j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 3 6 1 e3 6 6
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Feeding jejunostomy during Whipple is associated with increased morbidity James C. Padussis, MD,* Sabino Zani, MD, Dan G. Blazer, MD, Douglas S. Tyler, MD, Theodore N. Pappas, MD, and John E. Scarborough, MD Department of Surgery, Duke University Medical Center, Durham, North Carolina
article info
abstract
Article history:
Background: Placement of a feeding jejunostomy tube (FJ) is often performed during pan-
Received 27 June 2012
creaticoduodenectomy (PD). Few studies, however, have sought to determine whether such
Received in revised form
placement affects postoperative outcomes after PD.
16 September 2012
Materials and methods: This is a retrospective analysis of the National Surgical Quality
Accepted 10 October 2012
Improvement Program (NSQIP) database to determine the 30-d-postoperative mortality rate,
Available online 25 October 2012
major complication rate, and overall complication rate of jejunostomy tube placement at the time of PD. Univariate and multivariate comparison of postoperative outcomes between
Keywords:
patients with and without FJ placement during PD was performed on a total of 4930 patients.
Pancreaticoduodenectomy
Results: Thirty-day-postoperative mortality did not differ between the two groups (4.0% for
Feeding jejunostomy
patients with FJ versus 2.7% without, P ¼ 0.13), whereas overall morbidity (43.3% with FJ versus 34.6% without, P < 0.0001) and serious morbidity (29.5% with FJ versus 22.8% without, P < 0.0001)
NSQIP
were significantly higher in patients undergoing FJ placement during PD. The specific complications that occurred more frequently in FJ patients than patients without FJ included deep space surgical site infection, pneumonia, unplanned reintubation, acute renal failure, and sepsis. Conclusion: Although FJ placement during PD is considered to be routine at many institutions, our analysis of data from NSQIP suggest that FJ placement may be associated with increased postoperative morbidity. ª 2014 Elsevier Inc. All rights reserved.
1.
Introduction
Although enteral nutrition is strongly preferred to parenteral nutrition in the early postoperative period after pancreaticoduodenectomy (PD), or Whipple procedure, a subset of patients will develop complications such as delayed gastric emptying or pancreatic fistula that preclude or limit their ability to achieve adequate caloric intake orally [1e4]. Because these complications cannot be predicted a priori, some surgeons will routinely place feeding jejunostomy (FJ) catheters
in all of their PD patients in an effort to ensure that those patients who do go on to develop delayed gastric emptying or pancreatic fistula will still have a route available for enteral nutrition [5]. Given the known constellation of complications that can occur with FJ catheter placement and use, however, it is not clear whether the inclusion of this adjunctive procedure impacts the incidence of early postoperative morbidity associated with PD [6,7]. The objective of our analysis was to compare the early postoperative outcomes of patients undergoing PD with and without concurrent FJ tube placement.
* Corresponding author. Department of Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710. Tel.: þ1 919 450 5559. E-mail address: [email protected] (J.C. Padussis). 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2012.10.010
362
2.
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 3 6 1 e3 6 6
Materials and methods
The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) participant user files for 2005 through 2009 were used for this retrospective analysis. All patients with a primary Current Procedure Terminology code for PD (48150, 48152, 48153, 48154) and postoperative International Classification of Diseases, Ninth Revision diagnosis codes for non-endocrine malignant (152, 156.1, 156.2, 156.8, 156.9, 157, 157.1, 157.2, 157.3, 157.8, 157.9, or 197.4) or benign (211.2, 211.5, 211.6, or 230.8) neoplasm of the extrahepatic biliary tree, duodenum, ampulla of Vater, or non-islet pancreas were included for potential analysis. Patients were excluded if their procedure was designated as an emergency, or if they underwent a concomitant resection procedure at the time of PD (for example, colectomy, nephrectomy, hepatectomy other than wedge biopsy, or hysterectomy). The primary outcome measures for our analysis were 30-dpostoperative mortality rate, major complication rate, and overall complication rate. Patients were considered to have sustained