Diet Guidelines After Liver Resection: Optimizing Recovery and Regeneration

Following liver resection, a carefully managed diet plays a crucial role in promoting liver regeneration, preventing complications, and ensuring optimal patient recovery. Liver resection involves the surgical removal of a portion of the liver, and while the liver possesses remarkable regenerative capabilities, the postoperative period requires specific nutritional strategies to support healing and metabolic balance.

The Importance of Nutrition in Postoperative Recovery

Nutrition is particularly important in enhanced postoperative recovery, as it encourages early postoperative feeding. Malnutrition is a common problem for hospitalized patients, and 30-50% of hospitalized patients have malnutrition issues. Malnutrition affects prognosis and the quality of life of the patients. Since Wilmore and Kehlet first introduced the concepts of fast track protocols and enhanced recovery after surgery (ERAS) in 2001, a growing amount of attention has been paid to clinical research (1). ERAS encompasses multidisciplinary programs in nursing and anesthesia, nutrition and infusion therapy, and minimally invasive surgery. More than 400 related studies have been completed in the past 2 years after the introduction of postoperative care in the ERAS manual.

Metabolic Changes and Nutritional Needs After Liver Resection

Normal liver tissue has amazing regeneration ability. However, huge changes in biochemistry and metabolism after major hepatectomy may bring serious consequences and even threaten lives. If the nutrients are not supplemented properly, a series of serious consequences, such as jaundice, hepatic ascites, and hepatic failure, are likely to occur (3). Most liver resections minimize the incidence of postoperative metabolic problems by improving preoperative nutritional status and providing appropriate postoperative albumin and carbohydrate support. Appropriate management is necessary for postoperative metabolism and promoting liver recovery and regeneration. Additionally, patients undergoing liver resection are more likely to have significantly lower blood glucose levels, while patients undergoing total hepatectomy and liver transplantation have severe hypoglycemia. In any case, it is wise to rule out the danger of hypoglycemia. Standard operation involves monitoring blood glucose and continuing intravenous infusion of 10% glucose solution for at least a few days during the first phase or before supplying sufficient carbohydrates by oral feeding. Often following oral feeding of carbohydrates, blood sugar may be elevated for a few weeks. Considering that the liver is the site where albumin is synthesized, severe hypoalbuminemia will occur to a significant degree unless the route of feeding is replaced by parenteral administration. Albumin supplementation takes about a week, and by the end of the third postoperative week, the albumin level has basically returned to normal.

Several studies (4,5) have pointed out that patients with liver resection should choose a diet rich in branched-chain amino acids in the early postoperative period. Biliary tract surgery, such as bile duct repair, bile duct stone removal, and other operations, have a greater impact on liver function; thus, patients need to be supplemented with sufficient water after surgery to maintain acid-base balance. In the early postoperative period, high-energy nutritional support should be given intravenously, but fat intake should be restricted. With the gradual recovery of diet, parenteral nutrition supplementation can be gradually reduced after 2-3 weeks and finally stopped. The supply of bile salt preparations needs particular attention in patients with biliary obstruction and external biliary fistula.

Nutritional Principles After Liver Surgery

1. Patients need to note the following regarding nutritional principles after liver surgery:

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   • Avoid toxic substances related to food production methods (due to pesticides, agricultural chemicals, and herbicides).
   • Avoid food additives (colors, preservatives, flavorings).
   • Avoid certain cooking methods that develop toxic substances such as frying, roasting, and grilling.

2. Initial stage: 1-2 days after surgery

   • Patients may have delayed bowel movements
   • Side effects of many pain relievers
   • digestive function is reduced due to reduced liver function.
   • Risk of hypoglycemia
   • In this initial stage, patients need to do the following methods to recover, such as eating many small meals. Meals must ensure regular nutrition. Patients should eat thin porridge with a sufficient amount of minced meat, fish, and pureed vegetables.

3. Next stage

   • Taste disturbance, bitter sensation on the mouth.
   • Poor digestion, bloating, bowel disorders.
   • Reduced appetite and feeling of fullness soon after meals.
   • In this next stage, patients need to do the following methods to recover:
   • Use herbs and spices (thyme, parsley, basil, turmeric, ginger, lemon juice, wine, and apple cider vinegar).
   • Practice different cooking methods to change the taste and feel of the food.

