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Jing W, Wu S, Gao S, Shi X, Liu W, Ren Y, Ouyang L, Zheng K, Guo S, Wu C, Jin G. Early oral feeding versus nasojejunal early enteral nutrition in patients following pancreaticoduodenectomy: a propensity score-weighted analysis of 428 consecutive patients. Int J Surg 2024; 110:229-237. [PMID: 37755371 PMCID: PMC10793729 DOI: 10.1097/js9.0000000000000786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/10/2023] [Indexed: 09/28/2023]
Abstract
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.
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Affiliation(s)
- Wei Jing
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Shengyong Wu
- Department of Military Health Statistics, Navy Medical University, Shanghai, China
| | - Suizhi Gao
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Xiaohan Shi
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Wuchao Liu
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Yiwei Ren
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Liu Ouyang
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Kailian Zheng
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Shiwei Guo
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
| | - Cheng Wu
- Department of Military Health Statistics, Navy Medical University, Shanghai, China
| | - Gang Jin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University
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Noorian S, Kwaan MR, Jaffe N, Yaceczko SD, Chau LW. Perioperative nutrition for gastrointestinal surgery: On the cutting edge. Nutr Clin Pract 2023; 38:539-556. [PMID: 36847684 DOI: 10.1002/ncp.10970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 01/16/2023] [Accepted: 01/28/2023] [Indexed: 03/01/2023] Open
Abstract
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.
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Affiliation(s)
- Shaya Noorian
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Mary R Kwaan
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Nancee Jaffe
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Lydia W Chau
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
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Kokkinakis S, Kritsotakis EI, Maliotis N, Karageorgiou I, Chrysos E, Lasithiotakis K. Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis. Hepatobiliary Pancreat Dis Int 2022; 21:527-537. [PMID: 35513962 DOI: 10.1016/j.hbpd.2022.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 04/13/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years. DATA SOURCES A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression. RESULTS A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I2 = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I2 = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I2= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I2 = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I2 = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class. CONCLUSIONS Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.
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Affiliation(s)
- Stamatios Kokkinakis
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Evangelos I Kritsotakis
- Laboratory of Biostatistics, Division of Social Medicine, School of Medicine, University of Crete, Heraklion, Crete 71110, Greece
| | - Neofytos Maliotis
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Ioannis Karageorgiou
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Emmanuel Chrysos
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Konstantinos Lasithiotakis
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece.
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Cañamares-Orbís P, García-Rayado G, Alfaro-Almajano E. Nutritional Support in Pancreatic Diseases. Nutrients 2022; 14:4570. [PMID: 36364832 PMCID: PMC9656643 DOI: 10.3390/nu14214570] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 08/13/2023] Open
Abstract
This review summarizes the main pancreatic diseases from a nutritional approach. Nutrition is a cornerstone of pancreatic disease and is sometimes undervalued. An early identification of malnutrition is the first step in maintaining an adequate nutritional status in acute pancreatitis, chronic pancreatitis and pancreatic cancer. Following a proper diet is a pillar in the treatment of pancreatic diseases and, often, nutritional counseling becomes essential. In addition, some patients will require oral nutritional supplements and fat-soluble vitamins to combat certain deficiencies. Other patients will require enteral nutrition by nasoenteric tube or total parenteral nutrition in order to maintain the requirements, depending on the pathology and its consequences. Pancreatic exocrine insufficiency, defined as a significant decrease in pancreatic enzymes or bicarbonate until the digestive function is impaired, is common in pancreatic diseases and is the main cause of malnutrition. Pancreatic enzymes therapy allows for the management of these patients. Nutrition can improve the nutritional status and quality of life of these patients and may even improve life expectancy in patients with pancreatic cancer. For this reason, nutrition must maintain the importance it deserves.
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Affiliation(s)
- Pablo Cañamares-Orbís
- Gastroenterology, Hepatology and Nutrition Unit, San Jorge University Hospital, Martínez de Velasco Avenue 36, 22004 Huesca, Spain
| | - Guillermo García-Rayado
- Digestive Disease Department, Lozano Blesa University Clinic Hospital, San Juan Bosco Avenue 15, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), San Juan Bosco Avenue 13, 50009 Zaragoza, Spain
| | - Enrique Alfaro-Almajano
- Digestive Disease Department, Lozano Blesa University Clinic Hospital, San Juan Bosco Avenue 15, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), San Juan Bosco Avenue 13, 50009 Zaragoza, Spain
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Halle-Smith JM, Pande R, Powell-Brett S, Pathak S, Pandanaboyana S, Smith AM, Roberts KJ. Early oral feeding after pancreatoduodenectomy: a systematic review and meta-analysis. HPB (Oxford) 2022; 24:1615-1621. [PMID: 35606323 DOI: 10.1016/j.hpb.2022.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 02/17/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The effect of early oral feeding (EOF) after pancreatoduodenectomy (PD) upon perioperative complications and outcomes is unknown, therefore the aim of this systematic review and meta-analysis was to investigate the effect of EOF on clinical outcomes after PD, such as postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and length of stay (LOS). METHODS A systematic review and meta-analysis was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance and assimilated evidence from studies reporting outcomes for patients who received EOF after PD compared to enteral tube feeding (EN) or parenteral nutrition (PN). RESULTS Four studies reported outcomes after EOF compared to EN/PN after PD and included 553 patients. Meta-analyses showed no difference in rates of CR-POPF (OR 0.74; 95%CI 0.44-1.24; p = 0.25) or DGE (Grade B/C) (OR 0.83; 95%CI 0.31-2.21; p = 0.70). LOS was significantly shorter in the EOF group compared to the EN/PN group (Mean Difference -3.40 days; 95% -6.11-0.70 days; p = 0.01). CONCLUSION Current available evidence suggests that EOF after PD is not associated with increased risk of DGE, does not exacerbate POPF and appears to reduce length of stay.
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Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom.
| | - Rupaly Pande
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Sarah Powell-Brett
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Samir Pathak
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, United Kingdom
| | - Sanjay Pandanaboyana
- Hepatobiliary and Pancreatic Surgery Unit, Newcastle Upon Tyne Teaching Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Andrew M Smith
- Hepatobiliary and Pancreatic Surgery Unit, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, United Kingdom
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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Kapoor D, Barreto SG, Perwaiz A, Singh A, Chaudhary A. Can we predict the need for nutritional support following pancreatoduodenectomy? Pancreatology 2022; 22:160-167. [PMID: 34893447 DOI: 10.1016/j.pan.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/08/2021] [Accepted: 11/28/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The practice of routine placement of a tube jejunostomy at the time of pancreatoduodenectomy has given way to a more selective approach. However, the indications of establishing enteral access at the time of surgery remain poorly defined. This study aimed to assess the preoperative and intraoperative factors associated with the need for nutritional support after pancreatoduodenectomy, to guide decision-making for the establishment of intraoperative feeding access. METHODS Retrospective study, analyzing the data of 562 consecutive patients, who underwent pancreatoduodenectomy between March 2013 to December 2020. Univariate and multiple logistic regression analysis was carried out to ascertain the factors associated with the initiation of and need for nutritional support for more than 7 days postop. The utility of tube jejunostomy was studied in patients in whom it was performed. RESULTS Of 562 patients, 105 (18.7%) needed nutritional support. A tube jejunostomy was performed in 46 (8.2%) patients, parenteral nutrition was used in 83 (14.8%), and nasojejunal tube placed in 28 (4.9%) patients. On logistic regression analysis, age, serum albumin <3.0 gm/dl and operative blood loss were independently associated with the initiation of supportive nutrition, while preoperative gastric outlet obstruction (OR 3.105, 95% CI1.201-8.032, p = 0.019) and serum albumin <3.0 gm/dl (OR 2.669, 95% CI 1.131-6.300, p = 0.025) were associated with the need for prolonged nutritional support. The maximal benefit of tube jejunostomy was in patients with mental health disorders (83.3%). CONCLUSION Tube jejunostomy for nutritional support after pancreatoduodenectomy can be considered in patients with preoperative gastric outlet obstruction, serum albumin <3.0 gm/dl and mental health disorders.
