Compliance with enhanced recovery after surgery predicts long-term outcome after hepatectomy for cholangiocarcinoma

Table 1 Hepatic resection enhanced recovery program after surgery pathway

ERAS item	Goals
Preoperative counseling	Patients receive dedicated education, full care pathway, details of operation and associated complication, and estimated length of hospital stay with clear verbal and wriinstruction
Preoperative fasting and preoperative carbohydrates load	Preoperative fasting 6 h for solids and 2 h for liquids. Carbohydrate loading evening before the day of surgery and 2 h before induction of anesthesia
Pre-anesthetic anxiolytic	Short-acting anxiolytics prior to the induction of anesthesia
VTE prophylaxis	Low-molecular weight heparin or unfragmented heparin administration 2-12 h before surgery
Antimicrobial prophylaxis and skin preparation	Single dose intravenous antibiotics administration before skin incision and less than 1 h before hepatectomy
Prophylactic nasogastric intubation	No use of prophylactic nasogastric intubation
Preventing intraoperative hypothermia	Maintenance of perioperative normothermia using forced air blankets and controlling temperature of the operating room
Fluid management (CVP monitoring)	The maintenance of low CVP (below 5 cm H2O) with close monitoring during liver transection phase
Prophylactic abdominal drainage	None or minimize the use of prophylactic abdominal drainage
Early mobilization	Begin to walk around the ward at least 3 times a day
Postoperative glycemic control	Insulin therapy to maintain normoglycemia before full oral intake
Preventing PONV	Patients should receive PONV prophylaxis with 2 anti-emetic drugs until POD3
Multimodal analgesia	Multimodal analgesia combined with wound infusion analgesia or intrathecal opiates. Removal of epidural analgesia before POD3
Initial oral analgesic drug at POD1	Initial oral analgesic drug at POD1
Early NG tube removal at POD1	Removal of NG tube at POD1 unless there was > 400 mL/d drainage
Postoperative nutrition and early oral intake	Patients can eat soft diet at POD2
Removal of urinary catheter POD2	Removal of urinary catheter POD2

VTE: Venous thromboembolism; POD: Postoperative day; ERAS: Enhanced recovery program after surgery; PONV: Postoperative nausea and vomiting; NG: Nasogastric; CVP: Central venous pressure.