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

Abstract

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.

Keywords

ERAS pancreaticoduodenectomy (PD)hepatectomy hepatopancreatobiliary (HPB) oncology prehabilitation goal-directed fluid therapy (GDFT)multimodal analgesia adjuvant chemotherapy timing

Introduction

Enhanced Recovery After Surgery (ERAS) represents a paradigm shift in perioperative medicine. Emerging from Henrik Kehlet’s pioneering work in the 1990s, ERAS demonstrated that multimodal strategies, including optimising analgesia, nutrition, mobilisation and fluid balance, could dramatically shorten hospital stay after colorectal surgery without increasing morbidity.^[1] Building on this foundation, the ERAS→ Society, led by Kehlet, Fearon and Ljungqvist, formalised the first colorectal guidelines in 2005, creating a model that would spread globally.^[2,3]

Within colorectal surgery, ERAS has matured into standard practice. Large systematic reviews and meta-analyses consistently show reduced postoperative complications, earlier return of bowel function and shorter hospital stays, often by 2–3 days, when protocols are implemented comprehensively rather than piecemeal.^[4] This success naturally provoked the question: Can ERAS be transitioned seamlessly into hepatopancreatobiliary (HPB) oncology?

HPB resections pose a different order of magnitude in surgical stress. Pancreaticoduodenectomy (PD) is associated with delayed gastric emptying (DGE), pancreatic fistula and profound catabolic stress, while major hepatectomy can involve substantial blood loss, coagulopathy and postoperative liver dysfunction. In oncologic contexts, these challenges are compounded by malnutrition, cholestasis or immunosuppression from chemotherapy. Applying colorectal-derived ERAS protocols wholesale risks oversimplifying these complexities.

Recognising this, the ERAS Society released speciality-specific guidelines for liver resection (2016) and pancreatic surgery (2019).^[5,6] Early evidence is encouraging. A 2019 meta-analysis of randomised controlled trials in PD reported reduced overall complications and length of stay without increasing readmission rates under ERAS protocols.^[7] Similarly, systematic reviews of ERAS in hepatectomy show reductions in pulmonary complications, enhanced mobilisation and decreased hospital stay by nearly 3 days.^[8] Yet heterogeneity remains: Compliance with ERAS pathways across centres is variable and not all components translate with equal benefit in HPB contexts.

This narrative review, therefore, addresses a critical question: Does ERAS truly translate seamlessly from colorectal to HPB oncology or do these protocols demand adaptation? By synthesising evidence, including randomised trials, meta-analyses and systematic reviews, we aim to provide a one-stop reference for ERAS in pancreatic, hepatic and biliary oncologic surgery. In doing so, we will explore where principles converge, where divergences demand caution and how future refinements may shape enhanced recovery in this uniquely demanding surgical domain.

Core Principles of Eras and Biological Rationale

ERAS hinges on taming the surgical stress response, a whirlwind of hormonal shifts, catabolism, insulin resistance, fluid imbalance and immunosuppression, that slows recovery. Multimodal strategies such as early feeding, minimised fasting, goal-directed fluid therapy (GDFT) and early ambulation have been shown to accelerate return to baseline physiology.^[9,10]

Translating ERAS to HPB oncology requires nuance. Major liver resections involve significant blood loss, thermal dysregulation and risk of postoperative liver insufficiency. GDFT, balancing fluids with hemodynamic guidance, is crucial to avoid venous congestion while preserving tissue perfusion.^[11] A randomised trial comparing GDFT with low central venous pressure (CVP) fluid restriction strategies found no significant differences in blood loss or morbidity, suggesting that HPB surgery resists ‘one-size-fits-all’ approaches.^[12]

Pancreatic surgery brings its own complications, particularly DGE and pancreatic fistula. ERAS interventions such as early oral intake, selective drainage and avoidance of routine nasogastric decompression specifically address these problems.^[13]

Effective analgesia is another cornerstone. Multimodal, opioid-sparing regimens, utilising thoracic epidurals, transversus abdominis plane (TAP) blocks and non-opioid adjuncts, reduce ileus, enhance mobilisation and blunt opioid-induced immunosuppression.^[14] However, compliance with these strategies in real-world HPB settings remains variable, influenced by institutional anaesthetic practices.

Nutrition is equally critical. HPB oncology patients are often malnourished due to cachexia, biliary obstruction or chemotherapy. Prehabilitation and preoperative carbohydrate loading help counteract catabolic stress and immunonutrition has shown benefit in high-risk surgical cohorts.^[15]

A consolidated mapping of ERAS domains to biological targets with HPB-specific adaptations is summarised in Table 1.

Table 1.

