Pancreaticoduodenectomy For Pancreatic Cancer Research Articles

Total Superior Mesenteric Artery Nerve Plexus Preservation During Pancreaticoduodenectomy for Pancreatic Cancer.

Superior mesenteric artery (SMA) nerve plexus (PLsma) dissection has been performed to achieve R0 resection in pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) in high-volume centers. However, full-extent PLsma preservation in PD is employed in our institution. The feasibility of the PLsma preservation strategy was investigated. Between January 2010 and December 2020, 156 patients underwent PLsma preservation PD for PDAC at our institution. Of these, 118 patients had resectable PDAC (R group) and 38 patients had borderline resectable artery (BR-A group). Clinical and oncological outcomes focusing on local recurrence, patient prognoses, and morbidities (including postoperative refractory diarrhea) were retrospectively analyzed and our postoperative outcomes were compared with those of other institutions. Pathological R0 resection by PLsma preservation PD was achieved in 96 R group patients (81.4%) and 27 BR-A group patients (71.1%). The median postoperative hospital stay was 15.0days in both groups. Local site-only recurrence was observed in 10.2% (12/118) of R-group and 10.5% (4/38) of BR-A-group patients, whereas distant site-only recurrence occurred in 21.2% (25/118) of R-group and 28.9% (11/38) of BR-A-group patients. Median survival times were 64.3months (R group) and 35.4months (BR-A group, p = 0.07). Median disease-free survival (DFS) times were 31.0months (R group) and 12.0months (BR-A group). No diarrhea requiring opioids was observed in either group. These results were equal or superior to those of PLsma dissection PD in other institutions. PLsma preservation in PD was feasible compared to PLsma dissection in recurrence and overall survival.

Neoadjuvant chemotherapy associated with isotoxic high-dose stereotactic body radiotherapy does not increase postoperative complications after pancreaticoduodenectomy for nonmetastatic pancreatic cancer.

The role of radiotherapy in the therapeutic sequence of nonmetastatic pancreatic cancer (PC) is controversial, including isotoxic high-dose stereotactic body radiotherapy (iHD-SBRT). This study aimed to compare postoperative outcome of patients with nonmetastatic PC undergoing neoadjuvant treatment (NAT) including iHD-SBRT versus upfront pancreaticoduodenectomy (PD). All patients undergoing PD for PC from 2017 to 2021 were retrospectively analyzed, identifying patients receiving NAT with iHD-SBRT. Toxicity of treatments and postoperative outcome were assessed and analyzed in a propensity score-matched population. Eighty-nine patients underwent upfront surgery (surgery group) and 22 after NAT and iHD-SBRT (SBRT group). No major side effects SBRT-related were identified preoperatively. Postoperative morbidity was similar between groups. There was no postoperative death in SBRT group, and six in surgery group (p = 0.597). No difference was observed in the rates of complications related to pancreatic surgery. The postoperative hospital stay was shorter in SBRT versus surgery groups (p = 0.016). After propensity score matching, no significant difference in the postoperative morbidity was observed between groups. Incorporation of iHD-SBRT in the NAT sequence before PD for PC did not increase postoperative morbidity compared with upfront surgery. These results confirm the feasibility and safety of iHD-SBRT for the upcoming STEREOPAC trial.

Association between patient's age and the utility of prognostic markers after pancreaticoduodenectomy for pancreatic cancer

Background ＆ aimsOptimizing treatments balancing prognosis and therapeutic invasiveness is important in the management of pancreatic cancer (PC) owing to global ageing. This study aimed to verify the different utility of biomarkers by patients’ age. Materials ＆ methodsThis is a single-center, retrospective cohort analysis involving 160 patients who undertook pancreaticoduodenectomy (PD) for PC. After comparing clinicopathological factors and survival after PD between aged (≥70 y/o) and young (＜70 y/o) patients, we compared neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), controlling nutrition (CONUT) score, carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19–9 as well as clinicopathological factors between long and short survivors in each group. We also performed Kaplan-Meyer analysis between patients stratified by biomarkers. ResultsOverall survival (OS) was significantly worse in aged patients (p = 0.002). In aged patients, CEA was significantly higher in short survivors. In young patients, CONUT score and CA19-9 were higher in short survivors. Kaplan-Meyer analysis showed that NLR and CEA stratified OS in aged patients, whereas CONUT score and CA19-9 could stratify OS in young patients. ConclusionOur current results suggest that these biomarkers had different impact on survivals according to the patients’ age.

