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Individual components of post-hepatectomy care pathways have differential impacts on length of stay. Am J Surg 2023; 225:53-57. [PMID: 36207173 DOI: 10.1016/j.amjsurg.2022.09.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The value of individual variable contributions to post-hepatectomy length of stay (LOS) are difficult to quantify within bundled care pathways. METHODS Poisson regression and marginal effects models for prolonged post-hepatectomy LOS (>25% median) included Kawaguchi-Gayet (KG) complexity, perioperative variables, and pathways (minimally-invasive = MIS; low-intermediate-risk = KGI/II; high-risk = KGIII; combination). RESULTS Median LOS was 2, 4, 5, and 5 days for MIS, KGI/II, KGIII and combination pathways (N = 978). Poisson regression identified age, intraoperative fluids, delayed diet tolerance, and combination cases as associated with increased LOS (p < 0.01). Marginal effects analysis demonstrated the following added probability of longer LOS: each year of age 0.03x, 250 mL intraoperative fluids 0.06x, each operative hour 0.2x, additional day before diet tolerance 0.4x, combination cases 0.7x. MIS was associated with 1.2x increased probability of shorter LOS. CONCLUSIONS Optimizing intraoperative fluids, operative time, and postoperative diet, while favoring MIS approach when feasible, may maximize effects of post-hepatectomy care pathways to reduce LOS.
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Mazzola A, Pittau G, Hong SK, Chinnakotla S, Tautenhahn HM, Maluf DG, Settmacher U, Spiro M, Raptis DA, Jafarian A, Cherqui D. When is it safe for the liver donor to be discharged home and prevent unnecessary re-hospitalizations? - A systematic review of the literature and expert panel recommendations. Clin Transplant 2022; 36:e14677. [PMID: 35429941 DOI: 10.1111/ctr.14677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Few data are available on discharge criteria after living liver donation (LLD). OBJECTIVES To identify the features for fit for discharge checklist after LLD to prevent unnecessary re-hospitalizations and to provide international expert recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. The critical outcomes included were complications rates and liver function (defined by elevated bilirubin and INR) (CRD42021260725). RESULTS Total 57/1710 studies were included in qualitative analysis and 28/57 on the final analysis. No randomized controlled trials were identified. The complications rate was reported in 20/28 studies and ranged from 7.8% to 71.2%. Post hepatectomy liver function was reported in 13 studies. The Quality of Evidence (QoE) was Low and Very-Low for complications rate and liver function test, respectively. CONCLUSIONS Monitoring and prevention of donor complications should be crucial in decision making of discharge. Pain and diet control, removal of all drains and catheters, deep venous thrombosis prophylaxis, and use routine imaging (CT scan or liver ultrasound) before discharge should be included as fit for discharge checklist (QoE; Low | GRADE of recommendation; Strong). Transient Impaired liver function (defined by elevated bilirubin and INR), a prognostic marker of outcome after liver resection, usually occurs after donor right hepatectomy and should be monitored. Improving trends for bilirubin and INR value should be observed by day 5 post hepatectomy and be included in the fit for discharge checklist. (QoE; Very-Low | GRADE; Strong).
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Affiliation(s)
- Alessandra Mazzola
- Department of Hepatology and Gastroenterology, Liver transplant unit, Pité-Salpêtrière Hospital, Paris, France
| | - Gabriella Pittau
- Liver transplant unit, Centre hépato biliaire Hopital Paul Brousse, Villejuif, France
| | - Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical School, Minneapolis, USA
| | | | - Daniel G Maluf
- Program in Transplantation, University of Maryland Medical School, Baltimore, Maryland, USA
| | - Utz Settmacher
- Department of General-, Visceral-, and Vascular Surgery, University Hospital, Jena, Germany
| | - Michael Spiro
- Department of Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery & Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Ali Jafarian
- Division HPB Surgery and Liver Transplantation, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Daniel Cherqui
- Liver transplant unit, Centre hépato biliaire Hopital Paul Brousse, Villejuif, France
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van Woerden V, Olij B, Fichtinger RS, Lodewick TM, Coolsen MME, Den Dulk M, Heise D, Olde Damink SWM, Dejong CHC, Neumann UP, van Dam RM. The orange-III study: the use of preoperative laxatives prior to liver surgery in an enhanced recovery programme, a randomized controlled trial. HPB (Oxford) 2022; 24:1492-1500. [PMID: 35410783 DOI: 10.1016/j.hpb.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/18/2022] [Accepted: 03/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study evaluates the effect of preoperative macrogol on gastrointestinal recovery and functional recovery after liver surgery combined with an enhanced recovery programme in a randomized controlled setting. METHODS Patients were randomized to either 1 sachet of macrogol a day, one week prior to surgery versus no preoperative laxatives. Postoperative management for all patients was within an enhanced recovery programme. The primary outcome was recovery of gastrointestinal function, defined as Time to First Defecation. Secondary outcomes included Time to Functional Recovery. RESULTS Between August 2012 and September 2016, 82 patients planned for liver resection were included in the study, 39 in the intervention group and 43 in the control group. Median Time to First Defecation was 4.0 days in the intervention group (IQR 2.8-5.0) and 4.0 days in the control group (IQR 2.9-5.0), P = 0.487. Median Time to Functional Recovery was day 6 (IQR 4.0-8.0) in the intervention group and day 5 (IQR 4.0-7.5) in the control group, P = 0.752. No significant differences were seen in complication rate, reinterventions or mortality. CONCLUSION This randomized controlled trial showed no advantages of 1 sachet of macrogol preoperatively combined with an enhanced recovery programme, for patients undergoing liver surgery.
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Affiliation(s)
- V van Woerden
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands
| | - Bram Olij
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; GROW: School for Oncology and Developmental Biology, Maastricht, the Netherlands
| | - Robert S Fichtinger
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands
| | - Toine M Lodewick
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands
| | - Mariëlle M E Coolsen
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; Nutrim School for Nutrition and Translational Research in Metabolism, the Netherlands
| | - Marcel Den Dulk
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; Nutrim School for Nutrition and Translational Research in Metabolism, the Netherlands; Department of Surgery, Uniklinik Aachen (UKA), Germany
| | - Daniel Heise
- Department of Surgery, Uniklinik Aachen (UKA), Germany
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; Nutrim School for Nutrition and Translational Research in Metabolism, the Netherlands; Department of Surgery, Uniklinik Aachen (UKA), Germany
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; Nutrim School for Nutrition and Translational Research in Metabolism, the Netherlands; GROW: School for Oncology and Developmental Biology, Maastricht, the Netherlands
| | - Ulf P Neumann
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; Department of Surgery, Uniklinik Aachen (UKA), Germany
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Centre (MUMC), the Netherlands; GROW: School for Oncology and Developmental Biology, Maastricht, the Netherlands; Department of Surgery, Uniklinik Aachen (UKA), Germany.
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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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Milliken D, Curtis S, Melikian C. Predicting morbidity in liver resection surgery: external validation of the revised frailty index and development of a novel predictive model. HPB (Oxford) 2021; 23:954-961. [PMID: 33168438 DOI: 10.1016/j.hpb.2020.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/21/2020] [Accepted: 10/19/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Perioperative complications of liver resection surgery are common but individual patient-level prediction is difficult. Most risk models are unvalidated and may not be clinically useful. We aimed to validate a risk prediction model for complications of liver resection, the Revised Frailty Index (rFI), at a high volume centre. We also aimed to derive a predictive model for complications in our cohort. METHODS Records were reviewed for 300 patients undergoing liver resection. The rFI's discrimination of 90-day major complications was assessed by receiver operating curve analysis. Logistic regression analysis was then used to fit rFI covariates to our dataset. A further analysis produced a model with optimal discrimination of 90-day major complications. RESULTS The rFI was a poor discriminator of 90-day major complications (AUROC 0.562) among patients at our centre. The rFI optimised fit model demonstrated improved discrimination of 90-day major complications (AUROC 0.685). We developed a novel model with improved fit and similar discrimination (AUROC 0.710). CONCLUSION We were unable to validate the rFI as a predictor of complications. We developed a novel model with discrimination at least equal to other published risk models. However, there is an unmet need for well-validated, clinically useful risk tools in this area.
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Affiliation(s)
- Don Milliken
- Royal Free Perioperative Research Group, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK.
| | - Sam Curtis
- Royal Free Perioperative Research Group, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Clare Melikian
- Royal Free Perioperative Research Group, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
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Qian J, Qian M, Ren Y, Ye L, Qian F, Jin L, Chen L, Xu H. Readiness for hospital discharge and influencing factors: a cross-sectional study on patients discharged with tubes from the department of hepatobiliary surgery. BMC Surg 2021; 21:121. [PMID: 33685424 PMCID: PMC7941921 DOI: 10.1186/s12893-021-01119-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/23/2021] [Indexed: 11/16/2022] Open
Abstract
Background To investigate the readiness for hospital discharge of patients discharged with tubes from the department of hepatobiliary surgery and to explore the influencing factors. Methods A cross-sectional survey was conducted for the 161 patients with tubes who were discharged from the department of hepatobiliary surgery of Shaoxing Second Hospital by using the modified Chinese version of Readiness for Hospital Discharge Scale (RHDS) and Quality of Discharge Teaching Scale (QDTS). General data of the patients, such as gender, age, BMI (body mass index), and educational level, were collected. Results According to the statistical results, the total score of the RHDS was 142.40 ± 23.98, and that of the QDTS was 148.14 ± 17.74. Multiple linear step-wise regression analysis revealed that the total score of the QDTS, residence and educational level were the independent influencing factors of the readiness for hospital discharge (p < 0.05). Conclusion The level of the readiness for hospital discharge of the 161 discharged patients with tubes from the department of hepatobiliary surgery was in the middle and lower level. For the patients who are far away from the hospital and have a low education level, we should pay more attention to health education and discharge teaching, so as to improve the readiness for hospital discharge of relatively vulnerable patients, reduce the incidence of adverse events after discharge with tubes, and ensure the health and safety of patients.
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Affiliation(s)
- Jingyu Qian
- Department of Hepatobiliary Surgery, Shaoxing Second Hospital, Zhejiang, Shaoxing, China
| | - Miaofang Qian
- Department of Hepatobiliary Surgery, Shaoxing Second Hospital, Zhejiang, Shaoxing, China
| | - Yanyan Ren
- Department of Hepatobiliary Surgery, Shaoxing Second Hospital, Zhejiang, Shaoxing, China
| | - Linyan Ye
- Department of Hepatobiliary Surgery, Shaoxing Second Hospital, Zhejiang, Shaoxing, China
| | - Fangfang Qian
- Department of Operation Rooms, Shaoxing People's Hospital, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Zhejiang, Shaoxing, China
| | - Linlin Jin
- Department of Operation Rooms, Shaoxing People's Hospital, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Zhejiang, Shaoxing, China
| | - Lili Chen
- Department of Operation Rooms, Shaoxing People's Hospital, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Zhejiang, Shaoxing, China
| | - Haixia Xu
- Department of General Surgery, Shaoxing People's Hospital, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), 568 Zhongxing North Road, Shaoxing, 312000, Zhejiang, China.
