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Bhat MY, Ali S, Gupta S, Ahmad Y, Lattoo MR, Ansari MJ, Patel A, Haq MFU, Parveen S. Feasibility, safety and effectiveness of the enhanced recovery after surgery protocol in patients undergoing liver resection. Ann Hepatobiliary Pancreat Surg 2024; 28:344-349. [PMID: 38825759 PMCID: PMC11341879 DOI: 10.14701/ahbps.24-034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/09/2024] [Accepted: 04/18/2024] [Indexed: 06/04/2024] Open
Abstract
Backgrounds/Aims The implementation of enhanced recovery after surgery (ERAS) protocols has demonstrated significant advantages for patients by mitigating surgical stress and expediting recovery across a spectrum of surgical procedures worldwide. This investigation seeks to assess the effectiveness of the ERAS protocol specifically in the context of major liver resections within our geographical region. Methods Our department conducted retrospective analysis of prospectively collected data, gathered from consenting individuals who underwent liver resections from January 2018 to December 2023. The assessment encompassed baseline characteristics, preoperative indications, surgical outcomes, and postoperative complications among patients undergoing liver surgery. Results Among the included 184 patients (73 standard care, 111 ERAS program), the baseline characteristics were similar. Median postoperative hospital stay differed significantly: 5 days (range: 3-13 days) in ERAS, and 11 days (range: 6-22 days) in standard care (p < 0.001). Prophylactic abdominal drainage was less in ERAS (54.9%) than in standard care (86.3%, p < 0.001). Notably, in ERAS, 88.2% initiated enteral feeding orally on postoperative day 1, significantly higher than in standard care (47.9%, p < 0.001). Early postoperative mobilization was more common in ERAS (84.6%) than in standard care (36.9%, p < 0.001). Overall complication rates were 21.9% in standard care, and 8.1% in ERAS (p = 0.004). Conclusions Our investigation highlights the merits of ERAS protocol; adherence to its diverse components results in significant reduction in hospital length of stay, and reduced occurrence of postoperative complications, improving short-term recovery post liver resection.
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Affiliation(s)
- Mohamad Younis Bhat
- Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Sadaf Ali
- Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Sonam Gupta
- Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Younis Ahmad
- Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Mohd Riyaz Lattoo
- Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Mohammad Juned Ansari
- Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Ajay Patel
- Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Mohd Fazl ul Haq
- Department of General Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Shaheena Parveen
- Department of Medical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
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Pirie KP, Wang A, Yu J, Teng B, Doane MA, Myles PS, Riedel B. Postoperative analgesia for upper gastrointestinal surgery: a retrospective cohort analysis. Perioper Med (Lond) 2023; 12:40. [PMID: 37464387 DOI: 10.1186/s13741-023-00324-0] [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: 10/19/2022] [Accepted: 07/03/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Thoracic epidural analgesia is commonly used for upper gastrointestinal surgery. Intrathecal morphine is an appealing opioid-sparing non-epidural analgesic option, especially for laparoscopic gastrointestinal surgery. METHODS Following ethics committee approval, we extracted data from the electronic medical records of patients at Royal North Shore Hospital (Sydney, Australia) that had upper gastrointestinal surgery between November 2015 and October 2020. Postoperative morphine consumption and pain scores were modelled with a Bayesian mixed effect model. RESULTS A total of 427 patients were identified who underwent open (n = 300), laparoscopic (n = 120) or laparoscopic converted to open (n = 7) upper gastrointestinal surgery. The majority of patients undergoing open surgery received a neuraxial technique (thoracic epidural [58%, n = 174]; intrathecal morphine [21%, n = 63]) compared to a minority in laparoscopic approaches (thoracic epidural [3%, n = 4]; intrathecal morphine [12%, n = 14]). Intrathecal morphine was superior over non-neuraxial analgesia in terms of lower median oral morphine equivalent consumption and higher probability of adequate pain control; however, this effect was not sustained beyond postoperative day 2. Thoracic epidural analgesia was superior to both intrathecal and non-neuraxial analgesia options for both primary outcomes, but at the expense of higher rates of postoperative hypotension (60%, n = 113) and substantial technique failure rates (32%). CONCLUSIONS We found that thoracic epidural analgesia was superior to intrathecal morphine, and intrathecal morphine was superior to non-neuraxial analgesia, in terms of reduced postoperative morphine requirements and the probability of adequate pain control in patients who underwent upper gastrointestinal surgery. However, the benefits of thoracic epidural analgesia and intrathecal morphine were not sustained across all time periods regarding control of pain. The study is limited by its retrospective design, heterogenous group of upper gastrointestinal surgeries and confounding by indication.
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Affiliation(s)
- Katrina P Pirie
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Australia.
- Central Clinical School, Monash University, Melbourne, Australia.
| | - Andy Wang
- Sydney Medical School (Northern), Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia
- Chris O'Brien Lifehouse, Sydney, Australia
- Department of Anaesthesia and Perioperative Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Joanna Yu
- Department of Anaesthesia and Perioperative Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Bao Teng
- Department of Anaesthesia and Perioperative Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Matthew A Doane
- Sydney Medical School (Northern), Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Anaesthesia and Perioperative Medicine, Royal North Shore Hospital, Sydney, Australia
- Kolling Research Institute, Sydney, Australia
- Northern Sydney Anaesthesia Research Institute, Sydney, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Department of Oncology, Sir Peter MacCallum, University of Melbourne, Melbourne, Australia
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Ren Q, Wu M, Li HY, Li J, Zeng ZH. Failure of enhanced recovery after surgery in liver surgery: a systematic review and meta analysis. Front Med (Lausanne) 2023; 10:1159960. [PMID: 37497275 PMCID: PMC10366385 DOI: 10.3389/fmed.2023.1159960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/14/2023] [Indexed: 07/28/2023] Open
Abstract
Purpose This study aimed to conduct a systematic review of the literature to identify and summarize the existing evidence regarding ERAS failure and related risk factors after hepatic surgery. The objective was to provide physicians with a better understanding of these factors so that they can take appropriate action to minimize ERAS failure and improve patient outcomes. Method A literature search of the PubMed MEDLINE, OVID, EMBASE, Cochrane Library, and Web of Science was performed. The search strategy involved terms related to ERAS, failure, and hepatectomy. Result A meta-analysis was conducted on four studies encompassing a total of 1,535 patients, resulting in the identification of 20 risk factors associated with ERAS failure after hepatic surgery. Four of these risk factors were selected for pooling, including major resection, ASA classification of ≥3, advanced age, and male gender. Major resection and ASA ≥ 3 were identified as statistically significant factors of ERAS failure. Conclusion The comprehensive literature review results indicated that the frequently identified risk factors for ERAS failure after hepatic surgery are linked to operative and anesthesia factors, including substantial resection and an American Society of Anesthesiologists score of 3 or higher. These insights will assist healthcare practitioners in taking prompt remedial measures. Nevertheless, there is a requirement for future high-quality randomized controlled trials with standardized evaluation frameworks for ERAS programs.
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Affiliation(s)
- Qiuping Ren
- Division of Liver Surgery, Department of General Surgery, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Nursing Key Laboratory of Sichuan Province, West China Medical Center, Sichuan Medical University, Chengdu, China
| | - Menghang Wu
- Division of Liver Surgery, Department of General Surgery, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hong Yu Li
- Division of Liver Surgery, Department of General Surgery, West China Hospital, West China School of Nursing, Sichuan University, Chengdu, China
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiafei Li
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zi Hang Zeng
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Desjardins P, Ménassa M, Desbiens F, Gagné JP, Hogue JC, Poirier É. Effect of single-shot intrathecal morphine versus continuous epidural analgesia on length of stay after gastrectomy for cancer: a retrospective cohort study. Gastric Cancer 2023; 26:648-652. [PMID: 37017792 DOI: 10.1007/s10120-023-01386-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 03/24/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Single-dose intrathecal opiates (ITO) could shorten the length of hospital stay compared to thoracic epidural analgesia (TEA). This study aimed to compare TEA with TIO in terms of length of hospital stay, pain control, and parenteral opioid consumption in patients undergoing gastrectomy for cancer. METHODS The patients who underwent gastrectomy for cancer in 2007-2018 at the CHU de Québec-Université Laval were included. The patients were grouped as TEA and intrathecal morphine (ITM). The primary outcome was the length of hospital of stay (LOS). The secondary outcomes were numeric rating scales (NRS) for pain and parenteral opioid consumption. RESULTS A total of 79 patients were included. There were no differences in preoperative characteristics between the two groups (all P > 0.05). The median LOS was shorter in the ITM group than in the TEA group (median, 7.5 vs. 10 days, P = 0.049). The opioids consumption at 12, 24, and 48 h postoperatively was significantly lower in the TEA group at all time points. The NRS score for pain was lower in the TEA group than in the ITM group at all time points (all P < 0.05). CONCLUSIONS Patients with ITM analgesia undergoing gastrectomy presented shorter LOS than those with TEA. ITM had an inferior pain control that did not have a clinical impact on recovery in the cohort studied. Given the limitations of this retrospective study, further trials are warranted.
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Affiliation(s)
- Philippe Desjardins
- Département d'Anesthésiologie, Quebec City, QC, Canada
- CHU de Québec, Université Laval, 10 Rue de L'Espinay, Québec, QC, G1L 3L5, Canada
| | | | | | - Jean-Pierre Gagné
- Département de Chirurgie, Faculté de Médecine, Université Laval, Pavillon Ferdinand-Vandry, 1050 Ave de La Médecine, Quebec City, QC, G1V 0A6, Canada
- CHU de Québec, Université Laval, 10 Rue de L'Espinay, Québec, QC, G1L 3L5, Canada
| | - Jean-Charles Hogue
- Axe Oncologie, Centre de Recherche du CHU de Québec, Université Laval, 1050 Chemin Ste-Foy, Québec City, QC, G1S 4L8, Canada
| | - Éric Poirier
- Département de Chirurgie, Faculté de Médecine, Université Laval, Pavillon Ferdinand-Vandry, 1050 Ave de La Médecine, Quebec City, QC, G1V 0A6, Canada.
- CHU de Québec, Université Laval, 10 Rue de L'Espinay, Québec, QC, G1L 3L5, Canada.
- Axe Oncologie, Centre de Recherche du CHU de Québec, Université Laval, 1050 Chemin Ste-Foy, Québec City, QC, G1S 4L8, Canada.
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Individual components of post-hepatectomy care pathways have differential impacts on length of stay. Am J Surg 2023; 225:53-57. [PMID: 36207173 DOI: 10.1016/j.amjsurg.2022.09.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The value of individual variable contributions to post-hepatectomy length of stay (LOS) are difficult to quantify within bundled care pathways. METHODS Poisson regression and marginal effects models for prolonged post-hepatectomy LOS (>25% median) included Kawaguchi-Gayet (KG) complexity, perioperative variables, and pathways (minimally-invasive = MIS; low-intermediate-risk = KGI/II; high-risk = KGIII; combination). RESULTS Median LOS was 2, 4, 5, and 5 days for MIS, KGI/II, KGIII and combination pathways (N = 978). Poisson regression identified age, intraoperative fluids, delayed diet tolerance, and combination cases as associated with increased LOS (p < 0.01). Marginal effects analysis demonstrated the following added probability of longer LOS: each year of age 0.03x, 250 mL intraoperative fluids 0.06x, each operative hour 0.2x, additional day before diet tolerance 0.4x, combination cases 0.7x. MIS was associated with 1.2x increased probability of shorter LOS. CONCLUSIONS Optimizing intraoperative fluids, operative time, and postoperative diet, while favoring MIS approach when feasible, may maximize effects of post-hepatectomy care pathways to reduce LOS.
