Liver resection

Liver resection is often the preferred treatment route for both primary and secondary liver tumours and in the UK alone over 1600 surgeries each year are carried out for colorectal metastasis alone.

“The trust carried out a retrospective audit and determined saw a significant reduction in the overall length of stay (LOS) in the ERAS group.”

Liver resection is often the preferred treatment route for both primary and secondary liver tumours and in the UK alone over 1600 surgeries each year are carried out for colorectal metastasis alone.

It is associated with a high rate of post-operative morbidity, increased length of stay (LOS) and major post-operative complications.

Enhanced recovery programs that encompass Goal Directed Fluid Therapy (GDFT) have been shown to significantly reduce morbidity, LOS and complications across many surgery types including liver surgery and often such programmes are based on Enhanced Recovery After Surgery (ERAS) Society recommendations.

Targeted fluid therapy or GDFT is used to optimise intravascular volume and subsequently, tissue perfusion and is particularly important in this surgery type as patients are relatively hypo-perfused during and after liver resection surgery.

Leeds teaching hospitals in the UK developed a multimodal enhanced recovery protocol in order to minimize the effects of surgery on post-operative pathophysiology in open liver resection patients.

This included Goal Directed Fluid Therapy (GDFT) using LiDCOrapid to direct perioperative fluid optimisation. They developed a stroke volume guided protocol to enable nurse and practitioner staff in PACU and HDU to administer fluid challenges.

This determined whether an alteration in patient’s physiological parameters was due to a change in systemic vascular resistance (SVR) or cardiac output (CO) and was corrected accordingly.

The trust carried out a retrospective audit and determined saw a significant reduction in the overall length of stay (LOS) in the ERAS group.

Within the subset of patients older than 70 and major resections only, a significantly shorter LOS was observed.  The incidence of postoperative complications was also significantly reduced within the ERAS group (P < 0.05).

RCT enhanced recovery versus standard care following open liver resection

RCT enhanced recovery versus standard care following open liver resection

Patient population
Open Liver Surgery.

LiDCO Monitor
LiDCOrapid as part of an enhanced recovery program (ERP).

Trial Design
Randomised ERP vs standard care.

Outcome Impact
LOS reduced by 3 days. Complications reduced from 27% to 7%.

BACKGROUND
Enhanced recovery programmes (ERPs) have been shown to reduce length of hospital stay (LOS) and complications in colorectal surgery. Whether ERPs have the same benefits in open liver resection surgery is unclear, and randomised clinical trials are lacking.

METHODS
Consecutive patients scheduled for open liver resection were randomised to an ERP group or standard care. Primary endpoints were time until medically fit for discharge (MFD) and LOS. Secondary endpoints were post-operative morbidity, pain scores, readmission rate, mortality, quality of life (QoL) and patient satisfaction. ERP elements included greater preoperative education, preoperative oral carbohydrate loading, post-operative goal-directed fluid therapy, early mobilization and physiotherapy. Both groups received standardized anesthesia with epidural analgesia.

RESULTS
The analysis included 46 patients in the ERP group and 45 in the standard care group. Median MFD time was reduced in the ERP group (3 days versus 6 days with standard care; P < 0·001), as was LOS (4 days versus 7 days; P < 0·001). The ERP significantly reduced the rate of medical complications (7 versus 27 per cent; P = 0·020), but not surgical complications (15 versus 11 per cent; P = 0·612), readmissions (4 versus 0 per cent; P = 0·153) or mortality (both 2 per cent; P = 0·987). QoL over 28 days was significantly better in the ERP group (P = 0·002). There was no difference in patient satisfaction.

CONCLUSION
ERPs for open liver resection surgery are safe and effective. Patients treated in the ERP recovered faster, were discharged sooner, and had fewer medical-related complications and improved QoL.

Enhanced recovery in the resection of colorectal liver metastases

Enhanced recovery in the resection of colorectal liver metastases

Patient Population
Resection of colorectal liver metastases.

LiDCO Monitor
LiDCOrapid as part of an enhanced recovery program (ERAS).

Trial Design
Before v after an ERAS introduction.

Outcome Impact
The probability that LOS would be > 10 days decreased to 7% from 25% & ICU utilization reduced from 75.5% to 54.7%.

BACKGROUND
There is limited evidence for the use of enhanced recovery after surgery (ERAS) in patients undergoing hepatectomy, and the impact of the evolution of ERAS over time has not been examined. This study sought to evaluate the effect of an evolving ERAS program in patients undergoing hepatectomy for colorectal liver metastases (CRLM).

METHODS
A multimodal ERAS program was introduced in 2/2008. Consecutive patients undergoing hepatectomy for CRLM between 2/2008 and 9/2012 were included in the study. Data were collected prospectively. Retrospective analysis compared an early ERAS cohort (2/2008-4/2010) with a later cohort with a matured ERAS program (5/2010-8/2012).

RESULTS
Length of stay reduced as experience of ERAS increased (Log-rank χ(2) = 10.43, P = 0.001). Although median length of stay remained unchanged (6 days), the probability of hospitalisation beyond 10 days was 25% in the early cohort compared with 7% in the later cohort. Critical care utilization reduced over time (75.5% vs. 54.7%, P < 0.0001). Complications occurred in 38.2%, with no difference in between cohorts. One postoperative death occurred in the early cohort (<0.3%).

CONCLUSIONS:
This study suggests that as the experience of ERAS evolves, there is a progressive reduction in hospitalisation and critical care admission. This is without any increase in morbidity and mortality.

