World Journal of Surgery

, Volume 38, Issue 5, pp 1127–1140 | Cite as

Is Current Perioperative Practice in Hepatic Surgery Based on Enhanced Recovery After Surgery (ERAS) Principles?

  • E. M. Wong-Lun-HingEmail author
  • R. M. van Dam
  • L. A. Heijnen
  • O. R. C. Busch
  • T. Terkivatan
  • R. van Hillegersberg
  • G. D. Slooter
  • J. Klaase
  • J. H. W. de Wilt
  • K. Bosscha
  • U. P. Neumann
  • B. Topal
  • L. A. Aldrighetti
  • C. H. C. Dejong



The worldwide introduction of multimodal enhanced recovery programs has also changed perioperative care in patients who undergo liver resection. This study was performed to assess current perioperative practice in liver surgery in 11 European HPB centers and compare it to enhanced recovery after surgery (ERAS) principles.


In each unit, 15 consecutive patients (N = 165) who underwent hepatectomy between 2010 and 2012 were retrospectively analyzed. Compliance was classified as “full,” “partial,” or “poor” whenever ≥80, ≥50, or <50 % of the 22 ERAS protocol core items were met. The primary study end point was overall compliance with the ERAS core program per unit and per perioperative phase.


Most patients were operated on for malignancy (91 %) and 56 % were minor hepatectomies. The median number of implemented ERAS core items was 9 (range = 7–12) across all centers. Compliance was partial in the preoperative (median 2 of 3 items, range = 1–3) and perioperative phases (median 5 of 10 items, range: 4–7). Median postoperative compliance was poor (median 2 of 9 items, range = 0–4). A statistically significant difference was observed between median length of stay and median time to recovery (7 vs. 5 days, P < 0.001).


Perioperative care among centers that perform liver resections varied substantially. In current HPB surgical practice, some elements of the ERAS program, e.g., preoperative counselling and minimal fasting, have already been implemented. Elements in the perioperative phase (avoidance of drains and nasogastric tube) and postoperative phase (early resumption of oral intake, early mobilization, and use of recovery criteria) should be further optimized.


Central Venous Pressure Parenchymal Transection Core Item PONV Prophylaxis Perform Liver Resection 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors thank all participating centers for their support and contribution to this study: in the Netherlands: Maastricht University Medical Center, Maastricht; Academic Medical Center, Amsterdam; Erasmus Medical Center, Rotterdam; University Medical Center Utrecht, Utrecht; Maxima Medical Center, Veldhoven; Medical Spectrum Twente, Enschede; Jeroen Bosch Hospital, Den Bosch; Radboud University Nijmegen Medical Center, Nijmegen; in Belgium: University Hospital Leuven, Leuven; in Germany: University Hospital Aachen, Aachen; and in Italy: San Raffaele Hospital, Milan.

Conflict of interest

The authors declare no conflicts of interest.


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Copyright information

© Société Internationale de Chirurgie 2013

Authors and Affiliations

  • E. M. Wong-Lun-Hing
    • 1
    Email author
  • R. M. van Dam
    • 1
    • 9
  • L. A. Heijnen
    • 1
  • O. R. C. Busch
    • 2
  • T. Terkivatan
    • 3
  • R. van Hillegersberg
    • 4
  • G. D. Slooter
    • 5
  • J. Klaase
    • 6
  • J. H. W. de Wilt
    • 7
  • K. Bosscha
    • 8
  • U. P. Neumann
    • 1
    • 9
  • B. Topal
    • 10
  • L. A. Aldrighetti
    • 11
  • C. H. C. Dejong
    • 1
    • 9
    • 12
  1. 1.Department of SurgeryMaastricht University Medical CenterMaastrichtThe Netherlands
  2. 2.Department of SurgeryAcademic Medical CenterAmsterdamThe Netherlands
  3. 3.Department of SurgeryErasmus Medical CenterRotterdamThe Netherlands
  4. 4.Department of SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
  5. 5.Department of SurgeryMaxima Medical CenterVeldhovenThe Netherlands
  6. 6.Department of SurgeryMedical Spectrum TwenteEnschedeThe Netherlands
  7. 7.Department of SurgeryRadboud University Nijmegen Medical CenterNijmegenThe Netherlands
  8. 8.Department of SurgeryJeroen Bosch HospitalDen BoschThe Netherlands
  9. 9.Department of SurgeryUniversity Hospital AachenAachenGermany
  10. 10.Department of SurgeryUniversity Hospital LeuvenLouvainBelgium
  11. 11.Department of SurgerySan Raffaele HospitalMilanItaly
  12. 12.Nutrim School for Nutrition, Toxicology and MetabolismMaastricht University Medical CenterMaastrichtThe Netherlands

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