Perioperative management for hepatic resection surgery

Learning objectives.

By the end of this article, you should be able to:

• •Discuss the evaluation of patients undergoing hepatic resection.
• •Implement strategies to minimise blood loss during parenchymal resection.
• •Identify the risk factors for liver failure after hepatectomy.
• •Adopt an evidence-based approach to the perioperative management of patients.

Key points.

• •Metastases from colorectal cancer remain the main indication for hepatic resection.
• •A hepatic remnant of 20–30% after resection is considered the minimum safe volume to prevent postoperative hepatic failure.
• •Enhanced recovery after surgery (ERAS) protocols for hepatic surgery have demonstrated a significant reduction in length of stay (LOS) and complications.
• •Anaesthetic and surgical strategies aimed at minimising blood loss are essential in minimising postoperative morbidity and mortality.

There are almost 3000 hepatic resections performed in the UK annually.¹ In the 1970s the mortality rate after hepatic resection surgery was ∼20%, with haemorrhage and hepatic failure common.² Advances in perioperative care have reduced this to 2–3% and it is now possible to safely resect up to 60% of the liver.^3,4 The improvement in outcomes may be attributed to several factors:

• (i)Better understanding of liver anatomy and physiology.
• (ii)Advances in management before resection: including future liver remnant (FLR) volume manipulation and new chemotherapy regimens.
• (iii)Surgical advances: minimally invasive techniques (laparoscopic, robotic surgery), better surgical instruments (Cavitron ultrasonic aspirator [CUSA, Integra LifeSciences Corporation, USA]—intelligent bipolar devices) and strategies to reduce intraoperative haemorrhage.
• (iv)Improved risk stratification, prehabilitation, enhanced recovery protocols, improved analgesic regimens and tailored critical care therapy.
• (v)Centralisation of hepatic surgery to large volume centres.

Despite this progress postoperative morbidity remains high (50–60%).⁵ This article reviews current trends in perioperative care for hepatic resection surgery.

Indications for hepatic resection surgery

Surgery is indicated for both benign (haemangiomas, adenomas and focal nodular hyperplasia) and malignant pathologies. Malignant lesions may be primary (80% hepatocellular carcinoma; 20% cholangiocarcinoma) or secondary—principally metastatic colorectal cancer.

Approximately 20% of patients with colorectal cancer have hepatic metastases at presentation with a further third developing them subsequently.⁶ The ability to resect these lesions has revolutionised the prognosis in this group, with a reported 33% 5-yr survival rate.⁷

Liver anatomy

The liver is highly vascular, receiving 20% of cardiac output (1.5 L min⁻¹); 30% via the hepatic artery and 70% from the portal vein. Venous drainage is via the right, middle and left hepatic veins, which drain directly into the inferior vena cava (IVC).

Anatomically the liver may be divided into four lobes; right and left (separated by the falciform ligament); and two posterior lobes—the caudate and quadrate. Alternatively, it may be divided it into eight functional segments each segment consisting of liver parenchyma, an efferent hepatic vein and a ‘portal triad’ (hepatic artery branch, afferent portal vein and an efferent bile duct). Understanding the segmental anatomy and blood supply is integral to planning and performance of surgery.

The liver parenchyma has the unique ability to regenerate via hyperplasia of the hepatocytes. This process commences within 24 h of resection with the liver typically reaching its original size by 6 months. However, complete functional recovery may occur within 2–3 weeks.⁸

Preoperative assessment

Thorough preoperative assessment is essential. Many patients are frail and deconditioned as a result of both the pathophysiological changes of cancer and its treatment. Preassessment is an opportunity for education, shared decision-making and evaluating the patient's suitability for operation.

Comorbidities

Optimisation of comorbidities such as anaemia and malnutrition are essential in reducing complications. Diabetes presents a particular risk: operative mortality in diabetic patients undergoing hepatic resection is higher when compared with non-diabetic patients. The reasons for this are multifactorial, with alterations in liver metabolism, decreased immune function and hepatic steatosis all contributing to postoperative liver dysfunction. It is therefore essential that glycaemic control and weight loss are optimised. Any cardiorespiratory issues must also be assessed in order to determine the individual's ability to cope with the potential haemodynamic changes induced by vascular exclusion during liver resection.