a major postoperative complication if they developed one or more of the following: organ/space surgical site infection, wound dehiscence, postoperative neurologic deficit (including stroke or coma greater than 24 h), cardiac arrest requiring cardiopulmonary resuscitation, myocardial infarction, bleeding requiring transfusion, pulmonary embolism, ventilator dependence for greater than 48 h, progressive renal insufficiency, acute renal failure, sepsis, or septic shock. Patients were considered to have sustained any complication if they developed one or more of the following: major complication (defined above), superficial surgical site infection, deep surgical site infection, pneumonia, unplanned intubation, peripheral nerve injury, graft/prosthesis failure, urinary tract infection, or deep venous thrombosis. Secondary outcome measures for our analysis included incidence of specific complications, reoperation rate, and postoperative length of hospital stay. The primary predictor variable for our analysis was placement of an FJ tube during PD, as indicated by the inclusion of CPT codes 44300 or 44015. Other predictor variables included malignant versus benign tumor, patient age, sex, body mass index, American Society of Anesthesiologists (ASA) physical status classification of 3 or greater, diabetes mellitus requiring therapy with non-insulin agents or insulin, current smoker within 1 y of operation, greater than two drinks of ethanol per day in the 2 wk prior to admission, dyspnea upon moderate exertion or at rest, partially or totally dependent functional status prior to surgery, ascites, esophageal varices, congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease (including history of myocardial infarction within the past 6 mo, prior percutaneous coronary intervention, prior cardiac surgery, and/or history of angina within 30 d prior to surgery), peripheral vascular disease (including history of revascularization or amputation for peripheral vascular disease and/or rest pain/gangrene), renal disease (including acute renal failure within 24 h prior to surgery and/ or need for dialysis within 2 wk prior to surgery), neurologic disease (including impaired sensorium, coma, hemiplegia/ hemiparesis, history of transient ischemic attacks, stroke with
neurologic deficit, tumor involving central nervous system, paraplegia/paraparesis, and/or quadriplegia/quadriparesis), preoperative wound infection, disseminated cancer, steroid use within 30 d prior to surgery for a chronic medical condition, chemotherapy for malignancy within 30 d prior to surgery, radiotherapy for malignancy within 90 d prior to surgery, or preoperative systemic inflammatory release syndrome (SIRS), sepsis, or septic shock. Several intraoperative variables were included as potential predictors of outcomes because of their potential reflection of overall procedure complexity. These variables included need for intraoperative transfusion, operative time, and incisional wound classification. Using the entire sample of NSQIP patients undergoing PD for neoplastic disease, analysis of the preoperative and intraoperative characteristics of patients undergoing PD with and without concomitant FJ tube placement was performed using Pearson c2 tests for categorical variables and MannWhitney rank sum tests for continuous variables. To account for the possibility that the decision to place an FJ tube was not random, one-to-one propensity matching techniques without replacement were used to create a cohort of PD patients with and without FJ tubes who were matched for known preoperative and intraoperative variables. Specifically, a nonparsimonious logistic regression model was created to estimate the likelihood of having an FJ tube placed intraoperatively. Both preoperative patient characteristics and intraoperative procedural characteristics were included as predictor variables in this model in order to adjust for patient condition and complexity of the index PD procedure. A propensity score for placement of an FJ tube ranging from 0 to 1 was then calculated for each patient using the logit coefficients for the predictors of FJ tube placement. These propensity scores were then used to create two groups of patients matched on their propensity for having an FJ tube placed, using a caliper matching algorithm with a caliper distance of 0.005 and with controls being used only once in the matching. Comparison of the preoperative and intraoperative characteristics of the matched cohort of patients was then performed using Wilcoxon signed rank tests for continuous variables and McNemar c2 tests for categorical variables. Primary and secondary outcome measures between the matched cohorts were compared in a similar manner. All statistical analyses were performed using Stata version 11.0 (StataCorp, College Station, TX).
