Variations in the type of nutritional support provided after pancreatoduodenectomy: results from an international multicentre retrospective cohort study

doi:10.21203/rs.3.rs-2084792/v1

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Variations in the type of nutritional support provided after pancreatoduodenectomy: results from an international multicentre retrospective cohort study

https://doi.org/10.21203/rs.3.rs-2084792/v1

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published 28 Feb, 2024

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Background/Objectives: An early oral diet is recommended after pancreatoduodenectomy (PD), however, the nutritional management of PD patients is known to be highly variable, and some centres still provide postoperative parenteral nutrition (PN) routinely. A proportion of patients who receive PN experience clinically significant complications underscoring its judicious use. Using a multicentre cohort, this study aimed to determine the proportion of PD patients that received postoperative nutritional support (NS), describe the variations in this support, and investigate whether receiving PN correlated with morbidity.

Subjects/Methods: Data was extracted from the Recurrence After Whipple’s (RAW) study database, a retrospective study of patients undergoing PD for histologically confirmed pancreatic, ampullary or distal bile duct malignancy.

Results: 1323 patients (89.2%) had data on their postoperative NS status available. Of these, 45.4% received postoperative NS. This was “enteral only”, “parenteral only”, and “enteral and parenteral” in 44.3%, 35.2% and 20.5% of cases, respectively. Body mass index <18.5 kg/m² (p=0.03), absence of preoperative biliary stenting (p=0.009) and serum albumin <36 g/L (p=0.009) all correlated with receiving postoperative NS. Among those who did not develop a serious postoperative complication (Clavien-Dindo grade ≥IIIa), one-fifth received PN.

Conclusion: Being underweight, not undergoing preoperative biliary stenting and having a low preoperative serum albumin all correlated with receiving postoperative NS. A considerable number of patients who had an uneventful recovery received PN; this should be reserved for those who are unable to take an oral diet.

Pancreaticoduodenectomy

Pancreatic ductal carcinoma

Cholangiocarcinoma

Nutritional status

Nutritional support

Nutritionists.

Pancreatoduodenectomy (PD) is the surgical treatment of choice in fit patients with a resectable pancreatic head or periampullary malignancy. Although potentially curative, around half of PD patients experience a postoperative complication and mortality rates remain high compared to other major surgical procedures. To address this, efforts should be made to ensure appropriate perioperative care is provided in order to obtain the best possible surgical outcomes. Although not supported by strong evidence, international guidelines recommend that patients should receive an oral diet in the early postoperative phase after PD unless there is a contraindication(1). They can then benefit from the potential gains of early enteral nutrition(2) without being exposed to the risks associated with more invasive forms of postoperative nutritional support (NS)(3). Indeed, early enteral nutrition has been shown to correlate with reduced length of hospital stay and reduced rates of delayed gastric emptying (DGE)(4, 5). However, the nutritional management of PD patients is known to be highly variable (6–8) and some centres still provide parenteral nutrition (PN) routinely. A proportion of patients who receive PN experience serious complications (9), so it should only be provided when clinically indicated. We aimed to determine the proportion of PD patients that received postoperative NS using data from a large multicentre retrospective cohort study and to describe the nature of this support. In addition, we aimed to determine the number of patients that received PN and investigate whether receiving PN correlated with morbidity.

This international multicentre retrospective cohort study was approved by North West - Greater Manchester South Research Ethics Committee as part of the Recurrence After Whipple’s (RAW) study (20/NW/0397) and University Hospitals Plymouth NHS Trust Research and Development Department. The study was also approved by the research and development departments of all collaborating centres. This study adhered to the standards laid down in the Declaration of Helsinki (revised 2013). Patients were included if they underwent PD for histologically confirmed pancreatic ductal adenocarcinoma (PDAC), ampullary adenocarcinoma (AA) or cholangiocarcinoma (CC) at one of twenty-nine participating centres between 1st June 2012 and 31st May 2015. The study involved twenty units from the United Kingdom (UK), three from Spain, two from Italy, and one from Australia, Austria, Pakistan and Sudan (Appendix 1). An attempt was made to include all eligible patients. The end date of 31st May 2015 was selected so that five-year follow-up data was available for all included patients. Patients lost to follow-up before five years were excluded (patients who died within five-years were included). Data was collected locally at each participating unit from physical and electronic patient records. If unavailable locally, follow-up data was collected from referring hospitals or regional cancer networks to reduce attrition bias. A purpose-built electronic database was created using REDCap (v11.0.3, Nashville, TN). Data was entered locally by the participating centres. The following details were collected: demographics, comorbidities, neoadjuvant therapy (if given), selected preoperative blood results, procedure and intraoperative findings, postoperative management and complications, histology results and adjuvant treatment (if given).

