A well-implemented ERAS protocol with good compliance is associated with a reduction in medical complications and length of hospital stay .
Enhanced recovery after surgery ( ERAS ) pathways are now implemented worldwide with strong evidence that adhesion to such protocol reduces medical complications , costs and hospital stay .
This concept has been applied for pancreatic surgery since the first published guidelines in 2012 .
This study presents the up date d ERAS recommendations for  pancreatoduodenectomy ( PD )  based on the best available evidence and on expert consensus .
Multicenter, Prospective Trial of Selective Drain Management for Pancreatoduodenectomy Using Risk Stratification
Objective : This multicenter study sought to prospect ively evaluate a drain management protocol for pancreatoduodenectomy ( PD ) . Background : Recent evidence suggests value for both selective drain placement and early drain removal for PD . Both strategies have been associated with reduced rates of clinical ly relevant pancreatic fistula (CR-POPF)—the most common and morbid complication after PD . Methods : The protocol was applied to 260 consecutive PDs performed at two institutions over 17 months . Risk for ISGPF CR-POPF was determined intraoperatively using the Fistula Risk Score ( FRS ) ; drains were omitted in negligible/low risk patients and drain fluid amylase ( DFA ) was measured on postoperative day 1 ( POD 1 ) for moderate/high risk patients . Drains were removed early ( POD 3 ) in patients with POD 1 DFA ⩽5,000 U/L , whereas patients with POD 1 DFA > 5,000 U/L were managed by clinical discretion . Outcomes were compared with a historical cohort ( N = 557 ; 2011–2014 ) . Results : Fistula risk did not differ between cohorts ( median FRS : 4 vs 4 ; P = 0.933 ) . No CR-POPFs developed in the 70 ( 26.9 % ) negligible/low risk patients . Overall CR-POPF rates were significantly lower after protocol implementation ( 11.2 vs 20.6 % , P = 0.001 ) . The protocol cohort also demonstrated lower rates of severe complication , any complication , reoperation , and percutaneous drainage ( all P < 0.05 ) . These patients also experienced reduced hospital stay ( median : 8 days vs 9 days , P = 0.001 ) . There were no differences between cohorts in the frequency of bile or chyle leaks . Conclusions : Drains can be safely omitted for one-quarter of PDs . Drain amylase analysis identifies which moderate/high risk patients benefit from early drain removal . This data -driven , risk-stratified approach significantly decreases the occurrence of clinical ly relevant pancreatic fistula
A well-implemented ERAS protocol with good compliance is associated with a reduction in medical complications and length of hospital stay .
Enhanced recovery after surgery ( ERAS ) pathways are now implemented worldwide with strong evidence that adhesion to such protocol reduces medical complications , costs and hospital stay .
This concept has been applied for pancreatic surgery since the first published guidelines in 2012 .
This study presents the up date d ERAS recommendations for  pancreatoduodenectomy ( PD )  based on the best available evidence and on expert consensus .