Service de chirurgie digestive, hépatobiliopancreatique et transplantation hépatique, hôpital Pitié Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France; Sorbonne Universités, 21, rue de l'École-de-Médecine, 75006 Paris, France; Unité de Recherche BQR SSPC « Simplification des Soins des Patients Complexes » Université de Picardie Jules Verne, 80080 Amiens, France.
Service de Chirurgie Digestive et Unité de Chirurgie Ambulatoire. CHU Estaing, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand, France; Groupe francophone de réhabilitation améliorée après chirurgie (GRACE), 63110 Beaumont, France.
J Visc Surg. 2019 Apr;156(2):127-137. doi: 10.1016/j.jviscsurg.2018.10.007. Epub 2018 Nov 14.
In a majority of cases, enhanced recovery after surgery program (ERP) leads to a reduced rate of postoperative complications and shortened hospital stays following digestive surgery. The program's preoperative, perioperative and postoperative measures are implemented by the members of a motivated multidisciplinary team. Having shown its merits in digestive surgery, ERP would be particularly useful in liver surgery due to the elevated rates of morbidity and mortality this type of operation continues to entail. The objective of this review was to evaluate the efficacy of ERP in liver surgery.
This is a systematic narrative review of the literature on the efficacy of ERP in liver surgery by laparotomy or laparoscopy.
Notwithstanding a number of studies (n=30: 5 randomized trials, 14 cohort studies and 11 meta-analyses) less sizable than with regard to digestive surgery in general and colorectal surgery in particular, analysis of the literature confirms that in liver surgery, ERP is associated with an overall decrease in complications by 30 to 60%, but without improvement in the rates of hospital readmission and postoperative mortality. All of the studies report a reduction in average length of stay (ALOS) by 2.3 days and in functional recovery, a more objective indicator than ALOS, by 2.5 days. As of now, the economic impact of the ERP programs in liver surgery is neither positive nor negative, the above-mentioned savings being counterbalanced by heightened costs for material and equipment. Laparoscopic surgery is independently associated with better outcomes in terms of complications, functional recovery and ALOS; that is why it is important to incorporate this surgical approach in ERP as often as possible. Given a lack of robust evidence, Prehabilitation, which is a preoperative optimization process leading to improved functional reserve, has yet to be assigned a place in ERP programs pertaining to liver surgery. Possible roadblocks to application of an ERP program can be overcome through coordination by a team leader, a motivated multidisciplinary team, training courses and dedicated teaching sessions.
ERP is a care improvement process that has a major play to play in organization of liver surgery, and its large-scale application is to be recommended.
在大多数情况下，手术后恢复计划（ERP）可降低消化道手术后的术后并发症发生率和住院时间。该计划的术前、围手术期和术后措施由积极的多学科团队成员实施。ERP 在消化道手术中已经显示出其优势，由于这种手术仍然存在较高的发病率和死亡率，因此在肝外科中尤其有用。本综述的目的是评估 ERP 在肝外科中的疗效。
这是对经剖腹或腹腔镜行肝外科手术的 ERP 疗效的系统叙述性文献综述。
尽管与一般消化道手术特别是结直肠手术相比，研究数量较少（n=30：5 项随机试验、14 项队列研究和 11 项荟萃分析），但对文献的分析证实，在肝外科中，ERP 可使总体并发症发生率降低 30%至 60%，但住院再入院率和术后死亡率没有改善。所有研究均报告平均住院时间（ALOS）缩短 2.3 天，功能恢复（比 ALOS 更客观的指标）缩短 2.5 天。到目前为止，肝外科 ERP 方案的经济影响既不积极也不消极，上述节省被材料和设备成本的增加所抵消。腹腔镜手术在并发症、功能恢复和 ALOS 方面具有独立的优势；因此，将这种手术方法尽可能纳入 ERP 非常重要。由于缺乏强有力的证据，术前优化过程（可改善功能储备）的预康复尚未被分配到肝外科的 ERP 方案中。通过团队负责人的协调、积极的多学科团队、培训课程和专门的教学课程，可以克服应用 ERP 方案的障碍。
ERP 是一种改善护理的过程，在肝外科的组织中具有重要作用，应广泛应用。