For the purposes of this study, postoperative NS referred to either: “enteral nutrition (EN) only” (i.e., nasogastric (NG)/nasojejunal (NJ) feeding or oral nutritional supplement drinks), “parenteral only” (PN), or “EN and PN”. An unplanned return to theatre was defined as any emergency return to theatre during the index admission. An unplanned readmission was defined as any emergency presentation to hospital within 30-days of discharge which involved at least one overnight stay. See Supplementary Information for full definitions of surgical complications. Ileus was defined clinically and intra-abdominal collections were diagnosed using either computed tomography (CT) or ultrasound (US). All surgical complications were classified using the Clavien-Dindo classification of surgical complications(10). Patients were classified as having a “complication typically associated with a postoperative NS requirement” if they developed any of the following: clinically relevant (grade B and C) postoperative pancreatic fistula (CR-POPF), bile leak, gastro-jejunal anastomotic leak, DGE, chyle leak or postoperative ileus.

Statistical Methods

Categorical data are presented as frequency counts and associated percentages, and continuous data are presented as means, with standard deviation (SD), or medians, with interquartile range (IQR) (Table 1). The patients were compared according to binary groupings (see Table 2), and the proportion of patients in each group that received postoperative NS was compared using Fisher’s exact test. Patients who received postoperative NS were then compared to those who did not (Table 3). Univariate tests were performed between the groups for each comparison. For continuous outcomes (age, BMI) where assumptions of being generated according to a normal distribution, these were analysed using Student’s t-test. Binary outcomes were compared using Fisher’s exact test, whilst the Mann-Whitney U test was used to compare the heavily skewed data from blood tests (see table legends for specific details). Using the same methods, patients were compared to one another by the form of postoperative NS they received (if any). Finally, patients were divided into those who experienced a CD grade ≥ IIIa complication versus those who did not, and those who experienced a complication typically associated with a postoperative NS requirement versus those who did not. Comparisons were made using Fisher’s exact test. A p-value < 0.05 was considered statistically significant. Statistical analyses were performed using Microsoft Excel (v2103, Redmond, WA) and GraphPad Prism (v9.3.1, San Diego, CA).

