Enhanced recovery after liver transplantation-a prospective analysis focusing on quality assessment

Background: Enhanced Recovery After Surgery (ERAS) is a multimodal approach for almost all types of surgical procedures, including liver transplantation (LTx). We developed an ERAS protocol for LTx based on previous experience and assessed it using benchmarks from the German Institute for Quality Management and Transparency in Healthcare (IQTIG). Methods: An ERAS protocol was developed and implemented in our center since 2018 for LTx, including preoperative, intraoperative, and postoperative procedures. From January 2021 to December 31st 2022, we conducted a prospective analysis including donor and recipient demographics, Model for End-Stage Liver Disease (MELD) score and medical history. Perioperative management, such as operative time, anhepatic phase time, intensive care unit (ICU) stay, morbidity and mortality as well as postoperative hospitalization, readmission and 1-year patient survival, were collected as outcome measures. Results: Sixty-eight consecutive liver transplant recipients were included. Mean age of the donors was 47 (36-55.5) years old, type of donation was in 41 donation after brain death (DBD), 26 donation after controlled circulatory death (DCD) and 1 donation after brain and cardiac death (DBCD). Mean age of the patients was 49.6 years (range, 26-68 years), 81% were male. The mean body mass index (BMI) of the recipients was 24 kg/m(2) (range, 15-37 kg/m(2)), mean MELD score was 15 (range, 6-39), 3 patients had a MELD score higher than 30. Fifty-three patients suffered from hepatitis B virus (HBV) related cirrhosis. Twenty-eight patients had hepatocellular carcinoma (HCC); 5 patients were diagnosed with alcohol related cirrhosis and primary biliary cirrhosis, autoimmune disease and drug induced cirrhosis, undefined cirrhosis, respectively. The mean operation time in our cohort was 6.73 hours, and the average anhepatic phase time was 68 minutes. No patient had intraoperative hypothermia. Tracheal extubation was performed in the ICU department within 6 hours post operation and the average ICU/intermediate care (IMC) unit stay was 4.5 days (range, 2-14 days). None of the patients required re-intubation. Postoperative complications with a CDC classification > II were seen in 16 patients (23.5%). Mean hospital stay was 21.7 days and readmission rate was 13 (19%). Neither acute rejection nor postoperative mortality during the hospital stay was recorded. One patient died from acute myocardial infarction after discharge. Conclusions: We developed an ERAS protocol in LTx, consisting of preoperative, perioperative and postoperative management and assessed the quality using benchmarks from IQTIG. Our study revealed that the proposed ERAS approach in LTx is feasible offering the opportunities of enhanced recovery and quality management.