Comparison of intraoperative versus delayed enteral feeding tube placement in patients undergoing a Whipple procedure

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.

Utility of gastrostomy tube placement at the time of pancreaticoduodenectomy

PURPOSE

The aim of this study is to investigate the utility of gastrostomy tube (G-tube) placement in reducing delayed gastric emptying (DGE) among patients undergoing pancreaticoduodenectomy (PD).

METHODS

We retrospectively reviewed consecutive patients undergoing PD from 2015 to 2020 at our institution. Thirty-day patient outcomes including DGE, length of stay (LOS), reoperation rates, and morbidity were analyzed in patients with or without G-tube placement.

RESULTS

128 patients with resectable pancreatic head cancer (54 females, median age 68.50 [59.00-74.00]) underwent PD (66 had G-tube placement and 62 did not). There was no significant difference in the incidence of DGE (n = 17 vs. n = 17, p = 0.612), and LOS between the groups. Postoperative ileus (p = 0.007) was significantly lower while atrial fibrillation (p = 0.037) was higher among the G-tube group. Gastrostomy-related complications (p = 0.001) developed in ten patients: skin-related complications (n = 6), tube dislodgement (n = 3) and clogging (n = 1). Nine patients required reoperation during index admission (n = 4 vs. n = 5, p = 1.000). There was no difference in 30-day readmissions (n = 7 vs. n = 5, p = 0.471) and no difference in 30 or 90-day mortality.

CONCLUSION

Gastrostomy tube placement during index PD did not affect the incidence of DGE. However, patients experienced significant morbidities due to G-tube-related complications. Placement of gastrostomy tubes at the index PD offers no clinical benefits.

Preoperative Hypoalbuminemia as a Predictor of Severe Postoperative Complications in Patients Undergoing Whipple Pancreatoduodenectomy

Background

Pancreaticoduodenectomy (PD) known as Whipple procedure is still one of the most complex abdominal surgeries used for treatment of periampullary tumors. PD is often followed with postoperative complications (pancreatic, biliar or intestinal fistula, haemorrhage, intraabdominal abscess, delayed gastric empting. Severe postoperative complications (SPC) can be reason for reoperation and reason of bad outcome of treatment and life treathening condition.

Objective

To investigate predicitive value of preoperative hypoalbuminemia for severe postoperative complications (SPC) in patients who have undergone Whipple pancreaticoduodenetomy (PD). However, no similiar study has been ever reported from our country until now.

Methods

In this retrospective-prospective study, 100 patients who have had Whipple pancreaticoduodenectomy for malignant periampullary tumors at the Department for Surgery of University Clinic Center Tuzla, Bosnia and Herzegovina were enrolled, from january of 2009 to decembre of 2021. All patients were preoperatively analysed according to serum albumine levels and presensce of hypolabuminemia (serum albumine levels <32g/l). Serum albumine biochemical test were done 1-2 days preoperatively. Clavien Dindo classification was used for determination patients with SPC. Patients who did not have SPC belonged to (I-II) Clavien Dindo group of patients while those who had SPC belonged to( III-V) Clavien Dindo group of patients.

Results

Out of 100 patients who have undergone pancreaticoduodenetomy, in 55 (55%) patients postoperative complications were noticed. Mortality rate was 18 (18%) and reoperation has been done in 20 cases (20%). SPC were noticed in 19 patients and most often were: delayed gastric emptying (20%), pancreatic fistula (13%) and intraabdominal collections (9%). Hypoalbuminemic patients had a significantly higher rate of severe postoperative complications ( p<0.05). Using hypoalbuminemia-SPC correlation analaysis, there is confirmed statistically significant correlation between hypoalbuminemia and SPC (ρ= 0.236; p<0.05).

Conclusion

Preoperative hypoalbuminemia can be used as predictor and prognostic factor for severe postoperative complications after Whipple pancreaticoduodenectomy. Identification and optimization of serum albumin level prior to Whipple pancreatoduodenectomy may improve surgical outcomes.

Replaced right hepatic artery passing anterior to pancreas: a rare and challenging anatomical variant during pancreaticoduodenectomy

Background

During pancreaticoduodenectomy proper dissection of local vessels is required. Normal coeliac and hepatic arterial anatomy can be found in only 50–70% of individuals. Good knowledge about aberrant vascular anatomies is necessary to avoid unnecessary complications.

Case presentation

An elderly gentleman presented to us with history of jaundice. Periampullary carcinoma with abnormal right and left hepatic artery morphology was discovered after a contrast enhanced computerized tomography scan.

