Effects of introducing an enhanced recovery after surgery programme for patients undergoing open hepatic resection.

OBJECTIVES: Enhanced recovery after surgery (ERAS) protocols are coming to represent the standard of care in many surgical procedures, yet data on their use following hepatic surgery are scarce. The aim of this study was to review outcomes after the introduction of an ERAS programme for patients undergoing open hepatic resection. METHODS: A retrospective review of patients undergoing open hepatic resection from March 2005 to June 2011 was carried out. The primary outcome measure was total hospital length of stay (LoS) (including readmissions). Principles associated with enhanced recovery after surgery were documented and analysed as independent predictors of hospital LoS. RESULTS: A total of 120 patients underwent 128 consecutive hepatic resections, 84 (65.6%) of which were performed in patients with underlying colorectal metastases and 64 (50.0%) of which comprised major hepatic resections. The median hospital LoS was reduced from 6 days to 3 days from the first to the fourth quartiles of the study population (P = 0.021). The proportion of patients suffering complications (26.6%) remained constant across the series. Readmissions increased from the first quartile (none of 32 patients) to the fourth quartile (seven of 32 patients) (P = 0.044). Following multivariate analysis, only the development of a complication (P < 0.001), total postoperative i.v. fluid (P = 0.003) and formation of an anastomosis (P = 0.006) were independent predictors of hospital LoS. CONCLUSIONS: An ERAS programme can be successfully applied to patients undergoing open hepatic resection with a reduction in hospital LoS, but an increase in the rate of readmissions.

A change in practice from epidural to intrathecal morphine analgesia for hepato-pancreato-biliary surgery.

BACKGROUND: This study was designed to audit the change of anesthetic practice from thoracic epidural analgesia (TEA) to intrathecal morphine (ITM) combined with patient-controlled analgesia (PCA) for hepato-pancreato-biliary (HPB) surgery. METHODS: All patients who underwent major HPB surgery and received TEA or ITM from March 2005 to March 2008 were identified. Patients who received PCA alone were used for comparison. Data were retrospectively collected and analyzed for success of TEA, perioperative intravenous fluid (IVF) volume administered, hypotension, complications, and hospital stay. RESULTS: During the study period, 51 (32%) patients received TEA, 79 (49%) received ITM plus PCA opiate, and 31 (19%) received PCA alone. The incidence of postoperative hypotension was significantly higher in those who received TEA compared with those who received ITM (21/51 (41%) vs. 7/79 (9%), P < 0.001). The median (range) perioperative IVF administration was higher in the TEA group compared with the ITM group for both the first 24 h (6 (3-11) liters vs. 5 (3-11) liters, P < 0.05) and in total (15.5 (5-48.5) liters vs. 9 (3-70) liters, P < 0.001). Respiratory complications occurred in five (10%) of the TEA group compared with one (1%) in the ITM group (P < 0.05). The median (range) hospital stay was longer in the TEA group compared with the ITM group (9 (3-36) days vs. 7 (3-55) days, P < 0.01). CONCLUSIONS: In a resource-limited setting, ITM, compared with TEA, is associated with a reduced incidence of postoperative hypotension, reduced IVF requirements, shorter hospital stay, and lowers the incidence of respiratory complication.