Editorial

Early Enteral vs. Total Parenteral Nutrition in Patients Undergoing Pancreaticoduodenectomy: A Randomized Multicenter Controlled Trial (Nutri-DPC). NJEEN Needs Cautious Recommendation!

Shailesh A Sable*
Department of Liver Transplant & HPB, Kokilaben Dhirubhai Ambani Hospital, India


*Corresponding author: Shailesh Anand Sable, Department of Liver Transplant & HPB, Kokilaben Dhirubhai Ambani Hospital, Arena I ii, 407/408, Poonam Garden, Opp Mira-Bhayander Road, Mira Road (East), Thane, Maharashtra Pin – 401107, India


Published: 20 Dec, 2017
Cite this article as: Sable SA. Early Enteral vs. Total Parenteral Nutrition in Patients Undergoing Pancreaticoduodenectomy: A Randomized Multicenter Controlled Trial (Nutri-DPC). NJEEN Needs Cautious Recommendation!. Clin Surg. 2017; 2: 1833.

Editorial

With great interest I have read the article entitled “Early Enteral Versus Total Parenteral Nutrition in Patients Undergoing Pancreaticoduodenectomy: A Randomized Multicenter Controlled Trial (Nutri-DPC)” by Julie Perinel et al. [1]. I would like to congratulate all the authors for this valuable study, and make some contributions. Recently published systematic review by Kjetil Soreide et al. [2] demonstrated POPF rate after pancreaticoduodenectomy in the range of 20% to 25% [2], while the overall POPF rates in the current study appears to be around 36.7% [1]. Suggesting there is a tendency of higher POPF in the given study as compared to the literature, which i feel is probably secondary to the high risk factors in this cohort of patients. Attributing POPF to NJEEF is unfair as there are various other confounding factors which are responsible for POPF are also present in the NJEEF arm (Soft pancreas- 8 vs. 3, Duct diameter ≤ 3 mm - 40.6 vs. 33.7 & Pre-op BMI 24.99 vs. 23.76) [2,3]. Not to mention there are around 6.79% patients where data is missing on the risk factors that may have indirectly attributed to high rate of POPF in NJEEF arm. Combination of high risk factors also play role in POPF apart from being individual risk factor [2,3]. Authors are proposing impact of nutritional effect on higher POPF in NJEEF; however the current study doesn’t demonstrate any significant difference between the two arms in terms of impact on nutrition [1]. Nutrition has never been substantially proven to be an independent risk factor in POPF. In the current study the percentage of patient having DGE (34.3 vs. 27) and duration of decompressive NGT removal (11.4 vs. 8.5) is higher in NJEEF arm suggesting more of a cause than effect of NJ tube [1]. Technique of PG or PJ has lot of bearing on POPF rate [2], authors have not mentioned any details regarding variegates of the technique. Overall POPF remains an area of debate in spite of multiple studies available.
The fundamental principle behind anatomical pathway of naso-jejunal tube and nasogastric tube is not so different theoretically and practically in a post Whipple’s case. Both of them cross esophago-gastric junction which is the major culprit for micro-aspiration and Eustachian tube blockade leading to middle ear infections. Only minor difference between the two is naso-jejunal tube crosses the gastro-jejunal anastomosis and that doesn’t explain the POPF in post pancreaticoduodenectomy patients. So with the results of current study one might either also not recommend NGT or accept NGT as confounding factor for the POPF and other complications. Scientifically it would be very difficult to correlate NJEEN to POPF and other complications especially in the presence of other confounding factors. Current study although may appear statistically significant against NJEEF but its clinical significance should be viewed with caution. It would be unfair to discourage NJEEN recommendation post pancreatico-duodenectomy without validation of these results in further studies with exclusion of confounding factors.

References

  1. Perinel J, Mariette C, Dousset B, Sielezneff I, Gainant A, Mabrut JY, et al. Early Enteral Versus Total Parenteral Nutrition in Patients Undergoing Pancreaticoduodenectomy: A Randomized Multicenter Controlled Trial (Nutri-DPC). Ann Surg. 2016;264(5):731-7.
  2. Søreide K, Labori KJ. Risk factors and preventive strategies for post-operative pancreatic fistula after pancreatic surgery: a comprehensive review. Scand J Gastroenterol. 2016;51(10):1147-54.
  3. Hu BY, Wan T, Zhang WZ, Dong JH. Risk factors for postoperative pancreatic fistula: Analysis of 539 successive cases of pancreaticoduodenectomy. World J Gastroenterol. 2016;22(34):7797-805.