Utility of feeding jejunostomy tubes in pancreaticoduodenectomy

Reduction of Postoperative Complications in Pancreatic Surgery by Standardizing Perioperative Management: An Observational Cohort Study

Introduction

Resection for pancreatic malignancy remains the gold standard for cure. Postoperative morbidity continues to be high even after technical innovations. This study evaluates the effectiveness of a standard perioperative pancreatic oncological surgery step-by-step protocol in reducing organ-specific complications.

Methods

In this observational cohort study, we analyzed the outcomes of oncologic pancreatic head resections from 2015 to 2022 after the implementation of a standard perioperative fail-safe protocol and compared these data with a historical cohort (2013-2014). In the study group, all patients were treated with preoperative limited mechanical bowel preparation, administration of a somatostatin analog, and a "pancreatic duct tube" in pancreatoduodenectomy. The primary outcome measure was the occurrence of postoperative organ-specific complications.

Results

A total of 151 patients were included in this study. The rate of postoperative pancreatic fistula (grade B and C) in the fail-safe group was 4.2%. Other organ-specific complications as postoperative hemorrhage (2.5%) and delayed gastric emptying (9.2%) also occurred less frequent than before implementation of the fail-safe protocol.

Conclusion

The use of this standardized fail-safe protocol for oncologic pancreatoduodenectomy can lead to a low postoperative morbidity with improved surgical outcomes.

Re-assessing the role of peri-operative nutritional therapy in patients with pancreatic cancer undergoing surgery: a narrative review

Pancreatic cancer is the most common medical condition that requires pancreatic resection. Over the last three decades, significant improvements have been made in the conditions and procedures related to pancreatic surgery, resulting in mortality rates lower than 5%. However, it is important to note that the morbidity in pancreatic surgery remains r latively high, with a percentage range of 30-60%. Pre-operative malnutrition is considered to be an independent risk factor for post-operative complications in pancreatic surgery, such as impaired wound healing, higher infection rates, prolonged hospital stay, hospital readmission, poor prognosis, and increased morbidity and mortality. Regarding the post-operative period, it is crucial to provide the best possible management of gastrointestinal dysfunction and to handle the consequences of alterations in food digestion and nutrient absorption for those undergoing pancreatic surgery. The European Society for Clinical Nutrition and Metabolism (ESPEN) suggests that early oral feeding should be the preferred way to initiate nourishing surgical patients as it is associated with lower rates of complications. However, there is ongoing debate about the optimal post-operative feeding approach. Several studies have shown that enteral nutrition is associated with a shorter time to recovery, superior clinical outcomes and biomarkers. On the other hand, recent data suggest that nutritional goals are better achieved with parenteral feeding, either exclusively or as a supplement. The current review highlights recommendations from existing evidence, including nutritional screening and assessment and pre/post-operative nutrition support fundamentals to improve patient outcomes. Key areas for improvement and opportunities to enhance guideline implementation are also highlighted.

Postoperative nutrition in the setting of enhanced recovery programmes

Patients undergoing major surgery for gastrointestinal cancer are at high risk of developing or worsening malnutrition and sarcopenia. In malnourished patients, preoperative nutritional support may not be sufficient and so postoperative support is advised. This narrative review addresses several aspects of postoperative nutritional care in the setting of enhanced recovery programmes. Early oral feeding, therapeutic diet, oral nutritional supplements, immunonutrition, and probiotics are discussed. When postoperative intake is insufficient, nutritional support favouring the enteral route is recommended. Whether this approach should use a nasojejunal tube or jejunostomy is still a matter of debate. In the setting of enhanced recovery programmes with early discharge, nutritional follow-up and care should be continued beyond the short time in hospital. In enhanced recovery programmes, the main specific aspects of nutrition are patient education, early oral intake, and post-discharge care. The other aspects do not differ from conventional care.

Impact of Early Enteral Nutrition on Delayed Gastric Emptying and Nutritional Status After Pancreaticoduodenectomy

BACKGROUND

Although early enteral nutrition (EEN) is an accepted practice after pancreaticoduodenectomy (PD), the impact of EEN on postoperative complications or nutritional status remains unclear. We aimed to investigate the impact of EEN on delayed gastric emptying (DGE) and nutritional status after PD.

METHODS

A total of 143 patients underwent PD between January 2012 and September 2020. We excluded patients who underwent a two-stage pancreatojejunostomy, in whom the enteral tube was accidentally pulled out, or with insufficient information in their medical records. The incidence of postoperative complications was compared between patients who received EEN (EEN group, n = 21) and those who did not (control group, n = 21) after propensity score matching. Univariate and multivariate analyses were performed to identify the risk factors affecting the incidence of these complications. Nutritional status was assessed at postoperative months 1, 3, and 6.

