Implementing an enhanced recovery program after liver surgery. Lessons from 100 cases

Abstract

Introduction: Implementing an enhanced recovery program (ERP) requires a coherent sequence starting from the preoperative period in order to improve postoperative outcomes. Compliance to the protocol is paramount to ensure protocol success. In the field of liver surgery, risk factors of compliance failure are poorly reported. Methods: Through an ERP (ERAS) dedicated to liver surgery, all consecutive patients who underwent hepatectomy from June to December 2018 were included (n=53). Perioperative outcomes were compared to 50 patients consecutively operated on before June 2018 (pre-ERAS group). Risk factors for compliance failure were identified. Results: There was no difference regarding patient demographics and hepatectomy extent (Table 1). Consequently to the ERP implementation, anaesthesioly and surgery data have evolved with a decrease in intraoperative vascular filling (p=0.005), estimated blood loss (p=0.082) and intraoperative drain (p<0.001). Postoperative time to deperfusion, oral feeding and bowel function recovery significantly decreased in the ERAS group (p=0.001). Postoperative severe morbidity rate (p=0.087) and inhospital length of stay (p=0.031) reduced significantly in the ERAS group. Compliance failure rate was higher in the postoperative period (48%), as compared to preoperatively (30%) and intraoperatively (20%, p<0.001). Upon univariate analysis, ASA>2, extended hepatectomy, low hemoglobin and albumin levels, high intraoperative vascular filling an estimated blood loss were associated with postoperative compliance failure. Upon multivariable analysis, ASA>2 (OR=4.765, p=0.015) and extended hepatectomy (OR=2.864, p=0.014) were independently associated with postoperative compliance failure. Conclusion: After implementing an ERP for liver surgery, peroperative and intraoperative practices have significantly changed, translating into improved postoperative outcomes. Postoperative compliance to the protocol remains challenging to reach, especially in frail patients and after extended hepatectomy. Prehabilitation to control preoperative factors could help improving outcomes.