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Efficacy of opioid spinal analgesia for postoperative pain management after pancreatoduodenectomy. HPB (Oxford) 2022; 24:1930-1936. [PMID: 35840502 DOI: 10.1016/j.hpb.2022.06.002] [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: 11/06/2021] [Revised: 04/12/2022] [Accepted: 06/09/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Efficacy of single-shot opioid spinal analgesia after pancreatoduodenectomy remains understudied and lacks comparison to standard continuous thoracic epidural analgesia (TEA). METHODS Pancreatoduodenectomy patients who underwent TEA or opioid spinal for postoperative pain management from 2015 to 2020 were included in this observational cohort study. Primary outcome was patient-reported mean daily pain scores. Secondary outcomes included postoperative morphine milligram equivalents (MMEs) and length of stay (LOS). Multivariable linear regression models were constructed to compare risk-adjusted outcomes. RESULTS 180 patients were included: 56 TEA and 124 opioid spinal. Compared to epidural patients, opioid spinal patients were more likely to be older (67.0 vs. 64.6, p=0.045), have greater BMI (26.5 vs. 24.4, p=0.02), and less likely to be smokers (19.4% vs. 41.1%, p=0.002). Opioid spinal, compared to TEA, was associated with lower intraoperative MMEs (0.25 vs. 22.7, p<0.001) and postoperative daily MMEs (7.9 vs. 10.3, p=0.03) on univariate analysis. However, after multivariable adjustment, there was no difference in average pain scores across the postoperative period (spinal vs. epidural: 4.18 vs. 4.14, p=0.93), daily MMEs (p=0.50), or LOS (p=0.23). DISCUSSION There was no significant difference in postoperative pain scores, opioid use, or LOS between patients managed with TEA or opioid spinal after pancreatoduodenectomy.
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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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Burchard PR, Melucci AD, Lynch O, Loria A, Dave YA, Strawderman M, Schoeniger LO, Galka E, Moalem J, Linehan DC. Intrathecal Morphine and Effect on Opioid Consumption and Functional Recovery after Pancreaticoduodenectomy. J Am Coll Surg 2022; 235:392-400. [PMID: 35758927 PMCID: PMC9371061 DOI: 10.1097/xcs.0000000000000261] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/03/2022] [Accepted: 03/22/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Single-shot intrathecal morphine (ITM) is an effective strategy for postoperative analgesia, but there are limited data on its safety, efficacy, and relationship with functional recovery among patients undergoing pancreaticoduodenectomy. STUDY DESIGN This was a retrospective review of patients undergoing pancreaticoduodenectomy from 2014 to 2020 as identified by the institutional NSQIP Hepato-pancreato-biliary database. Patients were categorized by having received no spinal analgesia, ITM, or ITM with transversus abdominus plane block (ITM+TAP). The primary outcomes were average daily pain scores from postoperative days (POD) 0 to 3, total morphine equivalents (MEQ) consumed over POD 0 to 3, and average daily inpatient MEQ from POD 4 to discharge. Secondary outcomes included the incidence of opioid related complications, length of stay, and functional recovery. RESULTS A total of 233 patients with a median age of 67 years were included. Of these, 36.5% received no spinal analgesia, 49.3% received ITM, and 14.2% received ITM+TAP. Average pain scores in POD 0 to 3 were similar by mode of spinal analgesia (none [2.8], ITM [2.6], ITM+TAP [2.3]). Total MEQ consumed from POD 0 to 3 were lower for patients who received ITM (121 mg) and ITM+TAP (132 mg), compared with no spinal analgesia (232 mg) (p < 0.0001). Average daily MEQ consumption from POD 4 to discharge was lower for ITM (18 mg) and ITM+TAP (13.1 mg) cohorts compared with no spinal analgesia (32.9 mg) (p = 0.0016). Days to functional recovery and length of stay were significantly reduced for ITM and ITM+TAP compared with no spinal analgesia. These findings remained consistent through multivariate analysis, and there were no differences in opioid-related complications among cohorts. CONCLUSIONS ITM was associated with reduced early postoperative and total inpatient opioid utilization, days to functional recovery, and length of stay among patients undergoing pancreaticoduodenectomy. ITM is a safe and effective form of perioperative analgesia that may benefit patients undergoing pancreaticoduodenectomy.
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Affiliation(s)
- Paul R Burchard
- From the Department of General Surgery, Division of Surgical Oncology (Burchard, Melucci, Loria, Dave, Schoeniger, Galka, Moalem, Linehan)
| | - Alexa D Melucci
- From the Department of General Surgery, Division of Surgical Oncology (Burchard, Melucci, Loria, Dave, Schoeniger, Galka, Moalem, Linehan)
| | - Olivia Lynch
- University of Rochester School of Medicine and Dentistry (Lynch)
| | - Anthony Loria
- From the Department of General Surgery, Division of Surgical Oncology (Burchard, Melucci, Loria, Dave, Schoeniger, Galka, Moalem, Linehan)
| | - Yatee A Dave
- From the Department of General Surgery, Division of Surgical Oncology (Burchard, Melucci, Loria, Dave, Schoeniger, Galka, Moalem, Linehan)
| | - Myla Strawderman
- Department of Biostatistics and Computational Biology (Strawderman), University of Rochester Medical Center, Rochester, NY
| | - Luke O Schoeniger
- From the Department of General Surgery, Division of Surgical Oncology (Burchard, Melucci, Loria, Dave, Schoeniger, Galka, Moalem, Linehan)
| | - Eva Galka
- From the Department of General Surgery, Division of Surgical Oncology (Burchard, Melucci, Loria, Dave, Schoeniger, Galka, Moalem, Linehan)
| | - Jacob Moalem
- From the Department of General Surgery, Division of Surgical Oncology (Burchard, Melucci, Loria, Dave, Schoeniger, Galka, Moalem, Linehan)
| | - David C Linehan
- From the Department of General Surgery, Division of Surgical Oncology (Burchard, Melucci, Loria, Dave, Schoeniger, Galka, Moalem, Linehan)
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Zhang Y, Yue H, Qin Y, Wang J, Zhao C, Cheng M, Han B, Han R, Cui W. Effect of Sufentanil Combined with Gabapentin on Acute Postoperative Pain in Patients Undergoing Intraspinal Tumor Resection: Study Protocol for a Randomized Controlled Trial. J Pain Res 2022; 15:2619-2628. [PMID: 36072908 PMCID: PMC9444033 DOI: 10.2147/jpr.s374898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/22/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Patients undergoing intraspinal tumor resection usually experience severe postoperative pain. Inadequate postoperative analgesia usually leads to severe postsurgical pain, which could cause patients to suffer from many other related complications. Recently, an increasing number of studies have found that gabapentin can relieve hyperalgesia, postoperative pain, and postoperative inflammation. However, there have been no reports on the use of gabapentin combined with sufentanil preoperatively for acute pain following intraspinal tumor resection. Study Design and Methods This is a protocol for a randomized, placebo-controlled, and double-blinded trial. One-hundred and sixty-eight participants with chronic pain related to the intraspinal tumor will be randomized into the gabapentin and placebo groups in a 1:1 ratio. In the gabapentin group, patients will be given 300 mg gabapentin orally 36 h, 24 h, and 12 h before surgery; the placebo group will receive a placebo orally at the same time points preoperatively. To estimate the efficacy and safety endpoints, all the researchers and patients will be blinded until the completion of this study. The primary outcome will be the consumption of sufentanil within 48 h postoperatively. The secondary outcomes include the visual analog scale pain score and Von Frey mechanical pain threshold 36 h and 24 h before and 24 h and 48 h after surgery, the incidence of postoperative nausea, vomiting, and drowsiness, the length of hospital stay and medical expenses. Discussion This trial is to evaluate the efficacy and safety of gabapentin combined with sufentanil for postoperative analgesia in patients who complain of pain before intraspinal tumor resection. The findings will provide a new strategy for multimode perioperative analgesia management in these patients.
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Affiliation(s)
- Yuan Zhang
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Hongli Yue
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yirui Qin
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jiajing Wang
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Chenyang Zhao
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Miao Cheng
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Bo Han
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Correspondence: Ruquan Han; Weihua Cui, Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, No. 119, Nan Si Huan Xi Lu, Fengtai District, Beijing, 100070, People’s Republic of China, Tel +8613701285393; Tel +8613701285393, Fax +861059976658, Email ;
| | - Weihua Cui
- Department of Anesthesiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, People’s Republic of China
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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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11
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Pirie K, Traer E, Finniss D, Myles PS, Riedel B. Current approaches to acute postoperative pain management after major abdominal surgery: a narrative review and future directions. Br J Anaesth 2022; 129:378-393. [PMID: 35803751 DOI: 10.1016/j.bja.2022.05.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/27/2022] [Accepted: 05/28/2022] [Indexed: 11/02/2022] Open
Abstract
Poorly controlled postoperative pain is associated with increased morbidity, negatively affects quality of life and functional recovery, and is a risk factor for persistent pain and longer-term opioid use. Up to 10% of opioid-naïve patients have persistent opioid use after many types of surgeries. Opioid-related side-effects and the opioid abuse epidemic emphasise the need for alternative, opioid-minimising, multimodal analgesic strategies, including neuraxial (epidural/intrathecal) techniques, truncal nerve blocks, and lidocaine infusions. The preference for minimally invasive surgical techniques has changed anaesthetic and analgesic requirements in abdominal surgery compared with open laparotomy, leading to a decline in popularity of epidural anaesthesia and an increasing interest in intrathecal morphine and truncal nerve blocks. Limited research exists on patient quality of recovery using specific analgesic techniques after intra-abdominal surgery. Poorly controlled postoperative pain after major abdominal surgery should be a research priority as it affects patient-centred short-term and long-term outcomes (including quality of life scores, return to function measurements, disability-free survival) and has broad community health and economic implications.
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Affiliation(s)
- Katrina Pirie
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; Central Clinical School, Monash University, Melbourne, Victoria, Australia.
| | - Emily Traer
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Damien Finniss
- Department of Anaesthesia & Pain Management, Royal North Shore Hospital, Sydney, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
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12
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Abdel-Kader AK, Romano DN, Foote J, Lin HM, Glasgow AM. Evaluation of the addition of bupivacaine to intrathecal morphine for intraoperative and postoperative pain management in open liver resections. HPB (Oxford) 2022; 24:202-208. [PMID: 34229975 DOI: 10.1016/j.hpb.2021.06.007] [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: 02/19/2021] [Revised: 05/29/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intrathecal morphine is a popular and effective regional technique for pain control after open liver resection, but its delayed analgesic onset makes it less useful for the intraoperative period. The aim of this retrospective study was to compare the analgesic efficacy and other secondary benefits of the addition of hyperbaric bupivacaine to intrathecal morphine ± fentanyl. We hypothesized that bupivacaine could serve as an analgesic "bridge" prior to the onset of intrathecal morphine/fentanyl thereby lowering opioid consumption and enhancing recovery. METHODS Cumulative intraoperative and postoperative opioid consumption as well as other intra- and postoperative variables were collected and compared between groups receiving intrathecal morphine alone or intrathecal morphine ± hyperbaric bupivacaine. RESULTS Sixty-eight patients were selected for inclusion. Cumulative intraoperative morphine consumption was significantly reduced in the bupivacaine group while other intraoperative parameters such as intravenous fluids, blood loss, and vasopressors did not differ. There was a statistically significant improvement in time to first bowel movement in the experimental group. DISCUSSION The intraoperative opioid sparing effects and improved time to bowel function with the addition of hyperbaric bupivacaine to intrathecal morphine may make this technique an easy and low risk method of enhancing recovery after open liver resection.
