Current evidence of nutritional therapy in pancreatoduodenectomy: Systematic review of randomized controlled trials

Re-assessing the role of peri-operative nutritional therapy in patients with pancreatic cancer undergoing surgery: a narrative review

Pancreatic cancer is the most common medical condition that requires pancreatic resection. Over the last three decades, significant improvements have been made in the conditions and procedures related to pancreatic surgery, resulting in mortality rates lower than 5%. However, it is important to note that the morbidity in pancreatic surgery remains r latively high, with a percentage range of 30-60%. Pre-operative malnutrition is considered to be an independent risk factor for post-operative complications in pancreatic surgery, such as impaired wound healing, higher infection rates, prolonged hospital stay, hospital readmission, poor prognosis, and increased morbidity and mortality. Regarding the post-operative period, it is crucial to provide the best possible management of gastrointestinal dysfunction and to handle the consequences of alterations in food digestion and nutrient absorption for those undergoing pancreatic surgery. The European Society for Clinical Nutrition and Metabolism (ESPEN) suggests that early oral feeding should be the preferred way to initiate nourishing surgical patients as it is associated with lower rates of complications. However, there is ongoing debate about the optimal post-operative feeding approach. Several studies have shown that enteral nutrition is associated with a shorter time to recovery, superior clinical outcomes and biomarkers. On the other hand, recent data suggest that nutritional goals are better achieved with parenteral feeding, either exclusively or as a supplement. The current review highlights recommendations from existing evidence, including nutritional screening and assessment and pre/post-operative nutrition support fundamentals to improve patient outcomes. Key areas for improvement and opportunities to enhance guideline implementation are also highlighted.

Role of robotic surgery as an element of Enhanced Recovery After Surgery protocol in patients undergoing pancreatoduodenectomy

BACKGROUND

Although the current trend in pancreatoduodenectomy (PD) has shifted from open surgery to minimally invasive surgery (MIS), evidence on the role of MIS as an element of Enhanced Recovery After Surgery (ERAS) in PD is limited. This study aimed to investigate the effect of robotic surgery using the ERAS protocol on the outcomes of patients undergoing PD.

METHODS

This retrospective study included 252 patients who underwent open PD (OPD) or robotic PD (RPD) managed using the ERAS protocol between January 2017 and March 2023. Outcomes stratified by the surgical approach were compared. Multivariable analyses were performed to evaluate the effect of ERAS items, including robotic surgery, on outcomes after PD.

RESULTS

Of 252 patients, 202 (80.2%) underwent OPD, and 50 (19.2%) underwent RPD. Multivariable analyses demonstrated that perioperative management center support (odds ratio [OR], 2.85; 95% CI, 1.14-7.72; P = .025), robotic surgery (OR, 6.40; 95% CI, 1.94-26.1; P = .002), early solid intake (OR, 2.84; 95% CI, 1.46-5.63; P = .002), and early drain removal (OR, 3.77; 95% CI, 2.04-7.06; P < .001) were significant ERAS items related to early discharge after PD.

CONCLUSION

Our study demonstrated that employing the ERAS protocol for OPD and RPD is feasible and safe. Moreover, our results suggested the role of robotic surgery as an element of the ERAS protocol for PD. A combination of ERAS protocols and MIS may be safe and feasible for accelerating postoperative recovery after PD.

Do some patients receive unnecessary parenteral nutrition after pancreatoduodenectomy? Results from an international multicentre study

Backgrounds/Aims

After pancreatoduodenectomy (PD), an early oral diet is recommended; however, the postoperative nutritional management of PD patients is known to be highly variable, with some centers still routinely providing parenteral nutrition (PN). Some patients who receive PN experience clinically significant complications, underscoring its judicious use. Using a large cohort, this study aimed to determine the proportion of PD patients who received postoperative nutritional support (NS), describe the nature of this support, and investigate whether receiving PN correlated with adverse perioperative outcomes.

Methods

Data were extracted from the Recurrence After Whipple's study, a retrospective multicenter study of PD outcomes.

Results

In total, 1,323 patients (89%) had data on their postoperative NS status available. Of these, 45% received postoperative NS, which was "enteral only," "parenteral only," and "enteral and parenteral" in 44%, 35%, and 21% of cases, respectively. Body mass index < 18.5 kg/m2 (p = 0.03), absence of preoperative biliary stenting (p = 0.009), and serum albumin < 36 g/L (p = 0.009) all correlated with receiving postoperative NS. Among those who did not develop a serious postoperative complication, i.e., those who had a relatively uneventful recovery, 20% received PN.

