Preoperative Nutritional Status, Postoperative Nutritional Support, and Clinical Outcome Following Pancreatic Surgery

  • Sebastian Haller
  • Pascal Probst
  • Phillip KnebelEmail author


Nutritional status and perioperative nutritional support have been shown to affect outcome after surgery. There are a multitude of different methods to assess a patient’s preoperative nutritional status, for example, biological measurements as well as clinical assessment scores. Only limited evidence exists on nutritional status and postoperative outcome after pancreatic surgery. Currently there is no gold standard for preoperative nutritional assessment, but recent studies indicate that measurements obtained via cross-sectional imaging are the most promising approach. For postoperative nutritional support after pancreatic surgery, different guidelines exist. Since evidence is insufficient, surgeons should base their treatment on patient-individual needs and their clinical experience. Also described in this chapter is the clinical pathway for patients undergoing pancreatic procedures at the University Hospital of Heidelberg.


Nutritional assessment Malnutrition Postoperative outcome Pancreatic surgery Pancreaticoduodenectomy Nutritional support 


  1. 1.
    Bistrian BR, Blackburn GL, Vitale J, Cochran D, Naylor J. Prevalence of malnutrition in general medical patients. JAMA. 1976;235(15):1567–70.CrossRefPubMedGoogle Scholar
  2. 2.
    Bistrian BR, Blackburn GL, Hallowell E, Heddle R. Protein status of general surgical patients. JAMA. 1974;230(6):858–60.CrossRefPubMedGoogle Scholar
  3. 3.
    Pirlich M, Luhrmann N, Schütz T. Mangelernährung bei Klinikpatienten: Diagnostik und klinische Bedeutung. Aktuel Ernahrungsmed. 1999;24:260–6.Google Scholar
  4. 4.
    Gariballa SE, Parker SG, Taub N, Castleden CM. Influence of nutritional status on clinical outcome after acute stroke. Am J Clin Nutr. 1998;68(2):275–81.CrossRefPubMedGoogle Scholar
  5. 5.
    Kyle UG, Pirlich M, Schuetz T, Luebke HJ, Lochs H, Pichard C. Prevalence of malnutrition in 1760 patients at hospital admission: a controlled population study of body composition. Clin Nutr. 2003;22(5):473–81.CrossRefPubMedGoogle Scholar
  6. 6.
    Andreyev HJ, Norman AR, Oates J, Cunningham D. Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies? Eur J Cancer. 1998;34(4):503–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Nixon DW, Heymsfield SB, Cohen AE, Kutner MH, Ansley J, Lawson DH, et al. Protein-calorie undernutrition in hospitalized cancer patients. Am J Med. 1980;68(5):683–90.CrossRefPubMedGoogle Scholar
  8. 8.
    Aviles A, Yanez J, Lopez T, Garcia EL, Guzman R, Diaz-Maqueo JC. Malnutrition as an adverse prognostic factor in patients with diffuse large cell lymphoma. Arch Med Res. 1995;26(1):31–4.PubMedGoogle Scholar
  9. 9.
    Giner M, Laviano A, Meguid MM, Gleason JR. In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists. Nutrition. 1996;12(1):23–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Bruun LI, Bosaeus I, Bergstad I, Nygaard K. Prevalence of malnutrition in surgical patients: evaluation of nutritional support and documentation. Clin Nutr. 1999;18(3):141–7. Scholar
  11. 11.
    van Bokhorst-de van der Schueren MA, Guaitoli PR, Jansma EP, de Vet HC. Nutrition screening tools: does one size fit all? A systematic review of screening tools for the hospital setting. Clin Nutr. 2014;33(1):39–58. Scholar
  12. 12.
    Sun Z, Kong XJ, Jing X, Deng RJ, Tian ZB. Nutritional risk screening 2002 as a predictor of postoperative outcomes in patients undergoing abdominal surgery: a systematic review and meta-analysis of prospective cohort studies. PLoS One. 2015;10(7):e0132857. Scholar
