Abstract
BackgroundEuropean nutritional guidelines recommend routine use of enteral feeding after pancreaticoduodenectomy (PD) whereas American guidelines do not. Data on the efficacy and, especially, complications of the various feeding strategies after PD are scarce. MethodsRetrospective monocenter cohort study in 144 consecutive patients who underwent PD during a period wherein the routine post-PD feeding strategy changed twice. Patients not receiving nutritional support (n=15) were excluded. Complications were graded according to the Clavien-Dindo classification and the International Study Group of Pancreatic Surgery (ISGPS) definitions. Analysis was by intention-to-treat. Primary endpoint was the time to resumption of normal oral intake. Results129 patients undergoing PD (111 pylorus preserving) were included. 44 patients (34%) received enteral nutrition via nasojejunal tube (NJT), 48 patients (37%) via jejunostomy tube (JT) and 37 patients (29%) received total parenteral nutrition (TPN). Groups were comparable with respect to baseline characteristics, Clavien ≥II complications (P=0.99), in-hospital stay (P=0.83) and mortality (P=0.21). There were no differences in time to resumption of normal oral intake (primary endpoint; NJT/JT/TPN: median 13, 16 and 14 days, P=0.15) and incidence of delayed gastric emptying (P=0.30). Duration of enteral nutrition was shorter in the NJT- compared to the JT- group (median 8 vs. 12 days, P=0.02). Tube related complications occurred mainly in the NJT-group (34% dislodgement). In the JT-group, relaparotomy was performed in three patients (6%) because of JT-leakage or strangulation leading to death in one patient (2%). Wound infections were most common in the TPN group (NJT/JT/TPN: 16%, 6% and 30%, P=0.02). ConclusionNone of the analysed feeding strategies was found superior with respect to time to resumption of normal oral intake, morbidity and mortality. Each strategy was associated with specific complications. Nasojejunal tubes dislodged in a third of patients, jejunostomy tubes caused few but potentially life-threatening bowel strangulation and TPN doubled the risk of infections.
Highlights
Pylorus-preserving pancreaticoduodenectomy (PD) is the treatment of choice formalignant neoplasms of the pancreatic head, ampulla, distal bile duct and duodenum.[1]
Of the 144 patients who had undergone a PD in the study period, 15 patients were excluded because they had no nutritional support (n09), received enteral nutrition via nasogastric tube (n04), underwent a modified surgical intervention or were transferred to another hospital (n01) leaving 129 patients eligible for further analysis
Baseline characteristics, including age, gender, body mass index (BMI), severe preoperative weight loss, indication for surgery, diagnosis, procedure and blood loss did not differ between the groups
Summary
Pylorus-preserving pancreaticoduodenectomy (PD) is the treatment of choice for (pre-)malignant neoplasms of the pancreatic head, ampulla, distal bile duct and duodenum.[1] PD is associated with a relatively high morbidity rate, including a high incidence of delayed gastric emptying.[2,3,4] The current guidelines of the European Society for Parenteral and Enteral Nutrition (ESPEN) recommend routine use of. Enteral and parenteral feeding after PD may be associated with complications, there are surprisingly little data available on this subject. European nutritional guidelines recommend routine use of enteral feeding after pancreaticoduodenectomy (PD) whereas American guidelines do not. Data on the efficacy and, especially, complications of the various feeding strategies after PD are scarce
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