Supportive Care in Cancer

, Volume 27, Issue 3, pp 981–990 | Cite as

Application of an early oral feeding protocol after pylorus-preserving pancreaticoduodenectomy

  • Jungmin Cho
  • Hyung Mi Kim
  • Mina Song
  • Joon Seong ParkEmail author
  • Seung-Min LeeEmail author
Original Article



This study evaluates the effect of an enhanced recovery after surgery (ERAS)-based nutrition support protocol on oral intake and weight change in patients who underwent pylorus-preserving pancreaticoduodenectomy (PPPD).


A 14-day postoperative nutrition support protocol was developed to initiate oral intake after 1 week of enteral tube feeding and parenteral nutrition (early oral feeding, EOF). Forty-eight patients who underwent PPPD participated in the study (non-EOF, n = 23; EOF, n = 25). General information, nutrition supply route and amount, blood chemistry, and weight changes were tracked.


The enteral tube feeding duration was 2.7 days shorter in the EOF group than in the non-EOF group. Furthermore, the EOF group started oral liquid and soft diets 1.1 and 2.5 days earlier than the non-EOF group, respectively. Compared with the non-EOF group, the EOF group reported a higher energy intake (22.1%; p = 0.001) and protein intake (17.4%; p = 0.000) via oral route. Although cumulative energy and protein intakes were similar in both groups, weight reduction in the EOF group (3.6 ± 0.1%, 2.2 ± 0.7 kg) was significantly less than the non-EOF group (8.2 ± 0.9%, 5.2 ± 0.5 kg). The blood levels of total protein and transferrin increased and prealbumin decreased, regardless of the EOF application. Serum albumin increased significantly only in the EOF group.


The EOF protocol developed for post-PPPD patients enables the early initiation and increase in the amount of oral intake while significantly alleviating weight loss.


Pylorus-preserving pancreaticoduodenectomy Early oral feeding Nutrition support protocol Oral diet intake Enteral tube feeding Weight change 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.


