Defining enhanced recovery in peri-hilar cholangiocarcinoma resection.


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Leonard Quinn1,Kulbir Mann2,Abdullah Malik1,Nicholas Bird2,Robert Jones1,Declan Dunne3,Stefan Stremitzer2,Carmen Lacasia-Purroy2,Graeme Poston2,Stephen Fenwick2,Hassan Malik2
1University of Liverpool,2University Hospital Aintree,3Royal Liverpool University Hospital

Abstract

Background

Enhanced recovery after surgery (ERAS) reduces complications and improves outcome. Studies addressing feasibility of ERAS in peri-hilar cholangiuocarcinoma (pCCA) resection are absent.   We implemented ERAS for all hepatectomy patients in 2009. This study is the first to fully describe ERAS in patients undergoing pCCA resection and defines achievable ERAS targets.

Method

Patients undergoing pCCA resection at University Hospital Aintree (January 2009 – October 2017) were identified from a prospective database. Key ERAS parameters are outlined in the results.

 

Patients were stratified high or low/intermediate risk on pre-operative cardiopulmonary exercise testing (CPET).   Oxygen uptake <11mls/kg/min was classified high risk. Major complications were defined as Clavien-Dindo Grade ≥IIIa. Chi Square, Mann Whitney and Kaplan Meier analyses were undertaken to compare high and low risk groups using SPSS.

Results

60 patients underwent resection. 14 were excluded (10 inpatient mortality and 4 incomplete datasets). 46 patients were analyzed - 20 high risk and 26 low/intermediate. Median age 65 (24 male: 22 female). 18 patients experienced major complications.

 

Key ERAS outcomes (medians) in those who did not experience major complication were: length of stay 8.5 days, duration critical care 2 days, inotropes 0.5 days, epidural 3 days, sat out day 2, mobilization day 3, urinary catheter removed day 4, NGT day 1, restoration oral nutrition day 2.

 

Comparing high and low risk groups, high risk patients required significantly longer critical care admission (p=0.014). There were no significant differences in length of stay (p=0.27), duration inotropes (p=0.38), epidural (p=0.34), urinary catheterization (p=0.11), nasogastric drainage (p=0.5), restoration enteral nutrition (p=0.45), mobilization (p=0.25) or 30 day readmission (p=0.59).

Conclusion

ERAS is feasible and safe in pCCA resection. Major complications are prevalent and tailoring of standard hepatectomy pathways is necessary. Patients deemed high risk pre-operatively require increased critical care, however they can otherwise achieve equivalent ERAS targets and should not be excluded.