A meta-analysis of the effect of early enteral nutrition versus total parenteral nutrition on patients after pancreaticoduodenectomy

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.

An Elemental Diet Reduces Chylous Ascites of Patients Undergoing Pancreatoduodenectomy in the Setting of Early Enteral Feeding

OBJECTIVES

The elemental diet (ED) is a formula to support nutritional status without increasing chylous burden. This study evaluates the efficacy of early ED feeding after pancreatoduodenectomy (PD).

MATERIALS AND METHODS

A prospective phase II study of consecutive patients who underwent PD with early ED feeding was conducted. Patient backgrounds, surgical outcomes, and ED feeding tolerability were compared with a historical cohort of 74 PD patients with early enteral feeding of a low residue diet (LRD).

RESULTS

The ED group comprised 104 patients. No patient in the ED group discontinued enteral feeding because of chylous ascites (CAs), whereas 17.6% of the LRD group experienced refractory CAs that disrupted further enteral feeding. The CAs rate was significantly decreased in the ED group compared with the LRD group (3.9% and 48.7%, respectively; P < 0.001). There was no significant difference in the incidence of major complications (ED: 17.3%, LRD: 18.9%; P = 0.844). Postoperative prognostic nutritional index was similar between the 2 groups ( P = 0.764). In multivariate analysis, enteral feeding formula, and sex were independent risk factors for CAs (LRD: P < 0.001, odds ratio, 22.87; female: P = 0.019, odds ratio, 2.78).

CONCLUSIONS

An ED reduces postoperative CAs of patients undergoing PD in the setting of early enteral feeding.

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.

Early oral feeding versus nasojejunal early enteral nutrition in patients following pancreaticoduodenectomy: a propensity score-weighted analysis of 428 consecutive patients

BACKGROUND

Notwithstanding that significant medical progress has been achieved in recent years, the optimal nutritional support method following pancreaticoduodenectomy (PD) remains uncertain. This study compared the safety and feasibility of early oral feeding (EOF) with nasojejunal early enteral nutrition (NJEEN) after PD.

METHODS

A retrospective cohort study was conducted on 428 consecutive patients who underwent PD between August 2018 and December 2020. During the first study phase, the routine postoperative feeding strategy was NJEEN, later replaced by EOF during the second study phase. The primary outcome was the incidence of delayed gastric emptying (DGE) following PD. Propensity score weighting was used to control for confounding factors.

RESULTS

Four hundred forty patients underwent PD during the overall study period, with 438 patients aged 18 years and older. Ten patients experienced accidental tube dislodgement or migration and were excluded from the study based on the exclusion criteria. Finally, 211 patients and 217 patients underwent EOF and NJEEN, respectively. After propensity score weighting, it was observed that patients who underwent postoperative EOF experienced a significantly lower DGE (B/C) rate compared to those who underwent postoperative NJEEN [7.38% (31/424) vs. 14.97% (62/413), P =0.0005]. Subgroup analyses according to the presence of soft pancreatic texture yielded consistent results. The EOF group exhibited lower DGE grade, DGE (B/C) rate [5.90% (11/194) vs. 22.07% (43/193), P <0.0001], postoperative gastrointestinal endoscopic intervention rate, and Clavien-Dindo Grade III or higher rate.

CONCLUSIONS

EOF is superior to NJEEN in reducing the incidence of grade B/C DGE after PD. The EOF procedure is safe and feasible and should be recommended as the optimal postoperative feeding method following PD.

Efficacy of Early Enteral Nutrition on Gastrointestinal Surgery Outcomes: A Systematic Review and Meta-Analysis

