Guidelines for Perioperative Care for Liver Transplantation: Enhanced Recovery After Surgery (ERAS) Recommendations : Transplantation

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Original Clinical Science—Liver

Guidelines for Perioperative Care for Liver Transplantation: Enhanced Recovery After Surgery (ERAS) Recommendations

Brustia, Raffaele MD1,2; Monsel, Antoine MD, PhD3,4,5; Skurzak, Stefano MD6; Schiffer, Eduardo MD7; Carrier, François Martin MD, PhD8,9,10; Patrono, Damiano MD, PhD11; Kaba, Abdourahamane MD, PhD12; Detry, Olivier MD, PhD13; Malbouisson, Luiz MD14; Andraus, Wellington MD, PhD15; Vandenbroucke-Menu, Franck MD16; Biancofiore, Gianni MD, PhD17; Kaido, Toshimi MD, PhD18; Compagnon, Philippe MD, PhD19; Uemoto, Shinji MD18; Rodriguez Laiz, Gonzalo MD, PhD20; De Boer, Marieke MD, PhD21; Orloff, Susan MD, PhD22; Melgar, Paola MD, PhD20; Buis, Carlijn MD, PhD21; Zeillemaker-Hoekstra, Miriam MD, PhD23; Usher, Helen MD24; Reyntjens, Koen MD25; Baird, Emily MD, PhD26; Demartines, Nicolas MD27; Wigmore, Stephen MD28; Scatton, Olivier MD, PhD29

Author Information
Transplantation 106(3):p 552-561, March 2022. | DOI: 10.1097/TP.0000000000003808



Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based, program of care developed to minimize the response to surgical stress.1,2

The concept is based on a multidisciplinary team working around the patient, to ensure the synergic application of 20 program elements throughout each phase of the patient’s journey.2 The implementation of ERAS recommendations in major surgery domains including colorectal,3 pancreatic,4 and liver5 surgery is associated with an improved recovery with a reduction in postoperative complications and hospital length of stay but without an increase in readmission rates.6-8

Liver transplantation (LT) is a life-saving treatment for end-stage liver disease,9 with 1 and 5 y survival of 83%–92% and 71%–87%, respectively.10-13 Despite these positive survival results, complications are common and frailty, preoperative comorbidities, surgical challenges, and postoperative immunosuppression are responsible for 40%–92% all-confounded morbidity.10,14-18

Liver surgery and LT share many points in common and the same principles of enhanced recovery may apply for LT. Nevertheless, little evidence exists on the application of an ERAS program in LT, apart from 2 feasibility studies reporting on the effectiveness of such a program on the length of stay after LT.19,20

This study aims to develop the specific ERAS Society recommendations for LT based on the best available evidence and on expert consensus.


An international panel of liver transplant surgeons and anesthesiologists from 12 international centers, including the steering committee (Liège, Belgium; Sao Paulo, Brazil; Montreal, Canada; Torino, Italy; Pisa, Italy; Kyoto, Japan; Groningen, the Netherlands; Paris, France; Alicante, Spain; Genève, Switzerland; Portland, USA; and Edinburgh, UK) were invited to participate.

These guidelines were realized according to the recommendations from the ERAS Society for standards for the development of Enhanced Recovery After Surgery21 and the Appraisal of Guidelines, Research and Evaluation recommendations,22 with LT surgeons, anesthesiologists, or LT hepatologists as target users.

Items Analyzed

The ERAS Guidelines for Liver Surgery5 were used as a working basis to develop the present guidelines, including the list of examined items. Hence, given some particular aspects of LT, a preliminary draft including the list of items on which the guideline would focus was submitted for approval to all the experts. These agreed to remove the Mechanical/Oral bowel preparation item, considered as irrelevant in LT context, and “prehabilitation,” “temporary portocaval shunt,” “early extubation,” and “postoperative education” items were added. The final list included 22 items. According to the methodology used for the development of the previous ERAS guidelines on Liver Surgery,5 22 different search equations were realized, 1 for each keywords group defining a validated ERAS item (preadmission counseling, prehabilitation, fluid and carbohydrate loading, no prolonged fasting, no/selective bowel preparation, antibiotic prophylaxis, thromboprophylaxis, no premedication, short-acting anesthetic agents, temporary portocaval shunt, mid-thoracic epidural anesthesia, no drains, avoidance of salt and water overload, maintenance of normothermia, no nasogastric tubes, prevention of nausea and vomiting, early extubation, early removal of catheter, early oral nutrition, early mobilization, nonopioid oral analgesia, stimulation of gut motility, postoperative education, and audit of compliance and outcomes).

