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Reyes MP, Pérez BS, González CS, Daga JAP, Villalba JS, Santoyo JS. Implementation of an ERAS protocol on cirrhotic patients in liver resection: a cohort study. Updates Surg 2024; 76:889-897. [PMID: 38493422 DOI: 10.1007/s13304-024-01769-8] [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: 03/27/2023] [Accepted: 01/29/2024] [Indexed: 03/19/2024]
Abstract
The development of laparoscopic liver surgery, the improvement in the perioperative care programs, and the surgical innovation have allowed liver resections on selected cirrhotic patients. However, the great majority of ERAS studies for liver surgery have been conducted on patients with normal liver parenchyma, while its application on cirrhotic patients is limited. The purpose of this study was to evaluate the implementation of an ERAS protocol in cirrhotic patients who underwent liver surgery. We present an analytical observational prospective cohort study, which included all adult patients who underwent a liver resection between December 2017 and December 2019 with an ERAS program. We compare the outcomes in patients cirrhotic (CG)/non-cirrhotic (NCG). A total of 101 patients were included. Thirty of these (29.7%) were patients ≥ 70 cirrhotic. 87% of the both groups had performed > 70% of the ERAS. Oral diet tolerance and mobilization on the first postoperative day were similar in both groups. The hospital stay was similar in both groups (2.9 days/2.99 days). Morbidity and mortality were similar; Clavien I-II (CG: 44% vs NCG: 30%) and Clavien ≥ III (CG: 3% vs NCG: 8%). Hospital re-entry was higher in the NCG. Overall mortality of the study was 1%. ERAS protocol compliance was associated with a decrease in complications (ERAS < 70%: 80% vs ERAS > 90%: 20%; p: 0.02) and decrease in severity of complications in both study groups. The application of the ERAS program in cirrhotic patients who undergo liver surgery is feasible, safe, and reproducible. It allows postoperative complications, mortality, hospital stay, and readmission rates comparable to those in standard patients.
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Affiliation(s)
- María Pérez Reyes
- Hospital Regional Universitario de Málaga, Avda. Carlos Haya s/n, Málaga, Spain.
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2
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Delabays C, Demartines N, Joliat GR, Melloul E. Enhanced recovery after liver surgery in cirrhotic patients: a systematic review and meta-analysis. Perioper Med (Lond) 2024; 13:24. [PMID: 38561792 PMCID: PMC10983761 DOI: 10.1186/s13741-024-00375-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 03/04/2024] [Indexed: 04/04/2024] Open
Abstract
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.
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Affiliation(s)
- Constant Delabays
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland.
| | - Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
| | - Emmanuel Melloul
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Lausanne, Switzerland
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3
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Wang Y, Zhang F, Zheng L, Yang W, Ke L. Enhanced recovery after surgery care to reduce surgical site wound infection and postoperative complications for patients undergoing liver surgery. Int Wound J 2023; 20:3540-3549. [PMID: 37218367 PMCID: PMC10588343 DOI: 10.1111/iwj.14227] [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: 04/20/2023] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/24/2023] Open
Abstract
This study comprehensively assessed the effect of enhanced recovery after surgery (ERAS) on wound infection and postoperative complications in patients undergoing liver surgery. The PubMed, EMBASE, MEDLINE, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang electronic databases were searched to collect published studies on the use of ERAS in liver surgery until December 2022. Literature selection was performed independently by two investigators according to the inclusion and exclusion criteria, and quality evaluation and data extraction were performed. RevMan 5.4 software was used in this study. Compared with the control group, the ERAS group showed a significantly lower incidence of postoperative wound infection (odds ratio [OR]: 0.59, 95% confidence interval [CI]: 0.41-0.84, P = .004) and overall postoperative complication rate (OR: 0.43, 95% CI: 0.33-0.57, P < .001) and significantly shorter postoperative hospital stay (mean difference: -2.30, 95% CI: -2.92 to -1.68, P < .001). Therefore, ERAS was safe and feasible when applied to liver resection, reducing the incidence of wound infection and total postoperative complications, and shortening the length of hospital stay. However, further studies are required to investigate the impact of ERAS protocols on clinical outcomes.
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Affiliation(s)
- Yu‐Ling Wang
- Department of HepatobiliaryTaizhou Hospital of Zhejiang ProvinceTaizhouZhejiangChina
| | - Fa‐Biao Zhang
- Department of HepatobiliaryTaizhou Hospital of Zhejiang ProvinceTaizhouZhejiangChina
| | - Ling‐E Zheng
- Department of Admissions Management CentreTaizhou Hospital of Zhejiang ProvinceTaizhouZhejiangChina
| | - Wei‐Wei Yang
- Department of HepatobiliaryTaizhou Hospital of Zhejiang ProvinceTaizhouZhejiangChina
| | - Lan‐Lan Ke
- Department of Admissions Management CentreTaizhou Hospital of Zhejiang ProvinceTaizhouZhejiangChina
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Kobayashi Y, Shindoh J, Kojima K, Akabane M, Kobayashi M, Okubo S, Matsumura M, Hashimoto M. Efficacy and safety of postoperative preemptive use of tolvaptan for patients with cirrhosis undergoing hepatectomy for hepatocellular carcinoma. Langenbecks Arch Surg 2023; 408:381. [PMID: 37770582 DOI: 10.1007/s00423-023-03117-7] [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: 06/27/2023] [Accepted: 09/19/2023] [Indexed: 09/30/2023]
Abstract
PURPOSE Optimal choice of diuretics in perioperative management remains unclear in enhanced recovery after liver surgery. This study investigated the efficacy and safety of tolvaptan (oral vasopressin V2-receptor antagonist) in postoperative management of patients with liver injury and hepatocellular carcinoma. METHODS The patients clinically diagnosed with liver cirrhosis were included in this study. Clinical outcomes of 51 prospective cohort managed with a modified postoperative protocol using tolvaptan (validation group) were compared with 83 patients treated with a conventional management protocol (control group). RESULTS Postoperative urine output were significantly larger and excessive body weight increase were reduced with no impairment in renal function or serum sodium levels in the validation group. Although the total amount of discharge and trend of serum albumin level were not significantly different among the groups, global incidence of postoperative morbidity was less frequent (19.6% vs. 44.6%, P=0.005) and postoperative stay was significantly shorter (8 days vs.10 days, P=0.008) in the validation group compared with the control group. CONCLUSIONS Tolvaptan could be safely used for the patients with injured liver in postoperative management after hepatectomy and potentially advantageous in the era of enhanced recovery after surgery with its strong diuretic effect and better fluid management.
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Affiliation(s)
- Yuta Kobayashi
- Department of Gastroenterological Surgery, Showa General Hospital, 8-1-1Hanakoganei, Kodaira-shi, Tokyo, 187-8510, Japan.
| | - Junichi Shindoh
- Hepato-Biliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Disease, Tokyo, Japan
| | - Kazutaka Kojima
- Hepato-Biliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Miho Akabane
- Hepato-Biliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Masahiro Kobayashi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
| | - Satoshi Okubo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Disease, Tokyo, Japan
| | - Masaru Matsumura
- Hepato-Biliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Disease, Tokyo, Japan
| | - Masaji Hashimoto
- Hepato-Biliary-Pancreatic Surgery Division, Department of Gastroenterological Surgery, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Disease, Tokyo, Japan
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5
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Pérez Reyes M, Sánchez Pérez B, León Díaz FJ, Pérez Daga JA, Mirón Fernández I, Santoyo Santoyo J. Implementation of an ERAS protocol on elderly patients in liver resection. Cir Esp 2023; 101:274-282. [PMID: 35918049 DOI: 10.1016/j.cireng.2022.07.019] [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: 04/29/2021] [Accepted: 12/08/2021] [Indexed: 04/21/2023]
Abstract
BACKGROUND The increase of quality of life, the improvement in the perioperative care programs, the use of the frailty index, and the surgical innovation has allowed to access of complex abdominal surgery for elderly patients like liver resection. Despite of this, in patients aged 70 or older there is a limitation for the implementation ERAS protocolos. The aim of this study is to evaluate the implementation ERAS protocol on elderly patients (≥70 years) undergoing liver resection. METHODS A prospective cohort study of patients who underwent liver resection from December 2017 to December 2019 with an ERAS program. We compare the outcomes in patients ≥70 years (G ≥ 70) versus <70 years (G < 70). The frailty was measured with the Physical Frailty Phenotype score. RESULTS A total of 101 patients were included. 32 of these (31.6%) were patients ≥70 years. 90% of the both groups had performed >70% of the ERAS. Oral diet tolerance and mobilization on the first postoperative day were quicker in <70 years group. The hospital stay was similar in both groups (3.07days/2.7days). Morbidity and mortality were similar; Clavien I-II(G ≥ 70:41% vs G < 70:30,5%) and Clavien ≥ III (G ≥ 70:6% vs G < 70:8.5%), like hospital readmissions. Mortality was <1%. ERAS protocol compliance was associated with a decrease in complications (ERAS < 70%:80% vs ERAS > 90%:20%; p = 0.02) and decrease in severity of complications in both study groups. Frailty was found in 6% of the elderly group; the only patient who died had a frailty index of 4. CONCLUSION Implementation of ERAS protocol for elderly patients is possible, with major improvements in perioperative outcomes, without an increase in morbidity, mortality neither readmissions.
