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 Epidural Blockade Arrests the Postoperative Decrease in Muscle Protein Fractional Synthetic Rate in Surgical Patients
Background : Epidural anesthesia with local anesthetics is associated with postoperative attenuation of nitrogen loss . The protein‐sparing effect could be the result of either a decreased protein breakdown or increased protein synthesis . Although the role of epidural local anesthetics in effectively limiting the increase in postoperative protein breakdown is established at the whole‐body level , it is necessary to determine whether the muscle protein fractional synthetic rate is directly modulated when nociceptive stimuli are blocked . Methods : Twelve otherwise healthy patients scheduled for elective colorectal surgery , who were receiving a constant intake of nitrogen ( 0.1 g [ center dot ] kg sup ‐1 [ center dot ] day sup ‐1 ) and calories ( 20 kcal [ center dot ] kg sup ‐1 [ center dot ] day sup ‐1 ) before and after surgery , were r and omly assigned to receive either general anesthesia ( with thiopentone , vecuronium , fentanyl , or enflurane ; control group , n = 6 ) or epidural anesthesia ( T3‐S5 sensory block with 0.75 % bupivacaine ) and general anesthesia ( epidural group , n = 6 ) . In the control group , postoperative analgesia was achieved with papaveretum given subcutaneously , whereas a continuous epidural bupivacaine infusion ( T8‐L5 sensory block ) was maintained for 48 h in the epidural group . The postabsorptive muscle protein fractional synthetic rate was determined using a 6‐h continuous infusion of13 C‐labeled leucine ( 1 mg [ center dot ] kg sup ‐1 [ center dot ] h sup ‐1 ) , and the13 C enrichment in muscle biopsy specimens before surgery and 48 h after surgery was measured . Results : Plateau13 C enrichment of plasma alpha‐ketoisocaproate ( taken to represent the intracellular leucine precursor pool enrichment for protein synthesis ) was achieved during the 6‐h infusion ( mean coefficient of variation was 2.8 % ) . Muscle protein synthesis at 48 h after operation compared with preoperative levels decreased significantly in the control group ( P = 0.03 ) . In contrast , it increased by 25 % in the epidural group . Although this was not significantly ( P = 0.15 ) different from preoperative levels , it was significantly greater than in the control patients . Conclusions : Epidural infusion of local anesthetics begun before surgery and continued during the first 48 h after operation significantly attenuates the decrease in the postabsorptive muscle protein synthesis rate associated with surgical injury . Effective block of nociceptive stimuli thus preserves tissue protein synthesis
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 .