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Wang Y, Zhang F, Zheng L, Yang W, Ke L. Enhanced recovery after surgery care to reduce surgical site wound infection and postoperative complications for patients undergoing liver surgery. Int Wound J 2023; 20:3540-3549. [PMID: 37218367 PMCID: PMC10588343 DOI: 10.1111/iwj.14227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/24/2023] Open
Abstract
This study comprehensively assessed the effect of enhanced recovery after surgery (ERAS) on wound infection and postoperative complications in patients undergoing liver surgery. The PubMed, EMBASE, MEDLINE, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang electronic databases were searched to collect published studies on the use of ERAS in liver surgery until December 2022. Literature selection was performed independently by two investigators according to the inclusion and exclusion criteria, and quality evaluation and data extraction were performed. RevMan 5.4 software was used in this study. Compared with the control group, the ERAS group showed a significantly lower incidence of postoperative wound infection (odds ratio [OR]: 0.59, 95% confidence interval [CI]: 0.41-0.84, P = .004) and overall postoperative complication rate (OR: 0.43, 95% CI: 0.33-0.57, P < .001) and significantly shorter postoperative hospital stay (mean difference: -2.30, 95% CI: -2.92 to -1.68, P < .001). Therefore, ERAS was safe and feasible when applied to liver resection, reducing the incidence of wound infection and total postoperative complications, and shortening the length of hospital stay. However, further studies are required to investigate the impact of ERAS protocols on clinical outcomes.
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Affiliation(s)
- Yu‐Ling Wang
- Department of HepatobiliaryTaizhou Hospital of Zhejiang ProvinceTaizhouZhejiangChina
| | - Fa‐Biao Zhang
- Department of HepatobiliaryTaizhou Hospital of Zhejiang ProvinceTaizhouZhejiangChina
| | - Ling‐E Zheng
- Department of Admissions Management CentreTaizhou Hospital of Zhejiang ProvinceTaizhouZhejiangChina
| | - Wei‐Wei Yang
- Department of HepatobiliaryTaizhou Hospital of Zhejiang ProvinceTaizhouZhejiangChina
| | - Lan‐Lan Ke
- Department of Admissions Management CentreTaizhou Hospital of Zhejiang ProvinceTaizhouZhejiangChina
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Xie F, Wang D, Ge J, Liao W, Li E, Wu L, Lei J. Robotic approach together with an enhanced recovery programme improve the perioperative outcomes for complex hepatectomy. Front Surg 2023; 10:1135505. [PMID: 37334205 PMCID: PMC10272522 DOI: 10.3389/fsurg.2023.1135505] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 05/04/2023] [Indexed: 06/20/2023] Open
Abstract
Objective Robotic surgery has more advantages than traditional surgical approaches to complex liver resection; however, the robotic approach is invariably associated with increased cost. Enhanced recovery after surgery (ERAS) protocols are beneficial in conventional surgeries. Methods The present study investigated the effects of robotic surgery combined with an ERAS protocol on perioperative outcomes and hospitalization costs of patients undergoing complex hepatectomy. Clinical data from consecutive robotic and open liver resections (RLR and OLR, respectively) performed in our unit in the pre-ERAS (January 2019-June 2020) and ERAS (July 2020-December 2021) periods were collected. Multivariate logistic regression analysis was performed to determine the impact of ERAS and surgical approaches-alone or in combination-on LOS and costs. Results A total of 171 consecutive complex liver resections were analyzed. ERAS patients had a shorter median LOS and decreased total hospitalization cost, without a significant difference in the complication rate compared with the pre-ERAS cohort. RLR patients had a shorter median LOS and decreased major complications, but with increased total hospitalization cost, compared with OLR patients. Comparing the four combinations of perioperative management and surgical approaches, ERAS + RLR had the shortest LOS and the fewest major complications, whereas pre-ERAS + RLR had the highest hospitalization costs. Multivariate analysis found that the robotic approach was protective against prolonged LOS, whereas the ERAS pathway was protective against high costs. Conclusions The ERAS + RLR approach optimized postoperative complex liver resection outcomes and hospitalization costs compared with other combinations. The robotic approach combined with ERAS synergistically optimized outcome and overall cost compared with other strategies, and may be the best combination for optimizing perioperative outcomes for complex RLR.
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Affiliation(s)
- Fei Xie
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Dongdong Wang
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jin Ge
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wenjun Liao
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Enliang Li
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Linquan Wu
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Province Engineering Research Center of Hepatobiliary Disease, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jun Lei
- Department of General Surgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Province Engineering Research Center of Hepatobiliary Disease, Second Affiliated Hospital of Nanchang University, Nanchang, China
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Jongkatkorn C, Luvira V, Suwanprinya C, Piampatipan K, Leeratanakachorn N, Tipwaratorn T, Titapun A, Srisuk T, Theeragul S, Jarearnrat A, Thanasukarn V, Pugkhem A, Khuntikeo N, Pairojkul C, Kamsa-Ard S, Bhudhisawasdi V. Compliance with enhanced recovery after surgery predicts long-term outcome after hepatectomy for cholangiocarcinoma. World J Gastrointest Surg 2023; 15:362-373. [PMID: 37032797 PMCID: PMC10080603 DOI: 10.4240/wjgs.v15.i3.362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/09/2022] [Accepted: 02/28/2023] [Indexed: 03/27/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) program has been proved to improve postoperative outcome for many surgical procedures, including liver resection. There was limited evidence regarding the feasibility and benefit of ERAS in patients who underwent liver resection for cholangiocarcinoma.
AIM To evaluate the feasibility of ERAS in patients who underwent liver resection for cholangiocarcinoma and its association with patient outcomes.
METHODS We retrospectively analyzed 116 cholangiocarcinoma patients who underwent hepatectomy at Srinagarind Hospital, Khon Kaen University between January 2015 and December 2016. The primary outcome was the compliance with ERAS. To determine the association between ERAS compliance and patient outcomes. the patients were categorized into those adhering more than and equal to 50% (ERAS ≥ 50), and below 50% (ERAS < 50) of all components. Details on type of surgical procedure, preoperative and postoperative care, tumor location, postoperative laboratory results, and survival time were evaluated. The compliance with ERAS was measured by the percentage of ERAS items achieved. The Kaplan-Meier curve was used for survival analysis.
RESULTS The median percentage of ERAS goals achieved was 40% (± 12%). Fourteen patients (12.1%) were categorized into the ERAS ≥ 50 group, and 102 patients were in the ERAS < 50 group. Postoperative hospital stay was significantly shorter in the ERAS ≥ 50 group [8.9 d, 95% confidence interval (CI): 7.3-10.4 d] than in the ERAS < 50 group (13.7 d, 95%CI: 12.2-15.2 d) (P = 0.0217). No hepatobiliary-related complications or in-hospital mortality occurred in the ERAS ≥ 50 group. Overall survival was significantly higher in the ERAS ≥ 50 group. The median survival of the patients in the ERAS < 50 group was 1257 d (95%CI: 853.2-1660.8 d), whereas that of the patients in the ERAS ≥ 50 group was not reached.
CONCLUSION Overall ERAS compliance for patients who underwent liver resection for cholangiocarcinoma is poor. Greater ERAS compliance could predict in-hospital, short-term, and long-term outcomes of the patients.
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Affiliation(s)
| | - Vor Luvira
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Chalisa Suwanprinya
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | | | | | - Theerawee Tipwaratorn
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Attapol Titapun
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Tharatip Srisuk
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Suapa Theeragul
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Apiwat Jarearnrat
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Vasin Thanasukarn
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Ake Pugkhem
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Narong Khuntikeo
- Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Chawalit Pairojkul
- Department of Pathology, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
| | - Supot Kamsa-Ard
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen 40002, Thailand
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Campagner A, Milella F, Guida S, Bernareggi S, Banfi G, Cabitza F. Assessment of Fast-Track Pathway in Hip and Knee Replacement Surgery by Propensity Score Matching on Patient-Reported Outcomes. Diagnostics (Basel) 2023; 13:diagnostics13061189. [PMID: 36980497 PMCID: PMC10047673 DOI: 10.3390/diagnostics13061189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/14/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
Total hip (THA) and total knee (TKA) arthroplasty procedures have steadily increased over the past few decades, and their use is expected to grow further, mainly due to an increasing number of elderly patients. Cost-containment strategies, supporting a rapid recovery with a positive functional outcomes, high patient satisfaction, and enhanced patient reported outcomes, are needed. A Fast Track surgical procedure (FT) is a coordinated perioperative approach aimed at expediting early mobilization and recovery following surgery and, accordingly, shortening the length of hospital stay (LOS), convalescence and costs. In this view, rapid rehabilitation surgery optimizes traditional rehabilitation methods by integrating evidence-based practices into the procedure. The aim of the present study was to compare the effectiveness of Fast Track versus Care-as-Usual surgical procedures and pathways (including rehabilitation) on a mid-term patient-reported outcome (PROs), the SF12 (with regard both to Physical and Mental Scores), 3 months after hip or knee replacement surgery, with the use of Propensity score-matching (PSM) analysis to address the issue of the comparability of the groups in a non-randomized study. We were interested in the evaluation of the entire pathways, including the postoperative rehabilitation stage, therefore, we only used early home discharge as a surrogate to differentiate between the Fast Track and Care-as-Usual rehabilitation pathways. Our study shows that the entire Fast Track pathway, which includes the post-operative rehabilitation stage, has a significantly positive impact on physical health-related status (SF12 Physical Scores), as perceived by patients 3 months after hip or knee replacement surgery, as opposed to the standardized program, both in terms of the PROs score and the relative improvements observed, as compared with the minimum clinically important difference. This result encourages additional research into the effects of Fast Track rehabilitation on the entire process of care for patients undergoing hip or knee arthroplasty, focusing only on patient-reported outcomes.
