1
|
Imai T, Asada Y, Matsuura K. Enhanced recovery pathways for head and neck surgery with free tissue transfer reconstruction. Auris Nasus Larynx 2024; 51:38-50. [PMID: 37558602 DOI: 10.1016/j.anl.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/01/2023] [Accepted: 08/01/2023] [Indexed: 08/11/2023]
Abstract
The enhanced recovery after surgery (ERAS) pathway is designed to facilitate recovery after surgery by packaging evidence-based protocols specific to each aspect of the perioperative period, including the preoperative, intraoperative, postoperative, and post-discharge periods. The ERAS pathway, which was originally developed for use with colonic resection, is now being expanded to include a variety of surgical procedures, and the ERAS Society has published a consensus review of the ERAS pathway for head and neck surgery with free tissue transfer reconstruction (HNS-FTTR). The ERAS pathway for HNS-FTTR consists of various important protocols, including early postoperative mobilization, early postoperative enteral nutrition, abolition of preoperative fasting, preoperative enteral fluid loading, multimodal pain management, and prevention of postoperative nausea and vomiting. In recent years, meta-analyses investigating the utility of the ERAS pathway in head and neck cancer surgery have also been presented, and all reports showed that the length of the postoperative hospital stay was reduced by the implementation of the ERAS pathway. The ERAS pathway is now gaining traction in the field of head and neck surgery; however, the details of its efficacy remain uncertain. We believe the future direction will require research focused on improving the quality of postoperative patient recovery and patient satisfaction. It will be important to use patient-reported outcomes to determine whether the ERAS pathway is actually beneficial.
Collapse
Affiliation(s)
- Takayuki Imai
- Department of Head and Neck Surgery, Miyagi Cancer Center, 47-1 Nodayama, Medeshima-Shiode, Natori, Miyagi 981-1293, Japan.
| | - Yukinori Asada
- Department of Head and Neck Surgery, Miyagi Cancer Center, 47-1 Nodayama, Medeshima-Shiode, Natori, Miyagi 981-1293, Japan
| | - Kazuto Matsuura
- Department of Head and Neck Surgery, National Cancer Center East, 6-5-1 Kashiwanoha, Kashiwa, Chiba 277-8577, Japan
| |
Collapse
|
2
|
Ren Q, Wu M, Li HY, Li J, Zeng ZH. Failure of enhanced recovery after surgery in liver surgery: a systematic review and meta analysis. Front Med (Lausanne) 2023; 10:1159960. [PMID: 37497275 PMCID: PMC10366385 DOI: 10.3389/fmed.2023.1159960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/14/2023] [Indexed: 07/28/2023] Open
Abstract
Purpose This study aimed to conduct a systematic review of the literature to identify and summarize the existing evidence regarding ERAS failure and related risk factors after hepatic surgery. The objective was to provide physicians with a better understanding of these factors so that they can take appropriate action to minimize ERAS failure and improve patient outcomes. Method A literature search of the PubMed MEDLINE, OVID, EMBASE, Cochrane Library, and Web of Science was performed. The search strategy involved terms related to ERAS, failure, and hepatectomy. Result A meta-analysis was conducted on four studies encompassing a total of 1,535 patients, resulting in the identification of 20 risk factors associated with ERAS failure after hepatic surgery. Four of these risk factors were selected for pooling, including major resection, ASA classification of ≥3, advanced age, and male gender. Major resection and ASA ≥ 3 were identified as statistically significant factors of ERAS failure. Conclusion The comprehensive literature review results indicated that the frequently identified risk factors for ERAS failure after hepatic surgery are linked to operative and anesthesia factors, including substantial resection and an American Society of Anesthesiologists score of 3 or higher. These insights will assist healthcare practitioners in taking prompt remedial measures. Nevertheless, there is a requirement for future high-quality randomized controlled trials with standardized evaluation frameworks for ERAS programs.
Collapse
Affiliation(s)
- Qiuping Ren
- Division of Liver Surgery, Department of General Surgery, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Nursing Key Laboratory of Sichuan Province, West China Medical Center, Sichuan Medical University, Chengdu, China
| | - Menghang Wu
- Division of Liver Surgery, Department of General Surgery, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hong Yu Li
- Division of Liver Surgery, Department of General Surgery, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiafei Li
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zi Hang Zeng
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
3
|
Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022. World J Surg 2023; 47:11-34. [PMID: 36310325 PMCID: PMC9726826 DOI: 10.1007/s00268-022-06732-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature. METHODS A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system. RESULTS A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy. CONCLUSIONS These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.
Collapse
|
4
|
Tatar C, Hinckley S, Holubar SD, Liska D, Delaney CP, Steele SR, Gorgun E. Does milk of
magnesia
impact length of hospital stay after major colorectal resection. ANZ J Surg 2022; 93:1248-1252. [DOI: 10.1111/ans.18196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 11/01/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Cihad Tatar
- Department of Colorectal Surgery Digestive Disease Institute, Cleveland Clinic Cleveland Ohio USA
| | - Sam Hinckley
- Department of Colorectal Surgery Digestive Disease Institute, Cleveland Clinic Cleveland Ohio USA
| | - Stefan D. Holubar
- Department of Colorectal Surgery Digestive Disease Institute, Cleveland Clinic Cleveland Ohio USA
| | - David Liska
- Department of Colorectal Surgery Digestive Disease Institute, Cleveland Clinic Cleveland Ohio USA
| | - Conor P. Delaney
- Department of Colorectal Surgery Digestive Disease Institute, Cleveland Clinic Cleveland Ohio USA
| | - Scott R. Steele
- Department of Colorectal Surgery Digestive Disease Institute, Cleveland Clinic Cleveland Ohio USA
| | - Emre Gorgun
- Department of Colorectal Surgery Digestive Disease Institute, Cleveland Clinic Cleveland Ohio USA
| |
Collapse
|
5
|
Mazzola A, Pittau G, Hong SK, Chinnakotla S, Tautenhahn HM, Maluf DG, Settmacher U, Spiro M, Raptis DA, Jafarian A, Cherqui D. When is it safe for the liver donor to be discharged home and prevent unnecessary re-hospitalizations? - A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14677. [PMID: 35429941 DOI: 10.1111/ctr.14677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Few data are available on discharge criteria after living liver donation (LLD). OBJECTIVES To identify the features for fit for discharge checklist after LLD to prevent unnecessary re-hospitalizations and to provide international expert recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. The critical outcomes included were complications rates and liver function (defined by elevated bilirubin and INR) (CRD42021260725). RESULTS Total 57/1710 studies were included in qualitative analysis and 28/57 on the final analysis. No randomized controlled trials were identified. The complications rate was reported in 20/28 studies and ranged from 7.8% to 71.2%. Post hepatectomy liver function was reported in 13 studies. The Quality of Evidence (QoE) was Low and Very-Low for complications rate and liver function test, respectively. CONCLUSIONS Monitoring and prevention of donor complications should be crucial in decision making of discharge. Pain and diet control, removal of all drains and catheters, deep venous thrombosis prophylaxis, and use routine imaging (CT scan or liver ultrasound) before discharge should be included as fit for discharge checklist (QoE; Low | GRADE of recommendation; Strong). Transient Impaired liver function (defined by elevated bilirubin and INR), a prognostic marker of outcome after liver resection, usually occurs after donor right hepatectomy and should be monitored. Improving trends for bilirubin and INR value should be observed by day 5 post hepatectomy and be included in the fit for discharge checklist. (QoE; Very-Low | GRADE; Strong).
Collapse
Affiliation(s)
- Alessandra Mazzola
- Department of Hepatology and Gastroenterology, Liver transplant unit, Pité-Salpêtrière Hospital, Paris, France
| | - Gabriella Pittau
- Liver transplant unit, Centre hépato biliaire Hopital Paul Brousse, Villejuif, France
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical School, Minneapolis, USA
| | | | - Daniel G Maluf
- Program in Transplantation, University of Maryland Medical School, Baltimore, Maryland, USA
| | - Utz Settmacher
- Department of General-, Visceral-, and Vascular Surgery, University Hospital, Jena, Germany
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Ali Jafarian
- Division HPB Surgery and Liver Transplantation, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Daniel Cherqui
- Liver transplant unit, Centre hépato biliaire Hopital Paul Brousse, Villejuif, France
| | | |
Collapse
|
6
|
van Woerden V, Olij B, Fichtinger RS, Lodewick TM, Coolsen MME, Den Dulk M, Heise D, Olde Damink SWM, Dejong CHC, Neumann UP, van Dam RM. The orange-III study: the use of preoperative laxatives prior to liver surgery in an enhanced recovery programme, a randomized controlled trial. HPB (Oxford) 2022; 24:1492-1500. [PMID: 35410783 DOI: 10.1016/j.hpb.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/18/2022] [Accepted: 03/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study evaluates the effect of preoperative macrogol on gastrointestinal recovery and functional recovery after liver surgery combined with an enhanced recovery programme in a randomized controlled setting. METHODS Patients were randomized to either 1 sachet of macrogol a day, one week prior to surgery versus no preoperative laxatives. Postoperative management for all patients was within an enhanced recovery programme. The primary outcome was recovery of gastrointestinal function, defined as Time to First Defecation. Secondary outcomes included Time to Functional Recovery. RESULTS Between August 2012 and September 2016, 82 patients planned for liver resection were included in the study, 39 in the intervention group and 43 in the control group. Median Time to First Defecation was 4.0 days in the intervention group (IQR 2.8-5.0) and 4.0 days in the control group (IQR 2.9-5.0), P = 0.487. Median Time to Functional Recovery was day 6 (IQR 4.0-8.0) in the intervention group and day 5 (IQR 4.0-7.5) in the control group, P = 0.752. No significant differences were seen in complication rate, reinterventions or mortality. CONCLUSION This randomized controlled trial showed no advantages of 1 sachet of macrogol preoperatively combined with an enhanced recovery programme, for patients undergoing liver surgery.
Collapse
Affiliation(s)
- V van Woerden
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands
| | - Bram Olij
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; GROW: School for Oncology and Developmental Biology, Maastricht, the Netherlands
| | - Robert S Fichtinger
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands
| | - Toine M Lodewick
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands
| | - Mariëlle M E Coolsen
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; Nutrim School for Nutrition and Translational Research in Metabolism, the Netherlands
| | - Marcel Den Dulk
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; Nutrim School for Nutrition and Translational Research in Metabolism, the Netherlands; Department of Surgery, Uniklinik Aachen (UKA), Germany
| | - Daniel Heise
- Department of Surgery, Uniklinik Aachen (UKA), Germany
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; Nutrim School for Nutrition and Translational Research in Metabolism, the Netherlands; Department of Surgery, Uniklinik Aachen (UKA), Germany
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; Nutrim School for Nutrition and Translational Research in Metabolism, the Netherlands; GROW: School for Oncology and Developmental Biology, Maastricht, the Netherlands
| | - Ulf P Neumann
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; Department of Surgery, Uniklinik Aachen (UKA), Germany
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; GROW: School for Oncology and Developmental Biology, Maastricht, the Netherlands; Department of Surgery, Uniklinik Aachen (UKA), Germany.
| |
Collapse
|
7
|
Xue B, Yu H, Luo X. Knowledge of enhanced recovery after surgery and influencing factors among abdominal surgical nurses: a multi-center cross-sectional study. Contemp Nurse 2022; 58:330-342. [PMID: 35965486 DOI: 10.1080/10376178.2022.2112723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are well established. Evidence describing nurses' knowledge of ERAS is limited. AIM To assess surgical nurses' knowledge of ERAS and identify factors that correlate with knowledge level. DESIGN An anonymous cross-sectional survey via an online social platform was conducted in the abdominal surgical specialty of 40 hospitals in ten cities in China. METHODS Nurses of abdominal surgery in hospitals were enrolled in this study. A self-administered questionnaire that was reviewed by an expert panel was used to assess the knowledge of ERAS in nurses. A generalised linear regression analysis was used to assess factors associated with nurses' knowledge regarding ERAS. RESULTS Overall survey participation was 91.8% (2230/2430). The mean score of ERAS-related knowledge among abdominal surgical nurses was 12.10 (SD = 3.79). ERAS knowledge differed according to gender, age, education level, professional title, years of working, specialised working years, ERAS training experience, surgical department, and type of hospital (p < 0.05). CONCLUSIONS Chinese nurses employed in abdominal surgical services need to improve the knowledge about ERAS protocols. Standardised training is recommended to improve nurses' ERAS-related knowledge, which can help nurses improve the quality of perioperative care and promote the recovery of patients.
