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Enhanced recovery programs in hepatobiliary surgery
Introduction
In the 1990s, initial reports of fast-track surgical principles detailed their application to cardiac surgery patients with the goal of reducing intensive care unit (ICU) stay. Afterward, a novel multimodal approach to perioperative care was described by Kehlet and Mogensen, resulting in a dramatic reduction in length of hospital stay (LOS) after colectomy. , After overcoming much skepticism and scrutiny, the ensuing paradigm shift in perioperative care of the surgical patient has resulted in their principles being applied across disciplines and in the formation of the Enhanced Recovery After Surgery (ERAS) Society ( https://www.erassociety.org ), which aims to disseminate and implement enhanced recovery best practices globally. Since the introduction of these practices, enhanced recovery program (ERP) principles have been successfully applied across the surgical spectrum and have now been adopted in other procedural (e.g., stem cell transplantation) and non-procedural (e.g., medical hospitalist) care.
Principles of enhanced recovery have been increasingly incorporated into the care of hepatobiliary (HB) surgery patients, with clinical trials and individual reports documenting improved outcomes with these programs. , Perhaps the earliest description of experience with ERPs and HB surgery came from Scotland, when Mackay and O’Dwyer published their small series of early discharge “fast-track” liver resection patients. In the same year, van Dam et al. described their initial experience with 61 patients who underwent hepatectomy under an ERP and compared outcomes with 100 consecutive hepatectomies before initiation of the protocol. Hepatectomy patients resumed oral intake earlier and had a decreased LOS compared with traditional pathway patients, along with similar rates of morbidity and mortality. Since that time, there has been an explosion of literature involving enhanced recovery after HB surgery, evaluating proposed pathways and operative strategies within an ERP framework.
HB surgery is unique from other fields in gastrointestinal (GI) surgery because of differing patient comorbidities and underlying chronic diseases that may require intervention, and thus the perioperative care plans must be different. Recent advances in surgical planning, perioperative care, and operative techniques have resulted in decreased morbidity and mortality after HB surgery. , Despite this, HB surgery remains difficult, with recognized rates of major complications as high as 30%, and mortality of up to 5% even at high-volume centers. , Of particular concern are high rates of digestive and pulmonary complications associated with HB surgery. Therefore a shift toward perioperative care aimed at a reduction in these adverse outcomes via early intervention allows for a faster, more efficient recovery. Lastly, it is important to note that ERPs are management strategies predicated on safe, effective, and meticulous surgical technique to deliver optimal outcomes and derive maximal benefit from these programs. In other words, an ERP cannot make up for substandard surgery.
HB surgery remains complex, with perioperative variables not found in other surgical disciplines; it also requires significant contributions from many members of the HB surgery care team. These major operations can be incredibly complex, requiring a large multidisciplinary effort that may function more effectively with a standardized plan. Therefore implementation of such a protocol for patients undergoing HB surgery requires commitment from surgeons, trainees, anesthesiologists, nursing staff, and patients themselves to adhere to the common core principles discussed below.
The “4 pillars” of enhanced recovery programs
Fundamental surgical principles, such as thromboembolic prophylaxis, prophylactic antibiosis, appropriate application of minimally-invasive approaches, and minimization of drains/lines/tubes are critical to ERPs. In addition, modern ERP approaches consist of effective patient education and engagement, upon which stand “4 pillars” of enhanced recovery: early postoperative feeding, goal-directed fluid therapy, opioid-sparing analgesia, and early ambulation ( Fig. 27.1 ). , These core components occur at different phases of the ERP along the spectrum of care of an HB surgical patient and will be discussed later in this chapter.
The foundation of all ERPs, patient engagement and education, is of critical importance. Much of enhanced recovery requires the participation of the patient (i.e., early ambulation) and thus all efforts within the pathway rest on a solid foundation of patient engagement. Effective education of both the patient and caregiver(s) in advance of and during recovery allows for a “team approach” that will lead to improved and enhanced outcomes.
Along with the “4 pillars,” other critical aspects of a comprehensive ERP are detailed later along the phases of care for HB surgical patients ( Table 27.1 ). Other aspects or program-specific elements exist; however, the following subjects remain most concordant with major published guidelines.
