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Updated guidelines on perioperative care for liver surgery by ERAS
Switzerland: A recent article, published in the World Journal of Surgery, reports updated Enhanced Recovery After Surgery (ERAS) guidelines on perioperative care for liver surgery. The ERAS guidelines in liver surgery were updated using a modified Delphi method based on a systematic review of the literature. Since the publication of the first ERAS guidelines in 2016, ERAS has...
Switzerland: A recent article, published in the World Journal of Surgery, reports updated Enhanced Recovery After Surgery (ERAS) guidelines on perioperative care for liver surgery.
The ERAS guidelines in liver surgery were updated using a modified Delphi method based on a systematic review of the literature.
Since the publication of the first ERAS guidelines in 2016, ERAS has been applied widely in liver surgery. The aim of the article by Nicolas Demartines, University of Lausanne (UNIL), Lausanne, Switzerland, and colleagues was to update the ERAS guidelines in liver surgery.
240 articles were finally included after the screening a total of 7541 manuscripts. Elaboration of twenty-five recommendation items was done. All of them obtained consensus following 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) had a strong recommendation grade. 3 novel items were introduced compared to the first published ERAS guidelines: preoperative biliary drainage in the cholestatic liver, prehabilitation in high-risk patients, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy.
- 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.
- 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.
- 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.
- 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).
Prevention of delayed gastric emptying (DGE)
- 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.
- 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.
- 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.
"These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery," the authors concluded. "Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed."
Joliat, GR., Kobayashi, K., Hasegawa, K. et al. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022. World J Surg (2022). https://doi.org/10.1007/s00268-022-06732-5
Medha Baranwal joined Medical Dialogues as an Editor in 2018 for Speciality Medical Dialogues. She covers several medical specialties including Cardiac Sciences, Dentistry, Diabetes and Endo, Diagnostics, ENT, Gastroenterology, Neurosciences, and Radiology. She has completed her Bachelors in Biomedical Sciences from DU and then pursued Masters in Biotechnology from Amity University. She has a working experience of 5 years in the field of medical research writing, scientific writing, content writing, and content management. She can be contacted at firstname.lastname@example.org. Contact no. 011-43720751