Conclusions

A considerable number of patients who had an uneventful recovery received PN. PN is not without risk, and should be reserved for those who are unable to take an oral diet. PD patients should undergo pre- and postoperative assessment by nutrition professionals to ensure they are managed appropriately, and to optimize perioperative outcomes.

Impact of Early Enteral Nutrition on Delayed Gastric Emptying and Nutritional Status After Pancreaticoduodenectomy

BACKGROUND

Although early enteral nutrition (EEN) is an accepted practice after pancreaticoduodenectomy (PD), the impact of EEN on postoperative complications or nutritional status remains unclear. We aimed to investigate the impact of EEN on delayed gastric emptying (DGE) and nutritional status after PD.

METHODS

A total of 143 patients underwent PD between January 2012 and September 2020. We excluded patients who underwent a two-stage pancreatojejunostomy, in whom the enteral tube was accidentally pulled out, or with insufficient information in their medical records. The incidence of postoperative complications was compared between patients who received EEN (EEN group, n = 21) and those who did not (control group, n = 21) after propensity score matching. Univariate and multivariate analyses were performed to identify the risk factors affecting the incidence of these complications. Nutritional status was assessed at postoperative months 1, 3, and 6.

RESULTS

The incidence of grade B/C DGE in the EEN group was significantly lower than that in the control group (4.8% vs. 28.6%, p = 0.03). There was no significant difference in overall morbidity, incidence of any other postoperative complications, or all-grade DGE. In multivariate analysis, EEN was associated with a reduction in the incidence of grade B/C DGE (p < 0.01). In the analysis of nutritional status, EEN was significantly associated with better nutritional status at postoperative month 1.

CONCLUSION

EEN can lead to a lower clinically relevant DGE rate and better nutritional status in the early postoperative period in patients undergoing PD.

Prediction values of a novel prognostic index hypoproteinemia combined with contaminated wounds for wound dehiscence after abdominal surgery in neonates.. [DOI: 10.21203/rs.3.rs-2517931/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background Abdominal Wound Dehiscence (AWD), occupying a large proportion of neonatal surgery is an essential complication of abdominal surgery, which can leads to severe consequences, including life-threatening. This study aims at exploring prediction value for AWD with potential joint factors of hypoproteinemia and incision type. Method The Cox proportional-hazards model (the Cox model) was applied to analyze clinical data came from 453 patients underwent neonatal laparotomy from June 2009 to June 2020. According to application of the random numbers, 453 cases were divided into two separate models randomly involving training set with 318 observations (70%) and validation set with 135 observations (30%), and then the models trained were validated based on the validation set. Investigation in the connection between hypoproteinemia, incision type, combined factors and AWD, were used for comparing those prediction values for AWD. Results With a median follow-up of 15 months, the incidence of neonatal AWD was 6.0% (27/453). Based on the univariate and multivariate Analysis using the Cox Regression Analysis, hypoproteinemia(HR = 7.005, P = 0.001) and joint factor༈HR = 6.901, P < 0.001༉were both the independent risk factors for neonatal AWD in training set. Meanwhile, hypoproteinemia and joint factor༈HR = 5.497, P = 0.045༉were both also the independent risk factors for neonatal AWD in validation models, which indicated that joint factor was the independent risk factor in both models. The summary ROC curve was estimated, and the area under the ROC curve (AUC) was calculated as a criterion for validating the models trained. The findings illustrated that AUC of joint prediction factor for AWD was higher than either that of hypoproteinemia༈0.759 vs. 0.638) or incision type factor ༈0.759 vs. 0.671༉singly. Conclusion The contribution of hypoproteinemia and incision type combined factor for predicting AWD is superior than that of them individually, resulting in a significant promotion in prediction efficiency and accuracy of predicting neonatal AWD.

Prevention and Treatment of Grade C Postoperative Pancreatic Fistula

Postoperative pancreatic fistula (POPF) is a troublesome complication after pancreatic surgeries, and grade C POPF is the most serious situation among pancreatic fistulas. At present, the incidence of grade C POPF varies from less than 1% to greater than 9%, with an extremely high postoperative mortality rate of 25.7%. The patients with grade C POPF finally undergo surgery with a poor prognosis after various failed conservative treatments. Although various surgical and perioperative attempts have been made to reduce the incidence of grade C POPF, the rates of this costly complication have not been significantly diminished. Hearteningly, several related studies have found that intra-abdominal infection from intestinal flora could promote the development of grade C POPF, which would help physicians to better prevent this complication. In this review, we briefly introduced the definition and relevant risk factors for grade C POPF. Moreover, this review discusses the two main pathways, direct intestinal juice spillover and bacterial translocation, by which intestinal microbes enter the abdominal cavity. Based on the abovementioned theory, we summarize the operation techniques and perioperative management of grade C POPF and discuss novel methods and surgical treatments to reverse this dilemma.