Conclusion

Despite the anomalous origin and anterior course of replaced right hepatic artery, Classical pancreatoduodenectomy with preservation of replaced right hepatic artery and regional lymphadenectomy with no major intra and post-operative problems was conducted by superior mesenteric artery first approach. Prior to major hepato-pancreatobiliary surgery, a thorough examination of a contrast enhanced computerized tomography scan is required to understand vascular anatomy, recognize anomalous vessels, and understand their significance. Nevertheless, if the abnormal vessel anatomy like replaced right hepatic artery are identified during surgery, a careful dissection of the anomalous vessel is essential to identify all vascular relationships and avoid irreversible injury.

Development and validation of a nomogram for predicting post-operative abdominal infection in patients undergoing pancreaticoduodenectomy

AIM

The aim of this retrospective study is to develop and validate a predictive nomogram for predicting the risk of post-operative abdominal infection (PAI) in patients undergoing pancreaticoduodenectomy (PD).

METHODS

A total of 360 patients who underwent PD were enrolled into this research and randomly divided into the development and validation group. The clinical data of patients were statistically compared and the nomogram was constructed based on the results of multivariate logistic regression analysis and stepwise (stepAIC) selection. The nomogram was internally and crossly validated by the development and validation cohort. The discriminatory ability of the nomogram was estimated by AUC (Area Under the receiver operating characteristic Curve), calibration curve and decision curve analysis.

RESULTS

After PD, post-operative abdominal infection occurred in 33.89% (n = 122) of patients. The nomogram showed that preoperative biliary drainage and C-reactive protein (CRP), direct bilirubin (DB), alkaline phosphatase (AKP) levels on the 3rd postoperative day (POD3) were independent prognostic factors for abdominal infection after PD. The internal and cross validation of Receiver Operating Characteristic (ROC) curve was statistically significant (AUC = 0.723 and 0.786, respectively). The calibration curves showed good agreement between nomogram predictions and actual observations. The decision curves showed that the nomogram was of great clinical value.

CONCLUSION

A nomogram based on perioperative risk factors such as preoperative biliary drainage, CRP, DB and AKP could simply and accurately predict the risk degree of PAI in patients undergoing PD.

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.

Friend or foe? Feeding tube placement at the time of pancreatoduodenectomy: propensity score case-matched analysis

BACKGROUND

The role of concomitant gastrostomy or jejunostomy feeding tube (FT) placement during pancreatoduodenectomy (PD) and its impact on patient outcomes remain controversial.

METHODS

NSQIP database was surveyed for patients undergoing PD between 2014 and 2017. FT placement was identified using CPT codes. Propensity scores were used to match the two groups (1:1) on baseline characteristics and intraoperative variables including pancreas specific ones (duct size, gland texture, underlying disease, wound class, use of wound protector, drain placement, type of pancreatic reconstruction and vascular reconstruction). Outcomes were compared. Finally, a subset analyses for patients with delayed gastric emptying (DGE) or postoperative pancreatic fistula (POPF) were performed.

RESULTS

Out of 15,224 PD, 1,104 (7.5%) had FT. POPF and DGE rates were 17% and 18%, respectively, for the entire cohort. Feeding jejunostomy was the most placed FT (88.2%). Patients with FT placement were more likely to be older (mean, 65.8 vs. 64.6 y), smokers (22.6% vs. 17.8%) who had preoperative weight loss (22.5% vs. 15.3%), ASA class ≥ 3 (80.8% vs. 77.5%), preoperative transfusion (1.5% vs. 0.84%), chemotherapy (22.8% vs. 17.5%), and radiation (14.5% vs. 6.8%, p < 0.05). The matched cohort included 880 patients in each group with completely balanced preoperative and intraoperative characteristics. In the matched cohort, patients with FT placement had higher overall morbidity (52.2% vs. 44.3%, p = 0.001), major morbidity (28.4% vs. 22.5%, p = 0.004), organ/space infection (14.4% vs. 10.9%, p = 0.026), re-operation (8.6% vs. 5.1%, p = 0.003), DGE (26.8% vs. 16.4%, p < 0.001), and longer mean hospital length of stay (12.9 vs. 11.2 days, p = 0.001) than those without FT. There was no difference in mortality (1.7% vs. 2.2%, p = 0.488) or readmission rate (20.2% vs. 17.2%, p = 0.099). In patients with DGE and POPF, FT placement was not associated with morbidity, mortality, length of stay, or readmission rate (p > 0.05).

