Results of a survey on peri-operative nutritional support in pancreatic and biliary surgery in Spain

Nu ición Hospi ala ia T abajo O iginal Nu ición a i icial ISSN (elec ónico): 1699-5198 - ISSN (papel): 0212-1611 - CODEN NUHOEQ S.V.R. 318 Resul s o a su ey on pe i-ope a i e nu i ional suppo in panc ea ic and bilia y su ge y in Spain Resul ados de una encues a sob e el sopo e nu icional pe iope a o io en la ci ugía panc eá ica y bilia en España Ca melo Loinaz1, Fede ico Ochando2, Emilio Vicen e3, Alejand o Se ablo4, Pablo López Cille o5, Miguel Ángel Gómez6, Juan Fab ega 7, E a is oVa o8, Albe Miya de León9, Cons an ino Fonde ila10, And és Valdi ieso11, Ge a do Blanco12, Belinda Sánchez13, Ra ael López Andúja 14, Yilian Fundo a15, Es eban Cuga 16, Luis Díez Vallada es17, Ja ie He e a18, Agus ín Ga cía Gil19, Ra ael Mo ales20, Fe nando Pa do21, Luis Saba e 22, José Ángel López Baena23, Luis Muñoz Bell is24, Elena Ma ín Pé ez25, Bal asa Pé ez Sabo ido26, Miguel Ángel Suá ez27, Juan Ca los Meneu28, Mai eAlbiol29, Al onso Sanjuanbeni o30, José Miguel Ramia31, Fe nando Pe ei a32, Glo ia Pasei o33, Juan Ca los Palomo34, Miguel León35, and GENPOCIRP (G upo Encues a Nu ición Pe iOpe a o ia en CIRugia Panc ea obilia ) 1Su ge y Depa men . Hospi al Uni e si a io 12 de Oc ub e. Mad id, Spain. 2Hospi al Uni e si a io Fundación Alco cón. Alco cón, Mad id. Spain. 3Hospi al Sanchina o. Mad id, Spain. 4Su ge y Depa men . Hospi al Uni e si a io Miguel Se e . Za agoza, Spain. 5Su ge y Depa men . Hospi al Uni e si a io Reina So ía. Có doba, Spain. 6Su ge y Depa men . Hospi al Uni e si a io Vi gen del Rocío. Se illa, Spain. 7Su ge y Depa men . Hospi al Uni e si a i de Bell i ge. Hospi ale de Llob ega , Ba celona. Spain. 8Su ge y Depa men . Hospi al Clínico Uni e si a io de San iago de Compos ela. A Co uña, Spain. 9Su ge y Depa men . Hospi al Cen al de As u ias. O iedo, Spain. 10Su ge y Depa men . Hospi al Clínic. Ba celona, Spain. 11Su ge y Depa men . Hospi al de C uces. Ba acaldo, Vizcaya. Spain. 12Su ge y Depa men . Hospi al Uni e si a io In an a C is ina. Badajoz, Spain. 13Su ge y Depa men . Hospi al Uni e si a io Ca los Haya. Málaga, Spain. 14Su ge y Depa men . Hospi al Uni e si a i i Poli ècnic La Fe. Valencia, Spain. 15Su ge y Depa men . Hospi al Uni e si a io Vi gen de las Nie es. G anada, Spain. 16Su ge y Depa men . Hospi al Mu ua Te assa. Te assa, Ba celona. Spain. 17Su ge y Depa men . Hospi al Clínico San Ca los. Mad id, Spain. 18Su ge y Depa men . Hospi al de Na a a. Pamplona, Spain. 19Su ge y Depa men . Hospi al Clínico Uni e si a io Lozano Blesa. Za agoza, Spain. 20Su ge y Depa men . Hospi al Uni e si a i Son Espases. Palma de Mallo ca, Spain. 21Su ge y Depa men . Clínica Uni e sidad de Na a a. Pamplona, Spain. 22Su ge y Depa men . Hospi al Clínico. Valencia, Spain. 23Su ge y Depa men . Hospi al Gene al Uni e si a io G ego io Ma añón. Mad id, Spain. 24Su ge y Depa men . Hospi al Uni e si a io de Salamanca. Salamanca, Spain. 25Su ge y Depa men . Hospi al Uni e si a io de La P incesa. Mad id, Spain. 