Congenital anomalies, congenital malformations, or birth defects can be defined as any structural or functional anomalies that develop prenatally and could be identified before, at birth, or later in life. Approximately 6% of babies are born with a congenital anomaly, which results in 2.4 million newborn deaths worldwide. This systematic review and meta-analysis ascertained the quantitative studies published in PubMed, ClinicalKey, Embase, CINAHL, Cochrane Library, and Google Scholar. Two authors independently screened and extracted the data from the primary studies that analyzed the efficacy of early enteral nutrition (EEN) on the postoperative outcome. This systematic review and meta-analysis adopted Cochrane Collaboration guidelines and reported using the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statement. The methodological quality of trials was assessed by Cochrane Collaboration's risk of bias tool. Six trials, representing 488 children, with age ranging from 10 days to 6.5 years, fulfilled the inclusion criteria. EEN has significantly shortened hospital stay, induced early fecal movement, and reduced postoperative wound infections in children with congenital gastrointestinal abnormalities undergoing gastrointestinal anastomosis compared with children who received late enteral nutrition. The review also found that the experimental group who received EEN had no significant impact on the anastomosis leakage, vomiting, and abdominal distension. EEN has some positive effects on postsurgery outcomes among children with congenital gastrointestinal anomalies undergoing gastrointestinal anastomosis.

Early vs delayed enteral nutrition or parenteral nutrition in hospitalized patients: An umbrella review of systematic reviews and meta-analyses of randomized trials

We conducted an umbrella review to summarize the existing evidence on the effect of early enteral nutrition (EEN) compared with other approaches, including delayed enteral nutrition (DEN), parenteral nutrition (PN), and oral feeding (OF) on clinical outcomes in hospitalized patients. We performed a systematic search up to December 2021, in MEDLINE (via PubMed), Scopus, and Institute for Scientific Information Web of Science. We included systematic reviews with meta-analyses (SRMAs) of randomized trials investigating EEN compared with DEN, PN, or OF for any clinical outcomes in hospitalized patients. We used "A Measurement Tool to Assess Systematic Reviews" (AMSTAR2) and the Cochrane risk-of-bias tool for assessing the methodological quality of the systematic reviews and their included trial, respectively. The certainty of the evidence was rated using the "Grading of Recommendations Assessment, Development, and Evaluation" (GRADE) approach. We included 45 eligible SRMAs contributing with a total of 103 randomized controlled trials. The overall meta-analyses showed that patients who received EEN had statistically significant beneficial effects on most outcomes compared with any control (ie, DEN, PN, or OF), including mortality, sepsis, overall complications, infection complications, multiorgan failure, anastomotic leakage, length of hospital stay, time to flatus, and serum albumin levels. No statistically significant beneficial effects were found for risk of pneumonia, noninfectious complications, vomiting, wound infection, as well as number of days of ventilation, intensive care unit days, serum protein, and pre-serum albumin levels. Our results indicate that EEN may be preferred over DEN, PN, and OF because of the beneficial effects on many clinical outcomes.

Perioperative nutrition for gastrointestinal surgery: On the cutting edge

Evidence on perioperative nutrition interventions in gastrointestinal surgery is rapidly evolving. We conducted a narrative review of various aspects of nutrition support, including formula choice and route of administration, as well as duration and timing of nutrition support therapy. Studies have demonstrated that nutrition support is associated with improved clinical outcomes in malnourished patients and those at nutrition risk, emphasizing the importance of nutrition assessment, for which several validated nutrition risk assessment tools exist. The assessment of serum albumin levels has fallen out of favor, as it is an unreliable marker of nutrition status, whereas imaging evidence of sarcopenia has prognostic value and may emerge as a standard component of nutrition assessment. Preoperatively, evidence supports limiting fasting to reduce insulin resistance and improve oral tolerance. Benefits to preoperative carbohydrate loading remain unclear, whereas literature suggests preoperative parenteral nutrition (PN) may reduce postoperative complications in high-risk patients with malnutrition or sarcopenia. Postoperatively, early oral feeding is safe with benefits in time to return of bowel function and reduced hospital stay. There is a signal for potential benefit to early postoperative PN in critically ill patients, though evidence is sparse. There has also been a recent emergence in randomized studies evaluating the use of ω-3 fatty acids, amino acids, and immunonutrition. Meta-analyses have reported favorable outcomes for these supplements, though individual studies are small and with significant methodological limitations and risk of bias, emphasizing the need for high-quality randomized studies to guide clinical practice.

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.

Efficacy of early enteral nutrition versus total parenteral nutrition for patients with gastric cancer complicated with diabetes mellitus: A systematic review and meta-analysis

AIM

This study aimed to synthesise available data and evaluate the clinical evidence regarding the effect of early enteral nutrition versus total parenteral nutrition on nutritional status and blood glucose in patients with gastric cancer complicated with diabetes mellitus after gastrectomy.

