Enhanced recovery after surgery in liver surgery

Abstract

Enhanced recovery after surgery (ERAS) or fast-track surgery protocols, have been implemented across surgical fields with positive impact on outcomes. These protocols represent a standardized and evidence-based multimodal perioperative strategy founded on a series of measures aiming to attenuate the physical and psychological stress responses to surgical insults, and to potentiate the postoperative rehabilitation of patients. The successful adoption of ERAS protocols in various specialties enabled its gradual acceptance in the complex field of liver surgery. Even though many elements have been adapted especially from colorectal surgery, a few elements of ERAS protocol are unique to liver surgery. The goals of enhanced recovery can be achieved with efforts beginning at the first interaction on outpatient basis. Core elements of this multidisciplinary effort include pre-operative counseling, shortened preoperative fasting, no pre-anesthetic medication, targeted antimicrobial prophylaxis and early withdrawal, preventing and treating of postoperative nausea and vomiting, minimally invasive approaches, avoidance of postoperative nasogastric decompression, preventing hypothermia, optimal perioperative fluid management, selective use of abdominal drains, early urinary catheter removal, optimal pain control, early oral feeding and mobilization. The available evidence from recent randomized controlled studies and meta-analyses comparing ERAS programs with traditional care in liver surgery suggests that length of hospital stay is shortened without increasing morbidity, mortality or readmission rates.

Keywords

Liver surgery / hepatic surgery / enhanced recovery after surgery / fast track / enhanced recovery

References

[1] Kehlet H.Manipulation of the metabolic response in clinical practice..World J Surg2000;24:690-5

[2] Page AJ,Spolverato G,Grant MC.Enhanced recovery after surgery protocols for open hepatectomy--physiology, immunomodulation, and implementation..J Gastrointest Surg2015;19:387-99

[3] Bardram L,Jensen P,Kehlet H.Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation..Lancet1995;345:763-4

[4] Ljungqvist O,Fearon KC.Enhanced recovery after surgery: a review..JAMA Surg2017;152:292-8

[5] Melloul E,Scott M,Prentis J.Guidelines for perioperative care for liver surgery: enhanced recovery after surgery (ERAS) society recommendations..World J Surg2016;40:2425-40

[6] MacKay G.Early discharge following liver resection for colorectal metastases..Scott Med J2008;53:22-4

[7] van Dam RM,Coolsen MM,Lassen K.Initial experience with a multimodal enhanced recovery programme in patients undergoing liver resection..Br J Surg2008;95:969-75

[8] Lin DX,Ye QW,Li LL.Implementation of a fast-track clinical pathway decreases postoperative length of stay and hospital charges for liver resection..Cell Biochem Biophys2011;61:413-9 PMCID:PMC3210369

[9] Wang C,Zhang W,Lv S.Enhanced recovery after surgery programs for liver resection: a meta-analysis..J Gastrointest Surg2017;21:472-86

[10] Wong-Lun-Hing EM,Heijnen LA,Terkivatan T.Is current perioperative practice in hepatic surgery based on enhanced recovery after surgery (ERAS) principles?.World J Surg2014;38:1127-40

[11] Gouin JP.The impact of psychological stress on wound healing: methods and mechanisms..Crit Care Nurs Clin North Am2012;24:201-13 PMCID:PMC3775570

[12] Lassen K,Slim K,de Aguilar-Nascimento JE.Guidelines for perioperative care for pancreaticoduodenectomy: enhanced recovery after surgery (ERAS®) society recommendations..World J Surg2013;37:240-58

[13] Disbrow EA,Owings JT.Effect of preoperative suggestion on postoperative gastrointestinal motility..West J Med1993;158:488-92 PMCID:PMC1022130

[14] Witte CL.Ileus and ignorance..West J Med1993;158:532-4 PMCID:PMC1022147

[15] Smith I,Murat I,O’Sullivan G.Perioperative fasting in adults and children: guidelines from the European society of anaesthesiology..Eur J Anaesthesiol2011;28:556-69

[16] Nygren J,Jacobsson H,Schnell PO.Preoperative gastric emptying. Effects of anxiety and oral carbohydrate administration..Ann Surg1995;222:728-34 PMCID:PMC1235021

