World J Surg (2014) 38:2683–2684 DOI 10.1007/s00268-014-2727-4
INVITED COMMENTARY
Enhanced Recovery Programs in Liver Surgery C. H. C. Dejong • R. M. van Dam
Published online: 15 August 2014 Ó Socie´te´ Internationale de Chirurgie 2014
In the study of Applicability of an Enhanced Recovery Program for Advanced Liver Surgery by a reknowned Japanese group, results are presented on using an enhanced recovery after surgery program in major liver surgery [1]. Takamoto et al. used recovery status on postoperative day 6 as the outcome measure, which was defined as independence from continuous medical intervention, with the exception of an abdominal drain. The authors show that it is feasible to apply an enhanced recovery after surgery (ERAS) program to major liver surgery. Over 80 % of the patients completed the program, and most of them achieved recovery by day 6 without an increase in morbidity or mortality. These results were obtained using a fairly conservative ERAS program with bowel preparation, oral intake commencing only on day 3, and intravenous feeding and epidural analgesia continuing until postoperative day 5. The authors are to be applauded for their excellent results. Although early discharge was not achieved because of restrictions imposed by the Japanese health care system, the study confirms that enhanced recovery programs are feasible and safe in major liver surgery. Equally, the study draws attention to the fact that time to recovery is a far more important and better outcome measure than time to discharge from the hospital. The latter
This is a commentary to the article available in DOI 10.1007/s00268014-2613-0 C. H. C. Dejong (&) R. M. van Dam Department of Surgery, Maastricht University Medical Center, Euregional HepatoPancreatoBiliary Collaboration AachenMaastricht, NUTRIM School for Nutrition Toxicology and Metabolism, and GROW School for Oncology & Developmental Biology, PO Box 5800, Maastricht, The Netherlands e-mail: [email protected]
is profoundly influenced by many factors that have little to do with patient recovery [2]. The first ERAS programs were introduced by Kehlet and Mogensen [3] in the 1990s. Those programs were initially implemented in colorectal surgery and have gradually found their way into general clinical practice. The feasibility and safety of ERAS programs in colorectal surgery has been shown in case control studies and randomized controlled trials, and this led to the inclusion of such programs in national and international guidelines on perioperative care in colorectal surgery [4]. Subsequently, the guidelines have been rolled out on a much wider scale, such as, for example, in the nationwide implementation of the ERAS colorectal surgery program in the Netherlands [5], later in the UK, and now in Sweden and Switzerland. In parallel to their success in colorectal surgery, ERAS programs have also been applied in other fields, including orthopedic, vascular, and thoracic surgery. The areas that have long been considered ‘‘no go’’ territory for enhanced recovery are the fields of upper gastrointestinal surgery and hepatopancreatobiliary surgery. The extent of the surgery in these fields and the frequent use of ‘‘risky’’ anastomoses proximally in the gastrointestinal tract have perpetuated conservatism among surgeons with respect to perioperative care. In the past decade, advances have particularly been made in the field of liver surgery. It is highly likely that this is so because, in most liver resections, there is no need for an anastomosis, drains are not usually necessary, and postoperative ileus is not really a problem. Hence, cohort studies have been conducted and randomized trials have confirmed the feasibility and safety of enhanced recovery programs in resectional liver surgery [6, 7]. These studies usually included patients who underwent relatively standard minor and major liver surgery.
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In the present article by Takamoto et al., new areas have been explored, investigating whether ERAS programs are also feasible in major liver resections combined with hepaticojejunostomies and thoracotomies. Where are we heading next in perioperative care in liver surgery? Complex surgery is performed in only a minority of patients and from a health care economic perspective it may therefore be more valuable to concentrate on ERAS implementation in the far larger patient groups undergoing relatively standard liver surgery. Along these lines, it is of interest to note that in colorectal surgery a slight but nonnegligible advantage has been shown for the laparoscopic approach within an ERAS setting [8]. The diffusion of laparoscopy in liver surgery has been much slower than in colorectal surgery, but it may be important to focus on the added value of laparoscopy in liver surgery in an ERAS setting [9, 10]. Minimal incisions and the laparoscopic approach may make epidural analgesia (with its risks as reported in the study by Takamoto et al.) redundant, as intercostal nerve blocks and patient controlled analgesia have become more popular in getting patients mobilized earlier. There is growing awareness that length of hospital stay (LOS) is not a good measure of outcome [11]. In fact, patient recovery is undeniably the most important outcome measure for every ERAS program. Thus, time required to achieve standardized recovery or discharge criteria is probably what should be measured—i.e., ‘‘time to readiness for discharge’’ [12]. It would be interesting to know whether the patients in the study by Takamoto et al. considered themselves to have recovered while still carrying an abdominal drain. Patient-reported outcomes should become an integral part of the assessment of ERAS programs. Finally, it is important to note that it is still unknown which elements of the ERAS program are crucial in determining both the short-term and longer-term outcomes of the patient journey [11, 13, 14]. This requires intensive research on large, preferably nationwide databases with adequately collected information on ERAS program elements.
