Oral Food Intake Versus Fasting on Postoperative Pancreatic Fistula After Distal Pancreatectomy: A Multi-Institutional Randomized Controlled Trial

Effects of early enteral nutrition on pancreatic fistula and long-term prognosis after distal pancreatectomy or enucleation of pancreatic tumours in a major academic university hospital in China: protocol for a single-centre randomised controlled trial

INTRODUCTION

Postoperative pancreatic fistula (POPF) remains one of the main complications following pancreatic resection. Despite pancreatic fistula having a low postoperative mortality rate, the readmission and intervention rates in patients with pancreatic fistula are still considerable. Although there are several studies on pancreatic fistula development after pancreaticoduodenectomy, there are only a few studies on the feeding protocols applied after distal pancreatectomy or enucleation of pancreatic tumours. We designed this trial to test the hypothesis that early feeding does not increase the incidence of POPF and positively influences the long-term prognosis in patients who undergo distal pancreatectomy or enucleation of pancreatic tumours.

METHODS AND ANALYSIS

This is a prospective randomised controlled trial that will be conducted in a single centre. A total of 106 patients undergoing distal pancreatectomy or enucleation of pancreatic tumours will be recruited after providing informed consent. They will be randomly assigned to either an early or late feeding group. The early feeding group will begin enteral nutrition on postoperative day (POD) 3, and the late feeding group will begin enteral nutrition on POD7. The primary outcome is the incidence of POPF. The secondary outcomes include the length of postoperative hospital stay, postoperative complications, and indicators of long-term prognosis.

ETHICS AND DISSEMINATION

Peking University Third Hospital Medical Science Research Ethics Committee approved the study (M2021395). Findings will be disseminated in a peer-reviewed journal and in national and/or international meetings to guide future practice.

TRIAL REGISTRATION NUMBER

ChiCTR2100053978.

Clinical characteristics and predictive factors of postoperative intra-abdominal abscess after distal pancreatectomy

PURPOSE

The postoperative mortality rate of distal pancreatectomy is lower than that of pancreaticoduodenectomy, although persistent complications may occur after distal pancreatectomy. Fluid collection (FC) is frequently observed after distal pancreatectomy; however, FC may occasionally progress to postoperative intra-abdominal abscess (PIAA), which requires conservative or progressive interventional treatment. This study aimed to compare the status between patients with or without PIAA, identify predictive factors for PIAA and clinically relevant postoperative pancreatic fistula, and investigate the clinical characteristics of patients with PIAA with interventional drainage.

METHODS

We retrospectively reviewed data of patients who underwent distal pancreatectomy between January 2012 and December 2019 at two high-volume centers, where hepatobiliary-pancreatic surgeries were performed by expert specialist surgeons. Logistic regression analysis was performed to determine the predictive factors for PIAA.

RESULTS

Overall, 242 patients were analyzed, among whom 49 (20.2%) had PIAA. The median postoperative period of PIAA formation was 9 (range: 3-49) days. Among the 49 patients with PIAA, 25 (51.0%) underwent percutaneous ultrasound, computed tomography, or endoscopic ultrasound-guided interventions for PIAA. In the univariate analysis, preoperative indices representing abdominal fat mass (i.e., body mass index, subcutaneous fat area, and visceral fat area) were identified as predictive factors for PIAA; in the multivariate analysis, C-reactive protein (CRP) level (continuous variable) on postoperative day (POD) 3 (odds ratio: 1.189, 95.0% confidence interval: 1.111 - 1.274; P < 0.001) was the only independent and significant predictive factor for PIAA.

CONCLUSIONS

CRP level on POD 3 was an independent and significant predictive factor for PIAA after distal pancreatectomy.

