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Perceptions of Experiences of Recovery After Pancreaticoduodenectomy—A Phenomenographic Interview Study

Andersson, Thomas K. MSc, RN; Engström, My PhD, RN; Bjerså, Kristofer MD, PhD, RN

Author Information
doi: 10.1097/NCC.0000000000001021
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Abstract

Globally, pancreatic cancer is the 12th most common form of malignancy, the seventh leading cause of cancer-related mortality in the year 2020, and with a 5-year survival of approximately 2%. In Sweden, there were 2034 new cases reported in 2020, making pancreatic cancer the seventh most common malignancy and the fourth leading cause of cancer-related death.1 Common signs and symptoms are abdominal pain, abnormal liver function tests, jaundice, new-onset diabetes, dyspepsia, nausea and vomiting, back pain, and weight loss.2 Diagnosis is often set in the later stages of the disease, resulting in approximately only 10% of patients being eligible for surgical intervention. Surgery, often in combination with chemotherapy, is the only treatment that offers potential cure.3

The majority of pancreatic tumors arise from the head of the pancreatic gland, and surgery usually involves resection of the whole or part of the pancreatic gland, for example, pancreaticoduodenectomy (PD), distal pancreatectomy, or total pancreatectomy. Even though surgical technique has developed over time, postoperative complications are common. According to the Swedish National Registry of Pancreatic Cancer, 66% of pancreaticoduodenectomies and total pancreatectomies suffer from complications related to the surgery.4 These national figures are comparable with other international studies.5,6 After surgery, patients are often affected by symptoms related to gastrointestinal functioning, eating, emotional well-being, pain, and fatigue, which have been found to remain for a long period.7,8

To improve and support postoperative recovery, multimodal and multidisciplinary clinical pathways have been developed in various surgical specialties. These protocols, referred to as enhanced recovery programs (ERPs) or fast-track protocols, contain interventions aimed at facilitating organ function and preventing deterioration of bodily functions related to the endocrine as well as the metabolic consequences of the surgical trauma. Initially, implemented in colorectal surgery, this model of care has resulted in reduced in-hospital length of stay (LoS), as well as reduced costs, complications, and burden of postoperative symptoms.9

In pancreatic surgery, current research suggests that when ERP is applied, reduction of LoS, lowering of postoperative infection rates, and overall fewer complications, especially mild ones, occur.10 Also, Galli et al11 explored patient experiences of receiving perioperative care based on ERP in pancreatic surgery. According to these findings, preadmission counseling helped the patients to prepare for surgery and to face the upcoming challenges during the perioperative phase. Further, involving caregivers, for example, family members, was crucial because of their vital part of patient recovery after discharge.

A previous systematic review stated patients who experienced motivation to be active and to participate in the recovery process when ERP was applied. However, disturbing symptoms and inconsistent information contributed to difficulties in participating in the program. Also, support from staff and informal caregivers, as well as patients’ experience of being seen as individuals, contributed to safety and early discharge, as informal caregivers were facilitators for safety and early discharge.12

As a process, recovery has a beginning and an end: beginning after a sudden deterioration in one or several of the human functions, for example, physical, psychological, social, or habitual (in this case caused by the surgical trauma), followed by the process of gradually regaining functions and independence, and ending where the patients have returned to their optimal preoperative state.13,14 However, there is no overall established definition of recovery, and recovery has been evaluated based on the interests of different stakeholders and on different time frames.15 Also, ERP brings new challenges for patients, such as demands on self-care and increased decision-making. Therefore, research focusing on exploring these challenges on existing experiences and practices, the context of interventions, and barriers and facilitators in pancreatic surgery can be revealed.16 Hence, the aim of this study was to explore patients’ perceptions of recovery after pancreatic surgery within an ERP. Also, this knowledge will allow for healthcare staff to be better prepared for patient needs during the initial recovery period in the hospital as well as after discharge.

Methods

Study Design

This qualitative study was conducted using a phenomenographic design.

Setting and Participants

A consecutive selection, with a strategic sample of patients who had undergone PD due to a pancreatic tumor at a regional surgical center in Sweden, was recruited from March 2018 to February 2019. Surgical treatment was recommended to all eligible patients at the regional multidisciplinary conference because of suspected pancreatic tumor. All patients were treated based on an ERP (Figure 1). The strategic selection was aimed at broad diversity concerning age and gender. Inclusion criteria were age ≥18 years and having undergone PD surgery related to pancreatic malignancy and excepting participation in the study. Exclusion criteria were lack of knowledge on how to communicate in Swedish and cognitive ability impaired to such an extent that feedback on memories and experiences was restricted.

