Effect of enhanced recovery after surgery program on patient-reported outcomes and function recovery in patients undergoing liver resection for hepatocellular carcinoma

Influence of Regional Analgesia on Self-Reported Quality of Sleep After Gynecological Abdominal Surgery: A Secondary Analysis of a Randomized Trial

OBJECTIVES

To determine whether intrathecal morphine (ITM) analgesia in abdominal surgery for presumed gynecological malignancy was associated with better self-reported sleep quality postoperatively compared with epidural analgesia (EDA), and to evaluate risk factors for bad sleep quality.

METHODS

A secondary analysis of a randomized open controlled trial, comparing ITM and EDA as postoperative analgesia in 80 women undergoing laparotomy under general anaesthesia in an enhanced recovery after surgery framework. A total of 38 women allocated to ITM and 39 to EDA completed the study. The Swedish Postoperative Symptoms Questionnaire assessed symptoms and sleep quality during the first postoperative week. Multiple logistic regression models evaluated risk factors. The results are presented as adjusted odds ratios with 95% CIs.

RESULTS

The sleep quality night-by-night did not differ significantly between the women who had ITM or EDA. Risk factors for bad sleep quality for night 1 were age (0.91; 0.84-0.99), operation time (1.02; 1.00-1.03), and opioid consumption (0.96; 0.91-0.99). For night 2, regular use of hypnotics preoperatively (15.81; 1.52-164.27) and opioid consumption (1.07; 1.00-1.14) were independent risk factors for bad sleep. After the second night, no risk factors were disclosed.

CONCLUSIONS

ITM and EDA did not appear to affect the sleep quality postoperatively differently in women undergoing laparotomy for presumed gynecological malignancy. Risk factors for self-reported bad sleep quality varied during the first 3 days after surgery. Younger age, longer operation time, and preoperative use of hypnotics were associated with bad sleep quality, whereas the effect of opioid consumption on sleep quality varied depending on the time since surgery. These findings merit further studies.

Comparison of clinical efficacy between LAPS and ALPPS in the treatment of hepatitis B virus-related hepatocellular carcinoma

Background

Insufficient post-operative future liver remnant (FLR) limits the feasibility of hepatectomy for patients. Staged hepatectomy is an effective surgical approach that can improve the resection rate of hepatocellular carcinoma (HCC). This study aimed to compare the safety and efficacy of laparoscopic microwave ablation and portal vein ligation for staged hepatectomy (LAPS) and classical associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in the treatment of hepatitis B virus (HBV)-related HCC.

Methods

Clinical data of patients with HBV-related HCC who underwent LAPS or ALPPS in our institute between January 2017 and May 2022 were retrospectively analysed.

Results

A total of 18 patients with HBV-related HCC were retrospectively analysed and divided into the LAPS group (n = 9) and ALPPS group (n = 9). Eight patients in the LAPS group and eight patients in the ALPPS group proceeded to a similar resection rate (88.9% vs 88.9%, P = 1.000). The patients undergoing LAPS had a lower total comprehensive complication index than those undergoing ALPPS but there was not a significant different between the two groups (8.66 vs 35.87, P = 0.054). The hypertrophy rate of FLR induced by ALPPS tended to be more rapid than that induced by LAPS (24.29 vs 13.17 mL/d, P = 0.095). The 2-year recurrence-free survival (RFS) was 0% for ALPPS and 35.7% for LAPS (P = 0.009), whereas the 2-year overall survival for ALPPS and LAPS was 33.3% and 100.0% (P = 0.052), respectively.

Conclusions

LAPS tended to induce lower morbidity and FLR hypertrophy more slowly than ALPPS, with a comparable resection rate and better long-term RFS in HBV-related HCC patients.

Validation of the Enhanced Recovery after Surgery (ERAS) society recommendations for liver surgery: a prospective, observational study

Background

Twenty-three recommendations were summarized by the Enhanced Recovery After Surgery (ERAS) society for liver surgery. The aim was to validate the protocol especially with regard to adherence and the impact on morbidity.

Methods

Using the ERAS Interactive Audit System (EIAS), ERAS items were evaluated in patients undergoing liver resection. Over a period of 26 months, 304 patients were prospectively enrolled in an observational study (DRKS00017229). Of those, 51 patients (non-ERAS) were enrolled before and 253 patients (ERAS) after the implementation of the ERAS protocol. Perioperative adherence and complications were compared between the two groups.