CONCLUSION

Patients with FT placement during PD tend to have higher postoperative morbidity and delayed recovery.

Impact of Vascular Anomalies on Pancreatoduodenectomy Procedure

Background

One of the critical steps during pancreatoduodenectomy (PD) procedure lies in identifying the complicated vascular anatomy of the resected area. The blood supply usually stems from branches of the celiac and the superior mesenteric arteries. However, only in 55-79% of surgeries, the anatomy of the blood vessels encountered by the surgeon is considered normal, while in the remaining cases, there are vascular variations that make these surgeries even more challenging. Any change or deviation from the known surgical course of PD makes surgery difficult and can result in an increase in intra/postoperative complications. In order to reduce difficulties encountered during PD, as well as reducing complication rates and improving surgical outcomes, a preliminary design, which includes preoperative identification of anatomical variations, is needed. The most accurate and accessible tool for identifying such variations is computed tomographic angiography (CTA). The aim of this retrospective study is to assess the prevalence of vascular anomalies encountered during PD, and examine whether there is an association between these anomalies and intra/postoperative morbidity and mortality.

Methods

A retrospective study over 5 years was performed at the HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel. The charts of all patients submitted to PD were reviewed, and all patients with vascular anomalies were included. The types of anatomical variant as well as other information were collected. For statistical purposes, the group of patients with vascular anomalies was compared to a control group with identical demographic characteristics. A statistical analysis on possible association between vascular anomalies and intra/postoperative complications (mainly bleeding) was performed.

Results

During the aforementioned period, 202 patients underwent PD, and in 41 (20.3%) vascular anomalies were identified. The majority of these patients (32/41) had single anatomical variant, where two and three anatomical variants were identified in seven and two patients, respectively. The most common vascular anomaly was replaced right hepatic artery, noticed in 34 patients (83%). The most common indication for PD for both groups (anatomical variant and control group) was pancreas adenocarcinoma (56%). Intraoperative complication, in the form of bleeding, developed in 6/41 patients (14.6%) of the anatomical variant group and none in the control group. Postoperative complication rates, including post- pancreatoduodenectomy hemorrhage (PPH), postoperative pancreatic fistula (POPF), intra-abdominal abscess and wound infection were almost identical for both groups. One case of death within 30 days occurred, and it was in the anatomical variant group.

Conclusions

Anatomical vascular anomalies are a common variant encountered during PD, with RRHA being the most common. Although postoperative morbidity and mortality are not affected by the presence of these anomalies, intraoperative bleeding rate is higher in this specific group, thus; a preoperative diagnosis by means of CTA is mandatory.

Postpancreatoduodenectomy Hemorrhage: Association between the Causes and the Severity of the Bleeding

Introduction

Of the complications following pancreatoduodenectomy (PD), postpancreatoduodenectomy hemorrhage (PPH) is the least common, but severe forms can be life-threatening without urgent treatment. While early PPH is mostly related to surgical hemostasis, late PPH is more likely due to complex physiopathological pathways secondary to different etiologies. The understanding of such etiologies could therefore be of great interest to help guide the treatment of severe, potentially life-threatening, late PPH cases.

Objective

The aim of this retrospective study was to assess the causes of PPH as a complication and explore a possible association between the causes and the severity of late PPH.

Methods

A retrospective study was performed at the HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel. The charts of all patients submitted for PD were reviewed, and all patients with PPH were included. The timing, cause, and severity of PPH as well as other information were collected. A statistical analysis on the possible association between cause and severity of late PPH was performed.

Results

A total of 347 patients underwent PD, 18 of whom (5.18%) developed PPH. Early PPH was reported in 1 patient (5.6%) with severe bleeding from the gastric staple line. Late PPH was reported in 17 patients (94.4%). The most common causes of late PPH were bleeding from a vascular pseudoaneurysm (PSA) reported in 6 patients, 1 with mild and 5 with severe hemorrhage, and bleeding from a gastroenteric anastomosis marginal ulcer reported in 6 patients, all with mild hemorrhage. No etiology was found in 5 patients with mild hemorrhage. A significant association was found between the severity of late hemorrhage and vascular PSA as the cause of the bleeding (p = 0.001). All PSA bleeding occurred in cases complicated by a postoperative pancreatic fistula (POPF), with a significant statistical association (p < 0.001).

