What is the recommended perioperative management for patients undergoing liver resection surgery?

Perioperative Management in Liver Resection Surgery

Enhanced Recovery After Surgery (ERAS) protocols should be implemented for all patients undergoing liver resection surgery to reduce morbidity, mortality, and improve quality of life. 1

Preoperative Management

Assessment and Optimization

• Nutritional Assessment and Support:

  • Perform nutritional assessment for all patients 1
  • For malnourished patients (weight loss >10% or >5% over 3 months, reduced BMI or low fat-free mass index):
    • Provide enteral supplementation 7-14 days before surgery 1
    • For severely malnourished patients, postpone surgery for at least 2 weeks 1

• Preoperative Liver Function Assessment:

  • Evaluate ICG R15 (indocyanine green retention rate) to determine safe resection volume 2
  • Apply Makuuchi criteria to select appropriate hepatectomy procedures 2
  • Consider portal vein embolization if future remnant liver volume is insufficient 2

• Biliary Drainage:

  • Perform biliary drainage in cholestatic liver (bilirubin >50 mmol/L) 1
  • For perihilar cholangiocarcinoma, use percutaneous rather than endoscopic drainage 1
  • Delay surgery until bilirubin drops below 50 mmol/L 1

• Lifestyle Modifications:

  • Counsel smoking cessation at least 4 weeks before surgery 1
  • Recommend alcohol cessation 4-8 weeks before surgery for heavy drinkers 1

• Prehabilitation:

  • Implement prehabilitation for high-risk patients (elderly, malnourished, overweight, smokers) 4-6 weeks before surgery 1

Day Before Surgery

• Fasting and Carbohydrate Loading:

  • Limit fasting to 6 hours for solids and 2 hours for liquids 1
  • Administer carbohydrate loading evening before surgery and 2-4 hours before anesthesia 1

• Preoperative Counseling:

  • Provide dedicated counseling about the procedure and recovery expectations 1
  • Consider using brochures and multimedia supports 1

Intraoperative Management

Anesthesia and Analgesia

• Pre-anesthetic Medication:

  • Avoid long-acting anxiolytics, particularly in elderly patients 1
  • Avoid preoperative gabapentinoids and NSAIDs 1
  • Adjust preoperative acetaminophen dosing based on extent of resection 1
  • Consider hyoscine patches for high PONV risk patients (avoid in elderly) 1

• Analgesia Strategy:

  • For open surgery: Use multimodal analgesia; thoracic epidural has disadvantages despite excellent pain control 1
  • Consider intrathecal opiates as part of multimodal approach 1
  • For laparoscopic surgery: Use multimodal analgesia with judicious IV opiates 1
  • Continuous local anesthetic wound infiltration provides equivalent analgesia to epidural with fewer complications 1
  • TAP blocks improve pain control and reduce opiate usage 1

Surgical Approach

• Minimally Invasive Surgery:

  • Prefer laparoscopic approach when appropriate and with trained teams 1
  • Laparoscopy reduces length of stay and complication rates 1

• Incision:

  • Tailor incision to patient's anatomy and tumor location 1
  • Avoid Mercedes-type incision due to higher hernia risk 1

Intraoperative Care

• Antimicrobial Prophylaxis:

  • Administer single-dose antibiotics (e.g., cefazolin) within 60 minutes before incision 1
  • For complex surgery with biliary reconstruction, consider targeted antibiotics based on bile culture 1
  • Use chlorhexidine-alcoholic solution for skin preparation 1

• Steroid Administration:

  • Administer methylprednisolone (500 mg) before hepatectomy in patients with normal liver parenchyma 1
  • Avoid in diabetic patients 1

• Fluid Management:

  • Maintain low central venous pressure (<5 cmH2O) during hepatic transection 1
  • Use balanced crystalloids rather than 0.9% saline or colloids 1, 3
  • Implement goal-directed fluid therapy to optimize cardiac output and end-organ perfusion 1

• Temperature Management:

  • Maintain perioperative normothermia using multimodal approaches (circulating water garments, forced warm air) 1

• Prophylactic Measures:

  • Do not use prophylactic nasogastric tubes 1
  • Avoid routine abdominal drainage for hepatectomy without biliary reconstruction 1

Postoperative Management

Immediate Care

• Thromboprophylaxis:

  • Start LMWH or unfragmented heparin postoperatively 1
  • Use intermittent pneumatic compression devices 1

• Early Oral Intake:

  • Implement normal diet from day one after surgery 1
  • Reserve artificial nutrition for malnourished patients or those with prolonged fasting due to complications 1

• Glycemic Control:

  • Maintain normoglycemia (<8.3 mmol/L) with insulin therapy 1, 3

• Mobilization:

  • Begin early mobilization from the operative day until discharge 1

Monitoring and Complication Management

• Liver Function Assessment:

  • Monitor liver function tests (ALT, AST, bilirubin, albumin, INR) 3
  • Apply "50-50 criteria" on postoperative day 5 to predict mortality risk 3
  • Use ultrasound with Doppler to assess vascular patency and detect complications 3

• PONV Management:

  • Use multimodal approach with at least 2 antiemetic drugs (e.g., dexamethasone and ondansetron) 1

• Prevention of Delayed Gastric Emptying:

  • Consider omental flap to cover cut liver surface after left-sided hepatectomy 1

Special Considerations

• Patients with Pre-existing Liver Disease:

  • Apply more stringent selection criteria 3
  • Child-Pugh class B and significant portal hypertension are contraindications to liver resection 3
  • Monitor more closely for signs of posthepatectomy liver failure 3

• Management of Liver Dysfunction:

  • For Grade A dysfunction: Increase monitoring frequency of liver function tests 3
  • For Grade B dysfunction: Consider ICU transfer and invasive hemodynamic monitoring 3
  • Consider additional imaging and hepatology consultation for persistent LFT elevation beyond 7 days 3