European Consensus on Peri- and Postoperative Care After Liver Resection: E-AHPBA – ESSO – Innsbruck Consensus | 2026

Introduction:

Liver resection remains a cornerstone treatment for primary and secondary hepatic malignancies, but postoperative morbidity is still substantial because outcomes depend on the interaction between patient fitness, underlying liver function, tumour biology, and surgical complexity. Clinical practice also remains variable, particularly in the prevention and management of bile leak, haemorrhage, thrombosis, infection, and post-hepatectomy liver failure.

This European multidisciplinary consensus used a modified Delphi process and systematic evidence review to standardize care across six key perioperative domains.

Why was this consensus needed?

Existing ERAS guidance does not fully address management of liver-specific postoperative complications.

Many practices remain based on institutional preference rather than uniform evidence.

Liver surgery involves a unique balance between bleeding and thrombosis, especially in the early postoperative period.

Complex complications such as bile leak and PHLF require coordinated, standardized pathways.

Key Takeaways:

Prehabilitation is strongly recommended, particularly in higher-risk patients undergoing major hepatectomy.

Nutritional screening and correction of malnutrition should form part of routine preoperative assessment.

Early postoperative mobilization is strongly supported and should be embedded within enhanced recovery pathways.

Routine abdominal drainage after uncomplicated liver resection should generally be avoided.

Antibiotic prophylaxis should be procedure-specific and limited in duration rather than prolonged routinely.

Extended antibiotics may be appropriate in selected high-risk situations, particularly when biliary contamination or bilio-enteric reconstruction is present.

Pharmacological thromboprophylaxis should be considered because hepatectomy patients remain at meaningful risk of venous thromboembolism despite postoperative coagulation abnormalities.

Timing of anticoagulant prophylaxis should balance bleeding risk against thrombotic risk and be individualized.

Portal vein thrombosis after liver resection requires early recognition and case-specific management according to extent, symptoms, and liver function.

Prevention of bile leak begins with meticulous operative technique and careful identification of high-risk transection surfaces and biliary reconstruction.

Routine drainage does not reliably prevent clinically relevant bile leakage and may itself delay recovery.

Suspected bile leak should be investigated promptly using biochemical testing and appropriate imaging.

Clinically significant bile leaks are best managed with a step-up approach, including drainage, endoscopic therapy, and selective reoperation.

Bilio-enteric anastomoses represent a particularly high-risk subgroup and require closer surveillance.

Post-hepatectomy haemorrhage prevention depends on careful operative technique, haemostasis, and correction of reversible perioperative risk factors.

Significant postoperative bleeding requires rapid assessment of haemodynamic status and early imaging or angiographic intervention where appropriate.

Post-hepatectomy liver failure (PHLF) remains one of the most serious complications after major liver resection.

Patients at risk of PHLF require close monitoring of bilirubin, INR, renal function, lactate, haemodynamics, and evolving organ dysfunction.

Management of established PHLF remains predominantly supportive and multidisciplinary, with early treatment of infection, circulatory failure, renal dysfunction, and other precipitating factors.

The consensus highlights major evidence gaps, particularly for thromboprophylaxis and treatment of PHLF, underscoring the need for prospective multicentre trials.

Clinical Impact:

The central message is that successful liver surgery depends not only on the operation itself but on a standardized perioperative pathway that begins before surgery and continues through early recognition and structured management of complications.

The strongest recommendations favor interventions that are simple and broadly implementable—prehabilitation, nutritional optimization, early mobilization, rational antibiotics, and avoidance of routine drains—while more complex areas such as anticoagulation and PHLF still require individualized decision-making.

Bottom Line:

Modern liver resection should be managed through standardized multidisciplinary pathways. Prehabilitation, early mobilization, appropriate nutrition, selective antibiotic and thromboprophylaxis strategies, avoidance of routine drainage, and structured management of bile leak, bleeding, and PHLF form the backbone of contemporary perioperative care.