Table 1

Summary of the 1323 patients who underwent pancreatoduodenectomy (PD) and had information on their postoperative nutritional support (NS) status available. ASA = American Society of Anesthesiologists, BMI = body mass index, CT = computed tomography, HDU = high dependency unit, ICU = intensive care unit, IQR = interquartile range, PG = pancreato-gastrostomy, PJ = pancreato-jejunostomy, SD = standard deviation. *Not included in percentages.
Mean age (years)	66.0 (SD: 9.8)
Female sex	579 (43.8%)
Mean BMI (kg/m²)	25.6 (SD: 4.4)	Unknown/not recorded: 525 (39.7%)
Preoperative biliary stent	857 (64.8%)
Received neoadjuvant chemotherapy	61 (4.6%)
Median preoperative serum bilirubin (µmol/L)	21 (IQR: 43)
Median preoperative serum albumin (g/L)	37 (IQR: 10)	Unknown/not recorded: 75 (5.7%)
ASA grade > II	465 (35.1%)	Unknown/not recorded: 1 (0.1%)
Type of PD performed	Classic Whipple: 660 (50.0%) Pylorus-preserving: 660 (50.0%)	Unknown/not recorded: 3*
Surgical approach	Open: 1,268 (98.4%) Laparoscopic: 9 (0.7%) Lap-assisted: 2 (0.2%)	Lap-open: 9 (0.7%) Unknown/not recorded: 35*
Procedure in addition to PD	77 (5.8%)
Pancreatic anastomosis	PJ: 1,039 (80.9%) PG: 246 (19.1%)	Unknown/not recorded: 38*
Venous resection performed	204 (15.4%)
Arterial resection performed	25 (1.9%)
Received an intraoperative blood transfusion	164 (18.1%)	Unknown/not recorded: 417*
Postoperative destination	Ward: 105 (8.1%) HDU/ICU: 1193 (91.9%)	Unknown/not recorded: 25*
Received postoperative NS	601 (45.4%)	Enteral only: 266 (44.3%) Parenteral only: 211 (35.2%) Enteral and parenteral: 123 (20.5%) Unknown/not recorded: 1*
Median length of stay (days)	13 (IQR: 10)	Unknown/not recorded: 65 (4.9%)
Unplanned return to theatre	71 (5.4%)
30-day readmission	134 (10.2%)	Unknown/not recorded: 3 (0.2%)
90-day mortality	51 (3.9%)

Table 2

Selected variables and the number of patients that received postoperative nutritional support (NS). Comparisons were made using Fisher’s exact test. *Denotes statistical significance.
Variable	Proportion who received post-op NS	p-value
Age (years) • < 75 vs ≥ 75	472/1067 (44.2%) vs 129/256 (50.4%)	0.081
Sex • Female vs male	251/579 (43.4%) vs 350/744 (47.0%)	0.182
Body mass index (kg/m²) • Underweight (< 18.5) vs ideal (18.5–24.9) • Ideal (18.5–24.9) vs overweight (≥ 25.0)	16/23 (69.6%) vs 165/365 (45.2%) 165/365 (45.2%) vs 209/410 (51.0%)	0.030* 0.114
Preoperative biliary stenting • Yes vs no	366/857 (42.7%) vs 233/464 (50.2%)	0.009*
Preoperative serum bilirubin (µmol/L) • < 40 vs ≥ 40	399/905 (44.1%) vs 202/418 (48.3%)	0.154
Preoperative serum albumin (g/L) • Low (< 36) vs normal (≥ 36)	258/507 (50.9%) vs 321/740 (43.3%)	0.009*
American Society of Anesthesiologists grade • <III vs >II	378/857 (44.1%) vs 223/465 (48.0%)	0.184
Type of pancreatoduodenectomy • Pylorus-resecting vs pylorus-preserving	291/660 (44.1%) vs 308/660 (46.7%)	0.376
Intraoperative blood transfusion • Yes vs no	84/164 (51.2%) vs 334/742 (45.0%)	0.166
Left theatre with a nasogastric tube in situ • Yes vs no	501/1005 (49.9%) vs 28/92 (30.4%)	0.0004*
Postoperative pancreatic fistula • Yes vs no	155/209 (74.2%) vs 446/1114 (40.0%)	< 0.0001*
Delayed gastric emptying • Yes vs no	129/167 (77.2%) vs 472/1156 (40.8%)	< 0.0001*
Intra-abdominal collection • Yes vs no	110/160 (68.8%) vs 491/1163 (42.2%)	< 0.0001*
Unplanned return to theatre • Yes vs no	55/74 (74.3%) vs 546/1249 (43.7%)	< 0.0001*