Postoperative Vertebral Bone Density Reduction after Pancreaticoduodenectomy for Pancreatic Cancer

Introduction: We can quantitatively estimate vertebral bone density by measuring Hounsfield (HU) units on CT images. Recently, it has been reported that reduction of vertebral bone density is associated with postoperative complications and oncologic outcomes. The aim of this study is to investigate clinical significances of vertebral bone density after pancreaticoduodenectomy (PD) for pancreas cancer.

Lymph Node Ratio Is a Reliable Prognostic Marker after Neoadjuvant Therapy and Pancreaticoduodenectomy for Pancreatic Cancer, but Does Not Predict the Utility of Adjuvant Therapy

Introduction: The role of additional adjuvant chemotherapy(AT) after neoadjuvant chemotherapy(NAT) and surgical resection for pancreatic ductal adenocarcinoma(PDAC) remains unclear. Lymph node ratio(LNR), defined as number of positive nodes divided by total resected nodes, is a well-established prognostic indicator for PDAC. The objective of this analysis was to determine if LNR predicts survival benefit attained from receipt of AT following NAT and resection. Methods: Patients who underwent pancreaticoduodenectomy after NAT from 2006-2017 with pathologically node-positive PDAC were identified using the National Cancer Database. Patients with metastatic disease or unknown lymph node status were excluded. Patients were grouped as receiving NAT plus AT, or NAT only. LNR within node-positive groups were compared with a cutoff of 0.15. Five-year overall survival was determined by Kaplan-Meier analysis and multivariate(MV) Cox proportional hazards modeling. Results: A total of 1,182 patients were included: 623 with LNR=0.1-0.14 and 559 with LNR>=0.15. Median survival was higher among LNR=0.1-0.14 than with LNR>=0.15(28.8 vs 20.5mos, log-rank p<.001). 606 patients received NAT plus AT, and 576 received NAT only. For patients with LNR=0.1-0.14, receipt of additional AT was associated with improved median survival of 33.9mos compared to 27.3mos(log-rank p=0.050). For LNR>=0.15, receipt of additional AT was associated with improved median survival of 23.3mos vs 18.2mos(log-rank p=0.0024). MV analysis revealed similar survival benefit from AT, with hazard ratios of 0.807(95%CI 0.678-0.960, p=0.0156) for LNR=0.1-0.14 and 0.79(95%CI 0.669-0.942, p=0.0084) for LNR>=0.15. Conclusion: Although LNR is a reliable prognostic indicator for PDAC, it does not predict the utility of AT after receipt of NAT.

Impact of Minimally Invasive Approach on the Attainment of a Textbook Oncologic Outcome Following Pancreaticoduodenectomy for Pancreatic Cancer

Introduction: Textbook oncologic outcome (TOO) is a composite outcome measure of short-term quality metrics following an oncologic operation. This study examined whether utilizing a minimally invasive approach increases the likelihood of attaining TOO. Methods: The 2010 – 2016 National Cancer Database was queried for patients with pancreatic adenocarcinoma who underwent PD. Patients were stratified into two groups: open pancreaticoduodenectomy (O – PD) and minimally invasive pancreaticoduodenectomy (MI – PD). Multivariable modeling was applied to compare outcomes while adjusting for patient/tumor characteristics. TOO was defined as having met five metrics previously established. Results: Of 13,863 patients identified, 87.4% underwent O – PD and 12.6% MI – PD. MI – PD patients were significantly more likely to have traveled farther for their care and to have been treated in an academic/research program. The MI – PD group had a significantly higher average number lymph node yield (p = 0.000) and were more likely to have received adjuvant chemotherapy (p = 0.018). A higher proportion of MI – PD patients met the following: adequate LAD, no prolonged LOS and no 30 – day readmission. 35.6 % of the MI – PD group achieved TOO compared to 28% of O – PD (p = 0.000). The MI – PD TOO group had significantly higher median OS compared to the O – PD TOO group. Adjusted regression models revealed MI – PD is significantly more likely to have no prolonged LOS, adequate LAD, and to have attained TOO. Conclusion: MI – PD significantly increases the likelihood of TOO. When achieved, MI – PD TOO is associated with a higher median OS.