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Affiliation(s)
- Amir K Abdel-Kader
- Department of Anesthesiology, Perioperative and Pain Medicine at the Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY, 10029, USA.
| | - Diana N Romano
- Department of Anesthesiology, Perioperative and Pain Medicine at the Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY, 10029, USA
| | - John Foote
- Department of Anesthesiology, Perioperative and Pain Medicine at the Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY, 10029, USA
| | - Hung-Mo Lin
- Department of Population Health Science and Policy at the Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY, 10029, USA
| | - Andrew M Glasgow
- Department of Anesthesiology, Perioperative and Pain Medicine at the Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Pl, New York, NY, 10029, USA
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13
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Chan KS, Wang B, Tan YP, Chow JJL, Ong EL, Junnarkar SP, Low JK, Huey CWT, Shelat VG. Sustaining a Multidisciplinary, Single-Institution, Postoperative Mobilization Clinical Practice Improvement Program Following Hepatopancreatobiliary Surgery During the COVID-19 Pandemic: Prospective Cohort Study. JMIR Perioper Med 2021; 4:e30473. [PMID: 34559668 PMCID: PMC8496752 DOI: 10.2196/30473] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The Enhanced Recovery After Surgery (ERAS) protocol has been recently extended to hepatopancreatobiliary (HPB) surgery, with excellent outcomes reported. Early mobilization is an essential facet of the ERAS protocol, but compliance has been reported to be poor. We recently reported our success in a 6-month clinical practice improvement program (CPIP) for early postoperative mobilization. During the COVID-19 pandemic, we experienced reduced staffing and resource availability, which can make CPIP sustainability difficult. OBJECTIVE We report outcomes at 1 year following the implementation of our CPIP to improve postoperative mobilization in patients undergoing major HPB surgery during the COVID-19 pandemic. METHODS We divided our study into 4 phases-phase 1: before CPIP implementation (January to April 2019); phase 2: CPIP implementation (May to September 2019); phase 3: post-CPIP implementation but prior to the COVID-19 pandemic (October 2019 to March 2020); and phase 4: post-CPIP implementation and during the pandemic (April 2020 to September 2020). Major HPB surgery was defined as any surgery on the liver, pancreas, and biliary system with a duration of >2 hours and with an anticipated blood loss of ≥500 ml. Study variables included length of hospital stay, distance ambulated on postoperative day (POD) 2, morbidity, balance measures (incidence of fall and accidental dislodgement of drains), and reasons for failure to achieve targets. Successful mobilization was defined as the ability to sit out of bed for >6 hours on POD 1 and ambulate ≥30 m on POD 2. The target mobilization rate was ≥75%. RESULTS A total of 114 patients underwent major HPB surgery from phases 2 to 4 of our study, with 33 (29.0%), 45 (39.5%), and 36 (31.6%) patients in phases 2, 3, and 4, respectively. No baseline patient demographic data were collected for phase 1 (pre-CPIP implementation). The majority of the patients were male (n=79, 69.3%) and underwent hepatic surgery (n=92, 80.7%). A total of 76 (66.7%) patients underwent ON-Q PainBuster insertion intraoperatively. The median mobilization rate was 22% for phase 1, 78% for phases 2 and 3 combined, and 79% for phase 4. The mean pain score was 2.7 (SD 1.0) on POD 1 and 1.8 (SD 1.5) on POD 2. The median length of hospitalization was 6 days (IQR 5-11.8). There were no falls or accidental dislodgement of drains. Six patients (5.3%) had pneumonia, and 21 (18.4%) patients failed to ambulate ≥30 m on POD 2 from phases 2 to 4. The most common reason for failure to achieve the ambulation target was pain (6/21, 28.6%) and lethargy or giddiness (5/21, 23.8%). CONCLUSIONS This follow-up study demonstrates the sustainability of our CPIP in improving early postoperative mobilization rates following major HPB surgery 1 year after implementation, even during the COVID-19 pandemic. Further large-scale, multi-institutional prospective studies should be conducted to assess compliance and determine its sustainability.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Bei Wang
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Yen Pin Tan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Ee Ling Ong
- Office of Clinical Governance, Tan Tock Seng Hospital, Singapore, Singapore
| | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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14
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Jones CN, Morrison BL, Kelliher LJ, Dickinson M, Scott M, Cecconi Ebm C, Karanjia N, Quiney N. Hospital Costs and Long-term Survival of Patients Enrolled in an Enhanced Recovery Program for Open Liver Resection: Prospective Randomized Controlled Trial. JMIR Perioper Med 2021; 4:e16829. [PMID: 33522982 PMCID: PMC7884210 DOI: 10.2196/16829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/15/2020] [Accepted: 01/10/2021] [Indexed: 12/20/2022] Open
Abstract
Background The clinical benefits of enhanced recovery programs (ERPs) have been extensively researched, but few studies have evaluated their cost-effectiveness. Our ERP for open liver resection is based closely on the guidelines produced by the Enhanced Recovery After Surgery Society (2016). This study follows on from a previous randomized controlled trial. We also undertook a long-term follow-up of the patients enrolled in the original trial alongside an analysis of the associated health economics. Objective We aimed to undertake a health economic and long-term survival analysis as part of a trial investigating the implementation of an ERP for open liver resection. Methods The enhanced recovery elements utilized included extra preoperative education, carbohydrate loading, oral nutritional supplements, postresection goal-directed fluid therapy (LiDCOrapid), early mobilization, and physiotherapy (twice a
day compared with once per day in the standard care group). A decision-analytic model was used to compare the study endpoints for ERP versus standard care provided to patients undergoing open liver resection. Outcomes obtained included costs per life-years gained. Resource use and costs were estimated from the perspective of the National Health Service of the United Kingdom. A decision tree and Markov model were constructed using results from our earlier trial and augmented by external data from other published clinical trials. Long-term follow-up was also undertaken for up to 5 years after the surgery, and data were analyzed to ascertain if the ERP conferred any benefit on long-term survival. Results Patients receiving ERP had an average life expectancy of 6.9 years versus 6.1 years in the standard care group. The overall costs were £9538.279 (£1=US $1.60) for ERP and £14,793.05 for standard treatment. This results in a cost-effectiveness ratio of –£6748.33/QALY. Patients receiving ERP required fewer visits to their general practitioner (P=.006) and required lesser help at home with day-to-day activities (P=.04) than patients in the standard care group. Survival was significantly improved at 2 years at 91% (42/46) for patients receiving ERP versus 73% (33/45) for the standard care group (P=.03). There was no statistically significant difference at 5 years after the surgery. Conclusions ERPs for patients undergoing open liver resection can improve their medium-term survival and are cost-effective for both hospital and community settings.
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Affiliation(s)
- Chris N Jones
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | - Ben L Morrison
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | | | | | - Michael Scott
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
| | | | | | - Nial Quiney
- Royal Surrey NHS Foundation Trust, Guildford, United Kingdom
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15
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Schwab M, Brindl N, Studier-Fischer A, Tu T, Gsenger J, Pilgrim M, Friedrich M, Frey PE, Achilles C, Leuck A, Bürgel T, Feisst M, Klose C, Tenckhoff S, Dörr-Harim C, Mihaljevic AL. Postoperative complications and mobilisation following major abdominal surgery with vs. without fitness tracker-based feedback (EXPELLIARMUS): study protocol for a student-led multicentre randomised controlled trial (CHIR-Net SIGMA study group). Trials 2020; 21:293. [PMID: 32293519 PMCID: PMC7092422 DOI: 10.1186/s13063-020-4220-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 03/02/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Postoperative complications following major abdominal surgery are frequent despite progress in surgical technique and perioperative care. Early and enhanced postoperative mobilisation has been advocated to reduce postoperative complications, but it is still unknown whether it can independently improve outcomes after major surgery. Fitness trackers (FTs) are a promising tool to improve postoperative mobilisation, but their effect on postoperative complications and recovery has not been investigated in clinical trials. METHODS This is a multicentre randomised controlled trial with two parallel study groups evaluating the efficacy of an enhanced and early mobilisation protocol in combination with FT-based feedback in patients undergoing elective major abdominal surgery. Participants are randomly assigned (1:1) to either the experimental group, which receives daily step goals and a FT giving feedback about daily steps, or the control group, which is mobilised according to hospital standards. The control group also receives a FT, however with a blackened screen; thus no FT-based feedback is possible. Randomisation will be stratified by type of surgery (laparoscopic vs. open). The primary endpoint of the study is postoperative morbidity within 30 days measured via the Comprehensive Complication Index. Secondary endpoints include number of steps as well as a set of functional, morbidity and safety parameters. A total of 348 patients will be recruited in 15 German centres. The study will be conducted and organised by the student-led German Clinical Trial Network SIGMA. DISCUSSION Our study aims at investigating whether the implementation of a simple mobilisation protocol in combination with FT-based feedback can reduce postoperative morbidity in patients undergoing major abdominal surgery. If so, FTs would offer a cost-effective intervention to enhance postoperative mobilisation and improve patient outcomes. TRIAL REGISTRATION Deutsches Register Klinischer Studien (DRKS, German Clinical Trials Register): DRKS00016755, UTN U1111-1228-3320. Registered on 06.03.2019.
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Affiliation(s)
- Marius Schwab
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Niall Brindl
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | | | - Thomas Tu
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Julia Gsenger
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Max Pilgrim
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Mirco Friedrich
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Pia-Elena Frey
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Christina Achilles
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Alexander Leuck
- Faculty of Medicine, University of Heidelberg, Im Neuenheimer Feld 346, 69120, Heidelberg, Germany
| | - Thore Bürgel
- Health Data Science Unit, University Hospital Heidelberg, BioQuant, Im Neuenheimer Feld 267, 69120, Heidelberg, Germany
| | - Manuel Feisst
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Christina Klose
- Institute of Medical Biometry and Informatics, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Solveig Tenckhoff
- CHIR-Net Coordination Centre at the Study Centre of the German Surgical Society (SDGC), University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Colette Dörr-Harim
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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16
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Niewiński G, Figiel W, Grąt M, Dec M, Morawski M, Patkowski W, Zieniewicz K. A Comparison of Intrathecal and Intravenous Morphine for Analgesia After Hepatectomy: A Randomized Controlled Trial. World J Surg 2020; 44:2340-2349. [PMID: 32112166 PMCID: PMC7266793 DOI: 10.1007/s00268-020-05437-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Effective analgesia is essential for patient recovery after liver resection. This study aimed to evaluate the effects of the addition of preoperative intrathecal morphine to multimodal intravenous analgesia in patients undergoing liver resection. METHODS In this single-blind randomized controlled trial, patients undergoing liver resection were randomly assigned to the patient-controlled analgesia with (ITM-IV) or without (IV) preoperative intrathecal morphine groups. All patients received acetaminophen and dexketoprofen. The primary outcome was pain severity at rest over three postoperative days, assessed using the numerical rating scale (NRS). RESULTS The study included 36 patients (18 in each group). The mean maximum daily NRS scores over the first three postoperative days in the ITM-IV and IV groups were 1.3, 1.1, and 0.3 and 1.6, 1.1, and 0.7, respectively (p = 0.580). No differences were observed in pain severity while coughing, with corresponding scores of 2.8, 2.1, and 1.1, respectively, in the ITM-IV group and 2.3, 2.2, and 1.5, respectively, in the IV group (p = 0.963). Proportions of patients reporting clinically significant pain at rest and while coughing were 11.1% and 44.4%, respectively, in the ITM-IV group, and 16.7% and 44.4%, respectively, in the IV group (both p > 0.999). Cumulative morphine doses in the ITM-IV and IV groups were 26 mg and 17 mg, respectively (p = 0.257). Both groups also showed similar time to mobilization (p = 0.791) and solid food intake (p = 0.743), sedation grade (p = 0.584), and morbidity (p = 0.402). CONCLUSIONS Preoperative intrathecal morphine administration provides no benefits to multimodal analgesia in patients undergoing liver resection. TRIAL REGISTRATION NUMBER Clinicaltrial.gov Identifier: NCT03620916.
