Fast-track Liver Transplantation: Results of our Full-fledged ERAS Protocol after 100 Months

Abstract

Purpose: 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 now report our results after 100 months of activity. Patients and Methods: Prospective cohort study of all the liver transplants performed since we started our program 100 months ago. Balanced general anesthesia, fluid restriction, thromboelastometry, inferior vena cava preservation and temporary portocaval shunt were strategies common to all cases. Our standard protocol for immunosuppression 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 very early. Results: A total of 316 liver transplants were performed in 302 patients (241M/61F) over 100 months, mean age 57.1±9.4 years, raw MELD score 15.2±7.8 (MELD-Na 17.2±8). Predominant etiologies were alcohol (n = 178) and HCV (n = 99), with hepatocellular carcinoma present in 166 (55%). Twenty-two of the 316 transplants were URGENT (7%) and thirteen of them were performed for Fulminant Hepatic Failure. Fourteen patients underwent combined liver and kidney transplants. The median operating time was 309min (range 167-546) with median cold ischemia time of 267min (130-628). We transfused PRBCs in the OR in 45 cases (14.2%) at an average of 2.4±1.2 units per case. Median ICU LOS was 12.7 hours, and median post-transplant hospital LOS was 4 days (2-82) with 43 patients (15.1%) going home by the 2nd postransplant day, 115 (40.5%) by the 3rd, and 167 (58.8%) by the 4th day, which defines the LOS of our fast-track group (2-4 days). Overall thirty-day-readmission rate was 35.6%, and it was significantly lower (28.7% vs. 45.3% p=0.0041) in the fast-track group. Patient survival was 87.5% at 1 year and 78.9% at five years for the entire series. Conclusion: Fast-Tracking of Liver Transplant patients is feasible and can be applied as the standard of care.