Copyright ©The Author(s) 2016.
World J Gastroenterol. Jul 28, 2016; 22(28): 6456-6468
Published online Jul 28, 2016. doi: 10.3748/wjg.v22.i28.6456
Table 1 Enhanced recovery pathway interventions for pancreatic surgery
Patient educationDedicated counseling providing patients with information and goals for recovery
Optimization of organ dysfunctionOptimization of patient comorbidities and patient conditioning
Oral immunonutritionOral immunonutrients should be taken for 5-7 d prior to surgery
Selective biliary drainageEndoscopic biliary drainage only indicated if serum bilirubin > 14.5 mg/dL, in case of cholangitis or planned neoadjuvant treatment
Avoid mechanical bowel preparationOral bowel preparation should not be used
Minimize fastingIntake of clear fluids up to 2 h before anesthesia, and solid food until 6 h before.
Carbohydrate loadingA carbohydrate drink should be given the morning before surgery
Thromboembolic disease prophylaxisLow molecular weight heparin should be administered
Antimicrobial prophylaxisAntibiotic prophylaxis should start 30-60 min before incision
Epidural and opioid sparing analgesiaAvoid opioids. Multimodal analgesia including thoracic epidural analgesia, acetaminophen, NSAIDs. Early transition to oral analgesics
PONV prophylaxisMultimodal nausea and vomit prophylaxis
Avoid hypothermiaActive cutaneous warming
Balanced intravenous infusionsAvoid fluid overload. Maintain near-zero fluid balance. Potential benefit in the use of goal directed fluid therapy.
Avoid nasogastric intubationNasogastric tube should be removed at the end of surgery
Glycemic controlAvoid hyperglycemia with frequent blood sugar monitoring and insulin infusion when necessary
Early removal of urinary drainageBladder catheter should be removed within postoperative day 2
Early removal of perianastomotic drainEarly drain removal in patients at low risk for pancreatic fistula
Early oral feedingPatients should be allowed a normal diet without restrictions as tolerated
Gastrointestinal stimulationOral laxative and chewing-gum should be started early after surgery
Early stop of intravenous infusionsIntravenous fluids should be stopped as soon as patients are able to tolerate oral liquids
Early mobilizationScheduled active mobilization should start from postoperative day 1
AuditSystematic audit on care processes and outcomes
Table 2 Study design and characteristics
StudyYearDesignSample size
Type of resection
Porter et al[53]2000Retrospective cohort8068PD, TP
Vanounou et al[54]2007Retrospective cohort14564PD
Kennedy et al[55]2007Retrospective cohort9244PD, TP
Balzano et al[56]2008Retrospective cohort252252PD
Kennedy et al[57]2009Retrospective cohort7140LP
Nikfarjam et al[58]2013Retrospective cohort2021PD
Abu Hilal et al[59]2013Retrospective cohort2420PD
Braga et al[60]2014Retrospective cohort115115PD
Kobayashi et al[61]2014Retrospective cohort100142PD
Nussbaum et al[62]2014Retrospective cohort50100LP
Nussbaum et al[63]2014Retrospective cohort100142PD
Coolsen et al[64]2014Retrospective cohort144186PD
Shao et al[65]2015Retrospective cohort325310PD
Sutcliffe et al[66]2015Retrospective cohort6565PD