Literature Search and Data Extraction

The coordinator center (Pitié Salpêtrière, Paris, France) realized a digital search Medline through PubMed for published studies and for ongoing trials, focusing on each validated ERAS item in the area of LT. Each single validated ERAS item was defined by a group of specific keywords extracted from official ERAS guidelines and 1 pilot study on ERAS and LT.2,3,5,19,23,24


Human adult patients (18 y or older) undergoing LT, with a graft (whole or split) coming from a deceased (after a brain or circulatory death) or living donor, no matter the indication for LT. Articles focusing on re-transplantation or combined LT (with kidney, heart, lung, pancreas, or intestine) were not considered because of different patterns of morbidity and mortality. Studies focusing on pediatric LT and experimental studies including animals were not considered for inclusion.

Intervention(s), Exposure(s)

No restriction on the type of intervention tested was applied, provided that the target population is composed of patients undergoing LT. According to the ERAS protocol, interventions could be during the preoperative, intraoperative, or postoperative period immediately after LT.



Main Outcome(s)

Outcomes assessed: all primary outcomes reported in the result section were extracted with the related definition, and severity score when provided. Measures of effect were classed (eg clinical outcome, surgical outcome, mortality, morbidity, recovery outcome, and patients reported outcomes)25 as well as the direction of effect (in favor vs against).


No restriction on study location or settings was applied.


We will consider articles reported in English, French, German, Italian, or Portuguese. Studies in other languages will be included only if the translation can be adequately obtained through Google translate.

Types of Study Included

Were considered for inclusion prospective or retrospective studies (cohorts or registry), case–control, or randomized clinical trials (RCTs). If relevant, reviews and meta-analyses were evaluated for inclusion. Case reports were excluded, as well as any study including <10 patients. Abstracts, letters to the editor, or conference posters were not considered for inclusion because of the lack of complete methods and results description.

Manual cross-references among the included studies were searched, for relevant related citations. The searches were done from April 15, 2019 to April 28, 2019. The results of the literature research were screened by 5 investigators (2 surgeons: R.B. and D.P.; 3 anesthesiologists: A.M., S.S., and E.S.) on the basis of title and abstract through an online support.26 Doubtful inclusions were resolved through discussion. A standardized data collection form, specifically designed for the purpose of this study, was used by 3 investigators for data extraction from published articles or for ongoing trials at After selection and inclusion for qualitative analysis, each trial was scored for quality (Risk of Bias tool—Cochrane collaboration’s tool,27 JADAD score,28 and GRADE).29

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement30: the protocol was registered on the International Prospective Register of Systematic Reviews31 current May 2019 (PROSPERO CRD42019132798).

Recommendation Drafting

Based on the results of the literature search, a working group composed of 3 investigators (R.B., A.M., and S.S.) prepared, for each item

  • (1) The supporting text: concise, focused on relevant publications to support the evidence of the recommendations. If necessary, a few additional publications could be cited to support and explain the supporting text but without providing an extensive review of the literature.
  • (2) The recommendation: was defined as a statement that contained a course of action such as a preventive or treatment activity. Recommendations should contain the verbs can/may (weak), should or shall (strong) depending on the recommendation grade. Recommendations were based not only on the quality of evidence but also on the balance between desirable and undesirable effects and on the values and the preferences. The latter implies that, in some cases, strong recommendations may be reached from low-quality data and vice versa.29
  • (3) The grade of evidence based on the Oxford level of evidence32 (ranging from 1 to 5) and GRADE quality of evidence29 (“high,” “moderate,” “low,” and “very low”). Shortly, the GRADE assessment approach provides a structured way to consider key factors that may increase or decrease confidence towards a synthesized body of evidence, and particularly on the quality of evidence in the body of literature supporting the evidence itself. The final analysis may be classified as high, moderate, low, and very low depending on the importance of outcomes, risk of bias, heterogeneity, indirectness, imprecision, and publication bias.21
  • (4) The strength of recommendation: there was not necessarily a 1:1 relation between strength of the recommendation (strong/weak) and the quality of the evidence. The strength of recommendation should also take into account criteria such as consistency of study results, the clinical relevance of endpoints (outcomes) and effect sizes, risk-benefit ratio, patient preferences, application to the relevant patient group, application to healthcare setting, legal and economic considerations. Based on these criteria, upgrading or downgrading of grades of recommendation was allowed.33