  13. 13.
    Kondrup J, Rasmussen HH, Hamberg O, Stanga Z, Ad Hoc EWG. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr. 2003;22(3):321–36.CrossRefPubMedGoogle Scholar
  14. 14.
    van Stijn MF, Korkic-Halilovic I, Bakker MS, van der Ploeg T, van Leeuwen PA, Houdijk AP. Preoperative nutrition status and postoperative outcome in elderly general surgery patients: a systematic review. JPEN J Parenter Enteral Nutr. 2013;37(1):37–43. Scholar
  15. 15.
    Schnelldorfer T, Adams DB. The effect of malnutrition on morbidity after surgery for chronic pancreatitis. Am Surg. 2005;71(6):466–72. discussion 72-3PubMedGoogle Scholar
  16. 16.
    Seltzer MH, Bastidas JA, Cooper DM, Engler P, Slocum B, Fletcher HS. Instant nutritional assessment. JPEN J Parenter Enteral Nutr. 1979;3(3):157–9.CrossRefPubMedGoogle Scholar
  17. 17.
    Sierzega M, Niekowal B, Kulig J, Popiela T. Nutritional status affects the rate of pancreatic fistula after distal pancreatectomy: a multivariate analysis of 132 patients. J Am Coll Surg. 2007;205(1):52–9. Scholar
  18. 18.
    Onodera T, Goseki N, Kosaki G. Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients. Nihon Geka Gakkai zasshi. 1984;85(9):1001–5.PubMedGoogle Scholar
  19. 19.
    Kanda M, Fujii T, Kodera Y, Nagai S, Takeda S, Nakao A. Nutritional predictors of postoperative outcome in pancreatic cancer. Br J Surg. 2011;98(2):268–74. Scholar
  20. 20.
    Shinkawa H, Takemura S, Uenishi T, Sakae M, Ohata K, Urata Y, et al. Nutritional risk index as an independent predictive factor for the development of surgical site infection after pancreaticoduodenectomy. Surg Today. 2013;43(3):276–83. Scholar
  21. 21.
    La Torre M, Ziparo V, Nigri G, Cavallini M, Balducci G, Ramacciato G. Malnutrition and pancreatic surgery: prevalence and outcomes. J Surg Oncol. 2013;107(7):702–8. Scholar
  22. 22.
    Stratton RJ, Hackston A, Longmore D, Dixon R, Price S, Stroud M, et al. Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. Br J Nutr. 2004;92(5):799–808.CrossRefPubMedGoogle Scholar
  23. 23.
    Probst P, Haller S, Dorr-Harim C, Bruckner T, Ulrich A, Hackert T, et al. Nutritional risk in major abdominal surgery: protocol of a prospective observational trial to evaluate the prognostic value of different nutritional scores in pancreatic surgery. JMIR Res Protoc. 2015;4(4):e132. Scholar
  24. 24.
    Probst P, Haller S, Bruckner T, Ulrich A, Strobel O, Hackert T, Diener MK, Büchler MW, Knebel P. Prospective trial to evaluate the prognostic value of different nutritional assessment scores in pancreatic surgery: NURIMAS Pancreas. Br J Surg. 2017;104(8):1053–62.CrossRefPubMedGoogle Scholar
  25. 25.
    Slankamenac K, Nederlof N, Pessaux P, de Jonge J, Wijnhoven BP, Breitenstein S, et al. The comprehensive complication index: a novel and more sensitive endpoint for assessing outcome and reducing sample size in randomized controlled trials. Ann Surg. 2014;260(5):757–62.; discussion 62-3. Scholar
  26. 26.
    Sledzianowski JF, Duffas JP, Muscari F, Suc B, Fourtanier F. Risk factors for mortality and intra-abdominal morbidity after distal pancreatectomy. Surgery. 2005;137(2):180–5. Scholar
  27. 27.
    House MG, Fong Y, Arnaoutakis DJ, Sharma R, Winston CB, Protic M, et al. Preoperative predictors for complications after pancreaticoduodenectomy: impact of BMI and body fat distribution. J Gastrointest Surg. 2008;12(2):270–8. Scholar
  28. 28.
    Noun R, Riachy E, Ghorra C, Yazbeck T, Tohme C, Abboud B, et al. The impact of obesity on surgical outcome after pancreaticoduodenectomy. JOP. 2008;9(4):468–76.PubMedGoogle Scholar
  29. 29.