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Affiliation(s)
- Deeksha Kapoor
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
| | - Savio George Barreto
- Division of Surgery & Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia.
| | - Azhar Perwaiz
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
| | - Amanjeet Singh
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
| | - Adarsh Chaudhary
- Division of GI Surgery, GI Oncology, Minimal Access and Bariatric Surgery, Institute of Digestive and Hepatobiliary Sciences, Medanta - the Medicity, Sector 38, Gurugram, Haryana, 122001, India.
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Huang H, Zhang Y, Shen L, Huang Y. Level of ERAS understanding affects practitioners' practice and perception of early postoperative resumption of oral intake: a nationwide survey. BMC Anesthesiol 2021; 21:279. [PMID: 34763674 PMCID: PMC8588702 DOI: 10.1186/s12871-021-01500-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/02/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Early postoperative resumption of oral intake is supposed to be safe and beneficial to patients recovery. However, practitioners still have great confusion and disagreement about postoperative resumption of oral intake. This is a nationwide survey to investigate the current status of clinical practice and practitioners' attitude toward postoperative resumption of oral intake along with their level of understanding of the ERAS guidelines. METHODS An anonymous web-based survey questionnaire via mobile social platform was carried out in mainland China from December 11-20, 2020. The Wilcoxon signed rank test or chi-square test was used to compare the propensity of the resumption of oral intake. RESULTS Totally 5370 responses were received, and 89% of them were from anesthesiology departments. The nature of the responses from clinical practitioners was highly diverse, but each of the three surgery types showed unique patterns of ERAS implementation. The respondents were more conservative regarding the commencement of both fluid and solid diets after gastrointestinal (GI) and hepato-pancreato-biliary (HPB) surgery than after non-abdominal (NA) surgery. Most respondents agreed that early oral intake is beneficial to reduce postoperative complications improve bowel recovery and overall outcome. 55% respondents considered themselves to have a better understanding of ERAS and tended to initiate oral intake early for all three surgery types (P < 0.001). CONCLUSIONS The postoperative resumption of oral intake is highly variable among GI, HPB and NA surgeries. A better understanding of ERAS would encourage practitioners to commence oral intake resumption much earlier.
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Affiliation(s)
- Huizhen Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Le Shen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China.
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
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Principe DR, Underwood PW, Korc M, Trevino JG, Munshi HG, Rana A. The Current Treatment Paradigm for Pancreatic Ductal Adenocarcinoma and Barriers to Therapeutic Efficacy. Front Oncol 2021; 11:688377. [PMID: 34336673 PMCID: PMC8319847 DOI: 10.3389/fonc.2021.688377] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/29/2021] [Indexed: 12/15/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis, with a median survival time of 10-12 months. Clinically, these poor outcomes are attributed to several factors, including late stage at the time of diagnosis impeding resectability, as well as multi-drug resistance. Despite the high prevalence of drug-resistant phenotypes, nearly all patients are offered chemotherapy leading to modest improvements in postoperative survival. However, chemotherapy is all too often associated with toxicity, and many patients elect for palliative care. In cases of inoperable disease, cytotoxic therapies are less efficacious but still carry the same risk of serious adverse effects, and clinical outcomes remain particularly poor. Here we discuss the current state of pancreatic cancer therapy, both surgical and medical, and emerging factors limiting the efficacy of both. Combined, this review highlights an unmet clinical need to improve our understanding of the mechanisms underlying the poor therapeutic responses seen in patients with PDAC, in hopes of increasing drug efficacy, extending patient survival, and improving quality of life.
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Affiliation(s)
- Daniel R. Principe
- Medical Scientist Training Program, University of Illinois College of Medicine, Chicago, IL, United States
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
| | | | - Murray Korc
- Department of Developmental and Cell Biology, University of California, Irvine, CA, United States
| | - Jose G. Trevino
- Department of Surgery, Division of Surgical Oncology, Virginia Commonwealth University, Richmond, VA, United States
| | - Hidayatullah G. Munshi
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Jesse Brown VA Medical Center, Chicago, IL, United States
| | - Ajay Rana
- Department of Surgery, University of Illinois at Chicago, Chicago, IL, United States
- Jesse Brown VA Medical Center, Chicago, IL, United States
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Friend or foe? Feeding tube placement at the time of pancreatoduodenectomy: propensity score case-matched analysis. Surg Endosc 2021; 36:2994-3000. [PMID: 34165639 DOI: 10.1007/s00464-021-08594-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 06/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The role of concomitant gastrostomy or jejunostomy feeding tube (FT) placement during pancreatoduodenectomy (PD) and its impact on patient outcomes remain controversial. METHODS NSQIP database was surveyed for patients undergoing PD between 2014 and 2017. FT placement was identified using CPT codes. Propensity scores were used to match the two groups (1:1) on baseline characteristics and intraoperative variables including pancreas specific ones (duct size, gland texture, underlying disease, wound class, use of wound protector, drain placement, type of pancreatic reconstruction and vascular reconstruction). Outcomes were compared. Finally, a subset analyses for patients with delayed gastric emptying (DGE) or postoperative pancreatic fistula (POPF) were performed. RESULTS Out of 15,224 PD, 1,104 (7.5%) had FT. POPF and DGE rates were 17% and 18%, respectively, for the entire cohort. Feeding jejunostomy was the most placed FT (88.2%). Patients with FT placement were more likely to be older (mean, 65.8 vs. 64.6 y), smokers (22.6% vs. 17.8%) who had preoperative weight loss (22.5% vs. 15.3%), ASA class ≥ 3 (80.8% vs. 77.5%), preoperative transfusion (1.5% vs. 0.84%), chemotherapy (22.8% vs. 17.5%), and radiation (14.5% vs. 6.8%, p < 0.05). The matched cohort included 880 patients in each group with completely balanced preoperative and intraoperative characteristics. In the matched cohort, patients with FT placement had higher overall morbidity (52.2% vs. 44.3%, p = 0.001), major morbidity (28.4% vs. 22.5%, p = 0.004), organ/space infection (14.4% vs. 10.9%, p = 0.026), re-operation (8.6% vs. 5.1%, p = 0.003), DGE (26.8% vs. 16.4%, p < 0.001), and longer mean hospital length of stay (12.9 vs. 11.2 days, p = 0.001) than those without FT. There was no difference in mortality (1.7% vs. 2.2%, p = 0.488) or readmission rate (20.2% vs. 17.2%, p = 0.099). In patients with DGE and POPF, FT placement was not associated with morbidity, mortality, length of stay, or readmission rate (p > 0.05). CONCLUSION Patients with FT placement during PD tend to have higher postoperative morbidity and delayed recovery.
