Program of gastrointestinal rehabilitation and early postoperative enteral nutrition: a prospective study

Enteral Nutrition in Operated-On Gastric Cancer Patients: An Update

It is well established that the preoperative nutritional status of gastric cancer (GC) patients significantly affects the prognosis of the operated patients, their overall survival, as well as the disease-specific survival. Existing data support that preoperative assessment of nutritional status and early correction of nutritional deficiencies exert a favorable effect on early postoperative outcomes. A variety of relevant indices are used to assess the nutritional status of GC patients who are candidates for surgery. The guidelines of almost all international organizations recommend the use of oral enteral nutrition (EN). Oncologically acceptable types of gastrectomy and methods of patient rehabilitation should take into account the expected postoperative nutritional status. The majority of data support that perioperative EN reduces complications and hospital stay, but not mortality. Oral EN in the postoperative period, albeit in small amounts, helps to reduce the weight loss that is a consequence of gastrectomy. Iron deficiency with or without anemia and low serum levels of vitamin B12 are common metabolic sequelae after gastrectomy and should be restored. EN also significantly helps patients undergoing neoadjuvant or adjuvant antineoplastic therapy. The occurrence of the so-called "postgastrectomy syndromes" requires dietary modifications and drug support. This review attempts to highlight the benefits of EN in GC patients undergoing gastrectomy and to emphasize the type of necessary nutritional management, based on current literature data.

A clinical study on gastric cancer patients administered EN and PN versus PN alone in enhanced recovery after surgery

Background and objectives

Enhanced recovery after surgery (ERAS) recommends avoiding enteral nutrition (EN) due to undesirable sequelae such as pulmonary aspiration and infections. Not using of EN in nongastric resections under ERAS pathways is often successful. However, parenteral nutrition (PN) alone followed by early postoperative oral feeding in gastric cancer patients, recommended by the ERAS guidelines, has unclear benefit and is only adopted after gastric resection. This study aimed to compute the postoperative outcomes of EN and PN compared to those of the ERAS-recommended nutritional pathway. Our secondary objective was to compare postoperative complications between the two groups.

Materials and methods

Of 173 gastrectomy patients, 116 patients were in the combined group (EN and PN), whereas 57 patients were in the PN alone group. Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS) version 26.0.0 software. The data were analyzed by one-way ANOVA, the independent sample t-test, or, in the case of several independent samples, by the Kruskal-Wallis test. Categorical data were analyzed by Pearson's χ2 test or Fisher's exact test.

Results

The observed indices included C-reactive protein (CRP), platelet (PLT), white blood cells (WBC), hemoglobin (Hb), albumin, and PRE-albumin. The secondary outcomes included length of hospital stay (LOS), cost, incidence of pulmonary infection, and total incidence of infection.

Conclusion

The combined mode of nutrition is feasible and is not associated with postoperative complications in gastric cancer patients under ERAS.

Prediction of postoperative infectious complications in elderly patients with colorectal cancer: a study based on improved machine learning

BACKGROUND

Infectious complications after colorectal cancer (CRC) surgery increase perioperative mortality and are significantly associated with poor prognosis. We aimed to develop a model for predicting infectious complications after colorectal cancer surgery in elderly patients based on improved machine learning (ML) using inflammatory and nutritional indicators.

METHODS

The data of 512 elderly patients with colorectal cancer in the Third Affiliated Hospital of Anhui Medical University from March 2018 to April 2022 were retrospectively collected and randomly divided into a training set and validation set. The optimal cutoff values of NLR (3.80), PLR (238.50), PNI (48.48), LCR (0.52), and LMR (2.46) were determined by receiver operating characteristic (ROC) curve; Six conventional machine learning models were constructed using patient data in the training set: Linear Regression, Random Forest, Support Vector Machine (SVM), BP Neural Network (BP), Light Gradient Boosting Machine (LGBM), Extreme Gradient Boosting (XGBoost) and an improved moderately greedy XGBoost (MGA-XGBoost) model. The performance of the seven models was evaluated by area under the receiver operator characteristic curve, accuracy (ACC), precision, recall, and F1-score of the validation set.

