Enhanced recovery pathways in pancreatic surgery: State of the art

Table 1 Enhanced recovery pathway interventions for pancreatic surgery

Element	Description
Preoperative
Patient education	Dedicated counseling providing patients with information and goals for recovery
Optimization of organ dysfunction	Optimization of patient comorbidities and patient conditioning
Oral immunonutrition	Oral immunonutrients should be taken for 5-7 d prior to surgery
Selective biliary drainage	Endoscopic biliary drainage only indicated if serum bilirubin > 14.5 mg/dL, in case of cholangitis or planned neoadjuvant treatment
Avoid mechanical bowel preparation	Oral bowel preparation should not be used
Minimize fasting	Intake of clear fluids up to 2 h before anesthesia, and solid food until 6 h before.
Carbohydrate loading	A carbohydrate drink should be given the morning before surgery
Intraoperative
Thromboembolic disease prophylaxis	Low molecular weight heparin should be administered
Antimicrobial prophylaxis	Antibiotic prophylaxis should start 30-60 min before incision
Epidural and opioid sparing analgesia	Avoid opioids. Multimodal analgesia including thoracic epidural analgesia, acetaminophen, NSAIDs. Early transition to oral analgesics
PONV prophylaxis	Multimodal nausea and vomit prophylaxis
Avoid hypothermia	Active cutaneous warming
Balanced intravenous infusions	Avoid fluid overload. Maintain near-zero fluid balance. Potential benefit in the use of goal directed fluid therapy.
Postoperative
Avoid nasogastric intubation	Nasogastric tube should be removed at the end of surgery
Glycemic control	Avoid hyperglycemia with frequent blood sugar monitoring and insulin infusion when necessary
Early removal of urinary drainage	Bladder catheter should be removed within postoperative day 2
Early removal of perianastomotic drain	Early drain removal in patients at low risk for pancreatic fistula
Early oral feeding	Patients should be allowed a normal diet without restrictions as tolerated
Gastrointestinal stimulation	Oral laxative and chewing-gum should be started early after surgery
Early stop of intravenous infusions	Intravenous fluids should be stopped as soon as patients are able to tolerate oral liquids
Early mobilization	Scheduled active mobilization should start from postoperative day 1
Audit	Systematic audit on care processes and outcomes

NSAID: Non-steroidal anti-inflammatory drugs; PONV: Postoperative nausea and vomit.