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Lv Q, Xiang YC, Qiu YY, Xiang Z. Safety and efficacy of the enhanced recovery after surgery protocol in hepatectomy for liver cancer. Clin Res Hepatol Gastroenterol 2024; 48:102493. [PMID: 39571193 DOI: 10.1016/j.clinre.2024.102493] [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: 06/28/2024] [Revised: 10/20/2024] [Accepted: 11/06/2024] [Indexed: 12/08/2024]
Abstract
PURPOSE The aim of this research was to evaluate the efficacy and safety of enhanced recovery after surgery (ERAS) protocol in hepatectomy patients with liver cancer. MATERIALS AND METHODS We searched three databases, including PubMed, Embase, and the Cochrane Library database, from inception to April 25, 2023. The outcomes were postoperative complications, and postoperative length of stay (PLOS). This study was performed by Stata (V. 16.0) software. RESULTS Twelve investigations involving 1,892 patients were included in this study. The ERAS group had lower overall postoperative complications [odds ratio (OR) = 0.49, I² = 54.89 %, 95 % confidence interval (CI) = 0.33-0.74, P = 0.00], postoperative Clavien-Dindo Grade 1-2 complications (OR = 0.39, I² = 55.14 %, 95 %CI = 0.23-0.69, P = 0.00), Clavien-Dindo Grade 3-4 complications (OR = 0.56, I² = 0.00 %, 95 %CI = 0.38-0.83, P = 0.00) , pneumonia (OR = 0.34, I² = 0.00 %, 95 %CI = 0.15-0.76, P = 0.01), ascites (OR = 0.25, I² = 0.00 %, 95 %CI = 0.09-0.68, P = 0.01), vomit (OR = 0.39, I² = 0.00 %, 95 %CI = 0.21-0.73, P = 0.00), intraoperative blood loss [mean difference (MD) = 1.69, I² = 0.00 %, 95 %CI = 1.15-2.47, P = 0.01], PLOS (MD = -0.42, I² = 94.87 %, 95 %CI = -0.86-0.03, P = 0.07), duration of abdominal drain (MD = -1.23, I² = 96.96 %, 95 %CI = -2.04 to -0.42, P = 0.00), and hospital readmission (OR = 0.44, I² = 0.00 %, 95 %CI = 0.23-0.85, P = 0.01) compared to the non-ERAS group. CONCLUSION For patients with liver cancer treated with ERAS. The ERAS protocol reduces the percentage of overall postoperative complications. Moreover, ERAS does not increase the rate of blood transfusions, hospital readmission, reoperation, or mortality.
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Affiliation(s)
- Quan Lv
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Ying-Chun Xiang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yan-Yu Qiu
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, China Academy of Medical Science & Peking Union Medical College, Beijing, , 100730, China
| | - Zheng Xiang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Chongqing Key Laboratory of Department of General Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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Spitzner A, Mieth M, Langan EA, Büchler MW, Michalski C, Billmann F. Influence of dental status on postoperative complications in major visceral surgical and organ transplantation procedures-the bellydent retrospective observational study. Langenbecks Arch Surg 2024; 409:284. [PMID: 39297959 PMCID: PMC11413042 DOI: 10.1007/s00423-024-03448-z] [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: 07/27/2024] [Accepted: 08/14/2024] [Indexed: 09/21/2024]
Abstract
PURPOSE The significance of dental status and oral hygiene on a range of medical conditions is well-recognised. However, the correlation between periodontitis, oral bacterial dysbiosis and visceral surgical outcomes is less well established. To this end, we study sought to determine the influence of dental health and oral hygiene on the rates of postoperative complications following major visceral and transplant surgery in an exploratory, single-center, retrospective, non-interventional study. METHODS Our retrospective non-interventional study was conducted at the Department of General, Visceral, and Transplant Surgery, University Hospital Heidelberg, Germany. Patients operated on between January 2018 and December 2019 were retrospectively enrolled in the study based on inclusion (minimum age of 18 years, surgery at our Department, intensive care / IMC treatment after major surgery, availability of patient-specific preoperative dental status assessment, documentation of postoperative complications) and exclusion criteria (minor patients or legally incapacitated patients, lack of intensive care or intermediate care (IMC) monitoring, incomplete documentation of preoperative dental status, intestinal surgery with potential intraoperative contamination of the site by intestinal microbes, pre-existing preoperative infection, absence of data regarding the primary endpoints of the study). The primary study endpoint was the incidence of postoperative complications. Secondary study endpoints were: 30-day mortality, length of hospital stay, duration of intensive care stay, Incidence of infectious complications, the microbial spectrum of infectious complication. A bacteriology examination was added whenever possible (if and only if the examination was safe for the patient)for infectious complications. RESULTS The final patient cohort consisted of 417 patients. While dental status did not show an influence (p = 0.73) on postoperative complications, BMI (p = 0.035), age (p = 0.049) and quick (p = 0.033) were shown to be significant prognostic factors. There was significant association between oral health and the rate of infectious complications for all surgical procedures (p = 0.034), excluding transplant surgery. However, this did not result in increased 30-day mortality rates, prolonged intensive care unit treatment or an increase in the length of hospital stay (LOS) for the cohort as a whole. In contrast there was a significant correlation between the presence of oral pathogens and postoperative complications for a group as a whole (p < 0.001) and the visceral surgery subgroup (p < 0.001). Whilst this was not the case in the cohort who underwent transplant surgery, there was a correlation between oral health and LOS in this subgroup (p = 0.040). Bacterial swabs supports the link between poor oral health and infectious morbidity. CONCLUSIONS Dental status was a significant predictor of postoperative infectious complications in this visceral surgery cohort. This study highlights the importance preoperative dental assessment and treatment prior to major surgery, particularly in the case of elective surgical procedures. Further research is required to determine the effect of oral health on surgical outcomes in order to inform future practice. TRIAL REGISTRATION Trial registered under the ethics-number S-082/2022 (Ethic Committee of the University Heidelberg).
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Affiliation(s)
- Anastasia Spitzner
- Praxis Dr. Dietmar Czech, Marktplatz 15, 16, 89073, Ulm, Germany
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Markus Mieth
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Ewan A Langan
- Department of Dermatology and Venerology, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
- Dermatological Sciences, University of Manchester, Manchester, UK
| | - Markus W Büchler
- Botton-Champalimaud Pancreatic Cancer Center, Champalimaud Foundation, Avenida Brasília, 1400-038, Lisboa, Portugal
| | - Christoph Michalski
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Franck Billmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
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Martensen AK, Moen EV, Brock C, Funder JA. Postoperative ileus-Establishing a porcine model. Neurogastroenterol Motil 2024; 36:e14872. [PMID: 39138548 DOI: 10.1111/nmo.14872] [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: 09/08/2023] [Revised: 03/05/2024] [Accepted: 07/11/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Postoperative ileus (POI), characterized by absent gastrointestinal motility, is a frequent complication following major abdominal surgery, with no current effective treatment possibilities. For further research in the treatment of this condition, we aimed to establish a porcine model of POI. METHODS A total of 12 Landrace pigs, weighing 60 kg, were included. Five animals were used as pilots to establish the surgical procedure, five animals received the same reproducible surgical procedure developed in the pilot experiments, while two animals were used as control. The primary endpoint was number of days to first stool. Intestinal motility was monitored using the SmartPill system. KEY RESULTS Four of the five pigs who underwent the final surgical procedure passed first stool on the third postoperative day (POD), and one passed first stool on the fifth POD. SmartPill data showed retention of the capsule in the stomach in four of five pigs with usable traces. CONCLUSION AND INFERENCES An experimental porcine model of POI was established, forming the basis for future studies in POI.
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Affiliation(s)
- A K Martensen
- Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
- Institute of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - E V Moen
- Department of Internal Medicine Viborg, Regional Hospital Viborg, Viborg, Denmark
| | - C Brock
- Mech-Sense, Aalborg University Hospital, Aalborg, Denmark
| | - J A Funder
- Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
- Institute of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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Dugan MM, Ross S, Christodoulou M, Pattilachan TM, Flores JA, Rosemurgy A, Sucandy I. Hospital readmissions after robotic hepatectomy for neoplastic disease: Analysis of risk factors, survival, and economical impact. A logistical regression and propensity score matched study. Am J Surg 2024; 234:92-98. [PMID: 38519401 DOI: 10.1016/j.amjsurg.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/04/2024] [Accepted: 03/10/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND As the first comprehensive investigation into hospital readmissions following robotic hepatectomy for neoplastic disease, this study aims to fill a critical knowledge gap by evaluating risk factors associated with readmission and their impact on survival and the financial burden. METHODS The study analyzed a database of robotic hepatectomy patients, comparing readmitted and non-readmitted individuals post-operatively using 1:1 propensity score matching. Statistical methods included Chi-square, Mann-Whitney U, T-test, binomial logistic regression, and Kaplan-Meier analysis. RESULTS Among 244 patients, 44 were readmitted within 90 days. Risk factors included hypertension (p = 0.01), increased Child-Pugh score (p < 0.01), and R1 margin status (p = 0.05). Neoadjuvant chemotherapy correlated with lower readmission risk (p = 0.045). Readmissions didn't significantly impact five-year survival (p = 0.42) but increased fixed indirect hospital costs (p < 0.01). CONCLUSIONS Readmission post-robotic hepatectomy correlates with hypertension, higher Child-Pugh scores, and R1 margins. The use of neoadjuvant chemotherapy was associated with a lower admission rate due to less diffuse liver disease in these patients. While not affecting survival, readmissions elevate healthcare costs.
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Affiliation(s)
- Michelle M Dugan
- Florida Atlantic University Schmidt College of Medicine, USA; Digestive Health Institute AdventHealth Tampa, USA
| | - Sharona Ross
- Digestive Health Institute AdventHealth Tampa, USA
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Thierry G, Beck F, Hardy PY, Kaba A, Blanjean A, Vandermeulen M, Honoré P, Joris J, Bonhomme V, Detry O. Impact of enhanced recovery program implementation on postoperative outcomes after liver surgery: a monocentric retrospective study. Surg Endosc 2024; 38:3253-3262. [PMID: 38653900 DOI: 10.1007/s00464-024-10796-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/10/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION It is still unclear whether enhanced recovery programs (ERPs) reduce postoperative morbidity after liver surgery. This study investigated the effect on liver surgery outcomes of labeling as a reference center for ERP. MATERIALS AND METHODS Perioperative data from 75 consecutive patients who underwent hepatectomy in our institution after implementation and labeling of our ERP were retrospectively compared to 75 patients managed before ERP. Length of hospital stay, postoperative complications, and adherence to protocol were examined. RESULTS Patient demographics, comorbidities, and intraoperative data were similar in the two groups. Our ERP resulted in shorter length of stay (3 days [1-6] vs. 4 days [2-7.5], p = 0.03) and fewer postoperative complications (24% vs. 45.3%, p = 0.0067). This reduction in postoperative morbidity can be attributed exclusively to a lower rate of minor complications (Clavien-dindo grade < IIIa), and in particular to a lower rate of postoperative ileus, after labeling. (5.3% vs. 25.3%, p = 0.0019). Other medical and surgical complications were not significantly reduced. Adherence to protocol improved after labeling (17 [16-18] vs. 14 [13-16] items, p < 0.001). CONCLUSIONS The application of a labeled enhanced recovery program for liver surgery was associated with a significant shortening of hospital stay and a halving of postoperative morbidity, mainly ileus.
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Affiliation(s)
- Gabriel Thierry
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium.
- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE ; Francophone Group for Enhanced Recovery After Surgery), Beaumont, France.
- Inflammation and Enhanced Rehabilitation Laboratory (Regional Anesthesia and Analgesia), GIGA-I3 Thematic Unit, GIGA-Research, Liege University, Liege, Belgium.