RESULTS

Five hundred twelve cases were included in this study; 125 cases (24%) had postoperative infectious complications. Postoperative infectious complications were notably associated with 10 items features: American Society of Anesthesiologists scores (ASA), operation time, diabetes, presence of stomy, tumor location, NLR, PLR, PNI, LCR, and LMR. MGA-XGBoost reached the highest AUC (0.862) on the validation set, which was the best model for predicting postoperative infectious complications in elderly patients with colorectal cancer. Among the importance of the internal characteristics of the model, LCR accounted for the highest proportion.

CONCLUSIONS

This study demonstrates for the first time that the MGA-XGBoost model with 10 risk factors might predict postoperative infectious complications in elderly CRC patients.

Early oral feeding following intestinal anastomosis surgery in infants: a multicenter real world study

Background

To prevent postoperative complications, delayed oral feeding (DOF) remains a common model of care following pediatric intestinal anastomosis surgery; however, early oral feeding (EOF) has been shown to be safe and effective in reducing the incidence of complications and fast recovery after pediatric surgery. Unfortunately, the evidence in support of EOF after intestinal anastomosis (IA) in infants is insufficient. Therefore, this study was primarily designed to evaluate the safety and efficacy of EOF. In addition, the current status of EOF application and associated factors that favor or deter EOF implementation were also assessed.

Methods

A total of 898 infants were divided into two groups (EOF group, n = 182; DOF group, n = 716), and the clinical characteristics were collected to identify the factors associated with EOF in infants. Complications and recovery were also compared to define the safety and efficacy after balancing the baseline data by propensity score matching (PSM) (EOF group, n = 179; DOF group, n = 319).

Results

The total EOF rate in infants with IA was 20.3%. Multivariate logistic regression revealed significant differences in the EOF rates based on IA site and weight at the time of surgery (OR = 0.652, 95% CI: 0.542-0.784, p < 0.001) and (OR = 1.188, 95% CI: 1.036-1.362, p = 0.013), respectively. The duration of total parenteral nutrition (TPN), parenteral nutrition (PN), and postoperative hospital stay were significantly shorter in the EOF group than the DOF group [2.0 (1.0, 2.0) d vs. 5.0 (3.0, 6.0) d; 6.0 (5.0, 8.0) d vs. 8.0 (6.0, 11.0) d; 10.0 (7.0, 14.0) d vs. 12.0 (9.0, 15.0) d, all p < 0.001]. The rates of abdominal distension and vomiting in the EOF group were significantly higher than the DOF group (17.9% vs. 7.2%, p < 0.001; 7.8% vs. 2.5%, p = 0.006); however, no differences were found in failure to initial OF, diarrhea, hematochezia, and anastomotic leakage between the two groups (p > 0.05).

Conclusion

The overall rate of EOF in infants following IA was low, and the sites of anastomosis and weight at surgery were two factors associated with EOF. Nevertheless, performing EOF in infants after IA was safe and effective, reduced PN usage, shortened the hospital stay, and did not increase the rate of severe complications.Clinical Trial Registration: ClinicalTrails.gov, identifier NCT04464057.

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).

Application of ERAS Protocol after VATS Surgery for Chronic Empyema in Immunocompromised Patients

Enhanced recovery after surgery protocols have shown improved clinical outcomes after lung resection surgery, but their application after empyema surgery is still limited. We retrospectively evaluated the outcomes of an adapted enhanced recovery after surgery (ERAS) protocol for immunocompromised patients who underwent video-assisted thoracoscopic surgery (VATS) surgery for chronic empyema between December 2013 and December 2021. The patients were divided into an ERAS group and a conventional treatment group. Peri-operative data were collected and compared between the two groups. The primary outcome was post-operative length of stay. Secondary outcomes were post-operative pain and post-operative complications (air leaks, atelectasis). A total of 86 patients, 45 in the ERAS group and 41 in the non-ERAS group, were considered. Chest tube duration (6.4 ± 2.3 vs. 13.6 ± 6.8 days) and post-operative length of stay (7.6 ± 1.6 vs. 16.9 ± 6.9 days) were significantly shorter in the ERAS group. The volume of chest drainage (103 ± 78 vs. 157 ± 89 mL/day) was significantly smaller in the ERAS group. There were no significant differences in operative time, blood loss, need for transfusion, tube reinsertion and median VAS score. The incidence of air leaks and atelectasis was significantly reduced in the ERAS group, as was the need for bronchoscopic aspiration. The application of an ERAS protocol after empyema VATS surgery for immunocompromised patients improved the surgical outcome, reducing the post-operative length of stay and rate of complications.