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Affiliation(s)
| | - Frida Milella
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milano, Italy
| | | | | | - Giuseppe Banfi
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milano, Italy
- Faculty of Medicine and Surgery, Università Vita-Salute San Raffaele, 20132 Milano, Italy
| | - Federico Cabitza
- IRCCS Istituto Ortopedico Galeazzi, 20157 Milano, Italy
- Dipartimento di Informatica, Sistemistica e Comunicazione, University of Milano-Bicocca, 20126 Milano, Italy
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Ni CY, Hou GJ, Tang YY, Wang JJ, Chen WJ, Yang Y, Wang ZH, Zhou WP. Quantitative study of the effects of early standardized ambulation on sleep quality in patients after hepatectomy. Front Surg 2022; 9:941158. [PMID: 36211277 PMCID: PMC9545172 DOI: 10.3389/fsurg.2022.941158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/26/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundSleep quality has been always an important problem for patients after hepatectomy. The main purpose of the study is to investigate the effects of early ambulation on sleep quality in patients after liver resection via a quantitative study.MethodsPatients undergoing liver tumor resection were randomly divided into two groups, and the Pittsburgh Sleep Quality Index (PSQI) was used to assess the postoperative activities and sleep quality.ResultsPatients who started early ambulation after liver resection had significantly better sleep quality, faster recovery of gastrointestinal function and shorter lengths of postoperative hospital stay compared with the control group. And there was no significant difference in the incidence of postoperative complications between the two groups.ConclusionEarly standardized physical activities are feasible for patients after liver resection, which can significantly improve patient's sleep quality, reduce patient's pain and the nursing workload, and achieve rapid recovery.
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Affiliation(s)
- Chun-yan Ni
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
- Suzhou Science / Technology Town Hospital, Suzhou, China
| | - Guo-jun Hou
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Ya-yuan Tang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Jing-jing Wang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Wen-jun Chen
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Yuan Yang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
- Correspondence: Yuan Yang Zhi-hong Wang Wei-ping Zhou
| | - Zhi-hong Wang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
- Correspondence: Yuan Yang Zhi-hong Wang Wei-ping Zhou
| | - Wei-ping Zhou
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
- Correspondence: Yuan Yang Zhi-hong Wang Wei-ping Zhou
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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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Early postoperative ERAS compliance predicts decreased length of stay and complications following liver resection. HPB (Oxford) 2022; 24:1425-1432. [PMID: 35135723 DOI: 10.1016/j.hpb.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 12/27/2021] [Accepted: 01/17/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) components for liver resection lack standardization and compliance. We evaluated our ERAS protocol and describe the association of postoperative ERAS compliance with length of stay (LOS) and complications. METHODS We retrospectively reviewed patients undergoing liver resection at our institution from 2016 to 2020. Pre- and post-ERAS outcomes and compliance at 72 h were compared with LOS and complications. LOS beyond 72 h was defined as LOS72. RESULTS 210 patients were included. Post-ERAS patients had significantly shorter LOS (5.1 vs. 7.3 days, p = 0.0014) with no difference in 30-day mortality, morbidity, or readmissions. ERAS components associated with shorter LOS72 were regular diet (HR 1.73), fluid discontinuation (HR 1.63), drain removal (HR 1.94), multimodal and oral analgesia (HR 1.51), and ambulation >100 ft (HR 2.23). LOS72 was 1-day for ≥9 ERAS component compliance, 4-days for 6-8 components, and 6-days for <6 components. 30-day complication rates for patients with ≥9 components by postoperative day 3 (POD3) were significantly lower than those with 6-8 (12 vs 32%). CONCLUSION ERAS decreases LOS after liver resection. Nutritional advancement, drain discontinuation, multimodal and oral analgesia, and ambulation >100 ft by POD3 are associated with decreased LOS72. Achieving ≥6 components by POD3 predicts decreased LOS72 and complications.
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Kuemmerli C, Fichtinger RS, Moekotte A, Aldrighetti LA, Aroori S, Besselink MGH, D’Hondt M, Díaz-Nieto R, Edwin B, Efanov M, Ettorre GM, Menon KV, Sheen AJ, Soonawalla Z, Sutcliffe R, Troisi RI, White SA, Brandts L, van Breukelen GJP, Sijberden J, Pugh SA, Eminton Z, Primrose JN, van Dam R, Hilal MA. Laparoscopic versus open resections in the posterosuperior liver segments within an enhanced recovery programme (ORANGE Segments): study protocol for a multicentre randomised controlled trial. Trials 2022; 23:206. [PMID: 35264216 PMCID: PMC8908665 DOI: 10.1186/s13063-022-06112-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 02/15/2022] [Indexed: 01/17/2023] Open
Abstract
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.
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Affiliation(s)
- Christoph Kuemmerli
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
| | - Robert S. Fichtinger
- Department of Surgery, Maastricht University Medical Centre+, 6202 AZ Maastricht, The Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Alma Moekotte
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
| | | | - Somaiah Aroori
- Peninsula HPB Unit, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Marc G. H. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mathieu D’Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Rafael Díaz-Nieto
- Hepatobiliary Surgery Unit, Aintree University Hospital, Liverpool, UK
| | - Bjørn Edwin
- Department of HPB Surgery, Oslo University Hospital, Oslo, Norway
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Centre, Moscow, Russia
| | - Giuseppe M. Ettorre
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | | | - Aali J. Sheen
- Department of Surgery, Manchester University Foundation Trust, Manchester, UK
| | - Zahir Soonawalla
- Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Robert Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Roberto I. Troisi
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Steven A. White
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Lloyd Brandts
- Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht UMC+, Maastricht, The Netherlands
| | - Gerard J. P. van Breukelen
- Department of Methodology and Statistics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jasper Sijberden
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Siân A. Pugh
- Department of Oncology, Addenbrooke’s Hospital, Cambridge, UK
| | - Zina Eminton
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - John N. Primrose
- Department of Surgery, University of Southampton, Southampton, UK
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Centre+, 6202 AZ Maastricht, The Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- GROW – School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Mohammed Abu Hilal
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
| | - on behalf of the ORANGE trials collaborative
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
- Department of Surgery, Maastricht University Medical Centre+, 6202 AZ Maastricht, The Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
- Peninsula HPB Unit, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
- Hepatobiliary Surgery Unit, Aintree University Hospital, Liverpool, UK
- Department of HPB Surgery, Oslo University Hospital, Oslo, Norway
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Centre, Moscow, Russia
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
- Institute of Liver Studies, Kings College Hospital, London, UK
- Department of Surgery, Manchester University Foundation Trust, Manchester, UK
- Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
- Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht UMC+, Maastricht, The Netherlands
- Department of Methodology and Statistics, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Oncology, Addenbrooke’s Hospital, Cambridge, UK
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
- Department of Surgery, University of Southampton, Southampton, UK
- GROW – School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
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Liu L, He L, Qiu A, Zhang M. Rapid rehabilitation effect on complications, wound infection, anastomotic leak, obstruction, and hospital re-admission for gastrointestinal surgery subjects: A meta-analysis. Int Wound J 2022; 19:1539-1550. [PMID: 35191597 PMCID: PMC9493214 DOI: 10.1111/iwj.13753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 12/14/2021] [Accepted: 01/06/2022] [Indexed: 11/30/2022] Open
Abstract
We performed a meta‐analysis to evaluate the effect of rapid rehabilitation on the curative effect of gastrointestinal surgery subjects. A systematic literature search up to October 2021 was done and 31 studies included 4448 subjects with gastrointestinal surgery at the start of the study: 2242 of them were provided with rapid rehabilitation and 2206 were standard care. They were reporting relationships about the effect of rapid rehabilitation on the curative effect of gastrointestinal surgery subjects. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to assess the effect of rapid rehabilitation on the curative effect of gastrointestinal surgery subjects using the dichotomous method with a random‐ or fixed‐effect model. Rapid rehabilitation had significantly lower complications (OR, 0.62; 95% CI, 0.54‐0.71, P < .001) and wound infection (OR, 0.73; 95% CI, 0.55‐0.98, P = .03) compared with standard care in subjects with gastrointestinal surgery. However, rapid rehabilitation had no significant effect on the anastomotic leak (OR, 0.90; 95% CI, 0.66‐1.22, P = .49), obstruction (OR, 0.92; 95% CI, −0.64 to 1.31, P = .65), and hospital re‐admission (OR, 0.78; 95% CI, 0.57‐1.08, P = .13) compared with standard care in subjects with gastrointestinal surgery. Rapid rehabilitation had significantly lower complications and wound infection, and had no significant effect on the anastomotic leak, obstruction, and hospital re‐admission compared with standard care in subjects with gastrointestinal surgery. Further studies are required to validate these findings.