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Davis MJ, Luu BC, Raj S, Abu-Ghname A, Buchanan EP. Multidisciplinary care in surgery: Are team-based interventions cost-effective? Surgeon 2021; 19:49-60. [PMID: 32220537 DOI: 10.1016/j.surge.2020.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 01/28/2020] [Accepted: 02/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multidisciplinary care has been shown to improve outcomes for patients, and interprofessional collaboration has been demonstrated to be beneficial for providers. In the field of surgery, although a large number of multidisciplinary care teams have been described, no study to date has examined whether or not these team-based interventions are generally cost-effective. This is the first systematic review to examine cost savings attributable to multidisciplinary care across all surgical fields. METHODS A comprehensive literature review of articles published on cost outcomes associated with multidisciplinary surgical teams was performed. Selected articles reported on cost outcomes directly attributable to a collaborative intervention. Cost savings were totaled on a per-patient basis. Each article was also reviewed to determine whether the authors ultimately recommended the team-based intervention described. RESULTS A total of 1421 articles were identified in the initial query, of which 43 met inclusion criteria. Thirty-nine studies (91%) reported multidisciplinary care to be cost effective, with an average cost savings among all studies of $5815 per patient. No significant differences in the amount of savings achieved were found between different intervention subtypes. All studies ultimately recommended (40) or gave mixed reviews (3) of multidisciplinary care, regardless of whether cost savings were achieved. CONCLUSION Multidisciplinary surgical care is beneficial not only in terms of patient and provider outcomes, but also in reference to its cost-effectiveness. Well-designed multidisciplinary teams tend to optimize perioperative care for all involved parties. Efforts to improve surgical care should employ multidisciplinary teams to promote both quality and cost-effective care.
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Affiliation(s)
- Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Bryan C Luu
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Sarth Raj
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, USA
| | - Edward P Buchanan
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX, USA.
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Jones CN, Morrison BL, Kelliher LJ, Dickinson M, Scott M, Cecconi Ebm C, Karanjia N, Quiney N. Hospital Costs and Long-term Survival of Patients Enrolled in an Enhanced Recovery Program for Open Liver Resection: Prospective Randomized Controlled Trial. JMIR Perioper Med 2021; 4:e16829. [PMID: 33522982 PMCID: PMC7884210 DOI: 10.2196/16829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/15/2020] [Accepted: 01/10/2021] [Indexed: 12/20/2022] Open
Abstract
Background The clinical benefits of enhanced recovery programs (ERPs) have been extensively researched, but few studies have evaluated their cost-effectiveness. Our ERP for open liver resection is based closely on the guidelines produced by the Enhanced Recovery After Surgery Society (2016). This study follows on from a previous randomized controlled trial. We also undertook a long-term follow-up of the patients enrolled in the original trial alongside an analysis of the associated health economics. Objective We aimed to undertake a health economic and long-term survival analysis as part of a trial investigating the implementation of an ERP for open liver resection. Methods The enhanced recovery elements utilized included extra preoperative education, carbohydrate loading, oral nutritional supplements, postresection goal-directed fluid therapy (LiDCOrapid), early mobilization, and physiotherapy (twice a
day compared with once per day in the standard care group). A decision-analytic model was used to compare the study endpoints for ERP versus standard care provided to patients undergoing open liver resection. Outcomes obtained included costs per life-years gained. Resource use and costs were estimated from the perspective of the National Health Service of the United Kingdom. A decision tree and Markov model were constructed using results from our earlier trial and augmented by external data from other published clinical trials. Long-term follow-up was also undertaken for up to 5 years after the surgery, and data were analyzed to ascertain if the ERP conferred any benefit on long-term survival. Results Patients receiving ERP had an average life expectancy of 6.9 years versus 6.1 years in the standard care group. The overall costs were £9538.279 (£1=US $1.60) for ERP and £14,793.05 for standard treatment. This results in a cost-effectiveness ratio of –£6748.33/QALY. Patients receiving ERP required fewer visits to their general practitioner (P=.006) and required lesser help at home with day-to-day activities (P=.04) than patients in the standard care group. Survival was significantly improved at 2 years at 91% (42/46) for patients receiving ERP versus 73% (33/45) for the standard care group (P=.03). There was no statistically significant difference at 5 years after the surgery. Conclusions ERPs for patients undergoing open liver resection can improve their medium-term survival and are cost-effective for both hospital and community settings.
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Affiliation(s)
- Chris N Jones
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | - Ben L Morrison
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | | | | | - Michael Scott
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | | | | | - Nial Quiney
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
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Joliat GR, Hübner M, Roulin D, Demartines N. Cost Analysis of Enhanced Recovery Programs in Colorectal, Pancreatic, and Hepatic Surgery: A Systematic Review. World J Surg 2020; 44:647-655. [PMID: 31664495 DOI: 10.1007/s00268-019-05252-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery programs (ERPs) have been shown to improve postoperative outcomes after abdominal surgery. This study aimed to review the current literature to assess if ERPs in colorectal, pancreas, and liver surgery induce cost savings. METHODS A systematic review was performed including prospective and retrospective studies comparing conventional management versus ERP in terms of costs. All kinds of ERP were considered (fast-track, ERAS®, or home-made protocols). Studies with no mention of a clear protocol and no reporting of protocol compliance were excluded. RESULTS Thirty-seven articles out of 144 identified records were scrutinized as full articles. Final analysis included 16 studies. In colorectal surgery, two studies were prospective (1 randomized controlled trial, RCT) and six retrospective, totaling 1277 non-ERP patients and 2078 ERP patients. Three of the eight studies showed no difference in cost savings between the two groups. The meta-analysis found a mean cost reduction of USD3010 (95% CI: 5370-650, p = 0.01) in favor of ERP. Among the five included studies in pancreas surgery (all retrospective, 552 non-ERP vs. 348 ERP patients), the mean cost reduction in favor of the ERP group was USD7020 (95% CI: 11,600-2430, p = 0.003). In liver surgery, only three studies (two retrospective and 1 RCT, 180 non-ERP vs. 197 ERP patients) were found, which precluded a sound cost analysis. CONCLUSIONS The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management. Cost data in liver surgery are scarce.
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Affiliation(s)
- Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Didier Roulin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Fakhar N, Sharifi A, Chavoshi Khamneh A, Kasraian Fard A, Heydar Z, Dashti SH, Jafarian A. Safety and Efficacy of Early Oral Feeding after Liver Transplantation with Roux-en-Y Choledochojejunostomy: A Single-Center Experience. Int J Organ Transplant Med 2020; 11:122-127. [PMID: 32913588 PMCID: PMC7471616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Early oral feeding, as one of the most important components of multimodal strategies referred to as Enhanced Recovery After Surgery (ERAS), is now widely adopted for optimization of post-operative recovery of surgical patients. OBJECTIVE To assess ERAS outcome in patients who underwent liver transplantation in our center. METHODS In a prospective study, patients who underwent liver transplantation from April 2015 to June 2018 at Imam Khomeini Hospital Complex, affiliated to Tehran University of Medical Sciences, Tehran, Iran, were enrolled in this study. Serum albumin, total iron-binding capacity (TIBC), and course of hospital stay were assessed. RESULTS 39 (23 male) patients who underwent choledochojejunostomy with Roux-en-Y anastomosis for liver transplantation were enrolled. The mean±SD pre-operative serum albumin and TIBC levels of patients were 3.0±0.6 (range: 1.9-4.1) g/dL and 304±75 (range: 154.0-437.0) µg/dL, respectively. The mean±SD time between the end of operation and starting oral feeding was 11.6±1.8 (range: 9.0-15.0) hours. All patients tolerated early oral feeding with liquids followed by solid foods; no vomiting reported in patients. Overall, patient survival rates at one month and three months were 89.7% and 89.7%, respectively. In our study, no leak of anastomosis was reported. CONCLUSION There was no major harm for ERAS after liver transplantation and it might be even helpful as in colorectal surgeries. As seen in our study, oral feeding was started as soon as possible after the end of operation in almost all patients and all of them tolerated early oral feeding. No one had vomiting or nausea.
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Affiliation(s)
- N. Fakhar
- Liver Transplantation Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Iran, Tehran
| | - A. Sharifi
- Department of Surgery, Imam Reza Educational and Treatment Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - A. Chavoshi Khamneh
- Liver Transplantation Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Iran, Tehran
| | - A. Kasraian Fard
- Department of General Surgery, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Z. Heydar
- Liver Transplantation Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Iran, Tehran
| | - S. H. Dashti
- Liver Transplantation Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Iran, Tehran
| | - A. Jafarian
- Liver Transplantation Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Iran, Tehran
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11
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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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12
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Weinberg L, Mackley L, Ho A, Mcguigan S, Ianno D, Yii M, Banting J, Muralidharan V, Tan CO, Nikfarjam M, Christophi C. Impact of a goal directed fluid therapy algorithm on postoperative morbidity in patients undergoing open right hepatectomy: a single centre retrospective observational study. BMC Anesthesiol 2019; 19:135. [PMID: 31366327 PMCID: PMC6668127 DOI: 10.1186/s12871-019-0803-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 07/12/2019] [Indexed: 12/27/2022] Open
Abstract
Background Right hepatectomy is a complex procedure that carries inherent risks of perioperative morbidity. To evaluate outcome differences between a low central venous pressure fluid intervention strategy and a goal directed fluid therapy (GDFT) cardiac output algorithm we performed a retrospective observational study. We hypothesized that a GDFT protocol would result in less intraoperative fluid administration, reduced complications and a shorter length of hospital stay. Methods Patients undergoing hepatectomy using an established enhanced recovery after surgery (ERAS) programme between 2010 and 2017 were extracted from a prospectively managed electronic hospital database. Inclusion criteria included adult patients, undergoing open right (segments V-VIII) or extended right (segments IV-VIII) hepatectomy. Primary outcome: amount of intraoperative fluid administration used between the two groups. Secondary outcomes: type and amount of vasoactive medications used, the development of predefined postoperative complications, hospital length of stay, and 30-day mortality. Complications were defined by the European Perioperative Clinical Outcome definitions and graded according to Clavien-Dindo classification. The association between GDFT and the amount of fluid and vasoactive medication used was investigated using logistic and linear regression models. Results Fifty-eight consecutive patients were identified. 26 patients received GDFT and 32 received Usual care. There were no significant differences in baseline patient characteristics. Less intraoperative fluid was used in the GDFT group: median (IQR) 2000 ml (1175 to 2700) vs. 2750 ml (2000 to 4000) in the Usual care group; p = 0.03. There were no significant differences in the use of vasoactive medications. Postoperative complications were similar: 9 patients (35%) in the GDFT group vs. 18 patients (56%) in the Usual care group; p = 0.10, OR: 0.41; (95%CI: 0.14 to 1.20). Median (IQR) length of stay for patients in the GDFT group was 7 days (6:8) vs. 9 days (7:13) in the Usual care group; incident rate ratio 0.72 (95%CI: 0.56 to 0.93); p = 0.012. There was no difference in perioperative mortality. Conclusions In patients undergoing open right hepatectomy with an established ERAS programme, use of GDFT was associated with less intraoperative fluid administration and reduced hospital length of stay when compared to Usual care. There were no significant differences in postoperative complications or mortality. Trial registration Australian New Zealand Clinical Trials Registry: no12619000558123 on 10/4/19.
