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
- 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.
- 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.
- 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.