PancreasNutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS)
Introduction
The metabolic stress response is a physiologic consequence of tissue damage and the resultant inflammatory response. Major surgery produces intense changes in metabolism and nutritional status through the activation of an inflammatory cascade and the release of stress hormones and cytokines; this response appears to be proportional to the extent of the operative trauma. Pancreatic resections are recognized as one of the most challenging operations because of the magnitude of the dissection and resection, the resultant global stress, and the relatively high rate of morbidity. Appropriate tissue healing and recovery/maintenance of organ function after such operations can lead to an effective and efficient metabolic response, which in turn necessitates adequate qualitative and quantitative nutritional substrates to be effective.
Malnourished patients or those who experience major complications after surgery may exhaust their nutritional reserves rapidly and thereby compromise their functional recovery and healing. Moreover, other pre-existing comorbidities of many cancer patients, such as diabetes, subclinical organ dysfunction, a defective immune response, and consequences of neoadjuvant treatments, may impair the functional reserve and lead to loss of muscle mass (sarcopenia) and its effects on recovery.
The aim of the present position statement is to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection and to define when and how appropriate nutritional support should be prescribed to provide substrates for an optimal metabolic response to improve both the short- and long-term outcomes.
Section snippets
Methods
Given the paucity of specific guidelines on optimal nutritional in the field of pancreatic surgery, a group of internationally recognized surgeons and pancreatologists with confirmed experience in the treatment of pancreatic diseases decided that the topic of nutritional evaluation and support was of importance in pancreatic surgery; therefore, a review of the existing literature, best practices, and any evidence-based studies was undertaken to develop recommendations on perioperative and
Is routine preoperative evaluation of the nutritional status and malnutrition risk indicated?
Although most patients undergo pancreatic surgery for cancer, the indications for pancreatic resection include a variety of benign and malignant diseases, each with a different impact on the preoperative nutritional status.3, 4, 5, 6 In a retrospective analysis, the rate of patients with pancreatic ductal adenocarcinoma (PDAC) who experienced body weight loss (WL) or impaired functional status or had moderate to high risk of malnutrition at diagnosis was greater than 50%.7
Malnutrition has been
References (221)
- et al.
Two thousand consecutive pancreaticoduodenectomies
J Am Coll Surg
(2015) - et al.
Definition and classification of cancer cachexia: an international consensus
Lancet Oncol
(2011) - et al.
Perioperative nutritional support of patients undergoing pancreatic surgery in the age of ERAS
Nutrition
(2014) - et al.
Cachexia but not obesity worsens the postoperative outcome after pancreatoduodenectomy in pancreatic cancer
Surgery
(2012) - et al.
Diagnostic criteria for malnutrition – An ESPEN Consensus Statement
Clin Nutr
(2015) - et al.
Educational and Clinical Practice Committee, European Society of Parenteral and Enteral Nutrition (ESPEN). ESPEN guidelines for nutrition screening 2002
Clin Nutr
(2003) - et al.
ESPEN guideline: clinical nutrition in surgery
Clin Nutr
(2017) Causes and mechanisms of hypoalbuminaemia
Clin Nutr
(2001)- et al.
Preoperative sarcopenia determinants in pancreatic cancer patients
Clin Nutr
(2017) - et al.
Impact total psoas volume on short- and long-term outcomes in patients undergoing curative resection for pancreatic adenocarcinoma: a new tool to assess sarcopenia
J Gastrointest Surg
(2015)
Preoperative sarcopenia strongly influences the risk of postoperative pancreatic fistula formation after pancreaticoduodenectomy
J Gastrointest Surg
Impact of preoperative quality as well as quantity of skeletal muscle on survival after resection of pancreatic cancer
Surgery
Sarcopenia and survival in patients undergoing pancreatic resection
Pancreatology
Impact of sarcopenia on outcomes following resection of pancreatic adenocarcinoma
J Gastrointest Surg
A high visceral adipose tissue-to-skeletal muscle ratio as a determinant of major complications after pancreatoduodenectomy for cancer
Nutrition
Sarcopenia is closely associated with pancreatic exocrine insufficiency in patients with pancreatic disease
Pancreatology
Anthropometric changes in patients with pancreatic cancer undergoing preoperative therapy and pancreatoduodenectomy
J Gastrointest Surg
Can comprehensive imaging analysis with analytic morphomics and geriatric assessment predict serious complications in patients undergoing pancreatic surgery?