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Affiliation(s)
- Grzegorz Niewiński
- Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Wojciech Figiel
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, 1A Banacha Street, 02-097, Warsaw, Poland.
| | - Michał Grąt
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, 1A Banacha Street, 02-097, Warsaw, Poland
| | - Marta Dec
- Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Morawski
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, 1A Banacha Street, 02-097, Warsaw, Poland
| | - Waldemar Patkowski
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, 1A Banacha Street, 02-097, Warsaw, Poland
| | - Krzysztof Zieniewicz
- Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, 1A Banacha Street, 02-097, Warsaw, Poland
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A Randomized Controlled Trial Comparing Epidural Analgesia Versus Continuous Local Anesthetic Infiltration Via Abdominal Wound Catheter in Open Liver Resection. Ann Surg 2019; 269:413-419. [PMID: 30080727 DOI: 10.1097/sla.0000000000002988] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
AIM To compare outcomes following open liver resection (OLR) between patients receiving thoracic epidural (EP) versus abdominal wound catheters plus patient-controlled analgesia (AWC-PCA). METHOD Patients were randomized 1:1 to either EP or AWC-PCA within an enhanced recovery protocol. Primary outcome was length of stay (LOS), other variables included functional recovery, pain scores, peak flow, vasopressor and fluid requirements, and postoperative complications. RESULTS Between April 2015 and November 2017, 83 patients were randomized to EP (n = 41) or AWC-PCA (n = 42). Baseline demographics were comparable. No difference was noted in LOS (EP 6 d (3-27) vs AWC-PCA 6 d (3-66), P = 0.886). Treatment failure was 20% in the EP group versus 7% in the AWC-PCA (P = 0.09). Preoperative anesthetic time was shorter in the AWC-PCA group, 49 minutes versus 62 minutes (P = 0.003). EP patients required more vasopressor support immediately postoperatively on day 0 (14% vs 54%, P = <0.001) and day 1 (5% vs 23%, P = 0.021). Pain scores were greater on day 0, afternoon of day 1 and morning of day 2 in the AWC-PCA group however were regarded as low at all time points. No other significant differences were noted in IV fluid requirements, nausea/sedation scores, days to open bowels, length of HDU, and postoperative complications. CONCLUSION AWC-PCA was associated with reduced treatment failure and a reduced vasopressor requirement than EP up to 2 days postoperatively. While the use of AWC-PCA did not translate into a shorter LOS in this study, it simplified patient management after OLR. EP cannot be routinely recommended following open liver resections.
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Cosgrave D, Vencken S, Galligan M, McGuinness S, Soukhin E, McMullan V, Nair S, Puttappa A, Boylan J, Hussain R, Conlon N, Doran P, Nichol A. The effect of a low‐dose naloxone infusion on the incidence of respiratory depression after intrathecal morphine administration for major open hepatobiliary surgery: a randomised controlled trial. Anaesthesia 2019; 75:747-755. [DOI: 10.1111/anae.14931] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2019] [Indexed: 12/13/2022]
Affiliation(s)
- D. Cosgrave
- Department of Anaesthesia St. Vincent's University Hospital Dublin Ireland
| | - S. Vencken
- Clinical Research Centre University College Dublin Ireland
| | - M. Galligan
- Clinical Research Centre University College Dublin Ireland
| | - S. McGuinness
- Department of Anaesthesia St. Vincent's University Hospital Dublin Ireland
- Department of Anaesthesia the National Maternity Hospital Dublin Ireland
| | - E. Soukhin
- Department of Anaesthesia Auckland City Hospital Auckland New Zealand
| | - V. McMullan
- Department of Anaesthesia Tallaght University Hospital Dublin Ireland
| | - S. Nair
- Liver transplantation and cardiac anaesthesia Kings College Hospital NHS Trust London UK
| | - A. Puttappa
- Department of Anaesthesia Addenbrookes Hospital Cambridge University Hospital NHS Trust Cambridge UK
| | - J. Boylan
- Department of Anaesthesia St. Vincent's University Hospital Dublin Ireland
| | - R. Hussain
- Clinical Research Centre St. Vincent's University Hospital Dublin Ireland
| | - N. Conlon
- Department of Anaesthesia St. Vincent's University Hospital Dublin Ireland
| | - P. Doran
- Australian and New Zealand Intensive Care Research Centre Monash University Melbourne Vic. Australia
| | - A. Nichol
- Department of Intensive Care Medicine St. Vincent's University Hospital Dublin Ireland
- Clinical Research Centre St. Vincent's University Hospital Dublin Ireland
- Australian and New Zealand Intensive Care Research Centre Monash University Melbourne Vic. Australia
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Tang JZJ, Weinberg L. A Literature Review of Intrathecal Morphine Analgesia in Patients Undergoing Major Open Hepato-Pancreatic-Biliary (HPB) Surgery. Anesth Pain Med 2019; 9:e94441. [PMID: 32280615 PMCID: PMC7118737 DOI: 10.5812/aapm.94441] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 10/25/2019] [Accepted: 11/12/2019] [Indexed: 01/27/2023] Open
Abstract
CONTEXT The optimal analgesic method for patients undergoing major open hepato-pancreatic-biliary surgery remains controversial. Continuous epidural infusion at the thoracic level remains the standard choice, however concerns have been raised due to associated complications. Single shot intrathecal morphine has emerged as a promising alternative offering similar analgesia with an enhanced safety profile. EVIDENCE ACQUISITION This review aimed to evaluate the literature comparing intrathecal morphine analgesia to other analgesic modalities following major open hepato-pancreatic-biliary surgery. The primary outcome was pain scores at rest and on movement 24 h after surgery. Secondary outcomes were postoperative opioid consumption within 72 postoperative hours, length of stay (LOS), intra-operative fluid administration and post-operative fluid administration within 72 postoperative hours, and overall systemic complication rate within 30 postoperative days. RESULTS Eleven trials matching the inclusion criteria were analysed. Intrathecal morphine resulted in equivalent or lower pain scores when contrasted to alternative techniques, but required higher amounts of postoperative opioid. Intrathecal morphine also offered reduced LOS and reduced fluid administration requirements to epidural analgesia, and there was no difference observed in major complication rate between analgesic modalities. CONCLUSIONS In summary the evidence suggests that intrathecal morphine may be a better first-line analgesic modality than epidural analgesia in the context of major open hepato-pancreatic-biliary surgery, but high-quality evidence supporting this is limited.
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20
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Perez Navarro G, Pascual Bellosta AM, Ortega Lucea SM, Serradilla Martín M, Ramirez Rodriguez JM, Martinez Ubieto J. Analysis of the postoperative hemostatic profile of colorectal cancer patients subjected to liver metastasis resection surgery. World J Clin Cases 2019; 7:2477-2486. [PMID: 31559283 PMCID: PMC6745336 DOI: 10.12998/wjcc.v7.i17.2477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 07/23/2019] [Accepted: 07/27/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Liver resection surgery has advanced greatly in recent years, and the adoption of fasttrack programs has yielded good results. Combination anesthesia (general anesthesia associated to epidural analgesia) is an anesthetic-analgesic strategy commonly used for the perioperative management of patients undergoing surgery of this kind, though there is controversy regarding the coagulation alterations it may cause and which can favor the development of spinal hematomas.
AIM To study the postoperative course of liver resection surgery, an analysis was made of the outcomes of liver resection surgery due to colorectal cancer metastases in our centre in terms of morbiditymortality and hospital stay according to the anesthetic technique used (general vs combination anesthesia).
METHODS A prospective study was made of 61 colorectal cancer patients undergoing surgery due to liver metastases under general and combination anesthesia between January 2014 and October 2015. The patient characteristics, intraoperative variables, postoperative complications, evolution of hemostatic parameters, and stay in intensive care and in hospital were analyzed.
RESULTS A total of 61 patients were included in two homogeneous groups: general anesthesia (n = 30) and combination anesthesia (general anesthesia associated to epidural analgesia) (n = 31). All patients had normal coagulation values before surgery. The international normalized ratio (INR) in both the general and combination anesthesia groups reached maximum values at 2448 h (mean 1.37 and 1.45 vs 1.39 and 1.41, respectively), followed by a gradual decrease. There was less intraoperative bleeding in the combination anesthesia group (769 mL) than in the general anesthesia group (1200 mL) (P < 0.05). Of the 61 patients, 38.8% in the general anesthesia group experienced some respiratory complication vs 6.6% in the combination anesthesia group (P < 0.001). The time to gastrointestinal tolerance was significantly correlated to the type of anesthesia, though not so the stay in critical care or the time to hospital discharge.
CONCLUSION Epidural analgesia in liver resection surgery was seen to be safe, with good results in terms of pain control and respiratory complications, and with no associated increase in complications secondary to altered hemostasis.
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Weinberg L, Ianno D, Churilov L, Mcguigan S, Mackley L, Banting J, Shen SH, Riedel B, Nikfarjam M, Christophi C. Goal directed fluid therapy for major liver resection: A multicentre randomized controlled trial. Ann Med Surg (Lond) 2019; 45:45-53. [PMID: 31360460 PMCID: PMC6642079 DOI: 10.1016/j.amsu.2019.07.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 06/30/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023] Open
Abstract
Background The effect a restrictive goal directed therapy (GDT) fluid protocol combined with an enhanced recovery after surgery (ERAS) programme on hospital stay for patients undergoing major liver resection is unknown. Methods We conducted a multicentre randomized controlled pilot trial evaluating whether a patient-specific, surgery-specific intraoperative restrictive fluid optimization algorithm would improve duration of hospital stay and reduce perioperative fluid related complications. Results Forty-eight participants were enrolled. The median (IQR) length of hospital stay was 7.0 days (7.0:8.0) days in the restrictive fluid optimization algorithm group (Restrict group) vs. 8.0 days (6.0:10.0) in the conventional care group (Conventional group) (Incidence rate ratio 0.85; 95% Confidence Interval 0.71:1.1; p = 0.17). No statistically significant difference in expected number of complications per patient between groups was identified (IRR 0.85; 95%CI: 0.45–1.60; p = 0.60). Patients in the Restrict group had lower intraoperative fluid balances: 808 mL (571:1565) vs. 1345 mL (900:1983) (p = 0.04) and received a lower volume of fluid per kg/hour intraoperatively: 4.3 mL/kg/hr (2.6:5.8) vs. 6.0 mL/kg/hr (4.2:7.6); p = 0.03. No significant differences in the proportion of patients who received vasoactive drugs intraoperatively (p = 0.56) was observed. Conclusion In high-volume hepatobiliary surgical units, the addition of a fluid restrictive intraoperative cardiac output-guided algorithm, combined with a standard ERAS protocol did not significantly reduce length of hospital stay or fluid related complications. Our findings are hypothesis-generating and a larger confirmatory study may be justified. Major liver resection is a complex procedure with up to 40% patients experiencing complications. Optimisation of perfusion and oxygen delivery to all organs remain the cornerstone of best hemodynamic care. Traditionally, a low central venous pressure strategy during major liver resection has been used to reduce venous bleeding. The impact of a restrictive cardiac output fluid optimisation algorithm during major liver surgery is unknown. After major hepatobiliary surgery, a fluid restrictive algorithm did not reduce length of hospital stay or complications.