- CREDEC: Centre de Recherche et d'Enseignement du Département de Chirurgie GIGA Metabolism, University of Liege, Domaine du Sart Tilman, Liege, Belgium.
| | - Florian Beck
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Anesthesia and Perioperative Neuroscience Laboratory, GIG-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Pierre-Yves Hardy
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE ; Francophone Group for Enhanced Recovery After Surgery), Beaumont, France
- Inflammation and Enhanced Rehabilitation Laboratory (Regional Anesthesia and Analgesia), GIGA-I3 Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Abdourahamane Kaba
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Inflammation and Enhanced Rehabilitation Laboratory (Regional Anesthesia and Analgesia), GIGA-I3 Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Arielle Blanjean
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE ; Francophone Group for Enhanced Recovery After Surgery), Beaumont, France
| | - Morgan Vandermeulen
- Department of Abdominal Surgery and Transplantation, Liege University Hospital, Liege, Belgium
- CREDEC: Centre de Recherche et d'Enseignement du Département de Chirurgie GIGA Metabolism, University of Liege, Domaine du Sart Tilman, Liege, Belgium
| | - Pierre Honoré
- Department of Abdominal Surgery and Transplantation, Liege University Hospital, Liege, Belgium
| | - Jean Joris
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE ; Francophone Group for Enhanced Recovery After Surgery), Beaumont, France
| | - Vincent Bonhomme
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Anesthesia and Perioperative Neuroscience Laboratory, GIG-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, Liege University Hospital, Liege, Belgium
- CREDEC: Centre de Recherche et d'Enseignement du Département de Chirurgie GIGA Metabolism, University of Liege, Domaine du Sart Tilman, Liege, Belgium
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Rao SJ, Solsky I, Gunawan A, Shen P, Levine E, Clark CJ. Phase 1 randomized trial of inpatient high-intensity interval training after major surgery. J Gastrointest Surg 2024; 28:528-533. [PMID: 38583906 DOI: 10.1016/j.gassur.2024.01.020] [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: 10/31/2023] [Revised: 01/03/2024] [Accepted: 01/13/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND High-intensity interval training (HIT) can provide physiologic benefits and may improve postoperative recovery but has not been evaluated in inpatients. This study aimed to evaluate the safety and tolerability of HIT after major surgery. METHODS We performed a phase I randomized study comparing HIT with low-intensity continuous ambulation (40 m) during the initial inpatient stay after major surgery at a large academic center. Clinicopathologic and pre- and post-exercise physiologic data were captured. Perceived exertion was measured throughout the intervention. RESULTS Twenty-two subjects were enrolled and randomized with 90% (20 subjects, 10 per arm) completing all aspects of the study. One patient declined participation in the exercise intervention. The HIT and continuous ambulation groups were relatively similar in terms of median age (65.5 vs 63.5), female sex (20% vs 40%), White race (90% vs 90%), having a cancer diagnosis (100% vs 80%), undergoing gastrointestinal surgery (60% vs 80%), median Karnofsky score (60 vs 60), and ability to independently ambulate preoperatively (100% vs 90%). All subjects completed the exercise without protocol deviation, cohort crossover, or safety events. Compared with the continuous ambulation group, the HIT group had higher end median perceived exertion (5.0 [IQR, 5.5] vs 3.0 [IQR, 1.8]), shorter overall time to complete assigned exercise (56.6 seconds vs 91.8 seconds), and a trend toward higher median gait speed over 40 m (0.71 m/s vs 0.44 m/s, P = .126). CONCLUSION HIT in the hospitalized postoperative patient is safe and may be implemented to help promote positive physiologic outcomes and recovery.
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Affiliation(s)
- Shambavi J Rao
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina, United States
| | - Ian Solsky
- Atrium Health Wake Forest Baptist, Division of Surgical Oncology, Winston-Salem, North Carolina, United States
| | - Antonius Gunawan
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina, United States
| | - Perry Shen
- Atrium Health Wake Forest Baptist, Division of Surgical Oncology, Winston-Salem, North Carolina, United States
| | - Edward Levine
- Atrium Health Wake Forest Baptist, Division of Surgical Oncology, Winston-Salem, North Carolina, United States
| | - Clancy J Clark
- Atrium Health Wake Forest Baptist, Division of Surgical Oncology, Winston-Salem, North Carolina, United States.
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Voigt KR, de Graaff MR, Verhoef C, Kazemier G, Swijneburg RJ, Mieog JSD, Derksen WJM, Buis CI, Gobardhan PD, Dulk MD, van Dam RM, Liem MSL, Leclercq WKG, Bosscha K, Belt EJT, Vermaas M, Kok NFM, Patijn GA, Marsman HM, van den Boezem PB, Klaase JM, Grünhagen DJ. Association of modified textbook outcome and overall survival after surgery for colorectal liver metastases: A nationwide analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107972. [PMID: 38278128 DOI: 10.1016/j.ejso.2024.107972] [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: 12/12/2023] [Accepted: 01/16/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Textbook outcome (TO) represents a multidimensional quality measurement, encompassing the desirable short-term outcomes following surgery. This study aimed to investigate whether achieving TO after resection of colorectal liver metastases (CRLM) surgery is related to better overall survival (OS) in a national cohort. METHOD Data was retrieved from the Dutch Hepato Biliary Audit. A modified definition of TO (mTO) was used because readmissions were only recorded from 2019. mTO was achieved when no severe postoperative complications, mortality, prolonged length of hospital stay, occurred and when adequate surgical resection margins were obtained. To compare outcomes of patients with and without mTO and reduce baseline differences between both groups propensity score matching (PSM) was used for patients operated on between 2014 and 2018. RESULTS Out of 6525 eligible patients, 81 % achieved mTO. For the cohort between 2014 and 2018, those achieving mTO had a 5-year OS of 46.7 % (CI 44.8-48.6) while non-mTO patients had a 5-year OS of 33.7 % (CI 29.8-38.2), p < 0.001. Not achieving mTO was associated with a worse OS (aHR 1.34 (95 % CI 1.17-1.53), p < 0.001. Median follow-up was 76 months., PSM assigned 519 patients to each group. In the PSM cohort patients achieving mTO, 5-year OS was 43.6 % (95 % CI 39.2-48.5) compared to 36.4 % (95 % CI 31.9-41.2) in patients who did not achieve mTO, p = 0.006. CONCLUSION Achieving mTO is associated with improved long-term survival. This emphasizes the importance of optimising perioperative care and reducing postoperative complications in surgical treatment of CRLM.
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Affiliation(s)
- Kelly R Voigt
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Michelle R de Graaff
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, the Netherlands; Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Rutger J Swijneburg
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Wouter J M Derksen
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Carlijn I Buis
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, the Netherlands
| | - Paul D Gobardhan
- Department of Surgery, Amphia Medical Centre, Breda, the Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands; Nutrim - School of Nutrition and Translational Research in Metabolism, Maastricht University, the Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mike S L Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | | | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's, Hertogenbosch, the Netherlands
| | - Eric J T Belt
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Maarten Vermaas
- Department of Surgery, IJsselland Hospital, Capelle Aan de Ijssel, the Netherlands
| | - Niels F M Kok
- Department of Surgery, Antoni van Leeuwenhoek - Dutch Cancer Institute, Amsterdam, the Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala, Zwolle, the Netherlands
| | - H M Marsman
- Department of Surgery, Onze Lieve Vrouwen Hospital, Amsterdam, the Netherlands
| | | | - Joost M Klaase
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, the Netherlands
| | - Dirk J Grünhagen
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
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Qi W, Dai J, Qiu Z, Wu Y, Wen T, Xie F, Gao F, Zhang Y, Li C. Nomogram to predict liver surgery-specific complications for hepatocellular carcinoma: A multicenter study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107119. [PMID: 37871467 DOI: 10.1016/j.ejso.2023.107119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 10/05/2023] [Accepted: 10/16/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND Early identification of patients at risk for surgical complications enables surgeons to make better treatment decisions and optimize resource utilization. We propose to develop a nomogram for predicting the risk of moderate-to-severe liver surgery-specific complications after hepatectomy in hepatocellular carcinoma (HCC) patients. METHODS We retrospectively enrolled HCC patients who underwent radical hepatectomy at four medical centers from January 2014 to January 2019 in southwestern China, randomly (7:3) divided into training and validation cohorts. We used least absolute shrinkage and selection operator (LASSO) logistic regression to build a nomogram model. RESULTS The nomogram model contained 6 variables: diabetes mellitus (yes vs. no, OR: 2.32, 95% CI: 1.16-4.64, P = 0.02), major hepatectomy (yes vs. no, OR: 2.65, 95% CI: 1.64-4.27, P < 0.001), platelets (PLT, ≥100 × 103/μl vs. <100 × 103/μl, OR: 0.53, 95% CI: 0.33-0.87, P = 0.01), prothrombin time (PT, >13 s vs. ≤13 s, OR: 1.78, 95% CI: 1.04-3.05, P = 0.04), albumin-indocyanine green evaluation grade (ALICE grade, grade B vs. grade A, OR: 2.06, 95% CI: 1.17-3.61, P = 0.01), and prognostic nutrient index (PNI, >48 vs. ≤48, OR: 0.55, 95% CI: 0.33-0.92, P = 0.02). The concordance index (C-index) and area under the receiver operating characteristic curve (AUC) were 0.751 (95% CI, 0.703-0.799) and 0.743 (95% CI, 0.653-0.833) for the training and validation cohorts, respectively. Decision curve analysis (DCA) showed that the nomogram had good clinical value. CONCLUSION We provide good preoperative predictors for the risk of moderate-to-high FABIB score complications in patients with HBV-related HCC posthepatectomy.
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Affiliation(s)
- Weili Qi
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Junlong Dai
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Zhancheng Qiu
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Youwei Wu
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Tianfu Wen
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Fei Xie
- Department of Hepatopancreatobiliary Surgery, Neijiang First People's Hospital, Neijiang, 641000, China
| | - Fengwei Gao
- HBPS Diseases Center for Diagnosis and Treatment of Leshan City, People's Hospital of Leshan, Leshan, 6140000, Sichuan Province, China
| | - Yu Zhang
- Organ Transplantation Center, Sichuan Provincial People's Hospital, Chengdu, 610072, Sichuan Province, China
| | - Chuan Li
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Uchino H, Nguyen-Powanda P, Tokuno J, Kouyoumdjian A, Fiore JF, Grushka J. Enhanced recovery protocols in trauma and emergency abdominal surgery: a scoping review. Eur J Trauma Emerg Surg 2023; 49:2401-2412. [PMID: 37505285 DOI: 10.1007/s00068-023-02337-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE Enhanced recovery protocols (ERP) have been shown to improve patient outcomes and is now regarded as standard of care in elective surgical setting. However, the literature addressing the use of ERP in trauma and emergency abdominal surgery (EAS) is limited and heterogenous. A scoping review was conducted to comprehensively assess the literature on ERP in trauma laparotomy and EAS. METHODS Three bibliographic databases were searched for studies addressing ERP in trauma laparotomy and EAS. We extracted the study characteristics including study design, country, year, surgical procedures, ERP components used, and outcomes. Reporting was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. RESULTS After screening of 1631 articles for eligibility, 39 studies were included in the review. There has been an increase in the number of articles in the field, with 44% of the identified studies published between 2020 and 2022. Fourteen different protocols were identified, with varying components for each operative phase (preoperative; 29, intraoperative; 20, postoperative; 27). The majority of the studies addressed the effectiveness of ERP on clinical outcomes (31/39: 79%). Only two studies (5%) included purely trauma populations. CONCLUSIONS Studies on ERP implementations in the EAS populations were published across a range of countries, with improved outcomes. However, a clear gap in ERP research on trauma laparotomy was identified. This scoping review indicates that standardization of care through ERP implementation has potential to improve the quality of care in both EAS and trauma laparotomy.
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Affiliation(s)
- Hayaki Uchino
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada.
