Enhanced Recovery After Surgery in Patients With Hepatocellular Carcinoma Undergoing Laparoscopic Hepatectomy

Safety and efficacy of the enhanced recovery after surgery protocol in hepatectomy for liver cancer

PURPOSE

The aim of this research was to evaluate the efficacy and safety of enhanced recovery after surgery (ERAS) protocol in hepatectomy patients with liver cancer.

MATERIALS AND METHODS

We searched three databases, including PubMed, Embase, and the Cochrane Library database, from inception to April 25, 2023. The outcomes were postoperative complications, and postoperative length of stay (PLOS). This study was performed by Stata (V. 16.0) software.

RESULTS

Twelve investigations involving 1,892 patients were included in this study. The ERAS group had lower overall postoperative complications [odds ratio (OR) = 0.49, I² = 54.89 %, 95 % confidence interval (CI) = 0.33-0.74, P = 0.00], postoperative Clavien-Dindo Grade 1-2 complications (OR = 0.39, I² = 55.14 %, 95 %CI = 0.23-0.69, P = 0.00), Clavien-Dindo Grade 3-4 complications (OR = 0.56, I² = 0.00 %, 95 %CI = 0.38-0.83, P = 0.00) , pneumonia (OR = 0.34, I² = 0.00 %, 95 %CI = 0.15-0.76, P = 0.01), ascites (OR = 0.25, I² = 0.00 %, 95 %CI = 0.09-0.68, P = 0.01), vomit (OR = 0.39, I² = 0.00 %, 95 %CI = 0.21-0.73, P = 0.00), intraoperative blood loss [mean difference (MD) = 1.69, I² = 0.00 %, 95 %CI = 1.15-2.47, P = 0.01], PLOS (MD = -0.42, I² = 94.87 %, 95 %CI = -0.86-0.03, P = 0.07), duration of abdominal drain (MD = -1.23, I² = 96.96 %, 95 %CI = -2.04 to -0.42, P = 0.00), and hospital readmission (OR = 0.44, I² = 0.00 %, 95 %CI = 0.23-0.85, P = 0.01) compared to the non-ERAS group.

CONCLUSION

For patients with liver cancer treated with ERAS. The ERAS protocol reduces the percentage of overall postoperative complications. Moreover, ERAS does not increase the rate of blood transfusions, hospital readmission, reoperation, or mortality.

Feasibility, safety and effectiveness of the enhanced recovery after surgery protocol in patients undergoing liver resection

Backgrounds/Aims

The implementation of enhanced recovery after surgery (ERAS) protocols has demonstrated significant advantages for patients by mitigating surgical stress and expediting recovery across a spectrum of surgical procedures worldwide. This investigation seeks to assess the effectiveness of the ERAS protocol specifically in the context of major liver resections within our geographical region.

Methods

Our department conducted retrospective analysis of prospectively collected data, gathered from consenting individuals who underwent liver resections from January 2018 to December 2023. The assessment encompassed baseline characteristics, preoperative indications, surgical outcomes, and postoperative complications among patients undergoing liver surgery.

Results

Among the included 184 patients (73 standard care, 111 ERAS program), the baseline characteristics were similar. Median postoperative hospital stay differed significantly: 5 days (range: 3-13 days) in ERAS, and 11 days (range: 6-22 days) in standard care (p < 0.001). Prophylactic abdominal drainage was less in ERAS (54.9%) than in standard care (86.3%, p < 0.001). Notably, in ERAS, 88.2% initiated enteral feeding orally on postoperative day 1, significantly higher than in standard care (47.9%, p < 0.001). Early postoperative mobilization was more common in ERAS (84.6%) than in standard care (36.9%, p < 0.001). Overall complication rates were 21.9% in standard care, and 8.1% in ERAS (p = 0.004).

Conclusions

Our investigation highlights the merits of ERAS protocol; adherence to its diverse components results in significant reduction in hospital length of stay, and reduced occurrence of postoperative complications, improving short-term recovery post liver resection.

Enhanced recovery after liver surgery in cirrhotic patients: a systematic review and meta-analysis

BACKGROUND

Few studies have assessed enhanced recovery after surgery (ERAS) in liver surgery for cirrhotic patients. The present meta-analysis assessed the impact of ERAS pathways on outcomes after liver surgery in cirrhotic patients compared to standard care.

METHODS

A literature search was performed on PubMed/MEDLINE, Embase, and the Cochrane Library. Studies comparing ERAS protocols versus standard care in cirrhotic patients undergoing liver surgery were included. The primary outcome was post-operative complications, while secondary outcomes were mortality rates, length of stay (LoS), readmissions, reoperations, and liver failure rates.

