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

Introduction Introduction and principals of enhanced recovery ERAS guidelines Survivorship

What is ERAS?

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

Marginal gains…

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 -

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

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 10-22 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)

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

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

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)

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)

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…..

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

Thank you!