Collapse
Affiliation(s)
- Bing Xue
- School of Nursing, Wuhan University, Wuhan, China
| | - Huidan Yu
- School of Nursing, Wuhan University, Wuhan, China
| | - Xianwu Luo
- School of Nursing, Wuhan University, Wuhan, China
| |
Collapse
|
8
|
Chan KS, Wang B, Tan YP, Chow JJL, Ong EL, Junnarkar SP, Low JK, Huey CWT, Shelat VG. Sustaining a Multidisciplinary, Single-Institution, Postoperative Mobilization Clinical Practice Improvement Program Following Hepatopancreatobiliary Surgery During the COVID-19 Pandemic: Prospective Cohort Study. JMIR Perioper Med 2021; 4:e30473. [PMID: 34559668 PMCID: PMC8496752 DOI: 10.2196/30473] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The Enhanced Recovery After Surgery (ERAS) protocol has been recently extended to hepatopancreatobiliary (HPB) surgery, with excellent outcomes reported. Early mobilization is an essential facet of the ERAS protocol, but compliance has been reported to be poor. We recently reported our success in a 6-month clinical practice improvement program (CPIP) for early postoperative mobilization. During the COVID-19 pandemic, we experienced reduced staffing and resource availability, which can make CPIP sustainability difficult. OBJECTIVE We report outcomes at 1 year following the implementation of our CPIP to improve postoperative mobilization in patients undergoing major HPB surgery during the COVID-19 pandemic. METHODS We divided our study into 4 phases-phase 1: before CPIP implementation (January to April 2019); phase 2: CPIP implementation (May to September 2019); phase 3: post-CPIP implementation but prior to the COVID-19 pandemic (October 2019 to March 2020); and phase 4: post-CPIP implementation and during the pandemic (April 2020 to September 2020). Major HPB surgery was defined as any surgery on the liver, pancreas, and biliary system with a duration of >2 hours and with an anticipated blood loss of ≥500 ml. Study variables included length of hospital stay, distance ambulated on postoperative day (POD) 2, morbidity, balance measures (incidence of fall and accidental dislodgement of drains), and reasons for failure to achieve targets. Successful mobilization was defined as the ability to sit out of bed for >6 hours on POD 1 and ambulate ≥30 m on POD 2. The target mobilization rate was ≥75%. RESULTS A total of 114 patients underwent major HPB surgery from phases 2 to 4 of our study, with 33 (29.0%), 45 (39.5%), and 36 (31.6%) patients in phases 2, 3, and 4, respectively. No baseline patient demographic data were collected for phase 1 (pre-CPIP implementation). The majority of the patients were male (n=79, 69.3%) and underwent hepatic surgery (n=92, 80.7%). A total of 76 (66.7%) patients underwent ON-Q PainBuster insertion intraoperatively. The median mobilization rate was 22% for phase 1, 78% for phases 2 and 3 combined, and 79% for phase 4. The mean pain score was 2.7 (SD 1.0) on POD 1 and 1.8 (SD 1.5) on POD 2. The median length of hospitalization was 6 days (IQR 5-11.8). There were no falls or accidental dislodgement of drains. Six patients (5.3%) had pneumonia, and 21 (18.4%) patients failed to ambulate ≥30 m on POD 2 from phases 2 to 4. The most common reason for failure to achieve the ambulation target was pain (6/21, 28.6%) and lethargy or giddiness (5/21, 23.8%). CONCLUSIONS This follow-up study demonstrates the sustainability of our CPIP in improving early postoperative mobilization rates following major HPB surgery 1 year after implementation, even during the COVID-19 pandemic. Further large-scale, multi-institutional prospective studies should be conducted to assess compliance and determine its sustainability.
Collapse
Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Bei Wang
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yen Pin Tan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Ee Ling Ong
- Office of Clinical Governance, Tan Tock Seng Hospital, Singapore, Singapore
| | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| |
Collapse
|
9
|
Jones CN, Morrison BL, Kelliher LJ, Dickinson M, Scott M, Cecconi Ebm C, Karanjia N, Quiney N. Hospital Costs and Long-term Survival of Patients Enrolled in an Enhanced Recovery Program for Open Liver Resection: Prospective Randomized Controlled Trial. JMIR Perioper Med 2021; 4:e16829. [PMID: 33522982 PMCID: PMC7884210 DOI: 10.2196/16829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/15/2020] [Accepted: 01/10/2021] [Indexed: 12/20/2022] Open
Abstract
Background The clinical benefits of enhanced recovery programs (ERPs) have been extensively researched, but few studies have evaluated their cost-effectiveness. Our ERP for open liver resection is based closely on the guidelines produced by the Enhanced Recovery After Surgery Society (2016). This study follows on from a previous randomized controlled trial. We also undertook a long-term follow-up of the patients enrolled in the original trial alongside an analysis of the associated health economics. Objective We aimed to undertake a health economic and long-term survival analysis as part of a trial investigating the implementation of an ERP for open liver resection. Methods The enhanced recovery elements utilized included extra preoperative education, carbohydrate loading, oral nutritional supplements, postresection goal-directed fluid therapy (LiDCOrapid), early mobilization, and physiotherapy (twice a
day compared with once per day in the standard care group). A decision-analytic model was used to compare the study endpoints for ERP versus standard care provided to patients undergoing open liver resection. Outcomes obtained included costs per life-years gained. Resource use and costs were estimated from the perspective of the National Health Service of the United Kingdom. A decision tree and Markov model were constructed using results from our earlier trial and augmented by external data from other published clinical trials. Long-term follow-up was also undertaken for up to 5 years after the surgery, and data were analyzed to ascertain if the ERP conferred any benefit on long-term survival. Results Patients receiving ERP had an average life expectancy of 6.9 years versus 6.1 years in the standard care group. The overall costs were £9538.279 (£1=US $1.60) for ERP and £14,793.05 for standard treatment. This results in a cost-effectiveness ratio of –£6748.33/QALY. Patients receiving ERP required fewer visits to their general practitioner (P=.006) and required lesser help at home with day-to-day activities (P=.04) than patients in the standard care group. Survival was significantly improved at 2 years at 91% (42/46) for patients receiving ERP versus 73% (33/45) for the standard care group (P=.03). There was no statistically significant difference at 5 years after the surgery. Conclusions ERPs for patients undergoing open liver resection can improve their medium-term survival and are cost-effective for both hospital and community settings.
Collapse
Affiliation(s)
- Chris N Jones
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | - Ben L Morrison
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | | | | | - Michael Scott
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | | | | | - Nial Quiney
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| |
Collapse
|
10
|
Nakanishi W, Miyagi S, Tokodai K, Fujio A, Sasaki K, Shono Y, Unno M, Kamei T. Effect of enhanced recovery after surgery protocol on recovery after open hepatectomy: a randomized clinical trial. Ann Surg Treat Res 2020; 99:320-328. [PMID: 33304859 PMCID: PMC7704272 DOI: 10.4174/astr.2020.99.6.320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/16/2020] [Accepted: 08/21/2020] [Indexed: 02/06/2023] Open
Abstract
Purpose Enhanced recovery after surgery (ERAS) is beneficial to patients undergoing digestive surgery. However, its efficacy in patients undergoing open hepatectomy remains unclear. Methods Consecutive patients scheduled for open hepatectomy were randomly assigned to undergo either ERAS or conventional postoperative management. The primary endpoint was the amount of time that elapsed before patients were considered medically fit for discharge (MFD) and length of hospital stay (LOHS). Secondary endpoints included morbidity, mortality, the time to first flatus, defecation, first walk, and freedom from infusion. Perioperative serum nutritional markers, insulin resistance, respiratory quotient (RQ), and resting energy expenditure (REE) were also assessed. Results Between August 2014 and March 2017, 57 patients were randomized into 2 groups; ERAS group (n = 29) and conventional management (n = 28). The median MFD was not significantly different between the ERAS and conventional management groups (6.5 vs. 7 days; P = 0.381). Recovery from gastrointestinal paresis was significantly quicker in the ERAS group (1.8 vs. 2.4 days; P = 0.004). There were no significant differences in serum markers, insulin resistance, RQ, and REE. Conclusion This trial did not demonstrate greater efficacy of the ERAS protocol following open hepatectomy in terms of the MFD and LOHS. However, the ERAS protocol was associated with better recovery from postoperative gastrointestinal paresis, suggesting that it is useful for patients undergoing open hepatectomy.
Collapse
Affiliation(s)
- Wataru Nakanishi
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shigehito Miyagi
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuaki Tokodai
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Atsushi Fujio
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kengo Sasaki
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshihiro Shono
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| |
Collapse
|
11
|
Giovinazzo F, Kuemmerli C, Moekotte A, Rawashdeh A, Suhool A, Armstrong T, Primrose J, Abu Hilal M. The impact of enhanced recovery on open and laparoscopic liver resections. Updates Surg 2020; 72:649-657. [PMID: 32418169 DOI: 10.1007/s13304-020-00786-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 05/02/2020] [Indexed: 01/11/2023]
Abstract
Enhanced recovery after surgery programs (ERP) have been implemented in many surgical specialties. Their impact in liver surgery is poorly understood and approach-specific ERPs have not yet been assessed. This retrospective study aims to analyse the effect of such programs on liver resection. All patients undergoing liver resection at a tertiary referral centre between January 2009 and April 2019 were identified. Primary outcome was the length of stay (LOS), secondary outcomes were functional recovery, complications and readmission rates. Patients in the ERP with different protocols for open, laparoscopic, major and minor resections were compared to a historical cohort. Of 1056 patients, 644 were treated within the ERP. A comparable duration of hospital stay [7 days (IQR (interquartile range) 6-12) vs 7 days (IQR 5-9) p = 0.047] and faster functional recovery with fewer complications was found in the ERP group [94 (50.5%) vs 103 (35.9%) p < 0.002]. Those advantages were smaller after open minor compared to open major resection. In patients undergoing laparoscopic resection no differences were observed except for a lower readmission rate [21 (9.3%) vs 13 (3.6%) p = 0.005]. Multivariable analysis showed that laparoscopy was associated with a shorter LOS. ERPs offer significant advantages in open liver surgery. Those advantages are less evident after laparoscopic resection.
Collapse
Affiliation(s)
- Francesco Giovinazzo
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Christoph Kuemmerli
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, Istituto Fondazione Poliambulanza, Via Bissolati 57, 25124, Brescia, Italy
| | - Alma Moekotte
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Arab Rawashdeh
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Amal Suhool
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Thomas Armstrong
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - John Primrose
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Mohammed Abu Hilal
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK.
- Department of Surgery, Istituto Fondazione Poliambulanza, Via Bissolati 57, 25124, Brescia, Italy.
| |
Collapse
|
12
|
Dudi-Venkata NN, Seow W, Kroon HM, Bedrikovetski S, Moore JW, Thomas ML, Sammour T. Safety and efficacy of laxatives after major abdominal surgery: systematic review and meta-analysis. BJS Open 2020; 4:577-586. [PMID: 32459069 PMCID: PMC7397346 DOI: 10.1002/bjs5.50301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 04/29/2020] [Indexed: 12/17/2022] Open
Abstract
Background Recovery of gastrointestinal function is often delayed after major abdominal surgery, leading to postoperative ileus (POI). Enhanced recovery protocols recommend laxatives to reduce the duration of POI, but evidence is unclear. This systematic review aimed to assess the safety and efficacy of laxative use after major abdominal surgery. Methods Ovid MEDLINE, Embase, Cochrane Library and PubMed databases were searched from inception to May 2019 to identify eligible RCTs focused on elective open or minimally invasive major abdominal surgery. The primary outcome was time taken to passage of stool. Secondary outcomes were time taken to tolerance of diet, time taken to flatus, length of hospital stay, postoperative complications and readmission to hospital. Results Five RCTs with a total of 416 patients were included. Laxatives reduced the time to passage of stool (mean difference (MD) −0·83 (95 per cent c.i. −1·39 to −0·26) days; P = 0·004), but there was significant heterogeneity between studies for this outcome measure. There was no difference in time to passage of flatus (MD −0·17 (−0·59 to 0·25) days; P = 0·432), time to tolerance of diet (MD −0·01 (−0·12 to 0·10) days; P = 0·865) or length of hospital stay (MD 0·01(−1·36 to 1·38) days; P = 0·992). There were insufficient data available on postoperative complications for meta‐analysis. Conclusion Routine postoperative laxative use after major abdominal surgery may result in earlier passage of stool but does not influence other postoperative recovery parameters. Better data are required for postoperative complications and validated outcome measures.