Core ERAS elements → biological target → HPB-specific adaptation

ERAS Domain	Specific Intervention (Examples)	Biological Target (Stress/Immune/Metabolic)	Pancreatic Surgery Adaptation	Liver Surgery Adaptation	Compliance Metric (Audit Target)	Evidence Grade*
Nutrition	Pre-operative carbohydrate loading (2–3 h pre-operative); early oral intake POD0–1; consider immunonutrition in malnourished	↓ Insulin resistance; ↓ catabolism; immune preservation	PD: Clear fluids POD0 → soft diet POD1–2; avoid routine NG; tailor for DGE risk	Major hepatectomy: Liquids POD0 if no nausea; advance diet as tolerated; avoid routine NG	≥80% started oral intake within 24 h	A
Fluids	GDFT (SV optimisation); low-CVP during transection; balanced crystalloids; vasopressors as needed	Hemodynamic stability; avoid oedema/congestion; maintain perfusion	Avoid fluid overload to limit DGE/ileus; early de-lines when safe	Maintain low-CVP (≈0–5 mmHg) during parenchymal transection; cautious replacement; selective albumin	≥75% cases with documented GDFT adherence	A-B
Analgesia	Multimodal non-opioid baseline (paracetamol ± NSAID if safe); regional blocks (TAP/ESP); selective thoracic epidural	↓ Opioid use; preserved gut motility; improved mobilisation; preserved immune	Prefer TAP/ESP for MIS or when hypotension is a concern; thoracic epidural analgesia (TEA) for open PD if coagulation permits	Favour TAP/ESP over TEA when coagulopathy risk; consider IV lidocaine per protocol	≥80% on opioid-sparing multimodal plan POD0	B
Mobilisation	Ambulation within 6–8 h post-op; daily step targets; incentive spirometry	↓ pulmonary complications; ↓ insulin resistance; VTE prevention synergy	Walk with drains/lines in situ; step goal >1000 on POD1	Ambulate POD0; rigorous respiratory exercises (esp. cirrhosis)	≥85% ambulate on POD0; documented spirometry use	A
Drains / NG	Selective drain placement; protocolised early removal; avoid routine NG tubes	↓ infection/collections; ↓ ileus; comfort	Selective drains; early removal guided by POD1 drain amylase per institutional threshold; avoid routine NG	Avoid routine drains; remove POD1–2 if output is low and non-bilious; avoid routine NG	Median drain day ≤3 (PD); ≤2 (hepatectomy)	B

Notes: * Evidence Grade: A = guideline + meta-analysis/RCT support; B = consistent cohort/observational data; C = expert consensus. Primary sources aligned with this manuscript’s reference numbers: ERAS pancreas guideline (World J Surg 2020)^[6]; ERAS liver guideline (World J Surg 2016)^[5]; ERAS liver guideline update (World J Surg 2023)^[35]; minimally invasive hepatectomy within ERAS, RCT (ORANGE II) (Br J Surg 2017)^[51]; prehabilitation trial (Br J Anaesth 2019).^[49] ESP^, erector spinae plane block; NG, nasogastric; NSAID, non-steroidal anti-inflammatory drug; ORANGE, Open vs Laparoscopic Left Lateral Sectionectomy trial; POD, post-operative day; SV, stroke volume; VTE, venous thrombo-embolism.

Final, enhanced recovery may influence oncologic outcomes. By reducing postoperative complications and accelerating recovery, ERAS can facilitate the timely initiation of adjuvant therapy and potentially improve long-term survival, reframing ERAS as not merely perioperative optimisation but also an oncologic strategy.^[16]

Risk-stratified prehabilitation and nutrition bundles tailored to HPB oncology are outlined in Table 2.

Table 2.

Prehabilitation and nutrition bundles by risk stratum (HPB ERAS)

