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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
276 Hepatoma Research ¦ Volume 2 ¦ September 30, 2016