Implementing ERAS Beyond High-Volume HPB Centers: Reduced ICU Utilization and Length of Stay After Pancreaticoduodenectomy

Background Pancreaticoduodenectomy (PD) is often a morbid procedure with a prolonged recovery time. Enhanced recovery after surgery (ERAS) protocols have been shown to improve outcomes at high-volume hepatopancreaticobiliary (HPB) centers, but data on their implementation and reproducibility in moderate-volume institutions remain limited. In 2018, we implemented a standardized ERAS protocol for patients undergoing PD at a Commission on Cancer (CoC)-accredited, moderate-volume teaching hospital with a mean annual PD volume of 30 cases. Components of this pathway included a nurse-led preoperative educational session, nutritional optimization, multimodal pain control, incentive spirometer use, and early ambulation. Methods A retrospective analysis of 200 patients who underwent PD between January 2015 and December 2022 compared ICU length of stay, overall hospital length of stay, and discharge disposition before and after the implementation of the standardized ERAS protocol. Patient demographics and clinical characteristics were similar between groups. Results Enhanced recovery after surgery implementation was associated with significant reductions in ICU stay (mean 3.13 days vs 0.82 days, P < .0001), reductions in hospital length of stay (mean 15.37 vs 11.21 days, P = .0012), and increases in favorable discharge disposition to home (73.1% vs 83.1%, P = .044). No remarkable differences were noted in readmission rates or death within 30 days after surgery. Discussion Implementation of a standardized ERAS program for PD can be successfully achieved at a moderate-volume institution with results comparable to those reported from specialized high-volume HPB centers. These findings support the broader applicability of ERAS for PD beyond major academic referral centers.