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Anaesthesia techniques and advanced monitoring in CANVAS patients - Implications for postoperative morbidity and patient recovery: A case report. Int J Surg Case Rep 2021; 83:106058. [PMID: 34098187 PMCID: PMC8187836 DOI: 10.1016/j.ijscr.2021.106058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Cerebellar ataxia, neuropathy and vestibular areflexia syndrome (CANVAS) is a rare multisystem neurodegenerative disorder. We describe our perioperative evaluation and care of a patient with CANVAS undergoing a pancreaticoduodenectomy for an ampullary adenocarcinoma, with a focus on perioperative risk stratification and optimisation, intraoperative advanced haemodynamic monitoring and the postoperative care. Case presentation A 69-year-old female with CANVAS presented with asymptomatic obstructive jaundice, icterus and abdominal pain. She had limited mobility and deconditioning due to severe generalised neuropathy. Computed tomography confirmed a resectable periampullary tumour. Her Duke Activity Status Index was 8.25 points and Edmonton Frailty Scale score was 11, confirming moderate frailty. However, the Charlson Comorbidity Index was five, indicative of a 21% estimated 10-year survival. Further risk stratification including respiratory function testing, echocardiography and cardiopulmonary exercise testing was conducted. The patient proceeded with surgery after multidisciplinary discussions with her treating medical teams. Discussion CANVAS is a rare and challenging condition requiring careful perioperative planning and management. There is no effective treatment for CANVAS. The management approach focuses on mitigating symptoms and improving quality of life. Given that no specific guidelines for managing these patients in the perioperative period have been provided, this report highlights several critical medical issues and implications that should be considered for the successful management of these patients. We demonstrate the role of specific anaesthesia techniques and advanced haemodynamic monitoring in both preventing postoperative morbidity and optimising patient recovery. Conclusion CANVAS is a rare and challenging condition in anaesthesia requiring careful perioperative planning and management. CANVAS is a rare multisystem neurological disorder There is no effective treatment for CANVAS Perioperative management for patients with CANVAS is complex Perioperative risk stratification requires multidisciplinary involvement CANVAS patients can present with unique anaesthesia challenges
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Liu X, Chen Q, Fu Y, Lu Z, Chen J, Guo F, Li Q, Wu J, Gao W, Jiang K, Dai C, Miao Y, Wei J. Early Nasojejunal Nutrition Versus Early Oral Feeding in Patients After Pancreaticoduodenectomy: A Randomized Controlled Trial. Front Oncol 2021; 11:656332. [PMID: 33996579 PMCID: PMC8118637 DOI: 10.3389/fonc.2021.656332] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/09/2021] [Indexed: 12/14/2022] Open
Abstract
Objective The aim of this study was to test the hypothesis that early oral feeding (EOF) is superior to early nasojejunal nutrition (ENN) after pylorus-preserving pancreaticoduodenectomy (PPPD) in terms of delayed gastric emptying (DGE). Background DGE is a common complication after PPPD. Although EOF after PPPD is recommended by several international guidelines, there is no randomized trial to support this recommendation. Methods From September 2016 to December 2017, a total of 120 patients undergoing PPPD were randomized into the ENN, EOF, or saline groups at a 1:1:1 ratio (40 patients in each group). The primary endpoint was the rate of clinically relevant DGE. Secondary endpoints included overall morbidity, postoperative pancreatic fistula, post-pancreatectomy hemorrhage, abdominal infection, length of hospital stay, reoperation rate, and in-hospital mortality. Results The baseline characteristics and operative parameters were comparable between the groups. The incidence of clinically relevant DGE varied significantly among the three groups (ENN, 17.5%; EOF, 10.0%; saline, 32.5%; p =0.038). The saline group had a higher clinically relevant DGE rate than the EOF group (p = 0.014). The saline group also had greater overall morbidities than the ENN and EOF groups (p = 0.041 and p = 0.006, respectively). There were no significant differences in other surgical complication rates or postoperative hospital stay. No mortality was observed in any of the groups. Conclusions Nutritional support methods were not related to DGE after PPPD. EOF was feasible and safe after PPPD, and additional ENN should not be routinely administered to patients after PPPD. Clinical Trial Registration ClinicalTrials.gov, identifier NCT03150615.
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Affiliation(s)
- Xinchun Liu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Department of General Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiuyang Chen
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yue Fu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zipeng Lu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jianmin Chen
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Feng Guo
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qiang Li
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Junli Wu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wentao Gao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kuirong Jiang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Cuncai Dai
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jishu Wei
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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12
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Lee B, Han HS, Yoon YS. Impact of Preoperative Malnutrition on Postoperative Long-Term Outcomes of Patients With Pancreatic Head Cancer. ANNALS OF SURGERY OPEN 2021; 2:e047. [PMID: 37638242 PMCID: PMC10455215 DOI: 10.1097/as9.0000000000000047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/24/2021] [Indexed: 12/20/2022] Open
Abstract
Objective To evaluate the association between preoperative malnutrition and long-term outcomes in patients with pancreatic head cancer who underwent curative pancreatoduodenectomy (PD). Methods From 2004 to 2018, 228 consecutive patients who underwent curative PD for pancreatic ductal adenocarcinoma were included. Preoperative malnutrition was defined by the Global Leadership Initiative in Malnutrition criteria. It is based on both phenotypic criteria (weight loss, low body mass index, and reduced muscle mass) and etiologic criteria (reduced intake or assimilation and inflammation). Results Seventy-five (32.9%) of 228 patients were classified as suffering from malnutrition. Preoperative malnutrition was associated with an increased risk of estimated blood loss (mL) (816.7 ± 875.2 vs 593.1 ± 489.9, P = 0.015) and longer hospital stay (days) (27.3 ± 15.7 vs 22.9 ± 17.7, P = 0.045). The median follow-up period was 24.5 months. The malnutrition group had poor overall survival compared with "without (WO)-malnutrition" group (P = 0.001) at 1 year (66.3% vs 81.3%), 3 years (18.0% vs 51.8%), and 5 years (12.0% vs 39.3%). The malnutrition group showed poor disease-free survival and cancer-specific survival compared with WO-malnutrition group (P = 0.001) at 1 year (38.9% vs 66.7%) and (69.0% vs 88.7%), 3 years (11.5% vs 45.1%) and (21.1% vs 61.6%), and 5 years (11.5% vs 37.3%) and (14.1% vs 51.2%). In multivariate analysis, the preoperative malnutrition was found to be the predictor of poor prognosis (harzard ratio = 2.29, 95% confidence interval = 1.60-3.29, P = 0.001). Conclusions Preoperative malnutrition is associated with poor prognosis in patients who underwent curative PD for pancreatic head cancer.
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Affiliation(s)
- Boram Lee
- From the Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Ho-Seong Han
- From the Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Yoo-Seok Yoon
- From the Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea
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13
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Current situation, consensus and controversy of perioperative nutrition management in pancreatic surgery: A narrative review. JOURNAL OF PANCREATOLOGY 2021. [DOI: 10.1097/jp9.0000000000000066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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14
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Trudeau MT, Casciani F, Gershuni VM, Maggino L, Ecker BL, Lee MK, Roses RE, DeMatteo RP, Fraker DL, Drebin JA, Vollmer CM. Defining postoperative weight change after pancreatectomy: Factors associated with distinct and dynamic weight trajectories. Surgery 2020; 168:1041-1047. [PMID: 32943201 DOI: 10.1016/j.surg.2020.07.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/10/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Weight change offers the simplest indication of a patient's recovery after an operation. There have been no studies that have thoroughly investigated postoperative weight dynamics after pancreatectomy. The aim of this study was to define postoperative weight change after a pancreatectomy and determine factors associated with optimal and poor weight trajectories. METHODS From 2004 to 2019, 1,090 proximal (65%) and distal (35%) pancreatectomies were performed in patients with adequate data in the medical records. Patient weights were acquired preoperatively and at postoperative months 1, 3, and 12. Optimal (top quartile, weight restoration) and poor (bottom quartile, persistent weight loss) postoperative weight cohorts were identified at 1 year postoperatively. RESULTS The median percentage weight change 1 year postpancreatectomy was -6.6% (interquartile range: -1.4% to -12.5%), -7.8% for proximal pancreatectomy, and -4.2% for distal pancreatectomy. For most patients (interquartile range cohort), the median percentage weight change at 1, 3, and 12 months was -6.2%, -7.2%, and -6.6%. The independent factors associated with weight restoration were age <65, nonobesity (body mass index <30kg/m2), receiving total parenteral nutrition/total enteral nutrition preoperatively, experiencing preoperative weight loss >10%, distal pancreatectomy, not undergoing vascular resection, and no readmission within 30 days. Conversely, persistent weight loss was associated with American Society of Anesthesiologists classes III to IV, obesity, malignancy, proximal pancreatectomy, blood loss ≥350mL, and experiencing readmission within 30 days. Focusing on pancreatic ductal adenocarcinoma (n = 372) patients, the factors associated with persistent weight loss were obesity, proximal pancreatectomy, and experiencing recurrence within 1 year; however, weight cohorts were not associated with overall survival for pancreatic ductal adenocarcinoma patients. CONCLUSION These data define weight kinetics after pancreatectomy. Ultimately, postoperative weight trajectories appear to be largely predetermined but may be mitigated by limiting readmissions and complications. Clinicians should use these data to identify patients who continue to lose weight between the first and third month postoperatively with a high suspicion for the requirement of nutritional monitoring or other interventions.