4. For the body to recover as quickly as possible and minimize side effects, people after liver surgery should pay attention to the following issues:

   • Use green vegetables to provide enough vitamin K in the patient's diet. This is an important substance in blood clotting.
   • Maintain intestinal flora balance by drinking probiotics such as liquid, yogurt.
   • Eat more foods such as lean meat, fish, shrimp, and crab to increase protein supplements for the body.
   • Limit harmful fructose in foods containing artificial sweeteners such as candy, soft drinks, and packaged foods.
   • Limit the use of animal fat, use vegetable oils such as peanut oil, rice oil, and olive oil to avoid causing inflammatory reactions, and balance blood sugar.

General Dietary Recommendations

After surgery, it is important to maintain a balanced diet and stay well-hydrated by drinking plenty of water. Most patients can resume their normal diet within a few days after surgery. However, the diet should include protein, green leafy vegetables, fresh fruit, and dairy products such as yogurt and skim milk. Some patients may have irregular bowel movements, which is common after liver surgery, but if the patients have acute discomfort for a long time, they should consult a doctor.

• Hydration: Aim to drink at least eight cups of fluid every day, primarily water, to support overall health and liver function.
• Protein: Consume three or more servings of lean proteins each day, such as lean meat, fish, shrimp, and crab, as protein is vital for tissue repair.
• Fruits and Vegetables: Include five or more servings of colorful fruits and vegetables each day to provide essential vitamins and minerals.
• Complex Carbohydrates: Incorporate several servings daily of complex carbohydrates like oats, shredded wheat, brown rice, quinoa, beans (legumes), or sweet potatoes to help stabilize blood sugar and provide sustained energy.
• Calcium-Rich Foods: Aim for three or more daily servings of calcium-rich foods to help protect bones from osteoporosis, a potential side effect of post-transplant drugs.
• Healthy Fats: Include healthy fats from oily fish (like salmon), olive oil, nuts, seeds, and avocados to help reduce cholesterol and blood pressure and support heart health.

Foods to Limit or Avoid

• Alcohol: After liver surgery, patients must not drink alcohol. You should also stop drinking alcohol before surgery. Heavy drinkers should immediately stop drinking alcohol and try to quit smoking. It is important to be honest with your doctor and discuss your drinking habits.
• Saturated and Trans Fats: Limit saturated or trans fats, which can raise cholesterol and increase the risk of heart disease.
• Sodium: Reduce sodium intake to avoid raising blood pressure, retaining fluid, and stressing the kidneys.
• Sugar: Minimize excess sugar consumption to prevent weight gain and diabetes.
• Harmful Fructose: Limit harmful fructose in foods containing artificial sweeteners such as candy, soft drinks, and packaged foods.
• Animal Fat: Limit the use of animal fat, use vegetable oils such as peanut oil, rice oil, and olive oil to avoid causing inflammatory reactions, and balance blood sugar.
• Undercooked Seafood: Avoid eating undercooked fish or shellfish, such as raw oysters or sushi, as they may contain bacteria that can cause serious illness.

Special Considerations

• Branched-Chain Amino Acids (BCAAs): Several studies (4,5) have pointed out that patients with liver resection should choose a diet rich in branched-chain amino acids in the early postoperative period. Research from 2015 suggests that branched-chain amino acid (BCAA) supplementation may help improve liver function in people with liver cancer.
• Probiotics: Maintain intestinal flora balance by drinking probiotics such as liquid, yogurt.
• Vitamin K: Use green vegetables to provide enough vitamin K in the patient's diet. This is an important substance in blood clotting.
• Bile Salt Preparations: The supply of bile salt preparations needs particular attention in patients with biliary obstruction and external biliary fistula.