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Affiliation(s)
- María Pérez Reyes
- Hospital Regional Universitario de Málaga, Universidad de Málaga, Málaga, Spain.
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6
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Early postoperative ERAS compliance predicts decreased length of stay and complications following liver resection. HPB (Oxford) 2022; 24:1425-1432. [PMID: 35135723 DOI: 10.1016/j.hpb.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 12/27/2021] [Accepted: 01/17/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) components for liver resection lack standardization and compliance. We evaluated our ERAS protocol and describe the association of postoperative ERAS compliance with length of stay (LOS) and complications. METHODS We retrospectively reviewed patients undergoing liver resection at our institution from 2016 to 2020. Pre- and post-ERAS outcomes and compliance at 72 h were compared with LOS and complications. LOS beyond 72 h was defined as LOS72. RESULTS 210 patients were included. Post-ERAS patients had significantly shorter LOS (5.1 vs. 7.3 days, p = 0.0014) with no difference in 30-day mortality, morbidity, or readmissions. ERAS components associated with shorter LOS72 were regular diet (HR 1.73), fluid discontinuation (HR 1.63), drain removal (HR 1.94), multimodal and oral analgesia (HR 1.51), and ambulation >100 ft (HR 2.23). LOS72 was 1-day for ≥9 ERAS component compliance, 4-days for 6-8 components, and 6-days for <6 components. 30-day complication rates for patients with ≥9 components by postoperative day 3 (POD3) were significantly lower than those with 6-8 (12 vs 32%). CONCLUSION ERAS decreases LOS after liver resection. Nutritional advancement, drain discontinuation, multimodal and oral analgesia, and ambulation >100 ft by POD3 are associated with decreased LOS72. Achieving ≥6 components by POD3 predicts decreased LOS72 and complications.
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7
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Lee B, Han HS. Tackling Surgical Morbidity and Mortality through Modifiable Risk Factors in Cancer Patients. Nutrients 2022; 14:nu14153107. [PMID: 35956284 PMCID: PMC9370480 DOI: 10.3390/nu14153107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 07/25/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022] Open
Abstract
Despite advances in surgical techniques, surgical morbidity and mortality remain important public health problems. Postoperative complications often lead to greater morbidity and mortality, as well as increased length of hospital stay and medical costs. Therefore, a reduction in postoperative complications is particularly important with regard to positive long-term outcomes in patients with cancer. To improve patients’ postoperative prognosis, it is necessary to screen for and focus on modifiable risk factors and their subsequent resolution. Recently, it was reported that nutritional status, inflammation and surgical approaches are related to postoperative morbidity and mortality. Therefore, in this review article, we describe the current evidence regarding modifiable risk factors influencing surgical morbidity and mortality as well as future directions for improved postoperative management in cancer patients.
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8
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Zhou X, Zhou X, Cao J, Hu J, Topatana W, Li S, Juengpanich S, Lu Z, Zhang B, Feng X, Shen J, Chen M. Enhanced Recovery Care vs. Traditional Care in Laparoscopic Hepatectomy: A Systematic Review and Meta-Analysis. Front Surg 2022; 9:850844. [PMID: 35392058 PMCID: PMC8980421 DOI: 10.3389/fsurg.2022.850844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/10/2022] [Indexed: 11/25/2022] Open
Abstract
Background Enhanced recovery care could alleviate surgical stress and accelerate the recovery rates of patients. Previous studies showed the benefits of enhanced recovery after surgery program in liver surgery, but the exact role in laparoscopic hepatectomy is still unclear. Aim We aimed to perform a meta-analysis to evaluate the safety and efficacy of enhanced recovery after a surgery program in laparoscopic hepatectomy. Methods The relative studies from a specific search of PUBMED, EMBASE, OVID, and Cochrane database from June 2008 to February 2022 were selected and included in this meta-analysis. The primary outcomes included length of hospital stay, duration to functional recovery, and overall postoperative complication rate. The secondary outcomes included operative time, intraoperative blood loss, cost of hospitalization, readmission rate, Grade I complication rate, and Grade II–V complication rate. Results A total of six studies with 643 patients [enhanced recovery care (n = 274) vs. traditional care (n = 369)] were eligible for analysis. These comprised three randomized controlled trials and three retrospective studies. Enhanced recovery care group was associated with decreased hospital stay [standard mean difference (SMD) = −0.56, 95% confidence interval (CI) = −0.83~−0.28, p < 0.0001], shorter duration to functional recovery (SMD = −1.14, 95% CI = −1.92~−0.37, p = 0.004), and lower cost of hospitalization Mean Difference (MD) = −1,539.62, 95% CI = −1992.85~−1086.39, p < 0.00001). Moreover, a lower overall postoperative complication rate was observed in enhanced recovery care group [Risk ratio (RR) = 0.64, 95% CI = 0.51~0.80, p < 0.0001] as well as lower Grade II–V complication rate (RR = 0.55, 95% CI = 0.38~0.80, p = 0.002), while there was no significant difference in intraoperative blood loss (MD = −65.75, 95% CI = −158.47~26.97, p = 0.16), operative time (MD = −5.44, 95% CI = −43.46~32.58, p = 0.78), intraoperative blood transfusion rate [Odds ratio (OR) = 0.71, 95% CI = 0.41~1.22, p = 0.22], and Grade I complication rate (RR = 0.73, 95% CI = 0.53~1.03, p = 0.07). Conclusion Enhanced recovery care in laparoscopic hepatectomy should be recommended, because it is not only safe and effective, but also can accelerate the postoperative recovery and lighten the financial burden of patients.
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Affiliation(s)
- Xueyin Zhou
- School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Xueyi Zhou
- Department of Nursing, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Jiasheng Cao
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Jiahao Hu
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Win Topatana
- Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
| | - Shijie Li
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Sarun Juengpanich
- Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
| | - Ziyi Lu
- Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Bin Zhang
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Xu Feng
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Jiliang Shen
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Mingyu Chen
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
- *Correspondence: Mingyu Chen
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Zhou J, He X, Wang M, Zhao Y, Wang L, Mao A, Wang L. Enhanced Recovery After Surgery in the Patients With Hepatocellular Carcinoma Undergoing Hemihepatectomy. Surg Innov 2022; 29:752-759. [PMID: 35238718 DOI: 10.1177/15533506211057628] [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: 11/15/2022]
Abstract
BACKGROUND This study aims to compare the effectiveness and safety of enhanced recovery after surgery (ERAS) in patients with hepatocellular carcinoma (HCC) undergoing hemihepatectomy. METHODS From January 2017 to June 2019, 54 and 56 patients were enrolled into the control and ERAS group, retrospectively. All the indicators related to operation, liver functions, and postoperative outcomes were included in the analysis. Propensity score matching (PSM) analysis identified 72 patients for further analysis. RESULTS The clinicopathological characteristics were well-matched after PSM, and there were no significant differences in the operative duration, blood loss, blood transfusion, hospital costs, and most postoperative indicators in these 2 groups. In the ERAS group, D-dimer and fibrin degradation product values were significantly reduced (3.57 (2.874.60) μg/ml vs 4.81 (3.948.29) μg/ml and 11.90 (10.0418.02) μg/ml vs 15.80 (11.5529.24) μg/ml; P = .002 and P = .023, respectively). The days that semiliquid diet was allowed after surgery (2.00 (2.003.00) days vs 5.00 (4.006.00) days, P < .001), abdominal drainage tube indwelling duration (5.00 (4.005.00) days vs 5.00 (4.756.25) days, P = .004), and hospital stay after surgery (6.00 (6.007.00) days vs 8.00 (7.0010.00) days, P < .001) were also significantly shorter. The proportion of patients requiring analgesic treatment was significantly lower in the postoperative day 2 and day 4 (P < .001 and P = .025, respectively). The morbidity was significantly less (36.11% vs 69.44%, P = .005). CONCLUSIONS ERAS programs are feasible and safe in HCC patients undergoing hemihepatectomy. Postoperative anticoagulant therapy may be one of the necessary steps.
