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ENHANCED RECOVERY AND PERIPHERAL NERVE BLOCK AFTER HEPATECTOMY
Lucas W. Thornblade*1, Tracy Kwan1, Jane H. Cardoso2, Eric Pan3, Gregory A. Dembo3, Raymond S. Yeung1, James O. Park1
1Department of Surgery , University of Washington, Seattle, WA; 2Transformation of Care Department, University of Washington, Seattle, WA; 3Department of Anesthesiology, University of Washington, Seattle, WA
Introduction: Protocols for standardizing perioperative care in colorectal surgery (Enhanced Recovery after Surgery—or ERAS) have been associated with improvements in return of bowel function, fewer adverse events, and reliably shorter length of stay (LOS). For operations such as liver resection—which frequently require ICU care and often a long LOS—there is little data on standardized perioperative care. Pain control after liver surgery can be challenging and routine epidural use is associated with iatrogenic hypotension and excess administration of fluid and blood products. We aimed to improve patient outcomes after hepatectomy through implementation of ERAS protocols and via innovative pain control strategies.
Methods: We report three phases of implementation of standardized perioperative care protocols for all patients undergoing hepatectomy at an academic quaternary referral center in Washington state. Phase I (January 2014-February 2015) comprised routine pre-ERAS care with pain control administered via epidural catheter for all open cases. In Phase II (March-December 2015), ERAS protocols including preoperative immunonutrition, medication coordination, glucose control, perioperative fluid restriction, and early postoperative dietary advancement and mobilization were implemented. All epidurals were replaced by intraoperative Transversus Abdominis Plane (TAP) block (bupivacaine) and catheter placement (continuous ropivacaine infusion). Finally, in Phase III (January-September 2016), TAP infusion catheters were replaced by one-time TAP block injection of liposomal bupivacaine at the time of surgery. We measured ICU utilization, LOS, direct costs, and patient satisfaction with anesthesia.
Results: A total of 120 patients underwent liver resection during this study [Phase I (n=56), Phase II (n=43), Phase III (n=23)]. ICU utilization decreased from 46% during Phase I to 12% and 9% during Phases II and III, respectively. Mean LOS was 5.1 days prior to ERAS (Phase I) and 4.4 days during both Phases II and III. The direct costs per case were $15,828; $14,775; and $13,673 over three phases of the study. 30% of patients with TAP catheters (Phase II) experienced leakage or catheter dysfunction. Rates of patients reporting they were “unsatisfied” with their pain control regimen were low for all phases (<15%).
Discussion: Standardization of care is central to improving outcomes after high-risk surgery. Here we report the innovative combination of enhanced recovery strategies and TAP block with liposomal bupivacaine. Our early experience suggests that the use of local anesthetic nerve block in place of epidural anesthesia may reduce both ICU utilization and costs without compromising pain control.
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