Nutritional Support Methods

• Oral Feeding: Oral feeding of nutritional supplements is the least invasive method. However, for patients who cannot tolerate oral feeding, the intake of nutrients is inadequate, as it is for those patients with delayed gastric emptying after surgery.
• Total Parenteral Nutrition (TPN): Total parenteral nutrition provides sufficient and complete nutritional needs. However, total parenteral nutrition may involve several potential complications. The delivery of high glucose loads requires sufficient insulin, and thus hyperglycemia, metabolic acidosis, and fluid excess may occur without careful monitoring.
• Enteral Nutrition: Since nutrients are directly delivered to the stomach, duodenum or jejunum, enteral nutrition is more “physiological” solution. Enteral nutrition stimulates the release of pancreaticobiliary secretion, and these luminal nutrients promote metabolism, regulate hormone levels in the gastrointestinal tract, and maintain normal gastrointestinal contraction and blood flow (11).

Addressing Specific Postoperative Issues

• Hypoglycemia: Patients undergoing liver resection are more likely to have significantly lower blood glucose levels, while patients undergoing total hepatectomy and liver transplantation have severe hypoglycemia. Standard operation involves monitoring blood glucose and continuing intravenous infusion of 10% glucose solution for at least a few days during the first phase or before supplying sufficient carbohydrates by oral feeding.
• Hypoalbuminemia: Considering that the liver is the site where albumin is synthesized, severe hypoalbuminemia will occur to a significant degree unless the route of feeding is replaced by parenteral administration. Albumin supplementation takes about a week, and by the end of the third postoperative week, the albumin level has basically returned to normal.
• Bowel Movements: You may notice that your bowel movements are not regular right after your surgery. This is common. Try to avoid constipation and straining with bowel movements. You may want to take a fibre supplement every day. If you have not had a bowel movement after a couple of days, ask your doctor about taking a mild laxative.

Additional Recovery Recommendations

• Rest: Doctors recommend that you rest and recover completely after liver surgery. You should take at least 4 to 6 weeks off from work. Patients should avoid strenuous activities such as cycling, running, or weight lifting immediately after surgery, as these activities put significant stress on the liver. It is advisable to stay indoors and avoid crowded places to avoid the risk of infection. Getting enough sleep is very important, so patients should be required to sleep for 6 to 7 hours a day.
• Wound Care: Since the surgery involves cutting through the skin, the incision must be carefully cared for after surgery. After removing the bandage, wash it with warm soapy water and pat dry. You can cover the incision with a bandage if needed. Remember to wash it daily to avoid any infection or complications.
• Activity: Try to walk each day. Start by walking a little more than you did the day before. Bit by bit, increase the amount you walk. Walking boosts blood flow and helps prevent pneumonia and constipation.
• Medicines: Your doctor will tell you if and when you can restart your medicines. He or she will also give you instructions about taking any new medicines. Take pain medicines exactly as directed.

The Role of the Prognostic Nutritional Index (PNI)

Many studies (8-10) have reported the influence of the prognostic nutritional index (PNI) on the postoperative efficacy of pancreatic surgery patients. Kanda et al. (8) analyzed the prognosis of 268 pancreatic cancer patients undergoing pancreatectomy. Multivariate analysis showed that lower preoperative PNI (not low albumin) was an independent prognostic factor leading to lower survival rates. Indeed, a significant association between lower preoperative albumin concentration and PNI and postoperative complications has been found. Sato et al. (9) analyzed the experience of 44 patients who had undergone distal pancreatectomy. The researchers noticed that the rapid reduction of postoperative PNI was related to the higher incidence of postoperative pancreatic fistula.

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Importance of a Multidisciplinary Approach

Effective nutritional management after liver resection often requires a multidisciplinary approach. This includes collaboration between surgeons, dietitians, nurses, and other healthcare professionals to assess the patient's nutritional status, develop an individualized nutrition plan, and monitor their progress.

Nutritional Support for Liver Transplant Recipients

A liver transplant is a life-saving procedure that removes your diseased liver and replaces it with a new liver from a donor. It’s a major surgery that requires lifelong changes to protect your new liver and keep yourself healthy. After you receive a new liver, there’s a chance that your immune system will reject it. Taking antirejection medications (immunosuppressants) will reduce that risk. The medications can save your liver, but they have potential side effects. They work by weakening your immune system, but that makes you more susceptible to infections and illnesses. A healthy, balanced diet is vital after your transplant. Eating well will help your body heal and give you more energy to resume exercise and regular activities.

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