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Page 6 of 12 Kumar et al. Mini-invasive Surg 2018;2:41 I http://dx.doi.org/10.20517/2574-1225.2018.49

Prophylactic drainage
An intense debate about the value and risk of prophylactic drainage in liver resections was raised in 2004
after a meta-analysis provided a strong ground to omit routine prophylactic drainage after major abdomi-
[70]
nal surgery . Recent data from RCTs and large retrospective studies suggest that there is no evidence
to support routine drain use after uncomplicated liver resections without bilio-enteric anastomosis [71,72] .
Furthermore a routine use policy may even lead to an increased risk of complications and 30-day readmis-
sions in major hepatectomy [73-75] . Overall, prophylactic drainage tubes should be used selectively and early
removal is recommended in the absence of complications in order to promote easier mobilization.

Postoperative mobilization and urinary catheter removal
Bed rest in critically ill patients or after surgery can lead to muscular atrophy, weakness, joint contracture,
thromboembolism, insulin resistance, microvascular dysfunction, systemic inflammation, atelectasis and
[76]
bed sores . Early physical activity during recovery from surgery has beneficial effect on many aspects
of physiological functions. Up to 85% of patients undergoing liver resection may be ambulatory by post-
[7]
[77]
operative day 3 . In a study by Yip et al. , sitting out of bed by POD 1 (P < 0.03), walking by POD 3 (P =
0.03) and removal of urinary catheter by POD 3 (P < 0.01) were independently associated with successful
completion of an ERAS protocol aiming at hospital discharge within 6 days after surgery. Delay in removal
[78]
of urinary catheter is enough to prolong hospital stay. In a RCT, Zaouter et al. demonstrated catheter
removal on POD 1 even with epidural analgesia had lower urinary infection rate and similar re-catheter-
[79]
ization rates. A recent RCT by Ni et al. including 120 patients has shown that patients undergoing liver
resection who perform early postoperative ambulation have statistically significant faster return of bowel
function and shorter LOS, without increased risk of complications. Hence, early ambulation could reduce
economic burden and nursing workload as well as increase patient comfort and satisfaction. In summary,
early “out of bed” mobilization with daily goals adjusted to each individual should start the day after liver
resection, as it is both feasible and safe, and it leads to faster patient recovery.

Postoperative nutrition and early oral intake
Allowing patients orally early after major upper GI surgery does not increase morbidity. A RCT on 427 pa-
tients, 66 of which had undergone hepatic resection or hepaticojejunostomy, confirmed the advantages and
[80]
safety of normal oral nutrition at will from postoperative day 1 . Use of laxatives resulted in earlier pas-
[81]
sage of stools but the overall rate of recovery was unaltered . Parenteral nutrition should be only used in
mal-nourished patients or patients expected to have a prolonged fasting (> 5 days) and longer recovery due
[5]
to complications or otherwise . In summary, it is nowadays recommended that patients under an ERAS
protocol should be allowed liquids the morning after surgery and switched to normal food by the evening
[5]
if there is a good tolerance there are no complications .

Postoperative glycemic control
Postoperative rise in blood glucose is expected due to deranged physiologic status of the body after major
surgery. During hepatectomy, blood glucose levels shoot up sharply after Pringle maneouvre due to aug-
[82]
[83]
mentation of glycogenolysis as a result of hypoxia . In line with this concept, Hanazaki et al. suggested
that ischemic preconditioning may reduce the hyperglycemia caused by disturbances of hepatic glucose
mechanism in association with ischemic reperfusion injury. Preoperative fasting combined with surgical
[2]
stress response reduces liver glycogen stores and promotes insulin resistance with hyperglycemia . Hyper-
glycemia is both a marker and cause of adverse outcomes both for diabetics and non-diabetic patients. The
Interleukins released also cause insulin resistance either by suppressing insulin receptors tyrosine kinase
activity or reduction of transmembrane glucose transporters expression, leading to hyperglycemia during
[84]
early postoperative period . It is therefore recommended to initiate insulin therapy early after liver resec-
[5]
tions in order to maintain normoglycemia .