Early Supplemental Enteral Nutrition After Pancreatoduodenectomy

Key Takeaways

• Early supplemental enteral nutrition was associated with a lower 90-day overall complication burden than oral nutrition alone in nutritionally at-risk patients.
• Overall morbidity and several individual pancreatic surgery complications did not differ significantly, while infectious and pulmonary complications were less frequent with enteral nutrition.
• Tube dislodgement and replacement were the main feeding-related issues, and the enteral approach was described as well tolerated in patients with Nutritional Risk Screening scores of 3 or higher.

In nutritionally at-risk patients undergoing pancreatoduodenectomy, early supplemental enteral nutrition via nasojejunal tube plus oral nutrition was associated with a lower 90-day complication burden than oral nutrition alone. Mean 90-day comprehensive complication index was 25.5 with enteral support and 35.8 with oral nutrition alone, a 10.3-point difference (95% CI, 1.8-18.8; P=.02). The randomized comparison included patients with a preoperative Nutritional Risk Screening score of at least 3. The primary endpoint was the 90-day comprehensive complication index, placing the focus on overall postoperative burden rather than any single event.

The NUTRIWHI randomized clinical trial was a parallel, open-label, superiority study at 3 tertiary centers in Switzerland and France. Patients scheduled for pancreatoduodenectomy were eligible with a Nutritional Risk Screening score of 3 or higher. Investigators randomized patients 1:1, and after 24 post-randomization dropouts, 118 patients were analyzed, 59 per group. Enteral feeding started immediately after surgery through an intraoperatively placed 8-French nasojejunal tube, and oral nutrition was standardized in both groups. Parenteral nutrition was standardized if calories remained below 50% of needs on postoperative day 3, and follow-up ended in January 2025.

Overall 90-day morbidity was not significantly different at 45/59 (76%) in the enteral group versus 51/59 (86%) in the oral group (RR for oral vs enteral, 1.13; 95% CI, 0.9-1.9; P=.18). Delayed gastric emptying, pancreatic fistula, hemorrhage, surgical site infection, length of stay, and 90-day readmission showed no significant differences, and major complications also showed only a nonsignificant difference. Infectious complications were less frequent with enteral nutrition at 12/59 (20%) versus 22/59 (37%) (RR for oral vs enteral, 1.83; 95% CI, 1.0-2.6; P=.04). Pulmonary complications were also less frequent at 3/59 (5%) versus 11/59 (19%) (RR for oral vs enteral, 3.66; 95% CI, 1.1-12.5; P=.02). The overall complication burden was lower, while many individual postoperative outcomes were similar between groups.

Feeding-related adverse events centered on the tube: 14 of 59 enteral patients removed it involuntarily and required replacement. Ten patients reported slight to moderate discomfort on postoperative day 3, the median enteral duration was 10 days, and 10 patients were discharged with ongoing enteral support. Three patients assigned to enteral nutrition did not receive it during hospitalization because of mechanical obstruction or failed tube insertion, and postoperative parenteral nutrition use was similar. Subgroup analyses in patients with Nutritional Risk Screening scores above 3, older age, diabetes, or biliary drainage suggested a lower burden, although those findings were underpowered and hypothesis-generating.

Overall, the enteral approach was described as well tolerated and associated with a lower postoperative burden in this at-risk group.