Individualized enhanced recovery after pancreaticoduodenectomy surgical pathways management: Key variables and optimization strategies

Abstract

Pancreaticoduodenectomy (PD) is a classic surgical procedure for treating benign and malignant lesions of the pancreatic head, duodenum, and periampullary region. Enhanced recovery after surgery (ERAS) has been widely applied to the perioperative management of PD by integrating a series of perioperative optimization measures. However, its pathways are difficult to adapt to individual differences among patients. In clinical practice, insufficient individual adaptation often leads to decreased ERAS compliance, poor rehabilitation outcomes, and even increased risk of complications. This article aims to systematically review the key variables in individualized PD-ERAS management, including core influencing factors at the patient, disease and surgical, and perioperative intervention levels. Based on this, individualized optimization strategies for each perioperative stage are proposed, providing evidence-based support and practical reference for optimizing perioperative management of PD, improving rehabilitation quality, and enhancing patient prognosis.

Key Words: Pancreaticoduodenectomy; Enhanced recovery after surgery; Individualized management; Evidence-based medicine

Core Tip: This review systematically examines key variables influencing individualized enhanced recovery after pancreaticoduodenectomy, encompassing patient-level factors, disease/surgical characteristics, and perioperative interventions. It proposes a stratified, dynamic optimization strategy for each surgical stage. This patient-tailored approach, prioritizing safety and precision, aims to enhance recovery after pancreaticoduodenectomy compliance, reduce mild complications, and improve postoperative outcomes, moving beyond standardized “one-size-fits-all” protocols.

INTRODUCTION

Pancreaticoduodenectomy (PD) is one of the most complex surgeries in abdominal surgery. It is mainly used to treat pancreatic head cancer, periampullary cancer, duodenal cancer, chronic pancreatitis and other pancreatic head and periampullary lesions[1]. This surgery involves the resection and reconstruction of multiple organs such as pancreas, duodenum, gallbladder and bile duct. It usually includes multiple anastomoses such as pancreaticojejunostomy, bile ductostomy and gastrojejunostomy. The surgery is highly invasive and difficult to operate. The incidence of perioperative complications is high. Among them, serious complications such as pancreatic fistula, postoperative bleeding, delayed gastric emptying (DGE) and infection can significantly increase the mortality and readmission rate of patients[2,3]. Enhanced recovery after surgery (ERAS) was first proposed by Danish surgeon Kehlet in 1997. Its core is to reduce the stress response of the patient’s body, protect organ function and accelerate the postoperative recovery of the patient by integrating a series of evidence-based optimization measures that are effective before, during and after surgery[4,5]. In recent years, the application of the ERAS concept in the perioperative period of PD has gradually matured. Systematic reviews have shown that PD-ERAS can significantly shorten the hospital stay, reduce the incidence of mild complications, reduce medical expenses, and does not increase the postoperative mortality rate[6].

However, most of the ERAS pathways currently used in clinical practice are standardized protocols, which do not fully consider the individual differences of patients and the significant differences in patients’ tolerance and response to ERAS measures. Epidemiological data from pancreatic surgery indicate that compliance with standardized ERAS protocols continues to be low, with only a minority of patients completing all protocol items[7]. This “one size fits all” model directly leads to poor compliance, uneven implementation, and failure to achieve expected rehabilitation benefits, which limits the promotion and application of the ERAS concept. Therefore, based on the individual characteristics of patients, identifying the key variables of PD-ERAS individualized management and constructing a hierarchical, dynamic and precise individualized optimization strategy has become the key to improving the quality of PD perioperative management and improving patient prognosis. This article systematically reviews the key variables and clinical optimization strategies of PD-ERAS individualized management in light of the relevant research progress at home and abroad in recent years, and provides a reference for clinical practice.

The complexity and high complication rate of PD dictate that standardized ERAS cannot meet clinical demands. Therefore, individualized management has become the key to improving prognosis. The overall workflow of individualized PD-ERAS management is illustrated in Figure 1.

