1. Preoperative recommendations
- Patients and their families should receive education about the surgery and expected recovery prior to their operation. (Level of evidence: Low)
- 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
- Patients should be allowed to eat solid foods until midnight the night before surgery (Level of evidence: High)
- 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)
- 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
- Perioperative pain control should be multimodal
- Minimization of opioid exposure is recommended to reduce opioid-related side effects
- 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
- 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)
- A detailed plan for the transition home should be in place to avoid prolonged use of opioids
- Surgical site infection prevention (see Best Practice in Surgery recommendations)
- Use of surgical drains
- Selective drainage is recommended for patients at high risk of fistula development based on the pancreatic fistula score (Level of evidence: Moderate)
- There is insufficient evidence to make recommendations for the use of drains in patients with a moderate to low risk of fistula
- If surgical drains are placed, early drain removal is encouraged (Level of evidence: Moderate)
- Prophylactic use of nasogastric tubes (NG) for decompression should be avoided except for patients undergoing a pancreaticogastrostomy (Level of evidence: High)
3. Postoperative recovery
- Perioperative pain control should be multimodal
- Routine use of somatostatin analogues (e.g. octreotide, pasireotide) are recommended to decrease rate of complications (Level of evidence: Moderate)
- Patients should be encouraged to participate in early mobilization once extubated (Level of evidence: Moderate)
- Patients should be encouraged to dangle on the side of their bed, walk, or sit in a chair on POD0
- Patients should be encouraged to walk at least twice on POD1 and every day until discharge
- Patients should be encouraged to sit up in a chair while awake during the day
- Patients should resume eating and drinking as soon as possible after surgery (Level of evidence: Moderate)
- Patients should be offered clear fluids 2 hours postoperatively provided they are awake, alert and capable of swallowing
- Patients should be offered solid food beginning POD1
- Patients should be encouraged to chew gum 3x/day for 5 minutes until they are tolerating solid food (Level of evidence: Moderate)
- Venous thromboembolism (VTE) prophylaxis is recommended for all patients (Level of evidence: Moderate)
- Perioperative VTE prophylaxis is recommended using either unfractionated or fractionated low-molecular-weight heparin (LMWH)
- VTE prophylaxis should be continued during postoperative hospitalization
- For patients with high thrombosis risk features (e.g. Caprini Risk Assessment Scores ≥ 7), VTE prophylaxis should be extended for 4 weeks postoperatively
- There is insufficient evidence to recommend routine use of prokinetic agents to enhance gastrointestinal motility