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Affiliation(s)
- Laurence Weinberg
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia. .,Department of Surgery, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia.
| | - Lois Mackley
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Alexander Ho
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Steven Mcguigan
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Damian Ianno
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Matthew Yii
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Jonathan Banting
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | | | - Chong Oon Tan
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Mehrdad Nikfarjam
- Department of Surgery, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Chris Christophi
- Department of Surgery, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
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13
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Weinberg L, Ianno D, Churilov L, Mcguigan S, Mackley L, Banting J, Shen SH, Riedel B, Nikfarjam M, Christophi C. Goal directed fluid therapy for major liver resection: A multicentre randomized controlled trial. Ann Med Surg (Lond) 2019; 45:45-53. [PMID: 31360460 PMCID: PMC6642079 DOI: 10.1016/j.amsu.2019.07.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 06/30/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023] Open
Abstract
Background The effect a restrictive goal directed therapy (GDT) fluid protocol combined with an enhanced recovery after surgery (ERAS) programme on hospital stay for patients undergoing major liver resection is unknown. Methods We conducted a multicentre randomized controlled pilot trial evaluating whether a patient-specific, surgery-specific intraoperative restrictive fluid optimization algorithm would improve duration of hospital stay and reduce perioperative fluid related complications. Results Forty-eight participants were enrolled. The median (IQR) length of hospital stay was 7.0 days (7.0:8.0) days in the restrictive fluid optimization algorithm group (Restrict group) vs. 8.0 days (6.0:10.0) in the conventional care group (Conventional group) (Incidence rate ratio 0.85; 95% Confidence Interval 0.71:1.1; p = 0.17). No statistically significant difference in expected number of complications per patient between groups was identified (IRR 0.85; 95%CI: 0.45–1.60; p = 0.60). Patients in the Restrict group had lower intraoperative fluid balances: 808 mL (571:1565) vs. 1345 mL (900:1983) (p = 0.04) and received a lower volume of fluid per kg/hour intraoperatively: 4.3 mL/kg/hr (2.6:5.8) vs. 6.0 mL/kg/hr (4.2:7.6); p = 0.03. No significant differences in the proportion of patients who received vasoactive drugs intraoperatively (p = 0.56) was observed. Conclusion In high-volume hepatobiliary surgical units, the addition of a fluid restrictive intraoperative cardiac output-guided algorithm, combined with a standard ERAS protocol did not significantly reduce length of hospital stay or fluid related complications. Our findings are hypothesis-generating and a larger confirmatory study may be justified. Major liver resection is a complex procedure with up to 40% patients experiencing complications. Optimisation of perfusion and oxygen delivery to all organs remain the cornerstone of best hemodynamic care. Traditionally, a low central venous pressure strategy during major liver resection has been used to reduce venous bleeding. The impact of a restrictive cardiac output fluid optimisation algorithm during major liver surgery is unknown. After major hepatobiliary surgery, a fluid restrictive algorithm did not reduce length of hospital stay or complications.
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Affiliation(s)
- Laurence Weinberg
- Director of Anesthesia, Austin Hospital; and A/Professor, Department of Surgery, Austin Health, The University of Melbourne, Victoria, Australia
| | - Damian Ianno
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Leonid Churilov
- Statistics and Decision Analysis Academic Platform, The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Victoria, Australia.,Department of Medicine (Austin Health), Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Steven Mcguigan
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Lois Mackley
- Department of Anesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Jonathan Banting
- Department of Anesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Shi Hong Shen
- Department of Anesthesia, Peter MacCallum Cancer Hospital, Victoria, Australia
| | - Bernhard Riedel
- Department of Anesthesia, Peter MacCallum Cancer Hospital, Victoria, Australia
| | - Mehrdad Nikfarjam
- Department of Surgery, Austin Hospital, The University of Melbourne, Victoria, Australia
| | - Chris Christophi
- Department of Surgery, Austin Hospital, The University of Melbourne, Victoria, Australia
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14
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Chinese Expert Consensus on Enhanced Recovery After Hepatectomy (Version 2017). Asian J Surg 2019; 42:11-18. [DOI: 10.1016/j.asjsur.2018.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 01/22/2018] [Accepted: 01/31/2018] [Indexed: 12/14/2022] Open
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15
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Abstract
The objective of this study was to compare fast-track (FT) recovery protocol with the conventional one in patients treated with major liver resection by evaluating perioperative morbidity, length of hospitalization, and readmission rate. Sixty-two patients suffering from malignant liver tumors were surgically treated from May 2012 to April 2014. After randomization, they were prospectively divided into two groups: Group A patients (n = 32) followed FT recovery protocol and Group B patients (n = 30) were treated with the conventional (CON) protocol. Postoperative morbidity, readmission rate, and median hospital stay in the two groups were studied. Fast-track protocol was associated with a decreased complication (25%, p = .002), whereas the risk of postoperative morbidity was 2.4 times higher in patients treated with the CON protocol (60%, p = .002). Readmission rate was not significantly different between the two groups (6.25%, p = .35). Age (p = .382) and body mass index (p = .818) were not a suspending factor for following the FT protocol. Overall length of stay (postoperative days) in the FT group was (mean ± SD) 5.75 ± .5 and in the CON group was 13.5 ± 6.7 (p < .001). Fast-track recovery protocol seems to be safe and particularly efficient in patients undergoing major liver resections.
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16
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Morrison B, Kelliher L, Jones C. Enhanced recovery for liver resection-early recovery pathway for hepatectomy: data-driven liver resection care and recovery. Hepatobiliary Surg Nutr 2018; 7:217-220. [PMID: 30046579 DOI: 10.21037/hbsn.2018.03.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Benjamin Morrison
- Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Leigh Kelliher
- Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Chris Jones
- Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
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17
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Enhanced Recovery via Peripheral Nerve Block for Open Hepatectomy. J Gastrointest Surg 2018; 22:981-988. [PMID: 29404987 PMCID: PMC5966330 DOI: 10.1007/s11605-017-3656-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 12/08/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are now commonplace in many fields of surgery, but only limited data exists for their use in hepatobiliary surgery. We implemented standardized ERAS protocols for all open hepatectomies and replaced thoracic epidurals with a transversus abdominis plane (TAP) block. METHODS We performed a retrospective cohort study of all patients undergoing open hepatectomy during the 14 months before and 19 months after implementation of an ERAS protocol at our institution (January 2014-September 2016). Trained abstractors reviewed charts for patient demographics, perioperative details, and healthcare utilization. All nursing-reported visual analog scale pain scores were sampled to identify patients with uncontrolled pain (daily mean score > 5). Outcomes included length of stay (LOS), costs, and 30-day readmission. RESULTS A total of 127 patients (mean age 54.6 ± 13.0 years, 44% female) underwent open liver resection (69 [54%] after ERAS implementation). ERAS protocols were associated with significantly lower rates of ICU admission (47 vs. 13%, p < 0.001), shorter LOS (median 5.3 vs. 4.3 days, p = 0.007), and lower median costs ($3566 less, p = 0.03). Readmission remained low throughout the study period (5% pre-ERAS, 4% during ERAS, p = 0.83). Rates of uncontrolled pain were either the same or better after ERAS implementation through post-operative day #3 (41% pre-ERAS, 23% during ERAS, p = 0.03). DISCUSSION The use of TAP block for hepatectomy as part of an ERAS protocol is associated with improved quality and cost of care. Surgeons performing liver resections should consider standardization of evidence-based best practices in all patients.
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18
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Bai J, Bai F, Zhu H, Xue D. The perceived and objectively measured effects of clinical pathways' implementation on medical care in China. PLoS One 2018; 13:e0196776. [PMID: 29734350 PMCID: PMC5937784 DOI: 10.1371/journal.pone.0196776] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 04/19/2018] [Indexed: 12/29/2022] Open
Abstract
Introduction Substantial resources have been expended on clinical pathways (CPs), but the reported effects of CPs on medical care vary considerably. This study sought to determine the effects of CPs on medical care in Chinese hospitals, including the perceived effects of CPs on medical care and the objectively measured patient outcomes. Methods Study data were obtained from 54 public hospitals in three provinces of China in 2015. Hospital questionnaires, employee surveys, and chart reviews were used to collect data related to hospital characteristics, the implementation of CPs and compliance status, perceived effects of CPs, and objectively measured patient outcomes. Logistic regression models and linear regression models were adopted in this study. Results The effects of CPs were not highly perceived by the hospitals or by the managers and physicians in China. The relatively low involvement in the implementation of and adherence to CPs resulted in CPs having no significant effects on hospital medical care as a whole. However, a chart review of 5 conditions in Chinese hospitals demonstrated that compliance with national CPs reduced the length of stay (LOS) and inpatient medical costs. Conclusions CPs should be implemented widely and followed closely to improve hospital medical care as a whole, and further studies should be conducted to identify the key elements of the effects of CPs on patient clinical outcomes.
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Affiliation(s)
- Jie Bai
- Department of Hospital Management, School of Public Health, Key Laboratory of Health Technology Assessment, National Health Commission (Fudan University), Fudan University, Shanghai, P.R. China
| | - Fei Bai
- Center for Medical Service Administration, National Health Commission of China, Beijing, P.R. China
| | - Hongbo Zhu
- Medical Administration and Management, Health and Family Planning Commission of Hubei Province, Wuhan, P.R. China
| | - Di Xue
- Department of Hospital Management, School of Public Health, Key Laboratory of Health Technology Assessment, National Health Commission (Fudan University), Fudan University, Shanghai, P.R. China
- * E-mail:
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19
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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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Furuhata H, Araki K, Ogawa T, Ikeda M. Effect on Completion of Clinical Pathway for Improving Clinical Indicator: Cases of Hospital Stay, Mortality Rate, and Comprehensive-Volume Ratio. J Med Syst 2017; 41:206. [PMID: 29134334 DOI: 10.1007/s10916-017-0857-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 11/01/2017] [Indexed: 12/26/2022]
Abstract
Many studies have analyzed the effects of clinical pathways, but most have considered only single diseases. The purpose of the present study was to exploratively analyze electronic medical records related to the use of clinical pathways, seeking trends that could usefully benefit clinical activity. From the data warehouse of University of Miyazaki Hospital, collected from April 2014 to March 2016, we retrospectively identified 6523 patients for whom a clinical pathway was applied. Other inclusion criteria were single hospitalization, the type of medical fee was comprehensive, and data were available so that all clinical indicators could be calculated. Two types of deviation from the clinical pathway were defined: cancellation (described in the clinical pathway but not implemented) and addition (not described in the clinical pathway but nevertheless implemented). If the code of International Classification of Diseases describing the clinical pathway differed from that describing where the medical resource was mostly spent, we considered this as indicating a complication. We compared principal clinical indicators (length of hospital stay, mortality rate, and comprehensive-volume ratio) by completion rate for the clinical pathway. Regardless of whether patients had complications, completing the clinical pathway was associated with a significant reduction in length of hospital stay. This finding indicated that length of hospital stay could be shortened if all medical treatments described in the clinical pathway were implemented. Our results demonstrated that it is possible to shorten the length of hospital stay by improving clinical pathways to include medical treatment for preventing complications.