Figure 1 Individualized pancreaticoduodenectomy enhanced recovery after surgery management pathway.

THEORETICAL BASIS AND CORE PRINCIPLES OF PD-ERAS INDIVIDUALIZED MANAGEMENT

Definition and connotation of individualized ERAS

PD-ERAS individualized management is based on the standardized ERAS pathway, combined with individual characteristics such as patient age, nutritional status, comorbidities, etiology, stage, degree of jaundice, and surgical factors such as surgical procedure and anastomosis method, to adjust and dynamically optimize various perioperative ERAS measures in a stratified manner, so as to achieve a precise rehabilitation management model. Its core connotation is not to deny the core framework of standardized ERAS, but to ensure the scientific and standardized nature of ERAS measures on the basis of evidence-based medicine, and to avoid the incompatibility of measures due to individual differences, so as to achieve the goal of safe, efficient and rapid rehabilitation. Existing studies have confirmed its feasibility[8].

Compared to standardized ERAS, personalized ERAS places greater emphasis on “dynamics” and “specificity” - rehabilitation strategies need to be adjusted in real time during the perioperative period based on changes in the patient’s condition and physical response. For example, postoperatively, the feeding rate is adjusted according to the patient’s gastrointestinal function recovery, the analgesia plan is optimized based on pain scores, and the monitoring intensity is adjusted based on complication risk stratification. At the same time, personalized ERAS prioritizes the patient’s subjective wishes and compliance, improving patient acceptance of the rehabilitation plan through preoperative education and psychological intervention, ensuring the smooth implementation of various optimization measures.

Core principles of personalized ERAS

PD-ERAS individualized management must follow the following core principles to ensure the safety and effectiveness of the rehabilitation strategy: (1) Safety first principle: All individualized optimization measures must be based on reducing the risk of complications and ensuring patient safety. Avoid ignoring safety hazards in pursuit of “rapid recovery”. For example, for patients at high risk of pancreatic fistula, the drainage tube indwelling time should not be shortened blindly[9,10]; (2) Stress reduction principle: The core goal is to reduce the stress response of the patient’s body to factors such as surgical trauma, anesthesia, and fasting through individualized intervention, and protect intestinal function, immune function and function of important organs[11]; (3) Organ protection principle: Protective measures should be formulated for important organs such as pancreas, liver, heart, and lungs, in combination with the individual patient’s condition. For example, for patients with cardiopulmonary insufficiency, drug therapy and intraoperative fluid management should be optimized[12]; (4) Precise intervention principle: Based on the stratification of key variables, differentiated interventions should be implemented for patients with different risk levels and different individual characteristics to avoid overtreatment and undertreatment; and (5) Multi-disciplinary team (MDT) collaboration principle: Integrate multidisciplinary resources such as surgery, anesthesiology, nursing, nutrition, rehabilitation, and pharmacy to form a collaborative management team to jointly formulate and implement individualized rehabilitation plans[13].

Differences between PD-ERAS and conventional abdominal surgery ERAS

Such as cholecystectomy and radical gastrectomy. These differences are mainly reflected in the following aspects: (1) Special characteristics of the pancreas: The pancreas is a digestive gland, and the pancreatic juice it secretes contains a variety of digestive enzymes. Postoperative pancreatic fistula can lead to serious complications such as abdominal infection and bleeding. Therefore, pancreatic fistula prevention and control is the core focus of PD-ERAS, while ordinary abdominal surgery does not have such special risks[14]; (2) Risk of multiple anastomoses: PD requires the completion of pancreaticojejunostomy, choledochojejunostomy, and gastrojejunostomy. The anastomoses are difficult to heal, and the incidence of complications such as postoperative DGE and anastomotic leakage is significantly higher than that of ordinary abdominal surgery[15]; (3) Concentration of high-risk complications: In addition to pancreatic fistula, PD is also prone to serious complications such as massive bleeding, bile leakage, and abdominal infection. Moreover, there are mutual influences among the complications, and a more rigorous individualized monitoring and intervention system needs to be established[16]; and (4) Patients’ underlying conditions vary greatly: PD patients are mostly middle-aged and elderly, and often have underlying problems such as jaundice, malnutrition, diabetes, and cardiopulmonary diseases. Individual differences are more significant, and the need for individualized management is higher. These differences mean that PD-ERAS cannot simply copy the standardized procedures of ordinary abdominal surgery; it must be individualized and optimized based on the characteristics of the surgery and the individual patient’s condition.

