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 .
Restrictive intraoperative fluid optimisation algorithm improves outcomes in patients undergoing pancreaticoduodenectomy: A prospective multicentre randomized controlled trial
We aim ed to evaluate perioperative outcomes in patients undergoing pancreaticoduodenectomy with or without a cardiac output goal directed therapy ( GDT ) algorithm .  We conducted a multicentre r and omised controlled trial in four high volume hepatobiliary-pancreatic surgery centres . We evaluated whether the additional impact of a intraoperative fluid optimisation algorithm would influence the amount of fluid delivered , reduce fluid related complications , and improve length of hospital stay .  Fifty-two consecutive adult patients were recruited . The median ( IQR ) duration of surgery was 8.6 hours ( 7.1:9.6 ) in the GDT group vs. 7.8 hours ( 6.8:9.0 ) in the usual care group ( p = 0.2 ) . Intraoperative fluid balance was 1005mL ( 475:1873 ) in the GDT group vs. 3300mL ( 2474:3874 ) in the usual care group ( p<0.0001 ) . Total volume of fluid administered intraoperatively was also lower in the GDT group : 2050mL ( 1313:2700 ) vs. 4088mL ( 3400:4525 ) , p<0.0001 and vasoactive medications were used more frequently . There were no significant differences in proportions of patients experiencing overall complications ( p = 0.179 ) ; however , fewer complications occurred in the GDT group : 44 vs. 92 ( Incidence Rate Ratio : 0.41 ; 95%CI 0.24 to 0.69 , p = 0.001 ) . Median ( IQR ) length of hospital stay was 9.5 days ( IQR : 7.0 , 14.3 ) in the GDT vs. 12.5 days in the usual care group ( IQR : 9.0 , 22.3 ) for an Incidence Rate Ratio 0.64 ( 95 % CI 0.48 to 0.85 , p = 0.002 ) . In conclusion , using a surgery-specific , patient-specific goal directed restrictive fluid therapy algorithm in this cohort of patients , can justify using enough fluid without causing oedema , yet as little fluid as possible without causing hypovolaemia i.e. “ precision ” fluid therapy . Our findings support the use of a perioperative haemodynamic optimization plan that prioritizes preservation of cardiac output and organ perfusion pressure by judicious use of fluid therapy , rational use of vasoactive drugs and timely application of inotropic drugs . They also suggest the need for further larger studies to confirm its findings
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 .