What is the recommended treatment approach for a patient undergoing hepatectomy (liver removal surgery), considering the Price 2 trial is not a standard protocol?

Hepatectomy Management: Enhanced Recovery After Surgery (ERAS) Protocol

For patients undergoing hepatectomy, implement the Enhanced Recovery After Surgery (ERAS) Society protocol, which provides comprehensive evidence-based perioperative management guidelines that reduce morbidity and optimize recovery. There is no "Price 2 trial" in hepatectomy literature; the standard of care follows ERAS guidelines established by international consensus. 1, 2

Preoperative Optimization

Nutritional Assessment and Support

• Screen all patients for malnutrition using weight loss >10-15% within 6 months, BMI <18.5 kg/m², or serum albumin <30 g/L (excluding liver/renal dysfunction). 1
• Provide oral nutritional supplements for 7 days preoperatively to at-risk patients. 1, 3
• Postpone surgery for at least 2 weeks in severely malnourished patients (>10% weight loss) to optimize nutritional status and allow weight gain. 1

Preoperative Fasting and Carbohydrate Loading

• Limit preoperative fasting to 6 hours for solids and 2 hours for liquids. 1
• Administer carbohydrate loading the evening before surgery and 2 hours before anesthesia induction. 1, 2

Medication Management

• Avoid long-acting anxiolytics; short-acting agents may be used for regional analgesia before anesthesia induction. 1, 3
• Avoid oral mechanical bowel preparation as it is not indicated before liver surgery. 1

Perioperative Prophylaxis

Thromboembolism Prevention

• Initiate LMWH or unfragmented heparin 2-12 hours before surgery, particularly for major hepatectomy. 1
• Apply intermittent pneumatic compression devices before anesthesia induction to further reduce thrombotic risk. 1
• Continue thromboprophylaxis postoperatively until patients are fully mobile, with consideration for 4-week extended prophylaxis in oncologic patients. 1, 3

Antimicrobial Prophylaxis

• Administer single-dose IV antibiotics less than 1 hour before skin incision. 1
• Do not continue postoperative "prophylactic" antibiotics as they provide no benefit. 1
• Use chlorhexidine 2% for skin preparation as it is superior to povidone-iodine. 1

Steroid Administration

• Consider methylprednisolone (30 mg/kg) 30 minutes to 2 hours before surgery in patients with normal liver parenchyma to decrease liver injury and intraoperative stress. 1
• Avoid steroids in diabetic patients due to impaired glycemic control after hepatectomy. 1, 3

Intraoperative Management

Surgical Approach

• Prioritize minimally invasive liver surgery (MILS) when feasible, particularly for anterolateral and superficial tumors, as it reduces postoperative length of stay and complications. 2
• Avoid Mercedes-type incision due to higher incisional hernia risk; incision choice otherwise depends on patient anatomy and lesion location. 1

Fluid Management

• Maintain low CVP (<5 cm H₂O) during hepatic transection with close monitoring to significantly reduce blood loss. 1, 2, 4
• Use balanced crystalloids (lactated Ringer's) as maintenance fluid rather than 0.9% saline or colloids to avoid hyperchloremic acidosis and renal dysfunction. 1, 4
• Implement goal-directed fluid therapy (GDFT) after hepatic resection to optimize cardiac output and restore tissue perfusion, particularly in patients with comorbidities. 2, 4

Intraoperative Monitoring

• Avoid prophylactic nasogastric intubation as it increases pulmonary complications. 1
• Maintain perioperative normothermia throughout liver resection. 1

Postoperative Management

Nutrition and Mobilization

• Initiate normal oral diet on postoperative day 1 for most patients. 1, 2
• Reserve enteral or parenteral feeding for malnourished patients or those with prolonged fasting due to complications (ileus >5 days, delayed gastric emptying). 1
• Encourage early mobilization from the morning after surgery until hospital discharge. 1, 3

Analgesia

• Avoid routine thoracic epidural analgesia (TEA) in open liver surgery for ERAS patients. 1
• Use wound infusion catheters or intrathecal opiates as alternatives combined with multimodal analgesia. 1

PONV and Glycemic Control

• Provide PONV prophylaxis with 2 antiemetic drugs using a multimodal approach. 1
• Maintain normoglycemia with insulin therapy postoperatively. 1

Monitoring for Complications

• Monitor weight gain closely; increase >3.5 kg on postoperative day 2 predicts major complications. 3, 4
• Avoid stimulation of bowel movement as it is not indicated after liver surgery. 1

Quality Benchmarks

Target perioperative mortality <3% and major morbidity <20% through proper patient selection, multiparametric risk assessment (liver function, portal hypertension, remnant liver volume, comorbidities), and adherence to ERAS protocols. 2, 5, 6

Common Pitfalls to Avoid

• Do not use prophylactic abdominal drainage routinely; evidence is non-conclusive for or against its use. 1
• Avoid excessive crystalloid administration as it can be as harmful as blood loss during hepatic surgery. 4
• Do not rely solely on conventional liver function tests in high-risk patients (large tumors, high alkaline phosphatase, preoperative chemotherapy, hepatoma); more discriminant testing is needed. 7