Biological impact of an enhanced recovery after surgery programme in liver surgery

Abstract Background The clinical and economic impacts of enhanced recovery after surgery (ERAS) programmes have been demonstrated extensively. Whether ERAS protocols also have a biological effect remains unclear. This study aimed to investigate the biological impact of an ERAS programme in patients undergoing liver surgery. Methods A retrospective analysis of patients undergoing liver surgery (2010–2018) was undertaken. Patients operated before and after ERAS implementation in 2013 were compared. Surrogate markers of surgical stress were monitored: white blood cell count (WBC), C-reactive protein (CRP) level, albumin concentration, and haematocrit. Their perioperative fluctuations were defined as Δvalues, calculated on postoperative day (POD) 0 for Δalbumin and Δhaematocrit and POD 2 for ΔWBC and ΔCRP. Results A total of 541 patients were included, with 223 and 318 patients in non-ERAS and ERAS groups respectively. Groups were comparable, except for higher rates of laparoscopy (24.8 versus 11.2 per cent; P < 0.001) and major resection (47.5 versus 38.1 per cent; P = 0.035) in the ERAS group. Patients in the ERAS group showed attenuated ΔWBC (2.00 versus 2.75 g/l; P = 0.013), ΔCRP (60 versus 101 mg/l; P <0.001) and Δalbumin (12 versus 16 g/l; P < 0.001) compared with those in the no-ERAS group. Subgroup analysis of open resection showed similar results. Multivariable analysis identified ERAS as the only independent factor associated with high ΔWBC (odds ratio (OR) 0.65, 95 per cent c.i. 0.43 to 0.98; P = 0.038), ΔCRP (OR 0.41, 0.23 to 0.73; P = 0.003) and Δalbumin (OR 0.40, 95 per cent c.i. 0.22 to 0.72; P = 0.002). Conclusion Compared with conventional management, implementation of ERAS was associated with an attenuated stress response in patients undergoing liver surgery.

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C-reactive protein as a marker of the surgical stress reduction within an ERAS protocol (Enhanced Recovery After Surgery) in colorectal surgery: A prospective cohort study

Journal of Surgical Oncology ◽

10.1002/jso.24909 ◽

2018 ◽

Vol 117 (4) ◽

pp. 717-724 ◽

Cited By ~ 14

Author(s):

Mercedes Cabellos Olivares ◽

María Labalde Martínez ◽

Miguel Torralba ◽

José R. Rodríguez Fraile ◽

Juan C. Atance Martínez

Keyword(s):

Cohort Study ◽

Colorectal Surgery ◽

Stress Reduction ◽

Prospective Cohort ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Surgical Stress ◽

C Reactive Protein ◽

Reactive Protein ◽

Eras Protocol

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Postoperative Level of C-Reactive Protein Is a Prognosticator After Esophageal Cancer Surgery With Perioperative Steroid Therapy and Enhanced Recovery After Surgery Care

In Vivo ◽

10.21873/invivo.11515 ◽

2019 ◽

Vol 33 (2) ◽

pp. 587-594 ◽

Cited By ~ 1

Author(s):

KAZUKI KANO ◽

TORU AOYAMA ◽

YUKIO MAEZAWA ◽

TSUTOMU HAYASHI ◽

TAKANOBU YAMADA ◽

...

Keyword(s):

Esophageal Cancer ◽

Steroid Therapy ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Cancer Surgery ◽

C Reactive Protein ◽

Reactive Protein ◽

Esophageal Cancer Surgery ◽

Postoperative Level

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Impact of enhanced recovery after surgery on open and laparoscopic liver surgery: A single center cohort study.

HPB ◽

10.1016/j.hpb.2020.04.492 ◽

2020 ◽

Vol 22 ◽

pp. S414

Author(s):

A. Moekotte ◽

F. Giovinazzo ◽

C. Kuemmerli ◽

A. Rawashdeh ◽

H. Clarke ◽

...

Keyword(s):

Cohort Study ◽

Liver Surgery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Single Center ◽

Laparoscopic Liver Surgery

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Impact of Enhanced Recovery After Surgery (ERAS) approach and minimally-invasive techniques on outcome of patients undergoing liver surgery for hepatocellular carcinoma. A comparative study from a single institution

Clinical Nutrition ESPEN ◽

10.1016/j.clnesp.2016.02.036 ◽

2016 ◽

Vol 12 ◽

pp. e41 ◽

Cited By ~ 2

Author(s):

Francesca Ratti ◽

Federica Cipriani ◽

Raffaella Reineke ◽

Marco Catena ◽

Laura Comotti ◽

...

Keyword(s):

Hepatocellular Carcinoma ◽

Minimally Invasive ◽

Comparative Study ◽

Liver Surgery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Minimally Invasive Techniques ◽

Single Institution ◽

Invasive Techniques

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Enhanced recovery after surgery (ERAS) pathway optimizes outcomes and costs for minimally invasive radical prostatectomy

Journal of International Medical Research ◽

10.1177/0300060520920072 ◽

2020 ◽

Vol 48 (6) ◽

pp. 030006052092007

Author(s):

Ying Xu ◽

Ao Liu ◽

Lu Chen ◽

Hai Huang ◽

Yi Gao ◽

...

