Specific Items of Enhanced Recovery After Surgery for Liver Surgery in Cirrhotic Patients: A Systematic Review

BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathways have been shown to be safe in patients undergoing hepatectomy. Due to cirrhosis-induced complications, specific or additional perioperative items might need to be implemented. This study systematically reviewed the literature to assess specific items to be included in future ERAS protocol for the perioperative management of cirrhotic patients undergoing hepatectomy. METHODS: A systematic review was performed until September 2024. Evaluated items were prevention and management of perioperative ascites, encephalopathy prevention, perioperative anticoagulation, perioperative nutrition, prophylactic abdominal drainage, postoperative analgesia, vascular filling, and prevention of liver failure. Levels of evidence were given for each specific item based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. RESULTS: A total of 3123 articles were screened, and 81 articles were included in the final analysis of the eight evaluated items. Five items had a moderate or high level of evidence. Summary of the five items with moderate/high evidence level were (i) preoperative ascites should be controlled before surgery, (ii) mechanical and pharmacological venous thromboembolism prophylaxis is recommended postoperatively if coagulation tests are within normal range, (iii) systematic drainage among patients with cirrhosis is not recommended, (iv) acetate-buffered solutions should be preferred over Hartmann solutions or 0.9% saline, and (v) portal hypertension should be optimized preoperatively, and minimal invasive surgery should be favored to decrease liver failure rates. CONCLUSION: This systematic review comprehensively evaluated specific perioperative items for cirrhotic patients undergoing liver surgery. Level of current evidence remains moderate, and future research are still needed to develop specific recommendations for ERAS in cirrhotic patients undergoing liver surgery.