TABLE 27.1
Essential Elements of Enhanced Recovery Programs by Preoperative, Perioperative, and Postoperative Phases of Care for the HB Surgery Patient
| PREOPERATIVE PHASE | PERIOPERATIVE PHASE | POSTOPERATIVE PHASE |
|---|---|---|
| Patient Evaluation | Clear Liquids up to 2 hours pre-procedure | Early Mobilization |
| Medical Optimization | VTE prophylaxis | Goal-Directed Fluid Therapy |
| Prehabilitation | Antimicrobial prophylaxis | Prevention of PONV |
| Nutritional Assessment | Avoidance or early discontinuation of NGT or abdominal drains | Early Nutrition |
| Education and Engagement | Goal-Directed Fluid Therapy | Opioid-Sparing Analgesia |
| Neuraxial and Regional Anesthesia | Educate on Discharge Criteria | |
| Opioid-Sparing Analgesia | ||
| Minimally-invasive Surgical Approaches, if possible |
Preoperative phase
Preoperative patient evaluation
A thorough preoperative evaluation is imperative for any patient being considered for HB surgery. A complete history and physical examination should include a review of all comorbidities, surgical history, medications, and detailed oncologic history. Determination and quantification of receipt of any prior cytotoxic/targeted/immunologic therapies is paramount. Specific to HB surgery, any risk factors for hepatic dysfunction, portal hypertension, or cirrhosis should be ascertained by inquiring about prior HB surgical history, including endoscopic procedures and detailed social history. Physical examination should include detection of any signs of hepatic dysfunction, including jaundice, ascites, or prior surgical scars.
Optimization of chronic comorbidities, both medically and with intervention, is critical to the quality of recovery after HB surgery (see Chapters 25 and 26 ). Borderline operability from a medical perspective must be uncovered because these patients (age >75 years, dependent function, lung disease, ascites/varices, myocardial infarction, stroke, steroids, weight loss >10%, and/or sepsis) have a threefold higher mortality after hepatectomy. Moreover, patients with more comorbidities are more likely to be discharged to a skilled nursing facility or nonroutine discharge after hepatopancreatic surgery. Optimization of comorbidities before planned hepatectomy may greatly influence outcome and allow for adherence to ERP principles.
Patient functional status must be evaluated thoroughly and potentially improved before planned HB surgery. Evaluation of functional status may be performed using reported grading tools (i.e., Eastern Cooperative Oncology Group Performance Status, Karnofsky Score, MD Anderson Symptom Inventory, Timed Up And Go). The concept of frailty as it applies to HB surgery is in evolution; however, objective tools such as these may identify patients that may be best suited for a coordinated “prehabilitation” program before surgical intervention. This allows for an improved “starting point” before physiologically stressful, complicated HB surgery. As it pertains to cardiopulmonary fitness, structured exercise programs have been shown to improve quality of life scores and exercise capacity before planned hepatectomy for colorectal liver metastases. Moreover, prehabilitation may be used as an opportunity to institute dietary and exercise programs aimed at reducing hepatic steatosis for patients deemed high risk and undergoing planned hepatectomy. Clearly, there are prime opportunities to potentially improve perioperative outcomes via preoperative optimization of HB surgical patients in the context of a comprehensive ERP (see Chapter 26 ).
Determining a patient’s baseline use of pain medications, primarily opioids, can be critical to the success of an enhanced recovery approach. Preoperative opioid use has been reported in almost 25% of patients reporting for surgery, and preoperative opioid prescriptions are associated with higher postoperative opioid requirements and increased readmissions. Moreover, opioid tolerance is associated with decreased compliance with ERPs, particularly in the postoperative period. Therefore this information is imperative because it may inform regional anesthesia strategies and postoperative multimodal therapy.
Preoperative education and patient engagement
Patients being cared for along an ERP for HB surgery must be engaged and educated thoroughly on the goals of the program and the reasons behind care decisions. Educational materials on operative approaches and expectations for day-to-day care while in the hospital, including pain control, diet, and ambulation, should be provided in a format that is easy to comprehend. Patients will require detailed information regarding opioid-sparing analgesia, including the use of multimodal agents and the efficacy of initial and repeated regional anesthetic nerve blocks. Although no studies have evaluated education, there is a shared recognition that these educational efforts create excitement in patients about the potential for decreased LOS after their HB surgery and increase their willingness to work toward this enhanced recovery. Beyond allowing for understanding of expectations, these efforts reduce patient anxiety and lead to increased compliance. The ERAS Society recommendations for liver surgery are that “routine and dedicated preoperative counseling and education” be provided to patients before undergoing liver surgery.
Preoperative nutrition
As with any elective surgical procedure, consideration of a patient’s baseline nutritional status and evaluation of potential nutritional deficits is critical during preparation for HB surgery (see Chapter 26 ). Important factors to consider include recent weight loss and obesity, body mass index (BMI), and laboratory evaluation of nutritional indices, such as albumin, prealbumin, ferritin, and relevant vitamins and micronutrients. , Beyond incorporation within the history and physical, several screening instruments are available, which may augment evaluation and have been shown to be useful in clinical practice. ,
When possible, every attempt should be made to remediate nutritional deficiencies. The ERAS Society recommendations for liver surgery suggest that patients found to be “at risk” receive 7 days of oral nutritional supplementation before elective liver surgery. At-risk patients are defined as having greater than 10% to 15% weight loss within 6 months, BMI less than 18.5 kg/m 2 , and serum albumin less than 30 g/L without any signs of liver or renal dysfunction.
Perioperative phase
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