Table 3

Comparison of patients who did and did not receive postoperative nutritional support (NS) after pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC), ampullary adenocarcinoma (AA) or cholangiocarcinoma (CC). *Denotes statistical significance. **Excluding patients who died within 90-days of PD. ASA = American Society of Anesthesiologists, BMI = body mass index, IQR = interquartile range, NG = nasogastric. Statistical methods: Student’s t-test: age, BMI, Mann Whitney U test: blood tests, length of stay, Fisher’s exact test: all other comparisons.
Variable	Post-op NS (n = 601)	No post-op NS (n = 722)	p-value
Mean age (years)	66.3 (SD: 9.9)	65.6 (SD: 9.7)	0.148
Female sex	251 (41.8%)	328 (45.4%)	0.182
Mean BMI (kg/m²)	25.6 (SD: 4.5)	25.5 (SD: 4.3)	0.926
Preoperative diabetes	133 (22.2%)	141 (19.5%)	0.248
Preoperative cardiovascular comorbidity	291 (48.4%)	299 (41.4%)	0.012*
Preoperative respiratory comorbidity	75 (12.5%)	66 (9.1%)	0.060
Prior history of cancer (excluding PDAC/AA/CC)	74 (12.3%)	90 (12.5%)	1.00
Preoperative biliary stent	366 (60.9%)	491 (68.0%)	0.008*
Neoadjuvant chemotherapy received	21 (3.5%)	40 (5.5%)	0.087
Median preoperative serum bilirubin (µmol/L)	21.5 (IQR: 46)	20 (IQR: 40)	0.724
Median preoperative serum albumin (g/L)	37 (IQR: 11)	39 (IQR: 9)	0.0003*
ASA grade > II	223 (37.1%)	242 (33.5%)	0.184
Venous resection performed	90 (15.0%)	114 (15.8%)	0.701
Intraoperative blood transfusion	84 (20.1%)	80 (16.4%)	0.166
Left theatre with NG tube in situ	501 (94.7%)	504 (88.7%)	0.0004*
Postoperative pancreatic fistula	155 (25.8%)	54 (7.5%)	< 0.0001*
Postoperative bile leak	31 (5.2%)	12 (1.7%)	0.0005*
Gastrojejunal anastomotic leak	13 (2.2%)	7 (1.0%)	0.111
Postpancreatectomy haemorrhage	52 (8.7%)	32 (4.4%)	0.002*
Delayed gastric emptying	129 (21.5%)	38 (5.3%)	< 0.0001*
Intra-abdominal collection	26 (4.3%)	50 (6.9%)	0.044*
Unplanned return to theatre	55 (9.2%)	19 (2.6%)	< 0.0001*
Median length of stay (days)	11 (IQR: 7)	12 (IQR: 6)	0.017*
30-day readmission	77 (12.8%)	57 (7.9%)	0.003*
90-day mortality	29 (4.8%)	22 (3.0%)	0.114
Commenced adjuvant chemotherapy**	342 (59.8%)	451 (64.4%)	0.092

A total of 3705 patients were assessed for eligibility by the collaborating centres and 2212 were excluded as they did not meet the inclusion criteria (Fig. 1). The lead centre removed nine cases as their entries were incomplete and a further 161 cases were excluded as their records did not include data on whether or not postoperative NS was provided. The final analysis included 1323 patients. Table 1 summarises the included patients' demographics and treatment details. The mean patient age was 66.0 years (SD: 9.8), and the mean body mass index (BMI) was 25.6 kg/m² (SD: 4.4). In total, 43.8% were female and 35.1% were American Society of Anesthesiologists (ASA) grade > II. Concerning the surgical approach, 50.0% underwent a classic PD and 50.0% underwent a pylorus-preserving PD. The median length of stay was 13 days (IQR: 10 days) and the 30-day unplanned readmission rate was 10.2%. In all, 5.4% of patients had an unplanned return to theatre and 90-day mortality was 3.9%.

In total, 601 patients (45.4%) received postoperative NS. Of these, 44.3% received enteral-only support, 35.2% received parenteral-only support, and 20.5% received both enteral and parenteral support. The type of postoperative NS received was not recorded in one patient. Underweight patients (BMI < 18.5 kg/m²) more commonly received postoperative NS than patients with a normal BMI (18.5–24.9 kg/m², 69.9% vs 45.2%, p = 0.03) (Table 2). Patients who underwent preoperative biliary stenting (PBS) received postoperative NS less often (42.7% vs 50.2%, p = 0.009), as did those with a normal preoperative serum albumin (≥ 36 g/L, 50.9% vs 43.3%, p = 0.009). Patients who experienced POPF, DGE, intra-abdominal collection or an unplanned return to theatre all received postoperative NS more often (all p < 0.0001).