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Affiliation(s)
- Hiroki Furuhata
- School of Knowledge Science, Japan Advanced Institute of Science and Technology, Ishikawa, Japan.
- Department of Medical Informatics, University of Miyazaki Hospital, Miyazaki, Japan.
| | - Kenji Araki
- Department of Medical Informatics, University of Miyazaki Hospital, Miyazaki, Japan
| | - Taisuke Ogawa
- Department of Medical Informatics, University of Miyazaki Hospital, Miyazaki, Japan
| | - Mitsuru Ikeda
- School of Advanced Science, Japan Advanced Institute of Science and Technology, Ishikawa, Japan
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21
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Damania R, Cocieru A. Impact of enhanced recovery after surgery protocols on postoperative morbidity and mortality in patients undergoing routine hepatectomy: review of the current evidence. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:341. [PMID: 28936435 DOI: 10.21037/atm.2017.07.04] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Enhanced recovery protocols are widely used in many areas of general surgery but had a limited penetration in perioperative management of patients undergoing liver resection. Recently, multiple publications described application of enhanced recovery after surgery (ERAS) program to hepatectomy patients but their definitive role is not established or accepted by hepatobiliary surgeons. METHODS A comprehensive literature review of published series in English language medical sources detailing ERAS program application for hepatectomy for the period of 2006-2016 is performed. RESULTS ERAS protocols are feasible and safe. They reduce length of stay in patients undergoing routine hepatectomy without negative impact on morbidity and mortality. There is potential for reduction of Clavien grade I-II complications, while major and surgical complications are similar to traditional care management group. CONCLUSIONS Application of ERAS program to patient undergoing hepatectomy reduces length of hospital stay without affecting perioperative morbidity or mortality and may represent a new standard of care for patients undergoing routine liver resection.
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Affiliation(s)
- Rahul Damania
- Northeastern Ohio Medical University, Rootstown, OH, USA
| | - Andrei Cocieru
- Northeastern Ohio Medical University, Rootstown, OH, USA.,Department of Surgery, Akron City Hospital, Akron, OH, USA
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22
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Xia Z, Qiao K, Wang H, Ning X, He J. Outcomes after implementing the enhanced recovery after surgery protocol for patients undergoing tuberculous empyema operations. J Thorac Dis 2017; 9:2048-2053. [PMID: 28840005 DOI: 10.21037/jtd.2017.06.90] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols provide recommendations for care in various surgical fields. However, there is scarce information on the application of these protocols in tuberculous empyema surgery. The purpose of this research is to evaluate the outcomes of ERAS recommendations for patients who received tuberculous empyema surgery. METHODS A retrospective analysis was performed on patients who underwent tuberculous empyema surgery in our hospital from March 2011 to March 2016. The patients were divided into an ERAS group and a conventional control group. The main outcome measure was the postoperative median length of stay (including readmissions). Principles related to ERAS were documented, and the postoperative median hospital stay was analyzed statistically between the two groups. RESULTS A total of 92 patients underwent 93 consecutive tuberculous empyema surgical treatments. The postoperative fasting time, chest tube duration, and length of stay were shorter in the ERAS group compared with the control group. The volume of chest tube drainage in the ERAS group was significantly smaller than that of the control group. No statistical differences were observed in the postoperative complications and reasons for readmission between the two groups. CONCLUSIONS Application of ERAS recommendations in patients receiving tuberculous empyema operations decreased the length of stay and chest tube drainage compared to the control group.
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Affiliation(s)
- Zhaohua Xia
- The First Clinical College, Southern Medical University, Guangzhou 510515, China.,Department of Thoracic Surgery, The Third People's Hospital of Shenzhen, Shenzhen 518000, China
| | - Kun Qiao
- Department of Thoracic Surgery, The Third People's Hospital of Shenzhen, Shenzhen 518000, China
| | - Haijiang Wang
- Department of Thoracic Surgery, The Third People's Hospital of Shenzhen, Shenzhen 518000, China
| | - Xinzhong Ning
- Department of Thoracic Surgery, The Third People's Hospital of Shenzhen, Shenzhen 518000, China
| | - Jianxing He
- The First Clinical College, Southern Medical University, Guangzhou 510515, China.,Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou 510120, China
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23
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Rao JH, Zhang F, Lu H, Dai XZ, Zhang CY, Qian XF, Wang XH, Lu L. Effects of multimodal fast-track surgery on liver transplantation outcomes. Hepatobiliary Pancreat Dis Int 2017; 16:364-369. [PMID: 28823365 DOI: 10.1016/s1499-3872(17)60020-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 11/30/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fast-track surgery and enhanced recovery after surgery have been applied to many surgical procedures; however, data on fast-track surgery and enhanced recovery after surgery following liver transplantation is limited. This study aimed to conduct a prospective study to determine the effects of fast-track surgery on prognosis after liver transplantation. METHODS This was a prospective, single-blinded, randomized study. One hundred twenty-eight patients undergoing liver transplantation were selected for the fast-track (FT group, n=54) or conventional process (NFT group, n=74). The primary endpoints were intensive care unit (ICU) stay and hospital stay. The secondary endpoints were as follows: operative time, anhepatic phase time, intraoperative blood loss, intraoperative blood transfusion volume, postoperative complications, readmission rate, and postoperative mortality. RESULTS There was no significant difference in preoperative demographics between the two groups. The median ICU stay was 2 days (range 1-7 days) in the FT group and 5 days (range 3-12 days) in the NFT group (P<0.01). Furthermore, the hospital stay was also significantly reduced in the FT group (P<0.01). The operative time, anhepatic phase time, intraoperative blood loss, and intraoperative blood transfusion volume were decreased in the FT group compared with the NFT group (P<0.05). Based on Spearman correlation analysis, the ICU stay and hospital stay may be positively correlated with operative time, anhepatic phase time and intraoperative blood loss. There were no differences in the incidence of postoperative complications, readmissions, and postoperative mortality between the two groups. CONCLUSION Fast-track procedures effectively reduce the ICU stay and hospital stay without adversely affecting prognosis. This study demonstrated that fast-track protocols are safe and feasible in liver transplantation.
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Affiliation(s)
- Jian-Hua Rao
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China
| | - Feng Zhang
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China
| | - Hao Lu
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China
| | - Xin-Zheng Dai
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China
| | - Chuan-Yong Zhang
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China
| | - Xiao-Feng Qian
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China
| | - Xue-Hao Wang
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China
| | - Ling Lu
- Liver Transplantation Center, First Affiliated Hospital of Nanjing Medical University; Key Laboratory of Living Donor Liver Transplantation of Ministry of Public Health, Nanjing 210029, China.
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Zhao Y, Qin H, Wu Y, Xiang B. Enhanced recovery after surgery program reduces length of hospital stay and complications in liver resection: A PRISMA-compliant systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017; 96:e7628. [PMID: 28767578 PMCID: PMC5626132 DOI: 10.1097/md.0000000000007628] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 07/05/2017] [Accepted: 07/10/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Many enhanced recovery after surgery (ERAS) guidelines have already been established in several kinds of surgeries. But due to concerns of the specific complications, it has not yet been considered the standard of care in liver surgery. OBJECTIVE The aim of this review is to assess the effect of ERAS in patients undergoing liver surgery. METHODS EMBASE, CNKI, PubMed, and the Cochrane Database were searched for randomized controlled trials (RCTs) comparing ERAS with conventional care in patients undergoing liver surgery. Subgroup meta-analysis between laparoscopic and open surgical approaches to liver resection was also conducted. RESULTS Seven RCTs were included, representing 996 patients. Length of stay (LOS) (MD -3.17, 95% CI: -3.99 to -2.35, P < .00001, I = 89%) and time to first flatus (MD -0.9, 95% CI: -1.36 to -0.45, P = .0001, I = 98%) were both reduced in the ERAS group. There were also fewer complications in the ERAS group (OR 0.52, 95% CI: 0.37-0.72, P < .0001, I = 0%). CONCLUSION The ERAS program can obviously enhance short-term recovery after liver resection. It is safe and worthwhile. A specific ERAS guideline for liver resection is recommended.
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Affiliation(s)
- Yiyang Zhao
- Sichuan University West China Hospital, Pediatric Surgery
| | - Han Qin
- Chengdu First People's Hospital, General Surgery, Chengdu, Sichuan, P.R. China
| | - Yang Wu
- Sichuan University West China Hospital, Pediatric Surgery
| | - Bo Xiang
- Sichuan University West China Hospital, Pediatric Surgery
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Preoperative Fasting among Adult Patients for Elective Surgery in a Kenyan Referral Hospital. INTERNATIONAL SCHOLARLY RESEARCH NOTICES 2017; 2017:2159606. [PMID: 28487877 PMCID: PMC5405382 DOI: 10.1155/2017/2159606] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 03/24/2017] [Accepted: 04/02/2017] [Indexed: 12/13/2022]
Abstract
Background. Preoperative fasting (POF) is physiologically and precautionary important during anesthesia and surgery. POF from midnight has been practiced despite the recommended shorter practice. Objective. Assessing preoperative fasting among adult patients scheduled for elective surgery at Kenyatta National Hospital (KNH). Methods. A descriptive cross-sectional study involving 65 surgical patients. A questionnaire of mixed questions on demographics, reasons, source of instructions, opinion on instructions, time, premedication practices, outcome, and complains on NPO was used. Analysis was quantitatively done with SPSS v. 22. Ethical approval was obtained from KNH-UoN ERC. Results. Of the respondents 93.8% lacked knowledge on the correct reasons for POF and felt that the instructions were unclear and less important <50%. POF instructions were administered by nurses 80%, anesthetists 15%, and surgeons 5%. Most of respondents (73.8%) fasted > 15 hours. The POF outcomes were rated moderately challenging as follows: prolonged wait for surgery 44.6%, thirst 43.1%, hunger 36.9%, and anxiety 29.2%. Conclusion. Nurses are critical in providing POF instructions and care, and patient knowledge level is a mirror reflection of the quality of interventions. This underscores the need to build capacity for nurses and strengthen the health system to offer individualized preoperative interventions as well as monitoring and clinical auditing of fasting practices.
