title: Early combined parenteral and enteral nutrition for pancreaticoduodenectomy - Retrospective cohort analysis.
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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: 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.
authors.forename: Pascal
authors.initials: P
authors.lastname: Probst
authors.affiliation: Department of Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400 Winterthur, Switzerland.
authors.forename: Daniel
authors.initials: D
authors.lastname: Keller
authors.affiliation: Department of Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400 Winterthur, Switzerland.
authors.forename: Johannes
authors.initials: J
authors.lastname: Steimer
authors.affiliation: Department of Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400 Winterthur, Switzerland.
authors.forename: Emanuel
authors.initials: E
authors.lastname: Gmür
authors.affiliation: Intensive Care Unit, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400 Winterthur, Switzerland.
authors.forename: Alois
authors.initials: A
authors.lastname: Haller
authors.affiliation: Department of Medicine, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400 Winterthur, Switzerland.
authors.forename: Reinhard
authors.initials: R
authors.lastname: Imoberdorf
authors.affiliation: Department of Medicine, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400 Winterthur, Switzerland.
authors.forename: Maya
authors.initials: M
authors.lastname: Rühlin
authors.affiliation: Department of Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400 Winterthur, Switzerland.
authors.forename: Hans
authors.initials: H
authors.lastname: Gelpke
authors.affiliation: Department of Surgery, Cantonal Hospital Winterthur, Brauerstrasse 15, 8400 Winterthur, Switzerland.
authors.forename: Stefan
authors.initials: S
authors.lastname: Breitenstein
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