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

Abstract

Background: Recent developments in perioperative pathophysiology and care have documented evidence-based, multimodal rehabilitation (fast-track) to hasten recovery and to decrease morbidity and hospital stay for several major surgical procedures. The aim of this study was to investigate the effect of introducing fast-track principles for perioperative care in unselected patients undergoing open or laparoscopic liver resection.Methods: This was a prospective study involving the first 100 consecutive patients who followed fasttrack principles for liver resection. Catheters and drains were systematically removed early, and patients were mobilized and started eating and drinking from the day of surgery. An opioid-sparing multimodal pain treatment was given for the first week. Discharge criteria were: pain sufficiently controlled by oral analgesics alone, patient comfortable with discharge and no untreated complications. Results: Median length of stay (LOS) for all patients was 5 days, with 2 days after laparoscopic versus 5 days following open resection (P < 0·001). Median LOS after minor open resections (fewer than 3segments) was 5 days versus 6 days for major resections (3 or more segments) (P < 0·001). Simple right or left hemihepatectomies had a median LOS of 5 days. The readmission rate was 6·0 per cent and 30-day mortality was zero.Conclusion: Fast-track principles for perioperative care were introduced successfully and are safe after liver resection. Routine discharge 2 days after laparoscopic resection and 4-5 days after open liver resection may be feasible.

Abandoning Prophylactic Abdominal Drainage after Hepatic Surgery: 10 Years of No-Drain Policy in an Enhanced Recovery after Surgery Environment

“…Finally, hospital LOS in other studies was longer [41] . The ERAS programme could explain this faster recovery [21,42] .…”

Patient outcomes and provider perceptions following implementation of a standardized perioperative care pathway for open liver resection

“…Although the introduction of standardized perioperative care pathways promoting best practices has accelerated recovery following other types of surgical procedure, data evaluating the implementation of similar best practices following liver surgery are lacking 4,6,11 . The few studies assessing ERAS protocols following liver surgery have demonstrated improved perioperative outcomes, but these reports are limited in their generalizability, small sample size and lack of adequate controls for comparison 5,12 . Given this, an evidence-based and standardized perioperative care pathway was designed and implemented prospectively among patients undergoing open liver surgery.…”

“…Initially introduced in the mid-1990s, the enhanced recovery after surgery (ERAS) programme represents one such paradigm designed to reduce the surgical stress response and accelerate postoperative recovery 3 . Promoting the adoption of evidence-based best practices, ERAS programmes focus on patient education, goal-directed fluid management, decreased use of unnecessary nasogastric tubes and peritoneal drains, minimal use of opioid analgesia, as well as early mobilization and resumption of oral intake 1,3,5,6 . Widely adopted for colorectal and orthopaedic surgery, these programmes have been effective in reducing length of stay and morbidity while improving the value of care and patient satisfaction after surgery 1,2,7 .…”

Laparoskopische Leberchirurgie

“…Die durch die laparoskopische Operation bereits deutlich verkürzte Erholungszeit [8,17,21] kann durch adäquate Anäs-thesieverfahren mit Periduralkatheter, frühzeitige Mobilisation und Ernährung sowie die frühzeitige Entfernung aller invasiven Zugänge noch weiter abgesenkt werden [22,26] Weitere Entwicklungen der minimalinvasiven Leberchirurgie gehen mit der Entwicklung von Robotersystemen einher [30]. Hier ist die Bedeutung bisher nicht absehbar.…”