26Su ge y Depa men . Hospi al Uni e si a io Río Ho ega. Valladolid, Spain. 27Su ge y Depa men . Hospi al Uni e si a io Vi gen de la Vic o ia. Málaga, Spain. 28Su ge y Depa men . Hospi al Rúbe Juan B a o. Mad id, Spain. 29Su ge y Depa men . Hospi al Uni e si a i de Gi ona Doc o Josep T ue a. Gi ona, Spain. 30Su ge y Depa men . Hospi al Uni e si a io Ramón y Cajal. Mad id, Spain. 31Su ge y Depa men . Hospi al Uni e si a io de Guadalaja a. Guadalaja a, Spain. 32Su ge y Depa men . Hospi al Uni e si a io de Fuenlab ada. Fuenlab ada, Mad id. Spain. 33Su ge y Depa men . Hospi al Uni e si a io In an a Leono . Mad id, Spain. 34Su ge y Depa men . Hospi al Vi gen de la Luz. Cuenca, Spain. 35Endoc inology Depa men . Hospi al Uni e si a io 12 de Oc ub e. Mad id, Spain Keywo ds: Panc eas. Bilia y. Su ge y. Nu i ion. Abs ac In oduc ion: a su ey on pe i-ope a i e nu i ional suppo in panc ea ic and bilia y su ge y among Spanish hospi als in 2007 showed ha ew su gical g oups ollowed he 2006 ESPEN guidelines. Ten yea s la e we sen a ques ionnai e o check he cu en si ua ion. Me hods: a ques ionnai e wi h 21 i ems sen o 38 cen e s, ela ed o as ing ime be o e and a e su ge y, nu i ional sc eening use and ype, ime and ype o pe i-ope a i e nu i ional suppo , and numbe o p ocedu es. Resul s: hi y- ou ins i u ions esponded. The median numbe o panc ea ic esec ions (head/ o al) was 29.5 (95 % CI: 23.0-35; ange, 5-68) ( o al, 1002); o su ge ies o bilia y malignancies (non-panc ea ic), 9.8 (95 % CI: 7.3-12.4; ange, 2-30); and o main bilia y esec ions o benign condi ions, 10.4 (95 % CI: 7.6-13.3; ange, 2-33). Be o e su ge y, only 41.2 % o he si es used nu i ional suppo (< 50 % used any nu i ional sc eening p ocedu e). The mean du a ion o p eope a i e as ing o solid oods was 9.3 h ( ange, 6-24 h); i was 6.6 h o liquids ( ange, 2-12). Following panc ea ic su ge y, 29.4 % ied o use ea ly o al eeding, bu 88.2 % o he su eyed eams used some nu i ional suppo ; 26.5 % o esponden s used TPN in 100 % o cases. Di e en pe cen ages o TPN and EN we e used in he o he cen e s. In malignan bilia y su ge y, 22.6 % used TPN always, and EN in 19.3 % o cases. Conclusions: TPN is he commones nu i ion app oach a e panc ea ic head su ge y. Only 29.4 % o he uni s used ea ly o al eeding, and 32.3 % used EN; 22.6 % used TPN egula ly a e su ge y o malignan bilia y umou s. The 2006 ESPEN guideline ecommenda ions a e no egula ly ollowed 12 yea s a e hei publica ion in ou coun y. Co espondence: Ca melo Loinaz. Su ge y Depa men . Hospi al Uni e si a io 12 de Oc ub e. A da. de Có doba, s/n. 28041 Mad id, Spain e-mail: [email p o ec ed] Loinaz C, Ochando F, Vicen e E, Se ablo A, López Cille o P, Gómez MÁ, Fab ega J, Va o E, Miya de LeónA, Fonde ila C, Valdi ieso A, Blanco G, Sánchez B, López Andúja R, Fundo a Y, Cuga E, Díez Vallada es L, He e aJ, Ga cía Gil A, Mo ales R, Pa do F, Saba e L, López Baena JÁ, Muñoz Bell is L, Ma ín Pé ez E, Pé ez Sabo ido B, Suá ez MÁ, Meneu JC, Albiol M, Sanjuanbeni o A, Ramia JM, Pe ei a F, Pasei o G, Palomo JC, LeónM and GENPOCIRP (G upo Encues a Nu ición Pe iOpe a o ia en