F1
Figure 1:
Local application of enhanced recovery program interventions.

In total, 37 patients matching the inclusion criteria were approached for participation on the day of their discharge from the hospital ward. At discharge, patients were asked about participation in the present study and received verbal and written information. Two weeks after discharge, the first author (T.K.A.) contacted those willing to participate, and the interview was scheduled.

Data Collection

Interviews were conducted adjacent to the first postoperative follow-up visit at the surgical polyclinic department, approximately 5 weeks after surgery. This occasion was chosen on the assumption that patients would have progressed in their postoperative recovery but would still have the direct postoperative in-hospital phase fresh in mind. A total of 26 interviews were scheduled; 19 were carried out by the first author (T.K.A.). Two additional pilot interviews not included in the data analysis were conducted by both T.K.A. and K.B. Patient recruitment is presented in Figure 2. Written informed consent was collected prior to start of the interview.

F2
Figure 2:
Study recruitment and inclusion.

The aim of the phenomenographic interview is to explore variations of perceptions of a specific phenomenon.17 In the present study, interviews started with an initiation question: “What does recovery mean to you?” Participants were encouraged to reflect on their experiences of recovering after the PD surgery, both during the in-hospital period and the posthospital period. Follow-up questions were used to further probe patients experiences, for example, “What was important to you when recovering at home after discharge?” and “What was important to you when recovering during your hospital stay?” Interviews were recorded using a mobile phone application and saved as digital audio files. Median recording time was 26 minutes 23 seconds, resulting in a total interview time of 481 minutes. Interviews were transcribed verbatim.

Conceptual Framework and Analysis

The analysis was conducted using a phenomenographic design, where the aim is to describe, analyze, and understand the diversity of perceptions of a phenomenon based on a person’s experience of this phenomenon. In phenomenography, there is a distinction between the first-order and the second-order perspective. The first-order perspective describes the world around us as perceived by the general population. The second-order perspective springs from how the world is perceived by each person based on their experiences of the phenomenon.18 The aim of phenomenographic research is to find and describe the second-order perspective of a phenomenon without reflecting on the first-order perspective. Analysis of the transcribed interviews was guided by the seven steps presented and used by Sjöström and Dahlgren19 within healthcare and nursing research:

  • (1) Familiarization: transcripts are read several times in order to get to know their content, as well as to correct errors.
  • (2) Compilation: answers on a specific question from each responder are identified and compiled.
  • (3) Condensation: the most relevant parts of individual answers are identified, eliminating redundant parts of the transcripts.
  • (4) Preliminary grouping: central concepts are grouped into categories.
  • (5) Comparison: a preliminary comparison of categories is made, and boundaries between categories are established.
  • (6) Naming: categories are named to describe their essence.
  • (7) Contrastive comparison: categories are compared, and their differences and similarities are described.

Ethics

Ethical approval was granted by the Regional Board of Ethics in Gothenburg, Sweden, Dnr: 856-16. This study was conducted according to the foundations in the Declaration of Helsinki.20 All participants received written and verbal information about the rationale and aim of the study and the principles for voluntary participation and informed that participation or relinquished involvement would not affect their current or future care. All data were treated confidentially and with full disclosure.

Findings

The analysis resulted in an outcome space, which is the phenomenographic frame for presentation of results, and comprised 5 unique categories relating to the patients’ perceptions of recovery during the first months after PD with ERP-structured care (Table 1). These 5 categories comprised 20 subcategories. In the following sections, each category is presented as a headline and each subcategory as a paragraph within that category.

Table 1 - Outcome Space a
Category Subcategory
To be as before Regaining function
Cessation of treatment and care
Doubts about full recovery
Affected by symptoms Restricted by pain
Hindered by eating-related symptoms
Bowel function
Being able to sleep
Postoperative rehabilitative exercise
Physical activity Beneficial exercises
Balance between exercise and rest
Understanding the process Personal preparation
Information and education
Met and unmet expectations
Recovery takes time
Facilitated by other people Encouragement and guidance
Aid in everyday life
aOutcome space: the result structure and content of the phenomenographic analysis tradition, comprising categories and subcategories.

To Be as Before

The essence of the meaning of recovery was a striving toward being as prior to surgery and being able to do things as before. This perception defined recovery as a return to preoperative physical functional status and being able to resume previous social activities. Recovery was perceived as a journey, where function and strength were regained.

