Adherence to early mobilisation: Key for successful enhanced recovery after liver resection

doi:10.1016/j.ejso.2016.07.015

European Journal of Surgical Oncology (EJSO)

Volume 42, Issue 10, October 2016, Pages 1561-1567

https://doi.org/10.1016/j.ejso.2016.07.015 Get rights and content

Abstract

Background

Enhanced Recovery After Surgery (ERAS) has been proven effective in liver surgery. Adherence to the ERAS pathway is variable. This study seeks to evaluate adherence to key components of an ERAS protocol in liver resection, and identify the components associated with successful clinical outcomes.

Method

All patients undergoing liver resections for two consecutive years were included in our ERAS pathway. Six key components of ERAS included preoperative assessment, nutrition and gastrointestinal function, postoperative analgesia, mobilisation and discharges. Successful accomplishment of ERAS was defined as hospital discharge by postop day (POD) 6. Adherences of these elements were compared between the successful and un-successful groups.

Results

During the studied period, 223 patients underwent liver resections, among which 103 had major hepatectomies. N = 147 patients (66%) were discharged within our ERAS protocol target (6 days). On multivariable analysis, sitting out of bed by POD 1 (p < 0.03), walking by POD 3 (p = 0.03), removal of urinary catheter by POD 3 (p < 0.01), and avoiding major complications (p < 0.01) were factors associated with successful completion to our ERAS protocol; whereas advanced age (p = 0.34) and discontinuation of PCA/epidural by POD 3 (p = 0.50) were not significant parameters. There was a significant difference in the length of stay (p < 0.01) following major and minor liver resection, of which the indications for surgery also varied significantly. There was no difference in hospital re-admission rate, and morbidity and mortality between major and minor liver resection.

Conclusions

Facilitating early mobilisation and reducing postoperative complications are keys to successful outcomes of ERAS in liver resection.

Introduction

Enhanced Recovery After Surgery (ERAS) is a ‘fast-track’ recovery process that has been proven effective in liver surgery as well as a variety of clinical settings including colorectal, urological and vascular surgery.1, 2, 3, 4, 5 It has been shown to be effective in reducing complications, hospital stay, and delivery cost efficiency for surgical care.⁵ It focuses in utilising a multimodal recovery strategy to minimise trauma of surgery, and accelerate postoperative recovery.⁶

Uptake of ERAS in liver surgery was slower to other surgical specialties owing to concerns adopting its methods. A systematic review in 2012 identified only six studies on ERAS during hepatobiliary surgery,⁷ and all of these studies were limited in terms of patient numbers.⁸ More recently, larger series have been published on ERAS following hepatectomy.2, 9, 10, 11 However, despite reporting on ‘consecutive hepatectomies’, with the exception of Dunne et al., all these series had exclusion criteria, including biliary reconstruction, hilar cholangiocarcinoma, and advanced age.9, 10, 11 The majority of these studies aimed to evaluate whether ERAS was feasible following liver surgery. A limited number of studies reported the outcomes of a true consecutive cohort of patients undergoing hepatectomy within an ERAS program.11, 12

Having all these multimodal approaches combined into a single clinical pathway, it is difficult to fully ascertain which key components within the pathway dictate outcome. This study seeks to evaluate adherence to key components of an ERAS protocol in liver resection, and identify the components associated with successful clinical outcomes.

Section snippets

Study cohort

We fully implemented our ERAS pathway for all patients undergoing hepatectomies in May 2010.² Our ERAS pathway has previously been described but is summarised in Table 1.²

All patients undergoing elective hepatectomy, including both laparoscopic and open surgeries, between May 2010 and June 2012 were included in our study. All data were prospectively collected. Data collected included adherence to six key elements of the ERAS protocol. These are preoperative assessment, operative factors,

Study population

During the studied period, 223 patients underwent hepatectomy within the ERAS program, of which 167 resections were for colorectal liver metastases, 15 for benign liver disease, 27 for hilar/intra-hepatic cholangiocarcinoma, and 17 for hepatocellular carcinoma (HCC). Among the 167 patients for colorectal liver metastases, 3 had laparoscopic liver resections. Median age was 67 years (range: 28–87). Of these 223 patients, 103 (46.2%) had a major hepatectomy, and 150 (67.3%) of them were male (see

Discussion

Achieving early mobilisation and early removal of urinary catheters were key to a successful ERAS pathway and early discharge following liver surgery. This is dependent on the avoidance of postoperative complications, as would be expected logically. However, age does not preclude patients from the enrolment to ERAS following hepatectomy.