Keyword(s):

Postoperative Complications ◽

Radical Prostatectomy ◽

Minimally Invasive ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Multivariable Analysis ◽

Conventional Care ◽

Conventional Group ◽

Hospitalization Costs ◽

The Impact

Objective To evaluate the impact of an enhanced recovery after surgery (ERAS) pathway on patients undergoing minimally invasive radical prostatectomy at a single institute. Methods In this retrospective study, 301 patients who underwent laparoscopic or robot-assisted laparoscopic radical prostatectomy from May 2014 to September 2018 were consecutively recruited. Before April 2017, the patients were treated with conventional care; all patients were treated with the ERAS pathway thereafter. The primary outcome was the postoperative length of hospital stay (LOS). The secondary outcomes were hospitalization costs and postoperative complications. Results In total, 138 patients were treated with the ERAS pathway, and the remaining patients underwent conventional care. The postoperative LOS was significantly shorter in the ERAS group than in the conventional group (median, 6 vs. 8 days). The hospitalization costs were also significantly lower in the ERAS group ($4086 vs. $5530). Ten (6.1%) patients in the ERAS group and 17 (12.3%) patients in the conventional group developed postoperative complications. The multivariable analysis showed that ERAS care was a significant independent predictive factor for a shortened LOS and reduced hospitalization costs. Conclusions The ERAS pathway was associated with a shortened LOS and reduced hospitalization costs for patients undergoing minimally invasive radical prostatectomy.

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Enhanced recovery after surgery: importance of compliance audits

Journal of Korean Medical Association ◽

10.5124/jkma.2021.64.12.820 ◽

2021 ◽

Vol 64 (12) ◽

pp. 820-825

Author(s):

Jung Hoon Bae

Keyword(s):

Clinical Outcomes ◽

Multidisciplinary Approach ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Surgical Stress ◽

Term Survival ◽

High Compliance ◽

Almost All ◽

Eras Protocol

Background: The enhanced recovery after surgery (ERAS) protocol is associated with improved clinical outcomes. However, implementation of ERAS in clinical practice is difficult because it requires a multidisciplinary approach and complex standardization. Moreover, maintenance and auditing of ERAS protocols is another challenge.Current Concepts: The ERAS society provides guidelines for surgery in almost all areas, and each guideline consists of approximately 20 items. Audits are performed to determine whether the items are being applied appropriately in a compliant manner as well as monitor and improve ERAS protocols. Numerous studies have reported that even with the application of the same ERAS protocol, postoperative short-term outcomes such as reductions of hospital stay and postoperative complications were better in the high-compliance group than in the low-compliance group. In addition, some recent studies have reported that application of ERAS protocols with high compliance can improve the long-term survival outcomes in cancer patients. In this regard, ERAS has been hypothesized to improve long-term oncological outcomes by minimizing surgical stress and reducing the postoperative inflammatory response and damage to immune function.Discussion and Conclusion: In addition to the development of appropriate protocols, auditing of compliance is also an important part of ERAS implementation. High compliance may lead to improved clinical outcomes.

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Enhanced Recovery After Surgery can Improve Patient Outcomes and Reduce Hospital Cost of Gastrectomy for Cancer in the West: A Propensity-Score-Based Analysis

Annals of Surgical Oncology ◽

10.1245/s10434-021-10079-x ◽

2021 ◽

Author(s):

Jacopo Weindelmayer ◽

Valentina Mengardo ◽

Angela Gasparini ◽

Michele Sacco ◽

Lorena Torroni ◽

...

Keyword(s):

Propensity Score ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Neoadjuvant Treatment ◽

Multivariable Analysis ◽

Hospital Costs ◽

Length Of Hospital Stay ◽

The West ◽

Median Reduction ◽

Eras Protocol

Abstract Background Data on ERAS for gastrectomy are scarce, and the majority of the studies come from Eastern countries. Patients in the West are older and suffer from more advanced tumors that impair their clinical condition and often require neoadjuvant treatment. This retrospective study assessed the feasibility and safety of an Enhanced Recovery After Surgery (ERAS) protocol for gastrectomy in a Western center. Methods We conducted a single-center study of 351 patients operated for gastric cancer: 103, operated from January 2015 to December 2016, followed the standard pathway, while 248, operated from January 2017 to December 2019, followed the ERAS program. The primary outcomes considered were length of hospital stay (LOS) and direct costs. Secondary outcomes were 90-day morbidity and mortality, readmission rate, and compliance with ERAS items. A propensity score (PS) was built on confounding variables. Results Compliance with ERAS items after the program was ≥ 70%. Univariable analysis evidenced a 2-day median reduction in LOS and a median cost reduction of €826 per patient in the ERAS group. PS-based multivariable analysis confirmed a significant, 2-day decrease in median LOS and a €1097 saving after ERAS introduction. Ninety-day mortality decreased slightly in ERAS group, while complications and readmissions did not change significantly. When complications were included in the multivariable analysis, ERAS retained its significance, although the effects on LOS and cost were blunted to a median reduction of 1 day and €775, respectively. Conclusions ERAS for gastrectomy improved patients’ recovery and reduced hospital costs without changes in morbidity, mortality, or readmission.

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Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Improve Clinical Outcomes in Liver Surgery: a Systematic Review and Meta-Analysis

Journal of Gastrointestinal Surgery ◽

10.1007/s11605-019-04499-0 ◽

2020 ◽

Vol 24 (4) ◽

pp. 918-932 ◽

Cited By ~ 2

Author(s):

L. Noba ◽

S. Rodgers ◽

C. Chandler ◽

A. Balfour ◽

D. Hariharan ◽

...

Keyword(s):

Cohort Studies ◽

Clinical Outcomes ◽

Liver Surgery ◽

Hospital Cost ◽

Standard Care ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Care Group ◽

Complication Rates ◽

Standard Care Group

Abstracts Background Enhanced recovery after surgery (ERAS) protocols are evidence-based, multimodal and patient-centred approach to optimize patient care and experience during their perioperative pathway. It has been shown to be effective in reducing length of hospital stay and improving clinical outcomes. However, evidence on its effective in liver surgery remains weak. The aim of this review is to investigate clinical benefits, cost-effectiveness and compliance to ERAS protocols in liver surgery. Methods A systematic literature search was conducted using CINAHL Plus, EMBASE, MEDLINE, PubMed and Cochrane for randomized control trials (RCTs) and cohort studies published between 2008 and 2019, comparing effect of ERAS protocols and standard care on hospital cost, LOS, complications, readmission, mortality and compliance. Results The search resulted in 6 RCTs and 21 cohort studies of 3739 patients (1777 in ERAS and 1962 in standard care group). LOS was reduced by 2.22 days in ERAS group (MD = −2.22; CI, −2.77 to −1.68; p < 0.00001) compared to the standard care group. Fewer patients in ERAS group experienced complications (RR, 0.71; 95% CI, 0.65–0.77; p = < 0.00001). Hospital cost was significantly lower in the ERAS group (SMD = −0.98; CI, −1.37 to – 0.58; p < 0.0001). Conclusion Our review concluded that the introduction of ERAS protocols is safe and feasible in hepatectomies, without increasing mortality and readmission rates, whilst reducing LOS and risk of complications, and with a significant hospital cost savings. Laparoscopic approach may be necessary to reduce complication rates in liver surgery. However, further studies are needed to investigate overall compliance to ERAS protocols and its impact on clinical outcomes.

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A Single Surgeons Experience with Enhanced Recovery after Surgery: An Army of One

The American Surgeon ◽

10.1177/000313481608200724 ◽

2016 ◽

Vol 82 (7) ◽

pp. 594-601 ◽

Cited By ~ 1

Author(s):

Catalina Mosquera ◽

Nicholas J. Koutlas ◽

Timothy L. Fitzgerald

Keyword(s):

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Univariate Analysis ◽

Intestinal Resection ◽

High Volume ◽

Before And After ◽

Individual Surgeon ◽

The Mean ◽

Eras Protocol ◽

Surgical Oncologist

The benefits of enhanced recovery after surgery (ERAS) have been demonstrated for multiple surgical procedures in high-volume programs. However, resources required for its implementation may be daunting to individual surgeons. Patients undergoing elective abdominal procedures from June 2013 to April 2015 by a surgical oncologist before and after the implementation of an ERAS protocol were reviewed. A total of 179 patients were included. The mean age of the patients was 63 years, and a majority of them were females (53.6%), white (61.5%), had a Charlson score of 0 to 2 (45.8%), and a Clavien complication grade of 0 to I (60.1%). The univariate analysis revealed that the ERAS protocol was associated with shorter length of stay (LOS) (6.2 vs 9.6 days), lower cost ($21,674 vs $30,380), and lower mortality (0 vs 3.3%); P < 0.05. Differences were noted in LOS and costs for all procedures, the differences were the greatest for hepatic resection (3.8 vs 8.4 days and $16,770 vs $28,589), intestinal resection/stoma closure (4.8 vs 7.6 days and $18,391 vs $22,239), and other abdominal procedures (5.0 vs 10.8 and $17,713 vs $30,900); P < 0.05. The differences were less for patients undergoing procedures for which postoperative pathways were already in place such as pancreatic (9 vs 10.8 days and $30,524 vs $34,291) and colorectal (5.3 vs 6.5 days and $20,733 vs $25,150) surgeries. P > 0.05. An ERAS program can be instituted by an individual surgeon with the benefits of decreased LOS, cost, and mortality.

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