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Enhanced Recovery via Peripheral Nerve Block for Open Hepatectomy

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Enhanced recovery after surgery (ERAS) protocols are now commonplace in many fields of surgery, but only limited data exists for their use in hepatobiliary surgery. We implemented standardized ERAS protocols for all open hepatectomies and replaced thoracic epidurals with a transversus abdominis plane (TAP) block.

Methods

We performed a retrospective cohort study of all patients undergoing open hepatectomy during the 14 months before and 19 months after implementation of an ERAS protocol at our institution (January 2014–September 2016). Trained abstractors reviewed charts for patient demographics, perioperative details, and healthcare utilization. All nursing-reported visual analog scale pain scores were sampled to identify patients with uncontrolled pain (daily mean score > 5). Outcomes included length of stay (LOS), costs, and 30-day readmission.

Results

A total of 127 patients (mean age 54.6 ± 13.0 years, 44% female) underwent open liver resection (69 [54%] after ERAS implementation). ERAS protocols were associated with significantly lower rates of ICU admission (47 vs. 13%, p < 0.001), shorter LOS (median 5.3 vs. 4.3 days, p = 0.007), and lower median costs ($3566 less, p = 0.03). Readmission remained low throughout the study period (5% pre-ERAS, 4% during ERAS, p = 0.83). Rates of uncontrolled pain were either the same or better after ERAS implementation through post-operative day #3 (41% pre-ERAS, 23% during ERAS, p = 0.03).

Discussion

The use of TAP block for hepatectomy as part of an ERAS protocol is associated with improved quality and cost of care. Surgeons performing liver resections should consider standardization of evidence-based best practices in all patients.

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Abbreviations

ASA:

American Society of Anesthesiologists

CVP:

central venous pressure

ERAS:

enhanced recovery after surgery

HPB:

hepatobiliary

ICU:

intensive care unit

IV:

intravenous

LOS:

length of stay

NSAID:

non-steroidal anti-inflammatory drug

OR:

operating room

PACU:

post-anesthesia care unit

PCA:

patient-controlled analgesia

POD:

post-operative day

SBP:

systolic blood pressure

SD:

standard deviation

TAP:

transversus abdominis plane

UOP:

urine output

References

  1. GustafssonUO, ScottMJ, SchwenkW, et al.Guidelines for perioperative care in elective colonic surgery: Enhanced recovery after surgery (ERAS®) society recommendations. World J Surg.2013;37(2):259–284. doi:https://doi.org/10.1007/s00268-012-1772-0.

    Article  PubMed  CAS  Google Scholar 

  2. SerclováZ, DytrychP, MarvanJ, et al.Fast-track in open intestinal surgery: prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456). Clin Nutr.2009;28(6):618–624. doi:https://doi.org/10.1016/j.clnu.2009.05.009.

    Article  PubMed  Google Scholar 

  3. PageAJ, EjazA, SpolveratoG, et al.Enhanced Recovery After Surgery Protocols for Open Hepatectomy: Physiology, Immunomodulation, and Implementation. J Gastrointest Surg.2015;19(2):387–399. doi:https://doi.org/10.1007/s11605-014-2712-0.

    Article  PubMed  Google Scholar 

  4. AhmedEA, MontaltiR, NicoliniD, et al.Fast track program in liver resection: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore).2016;95(28):e4154. doi:https://doi.org/10.1097/MD.0000000000004154.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Strong for Surgery. https://www.facs.org/quality-programs/strong-for-surgery/about. Accessed September 9, 2017.

  6. ThornbladeLW, VargheseTK, ShiX, et al.Preoperative Immunonutrition and Elective Colorectal Resection Outcomes. Dis Colon rectum.2017;60(1):68–75. doi:https://doi.org/10.1097/DCR.0000000000000740.

    Article  PubMed  PubMed Central  Google Scholar 

  7. PageA, RostadB, StaleyCA, et al.Epidural Analgesia in Hepatic Resection. J Am Coll Surg.2008;206(6):1184–1192. doi:https://doi.org/10.1016/j.jamcollsurg.2007.12.041.

    Article  PubMed  Google Scholar 

  8. TzimasP, ProutJ, PapadopoulosG, MallettS V. Epidural anaesthesia and analgesia for liver resection. Anaesthesia.2013;68(6):628–635. doi:https://doi.org/10.1111/anae.12191.

