Enteral Nutrition vs Parenteral Nutrition in the Management of Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy : A Prospective Observational Study

Enteral Nutrition vs Parenteral Nutrition in the Management of Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy : A Prospective Observational Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Enteral Nutrition vs Parenteral Nutrition in the Management of Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy : A Prospective Observational Study Rohith Kodali, Kunal Parasar, Utpal Anand, Basant Narayan Singh, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4481411/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose : Postoperative pancreatic fistula (POPF) poses a challenge to oral intake after Pancreaticoduodenectomy (PD). Various strategies such as enteral feeding via nasojejunal tube, feeding jejunostomy (FJ), and total parenteral nutrition , are employed to enhance postoperative nutrition. The routine adoption of FJ in PD remains a debatable topic. This study aims to assess and compare the efficacy of enteral feeding and parenteral nutrition in the management of POPF. Material and methods : Seventy patients who underwent classical PD at a tertiary care center in east India between July 2019 and December 2023 were randomly allocated to FJ and non-FJ in 1:1 ratio. The primary end point was procedure related complications (POPF, delayed gastric emptying, post pancreatectomy hemorrhage , bile leak, Clavien Dindo grade ³3), length of hospital stay,additional costs, 30-day mortality and tube-related complications. Results : Out of 70 patients who underwent PD 35 received FJ as part of the standard care while the remaining 35 patients with no FJ. The majority of POPF cases were Grade B (40 vs 31.4%). Patients with Grade B POPF who underwent routine FJ placement exhibited shorter fistula durations (3.9 vs. 5.2 weeks, p< 0.001) and reduced intraabdominal drain durations (26.4 vs. 34.9 days, p<0.001). No differences were observed in the incidence of complications , reoperation, length of hospital stay readmission and 30-day mortality. No adverse complications were associated with FJ placement. Conclusion : For PD patients requiring prolonged postoperative nutritional support due to POPF and DGE, routine FJ can be a safe and cost-effective approach. Pancreaticoduodenectomy Feeding jejunostomy Enteral nutrition Introduction Pancreaticoduodenectomy (PD), considered the gold standard surgical procedure for periampullary carcinoma, (PAC) has witnessed significant improvements in patient outcomes through centralized care. Institutions with high surgical volumes have achieved mortality rates below 2%, showcasing notable advancements in both short-term and long-term results. However, despite these strides, reported morbidity rates ranging from 30–60% highlight the persistent high surgical risks associated with PD. [ 1 ] Noteworthy complications post-PD include postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postoperative hemorrhage (PPH), biliary leaks, and infections. Despite significant technological advancements and procedural modifications over the past decade, POPF remains a prevalent complication, occurring in 3–45% of cases in high-volume hospitals conducting pancreatic resections. [ 2 , 3 ] POPF stands out as the primary cause of mortality and morbidity following PD, representing the most formidable challenge associated with the procedure. The International Study Group of Pancreatic Surgery (ISGPS) defines POPF as drainage output containing any measurable fluid volume with an amylase level exceeding three times the upper limit of the institutional normal serum amylase activity, and this should be associated with a clinically significant condition directly linked to the fistula. [ 4 ] The majority of patients with POPF are considered serious cases or clinically relevant in approximately 60% of instances, leading to prolonged hospital stays, additional therapies, and increased cost burdens. [ 5 ] POPF can have severe consequences, including nutritional deficiencies, sepsis, abscess formation, and hemorrhage, highlighting the potentially life-threatening nature of this condition. [ 6 ] Currently, there is no universally endorsed approach for treating POPF. However, conservative management, particularly nutritional supplementation, is widely recognized as a standard of care. [ 7 ]Moreover, nutritional support is considered an essential component of postoperative therapy, given the significant catabolic activity and compromised immune function in affected individuals. While the optimal nutritional approach for patients with POPF remains uncertain, two perioperative nutrition methods, namely Enteral Nutrition (EN) and Total Parenteral Nutrition (TPN), have shown effectiveness in improving clinical outcomes and reducing postoperative complications. Early Enteral Nutrition (EEN) has particularly demonstrated significant efficacy in restoring immune function and lowering the risk of sepsis. EN involves delivering nutrients directly into the small intestine through a tube, either via the nasojejunal route or jejunostomy. Randomized controlled trials have affirmed the benefits of EN compared to parenteral nutrition, resulting in faster fistula closure rates and shorter durations of POPF. [ 8 ]The decision to use feeding jejunostomy in patients experiencing POPF and DGE and its potential impact on early postoperative morbidity remains a topic of debate, given the known complications associated with its placement and usage. [ 9 ] This study aimed to compare the effectiveness of enteral and parenteral feeding in treating POPF. Material and methods This Prospective analysis was conducted at the tertiary hospital in eastern India utilizing an observational prospective study design to compare the relative efficacy of enteral and parenteral feeding in the treatment of POPF. The study cohort comprised a total of 70 patients who had undergone classical PD between July 2019 and August 2023. Sample size determination was based on the assumption that 50% of patients would respond favourably to enteral feeding (p = 0.5), for a 95% confidence level (Z = 1.96) and a margin of error of 0.05 (5%) required sample size was calculated to be 69. Institute ethical committee approval was obtained before the study was started and informed written consent was obtained from all patients before including them in the study (IEC/1044). The study was conducted in accordance with the principles of Helsinki. Inclusion criteria comprised elective open or laparoscopic-assisted PD for non-metastatic PAC and carcinoma head of the pancreas (HOP). Exclusion criteria encompassed patients with locally advanced PAC, borderline resectable HOP, those requiring vascular resection, neuroendocrine tumors, and benign pathology. Patients who presented with preoperative bilirubin > 15mg/dl and cholangitis underwent biliary drainage either endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD) in whom ERCP was not feasible. The majority of the patients underwent PD within 4 to 6 weeks after biliary drainage. The participants were randomly assigned to one of two groups using a table of random numbers with no specific preoperative criteria set for the decision to perform FJ. The first group underwent routine FJ placement, while the second group did not undergo FJ placement. The focus was on patients who developed POPF. A comprehensive range of variables were examined, including fistula duration, duration of drain placement, specifics of TPN, the need for imaging-guided intervention, complication rates assessed using the Clavien Dindo classification, length of hospital stay, treatment-related complications, additional cost implications, and 30-day mortality. After fulfilling the inclusion criteria, patients were subjected to classical PD. LAPD included laparoscopic resection, mobilization, and lymphadenectomy followed by mini-laparotomy for specimen extraction and reconstruction. We initially performed open pancreaticoduodenectomy (OPD) in the initial two years and later transitioned to laparoscopic-assisted pancreaticoduodenectomy (LAPD). All surgeries were done by the same surgeon. All FJ was placed 30cm distal to gastrojejunal anastomosis using a 10Fr Ryle’s tube by modified Witzels technique. Drains were routinely placed near choledochojejunal anastomosis and pancreaticojejunal anastomosis. Patients with the FJ group are compared with other cohort groups in whom feeding jejunostomy is not routinely done. Postoperative parameters like drain effluent, volume, and drain fluid amylase on POD3 and POD5 were assessed. Nasogastric tube volume was ascertained, and patients were allowed on an oral diet in both cohorts and assessed for tolerability from POD 3. Patients who did not tolerate oral diet had a nasogastric tube reinserted, and a prokinetic agent started. The Group of cohorts with FJ was allowed to continue the feeds from POD3. Patients who are unable to tolerate oral feeds with no FJ were subjected to TPN. At our institute post -PD patients requiring TPN will receive a standardized 1 -L formulation, maximizing protein and calorie intake. This standard formula administers 70g protein and 35g fat for a total caloric intake of 1140kcal/L