Advertisement

Early Versus Late Oral Refeeding After Pancreaticoduodenectomy for Malignancy: a Comparative Belgian-French Study in Two Tertiary Centers

  • Julie Navez
  • Catherine Hubert
  • Safi Dokmak
  • Isadora Frick De La Maza
  • Nicolas Tabchouri
  • Olivier Benoit
  • Hélène Hermand
  • Francis Zech
  • Jean-François Gigot
  • Alain SauvanetEmail author
Original Article
  • 57 Downloads

Abstract

Background

In the era of fast-track surgery, because pancreaticoduodenectomy (PD) carries a significant morbidity, surgeons hesitate to begin early oral feeding and achieve early discharge. We compared the outcome of two different approaches to the postoperative management of PD in two tertiary centers.

Methods

Of patients having undergone PD for malignancy from 2008 to 2017, 100 patients who received early postoperative oral feeding (group A) were compared to 100 patients from another center who received early enteral feeding and a delayed oral diet (group B). Surgical indication and approach and type of pancreatic anastomosis were similar between both groups. Postoperative outcomes were retrospectively reviewed.

Results

Patient characteristics were similar between both groups, except significantly more neoadjuvant treatment in group A (A = 20% vs. B = 9%, p < 0.01). Mortality rates were 3% and 4% in groups A and B, respectively (p = 0.71). The rate of severe postoperative morbidity was significantly lower in group A (13% vs. 26%, p = 0.02), resulting in a lower reoperation rate (p < 0.01). Delayed gastric emptying and clinically relevant pancreatic fistula were similar between both groups but chyle leaks were more frequent in group A (10% vs. 3%, p = 0.04). The median hospital stay was shorter in group A (16 vs. 20 days, p < 0.01).

Conclusion

In the present study, early postoperative oral feeding after PD was associated with a shorter hospital stay and did not increase severe postoperative morbidity or the rate of pancreatic fistula. However, it resulted in more chyle leaks and did not prevent delayed gastric emptying.

Keywords

Pancreaticoduodenectomy Early oral feeding Pancreatic fistula Delayed gastric emptying Chyle leaks 

Notes

Authors’ Contribution

All authors have contributed significantly to the study, according to the guidelines of the International Committee of Medical Journal Editors (ICMJE).

Compliance with Ethical Standards

Conflict of Interest

The authors declare that have no conflict of interest.

Supplementary material

11605_2019_4316_MOESM1_ESM.docx (16 kb)
ESM 1 (DOCX 15 kb)