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Wong-Lun-Hing EM, van Dam RM, van Breukelen GJP, Tanis PJ, Ratti F, van Hillegersberg R, Slooter GD, de Wilt JHW, Liem MSL, de Boer MT, Klaase JM, Neumann UP, Aldrighetti LA, Dejong CHC. Randomized clinical trial of open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery after surgery programme (ORANGE II study). Br J Surg 2017; 104:525-535. [PMID: 28138958 DOI: 10.1002/bjs.10438] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 10/28/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Laparoscopic left lateral sectionectomy (LLLS) has been associated with shorter hospital stay and reduced overall morbidity compared with open left lateral sectionectomy (OLLS). Strong evidence has not, however, been provided. METHODS In this multicentre double-blind RCT, patients (aged 18-80 years with a BMI of 18-35 kg/m2 and ASA fitness grade of III or below) requiring left lateral sectionectomy (LLS) were assigned randomly to OLLS or LLLS within an enhanced recovery after surgery (ERAS) programme. All randomized patients, ward physicians and nurses were blinded to the procedure undertaken. A parallel prospective registry (open non-randomized (ONR) versus laparoscopic non-randomized (LNR)) was used to monitor patients who were not enrolled for randomization because of doctor or patient preference. The primary endpoint was time to functional recovery. Secondary endpoints were length of hospital stay (LOS), readmission rate, overall morbidity, composite endpoint of liver surgery-specific morbidity, mortality, and reasons for delay in discharge after functional recovery. RESULTS Between January 2010 and July 2014, patients were recruited at ten centres. Of these, 24 patients were randomized at eight centres, and 67 patients from eight centres were included in the prospective registry. Owing to slow accrual, the trial was stopped on the advice of an independent Data and Safety Monitoring Board in the Netherlands. No significant difference in median (i.q.r.) time to functional recovery was observed between laparoscopic and open surgery in the randomized or non-randomized groups: 3 (3-5) days for OLLS versus 3 (3-3) days for LLLS; and 3 (3-3) days for ONR versus 3 (3-4) days for LNR. There were no significant differences with regard to LOS, morbidity, reoperation, readmission and mortality rates. CONCLUSION This RCT comparing open and laparoscopic LLS in an ERAS setting was not able to reach a conclusion on time to functional recovery, because it was stopped prematurely owing to slow accrual. Registration number: NCT00874224 ( https://www.clinicaltrials.gov).
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Affiliation(s)
- E M Wong-Lun-Hing
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Nutrim School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - R M van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Surgery, University Hospital Aachen, Aachen, Germany
| | - G J P van Breukelen
- Department of Methodology and Statistics, Maastricht University Medical Centre, Maastricht, The Netherlands
- CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - P J Tanis
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - F Ratti
- Department of Surgery, San Raffaele Hospital, Milan, Italy
| | - R van Hillegersberg
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - G D Slooter
- Department of Surgery, Maxima Medical Centre, Veldhoven, The Netherlands
| | - J H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M S L Liem
- Department of Surgery, Deventer Hospital, Deventer, The Netherlands
| | - M T de Boer
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - J M Klaase
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - U P Neumann
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Surgery, University Hospital Aachen, Aachen, Germany
| | | | - C H C Dejong
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Nutrim School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, The Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Surgery, University Hospital Aachen, Aachen, Germany
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Enhanced Recovery after Surgery Programs for Liver Resection: a Meta-analysis. J Gastrointest Surg 2017; 21:472-486. [PMID: 28101720 DOI: 10.1007/s11605-017-3360-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 01/03/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Due to the limited number of high-quality randomized controlled trials on enhanced recovery after surgery for hepatectomy, previous reviews have not been sufficiently comprehensive. Our objectives were to evaluate and compare the safety and efficacy of enhanced recovery after surgery programs and traditional care in patients undergoing open or laparoscopic surgery and to assess the optimized items for hepatectomy. METHODS We searched the PubMed, Embase, and the Cochrane Library databases for all the relevant studies regardless of study design. We assessed the methodological quality of the included studies and excluded studies of poor quality. We performed a meta-analysis using RevMan 5.3 software. RESULTS In total, 19 original studies with 2575 patients, including four randomized controlled trials and 15 non-randomized controlled trials, were analyzed. The meta-analysis demonstrated that enhanced recovery after surgery programs could reduce morbidity, hospital stays and cost, blood loss, and time to bowel function recovery for both open and laparoscopic surgery without increasing mortality, readmission rate, or transfusion rate. Twelve items were essential for liver surgery. CONCLUSIONS Enhanced recovery after surgery programs for hepatectomy are feasible and efficient. Further studies should optimize perioperative outcomes for liver surgery.
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Kapritsou M, Papathanassoglou ED, Bozas E, Korkolis DP, Konstantinou EA, Kaklamanos I, Giannakopoulou M. Comparative Evaluation of Pain, Stress, Neuropeptide Y, ACTH, and Cortisol Levels Between a Conventional Postoperative Care Protocol and a Fast-Track Recovery Program in Patients Undergoing Major Abdominal Surgery. Biol Res Nurs 2016; 19:180-189. [PMID: 28198198 DOI: 10.1177/1099800416682617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fast-track (FT) postoperative protocol in oncological patients after major abdominal surgery reduces complications and length of postoperative stay compared to the conventional (CON) protocol. However, stress and pain responses have not been compared between the two protocols. OBJECTIVES To compare stress, pain, and related neuropeptidic responses (adrenocorticotropic hormone [ACTH], cortisol, and neuropeptide Y [NPY]) between FT and CON protocols. METHOD A clinical trial with repeated measurements was conducted (May 2012 to May 2014) with a sample of 63 hepatectomized or pancreatectomized patients randomized into two groups: FT ( n = 29) or CON ( n = 34). Demographic and clinical data were collected, and pain (Visual Analog Scale [VAS] and Behavioral Pain Scale [BPS]) and stress responses (3 self-report questions) assessed. NPY, ACTH, and cortisol plasma levels were measured at T1 = day of admission, T2 = day of surgery, and T3 = prior to discharge. RESULTS ACTHT1 and ACTHT2 levels were positively correlated with self-reported stress levels (ρ = .43 and ρ = .45, respectively, p < .05) in the FT group. NPY levels in the FT group were higher than those in the CON group at all time points ( p ≤ .004); this difference remained significant after adjusting for T1 levels through analysis of covariance for age, gender, and body mass index ( F = .003, F = .149, F = .015, respectively, p > .05). CONCLUSIONS Neuropeptidic levels were higher in the FT group. Future research should evaluate this association further, as these biomarkers might serve as objective indicators of postoperative pain and stress.
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Affiliation(s)
- Maria Kapritsou
- 1 Hellenic Anticancer Institute, Saint Savvas Hospital, Athens, Greece
| | | | - Evangelos Bozas
- 3 Pediatric Research Laboratory, Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Ioannis Kaklamanos
- 4 Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
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Li M, Zhang W, Jiang L, Yang J, Yan L. Fast track for open hepatectomy: A systemic review and meta-analysis. Int J Surg 2016; 36:81-89. [PMID: 27773599 DOI: 10.1016/j.ijsu.2016.10.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 10/03/2016] [Accepted: 10/14/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Liver resection (LR) is preferred treatment for malignancies or benign masses of liver. Using multiple elements, fast track (FT) program was introduced to abdominal surgery associating with fast functional recovery and shorter hospital length of stay (LoS). This meta-analysis aims to evaluate the effect of FT program for patients following liver resection. MATERIALS AND METHODS We searched the PubMed/Medline, Cochrane Central Register of Controlled Trials (CENTRAL), Embase for trials up to December 2015 to compare the FT program to the conventional group. The main outcome was assessed of complication rate (including liver specific or general complication rate), thirty-day postoperative mortality, readmission rate and the length of hospital stay. RESULTS Four randomized control trials (RCTs) and three cohort trials (CTs) were to make a quantitative synthesis including 1027 patients. The LoS was reduced following FT groups (weighted mean difference [WMD], 2.24 days; 95% CI 3.69-0.79; P < 0.005). No significant differences were noted in overall complication (risk ratio [RR], 0.94; 95% CI, 0.79-1.12; p = 0.49), mortality (RR, 0.63; 95% CI, 0.19-2.15; p = 0.46) and readmission rate (RR, 0.99; 95% CI, 0.54-1.79; p = 0.97). However, the general complication showed a difference favoring FT group (RR, 0.68; 95% CI, 0.49-0.95; p = 0.03). CONCLUSIONS This review, firstly using the quantitative synthesis in FT program following LR, indicates that FT program can shorten the length of hospital stay and accelerate the postoperative recovery in a safe and effective ways without increasing in mortality, morbidity and readmission rate.
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Affiliation(s)
- Ming Li
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Wei Zhang
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Li Jiang
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Jiayin Yang
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China.
| | - Lunan Yan
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
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Impact of ERAS approach and minimally-invasive techniques on outcome of patients undergoing liver surgery for hepatocellular carcinoma. Dig Liver Dis 2016; 48:1243-8. [PMID: 27522551 DOI: 10.1016/j.dld.2016.06.032] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 06/25/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Aim of the study was to assess the impact of ERAS approach ("fluid restrictive and drainless") on open liver resections for HCC comparing their outcome with open resections in pre-ERAS period and with laparoscopic surgery. STUDY DESIGN 207 patients undergoing minor liver resection for HCC were divided into three groups: Group A, open minor resections in pre-ERAS period (95 patients); Group B, laparoscopic ERAS resections (55 patients); Group C, open ERAS resections (57 patients). RESULTS Blood loss was lower in group C and B compared with group A. Postoperative morbidity was 26.5% in group A, 16.3% in group B and 12.1% in group C (p<0.05). Ascites was less frequent in group B (7.5%) and C (6.2%) compared with group A (12%). Median time for functional recovery in group B (3 days) and C (3 days) was shorter compared with group A (5 days). CONCLUSIONS Laparoscopic approach confirms to be associated with reduced blood loss and postoperative morbidity. In patients who cannot be candidates to minimally-invasive approach, ERAS management seems to allow blood loss and postoperative morbidity reduction: indeed, results achieved in this group of patients are more similar to those of laparoscopy than to pre-ERAS open surgery.
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Siniscalchi A, Gamberini L, Bardi T, Laici C, Gamberini E, Francorsi L, Faenza S. Role of epidural anesthesia in a fast track liver resection protocol for cirrhotic patients - results after three years of practice. World J Hepatol 2016; 8:1097-1104. [PMID: 27660677 PMCID: PMC5026992 DOI: 10.4254/wjh.v8.i26.1097] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 06/22/2016] [Accepted: 08/15/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the potential benefits and risks of the use of epidural anaesthesia within an enhanced recovery protocol in this specific subpopulation.
METHODS A retrospective review was conducted, including all cirrhotic patients who underwent open liver resection between January 2013 and December 2015 at Bologna University Hospital. Patients with an abnormal coagulation profile contraindicating the placement of an epidural catheter were excluded from the analysis. The control group was composed by patients refusing epidural anaesthesia.
