ERAS in Liver Transplantation: Indian Researchers Map Barriers and Implementation Strategies

India: Enhanced Recovery After Surgery (ERAS) protocols, widely recognized for improving surgical outcomes, are now being explored in the context of liver transplantation—a domain traditionally resistant to standardized postoperative pathways.

In a recent review published in Apollo Medicine, Dr. Vijay Shankar and colleagues from Indraprastha Apollo Hospital, New Delhi, shed light on how ERAS strategies can be adapted to improve perioperative care in liver transplant recipients despite the inherent complexities of the procedure.

Enhanced Recovery After Surgery (ERAS), a multimodal, evidence-based approach to perioperative care, has significantly transformed surgical outcomes in various specialties. However, its adoption in liver transplant surgery has been limited due to the complexity of the procedure and patient variability. This review emphasizes that ERAS strategies, when tailored to the individual patient’s condition, donor factors, and surgical specifics, can significantly minimize surgical stress, lower complication rates, and shorten hospital stays.

“Earlier, postoperative ventilation and delayed enteral nutrition were routine in liver transplant recipients due to prolonged surgeries and hemodynamic instability. With the integration of ERAS principles such as prehabilitation, opioid-sparing anesthesia, and optimized fluid therapy, we have observed quicker extubation, faster ambulation, and earlier nutritional support in our patients,” Dr. Vijay Shankar told Medical Dialogues.

The review emphasizes the importance of selecting appropriate candidates for ERAS. Ideal patients include those with minimal hepatic encephalopathy, stable cardiopulmonary function, good nutritional reserves, and suitable graft characteristics. Preoperative optimization includes nutritional support, infection screening, and addressing psychological factors like depression and substance use.

Intraoperatively, the use of multimodal analgesia, controlled fluid administration, and refined surgical techniques such as reduced cold ischemia time and selective portocaval shunting supports early recovery. The article highlights that early extubation, even in high-risk cases, is now possible with individualized care and enhanced monitoring techniques like bispectral index-guided anesthesia.

Despite promising outcomes, Dr. Shankar acknowledges that implementing ERAS in liver transplantation presents unique challenges. “Successful implementation requires dedicated coordination among anesthesiologists, surgeons, intensivists, and nursing staff. We had to reframe traditional practices and rely heavily on structured team education and collaboration to make ERAS feasible,” he added.

Dr. Chitra Chatterji, co-author of the article, emphasized the critical role of institutional commitment and team synergy in ERAS execution. “Educating the full care team—surgeons, anesthetists, nurses, and allied staff—is crucial. ERAS is not a one-size-fits-all solution, and clinical judgment should always guide its application,” she told Medical Dialogues. She further noted that while enthusiasm for early extubation and mobilization is high, it must be balanced with caution to avoid complications such as falls due to residual vasoplegia.

The review also acknowledges the challenges in postoperative fluid management, often complicated by the misconception that hypervolemia prevents vascular thrombosis. Instead, point-of-care ultrasound is now being used to guide euvolemic strategies and reduce morbidity.

Even in pediatric liver transplant settings, ERAS is gaining traction, with studies supporting early extubation and the use of regional analgesic blocks.

The authors conclude that individualized ERAS pathways, supported by strong multidisciplinary collaboration, can significantly enhance recovery and reduce perioperative risks in liver transplant recipients. More studies are needed to validate protocols across diverse clinical settings in India.

Reference:

Shankar, V., Chatterji, C., & Chawla, S. Enhanced Recovery After Surgery (ERAS) Protocols in Liver Transplant Recipients—Challenges and Strategies for Implementation: A Review Article. Apollo Medicine. https://doi.org/10.1177/09760016241285693