The effect of enhanced recovery program for patients undergoing partial laparoscopic hepatectomy of liver cancer

Feasibility, safety and effectiveness of the enhanced recovery after surgery protocol in patients undergoing liver resection

Backgrounds/Aims

The implementation of enhanced recovery after surgery (ERAS) protocols has demonstrated significant advantages for patients by mitigating surgical stress and expediting recovery across a spectrum of surgical procedures worldwide. This investigation seeks to assess the effectiveness of the ERAS protocol specifically in the context of major liver resections within our geographical region.

Methods

Our department conducted retrospective analysis of prospectively collected data, gathered from consenting individuals who underwent liver resections from January 2018 to December 2023. The assessment encompassed baseline characteristics, preoperative indications, surgical outcomes, and postoperative complications among patients undergoing liver surgery.

Results

Among the included 184 patients (73 standard care, 111 ERAS program), the baseline characteristics were similar. Median postoperative hospital stay differed significantly: 5 days (range: 3-13 days) in ERAS, and 11 days (range: 6-22 days) in standard care (p < 0.001). Prophylactic abdominal drainage was less in ERAS (54.9%) than in standard care (86.3%, p < 0.001). Notably, in ERAS, 88.2% initiated enteral feeding orally on postoperative day 1, significantly higher than in standard care (47.9%, p < 0.001). Early postoperative mobilization was more common in ERAS (84.6%) than in standard care (36.9%, p < 0.001). Overall complication rates were 21.9% in standard care, and 8.1% in ERAS (p = 0.004).

Conclusions

Our investigation highlights the merits of ERAS protocol; adherence to its diverse components results in significant reduction in hospital length of stay, and reduced occurrence of postoperative complications, improving short-term recovery post liver resection.

Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials

Importance

A comprehensive review of the evidence exploring the outcomes of enhanced recovery after surgery (ERAS) guidelines has not been completed.

Objective

To evaluate if ERAS guidelines are associated with improved hospital length of stay, hospital readmission, complications, and mortality compared with usual surgical care, and to understand differences in estimates based on study and patient factors.

Data Sources

MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central were searched from inception until June 2021.

Study Selection

Titles, abstracts, and full-text articles were screened by 2 independent reviewers. Eligible studies were randomized clinical trials that examined ERAS-guided surgery compared with a control group and reported on at least 1 of the outcomes.

Data Extraction and Synthesis

Data were abstracted in duplicate using a standardized data abstraction form. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Risk of bias was assessed in duplicate using the Cochrane Risk of Bias tool. Random-effects meta-analysis was used to pool estimates for each outcome, and meta-regression identified sources of heterogeneity within each outcome.

Main Outcome and Measures

The primary outcomes were hospital length of stay, hospital readmission within 30 days of index discharge, 30-day postoperative complications, and 30-day postoperative mortality.

Results

Of the 12 047 references identified, 1493 full texts were screened for eligibility, 495 were included in the systematic review, and 74 RCTs with 9076 participants were included in the meta-analysis. Included studies presented data from 21 countries and 9 ERAS-guided surgical procedures with 15 (20.3%) having a low risk of bias. The mean (SD) Reporting on ERAS Compliance, Outcomes, and Elements Research checklist score was 13.5 (2.3). Hospital length of stay decreased by 1.88 days (95% CI, 0.95-2.81 days; I2 = 86.5%; P < .001) and the risk of complications decreased (risk ratio, 0.71; 95% CI, 0.59-0.87; I2 = 78.6%; P < .001) in the ERAS group. Risk of readmission and mortality were not significant.

Conclusions and Relevance

In this meta-analysis, ERAS guidelines were associated with decreased hospital length of stay and complications. Future studies should aim to improve implementation of ERAS and increase the reach of the guidelines.

The effect of early oral postoperative feeding on the recovery of intestinal motility after gastrointestinal surgery: a systematic review and meta-analysis of randomized clinical trials

Background and aims

Postoperative ileus is a frequent condition, leading to complications and a longer hospital stay. Few studies have demonstrated the benefit of early oral feeding in preventing ileus after gastrointestinal surgery. This study aims to evaluate the efficacy of early versus delayed oral feeding on the recovery of intestinal motility, length of hospital stay, and complications.

Methods

We conducted a systematic review and meta-analysis of randomized control trials, searching PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, and the ClincalTrials.gov until 31 December 2022. We evaluated the first passage of the stool, the first flatus, complications, length of postoperative stay, and vomiting. We assessed the risk of bias using the Cochrane risk of bias tool (version 2) for randomized trials and the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation methodology.

Results

We included 34 studies with a median sample size of 102 participants. With a moderate certainty of the evidence, the early oral feeding may reduce the time taken for the first passage of the stool (MD -0.99 days; CI 95% -1.25, -0.72), the first flatus (MD -0.70 days; CI 95% -0.87, -0.53), and the risk of complications (RR 0.69; CI 95% 0.59-0.80), while with a low certainty of evidence, it may reduce the length of stay (MD -1.31 days; CI 95% -1.59, -1.03). However, early feeding likely does not affect the risk of vomiting (RR 0.90; CI 95% 0.68, 1.18).

Conclusion

This review suggests that early oral feeding after gastrointestinal surgery may lead to a faster intestinal recovery, shorter postoperative stays, and fewer complications. However, careful interpretation is needed due to high heterogeneity and the moderate-to-low quality of evidence. Future studies should focus on the type and starting time of early oral feeding.

Effects of enhance recovery after surgery nursing program on the surgical site wound infection in patients undergoing laparoscopic hepatectomy for hepatocellular carcinoma: A meta-analysis

Our study aimed to investigate the effects of an enhanced recovery after surgery (ERAS) nursing program on surgical site wound infections (SSWI) and postoperative complications in patients undergoing laparoscopic hepatectomy (LH) for hepatocellular carcinoma. Computer searches of the PubMed, Cochrane Library, Web of Science, Embase, China National Knowledge Infrastructure and Wanfang databases were conducted to gather randomised controlled trials (RCTs) that were published from inception to September 2023. The target studies evaluated the effects of the ERAS nursing program in patients undergoing LH for hepatocellular carcinoma. Two independent authors screened the literature, extracted the data and performed quality assessments. Dichotomous variables were analysed using odds ratios (ORs) and 95% confidence intervals (CIs), as effect analysis statistics. Stata software (version 17.0) was used for data analysis. Eleven RCTs with 765 patients were included, with 383 patients in the ERAS group and 382 in the control group. The results revealed that the incidence of SSWI (OR = 0.32, 95%CI:0.15-0.71, p = 0.004) and postoperative complications (OR = 0.23, 95%CI:0.15-0.34, p < 0.001) were both significantly reduced in the ERAS group, compared with the control group. The ERAS nursing program, when applied to patients undergoing laparoscopic hepatic cancer resection, can effectively reduce the incidence of SSWI and postoperative complications, thus promoting postoperative recovery.

Impact of enhanced recovery pathways on patient-reported outcomes after abdominal surgery: a systematic review

INTRODUCTION

Evidence supports that enhanced recovery pathways (ERPs) reduce length of stay and complications; however, these measures may not reflect the perspective of patients who are the main stakeholders in the recovery process. This systematic review aimed to appraise the evidence regarding the impact of ERPs on patient-reported outcomes (PROs) after abdominal surgery.

METHODS

Five databases (Medline, Embase, Biosis, Cochrane, and Web of Science) were searched for randomized controlled trials (RCTs) addressing the impact of ERPs on PROs after abdominal surgery. We focused on distinct periods of recovery: early (within 7 days postoperatively) and late (beyond 7 days). Risk of bias was assessed using Cochrane's RoB 2.0. Results were appraised descriptively as heterogeneity hindered meta-analysis. Certainty of evidence was evaluated using GRADE.

