Objectives: The introduction of Enhanced recovery after surgery (ERAS) into pancreaticoduodenectomy (PD) has been thought difficult because of accompanying malnutrition, sarcopenia, aggressive surgery, and postoperative complications including postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE). In this study, we examined whether we could introduce ERAS into PD and achieve short postoperative hospital stay.
Methods: Our new strategy consists of three parts. Preoperatively, we routinely assess patients’ muscle strength and nutritional conditions and perform exercise and nutritional intervention for patients with sarcopenia or malnutrition according to the data. In other words, surgical indication is decided not by chronological age but physical age. Intraoperatively, we perform pancreatico-jejunostomy (modified Blumgart’s method) with our stent placement policy and gastro-jejunostomy preventing DGE. Postoperatively, early ambulation, early oral intake, and early drain removal are essential. We have implemented the above strategy since April 2020 and retrospectively examined its validity. Forty-one consecutive patients who underwent open PD with curative intent by January 2023 were enrolled. We examined various surgical outcomes including postoperative hospital stay.
Results: There were 26 men and 15 women. The median age was 68 years (range, 40-84). The preoperative diagnosis was pancreas head cancer in 18, distal bile duct cancer in 10 and so on. The median blood loss was 373 ml (25-1155). Grade B POPF was found in 3 patients (7%). No DGE was found. The median day of drain removal was POD 3. The median postoperative hospital stay was 8 days (6-26). All patients returned to their own homes.
Conclusions: We could successfully introduce ERAS into PD and achieve short postoperative hospital stay. We think this is “real minimally invasive surgery” irrespective of surgical methods.

Ischemia/reperfusion‐induced liver injury is a major complication in hepatic surgery that may result in cell death and organ failure. It is estimated to be primarily exacerbated by strong oxidative and nitrogen stress caused by reactive oxygen and nitrogen species, respectively. Quercetin, a plant‐derived flavonoid, is a potent antioxidant； however, only a few reports have examined the protective effects of quercetin pretreatment on ischemia/reperfusion‐induced liver injury in animal models. The possible mechanisms of the protective effects of quercetin include antiapoptotic effects and antioxidative effects, which may induce the inhibition of proinflammatory cytokine production. However, standard methods, such as the dosage of quercetin, its route of administration, and the interval from ischemic procedures to reperfusion, remain to be established in animal models. Further investigations should be conducted to elucidate the clinical efficacy of quercetin pretreatment on ischemia/reperfusion‐induced liver injury.

Reluctance to administer lipid emulsion to patients undergoing treatment or as recommended by a nutritional support team may arise due to various restrictions or concerns regarding potential adverse effects. This paper aimed to discuss the appropriate use of lipid emulsion in clinical settings to enhance patient safety and convenience. We performed a literature review to assess the importance of nutritional therapy and nutritional intervention, the merits and demerits of lipid emulsion administration, the current situation in Japan, and differences in lipid formulations. Herein, we address issues regarding the usage of lipid emulsion including: 1. administration rate, 2. drug mixing, 3. administration to critically ill patients, and 4. early postoperative usage.
Our findings suggest the following solutions to the individual issues: 1. Administration at a rate below 0.1 g/kg/hour is generally recommended, but faster administration is possible if necessary, depending on the case, 2. Administration from a piggy tube to basic infusion formulations poses no issues, 3. When administering to critically ill patients, second and third-generation fat emulsions are safe, but soybean oil should be applied cautiously, and 4. Fat emulsion administration immediately after surgery is possible, but considering endogenous energy mobilization, it is advisable to commence from the 3rd to 4th day onwards. The provisional conclusions of this study are as follows: 1. The introduction of medium-chain triglyceride formulations and fish oil (second and third-generation lipid emulsions), which are not currently available in Japan, is urgently needed, and 2. Individualized administration is necessary due to significant individual differences regarding their usage.