Chemotherapy

Neoadjuvant chemotherapy may reduce tumour size and facilitate resection. It has become an integral part of the multidisciplinary management of patients with metastatic colorectal cancer. However, many chemotherapeutic agents damage hepatic parenchyma, causing chemotherapy-associated steatohepatitis which is associated with increased perioperative morbidity and mortality. Chemotherapy may also be cardiotoxic, causing myocardial damage that can lead to arrhythmias, cardiomyopathies, heart failure and myocardial infarctions. Surgery should be delayed until to 4–6 weeks after completion of treatment to ameliorate the negative impact of neoadjuvant chemotherapy on postoperative morbidity.

Preoperative liver dysfunction and cirrhosis

Underlying liver disease is a major determinant of hepatic regenerative capacity and is a significant risk factor for post-hepatectomy liver failure (PHLF). Hepatocellular carcinoma often develops in patients with underlying liver cirrhosis and many of these patients show signs of chronic liver dysfunction (CLD). Hepatectomy in the context of cirrhosis is associated with a very high mortality rate, principally from PHLF.⁹ Accurate preoperative assessment of liver function is therefore essential, although currently no single factor or test can reliably predict postoperative liver dysfunction.

Scoring systems

Efforts to risk stratify patients with CLD have led to the development of a number of scoring systems to help decide whether liver surgery can be performed safely.

The Child–Turcotte–Pugh (CTP) system divides cirrhosis into three classes; A – least severe; B – moderate; C – most severe. It correlates strongly with mortality after hepatectomy. Class C is considered an absolute contraindication to surgery whereas patients of Class A are generally considered good candidates for hepatic resection. Although some Class B patients may undergo resection, the risks are significantly increased, and a limitation of the CTP system is in discriminating within this group.¹⁰

The model of end-stage liver disease (MELD) score is also used to predict perioperative risk in patients with CLD or end-stage liver disease. Whilst there is no clear cut-off level for elective surgery, a score between 10 and 15 is associated with increased risk.¹⁰

Volumetric assessment

Both CT and MRI may be used to estimate future liver remnant (FLR) volume, which most accurately correlates with FLR function and risk of PHLF. Future liver remnant of 20% is considered the minimum safe volume for patients with normal liver function, whereas 30–40% is required for patients who have severe steatohepatitis or have received hepatotoxic chemotherapy. At least 50% is necessary for patients with cirrhosis.¹¹

Estimation of functional reserve

Indocyanine green (ICG) dye retention rates are used to provide a quantitative assessment of dynamic hepatic function and calculate the minimum volume of liver that must remain to maintain essential liver function.¹² Impaired clearance of ICG is suggested when more than 15% of the dose remains in the plasma 15 min after injection. However, it is an unreliable tool in cases of hyperbilirubinemia and used only in specialised centres, as part of multidisciplinary team (MDT) evaluation.

Augmenting the FLR

Several strategies have been developed to generate compensatory hypertrophy of the FLR and reduce the risk of PHLF. Techniques used currently include portal vein embolisation (PVE); portal vein ligation and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS); and liver venous deprivation (LVD).

The ALPPS procedure is a two-staged hepatectomy that allows extensive resection in patients with an inadequate FLR. It induces rapid and significant hypertrophy of the FLR but is associated with higher perioperative morbidity. Its use is reserved for:

• (i)When the tumour margin is close to the FLR (or its vascular pedicle)
• (ii)Failed PVE
• (iii)Cases with a very limited starting FLR.

Preoperative LVD is the simultaneous embolisation of portal vein and one or two hepatic veins, leading to hypertrophy of the contralateral parenchyma. This technique has been shown to be safe and produce greater regeneration than portal vein embolisation alone.¹³

Intraoperative considerations

The main tenet of anaesthesia for hepatic resection surgery is to optimise the patient's haemodynamic status using judicious fluids and vasoactive agents in order to create conditions that minimise hepatic venous blood loss whilst maintaining end-organ perfusion. Standard techiques include a general anaesthetic, tracheal tube and controlled ventilation. Anaesthetic agents with minimal impact on liver blood flow should be used; long-acting agents should be avoided to achieve a clear-headed emergence with adequate pain relief; and postoperative nausea and vomiting (PONV) should be avoided. Large-bore i.v. access is essential. Central venous and arterial catheters allow for close haemodynamic monitoring. Cardiac output monitoring can be used to follow the cardiovascular changes associated with surgical manipulation of the liver or IVC, and potential intraoperative hypovolaemia with haemorrhage.

The requirement for invasive monitoring depends upon the patient's characteristics, size of resection, surgical approach (minimally invasive or open) and duration of the procedure. Blood loss can be sudden and catastrophic, and blood products should be readily available. Hypothermia should be avoided.

