Enhanced recovery after surgery in liver transplantation: Challenges and feasibility

Table 1 Common inclusion criteria (with incorporation of exclusion criteria)

Inclusion criteria	Brustia et al[8]	Xu et al[9]	Rao et al[7]
Meld score < 25	√	1	1
HCC	√	√	√
The first liver transplantation	√	√	√
Age > 18	√	> 16	> 16

¹All patients included in the three studies had a MELD score < 25. HCC: Hepatocellular carcinoma; MELD: Model for end-stage liver disease.

Table 2 Preoperative, intraoperative, and post-operative characteristics

Preoperative	Brustia et al[8]		Xu et al[9]		Rao et al[7]
	ERAS group, n = 10	CONTROL group, n = 20	ERAS group, n = 40	CONTROL group, n = 53	ERAS group, n = 54	CONTROL group, n = 74
Gender
Male	8	17	35	46	40	58
Female	2	3	5	7	1	16
Age, yr	60.1 (52.5-66.1)	58.2 (52.6-65.3)	49.5 (40-56.8)	53 (47-59)	52.4 + 15.2	55.8 + 14.3
Primary cause
Alcohol	7 (70%)	9 (45%)	7	3	6 (11.1)	10 (13.5)
Viral cirrhosis	7 (70%)	10 (50%)	11	16	30 (55.6)	40 (54.1)
HBV	2 (20%)	4 (20%)	NA	NA	NA	NA
HCV	6 (60%)	8 (40%)	NA	NA	NA	NA
Metabolic syndrome	2 (20%)	4 (20%)	NA	NA	NA	NA
Biliary disease	0	3 (15%)	NA	NA	NA	NA
HCC	9 (90%)	9 (45%)	17	24	18 (33.3)	24 (32.4)
MELD score	7 (6-10)	7 (6-9)	14 (9-22)	17 (14-19)	7.7 + 3.2	7.9 + 4.6
Intraoperative
Operative time	6.0 (5.9-8.4) h	6.7 (5.7-8.2) h	443.7 + 85.3min	453.5 + 62.3min	265 (215-360) min	325 (275-455) min
Anhepatic period	NA	NA	44.3 + 5.2 min	42.7 + 4.2 min	45 (35-70) min	60 (50-75) min
Blood loss	NA	NA	775 (525-1000) mL	800 (600-1000) mL	1100 (300-4200) mL	2900 (1600-7000) mL
Hypothermia during the operation (n, %)	NA	NA	0	12%	0	0
Postoperative
Early extubation (h)	2 (0-2)	7.5 (4.5-13.0)	0	6 (5.5-8)	NA	NA
ICU stay (d)	3 (2-4)	4.5 (3.0-8.3)	2 (2-3)	4 (4-5)	2 (1-7)	5 (3-15)
Complications (n, %)	5 (50%)	16 (80%)	9 (22.5%)	26 (49.1%)	10 (18.5%)	20 (27%)
Pain score after operation	3 (1.0-4.0) POD	4.5 (2.7-6.) POD	2.45+ 0.54	3.02+0.44	NA	NA
Postoperative hospital stay (d)	9.5 (9.0-10.5)	18 (14.3-24.3)	14.5 (12-17)	16 (15-18)	18 (15-32)	28 (23-35)
Readmission within 30 d after discharge	NA	NA	0	0	0	0

Categorical variables are reported using percentages; continuous variables are summarized using median and 25%-75% percentiles. ERAS: Enhanced recovery after Surgery; HBV: Hepatitis B virus; HCC: Hepatocellular carcinoma; HCV: Hepatitis C virus; ICU: Intensive care unit; MELD: Model for end-stage liver disease.

Table 3 Experimental ''fast trans'' protocol items

Preoperative	Brustia et al[8]	Xu et al[9]	Rao et al[7]
1 Outpatient counseling and information	√	√	√
2 Preoperative carbohydrate loading	√	√	√
3 Absence of preanesthetic medication (anxiolytic)	√
Intraoperative
4 Antimicrobial prophylaxis and skin preparation	√
5 Prevention of intraoperative hypothermia	√	√
6 Incision	√
7 Adapted IV filling	√	√	√
8 Temporary portocaval anastomosis	√
9 No prophylactic nasogastric intubation	√		√
10 No prophylactic abdominal drainage	√		√
11 Prevention of postoperative nausea and vomiting	√
12 Antithrombotic prophylaxis and/oranti-aggregation	√	√
13 Early extubation (< 6 h after the endof lt)	√	√	√
Postoperative
14 Early mobilization (POD1)	√	√	√
15 Patient-controlled analgesia	√	√
16 Gastric probe removal POD1	√	√
17 Clear liquid per OS POD1	√	√	√
18 Enteral feeding per OS POD1	√	√	√
19 Stop IV fluids POD1	√	√
20 Per OS analgesia (POD2)	√	√
21 Abdominal drain removal POD2	√
22 Urinary probe removal POD2	√	√	√
23 Stop IV analgesia POD3	√	√
24 Independent mobilization POD3	√	√	√
25 Daily revision of discharge criteria	√	√	√
26 Audit	√	√	√

ICU: Intensive care unit; IV: Intravenous; LT: Liver transplantation; POD: Post-operative day; PONV: Post-operative nausea and vomiting.