Delayed return of gastrointestinal function after hepatectomy in an ERAS program: incidence and risk factors

Expert review
Delayed return of gastrointestinal function after hepatectomy in an ERAS program: incidence and risk factorsSara Arfa et al. HPB. 2022 (1)

What is already known:
Oral nutrition can be initiated early after hepatectomy, and ERAS guidelines recommend oral nutrition after liver surgery (2). Moreover, one RCT and one recent meta-analysis showed that routine use of nasogastric tube was not recommended after hepatectomy (3,4). Use of laxatives after liver surgery might decrease the time to first stool but do not have an impact on postoperative complications (5).

What this paper adds:
This cross-sectional study from Besançon, France included 206 patients who underwent hepatectomy (86 major hepatectomies, 42%; 19 biliary resections, 9%; 20 combined vascular resections, 9%) and followed an ERAS pathway. Patients routinely received oral magnesium hydroxide twice a day until return of gastrointestinal function. It was not specified if patients received prokinetics during the postoperative period. A total of 41 patients (20%) had delayed return of gastrointestinal function, defined as need of nasogastric tube insertion. The authors found that older age, vascular reconstruction, anesthetic induction using gas, and epidural analgesia were independent risk factors for delayed return of gastrointestinal function. Major hepatectomy was more frequent in the group with delayed return of gastrointestinal function compared to the group without need of nasogastric tube insertion. Interestingly, left-sided resection – often associated more frequently with delayed gastric emptying than right hepatectomy – was not found as a predictive factor of delayed return of gastrointestinal function (p=0.404), but the number of left-sided resections in each group was not mentioned. The rates of biliary resections were also similar in both groups. This study showed that delayed return of gastrointestinal function was frequent after hepatectomy in ERAS patients and can have negative consequences (6 patients developed pneumonia, and 1 among them had to be intubated). It remains unclear if this delayed return of gastrointestinal function is mainly linked to delayed gastric emptying or to paralytic ileus. Future studies should focus on developing strategies to mitigate this delayed return of gastrointestinal function in patients at risk.

1. Arfa S, Turco C, Lakkis Z, et al (2022) Delayed return of gastrointestinal function after hepatectomy in an ERAS program: incidence and risk factors. HPB. Online ahead of print (PMID35484074)
2. Melloul E, Hübner M, Scott M, et al (2016) Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg 40:2425–2440
3. Ichida H, Imamura H, Yoshimoto J, et al (2016) Randomized Controlled Trial for Evaluation of the Routine Use of Nasogastric Tube Decompression After Elective Liver Surgery. J Gastrointest Surg 20:1324–1330
4. Wen Z, Zhang X, Liu Y, et al (2019) Is routine nasogastric decompression after hepatic surgery necessary? A systematic review and meta-analysis. Int J Nurs Stud 100:103406
5. Hendry PO, van Dam RM, Bukkems SF, et al (2010) Randomized clinical trial of laxatives and oral nutritional supplements within an enhanced recovery after surgery protocol following liver resection. Br J Surg 97:1198–1206