Infectious complications are the leading cause of morbidity and mortality after liver transplantation (LT) in our region, especially hospital-borne infections [1,2]. Furthermore, a lack of medical insurance adds a tremendous financial burden when these patients’ stay is prolonged for the management of multiple complications. Enhanced recovery after surgery (ERAS) has enabled fast-track LT at many centers around the world [3-5]. We, therefore, changed our transplant protocols for selected patients and applied a super-fast-track pathway (preoperation to discharge). Our patients were discharged at 5.5±1.6 days after LT on average. All are alive, are receiving regular follow-up, and have not experienced any complications until the time of writing this report. We therefore briefly present our super-fast-track discharge protocol. Nine blood group-compatible liver transplants were done between October 2021 and August 2022. Among them, three were living-donor LT and six were deceased-donor LT. Patients’ preoperative and perioperative demographics are shown in Table 1 and Fig. 1.

Table 1. Background demographic, preoperative, and postoperative characteristics of all recipients

Characteristic	Patient									Average	SD
	1	2	3	4	5	6	7	8	9
Age (yr)	49	42	67	50	44	51	49	39	52	49.2	8
Sex	Male	Male	Male	Male	Female	Male	Male	Male	Female	-	-
Primary etiology	Cryptogenic	NASH	NASH	Alcoholic	Cryptogenic	NASH with HCC	Cryptogenic	Alcoholic	NASH	-	-
Type of transplant	DDLT	LDLT	DDLT	LDLT	DDLT	LDLT	DDLT	DDLT	DDLT	-	-
Pretransplant decompensation	Ascites, jaundice, TIPS failure	UGI bleed, jaundice, ascites	Ascites, jaundice, HRS	Ascites, jaundice, recurrent HE	UGI bleed, jaundice	Jaundice, HCC within the Milan criteria	Ascites, jaundice	Ascites, jaundice, recurrent HE	Ascites, jaundice	-	-
MELD/CTP	17/B	18/B	23/C	20/C	20/C	17/B	21/C	23/C	18/C	-	-
Total blood transfusion (1 unit=250 mL)	3	1	2	2	1	3	1	2	1	1.8	0.8
Bench time (min)	35	30	25	15	31	25	38	32	40	30.1	7.7
CIT+WIT (min)	196	90	60	57	205	93	145	215	190	139	64.7
Total bilirubin (mg/dL)
Pretreatment	1.7	1.9	3.3	4.5	3.1	2.9	2.7	8.8	1.6	3.4	2.2
Postoperative day 0	1.7	1.2	1.6	6.9	3.7	0.8	4.1	6	2.9	3.2	2.2
Postoperative day 3	1.3	4.6	1	3.6	1.7	1.8	3.7	3.1	2.1	2.5	1.2
At discharge	0.9	2	0.8	2.9	1.1	1.1	1.3	1.7	1.2	1.4	0.7
Tacrolimus level at discharge	9.1	6.1	6.2	15.5	5.6	6.3	6.9	11.7	6.6	8.2	3.3
Day of discharge	4	6	4	4	4	6	8	8	6	5.6	1.7

SD, standard deviation; NASH, non-alcoholic steatohepatitis; HCC, hepatocellular carcinoma; DDLT, deceased donor liver transplantation; LDLT, living-donor LT; TIPS, transjugular intrahepatic portosystemic shunt; UGI, upper gastrointestinal; HRS, hepatorenal syndrome; HE, hepatic encephalopathy; MELD, model for end stage liver disease; CTP, Child-Turcotte-Pugh score; CIT, cold ischemic time; WIT, warm ischemic time.

Figure 1. (A) Trends in total bilirubin, (B) serum glutamic pyruvic transaminase (SGPT), and (C) serum glutamic-oxaloacetic transaminase (SGOT) in all nine patients at postoperative day (POD) 0, POD 3, and at the time of discharge.

Preoperative: our main aim was to optimize all patients’ conditions prior to LT. In short, they were given hepatoprotective medication and intravenous (IV) albumin (20%, 100 mL; Baxter) once a week and followed up once a week with blood biochemistry reports, and the medication was adjusted accordingly. Decompensation was managed quickly and the aim was to keep the patients infection-free during the preoperative period. Nutritional build-up was done as much as possible (high protein [60 g/day], no salt, and fluid restricted to <1.5 L per day).

Intraoperative: the anesthesia protocol was similar to that described in a previous study [3]. Surgery was performed according to the standard protocol. The total blood transfusion was minimized (1.8±0.8 units). The bench time was kept short (30.1±7.7 minutes). Induction was done with an IV injection of Solu-Medrol (500 mg; Pfizer). All nine patients were extubated on the table and then transferred to the liver intensive care unit (LICU) with continuous monitoring.

Postoperative: one critical care physician and a 1:1 nursing-to-patient ratio was maintained until the patient was discharged from the LICU. Early ambulation and oral intake were started 12 hours later. Liver Doppler ultrasonography and blood biochemistry were done twice a day until postoperative day (POD) 2. Central and arterial lines and the Foley catheter were removed on POD 2, and thereafter noninvasive monitoring was done until discharge. Immunosuppression (calcineurin inhibitors+mycophenolate mofetil) was started early, as soon as the lactate level was <2 mmol/L. IV Solu-Medrol was tapered and converted to oral prednisolone from POD 4. IV antibiotics were given until POD 3, until the trough level was adjusted to 8–10 ng/mL, and then converted to oral. Education for the patient and family on medication, hygiene, nutrition, and wound care was started on POD 1, and the patient was discharged with a home care nurse. Follow-up was done after 3 days with reports, and the medication was adjusted if needed. Then, patients were followed up once a week until 1 month, twice a week until 3 months, and thereafter at 3-month intervals until 1 year. In conclusion, herein we report our brief protocol for super-fast-track discharge of selected LT patients.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Author Contributions

Conceptualization: all authors. Data curation: SV. Formal analysis: SV, LKD. Supervision: SKN. Writing–original draft: SV, LKD. Writing–review & editing: all authors. All authors read and approved the final manuscript.