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.