Consensus Process (Delphi)

The strength of recommendation, quality of evidence, and conclusions were assessed and agreed by a 3 round e-Delphi process. The Delphi technique is a structured research tool for building consensus within a panel of experts around a specific topic through multiple interactions with questionnaires.34-36 We sought to compose a heterogeneous panel to bring a range of disciplinary viewpoints, mirroring the multidisciplinary management of LT across caregivers and the “core philosophy” of multimodal ERAS management. Experts in LT surgery, anesthesiology, and critical care from 12 high-volume LT centers (Liège, Belgium; Sao Paulo, Brazil; Montreal, Canada; Torino, Italy; Pisa, Italy; Kyoto, Japan; Groningen, the Netherlands; Paris, France; Alicante, Spain; Genève, Switzerland; Portland, USA; and Edinburgh, UK) were contacted by e-mail in November 2019 and invited to participate. There is no consensus on the sample size of participants required for a Delphi panel, but a minimum of 10 is considered acceptable.37 Here, we invited 27 experts in this phase.

We used the modified electronic Delphi design, where the “modified” term refers to the use of systematic literature review and expert discussion to drive the first provisional checklist for the initial questionnaire round rather than an open interview on a broad list of items.38,39 Online Delphi studies are free of charge compared with paper-based Delphi or face-to-face meetings and are particularly suitable when experts are scattered across countries.38 We consequently predefined a 3-phase sequence of rounds with iterative feedback.40 We solicited each expert up to 3 times after each round. The consensus was considered as reached if >80% the of experts rated the item within the highest region of the scale (7, 8, or 9 on the 9-point Likert scale).41 Once consensus was reached for a given item, that item was removed and no longer proposed in the following round. Experts were given 2 wk to respond to each round, followed by 2 reminders to complete the questionnaire that was sent out after 7 and 14 d. A 2-wk interval between rounds was used to summarize the data and develop the next questionnaire.

We did not plan an external revision of final recommendations, but an updating procedure will be proposed every 5 y.


Among the 2685 references identified by the PubMed search, 43 were included. From the search on, we identified 62 references and included 6 ongoing trials. The selection process is detailed in Figure 1, and the complete list of trials can be found in Supplemental Material Study List (SDC,

Flowchart of included studies.

Characteristics of the Included Trials

Among the included studies, 40 (93%) were from single centers, including a median of 105 (38.5–171.5) patients. The design was prospective in 25 (55.8%) of included studies, with 12 (27.9%) randomized. The experimental intervention was nonpharmacologic, pharmacologic, and combined in 23 (53.5%), 19 (44.2%), and 1 (2.3%) of studies.

The indication of LT was detailed in 32 studies (74.4%), with the use of deceased donor graft, living donor liver transplantation or both reported in 15 (34.9%), 9 (20.9%), and 3 (7.0%) of cases, respectively. The reported level of evidence according to the GRADE29 was rated as high in 3 (7%), moderate in 16 (37.2%), low in 16 (37.2%), and very low in 7 (16.3%) of the 43 published references. More details are presented in Table 1.