    Article  PubMed  CAS  Google Scholar 

  9. HebbardP.Subcostal transversus abdominis plane block under ultrasound guidance. Anesth Analg.2008;106(2):674–5; author reply 675. doi:https://doi.org/10.1213/ane.0b013e318161a88f.

    Article  PubMed  Google Scholar 

  10. IlfeldBM, ViscusiER, HadzicA, et al. Safety and Side Effect Profile of Liposome Bupivacaine (Exparel) in Peripheral Nerve Blocks. Reg Anesth Pain Med. 40(5):572–582. doi:https://doi.org/10.1097/AAP.0000000000000283.

  11. U.S. Bureau of Labor Statistics, Division of Consumer Prices and Price Indexes. Consumer Price Index. http://www.bls.gov/cpi/. Accessed November 20, 2016.

  12. LinDX, LiX, YeQW, LinF, LiLL, ZhangQY. Implementation of a Fast-Track Clinical Pathway Decreases Postoperative Length of Stay and Hospital Charges for Liver Resection. Cell Biochem Biophys.2011;61(2):413–419. doi:https://doi.org/10.1007/s12013-011-9203-7.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  13. NiCY, YangY, ChangYQ, et al.Fast-track surgery improves postoperative recovery in patients undergoing partial hepatectomy for primary liver cancer: A prospective randomized controlled trial. Eur J Surg Oncol.2013;39(6):542–547. doi:https://doi.org/10.1016/j.ejso.2013.03.013.

    Article  PubMed  CAS  Google Scholar 

  14. VanDamRM, HendryPO, CoolsenMME, et al.Initial experience with a multimodal enhanced recovery programme in patients undergoing liver resection. Br J Surg.2008;95(8):969–975. doi:https://doi.org/10.1002/bjs.6227.

    Article  PubMed  Google Scholar 

  15. DunneDFJ, YipVS, JonesRP, et al.Enhanced recovery in the resection of colorectal liver metastases. J Surg Oncol.2014;110(2):197–202. doi:https://doi.org/10.1002/jso.23616.

    Article  PubMed  Google Scholar 

  16. JonesC, KelliherL, DickinsonM, et al.Randomized clinical trial on enhanced recovery versus standard care following open liver resection. Br J Surg.2013;100(8):1015–1024. doi:https://doi.org/10.1002/bjs.9165.

    Article  PubMed  CAS  Google Scholar 

  17. SchultzNA, LarsenPN, KlarskovB, et al.Evaluation of a fast-track programme for patients undergoing liver resection. Br J Surg.2013;100(1):138–143. doi:https://doi.org/10.1002/bjs.8996.

    Article  PubMed  CAS  Google Scholar 

  18. ConnorS, CrossA, SakowskaM, LinscottD, WoodsJ. Effects of introducing an enhanced recovery after surgery programme for patients undergoing open hepatic resection. Hpb.2013;15(4):294–301. doi:https://doi.org/10.1111/j.1477-2574.2012.00578.x.

    Article  PubMed  Google Scholar 

  19. StootJH, vanDamRM, BuschOR, et al.The effect of a multimodal fast-track programme on outcomes in laparoscopic liver surgery: A multicentre pilot study. Hpb.2009;11(2):140–144. doi:https://doi.org/10.1111/j.1477-2574.2009.00025.x.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Sánchez-PérezB, Aranda-NarváezJM, Suárez-MuñozMA, et al.Fast-track program in laparoscopic liver surgery: Theory or fact?World J Gastrointest Surg.2012;4(11):246–250. doi:https://doi.org/10.4240/wjgs.v4.i11.246.

    Article  PubMed  PubMed Central  Google Scholar 

  21. BlindP-J, AnderssonB, TingstedtB, et al. Fast-track program for liver resection--factors prolonging length of stay. Hepatogastroenterology. 61(136):2340–2344. http://www.ncbi.nlm.nih.gov/pubmed/25699379.

  22. HeF, LinX, XieF, HuangY, YuanR. The effect of enhanced recovery program for patients undergoing partial laparoscopic hepatectomy of liver cancer. Clin Transl Oncol.2015;17(9):694–701. doi:https://doi.org/10.1007/s12094-015-1296-9.