Oncology Outcomes after Pancreaticoduodenectomy for Pancreatic Cancer by a Single HPB Surgeon in a High Volumen Centre in Bogota, Colombia

Background: Pancreaticoduodenectomy is a complex surgical procedure with acceptable mortality below 5 % and morbidity lower than 30%. Multidisciplinary team in a high-volume centre has been the key factor to increase quality and improve both surgical and oncology outcomes. Methods: Retrospective review of a prospective database was conducted. 130 consecutive pancreaticoduodenectomies (PD) were performed between 2014 and 2019. Socio-demographic characteristics, clinical and oncologic outcomes were evaluated. Results: 130 patients underwent PD between 2014 and 2019. Diabetes Mellitus was found in 20 % of cases. Average CA 19-9 was 440 UI/L. Median operative time average was 245 min. Post-operative length of stay was 11 days. Gastric reconstruction was done with Pancreato-jejunostomy in 110 patients and Pancreato-gastrostomy in 20 patients. Ductal Adenocarcinoma was found in 63.36%. Ampullary carcinoma was 24 %. POPF B:7 % y C:3.05%. DGE 6.85%. Mean lymph node ratio was 0,45 (SD 0,05). Lymph node 8A positive was found in 63,6 %. R0 and 3-year survival had positive Fisher correlation p <0,001. 50 % patients had survival after 20 months. Conclusion: High volume Centre and multidisciplinary team lead by a HPB surgeon is the most important factor to improve clinical and oncologic outcomes. Lymph node 8A has a significant impact on poor prognosis. Low length of stay, decrease surgical blood loss, and lower operative time were significant. Decrease mortality and better outcomes has been improving.PD has become a safe procedure to increase overall survival and disease-free survival.Mederi Hospital has become a referral centre with positive clinical and oncologic outcomes.

Micronutritional status after pylorus preserving duodenopancreatectomy: analysis of data from a randomized controlled trial

Physical frailty and nutritional malassimilation are often observed after pancreaticoduodenectomy for pancreatic cancer. But long-term data concerning the course of micronutrient status is still missing. Micronutrient status after pylorus preserving pancreaticoduodenectomy with a follow-up of 12 months was evaluated using data of a randomized controlled trial. 47 patients were randomized with respect to the physiotherapy regimen they received (intensified physiotherapy: n = 22; standard physiotherapy: n = 25). Nutritional status was recorded preoperatively and postoperatively after one week, 3, 6 and 12 months. BMI, body fat measurement and albumin, lipid, iron and bone metabolism parameters, vitamins A, B1 B6 and B12, homocysteine, folic acid, and trace elements were measured. Laboratory values were analyzed descriptively. Differences between the groups were analyzed using the t-test in SPSS. For vitamin D, B1, B6 and iron a deficiency over time could be demonstrated with 50% of all patients or more being below normal range. The other laboratory values were in low normal range after 3 months and later. Significant differences between groups were found in cholesterol, HDL and selenium levels (corrected p-values < 0.033 in all cases). Vitamin D and iron should be supplemented postoperatively in the long term, and vitamin B1 and B6 substitution should be considered in symptomatic patients. Levels of malnutrition induced fatigue should be comparable between both groups. However, the role of nutritional status on other health-related aspects such as quality of life should be the focus of further studies.Trial Registration Number in the German Registry for Clinical Studies: DRKS00006786; Date of Registration: 01.10.2014.

Peritoneal patch in vascular reconstruction during pancreaticoduodenectomy for pancreatic cancer: a single Centre experience

Background Concomitant venous resection during pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma with mesenterico-portal vein involvement is increasingly performed to achieve oncological resection. This study aims to report a single centre experience in peritoneal patch (PP) as autologous graft for vascular reconstruction (VR) during PD. Methods A retrospective analysis of all patients who underwent PD + VR with PP between December 2019 and September 2020 was performed, using a prospective collected database. Postoperative outcome and pathological margins were evaluated. Venous patency was assessed by computed tomography at day 7 and week 12 post surgery. Results Fifteen patients underwent PD + VR with PP reconstruction for pancreatic cancer, including one total pancreatectomy. VR consisted of lateral (n = 14) or tubular (n = 1) patch. The median PP length was 30 mm [26.3–33.8] and venous clamping time 30 min [27.5–39.0]. Computed tomography showed a patent VR in 93.3% and 53.3% after 7 days and 12 weeks, respectively; venous patency loss was always asymptomatic. The only postoperative VR-related complication was one mesenteric venous thrombosis. Five other patients experienced VR-unrelated complications: septic shock (n = 3), biliary fistula (n = 1) and post-traumatic subdural hematoma (n = 1). Mortality was nihil. At pathology, R0 resection (≥1 mm) was observed in 40.0% (6/15), venous margin was free in 46.7% (7/15), and venous wall was involved in 40.0% (6/15). Conclusions Use of PP as venous substitute during PD + VR is safe and feasible with an acceptable postoperative morbidity, and a decreased but asymptomatic venous patency after 12 weeks which should question the role of anticoagulation therapy.