[17] Sutherland AD,Davies JM.Effects of preoperative fasting on morbidity and gastric contents in patients undergoing day-stay surgery..Br J Anaesth1986;58:876-8

[18] Agarwal A,Singh H.Fluid deprivation before operation. The effect of a small drink..Anaesthesia1989;44:632-4

[19] Brady M,Stuart P.Preoperative fasting for adults to prevent perioperative complications..Cochrane Database Syst Rev2003;(4):CD004423

[20] Thorell A,Ljungqvist O.Insulin resistance: a marker of surgical stress..Curr Opin Clin Nutr Metab Care1999;2:69-78

[21] Bilku DK,Hall TC,Garcea G.Role of preoperative carbohydrate loading: a systematic review..Ann R Coll Surg Engl2014;96:15-22 PMCID:PMC5137663

[22] Hausel J,Thorell A,Ljungqvist O.Randomized clinical trial of the effects of oral preoperative carbohydrates on postoperative nausea and vomiting after laparoscopic cholecystectomy..Br J Surg2005;92:415-21

[23] Henriksen MG,Dela F,Haraldsted V.Effects of preoperative oral carbohydrates and peptides on postoperative endocrine response, mobilization, nutrition and muscle function in abdominal surgery..Acta Anaesthesiol Scand2003;47:191-9

[24] Mathur S,McCall JL,McIlroy K.Randomized controlled trial of preoperative oral carbohydrate treatment in major abdominal surgery..Br J Surg2010;97:485-94

[25] Dimick JB,Cowan JA.Complications and costs after high-risk surgery: where should we focus quality improvement initiatives?.J Am Coll Surg2003;196:671-8

[26] Uchiyama K,Ozawa S,Kawai M.Risk factors for postoperative infectious complications after hepatectomy..J Hepatobiliary Pancreat Sci2011;18:67-73

[27] Garwood RA,Thompson L.Infectious complications after hepatic resection..Am Surg2004;70:787-92

[28] Sugawara G,Yokoyama Y,Takahashi Y.The effect of preoperative biliary drainage on infectious complications after hepatobiliary resection with cholangiojejunostomy..Surgery2013;153:200-10

[29] Wu CC,Lin MC,P’eng FK.Prospective randomized trial of systemic antibiotics in patients undergoing liver resection..Br J Surg1998;85:489-93

[30] Hirokawa F,Miyamoto Y,Shimizu T.Evaluation of postoperative antibiotic prophylaxis after liver resection: a randomized controlled trial..Am J Surg2013;206:8-15

[31] Togo S,Matsuo K,Ueda M.Duration of antimicrobial prophylaxis in patients undergoing hepatectomy: a prospective randomized controlled trial using flomoxef..J Antimicrob Chemother2007;59:964-70

[32] Sugawara G,Ebata T,Yagi T.Duration of antimicrobial prophylaxis in patients undergoing major hepatectomy with extrahepatic bile duct resection: a randomized controlled trial..Ann Surg2018;267:142-8

[33] Gurusamy KS,Davidson BR.Methods of decreasing infection to improve outcomes after liver resections..Cochrane Database Syst Rev2011;;

[34] De Pietri L,Begliomini B,Marconi G.Thromboelastographic changes in liver and pancreatic cancer surgery: hypercoagulability, hypocoagulability or normocoagulability?.Eur J Anaesthesiol2010;27:608-16

[35] Dondero F,Mal H,Sauvanet A.Respiratory complications: a major concern after right hepatectomy in living liver donors..Transplantation2006;81:181-6

[36] Bezeaud A,Dondero F,Venisse L.Hypercoagulability after partial liver resection..Thromb Haemost2007;98:1252-6

[37] Cerutti E,Romagnoli R,Skurzak S.Thromboelastogram monitoring in the perioperative period of hepatectomy for adult living liver donation..Liver Transpl2004;10:289-94

[38] Melloul E,Vilgrain V,Paugam-Burtz C.Pulmonary embolism after elective liver resection: a prospective analysis of risk factors..J Hepatol2012;57:1268-75