METHODS

This systematic review and meta-analysis was designed, conducted and reported following the PRISMA guideline. We performed searches in PubMed, Embase, Medline, Web of Science, Cochrane Library, Chinese Biomedicine Literature Database, Chinese Scientific Journal Database, Chinese National Knowledge Infrastructure and Wanfang Database. The study designs were randomised controlled trials, quasi-randomised controlled trials, and controlled clinical trials. The trials compared early enteral nutrition (experimental group) with total parenteral nutrition (control group) in patients with gastric cancer complicated with diabetes mellitus after gastrectomy. The risk of bias was assessed using the Cochrane risk of bias tool.

RESULTS

A total of 19 trials (1255 patients) were included. Meta-analysis showed a significantly shorter length of hospital stay (days; mean difference -5.07, 95% confidence interval [CI] [-6.28, -3.86], p < 0.00001) and a lower post-operative complications rate (%; odds ratio 0.29, 95% CI [0.16, 0.50], p < 0.0001) in the early enteral nutrition group than in the total parenteral nutrition group. Compared with the total parenteral nutrition group, the early enteral nutrition group had lower blood glucose fluctuation values (mmol/L; mean difference -2.03, 95% CI [-2.44, -1.61], p < 0.00001), lower levels of glycosylated haemoglobin (%; mean difference -0.62, 95% CI [-1.22, -0.03], p = 0.04), higher levels of prealbumin (g/L; p = 0.002), transferrin (g/L; p = 0.002), total protein (g/L; p = 0.001) and haemoglobin (g/L; p = 0.005).

CONCLUSIONS

Early enteral nutrition may maintain stable blood glucose levels and improve nutritional status, leading to better therapeutic effectiveness in gastric cancer complicated with diabetes mellitus patients.

Incidence and risk factors for Chyle leak after pancreatic surgery for cancer: A comprehensive systematic review

BACKGROUND

Chyle leak (CL) is a clinically relevant complication after pancreatectomy. Its incidence and the associated risk factors are ill defined, and various treatments options have been described. There is no consensus, however, regarding optimal management. The present study aims to systematically review the literature on CL after pancreatectomy.

METHODS

A systematic review from PubMed, Scopus and Embase database was performed. Studies using a clear definition for CL and published from January 2000 to January 2021 were included. The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score was used to assess methodological quality.

RESULTS

Literature search found 361 reports, 99 of which were duplicates. The titles and abstracts of 262 articles were finally screened. The references from the remaining 181 articles were manually assessed. After the exclusions, 43 articles were thoroughly assessed. A total of 23 articles were ultimately included for this review. The number of patients varied from 54 to 3532. Incidence of post pancreatectomy CL varied from 1.3% to 22.1%. Main risk factors were the extent of the surgery and early oral or enteral feeding. CL dried up spontaneously or after conservative management within 14 days in 53% to 100% of the cases.

CONCLUSIONS

The extent of surgery is the most common predictor of risk of CL. Conservative treatment has been shown to be effective in most cases and can be considered the treatment of choice. We propose a management algorithm based on the current available evidence.

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 clinical effect of early enteral nutrition in liver-transplanted patients: a systematic review and meta-analysis

BACKGROUND

Appropriate nutritional support is critical for patients undergoing liver transplantation (LT). Early enteral nutrition (EEN) has been considered effective in critically ill patients. However, the clinical effect of EEN on liver-transplanted patients is unclear.

AIM

To evaluate the clinical effect of early enteral nutrition in patients receiving a liver transplant.

METHODS

A systematic search was performed on the Cochrane Library, PubMed, CINAHL, EMBASE, Web of Science, WanFang database, Chinese Biomedical Literature Database and China National Knowledge Infrastructure to collect relevant studies up to January, 2020. The results of these studies were pooled to calculate relative risk and mean differences with 95% confidence intervals for dichotomous data and continuous data. All statistical analysis was carried out by Review Manager 5.3.