Risk Stratum	Components (Exercise / Nutrition / Psych)	Duration (Weeks)	Objective Metrics (Examples)	‘Go / Defer’ Rule (Operate When…)	Audit Metric (Target)	Notes
Standard risk (well nourished, no jaundice, ASA ≤II)	Daily walking + inspiratory muscle training; protein 1.2–1.5 g/kg/day; micronutrient adequacy; expectation setting and pathway coaching	1–2	6-minute walk distance (6MWD) baseline; HGS baseline; PG-SGA A	Baseline optimisation session completed; patient demonstrates pathway literacy	≥90% complete pre-op ERAS education and IMT set-up	Short runway; focus on education/compliance
Malnourished (PG-SGA B/C or ≥10% wt loss)	Dietitian-led high-protein plan; ONS ± immunonutrition; light resistance training; psychosocial support	2–4	PG-SGA improves ≥1 class; prealbumin/albumin rising; weight stable ↑	PG-SGA improves and oral intake ≥75% of the target for ≥7 days	≥80% receive dietitian plan within 72 h of listing	Consider enteral supplements if PO is inadequate
Sarcopenic / Jaundiced (low HGS/CT-SMA; biliary obstruction)	Resistance + IMT; protein 1.5–2.0 g/kg/day; ONS ± immunonutrition; pruritus/sleep support	2–4 (after/selective PBD as indicated)	HGS ↑ ≥10%; 6MWD ↑ ≥25–50 m; bilirubin ↓ post-drainage; CRP trending ↓	Functional gains achieved and bilirubin trending down after adequate drainage	≥75% achieve HGS or 6MWD target before OT	Coordinate timing with drainage to avoid cholangitis
Chemotherapy-exposed / Frail (ECOG 2; recent neoadjuvant)	Low-impact aerobic + resistance; antiemetic optimisation; protein 1.5 g/kg/day; sleep/anxiety interventions	2–3	6MWD recovers to ≥80%-90% of pre-chemo; fatigue scores improved	Functional recovery ≥80% of baseline; no active chemo toxicity ≥CTCAE grade 2	Document pre-/post-chemo 6MWD in ≥80%	Avoid over-training; monitor cytopenias
Cirrhotic (Child-Pugh A)	IMT + gentle aerobic; salt-appropriate nutrition; protein 1.2–1.5 g/kg/day; diuretic review; fall-risk counselling	2–4	No ascites up-trend; INR stable; 6MWD ↑; NHFS/fall score stable	Euvolemia achieved; labs stable; functional targets met	≥80% have documented volume status check before OT	Escalate slowly; coordinate with hepatology

Notes: ONS = oral nutritional supplements; IMT = inspiratory muscle training; HGS = handgrip strength; PG-SGA = Patient-generated Subjective Global Assessment; CT-SMA = CT-derived skeletal muscle area; PBD = preoperative biliary drainage; OT = operating theatre; NHFS = nursing home/fall score surrogate.

* Evidence anchors aligned with your manuscript references: ERAS pancreas guideline^[6]; ERAS liver guideline/update^[35]; sarcopenia/prognostic data in HPB malignancy^[43]; prehabilitation randomised trial.^[49]

Evidence Grade (table concept): A = guideline + RCT/meta-analysis; B = consistent cohort data; C = expert consensus.

CRP, C-reactive protein; CTCAE, Common Terminology Criteria for Adverse Events; ECOG, Eastern Cooperative Oncology Group performance status; INR, international normalised ratio; MWD, 6-minute walk distance.

Eras in Pancreatic Surgery

Pancreatic surgery, particularly PD, remains one of the most complex abdominal operations, with morbidity rates exceeding 40% despite advances in surgical technique and perioperative care. DGE, postoperative pancreatic fistula (POPF) and infectious complications remain major concerns.^[17] The central question is whether ERAS pathways, so successful in colorectal surgery, can mitigate this burden in pancreatic oncology.

Evidence Base and Evolution

The ERAS Society issued its first speciality-specific guidelines for pancreatic surgery in 2019, providing structured recommendations for PD and distal pancreatectomy.^[18] These emphasised preoperative counselling, minimisation of fasting, carbohydrate loading, opioid-sparing analgesia, early mobilisation and selective drain use. Unlike colorectal protocols, these guidelines accounted for complications unique to pancreatic surgery.

Multiple meta-analyses confirm that ERAS is safe and beneficial. A systematic review pooling randomised controlled trial (RCT)s and cohort studies found ERAS reduced overall morbidity by nearly 20%, pulmonary complications by 30% and shortened hospital stay by 2–4 days compared with conventional care.^[19] Subsequent multicentre studies corroborated these results, reporting a faster return of bowel function, reduced infection rates and improved patient-reported outcomes under ERAS protocols.^[20,21]

Pancreaticoduodenectomy

Specific ERAS measures directly target PD-associated complications. Early removal of nasogastric tubes reduces DGE and pulmonary morbidity.^[22] Randomised evidence supports early oral intake as safe and effective, with no increase in POPF, while enhancing nutritional status and satisfaction.^[23]

Drain management has shifted from routine use to selective, early removal. RCTs show that timely removal, guided by drain fluid amylase, reduces intra-abdominal collections and shortens stay.^[24]

Analgesia is a critical component. Epidural analgesia, long considered standard, can delay mobilisation due to hypotension. Alternatives such as TAP blocks, erector spinae blocks or multimodal regimens maintain effective analgesia while facilitating earlier mobilisation.^[25,26]

Technique selection within ERAS should prioritise opioid-sparing and hemodynamic stability; a practical comparison of options is shown in Table 3.

Table 3.

