Luca Gianotti1, Marc G Besselink2, Marta Sandini3, Thilo Hackert4, Kevin Conlon5, Arja Gerritsen2, Oonagh Griffin5, Abe Fingerhut6, Pascal Probst4, Mohammed Abu Hilal7, Giovanni Marchegiani8, Gennaro Nappo9, Alessandro Zerbi9, Antonio Amodio10, Julie Perinel11, Mustapha Adham11, Massimo Raimondo12, Horacio J Asbun12, Asahi Sato13, Kyoichi Takaori13, Shailesh V Shrikhande14, Marco Del Chiaro15, Maximilian Bockhorn16, Jakob R Izbicki16, Christos Dervenis17, Richard M Charnley18, Marc E Martignoni19, Helmut Friess19, Nicolò de Pretis20, Dejan Radenkovic21, Marco Montorsi22, Michael G Sarr23, Charles M Vollmer24, Luca Frulloni20, Markus W Büchler4, Claudio Bassi8. 1. School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy. Electronic address: luca.gianotti@unimib.it. 2. Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands. 3. School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy. 4. Department of Surgery, University of Heidelberg, Heidelberg, Germany. 5. Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland. 6. University of Graz Hospital, Surgical Research Unit, Graz, Austria. 7. HPB Department, Southampton General Hospital, Southampton, UK. 8. Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy. 9. Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Milan, Italy. 10. Unit of Gastroenterology, University of Verona Hospital Trust, Verona, Italy. 11. Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon-Sud Faculty of Medicine, Lyon, France. 12. Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL. 13. Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan. 14. Department of GI and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India. 15. 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. 16. Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany. 17. University of Cyprus and Department of Surgical Oncology and HPB Surgery Metropolitan Hospital, Athens, Greece. 18. Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK. 19. Department of Surgery, Klinikum rechts der Isar, Technische Universität, München, Germany. 20. Department of Medicine, University of Verona, Verona, Italy. 21. Clinic for Digestive Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia. 22. Department of Surgery, Humanitas University, Humanitas Research Hospital, Milan, Italy. 23. Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN. 24. Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA.
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.
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.
Authors: Kevin P Shah; Katherine A Baugh; Lisa S Brubaker; George Van Buren; Nicole Villafane-Ferriol; Amy L McElhany; Sadde Mohamed; Eric J Silberfein; Cary Hsu; Nader N Massarweh; Hop S Tran Cao; Jose E Mendez-Reyes; William E Fisher Journal: J Surg Res Date: 2019-11-15 Impact factor: 2.192
Authors: Chris E Forsmark; Gong Tang; Hongzhi Xu; Marie Tuft; Steven J Hughes; Dhiraj Yadav Journal: Aliment Pharmacol Ther Date: 2020-04-06 Impact factor: 8.171