RESULTS

Fifty-six RCTs were identified [colorectal (n = 18), hepatopancreaticobiliary (HPB) (n = 11), upper gastrointestinal (UGI) (n = 10), gynecological (n = 7), urological (n = 7), general surgery (n = 3)]. Most trials had 'some concerns' (n = 30) or 'high' (n = 25) risk of bias. In the early postoperative period, ERPs improved patient-reported general health (colorectal, HPB, UGI, urological; very low to low certainty), physical health (colorectal, gynecological; very low to low certainty), mental health (colorectal, gynecological; very low certainty), pain (all specialties; very low to moderate certainty), and fatigue (colorectal; low certainty). In the late postoperative period, ERPs improved general health (HPB, UGI, urological; very low certainty), physical health (UGI, gynecological, urological; very low to low certainty), mental health (UGI, gynecological, urological; very low certainty), social health (gynecological; very low certainty), pain (gynecological, urological; very low certainty), and fatigue (gynecological; very low certainty).

CONCLUSION

This review supports that ERPs may have a positive impact on patient-reported postoperative health status (i.e., general, physical, mental, and social health) and symptom experience (i.e., pain and fatigue) after abdominal surgery; however, data were largely derived from low-quality trials. Although these findings contribute important knowledge to inform evidence-based ERP implementation, there remains a great need to improve PRO assessment in studies focused on postoperative recovery.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Retroperitoneal localized neuroblastoma in children: a comparison of enhanced recovery after surgery versus traditional care

PURPOSE

To investigate the clinical value of enhanced recovery after surgery (ERAS) protocols for children with neuroblastoma (NB).

METHODS

This retrospective review was conducted by using the electronic medical records of 48 children with retroperitoneal localized NB who underwent tumor resection (surgery for treatment, not diagnosis) between October 2016 and September 2021. The ERAS protocols for NB excision were implemented in 28 children (ERAS group), while 20 children received traditional care (TRAD group). The same group of pediatric surgeons performed all the tumor resections. Intraoperative fluid infusion, the extent of NB resection, time of early ambulation and time of first flatus, time to total enteral nutrition (TEN) after surgery, abdominal drainages, nasogastric tubes and urinary catheters used and duration, the Face/Legs/Activity/Cry/Consolability (FLACC) quantitative table on a postoperative day 1 (POD1), 3, 5, length of stay after surgery (LOS), hospitalization expense, postoperative complications, parental satisfaction rate and readmission rate of surgical wards within 30 days after operation were analyzed.

RESULTS

The median postoperative period of early mobilization, first flatus, TEN, LOS and total cost during hospitalization were 1.0 days, 2.0 days, 5.5 days, 9.0 days and 33,397.3 yuan in the ERAS group and 3.0 days, 3.0 days, 7.0 days, 11.0 days and 38,120.3 Yuan in the TRAD group, respectively (all p < 0.05). Median intraoperative fluid volume was 5.0 mL/kg/h compared to 8.0 mL/kg/h and the magnitude of decrease in FLACC scores from POD1 to POD5 was greater in the ERAS group (all p < 0.05). Abdominal drainages, urinary catheters and nasogastric tubes were removed earlier in the ERAS group (p < 0.05). The satisfaction of parents in the ERAS group was slightly higher, but the difference was not statistically significant (P = 0.762). There were no marked differences between the two groups in aspects of the extent of NB resection, operation-related complications and 30-day readmissions (all P = 1.000).

CONCLUSIONS

Application of ERAS protocols in localized retroperitoneal NBs resection in children is feasible and safe. However, applying ERAS protocols in the surgical resection of solid tumors in children still requires much more research, especially randomized prospective research.

Delayed return of gastrointestinal function after hepatectomy in an ERAS program: incidence and risk factors

BACKGROUND

Delayed return of gastrointestinal function (DGIF) after hepatectomy can involve increased morbidity and prolonged hospital stay. Yet, data on incidence and risks factors are lacking.

METHODS

All consecutive patients who underwent hepatectomy between June 2018 and December 2020 were included. All patients were included in an enhanced recovery after surgery (ERAS) program. DGIF was defined by the need for nasogastric tube (NGT) insertion after surgery. DGIF risk factors were identified.

RESULTS

Overall, 206 patients underwent hepatectomy. DGIF occurred in 41 patients (19.9%) after a median time of 2 days (range, 1-14). Among them, 6 patients (14.6%) developed aspiration pneumonia, of which one required ICU for mechanical ventilation. DGIF developed along with an intraabdominal complication in 7 patients (biliary fistula, n = 5; anastomotic fistula, n = 1; adhesive small bowel obstruction, n = 1). DGIF was associated with significantly increased severe morbidity rate (p = 0.001), prolonged time to normal food intake (p < 0.001) and hospital stay (p < 0.001) and significantly decreased overall compliance rate (p = 0.001). Independent risk factors of DGIF were age (p < 0.001), vascular reconstruction (p = 0.007), anaesthetic induction using volatiles (p = 0.003) and epidural analgesia (p = 0.004). Using these 4 variables, a simple DGIF risk score has been developed allowing patient stratification in low-, intermediate- and high-risk groups.

CONCLUSION

DGIF after hepatectomy was frequently observed and significantly impacted postoperative outcomes. Identifying risk factors remains critical for preventing its occurrence.

Systematic Review of Functional Outcomes in Cancer Rehabilitation

OBJECTIVE

To systematically review the evidence regarding rehabilitation interventions targeting optimal physical or cognitive function in adults with a history of cancer and describe the breadth of evidence as well as strengths and limitations across a range of functional domains.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Plus, Scopus, Web of Science, and Embase. The time scope was January 2008 to April 2019.

STUDY SELECTION

Prospective, controlled trials including single- and multiarm cohorts investigating rehabilitative interventions for cancer survivors at any point in the continuum of care were included, if studies included a primary functional outcome measure. Secondary data analyses and pilot/feasibility studies were excluded. Full-text review identified 362 studies for inclusion.

DATA EXTRACTION

Extraction was performed by coauthor teams and quality and bias assessed using the American Academy of Neurology (AAN) Classification of Evidence Scheme (class I-IV).

DATA SYNTHESIS

Studies for which the functional primary endpoint achieved significance were categorized into 9 functional areas foundational to cancer rehabilitation: (1) quality of life (109 studies), (2) activities of daily living (61 studies), (3) fatigue (59 studies), (4) functional mobility (55 studies), (5) exercise behavior (37 studies), (6) cognition (20 studies), (7) communication (10 studies), (8) sexual function (6 studies), and (9) return to work (5 studies). Most studies were categorized as class III in quality/bias. Averaging results found within each of the functional domains, 71% of studies reported statistically significant results after cancer rehabilitation intervention(s) for at least 1 functional outcome.

CONCLUSIONS

These findings provide evidence supporting the efficacy of rehabilitative interventions for individuals with a cancer history. The findings should be balanced with the understanding that many studies had moderate risk of bias and/or limitations in study quality by AAN criteria. These results may provide a foundation for future work to establish clinical practice guidelines for rehabilitative interventions across cancer disease types.

Early postoperative ERAS compliance predicts decreased length of stay and complications following liver resection

BACKGROUND

Enhanced recovery after surgery (ERAS) components for liver resection lack standardization and compliance. We evaluated our ERAS protocol and describe the association of postoperative ERAS compliance with length of stay (LOS) and complications.

METHODS

We retrospectively reviewed patients undergoing liver resection at our institution from 2016 to 2020. Pre- and post-ERAS outcomes and compliance at 72 h were compared with LOS and complications. LOS beyond 72 h was defined as LOS72.

RESULTS

210 patients were included. Post-ERAS patients had significantly shorter LOS (5.1 vs. 7.3 days, p = 0.0014) with no difference in 30-day mortality, morbidity, or readmissions. ERAS components associated with shorter LOS72 were regular diet (HR 1.73), fluid discontinuation (HR 1.63), drain removal (HR 1.94), multimodal and oral analgesia (HR 1.51), and ambulation >100 ft (HR 2.23). LOS72 was 1-day for ≥9 ERAS component compliance, 4-days for 6-8 components, and 6-days for <6 components. 30-day complication rates for patients with ≥9 components by postoperative day 3 (POD3) were significantly lower than those with 6-8 (12 vs 32%).

