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Enhanced recovery is a package of care that helps people recover faster from liver surgery: preparation and stopping smoking and heavy drinking beforehand, a short fast with a sugary drink, keyhole surgery where possible, good pain relief that keeps you mobile, no routine tubes or drains, eating and getting out of bed on the day of surgery, and blood clot prevention.
The ERAS Society liver surgery recommendations (2022; 25 items, all with more than 80% agreement after three Delphi rounds) grade each element by GRADE. Strong recommendations with high-quality evidence: smoking cessation at least 4 weeks and alcohol cessation 4 to 8 weeks before surgery for heavy drinkers; nutritional assessment for all, with 7 to 14 days of enteral supplementation for the malnourished; continuous wound infiltration or TAP block as part of analgesia; no routine nasogastric tube; no routine drain after hepatectomy without biliary reconstruction; early oral intake with a normal diet; insulin to keep glucose below 8.3 mmol/l; PONV prophylaxis with at least two drugs; and low central venous pressure during transection with balanced crystalloid. Strong with moderate evidence: fasting 2 hours for clear fluids and 6 hours for solids, postoperative LMWH or heparin plus intermittent pneumatic compression, chlorhexidine-alcohol skin preparation, laparoscopic resection in trained teams, normothermia, early mobilisation from the day of surgery, and audit of compliance. Weaker: prehabilitation for high-risk patients 4 to 6 weeks before (weak, moderate evidence; content not established), carbohydrate loading (weak, low), preoperative methylprednisolone 500 mg (weak, moderate), antibiotic within 60 minutes before incision (weak, moderate), and immunonutrition (not recommended). NICE NG180 (2020) offers an enhanced recovery programme to everyone having elective major or complex surgery and allows clear fluids until 2 hours before.
Why: People who know what to expect take part in their own recovery, for example by eating and walking early.
“Patients should receive preoperative information and counseling regarding the upcoming liver surgery. Brochures and multimedia supports might help to improve the verbal counseling.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level: Low. Grade of recommendation: Weak.
Why: Smoking and heavy drinking both raise the risk of complications, and stopping a few weeks ahead lowers it.
“Preoperative smoking cessation should be counseled at least 4 weeks prior to hepatectomy. Alcohol cessation is recommended for heavy drinkers (>24 g/day for women or >36 g/day for men) 4–8 weeks before surgery.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level: Smoking: high, alcohol: high. Grade of recommendation: Smoking: strong, alcohol: strong.
Why: Poorly nourished people have more complications, and a short period of feeding beforehand reduces them.
“A nutritional assessment is necessary prior to all hepatic surgery. Malnourished patients (i.e., weight loss >10% or >5% over 3 months and reduced body mass index or a low fat-free mass index) should be optimized with enteral supplementation at least 7–14 days prior to surgery.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level : High. Grade of recommendation : Strong.
Why: Getting fitter before surgery may help frail, older or malnourished people recover, though the best programme is not yet known.
“Prehabilitation should be performed in high-risk patients (elderly, malnourished or overweight patients, smokers, or patients with psychological disorder) prior to liver surgery.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level: Moderate. Grade of recommendation: Weak.
Why: Long fasting leaves people thirsty, dehydrated and more resistant to insulin; a sugary drink shortly before is safe.
“Preoperative fasting of 2 h for liquids and 6 h for solids before anesthesia is safe and can be recommended.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level: Preoperative fasting: moderate, carbohydrate loading: low. Grade of recommendation: Preoperative fasting: strong, carbohydrate loading: weak.
Why: Long-acting sedatives slow waking and getting up after the operation.
“Long-acting anxiolytic drugs should be avoided, particularly in the elderly.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level: Moderate. Grade of recommendation: Strong.
Why: One well-timed dose and the right skin antiseptic reduce wound infection; longer courses add no benefit.
“Antibiotic prophylaxis (such as cefazolin) within 60 min before surgical incision is recommended, with no benefit extending it into the postoperative period.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level: Antibiotics: moderate, skin preparation: moderate. Grade of recommendation: Antibiotics: weak, skin preparation: strong.
Why: Keyhole liver surgery shortens the hospital stay and reduces complications.
“In trained teams and when clinically appropriate, laparoscopic liver resection is recommended since it reduces postoperative length of stay and complication rates.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level : Moderate. Grade of recommendation : Strong.
Why: Low venous pressure reduces bleeding from the cut liver; warmth reduces infection and bleeding.
“Perioperative normothermia using multimodal temperature management (including circulating water garments or forced warm air) should be maintained during open and minimally invasive liver surgery.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level: Moderate. Grade of recommendation: Strong.
Why: These give pain relief as good as an epidural with fewer problems with low blood pressure and getting up.
“Continuous local anesthetic wound infiltration provides lower complication rates and overall equivalent analgesia to thoracic epidural analgesia.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level: High. Grade of recommendation: Strong.
Why: Tubes and drains add discomfort and delay recovery without preventing complications.
“The routine use of abdominal drain placement is not indicated for hepatectomy without biliary reconstruction.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level: High. Grade of recommendation: Strong.
Why: Nausea after surgery is common and delays eating and walking.
“Patients should receive postoperative nausea and vomiting prophylaxis with at least 2 antiemetic drugs such as dexamethasone and ondansetron.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level: High. Grade of recommendation: Strong.