All patients were started on FJ feeds on POD3 initially with an isotonic solution and then subsequently increased according to individual patient needs. Energy and fluid requirements were calculated accordingly, taking into account the total body weight. Infusion of feed commenced at 500ml of half-strength feeds on day one and increased every day until the calculated target volume was reached (35 ml/kg body weight/day – e.g. for a 70 kg patient = 2000–2500 kcal and 80–85 g of protein per day). Intravenous crystalloids were reduced proportionally as the enteral feeding was increased and discontinued once the target rate of enteral feeding was achieved. The aim was to maintain this rate until oral intake was established. Enteral feeding was discontinued when a free oral intake had been achieved, usually by the end of day 6 or 7. The outcome was defined as successful if jejunostomy was used for enteral nutrition after surgery and discontinued when patients achieved adequate oral nutrition or were discharged home on supplementary jejunal feeding. All FJ tubes were removed postoperatively after 6 weeks. Complications specific to TPN and central line related were noted (central line associated bloodstream infections (CLABSI), hyperglycaemia, liver function abnormalities and electrolyte abnormalities) .The complications related to feeding jejunostomy ( leak into the peritoneal cavity, tube dislodgement migration of tube outside the jejunal lumen, jejunal perforation, entero-cutaneous fistula, abscess (intra-abdominal or abdominal wall), tube block, tube detachment i.e. from anterior abdominal wall anchoring site, peritubular leak, and diarrhea. Statistical analyses were performed using the IBM Statistical Package for the Social Sciences (SPSS software version 26.0, Armonk, NY). PD-related morbidity between the two groups was compared using a t-test. FJ placement and the duration of TPN requirement in the study group without FJ placement were analyzed. The Levene's test, with a significance level of p ≤ 0.05, was employed to assess the assumption of equal variances. There were no missing patient data. Postoperative variables, including time of passing flatus, time of nasogastric tube (NGT) removal, time to oral intake, duration of fistula (in weeks), duration of the intra-abdominal drain (in days), and cost expenses (in USD United states dollar), were evaluated for intergroup comparisons. Results Table I compares demographic and operative parameters between patients with FJ (n = 35) and those without FJ (n = 35). No significant differences were found in age, gender distribution, BMI, ASA classification, haemoglobin, preoperative albumin, preoperative bilirubin levels, preoperative diagnosis (periampullary carcinoma vs. pancreatic head carcinoma), comorbidities (COPD, hypertension, diabetes). The proportion of patients who underwent preoperative biliary drainage was similar between the two groups .There were no significant differences in the rates of pancreas texture (intraoperative assessment) or duct diameter (measured on cross-sectional imaging) between the groups (p = 0.811 and p = 0.621). Additionally operative time, estimated blood loss, and number of blood transfusions were similar between the groups (p = 0.221, p = 0.117, p = 0.624, respectively). Table II compares postoperative complications between the two cohorts. POPF and DGE were the most common primary postoperative complications in both groups. Grade A DGE incidence was slightly lower in the FJ group compared to the non-FJ group (74.3% vs. 77.1%), while Grade B DGE incidence was slightly higher (40% vs. 28.6%). However, these differences were not statistically significant (p = 0.314 and p = 0.225, respectively).Grade B POPF accounted for 63.6% and 52.3% in both groups, respectively, with no significant difference. No instances of Grade C POPF were documented. Both superficial and deep surgical site infections showed comparable incidence rates between the groups. Eleven patients in the FJ group and nine patients in the non-FJ group required percutaneous image-guided pigtail drainage for intrabdominal collections. Additionally, one patient in the FJ group and two patients in the non-FJ group experienced bile leaks, all of which resolved with conservative management. Three cases of postoperative hemorrhage were identified, with two occurring in the FJ group. One patient underwent reexploration for bleeding from the mesenteric cut surface on postoperative day 2 (POD), while another underwent angiographic coil embolization for gastroduodenal artery stump bleeding on POD5. Similarly, one patient in the non-FJ group required reexploration for bleeding from the pancreatic cut margin near the pancreaticojejunal anastomosis on POD2. Clavien Dindo grade (≥III) complications were observed in 12(34.3%) vs. 10 (28.6%)demonstrating no significant difference between the two groups. Table III presents a comparative analysis of postoperative parameters between patients with and without FJ placement. The average time to pass flatus was 4 days in the FJ group and 5 days in the non-FJ group, showing no statistically significant difference (p = 0.732). NGT removal occurred at an average of 3 days postoperatively in the FJ group, compared to 5 days in the non-FJ group. The average time to oral intake was 7.21 days in the FJ group and 8 days in the non-FJ group, demonstrating no statistically significant difference (p = 0.099). However, the FJ group had a significantly shorter duration of fistula (3.92 weeks vs. 5.27 weeks, p < 0.001) and intra-abdominal drain placement (26.4 days vs. 34.9 days p < 0.001). Although the duration of hospital stay was shorter in the FJ group (7days vs. 9 days), the difference was not statistically significant (p = 0.212). There was one case of hospital mortality (2.9%) in the FJ group, while no mortality was reported in the non-FJ group. One mortality was recorded on POD 3 in a patient who underwent the operation for T3N2M0 with sepsis and disseminated intravascular coagulation. The readmission rates within 30 days were similar between the two groups, with 4 cases (11.4%) in each group (p = 1.000) with the majority of patients presented with either poor oral intake, DGE, and wound-related issues all of which were managed conservatively. Two patients (5.7%) in the FJ group and one patient (2.9%) in the non-FJ group required reoperation within 30 days postoperatively, with no significant difference observed (p = 0.555). The cost expenses were significantly lower in the FJ group (mean: $ 1005.3) compared to the non-FJ group (mean: $ 1308), demonstrating a significant difference (p < 0.001). Table IV presents the duration of the FJ feed requirement with routine FJ placement and the TPN requirement with no FJ placement. Among the 35 cases with routine FJ placement, 12 patients (34.3%) required FJ feed for less than 7 days postoperatively, indicating early cessation of FJ feed. The majority of patients, 22 (62.9%), required FJ feed between POD 7 and POD 30. Only one patient (2.8%) required FJ feed beyond POD 30, suggesting an extended requirement for enteral nutrition support. Among the 35 cases without FJ placement, 14 patients (40%) did not require TPN postoperatively, indicating a successful transition to oral nutrition. Nine patients (25.7%) required TPN for less than 3 days postoperatively, eleven patients (31.4%) required TPN for a duration ranging from 4 to 10 days postoperatively. Only one patient (2.9%) required TPN for more than 10 days postoperatively. No complications were encountered with FJ and five patients with TPN had central line-related infections which necessitated removal and sent for culture, antibiotics were started as per the culture report and two patients presented with liver enzyme alterations with TPN. Discussion POPF continues to pose a significant challenge for pancreatic surgeons. Around 60% of POPF cases are considered serious, leading to delayed hospital discharge and additional treatments and cost burden.[ 10 ] Complications associated with POPF include fluid and electrolyte imbalances, nutritional depletion, sepsis, abscess formation, and hemorrhage, highlighting the potentially life-threatening consequences.