TABLE 1. - Characteristics of the selected studies
Overall (n = 43)
Publication year
 2000 1 (2.3%)
 2002 1 (2.3%)
 2007 1 (2.3%)
 2009 1 (2.3%)
 2010 3 (7.0%)
 2011 2 (4.7%)
 2013 2 (4.7%)
 2014 5 (11.6%)
 2015 4 (9.3%)
 2016 7 (16.3%)
 2017 8 (18.6%)
 2018 4 (9.3%)
 2019 4 (9.3%)
Location corresponding author
 Africa 1 (2.3%)
 Asia 8 (18.6%)
 Australia 2 (4.7%)
 Europe 16 (37.2%)
 North America 13 (30.2%)
 South America 3 (7.0%)
Study design
 Cohort 17 (39.5%)
 RCT 12 (27.9%)
 Case-control 7 (16.3%)
 Before-after 6 (14.0%)
 Outcome research 1 (2.3%)
If observational
 Prospective 24 (55.8%)
 Retrospective 19 (44.2%)
 Unblinded 8 (18.6%)
 Double-blind 4 (9.3%)
 Single blind 1 (2.3%)
 Single center 40 (93.0%)
 Multicenter, National 2 (4.7%)
 Multicenter, International 1 (2.3%)
Total number of patients enrolled
 Mean (SD) 227 (496)
 Median (25th and 75th) 105 [40, 171]
Level of evidence, Oxford
 1 12 (27.9%)
 2 15 (34.9%)
 3 7 (16.3%)
 4 9 (20.9%)
Indication of LT (reported)
 Yes 32 (74.4%)
 No 11 (25.6%)
Type of graft
 Deceased donor 15 (34.9%)
 LDLT 9 (20.9%)
 Both 3 (7.0%)
 Not detailed 16 (37.2%)
Timing of intervention
 Preoperative (including prehabilitation) 3 (7.0%)
 Intraoperative or perioperative 24 (55.8%)
 Early postoperative (up to discharge) 11 (25.6%)
 Late postoperative or follow-up 5 (11.6%)
Class of intervention
 Medical treatment (including antibiotherapy) 13 (30.2%)
 Anesthesiology 11 (25.6%)
 Nutritional support 6 (14.0%)
 Physical therapy 5 (11.6%)
 Other 4 (9.3%)
 Surgical technique 3 (7.0%)
 Psychology education 1 (2.3%)
Type of intervention
 Nonpharmacologic 23 (53.5%)
 Pharmacologic 19 (44.2%)
 Combined 1 (2.3%)
Impact on morbidity
 Decreased 11 (25.6%)
 No difference 13 (30.2%)
 Unclear 2 (4.7%)
 Increased 1 (2.3%)
Impact on mortality
 No difference 16 (37.2%)
 Decreased 1 (2.3%)
 Unclear 1 (2.3%)
Impact on liver graft dysfunction
 Decreased 5 (11.6%)
 Increased 1 (2.3%)
 No difference 17 (39.5%)
Impact on length of stay
 Decreased 5 (11.6%)
 Increased 1 (2.3%)
 No difference 17 (39.5%)
JADAD score
 −2 1 (2.0%)
 −1 2 (4.0%)
 0 1 (2.0%)
 1 3 (6.0%)
 2 2 (4.0%)
 3 1 (2.0%)
 5 2 (4.0%)
 6 1 (2.0%)
GRADE level of evidence
 High 3 (6.0%)
 Moderate 19 (38.0%)
 Low 18 (36.0%)
 Very low 10 (20.0%)
Selection bias
 No 6 (14.0%)
 Unclear 1 (2.3%)
 Yes 5 (11.6%)
Allocation concealment bias
 No 6 (14.0%)
 Unclear 4 (9.3%)
 Yes 2 (4.7%)
Performance bias
 No 5 (11.6%)
 Yes 7 (16.3%)
Detection bias
 No 4 (9.3%)
 Yes 8 (18.6%)
Attrition bias
 No 6 (14.0%)
 Unclear 3 (7.0%)
 Yes 3 (7.0%)
LT, liver transplantation; LDLT, living donor liver transplantation; RCT, randomized controlled trial.

e-Delphi Process Results

Among the 27 experts invited, 21 (81%) replied from 12 international LT centers reporting a median volume of 70 (40–112.5) LT per year: n = 7 centers reported low-intermediate volume (<75 LT/y42-44), and 5 high-volume (>75–100 LT/y42-44).

The round-1 questionnaire was sent in November 2019, and data collection was completed within 3 mo, in February 2020. Figure 2 gives further information on the e-Delphi panel, with an average 15.7 ± 7.86 y of experience. After round 1, a consensus was reached for 16 of 22 criteria, with 2 of them requiring minor rewording. Changes were made to the wording used to describe the criteria, prompted by the panel’s suggestions, and after round 2, consensus was reached for all the remaining criteria. Figure 3 shows the trend of consensus rating for each criterion across the last 2 rounds.

Characteristics of the expert panelists (experience, specialty, and LT volume). LT, liver transplantation.
Trend of consensus rating for each criterion across the e-Delphi rounds. The asterisks on items 4 (antibiotic prophylaxis) and 13 (fluid and blood management) mean that an agreement was reached within the first round, but major rephrasing was proposed by the panel. The consensus rate was maintained above 80% for these 2 items during the second round.