… for me, recovery is to return to the state I was in before the surgery at large.

… after you have been ill for some reason, and it is the very journey toward being well that is recovery.

During the postoperative in-hospital phase, perceptions of the importance of different signs of recovery were emphasized. These signs were experienced as gradually regained physical strength and control over basic bodily functions such as voiding one’s bladder or gradually increasing physical activity.

…all the time I found small signs, as I say… I function, I urinated by myself…

The cessation of treatment and care interventions such as drains, tubes, and urinary catheters during the in-hospital phase was conceived as favorable for recovery. Informants perceiving these tubes as disturbing recovery also described them as shackling them to the bed, making it difficult to move or creating a fear of pulling them out by accident, that is, not being able to move sufficiently. However, all tubes were always accepted as a part of the care process, as they were attached only for a limited time, and having them removed was perceived as a good sign of recovery. One specific exception was the decompressing nasogastric tube, which was experienced as more troublesome than necessary because it constantly caused pain and discomfort and restricted informants’ ability to move.

… a sign of… recovery so to speak. That… “now we can remove this, it looks good,” like, so now we can remove these things.

The tube in the nose affected a lot, because the whole throat, it was just like when you had strep throat all the time. It was really annoying. It felt good to get rid of it.

Sometimes there were doubts whether full recovery could ever be achieved. These perceptions derived from experiences during the recovery phase at home when confronted with everyday life. There was a wide variety in perceptions of how long recovery would take. Also, being discharged was perceived not only as a sign of recovery but also as a facilitator for recovery by itself and being able to resume preoperative life.

…to be as close as possible where I was before this… happened to me. If I reach all the way, that might not… be possible…

Affected by Symptoms

Symptoms and symptom management were perceived to affect recovery to a varying extent. Some informants experienced no symptoms affecting recovery, whereas others experienced more symptoms than expected. However, more prominent symptoms were perceived as delaying recovery, hindering the possibility of being active, and leading to a perceived prolonged hospital stay. Symptoms with negative effects on recovery, such as pain, nausea, lack of appetite, and inability to sleep, were experienced during the in-hospital phase.

…I was so nauseous that I even vomited…

…I have no appetite. I’m not hungry. I could be without food the whole day, I think. Without me thinking about it…

Pain, most prevalent during the first postoperative days, was perceived as having a major impact on recovery, as this restricted the possibility to mobilize during the in-hospital phase. However, pain was experienced in various ways and was therefore perceived as having more or less impact on recovery during the in-hospital phase. After discharge, pain was perceived as having less effect on recovery as its intensity decreased and analgesic use was gradually reduced.

The first period, the first week it was to escape the pain.

…It was hard to get out and into the bed and so on, and you should get out to the corridor to walk with that walking frame and so on.

Recovery was also restricted by intolerance to smells, experiencing no hunger, or an altered taste sensation, hence causing nutritional problems at home and delaying recovery. To manage these symptoms, self-care interventions, such as taking nutritional supplements, adjusting food content, and changing meal frequencies, were applied. However, the perception of nutritional supplements was mixed, as they could be perceived as “revolting” as well as acceptable. Also, continued weight loss after discharge was perceived as discouraging and a setback in recovery. Weight loss was perceived as threatening in relation to recovery, as this might affect the possibility of tolerating adjuvant chemotherapy.

…feel hungry but then after eating three to four spoons, forks and then it is like, stop…

…maybe you should eat less and more frequently… then I have gotten these supplements, so I take one every day.

Altered bowl function and stool were perceived as major symptom areas hindering recovery. Constipation was not only a problem in itself, both during the in-hospital stay and at home, but also contributed to other symptoms such as eating-related symptoms, which were perceived as affecting recovery because they delayed discharge.

…my stomach was not working. I had a huge problem with that…

Sleep was perceived as important to recovery. Improved sleep, such as being able to sleep for a longer period without waking up, was a sign of recovery. Also, as recovery progressed in a positive way, the need for sleep decreased. Sleeping problems led to exhaustion and during the in-hospital stay were connected to being disturbed by other informants or staff during the night. However, sleep improved after discharge as there was a better possibility of controlling the environment at home.

You have the tranquility. You don’t have the noise with the other patients. You don’t have the steps in the corridor at night. You don’t get woken up at nights. You get a good sleep and it is peaceful and calm at home.

Physical Activity

Physical activity was perceived as a major facilitator to enhance recovery during the in-hospital phase. This demanded personal engagement from the patient as well as attention from the healthcare staff.