  1. 1.
    Park J, Jang JY, Kim EJ, Kang M, Kwon W, Chang Y, Han I, Kim SW (2013) Effects of pancreatectomy on nutritional state, pancreatic function and quality of life. Br J Surg 100(8):1064–1070. CrossRefGoogle Scholar
  2. 2.
    Berry AJ (2014) Pancreatic enzyme replacement therapy during pancreatic insufficiency. Nutr Clin Pract 29(3):312–321. CrossRefGoogle Scholar
  3. 3.
    Sikkens EC, Cahen DL, van Eijck C, Kuipers EJ, Bruno MJ (2012) The daily practice of pancreatic enzyme replacement therapy after pancreatic surgery: a northern European survey: enzyme replacement after surgery. J Gastrointest Surg 16(8):1487–1492. CrossRefGoogle Scholar
  4. 4.
    Kang J, Park JS, Yoon DS, Kim WJ, Chung HY, Lee SM, Chang N (2016) A study on the dietary intake and the nutritional status among the pancreatic cancer surgical patients. Clin Nutr Res 5(4):279–289. CrossRefGoogle Scholar
  5. 5.
    Gangavatiker R, Pal S, Javed A, Dash NR, Sahni P, Chattopadhyay TK (2011) Effect of antecolic or retrocolic reconstruction of the gastro/duodenojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: a randomized controlled trial. J Gastrointest Surg 15(5):843–852. CrossRefGoogle Scholar
  6. 6.
    Kassin MT, Owen RM, Perez SD, Leeds I, Cox JC, Schnier K, Sadiraj V, Sweeney JF (2012) Risk factors for 30-day hospital readmission among general surgery patients. J Am Coll Surg 215(3):322–330. CrossRefGoogle Scholar
  7. 7.
    Pausch T, Hartwig W, Hinz U, Swolana T, Bundy BD, Hackert T, Grenacher L, Büchler MW, Werner J (2012) Cachexia but not obesity worsens the postoperative outcome after pancreatoduodenectomy in pancreatic cancer. Surgery 152(3):S81–S88. CrossRefGoogle Scholar
  8. 8.
    Gianotti L, Braga M, Gentilini O, Balzano G, Zerbi A, Di Carlo V (2000) Artificial nutrition after pancreaticoduodenectomy. Pancreas 21(4):344–351CrossRefGoogle Scholar
  9. 9.
    Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KC, Lobo DN, Demartines N (2012) Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 31(6):817–830. CrossRefGoogle Scholar
  10. 10.
    Braga M, Pecorelli N, Ariotti R, Capretti G, Greco M, Balzano G, Castoldi R, Beretta L (2014) Enhanced recovery after surgery pathway in patients undergoing pancreaticoduodenectomy. World J Surg 38(11):2960–2966. CrossRefGoogle Scholar
  11. 11.
    Lee CY, Lee YJ, Shin H, Park KM, Choi DR, Kim KH, Lee SG (2000) Comparison between a Pylorus-Preserving Pancreatoduodenectomy and a Classical Pancreatoduodenectomy Nutritional status and quality of life. J Korean Surg Soc 58(1):85–93Google Scholar
  12. 12.
    Jeon SH, Park KT, Jang HJ, Kim YH, Han DJ, Kim SC (2008) Clinical analysis for the postoperative complications of pancreaticoduodenectomy in the recent 5 years. Korean J Hepatobiliary Pancreat Surg 12(4):287–293Google Scholar
  13. 13.
    Liu C, Du Z, Lou C, Wu C, Yuan Q, Wang J, Shu G, Wang Y (2011) Enteral nutrition is superior to total parenteral nutrition for pancreatic cancer patients who underwent pancreaticoduodenectomy. Asia Pac J Clin Nutr 20(2):154–160Google Scholar
  14. 14.
    Nagata S, Fukuzawa K, Iwashita Y, Kabashima A, Kinoshita T, Wakasugi K, Maehara Y (2009) Comparison of enteral nutrition with combined enteral and parenteral nutrition in post-pancreaticoduodenectomy patients: a pilot study. Nutr J 8(1):1CrossRefGoogle Scholar
  15. 15.
    Grizas S, Gulbinas A, Barauskas G, Pundzius J (2008) A comparison of the effectiveness of the early enteral and natural nutrition after pancreatoduodenectomy. Medicina (Kaunas) 44(9):678–686CrossRefGoogle Scholar
  16. 16.
    Lermite E, Pessaux P, Brehant O, Teyssedou C, Pelletier I, Etienne S, Arnaud J-P (2007) Risk factors of pancreatic fistula and delayed gastric emptying after pancreaticoduodenectomy with pancreaticogastrostomy. J Am Coll Surg 204(4):588–596CrossRefGoogle Scholar
  17. 17.
    Martignoni ME, Friess H, Sell F, Ricken L, Shrikhande S, Kulli C, Büchler MW (2000) Enteral nutrition prolongs delayed gastric emptying in patients after Whipple resection. Am J Surg 180(1):18–23CrossRefGoogle Scholar
  18. 18.
    Hwang SE, Jung MJ, Cho BH, Yu HC (2014) Clinical feasibility and nutritional effects of early oral feeding after pancreaticoduodenectomy. Korean J Hepatobiliary Pancreat Surg 18(3):84–89CrossRefGoogle Scholar
  19. 19.
    Park JS, Chung H-K, Hwang HK, Kim JK, Yoon DS (2012) Postoperative nutritional effects of early enteral feeding compared with total parental nutrition in pancreaticoduodectomy patients: a prosepective, randomized study. J Korean Med Sci 27(3):261–267. CrossRefGoogle Scholar
  20. 20.
    Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P, Jauch K, Kemen M, Hiesmayr J, Horbach T (2006) ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr 25(2):224–244CrossRefGoogle Scholar
  21. 21.
    Sasaki M, Okamoto H, Johtatsu T, Kurihara M, Iwakawa H, Tanaka T, Shiomi H, Naka S, Kurumi Y, Tani T (2011) Resting energy expenditure in patients undergoing pylorus preserving pancreatoduodenectomies for bile duct cancer or pancreatic tumors. J Clin Biochem Nutr 48(3):183–186. CrossRefGoogle Scholar
