Cost-Benefit Analysis of the Implementation of an Enhanced Recovery Program in Liver Surgery

The Effect of Enhanced Recovery After Surgery Protocol on Surgical Site Infections in Liver Transplantation

Background: Liver surgeries are treatment modalities that require careful pre- and postoperative follow-up for both the surgeon and the patient. Infections are the leading causes of morbidity and mortality after liver transplantation. Infections are the most frequent cause of death between 30 and 180 days after liver transplantation. We aimed to investigate the effect of the Enhanced Recovery After Surgery (ERAS) protocol on the prevention of infections in liver transplant patients. Patients and Methods: The study included patients who underwent liver transplantation in Ataturk University Organ Transplantation Center between 2017 and 2022. Two patient groups with and without ERAS were formed. Blood and urine cultures were collected retrospectively, and those with positive blood cultures for bacteremia were recorded as infection development. The development of infection between the two groups was statistically compared. Also, all patients' length of intensive care stay, length of hospital stay, and duration of antibiotic use were recorded. These parameters were compared between both groups. Results: There was a statistically significant difference between the two groups in terms of infection development (p: 0.01). There was a statistically significant difference between the two groups in terms of duration of antibiotic use and length of hospital stay (Mann-Whitney U test; p: 0.00, p: 0.04, respectively). There was no statistically significant difference between the two groups in terms of length of intensive care stay. Conclusion: We concluded that the introduction of an ERAS protocol was associated with fewer infections, thus shortening the duration of antibiotic therapy and length of hospital stay, although the standardization of the protocols is difficult, especially in liver transplants.

Implementation of cardiac enhanced recovery after surgery at Lausanne University Hospital, our roadbook to certification

OBJECTIVES

Enhanced recovery after surgery (ERAS) is a multidisciplinary, patient-centred approach aimed at expediting recovery, improving clinical outcomes, and reducing healthcare costs. Initially developed for colorectal surgery, ERAS principles have been successfully applied across various surgical specialties, including cardiac surgery. This study outlines the implementation and certification process of the ERAS program in a tertiary cardiac surgical centre within the Heart-Vessel Department at Lausanne University Hospital.

METHODS

The implementation involved forming a multidisciplinary team, including cardiac surgeons, anaesthesiologists, intensivists, a cardiologist, clinical nurse specialists and physiotherapists. The ERAS nurse coordinator played a central role in organizing meetings, promoting the program, developing protocols, and collecting data. The certification process required adherence to ERAS guidelines, structured training and external evaluation. Key phases included pre-ERAS data collection, protocol dissemination, inclusion of the 1st patients, followed by analysis and full implementation.

RESULTS

Achieving certification required maintaining a compliance rate of over 70% with established protocols. The process involved overcoming various barriers, such as inconsistent practices and the need for multidisciplinary collaboration. In this paper, we provide some solutions to these challenges, including team education, regular meetings and continuous feedback loops. Preliminary data from the initial cohort showed improvements in early mobilization, opioid use, respiratory complications and shorter hospital stays.

CONCLUSIONS

The successful implementation of the ERAS program at our institution demonstrates the feasibility and benefits of a structured, multidisciplinary approach in cardiac surgery. Continuous self-assessment and adherence to guidelines are essential for sustained improvement in patient outcomes and healthcare efficiency.

From morbidity reduction to cost-effectiveness: Enhanced recovery after surgery (ERAS) society recommendations in minimal invasive liver surgery

PURPOSE

Minimal-invasive liver surgery (MILS) reduces surgical trauma and is associated with fewer postoperative complications. To amplify these benefits, perioperative multimodal concepts like Enhanced Recovery after Surgery (ERAS), can play a crucial role. We aimed to evaluate the cost-effectiveness for MILS in an ERAS program, considering the necessary additional workforce and associated expenses.

METHODS

A prospective observational study comparing surgical approach in patients within an ERAS program compared to standard care from 2018-2022 at the Charité - Universitätsmedizin Berlin. Cost data were provided by the medical controlling office. ERAS items were applied according to the ERAS society recommendations.

RESULTS

537 patients underwent liver surgery (46% laparoscopic, 26% robotic assisted, 28% open surgery) and 487 were managed by the ERAS protocol. Implementation of ERAS reduced overall postoperative complications in the MILS group (18% vs. 32%, p = 0.048). Complications greater than Clavien-Dindo grade II incurred the highest costs (€ 31,093) compared to minor (€ 17,510) and no complications (€13,893; p < 0.001). In the event of major complications, profit margins were reduced by a median of € 6,640.

CONCLUSIONS

Embracing the ERAS society recommendations in liver surgery leads to a significant reduction of complications. This outcome justifies the higher cost associated with a well-structured ERAS protocol, as it effectively offsets the expenses of complications.

Enhanced recovery after liver surgery in cirrhotic patients: a systematic review and meta-analysis

BACKGROUND

Few studies have assessed enhanced recovery after surgery (ERAS) in liver surgery for cirrhotic patients. The present meta-analysis assessed the impact of ERAS pathways on outcomes after liver surgery in cirrhotic patients compared to standard care.

METHODS

A literature search was performed on PubMed/MEDLINE, Embase, and the Cochrane Library. Studies comparing ERAS protocols versus standard care in cirrhotic patients undergoing liver surgery were included. The primary outcome was post-operative complications, while secondary outcomes were mortality rates, length of stay (LoS), readmissions, reoperations, and liver failure rates.

RESULTS

After evaluating 41 full-text manuscripts, 5 articles totaling 646 patients were included (327 patients in the ERAS group and 319 in the non-ERAS group). Compared to non-ERAS care, ERAS patients had less risk of developing overall complications (OR 0.43, 95% CI 0.31-0.61, p < 0.001). Hospitalization was on average 2 days shorter for the ERAS group (mean difference - 2.04, 95% CI - 3.19 to - 0.89, p < 0.001). Finally, no difference was found between both groups concerning 90-day post-operative mortality and rates of reoperations, readmissions, and liver failure.

CONCLUSION

In cirrhotic patients, ERAS protocol for liver surgery is safe and decreases post-operative complications and LoS. More randomized controlled trials are needed to confirm the results of the present analysis.

Impact of complexity in minimally invasive liver surgery on enhanced recovery measures: prospective study

BACKGROUND

Adherence to enhanced recovery after surgery (ERAS) protocols is crucial for successful liver surgery. The aim of this study was to assess the impact of minimally invasive liver surgery complexity on adherence after implementing an ERAS protocol.

METHODS

Between July 2018 and August 2021, a prospective observational study involving minimally invasive liver surgery patients was conducted. Perioperative treatment followed ERAS guidelines and was recorded in the ERAS interactive audit system. Kruskal-Wallis and ANOVA tests were used for analysis, and pairwise comparisons utilized Wilcoxon rank sum and Welch's t-tests, adjusted using Bonferroni correction.