KEY VARIABLES OF PD-ERAS INDIVIDUALIZED MANAGEMENT

The core of PD-ERAS individualized management is to identify key variables affecting rehabilitation outcomes, clarify the mechanisms of action and degree of influence of each variable, and provide a basis for stratified optimization. Combining clinical practice and relevant research, key variables can be divided into three categories: Patient-level, disease and surgery-level, and perioperative intervention-level. These variables are interconnected and mutually influential, jointly determining the formulation and implementation of individualized rehabilitation programs.

Patient level

Age and American Society of Anesthesiologists classification: Age is an important factor affecting postoperative recovery after PD surgery. Elderly patients have decreased organ function, and the incidence of postoperative complications and mortality are significantly higher than those of younger patients[17,18]. The American Society of Anesthesiologists classification can reflect the patient’s baseline health status. Patients with grade III to IV have serious underlying diseases, and their postoperative stress response is stronger and their recovery is slower. They require more rigorous individualized monitoring and intervention[19].

Nutritional status: A high incidence of preoperative malnutrition due to tumor consumption, jaundice, and eating disorders, which significantly increases the incidence of postoperative complications and prolongs hospital stay[20,21]. Sarcopenia, as an important manifestation of malnutrition, is closely related to postoperative complications such as pancreatic fistula and infection in PD patients, and can affect patients’ postoperative mobility and recovery speed[22]. Obese patients have an increased risk of postoperative incision infection, pulmonary infection, and DGE, and are more difficult to manage anesthesia and postoperative activities[23,24].

Comorbidities: PD patients often have multiple underlying diseases, among which diabetes, cardiopulmonary disease, liver dysfunction, and renal dysfunction are key factors affecting the implementation of ERAS. Diabetic patients have large fluctuations in blood glucose after surgery and are prone to complications such as infection, poor wound healing, and pancreatic fistula, requiring strict individualized blood glucose management[25]. Patients with cardiopulmonary disease need precise control of the depth of anesthesia and fluid management during surgery, and postoperative activities need to be gradually increased to avoid aggravating the burden on the cardiopulmonary system. Patients with obstructive jaundice have impaired liver function and abnormal coagulation function, and the risk of postoperative infection and bleeding increases. However, studies have shown that routine preoperative biliary decompression does not provide postoperative benefits and may increase overall complications and wound infection[26]. Individualized anti-jaundice treatment should be based on strict indications rather than routine, especially when total bilirubin is < 250 μmol/L.

Psychological state and compliance: Patients with PD are prone to negative emotions such as anxiety and depression due to the severity of the disease, high surgical risk and uncertain prognosis. Negative emotions can affect the patient’s immune function and rehabilitation compliance[27]. At the same time, the patient’s cognitive level, cultural background and social support will also affect their understanding and implementation of ERAS measures. Patients with poor compliance are prone to problems such as delayed eating and insufficient activity after surgery, which will affect the rehabilitation effect[28,29].