Analgesia strategies in HPB ERAS: Pros, risks and mobilisation impact

Technique	Advantages	Risks / Contraindications	Impact on Mobilisation	Typical Adjuncts	Preferred Use / Notes	Evidence Grade*
Thoracic epidural (TEA)	Excellent analgesia for open upper abdominal incisions; reduced opioid use; improved respiratory mechanics	Hypotension; urinary retention; risk with coagulopathy or thrombocytopenia (hepatectomy); epidural hematoma risk with anticoagulation	May delay early ambulation due to hypotension/lines; careful vasopressor support often required	Paracetamol; NSAID (if safe); low-dose opioid; ketamine as rescue	Open PD or major open hepatectomy when coagulation is normal and hemodynamic monitoring is available	A-B
Transversus abdominis plane (TAP) block	Opioid-sparing; hemodynamically stable; facilitates early ambulation; effective for incisional pain	Limited visceral pain coverage; catheter management for extended benefit	Favours early mobilisation; fewer hypotensive episodes vs. TEA	Paracetamol; NSAID; small-dose opioid; gabapentin/ pregabalin (select)	MIS distal pancreatectomy; open liver resections when TEA is undesirable (coagulopathy risk)	B
Erector spinae / Paravertebral block	Broad hemithorax/upper abdominal coverage; stable haemodynamics; catheterisable	Anatomical variability; anticoagulation protocols are still required	Supports early ambulation with low sympathetic block	Paracetamol; NSAID; ± low-dose opioid	Alternative to TEA for open HPB when hypotension or coagulation risk makes TEA suboptimal	B
IV lidocaine infusion (perioperative)	Potential reduction in ileus and opioid needs; anti-hyperalgesic	Requires monitoring; dose adjustment in liver dysfunction; CNS/cardiac toxicity if overdosed	May hasten GI recovery and reduce pain scores	Standard multimodal foundation (paracetamol ± NSAID)	Consider in open procedures where TEA is contraindicated; institutional protocol is essential	B-C
Opioid-sparing multimodal systemic	Simple, scalable, low-cost; reduces ileus and PONV	NSAID renal/bleeding risks; gabapentinoid sedation	Enables earlier feeding and ambulation vs. opioid-heavy regimens	Paracetamol; NSAID (if safe); ± gabapentinoid; antiemetic	Universal ERAS backbone in HPB; escalate to regional techniques if pain is uncontrolled	A
PCA opioid (rescue/backup)	On-demand titration; straightforward	Ileus, sedation, PONV; immunosuppression concerns	Can slow mobilisation and feeding if overused	Antiemetics; laxatives; limit background infusion	Keep as rescue within ERAS; prioritise non-opioid and regional first	C

Notes: * Evidence Grade: A = guideline + meta-analysis/RCT support; B = consistent cohort/observational data; C = expert consensus.

Primary sources aligned with this manuscript’s references: ERAS pancreas guideline^[6]; ERAS liver guideline^[5]; ERAS liver update^[35]; analgesia meta-analysis for open abdominal surgery^[14]; regional blocks review (paravertebral/ESP)^[26]; TAP vs. epidural randomised trial in liver resection.^[25]

Distal Pancreatectomy

Distal pancreatectomy benefits from minimally invasive approaches. Randomised evidence (Laparoscopic vs Open Distal Pancreatectomy trial (LEOPARD) trial) demonstrated that laparoscopic and robotic distal pancreatectomy, combined with ERAS, reduces blood loss, shortens stay by 2–3 days and expedites functional recovery compared with open procedures.^[27] Enhanced recovery also minimises opioid use and promotes earlier return to independence.^[28]

Compliance and Real-world Implementation

Despite encouraging results, ERAS implementation in pancreatic surgery faces real-world challenges. Compliance rates range from 55% to 75%, with frequent lapses in early feeding, mobilisation and drain removal.^[29] Barriers include institutional inertia, entrenched surgical dogma (particularly regarding drains and NG tubes) and anaesthetic preferences for epidural use. Importantly, high compliance correlates directly with improved outcomes, underscoring the need for multidisciplinary teamwork and cultural change.^[30]

Criteria-based policies for drains and nasogastric tubes, with audit targets, are summarised in Tables 4 and 5.

Table 4.

Drains and nasogastric (NG) management in HPB ERAS: Indications, removal criteria and outcomes

