Biological impact of an enhanced recovery after surgery programme in liver surgery

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.

Enhanced recovery after liver surgery in cirrhotic patients: a systematic review and meta-analysis

“…non-ERAS protocols for liver surgery were identified. Many of those studies included cirrhotic patients, but only five studies included cirrhotic patients only or had a subgroup analysis of cirrhotic patients, and could be included in the meta-analysis (Lunel et al 2021 ; Gonvers et al 2021 ; Qi et al 2018 ; Zheng et al 2020 ; Zhou et al 2021 ). If the terms “liver cancer” or “hepatocellular carcinoma” were taken into account in the search equation, no further article to include was found.…”

“…Three of four observational studies had prospective data collection. The surgical approach was laparoscopic and open liver resection for 4 studies (Lunel et al 2021 ; Gonvers et al 2021 ; Qi et al 2018 ; Zheng et al 2020 ), and laparoscopic only for 1 study (Zhou et al 2021 ). The 5 studies included a total of 1467 patients.…”

An algorithm based on the postoperative decrease of albumin (ΔAlb) to anticipate complications after liver surgery

“…As example of potential clinical application, it may help guiding decision whether to transfer patients to intensive care unit (ICU), intermediate care, or to the ward. Recent data from our group also highlighted the interest of following ERAS guidelines for liver surgery, showing a significantly lower ΔAlb in patients undergoing liver surgery with ERAS, compared to non-ERAS management (Gonvers et al 2021). Other important potential application would be to select patients who should benefit from specific therapeutic measures which would have to be tested with randomized clinical trials.…”

Postoperative decrease of albumin (ΔAlb) as early predictor of complications after gastrointestinal surgery: a systematic review

“…In liver surgery, ERAS has been shown to decrease ΔAlb compared to non-ERAS patients (median ΔAlb: 12 vs . 16 g/l, p < 0.001) (Gonvers et al, 2021 ).…”