Joliat et al[67]2015Prospective cohort27487PD
Morales Soriano et al[68]2015Retrospective cohort4144PD
Richardson et al[69]2015Retrospective cohort2244LP
Table 3 Enhanced recovery pathway elements used in comparative studies
Total number of ERP elements
Patient education and counsellingNo mechanical bowel preparationShorter preoperative fastingCarbohydrate loadingProphylactic antibioticsThromboembolic disease prophylaxisEpidural/multimodal analgesiaPrevention of nausea and vomitingPrevention of hypothermiaEarly nasogastric tube removalEarly removal of urinary catheterEarly discontinuation of IV fluidsGlycemic controlStandardized perianastomotic drain managementEarly oral feedingEarly mobilizationStimulation of GI function
Porter et al[53]4
Vanounou et al[54]7
Kennedy et al[55]9
Balzano et al[56]8
Kennedy et al[57]9
Nikfarjam et al[58]12
Abu Hilal et al[59]7
Braga et al[60]13
Kobayashi et al[61]6
Nussbaum et al[62]8
Nussbaum et al[63]9
Coolsen et al[64]14
Shao et al[65]4
Sutcliffe et al[66]13
Joliat et al[67]17
Morales Soriano et al[68]11
Richardson et al[69]10
Table 4 Postoperative length of stay and readmission rates
StudyPostoperative length of stay (d)
Readmission rates
ERPUsual careP valueERPUsual careP value
Porter et al[53]12150.00110 (15)9 (11)0.620
Vanounou et al[54]880.35713 (9)4 (6)0.508
Kennedy et al[55]713< 0.0017 (8)3 (7)> 0.05
Balzano et al[56]13 (7-110)15 (7-102)< 0.00118 (7)16 (6)0.865
Kennedy et al[57]Mean 7Mean 100.0375 (7)10 (25)0.027
Nikfarjam et al[58]8 (7-16)14 (8-29)< 0.0013 (15)00.107
Abu Hilal et al[59]8 (7-13)13 (10-20)0.0151 (1)2 (8)0.583
Braga et al[60]11 (5-51)13 (8-54)0.22614 (12)12 (10)0.835
Kobayashi et al[61]22 ± 1236 ± 24< 0.0012 (2)2 (2)0.689
Nussbaum et al[62]6 (5-9)7 (5-9)0.02615 (30)20 (20)0.219
Nussbaum et al[63]11 (8-18)13 (10-18)0.01531 (31)36 (25)0.850
Coolsen et al[64]14 (7-83)20 (9-132)< 0.05011 (13)14 (14)NR
Shao et al[65]14 ± 718 ± 8< 0.00143 (13)44 (14)0.725
Sutcliffe et al[66]9 (4-70)10 (4-114)0.1609 (15)5 (8)0.260
Joliat et al[67]15 (11-24)19 (14-29)0.029NRNRNR
Morales Soriano et al[68]14 ± 1.319 ± 20.0149 (10)4 (9)> 0.05
Richardson et al[69]3 (3-4)6 (5-10)< 0.0012 (9)8 (18)0.476
Table 5 Morbidity and mortality rates
StudyComplication rates
Mortality rates
ERPUsual careP valueERPUsual careP value
Porter et al[53]56 (70)52 (76)0.2102 (3)1 (1)0.870
Vanounou et al[54]77 (54)40 (62)0.2072 (1)1 (2)0.918
Kennedy et al[55]34 (37)19 (44)> 0.051 (1)1 (2)> 0.05
Balzano et al[56]119 (47)148 (59)0.0149 (4)7 (3)0.798
Kennedy et al[57]11 (16)15 (38)> 0.051 (1)1 (2)> 0.05
Nikfarjam et al[58]NRNRNRNR-
Abu Hilal et al[59]8 (40)6 (67)0.07700-
Braga et al[60]69 (60)76 (66)0.3394 (4)4 (4)1
Kobayashi et al[61]39 (39)54 (60)0.00401.10.957
Nussbaum et al[62]13 (26)24 (24)0.84200-
Nussbaum et al[63]43 (43)53 (41)0.7921 (1)4 (3)0.651
Coolsen et al[64]46 (53)48 (49)> 0.054 (5)6 (6)> 0.05
Shao et al[65]127 (39)173 (55.8)< 0.00140 (12)53 (17)NR
Sutcliffe et al[66]15 (34)15 (41)0.6502 (3)2 (3)1
Joliat et al[67]50 (68)71 (82)0.0463 (4)4 (5)1
Morales Soriano et al[68]12 (30)24 (55)0.02902 (2)> 0.05
Richardson et al[69]6 (27)17 (39)0.42100-