Context	Policy	Removal Criteria / Test	Outcome Impact	Exceptions / Cautions	Audit Metric (Target)	Evidence Grade*
Pancreaticoduodenectomy (PD): Intra-abdominal drains	Selective placement; early removal guided by output and POD1 drain amylase	POD1 drain amylase below institutional threshold; non-turbid, low-volume output; afebrile	↓ Intra-abdominal collections; ↓ LOS when removed early	Soft pancreas, small duct, high fistula risk: Maintain close monitoring even with early removal policy	Median drain day ≤3	A (ERAS guideline + RCT^[6,24])
PD: Nasogastric tube	Avoid routine NG; remove in theatre or early post-op	Tolerating oral sips; no gastric residuals/retching; stable haemodynamics	↓ DGE/respiratory issues; ↑ comfort and mobilisation	Severe gastric atony, aspiration risk: Consider short, criteria-based NG reinsertion	≥90% PDs without routine NG beyond POD0	A (ERAS guideline^[6])
Distal pancreatectomy-drains	Selective or omit in low-risk cases; early removal if used	POD1 amylase low; minimal serous output	↓ Collections; ↓ LOS with early removal	High-risk pancreatic stump (soft gland) or significant output: Delay removal	≥70% early removal ≤POD2 when placed	B (ERAS guideline + cohort^[6])
Major hepatectomy (non-biliary reconstruction)-drains	Avoid routine drains; use selectively	If placed: Low bilious output; no rising bilirubin; stable haemodynamics	No increase in bile leak with selective use; ↓ infection risk	Raw surface ooze, difficult haemostasis: Short-term drain is reasonable	≤20% routine drain use; removal ≤POD2 when used	A-B (ERAS liver guideline/update^[5,35])
Major hepatectomy: Nasogastric tube	Avoid routine NG	Clinical tolerance of oral fluids; no ileus	↓ Respiratory complications; earlier feeding	Massive transfusion/ileus: Individualised NG use	≥90% without NG beyond PACU/POD0	A-B (ERAS liver guideline/update^[5,35])
Hepatectomy with biliary-enteric anastomosis	Selective drains; remove when safe rather than fixed day	Non-bilious, low-volume output; no sepsis; normalising labs	Maintains safety while enabling early mobilisation/feeding	High-risk of bile leak/cholangitis: Extend drainage; stepwise diet	Document criteria-based removal in ≥80%	B (Guideline consensus^[5,35])

Notes: * Evidence Grade: A = guideline + meta-analysis/RCT support; B = consistent cohort/observational data; C = expert consensus.

Primary sources aligned with this manuscript’s reference numbers: ERAS pancreas guideline (World J Surg 2020)^[6]; ERAS liver guideline (World J Surg 2016)^[5]; ERAS liver guideline update (World J Surg/HPB)^[35]; early drain removal after PD, RCT (Ann Surg 2010).^[24]

Table 5.

Intraoperative fluid strategies in HPB ERAS: GDFT vs. low-CVP, targets and trade-offs

Strategy	Monitoring / Targets	Key Intraoperative Goals	Ideal Use-Cases	Early Post-op Considerations	Evidence Notes	Evidence Grade*
Goal-Directed Fluid Therapy (GDFT)	Advanced haemodynamics (stroke volume/cardiac output); dynamic indices (SVV/PPV); MAP ≥65 mmHg; small boluses to reach SV plateau; vasopressors as needed	Maintain perfusion without overload; avoid gut/liver oedema; reduce ileus and pulmonary issues	Major hepatectomy with variable physiology; open or MIS PD with labile hemodynamics	Early ‘de-resuscitation’ if positive balance; daily weight/ins-outs; oxygenation checks	ERAS liver guidelines endorse individualized, haemodynamics-guided therapy; meta-analysis/RCTs show reduced complications/LOS within ERAS pathways that include structured fluids^[35–38]	A-B
Low Central Venous Pressure (Low-CVP)	CVP ≈0–5 mmHg during parenchymal transection; MAP supported with vasopressors; restrict crystalloids during transection	Minimise venous back-bleeding; reduce blood loss and transfusion	Open hepatectomy with long transection; large tumours near major veins	Transition to balanced replacement after transection; monitor lactate/urine output	Considered safe/effective for blood loss control; no consistent superiority over GDFT, choice should be individualised^[35–38]	B
Hybrid / Context-adaptive	Low-CVP for transection, GDFT before/after; MAP ≥65 mmHg; dynamic indices to titrate	Combine blood-sparing with global perfusion optimisation	Complex resections; cirrhotic livers needing careful perfusion	Early ambulation; cautious fluids; diuresis if overloaded	Supported by guideline consensus and cohort data; aligns with ERAS emphasis on individualised fluids^[35–36]	B-C

Notes: * Evidence Grade: A = guideline + meta-analysis/RCT support; B = consistent cohort/observational data; C = expert consensus.

Primary sources aligned with this manuscript’s references: ERAS liver guideline (World J Surg 2016)^[35]; ERAS liver update (HPB 2022)^[36]; hepatectomy meta-analysis^[37]; ERAS hepatectomy RCT.^[38] MAP, mean arterial pressure.

Special Considerations in Pancreatic Oncology

ERAS in pancreatic oncology is complicated by frailty, sarcopenia and obstructive jaundice. These patients may not tolerate early feeding or rapid mobilisation as easily as healthier cohorts. Prehabilitation, tailored nutritional support and staged mobilisation strategies may be required to personalise ERAS pathways.^[31] Sarcopenia, in particular, predicts postoperative morbidity and delayed adjuvant therapy; thus, targeted interventions in this subgroup are a future priority.