RESULTS

A total of 243 patients were enrolled and categorized into four groups based on the Iwate criteria: low (n = 17), intermediate (n = 81), advanced (n = 74) and expert difficulty (n = 71). Complexity correlated with increased overall and major morbidity rate, as well as longer length of stay (all P < 0.001; standardized mean difference = 0.036, 0.451, 0.543 respectively). Adherence to ERAS measures decreased with higher complexity (P < 0.001). Overall adherence was 65.4%. Medical staff-centred adherence was 79.9%, while patient-centred adherence was 38.9% (P < 0.001). Complexity significantly affected patient-centred adherence (P < 0.001; standardized mean difference (SMD) = 0.420), but not medical staff-centred adherence (P = 0.098; SMD = 0.315). Postoperative phase adherence showed major differences among complexity groups (P < 0.001, SMD = 0.376), with mobilization measures adhered to less in higher complexity cases.

CONCLUSION

The complexity of minimally invasive liver surgery procedures impacts ERAS protocol adherence for each patient. This can be addressed using complexity-adjusted cut-offs and 'gradual adherence' based on the relative proportion of cut-off values achieved.

Enhanced recovery after surgery in primary liver cancer patients undergoing hepatectomy: experience from a large tertiary hospital in China

OBJECTIVE

Enhanced recovery after surgery (ERAS) has significant effects in gastrointestinal surgery, urology, and orthopedic department, but the application of ERAS in liver cancer patients undergoing hepatectomy is less reported. This study aims to identify the effectiveness and safety of ERAS in liver cancer patients undergoing hepatectomy.

METHODS

Patients who performed ERAS and no-ERAS after hepatectomy due to liver cancer from 2019 to 2022 were prospectively and retrospectively collected, respectively. Preoperative baseline data, surgical characteristics, and postoperative outcomes of patients in ERAS and non-ERAS groups were compared and analyzed. Logistic regression analysis was conducted to identify the risk factors of complications occurrence and prolonged hospital stay.

RESULTS

In total, 318 patients were included in the study, 150 and 168 individuals in the ERAS group and non-ERAS group, respectively. The preoperative baseline and surgical characteristics between the ERAS and non-ERAS groups were comparable and not statistically different. Postoperative visual analogue scale pain score, the median day of gastrointestinal function recovery postoperative, complications rate, and postoperative hospitalization days were lower in the ERAS group than in the non-ERAS group. In addition, multivariate logistic regression analysis found that the implementation of the ERAS was an independent protective factor for prolonged hospitalization stay and complications occurrence. The rate of rehospitalization after discharge (< 30 days) in the ERAS group was lower than that in the non-ERAS group, but there was no statistical difference between the two groups.

CONCLUSIONS

The application of ERAS in hepatectomy for patients with liver cancer is safe and effective. It can accelerate gastrointestinal function recovery postoperative, shorten the length of hospital stay, and reduce postoperative pain and complications.

An algorithm based on the postoperative decrease of albumin (ΔAlb) to anticipate complications after liver surgery

Background

Perioperative decrease of albumin (ΔAlb) appeared as a promising predictor of complications after digestive surgery, but its role after liver surgery remains unclear. This study aimed to analyze whether and how ΔAlb can be used to predict complications after liver surgery.

Methods

A bicentric retrospective analysis of patients undergoing liver surgery (2010–2016) was performed, following TRIPOD guidelines. The preoperative and postoperative difference of albumin was calculated on POD 0 and defined as ΔAlb. Patients with any missing variable were excluded. The primary endpoint was overall complications according to the Clavien classification. A multiparametric algorithm based on ΔAlb was generated to optimize prediction performance.

Results

A total of 110 patients were analyzed. At least one complication occurred in 66 (60%) patients. Patients with and without complication showed a ΔAlb of 15.8 vs. 9.5 g/L (p<0.001). Area under ROC curve (AUC) of ΔAlb was 0.75 (p<0.01.). The ΔAlb-based algorithm showed an AUC of 0.84 (p<0.01), significantly improving performance (p=0.03). Multivariable analysis identified ΔAlb as independent predictor of complications (HR, 1.12; 95% CI, 1.01–1.07; p = 0.002).

Conclusions

ΔAlb appeared as a promising predictor independently associated with the risk of complication after liver surgery. The study presents a novel decision-tree based on ΔAlb to anticipate complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-022-00285-w.

Comprehensive economic evaluation of enhanced recovery after surgery in hepatectomy

BACKGROUND

Enhanced recovery after surgery (ERAS) is attracting extensive attention and being widely applied to reduce postoperative stress and accelerate recovery. However, the economic benefits of ERAS are less clarified at the social level. We aimed to assess the economic impact of ERAS in hepatectomy from the perspectives of patients, hospitals and society, as well as identify the approach to create the economic benefits of ERAS.

METHODS

By combining the literature and national statistical data, the cost-effectiveness framework was clarified, and parameter values were determined. Cost-effectiveness analysis, cost-benefit analysis and cost-minimisation analysis were used to compare ERAS and conventional treatment from the perspectives of patients, hospitals and society. The capital flow diagram was used to analyse the change between them.

RESULTS

ERAS significantly reduced the economic burden of disease on patients ($8935.02 vs $10,470.02). The hospital received an incremental benefit in ERAS (the incremental benefit cost ratio value is 1.09), and the total social cost was reduced ($5958.67 vs $6725.80). Capital flow diagram analysis demonstrated that the average daily cost per capita in the ERAS group increased ($669.51 vs $589.98), whereas the benefits depended on the reduction of hospital stay and productivity loss.

CONCLUSION

The mechanism by which ERAS works is to reduce the average length of stay, thereby reducing the economic burden and productivity loss on patients and promoting the hospital bed turnover rate. Therefore, ERAS should further focus on accelerating the rehabilitation process, and more economic support (such as subsidies) should be given to hospitals to carry out ERAS.

Cost-Benefit Analysis of an Enhanced Recovery Program for Gastrectomy A Retrospective Controlled Analysis

Background

Enhanced recovery programs (ERP) demonstrated decreased postoperative complication rate and reduced length of stay (LOS). Recently, data on the financial impact revealed cost reduction for colorectal, liver and pancreatic surgery. The present study aimed to assess the cost-effectiveness of ERP in gastric surgery.

Methods

ERP based on enhanced recovery after surgery (ERAS®) society guidelines was implemented in our institution, in June 2014. Consecutive patients undergoing gastric surgery after ERP implementation (n = 71) were compared to a control group of consecutive patients operated before ERP implementation (n = 58). Primary endpoint was cost-effectiveness including detailed perioperative costs. Secondary endpoints were postoperative complications and LOS. Standard statistical testing (means, Mann–Whitney Fisher’s exact T test or Pearson Chi-square test) was used.

