Total parenteral nutrition in patients following pancreaticoduodenectomy: lessons from 1184 patients

Worsh, Cullen E.; Tatarian, Talar; Singh, Awinder P.; Pucci, Michael J.; Winter, Jordan M.; Yeo, Charles J.; Lavu, Harish

doi:10.1016/j.jss.2017.05.057

Cited by 14 publications

(12 citation statements)

References 22 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Pathophysiologically, post-PD DGE can be a consequence of a number of factors, such as perianastomotic edema delaying transit through the duodenojejunostomy, surgical disruption of enteric neural networks, postoperative ileus, and reductions in motilin levels that impair the synchrony of bowel motility. 31,32 We reasoned that a more conservative dietary advancement algorithm could allow for the resolution of generalized postoperative ileus, as well as the inflammation and tissue injury at the duodenojejunostomy before the initiation of significant oral intake. 33 Aside from these interventions, the WARP is equally as notable for the streamlining of resources and avoidance of more complex and costly ERAS interventions that have been advocated for in other settings.…”

Section: Discussionmentioning

confidence: 99%

Enhancing Patient Outcomes while Containing Costs after Complex Abdominal Operation: A Randomized Controlled Trial of the Whipple Accelerated Recovery Pathway

Lavu

McCall

Winter

et al. 2019

Journal of the American College of Surgeons

Self Cite

View full text Add to dashboard Cite

BACKGROUND: This study was designed to determine whether a standardized recovery pathway could reduce post-pancreaticoduodenectomy hospital length of stay to 5 days without increasing complication or readmission rates. STUDY DESIGN: Pancreaticoduodenectomy patients (high-risk patients excluded) were enrolled in an IRBapproved, prospective, randomized controlled trial (NCT02517268) comparing a 5-day Whipple accelerated recovery pathway (WARP) with our traditional 7-day pathway (control). Whipple accelerated recovery pathway interventions included early discharge planning, shortened ICU stay, modified postoperative dietary and drain management algorithm, rigorous physical therapy with in-hospital gym visit, standardized rectal suppository administration, and close telehealth follow-up post discharge. The trial was powered to detect an increase in postoperative day 5 discharge from 10% to 30% (80% power, a ¼ 0.05, 2sided Fisher's exact test, target accrual: 142 patients). RESULTS: Seventy-six patients (37 WARP, 39 control) were randomized from June 2015 to September 2017. A planned interim analysis was conducted at 50% trial accrual resulting in mandatory early stoppage, as the predefined efficacy end point was met. Demographic variables between groups were similar. The WARP significantly increased the number of patients discharged to home by postoperative day 5 compared with controls (75.7% vs 12.8%; p < 0.001) without increasing readmission rates (8.1% vs 10.3%; p ¼ 1.0). Overall complication rates did not differ between groups (29.7% vs 43.6%; p ¼ 0.24), but the WARP significantly reduced the time from operation to adjuvant therapy initiation (51 days vs 66 days; p ¼ 0.005) and hospital cost ($26,563 vs $31,845; p ¼ 0.011). CONCLUSIONS: The WARP can safely reduce hospital length of stay, time to adjuvant therapy, and cost in selected pancreaticoduodenectomy patients without increasing readmission risk.

show abstract

Section: Discussionmentioning

confidence: 99%

Enhancing Patient Outcomes while Containing Costs after Complex Abdominal Operation: A Randomized Controlled Trial of the Whipple Accelerated Recovery Pathway

Lavu

McCall

Winter

et al. 2019

Journal of the American College of Surgeons

Self Cite

View full text Add to dashboard Cite

show abstract

“…Despite advances in surgical technique and falling mortality rates, morbidity rates remain high following PD. 2 Poor nutrition can delay recovery and correlates with higher incidence of complications and poorer quality of life. 5,7,8 Furthermore, the presence of complications hinders the resumption of a normal oral intake leading to further nutritional deficit and increased hospitalisation time, a potential vicious cycle.…”

Section: Discussionmentioning

confidence: 99%

“…1 Centralisation of pancreatic surgery has led to improvement in both peri-operative and long-term outcomes, with a mortality rate of less than 2% being reported in high-volume centres. 2 Despite improvements in mortality, the operative risk remains high with reported morbidity rates of 30-60%. 3,4 Notable complications following this procedure include delayed gastric emptying (DGE), post-operative pancreatic fistula (POPF), biliary leak, post-operative haemorrhage (PPH) and infections, all of which contribute to the increase in length of hospital stay (LOS).…”

Section: Introductionmentioning

confidence: 99%

Enteral versus parenteral nutrition following pancreaticoduodenectomy: a systematic review and meta-analysis

