Fast Track Liver Transplantation: Lessons learned after 10 years running a prospective cohort study with an ERAS-like protocol - 04/04/23
, P Melgar Requena a, h, C Alcázar López a, h, M Franco Campello a, C Villodre Tudela a, h, P Bellot García b, h, M Rodríguez Soler b, h, C Miralles Maciá b, h, I Herrera Marante b, h, MT Pomares Mas b, h, P Mas Serrano c, h, L Gómez Salinas d, h, F Jaime Sánchez e, M Perdiguero Gil f, g, h, JM Ramia Ángel a, h, S Pascual Bartolomé b, h
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Abstract |
Fast Tracking in Liver Transplantation has been around for the past 25 years, although no substantial advancement, in the form of a comprehensive protocol, had been readily available. Few centers had embraced this goal, so before we started our program, a little over a decade ago, we adopted most of these ideas into a comprehensive pathway that would swiftly carry our patients from the preoperative stage through a safe home discharge. From day one, we have used this Fast Track pathway and applied it prospectively to every single patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our results after 10 years.
Patients and Methods |
All liver transplants performed at our center for the first 10 years since the start of the program (September 2012–September 2022) were included. Our standard protocol included balanced general anesthesia, fluid restriction, avoidance of transfusions, inferior vena cava preservation with temporary porto-caval shunt and thromboelastography. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early.
Results |
385 transplants were performed in 367 patients (287♂/80♀) over 120 months, mean age 57.4±9.5 years, raw MELD score 15.4±8.1. Predominant etiologies were alcohol (n=217) and HCV (n=108), with hepatocellular carcinoma present in 197 (53.7%). Eighteen patients underwent combined liver-and-kidney transplants. Mean operating time was 313±66 min with cold ischemia times of 281±85 min. Fifty-nine patients (15.3%) were transfused in the OR (2.3±1.1 units of PRBC). Extubation was immediate (< 30 min) in 365 cases (94.8%). Median ICU length of stay was 12.6 h, and median post-transplant hospital stay was 4 days (2–97) with 55 patients (15.8%) discharged home by the 2nd day, 141 (40.5%) by the 3rd day and 203 (58.3%) by the 4th day, which defined our Fast-Track group. The overall thirty-day-readmission rate was (34.5%), which became significantly lower (27.6% vs 44.1%, p=0.0014) in the Fast-Track group when compared to the regular discharge group. Patient survival was 87.6% at 1 year and 79.7% at 5 years.
Conclusion |
Fast-Tracking of Liver Transplant patients is very feasible and can be applied as the standard of care.
Le texte complet de cet article est disponible en PDF.Keywords : Fast track, Liver transplant, Hospital length of stay, Cost-effectiveness, ERAS, LOS, Early extubation, ICU length of stay
Alphabetical list of abbreviations : ERAS, HBV, HCC, HCV, HRS, ICU, LOS, MELD, NASH, PBC, PTLOS, PRBC, TPCS
Plan
Vol 10
Article 100151- mai 2023 Retour au numéro
Article précédent
- Cardiovascular assessment of candidates for liver transplant
- Manuel Lozano, Miguel Molina, Jesús Zarauza, Federico Castillo, Roberto Fernández-Santiago, Edward J. Anderson, Emilio Fábrega, Juan C. Rodríguez-Sanjuán
- A “return to normalcy” or establishing a “new normal”: The patient experience of liver transplantation
- Ingrid Woelfel, Daria Faulkner, Sandra Wong, Kenneth Washburn, Austin Schenk
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