Results

Both groups were comparable regarding demographic details. Mean (SD) overall costs per patient were lower in the ERP group (€33,418 (17,901) vs €39,804 (27,288), P = 0.027). Lower costs were found for anesthesia and operating room (−€2 356), intensive or intermediate care (−€8 629), medication (−€1 196)), physiotherapy (−€611), laboratory (−€1 625)) and blood transfusion (−€977). Overall complication rates in ERP and control group (51% vs 62%, P = 0.176) were similar. Mean length of stay (SD) (14(13) days vs 17(11) days, P = 0.037) was shorter in the ERP group.

Conclusion

ERP significantly reduces overall, preoperative and postoperative costs in patients undergoing major gastric surgery.

Recent advances in benign gynecological laparoscopic surgery

Minimally invasive surgery continues to transform the field of gynecological surgery and is now the standard of care for the surgical treatment of many diseases in gynecology. Owing to minimally invasive surgery's clear advantages, new advances in technology are being employed rapidly and enabling even the most complicated procedures to be performed less invasively. We examine recent literature on minimally invasive surgical innovations, advances, and common practices in benign gynecology that, from our point of view, made an impact on the way laparoscopic surgery is performed and managed in the last decade.

Impact of 2016 Enhanced Recovery After Surgery (ERAS) Recommendations on Outcomes after Hepatectomy in Cirrhotic and Non-Cirrhotic Patients

BACKGROUND

The Enhanced Recovery After Surgery (ERAS) society published new recommendations for hepatectomy in 2016. Few studies have assessed their clinical impact. The aim of this monocentric study was to assess the impact of those guidelines on outcomes after liver surgery with a special focus on cirrhotic patients.

METHOD

Postoperative outcomes of patients undergoing hepatectomy 30 months before and after ERAS implementation according to the 2016 ERAS guidelines were compared after inverse probability of treatment weighting (IPTW). Primary endpoint was 90-day morbidity.

RESULTS

From 2015 to 2020, 430 patients underwent hepatectomy including 226 procedures performed before and 204 after ERAS implementation. After IPTW, overall morbidity (42.5% vs. 64.7%, p < 0.001), Comprehensive Complication Index (CCI) score (14.3 vs. 20.8, p = 0.004), length of stay (10.4 vs. 13.7 days, p = 0.001) and textbook outcome (50% vs. 40.2%, p = 0.022) were significantly improved in the ERAS group, while mortality and severe complications were similar in both groups. In the non-cirrhosis subgroup (n = 321), these results were confirmed. However, in the cirrhosis subgroup (n = 105), no difference appeared on outcomes after hepatectomy with an overall morbidity (47.5% vs. 65.2%, p = 0.069) and a length of stay (8 vs. 9 days, p = 0.310) which were not significantly different. The compliance rate to ERAS guidelines was 60% in both cirrhotic and non-cirrhotic subgroups.

CONCLUSION

Perioperative ERAS program for hepatectomy results in improved outcomes with decreased rate of non-severe morbidity. Although those guidelines are not deleterious for cirrhotic patients, they probably require revisions to be more effective in this patient population.

Effectiveness of a Clinical Pathway for Hepatic Cystic Echinococcosis Surgery in Kashi Prefecture, Northwestern China: A Propensity Score Matching Analysis

Introduction

Surgical treatment for hepatic cystic ehinococcosis (CE) is not standardized in Kashi Prefecture. Previous evidence identified effectiveness of a clinical pathway in the field of liver surgery. However, proof of a clinical pathway program, especially for CE patients, is lacking. This study aimed to assess the validity of a clinical pathway for hepatic CE surgery performed on patients from Kashi Prefecture.

Methods

A clinical pathway was developed and implemented by a multidisciplinary team for patients undergoing hepatic CE surgery. Two groups were formed from patients undergoing hepatic CE surgery during a defined period before and after implementing a clinical pathway. Additionally, a propensity score matching analysis was performed.

Results

In the overall analysis (n = 258) as well as the matched analysis (n = 166), after implementing the clinical pathway, hospital stay was significantly reduced from 13 to 10 days and from 14 to 10 days, respectively (P < 0.05). Postoperative morbidity did not increase. Cost analysis showed a significant decrease in median costs of medication and nursing in favor of the clinical pathway (medication: 5400 CNY vs. 6400 CNY, P = 0.038; nursing: 3200 CNY vs. 4100 CNY, P = 0.02).

Conclusion

Implementing the clinical pathway for hepatic CE surgery is feasible and safe. The clinical pathway achieved significant reduction of hospital stay without compromising postoperative morbidity. Costs of medication and nursing are significantly reduced. The clinical pathway program is valid and propagable to a certain extent, especially in remote, poor-resourced medical centers in endemic areas.

Probability of Postoperative Complication after Liver Resection: Stratification of Patient Factors,Operative Complexity, and Use of Enhanced Recovery after Surgery

BACKGROUND

The current study aimed to assess the performance of the 3-level complexity classification that stratified liver resection procedures into 3 complexity grades (grade I, low; grade II, intermediate; and grade III, high complexity) and to evaluate whether the Enhanced Recovery after Surgery (ERAS) protocol improves postoperative outcomes for each complexity grade.

STUDY DESIGN

Consecutive patients undergoing open liver resection and laparoscopic liver resection at Lausanne University Hospital during 2010 to 2020 were assessed.

RESULTS

A total of 437 patients were included. Operative time, estimated blood loss, and length of hospital stay increased significantly, with a stepwise increase of the grades from I to III in open liver resection and laparoscopic liver resection (all, p < 0.05). The same trend for Comprehensive Complication Index was found in open liver resection (p < 0.005). Age (p = 0.004), 3-level complexity classification (grade II vs I; p = 0.001; grade III vs I; p < 0.001), no use of the ERAS protocol (p = 0.016), and biliary reconstruction (p < 0.001) were significant predictors for postoperative complication, defined as Comprehensive Complication Index ≥ 26.2 in a multivariable logistic regression analysis. The prediction model incorporating the 4 factors had a calculated Concordance Index of 0.735 and 0.742 based on the bootstrapping method. The use of ERAS protocol was associated with lower probability of postoperative complication for each complexity grade and age.

CONCLUSIONS

The use of ERAS protocol can decrease the probability of postoperative complication for each surgical complexity of liver resection and patient age. This finding emphasized the importance of tailoring perioperative management according to surgical complexity and patient age to improve outcomes after liver resection.

The clinical effect of early enteral nutrition in liver-transplanted patients: a systematic review and meta-analysis

BACKGROUND

Appropriate nutritional support is critical for patients undergoing liver transplantation (LT). Early enteral nutrition (EEN) has been considered effective in critically ill patients. However, the clinical effect of EEN on liver-transplanted patients is unclear.

AIM

To evaluate the clinical effect of early enteral nutrition in patients receiving a liver transplant.

METHODS

A systematic search was performed on the Cochrane Library, PubMed, CINAHL, EMBASE, Web of Science, WanFang database, Chinese Biomedical Literature Database and China National Knowledge Infrastructure to collect relevant studies up to January, 2020. The results of these studies were pooled to calculate relative risk and mean differences with 95% confidence intervals for dichotomous data and continuous data. All statistical analysis was carried out by Review Manager 5.3.