Why: Liver surgery carries a real clot risk, and prevention is safe for most people.
“Low molecular weight heparin or unfragmented heparin reduces the risk of thromboembolic events and should be routinely started postoperatively unless exceptional circumstances make this unsafe.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level: Use of low molecular weight heparin or unfragmented heparin: moderate, use of intermittent pneumatic compression devices: moderate. Grade of recommendation: Use of low molecular weight heparin or unfragmented heparin: strong, use of intermittent pneumatic compression devices: strong.
Why: Early eating supports healing and recovery; high blood sugar raises the risk of complications.
“Early oral intake with normal diet should be implemented after hepatectomy.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level: High. Grade of recommendation: Strong.
Why: Moving early reduces chest infections, clots and muscle loss.
“Early mobilization (out of bed) after liver surgery should be established from the operative day until hospital discharge.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level: Moderate. Grade of recommendation: Strong.
Why: Units that measure how often each element is delivered improve their results.
“Regular audit and feedback should be implemented and performed in liver surgery to monitor and improve postoperative outcomes and compliance to the ERAS program.”
ERAS Society (World Journal of Surgery) 2022 · Evidence level: Moderate. Grade of recommendation: Strong.
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
The ERAS Society liver surgery recommendations (2022) are the current specialty standard and are graded element by element (listed in the summary); NICE NG180 (2020) supports an enhanced recovery programme for all elective major surgery and the 2-hour clear-fluid fast. The two agree on fasting; ERAS recommends carbohydrate loading (weak, low evidence) where NICE says consider carbohydrate drinks for abdominal major surgery. Thoracic epidural is not preferred: wound infiltration and TAP block give equivalent analgesia with fewer complications (high, strong).
Where it differs: Uses a thoracic epidural as the main analgesia after open hepatectomy.
Evidence: ERAS 2022 says it 'can provide excellent analgesia but has significant disadvantages' (low blood pressure, delayed mobility) and recommends multimodal analgesia (strong, high evidence for open surgery), with wound infiltration giving lower complication rates and equivalent analgesia.
Where it differs: Gives a single 500 mg dose of methylprednisolone before liver resection.
Evidence: Recommended by ERAS 2022 with moderate evidence but a weak grade; no recommendation for people with diabetes.
Where it differs: Gives oral immune-enhancing formulas (arginine, omega-3 fatty acids, nucleotides) around surgery.
Evidence: Not recommended for liver surgery by ERAS 2022 because of a lack of evidence (low evidence, weak).
Enhanced recovery pathways feed people sooner, limit drips and drains and get them walking the day after an operation. Sixteen randomised trials in bowel surgery found 40 per cent fewer complications and stays more than two days shorter, but in 151 American hospitals given a full implementation programme, most failed to improve compliance with its elements.
Anaesthetic guidelines since at least 2011 say adults can drink clear fluids up to two hours before planned surgery and eat up to six hours before. In a study of 50 women having breast cancer surgery published in 2026, the average fast was 15 hours from food and 12 hours from fluids.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Offer an enhanced recovery programme for elective major or complex surgery “Offer an enhanced recovery programme to people having elective major or complex surgery .” | Not graded (NICE NG180 1.2.1) | NICE 2020 |
| Clear fluids until 2 hours before the operation “they may drink clear fluids until 2 hours before their operation” | Not graded (NICE NG180 1.4.1) | NICE 2020 |
| Carbohydrate drinks for abdominal major or complex surgery “Consider carbohydrate drinks before surgery for people having abdominal major or complex surgery .” | Not graded (NICE NG180 1.4.2, 'consider') | NICE 2020 |
| Immunonutrition not recommended in hepatic surgery “Due to the lack of evidence, the use of immunonutrition in hepatic surgery is not recommended yet.” | Evidence level : Low. Grade of recommendation : Weak. | ERAS Society (World Journal of Surgery) 2022 |
| Low central venous pressure during transection, balanced crystalloid maintenance “Low central venous pressure (below 5 cm H 2 O) with close monitoring is recommended during hepatic transection.” | Evidence level: High. Grade of recommendation: Strong. | ERAS Society (World Journal of Surgery) 2022 |
| No routine prophylactic nasogastric tube “Routine use of prophylactic nasogastric intubation is not recommended.” | Evidence level: High. Grade of recommendation: Strong. | ERAS Society (World Journal of Surgery) 2022 |
| Insulin to keep glucose below 8.3 mmol/l “Insulin therapy for maintenance of normoglycemia (<8.3 mmol/l) is recommended.” | Evidence level: High. Grade of recommendation: Strong. | ERAS Society (World Journal of Surgery) 2022 |
| Recommendations reached consensus “All of them obtained consensus (>80% agreement) after 3 Delphi rounds.” | All 25 items above 80% agreement after 3 Delphi rounds | ERAS Society (World Journal of Surgery) 2022 |
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Prehabilitation (the pre-treatment window), Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations.
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Prehabilitation (the pre-treatment window), Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back.
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Prehabilitation (the pre-treatment window), Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back.
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back.
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back, Enhanced recovery (ERAS) and perioperative nutrition.
Shares Hepatectomy (liver resection), Biliary tract cancer (cholangiocarcinoma), Hepatocellular carcinoma.