Analgesia

Effective pain control reduces the incidence of cardiorespiratory complications, encourages early return of bowel function, facilitates early mobilisation and may result in earlier recovery.¹⁴ The optimal strategy in hepatic resection is a subject of debate and depends on a variety of factors—not least surgical approach (open or minimally invasive). Thoracic epidural analgesia (TEA)—traditionally the gold standard in open liver resection—is no longer recommended in ERAS guidelines after the emergence of evidence suggesting alternative techniques are equally effective. A balanced, multimodal, opioid-sparing approach comprising regional techniques and analgesic adjuncts is currently favoured. Considerations include:

Paracetamol—despite fears of hepatotoxicity, paracetamol appears to be safe in all but the most extensive resections. Risk factors for hepatotoxicity include liver disease, age, malnutrition and intraoperative liver ischaemia.

NSAIDs—these are effective and opioid-sparing. They should be used if not contraindicated.

Intravenous opioids—reducing the use of opioids decreases the incidence of their adverse effects (e.g. PONV, respiratory depression) and promotes postoperative recovery. Despite this they remain in common use both during and after surgery.

Thoracic epidural analgesia—whilst a well-working epidural offers excellent analgesia, the risks of postoperative hypotension, fluid overload and impaired mobility alongside reportedly high failure rates and risk of complications (such as nerve injury and epidural haematoma) has seen a move towards the use of alternative techniques.

Intrathecal morphine (ITM)—spinal anaesthesia has a lower failure rate compared with TEA, and is often simpler and quicker to perform.¹⁵ A systematic review of 11 trials comparing ITM with other modes of analgesia in patients undergoing open hepatic surgery demonstrated equivalent or lower pain scores with ITM. Compared with TEA, ITM reduced requirements for fluids and hospital stay. There was no difference in the rate of major complications.¹⁶

Continuous wound infusion (CWI) catheters—CWI catheters are an opioid-sparing alternative to TEA and may be used in conjunction with other techniques (e.g. ITM). They may be sited subcutaneously, subfascially or preperitoneally and there is debate over the optimal placement. A recent meta-analysis showed preperitoneal catheters provided superior pain relief compared with subcutaneous catheters. Evidence comparing CWI catheters with TEA in open hepatic resection is conflicting, although current guidelines state that when all aspects of postoperative care are optimised, CWI catheters in conjunction with a multimodal analgesic regimen offers a clinically acceptable alternative to TEA.

Trunk blocks—there is growing interest in the use of transversus abdominal plane (TAP) blocks and erector spinae blocks as alternatives to TEA, although more clinical evidence is needed. In living donor liver resection, TAP blocks are associated with less opioid consumption, lower pain scores and shorter length of stay (LOS).¹⁷

Prevention of haemorrhage

Anaesthesia

During parenchymal resection with hepatic inflow occlusion, the main source of bleeding is backflow from the valveless hepatic veins. Control of central and thus hepatic venous pressure is crucial to reduce blood loss, with the aim of achieving a near ‘bloodless’ field. Various strategies aimed at decreasing central venous pressure (CVP) have been used including diuretics (furosemide—also a venodilator); vasodilator infusions (glyceryl trinitrate); opioid infusions (remifentanil); placing the patient in the Trendelenburg position; avoidance of PEEP (positive end-expiratory pressure); and fluid restriction until the parenchymal resection is complete.

Previous studies have demonstrated that CVP >5 cmH₂O significantly increases bleeding and although maintenance of low CVP (<5 cmH₂O) intraoperatively is a well-practiced technique, its effectiveness and safety remain under scrutiny.¹⁸ A low CVP may lead to cardiovascular instability, intraoperative hypovolaemia and reduced renal and hepatosplanchnic blood flow. Supplementary vasoconstrictor drugs are often required to maintain systemic perfusion pressure of other organs. Despite concerns over vasoconstrictor-associated splanchnic hypoperfusion causing secondary hepatic ischaemia, there is no evidence to support this, nor is there definitive evidence demonstrating a link between low CVP anaesthesia and renal insufficiency.

A meta-analysis of low CVP anaesthesia in hepatic resection demonstrated a reduction in blood loss and transfusion requirements but no improvement in clinical outcomes.¹⁹ Conversely a retrospective analysis of 135 hepatic resections found the use of CVP monitoring had no effect on intraoperative blood loss.²⁰ In minimally invasive surgery monitoring CVP is complicated by transmitted pressure from the pneumoperitoneum making targeted low CVP anaesthesia less applicable.

