| Enhanced recovery after surgery(ERAS)refers to the implementation of a series of evidence-based measures for reducing the psychological and physical stress of patients during perioperative period,so as to achieve the purpose of rapid rehabilitation after surgery.This concept was first proposed by professor Kehlet in the 1990s,and then successfully applied in the surgical fields including colorectal surgery.It was stated that the application of ERAS could reduce the incidence of postoperative complications by more than 30%and shorten the postoperative hospitalization time by more than 1 day.Since the concept of ERAS was put forward,it has experienced more than 20 years of development.The elements of early ERAS simply consisted of the following three elements:1.Combined with local anesthesia for reducing the incision pain;2.Early oral feeding for promoting the recovery of gastrointestinal function;3.Early mobilization for facilitating functional recovery.With the progress of surgical equipment and technology,the current ERAS protocol became more complicated.Although ERAS has achieved a lot progresses in many surgical fields,the application of ERAS in hepatopancreatobiliary surgery is still limited.The latest meta-analysis indicated that the ERAS protocol significantly reduced the overall incidence of postoperative complications,facilitated the postoperative recovery and shortened the postoperative length of hospital stay in liver resection patients.The results were consistent in patients receiving pancreatectomy.Our center adopted the idea of ERAS since 2017,and established a completed protocol on the basis of other accomplished guidelines and the latest research results.The protocol suggested that the preoperative counseling should be provided,and the nasogastric tube and urethral catheter should not be routinely placed.Early oral feeding and mobilization were recommended.Multiple modes of analgesia were applied to relieve the stress and pain of the patients,which effectively promoted the postoperative recovery of the patients.The purpose of present study was to evaluate the application of ERAS protocol in patients undergoing hepatopancreatobiliary surgery and prove that ERAS protocol can safely and effectively improve the prognosis of surgical patients.MethodsPresent study included 301 cases of hepatectomy and 36 cases of laparoscopic distal pancreatectomy in our center from May 2016 to June 2017.With the informed consent of patients and approval of the ethical committee,data including age,gender,body mass index(BMI),surgical approach,pathological diagnosis,operation time,intraoperative blood loss,etc,were retrospectively collected from the medical records.According to the surgical approach,the patients were divided into open surgery group and laparoscopic surgery group.The patients receiving ERAS protocol were divided into ERAS group,otherwise into the control group.Outcomes including operation time,intraoperative blood loss,postoperative hospital stay,first postoperative exhaust time,abdominal drainage volume on the first postoperative day,postoperative complications were collected.All data were anonymously analyzed.The statistic was performed by statistical software SPSS 19.0.Logistic regression analysis was performed for evaluating the postoperative complications.Variables reaching 10%significance in univariate analysis were included into multivariate analysis.p<0.05 was considered to be statistical significant.ResultsA total of 182 cases of laparoscopic hepatectomy were collected,including 49 cases in ERAS group and 133 cases in the control group.The median age of the enrolled patients was 57 years old,among which 63(34.6%)were females.The age(p =0.890),gender(p = 0.715),BMI(p = 0.768)and pathological results(p = 0.078)of the ERAS group showed no significant difference compared with the control group.Operative time in the ERAS group was 247.06 ± 115.19 mins,significantly longer than that in the control group(p = 0.001).There was no significant difference in intraoperative blood loss between the two groups(132.07 ± 182.80 mL in control group and 167.71 ± 160.86 mL in ERAS group,p = 0.194).After surgery,time to first flatus of patients in the ERAS group was 2.25 ± 0.78 days,significantly shorter than that of the control group(p = 0.002).Compared with the control group,postoperative length of hospital stay(LOS)in the ERAS group was also significantly shorter(6.15 ± 3.52 days vs.7.53 ± 3.77 days;p = 0.029).On the first day after surgery,the amount of abdominal drainage was equal between the two groups,136.30 ± 185.15 mL in the ERAS group and 135.89 ± 227.12 mL in the control group,showing no significant difference(p =0.991).In the control group,63.2%(84/133)of the patients experienced different degrees of postoperative complications,while the rate in the