The nutritional management of pancreatic resection patients is highly variable: Is it time for consensus guidelines?
Patients who undergo surgical resection for pancreatic cancer are often malnourished. This is known to affect operative outcomes yet there are no guidelines for the nutritional management of these patients. By Thomas B. Russell and Somaiah Aroori.
Surgical resection remains the only curative-intent treatment option for patients with cancer affecting the head of the pancreas or the periampullary region. Most patients who undergo pancreatoduodenectomy (PD) or total pancreatectomy (TP) are malnourished1 and this is known to increase the risk of postoperative complications1, 2. Despite this, there are no formal guidelines for the nutritional management of these patients. In addition, prior to our recent survey, little was known regarding practice at United Kingdom (UK) hospitals. We received a response from twenty-six out of thirty-one hepatopancreatobiliary (HPB) units (83.9%).
Since 2009 it has been recommended that the HPB multidisciplinary team (MDT) should include a specialist dietitian and that preoperative nutritional assessment is routine prior to PD/TP3. Whilst the direct impact of this on operative outcomes is unknown, the importance of dietitian involvement in elective surgery is increasingly being recognised as an essential component of perioperative care. At the very least, this helps to identify patients that may require additional nutritional support1, 3. A recent international survey of HPB surgeons suggested that less than half organise a preoperative nutrition consultation for patients who undergo pancreatic resection4. Similar estimates have been obtained from recent Spanish5 and Korean6 surveys. Phillips et al., who surveyed twenty-two UK HPB units in 2009, found just 23% received specialist dietetic input and just 18% assessed nutrition status preoperatively3. The results from our survey would suggest that the extent to which nutrition professionals are directly involved in patient care, and the level of sub-specialisation, has increased substantially over the past decade. We found almost all UK units now have a specialist dietetic service.
Patients who undergo PD/TP are predisposed to preoperative malnutrition due to pancreatic exocrine insufficiency (PEI), maldigestion, and malabsorption7. Risk screening (RS) is a straightforward process that can rapidly identify high-risk patients8. These patients can then be subject to a more in-depth assessment and management can be tailored accordingly. Our survey results suggest a quarter of UK units do not perform RS at all, not even selectively for high-risk patients. Whilst there is limited evidence to suggest this affects operative outcomes, La Torre et al. recently showed that RS is associated with reduced rate of surgical site infection and length of stay9.
In our survey, 12% of units routinely check micronutrient status. A recent survey by Martin et al. suggested that 11% of units perform this internationally4. In a recent single-centre study, over half of patients who underwent PD/TP were deficient in either zinc or vitamin D preoperatively11. These micronutrients, among others, are known to have essential roles in metabolic processes and immune function. Hence, deficiencies may affect operative outcomes. Routine analysis of specific vitamins/minerals would arguably allow for the identification and correction of deficiency/sub-clinical deficiency states.
Prehabilitation is the concept of enhancing general health and wellbeing in high-risk patients prior to surgery12. It aims to help patients “weather the storm” of major surgery and reduce the risk of morbidity12. Whilst evidence of its effectiveness in pancreatic surgery is lacking, this is starting to emerge13. Almost half of the units who responded to our survey do not provide any prehabilitation. In those who do, what is offered varies hugely between units (Figure 1). Further studies are required to guide how prehabilitation should be provided.
Figure 1: Which elements of prehabilitation do you offer patients who undergo pancreatic resection? Created using JotForm.com.
Prolonged postoperative fasting is detrimental to patients who undergo major surgery14. The Enhanced Recovery After Surgery (ERAS) society recommends that routine use of postoperative tube feeding is not indicated in PD/TP patients, and that tubes should only be placed in patients who require them clinically15. Patients should be commenced on a regular oral diet which should gradually be built up over a three-to-four-day period. Prior studies in colorectal cancer surgery have further supported allowing patients to eat at will in the early postoperative period16. Despite this, in our survey, almost a third of units claimed they did not allow patients to have even oral nutritional supplements until at least 72 hours postoperatively (Figure 2). Just one unit said they actively encouraged oral intake on postoperative day one. Similar results were obtained from the recent Spanish5 and Korean6 surveys mentioned previously. The international survey by Martin et al. suggested almost 40% of patients receive oral diet only on day-one, and that over half receive oral diet only on day-three4. It would seem UK, Spanish, and Korean units are reluctant to break old habits and encourage patients to take diet orally in the early postoperative period.
Figure 2: Do pancreatic resection patients receive nutritional support (enteral and/or parenteral) within 72 hours of their operation? Created using JotForm.com.
