Adherence to early mobilisation: Key for successful enhanced recovery after liver resection.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) has been proven effective in liver surgery. Adherence to the ERAS pathway is variable. This study seeks to evaluate adherence to key components of an ERAS protocol in liver resection, and identify the components associated with successful clinical outcomes. METHOD: All patients undergoing liver resections for two consecutive years were included in our ERAS pathway. Six key components of ERAS included preoperative assessment, nutrition and gastrointestinal function, postoperative analgesia, mobilisation and discharges. Successful accomplishment of ERAS was defined as hospital discharge by postop day (POD) 6. Adherences of these elements were compared between the successful and un-successful groups. RESULTS: During the studied period, 223 patients underwent liver resections, among which 103 had major hepatectomies. N = 147 patients (66%) were discharged within our ERAS protocol target (6 days). On multivariable analysis, sitting out of bed by POD 1 (p < 0.03), walking by POD 3 (p = 0.03), removal of urinary catheter by POD 3 (p < 0.01), and avoiding major complications (p < 0.01) were factors associated with successful completion to our ERAS protocol; whereas advanced age (p = 0.34) and discontinuation of PCA/epidural by POD 3 (p = 0.50) were not significant parameters. There was a significant difference in the length of stay (p < 0.01) following major and minor liver resection, of which the indications for surgery also varied significantly. There was no difference in hospital re-admission rate, and morbidity and mortality between major and minor liver resection. CONCLUSIONS: Facilitating early mobilisation and reducing postoperative complications are keys to successful outcomes of ERAS in liver resection.

Significance of 801 monoclonal proteins detected during 7 years of screening in a district general hospital.

This study describes the biochemical follow-up of 801 patients in whom a monoclonal protein had been detected, by screening protein electrophoresis, during a 7-year period. A further blood sample was obtained from 61% of the group and information was available on an additional 32%. Follow-up times ranged from 2 months to almost 8 years. The level of monoclonal protein was measured and any increase related to the level at detection, presence of reduced polyclonal immunoglobulins (RPI), and Bence Jones Protein (BJP). Seventeen (2.1%) monoclonal proteins had disappeared and 428 (88%) demonstrated no significant change in level. Only 26 (3.2%) patients showed a significant increase. This suggests that the majority of monoclonal proteins detected on screening electrophoresis are benign. The presence of BJP is still considered to be the most significant biochemical prognostic criterion. In contrast, finding RPI seems to be least useful. A monoclonal protein level greater than 19 g/l is usually associated with an immunocyte related disease as is an increase in the level of more than 6 g/l. Therefore, assessment of the benign or malignant nature of monoclonal proteins using biochemical prognostic criteria at detection alone is not sufficient. It is recommended that the minimum follow-up should involve review at 3 months and then at yearly intervals.