Extraordinary first jejunal arterial variation associated with annular pancreas undergoing pancreaticoduodenectomy for pancreatic cancer: a case report

PurposeAnnular pancreas encountered in adults and jejunal arterial variations are rare. Anatomical variations can cause conflicts between oncology and surgical safety.MethodsCase report of a 68-year-old man suffering from vomiting because of an annular pancreas and a ductal adenocarcinoma of the pancreas head invading the second portion of the duodenum.ResultsContrast-enhanced computed tomography showed multiple arterial variations describing the absence of the coeliac trunk such that the left gastric artery (LGA), splenic artery and superior mesenteric artery (SMA) were arising separately from the aorta. The accessory left hepatic artery arose from the LGA; and both the common hepatic artery and combined trunk of the replaced right hepatic artery with the higher replaced first jejunal artery separately arose close to the root of the SMA. The patient underwent curative pancreaticoduodenectomy which achieved 3 years of recurrence-free survival.ConclusionThis was an extraordinary case of annular pancreas with first jejunal arterial variation detailing an embryological interpretation as well as considerations for balancing short- and long-term outcomes.

Role of Node Dissection in Pancreatic Tumor Resection.

Pancreatic cancer is a lethal disease, and, even with modern therapies, the mortality has not decreased significantly in decades. The prognostic importance of lymph node status is well defined; however, the role of extended lymphadenectomy to improve local recurrence and overall survival remains debated. Six randomized controlled trials have evaluated the extent of lymph node dissection in pancreaticoduodenectomy for pancreatic cancer. We sought to review the current literature to evaluate the role of lymphadenectomy in pancreatic cancer. The impact of each trial and its contribution to the literature is discussed. Multiple randomized trials have failed to note an improvement in overall survival with extended lymphadenectomy for pancreatic cancer. Rather, extended lymphadenectomy was associated with increased morbidity, operating room time, and length of stay.

Impact of minimally invasive approach on the attainment of a textbook oncologic outcome following pancreaticoduodenectomy for pancreatic cancer

Impact of minimally invasive approach on the attainment of a textbook oncologic outcome following pancreaticoduodenectomy for pancreatic cancer

Lymph node ratio is a reliable prognostic marker after neoadjuvant therapy and pancreaticoduodenectomy for pancreatic cancer, but does not predict the utility of adjuvant therapy

Presenter: Alexandra Adams MD, MPH | Brooke Army Medical Center Background: Neoadjuvant chemotherapy (NAT) has been increasingly utilized for patients with pancreatic ductal adenocarcinoma (PDAC). However, the role of additional adjuvant chemotherapy (AT) after NAT and surgical resection remains unclear. The lymph node ratio (LNR), defined as the number of positive nodes divided by total resected nodes, is a well-established prognostic indicator for patients with resected PDAC, and could potentially help decipher which patients could avoid AT after NAT. The objective of this analysis was to determine if LNR predicts survival benefit from receipt of AT following NAT and surgical resection. Methods: Patients who underwent pancreaticoduodenectomy after NAT from 2006-2017 and had pathologically node positive PDAC were identified using the National Cancer Database. Patients with metastatic disease or unknown lymph node status were excluded. Patients were grouped as receiving NAT plus AT, or NAT only. The LNR within the node-positive groups were compared, with a cutoff of 0.15. Five-year overall survival was determined by Kaplan-Meier analysis and multivariate (MV) Cox proportional hazards modeling. Results: A total of 1,182 patients were included: 623 patients with LNR=0.01-0.14 and 559 with LNR>=0.15. Median survival was higher among patients with LNR=0.01-0.14 than those with LNR>=0.15 (28.8 vs 20.5 months, log-rank p=0.15, receipt of additional AT was associated with improved median survival of 23.3 months vs 18.2 months without AT (log-rank p=0.0024). MV analysis by Cox proportional hazards revealed similar survival benefit from AT, with hazard ratios of 0.807 (95% CI 0.678-0.960, p=0.0156) for LNR=0.01-0.14 and 0.794 (95% CI 0.669-0.942, p=0.0084) for LNR>=0.15. Conclusion: Although LNR is a reliable prognostic indicator for PDAC, it does not predict the utility of AT after receipt of NAT. Thus, while LNR may be useful in counseling patients regarding prognosis, we advise against using it as a discriminator for decisions regarding adjuvant therapy. Further investigation is needed into the best selection criteria for patients that would benefit from additional AT after receipt of NAT and pancreaticoduodenectomy.

