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 .
Intravenous versus epidural analgesia to reduce the incidence of gastrointestinal complications after elective pancreatoduodenectomy (the PAKMAN trial, DRKS 00007784): study protocol for a randomized controlled trial
Background Despite substantial improvements in surgical and anesthesiological practice s leading to decreased mortality of less than 5 % at high-volume centers , pancreatic surgery is still associated with high morbidity rates of up to 50 % . Attention is increasingly directed toward the optimization of perioperative management to reduce complications and enhance postoperative recovery . Currently , two different strategies for postoperative pain management after pancreatoduodenectomy are being routinely used : patient-controlled intravenous analgesia and thoracic epidural analgesia . Evidence is lacking to assess which strategy entails fewer postoperative complications . Methods / design The PAKMAN trial is design ed as an adaptive , pragmatic , r and omized , controlled , multicenter , open-label , superiority trial with two parallel study groups . A total of 370 patients scheduled for elective pancreatoduodenectomy will be r and omized after giving written informed consent , and 278 patients are needed for analysis . Patients with chronic pancreatitis , severe chronic obstructive pulmonary disease ( COPD ) , American Society of Anesthesiologists ( ASA ) physical status classification ≥ IV , or chronic pain syndrome will be excluded . The group A intervention includes intraoperative general anesthesia and postoperative patient-controlled intravenous analgesia ; the group B intervention comprises combined intraoperative general anesthesia and epidural analgesia with postoperative epidural analgesia . The primary endpoint of this trial is a composite of the gastrointestinal complications ( delayed gastric emptying , pancreatic fistula , biliary leak , gastrointestinal bleeding , and postoperative ileus ) up to postoperative day 30 . The aim is to investigate whether the frequency of gastrointestinal complications following pancreatoduodenectomy can be reduced by 15 % using postoperative , patient-controlled intravenous analgesia compared with epidural analgesia . Discussion Several previous studies investigating the two different strategies for postoperative pain management have mainly focused on their effectiveness in pain control . However , the PAKMAN trial is the first to compare them with regard to their impact on the surgical endpoint “ postoperative gastrointestinal complications ” after pancreatoduodenectomy . Trial registration German Clinical Trials Register ,
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 .