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Affiliation(s)
- Lixiu Liu
- Department of Colorectal Surgery, Harbin Medical University Cancer Hospital, Heilongjiang Haerbin, China
| | - Lihuang He
- Department of Oncology, Affiliated Hospital of Xiangnan University, Chenzhou, China
| | - Afang Qiu
- Department of Internal Medicine, Yantai Qishan hospital, Yantai, China
| | - Min Zhang
- Department of Outpatient, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China (Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital), Chengdu, China
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10
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Eimer C, Freier K, Weiler N, Frerichs I, Becher T. The Effect of Physical Therapy on Regional Lung Function in Critically Ill Patients. Front Physiol 2021; 12:749542. [PMID: 34616313 PMCID: PMC8488288 DOI: 10.3389/fphys.2021.749542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 08/23/2021] [Indexed: 02/04/2023] Open
Abstract
Early mobilization has become an important aspect of treatment in intensive care medicine, especially in patients with acute pulmonary dysfunction. As its effects on regional lung physiology have not been fully explored, we conceived a prospective observational study (Registration number: DRKS00023076) investigating regional lung function during a 15-min session of early mobilization physiotherapy with a 30-min follow-up period. The study was conducted on 20 spontaneously breathing adult patients with impaired pulmonary gas exchange receiving routine physical therapy during their intensive care unit stay. Electrical impedance tomography (EIT) was applied to continuously monitor ventilation distribution and changes in lung aeration during mobilization and physical therapy. Baseline data was recorded in the supine position, the subjects were then transferred into the seated and partly standing position for physical therapy. Afterward, patients were transferred back into the initial position and followed up with EIT for 30 min. EIT data were analyzed to assess changes in dorsal fraction of ventilation (%dorsal), end-expiratory lung impedance normalized to tidal variation (ΔEELI), center of ventilation (CoV) and global inhomogeneity index (GI index).Follow-up was completed in 19 patients. During exercise, patients exhibited a significant change in ventilation distribution in favor of dorsal lung regions, which did not persist during follow-up. An identical effect was shown by CoV. ΔEELI increased significantly during follow-up. In conclusion, mobilization led to more dorsal ventilation distribution, but this effect subsided after returning to initial position. End-expiratory lung impedance increased during follow-up indicating a slow increase in end-expiratory lung volume following physical therapy.
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Affiliation(s)
- Christine Eimer
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Kiel, Germany
| | - Katharina Freier
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Kiel, Germany
| | - Norbert Weiler
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Kiel, Germany
| | - Inéz Frerichs
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Kiel, Germany
| | - Tobias Becher
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Kiel, Germany
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11
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Effects of Combined Epidural Anesthesia and General Anesthesia on Cognitive Function and Stress Responses of Elderly Patients Undergoing Liver Cancer Surgery. JOURNAL OF ONCOLOGY 2021; 2021:8273722. [PMID: 34608389 PMCID: PMC8487374 DOI: 10.1155/2021/8273722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 02/08/2023]
Abstract
This study aimed at exploring the effects of combined epidural anesthesia and general anesthesia on the cognitive function and stress responses of elderly patients undergoing liver cancer surgery. One hundred and fifteen elderly patients were enrolled as research subjects. They were admitted to our hospital and underwent liver cancer surgery from August 2017 to May 2019. Fifty five cases were treated with general anesthesia (GA) (GA group), while the other sixty cases were treated with combined epidural anesthesia and general anesthesia (joint group). Scoring standards of Mini-Mental State Examination (MMSE) were used to evaluate the patients before and after operation. Their operating time, total fluid input (TFI), spontaneous breathing recovery time (SBRT), preoperative and postoperative indices of stress responses (epinephrine (EPI), cortisol (Cor), and norepinephrine (NE)), and postoperative adverse reactions were observed. There were statistically significant differences between the two groups with respect to anesthesia time, TFI, postoperative SBRT, and postoperative directional recovery time (DRT) (cP < 0.05). There was no difference in operating time, total fluid loss (TFL), and hospitalization time (P > 0.05). After operation, patients in both groups experienced a cognitive decline of different degrees and the MMSE scores decreased. There was no significant difference in the score between the two groups before operation and 3 days and 7 days after operation (P > 0.05). The score was significantly better in the joint group than that in the GA group at 6 hours and 1 day after operation (P < 0.05). There were no significant differences in levels of EPI, Cor, and NE between the two groups before operation (P > 0.05), but there were significant differences after operation. The total incidence of postoperative adverse reactions was 11.67% in the joint group and 25.45% in the GA group. In conclusion, combined epidural anesthesia and general anesthesia can significantly reduce postoperative cognitive dysfunction and inhibit postoperative stress responses in elderly patients undergoing liver cancer surgery. It has good application value in clinical practice.
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Lunel T, Mohkam K, Merle P, Bonnet A, Gazon M, Dumont PN, Ducerf C, Mabrut JY, Lesurtel M. Impact of 2016 Enhanced Recovery After Surgery (ERAS) Recommendations on Outcomes after Hepatectomy in Cirrhotic and Non-Cirrhotic Patients. World J Surg 2021; 45:2964-2974. [PMID: 34269842 DOI: 10.1007/s00268-021-06229-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Thibault Lunel
- Department of Digestive Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - Kayvan Mohkam
- Department of Digestive Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - Philippe Merle
- Hepatology Unit, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - Aurélie Bonnet
- Department of Anesthesiology, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - Mathieu Gazon
- Department of Anesthesiology, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - Paul-Noël Dumont
- Department of Digestive Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - Christian Ducerf
- Department of Digestive Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - Jean-Yves Mabrut
- Department of Digestive Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - Mickaël Lesurtel
- Department of Digestive Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France.
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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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14
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Kang T, Jia Z, Xing G, Zhou Q. Comparison of Clinical Outcomes Between Chinese Patients Receiving Hepatectomy With or Without Enhanced Recovery After Surgery Strategy. Front Surg 2021; 8:645935. [PMID: 33842531 PMCID: PMC8033151 DOI: 10.3389/fsurg.2021.645935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/16/2021] [Indexed: 11/13/2022] Open
Abstract
Purposes: For the first time in China, the current study was designed to compare the clinical outcomes between Chinese patients receiving hepatectomy with or without the enhanced recovery after surgery (ERAS) strategy. Methods: The current study enrolled 250 patients who would receive hepatectomy. Patients were randomized into two groups: ERAS group (n = 125, ERAS strategy) and control (n = 125, conventional care). Mortality, length of hospital stay, readmission, and complications were assessed over 30 days after the operation. Results: The average age of the whole cohort was 65 (63-68) years, with 152 males (60.8%). There was no difference between two groups in baseline features, such as age, sex, medical history, Child-Pugh hepatic function, American Society of Anaesthesiologists physical status, operative type, hepatectomy type, and hepatic pathology (P > 0.05 for all). There was no occurrence of death in the two groups. Patients in the ERAS group had significantly less occurrence of post-operative complications and a shorter length of hospital stay (P < 0.05 for all). Deep vein thrombosis occurred in seven patients in the control group, but did not occur in the ERAS group (P < 0.05). Patients in the two groups had similar occurrence of readmission (P > 0.05). Conclusions: ERAS strategy significantly decreased the occurrence of operative complications and shortened the length of hospital stay without any increase in mortality or readmission in Chinese patients receiving hepatectomy.