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World J Surg (2014) 38:2683–2684
References 1. Takamoto T, Hashimoto T, Inoue K et al (2014) Applicability of an enhanced recovery program for advanced liver surgery. World J Surg. doi:10.1007/s00268-014-2613-0 2. Maessen JM, Dejong CH, Kessels AG et al (2008) Length of stay: an inappropriate readout of the success of enhanced recovery programs. World J Surg 32:971–975. doi:10.1007/s00268-0079404-9 3. Kehlet H, Mogensen T (1999) Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg 86:227–230 4. Fearon KC, Ljungqvist O, Von Meyenfeldt M et al (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24:466–477 5. Gillissen F, Hoff C, Maessen JM et al (2013) Structured synchronous implementation of an enhanced recovery program in elective colonic surgery in 33 hospitals in the Netherlands. World J Surg 37:1082–1093. doi:10.1007/s00268-013-1938-4 6. Jones C, Kelliher L, Dickinson M et al (2013) Randomized clinical trial on enhanced recovery versus standard care following open liver resection. Br J Surg 100:1015–1024 7. van Dam RM, Hendry PO, Coolsen MM et al (2008) Initial experience with a multimodal enhanced recovery programme in patients undergoing liver resection. Br J Surg 95:969–975 8. Vlug MS, Wind J, Hollmann MW et al (2011) Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 254:868–875 9. Stoot JH, Van Dam RM, Busch OR et al (2009) The effect of a multimodal fast-track programme on outcomes in laparoscopic liver surgery: a multicentre pilot study. HPB (Oxf) 11:140–144 10. van Dam RM, Wong-Lun-Hing EM, van Breukelen GJ et al (2012) Open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery ERAS(R) programme (ORANGE II-trial): study protocol for a randomised controlled trial. Trials 13:54 11. Neville A, Lee L, Antonescu I et al (2014) Systematic review of outcomes used to evaluate enhanced recovery after surgery. Br J Surg 101:159–170 12. Fiore JF Jr, Faragher IG, Bialocerkowski A et al (2013) Time to readiness for discharge is a valid and reliable measure of shortterm recovery after colorectal surgery. World J Surg 37:2927–2934. doi:10.1007/s00268-013-2208-1 13. Adamina M, Gie´ O, Desmartines N et al (2013) Contemporary perioperative care strategies. Br J Surg 100:38–54 14. Nicholson A, Lowe MC, Parker J et al (2014) Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg 101:172–188
INVITED COMMENTARY
Enhanced Recovery Programs in Liver Surgery C. H. C. Dejong • R. M. van Dam
Published online: 15 August 2014 Ó Socie´te´ Internationale de Chirurgie 2014
In the study of Applicability of an Enhanced Recovery Program for Advanced Liver Surgery by a reknowned Japanese group, results are presented on using an enhanced recovery after surgery program in major liver surgery [1]. Takamoto et al. used recovery status on postoperative day 6 as the outcome measure, which was defined as independence from continuous medical intervention, with the exception of an abdominal drain. The authors show that it is feasible to apply an enhanced recovery after surgery (ERAS) program to major liver surgery. Over 80 % of the patients completed the program, and most of them achieved recovery by day 6 without an increase in morbidity or mortality. These results were obtained using a fairly conservative ERAS program with bowel preparation, oral intake commencing only on day 3, and intravenous feeding and epidural analgesia continuing until postoperative day 5. The authors are to be applauded for their excellent results. Although early discharge was not achieved because of restrictions imposed by the Japanese health care system, the study confirms that enhanced recovery programs are feasible and safe in major liver surgery. Equally, the study draws attention to the fact that time to recovery is a far more important and better outcome measure than time to discharge from the hospital. The latter
This is a commentary to the article available in DOI 10.1007/s00268014-2613-0 C. H. C. Dejong (&) R. M. van Dam Department of Surgery, Maastricht University Medical Center, Euregional HepatoPancreatoBiliary Collaboration AachenMaastricht, NUTRIM School for Nutrition Toxicology and Metabolism, and GROW School for Oncology & Developmental Biology, PO Box 5800, Maastricht, The Netherlands e-mail: [email protected]
is profoundly influenced by many factors that have little to do with patient recovery [2]. The first ERAS programs were introduced by Kehlet and Mogensen [3] in the 1990s. Those programs were initially implemented in colorectal surgery and have gradually found their way into general clinical practice. The feasibility and safety of ERAS programs in colorectal surgery has been shown in case control studies and randomized controlled trials, and this led to the inclusion of such programs in national and international guidelines on perioperative care in colorectal surgery [4]. Subsequently, the guidelines have been rolled out on a much wider scale, such as, for example, in the nationwide implementation of the ERAS colorectal surgery program in the Netherlands [5], later in the UK, and now in Sweden and Switzerland. In parallel to their success in colorectal surgery, ERAS programs have also been applied in other fields, including orthopedic, vascular, and thoracic surgery. The areas that have long been considered ‘‘no go’’ territory for enhanced recovery are the fields of upper gastrointestinal surgery and hepatopancreatobiliary surgery. The extent of the surgery in these fields and the frequent use of ‘‘risky’’ anastomoses proximally in the gastrointestinal tract have perpetuated conservatism among surgeons with respect to perioperative care. In the past decade, advances have particularly been made in the field of liver surgery. It is highly likely that this is so because, in most liver resections, there is no need for an anastomosis, drains are not usually necessary, and postoperative ileus is not really a problem. Hence, cohort studies have been conducted and randomized trials have confirmed the feasibility and safety of enhanced recovery programs in resectional liver surgery [6, 7]. These studies usually included patients who underwent relatively standard minor and major liver surgery.
