Patient-Reported Outcomes Accurately Measure the Value of an Enhanced Recovery Program in Liver Surgery

  • Day R
  • Cleeland C
  • Wang X
  • et al.
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Abstract

BACKGROUND: Enhanced recovery (ER) pathways have become increasingly integrated into surgical practice. Studies that compare ER and traditional pathways often focus on outcomes confined to inpa-tient hospitalization and rarely assess a patient's functional recovery. The aim of this study was to compare functional outcomes for patients treated on an Enhanced Recovery in Liver Surgery (ERLS) pathway vs a traditional pathway. STUDY DESIGN: One hundred and eighteen hepatectomy patients rated symptom severity and life interference using the validated MD Anderson Symptom Inventory preoperatively and postoperatively at every outpatient visit until 31 days after surgery. The ERLS protocol included patient edu-cation, narcotic-sparing anesthesia and analgesia, diet advancement, restrictive fluid admin-istration, early ambulation, and avoidance of drains and tubes. RESULTS: Seventy-five ERLS pathway patients were clinically comparable with 43 patients simultaneously treated on a traditional pathway. The ERLS patients reported lower immediate postoperative pain scores and experienced fewer complications and decreased length of stay. As measured by symptom burden on life interference, ERLS patients were more likely to return to baseline functional status in a shorter time interval. The only independent predictor of faster return to baseline interference levels was treatment on an ERLS pathway (p ¼ 0.021; odds ratio ¼ 2.62). In addition, ERLS pathway patients were more likely to return to intended oncologic therapy (95% vs 87%) at a shorter time interval compared to patients on the traditional pathway (44.7 vs 60.2 days). CONCLUSIONS: In oncologic liver surgery, enhanced recovery's primary mechanism of action is reduction in life interference by postoperative surgical symptoms, allowing patients to return sooner to normal function and adjuvant cancer therapies. (J Am Coll Surg 2015;221:1023e1030. The ultimate goal of any surgery is to return the patient to at least their baseline functional status, if not an improved functional status compared with their preoperative state, as rapidly as possible and with the least amount of intercur-rent disability. Although fast-track surgical protocols have been reported for decades, 1,2 it is only recently that the enhanced recovery (ER) movement in perioperative care has significantly penetrated North American surgical prac-tice. Multiple recently published meta-analyses have cle-arly demonstrated that patients are benefiting from these changes in philosophy and practice. 3-5 Most commonly, the included studies focused on outcomes confined to inpa-tient hospitalization using concrete primary end points, including early return of bowel function, lower complica-tion rates, and/or shorter length of inpatient stay.

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Day, R. W., Cleeland, C. S., Wang, X. S., Fielder, S., Calhoun, J., Conrad, C., … Aloia, T. A. (2015). Patient-Reported Outcomes Accurately Measure the Value of an Enhanced Recovery Program in Liver Surgery. Journal of the American College of Surgeons, 221(6), 1023-1030e2. https://doi.org/10.1016/j.jamcollsurg.2015.09.011

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