Among the surveyed units that routinely provide nutritional support within seventy-two hours, over half provide this via the nasojejunal (NJ) route (the preferred enteral route as per the ERAS society)17. Compared to parenteral nutrition (PN), enteral nutrition (EN) has been shown to reduce infections, decrease mortality, reduce length of stay, and reduce financial costs18. Feeding via the NJ route, compared with jejunostomy tube feeding, has been shown to reduce morbidity and length of stay19. PN has numerous associated risks; these may outweigh the potential benefits, especially in those who are not malnourished and those who can tolerate EN1. Despite this, a quarter of the surveyed units provide PN routinely. A similar pattern was observed in the Spanish survey5.
Our survey findings are in keeping with those of Phillips et al., who concluded that there was no consensus regarding the best route for feeding following PD3. Phillips et al. found that a third of units routinely fed patients via the jejunostomy route and that NJ feeding was the second most common route3. We found that no units now routinely feed via the jejunostomy route, however, NJ feeding remains popular. Our domestic findings are in keeping with those of Martin et al., who concluded that postoperative nutritional management varies wildly internationally, and that less than two thirds of units have a local standard protocol for postoperative feeding4.
Pancreatic exocrine insufficiency following PD/TP can result in malnutrition-related complications20. 90–100% of patients with pancreatic cancer will have PEI to some degree21, 22. Benefits of early pancreatic exocrine replacement therapy (PERT) include weight gain, reduced stool frequency, increased fat absorption, and improved stool consistency23. PERT should be taken with all meals and snacks and can provide a 3.8-month survival benefit23 yet it is under-utilised24, 25. All of the units surveyed routinely provide PERT, however, there is great variation on when this is commenced. Half of units routinely commence PERT preoperatively and a quarter only prescribe PERT if patients are symptomatic of PEI. Current recommendations advise PERT should commence as soon as PEI is diagnosed/suspected.
In summary, the perioperative nutritional management of patients who undergo pancreatic resection varies hugely between UK HPB units and there is no consensus on optimal management. Robust studies are required which investigate the usefulness of routine preoperative nutritional assessment and prehabilitation before formal guidelines can be proposed.
Russell TB, Murphy P, Tanase A, Sen G, Aroori S. Results from a UK-wide survey: The nutritional assessment and management of pancreatic resection patients is highly variable. Eur J Clin Nutr 2022; https://www.nature.com/articles/s41430-021-01063-5.
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- Schnelldorfer, T.; Mauldin, P. D.; Lewin, D. N.; Adams, D. B. Distal pancreatectomy for chronic pancreatitis: risk factors for postoperative pancreatic fistula, J Gastrointest Surg. 2007, 11, 991-997.
- Phillips, M.; Lordan, J. T.; Menezes, N.; Karanjia, N. D. Feeding patients following pancreaticoduodenectomy: a UK national survey, Annals of the Royal College of Surgeons of England. 2009, 91, 385-388.
- Martin, D.; Joliat, G. R.; Halkic, N.; Demartines, N.; Schäfer, M. Perioperative nutritional management of patients undergoing pancreatoduodenectomy: an international survey among surgeons, HPB (Oxford). 2020, 22, 75-82.
- Loinaz Segurola, C.; Ochando Cerdán, F.; Vicente López, E., et al. Results of a survey on peri-operative nutritional support in pancreatic and biliary surgery in Spain, Nutr Hosp. 2020, 37, 238-242.
- Shin, S. H.; Kang, W.-H.; Han, I. W., et al. National survey of Korean hepatobiliary-pancreatic surgeons on attitudes about the enhanced recovery after surgery protocol, Annals of hepato-biliary-pancreatic surgery. 2020, 24, 477-483.
- Kim, E.; Kang, J. S.; Han, Y., et al. Influence of preoperative nutritional status on clinical outcomes after pancreatoduodenectomy, HPB (Oxford). 2018, 20, 1051-1061.
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- Murphy, D. P.; Kanwar, M. A.; Stell, M. D.; Briggs, M. C.; Bowles, M. M.; Aroori, M. S. The prevalence of micronutrient deficiency in patients with suspected pancreatico-biliary malignancy: Results from a specialist Hepato-Biliary and Pancreatic unit, European Journal of Surgical Oncology.
- Murphy, D. P.; Kanwar, M. A.; Stell, M. D.; Briggs, M. C.; Bowles, M. M.; Aroori, M. S. The prevalence of micronutrient deficiency in patients with suspected pancreatico-biliary malignancy: Results from a specialist Hepato-Biliary and Pancreatic unit, Eur J Surg Oncol. 2021, 47, 1750-1755.
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- Lassen, K.; Coolsen, M. M.; Slim, K., et al. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations, World J Surg. 2013, 37, 240-258.
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- Lassen, K.; Coolsen, M. M. E.; Slim, K., et al. Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations, World Journal of Surgery. 2013, 37, 240-258.
- Osland, E.; Yunus, R. M.; Khan, S.; Memon, M. A. Early versus traditional postoperative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis, JPEN J Parenter Enteral Nutr. 2011, 35, 473-487.
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