Table 3 compares patients who received postoperative NS to those who did not. The former more frequently had a cardiovascular comorbidity (48.4% vs 41.4%, p = 0.012) and had less often undergone PBS (60.9% vs 68.0%, p = 0.008). POPF (25.8% vs 7.5%, p < 0.0001), bile leak (5.2% vs 1,7%, p = 0.0005), DGE (21.5% vs 5.3%, p < 0.0001), post-pancreatectomy haemorrhage (8.7% vs 4.4%, p = 0.002), an unplanned return to theatre (9.2% vs 2.6%, p < 0.0001) and 30-day readmission (12.8% vs 7.9%, p = 0.003) were all significantly more common in the postoperative NS group. Patients who did not receive postoperative NS were no more likely to commence adjuvant chemotherapy (59.8% vs 64.4%, p = 0.092).

Table 4a compares patients by the type of postoperative NS they received and Table 4b compares patients who received EN only to those who received PN (with or without EN). Patients who received PN were more likely to have experienced POPF (34.4% vs 15.0%, p < 0.0001), an unplanned return to theatre (12.9% vs 4.5%, p = 0.0003) or 90-day mortality (7.2% vs 1.9%, p = 0.003). Length of stay and adjuvant chemotherapy rates were similar. Table 5a compares patients who experienced major morbidity (at least one Clavien-Dindo grade ≥ IIIa complication) to those who did not. Patients who experienced major morbidity were significantly more likely to have received postoperative NS (70.4% vs 40.3%, p < 0.00001). Both groups had a similar number of patients that received EN (17.3% vs 20.7%, p = 0.27). A significantly higher proportion of patients received PN (+/-EN) in the major morbidity group (49.6% vs 19.6%, p < 0.00001). In total, 215 patients (19.5%) who did not have a major complication documented received PN. Similarly, 131 patients (15.1%) who did not develop a complication typically associated with a requirement for postoperative NS still received PN (Table 5b).

Table 4: Type of postoperative nutritional support received, selected outcomes (A), and enteral vs parenteral nutrition (B). *Denotes statistical significance. **Excludes patients who died within 90-days of PD. NG = nasogastric. The type of nutritional support was unknown/not recorded in one patient (excluded from the above). Statistical methods: Mann Whitney U test: length of stay, Fisher’s exact test: all other comparisons.

	Type of postoperative nutritional support received
	Enteral only	Parenteral only	Enteral + parenteral	None
Number of patients	266	211	123	722
Left theatre with NG tube in situ	208 (94.5%)	187 (94.9%)	106 (94.6%)	504 (88.7%)
Postoperative pancreatic fistula	40 (15.0%)	68 (32.2%)	47 (28.2%)	54 (7.5%)
Median length of stay (days)	11 (IQR: 7)	11 (IQR: 7)	11 (IQR: 7)	12 (IQR: 6)
Unplanned return to theatre	12 (4.5%)	21 (10.0%)	22 (17.9%)	19 (2.6%)
90-day mortality	5 (1.9%)	17 (8.1%)	7 (5.7%)	22 (3.0%)
Commenced adjuvant chemotherapy**	159 (60.9%)	112 (57.7%)	71 (61.2%)	451 (64.4%)

	Type of postoperative nutritional support received
	Enteral only	Parenteral +/- enteral	p-value
Number of patients	266	334	N/A
Left theatre with NG tube in situ	208/220 (94.5%)	293/309 (94.8%)	1.00
Postoperative pancreatic fistula	40 (15.0%)	115 (34.4%)	<0.0001*
Median length of stay (days)	11 (IQR: 7)	11 (IQR: 6)	0.743
Unplanned return to theatre	12 (4.5%)	43 (12.9%)	0.0003*
90-day mortality	5 (1.9%)	24 (7.2%)	0.003*
Commenced adjuvant chemotherapy**	159 (60.9%)	183 (59.0%)	0.669

Table 5: Comparing patients who experienced at least one Clavien-Dindo (CD) grade ≥IIIa complication to those who did not (A), and patients who experienced a complication typically associated with a postoperative nutritional support (NS) requirement to those who did not (B). Comparisons were made using Fisher’s exact test. EN = enteral nutrition, PN = parenteral nutrition. The included complications are outlined in the methods section.