Conclusions

The most common cause of PPH was bleeding from a vascular PSA; the majority of these cases involved severe bleeding with late presentation, and all were associated with a POPF formation. In such cases, early detection by computed tomography angiography is mandatory, thereby promoting urgent treatment by angiography of vascular bleeding complications following PD.

Pancreaticoduodenectomy: Outcomes of a complex surgical procedure from a developing country

BACKGROUND

Pancreaticoduodenectomy (PD) plays an integral part in the management of pancreatic, periampullary and duodenal cancers, along with a few other pathologies of this region. Despite advances in surgery PD continues to have significant morbidity and noteworthy mortality. The aim of this study is to provide an in-depth report on the patient characteristics, indications and the outcomes of PD) in a tertiary cancer hospital in Pakistan.

MATERIALS AND METHODS

The study population included patients who underwent PD between January 1, 2014 and march 31, 2019, at Shaukat Khanum Memorial Cancer Hospital and Research Center (SKMCH&RC) in Pakistan. The data was retrospectively analyzed from the Hospital Information System (HIS), which is a prospectively maintained patient electronic database of SKMCH&RC. Patient characteristics, procedural details and post-operative outcomes according to internationally accepted definitions were reported.

RESULTS

A total of 161 patients underwent PD at our hospital in the study period at a median age of 53 years, ranging from 19 to 78 years. 62% of the patients were males while 37% were females. Jaundice was the most common presenting symptom (64.6%), followed by abdominal pain (26.7%). PD with pancreaticogastrostomy was performed in 110 patients (68.3%), while pancreaticojejunostomy was performed in the rest of the cohort. Surgical site infection (SSI) was observed in 64 patients (40%). The incidence of Pancreatic Fistula grade C based on the International Study Group on Pancreatic Fistula (ISGPF) definition was 7.45% (n = 12). The 30 days mortality rate was 3.1%. Median survival of the cohort was 21 ±1.13 months and disease-free survival was 16±2.62 months.

CONCLUSION

PD can be performed with acceptable morbidity and mortality in a resource constrained country, as long as it is undertaken in a high-volume center. This is in keeping with data published from other well-reputed international centers.

Feeding patients with preoperative symptoms of gastric outlet obstruction after pancreatoduodenectomy: Early oral or routine nasojejunal tube feeding?

BACKGROUND

Early oral feeding is currently considered the optimal routine feeding strategy after pancreatoduodenectomy (PD). Some have suggested that patients with preoperative symptoms of gastric outlet obstruction (GOO) who undergo PD have such a high risk of developing delayed gastric emptying that these patients should rather receive routine postoperative tube feeding. The aim of this study was to determine whether clinical outcomes after PD in these patients differ between postoperative early oral feeding and routine tube feeding.

METHODS

We analyzed a consecutive multicenter cohort of patients with preoperative symptoms of GOO undergoing PD (2010-2013). Patients were categorized into two groups based on the applied postoperative feeding strategy (dependent on their center's routine strategy): early oral feeding or routine nasojejunal tube feeding.

RESULTS

Of 497 patients undergoing PD, 83 (17%) suffered from preoperative symptoms of GOO. 49 patients received early oral feeding and 29 patients received routine tube feeding. Time to resumption of adequate oral intake (primary outcome; 14 vs. 12 days, p = 0.61) did not differ between these two feeding strategies. Furthermore, overall complications and length of stay were similar in both groups. Of the patients receiving early oral feeding, 24 (49%) ultimately required postoperative tube feeding. In patients with an uncomplicated postoperative course, early oral feeding was associated with shorter time to adequate oral intake (8 vs. 12 days, p = 0.008) and shorter hospital stay (9 vs. 13 days, p < 0.001).

CONCLUSION

Also in patients with preoperative symptoms of GOO, early oral feeding can be considered the routine feeding strategy after PD.

Pancreatic cancer surgery and nutrition management: a review of the current literature