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada.
| | - Philip Nguyen-Powanda
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Junko Tokuno
- Steinberg Centre for Simulation and Interactive Learning, McGill University, Montreal, QC, Canada
| | - Araz Kouyoumdjian
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada
| | - Julio F Fiore
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Jeremy Grushka
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada
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10
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El-Kefraoui C, Do U, Miller A, Kouyoumdjian A, Cui D, Khorasani E, Landry T, Amar-Zifkin A, Lee L, Feldman LS, Fiore JF. Impact of enhanced recovery pathways on patient-reported outcomes after abdominal surgery: a systematic review. Surg Endosc 2023; 37:8043-8056. [PMID: 37474828 DOI: 10.1007/s00464-023-10289-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 07/05/2023] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Evidence supports that enhanced recovery pathways (ERPs) reduce length of stay and complications; however, these measures may not reflect the perspective of patients who are the main stakeholders in the recovery process. This systematic review aimed to appraise the evidence regarding the impact of ERPs on patient-reported outcomes (PROs) after abdominal surgery. METHODS Five databases (Medline, Embase, Biosis, Cochrane, and Web of Science) were searched for randomized controlled trials (RCTs) addressing the impact of ERPs on PROs after abdominal surgery. We focused on distinct periods of recovery: early (within 7 days postoperatively) and late (beyond 7 days). Risk of bias was assessed using Cochrane's RoB 2.0. Results were appraised descriptively as heterogeneity hindered meta-analysis. Certainty of evidence was evaluated using GRADE. RESULTS Fifty-six RCTs were identified [colorectal (n = 18), hepatopancreaticobiliary (HPB) (n = 11), upper gastrointestinal (UGI) (n = 10), gynecological (n = 7), urological (n = 7), general surgery (n = 3)]. Most trials had 'some concerns' (n = 30) or 'high' (n = 25) risk of bias. In the early postoperative period, ERPs improved patient-reported general health (colorectal, HPB, UGI, urological; very low to low certainty), physical health (colorectal, gynecological; very low to low certainty), mental health (colorectal, gynecological; very low certainty), pain (all specialties; very low to moderate certainty), and fatigue (colorectal; low certainty). In the late postoperative period, ERPs improved general health (HPB, UGI, urological; very low certainty), physical health (UGI, gynecological, urological; very low to low certainty), mental health (UGI, gynecological, urological; very low certainty), social health (gynecological; very low certainty), pain (gynecological, urological; very low certainty), and fatigue (gynecological; very low certainty). CONCLUSION This review supports that ERPs may have a positive impact on patient-reported postoperative health status (i.e., general, physical, mental, and social health) and symptom experience (i.e., pain and fatigue) after abdominal surgery; however, data were largely derived from low-quality trials. Although these findings contribute important knowledge to inform evidence-based ERP implementation, there remains a great need to improve PRO assessment in studies focused on postoperative recovery.
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Affiliation(s)
- Charbel El-Kefraoui
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Uyen Do
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Andrew Miller
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Araz Kouyoumdjian
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - David Cui
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON, Canada
| | - Elahe Khorasani
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Tara Landry
- Bibliothèque de la Santé, Université de Montréal, Montreal, QC, Canada
- Medical Libraries, McGill University Health Centre, Montreal, QC, Canada
| | | | - Lawrence Lee
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Liane S Feldman
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Julio F Fiore
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada.
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
- Department of Surgery, McGill University, Montreal, QC, Canada.
- Montreal General Hospital, 1650 Cedar Ave, R2-104, Montreal, QC, H3G 1A4, Canada.
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11
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Bedewy A, El-Kassas M. Anesthesia in patients with chronic liver disease: An updated review. Clin Res Hepatol Gastroenterol 2023; 47:102205. [PMID: 37678609 DOI: 10.1016/j.clinre.2023.102205] [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: 04/24/2023] [Revised: 08/18/2023] [Accepted: 09/04/2023] [Indexed: 09/09/2023]
Abstract
Anesthesia in chronic liver disease patients can be challenging because of the medications given or interventions performed and their effects on liver physiology. Also, the effects of liver disease on coagulation and metabolism should be considered carefully. This review focuses on anesthesia in patients with different chronic liver disease stages. A literature search was performed for Scopus and PubMed databases for articles discussing different types of anesthesia in patients with chronic liver disease, their safety, usage, and risks. The choice of anesthesia is of crucial importance. Regional anesthesia, especially neuroaxial anesthesia, may benefit some patients with liver disease, but coagulopathy should be considered. Regional anesthesia provides optimum intraoperative relaxation and analgesia that extends to the postoperative period while avoiding the side effects of intravenous anesthetics and opioids. Pharmacodynamics and pharmacokinetics of anesthetic medications must guard against complications related to overdose or decreased metabolism. The choice of anesthesia in chronic liver disease patients is crucial and could be tailored according to the degree of liver compensation and the magnitude of the surgical procedure.
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Affiliation(s)
- Ahmed Bedewy
- Anesthesia and Surgical Intensive Care Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Postal Code: 11795, Cairo, Egypt.
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12
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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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13
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Lambert J, Mair T, Arujunan K, Shugaba A, Uwadiae H, Livesey A, Ahmad R, Sgourakis G, Gaffney C, Subar D. The effect of the enhanced recovery programme on long-term survival following liver resection for colorectal liver metastases. Langenbecks Arch Surg 2023; 408:239. [PMID: 37337084 PMCID: PMC10279559 DOI: 10.1007/s00423-023-02968-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Enhanced recovery programmes are associated with improved short-term outcomes following liver surgery. The impact of enhanced recovery programmes on medium- and long-term outcomes is incompletely understood. This study aimed to assess the impact of an enhanced recovery programme on long-term survival in patients undergoing surgery for colorectal liver metastases. METHODS At a tertiary hepatobiliary centre, we analysed short-, medium- and long-term outcomes in consecutive patients undergoing liver resection for colorectal liver metastases. A five-year retrospective review was carried out comparing the enhanced recovery programme to standard care. RESULTS A total of 172 patients were included in the analysis: 87 on standard care and 85 on an enhanced recovery programme. Open surgery was performed in 122 patients: 74 (85.1%) and 48 (56.5%) patients in the standard care and enhanced recovery programme, respectively (p < 0.001). There was a significant reduction in the median (IQR) length of hospital stay in the enhanced recovery programme compared with standard care (7 (5) days vs. 8 (3) days, p = 0.0009). There was no significant difference in survival between standard care and the Enhanced Recovery Programme at one (p = 0.818), three (p = 0.203), and five years (p = 0.247). CONCLUSION An enhanced recovery programme was associated with a reduced length of hospital stay. There was no effect on the one-, three- and five-year survival.
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Affiliation(s)
- Joel Lambert
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
- Lancaster Medical School, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT, UK
| | - Thomas Mair
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
| | - Kalaiyarasi Arujunan
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
| | - Abdulwarith Shugaba
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
- Lancaster Medical School, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT, UK
| | - Harmony Uwadiae
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
| | - Anne Livesey
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
| | - Rami Ahmad
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
| | - Georgios Sgourakis
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
| | - Christopher Gaffney
- Lancaster Medical School, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT, UK.
| | - Daren Subar
- BRIDGES Research Group, Department of General and Hepatopancreatobiliary Surgery, East Lancashire Teaching Hospitals NHS Trust, Blackburn, BB2 3HH, UK
- Lancaster Medical School, Health Innovation One, Sir John Fisher Drive, Lancaster University, Lancaster, LA1 4AT, UK
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14
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Ravaioli F, De Maria N, Di Marco L, Pivetti A, Casciola R, Ceraso C, Frassanito G, Pambianco M, Pecchini M, Sicuro C, Leoni L, Di Sandro S, Magistri P, Menozzi R, Di Benedetto F, Colecchia A. From Listing to Recovery: A Review of Nutritional Status Assessment and Management in Liver Transplant Patients. Nutrients 2023; 15:2778. [PMID: 37375682 DOI: 10.3390/nu15122778] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/04/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
Liver transplantation (LT) is a complex surgical procedure requiring thorough pre- and post-operative planning and care. The nutritional status of the patient before, during, and after LT is crucial to surgical success and long-term prognosis. This review aims to assess nutritional status assessment and management before, during, and after LT, with a focus on patients who have undergone bariatric surgery. We performed a comprehensive topic search on MEDLINE, Ovid, In-Process, Cochrane Library, EMBASE, and PubMed up to March 2023. It identifies key factors influencing the nutritional status of liver transplant patients, such as pre-existing malnutrition, the type and severity of liver disease, comorbidities, and immunosuppressive medications. The review highlights the importance of pre-operative nutritional assessment and intervention, close nutritional status monitoring, individualised nutrition care plans, and ongoing nutritional support and monitoring after LT. The review concludes by examining the effect of bariatric surgery on the nutritional status of liver transplant recipients. The review offers valuable insights into the challenges and opportunities for optimising nutritional status before, during, and after LT.
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Affiliation(s)
- Federico Ravaioli
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Nicola De Maria
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Lorenza Di Marco
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Alessandra Pivetti
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Riccardo Casciola
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Carlo Ceraso
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Gabriella Frassanito
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Martina Pambianco
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Maddalena Pecchini
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Chiara Sicuro
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
| | - Laura Leoni
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Renata Menozzi
- Division of Metabolic Diseases and Clinical Nutrition, Department of Specialistic Medicines, University Hospital of Modena and Reggio Emilia, Largo del Pozzo 71, 41125 Modena, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Antonio Colecchia
- Gastroenterology Unit, Department of Medical Specialties, University Hospital of Modena, University of Modena & Reggio Emilia, 41121 Modena, Italy
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15
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Chen X, Zhou H, Gao J, Shi Y, Yu J, Zhang Y. External validation of postoperative nausea and vomiting risk scores in patients with liver cancer: A single-centre prospective cohort study. Eur J Oncol Nurs 2023; 65:102350. [PMID: 37321132 DOI: 10.1016/j.ejon.2023.102350] [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: 03/09/2023] [Revised: 05/01/2023] [Accepted: 05/21/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVES This study aimed to test the external validity of postoperative nausea and vomiting (PONV) risk assessment tools in patients undergoing hepatectomy, and to guide healthcare professionals' assessment of postoperative patients. BACKGROUND The identification of PONV risk is particularly important in the context of prevention. However, the predictive performance of the current PONV risk scores has not been confirmed in patients with liver cancer, and its applicability is still unknown. These uncertainties pose difficulties in performing routine risk assessment of PONV for patients with liver cancer in a clinical practice setting. METHODS Patients diagnosed with liver cancer and undergoing hepatectomy were prospectively consecutively recruited. All enrolled patients received PONV assessments and PONV risk assessments via the Apfel risk score and the Koivuranta risk score. Receiver operating characteristic curves (ROC curves) and calibration curves were used to assess the external validity. This study was reported according to the TRIPOD Checklist. RESULTS Among 214 PONV-assessed patients, 114 patients (53.3%) developed PONV. For the Apfel simplified risk score, the ROC area was 0.612 (95% confidence interval [CI]: 0.543-0.678) in the validation dataset, which demonstrated imperfect discrimination; the calibration curve showed poor calibration with a slope of 0.49. For the Koivuranta score, the ROC area was 0.628 (CI: 0.559-0.693) in the validation dataset, which showed limited discrimination; the calibration curve indicated an unsatisfactory calibration with a slope of 0.71. CONCLUSIONS The Apfel risk score and the Koivuranta risk score were not well validated in our study and disease-specific risk factors should be taken into account when updating or developing PONV risk stratification instruments.
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Affiliation(s)
- Xiao Chen
- Department of Nursing, Zhongshan Hospital of Fudan University, Shanghai, 200032, People's Republic of China.
| | - Haiying Zhou
- Department of Nursing, Zhongshan Hospital of Fudan University, Shanghai, 200032, People's Republic of China.
| | - Jian Gao
- Department of Biostatistics, Zhongshan Hospital of Fudan University, Shanghai, 200032, People's Republic of China.
| | - Yinghong Shi
- Department of Liver Disease, Zhongshan Hospital of Fudan University, Shanghai, 200032, People's Republic of China.
| | - Jingxian Yu
- Department of Nursing, Zhongshan Hospital of Fudan University, Shanghai, 200032, People's Republic of China.
| | - Yuxia Zhang
- Department of Nursing, Zhongshan Hospital of Fudan University, Shanghai, 200032, People's Republic of China.
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16
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Ye H, Wu H, Li B, Zuo P, Chen C. Application of cardiovascular interventions to decrease blood loss during hepatectomy: a systematic review and meta-analysis. BMC Anesthesiol 2023; 23:89. [PMID: 36949393 PMCID: PMC10032024 DOI: 10.1186/s12871-023-02042-y] [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: 11/07/2022] [Accepted: 03/13/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Perioperative bleeding and allogeneic blood transfusion are generally thought to affect the outcomes of patients. This meta-analysis aimed to determine the benefits and risks of several cardiovascular interventions in patients undergoing hepatectomy. METHODS In this systematic review and meta-analysis, randomised controlled trials (RCTs) were searched in the Cochrane Library, Medline, Embase, and Web of Science to February 02, 2023. RCTs focused on cardiovascular interventions aimed at reducing blood loss or blood transfusion requirements during hepatectomy were included. The primary outcomes were perioperative blood loss amount, number of patients requiring allogeneic blood transfusion and overall occurrence of postoperative complications. The secondary outcomes were operating time, perioperative mortality rate, postoperative liver and kidney function and length of hospital stay. RESULTS Seventeen RCTs were included in the analysis. A total of 841 patients who underwent hepatectomy in 10 trials were included in the comparative analysis between low central venous pressure (CVP) and control groups. The forest plots showed a low operative bleeding volume [(mean difference (MD): -409.75 mL, 95% confidence intervals (CI) -616.56 to -202.94, P < 0.001], reduced blood transfusion rate [risk ratio (RR): 0.47, 95% CI 0.34 to 0.65, P < 0.001], shortened operating time (MD: -13.42 min, 95% CI -22.59 to -4.26, P = 0.004), and fewer postoperative complications (RR: 0.76, 95% CI 0.58 to 0.99, P = 0.04) in the low CVP group than in the control group. Five and two trials compared the following interventions, respectively: 'acute normovolaemic haemodilution (ANH) vs control' and 'autologous blood donation vs control'. ANH and autologous blood donation could not reduce the blood loss amount but greatly decreased the number of patients requiring allogeneic blood transfusion. No benefits were found in the rate of mortality and length of postoperative hospital stay in any of the comparisons. CONCLUSION Lowering the CVP seems to be effective and safe in adult patients undergoing hepatectomy. ANH and autologous blood donation should be used as a part of blood management for suitable patients in certain circumstances. TRIAL REGISTRATION PROSPERO, CRD42022314061.