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Affiliation(s)
- Laurence Weinberg
- Director of Anesthesia, Austin Hospital; and A/Professor, Department of Surgery, Austin Health, The University of Melbourne, Victoria, Australia
| | - Damian Ianno
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Leonid Churilov
- Statistics and Decision Analysis Academic Platform, The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Victoria, Australia.,Department of Medicine (Austin Health), Melbourne Medical School, The University of Melbourne, Victoria, Australia
| | - Steven Mcguigan
- Department of Anesthesia, Austin Health, Victoria, Australia
| | - Lois Mackley
- Department of Anesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Jonathan Banting
- Department of Anesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - Shi Hong Shen
- Department of Anesthesia, Peter MacCallum Cancer Hospital, Victoria, Australia
| | - Bernhard Riedel
- Department of Anesthesia, Peter MacCallum Cancer Hospital, Victoria, Australia
| | - Mehrdad Nikfarjam
- Department of Surgery, Austin Hospital, The University of Melbourne, Victoria, Australia
| | - Chris Christophi
- Department of Surgery, Austin Hospital, The University of Melbourne, Victoria, Australia
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Use of Activity Tracking in Major Visceral Surgery-the Enhanced Perioperative Mobilization Trial: a Randomized Controlled Trial. J Gastrointest Surg 2019; 23:1218-1226. [PMID: 30298422 DOI: 10.1007/s11605-018-3998-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 09/23/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Early mobilization is one essential item within the enhanced recovery after surgery (ERAS) concept, but lacks solid evidence and a standardized assessment. The aim was to monitor and increase the postoperative mobilization of patients after major visceral surgery by providing a continuous step count feedback using activity tracking wristbands. METHODS The study was designed as a randomized controlled single-center trial (NCT02834338) with two arms (open and laparoscopic surgery). Participants were randomized to either receive feedback of their step counts using an activity tracker wristband or not. The primary study endpoint was the mean step count during the first 5 postoperative days (PODs). RESULTS A total of 132 patients were randomized. After laparoscopic operations, the average step count during PODs 1-5 was significantly increased by the feedback compared with the control group (P < 0.001); the cumulative step count (9867 versus 6103, P = 0.037) and activity time were also significantly increased. These results could not be confirmed in the open surgery arm. Possible reasons were a higher age and significantly more comorbidities in the open intervention group. Patients who achieved more than the median cumulative step count had a significantly shorter hospital stay and lower morbidity in both arms. The average step count also correlated with the length of hospital stay (R = - 0.341, P < 0.001). CONCLUSION This study is the first randomized controlled trial investigating the use and feasibility of activity tracking to monitor and enhance postoperative mobilization in abdominal surgery. Our results demonstrate that activity tracking can enhance perioperative mobilization after laparoscopic surgery. TRIAL REGISTRATION ClinicalTrials.gov: NCT02834338.
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Agarwal V, Divatia JV. Enhanced recovery after surgery in liver resection: current concepts and controversies. Korean J Anesthesiol 2019; 72:119-129. [PMID: 30841029 PMCID: PMC6458514 DOI: 10.4097/kja.d.19.00010] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/05/2019] [Indexed: 12/21/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) attenuates the stress response to surgery in the perioperative period and hastens recovery. Liver resection is a complex surgical procedure where the enhanced recovery program has been shown to be safe and effective in terms of postoperative outcomes. ERAS programs have been shown to be associated with lower morbidity, shortened postoperative stay, and reduced cost with no difference in mortality and readmission rates. However, there are challenges that are unique to hepatic resection such as safety after epidural catheterization and postoperative coagulopathy, intraoperative fluids and postoperative organ dysfunction, need for low central venous pressure to reduce blood loss, and non-lactate containing intravenous fluids. This narrative review briefly discusses these concerns and controversies and suggests revisiting some of the strong recommendations made by the ERAS society in light of the recent evidence.
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Affiliation(s)
- Vandana Agarwal
- Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jigeeshu V Divatia
- Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Kjølhede P, Bergdahl O, Borendal Wodlin N, Nilsson L. Effect of intrathecal morphine and epidural analgesia on postoperative recovery after abdominal surgery for gynecologic malignancy: an open-label randomised trial. BMJ Open 2019; 9:e024484. [PMID: 30837253 PMCID: PMC6430030 DOI: 10.1136/bmjopen-2018-024484] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 01/06/2019] [Accepted: 01/28/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We aimed to determine whether regional analgesia with intrathecal morphine (ITM) in an enhanced recovery programme (enhanced recovery after surgery [ERAS]) gives a shorter hospital stay with good pain relief and equal health-related quality of life (QoL) to epidural analgesia (EDA) in women after midline laparotomy for proven or assumed gynaecological malignancies. DESIGN An open-label, randomised, single-centre study. SETTING A tertiary referral Swedish university hospital. PARTICIPANTS Eighty women, 18-70 years of age, American Society of Anesthesiologists I and II, admitted consecutively to the department of Obstetrics and Gynaecology. INTERVENTIONS The women were allocated (1:1) to either the standard analgesic method at the clinic (EDA) or the experimental treatment (ITM). An ERAS protocol with standardised perioperative routines and standardised general anaesthesia were applied. The EDA or ITM started immediately preoperatively. The ITM group received morphine, clonidine and bupivacaine intrathecally; the EDA group had an epidural infusion of bupivacaine, adrenalin and fentanyl. PRIMARY AND SECONDARY OUTCOME MEASURES Primary endpoint was length of hospital stay (LOS). Secondary endpoints were QoL and pain assessments. RESULTS LOS was statistically significantly shorter for the ITM group compared with the EDA group (median [IQR]3.3 [1.5-56.3] vs 4.3 [2.2-43.2] days; p=0.01). No differences were observed in pain assessment or QoL. The ITM group used postoperatively the first week significantly less opioids than the EDA group (median (IQR) 20 mg (14-35 mg) vs 81 mg (67-101 mg); p<0.0001). No serious adverse events were attributed to ITM or EDA. CONCLUSIONS Compared with EDA, ITM is simpler to administer and manage, is associated with shorter hospital stay and reduces opioid consumption postoperatively with an equally good QoL. ITM is effective as postoperative analgesia in gynaecological cancer surgery. TRIAL REGISTRATION NUMBER NCT02026687; Results.
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Affiliation(s)
- Preben Kjølhede
- Children and Women’s Health, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Olga Bergdahl
- Department of Obstetrics and Gynecology, Vrinnevisjukhuset i Norrkoping, Norrkoping, Sweden
| | - Ninnie Borendal Wodlin
- Children and Women’s Health, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Lena Nilsson
- Department of Anesthesiology and Intensive Care, and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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25
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Smith NK, Demaria S, Katz D, Tabrizian P, Schwartz M, Miller JC, Hill B, Cardieri B, Kim SJ, Zerillo J. Intrathecal Morphine Administration Does Not Affect Survival After Liver Resection for Hepatocellular Carcinoma. Semin Cardiothorac Vasc Anesth 2019; 23:309-318. [DOI: 10.1177/1089253219832647] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction. Opioids may influence tumor recurrence and cancer-free survival in hepatocellular carcinoma (HCC). The relationship between intrathecal morphine administration, tumor recurrence, and patient survival after hepatectomy for HCC is unknown. Patients and Methods. This single-center, retrospective study included 1837 liver resections between July 2002 and December 2012; 410 cases were incorporated in the final univariate and multivariate analysis. Confirmatory propensity matching yielded 65 matched pairs (intrathecal morphine vs none). Primary outcomes were recurrence of HCC and survival. Secondary outcomes included characterization of factors associated with recurrence and survival. Results. Groups were similar except for increased coronary artery disease in the no intrathecal morphine group. All patients received volatile anesthesia. Compared with no intrathecal morphine (N = 307), intrathecal morphine (N = 103) was associated with decreased intraoperative intravenous morphine administration (median difference = 12.5 mg; 95% confidence interval [CI] = 5-20 mg). There was no difference in blood loss, transfusion, 3- or 5-year survival, or recurrence in the univariate analysis. Multivariate analysis identified covariates that significantly correlated with 5-year survival: intrathecal morphine (hazard ratio [HR] = 0.527, 95% CI = 0.296-0.939), lesion diameter (HR = 1.099, 95% CI = 1.060-1.141), vascular invasion (HR = 1.658, 95% CI = 1.178-2.334), and satellite lesions (HR = 2.238, 95% CI = 1.447-3.463). Survival analysis on the propensity-matched pairs did not demonstrate a difference in 5-year recurrence or survival. Discussion and Conclusion. Multivariate analysis revealed a significant association between intrathecal morphine and 5-year survival. This association did not persist after propensity matching. The association between intrathecal morphine and HCC recurrence and survival remains unclear and prospective work is necessary to determine whether an association exists.
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Affiliation(s)
| | - Samuel Demaria
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel Katz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Myron Schwartz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Bryan Hill
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Sang J. Kim
- Hospital for Special Surgery, New York, NY, USA
| | - Jeron Zerillo
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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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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Maria K, Evangelos KA, Dimitris KP, Maria K, Ioannis K, Margarita G. Postoperative stress and pain response applying fast-track protocol in patients undergoing hepatectomy. J Perioper Pract 2018; 29:368-377. [PMID: 30417764 DOI: 10.1177/1750458918812293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Aim To assess the clinical parameters and compare the stress and pain response between fast-track recovery protocol and conventional treatment in patients undergoing major liver resection. Methods Eighty-eight patients suffering from malignant liver tumours were surgically treated from May 2012 to March 2015. After randomisation, they were prospectively divided into two groups: group fast-track patients (n = 46) and group conventional treatment patients (n = 42). Demographic and clinical data were collected and patients were assessed with pain scale (behavioural observation scale and visual analog scale), while depression levels were evaluated with Zung self-rating depression scale and three Numeric Analog Scale self-reported questions. Peripheral blood samples were collected at time points: T1 on the admission day, T2 on the day of surgery and T3 on the day of discharge examining serum levels of adrenocorticotropic hormone and cortisol. Conclusion Fast-track recovery protocols seem to be associated with improvement in several clinical parameters, without compromising, biologic or emotional stress in patients undergoing major liver resection.
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Affiliation(s)
- Kapritsou Maria
- Chief Nurse of PACU, Hellenic Anticancer Hospital "Saint Savvas", Day Care Surgery "N. KOURKOULOS" Hellenic Anticancer Institute, "Saint Savvas" Hospital, Athens, Greece
| | | | | | - Kalafati Maria
- Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
| | - Kaklamanos Ioannis
- Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
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28
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Abstract
BACKGROUND Recent developments in perioperative pathophysiology and care have documented evidence-based, multimodal rehabilitation (fast-track) to hasten recovery and decrease morbidity and hospital stay in several major surgical procedures. The aim of this study was to investigate the effect over time of a modified previously published fast-track programme in unselected patients undergoing open or laparoscopic liver resection. METHODS A prospective study includes the first 121 consecutive patients following an updated fast-track programme for liver resection. High-dose methylprednisolone was given to all patients before surgery, catheters and drains were systematically removed early, and patients were mobilized and started eating and drinking from the day of surgery. An opioid-sparing multimodal pain treatment was given for the first week. The discharge criteria were (1) pain sufficiently controlled by oral analgesics only; (2) patient comfortable with discharge; (3) no untreated complications. RESULTS The median length of stay (LOS) for all patients was 4 days, with 2 days after laparoscopic vs. 4 days for open resections. The median LOS after major hepatectomies (≥3 segments) was 5 days. The readmission rate was 6% and the 30-day mortality zero. The LOS decreased compared to our first-generation fast-track programme with LOS 5 days. CONCLUSIONS Fast-track principles for perioperative care and early discharge are safe even after major liver resection. The introduction of high-dose steroids preoperatively might have facilitated a shorter LOS. Routine discharge on POD 1 or 2 after laparoscopic resection and on POD 4 after open liver resection has proven to be feasible.