  22. 22.
    Weijs PJ, Stapel SN, de Groot SD, Driessen RH, de Jong E, Girbes AR, van Schijndel RJS, Beishuizen A (2012) Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients a prospective observational cohort study. J Parenter Enter Nutr 36(1):60–68. CrossRefGoogle Scholar
  23. 23.
    Taylor BE, McClave SA, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA (2016) Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). Crit Care Med 44(2):390–438CrossRefGoogle Scholar
  24. 24.
    Shenkin A (2006) Serum prealbumin: is it a marker of nutritional status or of risk of malnutrition? Clin Chem 52(12):2177–2179CrossRefGoogle Scholar
  25. 25.
    Davis CJ, Sowa D, Keim KS, Kinnare K, Peterson S (2012) The use of prealbumin and C-reactive protein for monitoring nutrition support in adult patients receiving enteral nutrition in an urban medical center. J Parenter Enter Nutr 36(2):197–204. CrossRefGoogle Scholar
  26. 26.
    Lee SY, Bae SI, Yu HC (2015) Role of retinol binding protein as a biochemical markers for nutritional status assessment. Surg Metab Nutr 6(1):7–10. CrossRefGoogle Scholar
  27. 27.
    Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Heath CW Jr (1999) Body-mass index and mortality in a prospective cohort of U.S. adults. N Engl J Med 341(15):1097–1105. CrossRefGoogle Scholar
  28. 28.
    Park YH, Kim SE, Kim JY, Song YC, Hong SK (2009) Evaluating total parenteral nutrition after pylorus-preserving pancreatoduodenectomy (PPPD). Clin Nutr 2(1):1–5CrossRefGoogle Scholar
  29. 29.
    Wigmore S, Plester C, Richardson R, Fearon K (1997) Changes in nutritional status associated with unresectable pancreatic cancer. Br J Cancer 75(1):106CrossRefGoogle Scholar
  30. 30.
    McIntyre N, Holdsworth C, Turner D (1965) Intestinal factors in the control of insulin secretion. J Clin Endocrinol Metab 25(10):1317–1324CrossRefGoogle Scholar
  31. 31.
    Vernet O, Christin L, Schutz Y, Danforth E, Jequier E (1986) Enteral versus parenteral nutrition: comparison of energy metabolism in healthy subjects. Am J Physiol Endocrinol Metab 250(1):E47–E54CrossRefGoogle Scholar
  32. 32.
    DeFronzo RA, Ferrannini E, Hendler R, Wahren J, Felig P (1978) Influence of hyperinsulinemia, hyperglycemia, and the route of glucose administration on splanchnic glucose exchange. Proc Natl Acad Sci U S A 75(10):5173–5177CrossRefGoogle Scholar
  33. 33.
    Saltiel AR, Kahn CR (2001) Insulin signalling and the regulation of glucose and lipid metabolism. Nature 414(6865):799–806CrossRefGoogle Scholar
  34. 34.
    Frayn KN (2000) Visceral fat and insulin resistance—causative or correlative? Br J Nutr 83(S1):S71–S77CrossRefGoogle Scholar
  35. 35.
    Jeevanandam M, Legaspi A, Lowry SF, Horowitz GD, Brennan MF (1988) Effect of total parenteral nutrition on whole body protein kinetics in cachectic patients with benign or malignant disease. J Parenter Enter Nutr 12(3):229–236CrossRefGoogle Scholar
  36. 36.
    Taveroff A, McArdle AH, Rybka WB (1991) Reducing parenteral energy and protein intake improves metabolic homeostasis after bone marrow transplantation. Am J Clin Nutr 54(6):1087–1092CrossRefGoogle Scholar
  37. 37.
    Collins N (2001) The difference between albumin and prealbumin. Adv Skin Wound Care 14(5):235–236CrossRefGoogle Scholar
  38. 38.
    Gupta D, Lis CG (2010) Pretreatment serum albumin as a predictor of cancer survival: a systematic review of the epidemiological literature. Nutr J 9:69. CrossRefGoogle Scholar
  39. 39.
    Chen D, Bao L, Lu SQ, Xu F (2014) Serum albumin and prealbumin predict the poor outcome of traumatic brain injury. PLoS One 9(3):e93167. CrossRefGoogle Scholar
  40. 40.
    Relles DM, Richards NG, Bloom JP, Kennedy EP, Sauter PK, Leiby BE, Rosato EL, Yeo CJ, Berger AC (2013) Serum blood urea nitrogen and serum albumin on the first postoperative day predict pancreatic fistula and major complications after pancreaticoduodenectomy. J Gastrointest Surg 17(2):326–331. CrossRefGoogle Scholar
  41. 41.
    Phillips A, Gerald Shaper A, Whincup P (1989) Association between serum albumin and mortality from cardiovascular disease, cancer, and other causes. Lancet 334(8677):1434–1436. CrossRefGoogle Scholar
  42. 42.
    Cohn LH, Powell MR, Seidlitz L, Hamilton WK, Wylie EJ (1970) Fluid requirements and shifts after reconstruction of the aorta. Am J Surg 120(2):182–186Google Scholar
  43. 43.
    Guo D, Gong J, Cao L, Wei Y, Guo Z, Zhu W (2016) Laparoscopic surgery can reduce postoperative edema compared with open surgery. Gastroenterol Res Pract.

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Clinical Nutrition Program, Graduate School of Human Environmental SciencesYonsei UniversitySeoulSouth Korea
  2. 2.Department of Nutrition, Gangnam Severance HospitalYonsei University Health SystemSeoulSouth Korea
  3. 3.Department of Food and Nutritional Science, College of Human EcologyYonsei UniversitySeoulSouth Korea
  4. 4.Pancreatobiliary Cancer Clinic, Department of Surgery, Gangnam Severance HospitalYonsei University College of MedicineSeoulSouth Korea

Personalised recommendations