Journal of Gastrointestinal Surgery

, Volume 22, Issue 4, pp 684–694 | Cite as

The Effectiveness of a Clinical Pathway in Liver Surgery: a Case-Control Study

  • Sander Ovaere
  • Isabelle Boscart
  • Isabelle Parmentier
  • Pieter Jan Steelant
  • Tino Gabriel
  • Junior Allewaert
  • Hans Pottel
  • Franky Vansteenkiste
  • Mathieu D’Hondt
Original Article



In the field of liver surgery, evidence on the effectiveness of clinical pathways based on ERAS principles is limited.


This is a single-center observational study from a prospectively maintained database. Two cohorts were formed of all patients undergoing liver surgery during a defined period before (traditional management) and after introduction of a clinical pathway. Additionally, a case-match analysis—based on approach, tumor location, and Brisbane classification of resection—was performed. A cost analysis and patient satisfaction questionnaire were carried out.


In both the overall analysis (n = 229) as well as the case-match analysis (n = 100), hospital stay was significantly reduced from 8 to 4 days and from 6.5 to 4 days, respectively (p < 0.05). Postoperative morbidity (traditional management 11/50 vs clinical pathway 5/50; p = 1.00) and readmission rate did not increase. Cost analysis showed a significant decrease in postoperative costs in favor of the clinical pathway (traditional management €3666.7 vs clinical pathway €1912.2; p < 0.001). Overall, 92.3% of the survey questions were answered with satisfied (86.0%) or very satisfied (6.3%).


Implementation of clinical pathway for liver surgery is feasible and safe. A clinical pathway significantly reduces hospital stay without increasing postoperative morbidity and readmission rates. Postoperative costs are significantly reduced. Patient satisfaction is high.


Liver surgery ERAS Clinical pathway 


Author Contributions

Sander Ovaere: data analysis and writing, first author.

Isabelle Boscart: data collection and analysis.

Isabelle Parmentier: data collection and analysis.

Pieter Jan Steelant: study design and writing.

Tino Gabriel: study design and financial analysis.

Junior Allewaert: study design.

Hans Pottel: data collection and analysis.

Franky Vansteenkiste: study design and writing.

Mathieu D’Hondt: study design, data analysis and writing, senior author.

All authors meet all 4 criteria per the guidelines of the International Committee of Medical Journal Editors (ICMJE).

Compliance with Ethical Standards

The study was approved by the local ethics committee (AZGS2016072).

Conflict of Interest

The authors declare that they have no conflict of interest.