[ 11 ] Although there is no universally accepted treatment for POPF, conservative approaches such as nutritional supplementation are widely adopted, given the high catabolic activity and compromised immunity observed postoperatively. [ 7 ] Low-output, uncomplicated fistulas are best managed conservatively, whereas those enduring for 6 to 8 weeks and complicated by septic complications typically necessitate a more assertive strategy involving endoscopic and radiological interventions. [ 12 ] The economic burden of managing POPF is substantial due to increased healthcare resource utilization and prolonged hospital stays. Nutritional status and PD morbidity are closely related. Thus, feeding strategies aiming for rapid closure with minimal complications are preferred. However, evidence supporting a specific strategy remains inconclusive. [ 13 ] International guidelines recommend the oral diet in the early postoperative phase after PD even though not strongly supported in the existing literature. [ 14 , 15 ] Oral intake can stimulate the secretion of pancreatic juices, potentially exacerbating fistulas, while TPN bypasses this issue but may lead to negative long-term consequences. While some studies advocate for TPN due to high fistula closure rates, long-term usage can induce functional and morphological changes in liver and catheter related sepsis or thrombosis. [ 7 , 15 ]Conversely, enteral nutrition has shown benefits in terms of faster fistula closure rates, but its use is associated with adverse events like ileus and aspiration pneumonia. Conflicting results have further complicated the debate, with some suggesting oral nutrition as a viable treatment option for POPF. [ 16 , 17 ] Our current study aimed to examine the two cohorts of patients one with FJ as a mode of enteral nutrition and the other without FJ placement with TPN as required in cases of POPF, to assess the impact of nutrition method on the outcomes following PD. In our study patients in both groups were similar in terms of baseline characteristics. The groups were well-matched, reducing the potential for bias in subsequent analyses comparing outcomes between FJ and non-FJ groups. Patients had similar disease presentations and severity. FRS risk score was also similar across the groups, indicating no increased risk of POPF formation in either group. The incidence of post operative complications like DGE and POPF were similar in both the groups. While there was a slight increase in Grade B DGE in the FJ group, it was not statistically significant. This corroborates with the findings of a meta-analysis by Adiamah et al.[ 18 ] in which no statistically significant distinction was found in the relative risk of DGE between the two methods of nutritional delivery. The presence or absence of FJ placement also did not have a significant impact on the severity of POPF, with similar proportion of occurrence of Grade B POPF in both the groups in our study. These results also align with those of the meta-analysis conducted by Adiamah et al.[ 18 ], indicating no significant disparity in the risk of POPF (RR 0.88) among patients undergoing PD who were administered either EN or TPN . Consistent with the findings of the current study, other researchers have similarly observed no significant variances in the incidence of POPF across various nutritional pathways, such as EN and TPN.[ 7 , 19 , 20 ] In a systematic review of five routes of nutrition after PD, there were no significant differences in the occurrence of POPF. [ 21 ] The incidence of SSIs, intraabdominal collections, bile leaks and PPH showed no significant difference in the FJ group and the proportion of severe post operative complications requiring intervention (Clavien Dindo ≥ III) was comparable between patients with and without FJ placement. A meta analyses of 4 RCTs corroborated these findings, showing no significant differences in the occurrence of intra-abdominal complications and infections when comparing EEN with other nutritional routes. [ 22 ] While the results indicates that FJ placement does not significantly influence early postoperative outcomes such as the time to passing flatus and oral intake following PD, there are several noteworthy benefits associated with FJ placement. Patients with FJ placement demonstrated a significantly shorter duration of fistula and intra-abdominal drain placement, suggesting potential expedited resolution of postoperative complications common in PD. Klek et al. [ 8 ] had similar results in their study where they found that EEN ( through nasojejunal tube) lead to higher closure rates and quicker fistula closure. Patients on EEN showed a 60% closure rate compared to 37% on TPN. EEN was associated with a higher odds ratio for fistula closure (2.571) and a shorter median time to closure (27 days) compared to TPN. The proposed reasoning is that enteral feeding not only avoids stimulating the pancreas but also triggers the release of specific gut peptides, creating a negative feedback loop that inhibits pancreatic secretion. This mechanism, mediated by peptides like PYY and GLP-1, acts as an "ileal-brake" to regulate pancreatic exocrine secretion, contributing to the suppression of pancreatic activity. [ 23 – 25 ] In a study of 15,224 patients of PD with 7.5% had FJ placement experienced higher DGE, organ/space infection, re-operation, overall morbidity and longer hospital stays compared to those without FJ. However, there was no difference in mortality or readmission rate between the groups. Notably, in patients with DGE and POPF, FJ placement did not impact morbidity, mortality, length of stay, or readmission rate. [ 26 ] Enteral nutrition, when compared to parenteral nutrition, is linked to reduced complications, shorter hospital stays, and a positive cost-benefit evaluation. [ 27 ] However, a significant cost differential in our study favouring the FJ group suggests potential cost savings in managing postoperative complications, which holds significance for our resource limited patient community. Although it was not statistically significant, a trend towards shorter hospital stays was observed in the FJ group implying potential benefits in reducing healthcare burden. This study has several limitations, firstly, the relatively small sample size may limit the generalizability of the findings. Additionally, conducting the study at a single tertiary care center in East India may affect external validity due to regional practice variations. Moreover, the limited follow-up period may not address the long-term outcomes. Finally, despite random allocation of patients, unmeasured confounding factors may still influence the outcomes. Conclusion The routine use of FJ in PD does not significantly impact the incidence of major complications. Both enteral and parenteral nutrition strategies yield similar outcomes in terms of complications, length of hospital stay, and 30-day mortality. However, FJ placement is linked to shorter durations of fistula and intra-abdominal drain placement, indicating routine FJ can be a safe and cost-effective approach. Larger, multicenter trials are required to validate these findings and determine the optimal nutritional strategy following PD. Declarations Informed consent statement: Informed consent was taken from all participants involved in the study Ethical Approval: This study was conducted according to the guidelines of the Declaration of Helsinki and approved by Institute Ethical Board Committee, All India Institute of Medical Sciences, Patna, India. (Protocol code -IEC/1044) Assistance with the study: None Financial support and sponsorship: This study needed no external funding Conflict of interest: All authors declare no conflict of interest in the material, information, or techniques described. Author Contribution Dr. Rohith Kodali and Dr. Kunal Parasar made the study conception and design. Dr. Rohith Kodali and Dr. Basant Narayan Singh collected the data, analyzed it, and compiled the data. Dr. Kislay Kant and Dr. Utpal Anand helped in analysis and interpretation of the data. Dr. Saad Anwar and Dr.Bijit Saha drafted and revised the manuscript. 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Langenbecks Arch Surg 398(6):817–823. https://doi.org/10.1007/s00423-013-1089-y O’Keefe SJD (2006) Physiological response of the human pancreas to enteral and parenteral feeding. Curr Opin Clin Nutr Metab Care 9(5):622–628. https://doi.org/10.1097/01.mco.0000241675.63041.ca Morisset J (2008) Negative control of human pancreatic secretion: physiological mechanisms and factors. Pancreas 37(1):1–12. https://doi.org/10.1097/MPA.0b013e318161b99a Maljaars PWJ, Peters HPF, Mela DJ, Masclee A, a. M (2008) Ileal brake: a sensible food target for appetite control. A review. Physiol Behav 95(3):271–281. https://doi.org/10.1016/j.physbeh.2008.07.018 Soufi M, Al-Temimi M, Nguyen TK, House MG, Zyromski NJ, Schmidt CM et al (2022) Friend or foe? Feeding tube placement at the time of pancreatoduodenectomy: propensity score case-matched analysis. Surg Endosc 36(5):2994–3000. https://doi.org/10.1007/s00464-021-08594-9 Abunnaja S, Cuviello A, Sanchez JA (2013) Enteral and parenteral nutrition in the perioperative period: state of the art. Nutrients 5(2):608–623. https://doi.org/10.3390/nu5020608 Tables Table I- Comparision of demographic and operative parameters between two groups Variable With FJ (n=35) Without FJ (n=35) p-value Age (mean ± SD) 50.7± 10.1 51.0±15 0.918 Gender(Male /Female) (n) 25/10 17/18 0.051 BMI a (Median, IQR) 21 (1.5) 21(2) 0.740 ASA b classification (n,%) Class I Class II Class III 22 (62.9%) 13 (37.1%) 0 (0%) 20 (57.1%) 14 (40 %) 1 (2.9%) 0.568 Preoperative Albumin (Median, IQR) 3.12 (0.33) 3.32 (0.385) 0.134 Preoperative Hemoglobin (mean ± SD) 11.2±1.15 11±1.2 0.442 Jaundice (n,%) 33 (94.2%) 32 (91.4%) 0.643 Preoperative Bilirubin (Median, IQR) 13.2 (8.31) 11.6(10.3) 0.605 Preoperative Biliary drainage (n,%) 26 (74.2%) 23 (65.71%) 0.434 Diagnosis (n,%) Periampullary Carcinoma Pancreatic Head Carcinoma 31 (88.5%) 4 (11.4%) 35 (100 %) 0 0.522 Comorbidities COPD c (n,%) Hypertension (n,%) Diabetes (n,%) 4 (11.4%) 11(31.4%) 6 (17.1%) 3 (8.5%) 7 (20%) 10 (28.5%) 0.690 0.274 0.255 Soft pancreas (n,%) 17 (73.9%) 18 (51.4%) 0.811 Duct diameter <3mm (n,%) 12 (34.2%) 14 (40%) 0.621 Operative time (in minutes) (Median, IQR) 