Perioperative nutritional support of patients undergoing pancreatic surgery in the age of ERAS

Abstract

Objective: The results achieved through the Enhanced Recovery After Surgery (ERAS) approach in gastrointestinal surgery have led to its enthusiastic acceptance in pancreatic surgery. However, the ERAS program also involves an early oral feeding that is not always feasible after pancreatoduodenectomy. The aim of this review was to investigate in the literature whether the difficulty with early oral feeding in these patients was adequately balanced by perioperative enteral or parenteral nutritional support as recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines or whether these recommendations have lost value in the "bundle" of the ERAS.

Methods: We reanalyzed both ESPEN guidelines and literature regarding the ERAS program in surgical pancreatic patients.

Results: There was a high prevalence of malnutrition (and consequently of postoperative complications) in patients with pancreatic cancer, and there is evidence that many of these patients should be candidates for perioperative nutritional support according to ESPEN guidelines. The start of oral fluid and solid feeding was quite variable in literature reporting the use of ERAS in pancreatic cancer surgery, with a consistent gap between the recommended and the effective start of both the feedings. The use of nasogastric/jejunal tube or of a needle-catheter jejunostomy was discouraged by the ERAS guidelines but their use could prove beneficial in patients who are recognized at high risk for postoperative complications according to the scores available in the literature.

Conclusion: The current practice of the ERAS program in these patients appears to neglect some ESPEN recommendations. On the other hand, both ESPEN and ERAS recommendations could be combined for a supplemental benefit for the patient.

Keywords: Early oral feeding; Nutrition; Perioperative ERAS guidelines; Perioperative ESPEN guidelines; Postoperative parenteral nutrition; Postoperative tube feeding.