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29
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Morrison B, Kelliher L, Jones C. Enhanced recovery for liver resection-early recovery pathway for hepatectomy: data-driven liver resection care and recovery. Hepatobiliary Surg Nutr 2018; 7:217-220. [PMID: 30046579 DOI: 10.21037/hbsn.2018.03.13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Benjamin Morrison
- Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Leigh Kelliher
- Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Chris Jones
- Surrey Peri-operative Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
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30
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Cosgrave D, Galligan M, Soukhin E, McMullan V, McGuinness S, Puttappa A, Conlon N, Boylan J, Hussain R, Doran P, Nichol A. The NAPRESSIM trial: the use of low-dose, prophylactic naloxone infusion to prevent respiratory depression with intrathecally administered morphine in elective hepatobiliary surgery: a study protocol and statistical analysis plan for a randomised controlled trial. Trials 2017; 18:633. [PMID: 29284510 PMCID: PMC5747267 DOI: 10.1186/s13063-017-2370-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 11/21/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Intrathecally administered morphine is effective as part of a postoperative analgesia regimen following major hepatopancreaticobiliary surgery. However, the potential for postoperative respiratory depression at the doses required for effective analgesia currently limits its clinical use. The use of a low-dose, prophylactic naloxone infusion following intrathecally administered morphine may significantly reduce postoperative respiratory depression. The NAPRESSIM trial aims to answer this question. METHODS/DESIGN 'The use of low-dose, prophylactic naloxone infusion to prevent respiratory depression with intrathecally administered morphine' trial is an investigator-led, single-centre, randomised, double-blind, placebo-controlled, double-arm comparator study. The trial will recruit 96 patients aged > 18 years, undergoing major open hepatopancreaticobiliary resections, who are receiving intrathecally administered morphine as part of a standard anaesthetic regimen. It aims to investigate whether the prophylactic administration of naloxone via intravenous infusion compared to placebo will reduce the proportion of episodes of respiratory depression in this cohort of patients. Trial patients will receive an infusion of naloxone or placebo, commenced within 1 h of postoperative extubation continued until the first postoperative morning. The primary outcome is the rate of respiratory depression in the intervention group as compared to the placebo group. Secondary outcomes include pain scores, rates of nausea and vomiting, pruritus, sedation scores and adverse outcomes. We will also employ a novel, non-invasive, respiratory minute volume monitor (ExSpiron 1Xi, Respiratory Motion, Inc., 411 Waverley Oaks Road, Building 1, Suite 150, Waltham, MA, USA) to assess the monitor's accuracy for detecting respiratory depression. DISCUSSION The trial aims to provide a clear management plan to prevent respiratory depression after the intrathecal administration of morphine, and thereby improve patient safety. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02885948 . Registered retrospectively on 4 July 2016. Protocol Version 2.0, 3 April 2017. Protocol identification (code or reference number): UCDCRC/15/006 EudraCT registration number: 2015-003504-22. Registered on 5 August 2015.
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Affiliation(s)
| | - Marie Galligan
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Era Soukhin
- St Vincent's University Hospital, Dublin, Ireland
| | | | | | | | - Niamh Conlon
- St Vincent's University Hospital, Dublin, Ireland
| | - John Boylan
- St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Rabia Hussain
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Peter Doran
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Alistair Nichol
- St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland.,Monash University, Melbourne, VIC, Australia.,The Alfred Hospital, Melbourne, VIC, Australia
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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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32
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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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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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Kapritsou M, Papathanassoglou ED, Bozas E, Korkolis DP, Konstantinou EA, Kaklamanos I, Giannakopoulou M. Comparative Evaluation of Pain, Stress, Neuropeptide Y, ACTH, and Cortisol Levels Between a Conventional Postoperative Care Protocol and a Fast-Track Recovery Program in Patients Undergoing Major Abdominal Surgery. Biol Res Nurs 2016; 19:180-189. [PMID: 28198198 DOI: 10.1177/1099800416682617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fast-track (FT) postoperative protocol in oncological patients after major abdominal surgery reduces complications and length of postoperative stay compared to the conventional (CON) protocol. However, stress and pain responses have not been compared between the two protocols. OBJECTIVES To compare stress, pain, and related neuropeptidic responses (adrenocorticotropic hormone [ACTH], cortisol, and neuropeptide Y [NPY]) between FT and CON protocols. METHOD A clinical trial with repeated measurements was conducted (May 2012 to May 2014) with a sample of 63 hepatectomized or pancreatectomized patients randomized into two groups: FT ( n = 29) or CON ( n = 34). Demographic and clinical data were collected, and pain (Visual Analog Scale [VAS] and Behavioral Pain Scale [BPS]) and stress responses (3 self-report questions) assessed. NPY, ACTH, and cortisol plasma levels were measured at T1 = day of admission, T2 = day of surgery, and T3 = prior to discharge. RESULTS ACTHT1 and ACTHT2 levels were positively correlated with self-reported stress levels (ρ = .43 and ρ = .45, respectively, p < .05) in the FT group. NPY levels in the FT group were higher than those in the CON group at all time points ( p ≤ .004); this difference remained significant after adjusting for T1 levels through analysis of covariance for age, gender, and body mass index ( F = .003, F = .149, F = .015, respectively, p > .05). CONCLUSIONS Neuropeptidic levels were higher in the FT group. Future research should evaluate this association further, as these biomarkers might serve as objective indicators of postoperative pain and stress.
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Affiliation(s)
- Maria Kapritsou
- 1 Hellenic Anticancer Institute, Saint Savvas Hospital, Athens, Greece
| | | | - Evangelos Bozas
- 3 Pediatric Research Laboratory, Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Ioannis Kaklamanos
- 4 Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
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Li M, Zhang W, Jiang L, Yang J, Yan L. Fast track for open hepatectomy: A systemic review and meta-analysis. Int J Surg 2016; 36:81-89. [PMID: 27773599 DOI: 10.1016/j.ijsu.2016.10.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 10/03/2016] [Accepted: 10/14/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Liver resection (LR) is preferred treatment for malignancies or benign masses of liver. Using multiple elements, fast track (FT) program was introduced to abdominal surgery associating with fast functional recovery and shorter hospital length of stay (LoS). This meta-analysis aims to evaluate the effect of FT program for patients following liver resection. MATERIALS AND METHODS We searched the PubMed/Medline, Cochrane Central Register of Controlled Trials (CENTRAL), Embase for trials up to December 2015 to compare the FT program to the conventional group. The main outcome was assessed of complication rate (including liver specific or general complication rate), thirty-day postoperative mortality, readmission rate and the length of hospital stay. RESULTS Four randomized control trials (RCTs) and three cohort trials (CTs) were to make a quantitative synthesis including 1027 patients. The LoS was reduced following FT groups (weighted mean difference [WMD], 2.24 days; 95% CI 3.69-0.79; P < 0.005). No significant differences were noted in overall complication (risk ratio [RR], 0.94; 95% CI, 0.79-1.12; p = 0.49), mortality (RR, 0.63; 95% CI, 0.19-2.15; p = 0.46) and readmission rate (RR, 0.99; 95% CI, 0.54-1.79; p = 0.97). However, the general complication showed a difference favoring FT group (RR, 0.68; 95% CI, 0.49-0.95; p = 0.03). CONCLUSIONS This review, firstly using the quantitative synthesis in FT program following LR, indicates that FT program can shorten the length of hospital stay and accelerate the postoperative recovery in a safe and effective ways without increasing in mortality, morbidity and readmission rate.
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Affiliation(s)
- Ming Li
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Wei Zhang
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Li Jiang
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Jiayin Yang
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China.
| | - Lunan Yan
- Department of Liver Surgery, Liver Transplantation Division, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
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Adherence to early mobilisation: Key for successful enhanced recovery after liver resection. Eur J Surg Oncol 2016; 42:1561-7. [PMID: 27528466 DOI: 10.1016/j.ejso.2016.07.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 07/18/2016] [Accepted: 07/25/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) has been proven effective in liver surgery. Adherence to the ERAS pathway is variable. This study seeks to evaluate adherence to key components of an ERAS protocol in liver resection, and identify the components associated with successful clinical outcomes. METHOD All patients undergoing liver resections for two consecutive years were included in our ERAS pathway. Six key components of ERAS included preoperative assessment, nutrition and gastrointestinal function, postoperative analgesia, mobilisation and discharges. Successful accomplishment of ERAS was defined as hospital discharge by postop day (POD) 6. Adherences of these elements were compared between the successful and un-successful groups. RESULTS During the studied period, 223 patients underwent liver resections, among which 103 had major hepatectomies. N = 147 patients (66%) were discharged within our ERAS protocol target (6 days). On multivariable analysis, sitting out of bed by POD 1 (p < 0.03), walking by POD 3 (p = 0.03), removal of urinary catheter by POD 3 (p < 0.01), and avoiding major complications (p < 0.01) were factors associated with successful completion to our ERAS protocol; whereas advanced age (p = 0.34) and discontinuation of PCA/epidural by POD 3 (p = 0.50) were not significant parameters. There was a significant difference in the length of stay (p < 0.01) following major and minor liver resection, of which the indications for surgery also varied significantly. There was no difference in hospital re-admission rate, and morbidity and mortality between major and minor liver resection. CONCLUSIONS Facilitating early mobilisation and reducing postoperative complications are keys to successful outcomes of ERAS in liver resection.
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Ahmed EA, Montalti R, Nicolini D, Vincenzi P, Coletta M, Vecchi A, Mocchegiani F, Vivarelli M. Fast track program in liver resection: a PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2016; 95:e4154. [PMID: 27428206 PMCID: PMC4956800 DOI: 10.1097/md.0000000000004154] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND FT program (FT) is a multimodal approach used to enhance postoperative rehabilitation and accelerate recovery. It was 1st described in open heart surgery, then modified and applied successfully in colorectal surgery. FT program was described in liver resection for the 1st time in 2008. Although the program has become widely accepted, it has not yet been considered the standard of care in liver surgery. OBJECTIVES we performed this systematic review and meta-analysis to evaluate the impact of using the FT program compared to the traditional care (TC), on the main clinical and surgical outcomes for patients who underwent elective liver resection. METHODS PubMed/Medline, Scopus, and Cochran databases were searched to identify eligible articles that compared FT with TC in elective liver resection to be included in this study. Subgroup meta-analysis between laparoscopic and open surgical approaches to liver resection was also conducted. Quality assessment was performed for all the included studies. Odds ratios (ORs) and mean differences (MDs) were considered as a summary measure of evaluating the association in this meta-analysis for dichotomous and continuous data, respectively. A 95% confidence interval (CI) was reported for both measures. I was used to assess the heterogeneity across studies. RESULTS From 2008 to 2015, 3 randomized controlled trials (RCTs) and 5 cohort studies were identified, including 394 and 416 patients in the FT and TC groups, respectively. The length of hospital stay (LoS) was markedly shortened in both the open and laparoscopic approaches within the FT program (P < 0.00001). The reduced LoS was accompanied by accelerated functional recovery (P = 0.0008) and decreased hospital costs, with no increase in readmission, morbidity, or mortality rates. Moreover, significant results were found within the FT group such as reduced operative time (P = 0.03), lower intensive care unit admission rate (P < 0.00001), early bowel opening (P ≤ 0.00001), and rapid normal diet restoration (P ≤ 0.00001). CONCLUSION FT program is safe, feasible, and can be applied successfully in liver resection. Future RCTs on controversial issues such as multimodal analgesia and adherence rate are needed. Specific FT guidelines should be developed for liver resection.
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Affiliation(s)
- Emad Ali Ahmed
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
- Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Sohag University, Sohag, Egypt
| | - Roberto Montalti
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Daniele Nicolini
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Vincenzi
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Martina Coletta
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Andrea Vecchi
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Federico Mocchegiani
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
- Correspondence: Federico Mocchegiani, Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, A.O.U. “Ospedali Riuniti”, via Conca 71, 60126 Ancona, Italy (e-mail: )
| | - Marco Vivarelli
- Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
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Adherence to ERAS elements in major visceral surgery—an observational pilot study. Langenbecks Arch Surg 2016; 401:349-56. [DOI: 10.1007/s00423-016-1407-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 03/14/2016] [Indexed: 02/06/2023]
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Clark CJ, Ali SM, Zaydfudim V, Jacob AK, Nagorney DM. Safety of an Enhanced Recovery Pathway for Patients Undergoing Open Hepatic Resection. PLoS One 2016; 11:e0150782. [PMID: 26950852 PMCID: PMC4780831 DOI: 10.1371/journal.pone.0150782] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 02/17/2016] [Indexed: 01/22/2023] Open
Abstract
Background Enhanced recovery pathways (ERP) have not been widely implemented for hepatic surgery. The aim of this study was to evaluate the safety of an ERP for patients undergoing open hepatic resection. Methods A single-surgeon, retrospective observational cohort study was performed comparing the clinical outcomes of patients undergoing open hepatic resection treated before and after implementation of an ERP. Morbidity, mortality, and length of hospital stay (LOS) were compared between pre-ERP and ERP groups. Results 126 patients (pre-ERP n = 73, ERP n = 53) were identified for the study. Patient characteristics and operative details were similar between groups. Overall complication rate was similar between pre-ERP and ERP groups (37% vs. 28%, p = 0.343). Before and after pathway implementation, the median LOS was similar, 5 (IQR 4–7) vs. 5 (IQR 4–6) days, p = 0.708. After adjusting for age, type of liver resection, and ASA, the ERP group had no increased risk of major complication (OR 0.38, 95% CI 0.14–1.02, p = 0.055) or LOS greater than 5 days (OR 1.21, 95% CI 0.56–2.62, p = 0.627). Conclusions Routine use of a multimodal ERP is safe and is not associated with increased postoperative morbidity after open hepatic resection.
