Updated guidelines on perioperative care for liver surgery by ERAS

Preoperative counseling

• The authors recommend that patients should receive preoperative information and counseling regarding the upcoming liver surgery. Brochures and multimedia supports might be helpful to improve the verbal counseling.

Prehabilitation

• The authors recommend that prehabilitation be performed in high-risk patients (elderly, malnourished or overweight patients, smokers, or patients with psychological disorder) before liver surgery.
• Prehabilitation should be commenced 4–6 weeks before the operation depending upon the urgency of surgery.
• The content (physical exercises, dietary interventions, or anxiety reduction exercises) and duration of the prehabilitation program for liver surgery are not clearly established.

Preoperative biliary drainage (PBD)

• The authors recommend biliary drainage in cholestatic liver (>50 mmol/l).
• For perihilar cholangiocarcinoma, percutaneous biliary drainage should be preferred to endoscopic biliary drainage.
• Surgery should ideally not be performed until bilirubin level drops below 50 mmol/l.

Preoperative smoking and alcohol cessation

• The authors recommend counseling of preoperative smoking cessation at least 4 weeks prior to hepatectomy.
• For heavy drinkers (>24 g/day for women or >36 g/day for men), alcohol cessation is recommended 4–8 weeks before surgery.

Preoperative nutrition

• A nutritional assessment is necessary prior to all hepatic surgery.
• Malnourished patients (i.e., weight loss >10% or >5% over 3 months and reduced body mass index or a low fat-free mass index) should be optimized with enteral supplementation at least 7–14 days prior to surgery.

Perioperative oral immunonutrition

• The use of immunonutrition in hepatic surgery is not recommended yet due to the lack of evidence.

Preoperative fasting and preoperative carbohydrate load

• Preoperative fasting of 2 h for liquids and 6 h for solids before anesthesia is safe and can be recommended.
• The authors recommend carbohydrate loading the evening before liver surgery and 2–4 h before induction of anesthesia. Preoperative carbohydrate loading is safe and improves perioperative insulin resistance, but it is not clear if it is associated with a reduction of length of stay in liver surgery.

• The authors recommend to avoid long-acting anxiolytic drugs, particularly in the elderly.
• Preoperative gabapentinoids and nonsteroidal anti-inflammatory drugs are not recommended.
• Preoperative acetaminophen should be dose-adjusted according to extent of resection. Preoperative hyoscine patches can be used in patients with high risk for postoperative nausea and vomiting but should be avoided in the elderly.

Anti-thrombotic prophylaxis

• Low molecular weight heparin or unfragmented heparin reduces the risk of thromboembolic events and should be routinely started postoperatively unless exceptional circumstances make this unsafe.
• Intermittent pneumatic compression devices should be used to further reduce this risk.

Preoperative steroids administration

• The authors recommend steroid administration (methylprednisolone at a dose of 500 mg.
• No recommendation can be formulated on diabetic patients undergoing liver surgery.

Antimicrobial prophylaxis and skin preparation

• The authors recommend antibiotic prophylaxis (such as cefazolin) within 60 min before surgical incision, with no benefit extending it into the postoperative period.
• In case of complex liver surgery with biliary reconstruction, a targeted antibiotic pre-emptive regimen based on preoperative bile culture may be recommended, but its duration is unknown.
• Skin preparation with chlorhexidine-alcoholic solution is associated with a lower rate of surgical site infections, compared to povidone-iodine solution.

Minimally invasive approach

• Laparoscopic liver resection is recommended in trained teams and when clinically appropriate, since it reduces the postoperative length of stay and complication rates.

Postoperative glycemic control

• The authors recommend insulin therapy for maintenance of normoglycemia (<8.3 mmol/l).

• Use of an omental flap to cover the cut surface of the liver might reduce the risk of delayed gastric emptying after left-sided liver resection.

Early and scheduled mobilization

• Early mobilization (out of bed) after liver surgery should be established from the operative day until hospital discharge. ,
• No recommendation can be made regarding the optimal duration of mobilization.

Monitoring/audit

• Substantial literature exists supporting that audit and feedback improve outcomes in health care and surgery.
• Regular audit and feedback should be implemented and performed in liver surgery to monitor and improve postoperative outcomes and compliance to the ERAS program.

Fluid management

• Low central venous pressure (below 5 cm H₂O) with close monitoring is recommended during hepatic transection.
• As maintenance fluid balanced crystalloid should be preferred over 0.9% saline or colloids. Goal-directed fluid therapy optimizes cardiac output and end-organ perfusion. This may be particularly beneficial after the intraoperative liver resection during a low central venous pressure state to restore tissue perfusion.
• Patients who have comorbidities and reduced cardiac function may benefit most.

Postoperative nausea and vomiting (PONV) prophylaxis

• A multimodal approach to postoperative nausea and vomiting should be used.
• Patients should receive postoperative nausea and vomiting prophylaxis with at least 2 antiemetic drugs such as dexamethasone and ondansetron.