Results

Overall adherence increased from 45.2% in the non-ERAS group to 62.7% in the ERAS group (P<0.001). This was associated with significant improvements in the preoperative and postoperative phase (P<0.001), rather than in the outpatient and intraoperative phase (both P>0.05). Overall complications decreased from 41.2% (n=21) in the non-ERAS group to 26.5% (n=67) in the ERAS group (P=0.0423), which was mainly due to the reduction of grade 1-2 complications from 17.6% (n=9) to 7.6% (n=19) (P=0.0322). As for patients undergoing open surgery, implementation of ERAS lead to a reduction of overall complications in patients scheduled for minimally invasive liver surgery (MILS) (P=0.036).

Conclusions

Implementation of the ERAS protocol for liver surgery according to the ERAS guidelines of the ERAS Society reduced Clavien-Dindo grade 1-2 complications particularly in patients who underwent MILS. The ERAS guidelines are beneficial for the outcome, while adherence to the various items has not yet been satisfactorily defined.

Transcutaneous electrical acupoint stimulation combined with electroacupuncture promotes rapid recovery after abdominal surgery: Study protocol for a randomized controlled trial

Introduction

The most frequent complications after abdominal surgery include a decrease or loss of appetite, abdominal distension, abdominal pain caused by reduced gastrointestinal motility, anal arrest with intestinal distension and defecation, and nausea and vomiting due to anesthetic and opioid analgesic administration. These complications severely affect postoperative recovery, prolong hospital stay, and increase the financial burden. The objective of this study is to investigate the efficacy and safety of three acupoint stimulation modalities (electroacupuncture [EA], transcutaneous electrical acupoint stimulation [TEAS], and transcutaneous acupoint electrical stimulation combined with EA [TEAS+EA]), and two EA instrument waveforms (continuous wave and dilatational wave) for rapid recovery after abdominal surgery.

Methods and analysis

A total of 560 patients will be recruited and randomly allocated to receive one of the following seven interventions: continuous wave EA, continuous wave TEAS, continuous wave TEAS + EA, dilatational wave EA, dilatational wave TEAS, dilatational wave TEAS + EA, and a control. For this study, continuous waves at 2 Hz, and dilatational waves at 2/50 Hz would be selected. The points to be stimulated by EA are the bilateral Neiguan (PC6), Hegu (LI6), Zusanli (ST36), Shangjuxu (ST37), and Xiajuxu (ST39), and TEAS would stimulate the bilateral Liangmen (ST21) and Daheng (SP15). The control group will neither receive EA nor TEAS. All patients will undergo an enhanced recovery plan after surgery and be provided with standardized perioperative management. Treatment will start on the first postoperative day and be administered once daily in the morning until the patient regains spontaneous bowel movements and can tolerate oral intake of solid food. The primary outcome is a composite of time to first defecation and time to tolerance of a solid diet. Secondary outcomes include time to first exhaustion; time of first defecation; time of tolerance of a solid diet; time to the first ambulation; length of hospital stay from surgery to discharge; visual analog scale score for postoperative daily pain, nausea, and vomiting; incidence of postoperative complications; and treatment acceptability.

Discussion

This study will compare the efficacy and safety of three acupoint stimulation methods and two EA instrument waveforms for rapid recovery after abdominal surgery.

Trial Registration

Chinese Clinical Trial Registry (http://www.chictr.org.cn), ChiCTR2100043883.

Intrathecal hydromorphone for analgesia after partial hepatectomy: a randomized controlled trial

INTRODUCTION

There is substantial interest in adding intrathecal opioids, such as hydromorphone to the multimodal pain management strategies. We conducted a randomized controlled trial to examine whether adding intrathecal hydromorphone to a multimodal strategy could safely improve analgesic efficacy for patients undergoing partial hepatectomy.

METHODS

A total of 126 adult patients undergoing partial hepatectomy under general anesthesia were randomly assigned to receive intrathecal hydromorphone (100 μg) or no block. The primary outcome was the incidence of moderate to severe pain during movement at 24 hours after surgery. Secondary outcomes included the incidence of moderate to severe pain during rest or movement at different times within 72 hours, pain scores during rest or movement within 72 hours after surgery, analgesic use, adverse events, and indicators of postoperative recovery.

RESULTS

Among the 124 patients analyzed, the intrathecal hydromorphone group showed a lower incidence of moderate to severe pain during movement at 24 hours after surgery (29.0% vs 50%; RR 0.58, 95% CI 0.37 to 0.92) than the control group. However, the absolute difference in pain scores on a numerical rating scale was less than 1 between the two groups at 24 hours after surgery. Mild pruritus within the first 24 hours after surgery was more frequent in the intrathecal hydromorphone group (19.4% vs 4.8%; p=0.01).