RESULTS

The incidence of grade B/C DGE in the EEN group was significantly lower than that in the control group (4.8% vs. 28.6%, p = 0.03). There was no significant difference in overall morbidity, incidence of any other postoperative complications, or all-grade DGE. In multivariate analysis, EEN was associated with a reduction in the incidence of grade B/C DGE (p < 0.01). In the analysis of nutritional status, EEN was significantly associated with better nutritional status at postoperative month 1.

CONCLUSION

EEN can lead to a lower clinically relevant DGE rate and better nutritional status in the early postoperative period in patients undergoing PD.

Strategies and tactics to perform safe pancreaticoduodenectomy for 94-year-old patient: report of a case

Background

Despite improvement of postoperative management, pancreatoduodenectomy still has a high rate of major complications. Therefore, careful assessment is critically important when we consider high risk surgery for extremely elderly patients.

Case presentation

A 94-year-old man, who suffered dark urine, epigastric pain, and loss of appetite, was diagnosed as bile duct cancer and underwent endoscopic retrograde biliary drainage. He has past history of hypertension and paroxysmal atrial fibrillation. Computed tomography (CT) showed a nodule in the lower bile duct, which was slowly enhanced by dynamic CT. The patient was evaluated whether he overcomes pancreatoduodenectomy by cardiac ultrasonography, brain magnetic resonance angiography, nutritional evaluation (rapid turnover proteins), and CT-based general assessment, including sarcopenia and osteopenia. The patient was independent in activities of daily living and has enough ejection fraction of 65%, and examinations revealed no impairment of cognitive function, sarcopenia, and osteopenia. With a diagnosis of bile duct cancer with no distant metastasis, the patient underwent subtotal stomach-preserving pancreatoduodenectomy with lymph node dissection. Operation time was 299 min and estimated blood loss was 100 ml. Pathological examination revealed papillary adenocarcinoma of the bile duct (pT3N1M0 Stage IIIB). Enteral nutrition was given through jejunostomy and then the patient started oral intake after an evaluation of swallowing function. Postoperative course was uneventful and all drains including pancreatic duct stent, biliary stent, and jejunostomy were removed by 3 weeks after operation. The levels of rapid turnover proteins dropped at postoperative day 7, but recovered at 1 month after operation via appropriate nutrition and rehabilitation. He remains well with no evidence of tumor recurrence as of 1 year after resection.

Conclusions

We herein report successfully treated cases of bile duct cancer in 94-year-old patient by pancreatoduodenectomy with careful evaluation of osteopenia, sarcopenia and nutrition.

The PrEDICT-DGE score as a simple preoperative screening tool identifies patients at increased risk for delayed gastric emptying after pancreaticoduodenectomy

BACKGROUND

Morbidity after Pancreaticoduodenectomy (PD) has remained unchanged over the past decade. Delayed Gastric Emptying (DGE) is a major contributor with significant impact on healthcare-costs, quality of life and, for malignancies, even survival. We sought to develop a scoring system to aid in easy preoperative identification of patients at risk for DGE.

METHODS

The ACS-NSQIP dataset from 2014 to 2018 was queried for patients undergoing PD with Whipple or pylorus preserving reconstruction. 15,154 patients were analyzed using multivariable logistic regression to identify risk factors for DGE, which were incorporated into a prediction model. Subgroup analysis of patients without SSI or fistula (primary DGE) was performed.

RESULTS

We identified 9 factors independently associated with DGE to compile the PrEDICT-DGE score: Procedures (Concurrent adhesiolysis, feeding jejunostomy, vascular reconstruction with vein graft), Elderly (Age>70), Ductal stent (Lack of biliary stent), Invagination (Pancreatic reconstruction technique), COPD, Tobacco use, Disease, systemic (ASA>2), Gender (Male) and Erythrocytes (preoperative RBC-transfusion). PrEDICT-DGE scoring strongly correlated with actual DGE rates (R² = 0.95) and predicted patients at low, intermediate, and high risk. Subgroup analysis of patients with primary DGE, retained all predictive factors, except for age>70 (p = 0.07) and ASA(p = 0.30).

CONCLUSION

PrEDICT-DGE scoring accurately identifies patients at high risk for DGE and can help guide perioperative management.

Can we predict the need for nutritional support following pancreatoduodenectomy?