RESULTS

9 RCTs and 10 cohort studies with 1300 patients were included in this meta-analysis. Compared with TPN, EEN reduced postoperative infection rates, ICU hours, length of hospitalization, and the duration of bowel ventilation as well as strengthening the nutritional status and liver function of LT patients. There is no difference in mortality rates, blood glucose levels or gastrointestinal complications. Compared to TPN, the combined EN + PN method more effectively prevented infection.

CONCLUSION

For patients undergoing liver transplantation, early enteral nutrition with or without combination may considered as a better nutritional therapy than total parenteral nutrition.

Biological impact of an enhanced recovery after surgery programme in liver surgery

BACKGROUND

The clinical and economic impacts of enhanced recovery after surgery (ERAS) programmes have been demonstrated extensively. Whether ERAS protocols also have a biological effect remains unclear. This study aimed to investigate the biological impact of an ERAS programme in patients undergoing liver surgery.

METHODS

A retrospective analysis of patients undergoing liver surgery (2010-2018) was undertaken. Patients operated before and after ERAS implementation in 2013 were compared. Surrogate markers of surgical stress were monitored: white blood cell count (WBC), C-reactive protein (CRP) level, albumin concentration, and haematocrit. Their perioperative fluctuations were defined as Δvalues, calculated on postoperative day (POD) 0 for Δalbumin and Δhaematocrit and POD 2 for ΔWBC and ΔCRP.

RESULTS

A total of 541 patients were included, with 223 and 318 patients in non-ERAS and ERAS groups respectively. Groups were comparable, except for higher rates of laparoscopy (24.8 versus 11.2 per cent; P < 0.001) and major resection (47.5 versus 38.1 per cent; P = 0.035) in the ERAS group. Patients in the ERAS group showed attenuated ΔWBC (2.00 versus 2.75 g/l; P = 0.013), ΔCRP (60 versus 101 mg/l; P <0.001) and Δalbumin (12 versus 16 g/l; P < 0.001) compared with those in the no-ERAS group. Subgroup analysis of open resection showed similar results. Multivariable analysis identified ERAS as the only independent factor associated with high ΔWBC (odds ratio (OR) 0.65, 95 per cent c.i. 0.43 to 0.98; P = 0.038), ΔCRP (OR 0.41, 0.23 to 0.73; P = 0.003) and Δalbumin (OR 0.40, 95 per cent c.i. 0.22 to 0.72; P = 0.002).

CONCLUSION

Compared with conventional management, implementation of ERAS was associated with an attenuated stress response in patients undergoing liver surgery.

Cost Analysis of Enhanced Recovery Programs in Colorectal, Pancreatic, and Hepatic Surgery: A Systematic Review

BACKGROUND

Enhanced recovery programs (ERPs) have been shown to improve postoperative outcomes after abdominal surgery. This study aimed to review the current literature to assess if ERPs in colorectal, pancreas, and liver surgery induce cost savings.

METHODS

A systematic review was performed including prospective and retrospective studies comparing conventional management versus ERP in terms of costs. All kinds of ERP were considered (fast-track, ERAS^®, or home-made protocols). Studies with no mention of a clear protocol and no reporting of protocol compliance were excluded.

RESULTS

Thirty-seven articles out of 144 identified records were scrutinized as full articles. Final analysis included 16 studies. In colorectal surgery, two studies were prospective (1 randomized controlled trial, RCT) and six retrospective, totaling 1277 non-ERP patients and 2078 ERP patients. Three of the eight studies showed no difference in cost savings between the two groups. The meta-analysis found a mean cost reduction of USD3010 (95% CI: 5370-650, p = 0.01) in favor of ERP. Among the five included studies in pancreas surgery (all retrospective, 552 non-ERP vs. 348 ERP patients), the mean cost reduction in favor of the ERP group was USD7020 (95% CI: 11,600-2430, p = 0.003). In liver surgery, only three studies (two retrospective and 1 RCT, 180 non-ERP vs. 197 ERP patients) were found, which precluded a sound cost analysis.

CONCLUSIONS

The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management. Cost data in liver surgery are scarce.

Liver resections between 2014 and 2020 in the Lausanne University Hospital, Switzerland

Lausanne University Hospital is in the Francophone part of Switzerland and services a catchment population of about 1 million people. We recorded and analyzed baseline characteristics and surgical outcomes for 400 consecutive patients who underwent liver resection there between January 2014 and February 2020. Their pathological results were primary liver cancer (including hepatocellular carcinoma and intrahepatic cholangiocarcinoma): 21.8%, extrahepatic cholangiocarcinoma (including perihilar cholangiocarcinoma and gallbladder cancer): 5.3%, liver metastases: 51.8%, echinococcosis: 10.8%, adenoma: 3.0%, and other diagnoses: 7.5%. Global morbidity rate (Clavien-Dindo classification ≥ 1) was 45.5% with major complication (Clavien-Dindo classification ≥ 3) identified in 81 patients (20.3%). Of the 400 patients, two died within 30 days of surgery (0.5%) and five died within 90 days (1.3%). The 2017-2019 subgroup had a significantly greater percentage of patients aged ≥ 75 years (20.5%) than did the 2014-2016 subgroup (10.9%; p = 0.011) and a higher percentage of laparoscopic procedures than the earlier subgroup (2014-2016: 9.2%, 2017-2019: 32.5%; p < 0.001). We conclude that as the patient population ages, preoperative management and surgical techniques should be constantly improved.

Cost-effectiveness analysis of hernioplasties before and after the implementation of the ACERTO project

OBJECTIVE

to compare hospital costs and clinical outcomes in inguinal and incisional hernioplasty before and after implementation of the ACERTO project in a university hospital.

METHODS

retrospective study of 492 patients undergoing either inguinal hernioplasty (n=315) or incisional hernioplasty (n=177). The investigation involved two phases: between January 2002 and December 2005, encompassing cases admitted before the implementation of the ACERTO protocol (PRE-ACERTO period), and the other phase, with cases operated between January 2006 and December 2011, after the implementation of the protocol (ACERTO period). The main outcome variable was the comparison of the mean hospital costs between the two periods. As secondary endpoints, we analyzed the length of stay, the surgical site infection rate and mortality. We used the cost method suggested by Public Sector Cost Information System.

RESULTS

surgical site infection was higher (p = 0.039) in the first phase of the study for both inguinal hernia operations (2 (1.6%) versus 0 (0%) cases) and incisional hernioplasty (5 (7.6%) versus 3 (2.7%) cases). The length of stay decreased one day after the implementation of the ACERTO protocol (p=0.005). There was a reduction in costs per patient from R$ 4,328.58 per patient in the first phase to R$ 2,885.72 in the second phase (66.7% reduction).

CONCLUSION

there was a reduction in infectious morbidity, length of stay and hospital costs in hernioplasty after the implementation of the ACERTO protocol.

