Applicability of enhanced recovery program for advanced liver surgery.
BACKGROUND
Enhanced recovery programs (ERPs) have been developed in various surgical fields and have been shown to accelerate postoperative recovery without increasing the incidence of adverse events. Whether ERP can be safely applied to patients undergoing complex liver surgery with a risk of liver failure remains unclear.


METHODS
We created an ERP by rearranging our conventional postoperative treatments and applied this program to patients undergoing major hepatectomy between 2008 and 2013. The ERP elements included greater perioperative education, individualized postoperative fluid therapy, and early mobilization. The success of the ERP was evaluated on postoperative day (POD) 6 based on the criterion of independence from continuous medical intervention with the exception of an abdominal drainage tube. Adherence to each item in the ERP was evaluated, and risk factors for delayed accomplishment were analyzed.


RESULTS
Altogether, 200 patients were included, and 165 patients (82.5 %) completed the ERP. Multivariate analyses showed that (1) an age of 65 years or older and (2) a red blood cell transfusion were independent risk factors for delayed accomplishment. The performance of thoracotomy or choledocojejunostomy did not significantly affect accomplishment of the ERP. Oral intake starting on POD 1 was achieved in 179 patients (89.5 %), and termination of intravenous drip infusions on POD 5 was feasible in 72.5 %.


CONCLUSIONS
An ERP for major hepatectomy was completed in more than 80 % of the patients. Earlier bowel movement can be challenged. The liquid in-out balance should be adjusted on an individual basis, rather than uniformly, especially for patients over 65 years of age or who required a red blood cell transfusion.
Division of Hepato-Biliary-Pancreatic Surgery and Transplantation Surgery, Japanese Red Cross Medical Center, 4-1-22 Hiroo, Shibuya-ku, Tokyo, 150-8935, Japan, takamoto@nifty.com.
Takeshi
T
Takamoto
Takuya
T
Hashimoto
Kazuto
K
Inoue
Daisuke
D
Nagashima
Yoshikazu
Y
Maruyama
Yusuke
Y
Mitsuka
Osamu
O
Aramaki
Masatoshi
M
Makuuchi
D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001803:Blood Transfusion; D002768:Choledochostomy; D004434:Early Ambulation; D005260:Female; D005440:Fluid Therapy; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D017093:Liver Failure / Q000209:etiology; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic; D011182:Postoperative Care / Q000009:adverse effects / Q000379:methods*; D011300:Preoperative Care / Q000379:methods; D012307:Risk Factors; D016896:Treatment Outcome