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.