Oncology outcomes after pancreaticoduodenectomy for pancreatic cancer by a single HPB surgeon in a high volumen centre in Bogota, Colombia

Oncology outcomes after pancreaticoduodenectomy for pancreatic cancer by a single HPB surgeon in a high volumen centre in Bogota, Colombia

Precise anatomical resection based on structures of nerve and fibrous tissue around the superior mesenteric artery for mesopancreas dissection in pancreaticoduodenectomy for pancreatic cancer

Precise anatomical resection based on structures of nerve and fibrous tissue around the superior mesenteric artery for mesopancreas dissection in pancreaticoduodenectomy for pancreatic cancer

Long-term survival of two patients with pancreatic cancer after resection of liver and lung oligometastases: a case report

BackgroundThe efficacy of resection of pancreatic cancer metastases has not been established. We here report two patients with long-term survival after resection of lung and liver metastases.Case presentationThe first patient underwent distal pancreatectomy for pancreatic cancer. One year later, she underwent partial hepatectomy for a single liver metastasis. She subsequently underwent pulmonary resections 7, 7.5, 9, and 10 years later for pulmonary metastases from pancreatic cancer. Thus, this patient underwent five surgeries for metastases, one for a liver metastasis and four for lung metastases. All of the tumors were pathologically diagnosed as metastatic pancreatic cancer. She is currently alive without new recurrence 10 years after the initial diagnosis. The second patient underwent pancreaticoduodenectomy for pancreatic cancer. Four years later, she underwent a thoracoscopic partial resection for lung metastasis. The tumor was similar to the pancreatic cancer on pathological examination. She is currently alive without new recurrences 6 years after the initial diagnosis.ConclusionLong-term survival can be achieved in some patients with pancreatic cancer by resection of metachronous liver or lung metastases.

Precise anatomical resection based on structures of nerve and fibrous tissue around the superior mesenteric artery for mesopancreas dissection in pancreaticoduodenectomy for pancreatic cancer.

The aim of the present study was to investigate the feasibility of resection based on the nerve and fibrous tissue (NFT) structures around the superior mesenteric artery (SMA) for resectable pancreatic adenocarcinoma (R-PDAC) patients. NFTs around the SMA were classified into four "intensive NTFs area" with spreading the NFTs around the SMA and three SMA nerve plexus regions without branching nerves according to autopsy findings. Complete dissection of four "intensive NTFs areas" was performed by pre-exposing three SMA nerve plexus regions without branching nerves as "dissection-guiding points" with SMA nerve plexus preservation (NFT-based resection). Among 157 R-PDAC patients undergoing pancreaticoduodenectomy, surgical outcomes of 78 patients with NFT-based resection were compared with 59 patients with half-SMA nerve plexus dissection and 20 patients without NFTs dissection. In the NFT-based resection group, 76.5% had tumor involvement and metastasis in each intensive NTFs area. Operative time, blood loss, and postoperative diarrhea rate were significantly lower in NFT-based resection than in half-SMA nerve plexus group (321 vs 390min; P<.01, 228 vs 550mL; P<.01, 5.1% vs 15.3%; P=.04, respectively). R0 rate and median overall survival significantly improved in NFT-based resection than in non-NFT dissection group (93.6% vs 65.0%; P<.01, 49.6 vs 23.6months, P=.01). NFT-based resection may become a novel method for R-PDAC patients.

