Nutrition & Pancreatic Surgery

Abstract

The aim of the first part of this thesis was to determine the optimal feeding strategy after pancreatoduodenectomy. The available nutritional guidelines give conflicting recommendations and are all based on studies after major gastrointestinal surgery for cancer in general. We systematically reviewed the available literature regarding five different feeding strategies after pancreatoduodenectomy; oral diet, enteral nutrition via either a nasoenteral-, gastrojejunostomy or jejunostomy tube and total parenteral nutrition. Based on the available literature there seemed to be no evidence to support routine enteral or parenteral nutrition after pancreatoduodenectomy. In addition, our retrospective cohort study demonstrated that each feeding strategy including enteral or parenteral nutrition is associated with specific complications such as tube dislodgement, bowel strangulation and infections. Based on these findings we concluded that early oral feeding may be the preferred routine feeding strategy after pancreatoduodenectomy and designed an observational cohort study to evaluate whether a change in the routine feeding strategy from nasoenteral tube feeding to early oral feeding improved clinical outcomes. No negative impact of early oral feeding on postoperative morbidity was seen, while the time to resumption of adequate oral intake and length of hospital stay significantly decreased. This led us to conclude that early oral feeding with on-demand tube feeding is the feeding strategy of choice after pancreatoduodenectomy. Our study in patients at high risk of requiring postoperative tube feeding (i.e. with preoperative symptoms of gastric outlet obstruction (i.e. vomiting, dysphagia, nausea, loss of appetite and postprandial complaints) also showed no benefits of routine tube feeding. Up to 50 percent of patients within an oral feeding strategy ultimately require postoperative tube feeding via a nasoenteral feeding tube on-demand, because they do not tolerate oral feeding. Nasoenteral feeding tubes are typically placed endoscopically by gastroenterologists, which is bothersome for both patients and caregivers. In the second part of this thesis we aimed to investigate whether the task of nasoenteral feeding tube placement can be shifted from gastroenterologists at endoscopy departments to nurses at the patient’s bedside through the use of an electromagnetic guided tube placement system. We systematically reviewed the literature regarding nasoenteral feeding tube placement and reviewed our own retrospective data and concluded that bedside electromagnetic guided placement did not differ from endoscopic placement regarding feasibility and safety in critically ill or surgical patients with an unaltered upper gastrointestinal anatomy. Our subsequent prospective pilot study in patients with an altered anatomy after pancreatoduodenectomy demonstrated decreased success rates for both electromagnetic guided and endoscopic feeding tube placement. In the CORE trial, a multicenter randomized controlled trial, we aimed to determine non-inferiority of electromagnetic guided placement in terms of efficacy and to objectify the suggested advantages (e.g. logistics, patient discomfort and costs) compared with endoscopic placement of nasoenteral feeding tubes in surgical patients. Our results established non-inferiority of electromagnetic guided placement in terms of reinsertions and demonstrated logistical advantages and reduced overall healthcare costs, which led us to conclude that electromagnetic guidance may be considered the preferred technique for nasoenteral feeding tube placement.