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Affiliation(s)
- Jiamin Zhou
- Department of Hepatic Surgery, Shanghai Cancer Center, 89667Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, 89667Fudan University, Shanghai, China
| | - Xigan He
- Department of Hepatic Surgery, Shanghai Cancer Center, 89667Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, 89667Fudan University, Shanghai, China
| | - Miao Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, 89667Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, 89667Fudan University, Shanghai, China
| | - Yiming Zhao
- Department of Hepatic Surgery, Shanghai Cancer Center, 89667Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, 89667Fudan University, Shanghai, China
| | - Longrong Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, 89667Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, 89667Fudan University, Shanghai, China
| | - Anrong Mao
- Department of Hepatic Surgery, Shanghai Cancer Center, 89667Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, 89667Fudan University, Shanghai, China
| | - Lu Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, 89667Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, 89667Fudan University, Shanghai, China
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10
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Pérez Reyes M, Sánchez Pérez B, León Díaz FJ, Pérez Daga JA, Mirón Fernández I, Santoyo Santoyo J. Implementación del protocolo ERAS en ancianos sometidos a resección hepática. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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11
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Kaibori M, Matsui K, Shimada M, Kubo S, Hasegawa K. Update on perioperative management of patients undergoing surgery for liver cancer. Ann Gastroenterol Surg 2021; 6:344-354. [PMID: 35634181 PMCID: PMC9130899 DOI: 10.1002/ags3.12529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 11/12/2022] Open
Abstract
Hepatocellular carcinoma is often accompanied by chronic hepatitis or cirrhosis. Preoperative evaluation of liver function and postoperative nutritional management are critical in patients with hepatocellular carcinoma who undergo liver surgery. Although the incidence of postoperative complications and death has declined in Japan over the last 10 years, postoperative complications have not been fully overcome. Therefore, surgical procedures and perioperative management must be improved. Accurate preoperative evaluations of liver function, nutrition, inflammation, and body skeletal muscle are required. Determination of the optimal surgical procedure should consider not only tumor characteristics but also the physical reserve of the patient. Nutritional management of chronic liver disorders, especially maintaining protein synthesis for postoperative protein/energy, is important. Prophylactic antibiotics are recommended for short‐term use within 24 hours after surgery. Abdominal drainage is recommended for patients with cirrhosis who may develop large amounts of ascites, who are at risk of postoperative bleeding, or who may have bile leakage due to a large resection area. Postoperative exercise therapy may improve insulin resistance in patients with chronic liver damage. Implementation of an early/enhanced recovery after surgery program is recommended to reduce biological invasive responses and achieve early independence of physical activity and nutrition intake. We review the latest information on the perioperative management of patients undergoing liver resection for hepatocellular carcinoma.
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Affiliation(s)
- Masaki Kaibori
- Department of Surgery Kansai Medical University Osaka Japan
| | - Kosuke Matsui
- Department of Surgery Kansai Medical University Osaka Japan
| | - Mitsuo Shimada
- Department of Surgery Tokushima University Tokushima Japan
| | - Shoji Kubo
- Department of Hepato‐Biliary‐Pancreatic Surgery Osaka City University Graduate School of Medicine Osaka Japan
| | - Kiyoshi Hasegawa
- Hepato‐Biliary‐Pancreatic Surgery Division Department of Surgery Graduate School of Medicine The University of Tokyo Tokyo Japan
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12
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Zhou J, He X, Wang M, Zhao Y, Zhang N, Wang L, Mao A, Wang L. Enhanced Recovery After Surgery in Patients With Hepatocellular Carcinoma Undergoing Laparoscopic Hepatectomy. Front Surg 2021; 8:764887. [PMID: 34881286 PMCID: PMC8645578 DOI: 10.3389/fsurg.2021.764887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/21/2021] [Indexed: 01/08/2023] Open
Abstract
Objective: To compare the effectiveness and safety of enhanced recovery after surgery (ERAS) in patients with hepatocellular carcinoma (HCC) undergoing laparoscopic hepatectomy. Methods: From September 2016 to June 2019, 282 patients were enrolled, and ERAS was implemented since March 2018. All indicators related to surgery, liver function, and postoperative outcomes were included in the analysis. Propensity score matching (PSM) identified 174 patients for further comparison. Results: After PSM, the clinicopathological baselines were well-matched. The group showed significantly less intraoperative blood loss (100.00 [100.00–200.00] vs. 200.00 [100.00–300.00] ml, P = 0.001), fewer days before abdominal drainage tube removal (4.00 [3.00–4.00] days vs. 4.00 [3.00–5.00] days, P = 0.023), shorter hospital stay after surgery (6.00 [5.00–6.00] days vs. 6.00 [6.00–7.00] days, P < 0.001), and reduced postoperative morbidity (18.39 vs. 34.48%, P = 0.026). The proportion of patients with a pain score ≥ 4 was significantly lower in the ERAS group within the first 2 days after surgery (1.15 vs. 13.79% and 8.05 vs. 26.44%, P = 0.002 and P = 0.001, respectively). Pringle maneuver was performed more frequently in the ERAS group (70.11 vs. 18.39%, P < 0.001), and a significantly higher postoperative alanine aminotransferase level was also observed (183.40 [122.85–253.70] vs. 136.20 [82.93–263.40] U/l, P = 0.026). The 2-year recurrence-free survival was similar between the two groups (72 vs. 71%, P = 0.946). Conclusions: ERAS programs are feasible and safe and do not influence mid-term recurrence in HCC patients undergoing laparoscopic hepatectomy.
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Affiliation(s)
- Jiamin Zhou
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xigan He
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Miao Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yiming Zhao
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ning Zhang
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Longrong Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Anrong Mao
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Lu Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Feng J, Xu R, Li K, Li F, Gao M, Han Q, Feng H, Ye H. Effects of preoperative oral carbohydrate administration combined with postoperative early oral intake in elderly patients undergoing hepatectomy with acute-phase inflammation and subjective symptom burden: A prospective randomized controlled study. Asian J Surg 2021; 45:386-395. [PMID: 34362624 DOI: 10.1016/j.asjsur.2021.06.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/10/2021] [Accepted: 06/24/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has received increasing attention. Preoperative oral carbohydrate and postoperative early oral feeding (POC-PEOF) as the basic nutrition administration in the ERAS program suffers from low adherence. The role and benefits of administering POC-PEOF in elderly patients with hepatocellular carcinoma (HCC) are unclear. Therefore, the randomized controlled trial evaluated the effects of POC-PEOF in elderly patients with HCC undergoing hepatectomy with inflammation and patient self-reported symptom burden compared with the corresponding outcomes of traditional fasting protocols. METHODS Elderly patients with HCC (n = 126) were randomly assigned to two groups using the sealed envelope technique. Sixty-three patients were included in the intervention (POC-PEOF) group and received POC-PEOF administration, whereas the 63 patients in the control (FAST) group underwent conventional fasting. Acute-phase inflammation markers, patient self-reported symptom burdens, and postoperative outcomes were compared between the two groups. RESULTS The average age was 69.60 ± 5.00 years in the POC-PEOF group and 70.44 ± 6.15 years in the FAST group. Compared to prolonged fasting, POC-PEOF achieved significant positive results, including lower overall levels of inflammatory response mediators (CRP, IL-6) on postoperative day (POD) 1, POD 3, and POD 5 (P < 0.05), lower patient self-reported symptom burdens of thirst, hunger, anxiety and nausea (P < 0.05), faster gastrointestinal function return with shortened times to first flatus and first defecation (48.31 ± 13.24 h vs. 96.26 ± 23.12 h and 72.87 ± 21.12 h vs. 144.34 ± 23.31 h, and P = 0.034 and P = 0.013, respectively). Furthermore, the average postoperative hospitalization duration in the POC-PEOF group was shorter than that in the FAST group (6.93 ± 0.98 d vs. 8.12 ± 1.15 d, P = 0.042). There was no significant difference of total complications between the groups (25.39 % vs 36.51 %, RR 0.696, 95 % CI 0.408-0.187, P = 0.177). CONCLUSION POC-PEOF helps lessen acute-phase inflammation and relieves the subjective symptom burden, which can ensure better positive postoperative outcomes in elderly HCC patients undergoing hepatectomy.
