title: Factors associated with failure of enhanced recovery protocol in patients undergoing major hepatobiliary and pancreatic surgery: a retrospective cohort study.
abstract: OBJECTIVE
  This study examined the risk factors associated with failure of enhanced recovery protocol after major hepatobiliary and pancreatic (HBP) surgery.
  
  
  METHODS
  A retrospective cohort of 194 adult patients undergoing major HBP surgery at a university hospital in Hong Kong was followed up for 30 days. The patients were from a larger cohort study of 736 consecutive adults with preoperative urinary cotinine concentration to examine the association between passive smoking and risk of perioperative respiratory complications and postoperative morbidities.
  
  
  METHODS
  The primary outcome was failure of enhanced recovery protocol. This was defined as a composite measure of the following events: intensive care unit (ICU) stay more than 24 h after surgery, unplanned admission to ICU within 30 days after surgery, hospital readmission, reoperation and mortality.
  
  
  RESULTS
  There were 25 failures of enhanced recovery after HBP surgery (12.9%, 95% CI 8.5% to 18.4%). After adjusting for elective ICU admission, smokers (relative risk (RR ) 2.21, 95% CI 1.10 to 4.46), high preoperative alanine transaminase/glutamic-pyruvic transaminase (RR 3.55,95% CI 1.68 to 7.49) and postoperative morbidities (RR 2.69, 95% CI 1.30 to 5.56) were associated with failures of enhanced recovery in the generalised estimating equation risk model. Compared with those managed successfully, failures stayed longer in ICU (median 19 vs 25 h, p<0.001) and in hospital for postoperative care (median 7 vs 13 days, p=0.003).
  
  
  CONCLUSIONS
  Smokers and patients having high preoperative alanine transaminase/glutamic-pyruvic transaminase concentration or have a high risk of postoperative morbidities are likely to fail enhanced recovery protocol in HBP surgery programmes.
authors.affiliation: Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Anna
authors.initials: A
authors.lastname: Lee
authors.affiliation: Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Chun Hung
authors.initials: CH
authors.lastname: Chiu
authors.affiliation: Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Mui Wai Amy
authors.initials: MW
authors.lastname: Cho
authors.affiliation: Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Charles David
authors.initials: CD
authors.lastname: Gomersall
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Kit Fai
authors.initials: KF
authors.lastname: Lee
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: Yue Sun
authors.initials: YS
authors.lastname: Cheung
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong Wong Tze Lam - Hing Tak Centre of Surgical Outcome Research, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Paul Bo San
authors.initials: PB
authors.lastname: Lai
mesh_terms: D001662:Biliary Tract Surgical Procedures; D002985:Clinical Protocols; D015331:Cohort Studies; D005260:Female; D006498:Hepatectomy; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy; D019990:Perioperative Care; D011183:Postoperative Complications / Q000517:prevention & control; D020127:Recovery of Function; D012189:Retrospective Studies; D012307:Risk Factors; D017211:Treatment Failure