Effects of Fasting and Administration of Octreotide Acetate and Ulinastatin on Clinical Outcomes of Pancreatic Fistula after Pancreatoduodenectomy

Objective: Postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy is the most serious complication of these surgical procedures; therefore, we examine the effectiveness of fasting, and administration of octreotide acetate and ulinastatin as a method of prevention. Summary of Background Data : Although various drug therapies and surgical techniques have been used for the treatment of POPF, no decisive treatment for POPF exists. Methods: The clinical course of 30 patients who developed POPF was retrospectively evaluated and compared between no dietary intake (n=18), octreotide acetate (n=8), and ulinastatin (n=8) using an overlapping design. Patients were allocated to either the dietary intake or fasting (no dietary intake) group, and those in the no dietary intake group were further divided into the octreotide acetate or ulinastatin group. Results: Length of hospitalization was longer for the no dietary intake group than for the dietary intake group (p=0.002). When considering only grade B or C POPF cases, the no dietary intake group had a longer length of hospitalization and a higher white blood cell count on day 7 after the diagnosis of POPF than the dietary intake group (p&lt;0.05). The white blood cell count was also higher in the octreotide acetate group than in the ulinastatin group (p=0.021). The length of hospitalization was shorter in the ulinastatin group than in the octreotide acetate group (p=0.025). Conclusions: The use of no dietary intake, octreotide acetate, and ulinastatin do not seem to contribute to the clinical course of patients with POPF after pancreatoduodenectomy.

Level of ERAS understanding affects practitioners' practice and perception of early postoperative resumption of oral intake: a nationwide survey

BACKGROUND

Early postoperative resumption of oral intake is supposed to be safe and beneficial to patients recovery. However, practitioners still have great confusion and disagreement about postoperative resumption of oral intake. This is a nationwide survey to investigate the current status of clinical practice and practitioners' attitude toward postoperative resumption of oral intake along with their level of understanding of the ERAS guidelines.

METHODS

An anonymous web-based survey questionnaire via mobile social platform was carried out in mainland China from December 11-20, 2020. The Wilcoxon signed rank test or chi-square test was used to compare the propensity of the resumption of oral intake.

RESULTS

Totally 5370 responses were received, and 89% of them were from anesthesiology departments. The nature of the responses from clinical practitioners was highly diverse, but each of the three surgery types showed unique patterns of ERAS implementation. The respondents were more conservative regarding the commencement of both fluid and solid diets after gastrointestinal (GI) and hepato-pancreato-biliary (HPB) surgery than after non-abdominal (NA) surgery. Most respondents agreed that early oral intake is beneficial to reduce postoperative complications improve bowel recovery and overall outcome. 55% respondents considered themselves to have a better understanding of ERAS and tended to initiate oral intake early for all three surgery types (P < 0.001).

CONCLUSIONS

The postoperative resumption of oral intake is highly variable among GI, HPB and NA surgeries. A better understanding of ERAS would encourage practitioners to commence oral intake resumption much earlier.

Predictors of pancreatic fistula healing time after distal pancreatectomy

INTRODUCTION

Postoperative pancreatic fistula (POPF) is common after distal pancreatectomy (DP). Whilst extensive investigation into potential predictors has been carried out, there is little evidence regarding POPF healing time.

METHODS

This is a retrospective analysis of all consecutive DPs performed at the Department of General and Pancreatic Surgery, University of Verona Hospital Trust, from 2015 to 2019. Perioperative variables were analyzed identifying possible predictors of POPF healing time defined as days between surgery and last drain removal due to POPF.

RESULTS

A total of 496 patients were included. POPF rate was 28.2% and median POPF healing time was 30 days (95% CI 28-31). Independent predictors of POPF were body mass index (BMI) (OR 1.073, 95% CI 1.010-1.147, p = 0.040), operative time (OR 95% CI 1.002-1.009, P = .003), and postoperative acute pancreatitis (OR 3.793, 95% CI, 1.852-7.767, P < .001). Independent predictors of POPF healing time were female sex (HR 1.323, 95% CI 1.093-1.998, P = .042), preoperative pancreatic enzyme replacement therapy (HR 2.319, 95% CI 1.195-4.498, P = .013), ASA score 3 (HR 0.278, 95% CI 0.119-0.646, P = .003), pancreatic transection with ultrasonic dissector (HR 0.605, 95% CI 0.404-0.907, P = .015), and positive drain cultures (HR 0.635, 95% CI 0.443-0.910, P = .013).

CONCLUSION

POPF healing after DP is a slow process since only half of patients recover within 30 days of surgery. A longer healing time can be predicted early in the postoperative period with significant implications in therapeutic choices.

