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Page 8 of 12 Kumar et al. Mini-invasive Surg 2018;2:41 I http://dx.doi.org/10.20517/2574-1225.2018.49

Table 2. Outcomes of enhanced recovery after surgery protocols in liver resections
Length of stay, days
Ref. Year Study design n (Range) Morbidity Mortality Results compared to TC
Spelt et al. [96] 2011 Review 130 5-7 15%-46% 0%-1.8% Reduced LOS
Jones et al. [97] 2013 RCT 46 4 7% 2% Reduced LOS and morbidity
Improved QOL
Ni et al. [98] 2013 RCT 80 5.2 30% 0 Reduced morbidity, PONV, ileus and
LOS
Lower CRP
Lei et al. [99] 2014 Meta-analysis of RCT’s 187 4-9.2 20.9% 0 Reduced time to flatus, morbidity, LOS
He et al. [103] 2015 RCT 48 4-8 14.6% 0 Reduced LOS, time to flatus and cost
Improved QOL
Ni et al. [100] 2015 Meta-analysis of RCT’s 354 5 15.5% 0 Reduced morbidity, ileus and LOS
Liang et al. [105] 2016 RCT 80 6.2 22.5% 0 Reduced LOS, morbidity and cost
Li et al. [101] 2016 Meta -analysis 477 6-10 29.7% 0.02% Reduced LOS
Wang et al. [9] 2017 Meta-analysis 1297 2.5-10 28.4% 0.49% Reduced morbidity, LOS, cost and
blood loss
Rouxel et al. [102] 2018 Review 254 4-6.9 7%-24% 0.004% Reduced morbidity and LOS
RCT: randomized controlled trial; TC: traditional care; LOS: length of hospital stay; QOL: quality of life; PONV: postoperative nausea and
vomiting; CRP: C-reactive protein

Pre-operative
Pre-operative optimization on outpatient basis
Pre-admission counselling
Pre-operative instructions for incentive spirometry/chest physiotherapy/mobilization and oral intake
Printed material & pamphlets about disease, treatment plan and proposed management
Preoperative fasting after 12 midnight
Thromboprophylaxis with LMWH
PPI and anxiolytics

Intra-operative
Pre-anaesthetic medication
Epidural analgesia
Low CVP during transection /use of CUSA
Minimal net fluid balance
Drains

Post-operative
Nasogastric tube removed just at finish of surgery
Oral sips allowed as soon as patient conscious and oriented

POD 1
Ambulated to chair in the morning
Ambulated with support in the evening
Incentive spirometry initiated with active chest and limb physiotherapy
Arterial line removed
Thromboprophylaxis continued
Blood sugar monitoring and control with insulin

POD 2
Oral diet advanced to normal diet
Rectal suppositories/oral stool softeners
CVP line removed
Foley’s catheter removed

POD 3
Drain output monitored, drains cut on bag if quantity manageable
Drains removed if colour and quatity satisfactory
Planning and counselling about discharges
Discharge drug explanation
Explanation regarding importance of compliance

POD 4
Discharge from hospitals with advice of follow-up and care of drains and wound
Instruction regarding follow-up

Figure 1. Summary of the enhanced recovery after surgery protocol applied at our institute. LMWH: low molecular weight heparin; PPI:
proton-pump inhibitor; CVP: central venous pressure; CUSA: cavitron ultrasonic surgical aspirator; POD: postoperative day