Oncologic Implications

Beyond perioperative metrics, ERAS may influence oncologic outcomes. Reduced morbidity and faster recovery enable earlier initiation of adjuvant chemotherapy, often within the critical 8-week window post-surgery. A multicentre cohort demonstrated significantly higher rates of timely chemotherapy initiation among ERAS-compliant patients.^[32] Furthermore, reduced opioid exposure and attenuated stress responses may preserve perioperative immune function, with potential implications for recurrence risk.^[33]

Future Directions

Despite robust evidence, heterogeneity persists. Many studies remain single-centre and compliance varies across institutions. Ongoing RCTs are evaluating ERAS protocols in minimally invasive PD, aiming to standardise best practices and clarify oncologic benefits.^[34] Integration of digital health tools for compliance monitoring, biomarkers for risk stratification and multicentric collaborations will shape the next generation of pancreatic ERAS protocols.

Summary

In pancreatic surgery, ERAS is safe, feasible and beneficial. It reduces morbidity by nearly 20%, shortens hospital stay by 2–4 days and accelerates recovery without increasing mortality. However, translation from colorectal protocols is not seamless. Pancreatic-specific complications, patient frailty and compliance barriers necessitate adaptation.

Eras in Liver Surgery

Major liver resection represents a formidable physiologic challenge. Substantial blood loss, intravascular volume shifts, coagulopathy and the risk of post-hepatectomy liver failure (PHLF) have historically contributed to morbidity rates exceeding 30% in complex resections. While perioperative mortality is now under 5% in high-volume centres, the focus has shifted toward functional recovery, quality of life and timely resumption of oncologic treatment. ERAS pathways are increasingly employed to meet these aims.

Guidelines and Evidence

The ERAS→ Society released the first perioperative guidelines for liver surgery in 2016, emphasising multimodal care strategies such as preoperative optimisation, opioid-sparing analgesia, restrictive fluid therapy, early mobilisation and selective use of drains.^[35] An international update in 2022 expanded recommendations to include minimally invasive hepatectomy, refined transfusion thresholds and newer regional analgesia techniques.^[36]

The benefits are supported by high-quality evidence. A 2017 meta-analysis of more than 2,000 patients showed that ERAS reduced overall morbidity by nearly 30% and shortened median length of stay from approximately 10 to 7 days.^[37] A randomised trial confirmed that ERAS reduced pulmonary complications, facilitated earlier mobilisation and did not increase PHLF, even after extended resections.^[38] A large multicentre cohort study reinforced these findings, showing that hospitals with high compliance achieved the greatest reductions in complications, length of stay and costs.^[39]

Key Elements

Fluid management is central to hepatic ERAS. GDFT, guided by cardiac output monitoring, aims to avoid both hypoperfusion and venous congestion. Randomised comparisons with low-CVP techniques suggest both are safe, highlighting the need for individualised strategies.^[38]

Analgesia is another cornerstone. While thoracic epidurals provide strong analgesia, they are associated with hypotension and coagulopathy in liver surgery. Alternatives, such as TAP blocks, erector spinae blocks and multimodal systemic regimens, have gained favour, enabling earlier mobilisation without compromising pain control.^[36]

Minimally invasive hepatectomy has synergised with ERAS. An international series of more than 9,000 cases demonstrates reduced blood loss, lower narcotic requirements and hospital stay shortened by 3–4 days compared with open resections.^[40] Many of these series include both benign and malignant indications, but accumulating oncologic data suggest that outcomes in hepatocellular carcinoma and colorectal liver metastases are not compromised.

Cirrhotic Patients and Oncologic Outcomes

Cirrhosis complicates ERAS implementation. Evidence supports safety in Child-Pugh A patients, but caution is warranted in Child-Pugh B or C patients, where fluid balance and mobilisation must be carefully titrated. Regardless of background liver disease, ERAS has not been shown to compromise oncologic adequacy: microscopically margin-negative resection (R0) resection rates, lymph node yield and survival outcomes are equivalent to conventional care.^[39] Importantly, accelerated recovery allows earlier initiation of adjuvant therapy in colorectal liver metastases and hepatocellular carcinoma, potentially improving disease control.

Future Directions

Future refinements include multicentre RCTs evaluating ERAS in minimally invasive hepatectomy, digital compliance monitoring tools and tailored prehabilitation for frail or cirrhotic patients. As these data mature, ERAS is poised to become standard practice, aligning surgical precision with perioperative optimisation in hepatic oncology.

Summary

ERAS in liver surgery is safe, feasible and beneficial. It reduces complications by ~30%, shortens hospital stay by 2–3 days and supports faster recovery without compromising oncologic safety. Individualised care, especially for cirrhotic patients, multidisciplinary adherence and integration with minimally invasive approaches will define the next era of enhanced recovery in hepatic oncology.