In addition to these considerations, specific agents may be administered to reduce the risk of haemorrhage including tranexamic acid and vitamin K.

Surgery

Dissection devices

The CUSA uses ultrasonic energy to fragment and aspirate parenchymal tissue. It creates a precise transection plane allowing preservation of normal hepatic tissue. It exposes biliary and vascular structures that may then be ligated individually, generally using vascular staplers or suture ligation. Currently it is the most commonly used device for complex major hepatic resection. It should be noted that significant blood loss can go unnoticed during CUSA usage as the suction is at the point of resection, and accumulates in separate canisters from the standard suction devices, often hidden under drapes.

Haemostatic energy devices

These are used to control residual bleeding of the resected liver surface. They may be bipolar electrosurgical (e.g. LigaSure, Medtronic), ultrasonic (e.g. Harmonic scalpel, Johnson and Johnson) or a combination of both (e.g. Thunderbeat, Olympus Medical Systems). They function by both dividing and sealing blood and biliary vessels up to 5 mm in diameter and have been a significant advance in reducing blood loss especially in minimally invasive surgery.

The argon beam coagulator is a non-contact, monopolar electrocoagulation device that transmits radiofrequency electrical energy from a hand-held electrode across a jet of argon gas. The jet clears the field of pooled blood and evenly distributes electrical energy to the target tissue.

Topical haemostatic agents

Fibrin sealants are a group of topical haemostatic products that mimic the final stages of the blood coagulation process. Fibrin sealants are two-component products, containing thrombin and fibrinogen. During application these components are mixed allowing the thrombin to cleave the fibrinogen into monomers which then polymerise forming a fibrin gel.

Surgical vascular occlusion

Various hepatic vascular occlusion techniques have been used to reduce blood loss during surgical dissection. These include temporary hepatic inflow occlusion (Pringle manoeuvre) or inflow and outflow occlusion such as total vascular exclusion (TVE). These techniques are designed to isolate hepatic circulation (inflow, outflow, or both) from the systemic circulation, thereby reducing blood loss during dissection and transection of the hepatic parenchyma.

The Pringle manoeuvre is an example of an inflow occlusion method that involves clamping the hepatoduodenal ligament to interrupt blood flow in both the hepatic artery and portal vein. The subsequent decrease in venous return and increase in systemic vascular resistance may result in significant haemodynamic instability, and good communication between the surgeon and anaesthetist is essential during cases where it is being used. Prolonged continuous interruption of hepatic inflow (>1 h in normal liver or >30 min in pathological liver) may cause an ischaemia/reperfusion injury meaning occlusion is usually performed intermittently, allowing for 10–20 min of interrupted liver blood flow followed by a 5-min period of reperfusion. This protects the liver by limiting the total ischaemic time and inducing ischaemic preconditioning.²¹

Selective inflow occlusion can be achieved by hemihepatic or segmental occlusion of (branches of) the portal vein or hepatic artery. However, it requires extensive hilar dissection and is technically challenging limiting its use in practice.

Total vascular exclusion, the most complete liver clamping method, entails exclusion of the liver from the splanchnic and systemic circulations by total inflow occlusion associated with clamping of the IVC below and above the liver.

When tolerated, TVE produces the best conditions for minimising intraoperative blood loss. However, the risk of ischaemic injury to the FLR is high and it is associated with profound volume shifts, which can severely complicate the postoperative course. This technique is usually reserved for when massive blood loss from hepatic veins persists despite vascular inflow occlusion, or when the tumour is infiltrating the IVC/caval-hepatic junction, and resection of part of the IVC is required.

Minimally invasive liver resection

Minimally invasive liver resection (MILR) includes both laparoscopic liver resection and robotic liver resection. The indications for MILR are the same as those for open surgery. Preoperative evaluation and preparation is as for open surgery, as conversion rates may be as high as 20%.

It is estimated that ∼70% hepatectomies for colorectal metastases may be amenable to a minimally invasive approach. Patients with cirrhosis, ascites, or both may particularly benefit from MILR, with smaller incisions facilitating a faster recovery and reducing adhesions if further/staged surgery is required.

