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 .
Relationship Between Intraoperative Fluid Administration and Perioperative Outcome After Pancreaticoduodenectomy: Results of a Prospective Randomized Trial of Acute Normovolemic Hemodilution Compared With Standard Intraoperative Management
Background :  Pancreaticoduodenectomy ( PD ) can be associated with significant blood loss and transfusion requirements , with potential adverse short- and long-term consequences . The aim of this study was to determine whether acute normovolemic hemodilution ( ANH ) , an established blood conservation technique , reduces perioperative allogeneic transfusions in patients undergoing PD . Methods : One hundred thirty patients undergoing PD were r and omized to ANH or st and ard management ( STDM ) . In the ANH group , intraoperative blood collection was performed to a target hemoglobin of 8.0 g/dL ; crystalloid and colloid were used for volume replacement . Strict transfusion triggers were applied during and after operation . Perioperative complications were prospect ively assessed and grade d for severity . Results : From July 2005 to May 2009 , 209 patients were registered , 79 excluded , 65 were r and omized to ANH , and 65 to STD . The groups were well matched for demographic , operative , and histopathologic variables . Patients undergoing ANH received over 2 L more fluid intraoperatively ( 6250 mL , range 2000–11850 ) compared with patients undergoing STD ( 3900 mL , range 2000–9000 ) ( P < 0.001 ) . Transfusion rates were similar ( ANH = 16.9 % , 30 units vs STD = 18.5 % , 33 units ; P = 0.82 ) , as was overall perioperative morbidity ( ANH = 49.2 % vs STD = 47 % , P = 0.86 ) . There was , however , a trend toward more grade -3 complications in patients undergoing ANH ( 32 % vs 23.1 % STD , P = 0.17 ) , and complications related to the pancreatic anastomosis ( leak/fistula/abscess ) were significantly higher in the ANH group ( 21.5 % vs 7.7 % , P = 0.045 ) . The intraoperative fluid volume was higher for all patients with pancreatic anastomotic complications ( n = 19 ) , regardless of r and omization arm ( ANH 6000 mL , range 2800–11350 mL vs STD 5000 mL , range 2000–11850 mL , P < 0.042 ) . Conclusion : In this r and omized trial of patients undergoing PD , ANH did not reduce allogeneic transfusions and result ed in more pancreatic anastomotic complications , likely related to greater intraoperative fluid administration . The benefits of ANH do not necessarily extend to all procedures , and restrictive intravenous fluid management during PD may help improve postoperative outcome
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 .