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 .
A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy.
BACKGROUND Clinical ly relevant postoperative pancreatic fistulas ( CR-POPF ) are serious inherent risks of pancreatic resection . Preoperative CR-POPF risk assessment is currently inadequate and rarely disqualifies patients who need resection . The best evaluation of risk occurs intraoperatively , and should guide fistula prevention and response measures thereafter . We sought to develop a risk prediction tool for CR-POPF that features intraoperative assessment and reveals associated clinical and economic significance . STUDY DESIGN Based on International Study Group of Pancreatic Fistula classification , recognized risk factors for CR-POPF ( small duct , soft pancreas , high-risk pathology , excessive blood loss ) were evaluated during  pancreaticoduodenectomy .  An optimal risk score range model , selected from 3 different constructs , was first derived ( n = 233 ) and then vali date d prospect ively ( n = 212 ) . Clinical and economic outcomes were evaluated across 4 ranges of scores ( negligible risk , 0 points ; low risk , 1 to 2 ; intermediate risk , 3 to 6 ; high risk , 7 to 10 ) . RESULTS Clinical ly relevant postoperative pancreatic fistulas occurred in 13 % of patients . The incidence was greatest with excessive blood loss . Duct size < 5 mm was associated with increased fistula rates that rose with even smaller ducts . These factors , together with soft pancreatic parenchyma and certain disease pathologies , afforded a highly predictive 10-point Fistula Risk Score . Risk scores strongly correlated with fistula development ( p < 0.001 ) . Notably , patients with scores of 0 points never developed a CR-POPF , while fistulas occurred in all patients with scores of 9 or 10 . Other clinical and economic outcomes segregated by risk profile across the 4 risk strata . CONCLUSIONS A simple 10-point Fistula Risk Score derived during pancreaticoduodenectomy accurately predicts subsequent CR-POPF . It can be readily learned and broadly deployed . This prediction tool can help surgeons anticipate , identify , and manage this ominous complication from the outset
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 .