3.
Results
A total of 4930 patients meeting our inclusion and exclusion criteria were included for analysis: 633 (11.9%) who had an FJ tube placed during PD (FJ group) and 4297 (87.2%) who did not (No FJ group). As shown in Table 1, there were many significant differences between patients with and without FJ tubes when analyzing the entire NSQIP sample of PD patients. Patients in the FJ group were more likely to be nonwhite, more likely to have preoperative renal dysfunction, more likely to have a final diagnosis of a benign tumor, and more likely to require intraoperative transfusion. There was no significant difference
363
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 3 6 1 e3 6 6
Table 1 e Preoperative and intraoperative characteristics for entire NSQIP sample of PD patients, stratified by FJ tube placement. Preoperative or intraoperative variable
Age, y (mean SD) Female White Body mass index, kg/m2 (mean SD) ASA classification 3 Diabetes mellitus Tobacco use Heavy ethanol use Dyspnea Nonindependent functional status On mechanical ventilation Chronic obstructive pulmonary disease Preoperative pneumonia Ascites Esophageal varices Congestive heart failure Coronary artery disease Peripheral vascular disease Hypertension Renal disease Neurologic disorder Disseminated cancer Preoperative infected wound Steroids Weight loss Bleeding disorder Preoperative transfusion Chemotherapy in past 30 d Radiotherapy in past 90 d Preoperative sepsis/SIRS/septic shock Malignant tumor Nonclean Incisional wound Operative time, min (mean SD) Intraoperative packed red blood cell transfusion
All patients in NSQIP sample No FJ tube (n ¼ 4297, 87.2%)
FJ tube (n ¼ 633, 12.8%)
P value
65.4 11.9 2090 (48.6%) 3437 (80.0%) 26.8 6.0 223 (5.2%) 1012 (23.6%) 873 (20.3%) 137 (3.2%) 362 (8.4%) 15 (0.4%) 2 (0.1%) 177 (4.1%) 7 (0.2%) 28 (0.7%) 1 (0.02%) 15 (0.4%) 506 (11.8%) 69 (1.6%) 2317 (53.9%) 14 (0.3%) 237 (5.5%) 80 (1.9%) 36 (0.8%) 76 (1.8%) 877 (20.4%) 102 (2.4%) 2 (0.1%) 71 (1.7%) 112 (2.6%) 94 (2.2%) 1891 (44.0%) 386 (9.0%) 377 125 1311 (30.5%)
66.1 11.5 313 (49.5%) 470 (74.3%) 26.7 5.7 40 (6.3%) 166 (26.2%) 119 (18.8%) 19 (3.0%) 66 (10.4%) 3 (0.5%) 2 (0.3%) 33 (5.2%) 1 (0.2%) 2 (0.3%) 0 (0%) 4 (0.6%) 84 (13.3%) 6 (1.0%) 359 (56.7%) 6 (1.0%) 39 (6.2%) 10 (1.6%) 5 (0.8%) 15 (2.5%) 134 (21.2%) 17 (2.7%) 1 (0.2%) 14 (2.2%) 22 (3.5%) 19 (3.0%) 248 (39.2%) 63 (10.0%) 367 116 235 (37.1%)
0.21 0.7 0.001 0.54 0.24 0.14 0.37 0.8 0.1 0.63 0.03 0.2 0.98 0.31 0.7 0.28 0.28 0.21 0.19 0.02 0.51 0.62 0.9 0.19 0.66 0.63 0.29 0.31 0.21 0.2 0.02 0.43 0.06 0.001
between the two groups in the proportion of patients with preoperative weight loss or the overall operative time. When considering the entire NSQIP sample of patients, there was no significant difference on univariate analysis in the 30-d-postoperative mortality rate of FJ patients versus No FJ patients (4.0% versus 2.7%, P ¼ 0.09), although FJ patients did have a significantly higher incidence of major complications (29.5% versus 22.8%, P < 0.0001) and overall complications (43.3% versus 34.6%, P < 0.0001). To adjust for potentially important baseline differences between the No FJ and FJ groups from the entire NSQIP sample, we used propensity matching techniques to create a smaller cohort of patients in whom detectable baseline differences were minimized. As shown in Table 2, these techniques resulted in a smaller cohort of No FJ and FJ patients who were well matched for all of the preoperative and intraoperative variables that we included in our analysis. Table 3 shows the postoperative outcomes of No FJ and FJ patients in the propensity-matched cohort. The overall morbidity rate was significantly higher in FJ patients (43.3% versus 34.0%, odds ratio 1.46 [1.16e1.85], P ¼ 0.001), as was the major complication rate (29.5% versus 23.8%, 1.34 [1.04e1.75], P ¼ 0.03). There was no difference between the two groups,
however, in 30-d-postoperative mortality. A review of specific complications revealed the FJ group to have higher rates of postoperative deep surgical site infection, pneumonia, unplanned reintubation, acute renal failure, and sepsis (Table 3). The proportion of patients requiring reoperation did not differ significantly between the two groups, although patients in the FJ group did have a longer length of postoperative hospitalization.
4.