Collapse
Affiliation(s)
- N N Dudi-Venkata
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - W Seow
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - H M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - S Bedrikovetski
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - J W Moore
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - M L Thomas
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - T Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
13
|
Imai T, Kurosawa K, Asada Y, Momma Y, Takahashi M, Satake N, Azuma M, Suzuki A, Sasaki M, Morita S, Saijo S, Fujii K, Kishimoto K, Yamazaki T, Goto T, Matsuura K. Enhanced recovery after surgery program involving preoperative dexamethasone administration for head and neck surgery with free tissue transfer reconstruction: Single-center prospective observational study. Surg Oncol 2020; 34:197-205. [PMID: 32891330 DOI: 10.1016/j.suronc.2020.04.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 04/13/2020] [Accepted: 04/25/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND There are few reports on Enhanced Recovery After Surgery (ERAS)-based perioperative management following head and neck surgery with free tissue transfer reconstruction (HNS-FTTR). Here, we prospectively evaluated our ERAS program involving preoperative glucocorticoid administration in HNS-FTTR. METHODS This prospective study included 60 patients who underwent HNS-FTTR at the Miyagi Cancer Center from June 2017 to December 2018. Their treatment plan included receiving perioperative management in accordance with our head and neck ERAS program. Major outcomes of hospitalization periods, early mobilization, early enteral nutrition, and patient satisfaction were assessed, and blood date and vital signs were compared with control patients who underwent HNS-FTTR from January 2014 to September 2016 at our institution before ERAS was implemented. RESULTS The duration of hospital stay and the duration until completion of the discharge criteria was a median of 25 days and 17 days, respectively. Early mobilization was achieved in 86.0% of the patients at postoperative-day (POD)1 and 96.5% at POD2. Enteral nutrition was started in 80.1% at POD1 and 100% at POD2. Postoperative pain was controlled at mean VAS scores of 1.51-3.13. Clavien-Dindo grade II or higher postoperative complications were evident in 27.6% of the patients. The mean QOR40 score was 179.6 preoperatively, 146.1 at POD3, and 167.8 at POD7. Compared with the control group, there were significantly lower C-reactive protein levels, higher albumin levels, a lower body temperature, a lower neutrophil-to-lymphocyte ratio, less body weight fluctuation, and fewer incidences of decreased blood pressure in the ERAS group. CONCLUSION Patients who underwent HNS-FTTR with ERAS-based perioperative management achieved early mobilization, early enteral nutrition, favorable pain control, remarkable recovery of patient satisfaction at POD7, and there was evidence of better hemodynamic stability and less inflammatory response compared with control patients.
Collapse
Affiliation(s)
- Takayuki Imai
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan.
| | - Koreyuki Kurosawa
- Department of Plastic and Reconstructive Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Yukinori Asada
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Yumiko Momma
- Department of Nursing, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Maki Takahashi
- Department of Nursing, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Naoko Satake
- Department of Nursing, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Misato Azuma
- Department of Rehabilitation, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Ai Suzuki
- Department of Rehabilitation, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Megumi Sasaki
- Department of Nutrition, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Sinkichi Morita
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Satoshi Saijo
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Keitaro Fujii
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Kazuhiro Kishimoto
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Tomoko Yamazaki
- Department of Head and Neck Medical Oncology, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Takahiro Goto
- Department of Plastic and Reconstructive Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Kazuto Matsuura
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| |
Collapse
|
14
|
Schwab M, Brindl N, Studier-Fischer A, Tu T, Gsenger J, Pilgrim M, Friedrich M, Frey PE, Achilles C, Leuck A, Bürgel T, Feisst M, Klose C, Tenckhoff S, Dörr-Harim C, Mihaljevic AL. Postoperative complications and mobilisation following major abdominal surgery with vs. without fitness tracker-based feedback (EXPELLIARMUS): study protocol for a student-led multicentre randomised controlled trial (CHIR-Net SIGMA study group). Trials 2020; 21:293. [PMID: 32293519 PMCID: PMC7092422 DOI: 10.1186/s13063-020-4220-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 03/02/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Postoperative complications following major abdominal surgery are frequent despite progress in surgical technique and perioperative care. Early and enhanced postoperative mobilisation has been advocated to reduce postoperative complications, but it is still unknown whether it can independently improve outcomes after major surgery. Fitness trackers (FTs) are a promising tool to improve postoperative mobilisation, but their effect on postoperative complications and recovery has not been investigated in clinical trials. METHODS This is a multicentre randomised controlled trial with two parallel study groups evaluating the efficacy of an enhanced and early mobilisation protocol in combination with FT-based feedback in patients undergoing elective major abdominal surgery. Participants are randomly assigned (1:1) to either the experimental group, which receives daily step goals and a FT giving feedback about daily steps, or the control group, which is mobilised according to hospital standards. The control group also receives a FT, however with a blackened screen; thus no FT-based feedback is possible. Randomisation will be stratified by type of surgery (laparoscopic vs. open). The primary endpoint of the study is postoperative morbidity within 30 days measured via the Comprehensive Complication Index. Secondary endpoints include number of steps as well as a set of functional, morbidity and safety parameters. A total of 348 patients will be recruited in 15 German centres. The study will be conducted and organised by the student-led German Clinical Trial Network SIGMA. DISCUSSION Our study aims at investigating whether the implementation of a simple mobilisation protocol in combination with FT-based feedback can reduce postoperative morbidity in patients undergoing major abdominal surgery. If so, FTs would offer a cost-effective intervention to enhance postoperative mobilisation and improve patient outcomes. TRIAL REGISTRATION Deutsches Register Klinischer Studien (DRKS, German Clinical Trials Register): DRKS00016755, UTN U1111-1228-3320. Registered on 06.03.2019.
Collapse
Affiliation(s)
- Marius Schwab
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Niall Brindl
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | | | - Thomas Tu
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Julia Gsenger
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Max Pilgrim
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Mirco Friedrich
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Pia-Elena Frey
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Christina Achilles
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Alexander Leuck
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Thore Bürgel
- Health Data Science Unit, University Hospital Heidelberg, BioQuant, Im Neuenheimer Feld 267, 69120, Heidelberg, Germany
| | - Manuel Feisst
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Christina Klose
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Solveig Tenckhoff
- CHIR-Net Coordination Centre at the Study Centre of the German Surgical Society (SDGC), University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Colette Dörr-Harim
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
| |
Collapse
|
15
|
Perez Navarro G, Pascual Bellosta AM, Ortega Lucea SM, Serradilla Martín M, Ramirez Rodriguez JM, Martinez Ubieto J. Analysis of the postoperative hemostatic profile of colorectal cancer patients subjected to liver metastasis resection surgery. World J Clin Cases 2019; 7:2477-2486. [PMID: 31559283 PMCID: PMC6745336 DOI: 10.12998/wjcc.v7.i17.2477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 07/23/2019] [Accepted: 07/27/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Liver resection surgery has advanced greatly in recent years, and the adoption of fasttrack programs has yielded good results. Combination anesthesia (general anesthesia associated to epidural analgesia) is an anesthetic-analgesic strategy commonly used for the perioperative management of patients undergoing surgery of this kind, though there is controversy regarding the coagulation alterations it may cause and which can favor the development of spinal hematomas.
AIM To study the postoperative course of liver resection surgery, an analysis was made of the outcomes of liver resection surgery due to colorectal cancer metastases in our centre in terms of morbiditymortality and hospital stay according to the anesthetic technique used (general vs combination anesthesia).
METHODS A prospective study was made of 61 colorectal cancer patients undergoing surgery due to liver metastases under general and combination anesthesia between January 2014 and October 2015. The patient characteristics, intraoperative variables, postoperative complications, evolution of hemostatic parameters, and stay in intensive care and in hospital were analyzed.
RESULTS A total of 61 patients were included in two homogeneous groups: general anesthesia (n = 30) and combination anesthesia (general anesthesia associated to epidural analgesia) (n = 31). All patients had normal coagulation values before surgery. The international normalized ratio (INR) in both the general and combination anesthesia groups reached maximum values at 2448 h (mean 1.37 and 1.45 vs 1.39 and 1.41, respectively), followed by a gradual decrease. There was less intraoperative bleeding in the combination anesthesia group (769 mL) than in the general anesthesia group (1200 mL) (P < 0.05). Of the 61 patients, 38.8% in the general anesthesia group experienced some respiratory complication vs 6.6% in the combination anesthesia group (P < 0.001). The time to gastrointestinal tolerance was significantly correlated to the type of anesthesia, though not so the stay in critical care or the time to hospital discharge.
CONCLUSION Epidural analgesia in liver resection surgery was seen to be safe, with good results in terms of pain control and respiratory complications, and with no associated increase in complications secondary to altered hemostasis.
Collapse
|
16
|
Use of Activity Tracking in Major Visceral Surgery-the Enhanced Perioperative Mobilization Trial: a Randomized Controlled Trial. J Gastrointest Surg 2019; 23:1218-1226. [PMID: 30298422 DOI: 10.1007/s11605-018-3998-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 09/23/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Early mobilization is one essential item within the enhanced recovery after surgery (ERAS) concept, but lacks solid evidence and a standardized assessment. The aim was to monitor and increase the postoperative mobilization of patients after major visceral surgery by providing a continuous step count feedback using activity tracking wristbands. METHODS The study was designed as a randomized controlled single-center trial (NCT02834338) with two arms (open and laparoscopic surgery). Participants were randomized to either receive feedback of their step counts using an activity tracker wristband or not. The primary study endpoint was the mean step count during the first 5 postoperative days (PODs). RESULTS A total of 132 patients were randomized. After laparoscopic operations, the average step count during PODs 1-5 was significantly increased by the feedback compared with the control group (P < 0.001); the cumulative step count (9867 versus 6103, P = 0.037) and activity time were also significantly increased. These results could not be confirmed in the open surgery arm. Possible reasons were a higher age and significantly more comorbidities in the open intervention group. Patients who achieved more than the median cumulative step count had a significantly shorter hospital stay and lower morbidity in both arms. The average step count also correlated with the length of hospital stay (R = - 0.341, P < 0.001). CONCLUSION This study is the first randomized controlled trial investigating the use and feasibility of activity tracking to monitor and enhance postoperative mobilization in abdominal surgery. Our results demonstrate that activity tracking can enhance perioperative mobilization after laparoscopic surgery. TRIAL REGISTRATION ClinicalTrials.gov: NCT02834338.
Collapse
|
17
|
Izrailov RE, Tsvirkun VV, Alikhanov RB, Andrianov AV. [Eras protocol for laparoscopic Frey procedure (in Russian only)]. Khirurgiia (Mosk) 2019:60-64. [PMID: 30938358 DOI: 10.17116/hirurgia201903160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To assess the use of ERAS in laparoscopic Frey procedure. MATERIAL AND METHODS From August 2012 to November 2017 laparoscopic Frey procedure were performed in 35 patients. Fully laparoscopic were performed 31 (88.5%) procedures. We use fast-track protocol from 13 patients. We included from statistic analyses patients where procedure was changed or was conversion or was simultaneous procedure. The total number of patients analyzed was 27. The patients were divided into two groups: I - before the fast-track protocol (n=11), II - after the protocol implementation (n=16). RESULTS The operating time was 460 (365-530) minutes in I group and 420 (295-540) minutes in II group. Blood loss was 150 (5-300) and 150 (40-700) ml. The median postoperative stay period was 10 (5-25) days and 6.5 (3-11) days (p=0.007). CONCLUSION The combination of laparoscopic technologies and fast-track protocol reduces the duration of the postoperative stay period.
Collapse
Affiliation(s)
- R E Izrailov
- Moscow Clinical Scientific Center, 86 Shosse Entuziastov, 111123, Moscow, Russia
| | - V V Tsvirkun
- Moscow Clinical Scientific Center, 86 Shosse Entuziastov, 111123, Moscow, Russia
| | - R B Alikhanov
- Moscow Clinical Scientific Center, 86 Shosse Entuziastov, 111123, Moscow, Russia
| | - A V Andrianov
- Moscow Clinical Scientific Center, 86 Shosse Entuziastov, 111123, Moscow, Russia
| |
Collapse
|
18
|
Chinese Expert Consensus on Enhanced Recovery After Hepatectomy (Version 2017). Asian J Surg 2019; 42:11-18. [DOI: 10.1016/j.asjsur.2018.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 01/22/2018] [Accepted: 01/31/2018] [Indexed: 12/14/2022] Open
|
19
|
Abstract
The objective of this study was to compare fast-track (FT) recovery protocol with the conventional one in patients treated with major liver resection by evaluating perioperative morbidity, length of hospitalization, and readmission rate. Sixty-two patients suffering from malignant liver tumors were surgically treated from May 2012 to April 2014. After randomization, they were prospectively divided into two groups: Group A patients (n = 32) followed FT recovery protocol and Group B patients (n = 30) were treated with the conventional (CON) protocol. Postoperative morbidity, readmission rate, and median hospital stay in the two groups were studied. Fast-track protocol was associated with a decreased complication (25%, p = .002), whereas the risk of postoperative morbidity was 2.4 times higher in patients treated with the CON protocol (60%, p = .002). Readmission rate was not significantly different between the two groups (6.25%, p = .35). Age (p = .382) and body mass index (p = .818) were not a suspending factor for following the FT protocol. Overall length of stay (postoperative days) in the FT group was (mean ± SD) 5.75 ± .5 and in the CON group was 13.5 ± 6.7 (p < .001). Fast-track recovery protocol seems to be safe and particularly efficient in patients undergoing major liver resections.