	CD ≥IIIa complication	No CD ≥IIIa complication	p-value
Number of patients	226 (17.1%)	1097 (83.0%)	N/A
Received post-op NS	159 (70.4%)	442 (40.3%)	<0.00001*
Received EN only	39 (17.3%)	227 (20.7%)	0.274
Received PN (+/- EN)	112 (49.6%)	215 (19.6%)	<0.00001*

	Complication typically associated with post-op NS	No complication typically associated with post-op NS	p-value
Number of patients	454 (34.3%)	869 (65.7%)	N/A
Received post-op NS	297 (65.4%)	304 (35.0%)	<0.00001*
Received EN only	93 (20.5%)	173 (19.9%)	0.829
Received PN (+/- EN)	203 (44.7%)	131 (15.1%)	<0.00001*

This retrospective study describes the variations in nutritional support received by 1323 PD patients. Although not supported by strong evidence, international guidelines recommend PD patients receive early oral diet unless this is contraindicated. However, over a quarter of the patients in our study received PN. Additionally, considerable numbers received PN when they had not experienced a significant postoperative complication (Clavien-Dindo grade ≥ IIIa), or a complication typically associated with a requirement for postoperative NS. Although we do not know why individual patients were given PN, one can speculate and assume that there was a group that received PN without a strong indication, exposing these patients to avoidable risks such as line infection/sepsis, or deep vein thrombosis(11). PN can also result in metabolic complications such as electrolyte imbalance, dysglycaemia, cholestasis, hypertriglyceridemia and deranged liver function(12). As such, PN should only be used when the gastrointestinal tract is either inaccessible or not functioning(13). The involvement of qualified nutrition professionals in the early postoperative period is key to selecting which patients require PN as part of their management.

Traditionally, patients who underwent major gastrointestinal surgery were kept nil by mouth in the early postoperative phase and they were often routinely given PN or fed via the jejunal route. However, these artificial feeding methods are not without risk and guidelines now recommend allowing patients to take an oral diet in the early postoperative phase if this is feasible(14, 15). Implementation of these guidelines has been shown to correlate with reduced length of stay and reduced incidence of DGE(4, 5). If a patient cannot tolerate an oral diet or if oral intake is likely to be inadequate for more than seven days, EN via the jejunal route is advised(16). To our knowledge, no recent large studies have described the type of postoperative NS received by PD patients as we have done. However, several authors have compared the outcomes of patients receiving different types of postoperative NS. Takagi et al. recently performed a systematic review of 20 randomised controlled trials (RCTs) where, compared to PN, the safety and tolerability of EN following PD was demonstrated(17). Indeed, the authors highlighted that early oral intake with systemic nutritional support is essential to the enhanced recovery after surgery (ERAS) concept(17). Whilst patients who received EN had reduced length of stay compared to those who received PN (length of stay was similar in our study), the authors suggested that the effect of EN on postoperative complications was controversial. They concluded that postoperative EN should be selectively provided to PD patients and that preoperative EN should only be provided to patients with severe malnutrition(17).

