Application of enhanced recovery after hepatopancreatobiliary surgery: a single-center experience

Objective To investigate the clinical effect of enhanced recovery after surgery (ERAS)after hepatopancreatobiliary surgery and related factors associated with failure of the program. Methods The retrospective cohort study was adopted.The clinical data of 433 patients who underwent middle-large surgery (hepatectomy or pancreatectomy)at the Second Affiliated Hospital of Zhejiang University School of Medicine between August 2013 to January 2015 were collected.Of the 433 patients, 216 patients managed with ERAS program in the middle-large hepatic or pancreatic surgery between May 2014 and January 2015 were allocated to the ERAS group, 217 patients managed with traditional perioperative treatment between August 2013 and April 2014 were allocated to the traditional group.The following indexes of patients were collected and analyzed: (1) General information: gender, age, classification according to American Society of Anesthesiologists (ASA), concomitant disease, history of liver cirrhosis, primary disease, body mass index, smoking history, alcohol drinking history, total bilirubin (TBil), alanine aminotransferase (ALT), albumin (Alb).(2)Intraoperative status: surgical type (hepatic surgery, pancreatic surgery, biliary reconstruction in hepatic surgery, hepatic excision extension, method of pancreatic surgery), laparoscopic surgery, operation time, volume of intraoperative blood loss and intraoperative blood transfusion.(3)Postoperative efficacy: stage of complication, number of unplaned reoperation and readmission, number of patients with ICU care time >24 hours, durations of postoperative hospital stay, duration of postoperative hospital stay of patients with grade 0-Ⅱ complications and with grade Ⅲ-Ⅳ complication.Measurement data with normal distribution were presented as ±s and analyzed using the Student's t test.Measurement data with skewed distribution were presented as M(range)and analyzed using the Mann-Whitney test.Count data were analyzed using the chi-square test and Fisher exact probability. Univariate analysis was done by the chi-square test and multivariate analysis was done by the logistic regression model. Results (1)Intraoperative status: the cases of small-scale hepatic excision with biliary reconstruction, small-scale hepatic excision without biliary reconstruction, large-scale hepatic excision with biliary reconstruction, large-scale hepatic excision without biliary reconstruction, pancreaticoduodenectomy, other pancreatic surgery, laparoscpic surgery, operation time, volume of intraoperative blood loss and number of patients receiving blood transfusion were 29, 64, 31, 26, 43, 23, 23, (275±122) minutes, (308±254) mL and 42 in the ERAS group, and 27, 67, 34, 20, 47, 22, 20, (281±124) minutes, (356±288)mL and 45 in the traditional group, showing no significant difference between the 2 groups (χ2=1. 259, 0. 248, t =0. 509, 1. 788, χ2=0. 113, P >0.05). (2)Postoperative efficacy: the numbers of unplaned reoperation and readmission, number of patients with ICU care time >24 hours, duration of postoperative hospital stay of patients with grade Ⅲ-Ⅳ complication were 3, 11, 5, (18±10)days in the ERAS group, and 1, 6, 11, (22±16)days in the traditional group, showing no difference between the 2 groups ( t =-1. 279, P >0.05).The number of patients with stage Ⅰ-Ⅴ complication, duration of postoperative hospital stay, duration of postoperative hospital stay of patients with grade 0 -Ⅱ complication were 111, (11±8)days and (9±6)days in the ERAS group, and 136, (13±10)days and (10±5)days in the traditional group, showing significant differences between the 2 groups ( U =20 771.000, t =-2.547, -2. 631, P <0. 05).(3)Compliance of ERAS: the compliances of ERAS in preventative anti-vomiting, early removal of gastric tube, early liquid diet intake, early solid food intake, heparin anticoagulant therapy were 48. 7% , 77. 3% , 76. 7% , 72. 7% , 36. 7% in patients receiving hepatic surgery, and 63. 6% , 57. 6% , 60. 6% , 50. 0% , 51.5% in patients receiving pancreatic surgery, showing significant differences between the 2 groups (χ2=4. 126, 8. 743, 5. 834, 10. 455, 4. 171, P <0.05).(4)Univariate analysis showed that ASA classification, operation type and Alb were risk factors associated with failure of ERAS program(χ2=13. 383, 4. 365, 5. 953, P <0. 05).Extension of hepatic excision in patients receiving hepatic surgery was a risk factor associated with failure of ERAS program in liver surgery (χ2=14. 104, P <0.05).(5)Multivariate analysis showed that grade Ⅲ and Ⅳ of ASA and pancreatic surgery were independent risk factors associated with failure of ERAS program ( RR =4. 621, 2. 586, 95% confidence interval: 1. 709 -12. 490, 1. 010 -6. 615, P <0.05). Conclusions ERAS program is safe and feasible after middle-large hepatopancreatobiliary surgery (hepatectomy and /or pancreatectomy, and can reduce duration of postoperative hospital stay and complications.ERAS program is prone to failure in patients with grade Ⅲ and Ⅳ of ASA or undergoing pancreatic surgery after hepatopancreato-biliary surgery. Key words: Hepatopancreatobiliary disease; Enhanced recovery after surgery; Hepatopancreatobiliary surgery