Effects of multimodal fast-track surgery on liver transplantation outcomes

Rao JH, Zhang F, Lu H, Dai XZ, Zhang CY, Qian XF, Wang XH, Lu L. Hepatobiliary Pancreat Dis Int. 2017 Aug 15;16(4):364-369

What is already known:

Originally starting with colorectal surgery, ERAS protocols now exist for a huge number of different specialities and procedures. Liver transplantation is one the latest to be added to this list.

What this paper adds:

ERAS society guidelines currently don’t exist for liver transplantation, so the authors wrote their own. They stuck to the essential elements of preoperative education, minimising hypothermia, avoiding surgical drains, early extubation, early mobilisation and early enteral nutrition. The authors conducted a single-blinded randomised controlled trial. It is unclear who exactly is blinded but there is a suggestion it could be the patient. 128 patients were randomised over a two year period, into their new fast-tract protocol or their normal standard care. They demonstrated an impressive reduction in their ICU length of stay and hospital length of stay (5 days to 2 days, and from 28 days to 18 days). However there were no difference in complications, readmissions or mortality. Suggesting that at the very least an ERAS pathway for liver transplantation is feasible and safe.

Chris Jones, Guildford. @chrisnjones 


Minor laparoscopic liver resection: toward 1-day surgery?

de’Angelis N, Menahem B, Compagnon P, Merle JC, Brunetti F, Luciani A, Cherqui D, Laurent A. Surg Endosc. 2017 Nov;31(11):4458-4465

What is already known:

Twenty-four hour stays have been reported in specialities such as colorectal, robotic gynaecology surgery and even robotic prostate surgery. Liver surgery however has traditionally always been performed as open surgery, with prolonged lengths of stay and high potential for morbidity. But as laparoscopic techniques improve then that perception can and will change.

What this paper adds:

This was a small French cohort study of 24 patients undergoing minor (<3 segments) Laparoscopic Liver Resection. They all followed a comprehensive ERAS programme with a standardised anaesthetic and analgesic protocol. All were discharged on post-operative day one, less than 24 hours post-op. There were no complications, although there was 1 readmission (4.2%) who required antibiotics for a wound abscess. Demonstrating that even for potentially high-risk surgery, day stay is possible.

Chris Jones, Guildford. @chrisnjones 


Enhanced recovery in liver surgery decreases postoperative outpatient use of opioids.

Lillemoe HA et al (2019) Enhanced recovery in liver surgery decreases postoperative outpatient use of opioids. Surgery. May 15. pii: S0039-6060(19)30074-1. 

What is already known?

The opioid epidemic, as it has come to be known, is a worsening global crisis. The problem appears to largely stem from high rates of opioid prescriptions and patients stockpiling and passing-on prescribed opioids to other users both of which conspire towards addiction. One of the main principles of ERAS is that if multi-modal analgesia equating to opioid-sparing. Many studies have shown a reduction in the use of opioids in the immediate perioperative period in patients enrolled on an ERAS programme. There is currently no evidence that this has translated into a reduction in opioid use post-hospital discharge. There is, in fact, a suggestion that the opposite may be true in view of patients on ERAS programmes leaving hospital earlier with higher analgesia requirements at the point of discharge.

What this paper adds:

The authors believe this to be the first paper looking at post-discharge prescriptions and use of opioids at the first follow-up appointment for patients having undergone major oncological surgery – namely liver resection surgery. The paper demonstrates a startling reduction in prescriptions for “traditional” opioids in patients following an ERAS pathway (26% versus 79% in patients following standard care). By the first follow-up appointment significantly fewer patients in the ERAS group were taking “traditional” opioids. Both groups, however, reported similar pain scores at this stage of their treatment. The authors point out that the dramatic reduction in opioid prescriptions results in far fewer opioid pills being potentially available in the community to pass-on to other users. ERAS patients were more likely to be prescribed tramadol (a non-“traditional” opioid with comparatively little addictive potential). This, in turn, meant they were substantially less likely to require more addictive opioids, if any opioids at all, by first follow-up. This paper demonstrates the importance of continuing the principles of ERAS beyond the immediate post-operative period and the potential public health improvements this can lead to.