CIRugia Panc ea obilia ). Resul s o a su ey on pe i-ope a i e nu i ional suppo in panc ea ic and bilia y su ge y in Spain. Nu Hosp 2020;37(2):238-242 DOI: h p://dx.doi.o g/10.20960/nh.02895 Recei ed: 02/10/2019 • Accep ed: 06/01/2020 ©Copy igh 2020 SENPE y ©A án Ediciones S.L. Es e es un a ículo Open Access bajo la licencia CC BY-NC-SA (h p://c ea i ecommons.o g/licenses/by-nc-sa/4.0/). Pa o hese esul s we e shown as a pos e a he 40 h ESPEN Cong ess in Mad id in Sep embe 2018. Con lic o in e es : he au ho s decla e no con lic o in e es . 239RESULTS OF A SURVEY ON PERI-OPERATIVE NUTRITIONAL SUPPORT IN PANCREATIC AND BILIARY SURGERY IN SPAIN [Nu Hosp 2020;37(2):238-242] INTRODUCTION The issue o nu i ion a ound panc ea ic and bilia y su ge y has no been sol ed ye (1-3). Complex p ocedu es wi h a high a e o complica ions make i di icul o s anda dize he nu i ional suppo needed. Though mo ali y is less han 5 % in specialis cen e s, mo bidi y is a ound o exceeding 50 % (4-6). Malnu i ion be o e su ge y and as he e ec o su gical complica ions makes he nu i ional managemen o hese pa ien s an una oidable ask. We pe o med a na ionwide su ey in Spain in 2007 abou pe- iope a i e nu i ional managemen in panc ea obilia y su ge y. We con ac ed 33 su gical uni s and ecei ed esponses om 25 (75.7 %) o hem. The su ey was based on 18 simple ques ions ela ed o pe iope a i e nu i ional ca e habi s. The esul s we e published in he jou nal Nu ición Hospi ala ia (7). We ealized ha he si ua ion in Spain a ha ime was a om he ecommenda ions issued by ESPEN (8). Pa en e al nu i ion was he mos p e alen modali y o suppo (82.6 %), and en e al nu i ion ( ia a nasojejunal ube o je- junos omy) was used only in 21.7 % o Uni s in panc ea ic su ge y. Ten yea s la e , we decided o send a simila ques ionnai e o assess he cu en si ua ion in Spain. MATERIALS AND METHODS A ques ionnai e wi h 21 i ems was sen o 38 cen e s wi h known ac i i y in panc ea ic and bilia y su ge y. Ques ions we e ela ed o as ing ime (hou s) be o e and a e su ge y (liquid and solid), nu i ional sc eening use and ype, ime (days) and ype o pe i-ope a i e nu i ional suppo (en e al by ube o jejunos omy, pa en e al) and numbe o p ocedu es o each ype (panc ea ic and bilia y, benign and malignan ). The esul s ob ained om he di e en cen e s we e ans e ed o an Excel shee and analyzed. STATISTICAL ANALYSIS In he desc ip i e analysis, ca ego ical a iables a e p esen ed wi h hei equency dis ibu ion (numbe s and pe cen ages) and quan i a i e a iables as mean and median alues wi h con idence in e al (CI) and ange. RESULTS We ecei ed esponses om 34 ins i u ions (89.5 %). The me- dian numbe o panc ea ic esec ions (head and/o o al panc ea- ec omies) was 29.5 (95 % CI: 23.0-35; ange, 5-68) ( o alling 1,002 cases). Su ge y o bilia y malignancies (non-panc ea ic, abo e he panc ea ic gland) a e aged 9.8 (95 % CI: 7.3-12.4; ange, 2-30), and he mean numbe o main bilia y esec ions o benign condi ions, non ela ed o li e ansplan a ion econs uc- ion o he bilia y ee, was 10.4 (95 % CI: 7.6-13.3; ange, 2-33) (Fig. 