Within Table 2 are summarized the ERAS recommendations for each item and the respective level of evidence, and in the Supplemental Material Supporting Text (SDC, is exposed the rationale for each recommendation.

TABLE 2. - Summary of ERAS recommendations for each item and the respective level of evidence
ERAS item Summary Evidence level Grade of recommendation
1. Preoperative counseling Patients on the waiting list should receive dedicated, multidisciplinary educational counseling. 47,48 Low Strong
2. Prehabilitation Adapted physical therapy: there is no evidence yet of the benefit or harm of physical exercise in cirrhotic patients before liver transplantation. 49,50 Low Weak
Preoperative nutritional screening: patients with cirrhosis should be screened for malnutrition, using a validated tool, and addressed to a multidisciplinary team for nutritional intervention. 51,52 Moderate Strong
Preoperative nutrition: cirrhotic patients malnourished or in the preoperative period should receive 30–35 kcal × kg−1 × d−1 and a protein intake of 1.5 g × kg−1 × d−1, through a standard nutrition regimen minimizing periods of starvation, with no need of protein restriction in case of HE. 51 High Strong
Probiotics: some evidence supports the use of probiotics, before, or on the day of liver transplantation. The duration of the treatment and the number of strains included are variable across the studies. 53,54 High Weak
Preoperative immunonutrition: the available evidence is nonconclusive, and no recommendation can be given for systematic IN before LT. 55 High Weak
3. Perioperative fasting and carbohydrate loading Preoperative fasting: preoperative fasting does not need to exceed 6 h for solids and 2 h for liquids. Caution should be considered in case of risk factors for delayed gastric emptying (tense ascites, diabetes, or autonomic dysfunction). 5,51 Low Strong
Carbohydrate loading: carbohydrate loading may be recommended at patient admission for liver transplantation, at least 2 h before induction of anesthesia. 5,56 Caution should be considered in case of risk factors for delayed gastric emptying (tense ascites, diabetes, or autonomic dysfunction). Low Weak
4. Antimicrobial prophylaxis It is recommended to administer antibiotic prophylaxis only during the intraoperative period. Extending the duration of prophylaxis does not provide any advantages. Systematic selective digestive decontamination is not recommended. 57,58 Moderate Strong
5. Antithrombotic prophylaxis Antithrombotic prophylaxis: there is no evidence in favor or against thrombotic prophylaxis, but compressive stockings and intermittent pneumatic compression devices during LT may be recommended. Very low Weak
Anticoagulation prophylaxis: there is insufficient evidence to provide any formal recommendation on antiaggregation or anticoagulation. When available, the viscoelastic coagulation monitoring may be used to guide the therapeutic decision. Very low Weak
6. Anesthetic premedication Long-acting anxiolytic drugs should be avoided. Dose-adjusted, short-acting anxiolytics may be considered in selected patients. Very low Weak
7. Incision The choice of incision is at the surgeon’s discretion, depending on the graft and patient’s morphology. Mercedes-type incision may probably be avoided due to higher risk of incisional hernia. Low Weak
8. Temporary portocaval shunt The available pieces of evidence suggest that the use of a temporary portocaval surgical shunt may be beneficial in reducing the red blood cell transfusion requirement, length of stay, PNF, and mortality rates. 59,60 Its use is however submitted to the surgeon and anesthesiologist’s decision during surgery. Low Weak
9. Short-acting anesthetic protocol Short-acting anesthetics can be considered in LT, and within anesthetic gases, little evidence suggest that sevoflurane may be preferred to desflurane. 61 Cerebral or nociception monitoring anesthetic titration may be critically used. Neuromuscular monitoring should guide the appropriate level of muscle relaxation and reversal. Low Strong
10. Perioperative analgesia We recommend using multimodal and balanced analgesia to manage perioperative analgesia after LT. There is not enough published evidence to state in favor or against opioid-sparing management: PCA-based morphine may be considered, with caution among patients at high risk for delirium. TAP block may be considered, while TEA cannot be recommended after LT. 62,63 Low Strong
11. Early extubation Each patient undergoing LT should be screened for eligibility for early extubation (<3–8 h). 64 The eligibility should rely on published scores and on local policies and organization for postoperative monitoring. 65,66 Low Strong
12. Abdominal drainage There is insufficient evidence to recommend no routine drain policy in liver transplantation. 67 Whenever a drain is used, it may be advisable to remove it as soon as possible. It can be considered to systematically drain the peritoneal cavity of patients affected by refractory ascites. Low Weak
13. Fluid management A restrictive fluid management strategy may carefully be considered during LT over a more liberal one. 68 Indirect evidence from other major surgery populations suggests that a goal-directed fluid therapy may provide better outcomes than the standard of care. TEE may be considered to target fluid therapy. Low Weak
Intraoperative blood product management: when available, viscoelastic tests as thromboelastography or rotational thromboelastometry might be used to drive the management of blood products and factor concentrates during LT. 69 Low Weak
14. Perioperative normothermia Perioperative normothermia should be maintained during liver transplantation. 70,71 Low Strong
15. Prophylactic nasogastric probe Indirect evidence suggests that a routine postoperative nasogastric probe after liver transplantation is not indicated. Nasogastric tubes placed during surgery should be removed before reversal of anesthesia. Low Strong
16. Postoperative nausea and vomiting Indirect evidence suggests the use of a multimodal approach to PONV, with 2 antiemetic drugs as prophylaxis (eg 5-HT3 antagonist and steroids). Low Strong
17. Early oral nutrition Normal food oral intake and/or enteral nutrition (nasogastric tube or jejunostomy) should be started 12–24 h after liver transplantation, according to the patient’s tolerance. Parenteral nutrition should be considered as the very last option when the use of oral route (enteral feeding tubes or jejunostomy) is not possible. 51 Very low Strong
Nutritional supplements: there is no clear evidence of the benefit of nutritional supplements after liver transplantation. 72,73 Low Weak
18. Early mobilization Early mobilization after LT should be encouraged with early-goal-directed interventions, from the morning after LT until hospital discharge. 74–76 Physical rehabilitation may be continued after discharge. Moderate Strong
19. Glycemic control We recommend a protocolized approach to blood glucose management in LT patients targeting an upper blood glucose level of ≤ 180 mg/dL from the intraoperative period to the early postoperative period (first 24-48 h postoperatively in the absence of complications and/or organ failure). 77-80 Moderate Strong
20. Postoperative ileus There are no acknowledged strategies to prevent postoperative ileus after LT. Low Weak
21. Postoperative education Systematic educational programs after liver transplantation may increase patient awareness and knowledge on immunosuppressive therapy and on physical changes after LT. Such multidisciplinary programs could include a clinical pharmacist and should be continued over a long period after liver transplantation. 80-82 Low Strong
22. Audit Systematic audit improves compliance and clinical outcome in healthcare practice. 2,4,5 Moderate Strong
ERAS, enhanced recovery after surgery; HE, hepatic encephalopathy; IN, immunonutrition; LT, liver transplantation; PCA, patient controlled analgesia; PNF, primary non function; PONV, postoperative nausea and vomiting; TAP, transversus abdominis plane block; TEA, thoracic epidural analgesia; TEE, transesophageal echocardiography.