    Balentine CJ, Enriquez J, Cruz G, Hodges S, Bansal V, Jo E, et al. Obesity does not increase complications following pancreatic surgery. J Surg Res. 2011;170(2):220–5. Scholar
  30. 30.
    Bachmann J, Heiligensetzer M, Krakowski-Roosen H, Buchler MW, Friess H, Martignoni ME. Cachexia worsens prognosis in patients with resectable pancreatic cancer. J Gastrointest Surg. 2008;12(7):1193–201. Scholar
  31. 31.
    Wigmore SJ, Plester CE, Richardson RA, Fearon KC. Changes in nutritional status associated with unresectable pancreatic cancer. Br J Cancer. 1997;75(1):106–9.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Pausch T, Hartwig W, Hinz U, Swolana T, Bundy BD, Hackert T, et al. Cachexia but not obesity worsens the postoperative outcome after pancreatoduodenectomy in pancreatic cancer. Surgery. 2012;152(3 Suppl 1):S81–8. Scholar
  33. 33.
    Amini N, Spolverato G, Gupta R, Margonis GA, Kim Y, Wagner D, et al. Impact total psoas volume on short- and long-term outcomes in patients undergoing curative resection for pancreatic adenocarcinoma: a new tool to assess sarcopenia. J Gastrointest Surg. 2015;19(9):1593–602. Scholar
  34. 34.
    Peng P, Hyder O, Firoozmand A, Kneuertz P, Schulick RD, Huang D, et al. Impact of sarcopenia on outcomes following resection of pancreatic adenocarcinoma. J Gastrointest Surg. 2012;16(8):1478–86. Scholar
  35. 35.
    Joglekar S, Asghar A, Mott SL, Johnson BE, Button AM, Clark E, et al. Sarcopenia is an independent predictor of complications following pancreatectomy for adenocarcinoma. J Surg Oncol. 2015;111(6):771–5. Scholar
  36. 36.
    Weimann A, Breitenstein S, Breuer JP, Gabor SE, Holland-Cunz S, Kemen M, et al. Clinical nutrition in surgery. Chirurg. 2014;85(4):320–6. Scholar
  37. 37.
    Lassen K, Coolsen MME, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, et al. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr. 2012;31(6):817–30. Scholar
  38. 38.
    American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. Clinical guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients, 2009. JPEN J Parenter Enteral Nutr. 2009;33(3):255–9. Scholar
  39. 39.
    Nagata S, Fukuzawa K, Iwashita Y, Kabashima A, Kinoshita T, Wakasugi K, et al. Comparison of enteral nutrition with combined enteral and parenteral nutrition in post-pancreaticoduodenectomy patients: a pilot study. Nutr J. 2009;8(1):1–8. Scholar
  40. 40.
    Zhu XH, Wu YF, Qiu YD, Jiang CP, Ding YT. Effect of early enteral combined with parenteral nutrition in patients undergoing pancreaticoduodenectomy. World J Gastroenterol. 2013;19(35):5889–96. Scholar
  41. 41.
    Probst P, Keller D, Steimer J, Gmur E, Haller A, Imoberdorf R, et al. Early combined parenteral and enteral nutrition for pancreaticoduodenectomy—retrospective cohort analysis. Ann Med Surg (Lond). 2016;6:68–73. Scholar
  42. 42.
    Fink C, Diener MK, Bruckner T, Muller G, Paulsen L, Keller M, et al. Impact of preoperative patient education on prevention of postoperative complications after major visceral surgery: study protocol for a randomized controlled trial (PEDUCAT trial). Trials. 2013;14:271. Scholar
  43. 43.
    Probst P, Büchler E, Doerr-Harim C, Knebel P, Thiel B, Ulrich A, et al. Randomised controlled pilot trial on feasibility, safety and effectiveness of osteopathic MANipulative treatment following major abdominal surgery (OMANT pilot trial). Int J Osteopath Med. 2016;20:31–40. Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2018

Authors and Affiliations

  • Sebastian Haller
    • 1
  • Pascal Probst
    • 1
  • Phillip Knebel
    • 1
    Email author
  1. 1.Department of General, Visceral and Transplantation SurgeryUniversity of HeidelbergHeidelbergGermany

Personalised recommendations