Enhanced recovery after surgery pathway: association with lower incidence of wound complications and severe hypoalbuminemia in patients undergoing posterior lumbar fusion surgery

Background

Wound complications are associated with worse satisfaction and additional costs in patients undergoing posterior lumbar fusion (PLF) surgery, and the relationship between enhanced recovery after surgery (ERAS) pathway and wound complications remains poorly characterized.

Methods

In this retrospective single-center study, we compared 530 patients receiving ERAS pathway care with previous 530 patients in non-ERAS group. The primary aim of our study was to identify the relationship between the ERAS program and the incidence of postoperative wound-related complications and other complications following PLF surgery; other outcomes included the length of stay (LOS), 90-day hospital and rehabilitation center readmission.

Results

The average patient age was 65 yr. More patients with old cerebral infarction were in ERAS group (p < 0.01), and other demographics and comorbidities were similar between groups. Patients in the ERAS group had a lower incidence of postoperative wound-related complications than the non-ERAS group (12.4 vs. 17.8%, p = 0.02). The non-ERAS group had a significantly higher rate of wound dehiscence or poor wound healing (6% vs. 3%, p = 0.02). ERAS group had a lower incidence of severe postoperative hypoalbuminemia (serum albumin less than 30 g/L) (15.8% vs. 9.0% p < 0.01). Additionally, ERAS patients had shorter postoperative LOS (8.0 ± 1.5 vs. 9.5 ± 1.7, p < 0.01), lower rate of readmission within 90 days (1.9% vs. 6.4%, p < 0.01) and discharge to rehabilitation center (4.2% vs. 1.0%, p < 0.01).

Conclusion

ERAS pathway might help decrease the rates of postoperative wound complications and severe hypoalbuminemia following PLF surgery; additionally, it demonstrated that ERAS pathway was also associated with shorter LOS and lower rate of readmissions within 90 days.

Nursing Practice Based on Evidence-Based Concepts to Prevent Enteral Nutrition Complications for Critically Ill Neurosurgical Patients

Purpose

To explore the practical value of enteral nutrition care guided by evidence-based concepts in preventing enteral nutritional complications in critically ill neurosurgical patients.

Methods

Three hundred critically ill patients from March 2020 to October 2021 from our neurosurgery department were included in the study. Patients were divided into a control group (March to December 2020, n = 150) and a study group (January to October 2021, n = 150) according to the order of their admission. The control group received conventional enteral nutrition care, and the study group received enteral nutrition care based on evidence-based concept guidance. The levels of serum nutritional indicators [hemoglobin (Hb), albumin (ALB), and total protein (TP)], feeding compliance rate, the incidence of complications (gastric retention, bloating, diarrhea, reflux, vomiting, aspiration, stress ulcers, etc.), and prognosis during the observation period were compared between the two groups. The scores of the questionnaire of knowledge, attitude, and practice on nutrition among neurosurgical nurses before and after the implementation of evidence-based care were compared among nursing staff in the study group.

Results

At 1 and 2 weeks after enrollment, Hb, ALB, and TP levels were lower in both groups than before enrollment in the same group (P < 0.05). At 2 weeks after enrollment, Hb, ALB, and TP levels were higher in both groups than at 1 week after enrollment in the same group (P < 0.05). At 1 and 2 weeks after enrollment, Hb, ALB, and TP levels were higher in the study group than in the control group (P < 0.05). At 7 days after feeding, the feeding compliance rate was higher in the study group (94.67%) than in the control group (70.00%) (P < 0.05). The total complication rate was lower in the study group (8.00%) than in the control group (16.00%) (P < 0.05). The percentage of good prognosis was higher in the study group (34.00%) than in the control group (23.33%) (P < 0.05). After the implementation of evidence-based care, caregivers in the study group scored higher on nutrition knowledge, nutrition attitudes, and nutrition practices than those before the implementation (P < 0.05).