Discussion
In this analysis of 4930 patients with pancreatic neoplasms, we demonstrate that the concurrent placement of an FJ catheter during PD is associated with a significant increase in early postoperative morbidity and length of postoperative hospitalization. Although our use of ACS NSQIP subjects in our study has several important limitations, our findings nevertheless suggest that FJ catheters should be placed selectively, and not routinely, in patients who require PD for neoplastic disease. The fact that only 11.9% of PD patients in our analysis underwent concurrent FJ catheter placement during PD
364
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 3 6 1 e3 6 6
Table 2 e Preoperative and intraoperative characteristics for propensity-matched cohort of PD patients, stratified by FJ tube placement. Preoperative or intraoperative variable
Age, y (mean SD) Female White Body mass index, kg/m2 (mean SD) ASA classification 3 Diabetes mellitus Tobacco use Heavy ethanol use Dyspnea Nonindependent functional status On mechanical ventilation Chronic obstructive pulmonary disease Preoperative pneumonia Ascites Esophageal varices Congestive heart failure Coronary artery disease Peripheral vascular disease Hypertension Renal disease Neurologic disorder Disseminated cancer Preoperative infected wound Steroids Weight loss Bleeding disorder Preoperative transfusion Chemotherapy in past 30 d Radiotherapy in past 90 d Preoperative sepsis/SIRS/septic shock Malignant tumor Nonclean incisional wound Operative time, min (mean SD) Intraoperative packed red blood cell transfusion
Cohorts matched on propensity for FJ tube placement No FJ tube (n ¼ 623)
FJ tube (n ¼ 623)
P value
65.9 11.4 299 (48.0%) 475 (76.2%) 26.9 6.7 34 (5.5%) 173 (27.8%) 124 (19.9%) 22 (3.5%) 64 (10.3%) 0 (0%) 1 (0.2%) 34 (5.5%) 2 (0.3%) 1 (0.2%) 0 (0%) 4 (0.6%) 78 (12.5%) 5 (0.8%) 348 (55.9%) 4 (0.6%) 35 (5.6%) 6 (1.0%) 4 (0.6%) 21 (3.4%) 153 (24.6%) 15 (2.4%) 2 (0.3%) 17 (2.7%) 31 (5.0%) 17 (2.7%) 244 (39.2%) 55 (8.8%) 368 120 246 (39.5%)
66.1 11.5 306 (49.1%) 467 (75.0%) 26.7 5.7 38 (6.1%) 163 (26.2%) 118 (18.9%) 19 (3.1%) 64 (10.3%) 2 (0.3%) 1 (0.2%) 32 (5.1%) 1 (0.2%) 2 (0.3%) 0 (0%) 3 (0.5%) 81 (13.0%) 6 (1.0%) 352 (56.5%) 6 (1.0%) 36 (5.8%) 9 (1.4%) 4 (0.6%) 16 (2.6%) 132 (21.2%) 17 (2.7%) 1 (0.2%) 13 (2.1%) 22 (3.5%) 19 (3.1%) 245 (39.3%) 63 (10.1%) 366 115 229 (36.8%)
0.91 0.73 0.63 0.57 0.72 0.57 0.72 0.75 0.99 0.5 0.99 0.90 0.99 0.99 0.99 0.99 0.86 0.99 0.86 0.75 0.99 0.61 0.99 0.51 0.2 0.86 0.99 0.58 0.26 0.87 0.99 0.51 0.94 0.32
suggests that the practice of routinely placing these catheters is not pervasive, although previous investigators have found the incidence of concurrent feeding catheter placement to be more common [7]. For example, Yermilov et al. found that 23% of 1873 PD patients from the 1994e2003 California Cancer Registry underwent concurrent enterostomy tube placement [8]. Other single-center studies, meanwhile, have shown the incidence of concurrent jejunostomy tube placement during pancreatic resections to be as high as 48%e57% [7,9,10]. Potential reasons for the seemingly low rate of concurrent FJ catheter placement in our study are that our data source contains information from over 250 participating hospitals and encompasses a later time period than previous studies. The relatively low rate of FJ catheter placement in our analysis may reflect a temporal trend toward less frequent use of these catheters nationwide, although the ACS NSQIP database is not population based and therefore is not appropriate for temporal analyses. Comparing a propensity-matched cohort of FJ and No FJ patients who were well matched for all of the preoperative and intraoperative variables included in our analysis demonstrated that FJ catheter placement during PD was associated with a 27.3% increase in the overall incidence of
postoperative morbidity and a 23.9% increase in the rate of major complications. The specific complications tracked by ACS NSQIP that occurred more frequently in FJ patients than in No FJ patients included deep space surgical site infection, pneumonia, unplanned reintubation, acute renal failure, and sepsis. Although it is not possible to prove causality between FJ catheter placement/utilization and the increased incidence of these complications among patients in whom FJ catheters were placed, there is at least a theoretical basis for concluding that the FJ catheters might be implicated. For example, abdominal wall infection at the site of catheter insertion has been shown to occur in up to 16% of esophagectomy patients in whom FJ catheters were placed [11]. Similarly, the availability of FJ catheter tubes after PD allows enteral nutrition to be started early in the postoperative course. While early enteral nutrition has clear benefit with regard to restoration of nutrition, it has also been shown to adversely impact gastric emptying and respiratory mechanics, which may explain the higher rate of pneumonia and unplanned reintubation among the FJ patients in our analysis [9,12]. The benefits of enteral postoperative nutrition over total parenteral nutrition in patients undergoing major abdominal procedures such as PD have been clearly established [1,2,13,14].
