Adherence to early mobilisation: Key for successful enhanced recovery after 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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Cited by (41)
Erector spinae plane block versus subcostal transversus abdominis plane block in patients undergoing open liver resection surgery: A randomized controlled trial
2023, Anaesthesia Critical Care and Pain MedicineCitation 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 power of suction: Theory and practice in closed suction vs gravity drains and postoperative pancreatic fistulas
2022, American Journal of SurgeryCitation 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.
Progress in hepatectomy for hepatocellular carcinoma and peri-operation management
2020, Genes and DiseasesExploring the relation between preoperative physical functioning and the impact of major complications in patients following pancreatic resection
2020, HPBCitation 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