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Enhanced Recovery Programs in Hepatobiliary Surgery [ BLG]

Introduction

  • Enhanced Recovery Programs (ERPs) began in the 1990s to reduce ICU stay in cardiac surgery.
  • Kehlet and Mogensen introduced a multimodal approach reducing length of hospital stay (LOS) after colectomy.
  • Formation of the Enhanced Recovery After Surgery (ERAS) Society to promote best practices globally.
  • ERPs have been successfully applied across surgical disciplines, including hepatobiliary (HB) surgery.
  • Early HB surgery ERP experiences:
    • Mackay and O’Dwyer in Scotland reported early discharge in liver resection patients.
    • Van Dam et al. showed decreased LOS and earlier oral intake in hepatectomy patients under ERP.

Unique Aspects of Hepatobiliary Surgery

  • HB surgery patients often have complex comorbidities and underlying chronic diseases.
  • High rates of major complications (up to 30%) and mortality (up to 5%) despite advances.
  • Digestive and pulmonary complications are common.
  • ERPs aim to reduce adverse outcomes through early intervention.
  • Success relies on safe, effective, and meticulous surgical technique.

Implementation of ERPs in HB Surgery

  • HB surgery requires a multidisciplinary effort:
    • Surgeons, trainees, anesthesiologists, nursing staff, and patients.
  • Standardized plans and commitment are essential for effective ERPs.
  • Adherence to common core principles is crucial.

The "4 Pillars" of Enhanced Recovery Programs

  • Foundation: Effective patient education and engagement.
  • Fundamental Surgical Principles:
    • Thromboembolic prophylaxis.
    • Prophylactic antibiotics.
    • Use of minimally invasive approaches.
    • Minimization of drains/lines/tubes.
  • The 4 Pillars:
    1. Early postoperative feeding.
    2. Goal-directed fluid therapy.
    3. Opioid-sparing analgesia.
    4. Early ambulation.

Preoperative Phase

Preoperative Patient Evaluation

  • Thorough evaluation including:
    • Complete history and physical examination.
    • Review of comorbidities, surgical history, medications, and oncologic history.
  • Specific to HB surgery:
    • Assess for hepatic dysfunction, portal hypertension, and cirrhosis.
    • Look for signs like jaundice, ascites, and surgical scars.

Optimization of Chronic Comorbidities

  • Medical optimization is critical for recovery.
  • Identify borderline operability due to medical issues.
  • Optimization can improve outcomes and ERP adherence.

Patient Functional Status

  • Evaluate using grading tools (e.g., ECOG, Karnofsky Score).
  • Consider frailty and need for prehabilitation programs.
  • Exercise programs can enhance recovery and quality of life.

Preoperative Education and Patient Engagement

  • Critical importance in ERPs.
  • Provide clear educational materials on surgery and recovery.
  • Reduces anxiety and increases compliance.

Preoperative Nutrition

  • Assess nutritional status:
    • Recent weight loss, BMI, lab values (albumin, prealbumin).
  • Use screening instruments to identify risks.
  • Remediate deficiencies before surgery.
  • ERAS recommendations:
    • At-risk patients should have 7 days of oral nutritional supplementation pre-surgery.

Perioperative Phase

Perioperative Nutrition and Carbohydrate Loading

  • Maintain homeostasis and limit stress response.
  • Allow clear liquids up to 2 hours before anesthesia.
  • Preoperative carbohydrate loading can reduce insulin resistance and improve recovery.

Venous Thromboembolism (VTE) Prophylaxis

  • High risk of VTE in HB surgery patients.
  • Use chemoprophylaxis:
    • Low-molecular-weight heparin (LMWH) or unfractionated heparin 2–12 hours preoperatively.
  • Apply graded compression stockings and sequential compression devices (SCDs).

Antimicrobial Prophylaxis and Surgical Site Infection Prevention

  • Administer antibiotics within 1 hour before incision.
  • Re-dose appropriately during surgery.
  • Continue antibiotics for 24 hours postoperatively.
  • Use alcohol-based skin preparations (e.g., chlorhexidine-alcohol 2%).

Nasogastric Tubes and Abdominal Drainage

  • Avoid routine use of nasogastric (NG) tubes:
    • May increase pulmonary complications.
  • Omit abdominal drains if possible:
    • Drains can hinder mobilization and increase pain.

Intraoperative Fluid Management

  • Use goal-directed fluid therapy (GDFT):
    • Maintain euvolemia and avoid excess fluids.
  • Keep low central venous pressure (CVP) during hepatic transection to reduce blood loss.
  • Coordinate fluid management with the entire surgical team.

Neuraxial and Peripheral Regional Anesthesia Techniques

  • Aim for opioid-sparing analgesia.
  • Thoracic Epidural Anesthesia (TEA):
    • Provides superior pain control and earlier GI function return.
  • Peripheral nerve blocks (e.g., TAP block):
    • Alternative to TEA with fewer side effects.

Operative Approach

  • Minimally invasive surgery (MIS) is increasingly used:
    • Leads to fewer complications and faster recovery.
  • MIS should be performed by experienced surgeons within ERP protocols.

Postoperative Phase

Early Mobilization

  • Essential for enhanced recovery:
    • Improves pulmonary function and GI recovery.
    • Reduces risk of VTE.
  • Limit use of tubes and catheters to facilitate movement.

Postoperative Fluid Resuscitation

  • Continue GDFT postoperatively.
  • Monitor hemodynamics and adjust fluids accordingly.
  • Avoid over or under-resuscitation to prevent complications.

Postoperative Nausea and Vomiting Prophylaxis

  • Use multimodal antiemetic therapy:
    • Administer two antiemetic medications as per ERAS guidelines.
  • Identify patients at risk and prevent PONV proactively.

Diet and Nutrition

  • Early feeding is important:
    • Clear liquids on postoperative day 0.
    • Regular diet by postoperative day 1.
  • Avoid full-liquid diets unless necessary.

Pain Control and Opioid-Sparing Analgesia

  • Use a multimodal pain management approach:
    • Non-opioid medications (e.g., acetaminophen, NSAIDs).
    • Regional anesthesia techniques.
  • Benefits include:
    • Reduced opioid use.
    • Fewer side effects.
    • Improved patient satisfaction.

Future of Enhanced Recovery for HB Surgery

  • Expansion of MIS approaches and advanced anesthesia techniques.
  • Emphasis on prehabilitation and preoperative optimization.
  • Importance of implementation science:
    • Standardizing variables.
    • Measuring compliance.
    • Enhancing cross-program comparisons.
  • ERPs are evolving towards being the standard of care.

Conclusion

  • ERPs have significantly improved outcomes in HB surgery.
  • Focus on maintaining homeostasis and rapid recovery.
  • Requires a multidisciplinary approach tailored to HB patients.
  • Continued refinement and adherence to ERPs will enhance patient care.