Conclusion

The implementation of evidence-based nursing interventions in critically ill neurosurgical patients based on evidence-based concepts is of great clinical value in correcting their nutritional status, preventing enteral nutritional complications, improving prognosis, and enhancing the nutritional knowledge, attitudes, and practices of nursing staff.

Comparison of patient outcomes following enterotomy versus intestinal resection and anastomosis for treatment of intestinal foreign bodies in dogs

OBJECTIVE

To quantify the relative risk of intestinal dehiscence in dogs undergoing intestinal resection and anastomosis (IRA), compared with enterotomy, for surgical management of small intestinal foreign bodies, and to evaluate the association between nasogastric tube placement for early enteral nutrition (EEN) and hospitalization time.

ANIMALS

211 dogs undergoing 227 surgeries for intestinal foreign body removal.

PROCEDURES

Medical records were reviewed for dogs undergoing a single-site sutured enterotomy or IRA for foreign body intestinal obstruction between May 2008 and April 2018. Multivariable logistic regression was used to quantify the association between surgical procedure and dehiscence. Multiple linear regression was used to quantify the association of nasogastric tube placement with total hospitalization time.

RESULTS

Dehiscence rates were 3.8% (7/183) and 18.2% (8/44) for enterotomy and IRA, respectively. Overall dehiscence rate for all surgeries was 6.6% (15/227). The odds of intestinal dehiscence for IRA were 6.09 times (95% CI, 1.89 to 19.58) the odds for enterotomy. An American Society of Anesthesiologists score > 3 (OR, 4.49; 95% CI, 1.43 to 14.11) and an older age (OR, 1.02 [95% CI, 1.01 to 1.02] for each 1-month increase in age) were significantly associated with greater odds of intestinal dehiscence, regardless of surgical procedure. Placement of a nasogastric tube was not associated with intestinal dehiscence or decreased total hospitalization time when controlling for the year of surgery.

CONCLUSIONS AND CLINICAL RELEVANCE

Patients undergoing IRA were at a significantly higher risk of intestinal dehiscence, compared with patients undergoing enterotomy. Although this finding should not be used to recommend enterotomy over IRA, this information may be useful in guiding owner expectations and postoperative monitoring.

Clinical efficacy of different nutritional methods in patients after laparoscopic radical surgery for distal gastric cancer

BACKGROUND

The incidence of gastric cancer (GC) in Asian countries remains high. Surgical resection is the most effective treatment for GC. The postoperative nutritional support methods mainly include total parenteral nutrition (TPN), total enteral nutrition (TEN), and enteral parenteral nutrition (EPN). However, it is still controversial over the optimal postoperative nutrition method for GC patients.

AIM

To analyze the clinical efficacy of different nutritional methods in patients after laparoscopic radical surgery for distal GC.

METHODS

The patients who underwent laparoscopic radical surgery for distal GC at Jinhua Central Hospital from January 2017 to December 2019 were randomly divided into three groups (50 patients each) and given TPN, TEN, and EPN, respectively. The clinical efficacy, incidence of complications, postoperative hospitalization time, time to anal exhaust, and time to solid food intake were compared among the three groups.

RESULTS

On the 8^th day after surgery, the levels of plasma albumin and prealbumin were significantly higher in the TEN and EPN groups than in the TPN group (P < 0.05), and in the EPN group than in the TEN group (P < 0.05); the levels of C-reactive protein (CRP) were significantly lower in the TEN and EPN groups than in the TPN group (P < 0.05), and in the EPN group than in the TEN group (P < 0.05); the lymphocyte counts increased significantly compared with those on the 1st day after surgery in the TEN and EPN groups (P < 0.05), and the lymphocyte count in the EPN group was significantly higher than those in the TPN and TEN groups (P < 0.05). The incidence rates of postoperative complications in the TEN and EPN groups were significantly lower than that in the TPN group (P < 0.05). The postoperative hospitalization time (8.5 ± 0.7 d), time to anal exhaust (3.1 ± 0.3 d), and time to solid food intake (6.1 ± 0.6 d) in the EPN group were all significantly shorter than those in the TPN and TEN groups (P < 0.05).

CONCLUSION

The nutritional approach of EPN can improve the nutritional status of patients after laparoscopic radical surgery for distal GC, reduce the occurrence of complications, and shorten the length of hospital stay.