[39] Reddy SK,Barbas AS,Tsung A.Post-operative pharmacologic thromboprophylaxis after major hepatectomy: does peripheral venous thromboembolism prevention outweigh bleeding risks?.J Gastrointest Surg2011;15:1602-10

[40] Rasmussen MS,Wille-Jørgensen P.Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery..Cochrane Database Syst Rev2009;;

[41] Mastoraki A,Schizas D,Krinos N.Facing the challenge of venous thromboembolism prevention in patients undergoing major abdominal surgical procedures for gastrointestinal cancer..World J Gastrointest Oncol2018;10:328-35 PMCID:PMC6198300

[42] Reich H,DeCaprio J.Laparoscopic excision of benign liver lesions..Obstet Gynecol1991;78:956-8

[43] Gagner M,Dubuc J.Laparoscopic partial hepatectomy for liver tumor..Surg Endosc1992;6:97-8

[44] Azagra JS,Gilbart E.Laparoscopic anatomical (hepatic) left lateral segmentectomy-technical aspects..Surg Endosc1996;10:758-61

[45] Wakabayashi G,Geller DA,Kaneko H.Laparoscopic hepatectomy is theoretically better than open hepatectomy: preparing for the 2nd International Consensus Conference on laparoscopic liver resection..J Hepatobiliary Pancreat Sci2014;21:723-31

[46] Nguyen KT,Geller DA.World review of laparoscopic liver resection-2,804 patients..Ann Surg2009;250:831-41

[47] Buell JF,Geller DA,Iannitti D.The international position on laparoscopic liver surgery: the Louisville statement, 2008..Ann Surg2009;250:825-30

[48] Wakabayashi G,Geller DA,Kaneko H.Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka..Ann Surg2015;261:619-29

[49] Abu Hilal M,Zeidan B,Hallam MJ.Laparoscopic versus open left lateral hepatic sectionectomy: a comparative study..Eur J Surg Oncol2008;34:1285-8

[50] Viganò L,Laurent A.Laparoscopic liver resection: a systematic review..J Hepatobiliary Pancreat Surg2009;16:410-21

[51] Giuliani A,Ceriello A,La Manna G.Laparoscopic vs. open surgery for treating benign liver lesions: assessing quality of life in the first year after surgery..Updates Surg2014;66:127-33

[52] Morise Z,Cherqui D,Belli G.Can we expand the indications for laparoscopic liver resection? A systematic review and meta-analysis of laparoscopic liver resection for patients with hepatocellular carcinoma and chronic liver disease..J Hepatobiliary Pancreat Sci2015;22:342-52

[53] Guro H,Han HS,Choi Y.Current status of laparoscopic liver resection for hepatocellular carcinoma..Clin Mol Hepatol2016;22:212-8 PMCID:PMC4946407

[54] Fretland ÅA,Bjørnelv GMW,Kristiansen R.Laparoscopic versus open resection for colorectal liver metastases: the OSLO-COMET randomized controlled trial..Ann Surg2018;267:199-207

[55] Liu Z,Xiong X.Laparoscopic left lateral hepatic sectionectomy was expected to be the standard for the treatment of left hepatic lobe lesions: a meta-analysis..Medicine (Baltimore)2018;97:e9835 PMCID:PMC5839853

[56] Stoot JH,Busch OR,De Boer M.The effect of a multimodal fast-track programme on outcomes in laparoscopic liver surgery: a multicentre pilot study..HPB (Oxford)2009;11:140-4 PMCID:PMC2697877

[57] Ratti F,Reineke R,Paganelli M.The clinical and biological impacts of the implementation of fast-track perioperative programs in complex liver resections: a propensity score-based analysis between the open and laparoscopic approaches..Surgery2018;164:395-403

[58] Wangensteen OH. Inhibition ileus (paralytic), In The Therapeutic Problem in Bowel Obstruction. Springfield, Ill, CC Thomas, 1937

[59] Pessaux P,Dondéro F,Mantz J.Randomized clinical trial evaluating the need for routine nasogastric decompression after elective hepatic resection..Br J Surg2007;94:297-303

[60] Ephgrave KS,Pfaller M,Werkmeister L.Postoperative pneumonia: a prospective study of risk factors and morbidity..Surgery1993;114:815-9; discussion 819-21