Early mobilisations by sitting the patient out of bed by POD 1, and walking by POD 2 were associated with a successful adherence to ERAS criteria. In colorectal

Conflict of interest

None declared.

Source of funding

Self-funded.

Ethical approval

Ethical approval is not required for this study.

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Enhanced recovery after surgery in patients undergoing craniotomy: A meta-analysis
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Enhanced recovery after surgery (ERAS) is a multidisciplinary,and evidence-based perioperative care method. It is effective in shortening hospital stays and improving clinical outcomes. However, the application of ERAS in craniotomy lacks reliable evidence. The purpose of this study is to investigate the efficacy and safety of ERAS in craniotomy.
Studies of ERAS in craniotomy were systematically searched in PubMed, Embase, Cochrane, and Web of Science. Primary outcomes (total hospital stay and postoperative hospital stay, hospitalization cost, percent of patients with moderate to severe pain) and secondary outcomes (readmission rate and incidence of complication) were compared between ERAS and traditional perioperative care.
Of the 10 studies included in this meta-analysis, 6 were randomized-controlled trials (RCTs), 3 were cohort studies, and 1 was non-RCT. A total of 1275 patients were included, with 648 in the ERAS group and 627 in the control group. Compared with the control group, the ERAS group had a significantly shortened total length of stay (LOS) (MD = -2.437, 95% CI: −3.616, −1.077, P = 0.001) and postoperative LOS, reduced hospitalization cost (SMD = -0.631, 95% CI: −0.893, −0.369, P = 0.001), and lower percent of patients with moderate to severe pain. There was no significant difference in readmission rate between the two groups. Though, the ERAS group had a significantly lower risk of pneumonia than the control group.
ERAS is safe and effective for craniotomy as it shortens total and postoperative LOS, reduces hospitalization costs, decreases the percent of patients with moderate to severe pain.
Efficacy of prolonged intravenous lidocaine infusion for postoperative movement-evoked pain following hepatectomy: a double-blinded, randomised, placebo-controlled trial
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The analgesic effect of intravenous lidocaine varies with the duration of lidocaine infusion and surgery type. We tested the hypothesis that prolonged lidocaine infusion alleviates postoperative pain in patients recovering from hepatectomy over the first 3 postoperative days.
Patients undergoing elective hepatectomy were randomly assigned to receive prolonged i.v. lidocaine treatment or placebo. The primary outcome was incidence of moderate-to-severe movement-evoked pain at 24 h postoperatively. The secondary outcomes included incidence of moderate-to-severe pain during movement and at rest throughout the first 3 postoperative days, postoperative opioid consumption, and pulmonary complications. Plasma lidocaine concentration was also monitored.
We enrolled 260 subjects. Intravenous lidocaine lowered the incidence of moderate-to-severe movement-evoked pain at 24 h and 48 h postoperatively (47.7% vs 67.7%, P=0.001; 38.5% vs 58.5%, P=0.001) and reduced movement-evoked pain scores (3.7 [1.7] vs 4.2 [1.6]; mean difference 0.5 [95% confidence interval {CI}: 0.1–0.9]; P=0.018) and morphine equivalent consumption (47.2 [16.7] mg vs 52.6 [19.2] mg; mean difference 5.4 mg [95% CI: 1.0–9.8]; P=0.016) at 24 h postoperatively. Lidocaine also lowered the incidence of postoperative pulmonary complications (23.1% vs 38.5%; P=0.007). Median plasma lidocaine concentrations were 1.5, 1.9, and 1.1 μg ml⁻¹ (inter-quartile ranges: 1.1–2.1, 1.4–2.6, and 0.8–1.6, respectively) after bolus injection, at the end of the surgery, and 24 h postoperatively.
Prolonged intravenous lidocaine infusion reduced the incidence of moderate-to-severe movement-evoked pain for 48 h after hepatectomy. However, the reduction in pain scores and opioid consumption by lidocaine was below the minimal clinically important difference.
NCT04295330.
Erector spinae plane block versus subcostal transversus abdominis plane block in patients undergoing open liver resection surgery: A randomized controlled trial
