Effectiveness of preoperative nutritional supplementation on postoperative outcomes for patients undergoing pancreaticoduodenectomy for cancer

Abstract

Objective: The objective of this review was to synthesise the evidence regarding effectiveness of preoperative nutritional supplementation on postoperative outcomes for patients undergoing pancreaticoduodenectomy for cancer. Introduction: Pancreaticoduodenectomy surgery is complex, high-risk, and associated with significant postoperative morbidity. It remains the only curative option for patients with pancreatic cancer. Strategies to improve outcomes for patients are essential. Preoperative nutritional supplementation such as immunonutrition may enhance recovery from surgery and reduce complications. Inclusion criteria: This review considered randomised and quasi-randomised trials that recruited a minimum of one patient in intervention and control groups undergoing pancreaticoduodenectomy for cancer. Intervention groups could receive any form of nutritional supplementation for a minimum of 48 hours. Outcomes included infectious complications, anastomotic leak, pancreatic fistula, delayed gastric emptying, mortality, haemorrhage, and hospital length of stay. Methods: Electronic databases (MEDLINE, CINAHL, Scopus, Cochrane Library) and trial registers were searched for published and unpublished research. All articles from database inception to February 2021 in any language were included. One reviewer performed the literature search, screened texts for inclusion and extracted data. Two reviewers assessed methodological quality of the literature using the JBI critical appraisal tool. Statistical meta-analysis through synthesis and pooling of data for each intervention was completed where meaningful. Narrative findings are described where meta-analysis was not possible. Results: The search strategy generated 4688 studies for title and abstract screening. Seventeen trials were then included in this review, with six randomised controlled trials and two quasi-experimental studies on immunonutrition found suitable for meta-analysis. Other nutritional interventions included synbiotics and standard oral dietary formulas, with findings explored narratively. Critical appraisal found the majority of studies to be of moderate quality. Preoperative immunonutrition for three to seven days led to a decreased risk of postoperative infectious complications by 58%, which reached statistical significance (RR 0.42; 95% CI 0.28, 0.63; P = <0.0001). Furthermore, a reduced risk of wound infections (RR 0.39; 95% CI 0.2, 0.75; P = 0.005) and intrabdominal abscesses (RR 0.51; 95% CI 0.29, 0.92; P = 0.02) was identified in pooled results. There was no significant risk reduction for pancreatic fistula rates (RR 0.91; CI 0.64, 1.20; P = 0.59). Pooled results comparing preoperative immunonutrition to control for other types of infections, anastomotic leak, delayed gastric emptying, haemorrhage and mortality demonstrated no difference between groups, although findings were limited by small patient numbers. Immunonutrition may reduce hospital LOS but pooling of data was not possible due to inconsistencies in reporting across studies. The certainty of evidence for overall infectious complications, wound infections, pancreatic fistula and mortality was determined as moderate, while delayed gastric emptying results had low certainty. Conclusions: This study found that short term immunonutrition supplementation before pancreaticoduodenectomy reduces postoperative infectious complications. We suggest that preoperative immunonutrition can be an option to implement in clinical practice before pancreaticoduodenectomy. Further robust clinical trials with longer follow up are needed to establish if this translates to improved adjuvant chemotherapy completion rates and longer survival.