…it is training, of course, training—the physical activity. It is really important…

Postoperative rehabilitative exercises, such as walks, climbing stairs, stationary bikes, and positive expiratory pressure training, were perceived as methods beneficial to recovery. However, experiences of feeling unprepared for these activities so early in the postoperative phase were mentioned. Conversely, perceptions of dissatisfaction with the low rate and intensity of the activities were also expressed, with requests for even more attention from nurses and physiotherapists with regard to such postoperative activities.

…when there was a physiotherapist that got into her head that she would, after the operation, sit up for 2 hours, I believed she said. I thought she was joking.

…we are going to chase you and we are going to be all over you.” But I did not notice it. Not a single time!

During the in-hospital phase, training was perceived as a natural part of the care. After discharge, the training had to continue on the patient’s own initiative, often using the same methods as during the in-hospital phase. This continuum was perceived as important to maintain the recovery pace. However, this had to be adjusted for a balance between activity and rest, gradually progressing to increased intensity and frequency of the training.

…today I have routines: in the morning, start the morning with going up for breakfast. A half an hour walk with ski-sticks. Coming home, watch TV, and then it is out again, I guess…

…I take easy walks. Now I have extended the walk, I walk uphill so I get… get a little more pulse. And that, I think, is an improvement, then.

Understanding the Process

The recovery process was divided into the in-hospital and after-discharge phases. The informants’ own preparations and expectations would reflect perceived recovery both in hospital and after discharge.

… improvement curve then was like, it was a bit up and down, it was continuously improving. Just when you feel also, just when you been home, that it is, that it is up and down like that, but it gets better with time…

There was a perceived window of opportunity prior to the surgery for patients to prepare themselves for the upcoming surgery, which had an effect on the postoperative recovery. These preparations included increased physical activity for those who could manage it, but some perceived themselves as too tired to do any more than daily activities. Those who had lost a lot of weight tried to get more calories into their food to stop further deterioration of their physical capabilities, in order that they might have a more favorable postoperative recovery. The preoperative preadmission phase passed very quickly, and they experienced it as not giving them the time to worry. Furthermore, the preadmission phase was perceived as too short for making sufficient personal preparations for surgery.

…I was trying to rebuild my physical fitness before surgery, because it is a major operation, so they told me that if I’m… the fitter I am before surgery, the more it will benefit me afterward.

Preoperative information and education, written as well as verbal, was mostly experienced as favorable for the postoperative recovery but was perceived in different ways. Folders to read helped to explain the postoperative recovery period and helped informants to understand the extent of the surgery. However, some perceived it as too detailed and sometimes too extensive and felt that it should be less complicated, more general, and simpler, in order to make it easier to follow, for example, using pictures. Some perceived it to be very general and inadequate regarding the extent of the surgery and the impact it would have on physical functioning. Others found it adequate, making them feel safe and prepared.

They explained it like it was… like if it was his manner that… made you feel safe.

…got to know a lot of details and I got brochures to read and… what was going on.

The informants had various expectations of the postoperative process. There were expectations that surgery would bring more negative experiences that it actually did. When symptoms were affecting postoperative experiences, it was in a shorter perspective, but often these were coped with and managed successfully, contrary to the informant’s expectations.

I felt better than I thought I would after the operation. Because I knew it was a major operation, so I did not think I would feel that good afterward.

Recovery was perceived as something that occurs over a period; the time frame was unclear, but it was expected to take weeks, months, or years. These perceptions were based on knowledge obtained in preoperative information, expectations, and experiences of what had been achieved so far in the recovery journey. The in-hospital phase was perceived to be sufficient or even shorter than expected to reach a sufficient level of recovery. However, it could also be perceived as not long enough to enable the patient to reach a sufficient level of recovery for discharge.

… I’m absolutely not there yet. But, hopefully within… a month or two, maybe; I’m getting close, but it, it will take time.

I thought it would be longer. It was probably just enough.

Facilitated by Other People

Recovery was perceived as facilitated by other people, both healthcare personnel and relatives and friends. As surgery was experienced as having a major impact on the possibility to take part and function in everyday life, the path of recovery was perceived as dependent on other people.

During the in-hospital phase, healthcare personnel were important facilitators for recovery through encouragement and guidance about the recovery progress as well as instilling a feeling of safety. This further encouraged the informants to struggle on and to take responsibility for their own care. Besides encouragement and guidance, staff presence and overall observations enhanced the perceived feeling of safety, which also enhanced recovery.

…I’ve got a lot of pushing and coaching from you. You felt that you nurses and doctors and special… you were on top of me a bit.

