care days, situations requiring new surgeries, 30 and
      90 day mortality, the completion time of the criteria for passing to follow up care, and the
      total length of hospitalization. In addition, the need for readmissions is registered. The
      implementation of the ERAS protocol is followed by a separate tracking template, in which the
      nurses record the progress of the goals specified in the protocol on a daily basis. The
      results of the study are analyzed with the intention-to-treat principle.

      The main variable of the study is the treatment period at the university hospital. The side
      variables are the total treatment time, the total amount of complications, and the number of
      readmissions. The hypothesis is that recovery is faster in the ERAS group, but the occurrence
      of complications and readmissions are the same in both groups.

      A statistical power calculation, assuming 80% statistical power (1-β) and 5% significance
      level (α), was carried out with a continuous outcome superiority trial. The sample size was
      calculated using the main coefficient of variation assuming that in the standard protocolled
      patients the median of the discharge time is nine days and in the ERAS program for seven
      days, i.e. a presumption of approximately 20% decrease in treatment days. Three days were
      assumed to be the standard deviation. The sample size thus obtained is 36 per group, which is
      rounded up to approximately 80 patients in total.

      When evaluating the time spent collecting the data, it is assumed that 20% of the patients
      will drop out of the study for various reasons. In TAUH, approximately 100 PDs and 15 TP
      patients are operated in two years and approximately 70% of patients of PD are in a low risk
      of complications. Consequently, the number of patients to be collected in two years would be
      approximately 0.7 ∙ 0.8 ∙ 100 + 0.8 ∙ 15 ≈ 68, which is almost sufficient for the purpose of
      this study to achieve statistical significance. The estimated duration of the study is
      therefore little more than two years. However, the study will be continued as long as
      necessary to collect the required number of patients. When half of the final number of
      patients has been collected, an interim analysis is made of the differences in the groups. If
      the results of the ERAS protocol are at least as good as the standard group, the study will
      be continued.

      All recruited patients are asked for written consent for participation in the study. The
      research file is stored in the TAUH research register. Patient information and research
      results are treated confidentially in the manner required by the Finnish Personal Data Act.
      The final research results are reported at group level and the identification of individual
      investigators is not possible. The research funding is provided by the Tampereen Pancreatic
      Research Group the largest funders being the State Research Fund and Sigrid Jusélius
      Foundation. Also Finnish Medicine Foundation in providing personal funding.

      The research has been approved by the Ethics Committee of the Tampere University Hospital.
      The earlier ERAS studies have shown that their use is safe and in most cases beneficial to
      the patient. In this study, it is novel that only small complication risk patients are
      included in the study. In addition, halfway between the research is performed an interim
      analysis to ensure the safety of the ERAS protocol. Patient's own consent is asked before
      surgery, and information on the research is provided within the limits of the success of the
      study. Patient's refusal or suspension of study does not affect the patient's treatment in
      any way.
allocation: Randomized
intervention model: Parallel Assignment
intervention model description: Randomized controlled trial
primary purpose: Treatment
masking: Single (Participant)
measure: Days until discharge from university hospital
time frame: Up to 24 weeks
description: Time in days since the entry to hospital on the surgery day to the discharge day to follow up care or home
measure: Days until discharge from follow up care
time frame: Up to 24 weeks
description: Time in days since the entry to hospital on the surgery day to the discharge day from the follow up care
measure: Total number of complications
time frame: Postoperatively up to 24 weeks
description: Total number of postoperative complications
measure: Readmission frequency
time frame: From the discharge up to 24 weeks for any cause related to surgery
description: Number of readmissions in contrast to total patient number
arm group label: Enchanced recovery after surgery protocol
arm group type: Experimental
description: ERAS-protocol as described in low risk patients after pancreaticoduodenectomy or total pancreatectomy
arm group label: Standard protocol
arm group type: No Intervention
description: Standard recovery protocol after pancreaticoduodenectomy or total pancreatectomy
intervention type: Procedure
intervention name: ERAS protocol preoperative actions
description: First appointment:
- Enlightenment on the benefits and objectives of the ERAS protocol
Call to the patient day before the surgery:
Discussing the course, benefits and goals of care in ERAS 4 dl PreOp drink before bedtime
Operation day:
Fluid intake allowed 2 hours before surgery 2 dl PreOP drink 2 h before cutting
arm group label: Enchanced recovery after surgery protocol
intervention type: Procedure
intervention name: ERAS protocol intraoperative actions
description: Intraoperative:
Drains in the peripancreatic or perihepatic regions are not set unless the surgeon sees this particular reason The nasogastric tube is removed at the end of the surgery
arm group label: Enchanced recovery after surgery protocol
intervention type: Procedure
intervention name: ERAS protocol postoperative actions
description: Postoperatively:
Mobilization with nurses assisted Drinks allowed after 4h surgery
POP 1:
Drinking and normal food Removal of urinary catheter Intravenous liquids only if needed Mobilization Pain management by epidural cannula Discussion of the ERAS protocol Pancreatin capsules per os before eating
Postoperative day 2:
- Mobilization: As much as possible, autonomous movement
Postoperative day 3:
Ending epidural infusion cannula removal Mobilization as independently as possible
Pain relief: oxycodone/naloxone p.o. to keep mobilization possible:
Postoperative day 4:
Support and encouragement continues Pain management at a level that allows mobility
arm group label: Enchanced recovery after surgery protocol
criteria: 
gender: All
minimum age: 18 Years
maximum age: 99 Years
healthy volunteers: No
last name: Johanna Laukkarinen, MD-PhD
role: Study Director
affiliation: Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland
facility: 
country: Finland
responsible party type: Sponsor
mesh term: Pancreatic Fistula
mesh term: Gastroparesis
mesh term: Hemorrhage
mesh term: Fistula