BACKGROUND

The practice of routine placement of a tube jejunostomy at the time of pancreatoduodenectomy has given way to a more selective approach. However, the indications of establishing enteral access at the time of surgery remain poorly defined. This study aimed to assess the preoperative and intraoperative factors associated with the need for nutritional support after pancreatoduodenectomy, to guide decision-making for the establishment of intraoperative feeding access.

METHODS

Retrospective study, analyzing the data of 562 consecutive patients, who underwent pancreatoduodenectomy between March 2013 to December 2020. Univariate and multiple logistic regression analysis was carried out to ascertain the factors associated with the initiation of and need for nutritional support for more than 7 days postop. The utility of tube jejunostomy was studied in patients in whom it was performed.

RESULTS

Of 562 patients, 105 (18.7%) needed nutritional support. A tube jejunostomy was performed in 46 (8.2%) patients, parenteral nutrition was used in 83 (14.8%), and nasojejunal tube placed in 28 (4.9%) patients. On logistic regression analysis, age, serum albumin <3.0 gm/dl and operative blood loss were independently associated with the initiation of supportive nutrition, while preoperative gastric outlet obstruction (OR 3.105, 95% CI1.201-8.032, p = 0.019) and serum albumin <3.0 gm/dl (OR 2.669, 95% CI 1.131-6.300, p = 0.025) were associated with the need for prolonged nutritional support. The maximal benefit of tube jejunostomy was in patients with mental health disorders (83.3%).

CONCLUSION

Tube jejunostomy for nutritional support after pancreatoduodenectomy can be considered in patients with preoperative gastric outlet obstruction, serum albumin <3.0 gm/dl and mental health disorders.

Oligomeric Formulas in Surgery: A Delphi and Consensus Study

Nutritional management of patients with intestinal failure often includes the use of oligomeric formulas. Implementing the use of oligomeric formulas in surgical patients with maldigestion or malabsorption could be a nutritional strategy to be included in clinical protocols. We aim to generate knowledge from a survey focused on the effectiveness of nutritional therapy with oligomeric formulas with Delphi methodology. Each statement that reached an agreement consensus among participants was defined as a median consensus score ≥7 and as an interquartile range ≤3. The use of oligomeric formulas in surgical patients, starting enteral nutrition in the post-operative phase in short bowel syndrome and in nonspecific diarrhea after surgical procedures, could improve nutritional therapy implementation. Stakeholders agreed that early jejunal enteral nutrition with oligomeric formula is more effective compared to intravenous fluid therapy and it is useful in patients undergoing upper gastro-intestinal tract major surgery when malabsorption or maldigestion is suspected. Finally, oligomeric formulas may be useful when a feeding tube is placed distally to the duodenum. This study shows a practical approach to the use of oligomeric formulas in surgical patients with intestinal disorders and malabsorption, and it helps clinicians in the decision-making process.

Percutaneous Gastrojejunostomy Tube Insertion in Patients with Surgical Gastrojejunal Anastomoses: Analysis of Success Rates and Durability

Patients with a gastrojejunal anastomosis pose challenging anatomy for percutaneous gastrojejunostomy (GJ)-tube placement. A retrospective review of 24 patients (mean age 67.8 years, 13 males) with GJ anastomoses who underwent attempted GJ tube placement revealed infeasible placement in 6 patients (25%) due to an inadequate window for puncture. When a gastric puncture was achieved, GJ tube insertion was technically successful in 83% (15/18) of attempts, resulting in an overall technical success rate of 63% (15/24). The most common tube-related complication was the migration of the jejunal limb into the stomach, which occurred in 40% (6/15) of successful cases. No major procedure related complications were encountered.

Pancreatectomy, Islet Cell Transplantation, and Nutrition Considerations

Pancreatic islet transplantation is a reliable approach for treating insulin-deficient diabetes. This established β-cell replacement approach has shown considerable improvements in the last 2 decades. It has helped achieve metabolic homeostasis and safe outcomes for a subset of patients with type 1 diabetes and severe pancreatitis. Nutrition support, until recently, was considered as a secondary factor, merely identified as a means of providing all the necessary nutrients for such patients. However, new literature suggests that several factors, such as the route, timing, quantity, and composition of all the nutrients administered, have key disease-altering properties and are vital during the perioperative management of such patients. This review will highlight the benefits of performing the clinical islet transplantation on a subgroup of patients with type 1 diabetes and pancreatitis and summarize new data that identify the pivotal role of nutrition support as a critical intervention in their management.

