Comparison Of Postoperative Feeding Routes After Pancreaticoduodenectomy

Objective:Various postoperative feeding routes have been established and studied to improve patients’postoperative recovery after pancreaticoduodenectomy (PD). However, it still remains controversial about which route has the best efficacy and least incidence of postoperative complications. Meanwhile, there hasn’t been any quantitative meta-analysis or network meta-analysis to systematically review all the relevant randomized controlled trials (RCTs) published by now. We therefore performed a network meta-analysis to compare all the well-established and studied postoperative feeding routes after pancreaticoduodenectomy which have been published.Methods:We systematically searched PubMed, Embase, the Cochrane Library and finally found 12 RCTs published from 1994 to 2014, which respectively compared two or three of the 12 following feeding routes affecting patients’postoperative recovery:routine enteral feeding via a jejunostomy tube (JT), routine enteral feeding via a nasojejunal tube (NJT), total parenteral nutrition (TPN), early oral diet (Oral), JT combined with parenteral nutrition (JT+PN), NJT combined with parenteral nutrition (NJT+PN), cyclic enteral feeding via a jejunostomy tube (Cyclic JT), cyclic enteral feeding via a nasojejunal tube (Cyclic NJT), NJT combined with immune-enhancing parenteral nutrition (NJT+ImmuPN), immune-enhancing oral diet before surgery combined with postoperative immune-enhancing enteral feeding via a gastrojejunostomy tube (preOral+ImmuGJT), immune-enhancing enteral feeding via a gastrojejunostomy tube (ImmuGJT), immune-enhancing enteral feeding via a jejunostomy tube (ImmuJT). The main observational outcomes were postoperative complications and postoperative hospital stay. Analysis was done on an intention-to-treat basis.Results:By using the index of surface under the cumulative ranking curve (SUCRA) calculated within a Bayesian framework in WinBUGS, we ranked different feeding route under each observational outcome. After a comprehensive analysis of rank information, we found out that ImmuJT, Cyclic JT, preOral+ImmuGJT and NJT+PN showed obvious advantage of decreasing incidence of postoperative complications among all the 12 feeding methods, while TPN and ImmuGJT showed obvious disadvantage for patients’recovery from PD. As a controversial issue of whether postoperative early oral intake could benefit, our results showed that Oral was favored only under observational outcomes of major complications defined by Clavien-Dindo classification and sepsis with SUCRA values of 79.0 and 63.1, while was disfavored under observational outcomes of minor complications defined by Clavien-Dindo classification, infectious complications and pneumonia with SUCRA values of 35, 21.1 and 27.9. Considering sepsis could also belong to severe complications as major complications and patients who were able of using early oral diet were themselves in good physical conditions resulting in low incidence of severe complications, we inferred that feeding method of Oral was not favored, especially in terms of relevance to high incidence of minor infectious complications including pneumonia. Oddis ratios (ORs) of pairwise comparisons of all procedures on all outcomes of complications calculated also within a Bayesian random effects model showed no statistically significant difference except comparisons of TPN vs. preOral+ImmuGJT under outcome of infectious complications (125.1,95% credibility interval 1.671 to 774.6), Oral vs. preOral+ImmuGJT under outcome of infectious complications (175.7, 1.354 to 1098), preOral+ImmuGJT vs. ImmuGJT under outcome of infectious complications (0.1134,0.0011 to 0.6478), preOral+ImmuGJT vs. ImmuGJT under outcome of wound infection (0.1166,0.0001 to 0.7724), TPN vs. ImmuJT under outcome of digestive bleeding (14.05,1.378 to 66.42), which explained that addition of preoperative immune-enhancing oral nutrition could reinforce postoperative nutrition for better outcomes. What’s more, ImmuJT and preOral+ImmuGJT were quite better than TPN or Oral as concluded from that, which was consistent with the ranking results mentioned above. Besides, we found out that ranking results, especially those ranking results of JT, NJT+ImmuPN, Cyclic NJT and JT+PN under outcomes of bleeding-related and bleeding-irrelevant complications were almost completely opposite, which reminded us that postoperative bleeding-relevant and bleeding-irrelevant complications were quite different and should be preciously distinguished in clinical studies. We suggested that patients who had tendency of postoperative bleeding and those who didn’t have such tendency should be verified and distinguished for different proper feeding method.Conclusion:As derived from calculations within our network meta-analysis, ImmuJT, Cyclic JT, preOral+ImmuGJT and NJT+PN were among the best postoperative feeding routes for patient’s recovery after PD, while TPN and ImmuGJT were among the worst. Other results showed inconsistence of the rest feeding methods under different observational outcomes of postoperative complications. Among them, Oral showed unfit in terms of minor complications and infectious complications including pneumonia. JT, NJT+ImmuPN, Cyclic NJT and JT+PN showed significant opposite effects under outcomes of bleeding-relevant complications compared to bleeding-irrelevant complications, which reminded us that bleeding and non-bleeding complications might be quite different not only in clinical manifestation but also in underlying mechanism. Thus, we should remark such difference and distinguish patients with or without tendency of postoperative bleeding to using different way of postoperative nutrition support for the best individual clinical outcomes. After all, more RCTs compared these feeding routes are needed for further confirmation and deeper exploration.