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Kumar et al. Mini-invasive Surg 2018;2:41 I http://dx.doi.org/10.20517/2574-1225.2018.49 Page 3 of 12

Table 1. Core elements for enhanced recovery after surgery protocols in liver resections
Pre-operative Peri-operative Post-operative At discharge
• Education, counselling and • Antibiotic prophylaxis • No nasogastric tube • Normal or decreasing serum
exercise • Thromboembolic prophylaxis • Selective ICU transfer bilirubin
• No bowel preparation • Epidural analgesia • Multimodal analgesia • Good pain control with oral
• No preanesthetic medications • Short-acting i.v. anesthetic agent • Early removal of Foley’s catheter analgesia only
• Carbohydrate loading 2 h prior • Prevention of hypothermia • Early enteral intake • Tolerance of solid food
surgery • Optimal fluid balance no abdomi- • Early ambulation • No i.v. fluids
• Minimal fasting (2 h) nal drains or early removal • Early withdraw of i.v. fluids • Mobile independently or at
• Minimal incisions • Early restoration of normal diet the preoperative level
• Glucose Control • Willingness to go home
PONV prophylaxis • Normal body temperature
• No incision infection
ICU: intensive care unit; PONV: postoperative nausea and vomiting

Preoperative information and counselling
Fear and stress are common prior to surgery. Hospitalization is a stressful event that disturbs the physical
and psychological wellbeing of a patient. Stress due to apprehension of surgery leads to activation of sym-
pathetic axis and adrenaline overdrive. Increased cortisol and catecholamine production can significantly
[11]
impact the healing process and particularly the initial inflammatory phase . Although no high level
evidence exists certifying the beneficial impact of preoperative counseling and education on outcomes,
there is no doubt that education aids such as brochures, leaflets and online information help the patients
[5]
in decision making and enhance the validity of informed consent . Also, the engagement of visual media
regarding the recovery process and postoperative expectations improves overall compliance with feed-
[12]
ing and physiotherapy, hence reducing morbidity . Whatever approach is employed, detailed informa-
tion about the natural history of disease, surgical procedure, anesthesia, expected course of recovery and
complications reduces stress and anxiety related to the procedure, which positively impacts postoperative
outcomes. Earlier return of gastrointestinal (GI) motility has been shown in patients who received preop-
[13]
erative instruction compared to those who merely received information and reassurances . Therefore,
adequate counseling and communication with empathy may be all that is required sometimes to relieve
[14]
postoperative ileus during the post-operative period . Although there are no specific studies evaluating
the therapeutic effect of preoperative counseling and patient education before liver surgery, it is strongly
recommended for any ERAS protocol to include thorough preoperative information and counseling in or-
der to allay patients’ fear and reduce psychological stress.

Preoperative fasting
The concept of overnight fasting before surgery to ensure an empty stomach and avoid pulmonary com-
plications has been decisively challenged in recent years. Prolonged fasting leads to perioperative insulin
[15]
resistance, fever, symptoms like malaise, hunger, thirst, nausea and increases patients’ anxiety . Fasting
guidelines before surgery are based on gastric physiology and expert opinion, as there is limited evidence
that they improve outcomes. Clear liquids and gastric secretion move rapidly out of the stomach, and even
though glucose containing fluids leave the stomach more slowly, after 90 min the stomach is empty of clear
[16]
liquids regardless of type . Gastric residual volume averages about 25 mL in patients fasted overnight
prior to surgery, and clear liquids intake up to 2 h before surgery does not seem to affect this residual vol-
[19]
ume [17,18] . In a Cochrane database systematic review, Brady et al. have shown that a liberal fluid fasting
protocol does not increase the risk of aspiration or morbidity as compared to a conventional mid night
fasting policy. Surgical insult following overnight fasting results in an exaggerated catabolic response that
[2]
causes insulin resistance and prolongs recovery . In fact, insulin resistance is a central metabolic change
during surgical stress that is directly proportional to the magnitude of the operation and leads to hyper-
[2]
glycemia in non-diabetic patients . As a consequence, various endocrine and inflammatory systems are
stimulated. This results in an exacerbation of the existing postoperative catabolic state with marked loss