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Affiliation(s)
- Tieli Kang
- Department of Hepatobiliary Surgery, Inner Mongolia Xing'an Meng People's Hospital, Ulanhot, China
| | - Zhishuo Jia
- Department of Hepatobiliary Surgery, Inner Mongolia Xing'an Meng People's Hospital, Ulanhot, China
| | - Guoquan Xing
- Department of Hepatobiliary Surgery, Inner Mongolia Xing'an Meng People's Hospital, Ulanhot, China
| | - Quanhe Zhou
- Department of Hepatobiliary Surgery, Inner Mongolia Xing'an Meng People's Hospital, Ulanhot, China
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15
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Rao L, Liu X, Yu L, Xiao H. Effect of nursing intervention to guide early postoperative activities on rapid rehabilitation of patients undergoing abdominal surgery: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24776. [PMID: 33761639 PMCID: PMC9282128 DOI: 10.1097/md.0000000000024776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 01/27/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Postoperative complications after abdominal surgery are high, and there is no reliable intervention program to prevent them. Some studies have pointed out that early postoperative activities have advantages in preventing the occurrence of complications, but lack of evidence-based basis. The purpose of this study is to systematically evaluate the effect of nursing intervention is guiding early postoperative activities on the rapid recovery of patients undergoing abdominal surgery. METHODS China National Knowledge Infrastructure, Wanfang, China Science and Technology Journal Database and Chinese Biomedical Database, PubMed, Embase, Web of Science and the Cochrane Library will be searched by computer, and a randomized controlled study is conducted on early participation in exercise programs after abdominal surgery from the establishment of the database to January 2021. The language is limited to English and Chinese. The quality of the included study is independently extracted and the literature quality is evaluated by 2 researchers, and the included literature is analyzed by Meta using RevMan5.3 software. RESULTS This study will evaluate the effect of nursing intervention is guiding early postoperative activities on the rapid rehabilitation of patients undergoing abdominal surgery through the indexes of postoperative quality of life score, the incidence of complications, mortality, length of stay and so on. CONCLUSION This study will provide reliable evidence-based basis for establishing a reasonable and effective postoperative activity guidance program for patients undergoing abdominal surgery. ETHICS AND DISSEMINATION Private information from individuals will not be published. This systematic review also does not involve endangering participant rights. Ethical approval will not be required. The results may be published in a peer-reviewed journal or disseminated at relevant conferences. OSF REGISTRATION NUMBER DOI 10.17605/OSF.IO/59MD4.
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Affiliation(s)
- Lu Rao
- Guangzhou University of Chinese Medicine, Guangzhou
- Shenzhen Nanshan District Shekou People's Hospital, Shenzhen
| | - Xinjian Liu
- Shenzhen Nanshan District Shekou People's Hospital, Shenzhen
| | - Li Yu
- Shenzhen Nanshan District Shekou People's Hospital, Shenzhen
| | - Hui Xiao
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, China
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The Japan Society for Surgical Infection: guidelines for the prevention, detection, and management of gastroenterological surgical site infection, 2018. Surg Today 2020; 51:1-31. [PMID: 33320283 PMCID: PMC7788056 DOI: 10.1007/s00595-020-02181-6] [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] [Accepted: 10/30/2020] [Indexed: 12/27/2022]
Abstract
Background The guidelines for the prevention, detection, and management of gastroenterological surgical site infections (SSIs) were published in Japanese by the Japan Society for Surgical Infection in 2018. This is a summary of these guidelines for medical professionals worldwide. Methods We conducted a systematic review and comprehensive evaluation of the evidence for diagnosis and treatment of gastroenterological SSIs, based on the concepts of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The strength of recommendations was graded and voted using the Delphi method and the nominal group technique. Modifications were made to the guidelines in response to feedback from the general public and relevant medical societies. Results There were 44 questions prepared in seven subject areas, for which 51 recommendations were made. The seven subject areas were: definition and etiology, diagnosis, preoperative management, prophylactic antibiotics, intraoperative management, perioperative management, and wound management. According to the GRADE system, we evaluated the body of evidence for each clinical question. Based on the results of the meta-analysis, recommendations were graded using the Delphi method to generate useful information. The final version of the recommendations was published in 2018, in Japanese. Conclusions The Japanese Guidelines for the prevention, detection, and management of gastroenterological SSI were published in 2018 to provide useful information for clinicians and improve the clinical outcome of patients. Electronic supplementary material The online version of this article (10.1007/s00595-020-02181-6) contains supplementary material, which is available to authorized users.
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Knaak C, Spies C, Schneider A, Jara M, Vorderwülbecke G, Kuhlmann AD, von Haefen C, Lachmann G, Schulte E. Epidural Anesthesia in Liver Surgery-A Propensity Score-Matched Analysis. PAIN MEDICINE 2020; 21:2650-2660. [PMID: 32651587 DOI: 10.1093/pm/pnaa130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess the effects of epidural anesthesia (EA) on patients who underwent liver resection. DESIGN Secondary analysis of a prospective randomized controlled trial. SETTING This single-center study was conducted at an academic medical center. METHODS A subset of 110 1:1 propensity score-matched patients who underwent liver resection with and without EA were analyzed. Outcome measures were pain intensity ≥5 on a numeric rating scale (NRS) at rest and during movement on postoperative days 1-5, analyzed with logistic mixed-effects models, and postoperative complications according to the Clavien-Dindo classification, length of hospital stay (LOS), and one-year survival. One-year survival in the matched cohorts was compared using a frailty model. RESULTS EA patients were less likely to experience NRS ≥5 at rest (odds ratio = 0.06, 95% confidence interval [CI] = 0.01 to 0.28, P < 0.001). These findings were independent of age, sex, Charlson comorbidity index, baseline NRS, and surgical approach (open vs laparoscopic). The number and severity of postoperative complications and LOS were comparable between groups (P = 0.258, P > 0.999, and P = 0.467, respectively). Reduced mortality rates were seen in the EA group one year after surgery (9.1% vs 30.9%, hazard ratio = 0.32, 95% CI = 0.11 to 0.90, P = 0.031). No EA-related adverse events occurred. Earlier recovery of bowel function was seen in EA patients. CONCLUSIONS Patients with EA had better postoperative pain control and required fewer systemic opioids. Postoperative complications and LOS did not differ, although one-year survival was significantly improved in patients with EA. EA applied in liver surgery was effective and safe.
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Affiliation(s)
- Cornelia Knaak
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alice Schneider
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Maximilian Jara
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Gerald Vorderwülbecke
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Anna Dorothea Kuhlmann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Clarissa von Haefen
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Gunnar Lachmann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Erika Schulte
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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18
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Giovinazzo F, Kuemmerli C, Moekotte A, Rawashdeh A, Suhool A, Armstrong T, Primrose J, Abu Hilal M. The impact of enhanced recovery on open and laparoscopic liver resections. Updates Surg 2020; 72:649-657. [PMID: 32418169 DOI: 10.1007/s13304-020-00786-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 05/02/2020] [Indexed: 01/11/2023]
Abstract
Enhanced recovery after surgery programs (ERP) have been implemented in many surgical specialties. Their impact in liver surgery is poorly understood and approach-specific ERPs have not yet been assessed. This retrospective study aims to analyse the effect of such programs on liver resection. All patients undergoing liver resection at a tertiary referral centre between January 2009 and April 2019 were identified. Primary outcome was the length of stay (LOS), secondary outcomes were functional recovery, complications and readmission rates. Patients in the ERP with different protocols for open, laparoscopic, major and minor resections were compared to a historical cohort. Of 1056 patients, 644 were treated within the ERP. A comparable duration of hospital stay [7 days (IQR (interquartile range) 6-12) vs 7 days (IQR 5-9) p = 0.047] and faster functional recovery with fewer complications was found in the ERP group [94 (50.5%) vs 103 (35.9%) p < 0.002]. Those advantages were smaller after open minor compared to open major resection. In patients undergoing laparoscopic resection no differences were observed except for a lower readmission rate [21 (9.3%) vs 13 (3.6%) p = 0.005]. Multivariable analysis showed that laparoscopy was associated with a shorter LOS. ERPs offer significant advantages in open liver surgery. Those advantages are less evident after laparoscopic resection.
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Affiliation(s)
- Francesco Giovinazzo
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Christoph Kuemmerli
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, Istituto Fondazione Poliambulanza, Via Bissolati 57, 25124, Brescia, Italy
| | - Alma Moekotte
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Arab Rawashdeh
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Amal Suhool
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Thomas Armstrong
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - John Primrose
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Mohammed Abu Hilal
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK.
- Department of Surgery, Istituto Fondazione Poliambulanza, Via Bissolati 57, 25124, Brescia, Italy.
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Zhang Y, Zhang MW, Fan XX, Mao DF, Ding QH, Zhuang LH, Lv SY. Drug-eluting beads transarterial chemoembolization sequentially combined with radiofrequency ablation in the treatment of untreated and recurrent hepatocellular carcinoma. World J Gastrointest Surg 2020; 12:355-368. [PMID: 32903981 PMCID: PMC7448208 DOI: 10.4240/wjgs.v12.i8.355] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/08/2020] [Accepted: 07/19/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Drug-eluting beads transarterial chemoem-bolization (DEB-TACE) has the advantages of slow and steady release, high local concentration, and low incidence of adverse drug reactions compared to the traditional TACE. DEB-TACE combined with sequentially ultrasound-guided radiofrequency ablation (RFA) therapy has strong anti-cancer effects and little side effects, but there are fewer related long-term studies until now.
AIM To explore the outcome of DEB-TACE sequentially combined with RFA for patients with primary hepatocellular carcinoma (HCC).