1, numbe o p ocedu es). Be o e su ge y only 41.2 % o he g oups used nu i ional su- ppo and less han 50 % used any nu i ional sc eening me hod. The mean du a ion o p eope a i e solid ood as ing was 9.3 h ( ange, 6-24 h). I was 6 hou s in 11 cen e s and 8 hou s in 12. Mean p eope a i e as ing was 6.6 h o liquids ( ange, 2-12), i being 2 hou s in only 5 cen e s and 4 hou s in one. I was 6 o 8 hou s in he majo i y o Uni s (Fig. 2). Following panc ea ic su ge y, 29.4 % o esponden s ied o use ea ly o al eeding, bu 88.2 % o he g oups in ol ed used some nu- i ional suppo . In 26.5 % o he g oups TPN was used o 100 % o cases. I was used o 0-20 % o cases in 50 % o he esponding cen es (Fig. 3). The mean numbe o PN days was 6. Di e en pe cen ages o TPN and EN we e used in he o he cen e s. Six een cen e s did no use EN o PN in only 0-10 % o hei cases. Jejunos omy was used only in 3 cen e s (in 20-30 % o he pa ien s). Tube EN use was highly a iable – 26 cen e s did no use i , bu 12 we e using i in 1-90 % o hei cases. EN was used o a mean o 3.7 days (median, 5 days). Pos ope a i e o al eeding was ini ia ed a a median o 2 days (mean, 2.5 days) a e panc ea ec omy. One cen e s a ed i on pos -ope a i e day (POD) 0, 9 in POD 1, 9 in POD 2, and 15 in POD 3-5. The e was g ea a iabili y o solids; in 1 cen e hey s a ed hem on POD1, in 3 on POD 2, in 9 on POD 3, and in 1 on POD 8. Palab as cla e: Pánc eas. Bilia . Ci ugía. Nu ición. Resumen In oducción: ealizamos una encues a sob e sopo e nu icional pe iope a o io en ci ugía panc eá ica y bilia en hospi ales españoles en 2007, que mos ó que pocos g upos qui ú gicos seguían las guías de ESPEN 2006. Diez años después en iamos un cues iona io pa a comp oba la si uación ac ual. Mé odos: ein a y ocho cen os ecibie on un cues iona io con 21 p egun as sob e iempo de ayunas an es y después de la ci ugía, c ibado nu icional, du ación y ipo de sopo e nu icional pe iope a o io, y núme o de p ocedimien os. Resul ados: espondie on 34 g upos. La mediana de panc ea ec omías (cabeza/ o al) ue de 29,5 (IC 95 %: 23,0-35; ango, 5-68) ( o al, 1002), la de ci ugías bilia es malignas de 9,8 (IC 95 %: 7,3-12,4; ango, 2-30) y la de esecciones bilia es po pa ología benigna de 10,4 (IC 95 %: 7,6-13,3; ango, 2-33). Solo el 41,2 % de los g upos u ilizaban sopo e nu icional an es de la ci ugía (< 50 % habian e ec uado un c ibado nu icional). El iempo medio de ayuno p eope a o io pa a sólidos ue de 9,3 h ( ango, 6-24 h), y de 6,6 h pa a líquidos ( ango, 2-12). T as la panc ea ec omía, el 29,4 % habían in en ado adminis a una die a o al p ecoz, pe o el 88,2 % de los g upos usa on algún ipo de sopo e nu icional y el 26,5 % usa on NP en el 100 % de los casos. Los demás g upos usa on di e en es po cen ajes de NP y NE en sus casos. En la ci ugía bilia maligna, el 22,6 % u iliza on NP siemp e y NE en el 19,3 % de los casos. Conclusiones: la NP es el sopo e nu icional más u ilizado as la ci ugía de cabeza panc eá ica. Solo el 29,4 % de las unidades usan nu ición o al p ecoz y el 32,3 % emplean la NE as es e ipo de ci ugía. El 22,6 % de las ins i uciones usan NP habi ualmen e as la ci ugía de umo es bilia es malignos. Las guías ESPEN 2006 no se siguen de o ma habi ual en nues o país as más de 10 años desde su publicación. 