Eras in Biliary Surgery/Cholangiocarcinoma

Radical surgery for hilar cholangiocarcinoma and complex biliary malignancies is among the most demanding procedures in HPB oncology. These operations often require extended hepatectomy with biliary reconstruction, performed in patients who are jaundiced, malnourished or cholangitic. The physiological stress of such surgery, combined with the risks of bile leak, cholangitis and PHLF, poses challenges for implementing standardised ERAS pathways.

Evidence and Feasibility

Unlike pancreatic and hepatic surgery, there are no dedicated ERAS Society guidelines for biliary malignancies. Instead, practice has been adapted from liver surgery protocols. Early prospective studies suggest feasibility and benefit. In a Chinese cohort, ERAS shortened the median length of stay from 14 to 11 days and reduced infectious morbidity by nearly 20%, without increasing biliary leak after resection for hilar cholangiocarcinoma.^[41] Similarly, a French multicentre study of patients undergoing major hepatectomy with biliary reconstruction reported that ERAS reduced pulmonary complications and enabled earlier resumption of oral intake compared with conventional care.^[42] More recently, a single-centre analysis confirmed that ERAS for radical resection of hilar cholangiocarcinoma was safe and associated with fewer postoperative complications and faster functional recovery.^[43]

Challenges in Implementation

Preoperative biliary drainage represents a particular dilemma. While ERAS generally discourages unnecessary preoperative interventions, selective drainage is essential in jaundiced patients to reduce cholangitis risk and improve hepatic reserve. Surgeons also remain cautious about early drain removal and aggressive feeding after biliary-enteric reconstruction, fearing bile leaks and septic complications. Nutritional optimisation and immunonutrition are crucial, as sarcopenia and protein-calorie malnutrition are strong predictors of adverse outcomes.^[44]

Future Directions

The current evidence base is limited, largely derived from Asian and European single-centre series. Broader validation in multicentre and Western cohorts is urgently needed to establish generalisability. Until then, ERAS in cholangiocarcinoma should be viewed as a flexible framework, where core principles, early mobilisation, multimodal analgesia and restrictive fluid therapy are preserved, but elements such as drainage, nutrition and timing of oral intake are carefully individualised.

Comparative Analysis: Does Eras Translate Seamlessly?

The origins of ERAS lie in colorectal surgery, where standardised multimodal protocols consistently demonstrated reductions in morbidity, length of stay and costs.^[45] In high-volume colorectal centres, adherence rates frequently exceed 80%–90% and outcomes are now predictable and reproducible worldwide. This maturity naturally prompted attempts to extend ERAS principles to HPB oncology.

Yet translation has proven less straightforward. PD carries risks of DGE, pancreatic fistula and nutritional compromise, while major hepatectomy entails blood loss, coagulopathy and PHLF. Although meta-analyses confirm that ERAS reduces morbidity and shortens hospital stay by 2–4 days in both pancreatic and hepatic resections, the magnitude of benefit is more variable than in colorectal cohorts.^[46] Equally important, compliance rates in HPB ERAS are consistently lower, typically around 60%–70% with early feeding, drain management and fluid restriction being the most common areas of hesitation.^[47]

Patient profile also differs. Unlike many colorectal patients, those with HPB malignancies often present with obstructive jaundice, cholangitis, sarcopenia or chemotherapy-induced frailty, which complicates the straightforward application of standardised bundles. These comorbidities highlight that while the principles of ERAS, attenuation of surgical stress, early mobilisation, nutritional optimisation and multimodal analgesia are universal, the execution requires thoughtful, speciality-specific adaptation.

Encouragingly, ERAS has not been shown to compromise oncologic outcomes. Studies demonstrate equivalent R0 resection rates, nodal yield and long-term survival compared with conventional care. More importantly, ERAS facilitates earlier initiation of adjuvant chemotherapy, often within the critical 6–8 weeks window after pancreatic or hepatic resections, a factor directly linked to improved survival.^[48]

A quantitative summary of effect sizes for pancreatic and liver resections under ERAS versus conventional care is presented in Table 6.

Table 6.

Summary of effect sizes with ERAS vs. conventional care (pancreatic vs. liver resections)

Outcome	Pancreatic Surgery (ERAS vs. Conventional)	Liver Surgery (ERAS vs. Conventional)	Readmission / Mortality	Primary Evidence Anchor (See Refs)
Length of stay (LOS)	↓ ~2–4 days (centre and compliance-dependent)	↓ ~2–3 days	No increase in readmission or mortality	Pancreas meta-analysis^[46]; Liver meta-analysis,^[37] RCT^[38]
Overall complications	↓ ~20%–30%	↓ ~25%–30%	–	^[37,46]
Pulmonary complications	↓ ~20%–30%	↓ ~20%–30%	–	^[37,46]
GI recovery (DGE/ileus)	DGE ↓ modestly with early NG removal/early feeding; ileus ↓	Ileus ↓ with multimodal analgesia and early mobilisation	–	^[37,46]
POPF / bile leak / PHLF	POPF: Mixed; selective early drain removal ↓ collections/LOS	Bile leak: Mixed; PHLF not increased	–	^[37,38,46]
Time to functional recovery	Earlier return of bowel function and ambulation	Earlier mobilisation; faster discharge readiness	–	^[37,38,46]