… they knew exactly what to do, they knew exactly. They checked me all the time…

After discharge, relatives and friends were perceived as important facilitators in aiding recovery. This aid was experienced as support both in the practicalities of everyday life and social and emotional support, such as offering encouragement or company or just letting the informants know that they were in someone’s thoughts, and it was an essential part of recovery. The informants were sometimes forced to reach out to family members for aid during the first period after discharge until they could manage on their own.

Now she took 2 weeks off, now she will start working again at the end of the week eh. Without that then… I probably would have messed it up a lot more with everything.

I talked to my coworkers yesterday. And that they are thinking of me like that is also a very important part of recovery. That they are thinking of me and…

Discussion

To recover was perceived as to be as before surgery and to resume the activities and functions of everyday life. Restoration of physical functions was perceived as a part of that recovery. Physical functioning, the ability to be active, and gradually becoming more independent were the focus during the in-hospital period. The importance of physical functioning has previously been described by Gordon et al,21 who found that day-to-day living, physical health, and relationships influence core dimensions in recovery. Also, Allvin et al22 present recovery as regaining functions as well as reestablishing habitual and social activities. However, the multidimensional descriptions of the concept of recovery are not always visible in ERP-structured care as it is a bundle of medical interventions implemented and initiated within a specific time frame (Table 2).

Table 2 - Informants’ Demographics (n = 19)
Age, mean (min-max), y 66 (43-78)
Gender distribution (men/women), % 60/40
Days since discharge, mean (min-max) 25 (11-47)
Complications
according to Clavien-Dindo a
0 9
I 3
II 3
IIIa 2
IIIb 2
IV 0
V 0
aClavien-Dindo is a standard classification system for many surgical specialties to grade adverse events, for example, complications.

Although the informants understood the necessity and meaning of tubes and drains and hence accepted their presence, removal of drains and tubes was a relief, especially the nasogastric tube. Previous research confirms this, and within ERP, the use of nasogastric tubes and drains should be avoided.23 However, in pancreatic surgery, there are specific risks of anastomosis leakage, which needs to be taken into consideration. Further, in this study, drains were not perceived as a major discomfort as they were usually removed within the first days after surgery.

During the postoperative process, symptoms affected the recovery process to varying degrees. Previous research on patients recovering from pancreatic and general surgery describes problematic symptoms related to eating, bowel function, emotional well-being, fatigue, and pain.7,8,24,25 As these are common symptoms during the postoperative process, patients need to be prepared for this prior to the surgery, as well as before discharge, as a way to empower them to deal with the potential challenges ahead.

In the present study, physical activity was perceived as an important antecedent to recovery. In previous research, early mobilization programs have been shown to increase functional capacity, as well as reduce pain and enhance recovery and physical comfort.26,27 Enhanced recovery program also stresses the importance of early and frequent mobilization. However, sometimes expectations of early and intensive mobilization are affected by the patients’ symptoms and conditions, making it hard for them to comply as they try to balance symptoms with expectations of a fast recovery.12 By fostering patient empowerment, preconditioned by patient participation and patient-centeredness, patients’ control over issues important to their health will increase.28 In the present study, some informants perceived the early start of mobilization as difficult and were shocked by the “aggressive” mobilization strategy and unable to comply, as they were affected by symptoms. This might indicate the importance of working with recovery from a broader perspective, focusing on the empowerment of the patients and preparing them for what is expected from them during the early postoperative phase. Hence, there is a need for mental preparation as well as for physical optimization prior to surgery.

To prepare for surgery, the use of prehabilitation has been found to reduce postoperative morbidity and further decline of functional status. However, it is important that the exercise program is supervised and structured and has a patient-centered approach, for adequate adherence.29–31 Adjusting food intake and activity levels were things that informants did not only on their own initiative but also on recommendations from hospital staff, as these interventions are a part of standard preoperative education within ERP. Experiencing fatigue is a common symptom during recovery after general and pancreatic surgery, both early, in hospital, and later, after discharge.25 In previous studies, patients have managed fatigue by sleeping more during the day,7 and this need to rest and sleep during the day was also reported by our informants. However, making adjustments in daily activities and planning in order to make their physical resources last was also emphasized by them.