References

  1. 1.
    Wilmore DW, Kehlet H. Management of patients in fast track surgery. BMJ 2001; 322: 473–476.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008; 248: 189–198.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Venkat R, Puhan MA, Schulick RD et al. Predicting the risk of perioperative mortality in patients undergoing pancreaticoduodenectomy: a novel scoring system. Arch Surg 2011; 146: 1277–1284.CrossRefPubMedGoogle Scholar
  4. 4.
    Ragulin-Coyne E, Carroll JE, Smith JK et al. Perioperative mortality after pancreatectomy: a risk score to aid decision-making. Surgery 2012; 152: S120–127.CrossRefPubMedGoogle Scholar
  5. 5.
    Lassen K, Coolsen MM, Slim K et al. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations. World J Surg 2013; 37: 240–258.CrossRefGoogle Scholar
  6. 6.
    Coolsen MM, van Dam RM, van der Wilt AA et al. Systematic review and meta-analysis of enhanced recovery after pancreatic surgery with particular emphasis on pancreaticoduodenectomies. World J Surg 2013; 37: 1909–1918.CrossRefPubMedGoogle Scholar
  7. 7.
    Nguyen TC, Sohn TA, Cameron JL et al. Standard vs. radical pancreaticoduodenectomy for periampullary adenocarcinoma: a prospective, randomized trial evaluating quality of life in pancreaticoduodenectomy survivors. J Gastrointest Surg 2003; 7: 1–9; discussion 9-11.CrossRefPubMedGoogle Scholar
  8. 8.
    Sourrouille I, Gaujoux S, Lacave G et al. Five days of postoperative antimicrobial therapy decreases infectious complications following pancreaticoduodenectomy in patients at risk for bile contamination. HPB (Oxford) 2013; 15: 473–480.CrossRefGoogle Scholar
  9. 9.
    Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: 205–213.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Bassi C, Marchegiani G, Dervenis C et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 2017; 161: 584–591.CrossRefGoogle Scholar
  11. 11.
    Wente MN, Bassi C, Dervenis C et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007; 142: 761–768.CrossRefGoogle Scholar
  12. 12.
    Besselink MG, van Rijssen LB, Bassi C et al. Definition and classification of chyle leak after pancreatic operation: A consensus statement by the International Study Group on Pancreatic Surgery. Surgery 2017; 161: 365–372.CrossRefPubMedGoogle Scholar
  13. 13.
    Pessaux P, Regimbeau JM, Dondero F et al. Randomized clinical trial evaluating the need for routine nasogastric decompression after elective hepatic resection. Br J Surg 2007; 94: 297–303.CrossRefPubMedGoogle Scholar
  14. 14.
    Kunstman JW, Klemen ND, Fonseca AL et al. Nasogastric drainage may be unnecessary after pancreaticoduodenectomy: a comparison of routine vs selective decompression. J Am Coll Surg 2013; 217: 481–488.CrossRefPubMedGoogle Scholar
  15. 15.
    Fisher WE, Hodges SE, Cruz G et al. Routine nasogastric suction may be unnecessary after a pancreatic resection. HPB (Oxford) 2011; 13: 792–796.CrossRefGoogle Scholar
  16. 16.
    Story SK, Chamberlain RS. A comprehensive review of evidence-based strategies to prevent and treat postoperative ileus. Dig Surg 2009; 26: 265–275.CrossRefPubMedGoogle Scholar
  17. 17.
    Charoenkwan K, Matovinovic E. Early versus delayed oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database Syst Rev 2014; CD004508.Google Scholar
  18. 18.
    Pragatheeswarane M, Muthukumarassamy R, Kadambari D, Kate V. Early oral feeding vs. traditional feeding in patients undergoing elective open bowel surgery-a randomized controlled trial. J Gastrointest Surg 2014; 18: 1017–1023.CrossRefGoogle Scholar
  19. 19.
    Gerritsen A, Wennink RAW, Busch ORC et al. Feeding patients with preoperative symptoms of gastric outlet obstruction after pancreatoduodenectomy: Early oral or routine nasojejunal tube feeding? Pancreatology 2015; 15: 548–553.CrossRefPubMedGoogle Scholar
  20. 20.
    Baradi H, Walsh RM, Henderson JM et al. Postoperative jejunal feeding and outcome of pancreaticoduodenectomy. J Gastrointest Surg 2004; 8: 428–433.CrossRefPubMedGoogle Scholar
  21. 21.
    Perinel J, Mariette C, Dousset B et al. Early Enteral Versus Total Parenteral Nutrition in Patients Undergoing Pancreaticoduodenectomy: A Randomized Multicenter Controlled Trial (Nutri-DPC). Ann Surg 2016; 264: 731–737.CrossRefPubMedGoogle Scholar
  22. 22.