METHODS Seventy-six patients with primary HCC who underwent DEB-TACE sequentially combined with RFA were recruited. Forty patients with untreated HCC were included in Group A, and 36 patients with recurrent HCC were included in Group B. In addition, 40 patients with untreated HCC who were treated with hepatectomy were included in Group C. The serological examination, preoperative magnetic resonance imaging examination, and post-treatment computed tomography enhanced examination were performed for all patients. The efficacy was graded as complete remission (CR), partial remission (PR), stable disease and progressive disease at the 3rd, 6th, and 9th. All patients were followed up for 3 years and their overall survival (OS), disease-free survival (DFS) were assessed.
RESULTS The efficacy of Group A and Group C was similar (P > 0.05), but the alanine aminotransferase, aspartate aminotransferase and total bilirubin of Group A were lower than those of Group C (all P < 0.05). The proportions of CR (32.5%), PR (37.5%) were slightly higher than Group A (CR: 27.5%, PR: 35%), but the difference was not statistically significant (χ2 = 0.701, P = 0.873). No operational-related deaths occurred in Group A and Group C. The OS (97.5%, 84.7%, and 66.1%) and the DFS (75.0%, 51.7%, and 35.4%) of Group A at the 1st, 2nd, and 3rd year after treatment were similar with those of Group C (OS: 90.0%, 79.7%, and 63.8%; DFS: 80.0%, 59.7%, and 48.6%; P > 0.05). The OS rates in Group A and Group B (90%, 82.3%, and 66.4%) were similar (P > 0.05). The DFS rates in Group B (50%, 31.6%, and 17.2%) were lower than that of Group A (P = 0.013).
CONCLUSION The efficacy of DEA-TACE combined with RFA for untreated HCC is similar with hepatectomy. Patients with recurrent HCC could get a longer survival time through the combined treatment.
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Affiliation(s)
- Yan Zhang
- Department of Interventional Therapy, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo 315010, Zhejiang Province, China
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo 315010, Zhejiang Province, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo 315010, Zhejiang Province, China
| | - Mei-Wu Zhang
- Department of Interventional Therapy, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo 315010, Zhejiang Province, China
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo 315010, Zhejiang Province, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo 315010, Zhejiang Province, China
| | - Xiao-Xiang Fan
- Department of Interventional Therapy, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo 315010, Zhejiang Province, China
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo 315010, Zhejiang Province, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo 315010, Zhejiang Province, China
| | - Da-Feng Mao
- Department of Interventional Therapy, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo 315010, Zhejiang Province, China
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo 315010, Zhejiang Province, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo 315010, Zhejiang Province, China
| | - Quan-Hua Ding
- Department of Gastroenterology, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo 315010, Zhejiang Province, China
| | - Lu-Hui Zhuang
- Department of Interventional Therapy, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo 315010, Zhejiang Province, China
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo 315010, Zhejiang Province, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo 315010, Zhejiang Province, China
| | - Shu-Yi Lv
- Department of Interventional Therapy, Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo 315010, Zhejiang Province, China
- Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo 315010, Zhejiang Province, China
- Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo 315010, Zhejiang Province, China
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Fung AKY, Chong CCN, Lai PBS. ERAS in minimally invasive hepatectomy. Ann Hepatobiliary Pancreat Surg 2020; 24:119-126. [PMID: 32457255 PMCID: PMC7271107 DOI: 10.14701/ahbps.2020.24.2.119] [Citation(s) in RCA: 7] [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: 09/25/2019] [Revised: 01/23/2020] [Accepted: 01/29/2020] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Andrew K Y Fung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Charing C N Chong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Paul B S Lai
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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21
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Zhou JM, He XG, Wang M, Zhao YM, Shu L, Wang LR, Wang L, Mao AR. Enhanced recovery after surgery program in the patients undergoing hepatectomy for benign liver lesions. Hepatobiliary Pancreat Dis Int 2020; 19:122-128. [PMID: 31983674 DOI: 10.1016/j.hbpd.2019.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 12/31/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has shown effectiveness in terms of reducing the hospital stay and cost. However, the benefit of ERAS in patients undergoing hepatectomy for benign liver lesions is still unclear. METHODS ERAS was implemented in our center since March 1st, 2018. From September 2016 to February 2018, 109 patients were enrolled into the control group, and from March 2018 to June 2019, 124 patients were enrolled into the ERAS group. All the indicators related to operation, liver functions, and postoperative outcomes were included in the analysis. RESULTS The clinicopathologic baselines were similar in these two groups. A significantly higher proportion of patients underwent laparoscopic surgery in the ERAS group. On the whole, intraoperative blood loss (100.00 mL vs. 200.00 mL, P < 0.001), blood transfusion (3.23% vs. 10.09%, P = 0.033), total bilirubin (17.10 µmol/L vs. 21.00 µmol/L, P = 0.041), D-dimer (2.08 µg/mL vs. 2.57 µg/mL, P = 0.031), postoperative hospital stay (5.00 d vs. 6.00 d, P < 0.001), and postoperative morbidity (16.13% vs. 32.11%, P = 0.008) were significantly shorter or less in the ERAS group than those in the control group. After stratified by operation methods, ERAS group showed significantly shorter postoperative hospital stay in both open and laparoscopic operation (both P < 0.001). In patients underwent open surgery, ERAS group demonstrated significantly shorter operative duration (131.76 ± 8.75 min vs. 160.73 ± 7.23 min, P = 0.016), less intraoperative blood loss (200.00 mL vs. 450.00 mL, P = 0.008) and less postoperative morbidity (16.00% vs. 44.44%, P = 0.040). CONCLUSIONS ERAS program may be safe and effective for the patients underwent hepatectomy, especially open surgery, for benign liver lesions.
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Affiliation(s)
- Jia-Min Zhou
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai 200032, China
| | - Xi-Gan He
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai 200032, China
| | - Miao Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai 200032, China
| | - Yi-Ming Zhao
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai 200032, China
| | - Lian Shu
- Education Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Long-Rong Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai 200032, China
| | - Lu Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai 200032, China
| | - An-Rong Mao
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai 200032, China.
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22
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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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23
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Fujio A, Miyagi S, Tokodai K, Nakanishi W, Nishimura R, Mitsui K, Unno M, Kamei T. Effects of a new perioperative enhanced recovery after surgery protocol in hepatectomy for hepatocellular carcinoma. Surg Today 2019; 50:615-622. [PMID: 31797128 DOI: 10.1007/s00595-019-01930-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/18/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) protocols are becoming the standard of care in many surgical procedures, although data on their use following hepatectomy for hepatocellular carcinoma (HCC) are scarce. This study aimed to evaluate the effects of a new ERAS pathway in terms of the patient nutrition status after hepatectomy for HCC. METHODS This is a retrospective analysis of 97 consecutive patients treated with open or laparoscopic hepatectomy for HCC between January 2011 and August 2014. We compared the perioperative outcomes between patients whose treatment incorporated the ERAS pathway and control patients. The nutritional status was evaluated using the controlling nutritional status score. RESULTS The length of hospital stay (LOS) after both open and laparoscopic hepatectomy was shorter for the ERAS group than the control group. The days of ambulation and cessation of intravenous infusion were earlier and the postoperative nutrition status was statistically better in the ERAS group than in the control group. A multivariate analysis showed that being in the non-ERAS group was a risk factor of delayed discharge. There were no marked differences in the rate of severe complications between the two groups. CONCLUSIONS The ERAS pathway seems feasible and safe and results in a faster recovery, reduced LOS, improved nutrition status, and fewer severe complications.
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Affiliation(s)
- Atsushi Fujio
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan.
| | - Shigehito Miyagi
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan
| | - Kazuaki Tokodai
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan
| | - Wataru Nakanishi
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan
| | - Ryuichi Nishimura
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan
| | - Kazuhiro Mitsui
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-0872, Japan
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Zerillo J, Agarwal P, Poeran J, Zubizarreta N, Poultsides G, Schwartz M, Memtsoudis S, Mazumdar M, DeMaria S. Perioperative Management in Hepatic Resections: Comparative Effectiveness of Neuraxial Anesthesia and Disparity of Care Patterns. Anesth Analg 2019; 127:855-863. [PMID: 29933267 DOI: 10.1213/ane.0000000000003579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Complication rates after hepatic resection can be affected by management decisions of the hospital care team and/or disparities in care. This is true in many other surgical populations, but little study has been done regarding patients undergoing hepatectomy. METHODS Data from the claims-based national Premier Perspective database were used for 2006 to 2014. The analytical sample consisted of adults undergoing partial hepatectomy and total hepatic lobectomy with anesthesia care consisting of general anesthesia (GA) only or neuraxial and GA (n = 9442). The key independent variable was type of anesthesia that was categorized as GA versus GA + neuraxial. The outcomes examined were clinical complications and health care resource utilization. Unadjusted bivariate and adjusted multivariate analyses were conducted to examine the effects of the different types of anesthesia on clinical complications and health care resource utilization after controlling for patient- and hospital-level characteristics. RESULTS Approximately 9% of patients were provided with GA + neuraxial anesthesia during hepatic resection. In multivariate analyses, no association was observed between types of anesthesia and clinical complications and/or health care utilization (eg, admission to intensive care unit). However, patients who received blood transfusions were significantly more likely to have complications and intensive care unit stays. In addition, certain disparities of care, including having surgery in a rural hospital, were associated with poorer outcomes. CONCLUSIONS Neuraxial anesthesia utilization was not associated with improvement in clinical outcome or cost among patients undergoing hepatic resections when compared to patients receiving GA alone. Future research may focus on prospective data sources with more clinical information on such patients and examine the effects of GA + neuraxial anesthesia on various complications and health care resource utilization.