240 C. Loinaz e al. [Nu Hosp 2020;37(2):238-242] Figu e 3. Pe cen age dis ibu ion o pa en e al nu i ion use in pa ien s a e panc ea ec omy a he di e en s udy cen e s. Figu e 1. Numbe o p ocedu es o each ype – o al, mean by cen e , and ange. Figu e 2. Dis ibu ion o as ing ime o solid and liquid die in he uni s ha esponded o he su ey. In malignan bilia y su ge y, 22.6 % o cen e s used TPN always, and 6 addi ional cen e s in 40-80 %. EN was used in 19.3 % o cen e s. Fi e cen e s used EN in 10-80 % o cases, and 7 cen e s used nei he EN no PN. The use o a i icial nu i ion in benign bilia y su ge y was much less equen . Almos 80 % o he esponding Uni s used EN o PN in < 20 % o hei cases. Only 3 cen e s used PN in 50 % o hei cases. DISCUSSION Conce ned by he low adhe ence o Spanish cen e s o he 2006 ESPEN guidelines on en e al nu i ion a e panc ea ic su - ge y in 2007, we decided o e iew his issue a decade la e . En- e al nu i ion guidelines emained unchanged (8), and pa en e al nu i ion guidelines a e su ge y we e published sho ly a e ou i s su ey was ca ied ou (9). The ESPEN guidelines on clinical nu i ion in su ge y published in 2017 (10) a e an upda e o hose wo and he he Ge man Socie y o Nu i ional Medicine (DGEM) Guideline “Clinical Nu i ion in Su ge y” o 2013, bu hey con ain no subs an ial di e ences wi h espec o he p e ious guidelines in ela ion o nu i ion in uppe gas oin es inal o panc ea ic su - ge y. They appea ed a he same ime we had ou su ey eadied, simila o wha happened in 2006. We sen ou ques ionnai e o 38 cen e s wi h known ac i i y in panc ea ic su ge y, and ob ained a high esponse a e (89.5 %). Panc ea ec omies 1002 • Mean 29.5 (5-68) Non-panc ea ic bilia y malignancies su ge y 305 • Mean 5.8 (2-30) Hepa icojejunos omies 344 • Mean 10.4 (2-33) 2 6 8 10 12 24 4 6 8 12 P eope a i e solid die as ing P eope a i e liquid as ing 241RESULTS OF A SURVEY ON PERI-OPERATIVE NUTRITIONAL SUPPORT IN PANCREATIC AND BILIARY SURGERY IN SPAIN [Nu Hosp 2020;37(2):238-242] As cen e s we e o di e en sizes, he e was g ea a iabili y in he numbe o p ocedu es pe o med, anging om 5 o 68 pan- c ea ec omies (head o o al-gland esec ions) in a yea (2017), bu wi h a signi ican median o 29.5 su ge ies. Su ge y o ma- lignan bilia y ee umo s in ol ed ewe pa ien s as expec ed, wi h numbe s anging om 2 o 30. Finally, p ocedu es o be- nign bilia y p oblems, i.e., bilia y-en e ic anas omoses in he li e ansplan a ion se ing, in ol ed a median o 10 cases/cen e /yea . Malnu i ion and/o signi ican weigh loss in panc ea ic and bilia y cance pa ien s is no unusual (27-74 %) (11-12). All hese pa ien s should be nu i ionally e alua ed (3), bu he e a e s ill many cen e s ha do no use nu i ional sc eening ou inely. In ou ecen su ey, less han 50 % o Uni s used any nu i ional sc eening ool. Acco dingly, only 41.2 % o he esponding g oups we e using nu i ional