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Moosburner S, Dahlke PM, Neudecker J, Hillebrandt KH, Koch PF, Knitter S, Ludwig K, Kamali C, Gül-Klein S, Raschzok N, Schöning W, Sauer IM, Pratschke J, Krenzien F. From morbidity reduction to cost-effectiveness: Enhanced recovery after surgery (ERAS) society recommendations in minimal invasive liver surgery. Langenbecks Arch Surg 2024; 409:137. [PMID: 38653917 PMCID: PMC11039530 DOI: 10.1007/s00423-024-03329-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/19/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Minimal-invasive liver surgery (MILS) reduces surgical trauma and is associated with fewer postoperative complications. To amplify these benefits, perioperative multimodal concepts like Enhanced Recovery after Surgery (ERAS), can play a crucial role. We aimed to evaluate the cost-effectiveness for MILS in an ERAS program, considering the necessary additional workforce and associated expenses. METHODS A prospective observational study comparing surgical approach in patients within an ERAS program compared to standard care from 2018-2022 at the Charité - Universitätsmedizin Berlin. Cost data were provided by the medical controlling office. ERAS items were applied according to the ERAS society recommendations. RESULTS 537 patients underwent liver surgery (46% laparoscopic, 26% robotic assisted, 28% open surgery) and 487 were managed by the ERAS protocol. Implementation of ERAS reduced overall postoperative complications in the MILS group (18% vs. 32%, p = 0.048). Complications greater than Clavien-Dindo grade II incurred the highest costs (€ 31,093) compared to minor (€ 17,510) and no complications (€13,893; p < 0.001). In the event of major complications, profit margins were reduced by a median of € 6,640. CONCLUSIONS Embracing the ERAS society recommendations in liver surgery leads to a significant reduction of complications. This outcome justifies the higher cost associated with a well-structured ERAS protocol, as it effectively offsets the expenses of complications.
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Affiliation(s)
- Simon Moosburner
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| | - Paul M Dahlke
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jens Neudecker
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Karl H Hillebrandt
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| | - Pia F Koch
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Sebastian Knitter
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Kristina Ludwig
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Can Kamali
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Safak Gül-Klein
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Nathanael Raschzok
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Igor M Sauer
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, CCM | CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany.
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Dahlke PM, Benzing C, Lurje G, Malinka T, Raschzok N, Kamali C, Gül-Klein S, Schöning W, Hillebrandt KH, Pratschke J, Neudecker J, Krenzien F. Impact of complexity in minimally invasive liver surgery on enhanced recovery measures: prospective study. BJS Open 2024; 8:zrad147. [PMID: 38242574 PMCID: PMC10799324 DOI: 10.1093/bjsopen/zrad147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/30/2023] [Accepted: 10/31/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Adherence to enhanced recovery after surgery (ERAS) protocols is crucial for successful liver surgery. The aim of this study was to assess the impact of minimally invasive liver surgery complexity on adherence after implementing an ERAS protocol. METHODS Between July 2018 and August 2021, a prospective observational study involving minimally invasive liver surgery patients was conducted. Perioperative treatment followed ERAS guidelines and was recorded in the ERAS interactive audit system. Kruskal-Wallis and ANOVA tests were used for analysis, and pairwise comparisons utilized Wilcoxon rank sum and Welch's t-tests, adjusted using Bonferroni correction. RESULTS A total of 243 patients were enrolled and categorized into four groups based on the Iwate criteria: low (n = 17), intermediate (n = 81), advanced (n = 74) and expert difficulty (n = 71). Complexity correlated with increased overall and major morbidity rate, as well as longer length of stay (all P < 0.001; standardized mean difference = 0.036, 0.451, 0.543 respectively). Adherence to ERAS measures decreased with higher complexity (P < 0.001). Overall adherence was 65.4%. Medical staff-centred adherence was 79.9%, while patient-centred adherence was 38.9% (P < 0.001). Complexity significantly affected patient-centred adherence (P < 0.001; standardized mean difference (SMD) = 0.420), but not medical staff-centred adherence (P = 0.098; SMD = 0.315). Postoperative phase adherence showed major differences among complexity groups (P < 0.001, SMD = 0.376), with mobilization measures adhered to less in higher complexity cases. CONCLUSION The complexity of minimally invasive liver surgery procedures impacts ERAS protocol adherence for each patient. This can be addressed using complexity-adjusted cut-offs and 'gradual adherence' based on the relative proportion of cut-off values achieved.