DISCUSSION

Intrathecal hydromorphone 100 μg reduced the incidence of moderate to severe pain and pain scores during movement within 24 hours after partial hepatectomy. However, the difference in pain scores may not be clinically significant, and intrathecal hydromorphone 100 μg did not significantly improve other analgesic or functional outcomes. Further investigation is needed to optimize the intrathecal hydromorphone dose.

TRIAL REGISTRATION NUMBER

ChiCTR2000030652.

Effect of Enhanced Recovery after Surgery with Integrated Traditional Chinese and Western Medicine on Postoperative Stress Response of Patients with Gastrointestinal Tumors

Objective. To investigate the effect of enhanced recovery after surgery (ERAS) with integrated traditional Chinese and Western medicine on postoperative stress response of patients suffering from gastrointestinal tumors. Methods. A total of 74 patients with gastrointestinal tumors who underwent surgical treatment in our hospital from April 2019 to March 2021 were recruited and randomized into the control group and the observation group (1 : 1). The control group received routine treatment and care, while the observation group received ERAS plus integrated traditional Chinese and Western medicine. Clinical observation was performed regarding changes in preoperative mood and postoperative pain level in each group. Changes in expression levels of plasma cortisol, C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-β (TNF-β) before and after surgery were detected in each group. Time of patients’ first fart and defecation and complications after surgery in each group were recorded. Results. The visual analogue scale (VAS) of patients in the observation group after 12 and 24 h of surgery was significantly lower than that in the control group (12 h: observation group 2.0 (1.00, 3.00) vs. control group 4.00 (3.00, 5.00), $p=0.001$ ; 24 h: observation group 2.00 (1.00, 3.00) vs. control group 3.00 (2.00, 5.00), $p=0.005$ ). The preoperative anxiety degree of patients in the two groups was not statistically significant ( $p=0.489$ ). The plasma cortisol level of patients in the observation group after 24 and 48 h of surgery was significantly lower than that in the control group (24 h: observation group $426.54\pm 52.15$  nmol/L vs. control group $508.32\pm 41.08$  nmol/L, $p=0.001$ ; 48 h: observation group $287.19\pm 44.24$  nmol/L vs. control group $362.57\pm 43.46$  nmol/L, $p=0.001$ ). Patients’ postoperative CRP, IL-6, IL-8, and TNF-β expression levels in the observation group were remarkably lower than those in the control group at all time points. The first postoperative defecation came earlier in the observation group than that in the control group (observation group 76.00 h (64.50, 87.50) vs. control group 89.00 h (73.50, 116.00), $p=0.007$ ). There was 1 postoperative urinary tract infection in the observation group and 1 postoperative intestinal obstruction and 1 incisional wound infection in the control group. Conclusion. ERAS with integrated traditional Chinese and Western medicine could effectively reduce the postoperative stress response and inflammatory reaction in patients with gastrointestinal tumors, contributing to the safe and quick recovery of gastrointestinal functions of patients.

The Problem of Appetite Loss After Major Abdominal Surgery

Objective:

To systematically review the problem of appetite loss after major abdominal surgery.

Summary of Background Data:

Appetite loss is a common problem after major abdominal surgery. Understanding of etiology and treatment options is limited.

Methods:

We searched Medline, Cochrane Central Register of Controlled Trials, and Web of Science for studies describing postoperative appetite loss. Data were extracted to clarify definition, etiology, measurement, surgical influence, pharmacological, and nonpharmacological treatment. PROSPERO registration ID: CRD42021224489.

Results:

Out of 6144 articles, we included 165 studies, 121 of which were also analyzed quantitatively. A total of 19.8% were randomized, controlled trials (n = 24) and 80.2% were nonrandomized studies (n = 97). The studies included 20,506 patients undergoing the following surgeries: esophageal (n = 33 studies), gastric (n = 48), small bowel (n = 6), colon (n = 27), rectal (n = 20), hepatobiliary (n = 6), and pancreatic (n = 13). Appetite was mostly measured with the Quality of Life Questionnaire of the European Organization for Research and Treatment of Cancer (EORTC QLQ C30, n = 54). In a meta-analysis of 4 randomized controlled trials gum chewing reduced time to first hunger by 21.2 hours among patients who had bowel surgery. Other reported treatment options with positive effects on appetite but lower levels of evidence include, among others, intravenous ghrelin administration, the oral Japanese herbal medicine Rikkunshito, oral mosapride citrate, multidisciplin-ary-counseling, and watching cooking shows. No studies investigated the effect of well-known appetite stimulants such as cannabinoids, steroids, or megestrol acetate on surgical patients.

