Enhanced recovery after surgery in pancreatic surgery: a comparative systematic review of global practices, compliance variation, and clinical outcomes.

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols have been increasingly adopted in pancreatic surgery; however, substantial variation exists in their implementation and in reported outcomes. A comprehensive evidence map of ERAS guideline components and their global application in pancreatic surgery is lacking. Therefore, this systematic review aimed to map current ERAS protocols, evaluate compliance, and summarize associated clinical outcomes.

METHODS

Following PRISMA(Preferred Reporting Items for Systematic Reviews and Meta-Analyzes) guidelines, a systematic search of PubMed, Scopus, Web of Science, and international trial registries was conducted for studies published between 1980 and December 2025. Eligible studies included original, peer-reviewed English-language reports describing ERAS protocols in pancreatic surgery. Data were extracted and synthesized descriptively.

RESULTS

A total of 32 studies comprising 3930 patients were included. ERAS protocols demonstrated marked heterogeneity across centers and countries. Consistently implemented components included preoperative counseling, antimicrobial prophylaxis, thoracic epidural analgesia, early nasogastric tube removal, early mobilization, and structured discharge criteria. Compliance varied widely (approximately 35%-100%), with higher adherence generally being associated with a shorter length of stay (LOS). Most studies reported LOS ranging between 7 and 15 days. Morbidity ranged from 30% to 60%; mortality remained low (0.0-4.0%), and readmission rates varied from 0% to 19%. Limited cost analyzes suggested potential savings. Favorable predictors of recovery included early solid intake, early drain removal, avoidance of nasogastric tubes, early mobilization, low drain fluid amylase, and robotic surgery, whereas postoperative complications, higher body mass index or American Society of Anesthesiologists class, and intraoperative transfusion were associated with prolonged LOS or ERAS failure.

CONCLUSION

ERAS is widely used in pancreatic surgery with favorable outcomes, yet marked heterogeneity and variable compliance indicate a need for more standardized and consistently implemented protocols.