Kapoor et al. recently conducted a retrospective analysis of 562 PDs from a single Indian institution and 18.7% received postoperative NS(18). Whilst our figure of 45.4% was considerably higher, this included patients that received oral nutritional supplements only. In the Indian study, a tube jejunostomy was performed in 8.2% of patients, PN was provided for 14.8% and a NJ tube was placed in 4.9%. Increasing age, low preoperative serum albumin (< 3.0 g/dL) and high intraoperative blood loss were all independently associated with receiving postoperative NS. Low preoperative serum albumin and preoperative gastric outlet obstruction were predictors of requiring prolonged nutritional support(18). The authors concluded that a pre-emptive jejunostomy should be considered in patients with these risk factors. This is particularly relevant to patients with preoperative gastric outlet obstruction as a chronically dilated stomach regains its tone gradually. Hence, patients with this condition are likely to have poor tolerance to oral diet in the early postoperative period. Indeed, preoperative gastric outlet obstruction has been shown to correlate with postoperative DGE(19). This is also relevant in patients with very low serum albumin since this is associated with high morbidity rates and prolonged admission(20).

In our study, patients who experienced significant morbidity received PN more often. However, a considerable proportion of those who did not develop a serious complication still received PN. This contrasts with current guidelines which suggest patients should take an oral diet at will unless this is contraindicated. Similarly, over 15% of those who did not develop a complication typically associated with a postoperative NS requirement received PN. Whilst we do not know why PN was provided in each case, one could speculate and argue that this figure is too high. There were probably a group of patients that received PN inappropriately. These patients may have missed out on the potential benefits of early EN(2) whilst being subjected to the risks associated with an indwelling catheter and PN(3).

Our study has several limitations. Firstly, it is retrospective, so both recall bias and inadequate clinical documentation may have affected our findings. Although, after initial screening, a large proportion of patients were excluded, almost all were excluded for a valid reason. Of those excluded after the initial screen, just 18.2% were excluded because they were lost to follow-up or because their clinical records were lost/destroyed/no longer available. Further, standard practice will likely have differed between the included units. Whether or not postoperative NS was provided, and how this was provided, was entirely at the discretion of the treating team and no patients were included/excluded due to variations in practice. Also, we did not know the preoperative nutritional status of the included patients or the reason postoperative NS was provided to individual patients, i.e., whether this was routine practice or due to preoperative malnutrition or postoperative complications. As such, we can only comment on patterns of postoperative NS and cannot accurately identify risk factors for requiring postoperative NS. Our dataset does not contain the specific details of the postoperative NS provided, e.g., timing, dosing, or length of treatment. In addition, because of the way the data was collected, patients who were given oral nutritional supplements only will have been categorised as receiving postoperative NS. We could not distinguish these patients from those fed via the NG/NJ route. Furthermore, whilst we have a comprehensive complication profile for the patients involved, we cannot determine which complications resulted from postoperative NS. Therefore, we are unable to estimate the risks of postoperative NS. Finally, our data is historic and we accept that practice will have evolved. However, our study is a multicentre international study demonstrating that many PD patients receive PN when this may not be the optimal feeding method.

In conclusion, 45.4% of patients who underwent PD for pancreatic, ampullary or bile duct cancer received some form of postoperative NS and most of these received PN. Being underweight, not undergoing preoperative biliary stenting and having a low preoperative serum albumin all correlated with receiving postoperative NS. One-fifth of patients who did not experience a significant postoperative complication received PN. It may be that some of these patients were given PN unnecessarily. PD patients should undergo pre- and early postoperative nutritional assessment and have a nutritional treatment plan agreed in advance of surgery. This will likely increase the proportion that receives the most appropriate form of postoperative NS and result in marginal gains to surgical outcomes.

Data availability statement

The data supporting this study's findings are available in an anonymised format from the corresponding author upon reasonable request.

Acknowledgements

We would like to thank all those who contributed towards the Recurrence After Whipple’s (RAW) study.

Author contribution statement

Conceptualisation: TR, PL, PM, SA; Data collection: all authors; Formal analysis: TR, Funding acquisition: N/A; Investigation: all authors; Methodology: all authors; Project administration: TR, PL; Resources: all authors; Software: all authors; Supervision: SA; Validation: SA; Visualisation: all authors; Writing – original draft: TR; Writing – review and editing: all authors.

Funding

Nil.

Ethical approval

Competing interests

All authors declare that there are no competing interests.

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Variations in the type of nutritional support provided after pancreatoduodenectomy: results from an international multicentre retrospective cohort study

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