Fast-Track Liver Transplantation: Six-year Prospective Cohort Study with an Enhanced Recovery After Surgery (ERAS) Protocol

Gonzalo P Rodríguez-Laiz, Paola Melgar-Requena, Cándido F Alcázar-López, Mariano Franco-Campello, Celia Villodre-Tudela, Sonia Pascual-Bartolomé, Pablo Bellot-García, María Rodríguez-Soler, Cayetano F Miralles-Maciá, Patricio Más-Serrano, José A Navarro-Martínez, Francisco J Martínez-Adsuar, Luis Gómez-Salinas, Francisco A Jaime-Sánchez, Miguel Perdiguero-Gil, María Díaz-Cuevas, José M Palazón-Azorín, José Such-Ronda, Félix Lluís-Casajuana, José M Ramia-Ángel, Gonzalo P Rodríguez-Laiz, Paola Melgar-Requena, Cándido F Alcázar-López, Mariano Franco-Campello, Celia Villodre-Tudela, Sonia Pascual-Bartolomé, Pablo Bellot-García, María Rodríguez-Soler, Cayetano F Miralles-Maciá, Patricio Más-Serrano, José A Navarro-Martínez, Francisco J Martínez-Adsuar, Luis Gómez-Salinas, Francisco A Jaime-Sánchez, Miguel Perdiguero-Gil, María Díaz-Cuevas, José M Palazón-Azorín, José Such-Ronda, Félix Lluís-Casajuana, José M Ramia-Ángel

Abstract

Introduction: Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay, 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 patient undergoing liver transplantation at our institution, monitoring the results periodically. We now report our first six years results.

Patients and methods: Prospective cohort study of all the liver transplants performed at our institution for the first six years. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and temporary portocaval shunt were strategies common to all cases. Standard immunosuppression administered included steroids, tacrolimus (delayed in the setting of renal impairment, with basiliximab induction added) and mycophenolate mofetil. Tacrolimus dosing was adjusted using a Bayesian estimation methodology. Oral intake and ambulation were started early.

Results: A total of 240 transplants were performed in 236 patients (191♂/45♀) over 74 months, mean age 56.3±9.6 years, raw MELD score 15.5±7.7. Predominant etiologies were alcohol (n = 136) and HCV (n = 82), with hepatocellular carcinoma present in 129 (54.7%). Nine patients received combined liver and kidney transplants. The mean operating time was 315±64 min with cold ischemia times of 279±88 min. Thirty-one patients (13.1%) were transfused in the OR (2.4±1.2 units of PRBC). Extubation was immediate (< 30 min) in all but four patients. Median ICU length of stay was 12.7 hours, and median post-transplant hospital stay was 4 days (2-76) with 30 patients (13.8%) going home by day 2, 87 (39.9%) by day 3, and 133 (61%) by day 4, defining our fast-track group. Thirty-day-readmission rate (34.9%) was significantly lower (28.6% vs. 44.7% p=0.015) in the fast-track group. Patient survival was 86.8% at 1 year and 78.6% at five years.

Conclusion: Fast-Tracking of Liver Transplant patients is feasible and can be applied as the standard of care.

Conflict of interest statement

There are no conflicts of interests or disclosures to report.

Figures

Fig. 1
Fig. 1
Patient survival (entire series on the left and first vs second 3-year period on the right). 139x69mm (300 x 300 DPI)
Fig. 2
Fig. 2
Post-Transplant LOS in days according to Na-MELD (all discharged patients). 183x117mm (300 x 300 DPI)
Fig. 3
Fig. 3
Percentage of patients with plasma levels of tacrolimus within therapeutic range after liver transplantation

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