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.