410 (70) 430 (83) 0.221 Estimated Blood loss (in ml) (Median, IQR) 300 (300) 400 (250) 0.117 Number of Blood transfusions (Median, IQR) 1 (1) 1(1) 0.624 a- Body mass index, b- American Society of Anaesthesiologists, c- Chronic obstructive pulmonary disease Table II- Comparision of pancreaticoduodenectomy-related morbidity between two groups Variable With (n=35) n(%) Without FJ (n=35) n(%) p-value DGE a Grade A Grade B 26 (74.3%) 14 (40%) 12 (34.3%) 27 (77.1%) 10 (28.6%) 17 (48.6%) 0.314 0.225 POPF b Grade A Grade B Grade C 22 (62.8%) 8 (36.3%) 14 (63.6%) 0 21 (60%) 10 (47.6%) 11 (52.3%) 0 0.454 1.000 SSI c Superficial Deep 15 (42.9%) 11 (73.3%) 4. (26.6%) 14 (40%) 9 (64.2%) 5 (35.7%) 0.808 Bile leak 1 (2.9%) 2 (5.7%) 0.555 Pulmonary complications 3 (8.5%) 6 (17.1%) 0.284 Postoperative haemorrhage 2 (5.7%) 1 (2.9%) 0.555 Abdominal collections requiring drainage 11 (31.4%) 9 (25.7%) 0.597 Clavien Dindo Grade ( ³ III) 12 (34.3%) 10 (28.6%) 0.699 a- Delayed gastric emptying, b- Postoperative pancreatic fistula, c- Surgical site infection Table III- Comparison of postoperative parameters between two groups Variable With FJ (n=35) Without FJ (n=35) p-value Time of passing flatus (POD a ) 4 ±0.5 5 ±2 0.732 Time of NGT b removal (POD a ) 3±2.5 5±2 0.400 Time to oral intake (POD a ) 7.21±0.699 8 ±1.34 0.099 Duration of fistula (weeks) 3.92 ±0.9 5.27±0.786 <0.001 Duration of the intra-abdominal drain (days) 26.4±5.73 34.9±5.01 <0.001 Duration of hospital stay (days) 7±3 9±3 0.212 Hospital mortality 1 (2.9%) 0 0.314 Readmission (30-day) 4 (11.4%) 4 (11.4%) 1.000 Reoperation (30-day) 2 (5.7%) 1 (2.9%) 0.555 30-day mortality 1 (2.9%) 0 0.314 Cost expenses (USD c ) 1005.3±62.7 1308±68.9 <0.001 a- Postoperative day, b- Nasogastric tube, c- United States Dollar Table IV- Duration of FJ feed requirement with routine FJ placement and duration of TPN requirement with no FJ placement Duration of FJ feed requirement with routine FJ placement Number of cases(n=35) POD 30 01 Duration of TPN requirement with no FJ placement Number of cases(n=35) Not required 14 10 01 a- postoperative day Additional Declarations No competing interests reported. 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Institutions with high surgical volumes have achieved mortality rates below 2%, showcasing notable advancements in both short-term and long-term results. However, despite these strides, reported morbidity rates ranging from 30\u0026ndash;60% highlight the persistent high surgical risks associated with PD. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Noteworthy complications post-PD include postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postoperative hemorrhage (PPH), biliary leaks, and infections. Despite significant technological advancements and procedural modifications over the past decade, POPF remains a prevalent complication, occurring in 3\u0026ndash;45% of cases in high-volume hospitals conducting pancreatic resections. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] POPF stands out as the primary cause of mortality and morbidity following PD, representing the most formidable challenge associated with the procedure.\u003c/p\u003e \u003cp\u003eThe International Study Group of Pancreatic Surgery (ISGPS) defines POPF as drainage output containing any measurable fluid volume with an amylase level exceeding three times the upper limit of the institutional normal serum amylase activity, and this should be associated with a clinically significant condition directly linked to the fistula. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] The majority of patients with POPF are considered serious cases or clinically relevant in approximately 60% of instances, leading to prolonged hospital stays, additional therapies, and increased cost burdens. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] POPF can have severe consequences, including nutritional deficiencies, sepsis, abscess formation, and hemorrhage, highlighting the potentially life-threatening nature of this condition. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Currently, there is no universally endorsed approach for treating POPF. However, conservative management, particularly nutritional supplementation, is widely recognized as a standard of care. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]Moreover, nutritional support is considered an essential component of postoperative therapy, given the significant catabolic activity and compromised immune function in affected individuals.\u003c/p\u003e \u003cp\u003eWhile the optimal nutritional approach for patients with POPF remains uncertain, two perioperative nutrition methods, namely Enteral Nutrition (EN) and Total Parenteral Nutrition (TPN), have shown effectiveness in improving clinical outcomes and reducing postoperative complications. Early Enteral Nutrition (EEN) has particularly demonstrated significant efficacy in restoring immune function and lowering the risk of sepsis. EN involves delivering nutrients directly into the small intestine through a tube, either via the nasojejunal route or jejunostomy. Randomized controlled trials have affirmed the benefits of EN compared to parenteral nutrition, resulting in faster fistula closure rates and shorter durations of POPF. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]The decision to use feeding jejunostomy in patients experiencing POPF and DGE and its potential impact on early postoperative morbidity remains a topic of debate, given the known complications associated with its placement and usage. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] This study aimed to compare the effectiveness of enteral and parenteral feeding in treating POPF.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eThis Prospective analysis was conducted at the tertiary hospital in eastern India utilizing an observational prospective study design to compare the relative efficacy of enteral and parenteral feeding in the treatment of POPF. The study cohort comprised a total of 70 patients who had undergone classical PD between July 2019 and August 2023. Sample size determination was based on the assumption that 50% of patients would respond favourably to enteral feeding (p\u0026thinsp;=\u0026thinsp;0.5), for a 95% confidence level (Z\u0026thinsp;=\u0026thinsp;1.96) and a margin of error of 0.05 (5%) required sample size was calculated to be 69.\u003c/p\u003e \u003cp\u003eInstitute ethical committee approval was obtained before the study was started and informed written consent was obtained from all patients before including them in the study (IEC/1044). The study was conducted in accordance with the principles of Helsinki. Inclusion criteria comprised elective open or laparoscopic-assisted PD for non-metastatic PAC and carcinoma head of the pancreas (HOP). Exclusion criteria encompassed patients with locally advanced PAC, borderline resectable HOP, those requiring vascular resection, neuroendocrine tumors, and benign pathology. Patients who presented with preoperative bilirubin\u0026thinsp;\u0026gt;\u0026thinsp;15mg/dl and cholangitis underwent biliary drainage either endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD) in whom ERCP was not feasible. The majority of the patients underwent PD within 4 to 6 weeks after biliary drainage. The participants were randomly assigned to one of two groups using a table of random numbers with no specific preoperative criteria set for the decision to perform FJ. The first group underwent routine FJ placement, while the second group did not undergo FJ placement. The focus was on patients who developed POPF. A comprehensive range of variables were examined, including fistula duration, duration of drain placement, specifics of TPN, the need for imaging-guided intervention, complication rates assessed using the Clavien Dindo classification, length of hospital stay, treatment-related complications, additional cost implications, and 30-day mortality.