Collapse
|
20
|
Maria K, Evangelos KA, Dimitris KP, Maria K, Ioannis K, Margarita G. Postoperative stress and pain response applying fast-track protocol in patients undergoing hepatectomy. J Perioper Pract 2018; 29:368-377. [PMID: 30417764 DOI: 10.1177/1750458918812293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Aim To assess the clinical parameters and compare the stress and pain response between fast-track recovery protocol and conventional treatment in patients undergoing major liver resection. Methods Eighty-eight patients suffering from malignant liver tumours were surgically treated from May 2012 to March 2015. After randomisation, they were prospectively divided into two groups: group fast-track patients (n = 46) and group conventional treatment patients (n = 42). Demographic and clinical data were collected and patients were assessed with pain scale (behavioural observation scale and visual analog scale), while depression levels were evaluated with Zung self-rating depression scale and three Numeric Analog Scale self-reported questions. Peripheral blood samples were collected at time points: T1 on the admission day, T2 on the day of surgery and T3 on the day of discharge examining serum levels of adrenocorticotropic hormone and cortisol. Conclusion Fast-track recovery protocols seem to be associated with improvement in several clinical parameters, without compromising, biologic or emotional stress in patients undergoing major liver resection.
Collapse
Affiliation(s)
- Kapritsou Maria
- Chief Nurse of PACU, Hellenic Anticancer Hospital "Saint Savvas", Day Care Surgery "N. KOURKOULOS" Hellenic Anticancer Institute, "Saint Savvas" Hospital, Athens, Greece
| | | | | | - Kalafati Maria
- Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
| | - Kaklamanos Ioannis
- Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
| | | |
Collapse
|
21
|
Enhanced recovery after surgery for laparoscopic hepatectomy: Consensus of Chinese experts (2017). LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2018. [DOI: 10.1016/j.lers.2018.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
22
|
Moon A, Tangada A, Andikyan V, Chuang L. Enhanced Recovery after Surgery (ERAS) in Gynecologic Surgery—A Review. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2018. [DOI: 10.1007/s13669-018-0247-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
|
23
|
Imai T, Kurosawa K, Yamaguchi K, Satake N, Asada Y, Matsumoto K, Morita S, Saijo S, Aoi J, Fujii K, Kishimoto K, Goto T, Matsuura K. Enhanced Recovery After Surgery program with dexamethasone administration for major head and neck surgery with free tissue transfer reconstruction: initial institutional experience. Acta Otolaryngol 2018; 138:664-669. [PMID: 29385889 DOI: 10.1080/00016489.2018.1429651] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Enhanced Recovery After Surgery (ERAS) protocols promote recovery after various invasive surgeries. Likewise, preoperative glucocorticoid administration can reduce complications after some surgeries. However, the effects of ERAS protocols and glucocorticoid administration in patients undergoing major surgery for head and neck cancer have not been well described. The aim of this study was to evaluate the effect of an ERAS protocol with preoperative glucocorticoid administration in major surgery for head and neck cancer. METHODS This retrospective study included 28 patients who underwent major head and neck surgery with free tissue transfer reconstruction at our institution from September 2016 to May 2017, after implementation of an ERAS protocol with preoperative glucocorticoid administration. Outcomes in that group were compared with those in a control group that underwent surgery from January 2015 to September 2016, before implementation of the protocol. RESULTS Analysis revealed significantly less body weight fluctuation, lower C-reactive protein levels, higher albumin levels, and lower body temperature in the ERAS group than in the control group postoperatively. CONCLUSIONS Patients undergoing major surgery for head and neck cancer who were treated with the ERAS protocol and preoperative glucocorticoid administration had evidence of better hemodynamic stability and less inflammatory response than control patients.
Collapse
Affiliation(s)
- Takayuki Imai
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Koreyuki Kurosawa
- Department of Plastic Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Kayo Yamaguchi
- Department of Nursing, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Naoko Satake
- Department of Nursing, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Yukinori Asada
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Ko Matsumoto
- Department of Diagnostic Radiology, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Sinkichi Morita
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Satoshi Saijo
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Jiro Aoi
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Keitaro Fujii
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Kazuhiro Kishimoto
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Takahiro Goto
- Department of Plastic Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| | - Kazuto Matsuura
- Department of Head and Neck Surgery, Miyagi Cancer Center, Natori, Miyagi, Japan
| |
Collapse
|
24
|
Melloul E, Hübner M, Scott M, Snowden C, Prentis J, Dejong CHC, Garden OJ, Farges O, Kokudo N, Vauthey JN, Clavien PA, Demartines N. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg 2017; 40:2425-40. [PMID: 27549599 DOI: 10.1007/s00268-016-3700-1] [Citation(s) in RCA: 375] [Impact Index Per Article: 53.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) is a multimodal pathway developed to overcome the deleterious effect of perioperative stress after major surgery. In colorectal surgery, ERAS pathways reduced perioperative morbidity, hospital stay and costs. Similar concept should be applied for liver surgery. This study presents the specific ERAS Society recommendations for liver surgery based on the best available evidence and on expert consensus. METHODS A systematic review was performed on ERAS for liver surgery by searching EMBASE and Medline. Five independent reviewers selected relevant articles. Quality of randomized trials was assessed according to the Jadad score and CONSORT statement. The level of evidence for each item was determined using the GRADE system. The Delphi method was used to validate the final recommendations. RESULTS A total of 157 full texts were screened. Thirty-seven articles were included in the systematic review, and 16 of the 23 standard ERAS items were studied specifically for liver surgery. Consensus was reached among experts after 3 rounds. Prophylactic nasogastric intubation and prophylactic abdominal drainage should be omitted. The use of postoperative oral laxatives and minimally invasive surgery results in a quicker bowel recovery and shorter hospital stay. Goal-directed fluid therapy with maintenance of a low intraoperative central venous pressure induces faster recovery. Early oral intake and mobilization are recommended. There is no evidence to prefer epidural to other types of analgesia. CONCLUSIONS The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.
Collapse
Affiliation(s)
- Emmanuel Melloul
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Martin Hübner
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Michael Scott
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Chris Snowden
- Department of Perioperative and Critical Care Medicine, Freeman Hospital, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, The Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - James Prentis
- Department of Perioperative and Critical Care Medicine, Freeman Hospital, Newcastle upon Tyne, UK
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Center and NUTRIM School for Translational Research in Metabolism, Maastricht, The Netherlands
| | - O James Garden
- Department of Clinical Surgery, School of Clinical Sciences, The University of Edinburgh, Edinburgh, UK
| | - Olivier Farges
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, U.T. MD Anderson Cancer Center, Houston, TX, USA
| | - Pierre-Alain Clavien
- Swiss Hepato-pancreato-biliary and Transplantation Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| |
Collapse
|
25
|
Warner SG, Jutric Z, Nisimova L, Fong Y. Early recovery pathway for hepatectomy: data-driven liver resection care and recovery. Hepatobiliary Surg Nutr 2017; 6:297-311. [PMID: 29152476 PMCID: PMC5673763 DOI: 10.21037/hbsn.2017.01.18] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 11/11/2016] [Indexed: 12/22/2022]
Abstract
In recent years, great progress has been made toward safer hepatobiliary surgical interventions. This has resulted in more widely available treatments for patients who in the past were ineligible for curative resection of primary liver tumors, liver metastases, and advanced biliary tumors. However, the rise in procedures has seen increasingly heterogeneous perioperative management, yielding strikingly disparate outcomes. A number of groups have attempted to standardize perioperative care in an effort to create enhanced recovery pathways (ERPs) and provide clinicians with a dependable roadmap to success following hepatectomy. In the future, each aspect of perioperative care could be pre-ordained with emphasis on nutrition, anesthesia, prophylaxis, use of surgical drains, post-operative fluid and electrolyte management, and contact with physician extenders following discharge. This article reviews the data behind ERPs preceding and following hepatectomy. It includes primary data justifying practices in post-hepatectomy support. It also touches on the benefits of minimally invasive hepatectomy and offers future directions for research in peri-hepatectomy ERPs. Overall, this article seeks to formulate a pathway for practice based on data, with enough details to allow creation of rational order sets for efficient and superior practice.
Collapse
Affiliation(s)
- Susanne G. Warner
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Zeljka Jutric
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | | | - Yuman Fong
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| |
Collapse
|
26
|
Cao YH, Chi P, Zhao YX, Dong XC. Effect of bispectral index-guided anesthesia on consumption of anesthetics and early postoperative cognitive dysfunction after liver transplantation: An observational study. Medicine (Baltimore) 2017; 96:e7966. [PMID: 28858130 PMCID: PMC5585524 DOI: 10.1097/md.0000000000007966] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The objective of this study was to summarize the incidence of postoperative cognitive dysfunction (POCD) after 7days following liver transplantation (LT), and to evaluate the effectiveness of bispectral index (BIS) guided anesthetic intervention in reducing POCD. Additional serum concentrations of S100β and neuron-specific enolase (NSE) were detected during surgery to determine whether they were reliable predictors of POCD.Patients who underwent LT at Beijing YouAn Hospital Affiliated to Capital University of Medical Science from January 2014 to December 2015 were enrolled. BIS monitor was needed during surgery. Patients who underwent LT without BIS monitoring during August 2012 to December 2014 served as historical controls. A battery of 5 neuropsychological tests were performed and scored preoperatively and 7days after surgery. POCD was diagnosed by the method of one standard deviation (SD). The blood samples of BIS group were collected at 5 time points: just before induction of general anesthesia (T0), 60 minutes after skin incision (T1), 30 minutes after the start of the anhepatic phase (T2), 15 minutes after reperfusion of the new liver (T3), and at 24 hours after surgery (T4).A total of 33 patients were included in BIS group, and 27 in the control group. Mean arterial pressure was different between 2 groups at 30 minutes after the start of the anhepatic phase (P = .032). The dose of propofol using at anhepatic phase 30 min and new liver 15 min was lower in the BIS group than control group (0.042 ± 0.021 vs. 0.069 ± 0.030, P < .001; 0.053 ± 0.022 vs. 0.072 ± 0.020, P = .001). Five patients were diagnosed as having POCD after 7 days in the BIS group and the incidence of POCD was 15.15%. In the control group, 9 patients had POCD and the incidence of POCD was 33.33%. The incidence of POCD between 2 groups had no statistical difference (P = .089). S100β increased at stage of anhepatic 30 minutes (T2) and new liver 15 minutes (T3) compared with the stage of before anesthesia (T0) (1.49 ± 0.66 vs. 0.72 ± 0.53, P < .001; 1.92 ± 0.78 vs. 0.72 ± 0.53, P < .001). NSE increased at stage of anhepatic 30 minutes (T2) and new liver 15 minutes (T3) compared with the stage of before anesthesia (T0) (5.80 ± 3.03 vs. 3.58 ± 3.24, P = .001; 10.04 ± 5.65 vs. 3.58 ± 3.24, P < .001). At 24 hours after surgery, S100β had no difference compared to one before anesthesia (1.0 ± 0.62 vs. 0.72 ± 0.53, P = .075), but NSE still remained high (5.19 ± 3.64 vs. 3.58 ± 3.24, P = .043). There were no significant differences in the serum concentrations of S100β between patients with and without POCD at 5 time points of operation (P > .05). But at 24 hours after surgery, NSE concentrations were still high of patients with POCD (8.14 ± 3.25 vs. 4.81 ± 3.50, P = .035).BIS-guided anesthesia can reduce consumption of propofol during anhepatic and new liver phase. Patients in BIS group seem to have a mild lower incidence of POCD compared to controls, but no statistical significant. The influence of BIS-guided anesthesia on POCD needs to be further confirmed by large-scale clinical study. S100β protein and NSE are well correlative with neural injury, but NSE is more suitable for assessment of incidence of postoperative cognitive deficits after surgery.