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Affiliation(s)
- Maxwell T Trudeau
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Fabio Casciani
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Surgery, Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy
| | - Victoria M Gershuni
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Laura Maggino
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Surgery, Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy
| | - Brett L Ecker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Major K Lee
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Robert E Roses
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ronald P DeMatteo
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Douglas L Fraker
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jeffrey A Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York City, NY
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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15
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Nutritional considerations for the management of the older person with hepato-pancreatico-biliary malignancy. Eur J Surg Oncol 2020; 47:533-538. [PMID: 32362465 DOI: 10.1016/j.ejso.2020.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/04/2020] [Accepted: 04/14/2020] [Indexed: 01/06/2023] Open
Abstract
Malnutrition and cancer cachexia are prevalent in older people with hepato-pancreatico-biliary (HPB) malignancy, with the resultant loss of muscle mass and function accelerating normal age-associated losses. Unintentional weight loss may be missed in patients with pre-illness obesity, delaying diagnosis and limiting treatment potential and access. Sarcopenia and/or sarcopenic obesity increase the risk of dose-limiting chemotherapy toxicity, post-operative mortality and overall survival. The aetiology of malnutrition and weight loss is multi-factorial in patients with HPB malignancy, necessitating systematic evaluation of endocrine and exocrine function, and multi-modal therapeutic strategies. Prehabilitation aims to reduce the complications and side effects associated with treatment, aid recovery and improve quality of life, with the greatest benefits potentially being seen in high risk groups, such as people who are older and frail. Post-operatively, individualised nutritional support therapies targeting the preservation of weight and muscle indices are required to improve post-operative morbidity, and avoid delay or early cessation of any necessary adjuvant therapy.
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Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. World J Surg 2020; 44:2056-2084. [DOI: 10.1007/s00268-020-05462-w] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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17
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Cai J, Yang G, Tao Y, Han Y, Lin L, Wang X. A meta-analysis of the effect of early enteral nutrition versus total parenteral nutrition on patients after pancreaticoduodenectomy. HPB (Oxford) 2020; 22:20-25. [PMID: 31353255 DOI: 10.1016/j.hpb.2019.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 06/06/2019] [Accepted: 06/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND An appropriate nutritional support is an important consideration for patients undergoing pancreaticoduodenectomy (PD). Recently, early enteral nutrition (EEN) has been considered to be more effective than total parenteral nutrition (TPN) for the early recovery of patients after many digestive tract surgeries. However, there is little evidence to support EEN in patients undergoing PD. METHODS A systematic literature review was performed to identify relevant studies before December 2018. Statistical analysis was carried out using Review Manager 5.3. RESULTS Nine studies with 1258 patients were included in the meta-analysis. Six studies compared EEN and TPN and three compared two strategies combined vs. a single strategy. The length of hospital stay (LOS) in the EEN group was significantly shorter than that in the TPN group (P < 0.001). There was no difference in the risk of postoperative complications, infections, and mortality between the EEN and TPN groups. In the comparison of two combined strategies vs. one, no significant difference was seen in overall postoperative complications, LOS, or mortality. CONCLUSION Compared with TPN, EEN is a safe strategy and can substantially shorten the LOS of patients.
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Affiliation(s)
- Jie Cai
- Hospital Management Institute, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, 430071, China
| | - Gang Yang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yun Tao
- Hospital Management Institute, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, 430071, China
| | - Yong Han
- Hospital Management Institute, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, 430071, China
| | - Likai Lin
- Hospital Management Institute, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, 430071, China.
| | - Xinghuan Wang
- Hospital Management Institute, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, 430071, China.
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19
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Chen Z, Zhang Z, Lin B, Feng W, Meng F, Shi X. Relationship Between Early Oral Intake Post Pancreaticoduodenectomy and Chyle Leakage: A Retrospective Cohort Study. J INVEST SURG 2019; 34:575-582. [PMID: 31533484 DOI: 10.1080/08941939.2019.1663378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Early oral intake is strongly recommended according to the enhanced recovery after surgery (ERAS) guidelines because it can reduce complications and improve recovery. However, early oral intake has been indicated to be associated with chyle leakage (CL) after pancreatic surgery, which may lead to worsening of existing malnutrition and impeded recovery. This study investigated the relationship between early oral intake and CL and identified risk factors for CL to reduce its occurrence and promote recovery after pancreaticoduodenectomy. MATERIALS AND METHODS All patients who underwent pancreaticoduodenectomy between June 2014 and June 2018 were identified retrospectively. Patients were divided into the early-oral-intake and control groups according to whether they had early oral intake according to ERAS protocols. CL and other clinicopathological characteristics were recorded. Univariable and multivariable analyses assessed CL risk factors. RESULTS Early oral intake improved recovery, leading to a shorter postoperative hospital stay for the early-oral-intake group in comparison to that of the control group [13.6 (range, 12-68) vs. 17.8 (range, 14-83) days; p = 0.047] without increasing the incidence of CL and other complications. CL was diagnosed significantly earlier in the early-oral-intake group than in the control group [4.6 (range 3-5) vs. 6.7 (range 3-9) days; p = 0.001]. Early oral intake did not increase the grade severity (p = 0.845) or the costs (p = 0.241) or prolong postoperative hospital stays (p = 0.611). A primary diagnosis of malignancy, para-aortic lymph node dissection, lymphatic invasion, lymph node metastases, the number of harvested nodes, and the number of positive nodes were significantly associated with CL (p < 0.05), whereas early oral intake was not (p = 0.525). Multivariate analyses demonstrated that para-aortic lymph node dissection (p = 0.039) and the number of harvested nodes (p = 0.001) were independent risk variables. CONCLUSION This study provides significant evidence that early oral intake after pancreaticoduodenectomy is not associated with CL. The identification of the independent risk factors for CL can help prevent it.
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Affiliation(s)
- Zheng Chen
- Department of General Surgery, The Affiliated Suqian Hospital of Xuzhou Medical University, Suqian, China.,Suqian People's Hospital of Nanjing Drum Tower Hospital Group, Suqian, China
| | - Zhen Zhang
- Suqian People's Hospital of Nanjing Drum Tower Hospital Group, Suqian, China.,Department of Anesthesiology, The Affiliated Suqian Hospital of Xuzhou Medical University, Suqian, China
| | - Bin Lin
- Department of General Surgery, The Affiliated Suqian Hospital of Xuzhou Medical University, Suqian, China.,Suqian People's Hospital of Nanjing Drum Tower Hospital Group, Suqian, China
| | - Wei Feng
- Department of General Surgery, The Affiliated Suqian Hospital of Xuzhou Medical University, Suqian, China.,Suqian People's Hospital of Nanjing Drum Tower Hospital Group, Suqian, China
| | - Fanlai Meng
- Suqian People's Hospital of Nanjing Drum Tower Hospital Group, Suqian, China.,Department of Pathology, The Affiliated Suqian Hospital of Xuzhou Medical University, Suqian, China
| | - Xin Shi
- Department of General Surgery, The Affiliated Suqian Hospital of Xuzhou Medical University, Suqian, China.,Suqian People's Hospital of Nanjing Drum Tower Hospital Group, Suqian, China
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20
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Tankel J, Sahnan K, Neumann M, Carmel O, Dagan A, Reissman P, Ben Haim M. Enhanced Recovery Deviation and Failure After Pancreaticoduodenectomy: Causative Factors and Impact. J Surg Res 2019; 245:569-576. [PMID: 31494390 DOI: 10.1016/j.jss.2019.07.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/26/2019] [Accepted: 07/17/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) following pancreaticoduodenectomy (PD) is popular and safe. This study aimed to describe the incidence, causative factors, and clinical impact of deviation from and failure of an ERAS protocol. MATERIALS AND METHODS A prospective cohort analysis of elective PD patients managed according to an ERAS protocol between October 2015 and June 2018 was performed. Univariate and multivariate analyses identified variables associated with protocol deviation and failure. The relationship between protocol deviation and failure was also explored. RESULTS A total of 97 patients were identified comprising of 46 females and 51 males. The median age was 68 y (range 17-85). Twenty-one patients (21.6%) suffered serious complications, whereas two (2.1%) died perioperatively. The median length of stay (LoS) was 14 d (6-36). In total, 73 (75.3%) patients deviated, whereas 39 (40.2%) failed the protocol. On univariate analysis, protocol deviation was associated with male gender, surgery time ≥270 min, and prolonged LoS. On multivariate analysis only prolonged LoS remained significant. Only serious complications were associated with protocol failure on multivariate analysis. Protocol deviation was not associated with significant complications nor ERAS protocol failure. CONCLUSIONS ERAS protocol deviation does not alter the course of those destined to protocol failure. Greater understanding into the causative factors of either protocol deviation or failure may be the only way to personalize care and realize the maximal benefit of ERAS in this specific group of patients.
