Challenges in the implementation of Enhanced Recovery After Surgery (ERAS) pathway for major hepatectomy: A...

Enhanced Recovery After Surgery programs have shown benefit by improving patient outcomes in liver surgery. However, obtaining high compliance with Enhanced Recovery After Surgery may be challenging for patients with major hepatectomy. The aim of the study was to investigate the challenges related to the implementation of Enhanced Recovery After Surgery in major hepatectomy by assessing the compliance in detail.

All consecutive major hepatectomies (≥3 Couinaud segments) within An Enhanced Recovery After Surgery program were reviewed. The primary end point was the proportion of patients achieving high compliance (≥70%) with Enhanced Recovery After Surgery. Secondary end points included the institutional learning curve for improving compliance measured with the cumulative sum method and the clinical outcomes of patients with high compared with low compliance. Predictors of high compliance and of postoperative complications were assessed by a logistic regression model.

Two hundred-eighty-six patients were included. Median enhanced recovery after surgery compliance was 59 (interquartile range, 54-67), and 49 patients (17.1%) had a high compliance. The cumulative sum analysis identified an institutional learning curve of 143 cases encompassing the first 5 years of activity. Patients with high compliance increased 10-fold once the learning curve was completed, moving from 3% (4/143) to 31.5% (45/143) (P < .001). The improvement was mainly related to better compliance with intra- and postoperative enhanced recovery after surgery items. High compliance was associated with fewer complications (53.1 vs 69.1%; P = .045) and shorter hospital stay (8 vs 12 days; P = .002). The strongest independent predictor of high Enhanced Recovery After Surgery compliance was the use of minimally invasive surgery (odds ratio, 6.7; P < .001). High compliance was protective only against minor complications (Clavien-Dindo < IIIa).

The implementation of an Enhanced Recovery After Surgery program is challenging in major hepatectomy and in our study needed more than 140 cases to improve compliance. Minimally invasive surgery, when feasible, should be the preferred approach because it increases compliance, which may be associated with fewer complications and shorter hospital stay.