  1. 1.
    Bardram L, Funch-Jensen P, Jensen P, Crawford M.E, Kehlet H. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilization. The Lancet 1995;345:763–4Google Scholar
  2. 2.
    Richardson J, DiFabio F, Clarke H, Bajalan M, Davids J, AbuHilal M. Implementation of enhanced recovery programme for laparoscopic distal pancreatectomy: feasibility, safety and cost analysis. Pancreatology. 2015;15:185–90.CrossRefPubMedGoogle Scholar
  3. 3.
    Tang J, Humes DJ, Gemmil E, Welch NT, Parsons SL, Catton JA. Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages. Ann. R. Coll. Surg. Engl. 2013;95:323–8.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Coolsen MM, Wong-Lun-Hing EM, vanDam RM, van derWilt AA, SlimK, Lassen KA, DejongCH.Systematic review of outcomes in patients undergoing liver surgery in an enhanced recovery after surgery pathways. HPB. 2013;15(4):245–51.CrossRefPubMedGoogle Scholar
  5. 5.
    van Dam RM, Hendry PO, Coolsen MM, Bemelmans MH, Lassen K, Revhaug A, Fearon KC, Garden OJ, Dejong CH. Initial experience with a multimodal enhanced recovery programme in patients undergoing liver resection. Br J Surg. 2008;95(8):969–75.CrossRefPubMedGoogle Scholar
  6. 6.
    Ni CY, Yang Y, Chang YQ, Cai H, Xu B, Yang F, Lau WY, Wang ZH, Zhou WP. 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):542–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Lin DX, Li X, Ye QW, Lin F, Li LL, Zhang QY. Implementation of a fast-track clinical pathway decreases postoperative length of stay and hospital charges for liver resection. Cell Biochem Biophys. 2011;61(2):413–9.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    He F, Lin X, Xie F, Huang Y, Yuan R. The effect of enhanced recovery program for patients undergoing partial laparoscopic hepatectomy of liver cancer. Clin Transl Oncol.2015;17(9):694–701CrossRefPubMedGoogle Scholar
  9. 9.
    Wang C, Zheng G, Zhang W, Zhang F, Lv S, Wang A, Fang Z. Enhanced Recovery after Surgery Programs for Liver Resection: a Meta-analysis. J Gastrointest Surg.2017;21(3):472–86CrossRefPubMedGoogle Scholar
  10. 10.
    Belgihiti J, Clavien PA, Gadzijev E, Garden JO, Lau W, Makuuchi M, Strong RW. The brisbane 2000 terminology of liver anatomy and resections. HPB (Oxford)2000;2:333–9CrossRefGoogle Scholar
  11. 11.
    Clavien, Demartines, Dindo. Classification of Surgical Complications. A New Proposal With Evaluation in a Cohort of 6336 Patients and Results of a Survey. Ann Surg. 2004;240(2): 205–13CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Bilku DK, Dennison AR, Hall TC, Metcalfe MS, Garcea G. Role of preoperative carbohydrate loading: a systematic review. Ann R Coll Surg Engl. 2014; 96(1): 15–22.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Amer MA, Smith MD, Herbison GP, Plank LD, McCall JL. Network meta-analysis of the effect of preoperative carbohydrate loading on recovery after elective surgery. Br J Surg. 2017;104(3):187–197CrossRefPubMedGoogle Scholar
  14. 14.
    Ryckx A, Christiaens C, Clarysse M, Vansteenkiste F, Steelant PJ, Sergeant ParmentierI G, Pottel H, D'HondtM. Central Venous Pressure Drop After Hypovolemic Phlebotomy is a Strong Independent Predictor of Intraoperative Blood Loss During Liver Resection. Ann Surg Oncol (2017) 24: 1367–75.
  15. 15.
    D’Hondt M, Yoshihara E, Vansteenkiste F, Steelant PJ, Van Ooteghem B, Pottel H. Laparoscopic parenchymal preserving hepatic resections in semiprone position for tumors located in the posterosuperior segments. Langenbecks Arch Surg (2016) 401: 255. CrossRefPubMedGoogle Scholar
  16. 16.
    Ban D, Tanabe M, Ito H, Otsuka Y, Nitta H, Abe Y, Hasegawa Y, Katagiri T, Takagi C, Itano O, Kaneko H, Wakabayashi G. A novel difficulty scoring system for laparoscopic liver resection. J Hepatobiliary Pancreat Sci. 2014;21(10):745–53.CrossRefPubMedGoogle Scholar
  17. 17.
    Chang S, Laurent A, Tayar C, Karoui M, Cherqui D. Laparoscopy as a routine approach for left lateral sectionectomy. Br J Surg 2007;94:58–63CrossRefPubMedGoogle Scholar
  18. 18.