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Affiliation(s)
- James Tankel
- Department of General Surgery, Shaare Zedek Medical Centre, The Hebrew University School of Medicine, Jerusalem, Israel; Department of Surgery and Cancer, Imperial College Healthcare Trust, London, St Mary's Hospital, London, UK.
| | - Kapil Sahnan
- Department of Surgery and Cancer, Imperial College Healthcare Trust, London, St Mary's Hospital, London, UK
| | - Michael Neumann
- Department of General Surgery, Shaare Zedek Medical Centre, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Ofra Carmel
- Department of General Surgery, Shaare Zedek Medical Centre, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Amir Dagan
- Department of General Surgery, Shaare Zedek Medical Centre, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Petachia Reissman
- Department of General Surgery, Shaare Zedek Medical Centre, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Menahem Ben Haim
- Department of General Surgery, Shaare Zedek Medical Centre, The Hebrew University School of Medicine, Jerusalem, Israel
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21
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Potential Nutritional and Metabolomic Advantages of High Fat Oral Supplementation in Pancreatectomized Pancreaticobiliary Cancer Patients. Nutrients 2019; 11:nu11040893. [PMID: 31010058 PMCID: PMC6521063 DOI: 10.3390/nu11040893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 04/18/2019] [Indexed: 02/07/2023] Open
Abstract
We examined the effect of high fat oral nutritional supplement (HFS) on the nutritional status, oral intake, and serum metabolites of postoperative pancreaticobiliary cancer patients. Pancreaticobiliary cancer patients were voluntarily recruited. The HFS group received postoperative oral high fat supplementation (80% of total calories from fat; n = 12) until discharge; the control group (non-HFS; n = 9) received none. Dietary intake, anthropometry, blood chemistry, nutritional risk index (NRI), and serum metabolites analyzed by liquid chromatography tandem mass spectrometry were evaluated. Overall, cumulative caloric supply via parental and oral/enteral routes were not different between groups. However, oral fat intake, caloric intake, and NRI scores of the HFS group were higher than those of the non-HFS group with increased oral meal consumption. Oral caloric, fat, and meal intakes correlated with NRI scores. Metabolomics analysis identified 195 serum metabolites pre-discharge. Oral fat intake was correlated with 42 metabolites relevant to the glycerophospholipid pathway. Oral high fat-specific upregulation of sphingomyelin (d18:1/24:1), a previously reported pancreatic cancer-downregulated metabolite, and lysophosphatidylcholine (16:0) were associated with NRI scores. Provision of HFS in postoperative pancreatic cancer patients may facilitate the recovery of postoperative health status by increasing oral meal intake, improving nutritional status, and modulating serum metabolites
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22
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Gianotti L, Besselink MG, Sandini M, Hackert T, Conlon K, Gerritsen A, Griffin O, Fingerhut A, Probst P, Abu Hilal M, Marchegiani G, Nappo G, Zerbi A, Amodio A, Perinel J, Adham M, Raimondo M, Asbun HJ, Sato A, Takaori K, Shrikhande SV, Del Chiaro M, Bockhorn M, Izbicki JR, Dervenis C, Charnley RM, Martignoni ME, Friess H, de Pretis N, Radenkovic D, Montorsi M, Sarr MG, Vollmer CM, Frulloni L, Büchler MW, Bassi C. Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS). Surgery 2018; 164:1035-1048. [PMID: 30029989 DOI: 10.1016/j.surg.2018.05.040] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal nutritional therapy in the field of pancreatic surgery is still debated. METHODS An international panel of recognized pancreatic surgeons and pancreatologists decided that the topic of nutritional support was of importance in pancreatic surgery. Thus, they reviewed the best contemporary literature and worked to develop a position paper to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection. Strength of recommendation and quality of evidence were based on the approach of the grading of recommendations assessment, development and evaluation Working Group. RESULTS The measurement of nutritional status should be part of routine preoperative assessment because malnutrition is a recognized risk factor for surgery-related complications. In addition to patient's weight loss and body mass index, measurement of sarcopenia and sarcopenic obesity should be considered in the preoperative evaluation because they are strong predictors of poor short-term and long-term outcomes. The available data do not show any definitive nutritional advantages for one specific type of gastrointestinal reconstruction technique after pancreatoduodenectomy over the others. Postoperative early resumption of oral intake is safe and should be encouraged within enhanced recovery protocols, but in the case of severe postoperative complications or poor tolerance of oral food after the operation, supplementary artificial nutrition should be started at once. At present, there is not enough evidence to show the benefit of avoiding oral intake in clinically stable patients who are complicated by a clinically irrelevant postoperative pancreatic fistula (a so-called biochemical leak), while special caution should be given to feeding patients with clinically relevant postoperative pancreatic fistula orally. When an artificial nutritional support is needed, enteral nutrition is preferred whenever possible over parenteral nutrition. After the operation, regardless of the type of pancreatic resection or technique of reconstruction, patients should be monitored carefully to assess for the presence of endocrine and exocrine pancreatic insufficiency. Although fecal elastase-1 is the most readily available clinical test for detection of pancreatic exocrine insufficiency, its sensitivity and specificity are low. Pancreatic enzyme replacement therapy should be initiated routinely after pancreatoduodenectomy and in patients with locally advanced disease and continued for at least 6 months after surgery, because untreated pancreatic exocrine insufficiency may result in severe nutritional derangement. CONCLUSION The importance of this position paper is the consensus reached on the topic. Concentrating on nutritional support and therapy is of utmost value in pancreatic surgery for both short- and long-term outcomes.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy.
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Marta Sandini
- School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Thilo Hackert
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Kevin Conlon
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Arja Gerritsen
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Oonagh Griffin
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Abe Fingerhut
- University of Graz Hospital, Surgical Research Unit, Graz, Austria
| | - Pascal Probst
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Antonio Amodio
- Unit of Gastroenterology, University of Verona Hospital Trust, Verona, Italy
| | - Julie Perinel
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon-Sud Faculty of Medicine, Lyon, France
| | - Mustapha Adham
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon-Sud Faculty of Medicine, Lyon, France
| | - Massimo Raimondo
- Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL
| | - Horacio J Asbun
- Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL
| | - Asahi Sato
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kyoichi Takaori
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Marco Del Chiaro
- Pancreatic Surgery Unit - Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) - Karolinska Institutet at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christos Dervenis
- University of Cyprus and Department of Surgical Oncology and HPB Surgery Metropolitan Hospital, Athens, Greece
| | - Richard M Charnley
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marc E Martignoni
- Department of Surgery, Klinikum rechts der Isar, Technische Universität, München, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technische Universität, München, Germany
| | | | - Dejan Radenkovic
- Clinic for Digestive Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marco Montorsi
- Department of Surgery, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Michael G Sarr
- Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
| | - Markus W Büchler
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Parks L, Routt M, De Villiers A. Enhanced Recovery After Surgery. J Adv Pract Oncol 2018; 9:511-519. [PMID: 31086687 PMCID: PMC6505539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgical procedures. Meta-analyses, randomized controlled trials, and large prospective cohort studies were reviewed. Each item of the perioperative treatment pathway in the English language was examined and reviewed. Enhanced recovery after surgery items that were the strongest predictors for a shorter hospital stay and lower morbidity were absence of a nasogastric tube, early mobilization, early oral nutrition, early removal of the epidural, early removal of the urinary catheter, and utilization of nonopioid analgesia. Based on evidence available for each element of the perioperative care pathway, ERAS provides a protocol for perioperative care. This protocol allows for further evidence-based studies that are adequately powered between institutions.