Disease and surgical aspects

Etiology and disease severity: The causes of PD are divided into benign and malignant. Patients with malignant tumors often have tumor consumption, lymph node metastasis, etc., which result in a larger surgical scope, more severe trauma, and higher difficulty in postoperative rehabilitation[30]. The later the tumor stage, the worse the patient’s physical condition, the higher the risk of complications, and the greater the intensity of individualized intervention needs to be[31]. The degree of obstructive jaundice will also affect the rehabilitation effect. Patients with severe jaundice have severely impaired liver function and abnormal coagulation function. Strictly indicated and individualized preoperative anti-jaundice treatment is only suitable for severe hyperbilirubinemia accompanied by persistent cholangitis or severe pruritus; routine preoperative biliary decompression is not encouraged to avoid increasing complications[32].

Surgical methods and procedural factors: Surgical procedures are categorized into open PD, laparoscopic PD, and robot-assisted PD. The latter two are minimally invasive PD procedures, offering advantages such as less trauma, less postoperative pain, and faster bowel function recovery[33,34]. Therefore, their ERAS strategies differ from those of open PD. For example, patients with minimally invasive PD can resume eating and activity earlier after surgery. Whether or not the pylorus is preserved also affects the incidence of postoperative digestive tract infection (DGE). Patients with pylorus-preserving PD have a higher risk of DGE, requiring optimized postoperative gastrointestinal decompression and feeding strategies. In addition, the duration of surgery, amount of blood loss, and extent of lymph node dissection also affect postoperative recovery, necessitating postoperative monitoring and support based on individual circumstances.

Pancreatic fistula risk score: Pancreatic fistula is one of the most serious complications after PD surgery. Preoperative and intraoperative assessment of pancreatic fistula risk is crucial for developing individualized drainage and nutritional support strategies. The Fistula Risk Score (FRS) is widely used to classify patients into low, intermediate and high risk groups. However, some studies have shown that the predictive performance of FRS is unstable in real clinical practice. Therefore, FRS needs to be locally calibrated and adjusted based on specific patient populations and surgical approaches to improve its practical accuracy. High-risk patients require stricter pancreatic fistula prevention and control measures[35,36].

Perioperative intervention

Postoperative analgesia and antiemetics: Pain is severe after PD surgery. Poor pain control can affect patients’ postoperative activity, eating and sleeping, and delay recovery. Analgesia regimens need to be selected individually based on the patient’s pain score, age, comorbidities, etc.[37]. Postoperative nausea and vomiting (PONV) has a high incidence, especially in female, non-smokers and patients with a history of PONV[38]. Individualized antiemetic strategies need to be developed based on PONV risk stratification.

Nutritional support and eating: The pathways and timing of postoperative nutritional support, as well as the timing, speed, and types of food intake, need to be individually adjusted based on the patient’s gastrointestinal function recovery, nutritional status, surgical procedure, etc.[39].

Management of drainage tubes and catheters: Whether to leave an abdominal drainage tube, pancreatic duct drainage tube, gastric tube, or urinary catheter after PD surgery and for how long should they be left in place should be determined individually based on the patient’s risk of pancreatic fistula and the recovery of gastrointestinal function. Patients with low risk of pancreatic fistula may choose not to leave an abdominal drainage tube or shorten the time of drainage tube placement, while patients with high risk of pancreatic fistula need to prolong the time of drainage tube placement and strengthen the monitoring of drainage fluid[40]. Patients with good recovery of gastrointestinal function can have their gastric tube removed as early as possible to reduce patient discomfort.

Postoperative activity and complication monitoring variables: The timing and intensity of postoperative activities should be individualized according to the patient’s age, physical condition, surgical method, etc., transitioning from bedridden activities to bedside activities and out-of-bed activities, avoiding risks such as bleeding and wound dehiscence caused by excessive activity, while also avoiding complications caused by insufficient activity[41]. The frequency of monitoring complications such as drainage fluid, blood routine, liver and kidney function, and blood glucose should be adjusted according to the patient’s complication risk stratification. High-risk patients need to increase the monitoring frequency to detect and intervene in complications as early as possible[42]. In summary, the key variables affecting PD individualized ERAS are summarized, see Table 1.

