Optimal Perioperative Nutrition Therapy for Patients Undergoing Pancreaticoduodenectomy: A Systematic Review with a Component Network Meta-Analysis

Numerous strategies for perioperative nutrition therapy for patients undergoing pancreaticoduodenectomy (PD) have been proposed. This systematic review aimed to summarize the current relevant published randomized controlled trials (RCTs) evaluating different nutritional interventions via a traditional network meta-analysis (NMA) and component network meta-analysis (cNMA). EMBASE, MEDLINE, the Cochrane Library, and ClinicalTrials.gov were searched to identify the RCTs. The evaluated nutritional interventions comprised standard postoperative enteral nutrition by feeding tube (Postop-SEN), preoperative enteral feeding (Preop-EN), postoperative immunonutrients (Postop-IM), preoperative oral immunonutrient supplement (Preop-IM), and postoperative total parenteral nutrition (TPN). The primary outcomes were general, infectious, and noninfectious complications; postoperative pancreatic fistula (POPF); and delayed gastric emptying (DGE). The secondary outcomes were mortality and length of hospital stay (LOS). The NMA and cNMA were conducted with a frequentist approach. The results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Two primary outcomes, infectious complications and POPF, were positively influenced by nutritional interventions. Preop-EN plus Postop-SEN (OR 0.11; 95% CI 0.02~0.72), Preop-IM (OR 0.22; 95% CI 0.08~0.62), and Preop-IM plus Postop-IM (OR 0.11; 95% CI 0.03~0.37) were all demonstrated to be associated with a decrease in infectious complications. Postop-TPN (OR 0.37; 95% CI 0.19~0.71) and Preop-IM plus Postop-IM (OR 0.21; 95% CI 0.06~0.77) were clinically beneficial for the prevention of POPF. While enteral feeding and TPN may decrease infectious complications and POPF, respectively, Preop-IM plus Postop-IM may provide the best clinical benefit for patients undergoing PD, as this approach decreases the incidence of both the aforementioned adverse effects.

Effectiveness of Intensive Perioperative Nutrition Therapy Among Adults Undergoing Gastrointestinal And Oncological Surgery In Public Hospital: Study Protocol For A Pragmatic Randomised Control Trial.

Background: Perioperative malnutrition is common in patients undergoing gastrointestinal-oncology surgical and associated with longer hospital stays, increased post-operative complications, poorer quality of life and lower survival rate. Current practice emphasises the roles of early perioperative nutrition therapy as early intervention in order to combat the post-operative complications of patients and the implementation is now widely adopted. The aim of the study is to determine the effects of intensive perioperative nutrition therapy to overcome the post-operative complications in adult patients undergoing gastrointestinal and oncological surgery. Methods: This is a pragmatic randomised control trial study where elective admitted patients will be randomised into Intervention (SS) or Control (NN) Group. All data will be collected during a face to face interview, anthropometric measurement, blood sampling (albumin, white blood count, haemoglobin and c-reactive protein), handgrip strength and post-operative complications. Group SS will be receiving a tailored lifestyle and intensively supplemented with oral nutrition support as compared with Group NN that receive standard medical care. The primary outcomes are length of stay in hospital, bowel function and solid food toleration. Additional outcome measures are changes in biochemical profile, nutritional and functional status. The effects of intervention between groups towards outcome parameters will be analyse by using the SPSS General Linear Model (GLM) for repeated measure procedure.Discussion: The intervention implemented in this study will serve as a baseline data in providing an appropriate nutritional management in patients undergoing gastrointestinal and oncological surgery. Trial registration: ClinicalTrials.gov Protocol Registration and Results System (PRS), NCT04347772. Registered 20 November 2019, https://www.clinicaltrials.gov

