Ryan W Day1, Charles S Cleeland2, Xin S Wang2, Sharon Fielder1, John Calhoun3, Claudius Conrad1, Jean-Nicolas Vauthey1, Vijaya Gottumukkala4, Thomas A Aloia5. 1. Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX. 2. Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX. 3. Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, TX. 4. Department of Anesthesiology, The University of Texas MD Anderson Cancer Center, Houston, TX. 5. Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX. Electronic address: taaloia@mdanderson.org.
Abstract
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 patient's 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 recovery's 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.
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 patient's 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 recovery's 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.
Authors: Rebecca K Marcus; Heather A Lillemoe; David C Rice; Gabriel Mena; Brian K Bednarski; Barbra B Speer; Pedro T Ramirez; Javier D Lasala; Neema Navai; Wendell H Williams; Bradford J Kim; Rachel K Voss; Vijaya N Gottumukkala; Thomas A Aloia Journal: Ann Surg Oncol Date: 2019-01-09 Impact factor: 5.344
Authors: Nicolai A Schultz; Peter N Larsen; B Klarskov; L M Plum; Hans-Jørgen Frederiksen; Henrik Kehlet; Jens G Hillingsø Journal: World J Surg Date: 2018-06 Impact factor: 3.352
Authors: John R Romanelli; Pascal R Fuchshuber; Jonah James Stulberg; Rebecca Brewer Kowalski; Prashant Sinha; Thomas A Aloia; Rocco Orlando Journal: Surg Endosc Date: 2019-06-03 Impact factor: 4.584
Authors: Heather A Lillemoe; Rebecca K Marcus; Ryan W Day; Bradford J Kim; Nisha Narula; Catherine H Davis; Vijaya Gottumukkala; Thomas A Aloia Journal: Surgery Date: 2019-05-15 Impact factor: 3.982