365
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 3 6 1 e3 6 6
Table 3 e Postoperative outcomes for propensity-matched cohort of PD patients, stratified by FJ tube placement. Outcome measure
Cohorts matched on propensity for FJ tube placement No FJ tube (n ¼ 623)
FJ tube (n ¼ 623)
P value
34.0% 23.8% 2.4%
43.3% 29.5% 3.9%
0.001 0.03 0.2
60 (9.6%) 7 (1.1%) 64 (10.3%) 16 (2.6%) 24 (3.9%) 25 (4.0%) 10 (1.6%) 35 (5.6%) 7 (1.1%) 4 (0.6%) 37 (5.9%) 2 (0.3%) 0 (0%) 0 (0%) 6 (1.0%) 1 (0.2%) 11 (1.8%) 1 (0.2%) 11 (1.8%) 61 (9.8%) 32 (5.1%) 56 (9.0%) 9 (7e14) and 13.0 d
74 (11.9%) 21 (3.4%) 62 (10.0%) 19 (3.1%) 49 (7.9%) 43 (6.9%) 7 (1.1%) 44 (7.1%) 5 (0.8%) 15 (2.4%) 38 (6.1%) 4 (0.6%) 2 (0.3%) 0 (0%) 8 (1.3%) 6 (1.0%) 10 (1.6%) 1 (0.2%) 17 (2.7%) 90 (14.5%) 37 (5.9%) 60 (9.6%) 12 (9e18) and 15.1 d
0.24 0.01 0.93 0.74 0.004 0.03 0.63 0.36 0.77 0.02 0.99 0.69 0.5 0.99 0.79 0.13 0.99 0.99 0.34 0.02 0.62 0.78 48 h) Progressive renal insufficiency Acute renal failure Urinary tract infection Stroke Coma >24 h Peripheral nerve injury Cardiac arrest Myocardial infarction Bleeding within 72 h of procedure Graft/prosthetic failure Deep venous thrombosis Sepsis Septic shock Return to operating room Median (interquartile range) and mean length of stay
Furthermore, there is general but not uniform consensus that the establishment of early postoperative nutrition using some type of feeding tube will result in a lower incidence of postoperative morbidity than if enteral nutrition is delayed until PD patients can take nutrition orally [2,5,13,14]. The available adjuncts for providing enteric feeds include nasoenteric tubes (either nasoduodenal or nasojejunal), double-lumen gastrojejunostomy tubes, or FJ catheters. Each of these feeding routes is associated with its own constellation of potential complications. Although several single-center studies have compared the outcomes associated with these various adjunctive routes for enteral nutrition, none has been conclusively demonstrated as superior to the others [10,11,15,16]. As a result, there is no solid evidence to guide pancreatic surgeons in deciding whether or not to use a feeding tube or which type of tube to use. By demonstrating that concurrent FJ catheter placement during PD appears to significantly increase the risk of major postoperative complications, the findings of our analysis support the conclusions of other investigators who recommend only selective use of FJ catheters in patients who are severely malnourished preoperatively or who seem at highest risk for postoperative delayed gastric emptying or pancreatic fistula [8,9]. Our analysis has several important limitations. First, we compare only patients with and without FJ catheters and do not consider other potential enteral feeding adjuncts such as nasoenteric or gastrojejunal feeding tubes. We are therefore unable to reach any conclusions about the comparative
efficacy of these other types of tubes based on our analysis. Second, our data source does not include hospital or surgeon identifiers. We are therefore not able to determine what percentage of hospitals/surgeons employ a strategy of routine FJ catheter placement during Whipple procedures, and whether those hospitals/surgeons that do place FJ catheters routinely might have lower catheter-related complication rates compared with hospitals/surgeons that employ a selective FJ catheter placement strategy. Third, although our use of propensity score matching techniques was successful in creating a cohort of patients with and without FJ catheter placement who were well matched with respect to known patient- and procedure-related characteristics, this statistical approach is not without inherent limitations. Namely, we are unable to account for variables that might influence the decision to place an FJ catheter or contribute to the risk of postoperative morbidity (for example, tumor stage, preoperative nutritional status, and/or the occurrence of adverse intraoperative events) but that are not available in the NSQIP database. Thus, propensity score matching techniques cannot completely account for unmeasured variation across study groups, and therefore cannot be considered an adequate substitute for prospective randomized analysis. Fourth, NSQIP lacks information on procedure-specific complications such as pancreatic fistula and/or delayed gastric emptying. Whether or not FJ catheter placement might obviate the need for parenteral nutrition or otherwise mitigate the overall clinical impact of these specific complications cannot be
366
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 3 6 1 e3 6 6
ascertained from our data. Because of this limitation and the lack of information about other important outcome parameters (postoperative nutritional status, quality of life, delay in adjuvant therapy), our findings should not be interpreted as arguing against FJ catheter placement in individual patients. Despite these limitations, our analysis demonstrates that concurrent FJ catheter placement during PD is associated with a significant increase in the incidence of major postoperative complications and the length of postoperative hospitalization. Although the findings of this study cannot be used to guide the clinical decision making in individual patients, our analysis does suggest that FJ catheters should be placed selectively and not routinely during PD. Future research should focus on which patients are most likely to benefit from FJ catheter placement.