CONCLUSION

ERAS decreases LOS after liver resection. Nutritional advancement, drain discontinuation, multimodal and oral analgesia, and ambulation >100 ft by POD3 are associated with decreased LOS72. Achieving ≥6 components by POD3 predicts decreased LOS72 and complications.

Improving safety and efficacy with pharmacist medication reconciliation in orthopedic joint surgery within an enhanced recovery after surgery program

PURPOSE

To investigate the impact of medication reconciliation (MR), through avoidance of unintentional medication discrepancies, on enhanced recovery after surgery programs designed for older patients undergoing orthopedic joint surgery.  METHOD: Our study was divided into two phases. In the first phase, MR was performed for elderly patients undergoing orthopedic joint surgery. Types of medication discrepancies and their potential risks were analyzed. In the second phase, a controlled study was conducted in a subgroup of patients diagnosed with periprosthetic joint infection (PJI) and who were scheduled for two-stage revision. The primary goal was to investigate the impact of MR on length of stay for the first stage. The secondary goal was to investigate the time between the first admission and the reimplantation of a new prosthesis, the number of readmissions within 30 days, hospitalization cost.

RESULTS

A total of 506 medication discrepancies were identified in the included 260 patients. Intolerance had the highest incidence (n = 131, 25.7%). The Bayliff tool showed that 71.9% were assessed as level 2 risk, and 10.3% had a life-threatening risk. For patients with PJI, MR reduced the average length of stay in the first stage (16.3 days vs. 20.7 days, P = 0.03) and shortened the time (57.3 days vs. 70.5 days, P = 0.002) between the first admission and the reimplantation of a new prosthesis. The average cost of hospital stay ($8589.6 vs. $10,422.6, P = 0.021), antibiotics ($1052.2 vs. $1484.7, P = 0.032) and other medications ($691.5 vs. $1237.6, P = 0.014) per patient at our hospital were significantly decreased. Notably, significant improvements in patient satisfaction were seen in participants in the MR group.

CONCLUSION

Through MR by clinical pharmacists, medication discrepancies within the orthopedic ERAS program could be identified. For patients with periprosthetic joint infection, better patient satisfaction and clinical and economical outcomes can be achieved with this method.

Enhanced Recovery Care vs. Traditional Care in Laparoscopic Hepatectomy: A Systematic Review and Meta-Analysis

Background

Enhanced recovery care could alleviate surgical stress and accelerate the recovery rates of patients. Previous studies showed the benefits of enhanced recovery after surgery program in liver surgery, but the exact role in laparoscopic hepatectomy is still unclear.

Aim

We aimed to perform a meta-analysis to evaluate the safety and efficacy of enhanced recovery after a surgery program in laparoscopic hepatectomy.

Methods

The relative studies from a specific search of PUBMED, EMBASE, OVID, and Cochrane database from June 2008 to February 2022 were selected and included in this meta-analysis. The primary outcomes included length of hospital stay, duration to functional recovery, and overall postoperative complication rate. The secondary outcomes included operative time, intraoperative blood loss, cost of hospitalization, readmission rate, Grade I complication rate, and Grade II–V complication rate.

Results

A total of six studies with 643 patients [enhanced recovery care (n = 274) vs. traditional care (n = 369)] were eligible for analysis. These comprised three randomized controlled trials and three retrospective studies. Enhanced recovery care group was associated with decreased hospital stay [standard mean difference (SMD) = −0.56, 95% confidence interval (CI) = −0.83~−0.28, p < 0.0001], shorter duration to functional recovery (SMD = −1.14, 95% CI = −1.92~−0.37, p = 0.004), and lower cost of hospitalization Mean Difference (MD) = −1,539.62, 95% CI = −1992.85~−1086.39, p < 0.00001). Moreover, a lower overall postoperative complication rate was observed in enhanced recovery care group [Risk ratio (RR) = 0.64, 95% CI = 0.51~0.80, p < 0.0001] as well as lower Grade II–V complication rate (RR = 0.55, 95% CI = 0.38~0.80, p = 0.002), while there was no significant difference in intraoperative blood loss (MD = −65.75, 95% CI = −158.47~26.97, p = 0.16), operative time (MD = −5.44, 95% CI = −43.46~32.58, p = 0.78), intraoperative blood transfusion rate [Odds ratio (OR) = 0.71, 95% CI = 0.41~1.22, p = 0.22], and Grade I complication rate (RR = 0.73, 95% CI = 0.53~1.03, p = 0.07).

Conclusion

Enhanced recovery care in laparoscopic hepatectomy should be recommended, because it is not only safe and effective, but also can accelerate the postoperative recovery and lighten the financial burden of patients.

Laparoscopic versus open resections in the posterosuperior liver segments within an enhanced recovery programme (ORANGE Segments): study protocol for a multicentre randomised controlled trial

BACKGROUND

A shift towards parenchymal-sparing liver resections in open and laparoscopic surgery emerged in the last few years. Laparoscopic liver resection is technically feasible and safe, and consensus guidelines acknowledge the laparoscopic approach in the posterosuperior segments. Lesions situated in these segments are considered the most challenging for the laparoscopic approach. The aim of this trial is to compare the postoperative time to functional recovery, complications, oncological safety, quality of life, survival and costs after laparoscopic versus open parenchymal-sparing liver resections in the posterosuperior liver segments within an enhanced recovery setting.

METHODS

The ORANGE Segments trial is an international multicentre randomised controlled superiority trial conducted in centres experienced in laparoscopic liver resection. Eligible patients for minor resections in the posterosuperior segments will be randomised in a 1:1 ratio to undergo laparoscopic or open resections in an enhanced recovery setting. Patients and ward personnel are blinded to the treatment allocation until postoperative day 4 using a large abdominal dressing. The primary endpoint is time to functional recovery. Secondary endpoints include intraoperative outcomes, length of stay, resection margin, postoperative complications, 90-day mortality, time to adjuvant chemotherapy initiation, quality of life and overall survival. Laparoscopic liver surgery of the posterosuperior segments is hypothesised to reduce time to functional recovery by 2 days in comparison with open surgery. With a power of 80% and alpha of 0.04 to adjust for interim analysis halfway the trial, a total of 250 patients are required to be randomised.

DISCUSSION

The ORANGE Segments trial is the first multicentre international randomised controlled study to compare short- and long-term surgical and oncological outcomes of laparoscopic and open resections in the posterosuperior segments within an enhanced recovery programme.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03270917 . Registered on September 1, 2017. Before start of inclusion.

PROTOCOL VERSION

version 12, May 9, 2017.

Understanding conditional cumulative incidence of complications following liver resection to optimize hospital stay

BACKGROUND

After liver resection, the in-hospital observation periods associated with minimal risks for complications and unplanned readmission remains unclear. This study aimed to assess changes in risks of complications over time.

METHODS

Surgical complexity of liver resection was stratified into grades I (low complexity), II (intermediate), and III (high). The cumulative incidence rate and risk factors for complication ≥ Clavien-Dindo grade II (defined as treatment-requiring complications) were assessed.

RESULTS

Of 581 patients, grade I, II, and III resections were performed in 81 (13.9%), 119 (20.5%), and 381 patients (65.6%). Complexity grades (I vs. III, hazard ratio [HR] 0.45, P = 0.007; II vs. III, HR 0.60, P = 0.011) and background liver status (HR 1.76, P = 0.004) were risk factors for treatment-requiring complications. The cumulative incidence rate of treatment-requiring complications was higher after grade III resection than grade I resection (38.1% vs. 16.1%, P < 0.001) or grade II resection (38.1% vs. 25.2%, P = 0.019). Without cirrhosis/chronic hepatitis, the cumulative incidence rate of treatment-requiring complications decreased to less than 10% on postoperative day (POD) 3 after grade I resection, POD 5 after grade II resection, and POD 10 after grade III resection.

