title: Efficacy and complications of nasojejunal, jejunostomy and parenteral feeding after pancreaticoduodenectomy.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  129 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).
  
  
  CONCLUSIONS
  None 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.
authors.affiliation: Department of Surgery, University Medical Center Utrecht, HP G04.228, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands.
authors.forename: Arja
authors.initials: A
authors.lastname: Gerritsen
authors.forename: Marc G
authors.initials: MG
authors.lastname: Besselink
authors.forename: Kasia P
authors.initials: KP
authors.lastname: Cieslak
authors.forename: Menno R
authors.initials: MR
authors.lastname: Vriens
authors.forename: Elles
authors.initials: E
authors.lastname: Steenhagen
authors.forename: Richard
authors.initials: R
authors.lastname: van Hillegersberg
authors.forename: Inne H
authors.initials: IH
authors.lastname: Borel Rinkes
authors.forename: I Quintus
authors.initials: IQ
authors.lastname: Molenaar
mesh_terms: D000368:Aged; D005500:Follow-Up Studies; D006801:Humans; D007441:Intubation, Gastrointestinal / Q000009:adverse effects / Q000379:methods*; D007582:Jejunostomy / Q000009:adverse effects / Q000379:methods*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D016577:Pancreaticoduodenectomy; D010288:Parenteral Nutrition / Q000009:adverse effects / Q000379:methods*; D011182:Postoperative Care / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome