Ryan W. Day

Patient-Reported Outcomes Accurately Measure the Value of an Enhanced Recovery Program in Liver Surgery

BACKGROUND Enhanced recovery (ER) pathways have become increasingly integrated into surgical practice. Studies that compare ER and traditional pathways often focus on outcomes confined to inpatient hospitalization and rarely assess a patients functional recovery. The aim of this study was to compare functional outcomes for patients treated on an Enhanced Recovery in Liver Surgery (ERLS) pathway vs a traditional pathway. STUDY DESIGN One hundred and eighteen hepatectomy patients rated symptom severity and life interference using the validated MD Anderson Symptom Inventory preoperatively and postoperatively at every outpatient visit until 31 days after surgery. The ERLS protocol included patient education, narcotic-sparing anesthesia and analgesia, diet advancement, restrictive fluid administration, early ambulation, and avoidance of drains and tubes. RESULTS Seventy-five ERLS pathway patients were clinically comparable with 43 patients simultaneously treated on a traditional pathway. The ERLS patients reported lower immediate postoperative pain scores and experienced fewer complications and decreased length of stay. As measured by symptom burden on life interference, ERLS patients were more likely to return to baseline functional status in a shorter time interval. The only independent predictor of faster return to baseline interference levels was treatment on an ERLS pathway (p = 0.021; odds ratio = 2.62). In addition, ERLS pathway patients were more likely to return to intended oncologic therapy (95% vs 87%) at a shorter time interval compared to patients on the traditional pathway (44.7 vs 60.2 days). CONCLUSIONS In oncologic liver surgery, enhanced recoverys primary mechanism of action is reduction in life interference by postoperative surgical symptoms, allowing patients to return sooner to normal function and adjuvant cancer therapies.

Incomplete reporting of enhanced recovery elements and its impact on achieving quality improvement

Enhanced recovery (ER) protocols are used widely in surgical practice. As protocols are multidisciplinary with multiple components, it is difficult to compare and contrast reports. The present study examined compliance and transferability to clinical practice among ER publications related to colorectal surgery.

Advances in hepatectomy technique: Toward zero transfusions in the modern era of liver surgery

BACKGROUND Perioperative blood transfusions suppress immunity and increase hospital costs. Despite multiple improvements in perioperative care, rates of transfusion during/after hepatectomy are reported to range from 25 to 50%. The purpose of this study was to determine the current risk factors for perihepatectomy transfusion by assessing the impact of recent technical advances in liver surgery on transfusion rates. METHODS Using our prospectively maintained hepatobiliary tumor database from a high-volume center, a modern cohort of 2,249 hepatectomies (2004-2013) were identified. Patient and operative characteristics were compared between 2 time periods, 2004-2008 (n = 1,139) and 2009-2013 (n = 1,110). Throughout the study interval, transfusions were given based on clinical assessment and not triggered by laboratory thresholds. RESULTS Compared with the early cohort, the recent cohort had more patients with an American Society of Anesthesiologists score of ≥ 3 (79 vs 74%), preoperative chemotherapy (73 vs 68%), and a lesser median preoperative hemoglobin (12.9 vs 13.1 mg/dL) and platelet (215,000 vs 243,000) values (all P < .001). Despite these adverse risk factors, with an increasing use of the 2-surgeon resection technique (63 vs 50%), estimated blood loss (309 vs 394 mL), transfusion rates (6 vs 15%), and duration of stay (7.0 vs 8.4 days) were decreased (all P < .001) with no change in overall morbidity or mortality. Multivariate analysis of the recent cohort determined that the independent risk factors associated with transfusion were preoperative anemia and >350 mL of blood loss. The only independent factor associated with less transfusion was use of the 2-surgeon technique for hepatic parenchymal transection. CONCLUSION With the exception of patients with moderate to severe preoperative anemia requiring major hepatectomy, recent technical advances have decreased significantly the need for transfusion in liver surgery.

Venous Thromboembolism Prophylaxis in Liver Surgery

BackgroundAt a recently concluded Americas Hepato-Pancreato-Biliary Association Annual Meeting, a Clinical Practice Guidelines Conference Series was convened with the topic focusing on Venous Thromboembolism (VTE) Prophylaxis in Liver Surgery. The symposium brought together hepatobiliary surgeons from three continents as well as medical experts in hematology and coagulation.MethodsThe content of the discussion included literature reviews, evaluation of multi-institutional VTE outcome data, and examination of practice patterns at multiple high-volume centers.ResultsLiterature review demonstrated that, within gastrointestinal surgery, liver resection patients are at particularly high-risk for VTE. Recent evidence clearly indicates a direct relationship between the magnitude of hepatectomy and postoperative VTE rates, however, the PT/INR does not accurately reflect the coagulation status of the post-hepatectomy patient. Evaluation of available data and practice patterns regarding the utilization and timing of anticoagulant VTE prophylaxis led to recommendations regarding preoperative and postoperative thromboprophylaxis for liver surgery patients.ConclusionsThis conference was effective in consolidating our knowledge of coagulation abnormalities after liver resection. Based on the expert review of the available data and practice patterns, a number of recommendations were developed.

Managing Early and Late Postoperative Complications Following Gastric Surgery

Gastric cancer surgery is associated with morbidity rates of 20–30 % and 30-day mortality rates of 4–5 %, based on multi-institutional quality improvement program data. Patients who undergo total gastrectomy have higher morbidity and mortality rates than do patients who undergo subtotal gastrectomy. Resection of adjacent organs also increases the risk of major postoperative complications. Frequently reported complications after gastrectomy include wound and intra-abdominal infection, dehiscence, pulmonary complications, myocardial infarction, thromboembolic complications, and anastomotic leakage. In addition to the standard early postoperative complications of major abdominal surgery, patients undergoing gastric resection are prone to several unique clinical syndromes often referred to as postgastrectomy syndromes. Although these syndromes were more common when peptic ulcer disease was frequently treated with surgery, these syndromes may also manifest in long-term survivors of gastric cancer and therefore are important survivorship issues. Postgastrectomy syndromes and late complications discussed in this chapter include dumping syndrome, afferent limb syndrome, efferent limb syndrome, Roux stasis syndrome, bile reflux gastritis, and postvagotomy diarrhea.

Clinical Care Pathways in Cancer Surgery

Patients with resectable cancers present unique challenges to surgical and anesthetic teams. These patients frequently require invasive and lengthy procedures that incur higher levels of disability. At the same time, the pressure to return cancer surgery patients to adjuvant cancer therapies places an additional responsibility on care teams. To meet this need, many cancer centers are utilizing enhanced recovery pathways of care. Although many of the practices contained within these pathways have been vetted in non-oncologic and minimally invasive oncologic procedures, major oncologic surgery poses unique challenges to their implementation. The purpose of this review is to highlight the challenges and opportunities that enhanced recovery protocols bring to oncologic surgery. Additionally, special considerations for the measurement of recovery in cancer patients are discussed.