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 .
Epidural Analgesia for Pancreatoduodenectomy: A Critical Appraisal
Introduction Epidural analgesia has emerged as a commonly applied method to improve pain management and reduce perioperative complications in major abdominal surgery . However , there is no detailed analysis of its efficacy for pancreatic operations . This study compares clinical and economic outcomes after epidural and intravenous analgesia for pancreatoduodenectomy . Material and methods Data for 233 consecutive patients , who underwent pancreatoduodenectomy , were prospect ively acquired and retrospectively review ed at a single institution , pancreato-biliary specialty practice . From October 2001 to February 2007 , all patients were offered thoracic epidural analgesia , and those who declined received intravenous analgesia . Perioperative pain management was dictated as an element of a st and ardized clinical pathway for pancreatic resections . Clinical and economic outcomes were analyzed and compared for epidural analgesia and intravenous analgesia groups . Results One hundred eighty-five patients received epidural analgesia , and 48 received intravenous analgesia , with equivalent baseline patient demographics between the groups . Patients administered epidural analgesia had lower pain scores but significantly higher rates of major complications . Pancreatic fistulae and postoperative ileus occurred more frequently , and patients with epidural analgesia more often required discharge to rehabilitation facilities . A trend towards longer hospitalizations was observed among epidural analgesia patients , but total costs were statistically equivalent between the groups . Further analysis demonstrates that 31 % of epidural infusions were aborted before anticipated ( fourth postoperative day ) because of hemodynamic compromise and /or inadequate analgesia . These select patients required more transfusions , aggressive fluid resuscitation , and subsequently suffered even higher rates of gastrointestinal and respiratory complications , all attributing to higher costs . Multivariate analysis demonstrates that preoperative hematocrit concentration less than 36 % , elderly age ( > 75 years ) , and chronic pancreatitis predict failure of epidural infusions . Conclusion Thoracic epidural analgesia after pancreatic resections is associated with hemodynamic instability , which may compromise enteric anastomoses , gastrointestinal recovery , and respiratory function . These outcomes are exacerbated in poorly functioning epidurals and suggest that epidural analgesia may not be the optimal method for perioperative pain control when pancreatoduodenectomy is performed
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 .