Defining benchmarks for postoperative mobilization based on the recommendations of the Enhanced Recovery After Surgery (ERAS) program for liver surgery: a prospective study.

Abstract

Background: Early mobilization is a core component of the Enhanced Recovery After Surgery (ERAS) protocol, aiming to accelerate recovery and reduce postoperative complications. In the context of liver surgery, early mobilization is supposed to be associated with improved outcomes, yet the specific influence of timepoint and duration of mobilization remains unexplored. This study seeks to evaluate benchmarks of early mobilization within a structured ERAS program according to the ERAS guidelines to establish evidence-based recommendations for its timing and duration.

Methods: A prospective observational study was conducted on 1,076 patients undergoing liver surgery within an ERAS protocol that strictly followed the official ERAS Society recommendations. Mobilization data were collected from postoperative day (POD) 0 through POD 3 for specific liver resections, such as hepatectomy, limited liver resections, and comparisons between open (OR) and minimally invasive liver surgery (MILS). Two patient groups were defined based on the presence or absence of a textbook outcome (TO): Patients who achieved a TO were defined as no complications, no prolonged hospital stay, no readmissions, and no mortality (n = 261) vs. Patients who did not (n = 715; control group).

Results: Patients without complications, across all types of liver resections, were mobilized on POD 1, POD 2, and POD 3 for a median of 2 h (IQR 1-4), 4 h (2-6), and 5 h (4-7), respectively. This duration was significantly longer than in patients who experienced any type of postoperative complications (p < 0.001). A MILS right hepatectomy was associated with significantly shorter mobilization times on POD1 to POD3-2 h (1-3), 3 h (2-4), and 4 h (3-6), respectively-compared to a MILS segmentectomy, which showed mobilization times of 2 h (2-4), 4 h (3-6), and 6 h (4-7). In general, mobilization was 2 h longer in patients that underwent MILS in comparison to OR (p < 0.001). Shorter surgeries starting earlier in the day facilitated early mobilization on POD 0 (p < 0.001).

Conclusion: Our findings highlight the importance of postoperative mobilization and define cut-offs for the type of liver resection from easy to complex. However, applying a uniform cutoff for all types of liver resections appears more than questionable, given the procedure-specific differences in postoperative mobilization.