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Affiliation(s)
- Jinhua Feng
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China; National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, 610041, China; West China School of Nursing, Sichuan University, Chengdu, 610041, China.
| | - Ruihua Xu
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China; National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, 610041, China.
| | - Ka Li
- West China School of Nursing, Sichuan University, Chengdu, 610041, China.
| | - Fuyu Li
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Min Gao
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China; National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Qiang Han
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Huan Feng
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China; National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Hui Ye
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
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Effectiveness of a Clinical Pathway for Hepatic Cystic Echinococcosis Surgery in Kashi Prefecture, Northwestern China: A Propensity Score Matching Analysis. Infect Dis Ther 2021; 10:1465-1477. [PMID: 34125406 PMCID: PMC8322251 DOI: 10.1007/s40121-021-00466-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 05/24/2021] [Indexed: 11/17/2022] Open
Abstract
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.
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Abstract
INTRODUCTION Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment. METHODS Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment. RESULTS The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions. CONCLUSION Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.
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Pineda-Solis K, Burchard PR, Ruffolo LI, Schoeniger LO, Linehan DC, Moalem J, Galka E. Early Prediction of Length of Stay After Pancreaticoduodenectomy. J Surg Res 2020; 260:499-505. [PMID: 33358193 DOI: 10.1016/j.jss.2020.11.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/10/2020] [Accepted: 11/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is an evidence-based clinical pathway designed to standardize and optimize care. We studied the impact of ERAS and sought to identify the most important recommendations to predict shorter length of stay (LOS) after pancreaticoduodenectomy (PD). METHODS We retrospectively reviewed all patients undergoing PD at our institution between January 2014 and June 2018. We compared clinicopathologic outcomes for patients before and after ERAS implementation. We defined "A-recommendations" as those that were graded "strong" and had "moderate" or "high" levels of evidence. We then compared outcomes of the ERAS group with adherence to "A-recommendations" and performed a subset analysis of "A-recommendations" over the first 72 h after surgery, which we termed "early factors". RESULTS A total of 191 patients underwent PD during the study period. We excluded 87 patients who had minimally invasive PD (22), vascular reconstruction (53), or both (12). Of the 104 patients studied, 56 (54%) were pre-ERAS and 48 (46%) were ERAS. There were no differences in comorbidities or demographics between these groups, and morbidity, mortality, and readmission rates were also similar (P > 0.6). Median LOS was 3.5 d shorter in the ERAS group (7 versus 10.5 d, P < 0.001). Adherence to "A-recommendations" within ERAS was associated with a decreased LOS (r = -0.52 P = 0.0001). Patients with >5 "early factors" had a median LOS of 6 d, whereas patients with <5 "early factors" had a median LOS of 9 d (P = 0.008). CONCLUSIONS ERAS is an effective protocol that standardizes care and reduces LOS after PD. Implementation of ERAS resulted in a 3.5-day reduction in our LOS with no change in morbidity, mortality, or readmissions. Adherence to ERAS protocol "A-recommendations" and ≥5 "early factors" may be predictive of shortened LOS.
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Affiliation(s)
- Karen Pineda-Solis
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA.
| | - Paul R Burchard
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Luis I Ruffolo
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Luke O Schoeniger
- Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - David C Linehan
- Department of General Surgery, University of Rochester Medical Center, Rochester, New York, USA; Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Jacob Moalem
- Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Eva Galka
- Department of Surgical Oncology, University of Rochester Medical Center, Rochester, New York, USA
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Zhang X, Yang J, Chen X, Du L, Li K, Zhou Y. Enhanced recovery after surgery on multiple clinical outcomes: Umbrella review of systematic reviews and meta-analyses. Medicine (Baltimore) 2020; 99:e20983. [PMID: 32702839 PMCID: PMC7373593 DOI: 10.1097/md.0000000000020983] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previously, many meta-analyses have reported the impact of enhanced recovery after surgery (ERAS) programs on many surgical specialties. OBJECTIVES To systematically assess the effects of ERAS pathways on multiple clinical outcomes in surgery. DESIGN An umbrella review of meta-analyses. DATE SOURCES PubMed, Embase, Web of Science and the Cochrane Library. RESULTS The umbrella review identified 23 meta-analyses of interventional study and observational study. Consistent and robust evidence shown that the ERAS programs can significantly reduce the length of hospital stay (MD: -2.349 days; 95%CI: -2.740 to -1.958) and costs (MD: -$639.064; 95%CI:: -933.850 to -344.278) in all the surgery patients included in the review compared with traditional perioperative care. The ERAS programs would not increase mortality in all surgeries and can even reduce 30-days mortality rate (OR: 0.40; 95%CI: 0.23 to 0.67) in orthopedic surgery. Meanwhile, it also would not increase morbidity except laparoscopic gastric cancer surgery (RR: 1.49; 95%CI: 1.04 to 2.13). Moreover, readmission rate was increased in open gastric cancer surgery (RR: 1.92; 95%CI: 1.00 to 3.67). CONCLUSION The ERAS programs are considered to be safe and efficient in surgery patients. However, precaution is necessary for gastric cancer surgery.
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Affiliation(s)
- Xingxia Zhang
- West China School of Nursing/West China Hospital Gastrointestinal Surgery Department, Sichuan University
| | - Jie Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Xinrong Chen
- West China School of Nursing/West China Hospital Gastrointestinal Surgery Department, Sichuan University
| | - Liang Du
- Chinese Evidence-Based Medicine/Cochrane Center, Chengdu, China
| | - Ka Li
- West China School of Nursing/West China Hospital Gastrointestinal Surgery Department, Sichuan University
| | - Yong Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
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Scoville SD, Xourafas D, Ejaz AM, Tsung A, Pawlik T, Cloyd JM. Contemporary indications for and outcomes of hepatic resection for neuroendocrine liver metastases. World J Gastrointest Surg 2020; 12:159-170. [PMID: 32426095 PMCID: PMC7215975 DOI: 10.4240/wjgs.v12.i4.159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/21/2020] [Accepted: 03/05/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although surgical resection is associated with the best long-term outcomes for neuroendocrine liver metastases (NELM), the current indications for and outcomes of surgery for NELM from a population perspective are not well understood.
AIM To determine the current indications for and outcomes of liver resection (LR) for NELM using a population-based cohort.
METHODS A retrospective review of the 2014-2017 American College of Surgeons National Surgical Quality Improvement Program and targeted hepatectomy databases was performed to identify patients who underwent LR for NELM. Perioperative characteristics and 30-d morbidity and mortality were analyzed.
RESULTS Among 669 patients who underwent LR for NELM, the median age was 60 (interquartile range: 51-67) and 51% were male. While the number of metastases resected ranged from 1 to 9, the most common (45%) number of tumors resected was one. The majority (68%) of patients had a largest tumor size of < 5 cm. Most patients underwent partial hepatectomy (71%) while fewer underwent a right or left hepatectomy or trisectionectomy. The majority of operations were open (82%) versus laparoscopic (17%) or robotic (1%). In addition, 30% of patients underwent intraoperative ablation while 45% had another concomitant operation including cholecystectomy (28.8%), bowel resection (20.2%), or partial pancreatectomy (3.4%). Overall 30-d morbidity and mortality was 29% and 1.3%, respectively. On multivariate analysis, American Society of Anesthesiologists class ≥ 3 [odds ratios (OR), OR = 2.089, 95% confidence intervals (CI): 1.197-3.645], open approach (OR = 1.867, 95%CI: 1.148-3.036), right hepatectomy (OR = 1.618, 95%CI: 1.014-2.582), and prolonged operative time of > 230 min (OR = 1.731, 95%CI: 1.168-2.565) were associated with higher 30-d morbidity while intraoperative ablation and concomitant procedures were not.
CONCLUSION LR for NELM was performed with relatively low postoperative morbidity and mortality. Concomitant procedures performed at the time of LR did not increase morbidity.