Surgery remains the only curative treatment for pancreaticobiliary tumors. These patients typically present in a malnourished state. Various screening tools have been employed to help with preoperative risk stratification. Examples include the subjective global assessment (SGA), malnutrition universal screening tool (MUST), and nutritional risk index (NRI). Adequate studies have not been performed to determine if perioperative interventions, based on nutrition risk assessment, result in less morbidity and mortality. The routine use of gastric decompression with nasogastric sump tubes may be unnecessary following elective pancreatic resections. Instead, placement should be selective and employed on a case-by-case basis. A wide variety of feeding modalities are available, oral nutrition being the most effective. Artificial nutrition may be provided by temporary nasal tube (nasogastric, nasojejunal, or combined nasogastrojejunal tube) or surgically placed tube [gastrostomy (GT), jejunostomy (JT), gastrojejunostomy tubes (GJT)], and intravenously (parenteral nutrition, PN). The optimal tube for enteral feeding cannot be determined based on current data. Each is associated with a specific set of complications. Dual lumen tubes may be useful in the presence of delayed gastric emptying (DGE) as the stomach may be decompressed while feeds are delivered to the jejunum. However, all feeding tubes placed in the small intestine, except direct jejunostomies, commonly dislodge and retroflex into the stomach. Jejunostomies are associated with less frequent, but more serious complications. These include intestinal torsion and bowel necrosis. PN is associated with septic, metabolic, and access-related complications and should be the feeding strategy of last-resort. Enteral feeds are clearly preferred over parental nutrition. A sound understanding of perioperative nutrition may improve patient outcomes. Patients undergoing pancreatic cancer surgery should undergo multidisciplinary nutrition screening and intervention, and the surgical/oncological team should include nutrition professionals in managing these patients in the perioperative period.

Feeding jejunostomy tube placement in patients undergoing pancreaticoduodenectomy: an ongoing dilemma

BACKGROUND

Concomitant placement of feeding jejunostomy tubes (FJT) during pancreaticoduodenectomy is common, yet there are limited data regarding catheter-specific morbidity and associated outcomes. This information is crucial to appropriately select patients for feeding tube placement and to optimize perioperative nutrition strategies.

METHODS

A review of all patients undergoing pancreaticoduodenectomy with FJT placement was completed. Patients were grouped by the occurrence of FJT-related morbidity. Multivariable logistic regression was performed to identify predictors of FJT morbidity; these complications were then further defined. Finally, associated postoperative outcomes were compared between groups.

RESULTS

In total, 126 patients were included, of which 18 (14 %) had complications directly related to their FJT, including pericatheter infection (n = 6), pneumatosis intestinalis (n = 4), severe tube feed intolerance (n = 3), and primary catheter malfunction (n = 7). Following adjustment with logistic regression, preoperative hypoalbuminemia was identified as the only independent predictor of FJT complications (OR 2.23, p = 0.035). Patients with FJT complications were more likely to be initiated on total parenteral nutrition (TPN; 55.6 vs. 7.4 %, p -0.035) and to require TPN at discharge (16.7 vs. 0%, p = 0.003). Correspondingly, these patients resumed an oral diet later (14 vs. 8 days, p = 0.06). Both reoperation (50.0 vs. 6.5%, p < 0.001) and readmission (50.0 vs. 22.4%, p = 0.041) rates were higher among patients with FJT complications.

CONCLUSIONS

FJT-related morbidity is common among patients undergoing pancreaticoduodenectomy and is associated with inferior outcomes and other performance metrics. Preoperative malnutrition appears to predict FJT complications, creating an ongoing dilemma regarding FJT placement. In the future, it will be important to better define criteria for FJT placement during pancreaticoduodenectomy.

A standardized care plan is associated with shorter hospital length of stay in patients undergoing pancreaticoduodenectomy

BACKGROUND

In this retrospective review, we evaluate a standardized care plan (SCP) for patients undergoing pancreaticoduodenectomy, which included selective placement of feeding jejunostomy tubes (FJTs) and a perioperative fast-track recovery pathway (FTRP).

METHODS

A review of 242 patients undergoing pancreaticoduodenectomy was completed. Patients treated pre- and post-SCP implementation were compared. Univariate comparison followed by multivariable linear regression were performed to identify predictors of hospital length of stay (HLOS).

RESULTS

SCP patients (n = 100) were slightly older but otherwise similar to pre-SCP patients (n = 142). FJT placement occurred less frequently in SCP patients (38 versus 94%, P < 0.001). All SCP patients were initiated on the FTRP. Among SCP patients, an oral diet was introduced earlier (5 versus 8.5 d, P < 0.001) and HLOS was shorter (11 versus 13 d, P = 0.015). Readmission rates were similar. Following adjustment with linear regression, we confirmed SCP status as a predictor of HLOS. To assess SCP components, HLOS was evaluated separately based on FTRP status and FJT placement. Although both were highly associated with HLOS, neither was independently predictive in multivariable analysis.

CONCLUSIONS

Implementation of an SCP resulted in shorter HLOS without an increase in readmissions. Future studies are necessary to identify specific components of SCPs that most influence outcomes.