Perioperative Enteral Nutrition Improves Postoperative Recovery for Patients with Primary Liver Cancer: A Randomized Controlled Clinical Trial

OBJECTIVE

The role of perioperative protein-enriched enteral nutrition for patients with primary liver cancer is unclear. We investigated the efficacy of perioperative protein-enriched enteral nutrition for patients with primary liver cancer followed hepatectomy.

METHODS

Patients with primary liver cancer that underwent hepatectomy between January 2016 and 2018 were enrolled. Patients in the treatment group was given enteral nutrition (TP-MCT) in addition to the regular diet. The primary outcome measures were duration of hospital stay and length of postoperative hospital stay. Secondary outcome measures included time to first flatus and time to first defecation.

RESULTS

There was a significant reduction of time to first flatus and time to first defecation in the treatment group, when compared with the control group (time to first flatus: P = 0.001, time to first defecation: P < 0.001).

CONCLUSIONS

It is found that addition of protein-enriched enteral nutrition (TP-MCT) improved postoperative recovery for patients with primary liver cancer following hepatectomy, with a significant reduction in time to first flatus and time to first defecation.

Early intravenous administration of nutritional support (IVANS) in metastatic gastric cancer patients at nutritional risk, undergoing first-line chemotherapy: study protocol of a pragmatic, randomized, multicenter, clinical trial

Background

Malnutrition is common in cancer patients, particularly in those affected by gastrointestinal malignancies, and negatively affects treatment tolerance, survival, functional status, and quality of life (QoL). Nutritional support, including supplemental parenteral nutrition (SPN), has been recommended at the earliest opportunity in malnourished cancer patients. The limited available evidence on the efficacy of SPN in gastrointestinal cancer patients is positive, particularly with regards to QoL, body composition, and energy intake, but the evidence on survival is still scanty. Furthermore, studies regarding the early administration of SPN in combination with nutritional counseling from the beginning of first-line chemotherapy (CT) are lacking. We hypothesize that early systematic SPN in combination with nutritional counseling (NC), compared with NC alone, can benefit patients with previously untreated metastatic gastric cancer at nutritional risk undergoing first-line CT.

Methods

The aim of this pragmatic, multicenter, randomized (1:1), parallel-group, open-label, controlled clinical trial is to evaluate the efficacy in terms of survival, weight maintenance, body composition, QoL and feasibility of cancer therapy of early systematic SNP. This is in combination with NC, compared with NC alone, in treatment-naïve metastatic gastric cancer patients at nutritional risk undergoing first-line CT.

Discussion

Malnutrition in oncology remains an overlooked problem. Although the importance of SPN in gastrointestinal cancer patients has been acknowledged, no studies have yet evaluated the efficacy of early SPN in metastatic gastric patients undergoing CT. The present study, which guarantees the early provision of nutritional assessment and support to all the enrolled patients in accordance with the recent guidelines and recommendations, could represent one of the first proofs of the clinical effectiveness of early intensive nutritional support in cancer patients undergoing CT. This study could stimulate further large randomized trials in different cancer types, potentially resulting in the improvement of supportive care quality.

Trial registration

This study is registered on ClinicalTrials.gov: NCT03949907.

Acupuncture Combined with Early Enteral Nutrition on Patients with Postoperative Laparoscopic Common Bile Duct Exploration: A Prospective Randomized Trial

OBJECTIVE

To assess the efficiency of acupuncture combined with early enteral nutrition (EEN) in patients with postoperative laparoscopic common bile duct exploration.

METHODS

A total of 200 patients with postoperative laparoscopic bile duct exploration was randomized using sealed envelopes and assigned to the convenitional, EEN, acupuncture plus convenitional and acupuncture plus EEN groups, 50 cases in each group. Twelve hours after operation, the patients in EEN groups began to receive oral enteral nutrition, and the acupuncture approach was performed by acupuncturist in acupuncture plus conventional and acupuncture plus EEN groups. Acupuncture was given at Zusanli (ST 36), Shangjuxu (ST 37) and Xiajuxu (ST 39) with a depth of 15-20 mm, using the lifting-thrusting and twisting method to obtain Deqi sensation. The needles were maintained for 30 min. Treatment was given once daily, 3 times per section. After the intervention, the patients' characteristics, operation time, bleeding volume, postoperative time to first anal exhaust, postoperative complications including abdominal distension, diarrhea, gastric dilatation, intestinal obstruction, pharyngodynia, incision, abdominal and pulmonary infection and postoperative hospitalization days were assessed and compared in patients among 4 groups.

