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Immunonutrition and prehabilitation in pancreatic cancer surgery: A new concept in the era of ERAS® and neoadjuvant treatment

Published:December 22, 2022DOI:https://doi.org/10.1016/j.ejso.2022.12.006

      Highlights

      • Nutritional care and its optimization in pancreatic cancer patients appear still neglected in the real-world clinical practice.
      • Meta-analyses support the positive impact of Enhanced Recovery After Surgery pathway on postoperative recovery after pancreatoduodenectomy.
      • Most of the currently available studies support the use of preoperative oral immunonutrition in pancreatic cancer patients in order to decrease the risk of the postoperative infections and the hospital length of stay. However, additional, well-designed studies should be performed to confirm the available data.
      • Results from studies focusing on the implementation of prehabilitation programs in pancreatic cancer patients and including a nutritional intervention are encouraging but still limited. Appropriately powered and well-designed prospective studies should be performed to confirm preliminary data.
      • Surgeons and clinicians, working in the setting of a multidisciplinary team, should change their perspective from a rehabilitation-to a prehabilitation-based approach.

      Abstract

      Pancreatic cancer (PC) is an aggressive disease, with a growing incidence, and a poor prognosis. Neoadjuvant treatments in PC are highly recommended in borderline resectable and recently in upfront resectable PC. PC is characterized by exocrine insufficiency and nutritional imbalance, leading to malnutrition/sarcopenia. The concept of malnutrition in PC is multifaceted, as the cancer-related alterations create an interplay with adverse effects of anticancer treatments. All these critical factors have a negative impact on the postoperative and oncological outcomes. A series of actions and programs can be implemented to improve resectable and borderline resectable PC in terms of postoperative complications, oncological outcomes and patients’ quality of life. A timely nutritional evaluation and the implementation of appropriate evidence-based nutritional interventions in onco-surgical patients should be considered of importance to improve preoperative physical fitness. Unfortunately, nutritional care and its optimization are often neglected in real-world clinical practice. Currently available studies and ERAS® guidelines mostly support the use of pre- or perioperative medical nutrition, including immunonutrition, in order to decrease the rate of postoperative infections and length of hospital stay. Further data also suggest that medical nutrition should be considered proactively in PC patients, to possibly prevent severe malnutrition and its consequences on disease and treatment outcomes. This narrative review summarizes the most recent data related to the role of prehabilitation, ERAS® program, medical nutrition, and the timing of intervention on clinical outcomes of upfront resectable and borderline PC, and their potential implementation within the timeframe of neoadjuvant treatments.

      Keywords

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