\u003c/p\u003e \u003cp\u003eAfter fulfilling the inclusion criteria, patients were subjected to classical PD. LAPD included laparoscopic resection, mobilization, and lymphadenectomy followed by mini-laparotomy for specimen extraction and reconstruction. We initially performed open pancreaticoduodenectomy (OPD) in the initial two years and later transitioned to laparoscopic-assisted pancreaticoduodenectomy (LAPD). All surgeries were done by the same surgeon. All FJ was placed 30cm distal to gastrojejunal anastomosis using a 10Fr Ryle\u0026rsquo;s tube by modified Witzels technique. Drains were routinely placed near choledochojejunal anastomosis and pancreaticojejunal anastomosis. Patients with the FJ group are compared with other cohort groups in whom feeding jejunostomy is not routinely done. Postoperative parameters like drain effluent, volume, and drain fluid amylase on POD3 and POD5 were assessed. Nasogastric tube volume was ascertained, and patients were allowed on an oral diet in both cohorts and assessed for tolerability from POD 3. Patients who did not tolerate oral diet had a nasogastric tube reinserted, and a prokinetic agent started. The Group of cohorts with FJ was allowed to continue the feeds from POD3. Patients who are unable to tolerate oral feeds with no FJ were subjected to TPN. At our institute post -PD patients requiring TPN will receive a standardized 1 -L formulation, maximizing protein and calorie intake. This standard formula administers 70g protein and 35g fat for a total caloric intake of 1140kcal/L\u003c/p\u003e \u003cp\u003eAll patients were started on FJ feeds on POD3 initially with an isotonic solution and then subsequently increased according to individual patient needs. Energy and fluid requirements were calculated accordingly, taking into account the total body weight. Infusion of feed commenced at 500ml of half-strength feeds on day one and increased every day until the calculated target volume was reached (35 ml/kg body weight/day \u0026ndash; e.g. for a 70 kg patient\u0026thinsp;=\u0026thinsp;2000\u0026ndash;2500 kcal and 80\u0026ndash;85 g of protein per day). Intravenous crystalloids were reduced proportionally as the enteral feeding was increased and discontinued once the target rate of enteral feeding was achieved. The aim was to maintain this rate until oral intake was established. Enteral feeding was discontinued when a free oral intake had been achieved, usually by the end of day 6 or 7. The outcome was defined as successful if jejunostomy was used for enteral nutrition after surgery and discontinued when patients achieved adequate oral nutrition or were discharged home on supplementary jejunal feeding. All FJ tubes were removed postoperatively after 6 weeks.\u003c/p\u003e \u003cp\u003eComplications specific to TPN and central line related were noted (central line associated bloodstream infections (CLABSI), hyperglycaemia, liver function abnormalities and electrolyte abnormalities) .The complications related to feeding jejunostomy ( leak into the peritoneal cavity, tube dislodgement migration of tube outside the jejunal lumen, jejunal perforation, entero-cutaneous fistula, abscess (intra-abdominal or abdominal wall), tube block, tube detachment i.e. from anterior abdominal wall anchoring site, peritubular leak, and diarrhea.\u003c/p\u003e \u003cp\u003eStatistical analyses were performed using the IBM Statistical Package for the Social Sciences (SPSS software version 26.0, Armonk, NY). PD-related morbidity between the two groups was compared using a t-test. FJ placement and the duration of TPN requirement in the study group without FJ placement were analyzed. The Levene's test, with a significance level of p\u0026thinsp;\u0026le;\u0026thinsp;0.05, was employed to assess the assumption of equal variances. There were no missing patient data. Postoperative variables, including time of passing flatus, time of nasogastric tube (NGT) removal, time to oral intake, duration of fistula (in weeks), duration of the intra-abdominal drain (in days), and cost expenses (in USD United states dollar), were evaluated for intergroup comparisons.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable I compares demographic and operative parameters between patients with FJ (n\u0026thinsp;=\u0026thinsp;35) and those without FJ (n\u0026thinsp;=\u0026thinsp;35). No significant differences were found in age, gender distribution, BMI, ASA classification, haemoglobin, preoperative albumin, preoperative bilirubin levels, preoperative diagnosis (periampullary carcinoma vs. pancreatic head carcinoma), comorbidities (COPD, hypertension, diabetes). The proportion of patients who underwent preoperative biliary drainage was similar between the two groups .There were no significant differences in the rates of pancreas texture (intraoperative assessment) or duct diameter (measured on cross-sectional imaging) between the groups (p\u0026thinsp;=\u0026thinsp;0.811 and p\u0026thinsp;=\u0026thinsp;0.621). Additionally operative time, estimated blood loss, and number of blood transfusions were similar between the groups (p\u0026thinsp;=\u0026thinsp;0.221, p\u0026thinsp;=\u0026thinsp;0.117, p\u0026thinsp;=\u0026thinsp;0.624, respectively).\u003c/p\u003e \u003cp\u003eTable II compares postoperative complications between the two cohorts. POPF and DGE were the most common primary postoperative complications in both groups. Grade A DGE incidence was slightly lower in the FJ group compared to the non-FJ group (74.3% vs. 77.1%), while Grade B DGE incidence was slightly higher (40% vs. 28.6%). However, these differences were not statistically significant (p\u0026thinsp;=\u0026thinsp;0.314 and p\u0026thinsp;=\u0026thinsp;0.225, respectively).Grade B POPF accounted for 63.6% and 52.3% in both groups, respectively, with no significant difference. No instances of Grade C POPF were documented. Both superficial and deep surgical site infections showed comparable incidence rates between the groups. Eleven patients in the FJ group and nine patients in the non-FJ group required percutaneous image-guided pigtail drainage for intrabdominal collections. Additionally, one patient in the FJ group and two patients in the non-FJ group experienced bile leaks, all of which resolved with conservative management. Three cases of postoperative hemorrhage were identified, with two occurring in the FJ group. One patient underwent reexploration for bleeding from the mesenteric cut surface on postoperative day 2 (POD), while another underwent angiographic coil embolization for gastroduodenal artery stump bleeding on POD5. Similarly, one patient in the non-FJ group required reexploration for bleeding from the pancreatic cut margin near the pancreaticojejunal anastomosis on POD2. Clavien Dindo grade (\u0026ge;III) complications were observed in 12(34.3%) vs. 10 (28.6%)demonstrating no significant difference between the two groups.\u003c/p\u003e \u003cp\u003eTable III presents a comparative analysis of postoperative parameters between patients with and without FJ placement. The average time to pass flatus was 4 days in the FJ group and 5 days in the non-FJ group, showing no statistically significant difference (p\u0026thinsp;=\u0026thinsp;0.732). NGT removal occurred at an average of 3 days postoperatively in the FJ group, compared to 5 days in the non-FJ group. The average time to oral intake was 7.21 days in the FJ group and 8 days in the non-FJ group, demonstrating no statistically significant difference (p\u0026thinsp;=\u0026thinsp;0.099). However, the FJ group had a significantly shorter duration of fistula (3.92 weeks vs. 5.27 weeks, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and intra-abdominal drain placement (26.4 days vs. 34.9 days p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Although the duration of hospital stay was shorter in the FJ group (7days vs. 9 days), the difference was not statistically significant (p\u0026thinsp;=\u0026thinsp;0.212). There was one case of hospital mortality (2.9%) in the FJ group, while no mortality was reported in the non-FJ group. One mortality was recorded on POD 3 in a patient who underwent the operation for T3N2M0 with sepsis and disseminated intravascular coagulation. The readmission rates within 30 days were similar between the two groups, with 4 cases (11.4%) in each group (p\u0026thinsp;=\u0026thinsp;1.000) with the majority of patients presented with either poor oral intake, DGE, and wound-related issues all of which were managed conservatively. Two patients (5.7%) in the FJ group and one patient (2.9%) in the non-FJ group required reoperation within 30 days postoperatively, with no significant difference observed (p\u0026thinsp;=\u0026thinsp;0.555). The cost expenses were significantly lower in the FJ group (mean: \u003cspan\u003e$\u003c/span\u003e1005.3) compared to the non-FJ group (mean: \u003cspan\u003e$\u003c/span\u003e1308), demonstrating a significant difference (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eTable IV presents the duration of the FJ feed requirement with routine FJ placement and the TPN requirement with no FJ placement. Among the 35 cases with routine FJ placement, 12 patients (34.3%) required FJ feed for less than 7 days postoperatively, indicating early cessation of FJ feed. The majority of patients, 22 (62.9%), required FJ feed between POD 7 and POD 30. Only one patient (2.8%) required FJ feed beyond POD 30, suggesting an extended requirement for enteral nutrition support. Among the 35 cases without FJ placement, 14 patients (40%) did not require TPN postoperatively, indicating a successful transition to oral nutrition. Nine patients (25.7%) required TPN for less than 3 days postoperatively, eleven patients (31.4%) required TPN for a duration ranging from 4 to 10 days postoperatively. Only one patient (2.9%) required TPN for more than 10 days postoperatively. No complications were encountered with FJ and five patients with TPN had central line-related infections which necessitated removal and sent for culture, antibiotics were started as per the culture report and two patients presented with liver enzyme alterations with TPN.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePOPF continues to pose a significant challenge for pancreatic surgeons. Around 60% of POPF cases are considered serious, leading to delayed hospital discharge and additional treatments and cost burden.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Complications associated with POPF include fluid and electrolyte imbalances, nutritional depletion, sepsis, abscess formation, and hemorrhage, highlighting the potentially life-threatening consequences.