Collapse
Affiliation(s)
- Ying-Hao Cao
- Department of Anesthesiology, Beijing YouAn Hospital, Capital Medical University
| | - Ping Chi
- Department of Anesthesiology, Beijing YouAn Hospital, Capital Medical University
| | - Yan-Xing Zhao
- Department of Anesthesiology,Guang’anmen Hospital, China Acadamy of Chinese Medical Science, Beijing, China
| | - Xi-Chen Dong
- Department of Anesthesiology,Guang’anmen Hospital, China Acadamy of Chinese Medical Science, Beijing, China
| |
Collapse
|
27
|
Damania R, Cocieru A. Impact of enhanced recovery after surgery protocols on postoperative morbidity and mortality in patients undergoing routine hepatectomy: review of the current evidence. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:341. [PMID: 28936435 DOI: 10.21037/atm.2017.07.04] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Enhanced recovery protocols are widely used in many areas of general surgery but had a limited penetration in perioperative management of patients undergoing liver resection. Recently, multiple publications described application of enhanced recovery after surgery (ERAS) program to hepatectomy patients but their definitive role is not established or accepted by hepatobiliary surgeons. METHODS A comprehensive literature review of published series in English language medical sources detailing ERAS program application for hepatectomy for the period of 2006-2016 is performed. RESULTS ERAS protocols are feasible and safe. They reduce length of stay in patients undergoing routine hepatectomy without negative impact on morbidity and mortality. There is potential for reduction of Clavien grade I-II complications, while major and surgical complications are similar to traditional care management group. CONCLUSIONS Application of ERAS program to patient undergoing hepatectomy reduces length of hospital stay without affecting perioperative morbidity or mortality and may represent a new standard of care for patients undergoing routine liver resection.
Collapse
Affiliation(s)
- Rahul Damania
- Northeastern Ohio Medical University, Rootstown, OH, USA
| | - Andrei Cocieru
- Northeastern Ohio Medical University, Rootstown, OH, USA.,Department of Surgery, Akron City Hospital, Akron, OH, USA
| |
Collapse
|
28
|
Zhao Y, Qin H, Wu Y, Xiang B. Enhanced recovery after surgery program reduces length of hospital stay and complications in liver resection: A PRISMA-compliant systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017; 96:e7628. [PMID: 28767578 PMCID: PMC5626132 DOI: 10.1097/md.0000000000007628] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 07/05/2017] [Accepted: 07/10/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Many enhanced recovery after surgery (ERAS) guidelines have already been established in several kinds of surgeries. But due to concerns of the specific complications, it has not yet been considered the standard of care in liver surgery. OBJECTIVE The aim of this review is to assess the effect of ERAS in patients undergoing liver surgery. METHODS EMBASE, CNKI, PubMed, and the Cochrane Database were searched for randomized controlled trials (RCTs) comparing ERAS with conventional care in patients undergoing liver surgery. Subgroup meta-analysis between laparoscopic and open surgical approaches to liver resection was also conducted. RESULTS Seven RCTs were included, representing 996 patients. Length of stay (LOS) (MD -3.17, 95% CI: -3.99 to -2.35, P < .00001, I = 89%) and time to first flatus (MD -0.9, 95% CI: -1.36 to -0.45, P = .0001, I = 98%) were both reduced in the ERAS group. There were also fewer complications in the ERAS group (OR 0.52, 95% CI: 0.37-0.72, P < .0001, I = 0%). CONCLUSION The ERAS program can obviously enhance short-term recovery after liver resection. It is safe and worthwhile. A specific ERAS guideline for liver resection is recommended.
Collapse
Affiliation(s)
- Yiyang Zhao
- Sichuan University West China Hospital, Pediatric Surgery
| | - Han Qin
- Chengdu First People's Hospital, General Surgery, Chengdu, Sichuan, P.R. China
| | - Yang Wu
- Sichuan University West China Hospital, Pediatric Surgery
| | - Bo Xiang
- Sichuan University West China Hospital, Pediatric Surgery
| |
Collapse
|
29
|
Feinberg J, Nielsen EE, Korang SK, Halberg Engell K, Nielsen MS, Zhang K, Didriksen M, Lund L, Lindahl N, Hallum S, Liang N, Xiong W, Yang X, Brunsgaard P, Garioud A, Safi S, Lindschou J, Kondrup J, Gluud C, Jakobsen JC. Nutrition support in hospitalised adults at nutritional risk. Cochrane Database Syst Rev 2017; 5:CD011598. [PMID: 28524930 PMCID: PMC6481527 DOI: 10.1002/14651858.cd011598.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The prevalence of disease-related malnutrition in Western European hospitals is estimated to be about 30%. There is no consensus whether poor nutritional status causes poorer clinical outcome or if it is merely associated with it. The intention with all forms of nutrition support is to increase uptake of essential nutrients and improve clinical outcome. Previous reviews have shown conflicting results with regard to the effects of nutrition support. OBJECTIVES To assess the benefits and harms of nutrition support versus no intervention, treatment as usual, or placebo in hospitalised adults at nutritional risk. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid SP), Embase (Ovid SP), LILACS (BIREME), and Science Citation Index Expanded (Web of Science). We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp); ClinicalTrials.gov; Turning Research Into Practice (TRIP); Google Scholar; and BIOSIS, as well as relevant bibliographies of review articles and personal files. All searches are current to February 2016. SELECTION CRITERIA We include randomised clinical trials, irrespective of publication type, publication date, and language, comparing nutrition support versus control in hospitalised adults at nutritional risk. We exclude trials assessing non-standard nutrition support. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane and the Cochrane Hepato-Biliary Group. We used trial domains to assess the risks of systematic error (bias). We conducted Trial Sequential Analyses to control for the risks of random errors. We considered a P value of 0.025 or less as statistically significant. We used GRADE methodology. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life. MAIN RESULTS We included 244 randomised clinical trials with 28,619 participants that met our inclusion criteria. We considered all trials to be at high risk of bias. Two trials accounted for one-third of all included participants. The included participants were heterogenous with regard to disease (20 different medical specialties). The experimental interventions were parenteral nutrition (86 trials); enteral nutrition (tube-feeding) (80 trials); oral nutrition support (55 trials); mixed experimental intervention (12 trials); general nutrition support (9 trials); and fortified food (2 trials). The control interventions were treatment as usual (122 trials); no intervention (107 trials); and placebo (15 trials). In 204/244 trials, the intervention lasted three days or more.We found no evidence of a difference between nutrition support and control for short-term mortality (end of intervention). The absolute risk was 8.3% across the control groups compared with 7.8% (7.1% to 8.5%) in the intervention groups, based on the risk ratio (RR) of 0.94 (95% confidence interval (CI) 0.86 to 1.03, P = 0.16, 21,758 participants, 114 trials, low quality of evidence). We found no evidence of a difference between nutrition support and control for long-term mortality (maximum follow-up). The absolute risk was 13.2% in the control group compared with 12.2% (11.6% to 13%) following nutritional interventions based on a RR of 0.93 (95% CI 0.88 to 0.99, P = 0.03, 23,170 participants, 127 trials, low quality of evidence). Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.We found no evidence of a difference between nutrition support and control for short-term serious adverse events. The absolute risk was 9.9% in the control groups versus 9.2% (8.5% to 10%), with nutrition based on the RR of 0.93 (95% CI 0.86 to 1.01, P = 0.07, 22,087 participants, 123 trials, low quality of evidence). At long-term follow-up, the reduction in the risk of serious adverse events was 1.5%, from 15.2% in control groups to 13.8% (12.9% to 14.7%) following nutritional support (RR 0.91, 95% CI 0.85 to 0.97, P = 0.004, 23,413 participants, 137 trials, low quality of evidence). However, the Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.Trial Sequential Analysis of enteral nutrition alone showed that enteral nutrition might reduce serious adverse events at maximum follow-up in people with different diseases. We could find no beneficial effect of oral nutrition support or parenteral nutrition support on all-cause mortality and serious adverse events in any subgroup.Only 16 trials assessed health-related quality of life. We performed a meta-analysis of two trials reporting EuroQoL utility score at long-term follow-up and found very low quality of evidence for effects of nutritional support on quality of life (mean difference (MD) -0.01, 95% CI -0.03 to 0.01; 3961 participants, two trials). Trial Sequential Analyses showed that we did not have enough information to confirm or reject clinically relevant intervention effects on quality of life.Nutrition support may increase weight at short-term follow-up (MD 1.32 kg, 95% CI 0.65 to 2.00, 5445 participants, 68 trials, very low quality of evidence). AUTHORS' CONCLUSIONS There is low-quality evidence for the effects of nutrition support on mortality and serious adverse events. Based on the results of our review, it does not appear to lead to a risk ratio reduction of approximately 10% or more in either all-cause mortality or serious adverse events at short-term and long-term follow-up.There is very low-quality evidence for an increase in weight with nutrition support at the end of treatment in hospitalised adults determined to be at nutritional risk. The effects of nutrition support on all remaining outcomes are unclear.Despite the clinically heterogenous population and the high risk of bias of all included trials, our analyses showed limited signs of statistical heterogeneity. Further trials may be warranted, assessing enteral nutrition (tube-feeding) for different patient groups. Future trials ought to be conducted with low risks of systematic errors and low risks of random errors, and they also ought to assess health-related quality of life.
Collapse
Affiliation(s)
- Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Emil Eik Nielsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Steven Kwasi Korang
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Kirstine Halberg Engell
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Marie Skøtt Nielsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Kang Zhang
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Maria Didriksen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Lisbeth Lund
- Danish Committee for Health Education5. sal, Classensgade 71CopenhagenDenmark2100
| | - Niklas Lindahl
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Sara Hallum
- Cochrane Colorectal Cancer Group23 Bispebjerg BakkeBispebjerg HospitalCopenhagenDenmarkDK 2400 NV
| | - Ning Liang
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Wenjing Xiong
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese MedicineBeijingChina
| | - Xuemei Yang
- Fujian University of Traditional Chinese MedicineResearch Base of TCM syndromeNo。1,Qiu Yang RoadShangjie town,Minhou CountyFuzhouFujian ProvinceChina350122
| | - Pernille Brunsgaard
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Alexandre Garioud
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Sanam Safi
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Jane Lindschou
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmark2100
| | - Jens Kondrup
- Rigshospitalet University HospitalClinical Nutrition UnitAmager Boulevard 127, 2th9 BlegdamsvejKøbenhavn ØDenmark2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
| | | |
Collapse
|
30
|
Wong-Lun-Hing EM, van Dam RM, van Breukelen GJP, Tanis PJ, Ratti F, van Hillegersberg R, Slooter GD, de Wilt JHW, Liem MSL, de Boer MT, Klaase JM, Neumann UP, Aldrighetti LA, Dejong CHC. Randomized clinical trial of open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery after surgery programme (ORANGE II study). Br J Surg 2017; 104:525-535. [PMID: 28138958 DOI: 10.1002/bjs.10438] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 10/28/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Laparoscopic left lateral sectionectomy (LLLS) has been associated with shorter hospital stay and reduced overall morbidity compared with open left lateral sectionectomy (OLLS). Strong evidence has not, however, been provided. METHODS In this multicentre double-blind RCT, patients (aged 18-80 years with a BMI of 18-35 kg/m2 and ASA fitness grade of III or below) requiring left lateral sectionectomy (LLS) were assigned randomly to OLLS or LLLS within an enhanced recovery after surgery (ERAS) programme. All randomized patients, ward physicians and nurses were blinded to the procedure undertaken. A parallel prospective registry (open non-randomized (ONR) versus laparoscopic non-randomized (LNR)) was used to monitor patients who were not enrolled for randomization because of doctor or patient preference. The primary endpoint was time to functional recovery. Secondary endpoints were length of hospital stay (LOS), readmission rate, overall morbidity, composite endpoint of liver surgery-specific morbidity, mortality, and reasons for delay in discharge after functional recovery. RESULTS Between January 2010 and July 2014, patients were recruited at ten centres. Of these, 24 patients were randomized at eight centres, and 67 patients from eight centres were included in the prospective registry. Owing to slow accrual, the trial was stopped on the advice of an independent Data and Safety Monitoring Board in the Netherlands. No significant difference in median (i.q.r.) time to functional recovery was observed between laparoscopic and open surgery in the randomized or non-randomized groups: 3 (3-5) days for OLLS versus 3 (3-3) days for LLLS; and 3 (3-3) days for ONR versus 3 (3-4) days for LNR. There were no significant differences with regard to LOS, morbidity, reoperation, readmission and mortality rates. CONCLUSION This RCT comparing open and laparoscopic LLS in an ERAS setting was not able to reach a conclusion on time to functional recovery, because it was stopped prematurely owing to slow accrual. Registration number: NCT00874224 ( https://www.clinicaltrials.gov).