Laparoscopic hepatectomy enhances recovery for small hepatocellular carcinoma with liver cirrhosis by postoperative inflammatory response attenuation: a propensity score matching analysis with a conventional open approach

BACKGROUND

The concurrent presence of liver cirrhosis and hepatocellular carcinoma (HCC) poses a challenge for laparoscopic surgeons to establish a routine practice. The aim of this study was to gather evidence and produce recommendations on the safe and effective practice of laparoscopic hepatectomy for patients with solitary HCC (≤ 5 cm) and liver cirrhosis.

METHODS

Between October 2013 and October 2014, 356 curative hepatectomies were performed for patients pathologically diagnosed with solitary HCC (≤ 5 cm) accompanied by cirrhosis (stage 4 fibrosis). To overcome selection bias, a 1:2 match using propensity score matching analysis was conducted between laparoscopic and open hepatectomy. Perioperative outcomes were compared between the groups, including hospitalization, operation time, blood loss, and surgical complications. Perioperative inflammation-based markers, including systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) were collected from medical records and analyzed.

RESULTS

There were 43 and 77 patients in the laparoscopic and open groups, respectively. The laparoscopic group had less hepatic inflow occlusion (16.3% vs. 61%; P < 0.001), shorter operation time (155 vs. 170 min; P = 0.004), and shorter postoperative hospital stay (4 vs. 7 days; P < 0.001). Although the difference was not significant (P = 0.154), the rate of postoperative complications tended to be lower in the laparoscopic group (2.3%) compared with the open group (9.1%). The increase in postoperative SII, NLR, and LMR for laparoscopic hepatectomy were significantly lower than for open hepatectomy. NLR < 5.8 on postoperative day 3 was significantly correlated with shorter hospital stay (P < 0.001).

CONCLUSIONS

Compared with open hepatectomy, laparoscopic hepatectomy for selected HCC patients, even in the presence of cirrhosis, might result in better perioperative outcomes and postoperative inflammatory response attenuation, and ultimately promote faster recovery. This provides evidence for considering routine laparoscopic hepatectomy through careful selection of patients with HCC.

Ventral hernia patient outcomes postoperatively housed on surgical vs non-surgical units

BACKGROUND

Inpatient hospital units vary in staffing ratios, monitoring, procedural abilities, and experience with unique patients and diagnoses. The purpose of this study is to assess the impact of patient cohorting upon ventral hernia repair outcomes.

METHODS

An IRB-approved retrospective review of open ventral hernia repairs between August 2013 and July 2017 was performed. The information of all patient locations during hospitalization, time at location, post-anesthesia care unit duration (PACU), and intensive care unit (ICU) duration was collected. Patient demographics, comorbidities, operative details, cost, and patient outcomes were analyzed. Multivariable analysis of log length of stay (LOS) was assessed with adjustment for clinical and operative factors.

RESULTS

235 patients underwent open ventral hernia repair. 179 patients were admitted to surgical units, 33 non-surgical units, and 23 stayed on both units. Clinical characteristics including patient age, gender, BMI, and medical comorbidities were similar between patients boarded on surgical versus non-surgical units. Hernia, wound, and operative data were also statistically similar. Patients admitted to non-surgical units for any duration experienced longer hospital stay (4 vs. 6 days, p < 0.001). Patients housed on a non-surgical unit were more likely to transfer rooms than patients on surgical units, 42.9% vs. 10.1% (p < 0.001), respectively. Multivariable analysis of natural log-transformed LOS showed any stay on a non-surgical unit increased LOS by 1.0 days (95% Cl 0.9-1.2 days, p = 0.026). There were no differences in ICU or PACU stay, cost, or postoperative complications in patients housed on surgical versus non-surgical units.

CONCLUSIONS

Postoperative surgical patients had an increased length of stay when admitted to non-surgical units. More frequent room transfers occurred in patients admitted to non-surgical units. Evaluation of patient outcomes and LOS in open ventral hernia repair patients based on hospital unit is unique to this study.

Impact of postoperative weight gain on complications after liver surgery

BACKGROUND

Recent data has suggested that excessive perioperative weight gain may be associated with adverse outcomes after abdominal surgery, but this observation remains unexplored following liver surgery. The present study aimed to investigate the predictive value of perioperative weight fluctuation in predicting complications after liver surgery.

METHODS

Retrospective monocentric analysis of consecutive patients undergoing liver surgery between 2010 and 2016. Patients without available perioperative weight were excluded. Test variable was postoperative weight change (ΔWeight) measured on day 2 (POD2). Primary outcome was postoperative major morbidity according to Clavien classification (grades III-IV). Secondary outcomes were overall complications, Comprehensive Complication Index (CCI) and length of hospital stay (LoS). Area under the receiver operating characteristic curve (AUROC) and logistic regression with multivariable analysis were performed.

RESULTS

A total of 181 patients met the inclusion criteria. Major and overall postoperative complications were reported in 25 (14%) and 87 (48%) patients, respectively. On POD2, median ΔWeight was 2.6 Kg (IQR: 1.1-4.0). Patients with major complications showed increased ΔWeight of 4.2 Kg (IQR: 2.7-5.7), compared to 2.3 Kg (IQR: 0.9-3.7) in patients without major complications (p < 0.001). AUROC of ΔWeight for major complications was 0.74, determining an optimal cut-off of 3.5 Kg, which yielded a negative predictive value of 94%. Multivariable analysis identified ΔWeight ≥3.5 Kg as independent predictor of major complications (OR, 4.73; 95% CI, 1.51-14.80; p = 0.008).

CONCLUSION

ΔWeight ≥3.5 Kg was independently associated with major complications after liver surgery. Perioperative fluctuation of weight appears as an important predictor of adverse outcomes after liver surgery.

Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Improve Clinical Outcomes in Liver Surgery: a Systematic Review and Meta-Analysis

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are evidence-based, multimodal and patient-centred approach to optimize patient care and experience during their perioperative pathway. It has been shown to be effective in reducing length of hospital stay and improving clinical outcomes. However, evidence on its effective in liver surgery remains weak. The aim of this review is to investigate clinical benefits, cost-effectiveness and compliance to ERAS protocols in liver surgery.

METHODS

A systematic literature search was conducted using CINAHL Plus, EMBASE, MEDLINE, PubMed and Cochrane for randomized control trials (RCTs) and cohort studies published between 2008 and 2019, comparing effect of ERAS protocols and standard care on hospital cost, LOS, complications, readmission, mortality and compliance.

RESULTS

The search resulted in 6 RCTs and 21 cohort studies of 3739 patients (1777 in ERAS and 1962 in standard care group). LOS was reduced by 2.22 days in ERAS group (MD = -2.22; CI, -2.77 to -1.68; p < 0.00001) compared to the standard care group. Fewer patients in ERAS group experienced complications (RR, 0.71; 95% CI, 0.65-0.77; p = < 0.00001). Hospital cost was significantly lower in the ERAS group (SMD = -0.98; CI, -1.37 to - 0.58; p < 0.0001).

