Early combined parenteral and enteral nutrition for pancreaticoduodenectomy - Retrospective cohort analysis

Pascal Probst; Daniel Keller; Johannes Steimer; Emanuel Gmür; Alois Haller; Reinhard Imoberdorf; Maya Rühlin; Hans Gelpke; Stefan Breitenstein

doi:10.1016/j.amsu.2016.02.002

Early combined parenteral and enteral nutrition for pancreaticoduodenectomy - Retrospective cohort analysis

Ann Med Surg (Lond). 2016 Feb 4:6:68-73. doi: 10.1016/j.amsu.2016.02.002. eCollection 2016 Mar.

Authors

Pascal Probst¹, Daniel Keller², Johannes Steimer², Emanuel Gmür², Alois Haller³, Reinhard Imoberdorf⁴, Maya Rühlin⁴, Hans Gelpke², Stefan Breitenstein²

Affiliations

¹ Department of Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400 Winterthur, Switzerland; Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
² Department of Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400 Winterthur, Switzerland.
³ Intensive Care Unit, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400 Winterthur, Switzerland.
⁴ Department of Medicine, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400 Winterthur, Switzerland.

Abstract

Background: Suggested guidelines for nutritional support after pancreaticoduodenectomy are still controversial. Recent evidence suggests that combining enteral nutrition (EN) with parenteral nutrition (PN) improves outcome. For ten years, patients have been treated with Early Combined Parenteral and Enteral Nutrition (ECPEN) after PD. The aim of this study was to report on rationale, safety, effectiveness and outcome associated with this method.

Methods: Consecutive PD performed between 2003 and 2012 were analyzed retrospectively. Early EN and PN was standardized and started immediately after surgery. EN was increased to 40 ml/h (1 kcal/ml) over 24 h, while PN was supplemented based on a daily energy target of 25 kcal/kg. Standard enteral and parenteral products were used.

Results: Sixty-nine patients were nutritionally supplemented according to ECPEN. The median coverage of kcal per patients related to the total caloric requirements during the entire hospitalization (nutrition balance) was 93.4% (range: 100%-69.3%). The nutritional balance in patients with needle catheter jejunostomy (NCJ) was significantly higher than in the group with nasojejunal tube (97.1% vs. 91.6%; p < 0.0001). Mortality rate was 5.8%, while major complications (Clavien-Dindo 3-5) occurred in 21.7% of patients. Neither the presence of preoperative malnutrition nor the application of preoperative immunonutrition was associated with postoperative clinical outcome.

Conclusion: This is the first European study of ECPEN after PD. ECPEN is safe and, especially in combination with NCJ, provides comprehensive coverage of caloric requirements during the postoperative phase. Clinical controlled trials are needed to investigate potential benefits of complete energy supplementation during the early postoperative phase after PD.

Keywords: ABW, adjusted body weight; ASA, American Society of Anesthesiology; ASPEN, American Society for Parenteral and Enteral Nutrition; BMI, body mass index; CVC, central venous catheter; Clinical nutrition; DGE, delayed gastric emptying; DGEM, German Society for Nutritional Medicine; ECPEN, early combined parenteral and enteral nutrition; ERAS, Enhanced recovery after surgery; Early combined enteral and parenteral nutrition; IBW, ideal body weight; ICU, intensive care unit; NCJ, Needle catheter jejunostomy; NRS, nutritional risk screening; PD, Pancreaticoduodenectomy; POPF, postoperative pancreatic fistula; Pancreatic surgery; Pancreaticoduodenectomy; RCT, randomized controlled trial.