ERAS in liver transplantation: a decade running a comprehensive fast-track liver transplant protocol
Gonzalo Rodríguez Laiz1,7, Paola Melgar Requena1,7, Cándido F Alcázar López1,7, Mariano Franco Campello1,7, Celia Villodre Tudela1,7, José Manuel Ramia Ángel1,7, Pablo Bellot García2,7, María Rodríguez Soler2,7, Cayetano F Miralles Maciá2,7, Iván Herrera Marante2,7, M. Teresa Pomares Mas2,7, Patricio Más Serrano3,7, Miguel Perdiguero Gil4,7, María Díaz Cuevas4,7, Luis Gómez Salinas5,7, Francisco Ángel Jaime Sánchez6, Sonia Pascual Bartolomé2,7.
1Liver Transplantation and HBP Surgery, Hospital General Universitario de Alicante , Alicante, Spain; 2Hepatology and Liver Transplantation, Hospital General Universitario de Alicante, Alicante, Spain; 3Pharmacy and Pharmacokinetics, Hospital General Universitario de Alicante, Alicante, Spain; 4Nephrology and Renal Transplantation, Hospital General Universitario de Alicante , Alicante, Spain; 5Anesthesia and Surgical Critical Care, Hospital General Universitario de Alicante, Alicante, Spain; 6Critical Care Medicine, Hospital General Universitario de Alicante, Alicante, Spain; 7ISABIAL (Alicante Health and Biomedical Research Institute), Hospital General Universitario de Alicante, Alicante, Spain
Introduction: Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay (LOS), improve outcomes and reduce costs. We used this concept to design a comprehensive fast-track pathway (OR-to- discharge) before starting our liver transplant activity and then applied this protocol prospectively to every single patient undergoing liver transplantation at our institution, monitoring the results periodically. We report our results after a decade of activity.
Method: Prospective cohort study of all the liver transplants performed since we started our program in 2012. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and tempo- rary portocaval shunt were strategies common to all cases. Our standard pro- tocol for immunosuppression included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophe- nolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started very early. LOS data refers to patients who were discharged (either from ICU or from the hospital) after transplantation.
Results: A total of 359 liver transplants have been performed in 341 patients (269M/72F) over 114 months, mean age 57.3±9.5 years, raw MELD score 15.2±7.8 (MELD-Na 17.1±8.1). Predominant etiologies were alcohol (n = 203) and HCV (n = 105), with hepatocellular carcinoma present in 187 (52.1%). Twenty-six transplants were URGENT (7%) and 15 of them were performed for Fulminant Hepatic Failure. Eighteen patients underwent combined liver and kidney transplants. The median operating time was 307 min (range 167–546) with median cold ischemia time of 267 min (130–628). We transfused PRBCs in the OR in 51 cases (14.2%) at an average of 2.4 ± 1.2 units per case. Median ICU LOS was 12.7 h, and median post-transplant hospital LOS was 4 days (2–82) with 52 patients (16.3%) going home by the 2nd posttransplant day, 133 (41.6%) by the 3rd, and 190 (59.4%) by the 4th, which defines the LOS of our fast-track group (2–4 days). Overall thirty-day-readmission rate was 34.7%, and it was significantly lower (27.9% vs. 44.6% P = 0.002) in the fast-track group. Patient survival was 88% at 1 year and 79% at 5 years for the entire series.
Conclusion: Fast-Tracking of Liver Transplant patients is feasible and remains the standard of care for our entire liver transplant population.
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