CONCLUSION

Conditional complication risk analysis stratified by surgical complexity may be useful for optimizing in-hospital observation.

Association between compliance with enhanced recovery after surgery (ERAS) protocols and postoperative outcome in patients with primary liver cancer undergoing hepatic resection

Background

Enhanced recovery after surgery (ERAS) is a multidisciplinary, stress-minimizing approach that is associated with improved postoperative outcomes. However, whether the level of compliance with ERAS protocols impacts the postoperative outcome of patients with primary liver cancer undergoing liver resection is unknown. The study aimed to analyze the association between compliance with ERAS protocols and liver resection outcomes.

Methods

This prospective cohort study consecutively recruited patients with primary liver cancer who were scheduled for elective liver surgery between January 2019 and December 2020 at the Department of Biliary Surgery, West China Hospital of Sichuan University. Twenty individual ERAS items were assessed in all patients. The patients were divided into two groups according to their degree of compliance with the ERAS interventions: an ERAS-compliant (ERAS-C) group of individuals who complied with over 75% of the ERAS components and an ERAS-noncompliant (ERAS-N) group. The primary outcomes were ERAS compliance, occurrence of major complications within 30 days postoperatively, and length of postoperative hospital stay. The secondary outcomes were 30-day readmissions, reoperations and other rehabilitation indicators. The study was registered at www.chictr.org.cn (identity number ChiCTR2000040021).

Results

Overall, 436 patients were enrolled; their mean age was 54 years (interquartile range [IQR], 47–66). Of these patients, 206 were allocated to the ERAS-C group, and the other 230 patients comprised the ERAS-N group. The overall compliance rate was 70% (IQR, 65%-80%). The ERAS-C group had higher compliance rates [80.00% (IQR, 75.00–85.00%)] than the ERAS-N group [65.00% (IQR, 65.00–70.00%)], P < 0.001). The ERAS-C group had significantly fewer major complications (7.77% vs. 15.65%, OR, 0.449, 95% CI, 0.241–0.836, P = 0.012) and shorter postoperative hospital stays (5 days [IQR, 4–6] vs. 6 days [IQR, 5–7], P < 0.001) than the ERAS-N group. Subgroup analysis indicated that compliance rates greater than 80%, between 65 and 80%, and lower than 65% were associated with decreased major complication rates (6.25%, 8.48% and 22.83%, respectively) and shorter postoperative hospital stays. However, the rates of ICU stay, readmission, reoperation and mortality within 30 days after surgery were not different between groups (P > 0.05).

Conclusion

The results of this study suggest that higher compliance with ERAS components is associated with a lower incidence of major postoperative complications and a shorter postoperative hospital stay.

Enhanced Recovery After Surgery in Patients With Hepatocellular Carcinoma Undergoing Laparoscopic Hepatectomy

Objective: To compare the effectiveness and safety of enhanced recovery after surgery (ERAS) in patients with hepatocellular carcinoma (HCC) undergoing laparoscopic hepatectomy.

Methods: From September 2016 to June 2019, 282 patients were enrolled, and ERAS was implemented since March 2018. All indicators related to surgery, liver function, and postoperative outcomes were included in the analysis. Propensity score matching (PSM) identified 174 patients for further comparison.

Results: After PSM, the clinicopathological baselines were well-matched. The group showed significantly less intraoperative blood loss (100.00 [100.00–200.00] vs. 200.00 [100.00–300.00] ml, P = 0.001), fewer days before abdominal drainage tube removal (4.00 [3.00–4.00] days vs. 4.00 [3.00–5.00] days, P = 0.023), shorter hospital stay after surgery (6.00 [5.00–6.00] days vs. 6.00 [6.00–7.00] days, P < 0.001), and reduced postoperative morbidity (18.39 vs. 34.48%, P = 0.026). The proportion of patients with a pain score ≥ 4 was significantly lower in the ERAS group within the first 2 days after surgery (1.15 vs. 13.79% and 8.05 vs. 26.44%, P = 0.002 and P = 0.001, respectively). Pringle maneuver was performed more frequently in the ERAS group (70.11 vs. 18.39%, P < 0.001), and a significantly higher postoperative alanine aminotransferase level was also observed (183.40 [122.85–253.70] vs. 136.20 [82.93–263.40] U/l, P = 0.026). The 2-year recurrence-free survival was similar between the two groups (72 vs. 71%, P = 0.946).

Conclusions: ERAS programs are feasible and safe and do not influence mid-term recurrence in HCC patients undergoing laparoscopic hepatectomy.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Financial and Clinical Ramifications of Introducing a Novel Pediatric Enhanced Recovery After Surgery Pathway for Pediatric Complex Hip Reconstructive Surgery

BACKGROUND

Enhanced recovery after surgery pathways confer significant perioperative benefits to patients and are currently well described for adult patients undergoing a variety of surgical procedures. Robust data to support enhanced recovery pathway use in children are relatively lacking in the medical literature, though clinical benefits are reported in targeted pediatric surgical populations. Surgery for complex hip pathology in the adolescent patient is painful, often requiring prolonged courses of opioid analgesia. Postoperative opioid-related side effects may lead to prolonged recovery periods and suboptimal postoperative physical function. Excessive opioid use in the perioperative period is also a major risk factor for the development of opioid misuse in adolescents. Perioperative opioid reduction strategies in this vulnerable population will help to mitigate this risk.

METHODS

A total of 85 adolescents undergoing complex hip reconstructive surgery were enrolled into an enhanced recovery after surgery pathway (October 2015 to December 2018) and were compared with 110 patients undergoing similar procedures in previous years (March 2010 to September 2015). The primary outcome was total perioperative opioid consumption. Secondary outcomes included hospital length of stay, postoperative nausea, intraoperative blood loss, and other perioperative outcomes. Total cost of care and specific charge sectors were also assessed. Segmented regression was used to assess the effects of pathway implementation on outcomes, adjusting for potential confounders, including the preimplementation trend over time.

RESULTS

Before pathway implementation, there was a significant downward trend over time in average perioperative opioid consumption (-0.10 mg total morphine equivalents/90 days; 95% confidence interval [CI], -0.20 to 0.00) and several secondary perioperative outcomes. However, there was no evidence that pathway implementation by itself significantly altered the prepathway trend in perioperative opioid consumption (ie, the preceding trend continued). For postanesthesia care unit time, the downward trend leveled off significantly (pre: -5.25 min/90 d; 95% CI, -6.13 to -4.36; post: 1.04 min/90 d; 95% CI, -0.47 to 2.56; Change: 6.29; 95% CI, 4.53-8.06). Clinical, laboratory, pharmacy, operating room, and total charges were significantly associated with pathway implementation. There was no evidence that pathway implementation significantly altered the prepathway trend in other secondary outcomes.

CONCLUSIONS

The impacts of our pediatric enhanced recovery pathway for adolescents undergoing complex hip reconstruction are consistent with the ongoing improvement in perioperative metrics at our institution but are difficult to distinguish from the impacts of other initiatives and evolving practice patterns in a pragmatic setting. The ERAS pathway helped codify and organize this new pattern of care, promoting multidisciplinary evidence-based care patterns and sustaining positive preexisting trends in financial and clinical metrics.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of enhanced recovery on open and laparoscopic liver resections

Enhanced recovery after surgery programs (ERP) have been implemented in many surgical specialties. Their impact in liver surgery is poorly understood and approach-specific ERPs have not yet been assessed. This retrospective study aims to analyse the effect of such programs on liver resection. All patients undergoing liver resection at a tertiary referral centre between January 2009 and April 2019 were identified. Primary outcome was the length of stay (LOS), secondary outcomes were functional recovery, complications and readmission rates. Patients in the ERP with different protocols for open, laparoscopic, major and minor resections were compared to a historical cohort. Of 1056 patients, 644 were treated within the ERP. A comparable duration of hospital stay [7 days (IQR (interquartile range) 6-12) vs 7 days (IQR 5-9) p = 0.047] and faster functional recovery with fewer complications was found in the ERP group [94 (50.5%) vs 103 (35.9%) p < 0.002]. Those advantages were smaller after open minor compared to open major resection. In patients undergoing laparoscopic resection no differences were observed except for a lower readmission rate [21 (9.3%) vs 13 (3.6%) p = 0.005]. Multivariable analysis showed that laparoscopy was associated with a shorter LOS. ERPs offer significant advantages in open liver surgery. Those advantages are less evident after laparoscopic resection.