suppo be o e su ge y. The Espen Guidelines on En e al Nu i ion om 2006 (8) indi- ca ed EN e en in pa ien s wi hou ob ious unde nu i ion when i is an icipa ed ha he pa ien will be unable o ea o mo e han 7 days pe iope a i ely, and also in pa ien s who canno main- ain hei o al in ake abo e 60 % o he ecommended in ake o mo e han 10 days. A delay in su ge y o allow p eope a i e EN was ecommended o pa ien s a se e e nu i ional isk, de ined by he p esence o a leas one o he ollowing c i e ia: weigh loss > 10-15 % wi hin 6 mon hs, BMI < 18.5 kg/m2, Subjec i e Global Assessmen (SGA) G ade C, and se um albumin < 30 g/L (wi h no e idence o hepa ic o enal dys unc ion). The ISGPS (In e na ional S udy G oup on Panc ea ic Su ge y) posi ion pape (3) ecommends nu i ional suppo i one o he ollowing c i e ia is me (almos he same pa ame e s, bu con- side ing weigh loss only i > 15 % and adding he nu i ional isk sco e as an al e na i e o SGA): weigh loss > 15 % wi hin 6 mon hs, BMI < 18.5 kg/m2, SGA g ade C o nu i ional isk sco- e > 5, and se um albumin < 30 g/L (wi h no e idence o hepa ic o enal dys unc ion). As ega ds p eope a i e as ing, he e was g ea a iabili y in he du a ions epo ed by he esponding Uni s. Anes hesia socie y guidelines suppo he cu en use o 2 hou s as ing o liquids and 6 hou s as ing o solids (13-14), as he e is no e idence o a highe isk o aspi a ion when compa ed o adi ional, longe - ime schedules. We saw ha some su gical eams ollowed hese guidelines while o he s we e s ill using much longe as ing imes bo h o liquids and solids. The mos ecen ESPEN guidelines on clinical nu i ion in su ge y (10) s a e ha p eope a i e as ing om midnigh is unnecessa y in mos pa ien s wi h he highes g ade o ecommenda ion, as his had eached a e y s ong consensus among he au ho s (97 %). Pos ope a i e ea ly eeding is ano he issue ha has changed emendously in ecen yea s. The ESPEN 2017 guidelines e- commend o al in ake wi hin hou s in mos pa ien s (10). Recen me a-analyses showed signi ican bene i s in e ms o pos ope- a i e eco e y and in ec ion a es (15). The guidelines dealing wi h pe iope a i e ca e o panc ea icoduodenec omy, published by he ERAS Socie y (16), s a e ha mos pa ien s ole a e no - mal o al in ake soon a e elec i e panc ea icoduodenec omy, and ecommend allowing a no mal die a e su ge y wi hou esc ic- ions albei wi h cau ion, s a ing ca e ully and inc easing in ake acco ding o ole ance o e 3-4 days. Thei eccomenda ion is o use en e al ube eeding only o speci ic indica ions, and ha pa en e al nu i ion should no be employed ou inely. Bozze i and Ma iani challenge his poin o iew (16) a guing ha he e is a high p e alence o malnu i ion in pa ien s wi h panc ea ic cance , and he e is e idence ha many o hese pa ien s should be candida es o pe iope a i e nu i ional suppo acco ding o he ESPEN gui- delines. The e may be a gap be ween he ecommended and he e ec i e s a o eeding, and hough he ERAS guidelines discou- age he use o a nasogas ic/jejunal ube o o a needle-ca he e jejunos omy, hei use could p o e bene icial in pa ien s who a e