ERAS for Pancreatic Surgery

1. Preoperative recommendations
    1. Patients and their families should receive education about the surgery and expected recovery prior to their operation. (Level of evidence: Low)
      1. Patients and their families should receive information on: expected length of stay assuming there are no complications; length of preoperative fasting; pain control; early ambulation and feeding; and smoking cessation (if applicable) prior to surgery
    2. Patients should be allowed to eat solid foods until midnight the night before surgery (Level of evidence: High)
    3. Patients should be encouraged to drink clear fluids up to 2 hours before anesthesia administration. Clear fluids include coffee and tea (without milk), and drinks that are high in carbohydrates (i.e. apple juice and pulp-free orange juice) (Level of evidence: High)
      1. Patients should be assessed for gastroesophageal reflux disease, dysphagia symptoms, or other gastrointestinal motility disorders preoperatively as they may require individual recommendations for perioperative fasting (Level of evidence: Low)
2. Intraoperative recommendations
    1. Perioperative pain control should be multimodal
      1. Minimization of opioid exposure is recommended to reduce opioid-related side effects
      2. Patients and their families should receive information on: expected length of stay assuming there are no complications; length of preoperative fasting; pain control; early ambulation and feeding; and smoking cessation (if applicable) prior to surgery
      3. The following should also be considered part of the multimodal pain management regimen: intraoperative intravenous lidocaine, intravenous ketamine (especially for patients with chronic pain issues), regional analgesia (Level of evidence: Low-Moderate)
      4. A detailed plan for the transition home should be in place to avoid prolonged use of opioids
    2. Surgical site infection prevention (see Best Practice in Surgery recommendations)
    3. Use of surgical drains
      1. Selective drainage is recommended for patients at high risk of fistula development based on the pancreatic fistula score (Level of evidence: Moderate)
      2. There is insufficient evidence to make recommendations for the use of drains in patients with a moderate to low risk of fistula
      3. If surgical drains are placed, early drain removal is encouraged (Level of evidence: Moderate)
      4. Prophylactic use of nasogastric tubes (NG) for decompression should be avoided except for patients undergoing a pancreaticogastrostomy (Level of evidence: High)
3. Postoperative recovery
    1. Perioperative pain control should be multimodal
    2. Routine use of somatostatin analogues (e.g. octreotide, pasireotide) are recommended to decrease rate of complications (Level of evidence: Moderate)
    3. Patients should be encouraged to participate in early mobilization once extubated (Level of evidence: Moderate)
      1. Patients should be encouraged to dangle on the side of their bed, walk, or sit in a chair on POD0
      2. Patients should be encouraged to walk at least twice on POD1 and every day until discharge
      3. Patients should be encouraged to sit up in a chair while awake during the day
    4. Patients should resume eating and drinking as soon as possible after surgery (Level of evidence: Moderate)
      1. Patients should be offered clear fluids 2 hours postoperatively provided they are awake, alert and capable of swallowing
      2. Patients should be offered solid food beginning POD1
    5. Patients should be encouraged to chew gum 3x/day for 5 minutes until they are tolerating solid food (Level of evidence: Moderate)
    6. Venous thromboembolism (VTE) prophylaxis is recommended for all patients (Level of evidence: Moderate)
      1. Perioperative VTE prophylaxis is recommended using either unfractionated or fractionated low-molecular-weight heparin (LMWH)
      2. VTE prophylaxis should be continued during postoperative hospitalization
      3. For patients with high thrombosis risk features (e.g. Caprini Risk Assessment Scores ≥ 7), VTE prophylaxis should be extended for 4 weeks postoperatively
    7. There is insufficient evidence to recommend routine use of prokinetic agents to enhance gastrointestinal motility