Society for Surgery of the Alimentary Tract
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Allison N. Martin*, Timothy E. Newhook, Elsa M. Arvide, Whitney L. Dewhurst, Anny M. Jin, Hop S. Tran Cao, Yun Shin Chun, Jean-Nicolas Vauthey, Ching-Wei D. Tzeng
Surgical Oncology, The University of Texas MD Anderson Cancer Center Division of Surgery, Houston, TX

Background: Although enhanced recovery pathways (ERPs) have been established as safe and effective care strategies in hepatobiliary surgery, compliance with ERP components may or may not be correlated with outcomes such as length of stay (LOS).

Methods: Variables for a cohort of hepatectomy patients on our previously published risk-stratified post-hepatectomy pathways (RHPSPs) were prospectively collected (6/14/22 to 11/18/22). Compliance with pathway components, reasons for deviations, and 90-day postoperative outcomes were prospectively reviewed by one faculty and three advanced practice providers biweekly and compared with index hospitalization LOS.

Results: Among 103 patients, 11 (10.7%) were on the minimally invasive (MIS) pathway with median LOS 2 days (interquartile range, IQR 1-2), 39 (37.9%) were low-intermediate risk pathway with median LOS 3 days (IQR 3-4), 27 (26.2%) were high-risk pathway with median LOS 4 days (IQR 3-5), and 26 (25.2%) were combination operations with median LOS 5 days (4-6). The goal LOS was 2-3 days for low-intermediate risk patients and 3-4 days for high-risk patients. Pathway compliance was perfect for 56 patients (54%); the remaining 47 patients had at least one instance of pathway deviation (46%). By pathway, only 1 (9%) MIS patient, 16 (41%) low-intermediate risk patients, 13 (48%) high-risk patients and 17 (65%) combination surgery patients experienced a pathway deviation (p=0.015). Patients with at least one pathway deviation had an increased median LOS compared to those with perfect compliance (LOS 5 [IQR 4-6] vs. LOS 3 [IQR 2-3.5], p=0.018).

Linear regression demonstrated postoperative compliance factors associated with increasing LOS included postoperative days until advancement to solid food (coefficient 1.86, 95% confidence interval [CI] 1.1-2.6), p<0.001), days until solid food was tolerated for 24 hours (coefficent 1.6, 95% CI 0.7-2.6, p=0.002), and days to complete conversion to oral medications (coefficent 0.82, 95% CI 0.02-1.6, p=0.045). Other traditional compliance factors, including simply clear liquid diet tolerance, discontinuation of intravenous fluids (but not all intravenous medications), bladder catheter removal, and return of flatus, were not associated with reduced LOS (all p>0.30).

Conclusions: Despite imperfect compliance, median LOS for patients treated with risk-stratified post-hepatectomy pathways remains favorable for both low-intermediate and high-risk patients. Combination operations require further optimization and process improvements to identify barriers to pathway compliance and better outcomes. Focusing on the straightforward goals of solid food and oral medications may be associated with expedited discharge after hepatectomy.

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