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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
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