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Although there is no universally accepted treatment for POPF, conservative approaches such as nutritional supplementation are widely adopted, given the high catabolic activity and compromised immunity observed postoperatively. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Low-output, uncomplicated fistulas are best managed conservatively, whereas those enduring for 6 to 8 weeks and complicated by septic complications typically necessitate a more assertive strategy involving endoscopic and radiological interventions. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe economic burden of managing POPF is substantial due to increased healthcare resource utilization and prolonged hospital stays. Nutritional status and PD morbidity are closely related. Thus, feeding strategies aiming for rapid closure with minimal complications are preferred. However, evidence supporting a specific strategy remains inconclusive. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] International guidelines recommend the oral diet in the early postoperative phase after PD even though not strongly supported in the existing literature. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Oral intake can stimulate the secretion of pancreatic juices, potentially exacerbating fistulas, while TPN bypasses this issue but may lead to negative long-term consequences. While some studies advocate for TPN due to high fistula closure rates, long-term usage can induce functional and morphological changes in liver and catheter related sepsis or thrombosis. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]Conversely, enteral nutrition has shown benefits in terms of faster fistula closure rates, but its use is associated with adverse events like ileus and aspiration pneumonia. Conflicting results have further complicated the debate, with some suggesting oral nutrition as a viable treatment option for POPF. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Our current study aimed to examine the two cohorts of patients one with FJ as a mode of enteral nutrition and the other without FJ placement with TPN as required in cases of POPF, to assess the impact of nutrition method on the outcomes following PD.\u003c/p\u003e \u003cp\u003eIn our study patients in both groups were similar in terms of baseline characteristics. The groups were well-matched, reducing the potential for bias in subsequent analyses comparing outcomes between FJ and non-FJ groups. Patients had similar disease presentations and severity. FRS risk score was also similar across the groups, indicating no increased risk of POPF formation in either group. The incidence of post operative complications like DGE and POPF were similar in both the groups. While there was a slight increase in Grade B DGE in the FJ group, it was not statistically significant. This corroborates with the findings of a meta-analysis by Adiamah et al.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] in which no statistically significant distinction was found in the relative risk of DGE between the two methods of nutritional delivery.\u003c/p\u003e \u003cp\u003eThe presence or absence of FJ placement also did not have a significant impact on the severity of POPF, with similar proportion of occurrence of Grade B POPF in both the groups in our study. These results also align with those of the meta-analysis conducted by Adiamah et al.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], indicating no significant disparity in the risk of POPF (RR 0.88) among patients undergoing PD who were administered either EN or TPN\u003c/p\u003e \u003cp\u003e. Consistent with the findings of the current study, other researchers have similarly observed no significant variances in the incidence of POPF across various nutritional pathways, such as EN and TPN.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] In a systematic review of five routes of nutrition after PD, there were no significant differences in the occurrence of POPF. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe incidence of SSIs, intraabdominal collections, bile leaks and PPH showed no significant difference in the FJ group and the proportion of severe post operative complications requiring intervention (Clavien Dindo\u0026thinsp;\u0026ge;\u0026thinsp;III) was comparable between patients with and without FJ placement. A meta analyses of 4 RCTs corroborated these findings, showing no significant differences in the occurrence of intra-abdominal complications and infections when comparing EEN with other nutritional routes. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWhile the results indicates that FJ placement does not significantly influence early postoperative outcomes such as the time to passing flatus and oral intake following PD, there are several noteworthy benefits associated with FJ placement. Patients with FJ placement demonstrated a significantly shorter duration of fistula and intra-abdominal drain placement, suggesting potential expedited resolution of postoperative complications common in PD. Klek et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] had similar results in their study where they found that EEN ( through nasojejunal tube) lead to higher closure rates and quicker fistula closure. Patients on EEN showed a 60% closure rate compared to 37% on TPN. EEN was associated with a higher odds ratio for fistula closure (2.571) and a shorter median time to closure (27 days) compared to TPN. The proposed reasoning is that enteral feeding not only avoids stimulating the pancreas but also triggers the release of specific gut peptides, creating a negative feedback loop that inhibits pancreatic secretion. This mechanism, mediated by peptides like PYY and GLP-1, acts as an \"ileal-brake\" to regulate pancreatic exocrine secretion, contributing to the suppression of pancreatic activity. [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn a study of 15,224 patients of PD with 7.5% had FJ placement experienced higher DGE, organ/space infection, re-operation, overall morbidity and longer hospital stays compared to those without FJ. However, there was no difference in mortality or readmission rate between the groups. Notably, in patients with DGE and POPF, FJ placement did not impact morbidity, mortality, length of stay, or readmission rate. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eEnteral nutrition, when compared to parenteral nutrition, is linked to reduced complications, shorter hospital stays, and a positive cost-benefit evaluation. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] However, a significant cost differential in our study favouring the FJ group suggests potential cost savings in managing postoperative complications, which holds significance for our resource limited patient community. Although it was not statistically significant, a trend towards shorter hospital stays was observed in the FJ group implying potential benefits in reducing healthcare burden. This study has several limitations, firstly, the relatively small sample size may limit the generalizability of the findings. Additionally, conducting the study at a single tertiary care center in East India may affect external validity due to regional practice variations. Moreover, the limited follow-up period may not address the long-term outcomes. Finally, despite random allocation of patients, unmeasured confounding factors may still influence the outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe routine use of FJ in PD does not significantly impact the incidence of major complications. Both enteral and parenteral nutrition strategies yield similar outcomes in terms of complications, length of hospital stay, and 30-day mortality. However, FJ placement is linked to shorter durations of fistula and intra-abdominal drain placement, indicating routine FJ can be a safe and cost-effective approach. Larger, multicenter trials are required to validate these findings and determine the optimal nutritional strategy following PD.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eInformed consent statement: Informed consent was taken from all participants involved in the study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval:\u0026nbsp;\u003c/strong\u003eThis study was conducted according to the guidelines of the Declaration of Helsinki and approved by Institute Ethical Board Committee, All India Institute of Medical Sciences, Patna, India. (Protocol code -IEC/1044)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssistance with the study:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial support and sponsorship:\u0026nbsp;\u003c/strong\u003eThis study needed no external funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003eAll authors declare no conflict of interest in the material, information, or techniques described.