Impact of nasojejunal, jejunostomy and parenteral feeding after pancreaticoduodenectomy
A Gerritsen1, MG Besselink1, KP Cieslak1, MR Vriens1, E Steenhagen2, R van Hillegersberg1,
IH Borel Rinkes1 and IQ Molenaar1
1Department
of Surgery, University Medical Center Utrecht, The Netherlands
2Department
of Dietetics, Julius Center for Health Sciences and Primary Care, University Medical
Center Utrecht, The Netherlands
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. The aim of this study
was to compare the efficacy and complications of routine feeding after PD by nasojejunal tube (NJT),
jejunostomy tube (JT) or total parenteral nutrition (TPN).
We performed a retrospective 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.
129 patients undergoing PD (111 pylorus preserving) were included. 44 patients (34%) received
enteral nutrition via NJT, 48 patients (37%) via JT and 37 patients (29%) received 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 JTgroup (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). In a multivariable logistic
regression analysis, adjusting for differences in age, gender, BMI, year of procedure and surgeon,
there was no difference between the three strategies in the rate of morbidity or mortality.
Conclusions None of the analysed feeding strategies was found superior with respect of 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.