Collapse
Affiliation(s)
- E M Wong-Lun-Hing
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Nutrim School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - R M van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Surgery, University Hospital Aachen, Aachen, Germany
| | - G J P van Breukelen
- Department of Methodology and Statistics, Maastricht University Medical Centre, Maastricht, The Netherlands
- CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - P J Tanis
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - F Ratti
- Department of Surgery, San Raffaele Hospital, Milan, Italy
| | - R van Hillegersberg
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - G D Slooter
- Department of Surgery, Maxima Medical Centre, Veldhoven, The Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M S L Liem
- Department of Surgery, Deventer Hospital, Deventer, The Netherlands
| | - M T de Boer
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - J M Klaase
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - U P Neumann
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Surgery, University Hospital Aachen, Aachen, Germany
| | | | - C H C Dejong
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Nutrim School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, The Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Surgery, University Hospital Aachen, Aachen, Germany
| |
Collapse
|
31
|
Wolk S, Meißner T, Linke S, Müssle B, Wierick A, Bogner A, Sturm D, Rahbari NN, Distler M, Weitz J, Welsch T. Use of activity tracking in major visceral surgery-the Enhanced Perioperative Mobilization (EPM) trial: study protocol for a randomized controlled trial. Trials 2017; 18:77. [PMID: 28222805 PMCID: PMC5322788 DOI: 10.1186/s13063-017-1782-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 01/04/2017] [Indexed: 01/14/2023] Open
Abstract
Background Enhanced recovery after surgery (ERAS) programs are aimed at minimizing postoperative stress and accelerating postoperative recovery by implementing multiple perioperative principles. “Early mobilization” is one such principle, but the quality of assessment and monitoring is poor, and evidence of improved outcome is lacking. Activity trackers allow precise monitoring and automatic feedback to the patients to enhance their motivation for early mobilization. The aim of the study is to monitor and increase the postoperative mobilization of patients by giving them continuous automatic feedback in the form of a step count using activity-tracking wristbands. Methods/design Patients undergoing elective open and laparoscopic surgery of the colon, rectum, stomach, pancreas, and liver for any indication will be included. Further inclusion criteria are age between 18 and 75 years, American Society of Anesthesiologists Physical Status class less than IV, and a signed informed consent form. Patients will be stratified into two subgroups, laparoscopic and open surgery, and will be randomized 1:1 for automatic feedback of their step count using an activity tracker wristband. The control group will have no automatic feedback. The sample size (n = 30 patients in each of the four groups, overall n = 120) is calculated on the basis of an assumed difference in step count of 250 steps daily (intervention group versus control group). The primary study endpoint is the average step count during the first 5 postoperative days; secondary endpoints are the percentage of patients in the two groups who master the predefined mobilization (step count) targets, assessment of additional activity data obtained from the devices, assessment of preoperative mobility, length of hospital and intensive care unit stays, number of patients who receive physiotherapy, 30-day mortality, and overall 30-day morbidity. Discussion Early mobilization is a key element of ERAS. However, enhanced early mobilization is difficult to define, to assess objectively, and to implement in clinical practice. Consequently, there is a discrepancy between ERAS targets and actual practice, especially in patients undergoing major visceral surgery. This study is the first randomized controlled trial investigating the use and feasibility of activity tracking to monitor and enhance postoperative early mobilization. Trial registration ClinicalTrials.gov identifier: NCT02834338. Registered on 15 June 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1782-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Steffen Wolk
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Theresa Meißner
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Sebastian Linke
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Benjamin Müssle
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Ann Wierick
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Andreas Bogner
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Dorothée Sturm
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Nuh N Rahbari
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| |
Collapse
|
32
|
Li M, Zhang W, Jiang L, Yang J, Yan L. Fast track for open hepatectomy: A systemic review and meta-analysis. Int J Surg 2016; 36:81-89. [PMID: 27773599 DOI: 10.1016/j.ijsu.2016.10.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 10/03/2016] [Accepted: 10/14/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Liver resection (LR) is preferred treatment for malignancies or benign masses of liver. Using multiple elements, fast track (FT) program was introduced to abdominal surgery associating with fast functional recovery and shorter hospital length of stay (LoS). This meta-analysis aims to evaluate the effect of FT program for patients following liver resection. MATERIALS AND METHODS We searched the PubMed/Medline, Cochrane Central Register of Controlled Trials (CENTRAL), Embase for trials up to December 2015 to compare the FT program to the conventional group. The main outcome was assessed of complication rate (including liver specific or general complication rate), thirty-day postoperative mortality, readmission rate and the length of hospital stay. RESULTS Four randomized control trials (RCTs) and three cohort trials (CTs) were to make a quantitative synthesis including 1027 patients. The LoS was reduced following FT groups (weighted mean difference [WMD], 2.24 days; 95% CI 3.69-0.79; P < 0.005). No significant differences were noted in overall complication (risk ratio [RR], 0.94; 95% CI, 0.79-1.12; p = 0.49), mortality (RR, 0.63; 95% CI, 0.19-2.15; p = 0.46) and readmission rate (RR, 0.99; 95% CI, 0.54-1.79; p = 0.97). However, the general complication showed a difference favoring FT group (RR, 0.68; 95% CI, 0.49-0.95; p = 0.03). CONCLUSIONS This review, firstly using the quantitative synthesis in FT program following LR, indicates that FT program can shorten the length of hospital stay and accelerate the postoperative recovery in a safe and effective ways without increasing in mortality, morbidity and readmission rate.
Collapse
Affiliation(s)
- Ming Li
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Wei Zhang
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Li Jiang
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Jiayin Yang
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China.
| | - Lunan Yan
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| |
Collapse
|
33
|
Wada S, Hatano E, Yoh T, Seo S, Taura K, Yasuchika K, Okajima H, Kaido T, Uemoto S. Is routine abdominal drainage necessary after liver resection? Surg Today 2016; 47:712-717. [PMID: 27778103 DOI: 10.1007/s00595-016-1432-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 09/06/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE Prophylactic abdominal drainage is performed routinely after liver resection in many centers. The aim of this study was to examine the safety and validity of liver resection without abdominal drainage and to clarify whether routine abdominal drainage after liver resection is necessary. METHODS Patients who underwent elective liver resection without bilio-enteric anastomosis between July, 2006 and June, 2012 were divided into two groups, based on whether surgery was performed before or after, we adopted the no-drain strategy. The "former group" comprised 256 patients operated on between July, 2006 and June, 2009 and the "latter group" comprised 218 patients operated between July, 2009 and June, 2012. We compared the postoperative complications, percutaneous drainage, and postoperative hospital stay between the groups, retrospectively. RESULTS There were no significant differences in the rates of postoperative bleeding, intraabdominal infection, or bile leakage between the groups. Drain insertion after liver resection did not reduce the rate of percutaneous drainage. Postoperative hospital stay was significantly shorter in the latter group. CONCLUSION Routine abdominal drainage is unnecessary after liver resection without bilio-enteric anastomosis.
Collapse
Affiliation(s)
- Seidai Wada
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Etsuro Hatano
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Tomoaki Yoh
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Satoru Seo
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kojiro Taura
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kentaro Yasuchika
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hideaki Okajima
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Toshimi Kaido
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shinji Uemoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| |
Collapse
|
34
|
Adherence to early mobilisation: Key for successful enhanced recovery after liver resection. Eur J Surg Oncol 2016; 42:1561-7. [PMID: 27528466 DOI: 10.1016/j.ejso.2016.07.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 07/18/2016] [Accepted: 07/25/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) has been proven effective in liver surgery. Adherence to the ERAS pathway is variable. This study seeks to evaluate adherence to key components of an ERAS protocol in liver resection, and identify the components associated with successful clinical outcomes. METHOD All patients undergoing liver resections for two consecutive years were included in our ERAS pathway. Six key components of ERAS included preoperative assessment, nutrition and gastrointestinal function, postoperative analgesia, mobilisation and discharges. Successful accomplishment of ERAS was defined as hospital discharge by postop day (POD) 6. Adherences of these elements were compared between the successful and un-successful groups. RESULTS During the studied period, 223 patients underwent liver resections, among which 103 had major hepatectomies. N = 147 patients (66%) were discharged within our ERAS protocol target (6 days). On multivariable analysis, sitting out of bed by POD 1 (p < 0.03), walking by POD 3 (p = 0.03), removal of urinary catheter by POD 3 (p < 0.01), and avoiding major complications (p < 0.01) were factors associated with successful completion to our ERAS protocol; whereas advanced age (p = 0.34) and discontinuation of PCA/epidural by POD 3 (p = 0.50) were not significant parameters. There was a significant difference in the length of stay (p < 0.01) following major and minor liver resection, of which the indications for surgery also varied significantly. There was no difference in hospital re-admission rate, and morbidity and mortality between major and minor liver resection. CONCLUSIONS Facilitating early mobilisation and reducing postoperative complications are keys to successful outcomes of ERAS in liver resection.
Collapse
|
35
|
Chae HD, Kwak MA, Kim IH. Effect of Acupuncture on Reducing Duration of Postoperative Ileus After Gastrectomy in Patients with Gastric Cancer: A Pilot Study Using Sitz Marker. J Altern Complement Med 2016; 22:465-72. [PMID: 27219115 DOI: 10.1089/acm.2015.0161] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Postoperative ileus (POI) is a common problem after abdominal surgery. Acupuncture is being accepted as an option for reducing POI and managing various functional gastrointestinal disorders. Therefore, this pilot study was conducted to evaluate the effect of acupuncture on reducing duration of POI and other surgical outcomes in patients who underwent gastric surgery. DESIGN A prospective, randomized, controlled pilot study was conducted on patients who underwent gastric cancer surgery from January 2013 to December 2013. Ten patients were randomly assigned into the acupuncture (A) or nonacupuncture (NA) groups at a 1:1 ratio. INTERVENTIONS The acupuncture treatment was performed by Korean traditional medicine doctors (KMDs). The style of acupuncture was Korean. In the A group, acupuncture treatment was given once daily for 5 consecutive days starting on postoperative day 1. Each patient received acupuncture at 16 acupoints based on expert consensus provided by qualified and experienced KMDs. No acupuncture treatment was performed in the NA group. OUTCOME MEASURES The primary outcome measure was the number of remnant Sitz markers in the small intestine on abdominal radiography. Secondary outcome measures were time to first flatus, start of sips water, start of soft diet, hospital stay, and laboratory findings. RESULTS The A group had significantly fewer remnant Sitz markers in the small intestine on postoperative days 3 and 5 compared with those in the NA group (p = 0.025 and 0.005). A significant difference was observed in the numbers of remnant Sitz marker in the small intestine with respect to time difference by group (p = 0.019). The A group showed relatively better surgical outcomes, but without statistical significance. CONCLUSIONS Although further studies are warranted, acupuncture may reduce duration of POI after gastric surgery and could be a potential factor in enhanced recovery after surgery protocols.
Collapse
Affiliation(s)
- Hyun-Dong Chae
- 1 Department of Surgery, School of Medicine, Catholic University of Daegu , Daegu, Korea
| | - Min-Ah Kwak
- 2 Department of Internal Medicine, College of Korean Medicine, Daegu Haany University , Daegu, Korea
| | - In-Hwan Kim
- 1 Department of Surgery, School of Medicine, Catholic University of Daegu , Daegu, Korea
| |
Collapse
|
36
|
Bai X, Zhang X, Lu F, Li G, Gao S, Lou J, Zhang Y, Ma T, Wang J, Chen W, Huang B, Liang T. The implementation of an enhanced recovery after surgery (ERAS) program following pancreatic surgery in an academic medical center of China. Pancreatology 2016; 16:665-70. [PMID: 27090583 DOI: 10.1016/j.pan.2016.03.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 02/16/2016] [Accepted: 03/29/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The experience of implementing enhanced recovery after surgery (ERAS) programs in pancreatic surgery is limited. The aim of this study was to evaluate the feasibility of ERAS program in pancreatic surgery in an academic medical center of China. METHODS Between May 2014 and August 2015, 124 patients managed with an ERAS program following pancreatic surgery (ERAS group), were compared to a historical cohort of 63 patients, treated with traditional perioperative care between August 2013 and April 2014 (no-ERAS group). Postoperative hospital stay (POPH), unplanned reoperation, unplanned readmissions, mortality and complications were compared between the two groups. RESULTS Mean POPH of all patients was significantly reduced (p = 0.007) from 17.1 days (no-ERAS group) to 11.7 days (ERAS group). Especially, mean POPH was reduced significantly in ERAS group of patient with no (7.0 vs. 8.7, p = 0.020) or grade I-II (10.6 vs. 14.4, p = 0.001) complications. There was no difference of complication grades and types between two groups, as well as the rate of mortality, unplanned reoperation and readmission. CONCLUSION The ERAS program is safe and feasible for patients undergoing pancreatic surgery, and it can decrease the postoperative hospital stay.