RESULTS Of the 183 cirrhotic patients undergoing open liver resections, 57 had contraindications to the placement of an epidural catheter; of the remaining 126, 86 patients received general anaesthesia and 40 combined anaesthesia. The two groups presented homogeneous characteristics. Intraoperatively the metabolic data did not differ between the two groups, whilst the epidural group had a lower mean arterial pressure (P = 0.041) and received more colloid infusions (P = 0.007). Postoperative liver and kidney function did not differ significantly. Length of mechanical ventilation (P = 0.003) and hospital stay (P = 0.032) were significantly lower in the epidural group. No complications related to the epidural catheter placement or removal was recorded.
CONCLUSION The use of Epidural Anaesthesia within a fast track protocol for cirrhotic patients undergoing liver resections had a positive impact on the patient’s outcomes and comfort as demonstrated by a significantly lower length of mechanical ventilation and hospital stay in the epidural group. The technique appears to be safely manageable in this fragile population even though these results need confirmation in larger studies.
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Adherence to early mobilisation: Key for successful enhanced recovery after liver resection. Eur J Surg Oncol 2016; 42:1561-7. [PMID: 27528466 DOI: 10.1016/j.ejso.2016.07.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 07/18/2016] [Accepted: 07/25/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) has been proven effective in liver surgery. Adherence to the ERAS pathway is variable. This study seeks to evaluate adherence to key components of an ERAS protocol in liver resection, and identify the components associated with successful clinical outcomes. METHOD All patients undergoing liver resections for two consecutive years were included in our ERAS pathway. Six key components of ERAS included preoperative assessment, nutrition and gastrointestinal function, postoperative analgesia, mobilisation and discharges. Successful accomplishment of ERAS was defined as hospital discharge by postop day (POD) 6. Adherences of these elements were compared between the successful and un-successful groups. RESULTS During the studied period, 223 patients underwent liver resections, among which 103 had major hepatectomies. N = 147 patients (66%) were discharged within our ERAS protocol target (6 days). On multivariable analysis, sitting out of bed by POD 1 (p < 0.03), walking by POD 3 (p = 0.03), removal of urinary catheter by POD 3 (p < 0.01), and avoiding major complications (p < 0.01) were factors associated with successful completion to our ERAS protocol; whereas advanced age (p = 0.34) and discontinuation of PCA/epidural by POD 3 (p = 0.50) were not significant parameters. There was a significant difference in the length of stay (p < 0.01) following major and minor liver resection, of which the indications for surgery also varied significantly. There was no difference in hospital re-admission rate, and morbidity and mortality between major and minor liver resection. CONCLUSIONS Facilitating early mobilisation and reducing postoperative complications are keys to successful outcomes of ERAS in liver resection.
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Ahmed EA, Montalti R, Nicolini D, Vincenzi P, Coletta M, Vecchi A, Mocchegiani F, Vivarelli M. Fast track program in liver resection: a PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2016; 95:e4154. [PMID: 27428206 PMCID: PMC4956800 DOI: 10.1097/md.0000000000004154] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND FT program (FT) is a multimodal approach used to enhance postoperative rehabilitation and accelerate recovery. It was 1st described in open heart surgery, then modified and applied successfully in colorectal surgery. FT program was described in liver resection for the 1st time in 2008. Although the program has become widely accepted, it has not yet been considered the standard of care in liver surgery. OBJECTIVES we performed this systematic review and meta-analysis to evaluate the impact of using the FT program compared to the traditional care (TC), on the main clinical and surgical outcomes for patients who underwent elective liver resection. METHODS PubMed/Medline, Scopus, and Cochran databases were searched to identify eligible articles that compared FT with TC in elective liver resection to be included in this study. Subgroup meta-analysis between laparoscopic and open surgical approaches to liver resection was also conducted. Quality assessment was performed for all the included studies. Odds ratios (ORs) and mean differences (MDs) were considered as a summary measure of evaluating the association in this meta-analysis for dichotomous and continuous data, respectively. A 95% confidence interval (CI) was reported for both measures. I was used to assess the heterogeneity across studies. RESULTS From 2008 to 2015, 3 randomized controlled trials (RCTs) and 5 cohort studies were identified, including 394 and 416 patients in the FT and TC groups, respectively. The length of hospital stay (LoS) was markedly shortened in both the open and laparoscopic approaches within the FT program (P < 0.00001). The reduced LoS was accompanied by accelerated functional recovery (P = 0.0008) and decreased hospital costs, with no increase in readmission, morbidity, or mortality rates. Moreover, significant results were found within the FT group such as reduced operative time (P = 0.03), lower intensive care unit admission rate (P < 0.00001), early bowel opening (P ≤ 0.00001), and rapid normal diet restoration (P ≤ 0.00001). CONCLUSION FT program is safe, feasible, and can be applied successfully in liver resection. Future RCTs on controversial issues such as multimodal analgesia and adherence rate are needed. Specific FT guidelines should be developed for liver resection.
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Affiliation(s)
- Emad Ali Ahmed
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
- Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Sohag University, Sohag, Egypt
| | - Roberto Montalti
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Daniele Nicolini
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Vincenzi
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Martina Coletta
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Andrea Vecchi
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Federico Mocchegiani
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
- Correspondence: Federico Mocchegiani, Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, A.O.U. “Ospedali Riuniti”, via Conca 71, 60126 Ancona, Italy (e-mail: )
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
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Adherence to ERAS elements in major visceral surgery—an observational pilot study. Langenbecks Arch Surg 2016; 401:349-56. [DOI: 10.1007/s00423-016-1407-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 03/14/2016] [Indexed: 02/06/2023]
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Clark CJ, Ali SM, Zaydfudim V, Jacob AK, Nagorney DM. Safety of an Enhanced Recovery Pathway for Patients Undergoing Open Hepatic Resection. PLoS One 2016; 11:e0150782. [PMID: 26950852 PMCID: PMC4780831 DOI: 10.1371/journal.pone.0150782] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 02/17/2016] [Indexed: 01/22/2023] Open
Abstract
Background Enhanced recovery pathways (ERP) have not been widely implemented for hepatic surgery. The aim of this study was to evaluate the safety of an ERP for patients undergoing open hepatic resection. Methods A single-surgeon, retrospective observational cohort study was performed comparing the clinical outcomes of patients undergoing open hepatic resection treated before and after implementation of an ERP. Morbidity, mortality, and length of hospital stay (LOS) were compared between pre-ERP and ERP groups. Results 126 patients (pre-ERP n = 73, ERP n = 53) were identified for the study. Patient characteristics and operative details were similar between groups. Overall complication rate was similar between pre-ERP and ERP groups (37% vs. 28%, p = 0.343). Before and after pathway implementation, the median LOS was similar, 5 (IQR 4–7) vs. 5 (IQR 4–6) days, p = 0.708. After adjusting for age, type of liver resection, and ASA, the ERP group had no increased risk of major complication (OR 0.38, 95% CI 0.14–1.02, p = 0.055) or LOS greater than 5 days (OR 1.21, 95% CI 0.56–2.62, p = 0.627). Conclusions Routine use of a multimodal ERP is safe and is not associated with increased postoperative morbidity after open hepatic resection.
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Affiliation(s)
- Clancy J. Clark
- Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, United States of America
- * E-mail:
| | - Shahzad M. Ali
- Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Victor Zaydfudim
- Department of General Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Adam K. Jacob
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - David M. Nagorney
- Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota, United States of America
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Liang X, Ying H, Wang H, Xu H, Yu H, Cai L, Wang Y, Tong Y, Ji L, Luo R, Cai XJ. Enhanced Recovery Program Versus Traditional Care in Laparoscopic Hepatectomy. Medicine (Baltimore) 2016; 95:e2835. [PMID: 26937913 PMCID: PMC4779010 DOI: 10.1097/md.0000000000002835] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) has shown effectiveness in terms of reducing the hospital stay and cost associated with open liver resection. However, the benefit of ERAS in patients undergoing laparoscopic liver resection is still unclear, and clinical studies on this topic are limited.The ERAS program for laparoscopic liver resection was used in a group of 80 patients (ERAS group). The results were compared with those in a control group of 107 patients. All patients underwent laparoscopic liver resection. The primary endpoints were the postoperative hospital stay, defined as the number of days from surgery to discharge, and the hospitalization expense. The secondary endpoints were resumption of oral intake, readmissions, and complications.The median postoperative hospital stay was 6.2 ± 2.6 days in the ERAS group, which was significantly shorter than that in the control group (9.9 ± 5.9 d; P < 0.001). The hospitalization cost was $6871 ± 2571 in the ERAS group and $7948 ± 3630 in the control group (P = 0.020). The morbidity rate was 22.5% (18 of 80 patients) in the ERAS group and 43.9% (47 of 107 patients) in the control group (P = 0.002). There were no significant differences the in rate of readmission between the 2 groups.Enhanced recovery after surgery for laparoscopic liver resection is safe and effective. Patients in the ERPS group had a shorter hospital stay, fewer complications, and lower hospital costs.
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Affiliation(s)
- Xiao Liang
- From the Department of General Surgery (LX, YH, YH, CL, WY, TY, JL, LR, CX-J); Department of Anesthesiology (WH); and Department of Nursing (XH), The Sir Run Run Shaw Hospital, Medical College of Zhejiang University, Hangzhou, China
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Abstract
Postoperative fast-track recovery protocols combine various methods to support immediate care of patients who undergo major surgery. These protocols include control of postoperative pain and early beginning of oral diet and mobilization. The combination of these approaches may reduce the rate of postoperative complications and facilitate hospital discharge. The aim of this study was to evaluate progress and parameters of fast-track recovery after major liver and pancreatic resection. A descriptive bibliographical review from 2001 to 2012 via electronic databases such as MEDLINE, PubMed, and Google Scholar was undertaken. Articles that focused on a fast-track protocol were studied. Reports focusing on the implementation of a fast-track protocol in the postoperative recovery of patients after major hepatectomy or pancreatectomy were selected. Fast-track protocols may be applicable to patients recovering after major liver or pancreatic resection. Future research should be focused on particular parameters of the fast-track protocol separately.
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Day RW, Cleeland CS, Wang XS, Fielder S, Calhoun J, Conrad C, Vauthey JN, Gottumukkala V, Aloia TA. Patient-Reported Outcomes Accurately Measure the Value of an Enhanced Recovery Program in Liver Surgery. J Am Coll Surg 2015; 221:1023-30.e1-2. [PMID: 26611799 DOI: 10.1016/j.jamcollsurg.2015.09.011] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 09/09/2015] [Accepted: 09/09/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Enhanced recovery (ER) pathways have become increasingly integrated into surgical practice. Studies that compare ER and traditional pathways often focus on outcomes confined to inpatient hospitalization and rarely assess a patient's functional recovery. The aim of this study was to compare functional outcomes for patients treated on an Enhanced Recovery in Liver Surgery (ERLS) pathway vs a traditional pathway. STUDY DESIGN One hundred and eighteen hepatectomy patients rated symptom severity and life interference using the validated MD Anderson Symptom Inventory preoperatively and postoperatively at every outpatient visit until 31 days after surgery. The ERLS protocol included patient education, narcotic-sparing anesthesia and analgesia, diet advancement, restrictive fluid administration, early ambulation, and avoidance of drains and tubes. RESULTS Seventy-five ERLS pathway patients were clinically comparable with 43 patients simultaneously treated on a traditional pathway. The ERLS patients reported lower immediate postoperative pain scores and experienced fewer complications and decreased length of stay. As measured by symptom burden on life interference, ERLS patients were more likely to return to baseline functional status in a shorter time interval. The only independent predictor of faster return to baseline interference levels was treatment on an ERLS pathway (p = 0.021; odds ratio = 2.62). In addition, ERLS pathway patients were more likely to return to intended oncologic therapy (95% vs 87%) at a shorter time interval compared to patients on the traditional pathway (44.7 vs 60.2 days). CONCLUSIONS In oncologic liver surgery, enhanced recovery's primary mechanism of action is reduction in life interference by postoperative surgical symptoms, allowing patients to return sooner to normal function and adjuvant cancer therapies.