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Citation Excerpt :
Liver resection surgery is usually performed through either right subcostal or inversed l-shaped incision; both approaches are associated with significant postoperative pain. Therefore, intensive analgesic plan is essential to facilitate early mobilization and minimize complications [1]. The current guidelines recommended to include a regional anaesthetic technique, such as thoracic epidural or subcostal transversus abdominis plane block (TAPB), into the multimodal analgesia protocol to optimise pain management and reduce opioids consumption.
The aim of this study was to compare the analgesic efficacy of erector spinae plane block (ESPB) in relation to subcostal transversus abdominis plane block (TAPB) in patients undergoing open liver resection surgery.
In this randomized controlled trial, we included adult patients undergoing open liver resection surgery. After induction of general anaesthesia, the included patients were randomized to receive either ESPB (n = 30) or subcostal TAPB (n = 30). Postoperative pain was assessed using the numeric rating scale (NRS) at rest and during cough. Intravenous morphine boluses were used for management of breakthrough pain intra- and postoperatively. The study’s primary outcome was morphine consumption during the first 24 h postoperatively. Secondary outcomes included intraoperative morphine consumption, time to first postoperative morphine requirement, incidence of complications, and patient satisfaction.
Sixty patients were included and were available for the final analysis in this study. The intra-and postoperative morphine consumption were less in the ESPB group than the subcostal TAPB group (median [quartiles] morphine dose: 0 [0−0] vs 2 [0−5] mg, p = 0.007 and 20 [15–20] vs 25 [20−30] mg, p = 0.006, respectively). The time to first morphine requirement was longer in the ESPB group (median [quartiles]: 6.5 [5.5−6.5] h) than the subcostal TAPB group (median [quartiles]: 4.3 [1.0−6.5] h), P = 0.013. Patients in the ESPB group had lower incidence of sedation and higher level of satisfaction than the subcostal TAPB group.
In patients undergoing open liver resection surgery, ESPB provided superior analgesic properties than subcostal TAPB.
Clinical trial registration: NCT05253079, Principal investigator: Maha Mostafa, Date of registration: February 23, 2022.
URL: https://clinicaltrials.gov/ct2/show/NCT05253079
The power of suction: Theory and practice in closed suction vs gravity drains and postoperative pancreatic fistulas
2022, American Journal of Surgery
Citation Excerpt :
Suction drains utilize a negative pressure gradient to maintain suction within the abdomen, independent of positioning, while gravity drainage devices provide a route for fluid extraction due to the pressure differential between intra-abdominal and atmospheric pressure. The presence of surgical drains has been shown to hinder post-operative mobilization,5 and ERAS pathways commonly suggest minimizing surgical drain placement when appropriate.6 Whether the specific attributes of GDs and CSDs impact ease of care and alters patients’ ability to mobilize remains unclear, and preferences for drain method vary between providers.
Postoperative pancreatic fistula (POPF) is a feared complication in pancreatic resection. Gravity drainage (GD) is hypothesized to reduce POPF versus closed-suction drainage (CSD). We sought to evaluate this theory.
Six-hundred-twenty-nine patients undergoing pancreatic resection between 2013 and 2020 were analyzed with multivariable logistic regression for the outcomes of POPF and clinically-relevant POPF (crPOPF).
Three-hundred-ninety-seven patients (63.1%) underwent pancreaticoduodenectomy and 232 (36.9%) underwent distal pancreatectomy. Suction drains were placed in 588 patients (93.5%) whereas 41 (6.5%) had GDs. One-hundred-twenty-five (27.6%) experienced a POPF; 49 (10%) crPOPFs. On multivariable analysis, suction drainage was not associated with increased risk of POPF (OR 0.76, 95% CI 0.30–1.93, P = 0.57) or crPOPF (OR 0.99, 95% CI 0.30–3.26, P = 0.98).
Suction drainage does not promote POPF when compared to GDs. Drain type should be determined by surgeon preference, while taking into account nursing and patient-specific considerations especially when patients are discharged with drains.