Ben Morrison, Guildford


Enhanced recovery after surgery programs versus traditional perioperative care in laparoscopic hepatectomy

Yang R, Tao W, Chen YY, Zhang BH, Tang JM, Zhong S, Chen XX. Enhanced recovery after surgery programs versus traditional perioperative care in laparoscopic hepatectomy: A meta-analysis. Int J Surg. 2016 Dec;36(Pt A):274-282.

What is already known:

Multiple published trials, including a recent meta-analysis (Song et al 2016) have highlighted the benefits of implementing ERAS programs in patients undergoing open hepatectomy. However, with an increasing number of centers now moving towards a laparoscopic approach the evidence for using such programs within this cohort is less well established.

What this paper adds:

This meta-analysis, which includes 8 studies (3RCT and 5CCT), showed no significant difference when applying ERAS principles to intra-operative complications including blood loss, blood transfusion requirement and intra-operative surgical time. There was however a significant improvement in post-operative recovery with a reduced time to first oral intake, flatus and a decreased post-operative stay and complication rate. Re-admission rates were not analysed due to the lack of data in the reviewed studies and variance in study protocols.

Further studies may be required to determine the optimal ERAS protocol for patients undergoing a laparoscopic hepatectomy.

Emma Stewart, Guildford.


Safety of an Enhanced Recovery Pathway for Patients Undergoing Open Hepatic Resection

Clark CJ, Ali SM, Zaydfudim V, Jacob AK, Nagorney DM. Safety of an Enhanced Recovery Pathway for Patients Undergoing Open Hepatic Resection. PLoS One. 2016 Mar 7;11(3):e0150782.

What is already known:

There are several published studies relating to ERAS for open liver resection and a recent meta-analysis (Zhao et. al. 2017) demonstrated reduced hospital length of stay, time to first flatus and complications following implementation of an ERAS programme.

What this paper adds:

This retrospective observational cohort study did not demonstrate improvements in hospital length of stay or complication rates as others looking into ERAS for open liver resection have done. The study suggested that complication rates and ICU admissions were lower, albeit not statistically significant. The primary conclusion was that ERP implementation was safe in open liver resection. The study was limited to a single-surgeon and did not monitor compliance to the ERP protocol.

Ben Morrison, Guildford.


Outcomes after ERAS for liver resection surgery

Hughes MJ, Chong J, Harrison E, Wigmore S. Short-term outcomes after liver resection for malignant and benign disease in theage of ERAS. HPB (Oxford). 2016 Feb;18(2):177-82.

What is already known:

Predictors of postoperative morbidity have been studied at length over the years but there is less evidence for predictors of morbidity in patients undergoing ERAS programmes.

What this paper adds:

This is a retrospective study in a unit that is experienced in ERAS for liver surgery. In over 600 patients, using univariate and multivariate analysis, they found that only extended (liver) resection was a predictor of morbidity within an ERAS program for open liver resection surgery.

Chris Jones, Guildford.


How does implementing an ERAS program in one speciality affect other specialities?

Labgaa I, Jarrar G, Joliat GR, Allemann P, Gander S, Blanc C, Hübner M, Demartines N. Implementation of Enhanced Recovery (ERAS) in Colorectal Surgery Has a PositiveImpact on Non-ERAS Liver Surgery Patients. World J Surg. 2016 May;40(5):1082-91.

What is already known:

The majority of ERAS studies only look at the outcomes of the individual speciality being examined. This looks at the impact on different specialities undergoing different operations but being looked after on the same post-operative ward.

What this paper adds:

In this retrospective Swiss paper, a colorectal ERAS programme was introduced (but not for liver resection patients), and outcomes of all patients compared before the introduction of an official liver ERAS programme. Overall complication rates did not change but major complications were significantly reduced. Length of stay was reduced by 2 days without increasing readmission rates.

It demonstrates that a successful ERAS program in one speciality can have unintended benefits in other unrelated specialities, presumably by a Hawthorne type effect.

Chris Jones, Guildford.