Framework, component, and implementation of enhanced recovery pathways

The introduction of enhanced recovery pathways (ERPs) has led to a considerable paradigm shift towards evidence-based, multidisciplinary perioperative care. Such pathways are now widely implemented in a variety of surgical specialties, with largely positive results. In this narrative review, we summarize the principles, components and implementation of ERPs, focusing on recent developments in the field. We also discuss ‘special cases’ in ERPs, including: surgery in frail patients; emergency procedures; and patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19).

Risk factors and predictive model for abdominal wound dehiscence in neonates: a retrospective cohort study

BACKGROUND

Abdominal wound dehiscence (AWD) is a major complication of abdominal surgery, and neonates are a group with a high risk of AWD, which has serious consequences or can even result in death. The purpose of this study is to explore the risk factors for neonatal AWD and construct a predictive model.

METHODS

The clinical data of 453 cases that underwent neonatal laparotomy from June 2009 to June 2020 were retrospectively analyzed, among which 27 cases of AWD were identified. Nine factors, including gender, age at admission, weight at admission, preterm delivery, level of preoperative anaemia, hypoalbuminemia, operation time, incision length, and incision type, were analyzed to explore their correlation with neonatal AWD.

RESULTS

The incidence of neonatal AWD was 6.0% (27/453), among which partial wound dehiscence accounted for 4.9% (22/453) and complete wound dehiscence accounted for 1.1% (5/453). Hypoproteinemia and incision type were the independent risk factors for neonatal AWD, and weight at admission was a protective factor for AWD in the multivariate models. All these factors were incorporated to construct a nomogram, and a calibration curve was plotted. The result indicated that the actual risk was close to the predicted risk when the predicted risk rate was greater than about 35%.

CONCLUSIONS

Neonatal AWD is closely related to hypoproteinemia and incision contamination. Our predictive model showed the potential to provide an individualized risk estimate of AWD for neonatal patients undergoing abdominal surgery.Key messagesNeonatal abdominal wound dehiscence (AWD) has a serious consequence and the incidence of neonatal AWD was about 6.0% and the complete AWD morbidity is 1.1%.Hypoproteinemia and incision type were the independent risk factors for neonatal AWD.Our predictive model showed the potential to provide an individualized risk estimate of AWD for neonatal patients undergoing abdominal surgery.

Optimal Perioperative Nutrition Therapy for Patients Undergoing Pancreaticoduodenectomy: A Systematic Review with a Component Network Meta-Analysis

Numerous strategies for perioperative nutrition therapy for patients undergoing pancreaticoduodenectomy (PD) have been proposed. This systematic review aimed to summarize the current relevant published randomized controlled trials (RCTs) evaluating different nutritional interventions via a traditional network meta-analysis (NMA) and component network meta-analysis (cNMA). EMBASE, MEDLINE, the Cochrane Library, and ClinicalTrials.gov were searched to identify the RCTs. The evaluated nutritional interventions comprised standard postoperative enteral nutrition by feeding tube (Postop-SEN), preoperative enteral feeding (Preop-EN), postoperative immunonutrients (Postop-IM), preoperative oral immunonutrient supplement (Preop-IM), and postoperative total parenteral nutrition (TPN). The primary outcomes were general, infectious, and noninfectious complications; postoperative pancreatic fistula (POPF); and delayed gastric emptying (DGE). The secondary outcomes were mortality and length of hospital stay (LOS). The NMA and cNMA were conducted with a frequentist approach. The results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Two primary outcomes, infectious complications and POPF, were positively influenced by nutritional interventions. Preop-EN plus Postop-SEN (OR 0.11; 95% CI 0.02~0.72), Preop-IM (OR 0.22; 95% CI 0.08~0.62), and Preop-IM plus Postop-IM (OR 0.11; 95% CI 0.03~0.37) were all demonstrated to be associated with a decrease in infectious complications. Postop-TPN (OR 0.37; 95% CI 0.19~0.71) and Preop-IM plus Postop-IM (OR 0.21; 95% CI 0.06~0.77) were clinically beneficial for the prevention of POPF. While enteral feeding and TPN may decrease infectious complications and POPF, respectively, Preop-IM plus Postop-IM may provide the best clinical benefit for patients undergoing PD, as this approach decreases the incidence of both the aforementioned adverse effects.