Prevention and treatment of pancreatic fistula after pancreatic body and tail resection: current status and future directions

Postoperative pancreatic fistula (POPF) is the most common and critical complication after pancreatic body and tail resection. How to effectively reduce the occurrence of pancreatic fistula and conduct timely treatment thereafter is an urgent clinical issue to be solved. Recent research standardized the definition of pancreatic fistula and stressed the correlation between POPF classification and patient prognosis. According to the literature, identification of the risk factors for pancreatic fistula contributed to lowering the rate of the complication. Appropriate management of the pancreatic stump and perioperative treatment are of great significance to reduce the rate of POPF in clinical practice. After the occurrence of POPF, the treatment of choice should be determined according to the classification of the pancreatic fistula. However, despite the progress and promising treatment approaches, POPF remains to be a clinical issue that warrants further studies in the future.

The efficacy of polyglycolic acid felt reinforcement in preventing postoperative pancreatic fistula after pancreaticojejunostomy in patients with main pancreatic duct less than 3 mm in diameter and soft pancreas undergoing pancreatoduodenectomy (PLANET-PJ trial): study protocol for a multicentre randomized phase III trial in Japan and Korea

BACKGROUND

Partial pancreatoduodenectomy is performed for malignant and benign diseases of the pancreatic head region. The procedure is considered highly difficult and highly invasive. Postoperative pancreatic fistula (POPF) is an important complication because of several consequent complications, including intraabdominal haemorrhage, often increasing hospital stays and surgical mortality. Although many kinds of pancreaticojejunostomy aimed at reducing POPF have been examined to date, the technique has not yet been standardized. We devised a new method using double-coated polyglycolic acid felt after pancreaticojejunostomy. The aim of the PLANET-PJ trial is to evaluate the superiority of polyglycolic acid felt reinforcement in preventing POPF after pancreaticojejunostomy in patients undergoing partial pancreatoduodenectomy to previous anastomosis methods.

METHODS

Patients diagnosed with pancreatic or periampullary lesions in whom it is judged that the main pancreatic duct diameter was 3 mm or less on the left side of the portal vein without pancreatic parenchymal atrophy due to obstructive pancreatitis are considered eligible for inclusion. This study is designed as a multicentre randomized phase III trial in Japan and the Republic of Korea. Eligible patients will be centrally randomized to either group A (polyglycolic acid felt reinforcement) or group B (control). In total, 514 patients will be randomized in 31 high-volume centres in Japan and Republic of Korea. The primary endpoint is the incidence of POPF (International Study Group of Pancreatic Surgery grade B/C).

DISCUSSION

The PLANET-PJ trial evaluates the efficacy of a new method using double-coated polyglycolic acid felt reinforcement for preventing POPF after pancreaticojejunostomy. This new method may reduce POPF.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03331718 . University Hospital Medical Information Network Clinical Trials Registry, UMIN000029647. Registered on 30 November 2017. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000033874.

Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS)

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.

A Study on the Dietary Intake and the Nutritional Status among the Pancreatic Cancer Surgical Patients

The adequate dietary intake is important to maintain the nutritional status of the patients after pancreatic cancer surgery. This prospective study was designed to investigate the dietary intake and the nutritional status of the patients who had pancreatic cancer surgery. Thirty-one patients (15 men, 16 women) were enrolled and measured body weight, body mass index (BMI), nutritional risk index (NRI), and Malnutrition Universal Screening Tool (MUST). Actual oral intake with nutritional impact symptoms recorded on the clinical research foam at every meal and medical information were collected from electronic medical charts. The rates of malnutrition at admission were 45.1% (14/31) and 28.9% (9/31) by NRI and MUST method, respectively, but those were increased to 87% (27/31) and 86.6% (26/31) after operation on discharge. The median values of daily intake of energy, carbohydrates, fat, and protein were 588.1 kcal, 96.0 g, 11.8 g, and 27.0 g, respectively. Most patients (n = 20, 64.5%) experienced two or more symptoms such as anorexia, abdominal bloating and early satiety. There were negative correlations between C-reactive protein (CRP) levels and the intake of total energy, protein, fat, and zinc. The rates of malnutrition were increased sharply after surgery and the dietary intake also influenced the inflammatory indicators. The results suggested that need of considering special therapeutic diets for the patients who received pancreatic surgery.