Information and education were also perceived to affect recovery in a positive way. However, there were variations between informants. It is known that fear is associated with impaired recovery.32 Alanazi33 found that patient education, preoperatively and before discharge, could affect how patients managed their care. Also, research implies that educational needs should be assessed before discharge and tailored to meet individual needs.34 In the present study, informants perceived information to be lacking in both content and comprehensiveness, describing it as sometimes too much information and sometimes too little. Hence, there might be an indication that informants would benefit from an individualized approach to ERP. Also, a shorter LoS, forcing patients to take more responsibility for their own care, makes it even more important that education is focused on the patients’ individual needs, especially in the context of ERP, where patient participation is viewed as a necessity component. Therefore, it is important to let patients reach a sufficient level of recovery before discharge. This should be based on patients’ own perceptions of their recovery as well as on the standardized discharge criteria comprising medical, functional, and psychosocial dimensions, which set a threshold for safe discharge.

A short hospital stay was sometimes surprising to informants; they had expected it to be longer. Allvin et al22 explain recovery as a process that takes place over a period. Informants had various perceptions of their perceived functional recovery and symptoms, as well as LoS. As mentioned before, it might be of importance to be more in tune with the patient when discussing what is regarded as a sufficient level of recovery before discharge. The informants’ perceptions were often related to their symptom burden, as those who did not expect to feel as they did also refer to experiences of specific symptoms. Acknowledging patients’ expectations is important, as it affects their quality of life.35 Further, this underline the importance of structured and continued patient education, which might adjust expectations to a level that is realistic for the individual patient, preparing them for both the surgical impact and their postoperative recovery on their own after discharge.

The recovery process after pancreatic surgery is a personal journey. However, Allvin et al22 describe support and encouragement as a facilitator for recovery, both in hospital and after discharge. Informants perceived the hospital staff’s encouragement, motivating and guiding them in this new situation, as an essential part of recovery. The interaction between nurses and patients is described by Jangland et al,36 and patients should be viewed as unique individuals with strengths and weaknesses, as well as needs and resources. However, ERP traditionally consists of treatments, interventions, and routines aimed to prevent from complications and facilitating physical function. If ERP is to be successfully implemented, both at an individual as well as an organizational level, it must be viewed as the process it is, with the patient as an individual. By expanding the perspective of ERP and addressing the importance of the healthcare personnel–patient interaction, a new perspective could be added to ERP that might further strengthen person-centeredness in surgical care.

Limitations

In a phenomenographic study, trustworthiness is associated with how well the outcome space corresponds with the way the informants understand the phenomena.37 There are four criteria that are crucial in qualitative research: credibility, dependability, confirmability, and transferability.38 In the present study, credibility is established by the researcher’s familiarity with qualitative research and phenomenographic research design, as well as the concept of recovery, ERP, and pancreatic surgery. As the aim of the present study was to describe different perceptions of recovery after pancreatic surgery in the context of ERP, we argue that the phenomenographic study design is valid. Dependability is established by the description of the data collection and analysis process. Although only one researcher conducted the interviews, data were analyzed and discussed among all three authors. Confirmability was established by including excerpts from the interviews and description as proof of categories that originated from the data and not authors’ predispositions. Although findings in the present study are qualitative and unique to the specific context, transferability to other patients recovering from pancreatic surgery is strengthening through comparable findings from previous and adjacent research. However, to elevate transferability level, future research should include patients from several surgical centers using ERP in order to adjust for different caring traditions and routines. Nevertheless, the present study reveals important points regarding recovery after pancreatic surgery and hence provides evidence valuable in the evolution of ERP.

Conclusion

The present study focused on various areas of recovery, which took place between the in-hospital and after-discharge phases; physical experiences disturbed recovery, in contrast to social and emotional experiences, which facilitated recovery. Patients strove to resume their old lives and selves, picking up their lives where they had left them prior to disease and surgery. Enhanced recovery program may serve as a framework to establish best surgical care practice. However, the ERPs are mainly focused on the medical perspective. Variations in perceptions of recovery suggest that care may need to be more individualized concerning symptom management, rehabilitative interventions, and empowering of the patients, both in the preoperative and in the postoperative phase. Also, by promoting realistic expectations, as well as continuously working with individualized and meaningful patient education preoperatively and during the postoperative recovery process, patients could be better prepared for challenges during the entire recovery phase after pancreatic surgery. For future research, the patient perspective needs to be studied further. By using appropriate instruments to explore patient-reported outcomes over longer time after surgery, the effect and frequency of perceptions of ERP-based surgical care could be studied. Also, the concept of person- or patient-centered care and its place in the context of ERP needs to be explored further.

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Keywords:

Enhanced recovery after surgery; Interview; Pancreatic neoplasms; Pancreaticoduodenectomy; Perception

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