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Affiliation(s)
- Ryan W Day
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charles S Cleeland
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xin S Wang
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sharon Fielder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John Calhoun
- Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claudius Conrad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vijaya Gottumukkala
- Department of Anesthesiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Hughes MJ, Harrison EM, Peel NJ, Stutchfield B, McNally S, Beattie C, Wigmore SJ. Randomized clinical trial of perioperative nerve block and continuous local anaesthetic infiltration via wound catheter versus epidural analgesia in open liver resection (LIVER 2 trial). Br J Surg 2015; 102:1619-28. [PMID: 26447461 DOI: 10.1002/bjs.9949] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 08/04/2015] [Accepted: 08/25/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Analgesia after liver surgery remains controversial. A previous randomized trial of continuous wound infiltration (CWI) versus thoracic epidural analgesia (TEA) after liver surgery (LIVER trial) showed a faster recovery time in the wound infiltration group but better early postoperative pain scores in the TEA group. High-level evidence is, however, limited and opinion remains divided. The aim was to determine whether there is a difference in functional recovery time between patients having CWI plus abdominal nerve blocks versus TEA after liver resection. METHODS A randomized unblinded clinical trial of patients undergoing open liver resection was commenced in December 2012, with follow-up to August 2014. Patients were randomized to receive either wound catheter and nerve block (CWI group) or TEA for 48 h after surgery. The primary outcome measure was functional recovery time. Secondary outcomes were pain scores, complication rates, inflammatory response and central venous pressure (CVP) during transection. RESULTS Of 50 patients randomized initially to each group, 44 received TEA and 49 CWI. Median (i.q.r.) recovery time was 6·5 (5-9·75) and 5·75 (4-7) days in the TEA and CWI groups respectively (P = 0·036). Pain scores were not significantly different between the two groups, and there were no differences in morbidity, inflammatory response or CVP during transection. CONCLUSION Wound infiltration is associated with a reduced time to recovery after open liver resection compared with epidural analgesia. TEA does not offer an advantage over CWI in terms of attenuation of the inflammatory response or pain scores. REGISTRATION NUMBER NCT01747122 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- M J Hughes
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - E M Harrison
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - N J Peel
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - B Stutchfield
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S McNally
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - C Beattie
- Departments of Anaesthesia, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S J Wigmore
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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Fast-Track Programs for Liver Surgery: A Meta-Analysis. J Gastrointest Surg 2015; 19:1640-52. [PMID: 26160321 DOI: 10.1007/s11605-015-2879-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 06/22/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Plentiful publications have inspected the feasibility of fast-track surgery programs during hepatic surgery, but the potency of these studies has not been discussed profoundly so far. Our goal was to assess the effects of fast-track programs on surgical outcomes compared with traditional surgical plans for liver surgery. METHODS The following databases were searched: PubMed, Cochrane library, Embase, Science Citation Index Expanded, etc. Studies meeting our inclusion criteria were included. All interrelated data and the methodological quality of included studies were extracted and assessed. We applied risk ratio and weighted mean difference as the estimated effect measures. Sensitivity analysis was performed to perceive the reliability of our findings. RESULTS Altogether, 14 studies with 1400 patients were analyzed. Meta-analysis of randomized controlled trials demonstrated that implementation of fast-track surgery programs could observably decrease the total length of hospital stay, complication rate, postoperative first flatus time, and hospitalization expense, and did not compromise mortality and readmission rate. The above findings were also in line with the results of case-control studies. CONCLUSIONS Fast-track surgery programs are feasible and effective for liver surgery. Future studies should optimize fast-track surgery programs catering to liver surgery.
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Ni TG, Yang HT, Zhang H, Meng HP, Li B. Enhanced recovery after surgery programs in patients undergoing hepatectomy: A meta-analysis. World J Gastroenterol 2015; 21:9209-9216. [PMID: 26290648 PMCID: PMC4533053 DOI: 10.3748/wjg.v21.i30.9209] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 05/19/2015] [Accepted: 06/10/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the impact of enhanced recovery after surgery (ERAS) programs in comparison with traditional care on liver surgery outcomes.
METHODS: The PubMed, EMBASE, CNKI and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials (RCTs) comparing the ERAS program with traditional care in patients undergoing liver surgery. Studies selected for the meta-analysis met all of the following inclusion criteria: (1) evaluation of ERAS in comparison to traditional care in adult patients undergoing elective open or laparoscopic liver surgery; (2) outcome measures including complications, recovery of bowel function, and hospital length of stay; and (3) RCTs. The following exclusion criteria were applied: (1) the study was not an RCT; (2) the study did not compare ERAS with traditional care; (3) the study reported on emergency, non-elective or transplantation surgery; and (4) the study consisted of unpublished studies with only the abstract presented at a national or international meeting. The primary outcomes were complications. Secondary outcomes were length of hospital stay and time to first flatus.
RESULTS: Five RCTs containing 723 patients were included in the meta-analysis. In 10/723 cases, patients presented with benign diseases, while the remaining 713 cases had liver cancer. Of the five studies, three were published in English and two were published in Chinese. Three hundred and fifty-four patients were in the ERAS group, while 369 patients were in the traditional care group. Compared with traditional care, ERAS programs were associated with significantly decreased overall complications (RR = 0.66; 95%CI: 0.49-0.88; P = 0.005), grade I complications (RR = 0.51; 95%CI: 0.33-0.79; P = 0.003), and hospital length of stay [WMD = -2.77 d, 95%CI: -3.87-(-1.66); P < 0.00001]. Similarly, ERAS programs were associated with decreased time to first flatus [WMD = -19.69 h, 95%CI: -34.63-(-4.74); P < 0.0001]. There was no statistically significant difference in grade II-V complications between the two groups.
CONCLUSION: ERAS is a safe and effective program in liver surgery. Future studies should define the active elements to optimize postoperative outcomes for liver surgery.
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Takamoto T, Hashimoto T, Inoue K, Nagashima D, Maruyama Y, Mitsuka Y, Aramaki O, Makuuchi M. Applicability of enhanced recovery program for advanced liver surgery. World J Surg 2015; 38:2676-82. [PMID: 24838485 DOI: 10.1007/s00268-014-2613-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery programs (ERPs) have been developed in various surgical fields and have been shown to accelerate postoperative recovery without increasing the incidence of adverse events. Whether ERP can be safely applied to patients undergoing complex liver surgery with a risk of liver failure remains unclear. METHODS We created an ERP by rearranging our conventional postoperative treatments and applied this program to patients undergoing major hepatectomy between 2008 and 2013. The ERP elements included greater perioperative education, individualized postoperative fluid therapy, and early mobilization. The success of the ERP was evaluated on postoperative day (POD) 6 based on the criterion of independence from continuous medical intervention with the exception of an abdominal drainage tube. Adherence to each item in the ERP was evaluated, and risk factors for delayed accomplishment were analyzed. RESULTS Altogether, 200 patients were included, and 165 patients (82.5 %) completed the ERP. Multivariate analyses showed that (1) an age of 65 years or older and (2) a red blood cell transfusion were independent risk factors for delayed accomplishment. The performance of thoracotomy or choledocojejunostomy did not significantly affect accomplishment of the ERP. Oral intake starting on POD 1 was achieved in 179 patients (89.5 %), and termination of intravenous drip infusions on POD 5 was feasible in 72.5 %. CONCLUSIONS An ERP for major hepatectomy was completed in more than 80 % of the patients. Earlier bowel movement can be challenged. The liquid in-out balance should be adjusted on an individual basis, rather than uniformly, especially for patients over 65 years of age or who required a red blood cell transfusion.
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Affiliation(s)
- Takeshi Takamoto
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation Surgery, Japanese Red Cross Medical Center, 4-1-22 Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan,
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Dasari BVM, Rahman R, Khan S, Bennett D, Hodson J, Isaac J, Marudanayagam R, Mirza DF, Muiesan P, Roberts KJ, Sutcliffe RP. Safety and feasibility of an enhanced recovery pathway after a liver resection: prospective cohort study. HPB (Oxford) 2015; 17:700-6. [PMID: 26099347 PMCID: PMC4527855 DOI: 10.1111/hpb.12447] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 05/01/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND In contrast to colorectal surgery, enhanced recovery pathways (ERPs) have not yet become standard practice after major upper abdominal surgery. The aim of this study was to assess the feasibility and outcomes after implementation of an ERP after liver a resection. METHODS Patients who underwent a liver resection in two consecutive 6-month periods before (July-December 2013) and after (January-June 2014) implementation of an ERP were included in a prospective study. Patients who underwent live donation, ALPPS (associating liver partition with portal vein ligation for staged hepatectomy) or concomitant procedures were excluded. Peri-operative outcomes were compared between groups, and multivariate analysis of factors influencing the length of hospital stay (LOS) was performed. RESULTS Two hundred and eleven patients (93 pre-ERP and 91 post-ERP patients) underwent a liver resection during the study period. There was no significant difference in the median LOS (P = 0.907) and 30-day readmission rates (P = 0.645) between the groups. Severe (Clavien grade III-V) complications were reduced in ERP patients (13.9% versus 4.3%; P = 0.039). On multivariate analysis, an increased age (< 0.001), open resection (< 0.001) and complications (< 0.001) were associated with an increased LOS. CONCLUSION Enhanced recovery after a liver resection appears to be safe, feasible and may reduce severe complications. However, the LOS was significantly influenced by patient age, open surgery and post-operative complications, but not by an ERP.