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Affiliation(s)
- Hui Ye
- Department of Anesthesiology, ZhongDa Hospital, Southeast University, No. 87 Dingjiaqiao, Gulou District, Nanjing, Jiangsu Province, 210009, China.
| | - Hanghang Wu
- Department of Immunology, Ophthalmology and ENT, School of Medicine, Complutense University, Madrid, Spain
| | - Bin Li
- Department of Anesthesiology, ZhongDa Hospital, Southeast University, No. 87 Dingjiaqiao, Gulou District, Nanjing, Jiangsu Province, 210009, China
| | - Pengfei Zuo
- Department of Cardiology, ZhongDa Hospital, Southeast University, Nanjing, China
| | - Chaobo Chen
- Department of General Surgery, Xishan People's Hospital of Wuxi city, No. 1128 Dacheng Road, Xishan District, Wuxi, 214105, China.
- Department of Hepatic-Biliary-Pancreatic Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China.
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17
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Hackl F, Nazemian R, Saeed A, Cheah YL, Kaufman MD. Anesthesia and Enhanced Recovery for Robotic Living Donor Hepatectomy – A Narrative Review. JOURNAL OF LIVER TRANSPLANTATION 2023. [DOI: 10.1016/j.liver.2023.100148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
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18
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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: 1.0] [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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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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Arfa S, Turco C, Lakkis Z, Bourgeois S, Fouet I, Evrard P, Sennegon E, Roucoux A, Paquette B, Devaux B, Rietsch-Koenig A, Heyd B, Doussot A. Delayed return of gastrointestinal function after hepatectomy in an ERAS program: incidence and risk factors. HPB (Oxford) 2022; 24:1560-1568. [PMID: 35484074 DOI: 10.1016/j.hpb.2022.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/17/2022] [Accepted: 03/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Delayed return of gastrointestinal function (DGIF) after hepatectomy can involve increased morbidity and prolonged hospital stay. Yet, data on incidence and risks factors are lacking. METHODS All consecutive patients who underwent hepatectomy between June 2018 and December 2020 were included. All patients were included in an enhanced recovery after surgery (ERAS) program. DGIF was defined by the need for nasogastric tube (NGT) insertion after surgery. DGIF risk factors were identified. RESULTS Overall, 206 patients underwent hepatectomy. DGIF occurred in 41 patients (19.9%) after a median time of 2 days (range, 1-14). Among them, 6 patients (14.6%) developed aspiration pneumonia, of which one required ICU for mechanical ventilation. DGIF developed along with an intraabdominal complication in 7 patients (biliary fistula, n = 5; anastomotic fistula, n = 1; adhesive small bowel obstruction, n = 1). DGIF was associated with significantly increased severe morbidity rate (p = 0.001), prolonged time to normal food intake (p < 0.001) and hospital stay (p < 0.001) and significantly decreased overall compliance rate (p = 0.001). Independent risk factors of DGIF were age (p < 0.001), vascular reconstruction (p = 0.007), anaesthetic induction using volatiles (p = 0.003) and epidural analgesia (p = 0.004). Using these 4 variables, a simple DGIF risk score has been developed allowing patient stratification in low-, intermediate- and high-risk groups. CONCLUSION DGIF after hepatectomy was frequently observed and significantly impacted postoperative outcomes. Identifying risk factors remains critical for preventing its occurrence.
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Affiliation(s)
- Sara Arfa
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Célia Turco
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Zaher Lakkis
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Sandrine Bourgeois
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Isabelle Fouet
- Department of Anesthesiology and Intensive Care Medicine. CHU Besançon, France
| | - Philippe Evrard
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Elise Sennegon
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Alexandra Roucoux
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Brice Paquette
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Bénédicte Devaux
- Department of Anesthesiology and Intensive Care Medicine. CHU Besançon, France
| | - Anne Rietsch-Koenig
- Department of Anesthesiology and Intensive Care Medicine. CHU Besançon, France
| | - Bruno Heyd
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France
| | - Alexandre Doussot
- Department of Digestive Surgical Oncology -Liver Transplantation Unit, CHU Besançon, France.
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Li Y, Song Y, Zhang Y, Liu S. Progress in gallbladder cancer with lymph node metastasis. Front Oncol 2022; 12:966835. [PMID: 36072797 PMCID: PMC9441950 DOI: 10.3389/fonc.2022.966835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022] Open
Abstract
Gallbladder cancer (GBC) is a malignant tumor that originates from the mucosal lining of the gallbladder. It is distinctly regional and is common in certain geographic regions of developing countries. GBC has a high degree of insidiousness as well as a high propensity for metastatic spread, resulting in the majority of patients being diagnosed at an advanced stage. Lymph node metastasis (LNM) is fairly common in GBC patients and is an independent risk factor for a poor prognosis. This article is focused on the lymph node pathways and metastatic directions of GBC. Furthermore, it summarizes the different lymph node groupings, disease stages and treatments. In the future, it is of great significance to develop individualized treatment and predict the outcomes of GBC patients with different lymph node conditions.
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Affiliation(s)
- Yuhang Li
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Yinghui Song
- Central Laboratory of Hunan Provincial People's Hospital/The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Yujing Zhang
- Key Laboratory of Molecular Epidemiology of Hunan Province, School of Medicine, Hunan Normal University, Changsha, China
| | - Sulai Liu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Hunan Normal University, Changsha, China
- Central Laboratory of Hunan Provincial People's Hospital/The First Affiliated Hospital of Hunan Normal University, Changsha, China
- *Correspondence: Sulai Liu,
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22
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Abstract
Malnutrition is common in chronic liver diseases and worsens the patient's prognosis. Many liver disorders are associated with nutritional deficiencies. Some of the main factors that can lead to malnutrition in patients with chronic liver disease include decreased lipid absorption and reduced albumin production. In addition, these patients are sometimes candidates for a liver transplant that requires nutritional intervention after surgery to improve their prognosis. Thus, it is very important to recognise malnutrition in patients with liver failure in order to resolve it, mainly by a complete history of the patient, dietary survey, determination of muscle mass and a subjective assessment. To ensure a good nutritional status, exercise and lifestyle changes are considered, including dietary modifications, especially with a Mediterranean pattern. This article reviews these topics, including dietary modifications before and after liver transplantation. Additionally, nutritional recommendations are offered to patients with metabolic hepatic steatosis.
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Kuemmerli C, Fichtinger RS, Moekotte A, Aldrighetti LA, Aroori S, Besselink MGH, D’Hondt M, Díaz-Nieto R, Edwin B, Efanov M, Ettorre GM, Menon KV, Sheen AJ, Soonawalla Z, Sutcliffe R, Troisi RI, White SA, Brandts L, van Breukelen GJP, Sijberden J, Pugh SA, Eminton Z, Primrose JN, van Dam R, Hilal MA. Laparoscopic versus open resections in the posterosuperior liver segments within an enhanced recovery programme (ORANGE Segments): study protocol for a multicentre randomised controlled trial. Trials 2022; 23:206. [PMID: 35264216 PMCID: PMC8908665 DOI: 10.1186/s13063-022-06112-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 02/15/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND A shift towards parenchymal-sparing liver resections in open and laparoscopic surgery emerged in the last few years. Laparoscopic liver resection is technically feasible and safe, and consensus guidelines acknowledge the laparoscopic approach in the posterosuperior segments. Lesions situated in these segments are considered the most challenging for the laparoscopic approach. The aim of this trial is to compare the postoperative time to functional recovery, complications, oncological safety, quality of life, survival and costs after laparoscopic versus open parenchymal-sparing liver resections in the posterosuperior liver segments within an enhanced recovery setting. METHODS The ORANGE Segments trial is an international multicentre randomised controlled superiority trial conducted in centres experienced in laparoscopic liver resection. Eligible patients for minor resections in the posterosuperior segments will be randomised in a 1:1 ratio to undergo laparoscopic or open resections in an enhanced recovery setting. Patients and ward personnel are blinded to the treatment allocation until postoperative day 4 using a large abdominal dressing. The primary endpoint is time to functional recovery. Secondary endpoints include intraoperative outcomes, length of stay, resection margin, postoperative complications, 90-day mortality, time to adjuvant chemotherapy initiation, quality of life and overall survival. Laparoscopic liver surgery of the posterosuperior segments is hypothesised to reduce time to functional recovery by 2 days in comparison with open surgery. With a power of 80% and alpha of 0.04 to adjust for interim analysis halfway the trial, a total of 250 patients are required to be randomised. DISCUSSION The ORANGE Segments trial is the first multicentre international randomised controlled study to compare short- and long-term surgical and oncological outcomes of laparoscopic and open resections in the posterosuperior segments within an enhanced recovery programme. TRIAL REGISTRATION ClinicalTrials.gov NCT03270917 . Registered on September 1, 2017. Before start of inclusion. PROTOCOL VERSION version 12, May 9, 2017.
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Affiliation(s)
- Christoph Kuemmerli
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
| | - Robert S. Fichtinger
- Department of Surgery, Maastricht University Medical Centre+, 6202 AZ Maastricht, The Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Alma Moekotte
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
| | | | - Somaiah Aroori
- Peninsula HPB Unit, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Marc G. H. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mathieu D’Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Rafael Díaz-Nieto
- Hepatobiliary Surgery Unit, Aintree University Hospital, Liverpool, UK
| | - Bjørn Edwin
- Department of HPB Surgery, Oslo University Hospital, Oslo, Norway
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Centre, Moscow, Russia
| | - Giuseppe M. Ettorre
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | | | - Aali J. Sheen
- Department of Surgery, Manchester University Foundation Trust, Manchester, UK
| | - Zahir Soonawalla
- Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Robert Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Roberto I. Troisi
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Steven A. White
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Lloyd Brandts
- Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht UMC+, Maastricht, The Netherlands
| | - Gerard J. P. van Breukelen
- Department of Methodology and Statistics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jasper Sijberden
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Siân A. Pugh
- Department of Oncology, Addenbrooke’s Hospital, Cambridge, UK
| | - Zina Eminton
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - John N. Primrose
- Department of Surgery, University of Southampton, Southampton, UK
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Centre+, 6202 AZ Maastricht, The Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- GROW – School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Mohammed Abu Hilal
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
| | - on behalf of the ORANGE trials collaborative
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
- Department of Surgery, Maastricht University Medical Centre+, 6202 AZ Maastricht, The Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
- Peninsula HPB Unit, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
- Hepatobiliary Surgery Unit, Aintree University Hospital, Liverpool, UK
- Department of HPB Surgery, Oslo University Hospital, Oslo, Norway
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Centre, Moscow, Russia
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
- Institute of Liver Studies, Kings College Hospital, London, UK
- Department of Surgery, Manchester University Foundation Trust, Manchester, UK
- Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
- Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht UMC+, Maastricht, The Netherlands
- Department of Methodology and Statistics, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Oncology, Addenbrooke’s Hospital, Cambridge, UK
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
- Department of Surgery, University of Southampton, Southampton, UK
- GROW – School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
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Guidelines for Perioperative Care for Liver Transplantation: Enhanced Recovery After Surgery (ERAS) Recommendations. Transplantation 2022; 106:552-561. [PMID: 33966024 DOI: 10.1097/tp.0000000000003808] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based, program of care developed to minimize the response to surgical stress, associated with reduced perioperative morbidity and hospital stay. This study presents the specific ERAS Society recommendations for liver transplantation (LT) based on the best available evidence and on expert consensus. METHODS PubMed and ClinicalTrials.gov were searched in April 2019 for published and ongoing randomized clinical trials on LT in the last 15 y. Studies were selected by 5 independent reviewers and were eligible if focusing on each validated ERAS item in the area of adult LT. An e-Delphi method was used with an extended interdisciplinary panel of experts to validate the final recommendations. RESULTS Forty-three articles were included in the systematic review. A consensus was reached among experts after the second round. Patients should be screened for malnutrition and treated whenever possible. Prophylactic nasogastric intubation and prophylactic abdominal drainage may be omitted, and early extubation should be considered. Early oral intake, mobilization, and multimodal-balanced analgesia are recommended. CONCLUSIONS The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the e-Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.
