Editor's Note: Enhanced Recovery After Surgery (ERAS) has become a core concept in modern perioperative management. By implementing a series of evidence-based optimization measures, ERAS aims to reduce or mitigate the body's stress response, promoting faster recovery after surgery. However, many challenges remain in the implementation of ERAS that require attention and further exploration.At the 2024 Chinese Conference on Integrated Oncology (CCHIO), Dr. Yong Zeng from West China Hospital of Sichuan University delivered a keynote speech titled “Advances and Clinical Practice of Enhanced Recovery in Perioperative Liver Surgery.” His presentation provided valuable insights into the hospital’s experience in implementing and managing ERAS, and we have summarized the key points of his speech for reference and guidance.1. What Can ERAS Bring to Surgical Care?
A meta-analysis published in Clinical Nutrition explored the differences in outcomes between patients undergoing major elective open colorectal surgery under the ERAS pathway versus those receiving traditional perioperative care. This study included six research trials with 452 colorectal surgery patients, involving an average of nine ERAS interventions (ranging from 4 to 12). The results showed that the ERAS group had a reduction in average hospital stay by 2.55 days and a 47% decrease in complication rates.
In 2017, West China Hospital’s Liver Surgery Department conducted an internal comparison of operational indicators following the introduction of ERAS. The findings revealed that ERAS significantly reduced hospital stay, preoperative waiting times, and medical expenses.
Liver, bile, and pancreatic surgeries are known for their complexity, high levels of trauma, and postoperative complication rates. In recent years, the adoption of modern surgical concepts emphasizing precision, minimally invasive approaches, and damage control has laid a solid foundation for the application of ERAS. The publication of the 2015 Expert Consensus on Enhanced Recovery After Surgery for Hepatobiliary and Pancreatic Surgery has significantly promoted the development and application of ERAS principles in China, further supporting the steady advancement of minimally invasive liver surgery.
2. Key Points in the Perioperative Application of ERAS for Liver Resection
The core principle of ERAS is to reduce stress and trauma. Interventions aimed at minimizing the stress response include adequate pain management, minimizing surgical incisions, relieving pain, providing nutritional support, regulating anabolic and catabolic balance, preventing hypothermia, and reducing inflammatory responses through pharmacological means.
ERAS for liver resection should be implemented throughout the entire treatment process, spanning from pre-hospitalization, pre-surgery, intraoperative care, postoperative management, and post-discharge follow-up. The central focus is a patient-centered approach to diagnosis and treatment. At West China Hospital, the ERAS standard emphasizes careful preparation before surgery, meticulous management during surgery, and skillful care post-surgery. The main implementation areas are as follows:
Preoperative Planning
- Comprehensive Preoperative Education: Providing structured and standardized preoperative education is essential and should extend throughout the perioperative period until the patient is discharged. At West China Hospital, preoperative health education for liver resection aims to enhance patients’ and their families’ understanding of ERAS principles, alleviate negative emotions, and improve compliance with perioperative treatment measures. This approach encourages active participation by patients and their families, ultimately improving perioperative quality of life.
The education framework follows the “3Ws and 1H” model (What, Why, When, and How), as outlined in hospital-specific guidelines. Additionally, West China Hospital leverages modern information technology to overcome time and space constraints, improving the effectiveness of perioperative health education. Tailored educational materials are developed for patients of varying ages, cultural backgrounds, and ethnicities to ensure the quality of health education during the perioperative period.
- Revising Outdated Fasting Guidelines: Traditional perioperative protocols recommend fasting for 12 hours (overnight fasting) and water restriction for 6 hours before surgery. However, overnight fasting has been shown to cause insulin resistance, postoperative discomfort, and delayed digestive recovery. Research indicates that consuming clear fluids up to 2 hours before surgery does not increase complication rates. As such, it is now strongly recommended to limit fasting to 6 hours and allow clear fluids or liquid food up to 2 hours before surgery.
At West China Hospital, perioperative nutritional support under ERAS is tailored to individual patient needs. Nutritional assessments and management are conducted rigorously, starting from patient selection and continuing through postoperative recovery.
- Prophylactic Use of Antibiotics: Current guidelines strongly recommend the routine prophylactic use of antibiotics for Class II surgical wounds. However, routine preoperative administration of anti-anxiety medications is generally not recommended unless specifically indicated. These measures are evidence-based and aim to minimize the risk of infection and other complications.
2. Intraoperative Procedures
- Maintaining Body Temperature (Strong Recommendation): During surgery, the patient’s body temperature should remain above 36.0°C. According to the 2008 NICE perioperative temperature management guidelines, intravenous fluids or blood products should be warmed to 36°C using fluid-warming devices. For patients undergoing anesthesia lasting more than 30 minutes, or those at high risk of hypothermia even with shorter anesthesia times, warming devices should be used during surgery to maintain body temperature.