Enhanced Recovery After Surgery in Pediatric and Adolescent Gynecology: A Pilot Study

STUDY OBJECTIVE

Enhanced recovery after surgery (ERAS) protocols have been successfully implemented in adult gynecology as well as adult and pediatric colorectal and urologic surgery with reduction in narcotic use, complications, return to the system (RTS), length of stay (LOS), and improved patient satisfaction. There are no studies evaluating the use of ERAS in pediatric and adolescent gynecology (PAG). The goals of this study are to present initial patient outcomes using ERAS in PAG patients undergoing intra-abdominal gynecologic surgery to prove efficacy, patient satisfaction, and decreased narcotic use.

DESIGN

As a quality improvement measure in perioperative care, an ERAS protocol including preoperative, intraoperative, and postoperative components and a follow-up patient telephone call for pain assessment was implemented for all intra-abdominal gynecologic procedures. A retrospective study on implementation of ERAS components, outcomes, and patient satisfaction was then performed in participants meeting inclusion criteria.

SETTING

Large academic children's hospital.

PARTICIPANTS

Patients <25 years of age who underwent laparoscopic (LSC) or open abdominal (XLAP) gynecologic surgery using an ERAS protocol by the PAG service over a 12-month period.

INTERVENTIONS

An ERAS protocol including preoperative, intraoperative, and postoperative components and follow-up patient telephone call for pain assessment was implemented for all major gynecologic surgeries performed by the PAG service.

MAIN OUTCOME MEASURES

Patient satisfaction with the perioperative ERAS protocol along with components including pain management, narcotic use, LOS, RTS, and postoperative complications for various intra-abdominal gynecologic procedures.

RESULTS

A total of 40 participants met inclusion criteria for the study. Thirty-four (85%) participants underwent LSC procedures and six (15%) underwent XLAP. Of the LSC patients, 95% were discharged on postoperative day 0, and all XLAP patients and one LSC patient were discharged on postoperative day 1. In all, 95% of patients were discharged from the hospital requiring only non-narcotic ERAS medications. There were no readmissions or postoperative complications. All patients were satisfied with their postoperative pain control at their follow-up telephone call and clinic visit.

CONCLUSION

Implementation of a pediatric-specific ERAS protocol in children and adolescents undergoing gynecologic surgery is feasible and safe, and leads to less narcotic use without an increase in complications or decrease in patient satisfaction.

ERAS in minimally invasive hepatectomy

Open hepatectomy is associated with significant post-operative morbidity and mortality profile. The use of minimally invasive approach for hepatectomy can reduce the post-operative complication profile and total length of hospital stay. Enhanced recovery after surgery (ERAS) programs involve evidence-based multimodal care pathways designed to achieve early recovery for patients undergoing major surgery. This review will discuss the published evidence, challenges and future directions for ERAS in minimally invasive hepatectomy.

Enhanced recovery after surgery program in the patients undergoing hepatectomy for benign liver lesions

BACKGROUND

Enhanced recovery after surgery (ERAS) has shown effectiveness in terms of reducing the hospital stay and cost. However, the benefit of ERAS in patients undergoing hepatectomy for benign liver lesions is still unclear.

METHODS

ERAS was implemented in our center since March 1st, 2018. From September 2016 to February 2018, 109 patients were enrolled into the control group, and from March 2018 to June 2019, 124 patients were enrolled into the ERAS group. All the indicators related to operation, liver functions, and postoperative outcomes were included in the analysis.

RESULTS

The clinicopathologic baselines were similar in these two groups. A significantly higher proportion of patients underwent laparoscopic surgery in the ERAS group. On the whole, intraoperative blood loss (100.00 mL vs. 200.00 mL, P < 0.001), blood transfusion (3.23% vs. 10.09%, P = 0.033), total bilirubin (17.10 µmol/L vs. 21.00 µmol/L, P = 0.041), D-dimer (2.08 µg/mL vs. 2.57 µg/mL, P = 0.031), postoperative hospital stay (5.00 d vs. 6.00 d, P < 0.001), and postoperative morbidity (16.13% vs. 32.11%, P = 0.008) were significantly shorter or less in the ERAS group than those in the control group. After stratified by operation methods, ERAS group showed significantly shorter postoperative hospital stay in both open and laparoscopic operation (both P < 0.001). In patients underwent open surgery, ERAS group demonstrated significantly shorter operative duration (131.76 ± 8.75 min vs. 160.73 ± 7.23 min, P = 0.016), less intraoperative blood loss (200.00 mL vs. 450.00 mL, P = 0.008) and less postoperative morbidity (16.00% vs. 44.44%, P = 0.040).

CONCLUSIONS

ERAS program may be safe and effective for the patients underwent hepatectomy, especially open surgery, for benign liver lesions.

Endotracheal administration for intraoperative acute massive pulmonary embolism during laparoscopic hepatectomy: A case report

INTRODUCTION

Acute pulmonary embolism (APE) during an operation is a very urgent occurrence, especially when the patient with hemodynamic instability. Generally, drugs are administered intravenously; however, these drugs have little effects under most circumstances. We present a case of successful resuscitation in a patient with endotracheal administration.

PATIENT CONCERNS

A 67-year-old female presented for laparoscopic hepatectomy. Acute pulmonary gas embolism occurred during the operation with hemodynamic instability. The total amount of carbon dioxide and argon reached 300 mL. We used a novel way of administering drugs instead of intravenous administration for rescuing and the patient condition had improved greatly and was discharged from the hospital without any neurological deficits.

DIAGNOSES

A diagnosis of APE was made because of a lot of gas was extracted out from central venous catheter and sudden observable decrease in end-tidal CO2.

INTERVENTIONS

These measures included endotracheal administration, position adjustment, manual ventilation, and gas extraction.

OUTCOMES

The patient was discharged from the hospital and had no signs of neurological deficits.

CONCLUSION

Intravenous administration may not the best appropriate way of administration when patients occurred APE. Endotracheal administration as a unique method may work wonders and has the value of research and application.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Possible Preventable Causes of Unplanned Readmission After Elective Liver Resection, Results from a Non-academic Referral HPB Center

INTRODUCTION

Unplanned readmission is a common event after liver resection, and it is a burden for both patients and healthcare policy makers. This study evaluates the incidence of and reasons for unplanned readmission after liver resection, in order to identify possible preventable causes.

METHODS

In this single-center cohort study, data from patients who underwent liver resection for both malignant and benign indications from 2001 to 2016 at our institute were collected from a database with prospective data. Readmissions were analyzed for their reasons and risk factors. Patients with general complaints with no specific complications were categorized as failure to thrive.

RESULTS

In 406 patients, the readmission rate was 11.6%. Most patients were readmitted because of failure to thrive (35%), deep and superficial surgical site infection (28%), or cardiopulmonary complications (15%). A multivariate analysis revealed that unplanned readmission was associated with the occurrence of complications during index admission-with an odds ratio of 4.69 (CI 2.41-9.12, p < 0.001).

CONCLUSION

Readmission occurs in more than 1 in 10 patients after liver resection, and it is associated with a complicated course during index admission. One-third of readmissions occur because of failure to thrive and might be preventable. Future research in strategies to reduce readmission rates should focus on both the prevention of complications during index admission and programs at the interface between primary and secondary care.

