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

           of  randomization, a case match  design was chosen   The figure of the “case-manager nurse” was introduced
           as the most suitable to address this bias of a possibly   with the aim  of being a contact-person during
           higher severity of disease or of a different liver function   patients hospital stay and to monitor the early period
           in laparoscopic patients.                          following  discharge: indeed, thanks to the frequent
                                                              contact, the family and the patient himself  have the
           The present study reports how the application of fast-  feeling of a “protected-discharge”  regimen and any
           track management in the field of liver surgery for HCC   complication occurring at home is not misinterpreted
           allows to improve the results of open approach and   or misdiagnosed. This even allows to lower the rate
           to obtain a short term outcome similar to that of the   of unnecessary  or inappropriate  accesses  in  the
           laparoscopic  technique.  Despite  this,  laparoscopy   Emergency Department.
           confirms  its  advantage,  as  already  reported  in  most
           series and meta-analyses available until now in    The  issue of the impact  of prophylactic drainage
           the literature. [9-12]  Indeed, in spite of a comparable   in patients with  underlying  liver  impairment was
           incidence of postoperative hepatic decompensation   analysed  in  a  specifically  designed  randomized
                                                                           [15]
           (ascites) between the Lap- and the open-group,     controlled  trial,   which reported a detrimental  effect
           patients  in  the  open-group  more  frequently  required   of abdominal drainage on morbidity, without really be
           the introduction or the increase of diuretic therapy in   adequate in detection of bile leakages and bleedings.
                                                                                                   [16]
           the period after surgery. In cirrhotic patients indeed, the   A meta-analysis by Petrowsky  et al.,  including
           advantages  of  laparoscopy  include  the  preservation   all randomized trials [15,17,18]  focused on the issue of
           of wall portosystemic shunts and the round ligament,   drainages in liver surgery, concluded that there is a
           consequently no increases in portal pressure are   slight outcome advantage for nondrained patients.
           recorder:  this  is  the  physiopathological  basis  for  the   While in our first experience, the abdominal drainage
           increased risk of bleeding and ascites. [9,11,12]  Moreover,   was systematically avoided both in the laparoscopic
           the impact of laparoscopy on postoperative outcome,   and  in  the open approach.  In the  current  clinical
           due to negative effects related to inflammatory profile   practice we recommend the avoidance of drainage
           and coagulation homeostasis alterations, are reduced   unless there is any concern in terms of biliostasis or if
                                                              the transection surface can’t be easily drained by the
           compared to conventional surgery,  thanks to the   means of an eventual percutaneous approach. Indeed,
                                            [9]
           conceptual change in perioperative management      the avoidance of postoperative drainage as prescribed
           protocols,  that  was  recently  applied  even  in  open   by  ERAS  protocols  (unless  necessary  to  specifically
           surgery.  Factors  that  delay  postoperative  recovery   monitor  the  risk  of  biliary  fistula),  may  confer  an
           (pain, gut dysfunction and immobility) were targeted,   advantage to patients with impaired liver function.
           resulting in a reduction of the peri-operative stress and
           organ dysfunction.                                 The role of intraoperative volemic control was a flagship
                                                              issue in the ERAS protocol: indeed, maintenance of
           As widely reported in the literature, [4-8]  ERAS approach   patient’s hypovolemia and avoidance of water overload
           is based on several different items, with a different   seem to favourably affect the intraoperative outcome
           range of penetration and application among centers   of  candidates to  hepatic resection reducing blood
           implementing fast-track programs. Furthermore, Wong-  loss and transfusion rate. [19,20]  In laparoscopic  liver
           Lun-Hing  et al.  demonstrated that the advantage   surgery, the positive effect of hypovolemia is increased
                         [8]
           associated  with  this  perioperative  management   since it allows to reduce bleeding from hepatic veins:
           significantly correlates with compliance with the ERAS   indeed, this kind of  bleeding  can’t be controlled by
           program, so that there is further need to further optimize   portal triad clamping and it is frequently responsible
           the ERAS strategy within a multidisciplinary effort. In   for conversion to open approach. [21,22]  Cardiac preload
           our center, the implementation of fast-track was wide   has been traditionally  monitored  by central  venous
           since the beginning of the experience: then, after the   pressure,  while  recently, haemodynamic  changes
           first period of application, the protocol was revised by   during surgery have been successfully assessed using
           the multidisciplinary team to allow the use of a protocol   minimally-invasive devices like Flotrac/Vigileo that is
           tailored on the characteristics of both the institution   proved to be safe and reliable.  Since in cirrhotics
                                                                                           [23]
           and the series. Due to the relatively statistically limited   baseline systemic vascular resistance is lower and less
           power  of  a  comparison  between  the  first  and  the   sensitive to hemodynamic  changes, these patients
           subsequent experience related to a still reduced pool   have altered capability to respond to portal clamping
           of patients, the effective improvement of results along   so that intraoperative administration of vasopressors
           with the reappraisal of the protocol was not analyzed in   (norepinephrine  and dopamine)  might be required.
           the present series and was beyond study aims.      Crystalloid  administration  was generally  suspended
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