    Article  PubMed  CAS  Google Scholar 

  23. LiangX, YingH, WangH, et al.Enhanced Recovery Program Versus Traditional Care in Laparoscopic Hepatectomy. Med.2016;95(8):e2835. doi:https://doi.org/10.1097/MD.0000000000002835\r00005792-201602230-00030

  24. WuY, LiuF, TangH, et al.The analgesic efficacy of subcostal transversus abdominis plane block compared with thoracic epidural analgesia and intravenous opioid analgesia after radical gastrectomy. Anesth Analg.2013;117(2):507–513. doi:https://doi.org/10.1213/ANE.0b013e318297fcee.

    Article  PubMed  CAS  Google Scholar 

  25. KadamVR, VanWijkRM, MoranJL, MillerD. Epidural versus continuous transversus abdominis plane catheter technique for postoperative analgesia after abdominal surgery. Anaesth Intensive Care.2013;41(4):476–481.

    Google Scholar 

  26. NirajG, KelkarA, JeyapalanI, et al.Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery. Anaesthesia.2011;66(6):465–471. doi:https://doi.org/10.1111/j.1365-2044.2011.06700.x.

    Article  PubMed  CAS  Google Scholar 

  27. ErdoganMA, OzgulU, UçarM, et al. Effect of transversus abdominis plane block in combination with general anesthesia on perioperative opioid consumption, hemodynamics, and recovery in living liver donors: The prospective, double-blinded, randomized study. Clin Transplant.2017;31(4):1–5. doi:https://doi.org/10.1111/ctr.12931.

    Article  CAS  Google Scholar 

  28. KitlikA, ErdoganMA, OzgulU, et al.Ultrasound-guided transversus abdominis plane block for postoperative analgesia in living liver donors: A prospective, randomized, double-blinded clinical trial. J Clin Anesth.2017;37:103–107. doi:https://doi.org/10.1016/j.jclinane.2016.12.018.

    Article  PubMed  Google Scholar 

  29. OllierE, HeritierF, BonnetC, et al.Population pharmacokinetic model of free and total ropivacaine after transversus abdominis plane nerve block in patients undergoing liver resection. Br J Clin Pharmacol.2015;80(1):67–74. doi:https://doi.org/10.1111/bcp.12582.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  30. VadiveluN, MitraS, SchermerE, KodumudiV, KayeAD, UrmanRD. Preventive analgesia for postoperative pain control: A broader concept. Local Reg Anesth.2014;7(1):17–22. doi:https://doi.org/10.2147/LRA.S62160.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We would like to thank Michelle Shen Yan at the Surgical Outcomes Research Center for assistance in data collection. Research reported in this publication was supported by a grant from the National Institutes of Health under Award Number T32DK070555. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Authors and Affiliations

  1. Department of Surgery, University of Washington, 1959 NE Pacific Street, Suite BB-487, Box: 356410, Seattle, WA, USA

    Lucas W. Thornblade, Yongwoo D. Seo, Tracy Kwan, Raymond S. W. Yeung & James O. Park

  2. Transformation of Care Department, University of Washington, Seattle, WA, USA

    Jane H. Cardoso

  3. Department of Anesthesiology, University of Washington, Seattle, WA, USA

    Eric Pan & Gregory Dembo

Authors
  1. Lucas W. Thornblade
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  2. Yongwoo D. Seo
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  4. Jane H. Cardoso
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  5. Eric Pan
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Contributions

Thornblade: study design, data collection, analysis, manuscript writing.

Seo: data collection, manuscript review.

Kwan: study design, manuscript review.

Cardoso: study design, analysis.

Pan: project leadership, study design.

Dembo: project leadership, study design, manuscript review.

Yeung: project leadership, study design, manuscript review.

Park: project leadership, study design, analysis, manuscript review.

Corresponding author

Correspondence to Lucas W. Thornblade.

Ethics declarations

This study was approved by the University of Washington Internal Review Board (study #00000901).

Additional information

Meeting presentation: This work was presented as a poster at the 2017 Society of the Surgery for the Alimentary Tract Meeting

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Thornblade, L.W., Seo, Y.D., Kwan, T. et al. Enhanced Recovery via Peripheral Nerve Block for Open Hepatectomy. J Gastrointest Surg 22, 981–988 (2018). https://doi.org/10.1007/s11605-017-3656-y

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  • DOI: https://doi.org/10.1007/s11605-017-3656-y

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