Outcomes of Laparoscopic Liver Resection for Patients with Multiple Hepatocellular Carcinomas Meeting the Milan Criteria: A Propensity Score-Matched Analysis

Background: Until now, there is little knowledge about the value of laparoscopic liver resection (LLR) for patients with multiple hepatocellular carcinomas (HCC). This study was performed to assess the efficacy and outcomes of LLR versus open liver resection (OLR) for patients with multiple HCC meeting the Milan criteria.

Methods: One hundred fifteen patients with multiple HCC meeting the Milan criteria who underwent liver resection from April 2015 to March 2018 were enrolled into this study. According to the different surgical procedures, patients were divided into LLR group and OLR group. Perioperative and oncological outcomes were compared between the two groups after propensity score matching (PSM) with 1:1 match.

Results: Thirty three patients were included into each group after PSM with well-balanced basic level. The intraoperative blood loss in LLR group was less than OLR group before PSM (median, 200 vs. 300 mL, P = .004), but the difference was not statistically significant after PSM (median, 200 vs. 300 mL, P = .064). LLR group showed shorter postoperative hospital stay when compared with OLR group (median, 7 vs. 8 days, respectively, P = .014). The perioperative complications and early mortality were comparable in both groups. There were no significant differences in the term of overall survival (OS. P = .502) or recurrence-free survival (RFS. P = .887) between the two groups after PSM.

Conclusions: LLR could be safely and feasibly performed for patients with multiple HCC meeting the Milan criteria in selected patients. It does not increase the risks of postoperative complications and has a similar oncological outcomes compared to OLR.

The efficacy and safety of enhanced recovery after surgery (ERAS) program in laparoscopic digestive system surgery: A meta-analysis of randomized controlled trials

BACKGROUND

The enhanced recovery after surgery (ERAS) program has been applied to a variety of surgeries. However, the efficacy and safety of the ERAS program in laparoscopic digestive system surgery remain unclear. We conducted a meta-analysis to evaluate the ERAS program and traditional perioperative care (TPC) in laparoscopic digestive system surgery.

METHODS

We searched five electronic databases for eligible trials. STATA version 14.0 and Revman version 5.3 were used to analyze the data. The results were presented and analyzed by weighted mean difference (WMD) and risk ratio (RR) at their 95% confidence interval (CI).

RESULTS

Twenty-five randomized controlled trials (RCTs) of 2219 patients were included in our meta-analysis. The results revealed that the postoperative hospital stay (PHS) (WMD: 2.13 day, 95% CI: 2.56 to -1.70, p = 0.000), time to first flatus (WMD: 12.68 h, 95% CI: 15.95 to -9.41, p = 0.000), and time to defecation (WMD: 34.35 h, 95% CI: 46.82 to -21.88, p = 0.000) were significantly shorter in the ERAS group compared to the TPC group. Additionally, the overall postoperative complication rate (RR: 0.66, 95% CI: 0.49 to 0.88, p = 0.000) was markedly lower in patients using the ERAS program.

CONCLUSION

The results indicated that the ERAS program is associated with faster postoperative rehabilitation, shorter PHS, and better postoperative complication rates. The use of the ERAS program for laparoscopic digestive system surgery is more effective and safe than TPC, and it should be recommended. (PROSPERO registration number:CRD42018118551).

Comparison of Clinical Efficacy and Complications Between Laparoscopic Partial and Open Partial Hepatectomy for Liver Carcinoma: A Meta-Analysis

OBJECTIVE

To contrast the clinical effects and complications for the treatment of liver carcinoma in laparoscopic partial hepatectomy (LPH) and open partial hepatectomy (OPH).

METHODS

The multiple databases were adopted to search relevant studies, and the articles eventually satisfying the inclusion criteria were included. All the meta-analyses were conducted with the Review Manager 5.3, and to estimate the quality of each article risk of bias table was performed.

RESULTS

In the end, 17 studies including 3897 patients were involved, which eventually satisfied the eligibility criteria. The number of samples in LPH group and OPH group were 1723 and 2174, respectively. The results of heterogeneity test suggested that recurrence rate (odds ratio [OR] = -20.11, 95% confidence interval, CI [-35.93 to -4.29], P = .01; P for heterogeneity <.00001, I² = 100%), hospital days (mean difference (MD) = -2.21, 95% CI [-2.53 to -1.88], P < .000001; P for heterogeneity = .41, I² = 58%), and blood loss (MD = -68.09, 95% CI [-85.07 to -51.11], P < .00001; P for heterogeneity = .13, I² = 37%) were significantly different, whereas operating time (MD = 4.00, 95% CI [-17.50 to 25.49], P = .72; P for heterogeneity <.00001, I² = 99%) and complication events (OR = 0.68, 95% CI [0.46 to 1.01], P = .05; P for heterogeneity = .34, I² = 11%) between LPH and OPH were insignificantly different.

CONCLUSION

This study demonstrated that clinical efficacy of OPH was better than that of LPH to some extent, but LPH was a quicker recovery and less harmful therapy.

Enhanced Recovery After Surgery Programs for Laparoscopic Abdominal Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols or laparoscopic technique has been applied in various surgical procedures. However, the clinical efficacy of combination of the two methods still remains unclear. Thus, our aim was to assess the role of ERAS protocols in laparoscopic abdominal surgery.

METHODS

We performed a systematic literature search in various databases from January 1990 to October 2017. The results were analyzed according to predefined criteria.

RESULTS

In the present meta-analysis, the outcomes of 34 comparative studies (15 randomized controlled studies and 19 non-randomized controlled studies) enrolling 3615 patients (1749 in the ERAS group and 1866 in the control group) were pooled. ERAS group was associated with shorter hospital stay (WMD - 2.37 days; 95% CI - 3.00 to - 1.73; P 0.000) and earlier time to first flatus (WMD - 0.63 days; 95% CI - 0.90 to - 0.36; P 0.000). Meanwhile, lower overall postoperative complication rate (OR 0.62; 95% CI 0.51-0.76; P 0.000) and less hospital cost (WMD 801.52 US dollar; 95% CI - 918.15 to - 684.89; P 0.000) were observed in ERAS group. Similar readmission rate (OR 0.73, 95% CI 0.52-1.03, P 0.070) and perioperative mortality (OR 1.33; 95% CI 0.53-3.34; P 0.549) were found between the two groups.

CONCLUSIONS

ERAS protocol for laparoscopic abdominal surgery is safe and effective. ERAS combined with laparoscopic technique is associated with faster postoperative recovery without increasing readmission rate and perioperative mortality.

Enhanced Recovery via Peripheral Nerve Block for Open Hepatectomy

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.

Enhanced recovery after hepatectomy: A systematic review

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Implementation of an enhanced recovery protocol in pediatric colorectal surgery

PURPOSE

Enhanced recovery protocols (ERPs) have been shown to improve outcomes in adult surgical populations. Our purpose was to compare outcomes before and after implementation of an ERP in children undergoing elective colorectal surgery.

METHODS

A pediatric-specific colorectal ERP was developed and implemented at a single center starting in January 2015. A retrospective review was performed including 43 patients in the pre-ERP period (2012-2014) and 36 patients in the post-ERP period (2015-2016). Outcomes of interest included number of ERP interventions received, length of stay (LOS), complications, and readmissions.

RESULTS

The median number of ERP interventions received per patient increased from 5 to 11 from 2012 to 2016. The median LOS decreased from 5days to 3days in the post-ERP period (p=0.01). We observed a simultaneous decrease in median time to regular diet, mean dose of narcotics, and mean volume of intraoperative fluids (p<0.001). The complication rate (21% vs. 17%, p=0.85) and 30-day readmission rate (23% vs. 11%, p=0.63) were not significantly different in the pre- and post-ERP periods.

CONCLUSIONS

Implementation of a pediatric-specific ERP in children undergoing colorectal surgery is feasible, safe and may lead to improved outcomes. Further experience may highlight other opportunities for increased compliance and improved care.