RESULTS

9 RCTs and 10 cohort studies with 1300 patients were included in this meta-analysis. Compared with TPN, EEN reduced postoperative infection rates, ICU hours, length of hospitalization, and the duration of bowel ventilation as well as strengthening the nutritional status and liver function of LT patients. There is no difference in mortality rates, blood glucose levels or gastrointestinal complications. Compared to TPN, the combined EN + PN method more effectively prevented infection.

CONCLUSION

For patients undergoing liver transplantation, early enteral nutrition with or without combination may considered as a better nutritional therapy than total parenteral nutrition.

Comprehensive strategy for perioperative care of pancreaticoduodenectomy according to the risk stratification by pancreatic fistula and delayed gastric emptying

BACKGROUND/OBJECTIVE

Pancreaticoduodenectomy (PD) is highly invasive with unsatisfactory postoperative complication rates. Nutritional and fluid management after major surgery attracts much attention with regard to the reduction in severe postoperative complications. We retrospectively analyzed PD cases and proposed a novel strategy for perioperative fluid and nutritional therapy according to the risk stratification by pancreatic fistula (PF) and delayed gastric emptying (DGE).

METHODS

Between 2003 and 2018, 140 patients underwent PD at our institute of which 134 patients were enrolled. We evaluated the clinicopathological factors affecting severe (≥10%) body weight loss (BWL), factors affecting the incidence of PF and intraabdominal complications (IAC), and factors related to DGE.

RESULTS

Multivariate analysis indicated that male sex, severe PF, and DGE are significant risk factors for BWL ≥10%. PF and IAC were predominantly observed in male patients and those with non-pancreatic cancer. A fluid balance ≥6000 ml on postoperative day 2 was the sole risk factor for primary DGE. Secondary DGE significantly correlated with stomach preserving PD. Importantly, the average BWL was around 15% in grade B or C secondary DGE.

CONCLUSION

Severe postoperative complications resulted in significant BWL. Enteral feeding is unnecessary in cases with a hard pancreas and dilated pancreatic duct if appropriate perioperative fluid management is performed. Secondary DGE followed by PF or IAC is unavoidable to some extent, especially in the case of soft pancreas with a fine pancreatic duct. In such cases, enteral feeding with tube ileostomy should be considered, and stomach preserving PD is likely to be harmful.

Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review

Enhanced recovery after surgery (ERAS) initially started in the early 2000s as a series of protocols to improve the perioperative care of surgical patients. They aimed to increase patient satisfaction while reducing postoperative complications and postoperative length of stay. Despite these protocols being widely adopted in many fields of surgery, they are yet to be adopted in pancreatic transplantation: a high-risk surgery with often prolonged length of postoperative stay and high rate of complications. We have analysed the literature in pancreatic and transplantation surgery to identify the necessary preoperative, intra-operative and postoperative components of an ERAS pathway in pancreas transplantation.

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

AIM

Evidence of nutritional therapies in pancreatoduodenectomy (PD) has been shown. However, few studies focus on the association between different nutritional therapies and outcomes. The aim of this review was to summarize the current evidence of nutritional therapies such as enteral nutrition (EN), immunonutrition, and synbiotics on postoperative outcomes after PD.

METHODS

A systematic literature search of Embase, Medline Ovid, and Cochrane CENTRAL was done to summarize the available evidence, including randomized controlled trials, meta-analyses and reviews, regarding nutritional therapy in PD.

RESULTS

A total of 20 randomized controlled trials were included in this review. Safety and tolerability of EN in PD was shown. Giving postoperative EN can shorten length of stay compared to parenteral nutrition; however, the effect of EN on postoperative complications remains controversial. Postoperative EN should be given only on selective indications rather than routinely used, and preoperative EN is indicated only in patients with severe malnutrition. Giving preoperative immunonutrition is considered to reduce the incidence of infectious complications; however, evidence level is moderate and recommendation grade is weak. The beneficial effect of perioperative synbiotics on postoperative infectious complications is limited. Furthermore, the effectiveness of other nutritional supplements remains unclear.

CONCLUSION

Recently, evidence of enhanced recovery after surgery (ERAS) in PD has been increasing. Early oral intake with systematic nutritional support is an important aspect of the ERAS concept. Future well-designed studies should investigate the impact of systematic nutritional therapies on outcomes following PD.