131 PRACTICES IN PERIOPERATIVE NUTRITION PRECEDING OR FOLLOWING OESOPHAGECTOMY: RESULTS OF A EUROPEAN SURVEY

The route and type of peri-operative feeding after oesophagectomy varies widely across centres, usually based on local experiences and standing orders. The aim of this survey on perioperative nutrition after oesophagectomy (PONOS) was to create a snapshot the way perioperative nutrition preceding or following oesophagectomy is established across reference centres in Europe, and what the reasons are for preferring one method over another. Methods A survey consisting of four parts was distributed to the membership of 3 European, mainly surgical oriented scientific societies between October 2019 and January 2020. The first part contained some general questions regarding demographics of the participants and type of performed surgery. In the second section, centres were asked about practices in preoperative nutrition. The third section questioned participants about their practices in postoperative nutrition; in the last part the daily practice was reflected against the current available ESPEN guidelines. Results Fifty-one surgeons from 49 centres in 16 countries participated. The majority had a structured nutrition team in their institution. An Enhanced Recovery Pathway was implemented in 2/3 of centres. ESPEN guidelines were followed in 50% of centers. Routine preoperative nutritional assessment was performed in 84%. Preoperative nutritional support consisted mainly of enteral and oral support; immediate postoperatively mostly a combination of oral and enteral or enteral only; at discharge mostly a combination of oral and enteral or only oral nutritional supplementation were used. Timing, definition and means of postoperative oral intake also seemed to differ widely across centres. Conclusion The PONOS survey confirmed our assumption that perioperative feeding after oesophagectomy exists in a wide variety across European centres performing oesophageal resections for cancer. Survey based feedback to the surgical community draws attention to this often underexposed part of the surgical pathway of a patient. As such, this might further enhance the exchange of experiences in order to try to harmonise peri-operative feeding regimen.

Perioperative nutrition in the light of guidelines (and in the shadow of practice)

Nutritional support is one of the fundamental conditions of a successful outcome in malnourished or critically ill patients. Malnutrition is an important negative factor with impacts on postoperative morbidity and lethality in surgical patients. It is often observed in particularly in oncosurgical patients, in the elderly and in patients with chronic intestinal disease. The issue of malnutrition should be medically managed from the very moment the ill person becomes a patient. The effort of correcting malnutrition should extend over the entire perioperative period – from the beginning of the diagnostic procedure, during the hospital stay with surgery as applicable with postoperative nutrition therapy, to nutritional status monitoring after discharge and in the course of subsequent follow-up in the outpatient setting. Recent European and Czech guidelines adopted by the Czech Surgical Society and by the other societies exist for this complex issue. However, the use of these guidelines often encounters barriers in practice, and their implementation rate is thus rather low. Nutrition care is a mandatory part of the management of surgical patients both in the outpatient and hospital settings of the entire process. The article is a commented selection of nutritional guidelines of the European Society for Parenteral and Enteral Nutrition (ESPEN) of 2017 for surgical patients, and of those resulting from consensual voting of the working group of the Czech Society for Clinical Nutrition and Intensive Metabolic Care (SKVIMP) of 2018.

Perioperative nutrition care and dietetic practices in the scope of bariatric surgery in Saudi Arabia using adapted protocols for evaluation

Objectives: This study evaluates the availability of perioperative nutritional care protocols and the practices of bariatric registered dietitians in Saudi Arabia. The primary outcomes of the study were conducted using an adapted American survey “with permission.” Methods: A cross-sectional survey of a selected 32 dietitians providing bariatric services completed a self-administered online questionnaire from 12 hospitals in Jeddah, Saudi Arabia. Results: All surveyed dietitians were females, mainly Saudi nationals (93.9%, n = 30), and accredited by the Saudi Commission for Health Specialties (93.8%, n = 30). Only 37.5% (n = 6) of the dietitians were specialized in bariatric surgery. Perioperative common practices of dietitians included a conduct of screening for nutrition risk before (44%, n = 14) and after surgery (62.5%, n = 20) and applied a nutrition management protocol that is mainly based on the application of nutrition care process (62.5%, n = 20). Dietitians (81%, n = 26) reported the importance of having standardized protocols for nutritional management of patients undoing bariatric surgery, where 69% (n = 22) confirmed the availability of pre-operative written protocols in hospitals and 75% (n = 24) confirmed the existence of post-operative protocols. Pre-operative practices included using approaches for weight loss before surgery, for example, very low and low-calorie diet. Dietitians (25%, n = 8) see two to ten patients per month. The sleeve gastrectomy procedure is the most often performed surgery. Conclusion: This is the first study to evaluate the perioperative nutrition care protocols and practices related to bariatric surgery in Saudi Arabia. Perioperative bariatric protocols are available, but some dietitians are not aware of their availability and contents. Researchers emphasize the importance of creating national protocols by the Saudi Credentials Body to standardize practices within the field.