LEVEL OF EVIDENCE

Treatment Study. Level III.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Appropriateness of a pediatric-specific enhanced recovery protocol using a modified Delphi process and multidisciplinary expert panel

PURPOSE

Despite Enhanced Recovery After Surgery (ERAS) protocols demonstrating improved outcomes in a wide variety of adult surgical populations, these protocols are infrequently and inconsistently being used in pediatric surgery. Our purpose was to develop a pediatric-specific ERAS protocol for use in adolescents undergoing elective intestinal procedures.

METHODS

A modified Delphi process including extensive literature review, iterative rounds of surveys, and expert panel discussions was used to establish ERAS elements that would be appropriate for children. The 16-member multidisciplinary expert panel included surgeons, gastroenterologists, anesthesiologists, nursing, and patient/family representatives.

RESULTS

Building upon a national survey of surgeons in which 14 of 21 adult ERAS elements were considered acceptable for use in children, the 7 more contentious elements were investigated using the modified Delphi process. In final ranking, 5 of the 7 controversial elements were deemed appropriate for inclusion in a pediatric ERAS protocol. Routine use of insulin to treat hyperglycemia and avoidance of mechanical bowel preparation were not included in the final recommendations.

CONCLUSIONS

Using a modified Delphi process, we have defined an appropriate ERAS protocol comprised of 19 elements for use in adolescents undergoing elective intestinal surgery. Prospective validation studies of ERAS protocols in children are needed.

LEVEL OF EVIDENCE

Level V, Expert opinion.

Safety and efficacy of enhanced recovery after surgery (ERAS) programs in patients undergoing hepatectomy: A prospective randomized controlled trial

BACKGROUND AND AIM

Enhanced recovery after surgery (ERAS) programs, following a variety of perioperative treatments with evidence-based medical evidence, has indicated its validity to accelerate rehabilitation in a wide variety of surgical procedures. This randomized controlled trial (RCT) study was implemented to verify the safety and efficacy of the perioperative effects in patients undergoing hepatectomy with ERAS or with conventional surgery (CS).

METHODS

From August 2016 to November 2017, according to the inclusion criteria, 160 patients with liver diseases were suitable for participating in this experiment. Patients before liver resection were randomized into ERAS group (n = 80) and CS group (n = 80), and then the outcome measures were compared between the two groups.

RESULTS

Enhanced recovery after surgery group had significantly less complications than CS group (P = .009). Compared with CS group, patients in ERAS group had low peak of WBCs in postoperative day (POD1), ALT in POD1 and POD3 (P < .05), high value of ALB in POD3 and POD5 (P < .05), less pain and higher patient satisfaction (P < .001), earlier exhaust, oral feeding, ambulation and extubation time (P < .05),and also had less hospital stay and cost (P < .001). There were no significant differences in readmission rate (<30 days) between two groups (P = .772).

CONCLUSIONS

Enhanced recovery after surgery programs applied to patients undergoing hepatectomy can safely and effectively relieve stress response, reduce the incidence of complications, improve patient satisfaction, accelerate patient recovery, reduce financial burden, and bring economic benefits.

Patient-Reported Outcomes Are Associated With Enhanced Recovery Status in Patients With Bladder Cancer Undergoing Radical Cystectomy

BACKGROUND

Bladder cancer is a disease of the elderly that is associated with high morbidity in those treated with radical cystectomy. In this observational study of patients with bladder cancer undergoing radical cystectomy, we analyzed and compared patient-reported outcomes from those treated with Enhanced Recovery After Surgery (ERAS) methods versus those who received traditional perioperative care.

METHODS

We enrolled patients who underwent radical cystectomy at a high-volume tertiary care referral center from November 2013 to December 2016, when the ERAS concept was being introduced into postoperative care at our institution. Patients reported symptom outcomes using the MD Anderson Symptom Inventory preoperatively and on postoperative days 1 to 5. Mann-Whitney U tests were used to compare symptom burden between the ERAS and traditional-care groups. General linear mixed-effects models were used for longitudinal data; linear regression models were used for multivariable analysis.

RESULTS

Patients (N = 383) reported dry mouth, disturbed sleep, drowsiness, fatigue, pain, and lack of appetite as the most severe symptoms. Compared with the traditional-care group, the ERAS group had significantly less pain (est. = -0.98, P = .005), drowsiness (est. = -0.91, P = .009), dry mouth (est. = -1.21, P = .002), disturbed sleep (est. = -0.97, P = .01), and interference with functioning (est. = -0.70, P = .022) (adjusted for age, sex, surgical technique, and neoadjuvant chemotherapy status).

CONCLUSIONS

These results suggest that ERAS practice significantly reduced immediate postoperative symptom burden in bladder cancer patients recovering from radical cystectomy, supporting the use of patient-reported symptom burden as an outcome measure in perioperative care.

A survey of pediatric surgeons' practices with enhanced recovery after children's surgery

PURPOSE

Enhanced Recovery After Surgery (ERAS) protocols have been shown to improve outcomes in adult abdominal surgical populations. Our purpose was to survey pediatric surgeons' opinions regarding applicability of individual ERAS elements to children's surgery.

METHODS

A survey of the American Pediatric Surgical Association was conducted electronically. Using a 5-point Likert scale, respondents rated their willingness to implement 21 adult ERAS elements in an adolescent undergoing elective colorectal surgery.

RESULTS

Of an estimated 1052 members, 257 completed the survey (24%). The majority of the respondents (n=175, 68.4%) rated their familiarity with ERAS as "moderately", "very", or "extremely familiar". However only 19.2% (n=49) replied that they were "already implementing" an ERAS protocol in their practice. Most respondents replied that they were "already doing" or "definitely willing" to implement 14 of the 21 (67%) ERAS elements. For the remaining 7 elements, >10% of surgeons answered that they were only "somewhat willing" to, "uncertain" about or "unwilling" to implement these interventions.

CONCLUSIONS

Most respondents were willing to implement the majority of adult ERAS concepts in children undergoing abdominal surgery. However, we identified 7 elements that remain contentious. Further investigation regarding the safety and feasibility of these elements is warranted before applying them to children's surgery.

LEVEL OF EVIDENCE

Level V.

Enhanced Recovery After Surgery for Noncolorectal Surgery?: A Systematic Review and Meta-analysis of Major Abdominal Surgery

OBJECTIVE

To evaluate the impact of enhanced recovery after surgery (ERAS) protocols across noncolorectal abdominal surgical procedures.

BACKGROUND

ERAS programs have been studied extensively in colorectal surgery and adopted at many centers. Several studies testing such protocols have shown promising results in improving postoperative outcomes across various surgical procedures. However, surgeons performing major abdominal procedures have been slower to adopt these ERAS protocols.

METHODS

A systematic review was performed using "enhanced recovery after surgery" or "fast track" as search terms and excluded studies of colorectal procedures. Primary endpoints for the meta-analysis include length of stay (LOS) and complication rate. Secondary endpoints were time to first flatus, readmission rate, and costs.

RESULTS

A total of 39 studies (6511 patients) met inclusion and exclusion criteria. Among them 14 studies were randomized trials, and the remaining 25 studies were cohort studies. Meta-analysis showed a decrease in LOS of 2.5 days (95% confidence interval, CI: 1.8-3.2, P < 0.001) and a complication rate of 0.70 (95% CI: 0.56-0.86, P = 0.001) for patient treated in ERAS programs. There was also a significant reduction in time to first flatus of 0.8 days (95% CI: 0.4-1.1, P < 0.001) and cost reduction of $5109.10 (95% CI: $4365.80-$5852.40, P < 0.001). There was no significant increase in readmission rate (OR 1.03, 95% CI: 0.84-1.26, P = 0.80) in our analysis.

CONCLUSIONS

ERAS protocols decreased length of stay and cost by not increasing complications or readmission rates. This study adds to the evidence that ERAS protocols are safe to implement and are beneficial to surgical patients and the healthcare system across multiple abdominal procedures.

