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 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

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

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.

Pre-anesthetic medication

  • 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

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.

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.

“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

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