Pancreaticoduodenectomy: Effect of Nursing Instructions and Oral Postoperative Nutritional Supplementation on Patients Outcomes

Background: Adequate dietary oral intake is important to maintain nutritional status for patients after pancreaticoduodenectomy. Aim: This study was conducted to evaluate the effect of nursing instructions and oral postoperative nutritional supplementation on outcomes of patients following pancreaticoduodenectomy. Patients and methods: Research design: Quasi experimental (non-randomized) design. Sample and setting: Thirty-four adult patients diagnosed with pancreatic cancer and underwent pancreaticoduodenectomy was recruited from November 2021 to November 2022, in addition to 3 month follow-up period ended in February 2023. Patients were assigned non-randomly into 2 groups. Admitted patients during the first six months in hepatobiliary surgical unit at Al-Rajhi Liver and Gastroenterology Assiut University Hospital were included as control group (16 patients), while patients admitted during the next six months were included as study group (18 patients). Tools: Patient assessment sheet, short-form mini nutritional assessment scale, and Clavien-Dindo classification of surgical complications. Results: Study finding revealed a statistical significant difference (p = 0.0001) with improvement in study group after 3 months postoperatively regarding nutritional status and albumin and protein levels. Reduced length of hospital stay for study group 10 (55.6%) less than 10 days compared to control group 10 (62.5%) from 10-15 days. Complications did not occur in about one-third of study group 6 (33.3%) compared to 3 (18.8%) in control group. Conclusion: Nursing instructions and oral postoperative nutritional supplementation reduced hospital stay, improved nutritional status, albumin and protein levels and reduced postoperative complications. Recommendation: Nursing instructions (educational booklet) and oral postoperative nutritional supplementation should be utilized in all liver and gastroenterology hospitals as teaching guide for patients undergoing pancreaticoduodenectomy

Pancreatoduodenectomy is a surgical procedure for removal of tumors of the pancreatic head and the other periampullary structures.It is also known as the Whipple procedure.This surgical operation poses immense difficulties to surgeons as a result of complex as well as the highly difficult intra-abdominal dissection and repair of digestive system (1,2) .Pancreaticoduodenectomy is a complex operation that is associated with many potential postoperative complications.Many patients undergoing pancreaticoduodenectomy are malnourished due to their medical condition or difficulty eating in the face of abdominal pain or obstruction from pancreatic disease (3) .Most common postoperative complications of pancreaticoduodenectomy include pancreatic leak/fistula, bile leak, intra-abdominal abscess, delayed gastric emptying, pulmonary complications, gastrointestinal complications, or postoperative hemorrhage require blood transfusion or reopening.
Other postoperative complications related to surgical site include delayed wound healing, wound infection or dehiscence (4,5) .Malnutrition is shown to be a risk factor for postoperative complications following pancreatoduodenectomy.In addition, patients undergoing pancreatoduodenectomy, as patients with chronic pancreatitis or pancreatic cancer often are malnourished.The best route for postoperative nutrition following pancreatoduodenectomy remains unknown (6) .
The nutritional aspect after pancreatoduodenectomy is an essential component of management and therefore nutritional assessment is recommended before and after pancreato-duodenectomy.
Early initiation of oral intake with high protein supplement is recommended.However, there is no standardized protocol of nutrition progression after pancreato duodenectomy (7 ) .Nurses should provide nutritional requirements essential to neutral balance and not favor metabolic and protein catabolism, it is so relevant in pancreatoduodenectomy.The addition of oral postoperative nutritional supplementation to diet should be considered once intake is tolerated, as it can aid in meeting nutritional needs and avoid use of artificial nutrition (8,9 ) .Dietary assessment should be the standard of care.Nursing management should directed to proper assessment of patients` nutritional status, weight, and symptoms.Patients should be monitored for nausea, liquid balance and weight loss.Medical and nursing team must ensure proper assessment of dietary status before and after surgery.Nurses should support patients before and after discharge and encourage patients to take active role in their own recovery.nutritional instructions to improve their recovery (10) .
Significance of the study Patients following pancreaticoduodenectomy is suspected to develop many potential nutritional problems and postoperative complications.However, there is no supporting data for widespread postoperative nutritional supplementation.The current study is conducted in an attempt to provide guide supporting the integration of appropriate oral postoperative nutritional support into overall management of patients following pancreaticoduodenectomy and define how appropriate oral postoperative nutritional support should be prescribed to provide optimal outcome.

