Abstract
IntroductionEnhanced 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 methodsProspective 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.ResultsA 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.ConclusionFast-Tracking of Liver Transplant patients is feasible and can be applied as the standard of care
Highlights
Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay, improve outcomes and reduce costs
A total of 240 transplants were performed in 236 patients (191#/45$) over 74 months, mean age 56.3±9.6 years, raw Model for EndStage Liver Disease (MELD) score 15.5±7.7
We rationalized and designed our protocol based on the available knowledge
Summary
Enhanced recovery after surgery (ERAS) has been shown to facilitate discharge, decrease length of stay, improve outcomes and reduce costs. There are few studies that have evaluated the effects of protocols that incorporate previously established and validated interventions into a single compendium applied to liver transplant recipients These commonly referred to as ‘‘fast track’’ protocols are not routinely used at new centers since a learning curve is thought to be a prerequisite for the successful execution of the involved steps. The term ‘‘fast track’’ entails a comprehensive approach to the entire admission event, from the moment the patient sets foot in the hospital until the time of discharge It integrates several perioperative steps (maneuvers and techniques) most of which are already well-established and widely utilized, aimed at minimizing hospital stay without compromising patient’s safety [1, 2]. For the purpose of our protocol, we considered optimization of anesthesia, refinement in surgical technique, minimization of blood loss, precise intraoperative coagulation management, early extubation, aggressive postoperative rehabilitation with early oral nutrition and ambulation, a personalized immunosuppression, and adequate pain control
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