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Affiliation(s)
| | - Parul Agarwal
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jashvant Poeran
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nicole Zubizarreta
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - George Poultsides
- Department of Surgery, Stanford University Medical Center, Stanford, California
| | - Myron Schwartz
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stavros Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
| | - Madhu Mazumdar
- Institute for Healthcare Delivery Science, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York
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Quinn L, Mann K, Jones R, Bathla S, Stremitzer S, Dunne D, Lacasia C, Fenwick S, Malik H. Defining enhanced recovery after resection of peri-hilar cholangiocarcinoma. Eur J Surg Oncol 2019; 45:1439-1445. [DOI: 10.1016/j.ejso.2019.03.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/18/2019] [Accepted: 03/25/2019] [Indexed: 12/25/2022] Open
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26
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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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Zhao J, Hu J, Jiang Z, Wang G, Liu J, Wang H, Fang P, Liu X, Wang J, Li J. Outcome of Discharge Within 72 Hours of Robotic Gastrectomy Using Enhanced Recovery After Surgery Programs. J Laparoendosc Adv Surg Tech A 2018; 28:1279-1286. [PMID: 30148694 DOI: 10.1089/lap.2018.0051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
AIMS To evaluate the safety and outcome of discharge within 72 hours of a robotic gastrectomy together with enhanced recovery after surgery (ERAS) programs. MATERIALS AND METHODS In total, 108 consecutive patients received elective robotic gastrectomy for gastric cancer from April 2017 to September 2017. All patients attended ERAS programs, which do not routinely use nasogastric tubes but include early feeding, early ambulation, and standard discharge criteria, among other items. RESULTS The mean age was 58.7 ± 10.4 years old, and the mean body mass index was 22.9 ± 2.8 kg/m2. The mean postoperative length of hospital stay was 5.6 ± 8.0 days, and 13 patients (12.0%) exhibited a complication within 30 days with no mortality. A total of 38 patients (35.2%) were discharged within 72 hours of surgery. Patients were grouped based on being discharged within or after 72 hours. The rate of complications was significantly lower in patients discharged within 72 hours than patients discharged after 72 hours (1/38, 2.6% versus 12/70, 17.1%, P = .028). Although patients discharged within 72 hours showed lower readmission numbers, this difference was not statistically significant (1/38, 2.6% versus 8/70, 11.4%, P = .116). One month after surgery, loss of weight, loss of total protein, loss of albumin, and loss of prealbumin in patients discharged within 72 hours were less than those of patients discharged after 72 hours. CONCLUSION Complication and readmission rates are low in patients discharged within 72 hours of robotic gastrectomy when ERAS programs and standard discharge criteria are used.
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Affiliation(s)
- Jian Zhao
- 1 Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, China
| | - Jiawei Hu
- 1 Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, China
| | - Zhiwei Jiang
- 1 Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, China
| | - Gang Wang
- 1 Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, China
| | - Jiang Liu
- 1 Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, China
| | - Haifeng Wang
- 1 Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, China
| | - Peng Fang
- 1 Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, China
| | - Xinxin Liu
- 2 Department of Gastrointestinal Surgery, Clinical Medical School, Northern Jiangsu People's Hospital, Yangzhou University , Yangzhou, China
| | - Jian Wang
- 3 Department of Gastrointestinal Surgery, Suqian People's Hospital , Suqian, China
| | - Jieshou Li
- 1 Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University , Nanjing, China
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28
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Stockmann M, Vondran FWR, Fahrner R, Tautenhahn HM, Mittler J, Bektas H, Malinowski M, Jara M, Klein I, Lock JF. Randomized clinical trial comparing liver resection with and without perioperative assessment of liver function. BJS Open 2018; 2:301-309. [PMID: 30263981 PMCID: PMC6156169 DOI: 10.1002/bjs5.81] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 04/13/2018] [Indexed: 12/11/2022] Open
Abstract
Background Liver function tests may help to predict outcomes after liver surgery. The aim of this study was to evaluate the clinical impact on postoperative outcome and patient management of perioperative liver function testing using the LiMAx® test. Methods A multicentre RCT was conducted in six academic liver centres. Patients with intrahepatic tumours scheduled for open liver resection of at least one segment were eligible. Patients were randomized to undergo additional perioperative liver function tests (LiMAx® group) or standard care (control group). Patients in the intervention arm received two perioperative LiMAx® tests, one before the operation for surgical planning and another after surgery for postoperative management. The primary endpoint was the proportion of patients transferred directly to a general ward. Secondary endpoints were severe complications, length of hospital stay (LOS) and length of intermediate care/ICU (LOI) stay. Results Some 148 patients were randomized. Thirty‐six of 58 patients (62 per cent) in the LiMAx® group were transferred directly to a general ward, compared with one of 60 (2 per cent) in the control group (P < 0·001). The rate of severe complications was significantly lower in the LiMAx® group (14 per cent versus 28 per cent in the control group; P = 0·022). LOS and LOI were significantly shorter in the LiMAx® group (LOS: 10·6 versus 13·3 days respectively, P = 0·012; LOI: 0·8 versus 3·0 days, P < 0·001). Conclusion Perioperative use of the LiMAx® test improves postoperative management and reduces the incidence of severe complications after liver surgery. Registration number: NCT01785082 (
https://clinicaltrials.gov).
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Affiliation(s)
- M Stockmann
- Department of General, Visceral and Transplantation Surgery Charité - Universitätsmedizin Berlin Germany.,Department of General, Visceral and Vascular Surgery Evangelisches Krankenhaus Paul Gerhardt Stift Lutherstadt Wittenberg Germany
| | - F W R Vondran
- Department of General, Visceral and Transplant Surgery Hannover Medical School Hannover Germany
| | - R Fahrner
- Department of General, Visceral and Vascular Surgery University of Jena Jena Germany
| | - H M Tautenhahn
- Department of General, Visceral and Vascular Surgery University of Jena Jena Germany.,Department of Visceral, Transplant, Thoracic and Vascular Surgery University Hospital Leipzig Leipzig Germany
| | - J Mittler
- Department of Hepatobiliary and Transplantation Surgery Johannes Gutenberg University Mainz Germany
| | - H Bektas
- Department of General, Visceral and Transplant Surgery Hannover Medical School Hannover Germany.,Department of General, Visceral and Oncological Surgery Bremen Mitte Clinic Bremen Germany
| | - M Malinowski
- Department of General, Visceral and Transplantation Surgery Charité - Universitätsmedizin Berlin Germany.,Department of General, Visceral, Vascular and Paediatric Surgery University of Saarland Homburg Germany
| | - M Jara
- Department of General, Visceral and Transplantation Surgery Charité - Universitätsmedizin Berlin Germany
| | - I Klein
- Department of General, Visceral, Vascular and Paediatric Surgery University Hospital of Würzburg Würzburg Germany
| | - J F Lock
- Department of General, Visceral, Vascular and Paediatric Surgery University Hospital of Würzburg Würzburg Germany
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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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30
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Rouxel P, Beloeil H. Enhanced recovery after hepatectomy: A systematic review. Anaesth Crit Care Pain Med 2018; 38:29-34. [PMID: 29807132 DOI: 10.1016/j.accpm.2018.05.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/12/2018] [Accepted: 05/02/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Hepatectomy is a surgery with high postoperative complication rates. Enhanced recovery after surgery (ERAS) clinical pathways in liver surgery have been studied and may become a standard of care. However, few specific recommendations have been published so far. OBJECTIVE The aim of this study was to assess the efficacy and safety of the enhanced recovery program in liver surgery. METHODS Randomised controlled trials (RCTs) comparing ERAS group with traditional care published between 2007 and 2017 were included in this review. The outcomes were length of stay (LoS), complications, mortality and readmission rate for all liver surgeries except transplantation. RESULTS Five hundred and twenty-four patients randomised in 4 RCTs were analysed. Two hundred and fifty-four patients were in ERAS group and 270 patients in traditional care (TC) group. Two studies compared cares in laparoscopic surgery and 2 in open surgery. Postoperative LoS was significantly lower in the ERAS group whereas readmission and mortality rate were similar. ERAS group had also significant lower complication rate in 2 studies of the 4. The complication rate in the 2 other studies was similar. CONCLUSION ERAS protocols in liver surgery appeared to be safe and effective. Recent recommendations from the ERAS group in liver surgery are the only ones published so far. Other studies evaluating ERAS components in liver surgery and recommendations from scientific societies are needed to spread this clinical care pathway.