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Affiliation(s)
- Steven D Scoville
- Department of Surgery, Division of Surgical Oncology at The Ohio State University, James Cancer Center, Columbus, OH 43210, United States
- The Arthur G James Comprehensive Cancer Center and Solove Research Institute, The Ohio State University, Columbus, OH 43210, United States
| | - Dimitrios Xourafas
- Department of Surgery, Division of Surgical Oncology at The Ohio State University, James Cancer Center, Columbus, OH 43210, United States
- Department of Surgery, Harvard Medical School, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, United States
| | - Aslam M Ejaz
- Department of Surgery, Division of Surgical Oncology at The Ohio State University, James Cancer Center, Columbus, OH 43210, United States
- Department of Surgery, The Ohio State University, Columbus, OH 43210, United States
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology at The Ohio State University, James Cancer Center, Columbus, OH 43210, United States
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Timothy Pawlik
- Department of Surgery, Division of Surgical Oncology at The Ohio State University, James Cancer Center, Columbus, OH 43210, United States
- Department of Surgery, The Ohio State University, Columbus, OH 43210, United States
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology at The Ohio State University, James Cancer Center, Columbus, OH 43210, United States
- Department of Surgery, The Ohio State University, Columbus, OH 43210, United States
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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Zhou JM, He XG, Wang M, Zhao YM, Shu L, Wang LR, Wang L, Mao AR. Enhanced recovery after surgery program in the patients undergoing hepatectomy for benign liver lesions. Hepatobiliary Pancreat Dis Int 2020; 19:122-128. [PMID: 31983674 DOI: 10.1016/j.hbpd.2019.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 12/31/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has shown effectiveness in terms of reducing the hospital stay and cost. However, the benefit of ERAS in patients undergoing hepatectomy for benign liver lesions is still unclear. METHODS ERAS was implemented in our center since March 1st, 2018. From September 2016 to February 2018, 109 patients were enrolled into the control group, and from March 2018 to June 2019, 124 patients were enrolled into the ERAS group. All the indicators related to operation, liver functions, and postoperative outcomes were included in the analysis. RESULTS The clinicopathologic baselines were similar in these two groups. A significantly higher proportion of patients underwent laparoscopic surgery in the ERAS group. On the whole, intraoperative blood loss (100.00 mL vs. 200.00 mL, P < 0.001), blood transfusion (3.23% vs. 10.09%, P = 0.033), total bilirubin (17.10 µmol/L vs. 21.00 µmol/L, P = 0.041), D-dimer (2.08 µg/mL vs. 2.57 µg/mL, P = 0.031), postoperative hospital stay (5.00 d vs. 6.00 d, P < 0.001), and postoperative morbidity (16.13% vs. 32.11%, P = 0.008) were significantly shorter or less in the ERAS group than those in the control group. After stratified by operation methods, ERAS group showed significantly shorter postoperative hospital stay in both open and laparoscopic operation (both P < 0.001). In patients underwent open surgery, ERAS group demonstrated significantly shorter operative duration (131.76 ± 8.75 min vs. 160.73 ± 7.23 min, P = 0.016), less intraoperative blood loss (200.00 mL vs. 450.00 mL, P = 0.008) and less postoperative morbidity (16.00% vs. 44.44%, P = 0.040). CONCLUSIONS ERAS program may be safe and effective for the patients underwent hepatectomy, especially open surgery, for benign liver lesions.
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Affiliation(s)
- Jia-Min Zhou
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai 200032, China
| | - Xi-Gan He
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai 200032, China
| | - Miao Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai 200032, China
| | - Yi-Ming Zhao
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai 200032, China
| | - Lian Shu
- Education Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Long-Rong Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai 200032, China
| | - Lu Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai 200032, China
| | - An-Rong Mao
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai 200032, China.
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Noba L, Rodgers S, Chandler C, Balfour A, Hariharan D, Yip VS. Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Improve Clinical Outcomes in Liver Surgery: a Systematic Review and Meta-Analysis. J Gastrointest Surg 2020; 24:918-932. [PMID: 31900738 PMCID: PMC7165160 DOI: 10.1007/s11605-019-04499-0] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/11/2019] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- L. Noba
- School of Health in Social Science, University of Edinburgh, Old College, South Bridge, Edinburgh, EH8 9YL UK
| | - S. Rodgers
- School of Health in Social Science, University of Edinburgh, Old College, South Bridge, Edinburgh, EH8 9YL UK
| | - C. Chandler
- School of Health in Social Science, University of Edinburgh, Old College, South Bridge, Edinburgh, EH8 9YL UK
| | - A. Balfour
- Surgical Services, NHS Lothian, Edinburgh, EH1 3EG UK
| | - D. Hariharan
- Hepato-Pancreato-Biliary (HPB) Unit, Royal London Hospital (Barts Health NHS Trust), London, E1 1FR UK
| | - V. S. Yip
- Hepato-Pancreato-Biliary (HPB) Unit, Royal London Hospital (Barts Health NHS Trust), London, E1 1FR UK
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Okabayashi T, Sui K, Mastumoto T, Iwata J, Morita S, Iiyama T, Shimada Y. l-Carnitine Improves Postoperative Liver Function in Hepatectomized Patients. JPEN J Parenter Enteral Nutr 2019; 44:823-830. [PMID: 31599019 DOI: 10.1002/jpen.1720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 08/05/2019] [Accepted: 09/13/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND AIMS The effect of perioperative treatment with l-carnitine in hepatectomized patients is unclear. The objective of the current study is to evaluate the short-term outcomes after liver cancer surgery in patients treated with l-carnitine compared with nontreated patients. METHODS Patients with primary liver malignancies scheduled to undergo a hepatectomy were randomly assigned to receive either perioperative treatment with l-carnitine (carnitine group) or usual intake (control group). The primary endpoint of this study was the short-term outcome after liver surgery. RESULTS The study participants were randomly assigned into 2 groups: 106 patients in the control group and 102 patients in the perioperative l-carnitine supplementation group. The restoration of serum ammonia levels, prothrombin time, and peripheral neutrophil count at 3 days after the operation was significantly faster in the carnitine group than in the control group. Fewer patients in the carnitine group developed grade B posthepatic liver failure, according to the grading system of the International Study Group of Liver Surgery, than patients in the control group (20% vs 76%). The length of hospitalization was significantly shorter in patients in the carnitine group than in those in the control group. CONCLUSIONS We found that perioperative treatment with l-carnitine was significantly better than ordinary treatment in reducing postoperative serum ammonia levels, suggesting that l-carnitine may serve as a pivotal regulator of liver injury and repair and result in shorter postoperative hospitalization (ClinicalTrials.gov trial registration no. NCT03021876).
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Affiliation(s)
- Takehiro Okabayashi
- Department of Gastroenterological Surgery, Kōchi Health Sciences Center, Kōchi, Japan
| | - Kenta Sui
- Department of Gastroenterological Surgery, Kōchi Health Sciences Center, Kōchi, Japan
| | - Takatsugu Mastumoto
- Department of Gastroenterological Surgery, Kōchi Health Sciences Center, Kōchi, Japan
| | - Jun Iwata
- Department of Diagnostic Pathology, Kōchi Health Sciences Center, Kōchi, Japan
| | - Sojiro Morita
- Department of Radiology, Kōchi Health Sciences Center, Kōchi, Japan
| | - Tatsuo Iiyama
- Department of Biostatistics, National Center for Global Health and Medicine, Kōchi, Japan
| | - Yasuhiro Shimada
- Department of Clinical Oncology at Kōchi Health Sciences Center, Kōchi, Japan
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Philip J, Fairtile R, Cocieru A. Postoperative complications are main reason for noncompliance with enhanced recovery after surgery program in patients undergoing hepatectomy and pancreatectomy. JGH OPEN 2019; 4:236-240. [PMID: 32280770 PMCID: PMC7144759 DOI: 10.1002/jgh3.12250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/14/2019] [Accepted: 08/04/2019] [Indexed: 12/11/2022]
Abstract
Background and Aim Enhanced recovery after surgery (ERAS) protocols are reported to improve postoperative outcomes in patients undergoing a routine protocol and postoperative outcomes in patients undergoing hepatic and pancreatic resections at our institution. Methods A total of 99 consecutive patients at a single institution managed with a similar ERAS protocol were divided into the “early” (50 patients) and “late” (49 patients) cohorts. Both cohorts were statistically identical in demographics and range of surgical procedures performed. Postoperative complications, readmission, reoperation rates, and length of stay were analyzed. Categorical variables were statistically compared using Fisher's exact test and continuous variables using t‐test and Mann–Whitney U‐test when appropriate. Results There were 32 hepatectomies/18 pancreatectomies in the “early” cohort and 22 hepatectomies/29 pancreatectomies in the “late” cohort. The overall complication rate was 38.8%, with a 30‐day readmission rate and reoperation rate of 16.1 and 5%, respectively. There was one mortality (1%). Group‐specific overall complication rate (40 vs 38.7%, P = 0.8), readmission rate (20 vs 12.2%, P = 0.4), reoperation rate (6 vs 4%, P = 1.0), and mortality (2 vs 0%, P = 1.0) were not statistically significant between both groups. Conclusions Despite similar rates of adherence to the established ERAS 24 protocol, there was no improvement in median length of stay (7 days) between the “early” and “late” groups. The only reason for noncompliance with the ERAS protocol was development of surgery‐related complications.