Aim of the study
This study aimed to evaluate the effect of nursing instructions and oral postoperative nutritional supplementation on outcomes of patients following pancreaticoduodenectomy.

Research Hypothesis
This study hypothesized that patients undergoing pancreaticoduodenectomy will exhibit improvement in their outcomes post application of nursing instructions concerning proper nutrition and provide nutritional support; oral postoperative nutritional supplementation.

Operational definition
then reevaluated and modified by Dindo et al., (2004) (13)  (single organ dysfunction), IV b = the same as IV a but with multiple organ dysfunction, V = death.Grade (I-II) is considered low grade while (III-V) considered high grade.

Tools validity
Content of this study reviewed and also approved by five experts (three medicalsurgical nursing and two hepatobiliary surgery staff) to ensure validity of the current study content.Minor modifications were performed for the current study content according to the experts' opinion.The experts` opinion was concluded as the study content were valid and can be recommended.It was calculated and found to be very beneficial = (0.36).

Tools reliability
Reliability for (tool II: the short-form mini nutritional assessment scale) using internal consistency (Cronbach's α) was 0.61.Interrater reliability for (tool III: Clavien-Dindo grading system for the classification of surgical complications) was high ranged from "0.88 to 0.91".

Pilot study
It done on (10 percent "6 patients") of the current study sample to test tools "clarity" and "feasibility" and estimate time needed to fill out.Minor modification was done, so pilot study sample (patients)   1): relationship between preoperative and after 3 months postoperative short-form mini nutritional assessment scale for patients of study and control groups.It illustrates that highly statistically significant difference (P.value = 0.004) was found between preoperative and after 3 months postoperative short-form mini nutritional assessment scale scores for study group patients.More than half of study group patients were malnourished in preoperative assessment while the majority of them were at risk of malnutrition after 3 months postoperatively.
Non-statistically significant difference (P.value = 0.156) was found between preoperative and after 3 months postoperative short-form mini nutritional assessment scale scores for patients of control group; more than half of them were at risk of malnutrition in preoperative assessment while twothird of them were at malnourished after 3 months postoperatively.
. Improvement of postoperative outcomes of patients can lead to improving patients` nutritional status, reducing postoperative complications and cost savings for hospital.Advanced practitioners must be aware of the need for prompt and early nutritional consultations for those patients (15)   .So, this study aimed to evaluate effect of nursing instructions and oral postoperative nutritional supplementation on outcomes of patients following pancreaticoduodenectomy In the current study, non-statistically significant difference was found between patients of study and control groups regarding medical data included comorbidities, adjuvant chemotherapy, preoperative weight, BMI, protein level, albumin level and the short-form mini nutritional assessment scale scores.More than half of patients in both groups suffered from preoperative malnutrition.Fewer percent of patients had hypertension, diabetes mellitus, cardiac disease and/or pulmonary diseases.The majority of patients in both groups received adjuvant chemotherapy.In the same line, Wang et al., (2022) (16) (17) who stated that preoperative malnutrition is common health problem in cancer patients as a result of immunosuppression and inflammatory activity produced by the disease.In addition, study of Morita et al., (2019) (18) reported that postoperative chemotherapy was recommended for many pancreatic cancer patients.
In the current study, study group patients showed less length of hospital stay than patients in control group.More than half of patients in study group (fifty-five percent) hospitalized for less than ten days while more than half of patients in control group (sixty-two percent) hospitalized from ten to fifteen days.Also, non-statistically significance difference was found regarding readmission to hospital.A study conducted by Gerritsen et al., (2014) (19) on one hundred and two consecutive patients undergoing pancreaticoduodenectomy supported the result of the current study as they stated that introduction of early oral nutrition/feeding after pancreaticoduodenectomy reduced hospital stay.
