Feeding after pancreaticoduodenectomy: enteral, or parenteral, that is the question

Development of a nutritional index to evaluate the effectiveness of total parenteral nutrition during the early postoperative period after pancreaticoduodenectomy

Background

Malnutrition leads to adverse effects on the short- and long-term prognosis in patients with periampullary diseases who underwent surgery. Nutritional risk indicators based on albumin and body weight have been developed to evaluate nutritional status and nutritional therapy efficacy, but no standard objective measurement has been devised to evaluate nutritional status during the early period after pancreaticoduodenectomy (PD). Therefore, this study aimed to assess the efficacy of total parenteral nutrition (TPN) during the early postoperative period after PD.

Methods

We analyzed 28 patients with a periampullary disease-common bile duct cancer, ampulla of Vater cancer, pancreatic head cancer, neuroendocrine tumor, chronic pancreatitis-who have undergone PD from Jan. 1, 2012 to Dec. 31, 2016. For all the patients, TPN was administered from postoperative day (POD) 1 at 25 Kcal/kg ideal body weight. Various nutritional indicators were measured such as Body mass index, nutritional risk index, protein, albumin, prealbumin, C-reactive protein. The volume of skeletal muscle area, muscle density, visceral and subcutaneous fat areas were assessed two times, preoperatively and on POD 7 by CT scan at the 3rd lumbar spine (L3) level.

Results

Average age of the 28 study subjects (18 males and 10 females) was 63.5±9.7 years. Although there is no difference in BMI between preoperative result and POD 7, protein, albumin, and prealbumin levels were significantly lower POD 7 the preoperative (P<0.001), but CRP was higher (P<0.001), and prealbumin and CRP levels were negatively correlated (R=-0.682, P<0.01). Muscle mass increased postoperatively (P=0.02), but the amount of visceral fat decreased (P=0.00). Based on CRP, and muscle density results, muscle, visceral and subcutaneous fat masses did not change after PD.

Conclusions

In order to evaluate the nutritional status accurately after the hepato-biliary radical surgery, we suggest the muscle and fat mass measurement that can adjust the degree of inflammation during the early postoperative period.

Perioperative nutritional management of patients undergoing pancreatoduodenectomy: an international survey among surgeons

BACKGROUND

There is still a lack of good evidence regarding the optimal perioperative nutritional management for patients undergoing pancreatoduodenectomy (PD). The aim of this international survey was to assess the current practice among pancreatic surgeons.

METHODS

A web survey of 30 questions was sent to the members of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA). All members were invited by email to answer the online survey. A reminder was sent after 4 weeks.

RESULTS

In total 420 out of 2500 surgeons (17%) answered the survey. Almost half of the surgeons (44%) did not organize a preoperative nutritional consultation for their patients. Seventy-seven percent of the participants did not have specific nutritional thresholds before the operation. A majority (66%) routinely used biological parameters to detect or follow malnutrition. Regarding intraoperative details, 69% of the respondents routinely leaved a nasogastric tube at the end of PD for gastric drainage. Sixty-six percent of the participants reported a postoperative nutritional follow-up consultation during hospitalization, and 58% of them had established local standardized protocols for postoperative nutritional support.

CONCLUSION

Management of perioperative nutrition in patients undergoing PD was very disparate internationally. No specific preoperative nutritional thresholds were used, and postoperative feeding routes and timing were diverse.

Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS)

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.