Effects of Perioperative Probiotics and Synbiotics on Pancreaticoduodenectomy Patients: A Meta-Analysis of Randomized Controlled Trials

Post-pancreaticoduodenectomy infections cause mortality, morbidity, and prolonged antibiotic use. Probiotics or synbiotics may be advantageous for preventing postoperative infections, but their benefits on pancreaticoduodenectomy outcomes are controversial. This study evaluated the efficacy of probiotics and synbiotics in pancreaticoduodenectomy. The Embase, Web of Science, PubMed, and Cochrane Library databases were comprehensively searched for randomized controlled trials (RCTs) that evaluated the effects of probiotics or synbiotics on pancreaticoduodenectomy as of April 16, 2021. Outcomes included perioperative mortality, postoperative infectious complications, delayed gastric emptying, hospital stay length, and antibiotic-use duration. The results were reported as mean differences (MDs) and relative risks (RRs) with 95% confidence intervals (CI). Six RCTs involving 294 subjects were included. Probiotic or synbiotic supplementation did not reduce the perioperative mortality (RR, 0.34; 95% CI, 0.11, 1.03), but reduced the incidences of postoperative infection (RR, 0.49; 95% CI, 0.34, 0.70) and delayed gastric emptying (RR, 0.27; 95% CI, 0.09, 0.76) and also reduced the hospital stay length (MD, -7.87; 95% CI, -13.74, -1.99) and antibiotic-use duration (MD, -6.75; 95% CI, -9.58, -3.92) as compared to the controls. Probiotics or synbiotics can prevent infections, reduce delayed gastric emptying, and shorten the hospital stay and antibiotic-use durations in patients undergoing pancreaticoduodenectomy. These findings are clinically important for promoting recovery from pancreaticoduodenectomy, reducing the incidences of antibiotic resistance and iatrogenic infections, and reducing the medical burden.

The Biology of Anastomotic Healing-the Unknown Overwhelms the Known

BACKGROUND

Anastomotic complications are among the most devastating consequences of gastrointestinal surgery. Despite its high morbidity, the factors responsible for anastomotic regeneration following surgical construction remain poorly understood. The aim of this review is to provide an overview of the typical and atypical factors that have been implicated in anastomotic healing.

METHODS

A review and analysis of select literature on anastomotic healing was performed.

RESULTS

The healing of an anastomotic wound mirrors the phases of cutaneous wound healing- inflammation, proliferation, and remodeling. The evidence supporting much of the traditional dogma for optimal anastomotic healing (ischemia, tension, nutrition) is sparse. More recent research has implicated atypical factors that influence anastomotic healing, including the microbiome, the mesentery, and geometry. As technology evolves, endoscopic approaches may improve anastomotic healing and in some cases may eliminate the anastomosis altogether.

DISCUSSION

Much remains unknown regarding the mechanisms of anastomotic healing, and research should focus on elucidating the dynamics of healing at a molecular level. Doing so may help facilitate the transition from traditional surgical dogma to evidence-based medicine in the operating room.

Systematic review on immunonutrition in partial pancreatoduodenectomy

BACKGROUND

The effect of immunonutrition (IM) on postoperative outcomes has been investigated in gastrointestinal cancer surgery; however, strong evidence regarding IM in partial pancreatoduodenectomy (PD) is lacking. This study evaluated the effect of IM on short-term outcomes in patients undergoing PD.

METHODS

A systematic literature review of randomized controlled trials was conducted to identify the studies investigating the IM effect on outcomes in PD. Random-effects meta-analyses were conducted to calculate the pooled risk ratio (RR). Studies were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

Five studies were included in the meta-analysis. IM was associated with a lower incidence of overall complications (RR 0.74; 95% confidence interval (CI) 0.58, 0.94; P = 0.01; I² = 0%) and infectious complications (RR 0.60; 95% CI 0.42, 0.84; P = 0.003; I² = 0%). However, no significant association was noted in the incidence of major complications (RR 0.68; 95% CI 0.41, 1.12; P = 0.13), mortality (RR 0.79; 95% CI 0.16, 3.99; P = 0.78), postoperative pancreatic fistula (RR 0.92, 95% CI 0.59, 1.46; P = 0.74), and delayed gastric emptying (RR 1.09; 95% CI 0.55, 2.15; P = 0.81).

CONCLUSIONS

IM administration in PD can prevent the incidence of overall and infectious complications postoperatively (GRADE recommendation: moderate). However, IM has no impact on major complications, mortality, and PD-specific complications (GRADE recommendation: low).