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Affiliation(s)
- Clancy J. Clark
- Department of General Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, United States of America
- * E-mail:
| | - Shahzad M. Ali
- Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Victor Zaydfudim
- Department of General Surgery, University of Virginia, Charlottesville, Virginia, United States of America
| | - Adam K. Jacob
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - David M. Nagorney
- Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, Minnesota, United States of America
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Hughes MJ, Harrison EM, Peel NJ, Stutchfield B, McNally S, Beattie C, Wigmore SJ. Randomized clinical trial of perioperative nerve block and continuous local anaesthetic infiltration via wound catheter versus epidural analgesia in open liver resection (LIVER 2 trial). Br J Surg 2015; 102:1619-28. [PMID: 26447461 DOI: 10.1002/bjs.9949] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 08/04/2015] [Accepted: 08/25/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND Analgesia after liver surgery remains controversial. A previous randomized trial of continuous wound infiltration (CWI) versus thoracic epidural analgesia (TEA) after liver surgery (LIVER trial) showed a faster recovery time in the wound infiltration group but better early postoperative pain scores in the TEA group. High-level evidence is, however, limited and opinion remains divided. The aim was to determine whether there is a difference in functional recovery time between patients having CWI plus abdominal nerve blocks versus TEA after liver resection. METHODS A randomized unblinded clinical trial of patients undergoing open liver resection was commenced in December 2012, with follow-up to August 2014. Patients were randomized to receive either wound catheter and nerve block (CWI group) or TEA for 48 h after surgery. The primary outcome measure was functional recovery time. Secondary outcomes were pain scores, complication rates, inflammatory response and central venous pressure (CVP) during transection. RESULTS Of 50 patients randomized initially to each group, 44 received TEA and 49 CWI. Median (i.q.r.) recovery time was 6·5 (5-9·75) and 5·75 (4-7) days in the TEA and CWI groups respectively (P = 0·036). Pain scores were not significantly different between the two groups, and there were no differences in morbidity, inflammatory response or CVP during transection. CONCLUSION Wound infiltration is associated with a reduced time to recovery after open liver resection compared with epidural analgesia. TEA does not offer an advantage over CWI in terms of attenuation of the inflammatory response or pain scores. REGISTRATION NUMBER NCT01747122 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- M J Hughes
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - E M Harrison
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - N J Peel
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - B Stutchfield
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S McNally
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - C Beattie
- Departments of Anaesthesia, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S J Wigmore
- Departments of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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Hughes MJ, Ventham NT, Harrison EM, Wigmore SJ. Central venous pressure and liver resection: a systematic review and meta-analysis. HPB (Oxford) 2015; 17:863-71. [PMID: 26292655 PMCID: PMC4571753 DOI: 10.1111/hpb.12462] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 05/18/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND A liver resection under low central venous pressure (CVP) has become standard practice; however, the benefits beyond a reduction in blood loss are not well reported. Moreover, the precise method to achieve CVP reduction has not been established. A systematic review and meta-analysis of randomized controlled trials (RTCs) was performed to assess the effects of CVP on clinical outcome and to identify the optimum method of CVP reduction. METHODS EMBASE, Medline, PubMed and the Cochrane database were searched for trials comparing low CVP surgery with controls. The primary outcome was post-operative complications within 30 days. Secondary outcomes included estimated blood loss (EBL), blood transfusion rates and length of stay (LOS). Sub-group analysis was performed to assess the CVP reduction method on the outcome. RESULTS Eight trials were identified. No difference was observed in the morbidity rate between the high CVP and control groups [odds ratio (OR) = 0.96 (95% confidence interval (CI) 0.66, 1.40) P = 0.84, I(2) = 0%]. EBL [weighted mean difference (WMD) = -308.63 ml (95% CI -474.67, -142.58) P = < 0.001, I(2) = 73%] and blood transfusion rates [OR 0.65 (95% CI 0.44, 0.97) P = 0.040, I(2) = 37%] were significantly lower in the low CVP groups. Neither anaesthetic nor surgical methods of CVP reduction were associated with a reduced post-operative morbidity. CONCLUSION Low CVP surgery is associated with a reduction in EBL; however, this does not translate into an improvement in post-operative morbidity. The optimum method of CVP reduction has not been identified.
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Affiliation(s)
- Michael J Hughes
- Department of Clinical Surgery, Royal Infirmary of EdinburghEdinburgh, UK
| | - Nicholas T Ventham
- Department of Clinical Surgery, Royal Infirmary of EdinburghEdinburgh, UK
| | - Ewen M Harrison
- Department of Clinical Surgery, Royal Infirmary of EdinburghEdinburgh, UK
| | - Stephen J Wigmore
- Department of Clinical Surgery, Royal Infirmary of EdinburghEdinburgh, UK
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Fast-Track Programs for Liver Surgery: A Meta-Analysis. J Gastrointest Surg 2015; 19:1640-52. [PMID: 26160321 DOI: 10.1007/s11605-015-2879-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 06/22/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Plentiful publications have inspected the feasibility of fast-track surgery programs during hepatic surgery, but the potency of these studies has not been discussed profoundly so far. Our goal was to assess the effects of fast-track programs on surgical outcomes compared with traditional surgical plans for liver surgery. METHODS The following databases were searched: PubMed, Cochrane library, Embase, Science Citation Index Expanded, etc. Studies meeting our inclusion criteria were included. All interrelated data and the methodological quality of included studies were extracted and assessed. We applied risk ratio and weighted mean difference as the estimated effect measures. Sensitivity analysis was performed to perceive the reliability of our findings. RESULTS Altogether, 14 studies with 1400 patients were analyzed. Meta-analysis of randomized controlled trials demonstrated that implementation of fast-track surgery programs could observably decrease the total length of hospital stay, complication rate, postoperative first flatus time, and hospitalization expense, and did not compromise mortality and readmission rate. The above findings were also in line with the results of case-control studies. CONCLUSIONS Fast-track surgery programs are feasible and effective for liver surgery. Future studies should optimize fast-track surgery programs catering to liver surgery.
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Takamoto T, Hashimoto T, Inoue K, Nagashima D, Maruyama Y, Mitsuka Y, Aramaki O, Makuuchi M. Applicability of enhanced recovery program for advanced liver surgery. World J Surg 2015; 38:2676-82. [PMID: 24838485 DOI: 10.1007/s00268-014-2613-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery programs (ERPs) have been developed in various surgical fields and have been shown to accelerate postoperative recovery without increasing the incidence of adverse events. Whether ERP can be safely applied to patients undergoing complex liver surgery with a risk of liver failure remains unclear. METHODS We created an ERP by rearranging our conventional postoperative treatments and applied this program to patients undergoing major hepatectomy between 2008 and 2013. The ERP elements included greater perioperative education, individualized postoperative fluid therapy, and early mobilization. The success of the ERP was evaluated on postoperative day (POD) 6 based on the criterion of independence from continuous medical intervention with the exception of an abdominal drainage tube. Adherence to each item in the ERP was evaluated, and risk factors for delayed accomplishment were analyzed. RESULTS Altogether, 200 patients were included, and 165 patients (82.5 %) completed the ERP. Multivariate analyses showed that (1) an age of 65 years or older and (2) a red blood cell transfusion were independent risk factors for delayed accomplishment. The performance of thoracotomy or choledocojejunostomy did not significantly affect accomplishment of the ERP. Oral intake starting on POD 1 was achieved in 179 patients (89.5 %), and termination of intravenous drip infusions on POD 5 was feasible in 72.5 %. CONCLUSIONS An ERP for major hepatectomy was completed in more than 80 % of the patients. Earlier bowel movement can be challenged. The liquid in-out balance should be adjusted on an individual basis, rather than uniformly, especially for patients over 65 years of age or who required a red blood cell transfusion.
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Affiliation(s)
- Takeshi Takamoto
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation Surgery, Japanese Red Cross Medical Center, 4-1-22 Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan,
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Dasari BVM, Rahman R, Khan S, Bennett D, Hodson J, Isaac J, Marudanayagam R, Mirza DF, Muiesan P, Roberts KJ, Sutcliffe RP. Safety and feasibility of an enhanced recovery pathway after a liver resection: prospective cohort study. HPB (Oxford) 2015; 17:700-6. [PMID: 26099347 PMCID: PMC4527855 DOI: 10.1111/hpb.12447] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 05/01/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND In contrast to colorectal surgery, enhanced recovery pathways (ERPs) have not yet become standard practice after major upper abdominal surgery. The aim of this study was to assess the feasibility and outcomes after implementation of an ERP after liver a resection. METHODS Patients who underwent a liver resection in two consecutive 6-month periods before (July-December 2013) and after (January-June 2014) implementation of an ERP were included in a prospective study. Patients who underwent live donation, ALPPS (associating liver partition with portal vein ligation for staged hepatectomy) or concomitant procedures were excluded. Peri-operative outcomes were compared between groups, and multivariate analysis of factors influencing the length of hospital stay (LOS) was performed. RESULTS Two hundred and eleven patients (93 pre-ERP and 91 post-ERP patients) underwent a liver resection during the study period. There was no significant difference in the median LOS (P = 0.907) and 30-day readmission rates (P = 0.645) between the groups. Severe (Clavien grade III-V) complications were reduced in ERP patients (13.9% versus 4.3%; P = 0.039). On multivariate analysis, an increased age (< 0.001), open resection (< 0.001) and complications (< 0.001) were associated with an increased LOS. CONCLUSION Enhanced recovery after a liver resection appears to be safe, feasible and may reduce severe complications. However, the LOS was significantly influenced by patient age, open surgery and post-operative complications, but not by an ERP.
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Affiliation(s)
- Bobby V M Dasari
- The Liver Unit, Queen Elizabeth HospitalBirmingham, UK,Correspondence Bobby V. M. Dasari, The Liver Unit, Queen Elizabeth Hospital, Birmingham B15 2WB, UK. Tel: +44 772 762 1372. Fax: +121 414 1833. E-mail:
| | - Rasha Rahman
- The Liver Unit, Queen Elizabeth HospitalBirmingham, UK
| | - Shakeeb Khan
- The Liver Unit, Queen Elizabeth HospitalBirmingham, UK
| | - Davinia Bennett
- Department of Anaesthesia, Queen Elizabeth HospitalBirmingham, UK
| | - James Hodson
- Wolfson Laboratory, Queen Elizabeth HospitalBirmingham, UK
| | - John Isaac
- The Liver Unit, Queen Elizabeth HospitalBirmingham, UK
| | | | | | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth HospitalBirmingham, UK
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Kambakamba P, Slankamenac K, Tschuor C, Kron P, Wirsching A, Maurer K, Petrowsky H, Clavien PA, Lesurtel M. Epidural analgesia and perioperative kidney function after major liver resection. Br J Surg 2015; 102:805-12. [PMID: 25877255 DOI: 10.1002/bjs.9810] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 02/07/2015] [Accepted: 02/19/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Epidural analgesia (EDA) is a common analgesia regimen in liver resection, and is accompanied by sympathicolysis, peripheral vasodilatation and hypotension in the context of deliberate intraoperative low central venous pressure. This associated fall in mean arterial pressure may compromise renal blood pressure autoregulation and lead to acute kidney injury (AKI). This study investigated whether EDA is a risk factor for postoperative AKI after liver surgery. METHODS The incidence of AKI was investigated retrospectively in patients who underwent liver resection with or without EDA between 2002 and 2012. Univariable and multivariable analyses were performed including recognized preoperative and intraoperative predictors of posthepatectomy renal failure. RESULTS A series of 1153 patients was investigated. AKI occurred in 8·2 per cent of patients and was associated with increased morbidity (71 versus 47·3 per cent; P = 0·003) and mortality (21 versus 0·3 per cent; P < 0·001) rates. The incidence of AKI was significantly higher in the EDA group (10·1 versus 3·7 per cent; P = 0·003). Although there was no significant difference in the incidence of AKI between patients undergoing minor hepatectomy with or without EDA (5·2 versus 2·7 per cent; P = 0·421), a substantial difference in AKI rates occurred in patients undergoing major hepatectomy (13·8 versus 5·0 per cent; P = 0·025). In multivariable analysis, EDA remained an independent risk factor for AKI after hepatectomy (P = 0·040). CONCLUSION EDA may be a risk factor for postoperative AKI after major hepatectomy.