ERAS group was 42.9%(21/49),showing significant differences between the two groups(p = 0.014),while the difference in postoperative complication grades between the two groups was not statistically significant(p = 0.129).Liver function parameter values including alanine aminotransferase(ALT,p = 0.169),alanine aspartate aminotransferase(AST,p = 0.418),total bilirubin(TB,p = 0.422)and prothrombin time(PT,p = 0.228)were similar before and after laparoscopic hepatectomyA total of 119 patients who underwent open liver resection were included in this study,of which 20 were enrolled in the ERAS group and 99 in the control group.The median age of enrolled patients was 59 years old and 31 patients(26.1%)were female.The age(p = 0.487),gender(p = 0.119),BMI(p = 0.652)and pathological results(p =0.341)of the ERAS group showed no significant difference compared with the control group.The operation time of the ERAS group was 256.95 ± 107.42 minutes,significantly longer than that of the control group(203.75 ± 89.03 points,p=0.020).No significant differences in intraoperative blood loss were found between the ERAS group and the control group(160.75 ± 115.49 mL vs.199.09 ± 155.99 mL,p = 0.300).Time to first flatus(2.90 ± 0.97 days)was significantly shorter than that of the control group(3.46 ± 1.09 days,p = 0.035).The mean LOS in the ERAS group was 7.33 ± 1.64 days,significantly shorter than that of the control group(p = 0.028).On the first day after surgery,the amount of abdominal drainage was 190.00 ± 200.50 mL in the ERAS group and 168.75 ± 214.62 mL in the control group,with no significant difference between two groups(p = 0.685).There was no significant difference reagrding the value of biochemical parameters including ALT(p = 0.577),AST(p = 0.682),TB(p = 0.716)and PT(p = 0.441)during perioperative period.In total,68 patients(22.6%)suffered Grade Ⅱ-Ⅳ complications.Logistic multi-factor analysis found that ERAS protocol(risk ratio 0.376,95%confidence interval,0.163-0.868,p = 0.022),laparoscopic surgery(risk ratio 0.258,95%confidence interval,0.143-0.468,p<0.001)can significantly reduce the incidence of Clavien-Dindo Grade Ⅱ-Ⅳ complications.Operative time was an independent risk factor for Clavien-Dindo Grade Ⅱ-Ⅳ complications(risk ratio 1.005,95%confidence interval,1.002 to 1.008,p<0.001).36 cases of laparoscopic distal pancreatectomy were included,12 cases in the ERAS group and 24 cases in the control group.The median age was 59 years old(average 55 years old,ranging from 15 to 78 years),and 22 cases(61.1%)were female.There was no significant difference in age(p = 0.602),gender(p = 0.904)and BMI(p =0.613)between the two groups.The operation time of the ERAS group was 283.58 +60.96 minutes,and there was no significant difference from that of the control group(p=0.940).In the ERAS group,intraoperative blood loss was reduced,but the difference was not statistically significant(107.50 ± 92.748 mL in the ERAS group,195.83 ±198.317 mL in the control group,p = 0.154).Time to first flatus was 2.55 ± 0.82 days,significantly shorter than 3.32 ± 0.89 days(p = 0.026).Compared with the control group,the postoperative hospital stay in the ERAS group was shortened by an average of 2.3 days(7.45 ± 2.02 days vs.9.76 ± 2.98 days,p = 0.029).Abdominal drainage volume on the first day after surgery was similar between the two groups,88.18 ±130.20 mL in the ERAS group,and 49.88 ± 56.04 mL in the control group,showing no significant difference(p = 0.368).In the control group,66.7%(16/24)patients had different degrees of complications after surgery,while the rate of complications in the ERAS group was only 41.7%(5/12),with no significant difference between the two groups(p = 0.151).After classifying the complications through the clavien-dindo classification system,another comparison found that although the severity of complications in the ERAS group was lower than that in the control group,the difference was not statistically significant(p = 0.528).Conclusions:1.The application of ERAS protocol can significantly promote the recovery of gastrointestinal function,shorten the postoperative hospitalization time in patients receiving open and laparoscopic liver resection.2.The ERAS protocol can significantly reduce the incidence and severity of postoperative complications in patients receiving both open and laparoscopic liver resection.3.The ERAS protocol can significantly accelerate the recovery of postoperative gastrointestinal function and shorten the postoperative hospitalization time in patients receiving the laparoscopic distal pancreatectomy.4.The ERAS protocol can significantly reduce the incidence of overall postoperative complications in patients undergoing laparoscopic distal pancreatectomy,and the readmission rate dose not elevated. |
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