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For Whipple's operation, the diet resumption was slower, starting from the fifth postoperative day, and a normal diet was expected by the seventh. For patients who could not tolerate oral intake by the seventh day after surgery, parenteral nutrition was given with a target of 25�C30?kcal/kg. Outcome measure For the TAK-632 purposes of this study, we define failure of enhanced recovery protocol after HBP surgery as a composite measure of the following events: length of ICU stay more than 24?h after surgery, unplanned admission to ICU within 30?days after surgery, readmission to the hospital within 30?days after surgery, reoperation for complications and 30-day mortality. These events were chosen as markers of slow recovery and are common quality of care indicators. Unlike previous ERAS studies, we did not choose length of stay as a primary outcome as it has been shown that reductions in length of stay up to a median of 2?days may be related to changes in organisation of care and not to the effect of the ERAS programme.14 We collected patient demographics, smoking status, preoperative urinary cotinine concentration that was adjusted for creatinine level, American Society of Anesthesiologists�� Physical Status, Surgical Apgar Score,15 duration of surgery, ICU admission details, APACHE II (severity of illness score in patients admitted to ICU),16 preoperative Wnt inhibitor liver function tests, indocyanine green test and coagulation tests, and failure events from the hospital electronic Clinical Management System database. The research staff collected postoperative morbidities (pulmonary, infectious, renal, gastrointestinal, cardiovascular, neurological, haematological, wound and severe pain) on the third day after surgery using a reliable and valid Postoperative Morbidity Survey questionnaire.17 The EQ-5D index, a health-related quality of life using a US set of reference weights, was measured on the third day after surgery,18 as the greatest Ipatasertib chemical structure difference in EQ-5D index between ERAHBPS and standard care occurs between postoperative days 2 and 5.19 Current smoking was defined as no smoking cessation within 2?months before surgery or if the patient had an adjusted urinary cotinine concentration ��5 50?ng/mL within 48?h before surgery.10 The research staff was blinded to the urinary cotinine concentration results. Statistical analysis Continuous data were expressed as mean and SD or median and IQR. The 95% CI was estimated around the incidence of HBP surgery failure. Appropriate Student t tests, Mann-Whitney U tests, ��2 analyses or exact tests were used to compare factors associated with failure of enhanced recovery protocol. To adjust for multiple testing of individual postoperative morbidity events, a Bonferroni correction was used so that the significance criterion was set at p