    Shen Y, Jin W. Early enteral nutrition after pancreatoduodenectomy: a meta-analysis of randomized controlled trials. Langenbecks Arch Surg 2013; 398: 817–823.CrossRefPubMedGoogle Scholar
  23. 23.
    Kang CM, Lee JH. Pathophysiology after pancreaticoduodenectomy. World J Gastroenterol 2015; 21: 5794–5804.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Coolsen MM, van Dam RM, Chigharoe A et al. Improving outcome after pancreaticoduodenectomy: experiences with implementing an enhanced recovery after surgery (ERAS) program. Dig Surg 2014; 31: 177–184.CrossRefPubMedGoogle Scholar
  25. 25.
    Kobayashi S, Ooshima R, Koizumi S et al. Perioperative care with fast-track management in patients undergoing pancreaticoduodenectomy. World J Surg 2014; 38: 2430–2437.CrossRefPubMedGoogle Scholar
  26. 26.
    Williamsson C, Karlsson N, Sturesson C et al. Impact of a fast-track surgery programme for pancreaticoduodenectomy. Br J Surg 2015; 102: 1133–1141.CrossRefPubMedGoogle Scholar
  27. 27.
    Shao Z, Jin G, Ji W et al. The role of fast-track surgery in pancreaticoduodenectomy: a retrospective cohort study of 635 consecutive resections. Int J Surg 2015; 15: 129–133.CrossRefPubMedGoogle Scholar
  28. 28.
    Zouros E, Liakakos T, Machairas A et al. Improvement of gastric emptying by enhanced recovery after pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2016; 15: 198–208.CrossRefPubMedGoogle Scholar
  29. 29.
    Takagi K, Yoshida R, Yagi T et al. Effect of an enhanced recovery after surgery protocol in patients undergoing pancreaticoduodenectomy: A randomized controlled trial. Clin Nutr 2018.Google Scholar
  30. 30.
    Guilbaud T, Birnbaum DJ, Loubiere S et al. Comparison of different feeding regimes after pancreatoduodenectomy - a retrospective cohort analysis. Nutr J 2017; 16: 42.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Shrikhande SV, Sivasanker M, Vollmer CM et al. Pancreatic anastomosis after pancreatoduodenectomy: A position statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2017; 161: 1221–1234.CrossRefPubMedGoogle Scholar
  32. 32.
    Melloul E, Raptis DA, Clavien PA et al. Poor level of agreement on the management of postoperative pancreatic fistula: results of an international survey. HPB (Oxford) 2013; 15: 307–314.CrossRefGoogle Scholar
  33. 33.
    Fujii T, Nakao A, Murotani K et al. Influence of Food Intake on the Healing Process of Postoperative Pancreatic Fistula After Pancreatoduodenectomy: A Multi-institutional Randomized Controlled Trial. Ann Surg Oncol 2015; 22: 3905–3912.CrossRefPubMedGoogle Scholar
  34. 34.
    Strobel O, Brangs S, Hinz U et al. Incidence, risk factors and clinical implications of chyle leak after pancreatic surgery. Br J Surg 2017; 104: 108–117.CrossRefPubMedGoogle Scholar
  35. 35.
    Kuboki S, Shimizu H, Yoshidome H et al. Chylous ascites after hepatopancreatobiliary surgery. Br J Surg 2013; 100: 522–527.CrossRefPubMedGoogle Scholar
  36. 36.
    Hughes MJ, Ventham NT, McNally S et al. Analgesia after open abdominal surgery in the setting of enhanced recovery surgery: a systematic review and meta-analysis. JAMA Surg 2014; 149: 1224–1230.CrossRefPubMedGoogle Scholar
  37. 37.
    Eshuis WJ, van Eijck CH, Gerhards MF et al. Antecolic versus retrocolic route of the gastroenteric anastomosis after pancreatoduodenectomy: a randomized controlled trial. Ann Surg 2014; 259: 45–51.CrossRefPubMedGoogle Scholar
  38. 38.
    Denbo JW, Bruno ML, Cloyd JM et al. Preoperative Chemoradiation for Pancreatic Adenocarcinoma Does Not Increase 90-Day Postoperative Morbidity or Mortality. J Gastrointest Surg 2016; 20: 1975–1985.CrossRefPubMedGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  • Julie Navez
    • 1
    • 2
  • Catherine Hubert
    • 1
  • Safi Dokmak
    • 2
  • Isadora Frick De La Maza
    • 1
  • Nicolas Tabchouri
    • 2
  • Olivier Benoit
    • 2
  • Hélène Hermand
    • 2
  • Francis Zech
    • 3
  • Jean-François Gigot
    • 1
  • Alain Sauvanet
    • 2
    Email author
  1. 1.Hepato-Biliary and Pancreatic Surgery Division, Department of Abdominal Surgery and TransplantationCliniques Universitaires Saint-LucBrusselsBelgium
  2. 2.Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Pôle des Maladies de l’Appareil Digestif, et Université Paris VIIHôpital Beaujon, AP-HPParisFrance
  3. 3.Institute of Experimental and Clinical ResearchCliniques Universitaires Saint-LucBrusselsBelgium

Personalised recommendations