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Affiliation(s)
- Paul M Dahlke
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Christian Benzing
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Georg Lurje
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Thomas Malinka
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Nathanael Raschzok
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
| | - Can Kamali
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Safak Gül-Klein
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Karl H Hillebrandt
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Jens Neudecker
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, Charité–Universitätsmedizin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
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Sun BJ, Yue TM, Xu N, Fowler C, Lee B. Impact of Successful Implementation of an Enhanced Recovery After Surgery Protocol for Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2023; 30:8156-8165. [PMID: 37684372 DOI: 10.1245/s10434-023-14222-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/13/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) are complex operations for the treatment of peritoneal metastases. Enhanced recovery after surgery (ERAS) protocols are intended to standardize preoperative, intraoperative, and postoperative pathways, with the goal of improving patient care. This study describes feasibility and outcomes after implementing an ERAS protocol for CRS/HIPEC at a tertiary academic center. METHODS A single-institution experience of CRS/HIPEC was reviewed from January 2020 to March 2023. Patients were categorized according to whether they underwent CRS/HIPEC before or after ERAS initiation. Outcomes and protocol adherence were evaluated. RESULTS A total of 115 CRS/HIPEC operations were included-74 before and 41 after ERAS implementation. Median age was younger in the post-ERAS group, whereas sex, comorbidities, peritoneal carcinomatosis index, operation performed, and operative time were similar between groups. The most common primary cancer sites were gynecologic (40%), appendiceal (24%), and colorectal (22%). Adherence to all postoperative ERAS components was 76%. More post-ERAS patients ambulated by postoperative day (POD) 1 (90% vs. 54%; p < 0.001), tolerated liquid diet by POD 2 (88% vs. 32%; p < 0.001), and had foley removed by POD 3 (86% vs. 43%; p < 0.001). There was a trend toward decreased length of stay in the post-ERAS cohort (7 vs. 8 days; p = 0.092), with no difference in major complications, intensive care unit admission, or 30-day readmission. CONCLUSIONS Despite the heterogeneity of CRS/HIPEC operations, implementing an ERAS protocol for our patients was feasible and resulted in postoperative outcomes and adherence comparable with that of other major abdominal surgeries. This supports the potential for success in ERAS programs for CRS/HIPEC patients.
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Affiliation(s)
- Beatrice J Sun
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Tiffany M Yue
- Stanford University School of Medicine, Stanford, CA, USA
| | - Nova Xu
- Stanford University School of Medicine, Stanford, CA, USA
| | - Cedar Fowler
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Byrne Lee
- Department of Surgery, Section of Surgical Oncology, Stanford University School of Medicine, Stanford, CA, USA.
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Lyu Y, Wang B, Ye S, Chen J. Value of enhanced recovery after surgery in patients undergoing endoscopic retrograde cholangiopancreatography with intravenous anaesthesia for choledocholithiasis: a retrospective observational study. Wideochir Inne Tech Maloinwazyjne 2023; 18:487-493. [PMID: 37868287 PMCID: PMC10585471 DOI: 10.5114/wiitm.2023.130332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/11/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Enhanced recovery after surgery (ERAS) is rarely used in minimally invasive endoscopic surgery, especially in endoscopic retrograde cholangiopancreatography (ERCP). Aim This study evaluated the safety and efficacy of the ERAS protocol in patients undergoing ERCP for choledocholithiasis. Material and methods The study had a retrospective design and included patients with biliary tract stones who underwent ERCP between June 2019 and November 2022. Patients who received the ERAS protocol between June 2021 and November 2022 were enrolled as an ERAS group, and those who received traditional perioperative treatment between December 2019 and May 2021 were enrolled as a control group. Results A total of 349 patients were enrolled (ERAS group, n = 185; control group, n = 164). The cannulation and stone extraction success rates were significantly higher in the ERAS group than in the control group (p < 0.05). The incidence of postoperative pancreatitis was significantly lower in the ERAS group (p = 0.02), but there were no significant differences in other complications. The postoperative hospital stay was significantly shorter in the ERAS group than in the control group (p < 0.001), with no statistically significant differences in costs according to surgical period, or in total costs, between the 2 groups. Conclusions Application of the ERAS protocol is safe and feasible in patients undergoing ERCP for choledocholithiasis. The ERAS protocol can accelerate recovery, reduce postoperative pain, and shorten the hospital stay without increasing the cost of treatment.
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Affiliation(s)
- Yunxiao Lyu
- Department of Hepatobiliary Surgery, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang People's Hospital, Dongyang, Zhejiang, China
| | - Bin Wang
- Department of Hepatobiliary Surgery, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang People's Hospital, Dongyang, Zhejiang, China
| | - Shenjian Ye
- Department of Hepatobiliary Surgery, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang People's Hospital, Dongyang, Zhejiang, China
| | - Junmin Chen
- Department of Hepatobiliary Surgery, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang People's Hospital, Dongyang, Zhejiang, China
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