CONCLUSION

Our review concluded that the introduction of ERAS protocols is safe and feasible in hepatectomies, without increasing mortality and readmission rates, whilst reducing LOS and risk of complications, and with a significant hospital cost savings. Laparoscopic approach may be necessary to reduce complication rates in liver surgery. However, further studies are needed to investigate overall compliance to ERAS protocols and its impact on clinical outcomes.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The financial impact of an enhanced recovery after surgery (ERAS) protocol in an academic gynecologic oncology practice

OBJECTIVE

To determine the financial impact of an enhanced recovery after surgery (ERAS) protocol in gynecologic oncology patients.

METHODS

This study identified gynecologic oncology patients who were placed on the ERAS protocol after elective laparotomy from 10/2016-6/2017. A control group was identified from the year prior to ERAS implementation. Financial experts assisted in procuring data for these patient encounters, including payer status, direct and indirect costs, contribution margin, and length of stay (LOS). SPSS Statistics v. 24 was used for statistical analysis.

RESULTS

376 patients met criteria for inclusion: 179 in the ERAS group and 197 in the control group. Patient demographics were similar between the two cohorts. Payer status across the groups was not statistically significant in patients with private insurance (control 43.7% vs. ERAS 41.3%), Medicare (38.1% vs. 31.8%), or self-pay patients (12.2% vs. 15.1%). There was a significantly higher number of Medicaid patients in the ERAS group (6.1% vs. 11.7%; p = 0.05). Hospital direct costs ($5596 vs. 5346) and indirect costs ($5182 vs. $4954) per encounter were similar between groups. However, overall contribution margin per encounter decreased in the ERAS group ($11,619 vs. $8528; p = 0.01). LOS was significantly lower in the ERAS group (4.1 vs. 2.9 days; p = 0.04).

CONCLUSIONS

Implementation of the ERAS protocol in gynecologic oncology patients does not lead to increased costs for the patient or hospital system. The decreased contribution margin is likely due to a reduction in per diem payments caused by the reduction in LOS. On a per-patient-day basis, contribution margin was the same for both groups ($2877 vs $2857). The reduction in LOS also created capacity for additional cases, the financial impact of which was not evaluated.

Enhanced recovery after surgery (ERAS) programs for esophagectomy

A perioperative treatment protocol, enhanced recovery after surgery (ERAS) focuses on accelerating patient recovery. Previous studies confirmed that ERAS decreases surgical trauma and the stress response, which improved outcomes including reduced length of hospital stay (LOS) and decreased postoperative morbidity. While ERAS protocols have been successfully implemented in a variety of surgical disciplines (colorectal, bariatric, orthopedic, and gynecologic surgery), its use in esophageal surgery is still limited. This paper analyzes the feasibility and value of the ERAS protocol for esophageal surgery. Reviewing the literature found that implementation of ERAS resulted in decreased costs, length of stay and pulmonary specific complication reduction, but not overall morbidity. The evidence lacks randomized control trials. Further, the ERAS Society published recommendations for esophageal resection. This opportunity for unification of the protocol would make the studies more comparable and leads to stronger conclusions. Surgery specific items also require further confirmation. Nonetheless, the successful introduction of the ERAS protocol into a wide variety of surgical disciplines provides optimism for ERAS's effectiveness in esophageal surgery.

Enhanced recovery after surgery in liver resection: current concepts and controversies

Enhanced recovery after surgery (ERAS) attenuates the stress response to surgery in the perioperative period and hastens recovery. Liver resection is a complex surgical procedure where the enhanced recovery program has been shown to be safe and effective in terms of postoperative outcomes. ERAS programs have been shown to be associated with lower morbidity, shortened postoperative stay, and reduced cost with no difference in mortality and readmission rates. However, there are challenges that are unique to hepatic resection such as safety after epidural catheterization and postoperative coagulopathy, intraoperative fluids and postoperative organ dysfunction, need for low central venous pressure to reduce blood loss, and non-lactate containing intravenous fluids. This narrative review briefly discusses these concerns and controversies and suggests revisiting some of the strong recommendations made by the ERAS society in light of the recent evidence.

Enhanced Recovery in Liver Transplantation: A Feasibility Study

BACKGROUND

Enhanced Recovery After Surgery (ERAS) programmes after surgery are effective in reducing length of stay, functional recovery and complication rates in liver surgery (LS) with the indirect advantage of reducing hospitalisation costs. Preoperative comorbidities, challenging surgical procedures and complex post-operative management are the points that liver transplantation (LT) shares with LS. Nevertheless, there is little evidence regarding the feasibility and safety of ERAS programmes in LT.

METHODS

We designed a pilot, small-scale, feasibility study to assess the impact on hospital stay, protocol compliance and safety of an ERAS programme tailored for LT. The ERAS arm was compared with a 1:2 match paired control arm with similar characteristics. All patients with MELD <25 were included. A dedicated LT-tailored protocol was derived from publications on ERAS liver surgery.

RESULTS

Ten patients were included in the Fast-Trans arm. It was observed a 47% reduction of the total LOS, as compared to the control arm: 9.5 (9.0-10.5) days versus 18.0 (14.3-24.3) days, respectively, p <0.001. The protocol achieved 72.9% compliance. No differences were observed in terms of post-operative complications or readmission rates after discharge between the two arms. Overall, it was observed a reduction of length of stay in ICU and surgical ward in the Fast-Trans arm compared with the control arm.

CONCLUSION

Considered the main points in common between LS and LT, this small-scale study suggests that the application of an ERAS programme tailored to the LT setting is feasible. Further testing will be appropriate to generalise these findings.

Beyond surgery: clinical and economic impact of Enhanced Recovery After Surgery programs

Background

Enhanced Recovery After Surgery (ERAS) is a perioperative management based on multimodality and multidisciplinary work. ERAS has been shown to have important clinical and economic benefits, but its spread remains slow worldwide.

Discussion

This manuscript reviews the overall program benefits and focuses on important aspects for implementation well beyond surgery.

Summary

Implementation of ERAS pathways improves clinical outcomes and induces substantial economic gains. ERAS is the current surgical revolution.

Second Generation of a Fast-track Liver Resection Programme

BACKGROUND

Recent developments in perioperative pathophysiology and care have documented evidence-based, multimodal rehabilitation (fast-track) to hasten recovery and decrease morbidity and hospital stay in several major surgical procedures. The aim of this study was to investigate the effect over time of a modified previously published fast-track programme in unselected patients undergoing open or laparoscopic liver resection.

METHODS

A prospective study includes the first 121 consecutive patients following an updated fast-track programme for liver resection. High-dose methylprednisolone was given to all patients before surgery, catheters and drains were systematically removed early, and patients were mobilized and started eating and drinking from the day of surgery. An opioid-sparing multimodal pain treatment was given for the first week. The discharge criteria were (1) pain sufficiently controlled by oral analgesics only; (2) patient comfortable with discharge; (3) no untreated complications.