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Huang F, Wang M, Chen H, Cheng N, Wang Y, Wu D, Zhou S. Analgesia and patient comfort after enhanced recovery after surgery in uvulopalatopharyngoplasty: a randomised controlled pilot study. BMC Anesthesiol 2021; 21:237. [PMID: 34600487 PMCID: PMC8487110 DOI: 10.1186/s12871-021-01458-8] [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: 09/24/2020] [Accepted: 09/28/2021] [Indexed: 12/20/2022] Open
Abstract
Background Uvulopalatopharyngoplasty(UPPP) is the most prevalent surgical treatment of obstructive sleep apnea, but postoperative pharyngeal pain may affect patient comfort. The enhanced recovery after surgery pathway has been proved beneficial to many types of surgery but not to UPPP yet. The aim of this pilot study was to preliminarily standrize an enhanced recovery after surgery protocol for UPPP, to assess whether it has positive effects on reducing postoperative pharyngeal pain and improving patient comfort, and to test its feasibility for an international multicentre study. Methods This randomised controlled study analysed 116 patients with obstructive sleep apnoea (OSA) who were undergoing UPPP in a single tertiary care hospital. They were randomly divided according to treatment: the ERAS group (those who received ERAS treatment) and the control group (those who received traditional treatment). Ninety-five patients completed the assessment (ERAS group, 59 patients; control group, 36 patients). Pharyngeal pain and patient comfort were evaluated using a visual analogue scale (VAS) at 30 min and at 6, 12, 24 and 48 h after UPPP. Complications, hospitalisation duration, and hospital cost were recorded. Results The VAS scores for resting pain and swallowing pain were significantly lower in the ERAS group than those in the control group at 30 min and at 6, 12, 24 and 48 h after surgery. Patient comfort was improved in the ERAS group. The hospitalisation duration and cost were comparable between the groups. The incidence of complications showed an increasing trend in the ERAS group. Conclusion The ERAS protocol significantly relieved pharyngeal pain after UPPP and improved comfort in patients with OSA, which showed the prospect for an larger study. Meanwhile a potential increase of post-operative complications in the ERAS group should be noticed. Trial registration Chinese Clinical Trial Registry (23/09/2018, ChiCTR1800018537)
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Affiliation(s)
- Fei Huang
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Minxue Wang
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Huixin Chen
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Nan Cheng
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Yanling Wang
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Di Wu
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Shaoli Zhou
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China.
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Agarwal P, Frid I, Singer J, Zalatimo O, Schirmer CM, Kimmell KT, Agarwal N. Neurosurgery perception of Enhanced Recovery After Surgery (ERAS) protocols. J Clin Neurosci 2021; 92:110-114. [PMID: 34509236 DOI: 10.1016/j.jocn.2021.07.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/08/2021] [Accepted: 07/25/2021] [Indexed: 12/19/2022]
Abstract
Enhanced Recovery After Surgery (ERAS) protocols are widespread in several fields, particularly general surgery, and attempt to deliver surgical care at a lower cost while also improving patient outcomes. However, few institutions have implemented ERAS protocols in neurosurgery. As such, a survey of neurosurgeons on the current state of ERAS in neurosurgery was conducted to provide insight on scaling the practice nationally. A 15-question survey was designed to assess the implementation of andsatisfaction with ERAS protocols at individual institutions. A total of 39 responses were collected from 38 unique institutions. 58.9%(N = 23) reported implementation of neurosurgical ERAS protocols. 52.1% (N = 12) of the responses were neurosurgeons at academic institutions withneurosurgical residency programs. Most neurosurgeons used ERAS protocolsfor spine cases (N = 23), with only 17.3% (N = 4) employing ERAS protocolsfor cranial cases. 69.5% (N = 16) of survey participants reported that thedesign and implementation of ERAS was a multidisciplinary effort acrossmany departments, including neurosurgery, anesthesia, and pharmacy.Decreased costs and intensive care unit (ICU) admission were reported tobe unanticipated benefits of ERAS implementation. Unanticipated challenges to implementation of new protocols included difficulties withelectronic medical record (EMR) integration, agreement of protocoldetails amongst stakeholders, uniform implementation of protocols by allneurosurgeons, and lack of adaptability by multidisciplinary staff. Meandepartment satisfaction with ERAS protocol implementation was 4.00 +/- 0.81 (N = 22) on a 5-point Likert scale.
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Affiliation(s)
- Prateek Agarwal
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, United States
| | - Ilya Frid
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System and Geisinger Commonwealth School of Medicine, Wilkes-Barre, PA, United States
| | - Justin Singer
- Spectrum Health Medical Group, Department of Neurosurgery, Grand Rapids, MI, United States
| | - Omar Zalatimo
- Lifebridge Health, Department of Neurosurgery, The Sandra and Malcolm Berman Brain & Spine Institute, Baltimore, MD, United States
| | - Clemens M Schirmer
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System and Geisinger Commonwealth School of Medicine, Wilkes-Barre, PA, United States; Lifebridge Health, Department of Neurosurgery, The Sandra and Malcolm Berman Brain & Spine Institute, Baltimore, MD, United States; Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Kristopher T Kimmell
- Rochester Regional Health, Department of Neurosurgery, Rochester, NY, United States
| | - Nitin Agarwal
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, United States.
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Chua DW, Sim D, Syn N, Abdul Latiff JB, Lim KI, Sim YE, Abdullah HR, Lee SY, Chan CY, Goh BKP. Impact of introduction of an enhanced recovery protocol on the outcomes of laparoscopic liver resections: A propensity-score matched study. Surgery 2021; 171:413-418. [PMID: 34417027 DOI: 10.1016/j.surg.2021.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 07/04/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Presently, data on the impact of enhanced recovery protocols on the outcomes of laparoscopic liver resection remain limited. We performed propensity matched analysis comparing the outcomes between patients undergoing laparoscopic liver resection before and after the introduction of an enhanced recovery protocol. METHODS Between 2013 and 2019, 462 consecutive patients underwent laparoscopic liver resection by 3 surgeons of which 360 met the study inclusion criteria. There were 89 patients who underwent surgery under an enhanced recovery protocol and 271 without an enhanced recovery protocol. One-to-one propensity matched analysis was performed for 84 enhanced recovery protocol patients and 84 nonenhanced recovery protocol patients. RESULTS Comparisons between propensity matched cohorts revealed that patients who received laparoscopic liver resection with enhanced recovery protocol had reduced median blood loss (200 vs 300 mL, P = .013), postoperative stay (3 vs 4 days, P = .003), and lower open conversion rates (0% vs 8.3%, P = .008). There was no difference in other key perioperative outcomes such as operation time, postoperative morbidity, postoperative major morbidity, and 30-day readmission rates. CONCLUSION A combined approach of enhanced recovery protocol and laparoscopic liver resection was associated with improved perioperative outcomes as opposed to laparoscopic liver resection alone.
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Affiliation(s)
- Darren W Chua
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Dayna Sim
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Nicholas Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Kai-Inn Lim
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Yilin Eileen Sim
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Hairil Rizal Abdullah
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Duke-National University of Singapore Medical School, Singapore
| | - Ser Yee Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, Duke-National University of Singapore Transplant Center, Singapore
| | - Chung-Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, Duke-National University of Singapore Transplant Center, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke-National University of Singapore Medical School, Singapore; Liver Transplant Service, Duke-National University of Singapore Transplant Center, Singapore.
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Cost-Benefit Analysis of an Enhanced Recovery Program for Gastrectomy A Retrospective Controlled Analysis. World J Surg 2021; 45:3249-3257. [PMID: 34365531 PMCID: PMC8476461 DOI: 10.1007/s00268-021-06220-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 02/04/2023]
Abstract
Background Enhanced recovery programs (ERP) demonstrated decreased postoperative complication rate and reduced length of stay (LOS). Recently, data on the financial impact revealed cost reduction for colorectal, liver and pancreatic surgery. The present study aimed to assess the cost-effectiveness of ERP in gastric surgery. Methods ERP based on enhanced recovery after surgery (ERAS®) society guidelines was implemented in our institution, in June 2014. Consecutive patients undergoing gastric surgery after ERP implementation (n = 71) were compared to a control group of consecutive patients operated before ERP implementation (n = 58). Primary endpoint was cost-effectiveness including detailed perioperative costs. Secondary endpoints were postoperative complications and LOS. Standard statistical testing (means, Mann–Whitney Fisher’s exact T test or Pearson Chi-square test) was used. Results Both groups were comparable regarding demographic details. Mean (SD) overall costs per patient were lower in the ERP group (€33,418 (17,901) vs €39,804 (27,288), P = 0.027). Lower costs were found for anesthesia and operating room (−€2 356), intensive or intermediate care (−€8 629), medication (−€1 196)), physiotherapy (−€611), laboratory (−€1 625)) and blood transfusion (−€977). Overall complication rates in ERP and control group (51% vs 62%, P = 0.176) were similar. Mean length of stay (SD) (14(13) days vs 17(11) days, P = 0.037) was shorter in the ERP group. Conclusion ERP significantly reduces overall, preoperative and postoperative costs in patients undergoing major gastric surgery.
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Kone LB, Maker VK, Banulescu M, Maker AV. Epidural Analgesia Is Associated with Prolonged Length of Stay After Open HPB Surgery in Over 27,000 Patients. J Gastrointest Surg 2021; 25:1716-1726. [PMID: 32725519 DOI: 10.1007/s11605-020-04751-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The impact of epidural analgesia (EA) on postoperative morbidity and length of stay (LOS) after HPB surgery remains to be determined. These specific outcomes have been highlighted by the implementation of multiple enhanced recovery pathways (ERAS). The authors hypothesized that EA in the current environment may be associated with LOS and other outcomes. METHODS The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) databases from 2014 to 2017 for patients undergoing open hepatopancreaticobiliary (HPB) surgery were included in a retrospective cohort analysis with propensity score matching (PSM) comparing EA with control. RESULTS Twenty-seven thousand two hundred eighteen patients underwent open HPB surgery, of which 6048 (22%) received EA. There was an increase use of EA over time (from 19.3 to 25.5%, p = 0.001). On PSM, EA was associated with more than half of a day increase in LOS for both pancreatic (p < 0.001) and hepatic surgery (p < 0.001). Furthermore, for pancreatic surgery, there was an increase in urinary tract infection (2.5% vs. 3.3%, p = 0.018), time to drain removal (7.8 vs. 8.7 days, p < 0.001), and discharge to rehabilitation (2.9% vs. 4.3%, p = 0.029). For hepatic surgery, there was an increase in blood transfusion requirements (17% vs. 20%, p = 0.019). There were no differences in overall morbidity and mortality. CONCLUSION In this cohort of over 27,000 patients with granular surgical details, there was a significant increase in LOS associated with EA after HPB surgery, along with increased procedure-specific UTI and blood transfusion. With the ever-increasing need for standardized and efficient patient care pathways that reduce LOS, alternative analgesic adjuncts may be considered to optimize patient outcomes.
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Affiliation(s)
- Lyonell B Kone
- Department of Surgery, Division of Surgical Oncology, University of Illinois, 835 S. Wolcott St. MC790, Chicago, IL, 60612, USA
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Vijay K Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois, 835 S. Wolcott St. MC790, Chicago, IL, 60612, USA
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Mihaela Banulescu
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Ajay V Maker
- Department of Surgery, Division of Surgical Oncology, University of Illinois, 835 S. Wolcott St. MC790, Chicago, IL, 60612, USA.