J Gastrointest Surg
Cachexia worsens prognosis in patients with resectable pancreatic cancer
J Gastrointest Surg
Influence of cachexia and sarcopenia on survival in pancreatic ductal adenocarcinoma: a systematic review
Pancreatology
Prevalence of clinical implications of sarcopenic obesity in patients with solid tumors of the respiratory and gastrointestinal tracts: a population based study
Lancet Oncol
ESPEN guidelines on nutrition in cancer patients
Clin Nutr
Marked changes in body composition following neoadjuvant chemotherapy for oesophagogastric cancer
Clin Nutr
Relationships among body mass index, longitudinal body composition alterations, and survival in patients with locally advanced pancreatic cancer receiving chemoradiation: a pilot study
J Pain Symptom Manage
Nutrition support in clinical practice: review of published data and recommendations for future research directions. Summary of a conference sponsored by the National Institutes of Health, American Society for Parenteral and Enteral Nutrition, and American Society for Clinical Nutritio
Am J Clin Nutr
Enteral compared parenteral nutrition: a meta-analysis
Am J Clin Nutr
Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study
J Am Coll Surg
Napolitano LM. surgical site infections: reanalysis of risk factors
J Surg Res
Postoperative complications in gastrointestinal cancer patients: the joint role of the nutritional status and the nutritional support
Clin Nutr
Pancreaticogastrostomy has advantages over pancreaticojejunostomy on pancreatic fistula after pancreaticoduodenectomy
A meta-analysis of randomized controlled trials Int J Surg
Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS) Society recommendations
Clin Nutr
Deviation-based cost modeling: a novel model to evaluate the clinical and economic impact of clinical pathways
J Am Coll Surg
Implementation of enhanced recovery programme after pancreaticoduodenectomy: a single-centre UK pilot study
Pancreatology
Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement
PLoS Med
Going from evidence to recommendations
BMJ
Pancreatic cancer surgery and nutrition management: a review of the current literature
Hepatobiliary Surg Nutr
Nutritional status and nutritional support before and after pancreatectomy for pancreatic cancer and chronic pancreatitis
Indian J Surg Oncol
An overview of the diagnosis and management of nutrition in chronic pancreatitis
Nutr Clin Pract
Malnutrition and pancreatic surgery: prevalence and outcomes
J Surg Oncol
An explorative study of the views and experiences of food and weight loss in patients with operable pancreatic cancer perioperatively and following surgical intervention
Support Care Cancer
Perioperative Total Parenteral Nutrition in Surgical Patients
N Engl J Med
What is subjective global assessment of nutritional status?
Nutr Hosp
Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults
Br J Nutr
Screening for undernutrition in geriatric practice: developing the short-form Mini Nutritional Assessment (MNA-SF)
J Geront
Preoperative nutritional risk assessment in predicting postoperative outcome in patients undergoing major surgery
World J Surg
Prospective trial to evaluate the prognostic value of different nutritional assessment scores in pancreatic surgery (NURIMAS Pancreas)
Br J Surg
Hypoalbuminemia
Intern Emerg Med
Serum albumin and prealbumin in calorically restricted, nondiseased individuals: a systematic review
Am J Med
Effect of sarcopenia and visceral obesity on mortality and pancreatic fistula following pancreatic cancer surgery
Br J Surg
Prognostic significance of muscle attenuation in pancreatic cancer patients treated with neoadjuvant chemoradiotherapy
World J Surg
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