RESULTS

The median length of stay (LOS) for all patients was 4 days, with 2 days after laparoscopic vs. 4 days for open resections. The median LOS after major hepatectomies (≥3 segments) was 5 days. The readmission rate was 6% and the 30-day mortality zero. The LOS decreased compared to our first-generation fast-track programme with LOS 5 days.

CONCLUSIONS

Fast-track principles for perioperative care and early discharge are safe even after major liver resection. The introduction of high-dose steroids preoperatively might have facilitated a shorter LOS. Routine discharge on POD 1 or 2 after laparoscopic resection and on POD 4 after open liver resection has proven to be feasible.

Cost-benefit analysis of enhanced recovery after hepatectomy in Chinese Han population

BACKGROUND

Enhanced recovery after surgery (ERAS) programs have been proved effective for enhancing the clinical healing rate and reducing hospitalization cost in most countries of the world. It's a multi-model approach that designed to optimize perioperative pathway, attenuate the surgical stress response, and decrease postoperative complications.

OBJECTIVE

The economic benefit from the application of ERAS to colorectal surgery has been demonstrated in China. However, such economic benefit of ERAS programs for hepatectomy hasn't been clarified yet. This study was carried out to explore the clinical efficacy and cost effectiveness of ERAS in Chinese Han population after hepatectomy.

METHODS

ERAS program was implemented in our department for hepatectomy in December 2016. In total, 79 consecutive patients after hepatectomy were chosen as ERAS group (ERAS protocol) in coming half year while 121 consecutive patients after hepatectomy were chosen as Pre-ERAS group (traditional protocol) in past half year. The operation time, intraoperative blood loss, length of hospital stay (LOS), complication, readmission, and hospitalization cost of 2 groups were compared.

RESULTS

The LOS of ERAS group was 5.81 ± 1.79 days, significantly shorter than that of Pre-ERAS group (8.06 ± 3.40 d) (P = .000). The operation time was 168.03 ± 46.20 minutes for ERAS group and 175.41 ± 64.64 minutes for Pre-ERAS group respectively (P = .417). The intraoperative blood loss was 166.58 ± 194.13 mL (ERAS group) and 205.45 ± 279.63 mL (Pre-ERAS group) (P = .293). It should be noted that the hospitalization cost of ERAS group was 51556.18 ± 8926.05 Yuan (7835.05 ± 1355.45 US dollars), significantly less than that of Pre-ERAS group 60554.66 ± 15615.31 Yuan (9202.56 ± 2371.24 US dollars) (P = .000). The application of ERAS effectively saved 8998.48 Yuan (1367.51 US dollars) for each patient.

CONCLUSIONS

ERAS implementation for hepatectomy surgery is safe and feasible for Chinese Han population. It eventually enhanced the clinical healing rate. The benefits from such programs include a reduction of the LOS, complication, and readmission rates. So each patient has access to better medical service. It effectively relieved the financial burden of patients. The benefits from such programs include a reduction of the hospitalization cost, especially in medication cost. So each patient can afford the diseases.

The impact of enhanced recovery pathways on cost of care and perioperative outcomes in patients undergoing gastroesophageal and hepatopancreatobiliary surgery

INTRODUCTION

Enhanced recovery after surgery protocols have been increasingly adopted to standardize patient care and decrease overall costs. This study evaluated the impact of a prospectively implemented enhanced recovery after surgery protocol for patients undergoing surgery for gastroesophageal and hepatopancreatobiliary disease at an academic institution.

METHODS

Patients undergoing either hepatopancreatobiliary or gastroesophageal procedures between January 2013 and May 2017 were classified according to whether or not they were placed on an enhanced recovery after surgery protocol. Groups were compared along demographic, perioperative, outcomes, and financial variables.

RESULTS

Of a total of 377 patients, 149 were placed on an enhanced recovery after surgery protocol. There was a significant association between enhanced recovery after surgery protocol use and increased perioperative antibiotic use (98.0% enhanced recovery after surgery vs. 87.3% non-enhanced recovery after surgery, P < .001), decreased intraoperative crystalloid use (1,155 ± 705 mL enhanced recovery after surgery vs. 1,576 ± 826 non-enhanced recovery after surgery, P < .001), decreased requirement for intensive care unit stay (20.1% enhanced recovery after surgery vs. 36.4% non-enhanced recovery after surgery, P < .001), and decreased total hospital costs ($10,688.38 ± 10,518.22 vs. $15,439.22 ± 14,201.24, P < .001). On multivariable analysis, enhanced recovery after surgery protocol use was independently associated with decreased rate of intensive care unit admission (odds ratio 0.39, 95% confidence interval 0.23-0.66, P < .001).

CONCLUSION

Enhanced recovery after surgery pathways can be safely implemented in patients undergoing hepatopancreatobiliary and gastroesophageal procedures and can help standardize perioperative practices, decrease requirement for intensive care unit admission, and decrease total hospital costs.

Enhanced recovery after hepatectomy: A systematic review

BACKGROUND

Hepatectomy is a surgery with high postoperative complication rates. Enhanced recovery after surgery (ERAS) clinical pathways in liver surgery have been studied and may become a standard of care. However, few specific recommendations have been published so far.

OBJECTIVE

The aim of this study was to assess the efficacy and safety of the enhanced recovery program in liver surgery.

METHODS

Randomised controlled trials (RCTs) comparing ERAS group with traditional care published between 2007 and 2017 were included in this review. The outcomes were length of stay (LoS), complications, mortality and readmission rate for all liver surgeries except transplantation.

RESULTS

Five hundred and twenty-four patients randomised in 4 RCTs were analysed. Two hundred and fifty-four patients were in ERAS group and 270 patients in traditional care (TC) group. Two studies compared cares in laparoscopic surgery and 2 in open surgery. Postoperative LoS was significantly lower in the ERAS group whereas readmission and mortality rate were similar. ERAS group had also significant lower complication rate in 2 studies of the 4. The complication rate in the 2 other studies was similar.

CONCLUSION

ERAS protocols in liver surgery appeared to be safe and effective. Recent recommendations from the ERAS group in liver surgery are the only ones published so far. Other studies evaluating ERAS components in liver surgery and recommendations from scientific societies are needed to spread this clinical care pathway.

Improved analgesia and reduced post-operative nausea and vomiting after implementation of an enhanced recovery after surgery (ERAS) pathway for total mastectomy

Background

Enhanced Recovery After Surgery (ERAS) pathways have been shown in multiple surgical disciplines to improve outcomes, including reduced opioid consumption, length of stay, and post-operative nausea and vomiting (PONV). However, very few studies describe the application of ERAS to breast surgery and even fewer describe ERAS for outpatient surgery. We describe the implementation and efficacy of an Enhanced Recovery After Surgery (ERAS) pathway for total skin-sparing mastectomy with immediate reconstruction in an outpatient setting.