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
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Probability of Postoperative Complication after Liver Resection: Stratification of Patient Factors,Operative Complexity, and Use of Enhanced Recovery after Surgery. J Am Coll Surg 2021; 233:357-368.e2. [PMID: 34111534 DOI: 10.1016/j.jamcollsurg.2021.05.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/10/2021] [Accepted: 05/10/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The current study aimed to assess the performance of the 3-level complexity classification that stratified liver resection procedures into 3 complexity grades (grade I, low; grade II, intermediate; and grade III, high complexity) and to evaluate whether the Enhanced Recovery after Surgery (ERAS) protocol improves postoperative outcomes for each complexity grade. STUDY DESIGN Consecutive patients undergoing open liver resection and laparoscopic liver resection at Lausanne University Hospital during 2010 to 2020 were assessed. RESULTS A total of 437 patients were included. Operative time, estimated blood loss, and length of hospital stay increased significantly, with a stepwise increase of the grades from I to III in open liver resection and laparoscopic liver resection (all, p < 0.05). The same trend for Comprehensive Complication Index was found in open liver resection (p < 0.005). Age (p = 0.004), 3-level complexity classification (grade II vs I; p = 0.001; grade III vs I; p < 0.001), no use of the ERAS protocol (p = 0.016), and biliary reconstruction (p < 0.001) were significant predictors for postoperative complication, defined as Comprehensive Complication Index ≥ 26.2 in a multivariable logistic regression analysis. The prediction model incorporating the 4 factors had a calculated Concordance Index of 0.735 and 0.742 based on the bootstrapping method. The use of ERAS protocol was associated with lower probability of postoperative complication for each complexity grade and age. CONCLUSIONS The use of ERAS protocol can decrease the probability of postoperative complication for each surgical complexity of liver resection and patient age. This finding emphasized the importance of tailoring perioperative management according to surgical complexity and patient age to improve outcomes after liver resection.
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Cañamares-Orbis P, Bernal-Monterde V, Sierra-Gabarda O, Casas-Deza D, Garcia-Rayado G, Cortes L, Lué A. Impact of Liver and Pancreas Diseases on Nutritional Status. Nutrients 2021; 13:1650. [PMID: 34068295 PMCID: PMC8153270 DOI: 10.3390/nu13051650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/02/2021] [Accepted: 05/11/2021] [Indexed: 12/12/2022] Open
Abstract
Liver and pancreatic diseases have significant consequences on nutritional status, with direct effects on clinical outcomes, survival, and quality of life. Maintaining and preserving an adequate nutritional status is crucial and should be one of the goals of patients with liver or pancreatic disease. Thus, the nutritional status of such patients should be systematically assessed at follow-up. Recently, great progress has been made in this direction, and the relevant pathophysiological mechanisms have been better established. While the spectrum of these diseases is wide, and the mechanisms of the onset of malnutrition are numerous and interrelated, clinical and nutritional manifestations are common. The main consequences include an impaired dietary intake, altered macro and micronutrient metabolism, energy metabolism disturbances, an increase in energy expenditure, nutrient malabsorption, sarcopenia, and osteopathy. In this review, we summarize the factors contributing to malnutrition, and the effects on nutritional status and clinical outcomes of liver and pancreatic diseases. We explain the current knowledge on how to assess malnutrition and the efficacy of nutritional interventions in these settings.
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Affiliation(s)
- Pablo Cañamares-Orbis
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge, 22004 Huesca, Spain;
| | - Vanesa Bernal-Monterde
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain; (V.B.-M.); (O.S.-G.); (D.C.-D.)
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; (G.G.-R.); (L.C.)
| | - Olivia Sierra-Gabarda
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain; (V.B.-M.); (O.S.-G.); (D.C.-D.)
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; (G.G.-R.); (L.C.)
| | - Diego Casas-Deza
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, 50009 Zaragoza, Spain; (V.B.-M.); (O.S.-G.); (D.C.-D.)
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; (G.G.-R.); (L.C.)
| | - Guillermo Garcia-Rayado
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; (G.G.-R.); (L.C.)
- Service of Digestive Diseases, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
| | - Luis Cortes
- Instituto de Investigación Sanitaria (IIS) Aragón, 50009 Zaragoza, Spain; (G.G.-R.); (L.C.)
- Service of Digestive Diseases, Hospital Clínico Universitario Lozano Blesa, 50009 Zaragoza, Spain
| | - Alberto Lué
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge, 22004 Huesca, Spain;
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Yin Y, Cheng JW, Chen FY, Chen XX, Zhang X, Huang A, Guo DZ, Wang YP, Cao Y, Fan J, Zhou J, Yang XR. A novel preoperative predictive model of 90-day mortality after liver resection for huge hepatocellular carcinoma. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:774. [PMID: 34268387 PMCID: PMC8246173 DOI: 10.21037/atm-20-7842] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 02/28/2021] [Indexed: 01/27/2023]
Abstract
Background Hepatectomy for huge hepatocellular carcinoma (HCC) (diameter ≥10 cm) is characterized by high mortality. This study aimed to establish a preoperative model to evaluate the risk of postoperative 90-day mortality for huge HCC patients. Methods We retrospectively enrolled 1,127 consecutive patients and prospectively enrolled 93 patients with huge HCC who underwent hepatectomy (training cohort, n=798; validation cohort, n=329; prospective cohort, n=93) in our institute. Based on independent preoperative predictors of 90-day mortality, we established a logistic regression model and visualized the model by nomogram. Results The 90-day mortality rates were 9.6%, 9.2%, and 10.9% in the training, validation, and prospective cohort. The α-fetoprotein (AFP) level, the prealbumin levels, and the presence of portal vein tumor thrombosis (PVTT) were preoperative independent predictors of 90-day mortality. A logistic regression model, AFP-prealbumin-PVTT score (APP score), was subsequently established and showed good performance in predicting 90-day mortality (training cohort, AUC =0.87; validation cohort, AUC =0.91; prospective cohort, AUC =0.93). Using a cut-off of −1.96, the model could stratify patients into low risk (≤−1.96) and high risk (>−1.96) with different 90-day mortality rates (~30% vs. ~2%). Furthermore, the predictive performance for 90-day mortality and overall survival was significantly superior to the Child-Pugh score, the model of end-stage liver disease (MELD) score, and the albumin-bilirubin (ALBI) score. Conclusions The APP score can precisely predict postoperative 90-day mortality as well as long-term survival for patients with huge HCC, assisting physician selection of suitable candidates for liver resection and improving the safety and efficacy of surgical treatment.
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Affiliation(s)
- Yue Yin
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion (Fudan University), Ministry of Education; Shanghai Key Laboratory of Organ Transplantation, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian-Wen Cheng
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion (Fudan University), Ministry of Education; Shanghai Key Laboratory of Organ Transplantation, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Fei-Yu Chen
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion (Fudan University), Ministry of Education; Shanghai Key Laboratory of Organ Transplantation, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xu-Xiao Chen
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion (Fudan University), Ministry of Education; Shanghai Key Laboratory of Organ Transplantation, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin Zhang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion (Fudan University), Ministry of Education; Shanghai Key Laboratory of Organ Transplantation, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ao Huang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion (Fudan University), Ministry of Education; Shanghai Key Laboratory of Organ Transplantation, Zhongshan Hospital, Fudan University, Shanghai, China
| | - De-Zhen Guo
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion (Fudan University), Ministry of Education; Shanghai Key Laboratory of Organ Transplantation, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yu-Peng Wang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion (Fudan University), Ministry of Education; Shanghai Key Laboratory of Organ Transplantation, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ya Cao
- Cancer Research Institute, Central South University; Key Laboratory of Carcinogenesis and Cancer Invasion, Ministry of Education, Changsha, China
| | - Jia Fan
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion (Fudan University), Ministry of Education; Shanghai Key Laboratory of Organ Transplantation, Zhongshan Hospital, Fudan University, Shanghai, China.,Institute of Biomedical Sciences, Fudan University, Shanghai, China.,State Key Laboratory of Genetic Engineering, Fudan University, Shanghai, China
| | - Jian Zhou
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion (Fudan University), Ministry of Education; Shanghai Key Laboratory of Organ Transplantation, Zhongshan Hospital, Fudan University, Shanghai, China.,Institute of Biomedical Sciences, Fudan University, Shanghai, China.,State Key Laboratory of Genetic Engineering, Fudan University, Shanghai, China
| | - Xin-Rong Yang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University; Key Laboratory of Carcinogenesis and Cancer Invasion (Fudan University), Ministry of Education; Shanghai Key Laboratory of Organ Transplantation, Zhongshan Hospital, Fudan University, Shanghai, China
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Kang T, Jia Z, Xing G, Zhou Q. Comparison of Clinical Outcomes Between Chinese Patients Receiving Hepatectomy With or Without Enhanced Recovery After Surgery Strategy. Front Surg 2021; 8:645935. [PMID: 33842531 PMCID: PMC8033151 DOI: 10.3389/fsurg.2021.645935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/16/2021] [Indexed: 11/13/2022] Open
Abstract
Purposes: For the first time in China, the current study was designed to compare the clinical outcomes between Chinese patients receiving hepatectomy with or without the enhanced recovery after surgery (ERAS) strategy. Methods: The current study enrolled 250 patients who would receive hepatectomy. Patients were randomized into two groups: ERAS group (n = 125, ERAS strategy) and control (n = 125, conventional care). Mortality, length of hospital stay, readmission, and complications were assessed over 30 days after the operation. Results: The average age of the whole cohort was 65 (63-68) years, with 152 males (60.8%). There was no difference between two groups in baseline features, such as age, sex, medical history, Child-Pugh hepatic function, American Society of Anaesthesiologists physical status, operative type, hepatectomy type, and hepatic pathology (P > 0.05 for all). There was no occurrence of death in the two groups. Patients in the ERAS group had significantly less occurrence of post-operative complications and a shorter length of hospital stay (P < 0.05 for all). Deep vein thrombosis occurred in seven patients in the control group, but did not occur in the ERAS group (P < 0.05). Patients in the two groups had similar occurrence of readmission (P > 0.05). Conclusions: ERAS strategy significantly decreased the occurrence of operative complications and shortened the length of hospital stay without any increase in mortality or readmission in Chinese patients receiving hepatectomy.
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Affiliation(s)
- Tieli Kang
- Department of Hepatobiliary Surgery, Inner Mongolia Xing'an Meng People's Hospital, Ulanhot, China
| | - Zhishuo Jia
- Department of Hepatobiliary Surgery, Inner Mongolia Xing'an Meng People's Hospital, Ulanhot, China
| | - Guoquan Xing
- Department of Hepatobiliary Surgery, Inner Mongolia Xing'an Meng People's Hospital, Ulanhot, China
| | - Quanhe Zhou
- Department of Hepatobiliary Surgery, Inner Mongolia Xing'an Meng People's Hospital, Ulanhot, China
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Zhang Y, Gong Z, Chen S. Clinical application of enhanced recovery after surgery in the treatment of choledocholithiasis by ERCP. Medicine (Baltimore) 2021; 100:e24730. [PMID: 33663085 PMCID: PMC7909146 DOI: 10.1097/md.0000000000024730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 01/18/2021] [Indexed: 01/05/2023] Open
Abstract
This study aims to investigate the effect of applying enhanced recovery after surgery methods (ERAS) in perioperative nursing of choledocholithiasis following endoscopic retrograde cholangiopancreatography (ERCP) for treatment of biliary calculus.Clinical data from 161 patients who underwent ERCP surgery in Wuhan Union Hospital from January 2017 to December 2019 were retrospectively analyzed. A total of 78 patients received perioperative nursing using the ERAS concept (experimental group) and 83 patients received conventional perioperative nursing (control group). Group differences were compared for the time to first postoperative ambulation, exhausting time, time to first defecation and eating, intraoperative blood loss, postoperative complication incidence (pancreatitis, cholangitis, hemorrhage), white blood cell (WBC), and serum amylase (AMS) values at 24 hours, duration of nasobiliary duct indwelling, length of hospital stay, and hospitalization expenses.No significant between-group differences were noted for demographic characteristics (age, sex, BMI, ASA score, and comorbidity) (P > .05). Time to first ambulation, exhausting time, time to defecation and eating, and nasobiliary drainage time were shorter in the experimental group than the control group, and the differences were statistically significant (P < .05). There was no significant between-group difference in postoperative WBC values at 24 hours (P > .05), but the experimental group's AMS values at 24 hours postoperation were significantly lower than those of the controls (154.93 ± 190.01 vs 241.97 ± 482.64, P = .031). Postoperative complications incidence was 9.1% in the experimental group, which was significantly lower than the 20.4% in the control group, and this difference was statistically significant (P = .039). Compared with the control group, nasobiliary drainage time (26.53 ± 7.43 hours vs 37.56 ± 9.91 hours, P < .001), hospital stay (8.32 ± 1.55 days vs 4.56 ± 1.38 days, P < .001), and hospitalization expenses (36800 ± 11900 Yuan vs 28900 ± 6500 Yuan, P = .016) were significantly lower in the experimental group.ERAS is a safe and effective perioperative nursing application in ERCP for treating choledocholithiasis. It can effectively accelerate patients' recovery and reduce the incidence of complications; therefore, it is worthy of being applied and promoted in clinical nursing.