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Affiliation(s)
- P Kambakamba
- Department of Surgery, Swiss Hepatopancreatobiliary and Transplantation Center, Zurich, Switzerland
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DeSousa KA, Chandran R. Intrathecal morphine for postoperative analgesia: Current trends. World J Anesthesiol 2014; 3:191-202. [DOI: 10.5313/wja.v3.i3.191] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 03/31/2014] [Accepted: 07/14/2014] [Indexed: 02/07/2023] Open
Abstract
The practice of anesthesiology has always been governed by evidence-based medicine. The quick turnover rate of patients in the operating room and patient safety and satisfaction, have also further changed the way we practice anesthesia. The use of intrathecal (IT) opiates as an effective form of postoperative pain relief has been established for many years. Morphine was the first opioid used by IT route. In clinical practice, morphine is regarded as the gold standard, or benchmark, of analgesics used to relieve intense pain. Perhaps for this reason, IT morphine has been used for over 100 years for pain relief. IT morphine is one of the easiest, cost-effective and reliable techniques for postoperative analgesia and technical failures are rare. And yet there is no consensus amongst anesthesiologists regarding the dose of IT morphine. Like all other methods of pain relief, IT morphine also has some side effects and some of them are serious though not very common. This review article looks into some of the key aspects of the use of IT morphine for post-operative analgesia and various doses for different procedures are discussed. This article also describes the side effects of IT morphine and how to treat and prevent them.
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Hughes MJ, McNally S, Wigmore SJ. Enhanced recovery following liver surgery: a systematic review and meta-analysis. HPB (Oxford) 2014; 16:699-706. [PMID: 24661306 PMCID: PMC4113251 DOI: 10.1111/hpb.12245] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 01/17/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programmes aim to improve postoperative outcomes. They are being utilized increasingly in hepatic surgery. This review aims to evaluate the impact of ERAS programmes on outcomes following liver surgery. METHODS EMBASE, MEDLINE, PubMed and the Cochrane Database were searched for trials comparing outcomes in patients undergoing liver surgery utilizing ERAS principles with those in patients receiving conventional care. The primary outcome was occurrence of postoperative complications within 30 days. Secondary outcomes included length of stay (LoS), functional recovery and adherence to ERAS protocols. RESULTS Nine articles were included in the review, of which two were randomized controlled trials (RCTs). Overall complication rates were 25.0% (range: 11.5-46.4%) in ERAS patients, and 31.0% (range: 11.8-46.2%) in conventional care patients. Significantly reduced overall complication rates following ERAS care were demonstrated by a meta-analysis of the data reported in the two RCTs (odds ratio: 0.49, 95% confidence interval 0.28-0.84; P = 0.01) The median LoS reported by the studies was 5.0 days (range: 2.5-7.0 days) in ERAS patients, and 7.5 days (range: 3.0-11.0 days) in non-ERAS patients. Recovery milestones, when reported, were improved following ERAS care. CONCLUSIONS The adoption of ERAS protocols improves morbidity and LoS following liver surgery. Future ERAS programmes should accommodate the unique requirements of liver surgery in order to optimize postoperative outcomes.
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Affiliation(s)
- Michael J Hughes
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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Kasivisvanathan R, Abbassi-Ghadi N, Prout J, Clevenger B, Fusai GK, Mallett SV. A prospective cohort study of intrathecal versus epidural analgesia for patients undergoing hepatic resection. HPB (Oxford) 2014; 16:768-75. [PMID: 24467320 PMCID: PMC4113260 DOI: 10.1111/hpb.12222] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 12/18/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this prospective observational study was to compare peri/post-operative outcomes of thoracic epidural analgesia (TEA) versus intrathecal morphine and fentanyl patient-controlled analgesia (ITM+fPCA) for patients undergoing a hepatic resection (HR). METHOD Patients undergoing elective, one-stage, open HR for benign and malignant liver lesions, receiving central neuraxial block as part of the anaesthetic, in a high-volume hepato-pancreato-biliary unit, were included in the study. The primary outcome measure was post-operative length of stay (LoS). RESULTS A total of 73 patients (36 TEA and 37 ITM+fPCA) were included in the study. The median (IQR) post-operative LoS was 13 (11-15) and 11 (9-13) days in the TEA and ITM+fPCA groups, respectively (P = 0.011). There was significantly lower median intra-operative central venous pressure (P < 0.001) and blood loss (P = 0.017) in the TEA group, and a significant reduction in the time until mobilization (P < 0.001), post-operative intra-venous fluid/vasopressor requirement (P < 0.001/P = 0.004) in the ITM+fPCA group. Pain scores were lower at a clinically significant level 12 h post-operatively in the TEA group (P < 0.001); otherwise there were no differences out to day five. There were no differences in quality of recovery or postoperative morbidity/mortality between the two groups. CONCLUSION ITM+fPCA provides acceptable post-operative outcomes for HR, but may also increase the incidence of intra-operative blood loss in comparison to TEA.
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Affiliation(s)
| | - Nima Abbassi-Ghadi
- Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM, St Mary's HospitalLondon, UK
| | - Jeremy Prout
- Department of Anaesthesia, Royal Free London NHS Foundation TrustLondon, UK
| | - Ben Clevenger
- Department of Anaesthesia, Royal Free London NHS Foundation TrustLondon, UK
| | - Giuseppe K Fusai
- Department of Hepato-biliary Surgery and Liver Transplant Unit, University College London Royal Free CampusLondon, UK
| | - Susan V Mallett
- Department of Anaesthesia, Royal Free London NHS Foundation TrustLondon, UK
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Wong-Lun-Hing EM, van Dam RM, Welsh FKS, Wells JKG, John TG, Cresswell AB, Dejong CHC, Rees M. Postoperative pain control using continuous i.m. bupivacaine infusion plus patient-controlled analgesia compared with epidural analgesia after major hepatectomy. HPB (Oxford) 2014; 16:601-9. [PMID: 24151899 PMCID: PMC4105897 DOI: 10.1111/hpb.12183] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Accepted: 08/25/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES There is debate concerning the best mode of delivery of analgesia following liver resection, with continuous i.m. infusion of bupivacaine (CIB) plus patient-controlled i.v. analgesia (PCA) suggested as an alternative to continuous epidural analgesia (CEA). This study compares these two modalities. METHODS A total of 498 patients undergoing major hepatectomy between July 2004 and July 2011 were included. Group 1 received CIB + PCA (n = 429) and Group 2 received CEA (n = 69). Groups were analysed on baseline patient and surgical characteristics. Primary endpoints were pain severity scores and total opioid consumption. Secondary endpoints were pain management failures, need for rescue medication, postoperative (opioid-related) morbidity and hospital length of stay (LoS). RESULTS In both groups pain was well controlled and >70% of patients had no or minimal pain on PoDs 1 and 2. The numbers of patients experiencing severe pain were similar in both groups: PoD 1 at rest: 0.3% in Group 1 and 0% in Group 2 (P = 1.000); PoD 1 on movement: 8% in Group 1 and 2% in Group 2 (P = 0.338); PoD 2 at rest: 0% in Group 1 and 2% in Group 2 (P = 0.126), and PoD 2 on movement: 5% in Group 1 and 5% in Group 2 (P = 1.000). Although the CIB + PCA group required more opioid rescue medication on PoD 0 (53% versus 22%; P < 0.001), they used less opioids on PoDs 0-3 (P ≤ 0.001), had lower morbidity (26% versus 39%; P = 0.018), and a shorter LoS (7 days versus 8 days; P = 0.005). CONCLUSIONS The combination of CIB + PCA provides pain control similar to that provided by CEA, but facilitates lower opioid consumption after major hepatectomy. It has the potential to replace epidural analgesia, thereby avoiding the occurrence of rare but serious complications.
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Affiliation(s)
- Edgar M Wong-Lun-Hing
- Department of Surgery, Maastricht University Medical CentreMaastricht, the Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical CentreMaastricht, the Netherlands
| | | | - John K G Wells
- Hepato-biliary Unit, Hampshire Hospitals FTBasingstoke, UK
| | - Timothy G John
- Hepato-biliary Unit, Hampshire Hospitals FTBasingstoke, UK
| | | | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical CentreMaastricht, the Netherlands,NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht UniversityMaastricht, the Netherlands
| | - Myrddin Rees
- Hepato-biliary Unit, Hampshire Hospitals FTBasingstoke, UK
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Hughes M, Coolsen MME, Aahlin EK, Harrison EM, McNally SJ, Dejong CHC, Lassen K, Wigmore SJ. Attitudes of patients and care providers to enhanced recovery after surgery programs after major abdominal surgery. J Surg Res 2014; 193:102-10. [PMID: 25066187 DOI: 10.1016/j.jss.2014.06.032] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 06/07/2014] [Accepted: 06/18/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) is a well-established pathway of perioperative care in surgery in an increasing number of specialties. To implement protocols and maintain high levels of compliance, continued support from care providers and patients is vital. This survey aimed to assess the perceptions of care providers and patients of the relevance and importance of the ERAS targets and strategies. MATERIALS AND METHODS Pre- and post-operative surveys were completed by patients who underwent major hepatic, colorectal, or oesophagogastric surgery in three major centers in Scotland, Norway, and The Netherlands. Anonymous web-based and article surveys were also sent to surgeons, anesthetists, and nurses experienced in delivering enhanced recovery protocols. Each questionnaire asked the responder to rate a selection of enhanced recovery targets and strategies in terms of perceived importance. RESULTS One hundred nine patients and 57 care providers completed the preoperative survey. Overall, both patients and care providers rated the majority of items as important and supported ERAS principles. Freedom from nausea (median, 10; interquartile range [IQR], 8-10) and pain at rest (median, 10; IQR, 8-10) were the care components rated the highest by both patients and care providers. Early return of bowel function (median, 7; IQR, 5-8) and avoiding preanesthetic sedation (median, 6; IQR, 3.75-8) were scored the lowest by care providers. CONCLUSIONS ERAS principles are supported by both patients and care providers. This is important when attempting to implement and maintain an ERAS program. Controversies still remain regarding the relative importance of individual ERAS components.
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Affiliation(s)
- Michael Hughes
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom.
| | - Marielle M E Coolsen
- Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands
| | - Eirik K Aahlin
- Department of Gastrointestinal Surgery, University Hospital Northern Norway and Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Ewen M Harrison
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Stephen J McNally
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - C H C Dejong
- Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands
| | - Kristoffer Lassen
- Department of Gastrointestinal Surgery, University Hospital Northern Norway and Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Stephen J Wigmore
- Department of Clinical Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom
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