ecognized a high isk o pos ope a i e complica ions. The 2006 ESPEN guidelines suppo he use o en e al supple- men a ion in hose pa ien s ha a e no able o co e a leas 60 % o hei ene gy equi emen s by he o al ou e. This can be done by ube o jejunos omy eeding, and each me hod has i s p os and cons. Ou su ey showed ha jejunos omy was used only in 3 cen e s and in 20-30 % o pa ien s, and ha he use o ube EN was highly a iable, only in one hi d o he esponding cen e s and in e y di e en pe cen ages o pa ien s. Mo e wo ying is he widesp ead use o pa en e al nu i ion. In mo e han one qua e o he g oups TPN was used o 100 % o cases. I was used o 0-20 % o cases in 50 % o he esponding cen e s, bu in mo e han 80 % o pa ien s in 10 cen e s. The 2009 ESPEN guidelines (9) ecommend i s p eope a i e use in malnou ished hospi alized pa ien s who canno be adequa ely ed ei he o ally o en e ally, and he use o pos ope a i e pa en e al nu i ion in pa ien s who canno mee hei calo ic equi emen s wi hin 7-10 days whe he o ally o en e ally. Pa ien s on pa en e al nu i ion need close moni o ing o educe he isk o h omboem- bolic, in ec ious, and me abolic complica ions (17). As o he use o TPN in malignan bilia y su ge y, he su ey showed ha mo e han 20 % o he g oups assessed we e using i always, and 6 mo e uni s used i in 40-80 % o hei cases. These esul s show a libe al use o pa en e al nu i ion in his subg oup o pa ien s as well, some hing ha goes in pa allel wi h he policy ollowed in panc ea ic su ge y. This could no be jus i ied by he use o he cu en guidelines, unless a high p opo ion o he pa- ien s in ol ed we e unde nou ished be o e su ge y, some hing unusual nowadays and imposible o demons a e by he na u e o a simple su ey wi hou labo a o y and in-dep h nu i ional as- sessmen da a. Con e sely, he use o en e al nu i ion was sca ce (less han 20 % o he esponding Uni s, hough in 5 cen e s i was used o 10-80 % o cases). The esul s ob ained abou he use o a i icial nu i ion in he se ing o benign bilia y su ge y a e di e en , as expec ed. This su ge y is usually simple and less equen ly ollowed by se e- e complica ions, which explains ha almos 80 % o he Uni s assessed used EN o PN in < 20 % o hei cases. Bu s ill, 3 o he cen e s we e using PN in 50 % o hei cases, some hing ha sounds ou o he o dina y, and should be a eason o policy e iew. Po en ial me hodological inconsis encies o his wo k may be ela- ed o he na u e o he s udy. I being a su ey ha was sen o mos 242 C. Loinaz e al. [Nu Hosp 2020;37(2):238-242] o he di e en Uni s ha pe o m panc ea ic and bilia y su ge y in Spain, wi hou an audi made a e wa ds, makes i possible ha some o he esul s ecei ed do no exac ly ep esen he eal expe ience o some o he wo king g oups. Howe e , pe sonal co mmunica ions and in e pe sonal knowdlege suppo mos o he esul s shown, in many cases un o una ely dis an om cu en ecommenda ions. This publica ion may also wo k as a s imulus o change. CONCLUSIONS TPN is he mos usual nu i ional suppo a e panc ea ic head su ge y in Spain. 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