Notes: Effect sizes represent pooled or representative ranges across contemporary meta-analyses and randomised/controlled data. Benefits scale with protocol compliance (typically ~60%–70% in HPB vs. ≥80%–90% in mature colorectal programmes). Outcomes vary by case mix (frailty, jaundice and cirrhosis), surgical approach (open vs. minimally invasive) and institutional pathways.

Primary sources aligned with manuscript references: Pancreatic meta-analysis^[46]; hepatic meta-analysis^[37]; hepatic RCT within ERAS.^[38]

Future Directions and Conclusion

Although the evidence base for ERAS in HPB oncology has grown rapidly, its maturity lags behind colorectal surgery. To fully realise its potential, ERAS in HPB surgery must evolve across several key domains.

Future Directions

1. Precision ERAS and Risk Stratification

ERAS should move beyond a uniform pathway toward individualised recovery programmes. Incorporating biomarkers of frailty, sarcopenia and hepatic reserve will allow tailored interventions. Prehabilitation, encompassing exercise, nutrition and psychological support, has shown measurable benefits. In a randomised trial, prehabilitation improved preoperative 6-minute walk distance by 36 m and reduced postoperative complications in high-risk abdominal surgery patients.^[49] Such strategies are especially pertinent in frail, jaundiced or chemotherapy-exposed HPB patients.

2. Digital Health and Compliance Monitoring

Compliance remains the strongest predictor of ERAS success, yet real-world adherence averages only 60%–70% in HPB surgery. Mobile health applications and wearable devices are being piloted to track step counts, nutritional intake and analgesic use, providing real-time feedback to patients and clinicians. Early trials suggest these tools improve compliance rates by nearly 15%.^[50]

3. Minimally Invasive and Robotic Synergy

Combining ERAS with laparoscopic or robotic surgery offers synergistic benefits. In the ORANGE II trial, laparoscopic hepatectomy within ERAS shortened hospital stay by 3 days compared with open resection.^[51] Ongoing RCTs are evaluating whether minimally invasive PD in an ERAS framework can deliver similar benefits.

4. Global Expansion and Equity

Most high-quality ERAS studies come from Asia and Europe. For low- and middle-income countries, simplified, low-cost ERAS bundles, such as reduced preoperative fasting, early mobilisation and multimodal analgesia, can deliver meaningful improvements even in resource-constrained settings.^[52] Capacity-building and international collaborations will be critical to ensuring ERAS is accessible globally.

5. Oncologic Outcomes as Endpoints

Future trials must extend beyond perioperative outcomes to include recurrence, disease-free survival and chemotherapy delivery. A systematic review suggests that ERAS patients are 20%–30% more likely to initiate adjuvant therapy within the optimal 8-week window, a factor directly linked to survival.^[53] Establishing these long-term benefits would position ERAS as an oncologic, not just perioperative, strategy.

Conclusion

ERAS has transformed perioperative care in colorectal surgery and is now steadily reshaping HPB oncology. Evidence supports its ability to reduce morbidity, shorten length of stay by 2–4 days and improve functional recovery without compromising oncologic outcomes. However, translation is not seamless; protocols require tailoring to the unique physiologic challenges of pancreatic and hepatic resections and to the comorbidities of oncology patients. Looking ahead, precision-based ERAS, digital compliance tools, minimally invasive synergy and global equity will define the next era. With these refinements, ERAS is poised to become not just a perioperative adjunct but a new standard of care in HPB oncology, aligning surgical excellence with oncologic integrity.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Institutional ethical committee approval number

Not applicable (narrative review).

Informed Consent

Not applicable. This manuscript is a narrative review and does not involve human participants or identifiable patient data.

Credit author statement

Dr Supreet Kumar: Concept, design, literature synthesis, drafting, final approval.

Dr Vivek Tandon: Critical revision for intellectual content, surgical perspective.

Dr Deepak Govil: Senior oversight, critical revision and approval of final manuscript.

Data availability

No new data were generated or analysed in this study. Data sharing is not applicable.

Use of artificial intelligence

Artificial intelligence tools (ChatGPT, OpenAI, San Francisco, CA, USA) were used to assist in language refinement and formatting under the direct supervision of the corresponding author. The intellectual content, data interpretation, and final conclusions are entirely those of the authors.

Guarantor

Dr Supreet Kumar accepts full responsibility for the integrity and accuracy of the content.

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