Raffaele Brustia1,2, Antoine Monsel3,4,5, Stefano Skurzak6, Eduardo Schiffer7, François Martin Carrier8,9,10, Damiano Patrono11, Abdourahamane Kaba12, Olivier Detry13, Luiz Malbouisson14, Wellington Andraus15, Franck Vandenbroucke-Menu16, Gianni Biancofiore17, Toshimi Kaido18, Philippe Compagnon19, Shinji Uemoto18, Gonzalo Rodriguez Laiz20, Marieke De Boer21, Susan Orloff22, Paola Melgar20, Carlijn Buis21, Miriam Zeillemaker-Hoekstra23, Helen Usher24, Koen Reyntjens25, Emily Baird26, Nicolas Demartines27, Stephen Wigmore28, Olivier Scatton29. 1. Department of Hepatobiliary and Liver Transplantation Surgery, AP-HP, Hôpital de la Pitié-Salpêtrière, Paris, France. 2. Research Unit, Université de Picardie-Jules Verne, UR UPJV 7518 SSPC, Amiens, France. 3. Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris, France. 4. Immunology-Immunopathology-Immunotherapy (I3), Sorbonne Université, INSERM, UMR-S 959, Paris, France. 5. Biotherapy (CIC-BTi) and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Hôpital Pitié-Salpêtrière, AP-HP, Paris, France. 6. Department of Anesthesiology and Critical Care, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy. 7. Division of Anesthesiology, Department of Anesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva, Switzerland. 8. University of Montreal Hospital Center Research Center, Montreal, QC, Canada. 9. Department of Anesthesiology, University of Montreal Hospital Centre, Montreal, QC, Canada. 10. Division of Critical Care, Department of Medicine, University of Montreal Hospital Centre, Montreal, QC, Canada. 11. General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Corso Bramante, Torino, Italy. 12. Department of Anaesthesiology (AMH, A-SJM, AK, JLJ), Service of Abdominal Surgery, CHU Liège, University of Liège, Domaine du Sart Tilman, Liège, Belgium. 13. Division of Abdominal Surgery and Transplantation, University of Liège Hospital (CHU ULiège), Liège, Belgium. 14. Anesthesiology Division, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. 15. Digestive Organs Transplant Division, Gastroenterology Department, Sao Paulo University School of Medicine, Sao Paulo, Brazil. 16. HPB Surgery and Liver Transplantation Unit, CHUM University of Montreal, Montreal, QC, Canada. 17. Transplant Anesthesia and Critical Care Unit, University School of Medicine, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy. 18. Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan. 19. Division of Transplantation, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland. 20. Department of General & Digestive Surgery, Instituto de Investigación Sanitaria y Biomédica de Alicante, Hospital General Universitario de Alicante, Alicante, Spain. 21. Section Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. 22. Division of Abdominal Organ Transplantation, Department of Surgery, Oregon Health & Science University, Portland, OR. 23. Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. 24. Department of Anesthesiology and Critical Care, Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. 25. Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. 26. Department of Anesthesiology and Critical Care, Oregon Health & Science University, Portland, OR. 27. Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne UNIL, Rue du Bugnon, Lausanne, Switzerland. 28. Department of Clinical Surgery, University of Edinburgh and Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. 29. Department of Digestive, Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtriere, Sorbonne Université, Centre de Recherche de Saint-Antoine (CRSA), INSERM, Paris, France.
Abstract
BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based, program of care developed to minimize the response to surgical stress, associated with reduced perioperative morbidity and hospital stay. This study presents the specific ERAS Society recommendations for liver transplantation (LT) based on the best available evidence and on expert consensus. METHODS: PubMed and ClinicalTrials.gov were searched in April 2019 for published and ongoing randomized clinical trials on LT in the last 15 y. Studies were selected by 5 independent reviewers and were eligible if focusing on each validated ERAS item in the area of adult LT. An e-Delphi method was used with an extended interdisciplinary panel of experts to validate the final recommendations. RESULTS: Forty-three articles were included in the systematic review. A consensus was reached among experts after the second round. Patients should be screened for malnutrition and treated whenever possible. Prophylactic nasogastric intubation and prophylactic abdominal drainage may be omitted, and early extubation should be considered. Early oral intake, mobilization, and multimodal-balanced analgesia are recommended. CONCLUSIONS: The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the e-Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.
BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based, program of care developed to minimize the response to surgical stress, associated with reduced perioperative morbidity and hospital stay. This study presents the specific ERAS Society recommendations for liver transplantation (LT) based on the best available evidence and on expert consensus. METHODS: PubMed and ClinicalTrials.gov were searched in April 2019 for published and ongoing randomized clinical trials on LT in the last 15 y. Studies were selected by 5 independent reviewers and were eligible if focusing on each validated ERAS item in the area of adult LT. An e-Delphi method was used with an extended interdisciplinary panel of experts to validate the final recommendations. RESULTS: Forty-three articles were included in the systematic review. A consensus was reached among experts after the second round. Patients should be screened for malnutrition and treated whenever possible. Prophylactic nasogastric intubation and prophylactic abdominal drainage may be omitted, and early extubation should be considered. Early oral intake, mobilization, and multimodal-balanced analgesia are recommended. CONCLUSIONS: The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the e-Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.