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 .
Preoperative immunonutrition decreases postoperative complications by modulating prostaglandin E2 production and T-cell differentiation in patients undergoing pancreatoduodenectomy.
BACKGROUND An immune-enhancing diet has been used to alter eicosanoid synthesis , cytokine production , and immune function in an attempt to limit the undesired immune reactions after injury from surgery . This prospect i ve r and omized study was design ed to investigate the effect of preoperative immunonutrition on operative complications , and the participation of prostagl and in E2 ( PGE2 ) on T-cell differentiation in patients undergoing a severely stressful surgery . METHODS The enrolled patients who were scheduled to undergo pancreatoduodenectomy were r and omized into two groups . Patients in the immunonutrition group ( n = 25 ) received oral supplementation containing arginine , ω-3 fatty acids , and RNA for 5 days before the procedure in addition to a 50 % reduction in the amount of regular food . Patients in the control group ( n = 25 ) received no artificial nutrition and were allowed to consume regular food before surgery . All patients received early postoperative enteral infusion of a st and ard formula intended to provide 25 kcal/kg/day . The primary endpoint was the rate of infectious complications ; the secondary endpoint was immune responses . This study is registered with Clinical Trials.gov ( NCT01256034 ) . RESULTS Infectious complication rate and severity of complications ( Clavien-Dindo classification ) were lesser in the immunonutrition group than in the control group . mRNA expression levels of T-bet were greater in the immunonutrition group than in the control group ( P < .05 ) . Serum eicosapentaenoic acid and eicosapentaenoic acid/arachidonic acid ratios were greater in the immunonutrition group than in the control group ( P < .05 ) . The levels of plasma PGE2 were lesser in the immunonutrition group than in the control group ( P < .05 ) . CONCLUSION Preoperative immunonutrition modulates PGE2 production and T-cell differentiation and may protect against the aggravation of operative complications in patients undergoing pancreatoduodenectomy
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 .