Enhanced Recovery After Surgery: Hepatobiliary

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Key points

  • The goal of an effective Enhanced recovery after surgery (ERAS) program is the rapid return of the patient to normal life function and in the case of patients with cancer, return to intended oncologic therapies. Strategies for achieving these goals are minimization of perioperative stress, as well as excessive fluids and narcotics.

  • The foundation of ERAS lies in engagement and education of the patient and caregiver. Core components universal to all ERAS include: early oral feeding, goal-directed

The Foundation: Patient Evaluation, Education, and Engagement

As with any preoperative evaluation, the first steps in evaluating a patient for an enhanced recovery protocol are a preoperative history and physical examination. Providers should perform a detailed review of comorbidities that may result in an increased risk of adverse outcomes after general anesthesia and hepatobiliary surgery, including advanced age, preexisting lung or heart disease, and/or signs of portal hypertension. The presence of these and other medical conditions contributing to

Outcomes in hepatopancreatobiliary and compliance monitoring

Studies directly comparing enhanced recovery after HPB surgery with traditional care pathways show improvements in various metrics, namely LOS, pain-related measures, and morbidity. In a randomized trial, Jones and colleagues1 demonstrated that ERAS resulted in more timely discharge readiness and shortened LOS compared with standard care after open liver surgery (LOS 4 vs 7 days; P<.001). Surgical complications and patient satisfaction were, however, comparable between groups. In a

Patient-reported outcomes and return to intended oncologic treatment

As mentioned, the main goal of any ERAS pathway is to return the patient to his or her baseline function safely and quickly. However, functional recovery is rarely found in the medical record. Only the patient can relate their experience and their functional recovery, and validated patient-reported outcomes (PROs) are the only conduit to record these outcomes. While clinical outcomes research has shown objective improvements with ERAS compared to traditional pathways in regards to LOS,

Summary

ERAS protocols in hepatobiliary surgery are proven to improve outcomes such as LOS and postoperative complications. Recently, a shift toward analysis of long-term oncologic and patient-centered functional outcomes suggests the superiority in ERAS in these domains compared to traditional recovery, as well. Implementation strategies, compliance measurement and outcomes feedback have the potential to further the efficacy of ERAS in HPB Surgery.

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  • Cited by (26)

    • Use of Erector Spinae Fascial Plane Blocks in Enhanced Recovery for Open Abdominal Surgery

      2021, Journal of Surgical Research
      Citation Excerpt :

      Enhanced Recovery After Surgery (ERAS) programs have been increasingly adopted in hepatopancreatobiliary (HPB) surgery. The inclusion of multimodal pain regimens aims to both improve patient outcomes and decrease opioid prescribing in post-surgical patients.1,2 Thoracic epidural analgesia (TEA) has been the cornerstone of opioid-sparing anesthesia in ERAS programs for open abdominal procedures, providing regional pain control through neuraxial blockade using local anesthetic.

    • Epidural analgesia for hepatopancreatobiliary operations and postoperative urinary tract infections: an unrecognized association of “best-practices” and adverse outcomes

      2021, HPB
      Citation Excerpt :

      Enhanced Recovery after Surgery (ERAS) protocols for hepatobiliary and pancreas (HPB) operations1,2 have proven to be beneficial in reducing length of stay, decreasing cost, and improving clinical and patient reported outcomes, and are considered “best-practices” for the perioperative care of this and other surgical populations.3–5

    • Resident Participation as Co-Surgeon Does Not Adversely Impact Patient Outcomes in Pancreatic Surgery

      2020, Journal of Surgical Education
      Citation Excerpt :

      Ghaferi et al. showed that the ability of a hospital system to rescue a patient from postoperative complications is proportional to hospital volume for pancreatectomy, gastrectomy, and esophagectomy.13 Enhanced recovery programs (ERPs) for pancreatic surgery promote standardized perioperative protocols and have been shown to reduce hospital LOS without adversely affecting undesirable measures.14,15 Staff at our hospital—including anesthesiologists, intensivists, nurses, physical therapists, nutritionists, case managers, and social workers—routinely care for medically complex patients before and after they undergo pancreatic surgery.

    View all citing articles on Scopus

    Funding Sources: Dr H.A. Lillemoe is supported by a National Institutes of Health grant T32CA009599-29.

    The authors have no financial disclosures.

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