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Rohith Kodali and Dr. Kunal Parasar made the study conception and design. Dr. Rohith Kodali and Dr. Basant Narayan Singh collected the data, analyzed it, and compiled the data. Dr. Kislay Kant and Dr. Utpal Anand helped in analysis and interpretation of the data. Dr. Saad Anwar and Dr.Bijit Saha drafted and revised the manuscript. Dr. Rohith Kodali , Dr. Kunal Parasar and Dr. Utpal Anand helped with the proofreading. All authors finally reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eParray A, Bhandare MS, Pandrowala S, Chaudhari VA, Shrikhande SV (2021) Peri-operative, long-term, and quality of life outcomes after pancreaticoduodenectomy in the elderly: greater justification for periampullary cancer compared to pancreatic head cancer. 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Nutrients 5(2):608\u0026ndash;623. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/nu5020608\u003c/span\u003e\u003cspan address=\"10.3390/nu5020608\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable I- Comparision of demographic and operative parameters between two groups\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWith FJ (n=35)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWithout FJ \u0026nbsp;(n=35)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003eAge (mean\u0026nbsp;\u0026plusmn; SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e50.7\u0026plusmn; 10.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e51.0\u0026plusmn;15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.918\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003eGender(Male /Female)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; (n)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;25/10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e17/18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.051\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003eBMI\u003csup\u003ea\u003c/sup\u003e (Median, IQR)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e21 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e21(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.740\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003eASA\u003csup\u003eb\u003c/sup\u003e classification (n,%)\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eClass I\u003c/li\u003e\n \u003cli\u003eClass II\u003c/li\u003e\n \u003cli\u003eClass III\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e22 (62.9%)\u003c/p\u003e\n \u003cp\u003e13 (37.1%)\u003c/p\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20 (57.1%)\u003c/p\u003e\n \u003cp\u003e14 (40 %)\u003c/p\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.568\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003ePreoperative Albumin\u003c/p\u003e\n \u003cp\u003e(Median,\u0026nbsp;IQR)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e3.12 (0.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e3.32 (0.385)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.134\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003ePreoperative Hemoglobin\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(mean \u0026plusmn; SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e11.2\u0026plusmn;1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e11\u0026plusmn;1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.442\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003eJaundice (n,%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e33 (94.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e32 (91.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.643\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003ePreoperative Bilirubin\u003c/p\u003e\n \u003cp\u003e(Median,\u0026nbsp;IQR)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e13.2 (8.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e11.6(10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.605\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003ePreoperative Biliary drainage (n,%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e26 (74.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e23 (65.71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.434\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003eDiagnosis (n,%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003ePeriampullary Carcinoma\u003c/li\u003e\n \u003cli\u003ePancreatic Head Carcinoma\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e31 (88.5%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (11.4%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35 (100 %)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.522\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003eComorbidities\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eCOPD\u003csup\u003ec\u003c/sup\u003e (n,%)\u003c/li\u003e\n \u003cli\u003eHypertension (n,%)\u003c/li\u003e\n \u003cli\u003eDiabetes (n,%)\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (11.4%)\u003c/p\u003e\n \u003cp\u003e11(31.4%)\u003c/p\u003e\n \u003cp\u003e6 (17.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (8.5%)\u003c/p\u003e\n \u003cp\u003e7 (20%)\u003c/p\u003e\n \u003cp\u003e10 (28.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.690\u003c/p\u003e\n \u003cp\u003e0.274\u003c/p\u003e\n \u003cp\u003e0.255\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003eSoft pancreas (n,%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e17 (73.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e18 (51.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.811\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003eDuct diameter \u0026lt;3mm (n,%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e12 (34.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e14 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.621\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003eOperative time (in minutes)\u003c/p\u003e\n \u003cp\u003e(Median,\u0026nbsp;IQR)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e410 (70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e430 (83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.221\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003eEstimated Blood loss (in ml)\u003c/p\u003e\n \u003cp\u003e(Median,\u0026nbsp;IQR)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e300 (300)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e400 (250)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.117\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.94176372712146%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of Blood transfusions\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Median,\u0026nbsp;IQR)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.13144758735441%\" valign=\"top\"\u003e\n \u003cp\u003e1 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e1(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.624\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003ea- Body mass index, b- American Society of \u0026nbsp;Anaesthesiologists, c- Chronic obstructive pulmonary disease\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable II- Comparision of pancreaticoduodenectomy-related morbidity between two groups\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWith \u0026nbsp;(n=35)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003en(%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWithout FJ \u0026nbsp;(n=35)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003en(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003eDGE\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eGrade A\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGrade B\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e26 (74.3%)\u003c/p\u003e\n \u003cp\u003e14 (40%)\u003c/p\u003e\n \u003cp\u003e12 (34.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e27 (77.1%)\u003c/p\u003e\n \u003cp\u003e10 (28.6%)\u003c/p\u003e\n \u003cp\u003e17 (48.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003cp\u003e0.225\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003ePOPF\u003csup\u003eb\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGrade A\u003c/p\u003e\n \u003cp\u003eGrade B\u003c/p\u003e\n \u003cp\u003eGrade C\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e22 (62.8%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 \u0026nbsp; (36.3%)\u003c/p\u003e\n \u003cp\u003e14 (63.6%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e21 (60%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (47.6%)\u003c/p\u003e\n \u003cp\u003e11 (52.3%)\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.454\u003c/p\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003eSSI\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eSuperficial\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDeep\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e15 (42.9%)\u003c/p\u003e\n \u003cp\u003e11 (73.3%)\u003c/p\u003e\n \u003cp\u003e4. \u0026nbsp;(26.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e14 (40%)\u003c/p\u003e\n \u003cp\u003e9 \u0026nbsp; (64.2%)\u003c/p\u003e\n \u003cp\u003e5 \u0026nbsp; \u0026nbsp;(35.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.808\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003eBile leak\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e2 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.555\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003ePulmonary complications\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e3 (8.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e6 (17.