ERAS enables safe ≤ 100-hour discharge after pancreatoduodenectomy: a multicenter cohort study

BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathways have been increasingly adopted in gastrointestinal surgery; however, their application to pancreatoduodenectomy (PD) remains variable due to concerns regarding postoperative morbidity and safety (1-3). This study aimed to evaluate the impact of ERAS on postoperative outcomes and the feasibility of ultra-early discharge following PD. METHODS: A multicenter cohort study was conducted including 180 patients undergoing PD across four tertiary hepatopancreatobiliary centers. Sixty patients were managed prospectively under a standardized ERAS protocol, while 120 patients treated prior to ERAS implementation served as controls. Postoperative outcomes, including pancreatic fistula and delayed gastric emptying defined according to established criteria, were analyzed (4,5). Multivariate logistic regression was performed to identify predictors of discharge within ≤ 100 h. RESULTS: Baseline characteristics were comparable between groups. ERAS compliance exceeded 83% across key perioperative domains. Rates of clinically relevant pancreatic fistula were similar between groups (3.3% vs. 2.5%, p > 0.05). Delayed gastric emptying was significantly reduced in the ERAS cohort (13.3% vs. 31.7%, p = 0.011). Major complications (Clavien-Dindo ≥ III) occurred in 3.3% vs. 5.8%, readmission rates were 7.0% vs. 6.0%, and 90-day mortality was 3.3% vs. 1.7% in the ERAS and control groups, respectively. Mean length of stay was significantly shorter in the ERAS group (4.48 vs 10.91 days, respectively; p < 0.001), with 81.7% of patients achieving discharge within ≤100 hours compared to none in the control group. Importantly, while the majority of ERAS patients achieved early discharge, a small subset experienced prolonged hospital stay, resulting in partial overlap with the control group. ERAS implementation was the strongest independent predictor of early discharge. CONCLUSION: ERAS pathways in pancreatoduodenectomy are safe and reproducible, and enable substantial acceleration of postoperative recovery without increasing morbidity, supporting their integration into routine pancreatic surgical practice. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05192044.