123
2684
In the present article by Takamoto et al., new areas have been explored, investigating whether ERAS programs are also feasible in major liver resections combined with hepaticojejunostomies and thoracotomies. Where are we heading next in perioperative care in liver surgery? Complex surgery is performed in only a minority of patients and from a health care economic perspective it may therefore be more valuable to concentrate on ERAS implementation in the far larger patient groups undergoing relatively standard liver surgery. Along these lines, it is of interest to note that in colorectal surgery a slight but nonnegligible advantage has been shown for the laparoscopic approach within an ERAS setting [8]. The diffusion of laparoscopy in liver surgery has been much slower than in colorectal surgery, but it may be important to focus on the added value of laparoscopy in liver surgery in an ERAS setting [9, 10]. Minimal incisions and the laparoscopic approach may make epidural analgesia (with its risks as reported in the study by Takamoto et al.) redundant, as intercostal nerve blocks and patient controlled analgesia have become more popular in getting patients mobilized earlier. There is growing awareness that length of hospital stay (LOS) is not a good measure of outcome [11]. In fact, patient recovery is undeniably the most important outcome measure for every ERAS program. Thus, time required to achieve standardized recovery or discharge criteria is probably what should be measured—i.e., ‘‘time to readiness for discharge’’ [12]. It would be interesting to know whether the patients in the study by Takamoto et al. considered themselves to have recovered while still carrying an abdominal drain. Patient-reported outcomes should become an integral part of the assessment of ERAS programs. Finally, it is important to note that it is still unknown which elements of the ERAS program are crucial in determining both the short-term and longer-term outcomes of the patient journey [11, 13, 14]. This requires intensive research on large, preferably nationwide databases with adequately collected information on ERAS program elements.
123
World J Surg (2014) 38:2683–2684
References 1. Takamoto T, Hashimoto T, Inoue K et al (2014) Applicability of an enhanced recovery program for advanced liver surgery. World J Surg. doi:10.1007/s00268-014-2613-0 2. Maessen JM, Dejong CH, Kessels AG et al (2008) Length of stay: an inappropriate readout of the success of enhanced recovery programs. World J Surg 32:971–975. doi:10.1007/s00268-0079404-9 3. Kehlet H, Mogensen T (1999) Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg 86:227–230 4. Fearon KC, Ljungqvist O, Von Meyenfeldt M et al (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24:466–477 5. Gillissen F, Hoff C, Maessen JM et al (2013) Structured synchronous implementation of an enhanced recovery program in elective colonic surgery in 33 hospitals in the Netherlands. World J Surg 37:1082–1093. doi:10.1007/s00268-013-1938-4 6. Jones C, Kelliher L, Dickinson M et al (2013) Randomized clinical trial on enhanced recovery versus standard care following open liver resection. Br J Surg 100:1015–1024 7. van Dam RM, Hendry PO, Coolsen MM et al (2008) Initial experience with a multimodal enhanced recovery programme in patients undergoing liver resection. Br J Surg 95:969–975 8. Vlug MS, Wind J, Hollmann MW et al (2011) Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 254:868–875 9. Stoot JH, Van Dam RM, Busch OR et al (2009) The effect of a multimodal fast-track programme on outcomes in laparoscopic liver surgery: a multicentre pilot study. HPB (Oxf) 11:140–144 10. van Dam RM, Wong-Lun-Hing EM, van Breukelen GJ et al (2012) Open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery ERAS(R) programme (ORANGE II-trial): study protocol for a randomised controlled trial. Trials 13:54 11. Neville A, Lee L, Antonescu I et al (2014) Systematic review of outcomes used to evaluate enhanced recovery after surgery. Br J Surg 101:159–170 12. Fiore JF Jr, Faragher IG, Bialocerkowski A et al (2013) Time to readiness for discharge is a valid and reliable measure of shortterm recovery after colorectal surgery. World J Surg 37:2927–2934. doi:10.1007/s00268-013-2208-1 13. Adamina M, Gie´ O, Desmartines N et al (2013) Contemporary perioperative care strategies. Br J Surg 100:38–54 14. Nicholson A, Lowe MC, Parker J et al (2014) Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg 101:172–188