Table 1 Key variables influencing individualized enhanced recovery after surgery in pancreaticoduodenectomy.

Category	Key variables
Patient-level factors	Age, ASA classification, nutritional status, sarcopenia, obesity, diabetes, cardiopulmonary disease, liver/renal dysfunction, obstructive jaundice, psychological state, compliance
Disease-and surgery-level factors	Etiology (benign/malignant), tumor stage, jaundice severity, surgical approach (open/Laparoscopic/robotic), pancreatic texture, pancreatic duct diameter, FRS, operation time, blood loss
Perioperative intervention-level factors	Analgesia strategy, antiemetic regimen, nutritional support, catheter/drainage management, early mobilization, complication monitoring intensity

ASA: American Society of Anesthesiologists; FRS: Fistula Risk Score.

PD-ERAS PERIOPERATIVE INDIVIDUALIZED OPTIMIZATION STRATEGY BASED ON KEY VARIABLES

Individualized preoperative rehabilitation and preparation

Risk stratification and assessment system: Before surgery, a comprehensive risk stratification assessment system was established by combining key variables at the patient, disease, and surgical levels, classifying patients into low, medium, and high risk categories to provide a basis for the development of individualized pre-rehabilitation plans. The assessment content included: Age, American Society of Anesthesiologists classification, nutritional status [Nutritional Risk Screening 2002 (NRS-2002), Patient-Generated Subjective Global Assessment], diabetes, comorbidities such as cardiopulmonary diseases, degree of jaundice, tumor stage, pancreatic texture, pancreatic duct diameter, pancreatic fistula risk score, etc.[43,44].

Individualized nutritional intervention: Nutritional interventions are implemented according to the patient’s nutritional status: For patients with sarcopenia, resistance training and nutritional supplementation can be combined with nutritional support to improve sarcopenia status; for obese patients, they need to be guided to control their weight before surgery, avoid high sugar and high fat diets, and reduce the risk of postoperative complications[45,46].

For patients with severe jaundice complicated by acute cholangitis, severe itching, severely impaired liver function/coagulation dysfunction, individualized preoperative jaundice reduction can be selectively performed. For patients with total bilirubin < 250 μmol/L, routine preoperative biliary decompression is not recommended because it does not improve postoperative outcomes and may increase complications. Surgery can be performed directly to avoid unnecessary trauma and risk of infection.

Individualized optimization of comorbidities: For diabetic patients, fasting blood glucose and 2-hour postprandial blood glucose need to be controlled before surgery; for patients whose oral hypoglycemic agents are not effective, insulin should be injected subcutaneously before surgery, and the insulin dose should be adjusted according to the blood glucose monitoring results to avoid excessive blood glucose fluctuations. For patients with cardiopulmonary diseases, cardiopulmonary function tests should be completed before surgery to assess cardiopulmonary reserve; for patients with hypertension, blood pressure should be controlled before surgery and antihypertensive drugs that affect coagulation function should be avoided; for patients with chronic obstructive pulmonary disease, pulmonary function exercises should be performed before surgery, and bronchodilators and oxygen therapy should be given if necessary to improve pulmonary function[47].

Individualized preoperative bowel preparation and fasting/drink restriction: Recent studies have shown that routine bowel preparation is not required before PD surgery. Individualized bowel preparation is only necessary for patients with bowel obstruction or a high risk of bowel contamination. For elderly, malnourished, or diabetic patients, an appropriate amount of carbohydrate solution can be taken orally 2 hours before surgery to supplement energy and reduce preoperative stress.

Preoperative education and psychological intervention: Based on the patient’s cognitive level and cultural background, individualized preoperative education was conducted to explain the surgical procedure, ERAS measures, and key points for complication prevention to the patient and their family, thereby improving the patient’s understanding and compliance with the rehabilitation plan. For patients with negative emotions such as anxiety and depression, timely psychological intervention was provided, and drug treatment was combined when necessary to alleviate negative emotions and improve the patient’s mental state[48].

