Hepatic resections and enhanced recovery pathway: an Indian encounter

Objectives: Data for outcomes following implementation of ERAS for liver surgery are scarce, especially from the South Asian region where the age old adage of overnight fasting before surgery and prolonged immobilisation following surgery is still etched in the minds of patients and surgeons alike. The objective of this study was to assess outcomes following implementation of ERAS protocol in patients undergoing hepatic resection.
Methods: A Prospective Observational Institutional Review Board approved study was conducted between February 2014 and November 2015 in Tata Memorial Centre, including all patients who underwent hepatic resections. A team was formulated and educated regarding the elements of perioperative ERAS protocol. Resections were graded as major if ≥4 segments were resected and minor if <4 segments were resected. The primary outcomes assessed were postoperative length of stay in the hospital and complications (Clavien Dindo Classification). Secondary outcomes were compliance of the team with the ERAS protocol and functional recovery of patients.
Results: 124 patients underwent hepatic resection during this period; 60.5% were major hepatectomies. Compliance with the various elements was as follows: preoperative carbohydrate loading - 71% (n=88), venous thromboembolism prophylaxis - 91.1% (n=113), mid-thoracic epidural 82.3% (n=102). Median postoperative day of full mobilisation was 3 (Interquartile range/ IQR 3-5). The median postoperative hospital stay was 8 days (IQR 8-14) and median ICU stay 1 day (IQR 1-3). 21% of patients had major complications with a 4.8% mortality rate. Among patients who had <75% overall compliance with the ERAS protocol, 42.9% (n=36) developed complications; whereas when overall compliance was >75%, 27.5% (n=11) developed complications, though statistically insignificant. There was a significant difference in the median postoperative stay when the compliance was >75% (p=0.033); 27.5% (n=11) stayed more than 8 days post operatively vs. 47.6% (n=40) when the compliance was <75%.
Conclusion: The initial results achieved with implementation of the ERAS protocol in hepatic surgery are encouraging. Strict adherence to protocol may lead to better outcomes as seen with patients with good compliance rates to the ERAS protocol in this study.