Dunne DF, Yip VS, Jones RP, McChesney EA, et al. Enhanced recovery in the resection of colorectal liver metastases. J Surg Oncol. 2014. doi:10.1002/jso.23616

Study showed probability that LOS would be > 10 days decreased to 7% from 25% & ICU utilization reduced from 75.5% to 54.7%.

RCT early GDT after major surgery reduces complications and LOS

RCT early GDT after major surgery reduces complications and LOS

Patient Population
Post-surgical intensive care.

LiDCO Monitor
LiDCOplus oxygen delivery (DO2) Early goal-directed therapy (EGDT) target.

Trial Design
Randomised LiDCOplus EGDT target vs usual care.

Outcome Impact
Fewer EGDT patients developed complications – 27 patients (44%) vs 41 patients (68%) LOS was significantly reduced (11 days vs 14 days) and the mean stay was reduced by 12 days (17.5 days versus 29.5 days) a 41% reduction. EGDT decreased costs by £2,631 per patient and by £2,134 per hospital survivor. EGDT was found to prolong quality-adjusted life expectancy (by 9.8 months) and to bring incremental cost savings of £1,285.

INTRODUCTION
Goal-directed therapy (GDT) has been shown to improve outcome when commenced before surgery. This requires pre-operative admission to the intensive care unit (ICU). In cardiac surgery, GDT has proved effective when commenced after surgery. The aim of this study was to evaluate the effect of post-operative GDT on the incidence of complications and duration of hospital stay in patients undergoing general surgery.

METHODS
This was a randomised controlled trial with concealed allocation. High-risk general surgical patients were allocated to post-operative GDT to attain an oxygen delivery index of 600 ml min(-1) m(-2) or to conventional management. Cardiac output was measured by lithium indicator dilution and pulse power analysis. Patients were followed up for 60 days.

RESULTS
Sixty-two patients were randomised to GDT and 60 patients to control treatment. The GDT group received more intravenous colloid (1,907 SD +/- 878 ml versus 1,204 SD +/- 898 ml; p < 0.0001) and dopexamine (55 patients (89%) versus 1 patient (2%); p < 0.0001). Fewer GDT patients developed complications (27 patients (44%) versus 41 patients (68%); p = 0.003, relative risk 0.63; 95% confidence intervals 0.46 to 0.87). The number of complications per patient was also reduced (0.7 SD +/- 0.9 per patient versus 1.5 SD +/- 1.5 per patient; p = 0.002). The median duration of hospital stay in the GDT group was significantly reduced (11 days (IQR 7 to 15) versus 14 days (IQR 11 to 27); p = 0.001). There was no significant difference in mortality (seven patients (11.3%) versus nine patients (15%); p = 0.59).

CONCLUSION
Post-operative GDT is associated with reductions in post-operative complications and duration of hospital stay. The beneficial effects of GDT may be achieved while avoiding the difficulties of pre-operative ICU admission.

Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Crit Care. 2005;9 (6):687-693 & Ebm C, Cecconi M, Sutton L, Rhodes A. A Cost-Effectiveness Analysis of Postoperative Goal-Directed Therapy for High-Risk Surgical Patients. Crit Care Med. 2014. DOI: 10.1097/CCM0000000000000164

Fewer EGDT patients developed complications – 27 patients (44%) vs 41 patients (68%) LOS was significantly reduced (11 days vs 14 days) and the mean stay was reduced by 12 days (17.5 days versus 29.5 days) a 41% reduction. EGDT decreased costs by £2,631 per patient and by £2,134 per hospital survivor. EGDT was found to prolong quality-adjusted life expectancy (by 9.8 months) and to bring incremental cost savings of £1,285.

Enhanced Recovery After Liver Surgery (ERAS) in Liver Surgery

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LiDCOrapid – Hemodynamic Monitoring in Action

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“LiDCOrapid as part of an enhanced recovery program (ERP) Randomised ERP vs standard care showed reduced length of stay by 3 days and complications reduced from 27% to 7%”.
Jones et al. 2013

“Study showed probability that LOS would be > 10 days decreased to 7% from 25% & ICU utilization reduced from 75.5% to 54.7%”.
Dunne et al. 2014

“Fewer EGDT patients developed complications – 27 patients (44%) vs 41 patients (68%) LOS was significantly reduced (11 days vs. 14 days) and the mean stay was reduced by 12 days (17.5 days vs. 29.5 days) a 41% reduction.”
Pearse et al. 2014

The LiDCOunity monitor is a single platform which combines both the LiDCOplus and LiDCOrapid functions. This provides a single solution to monitoring needs throughout the hospital. The clinician can choose which mode is most appropriate to the clinical situation. The LiDCOunity can be used non-invasively, minimally invasively with a radial arterial line and can be calibrated with the lithium dilution technique.  Find out more

The LiDCOplus hemodynamic monitor provides a continuous, reliable and accurate assessment of the hemodynamic status of critical care and surgery patients.  The LiDCOplus is comprised of two technologies: a continuous arterial waveform analysis system (PulseCO™) coupled to a single point lithium indicator dilution calibration system.  Find out more

The LiDCOrapid monitor analyses the blood pressure waveform to provide more information in high-risk surgical and critically ill patients to help with fluid and drug management.  The LiDCOrapid uses the PulseCO™ algorithm which converts blood pressure to its constituent parts of flow (CO, SV) and resistance (SVR). The PulseCO™ algorithm is scaled to each patient with a nomogram using age, height, and weight.  Find out more