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Affiliation(s)
- Bobby V M Dasari
- The Liver Unit, Queen Elizabeth HospitalBirmingham, UK,Correspondence Bobby V. M. Dasari, The Liver Unit, Queen Elizabeth Hospital, Birmingham B15 2WB, UK. Tel: +44 772 762 1372. Fax: +121 414 1833. E-mail:
| | - Rasha Rahman
- The Liver Unit, Queen Elizabeth HospitalBirmingham, UK
| | - Shakeeb Khan
- The Liver Unit, Queen Elizabeth HospitalBirmingham, UK
| | - Davinia Bennett
- Department of Anaesthesia, Queen Elizabeth HospitalBirmingham, UK
| | - James Hodson
- Wolfson Laboratory, Queen Elizabeth HospitalBirmingham, UK
| | - John Isaac
- The Liver Unit, Queen Elizabeth HospitalBirmingham, UK
| | | | | | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth HospitalBirmingham, UK
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The effect of enhanced recovery program for patients undergoing partial laparoscopic hepatectomy of liver cancer. Clin Transl Oncol 2015; 17:694-701. [DOI: 10.1007/s12094-015-1296-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 05/02/2015] [Indexed: 12/14/2022]
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Zhu L, Li J, Li XK, Feng JQ, Gao JM. Impact of a clinical pathway on hospital costs, length of stay and early outcomes after hepatectomy for hepatocellular carcinoma. Asian Pac J Cancer Prev 2015; 15:5389-93. [PMID: 25041007 DOI: 10.7314/apjcp.2014.15.13.5389] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A clinical pathway (CP) can standardize and improve perioperative care for a number of interventions. In hepatic surgery, however, pertinent evidence is very limited. This study was conducted to implement a CP for hepatocellular carcinoma (HCC) patients undergoing hepatectomy, and to evaluate its effects on hospital costs, length of hospital stay (LOHS) and early clinical outcomes. MATERIALS AND METHODS Medical records for HCC patients undergoing hepatectomy were retrospectively reviewed before implementation of a CP (the non-CP group) from March 2012 to August 2012. This information was compared with the data collected prospectively from patients after implementation of the CP (the CP group) between September 2012 and April 2013. Hospital costs, LOHS and early clinical outcomes were evaluated and compared between groups. RESULTS There were no significant differences in terms of patient clinical characteristics between the two groups. For clinical outcome measures, no significant differences were found in postoperative complications, mortality and readmission rate. The hospital costs were significantly reduced from 24,844 RMB in the non-CP group to 19,761 RMB in the CP group (p<0.01). In addition, patients of the CP group also had shorter LOHS compared with the non-CP group (8.3 versus 12.3 days, p<0.001). CONCLUSIONS The CP proved to be an effective approach to minimize hospital costs and LOHS with hepatectomy for HCC without compromising patient care.
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Affiliation(s)
- Liang Zhu
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China E-mail :
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Page AJ, Ejaz A, Spolverato G, Zavadsky T, Grant MC, Galante DJ, Wick EC, Weiss M, Makary MA, Wu CL, Pawlik TM. Enhanced recovery after surgery protocols for open hepatectomy--physiology, immunomodulation, and implementation. J Gastrointest Surg 2015; 19:387-99. [PMID: 25472030 DOI: 10.1007/s11605-014-2712-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 11/19/2014] [Indexed: 01/31/2023]
Abstract
There has been recent interest in enhanced-recovery after surgery (ERAS®) or "fast-track" perioperative protocols in the surgical community. The subspecialty field of colorectal surgery has been the leading adopter of ERAS protocols, with less data available regarding its adoption in hepato-pancreato-biliary surgery. This review focuses on available data pertaining to the application of ERAS to open hepatectomy. We focus on four fundamental variables that impact normal physiology and exacerbate perioperative inflammation: (1) the stress of laparotomy, (2) the use of opioids, (3) blood loss and blood product transfusions, and (4) perioperative fasting. The attenuation of these inflammatory stressors is largely responsible for the improvements in perioperative outcomes due to the implementation of ERAS-based pathways. Collectively, the data suggest that the implementation of ERAS principles should be strongly considered in all patients undergoing hepatectomy.
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Affiliation(s)
- Andrew J Page
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Lei Q, Wang X, Tan S, Xia X, Zheng H, Wu C. Fast-track programs versus traditional care in hepatectomy: a meta-analysis of randomized controlled trials. Dig Surg 2014; 31:392-9. [PMID: 25547153 DOI: 10.1159/000369219] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 10/19/2014] [Indexed: 12/10/2022]
Abstract
BACKGROUND/AIMS The role of fast-track programs in hepatectomy is unclear. This meta-analysis aimed to evaluate the efficacy and safety of fast-track programs versus traditional care. METHODS We searched Pubmed, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar for relevant randomized controlled trials (RCTs) comparing fast-track with traditional care in hepatectomy. Length of hospital stay, time to first flatus, postoperative complications, operating time, and intraoperative blood loss were assessed. Meta-analyses were performed using RevMan 5.2 software. RESULTS Four original RCTs with 372 patients were included: 187 in the fast-track and 185 in the traditional care group. Fast-track patients had shorter hospital stay (WMD -2.32; 95% CI, -3.54 to -1.11; p < 0.001) and time to first flatus (WMD -0.99; 95% CI, -1.15 to -0.84; p < 0.001), and less postoperative complications (RR 0.66; 95% CI, 0.47 to 0.93; p < 0.05). However, there was significant heterogeneity between the studies regarding hospital stay (I(2) = 88%; p < 0.001). Operating time and intraoperative blood loss were not different. CONCLUSIONS Patients in fast-track programs had less time to first flatus and postoperative complications compared to traditional care. Fast-track programs may reduce the length of hospital stay. Larger, higher quality prospective RCTs are necessary to draw more robust conclusions.
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Affiliation(s)
- Qiucheng Lei
- Department of General Surgery, Jinling Hospital, Southern Medical University, Nanjing, Jiangsu Province, China
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Rosero EB, Cheng GS, Khatri KP, Joshi GP. Evaluation of epidural analgesia for open major liver resection surgery from a US inpatient sample. Proc AMIA Symp 2014; 27:305-12. [PMID: 25484494 PMCID: PMC4255849 DOI: 10.1080/08998280.2014.11929141] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The aim of this study was to assess the nationwide use of epidural analgesia (EA) and the incidence of postoperative complications in patients undergoing major liver resections (MLR) with and without EA in the United States. The 2001 to 2010 Nationwide Inpatient Sample was queried to identify adult patients undergoing MLR. A 1:1 matched cohort of patients having MLR with and without EA was assembled using propensity-score matching techniques. Differences in the rate of postoperative complications were compared between the matched groups. We identified 68,028 MLR. Overall, 5.9% of patients in the database had procedural codes for postoperative EA. A matched cohort of 802 patients per group was derived from the propensity-matching algorithm. Although use of EA was associated with more blood transfusions (relative risk, 1.36; 95% confidence interval, 1.12-1.65; P = 0.001) and longer hospital stay (median [interquartile range], 6 [5-8] vs 6 [4-8] days), the use of coagulation factors and the incidence of postoperative hemorrhage/hematomas or other postoperative complications were not higher in patients receiving EA. In conclusion, the use of EA for MLR is low, and EA does not seem to influence the incidence of postoperative complications. EA, however, was associated with an increased use of blood transfusions and a longer hospital stay.
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Affiliation(s)
- Eric B Rosero
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Gloria S Cheng
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kinnari P Khatri
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center, Dallas, Texas
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Hughes MJ, McNally S, Wigmore SJ. Enhanced recovery following liver surgery: a systematic review and meta-analysis. HPB (Oxford) 2014; 16:699-706. [PMID: 24661306 PMCID: PMC4113251 DOI: 10.1111/hpb.12245] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 01/17/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programmes aim to improve postoperative outcomes. They are being utilized increasingly in hepatic surgery. This review aims to evaluate the impact of ERAS programmes on outcomes following liver surgery. METHODS EMBASE, MEDLINE, PubMed and the Cochrane Database were searched for trials comparing outcomes in patients undergoing liver surgery utilizing ERAS principles with those in patients receiving conventional care. The primary outcome was occurrence of postoperative complications within 30 days. Secondary outcomes included length of stay (LoS), functional recovery and adherence to ERAS protocols. RESULTS Nine articles were included in the review, of which two were randomized controlled trials (RCTs). Overall complication rates were 25.0% (range: 11.5-46.4%) in ERAS patients, and 31.0% (range: 11.8-46.2%) in conventional care patients. Significantly reduced overall complication rates following ERAS care were demonstrated by a meta-analysis of the data reported in the two RCTs (odds ratio: 0.49, 95% confidence interval 0.28-0.84; P = 0.01) The median LoS reported by the studies was 5.0 days (range: 2.5-7.0 days) in ERAS patients, and 7.5 days (range: 3.0-11.0 days) in non-ERAS patients. Recovery milestones, when reported, were improved following ERAS care. CONCLUSIONS The adoption of ERAS protocols improves morbidity and LoS following liver surgery. Future ERAS programmes should accommodate the unique requirements of liver surgery in order to optimize postoperative outcomes.
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Affiliation(s)
- Michael J Hughes
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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Lee A, Chiu CH, Cho MWA, Gomersall CD, Lee KF, Cheung YS, Lai PBS. Factors associated with failure of enhanced recovery protocol in patients undergoing major hepatobiliary and pancreatic surgery: a retrospective cohort study. BMJ Open 2014; 4:e005330. [PMID: 25011990 PMCID: PMC4120378 DOI: 10.1136/bmjopen-2014-005330] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE This study examined the risk factors associated with failure of enhanced recovery protocol after major hepatobiliary and pancreatic (HBP) surgery. SETTING AND PARTICIPANTS A retrospective cohort of 194 adult patients undergoing major HBP surgery at a university hospital in Hong Kong was followed up for 30 days. The patients were from a larger cohort study of 736 consecutive adults with preoperative urinary cotinine concentration to examine the association between passive smoking and risk of perioperative respiratory complications and postoperative morbidities. OUTCOME MEASURES The primary outcome was failure of enhanced recovery protocol. This was defined as a composite measure of the following events: intensive care unit (ICU) stay more than 24 h after surgery, unplanned admission to ICU within 30 days after surgery, hospital readmission, reoperation and mortality. RESULTS There were 25 failures of enhanced recovery after HBP surgery (12.9%, 95% CI 8.5% to 18.4%). After adjusting for elective ICU admission, smokers (relative risk (RR ) 2.21, 95% CI 1.10 to 4.46), high preoperative alanine transaminase/glutamic-pyruvic transaminase (RR 3.55,95% CI 1.68 to 7.49) and postoperative morbidities (RR 2.69, 95% CI 1.30 to 5.56) were associated with failures of enhanced recovery in the generalised estimating equation risk model. Compared with those managed successfully, failures stayed longer in ICU (median 19 vs 25 h, p<0.001) and in hospital for postoperative care (median 7 vs 13 days, p=0.003). CONCLUSIONS Smokers and patients having high preoperative alanine transaminase/glutamic-pyruvic transaminase concentration or have a high risk of postoperative morbidities are likely to fail enhanced recovery protocol in HBP surgery programmes.
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Affiliation(s)
- Anna Lee
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Chun Hung Chiu
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Mui Wai Amy Cho
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Charles David Gomersall
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kit Fai Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Yue Sun Cheung
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Paul Bo San Lai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
- Wong Tze Lam – Hing Tak Centre of Surgical Outcome Research, The Chinese University of Hong Kong, Hong Kong
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