New care approach to liver operations speeds patient recovery

"What really matters is life function. Until now, we have been trying to add up a patient's pain, nausea, and fatigue, but what we really needed to look at is how those symptoms actually impact a patient's life function, because as it turns out, each patient experiences symptoms differently," said lead investigator Thomas A. Aloia, MD, FACS, associate professor, department of surgical oncology, The University of Texas MD Anderson Cancer Center, Houston. "We found that you could have very symptomatic people who were quite functional, and you could have mildly symptomatic people who were completely disabled."

This single-center study involved 118 patients undergoing both open and laparoscopic hepatectomy (surgical resection of the liver). In addition to traditional quality metrics like complications and length of stay, researchers collected data from a patient-reported outcomes tool called the MD Anderson Symptom Inventory (MDASI). All patients rated symptom severity and life interference using this validated survey, first preoperatively and again at every outpatient visit until 31 days after their operations.

Typically, surgeons counsel patients that they are not going to feel better for a month after the operation, and that their full recovery will take about six to eight weeks. "Enhanced recovery," however, is a multicomponent perioperative care protocol created to speed patients' recovery and return to normal life functions such as working and driving.

This type of fast-track care plan involves preoperative patient education, fewer narcotic painkillers used during and after an operation (which have side effects that can lengthen the hospital stay), and a quicker return to eating and walking as soon as possible after the operation.

In this study, 75 patients in the enhanced recovery group were compared with 43 patients in the traditional care group. All preoperative and postoperative care was the same for both groups, except the enhanced recovery part of it. The aim was to compare the difference between patients' functional outcomes.

The researchers found that patients treated in the enhanced recovery group were 2.6 times more likely to achieve their baseline functional status within 31 days than those who were treated with the traditional protocol.

"The only independent factor that correlated to faster return to baseline functional status, both in terms of absolute value and short time to recovery, was being on an enhanced recovery protocol," Dr. Aloia said. "It wasn't the size of the liver resection, the approach [laparoscopic versus open operation], or whether we used an epidural catheter for pain control or not."

In this study, enhanced recovery patients reported lower postoperative pain scores and experienced fewer complications and decreased length of stay. The breakthrough from this study is that most enhanced recovery studies stop measuring their outcome at length of hospital stay, with the sole purpose of shortening the hospital visit.

"At a cancer center, length of stay is pretty low on our list of importance; our true metric of success is getting people after cancer surgery back to cancer therapy," Dr. Aloia said.

The researchers also found that patients in the enhanced recovery group were more likely to return to chemotherapy (a measure researchers at this center created and call Return to Intended Oncologic Therapy or RIOT), (95 percent vs. 87 percent), and at a shorter time interval compared with patients in the traditional group (44.7 days vs. 60.2 days). Because some of the patients were not indicated to receive further cancer treatment in this part of the analysis, these results aren't statistically significant. Still, the researchers have no doubt that the trend is clear.

"With this study, we may have gotten one step closer to a scientific definition of recovery that could be used in other disease sites," Dr. Aloia said. "As enhanced recovery strategies evolve we may now have a tool to compare one approach with another to find out which one is better."

The researchers plan to test the patient-reported outcomes instrument in other disease sites. The MD Anderson Symptom Inventory (MDASI) is available online at MD Anderson Cancer Center, department of symptom research. There is a downloadable user's guide.*

"Four years of participation in the American College of Surgeons National Surgical Quality Improvement Program formed a quality assessment infrastructure at MD Anderson that facilitated this study," Dr. Aloia added. "Our participation in ACS NSQIP® definitely enhanced the culture of quality improvement and provided an infrastructure for the development of our enhanced recovery program."