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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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Abstract
INTRODUCTION Perioperative enhanced recovery after surgery (ERAS) concepts or fast-track are supposed to accelerate recovery after surgery, reduce postoperative complications and shorten the hospital stay when compared to traditional perioperative treatment. METHODS Electronic search of the PubMed database to identify systematic reviews with meta-analysis (SR) comparing ERAS and traditional treatment. RESULTS The presented SR investigated 70 randomized controlled studies (RCT) with 12,986 patients and 93 non-RCT (24,335 patients) concerning abdominal, thoracic and vascular as well as orthopedic surgery. The complication rates were decreased under ERAS following colorectal esophageal, liver and pulmonary resections as well as after implantation of hip endoprostheses. Pulmonary complications were reduced after ERAS esophageal, gastric and pulmonary resections. The first bowel movements occurred earlier after ERAS colorectal resections and delayed gastric emptying was less often observed after ERAS pancreatic resection. Following ERAS fast-track esophageal resection, anastomotic leakage was diagnosed less often as well as surgical complications after ERAS pulmonary resection. The ERAS in all studies concerning orthopedic surgery and trials investigating implantation of a hip endoprosthesis or knee endoprosthesis reduced the risk for postoperative blood transfusions. Regardless of the type of surgery, ERAS shortened hospital stay without increasing readmissions. CONCLUSION Numerous clinical trials have confirmed that ERAS reduces postoperative morbidity, shortens hospital stay and accelerates recovery without increasing readmission rates following most surgical operations.
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Elmore U, Vignali A, Maggi G, Delpini R, Rosati R. Enhanced Recovery After Emergency Surgery in the Elderly. EMERGENCY LAPAROSCOPIC SURGERY IN THE ELDERLY AND FRAIL PATIENT 2021:269-274. [DOI: 10.1007/978-3-030-79990-8_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Patel S, Suz P, Powers BD, Anaya DA. Epidural analgesia for hepatopancreatobiliary operations and postoperative urinary tract infections: an unrecognized association of "best-practices" and adverse outcomes. HPB (Oxford) 2021; 23:71-79. [PMID: 32414659 DOI: 10.1016/j.hpb.2020.04.013] [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: 01/13/2020] [Revised: 03/03/2020] [Accepted: 04/20/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Thoracic epidural analgesia (TEA) is considered "best-practices" for pain-control following HPB operations. It is unknown if TEA increases the risk of UTI. We sought to examine the association of TEA and UTI following HPB operations. METHODS A retrospective cohort study of patients undergoing elective HPB operations was performed (ACS-NSQIP [2014-2016]). Patients were categorized by TEA utilization. The primary outcome was UTI. Multivariable logistic regression models were created to examine the association of TEA with UTI; including sensitivity and interaction analyses for age and gender. RESULTS Among 28,571 patients included, 5764 (20.2%) had TEA. UTI occurred more frequently with TEA (3.5% vs. 2.2%, p < 0.01). After multivariable analysis, TEA was associated with increased risk of UTI (1.59 [1.34-1.89]); when stratified by age and gender, the association persisted with an incremental increased risk observed in males over 70 years (1.91 [1.41-2.59]). UTI was associated with increased risk of sepsis (16.8% vs. 5.6%, P < 0.001), LOS (9 versus 6 days, P < 0.001) and readmission rates (21.4% vs. 12.3%, P < 0.001). CONCLUSION Despite TEA recommended as a best-practice standard for HPB operations, the increased risk of UTI calls for evaluation of current practices and consideration of alternative strategies for high-risk vulnerable populations - elderly males.
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Affiliation(s)
- Sephalie Patel
- Department of Anesthesiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Pilar Suz
- Department of Anesthesiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Benjamin D Powers
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Daniel A Anaya
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.
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Gonvers S, Jurt J, Joliat GR, Halkic N, Melloul E, Hübner M, Demartines N, Labgaa I. Biological impact of an enhanced recovery after surgery programme in liver surgery. BJS Open 2020; 5:6043605. [PMID: 33688943 PMCID: PMC7944514 DOI: 10.1093/bjsopen/zraa015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 08/27/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The clinical and economic impacts of enhanced recovery after surgery (ERAS) programmes have been demonstrated extensively. Whether ERAS protocols also have a biological effect remains unclear. This study aimed to investigate the biological impact of an ERAS programme in patients undergoing liver surgery. METHODS A retrospective analysis of patients undergoing liver surgery (2010-2018) was undertaken. Patients operated before and after ERAS implementation in 2013 were compared. Surrogate markers of surgical stress were monitored: white blood cell count (WBC), C-reactive protein (CRP) level, albumin concentration, and haematocrit. Their perioperative fluctuations were defined as Δvalues, calculated on postoperative day (POD) 0 for Δalbumin and Δhaematocrit and POD 2 for ΔWBC and ΔCRP. RESULTS A total of 541 patients were included, with 223 and 318 patients in non-ERAS and ERAS groups respectively. Groups were comparable, except for higher rates of laparoscopy (24.8 versus 11.2 per cent; P < 0.001) and major resection (47.5 versus 38.1 per cent; P = 0.035) in the ERAS group. Patients in the ERAS group showed attenuated ΔWBC (2.00 versus 2.75 g/l; P = 0.013), ΔCRP (60 versus 101 mg/l; P <0.001) and Δalbumin (12 versus 16 g/l; P < 0.001) compared with those in the no-ERAS group. Subgroup analysis of open resection showed similar results. Multivariable analysis identified ERAS as the only independent factor associated with high ΔWBC (odds ratio (OR) 0.65, 95 per cent c.i. 0.43 to 0.98; P = 0.038), ΔCRP (OR 0.41, 0.23 to 0.73; P = 0.003) and Δalbumin (OR 0.40, 95 per cent c.i. 0.22 to 0.72; P = 0.002). CONCLUSION Compared with conventional management, implementation of ERAS was associated with an attenuated stress response in patients undergoing liver surgery.
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Affiliation(s)
- S Gonvers
- Department of Visceral Surgery, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - J Jurt
- Department of Visceral Surgery, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - G-R Joliat
- Department of Visceral Surgery, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - N Halkic
- Department of Visceral Surgery, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - E Melloul
- Department of Visceral Surgery, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - M Hübner
- Department of Visceral Surgery, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - N Demartines
- Department of Visceral Surgery, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - I Labgaa
- Department of Visceral Surgery, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Joliat GR, Hübner M, Roulin D, Demartines N. Cost Analysis of Enhanced Recovery Programs in Colorectal, Pancreatic, and Hepatic Surgery: A Systematic Review. World J Surg 2020; 44:647-655. [PMID: 31664495 DOI: 10.1007/s00268-019-05252-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Enhanced recovery programs (ERPs) have been shown to improve postoperative outcomes after abdominal surgery. This study aimed to review the current literature to assess if ERPs in colorectal, pancreas, and liver surgery induce cost savings. METHODS A systematic review was performed including prospective and retrospective studies comparing conventional management versus ERP in terms of costs. All kinds of ERP were considered (fast-track, ERAS®, or home-made protocols). Studies with no mention of a clear protocol and no reporting of protocol compliance were excluded. RESULTS Thirty-seven articles out of 144 identified records were scrutinized as full articles. Final analysis included 16 studies. In colorectal surgery, two studies were prospective (1 randomized controlled trial, RCT) and six retrospective, totaling 1277 non-ERP patients and 2078 ERP patients. Three of the eight studies showed no difference in cost savings between the two groups. The meta-analysis found a mean cost reduction of USD3010 (95% CI: 5370-650, p = 0.01) in favor of ERP. Among the five included studies in pancreas surgery (all retrospective, 552 non-ERP vs. 348 ERP patients), the mean cost reduction in favor of the ERP group was USD7020 (95% CI: 11,600-2430, p = 0.003). In liver surgery, only three studies (two retrospective and 1 RCT, 180 non-ERP vs. 197 ERP patients) were found, which precluded a sound cost analysis. CONCLUSIONS The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management. Cost data in liver surgery are scarce.
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Affiliation(s)
- Gaëtan-Romain Joliat
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Didier Roulin
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Lee JA, Young S, O'Connor V, DiFronzo LA. Safety and Efficacy of an Enhanced Recovery Protocol After Hepatic Resection. Am Surg 2020; 86:1396-1400. [PMID: 33125262 DOI: 10.1177/0003134820964492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Enhanced recovery protocols (ERPs) have shown to improve outcomes in multiple specialties and were recently applied to hepatic resections. The objective of this study was to determine the safety and efficacy of ERP in hepatic resection. Between 2013-2017, 208 patients underwent hepatectomy. The ERP included early ambulation, early oral intake, and multimodal analgesia. Primary study end points were hospital length of stay (LOS) and overall morbidity; secondary end points were return of bowel function (ROBF), 30-day readmission, and 90-day mortality. Major hepatectomies were selected for separate analysis. Overall, pre-ERP (N = 99) and ERP (N = 109) were similar in demographics. ERP patients had earlier oral intake and ROBF with similar overall morbidity. Although median LOS was 5 days, 43% of ERP patients had LOS ≤4 days vs. 27% in the pre-ERP cohort (P = .02). 30-day readmission was similar (12%), and 90-day mortality was 2.8% vs. 3.0% (pre-ERP vs. ERP, P = .90). In major hepatectomies, pre-ERP (N = 41) and ERP (N = 33) demographics and operative characteristics were similar. ERP patients had earlier oral intake and ROBF with similar morbidity and mortality. There was no significant difference in median LOS; however, 36% of the major hepatectomy ERP patients had LOS ≤4 days vs. 17% of pre-ERP patients, P = .06. In conclusion, ERP can be safely implemented in hepatectomy, with earlier oral intake and ROBF, shorter LOS in some patients, and no increase in morbidity or mortality.
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Affiliation(s)
- Jennifer A Lee
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Stephanie Young
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
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Bischoff SC, Bernal W, Dasarathy S, Merli M, Plank LD, Schütz T, Plauth M. ESPEN practical guideline: Clinical nutrition in liver disease. Clin Nutr 2020; 39:3533-3562. [PMID: 33213977 DOI: 10.1016/j.clnu.2020.09.001] [Citation(s) in RCA: 180] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Practical guideline is based on the current scientific ESPEN guideline on Clinical Nutrition in Liver Disease. METHODS It has been shortened and transformed into flow charts for easier use in clinical practice. The guideline is dedicated to all professionals including physicians, dieticians, nutritionists and nurses working with patients with chronic liver disease. RESULTS A total of 103 statements and recommendations are presented with short commentaries for the nutritional and metabolic management of patients with (i) acute liver failure, (ii) alcoholic steatohepatitis, (iii) non-alcoholic fatty liver disease, (iv) liver cirrhosis, and (v) liver surgery/transplantation. The disease-related recommendations are preceded by general recommendations on the diagnostics of nutritional status in liver patients and on liver complications associated with medical nutrition. CONCLUSION This practical guideline gives guidance to health care providers involved in the management of liver disease to offer optimal nutritional care.
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Affiliation(s)
- Stephan C Bischoff
- Department for Clinical Nutrition, University of Hohenheim, Stuttgart, Germany.
| | - William Bernal
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Srinivasan Dasarathy
- Division of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Manuela Merli
- Gastroenterology and Hepatology Unit, Sapienza University of Rome, Rome, Italy
| | - Lindsay D Plank
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Tatjana Schütz
- IFB Adiposity Diseases, Leipzig University Medical Centre, Leipzig, Germany
| | - Mathias Plauth
- Department of Internal Medicine, Municipal Hospital of Dessau, Dessau, Germany
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Utsumi M, Aoki H, Nagahisa S, Une Y, Kimura Y, Watanabe M, Taniguchi F, Arata T, Katsuda K, Tanakaya K. Nutritional assessment and surgical outcomes in very elderly patients undergoing pancreaticoduodenectomy: a retrospective study. Surg Today 2020; 51:941-953. [PMID: 33106898 DOI: 10.1007/s00595-020-02169-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/29/2020] [Indexed: 11/09/2022]
Abstract
PURPOSE To evaluate and compare the nutritional factors and clinical outcomes of pancreaticoduodenectomy between elderly and non-elderly patients. METHODS This retrospective study evaluated 122 consecutive patients who underwent pancreaticoduodenectomy from April 2008 to April 2020. Preoperative and postoperative nutritional factors (prognostic nutritional index), complication rates, and survival rates were compared between the elderly (≥ 80 years) and non-elderly (< 80 years) patient groups. Changes in nutrition markers were evaluated before surgery to 1 year after surgery. RESULTS A total of 20 elderly patients (16.4%) and 102 non-elderly patients (83.6%) underwent pancreaticoduodenectomy. Elderly patients had a significantly lower preoperative prognostic nutritional index than did non-elderly patients. At 3 months postoperatively, elderly patients had a lower albumin level and prognostic nutritional index. The median length of hospital stay was significantly longer (39.9 vs. 27 days, P = 0.004), the rate of death due to other diseases was higher, and the overall survival rate was significantly lower (1-/3-/5 year overall survival rates: 78.1%/26.7%/13.3% vs. 87.1%/54.4%/46.7%; log-rank test, P = 0.003) in the elderly group than in the non-elderly group. CONCLUSIONS The results suggest that careful patient selection and optimal perioperative care are necessary to determine whether pancreaticoduodenectomy is indicated for elderly patients.