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Affiliation(s)
- Pauline Rouxel
- Department of Anaesthesiology and Critical Care Medicine, CHU de Rennes, Université de Rennes, Inserm NumeCan, CIC 1414, 35000 Rennes, France
| | - Helene Beloeil
- Department of Anaesthesiology and Critical Care Medicine, CHU de Rennes, Université de Rennes, Inserm NumeCan, CIC 1414, 35000 Rennes, France.
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Ni CY, Wang ZH, Huang ZP, Zhou H, Fu LJ, Cai H, Huang XX, Yang Y, Li HF, Zhou WP. Early enforced mobilization after liver resection: A prospective randomized controlled trial. Int J Surg 2018; 54:254-258. [PMID: 29753000 DOI: 10.1016/j.ijsu.2018.04.060] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/15/2018] [Accepted: 04/13/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This randomized controlled study investigated the feasibility of early ambulation after liver resection and the effect of the amount of activity on postoperative recovery. METHODS A total of 120 patients who underwent liver resection were randomly divided into two groups for the comparative analysis of the following factors: amount of activity, pain control, sleeping state, perioperative gastrointestinal function recovery, incidence of complications and postoperative hospital stay. RESULTS Compared with the control group, patients undergoing liver resection performing early postoperative ambulation had faster gastrointestinal function recovery (First exhaust time 2.2 ± 1.4 vs. 3.3 ± 2.3 p < 0.01; First flatus time 2.3 ± 1.7 vs. 3.1 ± 2.5 p = 0.04) and shorter postoperative hospital stays (6.6 ± 2.3 vs. 7.7 ± 2.1 p = 0.01), with statistically significant differences. There was no significant difference in the incidence of postoperative complications between the two groups (p > 0.05). CONCLUSION Early ambulation after liver resection is safe and feasible. It can reduce the patient's pain and economic burden, increase the patient's comfort, reduce the nursing workload, achieve rapid recovery, and improve patient satisfaction.
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Affiliation(s)
- Chun-Yan Ni
- The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou 215153, Jiangsu Province, China; Suzhou Science & Technology Town Hospital, Suzhou 215153, Jiangsu Province, China; Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Zhi-Hong Wang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Zhi-Ping Huang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Hui Zhou
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Li-Juan Fu
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Hui Cai
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Xuan-Xuan Huang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Yuan Yang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.
| | - Hui-Fen Li
- The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou 215153, Jiangsu Province, China; Suzhou Science & Technology Town Hospital, Suzhou 215153, Jiangsu Province, China.
| | - Wei-Ping Zhou
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China.
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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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Enhanced Recovery After Surgery for Noncolorectal Surgery?: A Systematic Review and Meta-analysis of Major Abdominal Surgery. Ann Surg 2017; 267:57-65. [PMID: 28437313 DOI: 10.1097/sla.0000000000002267] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Enhanced recovery care versus traditional care after laparoscopic liver resections: a randomized controlled trial. Surg Endosc 2017; 32:2746-2757. [DOI: 10.1007/s00464-017-5973-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 10/30/2017] [Indexed: 12/11/2022]
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Melloul E, Hübner M, Scott M, Snowden C, Prentis J, Dejong CHC, Garden OJ, Farges O, Kokudo N, Vauthey JN, Clavien PA, Demartines N. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg 2017; 40:2425-40. [PMID: 27549599 DOI: 10.1007/s00268-016-3700-1] [Citation(s) in RCA: 372] [Impact Index Per Article: 53.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) is a multimodal pathway developed to overcome the deleterious effect of perioperative stress after major surgery. In colorectal surgery, ERAS pathways reduced perioperative morbidity, hospital stay and costs. Similar concept should be applied for liver surgery. This study presents the specific ERAS Society recommendations for liver surgery based on the best available evidence and on expert consensus. METHODS A systematic review was performed on ERAS for liver surgery by searching EMBASE and Medline. Five independent reviewers selected relevant articles. Quality of randomized trials was assessed according to the Jadad score and CONSORT statement. The level of evidence for each item was determined using the GRADE system. The Delphi method was used to validate the final recommendations. RESULTS A total of 157 full texts were screened. Thirty-seven articles were included in the systematic review, and 16 of the 23 standard ERAS items were studied specifically for liver surgery. Consensus was reached among experts after 3 rounds. Prophylactic nasogastric intubation and prophylactic abdominal drainage should be omitted. The use of postoperative oral laxatives and minimally invasive surgery results in a quicker bowel recovery and shorter hospital stay. Goal-directed fluid therapy with maintenance of a low intraoperative central venous pressure induces faster recovery. Early oral intake and mobilization are recommended. There is no evidence to prefer epidural to other types of analgesia. CONCLUSIONS The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.
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Affiliation(s)
- Emmanuel Melloul
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.,Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Martin Hübner
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Michael Scott
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Chris Snowden
- Department of Perioperative and Critical Care Medicine, Freeman Hospital, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, The Medical School, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - James Prentis
- Department of Perioperative and Critical Care Medicine, Freeman Hospital, Newcastle upon Tyne, UK
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Center and NUTRIM School for Translational Research in Metabolism, Maastricht, The Netherlands
| | - O James Garden
- Department of Clinical Surgery, School of Clinical Sciences, The University of Edinburgh, Edinburgh, UK
| | - Olivier Farges
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, U.T. MD Anderson Cancer Center, Houston, TX, USA
| | - Pierre-Alain Clavien
- Swiss Hepato-pancreato-biliary and Transplantation Center, Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital Lausanne, CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Abstract
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.
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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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38
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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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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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Yang XW, Chen JY, Yan WL, Du J, Wen ZJ, Yan XZ, Yang PH, Yang J, Zhang BH. Case-control study of the efficacy of retrogastric Roux-en-Y choledochojejunostomy. Oncotarget 2017; 8:81226-81234. [PMID: 29113382 PMCID: PMC5655277 DOI: 10.18632/oncotarget.16006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 02/28/2017] [Indexed: 01/04/2023] Open
Abstract
The traditional, retrocolic/antegastric Roux-en-Y choledochojejunostomy is technically complicated, and the incidence of postoperative complications remains high. Here we report the outcome of 59 consecutively treated patients (study group, SG) that underwent a new choledochojejunostomy method in which the jejunal loop is passed behind the antrum pyloricum (retrogastric route). A retrospective comparison was made between this group of patients and 187 patients (control group, CG) that underwent conventional Roux-en-Y choledochojejunostomy (antegastric route). Baseline clinicopathological characteristics were similar in both groups, except for the BMI, which was significantly higher in the SG. The time spent on constructing the anastomosis, as well as overall postoperative complications, did not differ between groups. Compared with the CG, the incidence of postoperative delayed gastric emptying was decreased in the SG, and the time elapsed before the patients' first postoperative liquid food consumption was shorter. We ascribe these beneficial effects to the superiority of the modified, retropyloric choledochojejunostomy approach, and propose that this surgical technique is particularly suitable for obese patients, especially those with a short ascending bowel loop.
