Successful introduction of ERAS in pancreaticoduodenectomy : What is real minimally invasive surgery?

<p>Objectives: The introduction of Enhanced recovery after surgery (ERAS) into pancreaticoduodenectomy (PD) has been thought difficult because of accompanying malnutrition, sarcopenia, aggressive surgery, and postoperative complications including postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE). In this study, we examined whether we could introduce ERAS into PD and achieve short postoperative hospital stay.<br>Methods: Our new strategy consists of three parts. Preoperatively, we routinely assess patients’ muscle strength and nutritional conditions and perform exercise and nutritional intervention for patients with sarcopenia or malnutrition according to the data. In other words, surgical indication is decided not by chronological age but physical age. Intraoperatively, we perform pancreatico-jejunostomy (modified Blumgart’s method) with our stent placement policy and gastro-jejunostomy preventing DGE. Postoperatively, early ambulation, early oral intake, and early drain removal are essential. We have implemented the above strategy since April 2020 and retrospectively examined its validity. Forty-one consecutive patients who underwent open PD with curative intent by January 2023 were enrolled. We examined various surgical outcomes including postoperative hospital stay.<br> Results: There were 26 men and 15 women. The median age was 68 years (range, 40-84). The preoperative diagnosis was pancreas head cancer in 18, distal bile duct cancer in 10 and so on. The median blood loss was 373 ml (25-1155). Grade B POPF was found in 3 patients (7%). No DGE was found. The median day of drain removal was POD 3. The median postoperative hospital stay was 8 days (6-26). All patients returned to their own homes.<br>Conclusions: We could successfully introduce ERAS into PD and achieve short postoperative hospital stay. We think this is “real minimally invasive surgery” irrespective of surgical methods.</p>