references
[1] Brennan MF, Pisters PWT, Posner M, Quesada O, Shike M. A prospective randomized trial of total parenteral nutrition after major pancreatic resection for malignancy. Ann Surg 1994;220:436. [2] Braunschweig CI, Levy P, Sheean PM, Wang X. Enteral compared with parenteral nutrition: a meta-analysis. Am J Clin Nutr 2001;74:534. [3] van Berge Henegouwen MI, van Gulik TM, DeWit LT, et al. Delayed gastric emptying after standard pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: an analysis of 200 consecutive patients. J Am Coll Surg 1997;185:373. [4] Winter JM, Cameron JL, Campbell KA, et al. 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg 2006;10:1199. discussion 1210. [5] Baradi H, Walsh RM, Henderson JM, Vogt D, Popovich M. Postoperative jejunal feeding and outcome of pancreaticoduodenectomy. J Gastrointest Surg 2004;8:428.
[6] Sarr MG. Appropriate use, complications and advantages demonstrated in 500 consecutive needle catheter jejunostomies. Br J Surg 1999;86:557. [7] Myers JG, Page CP, Stewart RM, Schwesinger WH, Sirinek KR, Aust JB. Complications of needle catheter jejunostomy in 2,022 consecutive applications. Am J Surg 1995;170:547. [8] Yemilov I, Sekeris E, Bentrem DJ, et al. Utilization of parenteral nutrition following pancreaticoduodenectomy: is routine jejunostomy tube placement warranted? Dig Dis Sci 2009;54:1582. [9] Martignoni ME, Friess H, Sell F, et al. Enteral nutrition prolongs delayed gastric emptying in patients after whipple resection. Am J Surg 2000;180:18. [10] Gerritsen A, Besselink MG, Cieslak KP, et al. Efficacy and complications of nasojejunal, jejunostomy and parenteral feeding after pancreaticoduodenectomy. J Gastrointest Surg 2012;16:1144. [11] Han-Geurts IJM, Hop WC, Verhoef C, Tran KTC, Tilanus HW. Randomized clinical trial comparing feeding jejunostomy with nasoduodenal tube placement in patients undergoing oesophagectomy. Br J Surg 2007;94:31. [12] Watters JM, Kirkpatrick SM, Norris DB, Shamji FM, Wells GA. Immediate postoperative enteral feeding results in impaired respiratory mechanics and decreased mobility. Ann Surg 1997;226:369. discussion 377. [13] Moore FA, Feliciano DV, Andrassy RJ, et al. Early enteral feeding, compared with parenteral, reduces postopertative septic complications. Ann Surg 1992;216:172. [14] Okabayashi T, Kobayashi M, Nishimori I, et al. Benefits of early postoperative jejunal feeding in patients undergoing duodenohemipancreatectomy. World J Gastroenterol 2006;12:89. [15] Mack LA, Kaklamanos IG, Livingstone AS, et al. Gastric decompression and enteral feeding through a double-lumen gastrojejunostomy tube improves outcomes after pancreaticoduodenectomy. Ann Surg 2004;240:845. [16] Abu-Hilal M, Hemandas AK, McPhail M, et al. A comparative analysis of safety and efficacy of different methods of tube placement for enteral feeding following major pancreatic resection. A non-randomized study. J Pancreas 2010;11:8.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Feeding jejunostomy during Whipple is associated with increased morbidity James C. Padussis, MD,* Sabino Zani, MD, Dan G. Blazer, MD, Douglas S. Tyler, MD, Theodore N. Pappas, MD, and John E. Scarborough, MD Department of Surgery, Duke University Medical Center, Durham, North Carolina
article info
abstract
Article history:
Background: Placement of a feeding jejunostomy tube (FJ) is often performed during pan-
Received 27 June 2012
creaticoduodenectomy (PD). Few studies, however, have sought to determine whether such
Received in revised form
placement affects postoperative outcomes after PD.
16 September 2012
Materials and methods: This is a retrospective analysis of the National Surgical Quality
Accepted 10 October 2012
Improvement Program (NSQIP) database to determine the 30-d-postoperative mortality rate,
Available online 25 October 2012
major complication rate, and overall complication rate of jejunostomy tube placement at the time of PD. Univariate and multivariate comparison of postoperative outcomes between
Keywords:
patients with and without FJ placement during PD was performed on a total of 4930 patients.
Pancreaticoduodenectomy
Results: Thirty-day-postoperative mortality did not differ between the two groups (4.0% for
Feeding jejunostomy
patients with FJ versus 2.7% without, P ¼ 0.13), whereas overall morbidity (43.3% with FJ versus 34.6% without, P < 0.0001) and serious morbidity (29.5% with FJ versus 22.8% without, P < 0.0001)
NSQIP
were significantly higher in patients undergoing FJ placement during PD. The specific complications that occurred more frequently in FJ patients than patients without FJ included deep space surgical site infection, pneumonia, unplanned reintubation, acute renal failure, and sepsis. Conclusion: Although FJ placement during PD is considered to be routine at many institutions, our analysis of data from NSQIP suggest that FJ placement may be associated with increased postoperative morbidity. ª 2014 Elsevier Inc. All rights reserved.