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Affiliation(s)
- Lisa Parks
- The Ohio State University Wexner Medical Center, James Cancer Hospital, and Solove Research Institute, Columbus, Ohio;
| | | | - Allison De Villiers
- The Ohio State University Wexner Medical Center, James Cancer Hospital, and Solove Research Institute, Columbus, Ohio;
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Sethuraman SA, Dhar VK, Habib DA, Sussman JE, Ahmad SA, Shah SA, Tsuei BJ, Sussman JJ, Abbott DE. Tube Feed Necrosis after Major Gastrointestinal Oncologic Surgery: Institutional Lessons and a Review of the Literature. J Gastrointest Surg 2017; 21:2075-2082. [PMID: 28956273 DOI: 10.1007/s11605-017-3593-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 09/15/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Small bowel necrosis after enteral feeding through a jejunostomy tube (tube feed necrosis, TFN) is a rare, serious complication of major abdominal surgery. However, strategies to reduce the incidence and morbidity of TFN are not well established. Here, in the largest series of TFN presented to date, we report our institutional experience and a comprehensive review of the literature. METHODS Eight patients who experienced TFN from 2000 to 2014 after major abdominal surgery for oncologic indications at the University of Cincinnati were reviewed. Characteristics of post-operative courses and outcomes were reviewed prior to and after a change in tube-feeding protocol. The existing literature addressing TFN over the last three decades was also reviewed. RESULTS Patients with TFN ranged from 50 to 74 years old and presented with upper gastrointestinal tract malignancies amenable to surgical resection. Six and two cases of TFN occurred following pancreatectomy and esophagectomy, respectively. Prior to TF protocol changes, which included initiation at a low rate, titrating up more slowly and starting at one-half strength TF, three of six cases of TFN (50%) resulted in mortality. With the new TF protocol, there were no deaths, goal TF rate was achieved 3 days later, symptoms of TFN were recognized 3 days earlier, and re-operation was conducted 1 day earlier. CONCLUSION This case series describes a change in clinical practice that is associated with decreased morbidity and mortality of TFN. Wider implementation and further refinement of this tube-feeding protocol may reduce TFN incidence at other institutions and in patients with other conditions requiring enteral nutrition.
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Affiliation(s)
- S A Sethuraman
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - V K Dhar
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - D A Habib
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - J E Sussman
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - S A Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - S A Shah
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - B J Tsuei
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - J J Sussman
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, K4/742, Madison, WI, 53792, USA.
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Gilliland TM, Villafane-Ferriol N, Shah KP, Shah RM, Tran Cao HS, Massarweh NN, Silberfein EJ, Choi EA, Hsu C, McElhany AL, Barakat O, Fisher W, Van Buren G. Nutritional and Metabolic Derangements in Pancreatic Cancer and Pancreatic Resection. Nutrients 2017; 9:nu9030243. [PMID: 28272344 PMCID: PMC5372906 DOI: 10.3390/nu9030243] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 02/20/2017] [Accepted: 02/28/2017] [Indexed: 12/15/2022] Open
Abstract
Pancreatic cancer is an aggressive malignancy with a poor prognosis. The disease and its treatment can cause significant nutritional impairments that often adversely impact patient quality of life (QOL). The pancreas has both exocrine and endocrine functions and, in the setting of cancer, both systems may be affected. Pancreatic exocrine insufficiency (PEI) manifests as weight loss and steatorrhea, while endocrine insufficiency may result in diabetes mellitus. Surgical resection, a central component of pancreatic cancer treatment, may induce or exacerbate these dysfunctions. Nutritional and metabolic dysfunctions in patients with pancreatic cancer lack characterization, and few guidelines exist for nutritional support in patients after surgical resection. We reviewed publications from the past two decades (1995–2016) addressing the nutritional and metabolic status of patients with pancreatic cancer, grouping them into status at the time of diagnosis, status at the time of resection, and status of nutritional support throughout the diagnosis and treatment of pancreatic cancer. Here, we summarize the results of these investigations and evaluate the effectiveness of various types of nutritional support in patients after pancreatectomy for pancreatic adenocarcinoma (PDAC). We outline the following conservative perioperative strategies to optimize patient outcomes and guide the care of these patients: (1) patients with albumin < 2.5 mg/dL or weight loss > 10% should postpone surgery and begin aggressive nutrition supplementation; (2) patients with albumin < 3 mg/dL or weight loss between 5% and 10% should have nutrition supplementation prior to surgery; (3) enteral nutrition (EN) should be preferred as a nutritional intervention over total parenteral nutrition (TPN) postoperatively; and, (4) a multidisciplinary approach should be used to allow for early detection of symptoms of endocrine and exocrine pancreatic insufficiency alongside implementation of appropriate treatment to improve the patient’s quality of life.
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Affiliation(s)
- Taylor M Gilliland
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Nicole Villafane-Ferriol
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Kevin P Shah
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Rohan M Shah
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Hop S Tran Cao
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Nader N Massarweh
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Eric J Silberfein
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Eugene A Choi
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Cary Hsu
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Amy L McElhany
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - Omar Barakat
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - William Fisher
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
| | - George Van Buren
- The Elkins Pancreas Center, Michael E. DeBakey Department of Surgery, and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX 77030, USA.
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Abstract
Enhanced recovery programs (ERP) are without any doubt a major innovation in the care of surgical patients. This multimodal approach encompasses elements of both medical and surgical care. The goal of this in-depth review is to analyze the surgical aspects of ERP, underlining the scientific rationale behind each element of ERP after surgery and in particular, the role of mechanical bowel preparation before colorectal surgery, the place of minimal access surgery, the utility of nasogastric tube, abdominal drainage, bladder catheters and early re-feeding. Publication of factual data has allowed many dogmas to be discarded.
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Affiliation(s)
- P Mariani
- Département de Chirurgie Oncologique, Institut Curie, 26 rue d'Ulm, 75248 Paris Cedex 05, France.
| | - K Slim
- Service de Chirurgie Digestive & Unité de Chirurgie Ambulatoire CHU Estaing Clermont-Ferrand et GRACE (Groupe Francophone de Réhabilitation Améliorée après Chirurgie), France
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Pecorelli N, Nobile S, Partelli S, Cardinali L, Crippa S, Balzano G, Beretta L, Falconi M. Enhanced recovery pathways in pancreatic surgery: State of the art. World J Gastroenterol 2016; 22:6456-6468. [PMID: 27605881 PMCID: PMC4968126 DOI: 10.3748/wjg.v22.i28.6456] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/21/2016] [Accepted: 06/13/2016] [Indexed: 02/06/2023] Open
Abstract
Pancreatic surgery is being offered to an increasing number of patients every year. Although postoperative outcomes have significantly improved in the last decades, even in high-volume centers patients still experience significant postoperative morbidity and full recovery after surgery takes longer than we think. In recent years, enhanced recovery pathways incorporating a large number of evidence-based perioperative interventions have proved to be beneficial in terms of improved postoperative outcomes, and accelerated patient recovery in the context of gastrointestinal, genitourinary and orthopedic surgery. The role of these pathways for pancreatic surgery is still unclear as high-quality randomized controlled trials are lacking. To date, non-randomized studies have shown that care pathways for pancreaticoduodenectomy and distal pancreatectomy are safe with no difference in postoperative morbidity, leading to early discharge and no increase in hospital readmissions. Hospital costs are reduced due to better organization of care and resource utilization. However, further research is needed to clarify the effect of enhanced recovery pathways on patient recovery and post-discharge outcomes following pancreatic resection. Future studies should be prospective and follow recent recommendations for the design and reporting of enhanced recovery pathways.
