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 .
Continuous wound infiltration versus epidural analgesia after hepato-pancreato-biliary surgery (POP-UP): a randomised controlled, open-label, non-inferiority trial.
BACKGROUND Epidural analgesia is the international st and ard for pain treatment in abdominal surgery . Although some studies have advocated continuous wound infiltration with local anaesthetics , robust evidence is lacking , especially on patient-reported outcome measures . We aim ed to determine the effectiveness of continuous wound infiltration in hepato-pancreato-biliary surgery . METHODS In this r and omised controlled , open label , non-inferiority trial ( POP-UP ) , we enrolled adult patients undergoing hepato-pancreato-biliary surgery by subcostal or midline laparotomy in two Dutch hospitals . Patients were central ly r and omised ( 1:1 ) to receive either pain treatment with continuous wound infiltration using bupivacaine plus patient-controlled analgesia with morphine or to receive ( patient-controlled ) epidural analgesia with bupivacaine and sufentanil . All patients were treated within an enhanced recovery setting . R and omisation was stratified by centre and type of incision . The primary outcome was the mean Overall Benefit of Analgesic Score ( OBAS ) from day 1 - 5 , a vali date d composite endpoint of pain scores , opioid side-effects , and patient satisfaction ( range 0 [ best ] to 28 [ worst ] ) . Analysis was per- protocol . The non-inferiority limit of the mean difference was + 3·0 . This trial is registered with the Netherl and s Trial Registry , number NTR4948 . FINDINGS Between Jan 20 , 2015 , and Sept 16 , 2015 , we r and omly assigned 105 eligible patients : 53 to receive continuous wound infiltration and 52 to receive epidural analgesia . One patient in the continuous wound infiltration group discontinued treatment , as did five in the epidural analgesia group ; of these five patients , preoperative placement failed in three ( these patients were treated with continuous wound infiltration instead ) , one patient refused an epidural , and data for the primary endpoint was lost for one . Thus , 55 patients were included in the continuous wound infiltration group and 47 in the epidural analgesia group for the per- protocol analyses . Mean OBAS was 3·8 ( SD 2·4 ) in the continuous wound infiltration group versus 4·4 ( 2·2 ) in the epidural group ( mean difference -0·62 , 95 % CI -1·54 to 0·30 ) . Because the upper bound of the one-sided 95 % CI did not exceed + 3·0 , non-inferiority was shown . Four ( 7 % ) patients in the continuous wound infiltration group and five ( 11 % ) of those in the epidural group had an adverse event . One patient in the continuous wound infiltration group had a serious adverse event ( temporary hypotension and arrhythmia after bolus injection ) ; no serious adverse events were noted in the epidural group . INTERPRETATION These data suggest that continuous wound infiltration is non-inferior to epidural analgesia in hepato-pancreato-biliary surgery within an enhanced recovery setting . Further large-scale trials are required to make a definitive assessment of non-inferiority . FUNDING Academic Medical Centre , Amsterdam , Netherl and
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 .