Enhanced recovery after liver surgery improves function faster than traditional recovery

Patients who participated in an enhanced recovery program after oncologic liver surgery returned to normal function and to adjuvant cancer therapy sooner than patients given a traditional approach to perioperative care, according to a study published online October 20, 2015 in the Journal of the American College of Surgeons.

This study involved 118 patients undergoing open or laparoscopic hepatectomy at the University of Texas MD Anderson Cancer Center, in Houston, TX. Investigators compared 75 patients on the enhanced recovery in liver surgery (ERLS) pathway with 43 clinically comparable patients on a traditional pathway.

The ERLS protocol included preoperative patient education, narcotic-sparing anesthesia and analgesia, avoidance of drains and tubes, restrictive administration of fluids, a rapid return to eating, and walking on the first post-op day.

The researchers found that patients in the enhanced recovery group were 2.6 times more likely to achieve their baseline functional status within 31 days than patients who had the traditional protocol.

“The only independent factor that correlated to faster return to baseline functional status, both in terms of absolute value and short time to recovery, was being on an enhanced recovery protocol,” said lead investigator Thomas A. Aloia, MD, FACS, associate professor in the department of surgical oncology at the MD Anderson Cancer Center. “It wasn’t the size of the liver resection, the approach [laparoscopic or open operation], or whether we used an epidural catheter for pain control or not.”

Enhanced recovery patients also reported lower postoperative pain scores, experienced fewer complications, and had shorter lengths of stay.

This investigation was different in that most enhanced recovery studies stop measuring outcomes at length of hospital stay, with the sole purpose of shortening the hospital visit. “At a cancer center, length of stay is pretty low on our list of importance; our true metric of success is getting people after cancer surgery back to cancer therapy,” Dr. Aloia said.

This study bears that out. Patients in the ERLS group were more likely to return to chemotherapy than patients in the traditional recovery group (95% vs 87%), and, furthermore, to return to it sooner (44.7 days vs 60.2 days).

Another novel twist to this study was the inclusion of a patient-reported outcomes tool—the MD Anderson Symptom Inventory (MDASI). Using this validated survey, all patients rated symptom severity and life interference, first preoperatively and again at every outpatient visit until 31 days after surgery.

“What really matters is life function,” Dr. Aloia said. “Until now, we have been trying to add up a patient’s pain, nausea, and fatigue, but what we really needed to look at is how those symptoms actually impact a patient’s life function, because as it turns out, each patient experiences symptoms differently.”

He added, “With this study, we may have gotten one step closer to a scientific definition of recovery that could be used in other disease sites," he added. "As enhanced recovery strategies evolve, we may now have a tool to compare one approach with another to find out which one is better.”