Methods

We implemented an evidence-based, multimodal ERAS pathway for all patients undergoing total skin-sparing mastectomy surgery with immediate reconstruction at a single 23-h stay surgery center. Highlights of the ERAS pathway included: preoperative acetaminophen, gabapentin, and scopolamine; regional anesthesia for the breast (Pectoral blocks type 1 and 2 or paravertebral block); and intraoperative dexamethasone and ondansetron. This retrospective study included all American Society of Anesthesiology (ASA) Class 1–3 patients undergoing total skin-sparing mastectomy surgery with immediate reconstruction between July 2013 and April 2016. We compared 96 patients who were in the ERAS pathway (ERAS group) to a retrospective cohort of 276 patients (Pre group). The primary outcome was total perioperative opioid consumption. Secondary outcomes were highest postoperative pain scores, incidence of PONV, and length of stay.

Results

Patients in the ERAS group had significantly lower total perioperative opioid consumption compared to the Pre group (mean (SD): 111.4 mg (46.0) vs. 163.8 mg (73.2) oral morphine equivalents, p < 0.001). Patients in the ERAS group also had a lower incidence of PONV (28% vs. 50%, p < 0.001). Patients in the ERAS group reported less pain in the recovery room, with a two-point decrease in highest pain score (median [interquartile range (IQR)]: 4 [2,6] in ERAS group vs. 6 [4,7] in Pre group, p < 0.001). There was no clinically significant difference in length of stay (median [IQR]: 1144 min [992, 1259] in ERAS group vs. 1188 [1058, 1344] in Pre group, p = 0.006).

Conclusion

Implementation of an ERAS pathway for total skin-sparing mastectomy with reconstruction that incorporates regional anesthesia is feasible in a 23-h-stay hospital. Patients in the ERAS pathway had improved post-operative analgesia and reduced post-operative nausea and vomiting.

Electronic supplementary material

The online version of this article (10.1186/s12871-018-0505-9) contains supplementary material, which is available to authorized users.

The Effectiveness of a Clinical Pathway in Liver Surgery: a Case-Control Study

BACKGROUND

In the field of liver surgery, evidence on the effectiveness of clinical pathways based on ERAS principles is limited.

METHODS

This is a single-center observational study from a prospectively maintained database. Two cohorts were formed of all patients undergoing liver surgery during a defined period before (traditional management) and after introduction of a clinical pathway. Additionally, a case-match analysis-based on approach, tumor location, and Brisbane classification of resection-was performed. A cost analysis and patient satisfaction questionnaire were carried out.

RESULTS

In both the overall analysis (n = 229) as well as the case-match analysis (n = 100), hospital stay was significantly reduced from 8 to 4 days and from 6.5 to 4 days, respectively (p < 0.05). Postoperative morbidity (traditional management 11/50 vs clinical pathway 5/50; p = 1.00) and readmission rate did not increase. Cost analysis showed a significant decrease in postoperative costs in favor of the clinical pathway (traditional management €3666.7 vs clinical pathway €1912.2; p < 0.001). Overall, 92.3% of the survey questions were answered with satisfied (86.0%) or very satisfied (6.3%).

DISCUSSION

Implementation of clinical pathway for liver surgery is feasible and safe. A clinical pathway significantly reduces hospital stay without increasing postoperative morbidity and readmission rates. Postoperative costs are significantly reduced. Patient satisfaction is high.

Perioperative nutrition and enhanced recovery after surgery in gastrointestinal cancer patients. A position paper by the ESSO task force in collaboration with the ERAS society (ERAS coalition)

Malnutrition in cancer patients - in both prevalence and degree - depends primarily on tumor stage and site. Preoperative malnutrition in surgical patients is a frequent problem and is associated with prolonged hospital stay, a higher rate of postoperative complications, higher re-admission rates, and a higher incidence of postoperative death. Given the focus on the cancer and its cure, nutrition is often neglected or under-evaluated, and this despite the availability of international guidelines for nutritional care in cancer patients and the evidence that nutritional deterioration negatively affects survival. Inadequate nutritional support for cancer patients should be considered ethically unacceptable; prompt nutritional support must be guaranteed to all cancer patients, as it can have many clinical and economic advantages. Patients undergoing multimodal oncological care are at particular risk of progressive nutritional decline, and it is essential to minimize the nutritional/metabolic impact of oncological treatments and to manage each surgical episode within the context of an enhanced recovery pathway. In Europe, enhanced recovery after surgery (ERAS) and routine nutritional assessment are only partially implemented because of insufficient awareness among health professionals of nutritional problems, a lack of structured collaboration between surgeons and clinical nutrition specialists, old dogmas, and the absence of dedicated resources. Collaboration between opinion leaders dedicated to ERAS from both the European Society of Surgical Oncology (ESSO) and the ERAS Society was born with the aim of promoting nutritional assessment and perioperative nutrition with and without an enhanced recovery program. The goal will be to improve awareness in the surgical oncology community and at institutional level to modify current clinical practice and identify optimal treatment options.

ERAS-Value based surgery

This paper reviews implementation of ERAS and its financial implications. Literature on clinical outcomes and financial implications were reviewed. Reports from many different surgery types shows that implementation of ERAS reduces complications and shortens hospital stay. These improvements have major impacts on reducing the cost of care even when costs for implementation, and investment in time for personnel and training is accounted for. The conclusion is that ERAS is an excellent example of value based surgery.

The History of Enhanced Recovery After Surgery and the ERAS Society

This short historical overview explains the development of enhanced recovery from a small group of surgeons in European academic centers to the establishment of ERAS^®Society, a not-for-profit multiprofessional multidisciplinary medical-academic society, reaching all major continents and involving a wide range of surgical and anesthesia disciplines.

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

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.

Enhanced Recovery after Surgery Programs for Liver Resection: a Meta-analysis

BACKGROUND AND AIMS

Due to the limited number of high-quality randomized controlled trials on enhanced recovery after surgery for hepatectomy, previous reviews have not been sufficiently comprehensive. Our objectives were to evaluate and compare the safety and efficacy of enhanced recovery after surgery programs and traditional care in patients undergoing open or laparoscopic surgery and to assess the optimized items for hepatectomy.

METHODS

We searched the PubMed, Embase, and the Cochrane Library databases for all the relevant studies regardless of study design. We assessed the methodological quality of the included studies and excluded studies of poor quality. We performed a meta-analysis using RevMan 5.3 software.

RESULTS

In total, 19 original studies with 2575 patients, including four randomized controlled trials and 15 non-randomized controlled trials, were analyzed. The meta-analysis demonstrated that enhanced recovery after surgery programs could reduce morbidity, hospital stays and cost, blood loss, and time to bowel function recovery for both open and laparoscopic surgery without increasing mortality, readmission rate, or transfusion rate. Twelve items were essential for liver surgery.

CONCLUSIONS

Enhanced recovery after surgery programs for hepatectomy are feasible and efficient. Further studies should optimize perioperative outcomes for liver surgery.