Enhanced Recovery After Surgery (ERAS) in Hepatopancreatobiliary Oncology: Seamless Translation or Tailored Adaptation?

Background: Enhanced Recovery After Surgery (ERAS) improves outcomes in colorectal surgery, but whether its principles translate seamlessly to hepatopancreatobiliary (HPB) oncology, where pancreaticoduodenectomy (PD) and major hepatectomy carry unique physiologic hazards, remains uncertain. Objective: To synthesise contemporary evidence on ERAS in pancreatic and hepatic cancer surgery and determine if direct transfer from colorectal pathways is appropriate or if speciality-specific adaptation is required. Methods: Narrative review of ERAS Society guidelines, randomised trials, multicentre cohorts and systematic reviews/meta-analyses addressing prehabilitation and nutrition, goal-directed fluid therapy (GDFT), multimodal or regionally augmented analgesia, early feeding and mobilisation, selective drain and nasogastric (NG) management and integration with minimally invasive approaches. Outcomes included morbidity, length of stay, readmission, oncologic adequacy and timing of adjuvant therapy. Results: ERAS for pancreatic and liver resections is feasible and safe, shortening hospital stay by ~2–4 days and reducing complications by ~20%–30% without increasing readmissions or mortality. Oncologic metrics (microscopically margin-negative resection [R0] margin and nodal yield) are preserved and ERAS pathways more often enable initiation of adjuvant chemotherapy within 6–8 weeks. Translation is not uniform: Compliance, an independent determinant of benefit, tends to be lower in HPB (~60%–70%) than in mature colorectal programmes (≥80%–90%), largely due to caution with early oral intake, selective or early drain removal and fluid restriction. Patient factors common in HPB oncology (obstructive jaundice, cholangitis, sarcopenia and chemotherapy-related frailty) necessitate tailored prehabilitation and individualised fluid and analgesia strategies. Evidence for ERAS in biliary malignancies is promising but limited. Conclusions: ERAS principles are universal, but their execution in HPB oncology demands thoughtful adaptation. Precision-based pathways, digital tools to improve adherence, synergy with minimally invasive surgery and trials incorporating oncologic endpoints should define the next phase of ERAS in HPB cancer care.