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Early Oral Feeding as Compared With Traditional Timing of Oral Feeding After Upper Gastrointestinal Surgery. Ann Surg 2016; 264:54-63. [PMID: 26779983 DOI: 10.1097/sla.0000000000001644] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Early Versus Delayed Postoperative Feeding After Major Gynaecological Surgery and its Effects on Clinical Outcomes, Patient Satisfaction, and Length of Stay: A Randomized Controlled Trial. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 37:1079-85. [PMID: 26637080 DOI: 10.1016/s1701-2163(16)30073-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To compare early versus delayed postoperative feeding in women undergoing major gynaecological surgery with regard to clinical outcomes, duration of postoperative stay, and patient satisfaction. METHODS We conducted a parallel-randomized controlled trial at a tertiary care centre in Montreal, Quebec, between June 2000 and July 2001. Patients undergoing major gynaecological surgery were randomized following a 1:1 allocation ratio to receive either early postoperative feeding in which oral clear fluids were begun up to six hours after surgery followed by solid foods as tolerated, or delayed postoperative feeding, in which clear fluids were begun on the first postoperative day and solid foods on the second or third day as tolerated. The primary outcomes analyzed were duration of postoperative stay and patient satisfaction. Secondary outcomes included mean time to appetite, passage of flatus, and bowel movement, as well as the presence of symptoms of paralytic ileus. RESULTS A total of 119 patients were randomized; 61 patients were assigned to the early feeding group and 58 to the delayed feeding group. Demographic characteristics, including age, weight, smoking status, and prior surgical history were comparable between both groups. There was no difference in length of postoperative stay between the two groups (86.4 ± 21.0 hours in the early feeding group vs. 85.6 ± 26.2 hours in the delayed feeding group; P > 0.05). No significant difference was noted in patient satisfaction (P > 0.05). No difference was found in the frequency of postoperative ileus, mean time to appetite, passage of flatus, or first bowel movement. CONCLUSION The introduction of early postoperative feeding appears to be safe and well tolerated by patients undergoing major gynaecological surgery. The duration of postoperative stay, patient satisfaction, and gastrointestinal symptoms are comparable between patients undergoing early or delayed postoperative feeding.
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Kasiraj AC, Harmoinen J, Isaiah A, Westermarck E, Steiner JM, Spillmann T, Suchodolski JS. The effects of feeding and withholding food on the canine small intestinal microbiota. FEMS Microbiol Ecol 2016; 92:fiw085. [PMID: 27106050 DOI: 10.1093/femsec/fiw085] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2016] [Indexed: 12/20/2022] Open
Abstract
Prolonged lack of enteral feeding has a negative impact on gut physiology, potentially via microbiota modulation. The aims were to investigate the impact of fasting and post-prandial changes in canine jejunal microbiota. To study post-prandial effects, jejunal brushings were analyzed in 8 healthy fistulated dogs 15 min before feeding (baseline) and hourly for 8 h after feeding. To study effects of withholding food (WF), daily samples were collected for 15 days from 5 dogs. The first 5 days (PRE) dogs were fed regular diet. Food was withheld the next 5 days (days 6-10). For days 11-15 (POST), the original diet was reintroduced. Microbiota was characterized via denaturing gradient gel electrophoresis and 454-pyrosequencing of 16S rRNA genes. In the post-prandial study, no changes in microbiome structure were seen after feeding (ANOSIM, P = 0.28), but Betaproteobacteria (P = 0.04) and Bacteroidales decreased compared to baseline. Species richness decreased by 300 min (P = 0.04). During WF, microbiota structure differed from PRE and POST period (P = 0.001). During WF, species richness did not vary over time (P = 0.69). In conclusion, a prolonged period of food withholding results in altered jejunal microbiota. How these changes affect the microbiota metabolism warrants further studies.
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Affiliation(s)
- Alyssa C Kasiraj
- Department of Small Animal Clinical Sciences, Gastrointestinal Laboratory, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843-4474, USA
| | - Jaana Harmoinen
- Department of Equine and Small Animal Medicine, Helsinki University, 00014 Helsinki, Finland
| | - Anitah Isaiah
- Department of Small Animal Clinical Sciences, Gastrointestinal Laboratory, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843-4474, USA
| | - Elias Westermarck
- Department of Equine and Small Animal Medicine, Helsinki University, 00014 Helsinki, Finland
| | - Jörg M Steiner
- Department of Small Animal Clinical Sciences, Gastrointestinal Laboratory, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843-4474, USA
| | - Thomas Spillmann
- Department of Equine and Small Animal Medicine, Helsinki University, 00014 Helsinki, Finland
| | - Jan S Suchodolski
- Department of Small Animal Clinical Sciences, Gastrointestinal Laboratory, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX 77843-4474, USA
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Implementation of an Enhanced Recovery Pathway After Pancreaticoduodenectomy in Patients with Low Drain Fluid Amylase. World J Surg 2016; 39:2023-30. [PMID: 25809067 DOI: 10.1007/s00268-015-3051-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The safety and feasibility of an enhanced recovery pathway (ERP) after pancreatic surgery is largely unknown. Our aim was to prospectively evaluate a targeted ERP after pancreaticoduodenectomy (PD), using first postoperative day (POD) drain fluid amylase (DFA1) values to identify patients at low risk of pancreatic fistula (PF). PATIENTS AND METHODS Non-randomized cohort study of 130 consecutive patients. Perioperative outcomes were compared before (pre-ERP; N=65) and after (post-ERP; N=65) implementation of an ERP. Patients in each group were stratified according to the risk of PF using DFA1<350 IU/l. Low-risk patients in the post-ERP group were selected for early oral intake and early drain removal. RESULTS 81/130 patients had a DFA1<350. Incidence of PF was significantly lower in low-risk patients (9 vs. 45%, P=0.0001). In low-risk patients, morbidity (43 vs. 36%) and mortality (2.7 vs. 4.5%) were similar for both pre- and post-ERP patients. Hospital stay (median 9 vs. 7 days, P=0.03) and 30-day readmissions (17 vs. 2%, P=0.04) were lower in low-risk patients in the post-ERP group. In high-risk patients, there was no difference in outcomes between pre- and post-ERP. CONCLUSION Patients at low risk of PF after PD can be identified by first POD DFA1. Enhanced recovery after PD is safe and leads to improved short-term outcomes in low-risk patients.
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Electromagnetic-Guided Versus Endoscopic Placement of Nasojejunal Feeding Tubes After Pancreatoduodenectomy: A Prospective Pilot Study. Pancreas 2016; 45:254-9. [PMID: 26390422 DOI: 10.1097/mpa.0000000000000448] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE An altered anatomy such as after pancreatoduodenectomy is currently seen as relative contraindication for bedside electromagnetic (EM)-guided nasojejunal feeding tube placement. The aim of this study was to determine the feasibility and safety of bedside EM-guided placement of nasojejunal feeding tubes as compared with endoscopy in patients after pancreatoduodenectomy. METHODS We performed a prospective monocenter pilot study in patients requiring enteral feeding after pancreatoduodenectomy (July 2012-March 2014). Primary end point was the success rate of primary tube placement confirmed on plain abdominal x-ray followed by successful enteral feeding. RESULTS Overall, 53 (42%) of 126 patients who underwent pancreatoduodenectomy required a nasojejunal feeding tube, of which 36 were placed under EM guidance and, in 17, it was placed by endoscopy. Initial tube placement was successful in 21 (58%) of 36 patients with EM guidance and 9 (53%) of 17 patients with endoscopy (P = 0.71). No complications occurred during the placement procedures. Dislodgement and/or blockage of the tube occurred in 14 (39%) of 36 patients in the EM-guided group and 8 (47%) of 17 patients in the endoscopic group (P = 0.57). CONCLUSIONS Bedside EM-guided placement of nasojejunal feeding tubes by nurses was equally successful as endoscopic placement in patients after pancreatoduodenectomy.