Effect of home enteral nutrition after pancreaticoduodenectomy

OBJECTIVES

Providing home enteral nutrition (HEN) might prevent further deterioration of nutritional status and reduce complication risk after very invasive abdominal surgery. The aim of this study was to assess the effect of HEN after pancreaticoduodenectomy (PD).

METHODS

Between January 2013 and July 2016, 150 consecutive patients underwent PD. All patients received postoperative enteral nutrition until discharge. HEN (400 or 800 kcal/d) was introduced in March 2015 for patients with reduced food intake (daily, <15 kcal/kg ideal body weight) at discharge (HEN group). Patients with low intake at discharge treated before March 2015 were considered historical controls (non-HEN group). All patients received postoperative enteral nutrition until discharge. Primary outcomes measures included morbidity rate and nutritional status including body weight and blood examination from discharge until postoperative day (POD) 90.

RESULTS

The HEN and non-HEN groups included 24 and 39 patients, respectively. HEN was provided for a median of 68 d (range, 21-90 d) and two patients (8.4%) developed tube obstruction during HEN. The HEN group showed significantly lower rate of morbidity of Clavien-Dindo grade II from discharge to POD 90 or higher (4 of 24, 16.7% versus 17 of 39, 46.1%; P = 0.031) and significantly higher rate of increase in body weight (median: 4.9% versus -4%; P = 0.003), serum albumin levels on POD 90 (median: 3.8 versus 3.5 g/dL; P = 0.020), and prognostic nutritional index (median: 48.5 versus 42.5; P = 0.012). Multivariate logistic analysis demonstrated that body weight at discharge (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.53-0.97) and not receiving HEN (OR, 3.86; 95% CI, 1.81-15.2) were prognostic factors for morbidity after discharge.

CONCLUSION

HEN is safe and may reduce postdischarge morbidity and improve nutritional status after PD.

Discharge destination following pancreaticoduodenectomy: A NSQIP analysis of predictive factors and post-discharge outcomes

INTRODUCTION

Pancreaticoduodenectomy is a complex surgical procedure. The purpose of this study was to identify factors associated non-home discharge destination and to characterize outcomes after non-home discharge.

METHODS

10,719 pancreaticoduodenectomy cases contained in the National Surgical Quality Improvement Program (NSQIP) Targeted Pancreatectomy dataset (years 2014-2016) were examined with univariate and multivariate logistic regression.

RESULTS

1336 patients (12.5%) were discharged to rehabilitation, skilled care, or acute care facilities. Preoperative factors significantly associated with non-home discharge on multivariate analysis were female gender, older age, elevated BMI, poor functional status or dyspnea, smoking, low albumin, COPD, and ascites. Intraoperative factors significantly associated with non-home discharge destination on multivariate analysis were longer operative time, open surgery, softer pancreatic texture, drain placement, and jejunostomy tube placement. A nomogram was generated for estimating probability of non-home discharge immediately after surgery.

CONCLUSION

Preoperative and intraoperative factors can be used to predict probability of non-home discharge immediately after completion of pancreaticoduodenectomy.

Delayed gastric emptying following pancreatoduodenectomy with alimentary reconstruction according to Roux-en-Y or Billroth-II

Background

Delayed gastric emptying (DGE) remains the most frequent complication following pancreatoduodenectomy (PD) with published incidences as high as 61%. The present study investigates the impact of bowel reconstruction techniques on DGE following classic PD (Whipple-Kausch procedure) with pancreatogastrostomy (PG).

Methods

We included 168 consecutive patients who underwent PD with PG with either Billroth II type (BII, n = 78) or Roux-en-Y type reconstruction (ReY, n = 90) between 2004 and 2015. Excluded were patients with conventional single loop reconstruction after pylorus preserving procedures. DGE was classified according to the 2007 International Study Group of Pancreatic Surgery definition. Patients were analyzed regarding severity of DGE, morbidity and mortality, length of hospital stay and demographic factors.

Results

No difference was observed between BII and ReY regarding frequency of DGE. Overall rate for clinically relevant DGE was 30% (ReY) and 26% (BII). BII and ReY did not differ in terms of demographics, morbidity or mortality. DGE significantly prolongs ICU (four vs. two days) and hospital stay (20.5 vs. 14.5 days). Risk factors for DGE development are advanced age, retrocolic reconstruction, postoperative hemorrhage and major complications.

Conclusions

The occurrence of DGE can not be influenced by the type of alimentary reconstruction (ReY vs. BII) following classic PD with PG. Old age and major complications could be identified as important risk factors in multivariate analysis.

Trial registration

German Clinical Trials Register (DRKS) DRKS00011860. Registered 14 March 2017.