Enhanced recovery after liver surgery

Abstract

Introduction Liver resection offers curative treatment to a number of malignant conditions. It has traditionally been associated with poor post-operative outcomes. More recently a mortality rate of less than five per cent has become established but morbidity remains high. Enhanced Recovery After Surgery (ERAS) has become established practice in a number of surgical specialties and has shown improvement in post-operative outcomes. ERAS has been introduced for liver resection however practice is less well established and liver surgery has several complexities that need to be accommodated in order to optimise post-operative care. The following thesis aims to identify areas that require clarification and investigate peri-operative care components to establish optimum practice. Methods Systematic review and meta-analysis were performed to identify areas that required clarification and were lacking in sufficient evidence to guide practice. A randomised controlled trial was performed to compare established areas of practice. Prospective observational studies were performed when exploratory investigation was required. Retrospective analysis of a prospectively collected database was performed to identify risk factors for post-operative morbidity. Patients included in the above trials underwent liver resection at the Royal Infirmary of Edinburgh, UK, between December 2012 and August 2014. Results Post-operative analgesia after liver resection was identified as being an area that was controversial. Continuous wound infiltration was shown to offer improved recovery times when compared to epidural with no significant associated disadvantages. After retrospective review of 603 liver resections, extended resection was observed to be associated with high morbidity rates. It was hypothesised that post-operative nutritional requirements might be higher in these patients. This was not found to be the case but post-operative energy requirements were found to be difficult to predict after liver resection, suggesting the benefits of real-time monitoring of energy expenditure. Finally acetaminophen metabolism was suspected of being altered after major resection. An observational study suggested that despite altered metabolism, glutathione deficiency was not observed after major resection and so liver volume was not a contra-indication to acetaminophen administration. Summary Liver resection offers a complex set of conditions on which to base an enhanced recovery protocol. Current ERAS literature does not completely address these issues. This thesis has investigated several aspects of care unique to liver surgery in an attempt to optimise peri-operative care and improve post-operative outcome after liver surgery.