1.
Introduction
Although enteral nutrition is strongly preferred to parenteral nutrition in the early postoperative period after pancreaticoduodenectomy (PD), or Whipple procedure, a subset of patients will develop complications such as delayed gastric emptying or pancreatic fistula that preclude or limit their ability to achieve adequate caloric intake orally [1e4]. Because these complications cannot be predicted a priori, some surgeons will routinely place feeding jejunostomy (FJ) catheters
in all of their PD patients in an effort to ensure that those patients who do go on to develop delayed gastric emptying or pancreatic fistula will still have a route available for enteral nutrition [5]. Given the known constellation of complications that can occur with FJ catheter placement and use, however, it is not clear whether the inclusion of this adjunctive procedure impacts the incidence of early postoperative morbidity associated with PD [6,7]. The objective of our analysis was to compare the early postoperative outcomes of patients undergoing PD with and without concurrent FJ tube placement.
* Corresponding author. Department of Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710. Tel.: þ1 919 450 5559. E-mail address: [email protected] (J.C. Padussis). 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2012.10.010
362
2.
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 3 6 1 e3 6 6
Materials and methods
The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) participant user files for 2005 through 2009 were used for this retrospective analysis. All patients with a primary Current Procedure Terminology code for PD (48150, 48152, 48153, 48154) and postoperative International Classification of Diseases, Ninth Revision diagnosis codes for non-endocrine malignant (152, 156.1, 156.2, 156.8, 156.9, 157, 157.1, 157.2, 157.3, 157.8, 157.9, or 197.4) or benign (211.2, 211.5, 211.6, or 230.8) neoplasm of the extrahepatic biliary tree, duodenum, ampulla of Vater, or non-islet pancreas were included for potential analysis. Patients were excluded if their procedure was designated as an emergency, or if they underwent a concomitant resection procedure at the time of PD (for example, colectomy, nephrectomy, hepatectomy other than wedge biopsy, or hysterectomy). The primary outcome measures for our analysis were 30-dpostoperative mortality rate, major complication rate, and overall complication rate. Patients were considered to have sustained a major postoperative complication if they developed one or more of the following: organ/space surgical site infection, wound dehiscence, postoperative neurologic deficit (including stroke or coma greater than 24 h), cardiac arrest requiring cardiopulmonary resuscitation, myocardial infarction, bleeding requiring transfusion, pulmonary embolism, ventilator dependence for greater than 48 h, progressive renal insufficiency, acute renal failure, sepsis, or septic shock. Patients were considered to have sustained any complication if they developed one or more of the following: major complication (defined above), superficial surgical site infection, deep surgical site infection, pneumonia, unplanned intubation, peripheral nerve injury, graft/prosthesis failure, urinary tract infection, or deep venous thrombosis. Secondary outcome measures for our analysis included incidence of specific complications, reoperation rate, and postoperative length of hospital stay. The primary predictor variable for our analysis was placement of an FJ tube during PD, as indicated by the inclusion of CPT codes 44300 or 44015. Other predictor variables included malignant versus benign tumor, patient age, sex, body mass index, American Society of Anesthesiologists (ASA) physical status classification of 3 or greater, diabetes mellitus requiring therapy with non-insulin agents or insulin, current smoker within 1 y of operation, greater than two drinks of ethanol per day in the 2 wk prior to admission, dyspnea upon moderate exertion or at rest, partially or totally dependent functional status prior to surgery, ascites, esophageal varices, congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease (including history of myocardial infarction within the past 6 mo, prior percutaneous coronary intervention, prior cardiac surgery, and/or history of angina within 30 d prior to surgery), peripheral vascular disease (including history of revascularization or amputation for peripheral vascular disease and/or rest pain/gangrene), renal disease (including acute renal failure within 24 h prior to surgery and/ or need for dialysis within 2 wk prior to surgery), neurologic disease (including impaired sensorium, coma, hemiplegia/ hemiparesis, history of transient ischemic attacks, stroke with
neurologic deficit, tumor involving central nervous system, paraplegia/paraparesis, and/or quadriplegia/quadriparesis), preoperative wound infection, disseminated cancer, steroid use within 30 d prior to surgery for a chronic medical condition, chemotherapy for malignancy within 30 d prior to surgery, radiotherapy for malignancy within 90 d prior to surgery, or preoperative systemic inflammatory release syndrome (SIRS), sepsis, or septic shock. Several intraoperative variables were included as potential predictors of outcomes because of their potential reflection of overall procedure complexity. These variables included need for intraoperative transfusion, operative time, and incisional wound classification. Using the entire sample of NSQIP patients undergoing PD for neoplastic disease, analysis of the preoperative and intraoperative characteristics of patients undergoing PD with and without concomitant FJ tube placement was performed using Pearson c2 tests for categorical variables and MannWhitney rank sum tests for continuous variables. To account for the possibility that the decision to place an FJ tube was not random, one-to-one propensity matching techniques without replacement were used to create a cohort of PD patients with and without FJ tubes who were matched for known preoperative and intraoperative variables. Specifically, a nonparsimonious logistic regression model was created to estimate the likelihood of having an FJ tube placed intraoperatively. Both preoperative patient characteristics and intraoperative procedural characteristics were included as predictor variables in this model in order to adjust for patient condition and complexity of the index PD procedure. A propensity score for placement of an FJ tube ranging from 0 to 1 was then calculated for each patient using the logit coefficients for the predictors of FJ tube placement. These propensity scores were then used to create two groups of patients matched on their propensity for having an FJ tube placed, using a caliper matching algorithm with a caliper distance of 0.005 and with controls being used only once in the matching. Comparison of the preoperative and intraoperative characteristics of the matched cohort of patients was then performed using Wilcoxon signed rank tests for continuous variables and McNemar c2 tests for categorical variables. Primary and secondary outcome measures between the matched cohorts were compared in a similar manner. All statistical analyses were performed using Stata version 11.0 (StataCorp, College Station, TX).