[61] Dureuil B,Cantineau JP,Desmonts JM.Diaphragmatic contractility after upper abdominal surgery..J Appl Physiol (1985)1986;61:1775-80

[62] Olesen KL,Bardram L.Value of nasogastric tube after colorectal surgery..Acta Chir Scand1984;150:251-3

[63] Vermeulen H,Busch OR.Nasogastric intubation after abdominal surgery: a meta-analysis of recent literature..Arch Surg2006;141:307-14

[64] Bauer JJ,Salky BA.Is routine postoperative nasogastric decompression really necessary?.Ann Surg1985;201:233-6 PMCID:PMC1250647

[65] Friedman M,Shelton V,Chilis T.Laryngeal injuries secondary to nasogastric tubes..Ann Otol Rhinol Laryngol1981;90:469-74

[66] Manning BJ,McGreal G,Redmond HP.Nasogastric intubation causes gastroesophageal reflux in patients undergoing elective laparotomy..Surgery2001;130:788-91

[67] Taylor FW.Electrolyte loss by postoperative nasal-gastric suction..AMA Arch Surg1953;66:538-44

[68] Nelson R,Tse B.Prophylactic nasogastric decompression after abdominal surgery..Cochrane Database Syst Rev2007;(3):CD004929

[69] Ichida H,Yoshimoto J,Ishizaki Y.Randomized controlled trial for evaluation of the routine use of nasogastric tube decompression after elective liver surgery..J Gastrointest Surg2016;20:1324-30

[70] Petrowsky H,Rousson V.Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-analyses..Ann Surg2004;240:1074-84; discussion 1084-5 PMCID:PMC1356522

[71] Wada S,Yoh T,Taura K.Is routine abdominal drainage necessary after liver resection?.Surg Today2017;47:712-7

[72] Gurusamy KS,Davidson BR.Routine abdominal drainage for uncomplicated liver resection..Cochrane Database Syst Rev2007;(3):CD006232

[73] Squires MH3rd,Fisher SB,Weber SM.Value of primary operative drain placement after major hepatectomy: a multi-institutional analysis of 1,041 patients..J Am Coll Surg2015;220:396-402

[74] Sun HC,Lu L,Ye QH.Randomized clinical trial of the effects of abdominal drainage after elective hepatectomy using the crushing clamp method..Br J Surg2006;93:422-6

[75] Kim YI,Hwang VJ.Comparison of abdominal drainage and no-drainage after elective hepatectomy: a randomized study..Hepatogastroenterology2014;61:707-11

[76] Brower RG.Consequences of bed rest..Crit Care Med2009;37:S422-8

[77] Yip VS,Samuels S,Lacasia C.Adherence to early mobilisation: key for successful enhanced recovery after liver resection..Eur J Surg Oncol2016;42:1561-7

[78] Zaouter C,Carli F.Less urinary tract infection by earlier removal of bladder catheter in surgical patients receiving thoracic epidural analgesia..Reg Anesth Pain Med2009;34:542-8

[79] Ni CY,Huang ZP,Fu LJ.Early enforced mobilization after liver resection: a prospective randomized controlled trial..Int J Surg2018;54:254-8

[80] Lassen K,Fetveit T,Sigurdsson HK.Allowing normal food at will after major upper gastrointestinal surgery does not increase morbidity: a randomized multicenter trial..Ann Surg2008;247:721-9

[81] Hendry PO,Bukkems SF,Parks RW.Randomized clinical trial of laxatives and oral nutritional supplements within an enhanced recovery after surgery protocol following liver resection..Br J Surg2010;97:1198-206

[82] Maeda H,Nishimori I,Sugimoto T.Hyperglycemia during hepatic resection: continuous monitoring of blood glucose concentration..Am J Surg2010;199:8-13

[83] Hanazaki K,Ichikawa K.Ischemic preconditioning may reduce hyperglycemia associated with intermittent Pringle maneuver in hepatic resection..J Hepatobiliary Pancreat Sci2013;20:257