Progress in hepatectomy for hepatocellular carcinoma and peri-operation management
2020, Genes and Diseases
The global incidence of liver cancer continues to grow. Liver cancer, especially hepatocellular carcinoma, has high recurrence and mortality rates. Here, we review the past decade's diagnostic, therapeutic, and management strategies for hepatocellular carcinoma, and summarize new patient management approaches, including enhanced recovery after surgery, targeted therapy, and immunotherapy. We compare traditional and innovative management methods, which comprise developments in precision medicine, and consider their limitations. Ongoing innovation and technological advances enable surgeons to gain deeper understandings of the multidimensionality of hepatocellular carcinoma, thereby promoting the continuous development of precision therapy.
Exploring the relation between preoperative physical functioning and the impact of major complications in patients following pancreatic resection
2020, HPB
Citation Excerpt :
Postoperatively, patients were admitted to the HPB surgical ward as soon as possible, unless admission to the intensive care unit was warranted due to intra-operative events or postoperative complications. All patients received postoperative physical therapy once a day (starting at postoperative day 1) focusing on airway clearing exercises and regaining functional independence by early mobilisation, adapted to the individual patient's needs and progress.28–30 Recovery of physical functioning was monitored using the modified Iowa level of assistance scale (mILAS), scoring on the ability to perform five functional tasks.31,32
This study aimed to evaluate the association between preoperative level of physical functioning and time to recovery of physical functioning, postoperative complications, and the impact of postoperative major complications in patients undergoing elective pancreatic resection. Additionally, prediction models to identify high-risk patients for developing a major complication were externally validated.
Perioperative data of patients who underwent pancreatic resection were analysed. Primary outcomes were time to recovery of physical functioning and postoperative major complications. Impact of a major complication was explored by evaluating its effect on time to recovery of physical functioning. Risk-prediction models were retrieved following a systematic review.
Multivariable analysis (n = 63) showed that ASA grade III (OR 3.498) and preoperative platelet count (OR 1.005) were associated with major complications, whereas aerobic capacity (OR 0.347) was associated with time to recovery of physical functioning. Age, preoperative aerobic capacity, functional mobility, and perceived level of functional capacity were associated with the impact of a major complication. The AUC of two risk prediction models were 0.556 and 0.701.
Preoperative parameters of physical function were associated with postoperative outcomes and may be useful in outcome prediction, although future approaches should not only register the incidence of major complications but also take the impact of a complication on a patient's physical functioning into account.

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Adherence to early mobilisation: Key for successful enhanced recovery after liver resection

Abstract

Background

Method

Results

Conclusions

Introduction

Section snippets

Study cohort

Study population

Discussion

Conflict of interest

Source of funding

Ethical approval

HPB (Oxf)

Urology

Surgery

Br J Anaesth

HPB (Oxf)

Eur J Surg Oncol

HPB (Oxf)

Enhanced recovery in the resection of colorectal liver metastases

J Surg Oncol

Optimal clinical pathway for the patient with type B acute aortic dissection

Circ J

Enhanced recovery programmes in hepatobiliary and pancreatic surgery: a systematic review

Ann R Coll Surg Engl

Randomized clinical trial on enhanced recovery versus standard care following open liver resection

Br J Surg

Evaluation of a fast-track programme for patients undergoing liver resection

Br J Surg

Enhanced recovery protocol after liver resection

Br J Surg

Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey

Ann Surg

Nomenclature of hepatic anatomy and resections: a review of the Brisbane 2000 system

J Hepatobiliary Pancreat Surg