From researchers' point of view, a shortening of hospital stay through the introduction of nursing instructions and oral postoperative nutritional supplementation reduced the length of hospital stay for study group patients.In the current study, non-statistically significant difference was found between patients of study and control groups regarding weight and BMI after 3 months postoperatively.Both groups suffered from postoperative weight loss after 3 months postoperatively with statistically significant difference.The current study supported by the study of Morita et al., (2019) (18) who stated that weight loss and low BMI was obvious among patients after pancreaticoduodenectomy and explained that adjuvant chemotherapy after pancreaticoduodenectomy significantly influence patients prognosis led to significant reduction in weight and BMI.Body weight loss (≥10 %) after pancreaticoduodenectomy is predictive of chemotherapy discontinuation and recommended that adequate nutritional is necessary for patients receiving adjuvant chemotherapy.The findings of current study demonstrated that protein level, albumin level and the short-form mini nutritional assessment scale scores showed significant improvement in study group patients than control group patients after 3 months.The majority of study group patients were at risk of malnutrition after 3 months postoperatively while two-third of control group patients were malnourished after 3 months postoperatively.Also, the findings illustrated positive correlation between albumin level, protein level, and the shortform mini nutritional assessment scale for study group patients with statistical significant difference.
In this regard, a study of Rungsakulkij et al., (2019) (20) (19) who conducted on one hundred and two consecutive patients underwent pancreaticoduodenectomy supported the finding of present study which stated that introduction of early oral nutrition after pancreaticoduodenectomy reduced length of hospital stay and there was nonstatistically difference in the incidence of postoperative complications of Clavien-Dindo between the two groups of patients.The current study finding supported by study of Karim et al., (2018) (4) who stated that pancreaticoduodenectomy has high rate of postoperative complications.Higher rate of postoperative wound infection and bleeding was found.Other complications included pancreatic leak and fistula, pulmonary complications, and intra-abdominal collections.From the researchers point of view, nutritional status and postoperative complications are key factors that affect recovery of pancreatic cancer patients who underwent pancreaticoduodenectomy.So, oral nutritional support provided to patients of study group helped in improving nutritional status of patients and reducing postoperative complications.Finally, consequences of malnutrition on patients` postoperative outcomes included higher rate of postoperative complications, increased length of hospital day and poor survivals.So, nutritional intervention for patients with pancreatic cancer and underwent pancreaticoduodenectomy was recommended to lower the impact of malnutrition on patients` outcomes and to offer hope for prolonged survival (14,21,22) .

Study limitations
1. Small sample size.
2. The present study covered a short observation/follow up period.

Conclusions
The study findings implied that nutritional status of patients following pancreaticoduodenectomy was associated with postoperative outcomes.Oral postoperative adequate nutritional supplementation was important to improve postoperative outcome of patients underwent pancreaticoduodenectomy. Nursing instructions and oral postoperative nutritional supplementation improved patients` outcomes; lessen postoperative hospital stay, improve nutritional status, increased albumin and protein levels and fewer postoperative complications.

Recommendations
The current study recommends that: 1. Nursing instructions and oral postoperative nutritional supplementation should be provided for all patients underwent pancreaticoduodenectomy to reduce length of hospital stay, improve nutritional status, albumin and protein levels, and reduce postoperative complications.

Nursing instructions and oral postoperative
nutritional supplementation should be started as early as possible and encouraged as a routine practice for patients underwent pancreaticoduodenectomy.

3.
Vol. 29.No. 2 (Suppl) ,May 2023 Introduction Pancreatic cancer is considered the fourth common cause of cancer death despite advancement in the medical and surgical care.

Figure 2 .Figure 3 .
Figure 2. Correlation between albumin level and protein level for study group patients

Figure 4 .
Figure 4. Correlation between albumin level and the short-form mini nutritional assessment scale for study group patients

II. The short-form mini nutritional assessment scale It was designed by Rubenstein et al., (2001) (
the study sample size as thirty patients (fifteen per group).Power 95 percent, Vol.29.No. 2 (Suppl) ,May 2023