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Affiliation(s)
- Justus Philip
- Department of Surgery Summa Akron City Hospital Akron Ohio USA
| | - Richard Fairtile
- Department of Anesthesiology Summa Akron City Hospital Akron Ohio USA
| | - Andrei Cocieru
- Department of Surgery Summa Akron City Hospital Akron Ohio USA.,Department of Anesthesiology Summa Akron City Hospital Akron Ohio USA.,Northeastern Ohio Medical University Roostown Ohio USA
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Laparoscopic Resection for Adenocarcinoma of the Stomach or Gastroesophageal Junction Improves Postoperative Outcomes: a Propensity Score Matching Analysis. J Gastrointest Surg 2019; 23:730-738. [PMID: 30284200 DOI: 10.1007/s11605-018-3982-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/17/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Minimally invasive resection for upper gastrointestinal tumors has been associated with favorable results. However, the role of laparoscopic surgery (LS) in the multimodal treatment of patients with advanced adenocarcinoma of the stomach or gastroesophageal junction needs further investigation. METHODS Clinicopathological data of patients who underwent gastrectomy between 2005 and 2017 were assessed. Outcomes of patients undergoing LS were compared with those of patients treated with a conventional open resection (OR) using a 1:1 propensity score matching analysis. RESULTS Curative resection for adenocarcinoma of the stomach or gastroesophageal junction was performed in 417 patients during the study period. Beginning in June 2014, the majority of patients underwent LS (n = 72) and they were matched with 72 patients who were treated with an OR. The majority of patients treated with LS (89%) had advanced cancer (UICC stages II and III) and 82% of them received neoadjuvant chemotherapy. LS was significantly associated with a higher number of harvested lymph nodes (26 (9-62) vs. 21 (4-46), P = .007), a lower 90-day major complication rate (13 vs. 26%, P = .035), and a lower length of hospital stay (14 vs. 16 days, P = .001). After a median follow-up time of 32 months, 1-year overall survival rate was higher after LS than after OR (93 vs. 74%, P = .126); however, results did not reach statistical significance. CONCLUSION LS for adenocarcinoma of the stomach or gastroesophageal junction is feasible and significantly reduces major postoperative morbidity resulting in a reduced length of hospital stay. Therefore, LS should be preferably considered for the curative treatment of patients with these malignancies.
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Brustia R, Monsel A, Conti F, Savier E, Rousseau G, Perdigao F, Bernard D, Eyraud D, Loncar Y, Langeron O, Scatton O. Enhanced Recovery in Liver Transplantation: A Feasibility Study. World J Surg 2019; 43:230-241. [PMID: 30094639 DOI: 10.1007/s00268-018-4747-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Raffaele Brustia
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France.,Sorbonne Universités, Paris, France
| | - Antoine Monsel
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Universités, Paris, France
| | - Filomena Conti
- Liver Transplantation and Hepatology Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, 75013, France.,Sorbonne Universités, Paris, France
| | - Eric Savier
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France
| | - Geraldine Rousseau
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France.,Sorbonne Universités, Paris, France
| | - Fabiano Perdigao
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France
| | - Denis Bernard
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Daniel Eyraud
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Yann Loncar
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Olivier Langeron
- Multidisciplinary Intensive Care Unit, Department of Anaesthesiology and Critical Care, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Universités, Paris, France
| | - Olivier Scatton
- Liver Transplantation Surgical Programme and Hepatobiliary Surgical Department, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83 Boulevard de l'Hôpital, Paris, France. .,Sorbonne Universités, Paris, France.
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Teixeira UF, Goldoni MB, Waechter FL, Sampaio JA, Mendes FF, Fontes PRO. ENHANCED RECOVERY (ERAS) AFTER LIVER SURGERY:COMPARATIVE STUDY IN A BRAZILIAN TERCIARY CENTER. ACTA ACUST UNITED AC 2019; 32:e1424. [PMID: 30758472 PMCID: PMC6368150 DOI: 10.1590/0102-672020180001e1424] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 10/16/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND After the publication of the first recommendations of ERAS Society regarding colonic surgery, the proposal of surgical stress reduction, maintenance of physiological functions and optimized recovery was expanded to other surgical specialties, with minimal variations. AIM To analyze the implementation of ERAS protocols for liver surgery in a tertiary center. METHODS Fifty patients that underwent elective hepatic surgery were retrospectively evaluated, using medical records data, from June 2014 to August 2016. After September 2016, 35 patients were prospectively evaluated and managed in accordance with ERAS protocol. RESULTS There was no difference in age, type of hepatectomy, laparoscopic surgery and postoperative complications between the groups. In ERAS group, it was observed a reduction in preoperative fasting and in the length of hospital stay by two days (p< 0.001). Carbohydrate loading, j-shaped incision, early oral feeding, postoperative prevention of nausea and vomiting and early mobilization were also significantly related to ERAS group. Oral bowel preparation, pre-anesthetic medication, sub-costal incision, prophylactic nasogastric intubation and abdominal drainage were more common in control group. CONCLUSION Implementation of ERAS protocol is feasible and beneficial for health institutions and patients, without increasing morbidity and mortality.
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Affiliation(s)
| | | | | | | | - Florentino Fernandes Mendes
- Department of Anesthesiology, Federal University of Health Sciences of Porto Alegre / Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
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Rebibo L, Leourier P, Badaoui R, Le Roux F, Lorne E, Regimbeau JM. Minor laparoscopic liver resection as day-case surgery (without overnight hospitalisation): a pilot study. Surg Endosc 2019; 33:261-271. [PMID: 29943064 DOI: 10.1007/s00464-018-6306-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/18/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Day-case surgery (DCS) has become increasingly popular over recent years, as has laparoscopic liver resection (LLR) for the treatment of benign or malignant liver tumours. The purpose of this prospective study was to demonstrate the feasibility of minor LLR as DCS. METHODS Prospective, intention-to-treat, non-randomised study of patients undergoing minor LLR between July 2015 and December 2017. Exclusion criteria were resection by laparotomy, major LLR, difficult locations for minor LLR, history of major abdominal surgery, hepatobiliary procedures without liver parenchyma resection, cirrhosis with Child > A and/or portal hypertension, significant medical history and exclusion criteria for DCS. The primary endpoint was the unplanned overnight admission rate. Secondary endpoints were the reason for exclusion, complication data, criteria for DCS evaluation, satisfaction and compliance with the protocol. RESULTS One hundred sixty-seven patients underwent liver resection during the study period. LLR was performed in 92 patients (55%), as DCS in 23 patients (25%). Reasons for minor LLR were liver metastasis (n = 9), hepatic adenoma (n = 5), hepatocellular carcinoma (n = 4), ciliated hepatic foregut cyst (n = 2) and other benign tumours (n = 3). All day-case minor LLR, except two patients, consisted of single wedge resection, while one patient underwent left lateral sectionectomy. There were four unplanned overnight admissions (17.4%), one unscheduled consultation (4.3%), two hospital readmissions (8.6%) and no major complications/mortality. Compliance with the protocol was 69.5%. Satisfaction rate was 91%. CONCLUSION In selected patients, day-case minor LLR is feasible with acceptable complication and readmission rates. Day-case minor LLR can therefore be legitimately proposed in selected patients.
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Affiliation(s)
- Lionel Rebibo
- Department of Digestive Surgery, Amiens University Hospital, Avenue René Laennec, 80054, Amiens Cedex 01, France
| | - Pauline Leourier
- Department of Digestive Surgery, Amiens University Hospital, Avenue René Laennec, 80054, Amiens Cedex 01, France
| | - Rachid Badaoui
- Department of Anaesthesiology, Amiens University Hospital, Avenue René Laennec, 80054, Amiens Cedex 01, France
| | - Fabien Le Roux
- Department of Digestive Surgery, Amiens University Hospital, Avenue René Laennec, 80054, Amiens Cedex 01, France
| | - Emmanuel Lorne
- Department of Anaesthesiology, Amiens University Hospital, Avenue René Laennec, 80054, Amiens Cedex 01, France.,SSPC (Simplification des Soins des Patients Complexes) - Clinical Research Unit, University of Picardie Jules Verne, 80054, Amiens Cedex 01, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens University Hospital, Avenue René Laennec, 80054, Amiens Cedex 01, France. .,SSPC (Simplification des Soins des Patients Complexes) - Clinical Research Unit, University of Picardie Jules Verne, 80054, Amiens Cedex 01, France. .,Service de chirurgie digestive, Hôpital Sud, CHU d'Amiens, Avenue René Laennec, 80054, Amiens Cedex 01, France.