[84] Durczynski A,Wojciechowska-Durczynska K,Hogendorf P.Major liver resection results in early exacerbation of insulin resistance, and may be a risk factor of developing overt diabetes in the future..Surg Today2013;43:534-8 PMCID:PMC3627012

[85] Carlisle JB.Drugs for preventing postoperative nausea and vomiting..Cochrane Database Syst Rev2006;(3):CD004125

[86] Henzi I,Tramèr MR.Metoclopramide in the prevention of postoperative nausea and vomiting: a quantitative systematic review of randomized, placebo-controlled studies..Br J Anaesth1999;83:761-71

[87] Gan TJ,Habib AS,Kranke P.Consensus guidelines for the management of postoperative nausea and vomiting..Anesth Analg2014;118:85-113

[88] Saidi RF,Verb S,Nalbantoglu I,Jacobs MJ.The effect of methylprednisolone on warm ischemia-reperfusion injury in the liver..Am J Surg2007;193:345-7; discussion 347-8

[89] Alegre ML,Depierreux M,Deschodt-Lanckman M.Cytokine release syndrome induced by the 145-2C11 anti-CD3 monoclonal antibody in mice: prevention by high doses of methylprednisolone..J Immunol1991;146:1184-91

[90] Richardson AJ,Lam VW.Use of pre-operative steroids in liver resection: a systematic review and meta-analysis..HPB (Oxford)2014;16:12-9 PMCID:PMC3892310

[91] Li N,Weng JF,Zhu GH.Short-term administration of steroids does not affect postoperative complications following liver resection: evidence from a meta-analysis of randomized controlled trials..Hepatol Res2015;45:201-9

[92] Schmidt SC,Langrehr JM,Mittler J.Preoperative high-dose steroid administration attenuates the surgical stress response following liver resection: results of a prospective randomized study..J Hepatobiliary Pancreat Surg2007;14:484-92

[93] Yamashita Y,Hamatsu T,Tanaka S.Effects of preoperative steroid administration on surgical stress in hepatic resection: prospective randomized trial..Arch Surg2001;136:328-33

[94] Streetz KL,Manns MP.Interleukin 6 and liver regeneration..Gut2000;47:309-12 PMCID:PMC1727989

[95] Glanemann M,Kuntze R,Dikopoulos N.Ischemic preconditioning and methylprednisolone both equally reduce hepatic ischemia/reperfusion injury..Surgery2004;135:203-14

[96] Spelt L,Sturesson C,Andersson R.Fast-track programmes for hepatopancreatic resections: where do we stand?.HPB (Oxford)2011;13:833-8 PMCID:PMC3244621

[97] Jones C,Dickinson M,Worthington T.Randomized clinical trial on enhanced recovery versus standard care following open liver resection..Br J Surg2013;100:1015-24

[98] Ni CY,Chang YQ,Xu B.Fast-track surgery improves postoperative recovery in patients undergoing partial hepatectomy for primary liver cancer: a prospective randomized controlled trial..Eur J Surg Oncol2013;39:542-7

[99] Lei Q,Tan S,Zheng H.Fast-track programs versus traditional care in hepatectomy: a meta-analysis of randomized controlled trials..Dig Surg2014;31:392-9

[100] Ni TG,Zhang H,Li B.Enhanced recovery after surgery programs in patients undergoing hepatectomy: a meta-analysis..World J Gastroenterol2015;21:9209-16 PMCID:PMC4533053

[101] Li M,Jiang L,Yan L.Fast track for open hepatectomy: a systemic review and meta-analysis..Int J Surg2016;36:81-9

[102] Rouxel P.Enhanced recovery after hepatectomy: a systematic review..Anaesth Crit Care Pain Med2018;;

[103] He F,Xie F,Yuan R.The effect of enhanced recovery program for patients undergoing partial laparoscopic hepatectomy of liver cancer..Clin Transl Oncol2015;17:694-701

[104] Joliat GR,Hübner M,Griesser AC.Cost-benefit analysis of the implementation of an enhanced recovery program in liver surgery..World J Surg2016;40:2441-50

[105] Liang X,Wang H,Yu H.Enhanced recovery program versus traditional care in laparoscopic hepatectomy..Medicine (Baltimore)2016;95:e2835 PMCID:PMC4779010