Short-term clinical outcomes of enteral nutrition versus parenteral nutrition after surgery for pancreatic cancer: a meta-analysis

Background: The short-term clinical outcomes between early enteral nutrition (EEN) and total parenteral nutrition (TPN) after pancreaticoduodenectomy (PD) for pancreatic cancer were not clear. Methods: We searched the PubMed, Embase, Web of Science, Chinese National Knowledge Infrastructure (CNKI) and Wanfang databases to identify randomized controlled studies comparing EEN and TPN after PD for pancreatic cancer. Then a meta-analysis was conducted. Results: Seven studies with 486 patients were included in the analysis. After surgery, patients in EEN group had higher level of plasma total protein (TP) [weighted mean difference (WMD): 1.83, 95% confidence interval (CI): 0.33–3.32, P=0.02], while the albumin (ALB) level was similar between the two groups (WMD: 0.25, 95% CI: –4.07–4.56, P=0.91). As for the bowel function, EEN group had shorter exhaust time (WMD: –0.66, 95% CI: –0.81 to –0.51, P Conclusions: Compared to TPN, EEN showed better outcomes in improving the nutritional status and bowel function as well as decreasing complication rate and hospital stay after PD in patients with pancreatic cancer.

Treatment of bleeding from a portion of pancreatojejunostomy after pancreaticoduodenectomy with division of the splenic vein: two case reports

BackgroundThere is no definitive strategy for gastrointestinal bleeding due to left-sided portal hypertension after pancreaticoduodenectomy (PD) for pancreatic cancer (PC) with concomitant portal vein resection (PVR).Case presentationCase 1: A 70-year-old woman underwent a PD for PC with PVR. Seven years after her surgery, she suffered severe anemia with suspected gastrointestinal bleeding. Computed tomography scan (CT) revealed varices at a portion of the pancreaticojejunostomy (PJ). Angiography revealed that splenic venous flow drained into the varices and then into the portal vein. A diagnosis of bleeding varices of the PJ due to left-sided portal hypertension was made. Following a partial splenic artery embolization, her anemia improved.Case 2: An 80-year-old male underwent a PD for pancreatic head cancer combined with resection of the confluence of the portal and splenic veins with a reconstruction between the portal and superior mesenteric veins. Eighteen months after his surgery, he developed melena with negative endoscopy findings in his large and small bowel. CT revealed varices at the site of the PJ that communicated with the jejunal and portal veins. He underwent obliteration of the varices via a trans-portal-venous approach. As a result, he remained without melena until he died of PC 17 months after the embolization.ConclusionsLeft-sided portal hypertension following a PD with bleeding varices can be treated by interventional radiology with minimal invasiveness.

Short-term clinical outcomes of enteral nutrition versus parenteral nutrition after surgery for pancreatic cancer: a meta-analysis.

BackgroundThe short-term clinical outcomes between early enteral nutrition (EEN) and total parenteral nutrition (TPN) after pancreaticoduodenectomy (PD) for pancreatic cancer were not clear.MethodsWe searched the PubMed, Embase, Web of Science, Chinese National Knowledge Infrastructure (CNKI) and Wanfang databases to identify randomized controlled studies comparing EEN and TPN after PD for pancreatic cancer. Then a meta-analysis was conducted.ResultsSeven studies with 486 patients were included in the analysis. After surgery, patients in EEN group had higher level of plasma total protein (TP) [weighted mean difference (WMD): 1.83, 95% confidence interval (CI): 0.33–3.32, P=0.02], while the albumin (ALB) level was similar between the two groups (WMD: 0.25, 95% CI: –4.07–4.56, P=0.91). As for the bowel function, EEN group had shorter exhaust time (WMD: –0.66, 95% CI: –0.81 to –0.51, P<0.001) and bowel movement time (WMD: –2.27, 95% CI: –2.61 to –1.94, P<0.001) than TPN group. EEN group also had lower short-term total complication rate [relative risk (RR): 0.68, 95% CI: 0.51–0.92, P=0.01] and postoperative hemorrhage rate (RR: 0.22, 95% CI: 0.06–0.75, P=0.02), while there was no significant difference in infection rate (RR: 0.68, 95% CI: 0.38–1.22, P=0.20), pancreatic fistula rate (RR: 0.63, 95% CI: 0.35–1.16, P=0.14) and delayed gastric emptying (DGE) rate (RR: 0.72, 95% CI: 0.39–1.33, P=0.29) between the groups. In addition, EEN group had shorter hospital stay (WMD: –1.53, 95% CI: –2.12 to –0.94, P<0.001).ConclusionsCompared to TPN, EEN showed better outcomes in improving the nutritional status and bowel function as well as decreasing complication rate and hospital stay after PD in patients with pancreatic cancer.