This systematic review highlights how currently available evidence on enhanced recovery pathways in LT is scarce and lacks standardization. The highest level of evidence (level 1 or 2) was available for 13 of 22 items. Although the value of ERAS pathways has now been demonstrated in the liver, colorectal and pancreas surgery showing benefit in morbidity, cost, and medico-economic outcomes, there is a clear need to perform high-quality studies to confirm the benefit of ERAS pathways in LT. In conclusion, the proposed ERAS pathway for LT is based on the best available evidence, which still needs to be further explored.

To allow benchmarking and comparison across trials using the new proposed LT ERAS recommendations, there is a need for consensual and standardized outcomes in LT, which are currently lacking.25 In this line, standardized and consensual checklist criteria to assess readiness for hospital discharge (or functional recovery) after LT was recently proposed.45 Moreover, as highlighted by Muller et al.46 in a multicenter analysis to define benchmarks in LT, 82% of patients developed at least 1 complication during 1-y follow-up. When the latter is taken into account, probably the weight of morbidity as an outcome in ERAS guidelines validation should be reconsidered.

Lastly, as with all existing ERAS pathways, the assessment of adherence to the protocol (compliance) is of utmost importance, and the compliance with the new proposed LT ERAS protocol should be documented, as part of the further trial to allow benchmarking.


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