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Ratti et al. Fast-track management in patients with HCC

programmes (enhanced recovery after surgery, ERAS) applied to LLR and in 2011 these principles were
which allowed to achieve a significant gain in terms broadened to encompass even OLR. From 2012 on,
of postoperative outcome in many abdominal surgical a dedicated, “ERAS items-based” database was used
procedures. Many factors have a recognized impact to prospectively collect data from these procedures
[4]
on delayed postoperative recovery (pain, gut dysfunction and to improve their reproducibility and comparability.
and immobility): to reduce peri-operative stress and organ During the study period (2012-2016), 203 resections
dysfunction, fast-track programmes were developed for HCC were performed. Procedures with any of
with the rationale of targeting these factors and with the the following characteristics were identified and
aim of accelerating postoperative recovery and reduce excluded: re-resections, need for associated vascular
length of stay, even lowering the rate of postoperative or biliary reconstruction, major vascular involvement
complications. Furthermore, it is reported that the or thrombosis, extra-hepatic disease. A group of 156
[5]
establishment and adoption of evidence-based practice eligible resections was obtained. Among these, 81 had
guidelines improves surgical outcomes: with this aim, a been operated on by an open approach.
[6]
dedicated and specific program with well-defined recovery
and discharge criteria was developed and applied into With a ratio of 1:1 patients undergoing open liver
daily clinical practice of centres with a strong commitment resection were matched with those who had undergone
in minimally-invasive approach. Thanks to encouraging LLR for HCC, to constitute the open-group (n = 60,
results, many items of ERAS program have been more study group) and the Lap-group, (n = 60, control
extensively implemented and their application was group). Propensity scores were used to achieved the
extended even to conventional open surgery. [7,8] matching, with the following 6 covariates included:
age, American Society of Anesthesiology score,
The preservation of wall portosystemic shunts is one Child-Pugh class, tumor size, nodularity, and extent of
of the advantages of laparoscopic approach when hepatectomy.
performed in patients with hepatocellular carcinoma
(HCC), with a favourable impact on postoperative Preoperative workup
outcome leading to a reduced rate of hepatic Liver function tests (to assess Child-Pugh classification)
decompensation. [9,10] Many reports, including a meta- and serum tumor markers, abdominal ultrasonography,
analysis from Zhou et al. concluded that laparoscopic thoracoabdominal imaging were used as a standard
[11]
preoperative assessment. Weekly multidisciplinary
liver resection (LLR) for HCC allows to obtain more meetings, including liver surgeons, radiologists and
favourable outcomes compared with open liver medical oncologist were systematically performed,
resection (OLR) in terms of its perioperative results, discussing patients who were potential candidates
although it does not negatively affect the oncological for LLR to define the final indication for the surgical
outcomes. However, while most studies evaluating procedure and both the type and the resection
the results of LLR and OLR for HCC are retrospective technique.
series collected out of the fast-track perspective,
[12]
patients affected by HCC, requiring liver resection but Surgical technique
unsuitable for laparoscopy, might benefit from ERAS A right subcostal extended to midline incision was
management since they have a baseline higher risk performed in open cases. The ‘‘French’’ position was
of postoperative complications due to peri-operative used to place patients submitted to laparoscopic
stress. To our knowledge, no specific report exists to resections, with the first surgeon standing between
prospectively evaluate this topic. The present study the patient’s legs and one assistant on each side. A
was designed to assess the implications of ERAS 4-trocar configuration was generally used with a 15 mm
approach in patients submitted to open liver resection port to house the 30° laparoscope. The SonoSurg
for HCC comparing their short term outcome with system (Olympus, Tokyo, Japan) integrating both the
patients treated by laparoscopic approach, in a case- ultrasonic coagulating cutter and the conventional
matched design using propensity scores. ultrasonic dissector was used to perform the hepatic
transaction. Pringle maneuver was used to control
[13]
METHODS intraoperative bleeding.
Study population Perioperative management
In total 2,058 liver resections were performed at The ERAS multimodal protocol was adapted from
the Hepatobiliary Surgery Division of San Raffaele the initial model to elective liver surgery, with the
[7]
Hospital, Milano in the period between January 2004 main goal to enhance functional recovery [Table 1]. A
and April 2016. Of these, 469 (22.8%) were performed specific anaesthesiological management protocol was
for HCC. Fast-track principles were systematically also developed to guide both intraoperative monitoring
272 Hepatoma Research ¦ Volume 2 ¦ September 30, 2016