Intraoperative individualized precision control

Goal-directed fluid therapy and circulation management: Based on the patient’s intraoperative blood loss, urine output, central venous pressure, and stroke volume variability, the volume and rate of fluid resuscitation should be adjusted individually to maintain intraoperative circulatory stability and avoid organ insufficiency due to volume depletion or pulmonary and intestinal edema due to volume overload. For elderly patients or those with cardiopulmonary or renal insufficiency, fluid resuscitation volume must be strictly controlled, with crystalloid solutions being the preferred choice, and colloid solutions supplemented when necessary. Fluids that may affect renal function should be avoided.

Body temperature protection and coagulation management: Intraoperative hypothermia can lead to complications such as abnormal coagulation function, increased risk of infection, and delayed anesthesia recovery. Therefore, it is necessary to strengthen intraoperative temperature management[49]. According to the patient’s age and operation duration, individualized warming measures should be taken to maintain the intraoperative temperature above 36.0 ℃. For elderly and weak patients, it is necessary to strengthen temperature monitoring to avoid hypothermia. The patient’s coagulation function should be assessed before operation. For patients with coagulation dysfunction, vitamin K and coagulation factors should be supplemented before operation. Drugs that affect coagulation function should be avoided during operation. Coagulation function should be closely monitored during operation. Coagulation substances should be supplemented in a timely manner according to the monitoring results to avoid excessive intraoperative bleeding.

Minimally invasive surgical technique selection and individualized anastomosis technology: For young patients with good physical condition and early tumor stage, minimally invasive PD can be preferred to reduce surgical trauma and accelerate postoperative recovery[50]. For elderly patients with serious underlying diseases and late tumor stage, open PD can be chosen to reduce surgical risks[51]. For patients with soft pancreas and thin pancreatic duct, pancreaticojejunostomy can be used to reduce the risk of pancreatic fistula. For patients with hard pancreas and thick pancreatic duct, pancreaticojejunostomy is used, which is simpler to operate and the anastomosis heals more firmly[52].

Individualized placement of drainage tubes: The placement and duration of the drainage tube are determined by locally calibrated pancreatic fistula risk stratification. The fixed threshold of FRS should not be relied on, and risk stratification should be comprehensively judged based on local patient characteristics, pancreatic texture, duct diameter, surgical technique, etc. Patients with low pancreatic fistula risk may choose not to place an abdominal drainage tube or only place one drainage tube. The tube can be removed 24-48 hours after surgery when the drainage volume is small and the color is clear. Patients with medium to high pancreatic fistula risk need to place two abdominal drainage tubes and strengthen the monitoring of drainage fluid. The drainage tubes are gradually removed when the drainage volume is < 50 mL/day, the amylase level is normal, and there are no symptoms such as abdominal pain or fever. For patients with high pancreatic fistula risk, a pancreatic duct drainage tube can be placed at the same time to further reduce the risk of pancreatic fistula[53].

Postoperative individualized rehabilitation and complication prevention

Individualized multimodal analgesia: Based on the patient’s pain score (NRS), age, comorbidities, etc., an individualized multimodal analgesia plan is formulated: For young patients with poor pain tolerance and NRS score ≥ 7, an enhanced analgesia plan of “opioids + nonsteroidal anti-inflammatory drugs + nerve block” is adopted to control pain in a timely manner; for elderly patients with respiratory failure, good pain tolerance and NRS score ≤ 4, the dosage of opioids is reduced, and nonsteroidal anti-inflammatory drugs + nerve block is preferred to avoid the adverse reactions of opioids[54].

Stratified prevention and intervention of PONV: Low risk of postoperative PONV do not require routine use of antiemetics postoperatively, but only need close monitoring; patients at medium risk are given a single antiemetic; patients at high risk are given a combination of antiemetics postoperatively, while reducing the dosage of opioids to avoid inducing PONV. For patients who develop PONV postoperatively, the antiemetic regimen should be adjusted promptly, and fluids should be replenished to prevent dehydration.

