1. 3 Hepatic Insufficiency
Enhanced Recovery Liver Resection Surgery: a single blinded randomised controlled trial
Jones C1, Kelliher L 1, Dickinson M 1, Scott M1, Vandravela T, Karanjia N2, Worthington T2, Quiney N1.
1Department of Anaesthesia. 2Department of Hepatopancreatobiliary Surgery. Royal Surrey County Hospital NHS Trust. UK
Background
Results (cont.)
Enhanced Recovery Programs (ERP’s) were first introduced in open colorectal surgery where they have been shown to reduce postoperative length of stay (PLoS) and complications [1,2]. However there is limited evidence to show whether they provide the same benefit in liver resection surgery. To date there have been no prospective trials, only two small pilot studies [3,4] using some aspects of ERP’s for liver resection surgery. We have therefore designed a comprehensive ERP to see if short term recovery and morbidity can be improved with the introduction of an ERP for open liver resection.
(Median+IQR)
ERP
Standard group
Time to readiness for Discharge
4 (3-4.5)
6 (5.25-7)
Actual Length of stay
4 (3-5)
7 (6-8)
Table 2: Postoperative Length of Stay, in days (Median & Interquartile Range)
ERP
Standard group
Extended Right Hemi-hepatecomy 4 1
Right Hepatectomy 6
Left Hepatectomy 2
Tri-segmentectomy
Bi-segmentectomy 7
Segmentectomy 3
Wedge resections 5 8
Weight of specimen (grams – median)
649
188
Blood loss (mls – median)
530
341
Methods
This is a single blinded randomised controlled trial, looking at all adult patients undergoing elective liver resection. Patients are randomised by sealed envelopes into either ER group or Control (standard) group. Group allocation will be unblinded to the patients and researchers, but to reduce bias both groups will be treated using strict protocols. Two independent assessors (blinded to group allocation) will assess readiness for discharge using strict criteria: good pain control with oral analgesia, tolerance of solid food, independently mobile, normal or decreasing serum bilirubin, and patient willing to be discharged. The key differences between the two groups are that the ER group received extra preoperative education, carbohydrate loading and nutritional supplements, post-resection goal-directed fluid therapy (using LiDCOrapid™) and early mobilization and physiotherapy. Morbidity was measured using POMS, an 18 item valid and reliable measure addressing nine domains of postoperative morbidity [5].
Table 3: Operational details
ERP
Standard group
Morbidity
(POMS)
1 Infectious
1 Neurological
3 GI
2 Infectious
1 CVS
Surgical complications
3 Hepatic Insufficiency
2 Bile Leak
2 Bile leak
Mortality 1
Readmissions 2
Results
Table 4: Complications
Results are available for the first 50 patients (out of the 90 needed to power the study), 25 in each group.
Conclusions
ERP
Standard group
Age years (mean + SD)
58.9 (10.6)
66.9 (12.7)
Gender M:F
16:9
15:10
BMI (kg/m2) mean
25.9
27.0
Pathology
Colorectal Liver Mets 17 16
Other Metastatic Dx 6 4
Benign Dx 2 5
Based on a historical average PLoS of 9 days and morbidity of 23.7% the ERP has reduced this stay to an average of 4 days with only 5 (20%) of patients having a surgical complication or morbidity, (versus 7 patients (28%) in the standard group.
ERP for liver resection surgery appears safe and can reduce Postoperative Length of Stay.
Table 1: Patient demographic details
References
23-hour-stay Laparoscopic Colectomy. Levy BF, Scott MJ, Fawcett WJ, Rockall TA. Diseases of the Colon & Rectum July 2009;52(7):
The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Varadhan KK, Neal KR, Dejong CHC, Fearon KCH, Ljungqvist O, Lobo DN. Clinical Nutrition 2010;29(4):
The effect of a multimodal fast-track programme on outcomes in laparoscopic liver surgery: a multicentre pilot study. Stoot JH, van Dam RR et al. HPB 2009;11:
Initial experience with a multimodal enhanced recovery programme in patients undergoing liver resection. Van Dam RM, Hendry PO et al. British Journal of Surgery 2008;95:
The postoperative Morbidity Survey was validated and used to describe morbidity after major surgery. Grocott MP, Browne JP, Van der Meulen et al. J Clin Epidemiol. 2007;60(9):919-28