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Pancreatic Fistula and Delayed Gastric Emptying After Pancreatectomy: Where do We Stand? Indian J Surg 2015; 77:409-25. [PMID: 26722205 DOI: 10.1007/s12262-015-1366-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/30/2015] [Indexed: 12/13/2022] Open
Abstract
Pancreatic resection has become a feasible treatment of pancreatic neoplasms, and with improvements in surgical techniques and perioperative management, mortality associated with pancreatic surgery has decreased considerably. Despite this improvement, a high rate of complications is still associated with these procedures. Among these complications, delayed gastric emptying (DGE) and postoperative pancreatic fistula (POPF) have a substantial impact on patient outcomes and burden our healthcare system. Technical modifications and postoperative approaches have been proposed to reduce rates of both POPF and DGE in patients undergoing pancreatectomy; however, to date, their rates have remained unchanged. In the present study, we summarize the findings of the most significant studies that have investigated these complications. In particular, several studies focused on technical modifications including extent of dissection, stent placement, nature of anastomosis, type of reconstruction, and application of biological or non-biological agents to site of anastomosis. Moreover, postoperatively, drain placement, duration of drain usage, postoperative feeding, and use of pharmacological agents were studied to reduce rates of POPF and DGE. In this review, we summarize the most relevant literature on this fundamental aspect of pancreatic surgery. Despite studies identifying the potential benefit of technical modifications and postoperative approaches, these findings remain controversial and suggest need for further extensive investigation. Most importantly, we recommend that all surgeons performing these procedures base their practice on the most updated and highest available level of evidence.
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Peut-on nourrir précocement un patient ayant une suture digestive ? NUTR CLIN METAB 2015. [DOI: 10.1016/j.nupar.2015.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Gerritsen A, Wennink RAW, Busch ORC, Borel Rinkes IHM, Kazemier G, Gouma DJ, Molenaar IQ, Besselink MGH. Feeding patients with preoperative symptoms of gastric outlet obstruction after pancreatoduodenectomy: Early oral or routine nasojejunal tube feeding? Pancreatology 2015; 15:548-553. [PMID: 26235830 DOI: 10.1016/j.pan.2015.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 07/03/2015] [Accepted: 07/05/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Early oral feeding is currently considered the optimal routine feeding strategy after pancreatoduodenectomy (PD). Some have suggested that patients with preoperative symptoms of gastric outlet obstruction (GOO) who undergo PD have such a high risk of developing delayed gastric emptying that these patients should rather receive routine postoperative tube feeding. The aim of this study was to determine whether clinical outcomes after PD in these patients differ between postoperative early oral feeding and routine tube feeding. METHODS We analyzed a consecutive multicenter cohort of patients with preoperative symptoms of GOO undergoing PD (2010-2013). Patients were categorized into two groups based on the applied postoperative feeding strategy (dependent on their center's routine strategy): early oral feeding or routine nasojejunal tube feeding. RESULTS Of 497 patients undergoing PD, 83 (17%) suffered from preoperative symptoms of GOO. 49 patients received early oral feeding and 29 patients received routine tube feeding. Time to resumption of adequate oral intake (primary outcome; 14 vs. 12 days, p = 0.61) did not differ between these two feeding strategies. Furthermore, overall complications and length of stay were similar in both groups. Of the patients receiving early oral feeding, 24 (49%) ultimately required postoperative tube feeding. In patients with an uncomplicated postoperative course, early oral feeding was associated with shorter time to adequate oral intake (8 vs. 12 days, p = 0.008) and shorter hospital stay (9 vs. 13 days, p < 0.001). CONCLUSION Also in patients with preoperative symptoms of GOO, early oral feeding can be considered the routine feeding strategy after PD.
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Affiliation(s)
- Arja Gerritsen
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Roos A W Wennink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olivier R C Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Geert Kazemier
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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Gerritsen A, van der Poel MJ, de Rooij T, Molenaar IQ, Bergman JJ, Busch OR, Mathus-Vliegen EM, Besselink MG. Systematic review on bedside electromagnetic-guided, endoscopic, and fluoroscopic placement of nasoenteral feeding tubes. Gastrointest Endosc 2015; 81:836-47.e2. [PMID: 25660947 DOI: 10.1016/j.gie.2014.10.040] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 10/30/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Nasoenteral tube feeding is frequently required in hospitalized patients to either prevent or treat malnutrition, but data on the optimal strategy of tube placement are lacking. OBJECTIVE To compare the efficacy and safety of bedside electromagnetic (EM)-guided, endoscopic, and fluoroscopic placement of nasoenteral feeding tubes in adults. DESIGN Systematic review of the literature. PATIENTS Adult hospitalized patients requiring nasoenteral feeding. INTERVENTIONS EM-guided, endoscopic, and/or fluoroscopic nasoenteral feeding tube placement. MAIN OUTCOME MEASUREMENTS Success rate of tube placement and procedure- or tube-related adverse events. RESULTS Of 354 screened articles, 28 studies were included. Data on 4056 patients undergoing EM-guided (n = 2921), endoscopic (n = 730), and/or fluoroscopic (n = 405) nasoenteral feeding tube placement were extracted. Tube placement was successful in 3202 of 3789 (85%) EM-guided procedures compared with 706 of 793 (89%) endoscopic and 413 of 446 (93%) fluoroscopic procedures. Reinsertion rates were similar for EM-guidance (270 of 1279 [21%] patients) and endoscopy (64 of 394 [16%] patients) or fluoroscopy (10 of 38 [26%] patients). The mean (standard deviation) procedure time was shortest with EM-guided placement (13.4 [12.9] minutes), followed by endoscopy and fluoroscopy (14.9 [8.7] and 16.2 [23.6] minutes, respectively). Procedure-related adverse events were infrequent (0.4%, 4%, and 3%, respectively) and included mainly epistaxis. The tube-related adverse event rate was lowest in the EM-guided group (36 of 242 [15%] patients), followed by fluoroscopy (40 of 191 [21%] patients) and endoscopy (115 of 384 [30%] patients) and included mainly dislodgment and blockage of the tube. LIMITATIONS Heterogeneity and limited methodological quality of the included studies. CONCLUSION Bedside EM-guided placement of nasoenteral feeding tubes appears to be as safe and effective as fluoroscopic or endoscopic placement. EM-guided tube placement by nurses may be preferred over more costly procedures performed by endoscopists or radiologists, but randomized studies are lacking.
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Affiliation(s)
- Arja Gerritsen
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Thijs de Rooij
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands.
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Implementation of an Enhanced Recovery Pathway After Pancreaticoduodenectomy in Patients with Low Drain Fluid Amylase. World J Surg 2015. [PMID: 25809067 DOI: 10.1007/s00268–015-3051-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The safety and feasibility of an enhanced recovery pathway (ERP) after pancreatic surgery is largely unknown. Our aim was to prospectively evaluate a targeted ERP after pancreaticoduodenectomy (PD), using first postoperative day (POD) drain fluid amylase (DFA1) values to identify patients at low risk of pancreatic fistula (PF). PATIENTS AND METHODS Non-randomized cohort study of 130 consecutive patients. Perioperative outcomes were compared before (pre-ERP; N=65) and after (post-ERP; N=65) implementation of an ERP. Patients in each group were stratified according to the risk of PF using DFA1<350 IU/l. Low-risk patients in the post-ERP group were selected for early oral intake and early drain removal. RESULTS 81/130 patients had a DFA1<350. Incidence of PF was significantly lower in low-risk patients (9 vs. 45%, P=0.0001). In low-risk patients, morbidity (43 vs. 36%) and mortality (2.7 vs. 4.5%) were similar for both pre- and post-ERP patients. Hospital stay (median 9 vs. 7 days, P=0.03) and 30-day readmissions (17 vs. 2%, P=0.04) were lower in low-risk patients in the post-ERP group. In high-risk patients, there was no difference in outcomes between pre- and post-ERP. CONCLUSION Patients at low risk of PF after PD can be identified by first POD DFA1. Enhanced recovery after PD is safe and leads to improved short-term outcomes in low-risk patients.
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