Individualized diet and nutritional support: For patients with minimally invasive PD and patients with good gastrointestinal function recovery, enteral nutrition can be started 24-48 hours after surgery and gradually transitioned to liquid diet, semi-liquid diet and regular diet; for patients with open PD and patients at high risk of DGE, enteral nutrition should be started appropriately 48-72 hours after surgery to avoid premature eating which may aggravate DGE[55].

For patients who can eat normally and have good nutritional status, oral nutrition is preferred; for patients who eat insufficiently and are malnourished, enteral nutrition is combined; for patients who cannot tolerate enteral nutrition, parenteral nutrition is given for a short period of time, and enteral nutrition is gradually transitioned after gastrointestinal function recovers. At the same time, dietary plans are adjusted according to the patient’s comorbidities. For example, diabetic patients need to choose a low-sugar, high-fiber diet to control blood sugar; obese patients need to control total calorie intake and avoid high-fat diets[56].

Individualization of postoperative activities: On the first day after surgery, patients were instructed to engage in bed activities to avoid complications such as lung infection and deep vein thrombosis caused by immobility. On the second and third days after surgery, patients in good physical condition and without complications were instructed to engage in bedside activities and gradually increase the activity time. On the fourth and fifth days after surgery, patients were instructed to get out of bed and gradually increase the distance of their activities. About one week after surgery, patients were instructed to engage in appropriate rehabilitation training based on their recovery. For elderly patients, patients with cardiopulmonary diseases, or patients with slow postoperative recovery, the timing of activities should be appropriately delayed and the intensity of activities reduced to avoid adverse events caused by excessive activities. For patients with postoperative complications, out-of-bed activities should be suspended until the complications are controlled before gradually resuming activities[57].

Stratified monitoring and intervention of complications: For patients with low risk of pancreatic fistula, the use of somatostatin drugs should be reduced postoperatively, and only the drainage fluid volume and amylase level need to be monitored. For patients with intermediate to high risk of pancreatic fistula, somatostatin drugs should be administered postoperatively to inhibit pancreatic juice secretion, the indwelling time of the drainage tube should be prolonged, and the drainage fluid monitoring should be strengthened. Once pancreatic fistula is found, the drainage plan should be adjusted in time, nutritional support should be strengthened, and interventional or surgical treatment should be performed if necessary. For patients with high risk of DGE, the gastrointestinal decompression time should be prolonged postoperatively, gastrointestinal motility drugs should be administered, the nutritional support pathway should be adjusted, and the intake of solid food should be avoided too early. For patients who have already developed DGE, fasting and fluid restriction should be implemented, gastrointestinal decompression should be strengthened, and parenteral nutrition support should be combined. After the gastrointestinal function recovers, eating should be gradually resumed[58,59].

Postoperatively, closely monitor the patient’s vital signs, drainage fluid color and volume. For patients at high risk of bleeding, strengthen the use of hemostatic drugs, monitor blood routine and coagulation function, and provide blood transfusion if necessary. For patients at high risk of infection, administer prophylactic antibiotics postoperatively, strengthen incision care and drainage tube care, monitor body temperature and blood routine, and adjust the antibiotic regimen promptly if signs of infection appear.

Individualized removal of catheters: For patients with good gastrointestinal function recovery, no nausea or vomiting, and normal bowel sounds, the gastric tube can be removed 24-48 hours after surgery; for patients with high risk of DGE or those who experience nausea and vomiting after surgery, the gastric tube should be left in place for an appropriate period of time until gastrointestinal function improves before removal[60]. 24-48 hours after surgery, when the patient can urinate independently and has no difficulty urinating, the urinary catheter can be removed; for elderly patients or those with urinary dysfunction, the urinary catheter should be left in place for an appropriate period of time, and the patient should be guided to perform bladder function training to avoid urinary retention. Individualized removal should be performed according to the risk of pancreatic fistula and the drainage fluid situation, to avoid premature removal leading to complications such as pancreatic fistula and abdominal infection, and to avoid excessive indwelling which increases patient discomfort.