RESULTS

After evaluating 41 full-text manuscripts, 5 articles totaling 646 patients were included (327 patients in the ERAS group and 319 in the non-ERAS group). Compared to non-ERAS care, ERAS patients had less risk of developing overall complications (OR 0.43, 95% CI 0.31-0.61, p < 0.001). Hospitalization was on average 2 days shorter for the ERAS group (mean difference - 2.04, 95% CI - 3.19 to - 0.89, p < 0.001). Finally, no difference was found between both groups concerning 90-day post-operative mortality and rates of reoperations, readmissions, and liver failure.

CONCLUSION

In cirrhotic patients, ERAS protocol for liver surgery is safe and decreases post-operative complications and LoS. More randomized controlled trials are needed to confirm the results of the present analysis.

Compliance with enhanced recovery after surgery predicts long-term outcome after hepatectomy for cholangiocarcinoma

BACKGROUND

Enhanced recovery after surgery (ERAS) program has been proved to improve postoperative outcome for many surgical procedures, including liver resection. There was limited evidence regarding the feasibility and benefit of ERAS in patients who underwent liver resection for cholangiocarcinoma.

AIM

To evaluate the feasibility of ERAS in patients who underwent liver resection for cholangiocarcinoma and its association with patient outcomes.

METHODS

We retrospectively analyzed 116 cholangiocarcinoma patients who underwent hepatectomy at Srinagarind Hospital, Khon Kaen University between January 2015 and December 2016. The primary outcome was the compliance with ERAS. To determine the association between ERAS compliance and patient outcomes. the patients were categorized into those adhering more than and equal to 50% (ERAS ≥ 50), and below 50% (ERAS < 50) of all components. Details on type of surgical procedure, preoperative and postoperative care, tumor location, postoperative laboratory results, and survival time were evaluated. The compliance with ERAS was measured by the percentage of ERAS items achieved. The Kaplan-Meier curve was used for survival analysis.

RESULTS

The median percentage of ERAS goals achieved was 40% (± 12%). Fourteen patients (12.1%) were categorized into the ERAS ≥ 50 group, and 102 patients were in the ERAS < 50 group. Postoperative hospital stay was significantly shorter in the ERAS ≥ 50 group [8.9 d, 95% confidence interval (CI): 7.3-10.4 d] than in the ERAS < 50 group (13.7 d, 95%CI: 12.2-15.2 d) (P = 0.0217). No hepatobiliary-related complications or in-hospital mortality occurred in the ERAS ≥ 50 group. Overall survival was significantly higher in the ERAS ≥ 50 group. The median survival of the patients in the ERAS < 50 group was 1257 d (95%CI: 853.2-1660.8 d), whereas that of the patients in the ERAS ≥ 50 group was not reached.

CONCLUSION

Overall ERAS compliance for patients who underwent liver resection for cholangiocarcinoma is poor. Greater ERAS compliance could predict in-hospital, short-term, and long-term outcomes of the patients.

Effects of Nursing Care Using a Fast-Track Surgery Approach in 49 Patients with Early-Stage Hepatocellular Carcinoma Undergoing First-Line Treatment with Radiofrequency Ablation: A Retrospective Study

BACKGROUND Fast-track surgery (FTS), also known as enhanced recovery after surgery (ERAS), includes a coordinated perioperative approach to patient care that aims to facilitate postoperative recovery. The role of nursing care is central to the concept of FTS. This retrospective study aimed to evaluate the effects of nursing care using an FTS approach in 49 patients with early-stage hepatocellular carcinoma (HCC) undergoing first-line treatment with radiofrequency ablation (RFA). MATERIAL AND METHODS A retrospective analysis was made of 49 patients with early-stage hepatocellular carcinoma who underwent first-line treatment with radiofrequency ablation in the Department of Hepatobiliary Surgery in our hospital from January 2020 to December 2021. The nurses have been nursing the patients in accordance with the requirements of FTS from 2021. Compared with the data of patients receiving traditional nursing, the detailed differences in postoperative recovery, pain score, complication rate, liver and kidney function, and nursing satisfaction were analyzed. RESULTS After applying the FTS nursing model, the patients had significantly shorter time to first flatus, infusion, postoperative hospital stay, and lower total hospitalization expenses (P<0.05). Moreover, the Numerical Pain Rating Scale score was lower than that in the control group, the postoperative complications in the 2021 group were lower than those in the 2020 group, and the nursing satisfaction was also better than that of the 2020 group (P<0.05). CONCLUSIONS Nursing care using a fast-track surgery approach with early-stage hepatocellular carcinoma patients undergoing first-line treatment with radiofrequency ablation is better than conventional nursing, and improves recovery of patients.

