ERAS protocols and 'step-up' complication management are associated with improved short-term outcomes following elective total pancreatectomy: A multicenter cohort study.

Background Total pancreatectomy remains associated with substantial morbidity and mortality, largely driven by postoperative complications and failure-to-rescue (FTR). ERAS and 'step-up' strategies are each associated with improved outcomes after pancreatic surgery, yet their combined effect following pylorus-preserving total pancreatectomy (PPTP) remains poorly defined. Methods This retrospective multicenter cohort study analyzed 429 patients undergoing elective PPTP. The reference cohort from Charité University Hospital (n=236, 2014–2023) was stratified into pre-ERAS and ERAS trial periods, the latter coinciding with 'step-up' complication management procedures (2019–2023). Institutional data were prospectively recorded via the EIAS and benchmarked against national ERAS (n=80) and non-ERAS centers (n=113). Adjusted multivariable Cox regression and Kaplan-Meier analyses assessed survival and recovery. Results ERAS combined with 'step-up' management was associated with significantly shorter length of stay (17.9 vs 25.6 days; p<0.001), fewer major complications (19.7% vs 41.4%; p<0.001) and a non-significant 30d mortality reduction (2.2% vs 7.1%; p=0.09), confirmed also via adjusted regression analyses. Mean interventions per patient decreased by 52.9% (p=0.01) with a shift from surgical (41.5% to 28.1%) to interventional treatments (50.0% to 63.2%; p=0.005). High ERAS adherence (≥80%) correlated with earlier ICU and hospital discharge. Major complications and vascular reconstruction were the strongest predictors of impaired survival. Conclusions Combined ERAS and 'step-up' management was associated with improved safety and recovery after PPTP supporting broader implementation of standardized multidisciplinary perioperative care after total pancreatectomy.