RESULTS

Postoperative time to first anal exhaust in the convenitional group was longer compared with the other 3 groups (P<0.05), and was shorter in the acupuncture plus EEN group than those of the convenitional, acupuncture plus convenitional and EEN groups (P<0.01). The acupuncture plus EEN group showed significant decrease in the incidence of complications and less postoperative hospitalization days compared with the other groups (P<0.05 or P<0.01). There was no readmission.

CONCLUSION

After laparoscopic bile duct exploration, acupuncture combined with EEN treatment significantly improves the patients' gastrointestinal function, reduces complications, and shortens postoperative hospitalization days.

The evolution of fast track protocols after oesophagectomy

Fast track is a standardised goal directed patient's care pathway that aims to facilitate recovery following surgery. Currently, there are large variations in the fast track protocols used in oesophagectomy due to the complexity of the procedure. The objective of this systematic review is to assess the evolution of fast track protocols following oesophagectomy since its implementation and the resulting effect on postoperative outcomes. Relevant electronic databases were searched for studies assessing the clinical outcome from fast track in oesophagectomy and also those assessing the effects of the individual key components in fast track protocols. The search yielded twenty-three publications regarding fast track implementation in oesophagectomy. A pattern of consistent evolution in fast-track protocols was clearly demonstrated and these have shown variations in the core-identified components across the studies. However, evolution in fast track protocols over time showed, an overall improvement in length of stay, anastomotic leak, pulmonary complications and mortality over time. Thirty publications were included that evaluated specific components of fast track protocols, with an increasing trend towards addressing the nutritional aspect in oesophagectomy care in more recent years. The variations in the key components of fast track protocol of care identify the need for continued assessment and identification for areas of improvement. In the future incremental gains through focused improvements in key components will lend itself to even better postoperative outcomes and patient experience during oesophageal cancer treatment.

Impact of enhanced recovery after surgery programs on pancreatic surgery: A meta-analysis

AIM

To evaluate the impact of enhanced recovery after surgery (ERAS) programs on postoperative complications of pancreatic surgery.

METHODS

Computer searches were performed in databases (including PubMed, Cochrane Library and Embase) for randomized controlled trials or case-control studies describing ERAS programs in patients undergoing pancreatic surgery published between January 1995 and August 2017. Two researchers independently evaluated the quality of the studies’ extracted data that met the inclusion criteria and performed a meta-analysis using RevMan5.3.5 software. Forest plots, demonstrating the outcomes of the ERAS group vs the control group after pancreatic surgery, and funnel plots were used to evaluate potential publication bias.

RESULTS

Twenty case-control studies including 3694 patients, published between January 1995 and August 2017, were selected for the meta-analysis. This study included the ERAS group (n = 1886) and the control group (n = 1808), which adopted the traditional perioperative management. Compared to the control group, the ERAS group had lower delayed gastric emptying rates [odds ratio (OR) = 0.58, 95% confidence interval (CI): 0.48-0.72, P < 0.00001], lower postoperative complication rates (OR = 0.57, 95%CI: 0.45-0.72, P < 0.00001), particularly for the mild postoperative complications (Clavien-Dindo I-II) (OR = 0.71, 95%CI: 0.58-0.88, P = 0.002), lower abdominal infection rates (OR = 0.70, 95%CI: 0.54-0.90, P = 0.006), and shorter postoperative length of hospital stay (PLOS) (WMD = -4.45, 95%CI: -5.99 to -2.91, P < 0.00001). However, there were no significant differences in complications, such as, postoperative pancreatic fistulas, moderate to severe complications (Clavien-Dindo III- V), mortality, readmission and unintended reoperation, in both groups.

CONCLUSION

The perioperative implementation of ERAS programs in pancreatic surgery is safe and effective, can decrease postoperative complication rates, and can promote recovery for patients.