Collapse
Affiliation(s)
- Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoyu Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Fangyan Lu
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guogang Li
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shunliang Gao
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianying Lou
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tao Ma
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ji Wang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Chen
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bingfeng Huang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Collaborative Innovation Center for Cancer Medicine, Zhejiang University, Hangzhou, China.
| |
Collapse
|
37
|
Adherence to ERAS elements in major visceral surgery—an observational pilot study. Langenbecks Arch Surg 2016; 401:349-56. [DOI: 10.1007/s00423-016-1407-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 03/14/2016] [Indexed: 02/06/2023]
|
38
|
Abstract
The formation of SCFA is the result of a complex interplay between diet and the gut microbiota within the gut lumen environment. The discovery of receptors, across a range of cell and tissue types for which short chain fatty acids SCFA appear to be the natural ligands, has led to increased interest in SCFA as signaling molecules between the gut microbiota and the host. SCFA represent the major carbon flux from the diet through the gut microbiota to the host and evidence is emerging for a regulatory role of SCFA in local, intermediary and peripheral metabolism. However, a lack of well-designed and controlled human studies has hampered our understanding of the significance of SCFA in human metabolic health. This review aims to pull together recent findings on the role of SCFA in human metabolism to highlight the multi-faceted role of SCFA on different metabolic systems.
Collapse
Affiliation(s)
- Douglas J. Morrison
- Scottish Universities Environmental Research Centre, University of Glasgow, East Kilbride, Scotland
| | - Tom Preston
- Scottish Universities Environmental Research Centre, University of Glasgow, East Kilbride, Scotland
| |
Collapse
|
39
|
Abstract
The formation of SCFA is the result of a complex interplay between diet and the gut microbiota within the gut lumen environment. The discovery of receptors, across a range of cell and tissue types for which short chain fatty acids SCFA appear to be the natural ligands, has led to increased interest in SCFA as signaling molecules between the gut microbiota and the host. SCFA represent the major carbon flux from the diet through the gut microbiota to the host and evidence is emerging for a regulatory role of SCFA in local, intermediary and peripheral metabolism. However, a lack of well-designed and controlled human studies has hampered our understanding of the significance of SCFA in human metabolic health. This review aims to pull together recent findings on the role of SCFA in human metabolism to highlight the multi-faceted role of SCFA on different metabolic systems.
Collapse
Affiliation(s)
- Douglas J. Morrison
- Scottish Universities Environmental Research Centre, University of Glasgow, East Kilbride, Scotland
| | - Tom Preston
- Scottish Universities Environmental Research Centre, University of Glasgow, East Kilbride, Scotland
| |
Collapse
|
40
|
Bond‐Smith G, Belgaumkar AP, Davidson BR, Gurusamy KS. Enhanced recovery protocols for major upper gastrointestinal, liver and pancreatic surgery. Cochrane Database Syst Rev 2016; 2:CD011382. [PMID: 26829903 PMCID: PMC8765738 DOI: 10.1002/14651858.cd011382.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND 'Fast-track surgery' or 'enhanced recovery protocol' or 'fast-track rehabilitation', incorporating one or more elements of preoperative education, pain relief, early mobilisation, enteral nutrition and growth factors, may improve health-related quality of life and reduce length of hospital stay and costs. The role of enhanced recovery protocols in major upper gastrointestinal, liver and pancreatic surgery is unclear. OBJECTIVES To assess the benefits and harms of enhanced recovery protocols compared with standard care (or usual practice) in major upper gastrointestinal, liver and pancreatic surgery. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library; 2015, Issue 3), MEDLINE, EMBASE and Science Citation Index Expanded until March 2015 to identify randomised trials. We also searched the references of included trials to identify further trials. SELECTION CRITERIA We considered only randomised controlled trials (RCTs) performed in people undergoing major upper gastrointestinal, liver and pancreatic surgery, irrespective of language, blinding or publication status for inclusion in the review. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials and independently extracted data. We calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CIs) using both fixed-effect and random-effects models using Review Manager 5, based on available case analysis. MAIN RESULTS Ten studies met the inclusion criteria for the review, and nine studies provided information on one or more outcomes for the review. A total of 1014 participants were randomly assigned to the enhanced recovery protocol (499 participants) or standard care (515 participants) in the nine RCTs. Most of the trials included low anaesthetic risk participants with high performance status undergoing different upper gastrointestinal, liver and pancreatic surgeries. Eight trials incorporated more than one element of the enhanced recovery protocol. All of the trials were at high risk of bias. The overall quality of evidence was low or very low.None of the trials reported long-term mortality, medium-term health-related quality of life(three months to one year), time to return to normal activity, or time to return to work. The difference between the enhanced recovery protocol and standard care were imprecise for short-term mortality (enhanced recovery protocol: 4/425 (adjusted proportion = 0.6%); standard care: 1/443 (0.2%); seven trials; 868 participants; RR 2.79; 95% CI 0.44 to 17.73; very low quality evidence), proportion of people with serious adverse events (enhanced recovery protocol: 4/157 (adjusted proportion = 0.6%); standard care: 0/184 (0.0%); two trials; 341 participants; RR 5.57; 95% CI 0.68 to 45.89; very low quality evidence), number of serious adverse events (enhanced recovery protocol: 34/421 (8 per 100 participants); standard care: 46/438 (11 per 100 participants); seven trials; 859 participants; rate ratio 0.72; 95% CI 0.45 to 1.13; very low quality evidence), health-related quality of life (four trials; 373 participants; SMD 0.29; 95% CI -0.04 to 0.62; very low quality evidence) and hospital readmissions (enhanced recovery protocol: 14/355 (adjusted proportion = 3.3%); standard care: 9/378 (2.4%); seven trials; 733 participants; RR 1.4; 95% CI 0.69 to 2.87; very low quality evidence). The enhanced recovery protocol group had a lower proportion of people with mild adverse events (enhanced recovery protocol: 31/254 (adjusted proportion = 10.9%); standard care: 51/271 (18.8%); four trials; 525 participants; RR 0.58; 95% CI 0.39 to 0.85; low quality evidence), fewer number of mild adverse events (enhanced recovery protocol: 69/499 (13 per 100 participants); standard care: 128/515 (25 per 100 participants); nine trials; 1014 participants; rate ratio 0.52; 95% CI 0.39 to 0.70; low quality evidence), shorter length of hospital stay (nine trials; 1014 participants; MD -2.19 days; 95% CI -2.53 to -1.85; low quality evidence) and lower costs (four trials; 282 participants; MD USD -6300; 95% CI -8400 to -4200; low quality evidence) than standard care group. AUTHORS' CONCLUSIONS Based on low quality evidence, enhanced recovery protocols may reduce length of hospital stay and costs (primarily because of reduction in hospital stay) in people undergoing major upper gastrointestinal, liver and pancreatic surgeries. However, the validity of the results is uncertain because of the risk of bias in the trials and the way the outcomes were measured. Future RCTs should be conducted with low risk of bias, and measure clinically important outcomes for including the three months to one year period.
Collapse
Affiliation(s)
- Giles Bond‐Smith
- Churchill HospitalDepartment of Hepatobiliary SurgeryOxfordUKOx3 7L3
| | - Ajay P Belgaumkar
- Royal Free London NHS Foundation TrustHPB and Liver Transplant Surgery, 8 SouthPond StreetLondonUKNW3 2QG
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryPond StreetLondonUKNW3 2QG
| | | | | |
Collapse
|
41
|
Hughes MJ, Chong J, Harrison E, Wigmore S. Short-term outcomes after liver resection for malignant and benign disease in the age of ERAS. HPB (Oxford) 2016; 18:177-182. [PMID: 26902137 PMCID: PMC4814591 DOI: 10.1016/j.hpb.2015.10.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 08/29/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Enhanced Recovery After Surgery protocols have been implemented effectively after liver resection and provide benefits in terms of general morbidity rates. In order to optimise peri-operative care protocols and minimise morbidity, further investigation is required to identify factors associated with poor outcome after liver resection. METHODS A retrospective analysis of patients undergoing liver resection and enhanced recovery care between January 2006 and September 2012 was conducted. Data were collected on patient outcome and demographics, operative and pathological details. Univariate and multivariate analyses were performed to determine independent predictors of adverse outcome. RESULTS 603 patients underwent liver resection during the study period. Morbidity and mortality rates were 34.3% and 1.5% respectively. The only predictor of major morbidity was extended resection (OR 4.079; 95% CI 2.177-7.642). CONCLUSIONS Extended resection is associated with major morbidity. When determining optimum peri-operative care, ERAS protocols must incorporate care components that can mitigate against morbidity associated with extended resection.
Collapse
Affiliation(s)
- Michael J. Hughes
- Correspondence Michael J. Hughes, Department of Clinical Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK. Tel: +44 (0)7734429759. Fax: +44 (0)131 242 3617.
| | | | | | | |
Collapse
|
42
|
Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations--Part II. Gynecol Oncol 2016; 140:323-32. [PMID: 26757238 PMCID: PMC6038804 DOI: 10.1016/j.ygyno.2015.12.019] [Citation(s) in RCA: 274] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 12/14/2015] [Accepted: 12/21/2015] [Indexed: 12/15/2022]
|
43
|
Yao H, Bian X, Mao L, Zi X, Yan X, Qiu Y. Preoperative Enteral Nutritional Support in Patients Undergoing Hepatectomy for Hepatocellular Carcinoma: A Strengthening the Reporting of Observational Studies in Epidemiology Article. Medicine (Baltimore) 2015; 94:e2006. [PMID: 26579806 PMCID: PMC4652815 DOI: 10.1097/md.0000000000002006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
To compare the short-term outcomes between hepatocellular carcinoma (HCC) patients with and those without preoperative nutrition on the basis of postoperative enteral nutrition.HCC patients with postoperative enteral nutrition who underwent liver resection between February 2010 and December 2014 in Nanjing Drum Tower Hospital were considered for the study: 43 patients with and 36 patients without preoperative nutrition. Primary endpoint was the incidence of overall complications. Secondary endpoints were infectious and major complications.In the preoperative enteral nutrition group, shorter length of postoperative hospital stay (10.5 ± 2.7 versus 13.7 ± 6.3 days, P = 0.007), less exogenous albumin infusion (10.2 ± 22.4 versus 47.8 ± 97.7 g, P = 0.030), earlier first exhaust time (2.7 ± 0.8 versus 3.0 ± 0.9 days, P = 0.043), and first defection time (3.5 ± 0.9 versus 4.4 ± 1.4 days, P = 0.001) were observed. No significant differences were observed in the incidence of overall complications (32.6% versus 52.8%, P = 0.070), infectious complications (7.0% versus 8.3%, P = 1), and major complications (14.0% versus 11.1%, P = 0.969) between the preoperative enteral nutrition and control group.Preoperative enteral nutrition could improve short-term outcomes of HCC patients via accelerating the recovery of gastrointestinal function and shortening the length of postoperative hospital stay.
