Effect of early enteral nutrition after hepatectomy in hepatocellular carcinoma patients

Enhanced recovery after hepatopancreaticobiliary surgery: A single-center case control study

Backgrounds/Aims

The aim of this study was to find the safety and effectiveness of enhanced recovery after surgery (ERAS) in patients who undergo hepatopancreaticobiliary (HPB) surgeries and its association with the postoperative complications and survival rate of the patients.

Methods

This study was conducted on patients who underwent HPB surgeries in Imam Khomeini Hospital Complex, Iran from 2018 to 2020. Patients who underwent surgery after from 2019 to February 2020 considered as the ERAS group (n=47) in which ERAS was implemented postoperatively including removing nasogastric tube and initiating surgical diet at 6 hours post operation, and removing intraabdominal drains and Foley catheter at postoperative day one. Other patients (n=43) were considered as the control group in which conventional postoperative care was implemented.

Results

Ninety patients with the mean age of 47.3±13.3 yrs/old (range= 17-76) including 39 females were enrolled into the study. There were no significant differences between the demographic and preoperative comorbidities between the two groups. Pain severity of the patients in the ERAS group was significantly lower than the control group (visual analogue scales of 3.4±0.77 vs. 4.47±0.88, p<0.001). However, there were no significant differences between the other postoperative data between the two groups. One patient in each group died during hospitalization period due to myocardial infarction.

Conclusions

ERAS may be safe and effective in patients who undergo HPB surgery and may be associated with less severe postoperative pain.

ENHANCED RECOVERY (ERAS) AFTER LIVER SURGERY:COMPARATIVE STUDY IN A BRAZILIAN TERCIARY CENTER

BACKGROUND

After the publication of the first recommendations of ERAS Society regarding colonic surgery, the proposal of surgical stress reduction, maintenance of physiological functions and optimized recovery was expanded to other surgical specialties, with minimal variations.

AIM

To analyze the implementation of ERAS protocols for liver surgery in a tertiary center.

METHODS

Fifty patients that underwent elective hepatic surgery were retrospectively evaluated, using medical records data, from June 2014 to August 2016. After September 2016, 35 patients were prospectively evaluated and managed in accordance with ERAS protocol.

RESULTS

There was no difference in age, type of hepatectomy, laparoscopic surgery and postoperative complications between the groups. In ERAS group, it was observed a reduction in preoperative fasting and in the length of hospital stay by two days (p< 0.001). Carbohydrate loading, j-shaped incision, early oral feeding, postoperative prevention of nausea and vomiting and early mobilization were also significantly related to ERAS group. Oral bowel preparation, pre-anesthetic medication, sub-costal incision, prophylactic nasogastric intubation and abdominal drainage were more common in control group.

CONCLUSION

Implementation of ERAS protocol is feasible and beneficial for health institutions and patients, without increasing morbidity and mortality.

Red blood cell transfusion in liver resection

BACKGROUND

Several modalities exist for the management of hepatic neoplasms. Resection, the most effective approach, carries significant risk of hemorrhage. Blood loss may be corrected with red blood cell transfusion (RBCT) in the short term, but may ultimately contribute to negative outcomes.

PURPOSE

Using available literature, we seek to define the frequency and risk factors of blood loss and transfusion following hepatectomy. The impact of blood loss and RBCT on short- and long-term outcomes is explored with an emphasis on peri-operative methods to reduce hemorrhage and transfusion.

RESULTS

Following hepatic surgery, 25.2-56.8% of patients receive RBCT. Patients who receive RBCT are at increased risk of surgical morbidity in a dose-dependent manner. The relationship between blood transfusion and surgical mortality is less apparent. RBCT might also impact long-term oncologic outcomes including disease recurrence and overall survival. Risk factors for bleeding and blood transfusion include hemoglobin concentration < 12.5 g/dL, thrombocytopenia, pre-operative biliary drainage, presence of background liver disease (such as cirrhosis), coronary artery disease, male gender, tumor characteristics (type, size, location, presence of vascular involvement), extent of hepatectomy, concomitant extrahepatic organ resection, and operative time. Strategies to mitigate blood loss or transfusion include pre-operative (iron, erythropoietin), intra-operative (vascular occlusion, parenchymal transection techniques, hemostatic agents, antifibrinolytics, low central pressure, hemodilution, autologous blood recycling), and post-operative (normothermia, correction of coagulopathy, optimization of nutrition, restrictive transfusion strategy) methods.

CONCLUSION

Blood loss during hepatectomy is common and several risk factors can be identified pre-operatively. Blood loss and RBCT during hepatectomy is associated with post-operative morbidity and mortality. Disease-free recurrence, disease-specific survival, and overall survival may be associated with blood loss and RBCT during hepatectomy. Attention to pre-operative, intra-operative, and post-operative strategies to reduce blood loss and RBCT is necessary.