Department of Surgery, University of Washington, 1959 NE Pacific Street, Suite BB-487, Box: 356410, Seattle, WA, USA.
Transformation of Care Department, University of Washington, Seattle, WA, USA.
J Gastrointest Surg. 2018 Jun;22(6):981-988. doi: 10.1007/s11605-017-3656-y. Epub 2018 Feb 5.
Enhanced recovery after surgery (ERAS) protocols are now commonplace in many fields of surgery, but only limited data exists for their use in hepatobiliary surgery. We implemented standardized ERAS protocols for all open hepatectomies and replaced thoracic epidurals with a transversus abdominis plane (TAP) block.
We performed a retrospective cohort study of all patients undergoing open hepatectomy during the 14 months before and 19 months after implementation of an ERAS protocol at our institution (January 2014-September 2016). Trained abstractors reviewed charts for patient demographics, perioperative details, and healthcare utilization. All nursing-reported visual analog scale pain scores were sampled to identify patients with uncontrolled pain (daily mean score > 5). Outcomes included length of stay (LOS), costs, and 30-day readmission.
A total of 127 patients (mean age 54.6 ± 13.0 years, 44% female) underwent open liver resection (69 [54%] after ERAS implementation). ERAS protocols were associated with significantly lower rates of ICU admission (47 vs. 13%, p < 0.001), shorter LOS (median 5.3 vs. 4.3 days, p = 0.007), and lower median costs ($3566 less, p = 0.03). Readmission remained low throughout the study period (5% pre-ERAS, 4% during ERAS, p = 0.83). Rates of uncontrolled pain were either the same or better after ERAS implementation through post-operative day #3 (41% pre-ERAS, 23% during ERAS, p = 0.03).
The use of TAP block for hepatectomy as part of an ERAS protocol is associated with improved quality and cost of care. Surgeons performing liver resections should consider standardization of evidence-based best practices in all patients.
加速康复外科（ERAS）方案目前在许多外科领域中已很常见，但在肝胆外科中应用的相关数据有限。我们为所有开腹肝切除术实施了标准化的 ERAS 方案，并将胸硬膜外阻滞替换为腹横平面阻滞（TAP 阻滞）。
我们对我院实施 ERAS 方案前后 14 个月（2014 年 1 月至 2016 年 9 月）的所有开腹肝切除术患者进行了回顾性队列研究。经过培训的研究人员查阅了病历，以了解患者的人口统计学、围手术期详细信息和医疗保健使用情况。所有护理报告的视觉模拟评分（VAS）疼痛评分均被抽取，以识别出疼痛控制不佳的患者（每日平均评分>5）。结果包括住院时间（LOS）、费用和 30 天再入院率。
共 127 例患者（平均年龄 54.6±13.0 岁，44%为女性）接受了开腹肝切除术（ERAS 实施后 69 例[54%]）。ERAS 方案与 ICU 入院率显著降低（47%比 13%，p<0.001）、住院时间缩短（中位数 5.3 比 4.3 天，p=0.007）和中位费用降低（减少 3566 美元，p=0.03）相关。在整个研究期间，再入院率保持较低水平（ERAS 实施前为 5%，ERAS 实施期间为 4%，p=0.83）。ERAS 实施后，直至术后第 3 天，疼痛控制不佳的发生率保持不变或改善（ERAS 实施前为 41%，ERAS 实施期间为 23%，p=0.03）。
将 TAP 阻滞用于肝切除术作为 ERAS 方案的一部分，可改善医疗质量和成本效益。行肝切除术的外科医生应考虑在所有患者中标准化基于证据的最佳实践。