Adiamah

Ranat

Gomez

2019

HPB

View full text Add to dashboard Cite

Background:The need for nutritional support following pancreaticoduodenectomy is well recognised due to the high prevalence of malnutrition, but the optimal delivery route is still debated. This metaanalysis evaluated postoperative outcomes in patients receiving enteral or parenteral nutrition. Methods: EMBASE, MEDLINE and Cochrane databases were searched to identify randomised controlled trials comparing enteral and parenteral nutrition in patients undergoing pancreaticoduodenectomy. The primary outcome measure was delayed gastric emptying (DGE). Secondary outcome measures included length of hospital stay (LOS); postoperative pancreatic fistula (POPF); postpancreaticoduodenectomy haemorrhage (PPH); and infective complications (IC). Results: Five randomised controlled trials met inclusion criteria and reported on 690 patients (enteral nutrition n = 383; and parenteral nutrition n = 307). Median age was 61.5 years (interquartile range 60.1-63.6). The pooled relative risk (RR) of the primary outcome, DGE, was 0.97 (95% confidence interval (CI) 0.52-1.81, p = 0.93). There were no statistically significant difference in the secondary outcome measures of POPF (RR 1.07, 95% CI 0.42-2.76, p = 0.88); PPH (RR 0.67, 95% CI 0.31-1.48, p = 0.33) and infectious complications (RR 0.76, 95% CI 0.50-1.17, p = 0.22). However, LOS favoured enteral nutrition, weighted mean difference −1.63 days (95% CI -2.80, −0.46, p = 0.006).Conclusions: EN is associated with a significantly shorter LOS compared to PN in patients undergoing pancreaticoduodenectomy.

show abstract

“…Therefore, special attention on post-operative nutritional management after PD is essential. There are very few published clinical information56789 focusing on the postoperative feeding after PD. Clinical practices on post-operative nutrition support after PD vary from center to center.…”

Section: Introductionmentioning

confidence: 99%

“…Clinical practices on post-operative nutrition support after PD vary from center to center. It includes partial parenteral nutrition,6 total parenteral nutrition,6 enteral feeding through jejunostomy tube7 or nasojejunal tube8 or a combination of both the enteral and parenteral feeding 89. The time of giving enteral feeding after PD is also different from center to center.…”

Section: Introductionmentioning

confidence: 99%

Effect of early and delay starting of enteral feeding in post-pancreaticoduodenectomy patients

Das

Haque

Uddin

et al. 2019

Ann Hepatobiliary Pancreat Surg

View full text Add to dashboard Cite

Backgrounds/Aims This study was undertaken to see the effect of early starting of enteral feeding after pancreatoduodenectomy (PD). The results were compared with existing nutritional practice in which enteral feeding started, usually after 7 to 8 postoperative day (PODs) in our institute. Methods Thirty patients whome underwent a PD from January 2016 to December 2016 were included in the study. They were divided into two groups, I and II. In group I (n=15), enteral feeding was started from the 2 nd POD through the nasojejunal feeding tube along with parenteral partial nutrition support. In group II (n=15), no enteral feeding was given up to seventh and eighth PODs, except the perenteral feeding. Post-operatively, serum albumin levels, total lymphocyte count, total bilirubin levels, serum alkaline phosphate levels were measured for two weeks postoperatively in all the patients for assessing nutritional, immunological and cholestasis status. The mortality, morbidity and lengths of post-operative hospital stay were also recorded. Results Postoperatively, the serum albumin level and lymphocyte count decreased from the pre-operative level on the third POD and it gradually increased from the seventh POD onwards in both groups. However, they remained persistently higher in group I than group II. The total bilirubin and alkaline phosphatase decreased to normal levels within the seventh POD in Group I. However, they remained higher than normal levels on POD 14 in Group II. The morbidity and hospital stay was significantly lower in group I than group II. Conclusions Early enteral feeding should be considered after PD. This is because it will improve nutritional, immunological status and cholestasis. Therefore, it reduces morbidity and shortens the hospital stay.

show abstract

Total parenteral nutrition in patients following pancreaticoduodenectomy: lessons from 1184 patients

Cited by 14 publications

References 22 publications

Enhancing Patient Outcomes while Containing Costs after Complex Abdominal Operation: A Randomized Controlled Trial of the Whipple Accelerated Recovery Pathway

Enhancing Patient Outcomes while Containing Costs after Complex Abdominal Operation: A Randomized Controlled Trial of the Whipple Accelerated Recovery Pathway

Enteral versus parenteral nutrition following pancreaticoduodenectomy: a systematic review and meta-analysis

Effect of early and delay starting of enteral feeding in post-pancreaticoduodenectomy patients

Contact Info

Product

Resources

About