Enhanced recovery program versus traditional care after hepatectomy: A meta-analysis

To assess the safety and efficacy of enhanced recovery after surgery (ERAS) as compared with the traditional care in patients undergoing liver surgery and optimization of enhanced recovery programs.Literature, until August 2016, was searched to identify the comparative studies evaluating preoperative hospital stay time, complications, and C-reactive protein (CRP). Pooled odds ratios (OR) or weighted mean differences (WMDs) were calculated with either the fixed or random effect model.These studies included a total of 524 patients: 254 treated with ERAS and 270 with traditional care. The postoperative recovery time and length of hospital stay were significantly better than the control group (WMD -2.72; 95% confidence interval [CI] -3.86 to -1.57; WMD -2.67; 95% CI -3.68 to -1.65, respectively). The overall complications, grade I, and Grand II-V complications were significantly favorable to the ERAS group (OR, 0.45 [95% CI, 0.30-0.67]; OR, 0.55 [95% CI, 0.31-0.98]; OR, 0.49 [95% CI, 0.32-0.76], respectively). The concentration of CRP in the control group was significantly higher than that in the ERAS group on postoperative day 5 (WMD -21.68; 95% CI -29.30 to -14.05). Time to first flatus (WMD -0.93; 95% CI -1.41 to -0.46) was significantly shortened in the ERAS group.The evidence indicates that ERAS following liver surgery is safe, effective, and feasible. Therefore, further are essential for optimizing the ERAS protocols.

Enhanced recovery after surgery program reduces length of hospital stay and complications in liver resection: A PRISMA-compliant systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Many enhanced recovery after surgery (ERAS) guidelines have already been established in several kinds of surgeries. But due to concerns of the specific complications, it has not yet been considered the standard of care in liver surgery.

OBJECTIVE

The aim of this review is to assess the effect of ERAS in patients undergoing liver surgery.

METHODS

EMBASE, CNKI, PubMed, and the Cochrane Database were searched for randomized controlled trials (RCTs) comparing ERAS with conventional care in patients undergoing liver surgery. Subgroup meta-analysis between laparoscopic and open surgical approaches to liver resection was also conducted.

RESULTS

Seven RCTs were included, representing 996 patients. Length of stay (LOS) (MD -3.17, 95% CI: -3.99 to -2.35, P < .00001, I = 89%) and time to first flatus (MD -0.9, 95% CI: -1.36 to -0.45, P = .0001, I = 98%) were both reduced in the ERAS group. There were also fewer complications in the ERAS group (OR 0.52, 95% CI: 0.37-0.72, P < .0001, I = 0%).

CONCLUSION

The ERAS program can obviously enhance short-term recovery after liver resection. It is safe and worthwhile. A specific ERAS guideline for liver resection is recommended.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Enhanced recovery after surgery programs versus traditional perioperative care in laparoscopic hepatectomy: A meta-analysis

OBJECTIVE

Enhanced recovery after surgery (ERAS) programs are a series of measures being taken during the perioperation to alleviate surgical stress and accelerate the recovery rate of patients. Although several studies reported the efficacy of ERAS in liver surgery, the role of ERAS in laparoscopic hepatectomy is still unclear. This meta-analysis is aimed to evaluate the efficacy and safety of ERAS programs versus traditional care in laparoscopic hepatectomy.

METHODS

We searched PubMed, EMBASE, the Cochrane Library, CNKI, Wang Fang Database and VIP Database for randomized controlled trials (RCTs) or clinical controlled trials (CCTs) concerning using ERAS in laparoscopic hepatectomy. Data collection ended in June 1st, 2016. The main end points were intraoperative blood loss, intraoperative blood transfusion, operative time, the cost of hospitalization, time to first flatus, the time to first diet after surgery, duration of postoperative hospital stay, total postoperative complication rate, gradeⅠcomplication rate, grade Ⅱ-Ⅴcomplication rate.

RESULTS

8 studies with 580 patients were eligible for analysis. There were 292 cases in ERAS group and 288 cases in traditional perioperative care (CTL) group. Compared with CTL group, ERAS group was associated with significantly accelerated of time to first diet after surgery (SMD = -1.79, 95%CI: -3.19 ∼ -0.38, P = 0.01), time to first flatus (MD = -0.51, 95%CI: -0.91 ∼ -0.12, P = 0.01). Meanwhile, it was associated with significantly decreased of duration of the postoperative hospital stay (MD = -3.31, 95%CI: -3.95 ∼ -2.67, P < 0.00001), cost of hospitalization (MD = -1.0, 95%CI: -1.49 ∼ -0.51, P < 0.0001), total postoperative complication rate (OR = 0.34, 95%CI: 0.15-0.75, P = 0.008), gradeⅠcomplication rate (OR = 0.37, 95%CI: 0.22-0.64, P = 0.0003) and gradeⅡ-Ⅴcomplication rate (OR = 0.49, 95%CI: 0.32-0.77, P = 0.002). Whereas there was no significantly difference in intraoperative blood loss (P > 0.05), intraoperative blood transfusion (P > 0.05), operative time (P > 0.05) between ERAS group and CTL group.

CONCLUSION

Application of ERAS in laparoscopic hepatectomy is safe and effective, and it could accelerate the postoperative recovery and lighten the financial burden of patients.

Anesthetic and operative considerations for laparoscopic liver resection

We enumerate the broad range of anesthetic considerations that affect the outcome of patients undergoing laparoscopic liver resection. Key elements for excellent outcomes after laparoscopic liver resection are careful patient selection and risk stratification, appropriate monitoring, techniques to reduce blood loss and transfusion, and active recovery management. Although some of these key elements are the same for open liver operation, there are specific anesthetic considerations of which both the surgical and anesthesia teams must be aware to achieve optimal patient outcomes after laparoscopic liver resection. While unique advantages of laparoscopic liver resection typically include decreased intraoperative bleeding, transfusion requirements, and a lower incidence of postoperative ascites, specific challenges include management of the complicated interplay between low-volume anesthesia and increased intraabdominal pressure due to pneumoperitoneum, with additional considerations regarding circulatory support to treat acute blood loss with need for emergent conversion in some cases. This article will address in detail the preoperative, intraoperative, and postoperative anesthetic considerations for patients undergoing laparoscopic liver resection that both the surgical and anesthesia team should be aware of to optimize outcomes.

Fast track program in liver resection: a PRISMA-compliant systematic review and meta-analysis

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.

The enhanced recovery after surgery (ERAS) program in liver surgery: a meta-analysis of randomized controlled trials

The enhanced recovery after surgery (ERAS) program aims to attenuate the surgical stress response and decrease postoperative complications. It has increasingly replaced conventional approaches in surgical care. To evaluate the benefits and harms of the ERAS program compared to conventional care in patients undergoing liver surgery. We searched the MEDLINE, PubMed, EMBASE and Cochrane databases. All RCTs that compared the ERAS program with conventional care were selected. Four RCTs were eligible for analysis, which included 634 patients (309 ERAS vs. 325 conventional). Overall morbidity (RR 0.67; 95 % CI 0.48–0.92; p = 0.01), primary length of stay (WMD −2.71; 95 % CI −3.43 to −1.99; p < 0.00001), total length of stay (WMD −2.10; 95 % CI −3.96 to −0.24; p = 0.03), time of functional recovery (WMD −2.30; 95 % CI −3.77 to −0.83; p = 0.002), and time to first flatus (SMD, −0.52; 95 % CI −0.69 to −0.35; p < 0.00001) were significantly shortened in the ERAS group. Quality of life was also better in the ERAS group. However, no significant differences were noted in mortality, readmission rates, operative time and intraoperative blood loss. The ERAS Program for liver surgery significantly reduced overall morbidity rates, accelerated functional recovery, and shortened the primary and total hospital stay without compromising readmission rates. Therefore, ERAS appears to be safe and effective. However, the conclusions are limited because of the low methodological quality of the analyzed studies. Further studies are needed to provide more solid evidence.