- Selective Use of Drainage Tubes in Hepatobiliary Surgery (Strong Recommendation): Routine placement of drainage tubes is not recommended for hepatobiliary surgery. Studies show that routine drainage does not reduce postoperative complications. Additionally, percutaneous drainage after bile leaks or encapsulated fluid collections does not increase the risk of severe complications. There is no high-level evidence indicating that routine drainage reduces postoperative complications or provides any other benefits.
- Minimizing Surgical Incision Trauma: Trauma from surgical incisions is a major source of stress for patients, and postoperative complications can directly impact recovery. Surgery should be performed with precision, minimal invasiveness, and damage control to reduce surgical stress. Common incision types for open liver resection include midline incisions, reverse L-shaped incisions, Mercedes incisions, and subcostal incisions extending to the left side. Studies show no significant difference in postoperative pneumonia rates among these incision types. However, reverse L-shaped incisions provide better liver exposure, while Mercedes incisions may increase the risk of incisional hernias. Subcostal incisions involve muscle dissection and may increase trauma, chronic pain due to nerve injury, and pulmonary complications. To further reduce incision-related trauma, studies suggest local peritoneal infiltration with 0.2% ropivacaine (20–40 ml) during surgery to alleviate central sensitization.
3. Postoperative Interventions
- Early Removal of Drainage Tubes: Drainage tubes, including nasogastric tubes (removed on postoperative day 1–2), urinary catheters (removed on postoperative day 1–2), and unnecessary drains, should be removed as early as possible.
- Early Enteral Nutrition Support: To stimulate intestinal motility, patients can start consuming clear fluids as early as 2 hours after returning to the ward or immediately after the nasogastric tube is removed, gradually transitioning to liquid and soft diets. Laxatives such as lactulose are recommended to accelerate gastrointestinal motility, along with simethicone to alleviate bloating. Unnecessary high-flow oxygen therapy should be avoided to reduce abdominal distension.
- Goal-Directed Fluid Therapy (GDFT): Individualized fluid management is crucial postoperatively to maintain appropriate circulatory volume. For the first three days after liver resection, intravenous fluid intake should be limited to 50% of physiological requirements, with adjustments based on circulatory needs. As most patients can resume oral intake early, additional intravenous fluids can usually be discontinued by postoperative days 2–3.
- Managing Postoperative Nausea and Vomiting: Anti-nausea medications such as metoclopramide or serotonin receptor antagonists (e.g., ondansetron) can prevent postoperative nausea and vomiting. For dizziness caused by opioid pain relief, oral scopolamine (motion sickness medication) can help control symptoms.
- Preventing Complications After Liver Resection: To prevent thrombotic complications, prophylactic medications or mechanical thromboprophylaxis should be applied. Patients with a Caprini score of ≥3 are advised to receive low-molecular-weight heparin (LMWH), while those at high risk of bleeding should use intermittent pneumatic compression (IPC) until bleeding risk decreases, after which medication can be introduced. Pulmonary complications can be prevented using sequential techniques for airway clearance, including suction, percussion, and coughing, with bedside guidance from the nursing team.
- Postoperative Pain Management: Pain control is a critical component of ERAS. Surveys in China reveal that over 90% of abdominal surgery patients experience moderate to severe postoperative pain. Multimodal analgesia is recommended, encompassing preoperative and intraoperative preventive pain management to reduce postoperative pain sensitization. Postoperative pain control options include epidural anesthesia, patient-controlled analgesia pumps, incision-controlled analgesia pumps, and transverse abdominis plane (TAP) or rectus sheath blocks. At West China Hospital, a dedicated nursing team uses VAS pain scoring and checklists to monitor and evaluate patients’ pain levels, ensuring timely adjustments to pain management plans.
- Early Postoperative Mobilization: Early, structured mobilization is a hallmark of ERAS and promotes recovery across multiple systems, including gastrointestinal, musculoskeletal, and respiratory systems. It also reduces the risks of pulmonary infections, pressure sores, and deep vein thrombosis.
4. Discharge Management
The goal of ERAS is not merely to achieve faster discharge but to accelerate postoperative recovery, thereby shortening hospital stays. It is essential not to equate ERAS with simply reducing hospitalization duration.
Discharge standards must be clearly defined. In China, current guidelines state that discharge is appropriate when patients can manage basic self-care, maintain normal body temperature, have stable white blood cell counts, exhibit normal organ function, manage pain with oral medication, and tolerate normal oral intake without signs of infection. In summary, if a patient has manageable pain, does not require intravenous medication, and has resumed oral intake, they are fit for discharge.
At West China Hospital, a robust follow-up management system is in place for patients discharged after liver resection.
In conclusion, ERAS emphasizes reducing surgical trauma and stress while promoting recovery, aiming for “zero pain and no risk.” It reflects a patient-centered approach to modern medicine and represents the direction and standard for surgical development. While applying ERAS, it is vital to recognize that its goal is to accelerate perioperative recovery, not simply to shorten hospital stays. This approach must not increase readmission rates post-discharge. As surgical techniques continue to evolve, ERAS must also adapt, further enhancing recovery outcomes for patients.