Comparison with open liver resection

Technical aspects

Advantages of MILR are that it offers improved visualisation and reduced venous bleeding during parenchymal transection because of the tamponade effect of pneumoperitoneum. Potential disadvantages of MILR include the loss of tactile feedback (in robotic surgery), inability to manually palpate the liver (although this can be offset with intraoperative ultrasound) and inability to quickly obtain vascular control in cases of unexpected bleeding. These disadvantages may be mitigated by use of a hand port or the minimally invasive Pringle manoeuvre.

Perioperative outcomes

Minimally invasive liver resection has been associated with decreased LOS, blood loss, postoperative pain, wound infection rates and greater patients' satisfaction when compared with open surgery.

Considerations for anaesthesia

The considerations for anaesthesia for MILR are similar to those for open surgery. Appropriate selection of patients is essential. Minimally invasive liver resection may be technically more challenging for the surgeon and the patient's ability to tolerate a potentially prolonged pneumoperitoneum with carbon dioxide insufflation must be considered, particularly of there is coexisting cardiac or respiratory dysfunction. Central venous pressure monitoring in the context of a pneumoperitoneum is unreliable and many centres are electing to omit routine CVP catheter placement.

Postoperative care

Depending on local resources, many patients may go directly to a surgical ward after smaller or minimally invasive hepatectomy. Those undergoing more extensive or open resec-tions usually require closer monitoring in the postoperative period and therefore need a high dependency or critical care area.

Most patients should be able to resume oral intake within a few hours after surgery. Artificial enteral or parenteral nutrition should be reserved for only specific cases where there is prolonged postoperative ileus or concerns over malnutrition. Intravenous fluids should be discontinued when hydration and circulating volume are adequate. Patients often remain very responsive to fluids in the immediate period after surgery, especially after major resections, and goal-directed fluid therapy may need to continue for a limited period.

Early ambulation is a key component of ERAS protocols and is associated with reduced rates of ileus, pulmonary complications and thromboembolic events.

Enhanced recovery after surgery protocols for hepatic surgery have demonstrated a significant reduction in LOS, time until medically fit for discharge and complications. A full discussion of ERAS is beyond the scope of this article, but a summary of the main recommendations is tabulated below (Table 1).²²

Table 1.

ERAS guidelines for hepatic resection surgery (2016).

ERAS recommendation	Summary
Preoperative counselling	Routine dedicated preoperative counselling and education before liver surgery.
Perioperative nutrition	Patients at risk should receive nutritional supplements 7 days before surgery. If severely malnourished, surgery should be postponed for at least 2 weeks to improve nutritional status and allow patients to gain weight.
Preoperative fasting and preoperative carbohydrates load	Preoperative fasting does not need to exceed 6 h for solids and 2 h for liquids. Carbohydrate loading is recommended the evening before liver surgery and 2 h before induction of anaesthesia.
Oral bowel preparation	Oral bowel preparation is not indicated before liver surgery.
Premedication	Long-acting anxiolytic drugs should be avoided. Short-acting anxiolytics may be used to perform regional anaesthesia before induction of anaesthesia.
Thromboprophylaxis	Low molecular weight heparin or unfractionated heparin should be started 2–12 h before surgery, particularly in major hepatectomy. Intermittent pneumatic compression stockings should be added to further decrease this risk.
Antimicrobial prophylaxis and skin preparation	Single dose i.v. antibiotics should be given before skin incision and <1 h before hepatectomy. Postoperative ‘prophylactic’ antibiotics are not recommended.
	Skin preparation with chlorhexidine 2% is superior to povidone-iodine solution.
Incision	Increased used of midline incision approach for accessible lesion. Mercedes-Benz incision has a higher incisional hernia risk.
Minimally invasive approach	Approach can be used by surgeons with experience.
Prophylactic nasogastric tubes	Routine insertion not recommended; if used remove at the end of surgery.
Prophylactic abdominal drain	Inconclusive evidence
Temperature control	Maintain normothermia
Postoperative nutrition and early oral intake	Encourage oral intake after Day 1, for malnourished or patients with prolonged fasting because of complications consider enteral or parenteral feeding after Day 5.
Postoperative glycaemic control	Insulin recommended to maintain normoglycaemia.
Stimulation of bowel movement	Not indicated after liver surgery.
Early mobilisation	Encourage early mobilisation from the morning after operation until discharge.
Analgesia	Routine TEA cannot be recommended for open liver surgery. Wound infusion catheter or intrathecal opiates can be a good alternative.
Prevention of postoperative nausea and vomiting	Patients should receive two antiemetics and a multimodal approach.
Fluids management	Balanced crystalloids. Low CVP (<5 cmH2O) during resection phase, aiming for euvolaemia when complete.