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.284\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative haemorrhage\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e2 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.555\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003eAbdominal collections requiring drainage\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e11 (31.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e9 (25.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.597\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003eClavien Dindo Grade (\u0026nbsp;\u0026sup3;\u0026nbsp;III)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e12 (34.3%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e10 (28.6%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.699\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;a- Delayed gastric emptying, b- Postoperative pancreatic fistula, c- Surgical site infection\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable III- Comparison of postoperative parameters between two groups\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWith FJ (n=35)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWithout FJ \u0026nbsp;(n=35)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003eTime of passing flatus (POD\u003csup\u003ea\u003c/sup\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e4 \u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e5 \u0026plusmn;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.732\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003eTime of NGT\u003csup\u003eb\u003c/sup\u003e removal (POD\u003csup\u003ea\u003c/sup\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e3\u0026plusmn;2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e5\u0026plusmn;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.400\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003eTime to oral intake (POD\u003csup\u003ea\u003c/sup\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e7.21\u0026plusmn;0.699\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e8 \u0026plusmn;1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.099\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003eDuration of fistula (weeks)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e3.92 \u0026plusmn;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e5.27\u0026plusmn;0.786\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003eDuration of the intra-abdominal drain (days)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e26.4\u0026plusmn;5.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e34.9\u0026plusmn;5.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003eDuration of hospital stay (days)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e7\u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e9\u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.212\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003eHospital mortality\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003eReadmission (30-day)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e4 (11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e4 (11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003eReoperation (30-day)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e2 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.555\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003e30-day mortality\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e0.314\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.615640599001665%\" valign=\"top\"\u003e\n \u003cp\u003eCost expenses (USD\u003csup\u003ec\u003c/sup\u003e)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.45757071547421%\" valign=\"top\"\u003e\n \u003cp\u003e1005.3\u0026plusmn;62.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.29450915141431%\" valign=\"top\"\u003e\n \u003cp\u003e1308\u0026plusmn;68.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.632279534109816%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;a- Postoperative day, b- Nasogastric tube, c- United States Dollar \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable IV- Duration of FJ feed requirement with routine FJ placement and duration of TPN requirement with no FJ placement\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.678899082568805%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of FJ feed requirement with routine FJ placement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.321100917431195%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of cases(n=35)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.678899082568805%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; POD\u003csup\u003ea\u003c/sup\u003e 7\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.321100917431195%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.678899082568805%\" valign=\"top\"\u003e\n \u003cp\u003ePOD 7-POD 30\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.321100917431195%\" valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.678899082568805%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt; POD 30\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.321100917431195%\" valign=\"top\"\u003e\n \u003cp\u003e01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.678899082568805%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of TPN requirement with no FJ placement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.321100917431195%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of cases(n=35)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.678899082568805%\" valign=\"top\"\u003e\n \u003cp\u003eNot required\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.321100917431195%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.678899082568805%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 3days\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.321100917431195%\" valign=\"top\"\u003e\n \u003cp\u003e09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.678899082568805%\" valign=\"top\"\u003e\n \u003cp\u003e4-10\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.321100917431195%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.678899082568805%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026gt; 10\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.321100917431195%\" valign=\"top\"\u003e\n \u003cp\u003e01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ea- postoperative day\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pancreaticoduodenectomy, Feeding jejunostomy, Enteral nutrition","lastPublishedDoi":"10.21203/rs.3.rs-4481411/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4481411/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: Postoperative pancreatic fistula (POPF) poses a challenge to oral intake after Pancreaticoduodenectomy (PD). Various strategies such as enteral feeding via nasojejunal tube, feeding jejunostomy (FJ), and total parenteral nutrition , are employed to enhance postoperative nutrition. The routine adoption of FJ in PD remains a debatable topic. This study aims to assess and compare the efficacy of enteral feeding and parenteral nutrition in the management of POPF.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterial and methods\u003c/strong\u003e: Seventy patients who underwent classical PD at a tertiary care center in east India between July 2019 and December 2023 were randomly allocated \u0026nbsp;to FJ and non-FJ in 1:1 ratio. The primary end point was procedure related complications (POPF, delayed gastric emptying, post pancreatectomy hemorrhage , bile leak, Clavien Dindo grade ³3), length of hospital stay,additional costs, 30-day mortality and tube-related complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Out of 70 patients who underwent PD 35 received FJ as part of the standard care while the remaining 35 patients with no FJ. The majority of POPF cases were Grade B (40 vs 31.4%). Patients with Grade B POPF who underwent routine FJ placement exhibited shorter fistula durations (3.9 vs. 5.2 weeks, p\u0026lt; 0.001) and reduced intraabdominal drain durations (26.4 vs. 34.9 days, p\u0026lt;0.001). No differences were observed in the incidence of complications , reoperation, length of hospital stay readmission and 30-day mortality. No adverse complications were associated with FJ placement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: For PD patients requiring prolonged postoperative nutritional support due to POPF and DGE, routine FJ can be a safe and cost-effective approach.\u003c/p\u003e","manuscriptTitle":"Enteral Nutrition vs Parenteral Nutrition in the Management of Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy : A Prospective Observational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-14 05:36:40","doi":"10.21203/rs.3.rs-4481411/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ef3967ac-21e4-4388-a2aa-74556e06a232","owner":[],"postedDate":"June 14th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-09T04:31:27+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-14 05:36:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4481411","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4481411","identity":"rs-4481411","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}