Conclusions:

Appetite loss after major abdominal surgery is common and associated with increased morbidity and reduced quality of life. Recent studies demonstrate the influence of reduced gastric volume and ghrelin secretion, and increased satiety hormone secretion. There are various treatment options available including level IA evidence for postoperative gum chewing. In the future, surgical trials should include the assessment of appetite loss as a relevant outcome measure.

Transcutaneous electrical acupoint stimulation combined with electroacupuncture for rapid recovery of patients after laparotomy for gastrointestinal surgery: a study protocol for a randomised controlled trial

INTRODUCTION

Abdominal surgery is associated with common complications, including decreased or poor appetite, abdominal distension, abdominal pain caused by decreased or absent gastrointestinal motility, anal arrest with flatus and defecation, and nausea and vomiting resulting from the use of anaesthetics and opioid analgesics. These complications seriously affect postoperative recovery, prolong hospital stay and aggravate patient burden. This study aims to investigate for the first time the efficacy of transcutaneous electrical acupoint stimulation (TEAS) combined with electroacupuncture (EA) therapy for rapid recovery after laparotomy for gastrointestinal surgery. There have been no clinical studies of this combination therapy.

METHODS AND ANALYSIS

This will be a prospective, single-centre, three-arm, randomised controlled trial. A total of 480 patients undergoing abdominal surgery will be stratified according to surgery type (ie, gastric or colorectal procedure) and randomised into three groups; namely, the EA, TEAS +EA and control groups. The control group will receive enhanced recovery after surgery (ERAS)-standardised perioperative management, including preoperative education, optimising the anaesthesia scheme, avoiding intraoperative hypothermia, restrictive fluid infusion and reducing surgical trauma. The EA group will receive EA stimulation at LI4, PC6, ST36, ST37 and ST39 based on the ERAS-standardised perioperative management. Moreover, the TEAS +EA group will receive ERAS-standardised perioperative management; EA stimulation at the LI4, PC6, ST36, ST37 and ST39; and TEAS stimulation at ST21 and SP15. The primary outcome will be the GI-2 (composite outcome of time to first defaecation and time to tolerance of a solid diet). Secondary outcomes will include the time of first passage of flatus, time to first defaecation, time to tolerance of a solid diet, time to first ambulation, hospital duration from operation to discharge, pain and nausea vomiting scores on the Visual Analogue Scale, medication use, incidence of postoperative complications and evaluation of treatment modality acceptability. All statistical analyses will be performed based on the intention-to-treat principle.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Ethics Committee on Biomedical Research, West China Hospital of Sichuan University (approval number: 2021; number 52). The results are expected to be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2100045646.

ERAS Protocol for Perioperative Care of Patients Treated with Laparoscopic Nonanatomic Liver Resection for Hepatocellular Carcinoma: The ISMETT Experience

Background: Liver resection (LR) remains the best therapeutic option for patients with early-stage hepatocellular carcinoma (HCC) with preserved hepatic function and who are not eligible for liver transplantation. After its inception, the enhanced recovery after surgery (ERAS) protocol was widely used for treating patients with liver cancer, although there are still no clear indications for improving upon it in both open and laparoscopic surgery. Objective: This study aims to describe our institute's experience in the application of the ERAS protocol in a cohort of HCC patients, and to explore possible factors that could have an impact on postoperative outcomes. Materials and Methods: We retrospectively analyzed our experience with LR performed from September 2017 to January 2020 in patients treated with ERAS protocol, focusing on describing impact on postoperative nutrition, analgesic requirements, and length of hospitalization. Demographics, operative factors, and postoperative complications of patients were reviewed. Results: During the study period, 89 HCC patients were eligible for LR, and 75% of patients presented with liver cirrhosis. The most prevalent among etiologic factors was hepatitis C virus infection (53 patients out of 89, 60%), followed by nonalcoholic steatohepatitis (18 patients, 20%). The median age was 70 years. Liver cirrhosis did not have an impact on postoperative course of patients. Patients who underwent laparoscopic surgery and nonanatomic LR experienced low complication rates, shorter length of stay, and shorter time of intravenous analgesic requirements. Conclusions: Continual refinement with ERAS protocol for treating HCC patients based on perioperative counseling and surgical decision-making is crucial to guarantee low complication rates, and reduce patient morbidity and time for recovery.