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Successful introduction of ERAS in pancreaticoduodenectomy: what is real minimally invasive surgery?
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Toshimi Kaido, Yosuke Miyachi, Koichiro Mitsuoka, Mariko Sanbonmatsu
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Published online June 27, 2025
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DOI: https://doi.org/10.15747/ACNM.25.0014
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 Abstract
 ePub
- Purpose
The introduction of Enhanced Recovery After Surgery (ERAS) protocols for pancreaticoduodenectomy (PD) has been considered challenging due to factors such as preexisting malnutrition, sarcopenia, the complexity of the surgery, and the high incidence of postoperative complications, including postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE). This study aimed to determine whether ERAS could be implemented in PD to achieve shorter postoperative hospital stays.
Methods
Our novel approach consists of three components. Preoperatively, we routinely assess patients' muscle strength and nutritional status and initiate exercise and nutritional interventions for those identified with sarcopenia or malnutrition. Intraoperatively, we perform pancreaticojejunostomy using a modified Blumgart’s technique with our stent placement policy and utilize gastrojejunostomy methods to prevent DGE. Postoperatively, we emphasize early ambulation, early oral intake, and prompt drain removal. Since April 2020, we have employed this strategy and retrospectively evaluated its effectiveness. We enrolled 41 consecutive patients who underwent open PD with curative intent by January 2023. Various surgical outcomes, including postoperative hospital stay, were analyzed.
Results
There were 26 men and 15 women, with a median age of 68 years (range, 40–84 years). Preoperative diagnoses included pancreatic head cancer (18 patients), distal bile duct cancer (10 patients), and others. Median intraoperative blood loss was 373 mL (range, 25–1,155 mL). Grade B POPF occurred in three patients (7%). No cases of DGE were observed. The median day of drain removal was postoperative day 3. The median postoperative hospital stay was 8 days (range, 6–26 days).
Conclusion
We successfully implemented ERAS protocols in PD and achieved a significantly reduced postoperative hospital stay. We propose that this approach constitutes “real minimally invasive surgery,” independent of the specific surgical technique used.
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E-submission
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