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Buhrman WC, Lyman WB, Kirks RC, Passeri M, Vrochides D. Current State of Enhanced Recovery After Surgery in Hepatopancreatobiliary Surgery. J Laparoendosc Adv Surg Tech A 2018; 28:1471-1475. [DOI: 10.1089/lap.2018.0314] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- William C. Buhrman
- Department of Anesthesiology, Carolinas Medical Center, Charlotte, North Carolina
| | - William B. Lyman
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Russell C. Kirks
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Michael Passeri
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Li Z, Zhao Q, Bai B, Ji G, Liu Y. Enhanced Recovery After Surgery Programs for Laparoscopic Abdominal Surgery: A Systematic Review and Meta-analysis. World J Surg 2018; 42:3463-3473. [PMID: 29750324 DOI: 10.1007/s00268-018-4656-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols or laparoscopic technique has been applied in various surgical procedures. However, the clinical efficacy of combination of the two methods still remains unclear. Thus, our aim was to assess the role of ERAS protocols in laparoscopic abdominal surgery. METHODS We performed a systematic literature search in various databases from January 1990 to October 2017. The results were analyzed according to predefined criteria. RESULTS In the present meta-analysis, the outcomes of 34 comparative studies (15 randomized controlled studies and 19 non-randomized controlled studies) enrolling 3615 patients (1749 in the ERAS group and 1866 in the control group) were pooled. ERAS group was associated with shorter hospital stay (WMD - 2.37 days; 95% CI - 3.00 to - 1.73; P 0.000) and earlier time to first flatus (WMD - 0.63 days; 95% CI - 0.90 to - 0.36; P 0.000). Meanwhile, lower overall postoperative complication rate (OR 0.62; 95% CI 0.51-0.76; P 0.000) and less hospital cost (WMD 801.52 US dollar; 95% CI - 918.15 to - 684.89; P 0.000) were observed in ERAS group. Similar readmission rate (OR 0.73, 95% CI 0.52-1.03, P 0.070) and perioperative mortality (OR 1.33; 95% CI 0.53-3.34; P 0.549) were found between the two groups. CONCLUSIONS ERAS protocol for laparoscopic abdominal surgery is safe and effective. ERAS combined with laparoscopic technique is associated with faster postoperative recovery without increasing readmission rate and perioperative mortality.
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Affiliation(s)
- Zhengyan Li
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China.
| | - Qingchuan Zhao
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China.
| | - Bin Bai
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
| | - Gang Ji
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
| | - Yezhou Liu
- Department of Surgery, Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, No. 127 Changle West Road, Xian, 710032, China
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Abstract
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.
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Roife D, Santamaria-Barria JA, Kao LS, Ko TC, Wray CJ. Surrogate indicators of quality are associated with survival following surgical treatment for hepatocellular carcinoma. J Surg Oncol 2018; 118:463-468. [PMID: 30196558 DOI: 10.1002/jso.25190] [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: 02/03/2018] [Accepted: 06/27/2018] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Quality/core measures have been collected for over 10 years. Studies have demonstrated hospital performance is related to postoperative outcomes. We hypothesize that hospital quality measures are associated with long-term survival following surgical resection for hepatocellular carcinoma (HCC). METHODS The National Cancer Data Base was queried for all HCC cases. Individual hospitals were deidentified. Quality markers were defined as hospital-specific median length of stay (LOS), 30-day mortality rate and readmit rate. A Cox regression stratified by stage estimated survival. To minimize confounding, a landmark analysis was estimated for patients that survived greater than 30 days. RESULTS A total of 16 202 HCC patients underwent surgical resection and 996 (6.1%) died within 30 days following surgery. Calculated by unique hospital, median 30-day death rate was 4.6% (interquartile range [IQR]: 1.2% to 7.6%). Thirty-day readmit rate was 2.6% (IQR: 0% to 5.9%) and median LOS was 8.0 days (IQR: 6.5 to 9.2). In the multivariate Cox regression, 30-day death rate (hazard ratio [HR], 1.89; 95% confidence interval [CI]: 1.32 to 2.71) and longer LOS (HR, 1.02; 95% CI: 1.01 to 1.02) were associated with worse survival. Higher 30-day readmission rate was associated with improved survival (HR, 0.61; 95% CI, 0.38 to 0.97). CONCLUSIONS Hospital-level surrogate markers of surgical quality appear to be significantly associated with HCC survival following resection. Patients treated in higher 30-day mortality centers, experienced worse outcomes. Individual hospitals should critically review disease-specific outcomes following resection to identify areas for improvement.
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Affiliation(s)
- David Roife
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Juan A Santamaria-Barria
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Lillian S Kao
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Tien C Ko
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Curtis J Wray
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
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Analysis of results after the implementation of fast recovery protocols in hepatopancreatobiliary surgery. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2018. [DOI: 10.1097/cj9.0000000000000067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Rouxel P, Beloeil H. Enhanced recovery after hepatectomy: A systematic review. Anaesth Crit Care Pain Med 2018; 38:29-34. [PMID: 29807132 DOI: 10.1016/j.accpm.2018.05.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/12/2018] [Accepted: 05/02/2018] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Pauline Rouxel
- Department of Anaesthesiology and Critical Care Medicine, CHU de Rennes, Université de Rennes, Inserm NumeCan, CIC 1414, 35000 Rennes, France
| | - Helene Beloeil
- Department of Anaesthesiology and Critical Care Medicine, CHU de Rennes, Université de Rennes, Inserm NumeCan, CIC 1414, 35000 Rennes, France.
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Ni CY, Wang ZH, Huang ZP, Zhou H, Fu LJ, Cai H, Huang XX, Yang Y, Li HF, Zhou WP. Early enforced mobilization after liver resection: A prospective randomized controlled trial. Int J Surg 2018; 54:254-258. [PMID: 29753000 DOI: 10.1016/j.ijsu.2018.04.060] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/15/2018] [Accepted: 04/13/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This randomized controlled study investigated the feasibility of early ambulation after liver resection and the effect of the amount of activity on postoperative recovery. METHODS A total of 120 patients who underwent liver resection were randomly divided into two groups for the comparative analysis of the following factors: amount of activity, pain control, sleeping state, perioperative gastrointestinal function recovery, incidence of complications and postoperative hospital stay. RESULTS Compared with the control group, patients undergoing liver resection performing early postoperative ambulation had faster gastrointestinal function recovery (First exhaust time 2.2 ± 1.4 vs. 3.3 ± 2.3 p < 0.01; First flatus time 2.3 ± 1.7 vs. 3.1 ± 2.5 p = 0.04) and shorter postoperative hospital stays (6.6 ± 2.3 vs. 7.7 ± 2.1 p = 0.01), with statistically significant differences. There was no significant difference in the incidence of postoperative complications between the two groups (p > 0.05). CONCLUSION Early ambulation after liver resection is safe and feasible. It can reduce the patient's pain and economic burden, increase the patient's comfort, reduce the nursing workload, achieve rapid recovery, and improve patient satisfaction.
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Affiliation(s)
- Chun-Yan Ni
- The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou 215153, Jiangsu Province, China; Suzhou Science & Technology Town Hospital, Suzhou 215153, Jiangsu Province, China; Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Zhi-Hong Wang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Zhi-Ping Huang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Hui Zhou
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Li-Juan Fu
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Hui Cai
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Xuan-Xuan Huang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Yuan Yang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.
| | - Hui-Fen Li
- The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou 215153, Jiangsu Province, China; Suzhou Science & Technology Town Hospital, Suzhou 215153, Jiangsu Province, China.
| | - Wei-Ping Zhou
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.
