Pancreatic surgery, and especially PD, is considered as a complex and high-risk surgical procedure. While the mortal­ity has signicantly decreased to less than 5% with the cen­tralization in high volume centers, the morbidity remains high (30–60%) with prolonged LOS [8]. Postoperative com­plications such as postoperative pancreatic stula (POPF), delayed gastric emptying (DGE) and surgical site infections (SSI) contribute to delay the recovery and increase the LOS [9, 10]. Besides, pancreatic surgery remains challenging because several questions remain unsolved considering pro­phylactic abdominal drainage, preoperative biliary drainage and early feeding in patients at high risk of DGE or ileus. In this context, the implementation of ERAS program could contribute to reduce postoperative complications, to shorten LOS and to standardize the practice in pancreatic surgery.

cer. Prophylaxis of nausea and vomiting (PONV) is started and consisted of at least two different antiemetics. Antimicrobial prophylaxis is administrated less than 60min before skin incision and repeated according to the duration of procedure. If bile culture is positive, antibiotics should be considered for the postoperative course. Postoperative anal­gesia is ensured using a thoracic epidural for open PD or preperitoneal wound catheters in case of contraindication to avoid opioid. To prevent hypothermia, a body-bear hugger and warming set for intravenous infusions are used to main­tain temperature above 36°C.Perioperatively, dened proto­cols are used to maintain normoglycemia and a goal-directed uid therapy algorithm is used to avoid uid overload. The nasogastric tube is inserted during the surgery and removed before the reversal of anesthesia. There are still concerns about the safety of minimally invasive PD.Laparoscopic PD should be performed only in high volume and expert centers with selected patients. Robotic PD is not recommended. Management of prophylactic drainage after PD continued to be controversial and the level of evidence is too low to con­clude. Guidelines recommend systematic drainage and early removal at 72h in patients at low risk (i.e., amylase content in drain <5000U/L on POD1). Systematic use of somatosta­tin analogues to prevent clinically relevant POPF (CR-POPF) is not recommended due to the lack of evidence. Urinary catheter should be removed on POD1. The patients followed an early oral feeding program according to tolerance. Chewing gums and pharmacological agents (alvimopan and mosapride) may accelerate bowel recovery. Early mobiliza­tion is started from day 0. The strength of ERAS program, when compared to other enhanced recovery programs (ERP), is a proper and structured audit system including a prospec­tive database, regular internal and external audits to provide

the studies and costs are mostly assessed as a secondary out­come [36]. Specic studies on the subject are needed such as standardization of cost analysis.

Measuring the compliance is essential to analyze the suc­cess of the implementation of ERAS program into daily practice. In pancreatic surgery, only few studies reported the compliance to ERAS program. While compliance with pre­and intraoperative ERAS items was high (70–100%), the postoperative ERAS items were more difcult to implement with success (30–88%) [14, 20, 21, 27, 37, 38]. In addition, the level of compliance was signicantly correlated with postoperative outcomes [14, 21, 37, 38]. In the study of Braga etal., the subgroup analysis showed a higher compli­ance in uneventful patients, while a lower compliance was found in patients with major complications [14]. In two single-center studies, patients with high compliance had fewer postoperative complications and shorten LOS [21,