1. Pancreatic surgery & nutritional support
Mary E. Phillips BSc (Hons) RD DipADP
Advanced Specialist Dietitian (hepato-pancreatico-biliary surgery)
Regional HPB Centre (Surrey & Sussex),
Royal Surrey County Hospital, Guildford, UK
Declarations:
Honoria received from Mylan, Nutricia, Abbott Nutrition, Vitaflo, Merck and Sanofi

2. Introduction Introduction and principals of enhanced recovery
ERAS guidelines
Survivorship

3. What is ERAS?

5. ERAS principals Pre-operative optimisation Optimise nutritional status
Optimise diabetic care
Check for anaemia
Carbohydrate loading
Pre-operative counselling
Avoidance of bowel preparation
Goal directed fluid therapy
Avoid ‘tubes’
Avoid ‘nil by mouth’
Early mobilisation
Early reintroduction of oral
intake
Routine use of oral
nutritional supplement
drinks

6. Marginal gains…

8. Recommendation
Strength of evidence
Routine pre-operative nutrition is not warranted, significantly malnourished patients should be optimised with oral / enteral nutrition pre-operatively
Very low
Weak
Pre-operative carbohydrate loading in non diabetics
Low
Strong
Patients should be allowed normal diet after surgery without restriction, begin carefully and increase over 3-4 days
Moderate
Enteral tube feeding should only be given on specific indications -

9. Evidence? 191 References 31 articles specific to pancreatic surgery
5 observational trials on implementing ERAS
7 trials on biliary drainage
1 trial examining laparoscopic pancreatico-duodenectomy
1 trial on use of epidural
2 trials on routine NG decompression
8 trials examining pancreatic fistula
3 trials exploring delayed gastric emptying
1 trial on glycaemic control
3 trials on nutrition

10. Evidence? 191 Refences 31 articles specific to pancreatic surgery
3 trials on nutrition
TPN vs. Jejunostomy tube insertion after PD
ESPEN guidelines
Goonetilleke et al, 2006: systematic review on peri-operative nutrition
4 trials: n=201 Enteral nutrition; n=71 Immune enhancing nutrition; n=128 TPN; n=71 Control
Duration of feeding days
Reduced complications in EN vs. TPN; and Control vs. TPN
Mortality – not significant
LOS: EN better than TPN; Control better than EN in 1 trial (n=30)

12. Post operative complications
Pancreatic leak (NJ feeding, sips of water, octreotide)
Ileus (TPN)
Delayed gastric emptying (NJ feeding)
Chyle leak (No TPN in last 7 years)
Failure to thrive (NJ feeding)
Oral thrush
Constipation

13. Long term follow up clinic
5 year survival PDAC after resection = 29%
5 year survival Neuroendocrine after resection = 55%
Average GP will see 2 patients who have had pancreatic head resection in their entire career…… (PCA stats)
Complex multi-factoral disease……
6 monthly review in CNS and Dietitian led clinic
Standardises review
Co-ordinates scans
Assesses nutritional status / PERT/ DM / compliance
Looks for long term complications….. Av

14. Long term issues Vitamin A deficiency night blindness (case reports)
Osteoporosis (>2/3 after roux en Y; 8/13 low BMD 5 years after total pancreatectomy )
Vitamin E deficiency myopathy (case reports)
Anaemia (clinical review – care with adenoma/co-morbidity)
Subclinical anaemia resulting in fatigue and anxiety (Observational study - Armstrong et al, 2007)
B12 deficiency (long term PPI use / distal gastrectomy)
Zinc deficiency (retrospective audits, case reports)

15. Why micronutrients? Role of the Duodenum Calcium (+jejunum)
Phosphorus (+jejunum
Magnesium (+jejunum , ileum)
Iron (+jejunum)
Copper (+stomach)
Selenium……
Thiamine (+jejunum)
Riboflavin (+jejunum)
Niacin (+jejunum)
Biotin (+jejunum)
Folate (+jejunum , ileum)
Vitamin A, (+jejunum)
Vitamin D (+jejunum , ileum)
Vitamin E (+jejunum)
Vitamin K (+jejunum, ileum, colon)

16. What else Type 3c diabetes
Post op 8-23%
Up to 50% in long term follow up (median 27 months)
Bile acid diarrhoea – formally known as BAM..
Concurrent cholecystectomy.
Asynchrony
SIBO
65% in PEI (Bordin et al, 2013)
NAFLD
7-40% following pancreatectomy
Risk of developing cirrhosis
Aetiology – malabsorption of AA; deposition of triglycerides in liver: treated with PERT
Re-occurrence…..

17. Conclusions Reduction in LOS maintained with ERAS
Intensive post op follow up prevents readmissions
Long term follow up allows early detection of complications

18. Thank you!