Variations in Textbook Oncologic Outcomes After Curative-Intent Resection: Early Versus Intermediate Hepatocellular Carcinoma Based on Barcelona Clinic Liver Cancer Criteria and Child-Pugh Classification

BACKGROUND

The impact of early versus intermediate hepatocellular carcinoma (HCC) on short-term "optimal" outcomes remains ill-defined. This study sought to define the incidence of textbook oncologic outcomes (TOO), as well as to identify factors associated with TOO among patients with early versus intermediate HCC.

METHODS

Patients who underwent curative-intent liver resection for HCC (1998-2020) were identified from a multi-institutional database. Textbook oncologic outcome (TOO) was defined as negative surgical margins, no return to the operating room, no extended hospital stay, no severe complications, and no 90-day mortality or readmission. Patients were stratified as early HCC (BCLC 0 or BCLC A/Child-Pugh A) or intermediate HCC (BCLC A/Child-Pugh B or BCLC B). Multivariate logistic regression analysis was used to assess factors associated with TOO.

RESULTS

Among 1383 patients, the overall incidence of TOO was 69.0%. Patients with intermediate HCC were less likely to achieve a TOO (early [71.6 %] vs. intermediate [60.1%]; p < 0.001). On multivariate analysis, factors associated with decreased odds of a TOO were high tumor burden (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.33-1.00), high aspartate transaminase-platelet ratio index (APRI) (OR, 0.46; 95% CI, 0.30-0.70), Charlson Comorbidity Index (CCI) greater than 3 (OR, 0.67; 95% CI, 0.49-0.91), major liver resection (OR, 0.68; 95% CI, 0.52-0.90), and intermediate HCC (OR, 0.68; 95% CI, 0.50-0.93) (all p < 0.05). Notably, although high APRI, CCI greater than 3, and major liver resection contributed to lower odds of a TOO in early HCC, the only factor that adversely impacted TOO in intermediate HCC was high tumor burden.

CONCLUSIONS

Patients with intermediate HCC and early HCC patients with liver dysfunction, comorbidities, or an extensive resection were less likely to achieve an "optimal" postoperative outcome.

Effect of rapid rehabilitation nursing on inflammation and liver function after laparoscopic radical resection of primary liver cancer

OBJECTIVE

To explore the effect of rapid rehabilitation nursing on inflammation and liver function in patients with primary liver cancer (PLC) after laparoscopic radical resection.

METHODS

A total of 124 PLC patients who underwent laparoscopic radical surgery in the Zhuji People's Hospital of Zhejiang Province from April 2019 to July 2021 were enrolled in this retrospective study. Among them, 65 patients who received rapid rehabilitation nursing were assigned into the observation group (OG), and the other 59 with routine nursing were considered to be the control group (CG). The pain before operation (T0), 3 days after operation (T1) and 7 days after operation (T2) was evaluated by visual analogue scale (VAS). The perioperative related indexes and nursing satisfaction were compared. The levels of liver function indexes alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL) and inflammatory factors C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) were measured before operation, 1 day and 7 days after operation. Finally, the incidence of postoperative complications was counted, the 6-month survival rate of both groups of patients was compared.

RESULTS

There was no obvious difference in VAS scores between the two groups at T0 (P>0.050), but the VAS scores at T1 and T2 in the OG were lower than those in the CG (P<0.001). There was no marked difference in the total operation time. Compared with the CG, the time to first exhaust, catheter indwelling and hospitalization in the OG were shorter (P<0.001) and the nursing satisfaction rate was higher (P<0.05). There was no obvious difference in ALT, AST and TBIL on the 1st day after operation (P>0.05); however, on the 7th day after operation, ALT and AST were lower while TBIL was higher in the OG (all P<0.05). There was no marked difference in CRP, IL-6 and TNF-α between the two groups on postoperative day 1 (P>0.05), but the levels were lower in the OG than those in the CG on postoperative day 7 (all P<0.05), and the total incidence of adverse reactions in the OG was lower (P<0.05). There was no statistical difference in the postoperative survival rate between both groups of patients (P>0.05). Age, number of lesions, tumor size, Child-Pugh grade, AST, TBIL, CRP, IL-6, TNF-α were associated with the survival rate of patients.

CONCLUSION

Rapid rehabilitation nursing can effectively reduce adverse reactions after laparoscopic radical resection of PLC. Thus, it has a high application value in future clinical treatment.