    Vigano L, Laurent A, Tayar C, Tomatis M, Ponti A, Cherqui D. The learning curve in laparoscopic liver resection: improved feasibility and reproducibility. Ann Surg 2009;250:772–82CrossRefPubMedGoogle Scholar
  19. 19.
    Chan FK, Cheng KC, Yeung YP. Laparoscopic liver resection: lessons learnt after 100 cases. Hong Kong Med J 2014;20:386–92.PubMedGoogle Scholar
  20. 20.
    Mackay G, O'Dwyer PJ. Early discharge following liver resection for colorectal metastases. Scott Med J. 2008;53(2):22–4.CrossRefPubMedGoogle Scholar
  21. 21.
    Dasari BV, Rahman R, Khan S, Bennett D, Hodson J, Isaac J, Marudanayagam R, Mirza DF, Muiesan P, Roberts KJ, Sutcliffe RP. Safety and feasibility of an enhanced recovery pathway after a liver resection: prospective cohort study. HPB (Oxford). 2015;17(8):700–6.CrossRefGoogle Scholar
  22. 22.
    Stoot JH, van Dam RM, Busch OR, van Hillegersberg R, DeBoer M, Olde Damink SW, Bemelmans MH, Dejong CH. The effect of a multimodal fast-track programme on outcomes in laparoscopic liver surgery: a multicentre pilot study. HPB 2009; 11:140–4.Google Scholar
  23. 23.
    Jones C, Kelliher L, Dickinson M, Riga A, Worthington T, Scott MJ, Vandrevala T, Fry CH, Karanjia N, Quiney N. Randomized clinical trial on enhanced recovery versus standard care following open liver resection. Br J Surg. 2013; 100: 1015–24.CrossRefPubMedGoogle Scholar
  24. 24.
    Ahmed EA, Montalti R, Nicolini D, Vincenzi P, Coletta M, Vecchi A, Mocchegiani F, Vivarelli M. Fast track program in liver resection: a PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore). 2016;95(28):e4154.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Macfie J. Enhanced Recovery After Surgery Is Obsolete. Dis Colon rectum. 2016;59(10):1002–3Google Scholar
  26. 26.
    Lemanu DP, Singh PP, Stowers MD, Hill AG. A systematic review to assess cost effectiveness of enhanced recovery after surgery programmes in colorectal surgery. Colorectal Dis. 2014;16(5):338–46CrossRefPubMedGoogle Scholar
  27. 27.
    Zehr KJ, Dawson PB, Yang SC, Heitmiller RF. Standardized clinical care pathways for major thoracic cases reduce hospital costs. Ann Thorac Surg 1998; 66: 914–19.CrossRefPubMedGoogle Scholar
  28. 28.
    Joliat GR, LabgaaI, Hübner M, Blanc C, Griesser AC, Schäfer M, Demartines N. Cost-Benefit Analysis of the Implementation of an Enhanced Recovery Program in Liver Surgery. World J Surg. 2016;40(10):2441–50.CrossRefPubMedGoogle Scholar
  29. 29.
    Jones EL, Wainwright TW, Foster JD. A systematic review of patient reported outcomes and patient experience in enhanced recovery after orthopaedic surgery.Ann R Coll Surg Engl. 2014;96(2):89–94.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Kalogera E, Bakkum-Gamez JN, Jankowski CJ. Enhanced recovery in gynecologic surgery. Obstet Gynecol. 2013;122:319–28.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Khan S, Wilson T, Ahmed J, Owais A, MacFie J. Quality of life and patient satisfaction with enhanced recovery protocols. Colorectal Dis. 2010;12(12):1175–82.CrossRefPubMedGoogle Scholar
  32. 32.
    Polle SW, Wind J, Fuhring JW, Hofland J, Gouma DJ, Bemelman WA. Implementation of a fast-track perioperative care program: what are the difficulties?Dig Surg. 2007;24(6):441–9.CrossRefPubMedGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2017

Authors and Affiliations

  • Sander Ovaere
    • 1
  • Isabelle Boscart
    • 1
  • Isabelle Parmentier
    • 2
  • Pieter Jan Steelant
    • 3
  • Tino Gabriel
    • 4
  • Junior Allewaert
    • 5
  • Hans Pottel
    • 6
  • Franky Vansteenkiste
    • 1
  • Mathieu D’Hondt
    • 1
  1. 1.Department of Digestive and Hepatobiliary/Pancreatic SurgeryGroeninge HospitalKortrijkBelgium
  2. 2.Department of Oncology and StatisticsGroeninge HospitalKortrijkBelgium
  3. 3.Department of AnesthesiaGroeninge HospitalKortrijkBelgium
  4. 4.Financial DepartmentGroeninge HospitalKortrijkBelgium
  5. 5.Pharmacology DepartmentGroeninge HospitalKortrijkBelgium
  6. 6.Interdisciplinary Research CenterCatholic University LeuvenKortrijkBelgium

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