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Na HS, Oh AY, Ryu JH, Koo BW, Nam SW, Jo J, Park JH. Intraoperative Nefopam Reduces Acute Postoperative Pain after Laparoscopic Gastrectomy: a Prospective, Randomized Study. J Gastrointest Surg 2018; 22:771-777. [PMID: 29374350 DOI: 10.1007/s11605-018-3681-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 01/04/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND We assessed whether intraoperative nefopam would reduce opioid consumption and relieve postoperative pain in patients undergoing laparoscopic gastrectomy. METHODS The 60 enrolled patients were randomly assigned to the control (n = 32) or nefopam (n = 28) group. All patients were blinded to their group assignment. We administered 100 ml of normal saline only (control group) or 20 mg of nefopam mixed in 100 ml normal saline (nefopam group) after anesthesia induction and at the end of surgery. The cumulative amount of fentanyl via intravenous patient-controlled analgesia (PCA), incidence of rescue analgesic medication, and numerical rating scale (NRS) for postoperative pain were evaluated along with the total remifentanil consumption. RESULTS The mean infusion rate of remifentanil was significantly lower in the nefopam group (0.08 ± 0.05 μg/kg/min) than in the control group (0.13 ± 0.06 μg/kg/min) (P < 0.001). Patients in the nefopam group required less fentanyl via intravenous PCA than those in the control group during the first 6 h after surgery (323.8 ± 119.3 μg vs. 421.2 ± 151.6 μg, P = 0.009). Additionally, fewer patients in the nefopam group than in the control group received a rescue analgesic during the initial 6 h postoperatively (78.6 vs. 96.9%, P = 0.028). The NRS measured while patients were in the post-anesthetic care unit was significantly lower in the nefopam group than in the control group (3.8 ± 1.1 vs. 4.8 ± 1.4, P = 0.012). The subsequent NRS obtained after patients had been transferred to the general ward was comparable between the two groups during the following postoperative period. CONCLUSIONS Intraoperative nefopam decreased postoperative pain and opioid consumption in the acute postoperative period after laparoscopic gastrectomy. Hence, nefopam may be considered as a component of multimodal analgesia after laparoscopic gastrectomy.
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Affiliation(s)
- Hyo-Seok Na
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Ah-Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea. .,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Jung-Hee Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Bon-Wook Koo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Sun-Woo Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Jihoon Jo
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
| | - Jae-Hee Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
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Pujic B, Kendrisic M, Shotwell M, Shi Y, Baysinger CL. A Survey of Enhanced Recovery After Surgery Protocols for Cesarean Delivery in Serbia. Front Med (Lausanne) 2018; 5:100. [PMID: 29719833 PMCID: PMC5913329 DOI: 10.3389/fmed.2018.00100] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/27/2018] [Indexed: 12/16/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols have been described for patients undergoing colon surgery. Similar protocols for cesarean delivery (CD) have been developed recently. CD is one of the most commonly performed surgical procedures, and adoption of ERAS protocols following CD might benefit patients and the health-care system. We aimed to determine which Serbian hospitals reported ERAS protocols, which elements of ERAS protocols were used in CD patients, and whether ERAS and non-ERAS hospitals differed. The survey was sent to all hospitals with obstetric services and 46 of 49 responded. The questionnaire asked whether ERAS protocols had been formally adopted for surgical patients and about their use in CD patients. Specific questions on elements described in other obstetric ERAS protocols for CD included preoperative patient preparation, type of anesthesia and temperature monitoring used for CD, maternal/neonatal contact, and time to discharge. ERAS protocols are used in 24% of surveyed hospitals, 84% admit the patient the day before elective CDs, 87% use a maternal bowel preparation morning on the day of CD, and 80% administer maternal deep venous thrombosis prophylaxis. Only 33% remove IV in the first postoperative day, and 89% of women do not eat solid food until the day following their CD. Neuraxial anesthesia is used in 46% of elective CDs in ERAS hospitals compared to 9% in non-ERAS hospitals (P < 0.01), and neuraxial narcotics for post CD analgesia are given more often in ERAS hospitals. Thirty-six percentage of ERAS patients are discharged within 3 days vs. none in the non-ERAS group. Few elements of ERAS protocols reported from other centers outside Serbia are employed in Serbian hospitals performing CD. Despite significant changes that have been made recently in CD care, enhanced recovery after CD could be significantly improved in Serbian hospitals.
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Affiliation(s)
- Borislava Pujic
- Clinical Center Vojvodina, Obstetrics and Gynecology Hospital, Novi Sad, Serbia
| | | | - Matthew Shotwell
- Department of Biostatistics, School of Medicine, Vanderbilt University, Nashville, TN, United States
| | - Yaping Shi
- Department of Biostatistics, School of Medicine, Vanderbilt University, Nashville, TN, United States
| | - Curtis L Baysinger
- Department of Anesthesiology, School of Medicine, Vanderbilt University, Nashville, TN, United States
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Ovaere S, Boscart I, Parmentier I, Steelant PJ, Gabriel T, Allewaert J, Pottel H, Vansteenkiste F, D'Hondt M. The Effectiveness of a Clinical Pathway in Liver Surgery: a Case-Control Study. J Gastrointest Surg 2018; 22:684-694. [PMID: 29274000 DOI: 10.1007/s11605-017-3653-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/08/2017] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Sander Ovaere
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium
| | - Isabelle Boscart
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium
| | - Isabelle Parmentier
- Department of Oncology and Statistics, Groeninge Hospital, President Kennedylaan 4, Kortrijk, Belgium
| | - Pieter Jan Steelant
- Department of Anesthesia, Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium
| | - Tino Gabriel
- Financial Department, Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium
| | - Junior Allewaert
- Pharmacology Department, Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium
| | - Hans Pottel
- Interdisciplinary Research Center, Catholic University Leuven, Campus Kortrijk, Etienne Sabbelaan 53, 8500, Kortrijk, Belgium
| | - Franky Vansteenkiste
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium.
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Liver Function Assessment Using Technetium 99m-Galactosyl Single-Photon Emission Computed Tomography/CT Fusion Imaging: A Prospective Trial. J Am Coll Surg 2017; 225:789-797. [PMID: 28912030 DOI: 10.1016/j.jamcollsurg.2017.08.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/24/2017] [Accepted: 08/25/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND The prediction of postoperative liver function remains a largely subjective practice based on CT volumetric analysis. However, future liver volume after a hepatectomy is not the only factor that contributes to postoperative liver function and outcomes. STUDY DESIGN In this prospective trial, 185 consecutive patients who underwent liver operations between 2014 and 2015 were studied. Volumetric and functional rates of remnant liver were measured using technetium 99m-galactosyl human serum albumin single-photon emission computed tomography/CT fusion imaging to evaluate post-hepatectomy remnant liver function. Remnant indocyanine green clearance rate using galactosyl (KGSA) (KGSA × functional rate) was used to predict future remnant liver function. Hepatectomy was considered safe for patients with remnant KGSA values ≥0.05, and the primary end point was to determine the accuracy and reliability of this criteria. The prediction of the 90-day major complication and mortality rates was assessed. RESULTS Median hospital stay was 9 days and median ICU stay was 1 day, with only 1 in-hospital death (90-day mortality rate 0.5%). Overall morbidity rate evaluated according to the Clavien-Dindo classification was 9%. For post-hepatectomy liver failure definitions, the International Study Group of Liver Surgery definition was fulfilled in 14 patients (8%), with the majority being grade B (50%), compared with 2 patients (1%) fulfilling the "50-50" criteria, and 0 patients (0%) fulfilling the PeakBili >7 criteria. CONCLUSIONS Results of this study showed that remnant KGSA provided information that allowed us to predict remnant liver function. This information will be important for surgeons when deciding on a treatment plan for patients with liver diseases. (ClinicalTrials.gov ID: NCT02013895).
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van Dijk DPJ, van Woerden V, Cakir H, den Dulk M, Olde Damink SWM, Dejong CHC. ERAS: Improving outcome in the cachectic HPB patient. J Surg Oncol 2017; 116:617-622. [PMID: 28767125 PMCID: PMC5697643 DOI: 10.1002/jso.24767] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 06/28/2017] [Indexed: 12/14/2022]
Abstract
The enhanced recovery after surgery (ERAS) program has reduced postoperative morbidity and duration of hospital stay but not mortality in patients undergoing hepatopancreatobiliary (HPB) surgery. Many HPB patients suffer from cancer cachexia, a syndrome of severe weight and muscle loss. This may affect outcomes of HPB surgery even within an ERAS program. A tailored ERAS approach may be essential in further improving outcome in this vulnerable patient category.
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Affiliation(s)
- David P J van Dijk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Victor van Woerden
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Hamit Cakir
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.,Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.,Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany.,GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
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