Postoperative complications

The incidence of complications after hepatic surgery varies from 20% to 50%. The most common surgical complications are summarised in Table 2.

Table 2.

Complications after hepatic resection surgery. Hb, haemoglobin; INR, international normalised ratio.

Complication	Incidence	Time of onset	Presentation
Infection of surgical wound or incision	30%	Within a week after operation	Swelling, exudation at incision site, wound dehiscence (severe infection)
Bile leaks	4–17%23	Days after operation	Attributable to surgical iatrogenic injury, incomplete bile duct anastomosis or truncation of the distal bile duct in the residual liver
			Persistent bilious drainage in drain bag
			Systemically unwell
Biliary fistulae	4–27%23	Days to weeks after operation	Abdominal pain, rebound tenderness, muscle tension and bile leakage from the drainage tube (increased bilirubin in bile drain bag)
Post-hepatectomy liver failure	8–12%23	Day 5 onwards after surgery	Increased INR and hyperbilirubinaemia on or after postoperative Day 5
The acquired deterioration of the ability of the liver to maintain its synthetic, excretory and detoxifying functions
Post-hepatectomy haemorrhage	Below 3% (in dedicated centres)23	Immediate: during surgery	Residual liver surface bleeding and incomplete intraoperative haemostasis
A decrease in Hb >30 g L−1 after the end of surgery compared with postoperative baseline level; or any postoperative transfusion of red blood cells for a decreasing Hb concentration; or the need for reintervention (laparotomy, embolisation) to stop the bleeding		Delayed: after surgery	Hepatic venous congestion and raised venous pressures exacerbated by patients’ body movement, such as turning over or coughing severely.
Others: intra-abdominal sepsis, liver or renal dysfunction, respiratory failure, systemic sepsis

Post-hepatectomy liver failure represents a major cause of postoperative morbidity, increasing LOS, and requires additional therapeutic interventions. Risk factors for developing PHLF include:²⁴

• •Patient-related factors – diabetes mellitus; obesity; metabolic syndrome; malnutrition; cholangitis; age >65.
• •Surgical factors – intraoperative blood loss >1200 ml; intraoperative transfusion; need for associated resection (e.g. colon); inadequate FLR (<20% in case of normal underlying liver function); extended liver resection (>50% liver volume); longer operative duration (>240 min); occurrence of other postoperative complications.
• •Preoperative liver dysfunction – cirrhosis; steatohepatitis; steatosis; sinusoidal injury; hyperbilirubinaemia; chemotherapy-associated liver injury.

The principles of managing PHLF are similar to the priniciples of managing acute liver failure. Liver support systems have provided some hope, acting as a bridge to transplantation, which remains the definitive management in cases unresponsive to supportive care.

Other significant non-surgical complications that affect mortality include intra-abdominal sepsis, major bleeding, renal dysfunction, respiratory failure and systemic sepsis. The principal predictors for the development of postoperative complications are ASA grade, age, extent of resection, simultaneous extrahepatic resection, perioperative blood transfusion and preoperative cirrhosis. Complication types and incidence are similar after MILR.

Conclusions

Liver resection surgery is highly complex surgery requiring an expert multidisciplinary team in a dedicated centre. Shared decision-making, educating patients and coordination of perioperative care reduces morbidity and mortality.

Declaration of interests

The authors declare that they have no conflicts of interest.

Acknowledgements

Dr Rajiv Lahiri, consultant hepatobiliary surgeon, Royal Surrey NHS Foundation Trust.

Biographies

Jaishel Patel BSc FRCA is a speciality registrar in anaesthesia undertaking a perioperative fellowship at the Royal Marsden Hospital and Royal Surrey NHS Foundation Trust.

Chris Jones FRCA MD (Res) is a consultant anaesthetist and clinical lead at the Royal Surrey Hospital NHS Trust and St Luke's Cancer Centre. His MD thesis was on enhanced recovery for open liver resection surgery, and he is the current Enhanced Recovery After Surgery (ERAS) Society website editor.

Derek Amoako FRCA is a consultant anaesthetist and the clinical lead for hepatobiliary and pancreatic surgery at King's College Hospital, London. His focus is on innovation and the perioperative management of the high-risk patient, developing a prehabilitation app to improve patient outcomes.

Matrix codes: 1A01, 2A03, 3A04

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