From the Guidelines
A compelling clinical research question for liver surgery is: "Does the implementation of enhanced recovery after surgery (ERAS) protocols specifically tailored for complex hepatectomies reduce post-operative complications and length of hospital stay compared to traditional care pathways?" This question addresses a significant gap in the literature as most ERAS protocols have been developed for colorectal surgery and have been applied to liver surgery without sufficient evidence-based modifications for the unique physiological challenges of hepatic resections 1. To investigate this, researchers would need to develop a comprehensive ERAS protocol specifically for hepatectomies that includes elements such as:
- Pre-operative carbohydrate loading (400ml of maltodextrin solution 2-3 hours before surgery)
- Minimal fasting
- No routine nasogastric tubes
- Early mobilization within 24 hours post-surgery
- Early oral feeding starting 4-6 hours after surgery
- Goal-directed fluid therapy targeting a stroke volume variation <12%
- Multimodal non-opioid analgesia (including TAP blocks with 20ml of 0.25% bupivacaine on each side) The physiological rationale behind this research is that the liver's unique role in metabolism, coagulation, and drug clearance creates distinct challenges during the perioperative period that may require specialized approaches beyond standard ERAS protocols 1. Additionally, the significant stress response and metabolic alterations following major hepatectomies might benefit from tailored interventions to optimize recovery and reduce complications such as post-hepatectomy liver failure, bile leaks, and infectious complications 1. Recent guidelines also support the use of portal vein embolization (PVE) to increase the future liver remnant volume and reduce the risk of post-operative liver failure 1. The development of a tailored ERAS protocol for complex hepatectomies could lead to improved outcomes and reduced morbidity and mortality in patients undergoing liver surgery 1.
Some key considerations for this research question include:
- The need for a multidisciplinary approach to develop and implement a comprehensive ERAS protocol for hepatectomies
- The importance of careful patient selection and pre-operative evaluation to identify patients who may benefit from a tailored ERAS protocol
- The potential for PVE and other pre-operative interventions to improve outcomes in patients undergoing complex hepatectomies
- The need for ongoing monitoring and evaluation of patient outcomes to refine and improve the ERAS protocol over time 1.
From the Research
Clinical Research Question
- What is the efficacy of N-acetylcysteine in preventing postoperative liver failure in patients undergoing liver resection, and what are the potential risks and benefits associated with its use in this context?
Gap in the Literature
- Despite several studies investigating the use of N-acetylcysteine in liver resection surgery 2, 3, the current evidence does not support its routine use in this setting.
- However, recent studies suggest that N-acetylcysteine may have a role in improving transplant-free survival and reducing hospital stay in patients with non-acetaminophen-induced acute liver failure 4, 5.
- Further research is needed to determine the optimal use of N-acetylcysteine in liver resection surgery and to identify patients who may benefit from its use.
Potential Research Directions
- Investigate the efficacy of N-acetylcysteine in preventing postoperative liver failure in patients undergoing liver resection, using a randomized controlled trial design.
- Examine the potential risks and benefits associated with the use of N-acetylcysteine in this context, including its effects on delirium, overall complications, and mortality.
- Explore the use of dynamic liver function tests to identify patients at high risk of postoperative liver failure and to guide the use of N-acetylcysteine in this population 6.