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BACKGROUND: Implementation of enhanced recovery and fast-tract care pathways in colorectal surgery have demonstrated decreased overall cost and length of stay (LOS) while resulting in no significant increase in perioperative morbidity and readmission rate. Similar pathways are yet established for liver surgery due to concern for perioperative coagulopathy, hepatic dysfunction, and perioperative volume management. The aim of this study was to evaluate the safety of an enhanced recovery pathway (ERP) for patients undergoing open liver resection.
METHODS: A single-institution, observational cohort study was performed by comparing the clinical outcomes of patients treated before and after implementation of an ERP. The ERP included pre-operative oral celecoxib and gabapentin, standardized anesthetic including general anesthesia, intrathecal analgesia, and postoperative nausea prophylaxis, and a standardized post-operative care regimen. Clinical outcomes including morbidity, mortality, reoperation, LOS, and readmission rate were compared between ERP and non-ERP cohorts on an intention-to-treat basis.
RESULTS: A total of 126 patients (ERP = 53, non-ERP=73) were included in the study. Patient characteristics and operative details including ASA (p = 0.71), diagnosis (p = 0.32), type of liver resection (p = 0.86), and estimated blood loss (p = 0.81) were similar between groups. Overall complication rate was slightly lower in the ERP cohort, but not statistically significant (28.3% vs. 37.0%, p = 0.86). Before and after pathway implementation, the median LOS remained identical (5 days vs. 5 days, p = 0.71). No differences were identified for reoperation rate (2.7% vs 3.8%, p = 1.00), complication requiring ICU transfer (13.7% vs. 7.6%, p = 0.40), or readmission (2.7% vs 3.8%, p = 1.00). After adjusting for age, type of resection, and ASA, ERP and non-ERP patients had no increased risk of major complication (OR 0.38, 95% CI 0.14-1.02, p = 0.06) or LOS greater than 5 days (OR 1.21, 95% CI 0.18-2.62, p = 0.62).
CONCLUSIONS: Routine use of a multimodal ERP is safe and is not associated with increased the post-operative morbidity after major open liver resection. However, the current study found that LOS was unchanged for patients treated with an ERP compared to conventional management.