Collapse
Affiliation(s)
- Hui Yao
- From the Department of Hepatopancreatobiliary Surgery, Drum Tower Hospital, Medical School of Nanjing University (HY, XB, LM, XY, YQ) and Department of Hepatopancreatobiliary Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China (XZ)
| | | | | | | | | | | |
Collapse
|
44
|
Hughes MJ, Harrison EM, Peel NJ, Stutchfield B, McNally S, Beattie C, Wigmore SJ. Randomized clinical trial of perioperative nerve block and continuous local anaesthetic infiltration via wound catheter versus epidural analgesia in open liver resection (LIVER 2 trial). Br J Surg 2015; 102:1619-28. [PMID: 26447461 DOI: 10.1002/bjs.9949] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 08/04/2015] [Accepted: 08/25/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Analgesia after liver surgery remains controversial. A previous randomized trial of continuous wound infiltration (CWI) versus thoracic epidural analgesia (TEA) after liver surgery (LIVER trial) showed a faster recovery time in the wound infiltration group but better early postoperative pain scores in the TEA group. High-level evidence is, however, limited and opinion remains divided. The aim was to determine whether there is a difference in functional recovery time between patients having CWI plus abdominal nerve blocks versus TEA after liver resection. METHODS A randomized unblinded clinical trial of patients undergoing open liver resection was commenced in December 2012, with follow-up to August 2014. Patients were randomized to receive either wound catheter and nerve block (CWI group) or TEA for 48 h after surgery. The primary outcome measure was functional recovery time. Secondary outcomes were pain scores, complication rates, inflammatory response and central venous pressure (CVP) during transection. RESULTS Of 50 patients randomized initially to each group, 44 received TEA and 49 CWI. Median (i.q.r.) recovery time was 6·5 (5-9·75) and 5·75 (4-7) days in the TEA and CWI groups respectively (P = 0·036). Pain scores were not significantly different between the two groups, and there were no differences in morbidity, inflammatory response or CVP during transection. CONCLUSION Wound infiltration is associated with a reduced time to recovery after open liver resection compared with epidural analgesia. TEA does not offer an advantage over CWI in terms of attenuation of the inflammatory response or pain scores. REGISTRATION NUMBER NCT01747122 ( http://www.clinicaltrials.gov).
Collapse
Affiliation(s)
- M J Hughes
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - E M Harrison
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - N J Peel
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - B Stutchfield
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S McNally
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - C Beattie
- Departments of Anaesthesia, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S J Wigmore
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| |
Collapse
|
45
|
Kiyasu Y, Tsunoda A, Ohta T, Kusanagi H. Recovery of gastric ileus following laparoscopic ventral rectopexy within an enhanced recovery protocol. Surg Today 2015; 46:895-900. [PMID: 26407699 DOI: 10.1007/s00595-015-1255-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 08/21/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE The enhanced recovery after surgery (ERAS) protocol has had limited adoption in laparoscopic ventral rectopexy (LVR), and the extent of gastric ileus shortly after LVR remains unknown. This study was designed to assess the degree of gastric emptying shortly after LVR within an ERAS protocol. METHODS From August 2012 to June 2014, 40 patients diagnosed with external or internal rectal prolapse were recruited. All patients underwent LVR within an ERAS protocol. Carbohydrate solution (CS) was administered before and 5 h after surgery on the same day. The pyloric area (PA) was measured using ultrasonography before and after each CS intake. RESULTS The PA was measured in 34 patients. The PA measured prior to CS intake, before surgery, was not significantly different from that after surgery. The rate of increase in the PA, which was calculated by the PA measured 1 h after CS intake divided by the PA measured prior to CS intake before surgery, was not significantly different from that after surgery. The postoperative hospital stay was 1 (1-2) day, and 36 patients (90 %) were discharged on the first postoperative afternoon. CONCLUSION Postoperative gastric ileus was resolved in most cases within 5 h after LVR under an ERAS protocol.
Collapse
Affiliation(s)
- Yoshiyuki Kiyasu
- Department of Gastroenterological Surgery, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan.
| | - Akira Tsunoda
- Department of Gastroenterological Surgery, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Tomoyuki Ohta
- Department of Gastroenterological Surgery, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Hiroshi Kusanagi
- Department of Gastroenterological Surgery, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| |
Collapse
|
46
|
Savikko J, Ilmakunnas M, Mäkisalo H, Nordin A, Isoniemi H. Enhanced recovery protocol after liver resection. Br J Surg 2015; 102:1526-32. [PMID: 26331595 DOI: 10.1002/bjs.9912] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 02/23/2015] [Accepted: 07/08/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Enhanced recovery protocols (ERPs) accelerate patient recovery and shorten hospital stay by optimization of perioperative care. However, experience with ERPs is still limited in liver surgery. METHODS The implementation of a multimodal ERP was studied in patients who underwent open and laparoscopic liver surgery. An opioid-sparing pain treatment was chosen together with early mobilization and oral feeding, as well as restricted use of abdominal drains and catheters. Date to discharge, postoperative complications and patient satisfaction were assessed. A historical cohort of patients who underwent liver resection served as a control group. RESULTS Some 134 liver resections (126 open, 8 laparoscopic) were performed between April 2013 and March 2014. Operations were carried out mostly for malignant liver tumours. One hundred and six (79.1 per cent) of the 134 patients were discharged by the fifth postoperative day. The median (range) postoperative hospital stay was 4 (2-11) days, compared with 6 (4-16) days for the control group (P < 0.001). Only four patients in the ERP group were readmitted and the 30-day mortality rate was zero. CONCLUSION An ERP for perioperative care after liver surgery was introduced safely and effectively. Discharge within 4 days is achievable with no increase in adverse events and good patient satisfaction.
Collapse
Affiliation(s)
- J Savikko
- Departments of Transplantation and Liver Surgery, Helsinki University Hospital, Helsinki, Finland
| | - M Ilmakunnas
- Departments of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland
| | - H Mäkisalo
- Departments of Transplantation and Liver Surgery, Helsinki University Hospital, Helsinki, Finland
| | - A Nordin
- Departments of Transplantation and Liver Surgery, Helsinki University Hospital, Helsinki, Finland
| | - H Isoniemi
- Departments of Transplantation and Liver Surgery, Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
47
|
Hughes MJ, Harrison EM, Wigmore SJ. Energy Expenditure After Liver Resection: Validation of a Mobile Device for Estimating Resting Energy Expenditure and an Investigation of Energy Expenditure Change After Liver Resection. JPEN J Parenter Enteral Nutr 2015; 41:766-775. [DOI: 10.1177/0148607115601969] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Michael J. Hughes
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Ewen M. Harrison
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Stephen J. Wigmore
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| |
Collapse
|
48
|
Ni TG, Yang HT, Zhang H, Meng HP, Li B. Enhanced recovery after surgery programs in patients undergoing hepatectomy: A meta-analysis. World J Gastroenterol 2015; 21:9209-9216. [PMID: 26290648 PMCID: PMC4533053 DOI: 10.3748/wjg.v21.i30.9209] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 05/19/2015] [Accepted: 06/10/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the impact of enhanced recovery after surgery (ERAS) programs in comparison with traditional care on liver surgery outcomes.
METHODS: The PubMed, EMBASE, CNKI and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials (RCTs) comparing the ERAS program with traditional care in patients undergoing liver surgery. Studies selected for the meta-analysis met all of the following inclusion criteria: (1) evaluation of ERAS in comparison to traditional care in adult patients undergoing elective open or laparoscopic liver surgery; (2) outcome measures including complications, recovery of bowel function, and hospital length of stay; and (3) RCTs. The following exclusion criteria were applied: (1) the study was not an RCT; (2) the study did not compare ERAS with traditional care; (3) the study reported on emergency, non-elective or transplantation surgery; and (4) the study consisted of unpublished studies with only the abstract presented at a national or international meeting. The primary outcomes were complications. Secondary outcomes were length of hospital stay and time to first flatus.
RESULTS: Five RCTs containing 723 patients were included in the meta-analysis. In 10/723 cases, patients presented with benign diseases, while the remaining 713 cases had liver cancer. Of the five studies, three were published in English and two were published in Chinese. Three hundred and fifty-four patients were in the ERAS group, while 369 patients were in the traditional care group. Compared with traditional care, ERAS programs were associated with significantly decreased overall complications (RR = 0.66; 95%CI: 0.49-0.88; P = 0.005), grade I complications (RR = 0.51; 95%CI: 0.33-0.79; P = 0.003), and hospital length of stay [WMD = -2.77 d, 95%CI: -3.87-(-1.66); P < 0.00001]. Similarly, ERAS programs were associated with decreased time to first flatus [WMD = -19.69 h, 95%CI: -34.63-(-4.74); P < 0.0001]. There was no statistically significant difference in grade II-V complications between the two groups.
CONCLUSION: ERAS is a safe and effective program in liver surgery. Future studies should define the active elements to optimize postoperative outcomes for liver surgery.
Collapse
|
49
|
Takamoto T, Hashimoto T, Inoue K, Nagashima D, Maruyama Y, Mitsuka Y, Aramaki O, Makuuchi M. Applicability of enhanced recovery program for advanced liver surgery. World J Surg 2015; 38:2676-82. [PMID: 24838485 DOI: 10.1007/s00268-014-2613-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery programs (ERPs) have been developed in various surgical fields and have been shown to accelerate postoperative recovery without increasing the incidence of adverse events. Whether ERP can be safely applied to patients undergoing complex liver surgery with a risk of liver failure remains unclear. METHODS We created an ERP by rearranging our conventional postoperative treatments and applied this program to patients undergoing major hepatectomy between 2008 and 2013. The ERP elements included greater perioperative education, individualized postoperative fluid therapy, and early mobilization. The success of the ERP was evaluated on postoperative day (POD) 6 based on the criterion of independence from continuous medical intervention with the exception of an abdominal drainage tube. Adherence to each item in the ERP was evaluated, and risk factors for delayed accomplishment were analyzed. RESULTS Altogether, 200 patients were included, and 165 patients (82.5 %) completed the ERP. Multivariate analyses showed that (1) an age of 65 years or older and (2) a red blood cell transfusion were independent risk factors for delayed accomplishment. The performance of thoracotomy or choledocojejunostomy did not significantly affect accomplishment of the ERP. Oral intake starting on POD 1 was achieved in 179 patients (89.5 %), and termination of intravenous drip infusions on POD 5 was feasible in 72.5 %. CONCLUSIONS An ERP for major hepatectomy was completed in more than 80 % of the patients. Earlier bowel movement can be challenged. The liquid in-out balance should be adjusted on an individual basis, rather than uniformly, especially for patients over 65 years of age or who required a red blood cell transfusion.
Collapse
Affiliation(s)
- Takeshi Takamoto
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation Surgery, Japanese Red Cross Medical Center, 4-1-22 Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan,
| | | | | | | | | | | | | | | |
Collapse
|
50
|
Dasari BVM, Rahman R, Khan S, Bennett D, Hodson J, Isaac J, Marudanayagam R, Mirza DF, Muiesan P, Roberts KJ, Sutcliffe RP. Safety and feasibility of an enhanced recovery pathway after a liver resection: prospective cohort study. HPB (Oxford) 2015; 17:700-6. [PMID: 26099347 PMCID: PMC4527855 DOI: 10.1111/hpb.12447] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 05/01/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND In contrast to colorectal surgery, enhanced recovery pathways (ERPs) have not yet become standard practice after major upper abdominal surgery. The aim of this study was to assess the feasibility and outcomes after implementation of an ERP after liver a resection. METHODS Patients who underwent a liver resection in two consecutive 6-month periods before (July-December 2013) and after (January-June 2014) implementation of an ERP were included in a prospective study. Patients who underwent live donation, ALPPS (associating liver partition with portal vein ligation for staged hepatectomy) or concomitant procedures were excluded. Peri-operative outcomes were compared between groups, and multivariate analysis of factors influencing the length of hospital stay (LOS) was performed. RESULTS Two hundred and eleven patients (93 pre-ERP and 91 post-ERP patients) underwent a liver resection during the study period. There was no significant difference in the median LOS (P = 0.907) and 30-day readmission rates (P = 0.645) between the groups. Severe (Clavien grade III-V) complications were reduced in ERP patients (13.9% versus 4.3%; P = 0.039). On multivariate analysis, an increased age (< 0.001), open resection (< 0.001) and complications (< 0.001) were associated with an increased LOS. CONCLUSION Enhanced recovery after a liver resection appears to be safe, feasible and may reduce severe complications. However, the LOS was significantly influenced by patient age, open surgery and post-operative complications, but not by an ERP.
Collapse
Affiliation(s)
- Bobby V M Dasari
- The Liver Unit, Queen Elizabeth HospitalBirmingham, UK,Correspondence Bobby V. M. Dasari, The Liver Unit, Queen Elizabeth Hospital, Birmingham B15 2WB, UK. Tel: +44 772 762 1372. Fax: +121 414 1833. E-mail:
| | - Rasha Rahman
- The Liver Unit, Queen Elizabeth HospitalBirmingham, UK
| | - Shakeeb Khan
- The Liver Unit, Queen Elizabeth HospitalBirmingham, UK
| | - Davinia Bennett
- Department of Anaesthesia, Queen Elizabeth HospitalBirmingham, UK
| | - James Hodson
- Wolfson Laboratory, Queen Elizabeth HospitalBirmingham, UK
| | - John Isaac
- The Liver Unit, Queen Elizabeth HospitalBirmingham, UK
| | | | | | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth HospitalBirmingham, UK
| | | | | |
Collapse
|