Factors associated with failure of enhanced recovery protocol in patients undergoing major hepatobiliary and pancreatic surgery: a retrospective cohort study

Abstract

ObjectiveThis study examined the risk factors associated with failure of enhanced recovery protocol after major hepatobiliary and pancreatic (HBP) surgery.Setting and participantsA retrospective cohort of 194 adult patients undergoing major HBP surgery at a university hospital in Hong Kong was followed up for 30 days. The patients were from a larger cohort study of 736 consecutive adults with preoperative urinary cotinine concentration to examine the association between passive smoking and risk of perioperative respiratory complications and postoperative morbidities.Outcome measuresThe primary outcome was failure of enhanced recovery protocol. This was defined as a composite measure of the following events: intensive care unit (ICU) stay more than 24 h after surgery, unplanned admission to ICU within 30 days after surgery, hospital readmission, reoperation and mortality.ResultsThere were 25 failures of enhanced recovery after HBP surgery (12.9%, 95% CI 8.5% to 18.4%). After adjusting for elective ICU admission, smokers (relative risk (RR ) 2.21, 95% CI 1.10 to 4.46), high preoperative alanine transaminase/glutamic-pyruvic transaminase (RR 3.55,95% CI 1.68 to 7.49) and postoperative morbidities (RR 2.69, 95% CI 1.30 to 5.56) were associated with failures of enhanced recovery in the generalised estimating equation risk model. Compared with those managed successfully, failures stayed longer in ICU (median 19 vs 25 h, p<0.001) and in hospital for postoperative care (median 7 vs 13 days, p=0.003).ConclusionsSmokers and patients having high preoperative alanine transaminase/glutamic-pyruvic transaminase concentration or have a high risk of postoperative morbidities are likely to fail enhanced recovery protocol in HBP surgery programmes.

Enhanced Recovery Pathways in Hepato-pancreato-biliary Surgery

“…Postoperative complications that led to deviations from the proposed pathway generally concerned drains, nutrition, and supplementary investigations, and were adapted according to clinical evaluation. A recently published retrospective cohort study identified factors associated with "failure" of a HPB pathway [ 23 ], defined as length of stay in the intensive care unit (ICU) more than 24 h after surgery, unplanned admission to ICU within 30 days, readmission to the hospital within 30 days after surgery, reoperation for complications and/or 30-day mortality. Predictive factors of ERP failure were smoking, high preoperative alanine transaminase/glutamicpyruvic transaminase concentration (defined as more than 67 IU/L in men and more than 55 IU/L in women), or postoperative complications.…”

Enhanced Recovery Deviation and Failure After Pancreaticoduodenectomy: Causative Factors and Impact

“…The definition of ERAS protocol failure used for the pupose of this study was also based on a composite measure described previously 13 and included any one of the following events: length of intensive care units (ICU) admission >24 h immediately after surgery; unplanned ICU admission within 30 d after surgery; unplanned hospital readmission within the 30 d after surgery; reoperation for complications within the 30 d following surgery; and 30-d mortality.…”

“…6 However, despite the best efforts of both clinicians and patients, there will be some patients who will either deviate from the ERAS protocol or fail ERAS' key goals. For those patients undergoing cardiac, 9 colorectal, [10][11][12] and hepatobiliary surgery, 13 models have been created to identify variables that may result in either deviation or failure. There have been no such efforts for those patients undergoing PD.…”

Current advances in liver surgery

“…[2,[6][7][8][9][10][11][12] The drastic decline in operative morbidity and mortality is attributed to improvements in meticulous patient selection, surgical techniques and equipment, as well as perioperative care. [8,[13][14][15][16] It is also attributed to the early detection and removal of smaller hepatomas. [17] In the recent two decades, minimally invasive surgery was introduced initially for cholecystectomy and has further extended its application to hepatectomy.…”