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Affiliation(s)
- Xin-Wei Yang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Jun-Yi Chen
- Department of General Surgery, the Fourth People's Hospital of Shanghai, Shanghai, China
| | - Wen-Liang Yan
- Department of Dermatology, Jinling Hospital, Nanjing, China
| | - Jing Du
- Second Military Medical University, Shanghai, China
| | - Zhi-Jian Wen
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Xing-Zhou Yan
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Ping-Hua Yang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Jue Yang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
| | - Bao-Hua Zhang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China
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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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Wolk S, Meißner T, Linke S, Müssle B, Wierick A, Bogner A, Sturm D, Rahbari NN, Distler M, Weitz J, Welsch T. Use of activity tracking in major visceral surgery-the Enhanced Perioperative Mobilization (EPM) trial: study protocol for a randomized controlled trial. Trials 2017; 18:77. [PMID: 28222805 PMCID: PMC5322788 DOI: 10.1186/s13063-017-1782-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 01/04/2017] [Indexed: 01/14/2023] Open
Abstract
Background Enhanced recovery after surgery (ERAS) programs are aimed at minimizing postoperative stress and accelerating postoperative recovery by implementing multiple perioperative principles. “Early mobilization” is one such principle, but the quality of assessment and monitoring is poor, and evidence of improved outcome is lacking. Activity trackers allow precise monitoring and automatic feedback to the patients to enhance their motivation for early mobilization. The aim of the study is to monitor and increase the postoperative mobilization of patients by giving them continuous automatic feedback in the form of a step count using activity-tracking wristbands. Methods/design Patients undergoing elective open and laparoscopic surgery of the colon, rectum, stomach, pancreas, and liver for any indication will be included. Further inclusion criteria are age between 18 and 75 years, American Society of Anesthesiologists Physical Status class less than IV, and a signed informed consent form. Patients will be stratified into two subgroups, laparoscopic and open surgery, and will be randomized 1:1 for automatic feedback of their step count using an activity tracker wristband. The control group will have no automatic feedback. The sample size (n = 30 patients in each of the four groups, overall n = 120) is calculated on the basis of an assumed difference in step count of 250 steps daily (intervention group versus control group). The primary study endpoint is the average step count during the first 5 postoperative days; secondary endpoints are the percentage of patients in the two groups who master the predefined mobilization (step count) targets, assessment of additional activity data obtained from the devices, assessment of preoperative mobility, length of hospital and intensive care unit stays, number of patients who receive physiotherapy, 30-day mortality, and overall 30-day morbidity. Discussion Early mobilization is a key element of ERAS. However, enhanced early mobilization is difficult to define, to assess objectively, and to implement in clinical practice. Consequently, there is a discrepancy between ERAS targets and actual practice, especially in patients undergoing major visceral surgery. This study is the first randomized controlled trial investigating the use and feasibility of activity tracking to monitor and enhance postoperative early mobilization. Trial registration ClinicalTrials.gov identifier: NCT02834338. Registered on 15 June 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1782-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Steffen Wolk
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Theresa Meißner
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Sebastian Linke
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Benjamin Müssle
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Ann Wierick
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Andreas Bogner
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Dorothée Sturm
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Nuh N Rahbari
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
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Impact of Enhanced Recovery After Surgery and Fast Track Surgery Pathways on Healthcare-associated Infections. Ann Surg 2017; 265:68-79. [DOI: 10.1097/sla.0000000000001703] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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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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Xu X, Wang Y, Feng T, Zhao X, Liao Y, Ji W, Li J. Nonstrict and individual enhanced recovery after surgery (ERAS) in partial hepatectomy. SPRINGERPLUS 2016; 5:2011. [PMID: 27933266 PMCID: PMC5122531 DOI: 10.1186/s40064-016-3688-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 11/15/2016] [Indexed: 12/20/2022]
Abstract
Background We aimed to evaluate postoperative recovery and short-term outcomes of patients undergoing partial hepatectomy managed with a nonstrict and individual enhanced recovery after surgery (ERAS) program. Methods A retrospective analysis of 168 partial hepatectomy patients in our institution was included. The discharged day and the respective impact of element application throughout the duration were analyzed. Results When all the required elements of ERAS were fully implemented, the median discharge day was 6. The more deviation occurred, the more delayed the patient discharged (P < 0.01). Preoperative ASA score, basic conditions of patients and ages were revealed closely associated with discharge day (P < 0.001). Without or an early removal of tubes and early oral feeding reduced hospital stay statistically (P < 0.01). Early discharge of patients (<3 days) did not show an increased complication incidence or readmission (P > 0.05). Conclusion Nonstrict and individual use of ERAS in partial hepatectomy reduced postoperative length of stay without increasing complication rate. Our study proposes a modulation of ERAS according to the needs and acceptance of patients. In a word, better optionally required rather than mandatorily meet.
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Affiliation(s)
- Xingwei Xu
- Jinling Hospital, Research Institute of General Surgery, Nanjing University, School of Medicine, Nanjing, 210002 Jiangsu Province People's Republic of China
| | - Yingbin Wang
- General Surgery, General Hospital of Tisco Affiliated to Shanxi Medical University, Taiyuan, 030008 Shanxi Province People's Republic of China
| | - Tao Feng
- Jinling Hospital, Research Institute of General Surgery, Nanjing University, School of Medicine, Nanjing, 210002 Jiangsu Province People's Republic of China
| | - Xin Zhao
- Jinling Hospital, Research Institute of General Surgery, Nanjing University, School of Medicine, Nanjing, 210002 Jiangsu Province People's Republic of China
| | - Yannian Liao
- Jinling Hospital, Research Institute of General Surgery, Nanjing University, School of Medicine, Nanjing, 210002 Jiangsu Province People's Republic of China
| | - Wu Ji
- Jinling Hospital, Research Institute of General Surgery, Nanjing University, School of Medicine, Nanjing, 210002 Jiangsu Province People's Republic of China
| | - Jieshou Li
- Jinling Hospital, Research Institute of General Surgery, Nanjing University, School of Medicine, Nanjing, 210002 Jiangsu Province People's Republic of China
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Lau CSM, Chamberlain RS. Enhanced Recovery After Surgery Programs Improve Patient Outcomes and Recovery: A Meta-analysis. World J Surg 2016; 41:899-913. [DOI: 10.1007/s00268-016-3807-4] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Thiele RH, Raghunathan K, Brudney CS, Lobo DN, Martin D, Senagore A, Cannesson M, Gan TJ, Mythen MMG, Shaw AD, Miller TE. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery. Perioper Med (Lond) 2016; 5:24. [PMID: 27660701 PMCID: PMC5027098 DOI: 10.1186/s13741-016-0049-9] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 08/24/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Enhanced recovery may be viewed as a comprehensive approach to improving meaningful outcomes in patients undergoing major surgery. Evidence to support enhanced recovery pathways (ERPs) is strong in patients undergoing colorectal surgery. There is some controversy about the adoption of specific elements in enhanced recovery "bundles" because the relative importance of different components of ERPs is hard to discern (a consequence of multiple simultaneous changes in clinical practice when ERPs are initiated). There is evidence that specific approaches to fluid management are better than alternatives in patients undergoing colorectal surgery; however, several specific questions remain. METHODS In the "Perioperative Quality Initiative (POQI) Fluids" workgroup, we developed a framework broadly applicable to the perioperative management of intravenous fluid therapy in patients undergoing elective colorectal surgery within an ERP. DISCUSSION We discussed aspects of ERPs that impact fluid management and made recommendations or suggestions on topics such as bowel preparation; preoperative oral hydration; intraoperative fluid therapy with and without devices for goal-directed fluid therapy; and type of fluid.
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Affiliation(s)
- Robert H Thiele
- Departments of Anesthesiology and Biomedical Engineering, Divisions of Cardiac, Thoracic, and Critical Care Anesthesiology, UVA Enhanced Recovery after Surgery (ERAS) Program, University of Virginia School of Medicine, Charlottesville, VA USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710 USA
| | - C S Brudney
- Duke University and Durham VA Medical Center, Durham, NC USA
| | - Dileep N Lobo
- Gastrointestinal Surgery, National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH UK
| | - Daniel Martin
- Division of Surgery and Interventional Science, University College London, Royal Free Hospital, London, NW3 2QG UK ; Anaesthetic Department, Royal Free Perioperative Research Group, Royal Free Hospital, London, NW3 2QG UK
| | - Anthony Senagore
- Department of Surgery, University of Texas-Medical Branch at Galveston, Galveston, TX 77555 USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA USA
| | - Tong Joo Gan
- Department of Anesthesiology, Stony Brook University School of Medicine, Stony Brook, NY USA
| | - Michael Monty G Mythen
- University College London Hospitals, National Institute of Health Research Biomedical Research Centre, London, UK
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Timothy E Miller
- Division of General, Vascular and Transplant Anesthesia, American Society for Enhanced Recovery, Duke University Medical Center, Durham, NC 27710 USA
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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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Meng H, Yang J, Yan L. Donor Safety in Adult-Adult Living Donor Liver Transplantation: A Single-Center Experience of 356 Cases. Med Sci Monit 2016; 22:1623-9. [PMID: 27178367 PMCID: PMC4918531 DOI: 10.12659/msm.898440] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background As an important means to tackle the worldwide shortage of liver grafts, adult-adult living donor liver transplantation (A-ALDLT) is the most massive operation a healthy person could undergo, so donor safety is of prime importance. However, most previous research focused on recipients, while complications in donors have not been fully described or investigated. Material/Methods To investigate donor safety in terms of postoperative complications, the clinical data of 356 A-ALDLT donors in our center from January 2002 to September 2015 were retrospectively analyzed. These patients were divided into a pre-2008 group (before January 2008) and a post-2008 group (after January 2008). Donor safety was evaluated with regard to the type, frequency, and severity of postoperative complications. Results There were no donor deaths in our center during this period. The overall complication rate was 23.0% (82/356). The proportion of Clavien I, II, III, and IV complications was 51.2% (42/82), 25.6% (21/82), 22.0% (18/82), and 1.2% (1/82), respectively. In all the donors, the incidence of Clavien I, II, III, and IV complications was 11.8% (42/356), 5.9% (21/356), 5.1% (18/356), and 0.3% (1/356), respectively. The overall complication rate in the post-2008 group was significantly lower than that in the pre-2008 group (18.1% (41/227) vs. 32.6% (42/129), P<0.01). Biliary complications were the most common, with an incidence of 8.4% (30/356). Conclusions The risk to A-ALDLT donors is controllable and acceptable with improvement in preoperative assessment and liver surgery.
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Affiliation(s)
- Haipeng Meng
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Jiayin Yang
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Lunan Yan
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
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