MDT collaborative practice for individualized PD-ERAS

MDT collaboration ensures individualized ERAS strategies are implemented safely and effectively. The team includes surgeons, anesthesiologists, nutritionists, nurses, pharmacists, and rehabilitation therapists.

Division of responsibilities: Surgeons lead risk stratification, surgical planning, and complication management. Anesthesiologists performed preoperative assessment, intraoperative goal-directed fluid therapy, and circulatory control. Dietitians perform nutritional screenings and design personalized perioperative nutritional support. Nurses provide education, monitor recovery, and promote early mobilization and catheter removal. Pharmacists optimize analgesia, antiemetics, and medication safety. Rehabilitation therapists design graded early mobility programs.

Perioperative collaboration: Before surgery, MDT assessment and risk-based plan development. Intraoperative real-time coordination of fluid, temperature, and hemodynamic stability. Postoperative daily joint rounds were performed to dynamically adjust analgesia, nutrition, and activity. Based on the above, the perioperative personalized ERAS strategy is summarized, see Table 2.

Table 2 Perioperative individualized enhanced recovery after surgery optimization strategies for pancreaticoduodenectomy.

Perioperative stage	Individualized management strategies
Preoperative	Comprehensive risk stratification; targeted nutritional intervention; selective preoperative biliary drainage (TB ≥ 250 μmol/L); comorbidity optimization; MDT evaluation; personalized education
Intraoperative	Goal-directed fluid therapy; intraoperative warming; personalized anastomosis; locally calibrated FRS-guided drainage placement
Postoperative	Risk-stratified multimodal analgesia; graded enteral/oral feeding; progressive early mobilization; risk-adjusted catheter removal; stratified complication monitoring

TB: Total bilirubin; MDT: Multi-disciplinary team; FRS: Fistula Risk Score.

LIMITATIONS

It should be emphasized that although ERAS and individualized ERAS strategies can reduce perioperative stress and mild postoperative complications, their preventive effect on severe complications (such as clinically relevant pancreatic fistula, massive hemorrhage, bile leakage, and severe abdominal infection) after PD may be overestimated. These severe complications are mainly determined by the patient’s baseline condition, tumor characteristics, pancreatic texture, anastomotic technique, and surgical complexity, and cannot be completely resolved by ERAS or individualized management alone. Clinicians should maintain objective understanding and avoid the misconception that “individualized ERAS can eliminate all complications”. The primary goal of individualized PD-ERAS is to optimize recovery on the premise of safety, rather than completely prevent severe perioperative risks.

CONCLUSION

The complexity and high complication rate of PD dictate that its ERAS management cannot adopt a standardized “one-size-fits-all” approach. Individualized management is key to improving the effectiveness of PD-ERAS implementation and enhancing patient outcomes. The core of individualized PD-ERAS management is identifying key variables at the patient, disease and surgical, and perioperative intervention levels. By combining individual patient characteristics with evidence-based medicine, a stratified, dynamic, and precise perioperative optimization strategy can be developed, encompassing all aspects from preoperative pre-rehabilitation and intraoperative precise control to postoperative individualized rehabilitation. In summary, individualized management of PD-ERAS, with its core principles of “safety first, precise intervention, and dynamic adjustment”, can effectively reduce surgical stress, lower mild complication rates, shorten hospital stays, and improve patient outcomes, demonstrating significant clinical value. In clinical practice, it is necessary to flexibly apply individualized optimization strategies based on each patient’s individual circumstances to continuously improve the quality of perioperative management of PD and promote the development of ERAS in pancreatic surgery.