Validation of the Enhanced Recovery after Surgery (ERAS) society recommendations for liver surgery: a prospective, observational study

Abstract

Background: Twenty-three recommendations were summarized by the Enhanced Recovery After Surgery (ERAS) Society for liver surgery. The aim was to validate the protocol especially with regard to adherence and the impact on morbidity.Methods: Using the ERAS Interactive Audit System (EIAS), ERAS items were evaluated in patients undergoing liver resection. Over a period of 26 months, 304 patients were prospectively enrolled in an observational study (DRKS00017229). Of those, 51 patients were enrolled before (non-ERAS) and 253 patients (ERAS) after the implementation of the ERAS protocol. Perioperative adherence and complications were compared between the two groups.Results: Overall adherence increased from 45.2% in the non-ERAS group to 62.7% in the ERAS group (P<0.001). This was associated with significant improvements in the preoperative and postoperative phase (P<0.001), rather than in the outpatient and intraoperative phase (both P>0.05). Overall complications decreased from 41.2% (n=21) in the non-ERAS group to 26.5% (n=67) in the ERAS group (P=0.0423), which was mainly due to the reduction of grade 1-2 complications from 17.6% (n=9) to 7.6% (n=19) (P=0.0322). As for patients undergoing open surgery, implementation of ERAS lead to a reduction of overall complications in patients scheduled for minimally invasive liver surgery (MILS) (P=0.036).Conclusions: Implementation of the ERAS protocol for liver surgery according to the ERAS guidelines of the ERAS Society reduced Clavien-Dindo grade 1-2 complications particularly in patients who underwent MILS. The ERAS guidelines are beneficial for the outcome, while adherence to the various items has not yet been satisfactorily defined.

From morbidity reduction to cost-effectiveness: Enhanced recovery after surgery (ERAS) society recommendations in minimal invasive liver surgery

“…Our data revealed a notable reduction in overall perioperative complications with the implementation of the ERAS protocol. Specifically, ERAS was associated with a significant decrease in Clavien-Dindo Grade I and II complications, in line with our previous publication covering a shorter time period [ 6 ]. Notably, when MILS and ERAS were combined, the most favorable outcomes were observed, with the lowest overall complication rate, fewer mild complications, and substantially fewer severe complications compared to patients not following the ERAS protocol.…”

“…No routine low-molecular weight heparin was administered preoperatively and although early postoperative mobilization and physiotherapy was encouraged, it did not follow a stringent path. The perioperative treatment was based on the ERAS protocol of the ERAS society and documented with the ERAS Interactive Audit System (EIAS, Encare, Stockholm, Sweden) [ 6 ]. Following the implementation of the ERAS protocol, a total of 506 patients (487 with complete costs data) were treated from March 2019 to June 2022.…”

“…The applied ERAS protocol was based on the first iteration of the official ERAS guidelines for liver surgery of the ERAS Society from 2016 and was adapted according to the revised 2022 Guidelines [ 4 , 5 ]. The ERAS protocol was implemented in 2019 and supervised by an ERAS core team, consisting of surgeons, anesthesiologists, physiotherapists, nursing staff and ERAS nurses [ 6 ]. Based on the ERAS measures of the EIAS, standard operating procedures as well as patient information brochures and patient diaries were created.…”

“…Adhering to a well-defined standardized pathway empowers a collaborative effort among surgeons, anesthesiologists, physiotherapists, nursing staff, and specialized ERAS nurses, resulting in a notable reduction of postoperative morbidity. This notably encompasses mitigating postoperative complications Clavien-Dindo grade I or II, such as pulmonary and cardiac complications, and reduces the overall length of hospital stay [ 6 – 8 ].…”

“…Our team has validated the ERAS guidelines for liver surgery for the first time, as established by the ERAS Society [ 6 ]. Through our study, we successfully demonstrated a notable reduction in the rate of complications.…”