ERAS Versus ERAS Plus Artificial Nutrition in Open Pancreatoduodenectomy

Background

The enhanced recovery after surgery (ERAS) protocol is currently considered the gold-standard clinical pathway for perioperative care (1). This protocol is a bundle of interventions derived from the best evidence-based perioperative treatments (1). The aim of the ERAS protocol is to accelerate patient recovery through the reduction of the dysmetabolic consequences of surgical and anesthesiology injury. When the ERAS protocol is implemented, it has been shown a reduction of the rate of surgery-related complication, length of hospital stay, and health care costs (1).

The achievement of single ERAS items also facilitates a faster recovery of oral food intake and of several key metabolic pathways (2). Appropriate tissue healing and recovery/maintenance of organ function after an operation needs an effective and efficient metabolic response, which in turn necessitates adequate qualitative and quantitative nutritional substrates to be effective. Most of the evidence on the advantages of implementing an ERAS program are derived from trials conducted in patients undergoing colorectal surgery. In this cohort the baseline nutritional risk and the rate of malnutrition is less than 10% (3). Moreover, the growing use of minimally invasive techniques has facilitated a faster recovery of bowel function and optimal tolerance of early food resumption after surgery (4). As a result, patients who receive a laparoscopic colorectal resection easily tolerate at once the reintroduction of normal food after the operation and can achieve the full nutritional requirement within 2/3 days (5).

Conversely, major pancreatic resections represent one of the most complex and challenging abdominal operation that do not fit with laparoscopic approach with exception of very selective cases (6). Furthermore, the proportion of patients having a high nutritional risk or are malnourished at baseline is higher than 80% (7). On the top, pancreatic surgery is characterized by peculiar complications such as primary delayed gastric emptying (DGE) or secondary DGE after the occurrence of a pancreatic fistula. These events are frequent (up to 50%) (8) and deeply compromise the regular resumption of oral feeding posing patients at risk of severe underfeeding. Therefore, beside the fact that early oral feeding after pancreatic surgery seems safe, there are no convincing data on whether the goal of attaining adequate nutritional needs is accomplished by a pure ERAS protocols (9) which endorse the use of artificial nutrition only in selected cases (6). However, the level of evidence is low. In fact, only one trial has specifically addressed this issue (10). In this study, the mean daily calorie and protein intakes in the first 2 weeks were similar in the ERAS group and the other group managed conventionally, despite the fact that during the first five post-operative days, the mean daily intakes of calories and proteins slightly favored the ERAS group. Overall, the authors showed that the total energy goals through oral feeding were quite low in both groups.

Many of the published studies did not analyze the compliance with ERAS protocols and reported incomplete data, particularly on early oral feeding (11,12). Robertson et al. (13) reported compliance rates of 82% for resumption of oral fluids and 86% for tolerance of the diet. Conversely, in another large trial (14), postoperative oral liquids were tolerated by 55% of the patients and solid food in 53%, but compliance dropped substantially in patients with major complications.