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Affiliation(s)
- Masashi Utsumi
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan.
| | - Hideki Aoki
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Seiichi Nagahisa
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Yuta Une
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Yuji Kimura
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Megumi Watanabe
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Fumitaka Taniguchi
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Takashi Arata
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Koh Katsuda
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
| | - Kohji Tanakaya
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, 1-1-1 Atago-machi, Iwakuni-shi, Yamaguchi, 740-8510, Japan
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Zhang X, Yang J, Chen X, Du L, Li K, Zhou Y. Enhanced recovery after surgery on multiple clinical outcomes: Umbrella review of systematic reviews and meta-analyses. Medicine (Baltimore) 2020; 99:e20983. [PMID: 32702839 PMCID: PMC7373593 DOI: 10.1097/md.0000000000020983] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previously, many meta-analyses have reported the impact of enhanced recovery after surgery (ERAS) programs on many surgical specialties. OBJECTIVES To systematically assess the effects of ERAS pathways on multiple clinical outcomes in surgery. DESIGN An umbrella review of meta-analyses. DATE SOURCES PubMed, Embase, Web of Science and the Cochrane Library. RESULTS The umbrella review identified 23 meta-analyses of interventional study and observational study. Consistent and robust evidence shown that the ERAS programs can significantly reduce the length of hospital stay (MD: -2.349 days; 95%CI: -2.740 to -1.958) and costs (MD: -$639.064; 95%CI:: -933.850 to -344.278) in all the surgery patients included in the review compared with traditional perioperative care. The ERAS programs would not increase mortality in all surgeries and can even reduce 30-days mortality rate (OR: 0.40; 95%CI: 0.23 to 0.67) in orthopedic surgery. Meanwhile, it also would not increase morbidity except laparoscopic gastric cancer surgery (RR: 1.49; 95%CI: 1.04 to 2.13). Moreover, readmission rate was increased in open gastric cancer surgery (RR: 1.92; 95%CI: 1.00 to 3.67). CONCLUSION The ERAS programs are considered to be safe and efficient in surgery patients. However, precaution is necessary for gastric cancer surgery.
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Affiliation(s)
- Xingxia Zhang
- West China School of Nursing/West China Hospital Gastrointestinal Surgery Department, Sichuan University
| | - Jie Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Xinrong Chen
- West China School of Nursing/West China Hospital Gastrointestinal Surgery Department, Sichuan University
| | - Liang Du
- Chinese Evidence-Based Medicine/Cochrane Center, Chengdu, China
| | - Ka Li
- West China School of Nursing/West China Hospital Gastrointestinal Surgery Department, Sichuan University
| | - Yong Zhou
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
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Utsumi M, Aoki H, Nagahisa S, Nishimura S, Une Y, Kimura Y, Watanabe M, Taniguchi F, Arata T, Katsuda K, Tanakaya K. Preoperative predictive factors of pancreatic fistula after pancreaticoduodenectomy: usefulness of the CONUT score. Ann Surg Treat Res 2020; 99:18-25. [PMID: 32676478 PMCID: PMC7332320 DOI: 10.4174/astr.2020.99.1.18] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/20/2020] [Accepted: 02/13/2020] [Indexed: 12/20/2022] Open
Abstract
Purpose Postoperative pancreatic fistula (POPF) is the most important factor affecting morbidity and mortality after pancreaticoduodenectomy (PD). Patients with a high controlling nutritional status (CONUT) score, which is used to assess nutritional status, are expected to have high morbidity rates. This study aimed to determine the usefulness of the CONUT score. Methods Data from 97 consecutive cases of PD performed in the Department of Surgery of Iwakuni Clinical Center, from April 2008 to May 2018, were included. Preoperative patient data, including sex, age, and hypertension, and postoperative complication data were collected to analyze pancreatic fistula occurrence. Results Of the 97 patients, 2 9 patients (29.8%) were diagnosed with POPF ≥ B, with 26 cases (26.8%) classified as grade B and 3 (3.1%) as grade C. The mortality rate was 2.1% (2 of 97). In the univariate analysis, a significant association was observed between POPF and the following factors: body mass index (BMI) ≥ 22 kg/m2, high CONUT score, nonpancreatic carcinoma, and CT attenuation values. In multivariate analysis, BMI ≥ 22 kg/m2 (odds ratio [OR], 6.16; P < 0.001), high CONUT score (OR, 3.77; P = 0.009), nonpancreatic carcinoma (OR, 5.72; P = 0.009), and CT attenuation values (late/early ratio) in the pancreas (OR, 9.07; P = 0.006) were independent risk factors for POPF. Conclusion Patients with a high CONUT score are at high risk of POPF. Further study correlating preoperative nutritional intervention with risk of POPF is necessary.
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Affiliation(s)
- Masashi Utsumi
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Hideki Aoki
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Seiichi Nagahisa
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Seitaro Nishimura
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Yuta Une
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Yuji Kimura
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Megumi Watanabe
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Fumitaka Taniguchi
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Takashi Arata
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Koh Katsuda
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
| | - Kohji Tanakaya
- Department of Surgery, National Hospital Organization, Iwakuni Clinical Center, Yamaguchi, Japan
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Fung AKY, Chong CCN, Lai PBS. ERAS in minimally invasive hepatectomy. Ann Hepatobiliary Pancreat Surg 2020; 24:119-126. [PMID: 32457255 PMCID: PMC7271107 DOI: 10.14701/ahbps.2020.24.2.119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/23/2020] [Accepted: 01/29/2020] [Indexed: 02/07/2023] Open
Abstract
Open hepatectomy is associated with significant post-operative morbidity and mortality profile. The use of minimally invasive approach for hepatectomy can reduce the post-operative complication profile and total length of hospital stay. Enhanced recovery after surgery (ERAS) programs involve evidence-based multimodal care pathways designed to achieve early recovery for patients undergoing major surgery. This review will discuss the published evidence, challenges and future directions for ERAS in minimally invasive hepatectomy.
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Affiliation(s)
- Andrew K Y Fung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Charing C N Chong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Paul B S Lai
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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Ren QP, Luo YL, Xiao FM, Wen TF, Wu MH, Juan-Wan, Xie ZR. Effect of enhanced recovery after surgery program on patient-reported outcomes and function recovery in patients undergoing liver resection for hepatocellular carcinoma. Medicine (Baltimore) 2020; 99:e20062. [PMID: 32443312 PMCID: PMC7254517 DOI: 10.1097/md.0000000000020062] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The aim of this study was to investigate the effect of enhanced recovery after surgery (ERAS) on perioperative outcomes, with an emphasis on patient-reported outcomes (PROs) and functional recovery.We compared the clinical outcomes in a cohort of 275 patients undergoing liver resection before and after the implementation of ERAS. The PROs were preoperatively and postoperatively compared until 14 days after surgery using the MD Anderson Symptom Inventory.The patients in the ERAS group experienced fewer symptoms and a shorter functional recovery time than the patients in the non-ERAS group. The group × time interactions were different between the groups for pain (F = 4.70, P = .001) and walking (F = 2.75, P = .03). On the 3rd, 4, and 5th days after surgery, the ERAS group experienced less pain and more walking than the non-ERAS group. The ERAS group experienced less fatigue (0.407 [95% confidence interval, CI: -0.795, -0.020], P = .035), less sleep interference (0.615 [95% CI: -1.215, -0.014], P = .045), a lower rate of reduced appetite (0.281 [95% CI: -0.442, -0.120], P = .001), and less abdominal distension (0.262 [95% CI: -0.504, -0.020], P = .034) than the non-ERAS group. Those in the ERAS group had a significantly shorter median time from surgery to mild fatigue (5.41 vs 6.87 days, P = .003), mild pain (4.45 vs 6.09 days, P = .001), mild interference when walking (3.85 vs 5.54 days, P < .001), and mild interference when sleeping (5.49 vs 7.43 days, P < .001). ERAS patients were more likely than non-ERAS patients to achieve a functional recovery (5.70 vs 6.79 days, P < .001) status in a shorter time period. The ERAS pathway, operation time, and the minimally invasive approach were independent predictors of functional recovery time.In hepatocellular carcinoma liver resection patients, the primary mechanism of ERAS is to reduce the postoperative interference burden and promote rapid functional recovery.
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Hajibandeh S, Hajibandeh S, Bill V, Satyadas T. Meta-analysis of Enhanced Recovery After Surgery (ERAS) Protocols in Emergency Abdominal Surgery. World J Surg 2020; 44:1336-1348. [DOI: 10.1007/s00268-019-05357-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Li Q, Li R, Zhang H, Chen T, Cao Y, Deng P, Ruan S, Lin C, Chen N. ERAS Optimization of Cluster Intervention Strategies in Perioperative Period of Acute Stanford Type A Aortic Dissection. Health (London) 2020. [DOI: 10.4236/health.2020.1211106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Noba L, Rodgers S, Chandler C, Balfour A, Hariharan D, Yip VS. Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Improve Clinical Outcomes in Liver Surgery: a Systematic Review and Meta-Analysis. J Gastrointest Surg 2020; 24:918-932. [PMID: 31900738 PMCID: PMC7165160 DOI: 10.1007/s11605-019-04499-0] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 12/11/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are evidence-based, multimodal and patient-centred approach to optimize patient care and experience during their perioperative pathway. It has been shown to be effective in reducing length of hospital stay and improving clinical outcomes. However, evidence on its effective in liver surgery remains weak. The aim of this review is to investigate clinical benefits, cost-effectiveness and compliance to ERAS protocols in liver surgery. METHODS A systematic literature search was conducted using CINAHL Plus, EMBASE, MEDLINE, PubMed and Cochrane for randomized control trials (RCTs) and cohort studies published between 2008 and 2019, comparing effect of ERAS protocols and standard care on hospital cost, LOS, complications, readmission, mortality and compliance. RESULTS The search resulted in 6 RCTs and 21 cohort studies of 3739 patients (1777 in ERAS and 1962 in standard care group). LOS was reduced by 2.22 days in ERAS group (MD = -2.22; CI, -2.77 to -1.68; p < 0.00001) compared to the standard care group. Fewer patients in ERAS group experienced complications (RR, 0.71; 95% CI, 0.65-0.77; p = < 0.00001). Hospital cost was significantly lower in the ERAS group (SMD = -0.98; CI, -1.37 to - 0.58; p < 0.0001). CONCLUSION Our review concluded that the introduction of ERAS protocols is safe and feasible in hepatectomies, without increasing mortality and readmission rates, whilst reducing LOS and risk of complications, and with a significant hospital cost savings. Laparoscopic approach may be necessary to reduce complication rates in liver surgery. However, further studies are needed to investigate overall compliance to ERAS protocols and its impact on clinical outcomes.
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Affiliation(s)
- L. Noba
- School of Health in Social Science, University of Edinburgh, Old College, South Bridge, Edinburgh, EH8 9YL UK
| | - S. Rodgers
- School of Health in Social Science, University of Edinburgh, Old College, South Bridge, Edinburgh, EH8 9YL UK
| | - C. Chandler
- School of Health in Social Science, University of Edinburgh, Old College, South Bridge, Edinburgh, EH8 9YL UK
| | - A. Balfour
- Surgical Services, NHS Lothian, Edinburgh, EH1 3EG UK
| | - D. Hariharan
- Hepato-Pancreato-Biliary (HPB) Unit, Royal London Hospital (Barts Health NHS Trust), London, E1 1FR UK
| | - V. S. Yip
- Hepato-Pancreato-Biliary (HPB) Unit, Royal London Hospital (Barts Health NHS Trust), London, E1 1FR UK
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