3.
Results
A total of 4930 patients meeting our inclusion and exclusion criteria were included for analysis: 633 (11.9%) who had an FJ tube placed during PD (FJ group) and 4297 (87.2%) who did not (No FJ group). As shown in Table 1, there were many significant differences between patients with and without FJ tubes when analyzing the entire NSQIP sample of PD patients. Patients in the FJ group were more likely to be nonwhite, more likely to have preoperative renal dysfunction, more likely to have a final diagnosis of a benign tumor, and more likely to require intraoperative transfusion. There was no significant difference
363
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 3 6 1 e3 6 6
Table 1 e Preoperative and intraoperative characteristics for entire NSQIP sample of PD patients, stratified by FJ tube placement. Preoperative or intraoperative variable
Age, y (mean SD) Female White Body mass index, kg/m2 (mean SD) ASA classification 3 Diabetes mellitus Tobacco use Heavy ethanol use Dyspnea Nonindependent functional status On mechanical ventilation Chronic obstructive pulmonary disease Preoperative pneumonia Ascites Esophageal varices Congestive heart failure Coronary artery disease Peripheral vascular disease Hypertension Renal disease Neurologic disorder Disseminated cancer Preoperative infected wound Steroids Weight loss Bleeding disorder Preoperative transfusion Chemotherapy in past 30 d Radiotherapy in past 90 d Preoperative sepsis/SIRS/septic shock Malignant tumor Nonclean Incisional wound Operative time, min (mean SD) Intraoperative packed red blood cell transfusion
All patients in NSQIP sample No FJ tube (n ¼ 4297, 87.2%)
FJ tube (n ¼ 633, 12.8%)
P value
65.4 11.9 2090 (48.6%) 3437 (80.0%) 26.8 6.0 223 (5.2%) 1012 (23.6%) 873 (20.3%) 137 (3.2%) 362 (8.4%) 15 (0.4%) 2 (0.1%) 177 (4.1%) 7 (0.2%) 28 (0.7%) 1 (0.02%) 15 (0.4%) 506 (11.8%) 69 (1.6%) 2317 (53.9%) 14 (0.3%) 237 (5.5%) 80 (1.9%) 36 (0.8%) 76 (1.8%) 877 (20.4%) 102 (2.4%) 2 (0.1%) 71 (1.7%) 112 (2.6%) 94 (2.2%) 1891 (44.0%) 386 (9.0%) 377 125 1311 (30.5%)
66.1 11.5 313 (49.5%) 470 (74.3%) 26.7 5.7 40 (6.3%) 166 (26.2%) 119 (18.8%) 19 (3.0%) 66 (10.4%) 3 (0.5%) 2 (0.3%) 33 (5.2%) 1 (0.2%) 2 (0.3%) 0 (0%) 4 (0.6%) 84 (13.3%) 6 (1.0%) 359 (56.7%) 6 (1.0%) 39 (6.2%) 10 (1.6%) 5 (0.8%) 15 (2.5%) 134 (21.2%) 17 (2.7%) 1 (0.2%) 14 (2.2%) 22 (3.5%) 19 (3.0%) 248 (39.2%) 63 (10.0%) 367 116 235 (37.1%)
0.21 0.7 0.001 0.54 0.24 0.14 0.37 0.8 0.1 0.63 0.03 0.2 0.98 0.31 0.7 0.28 0.28 0.21 0.19 0.02 0.51 0.62 0.9 0.19 0.66 0.63 0.29 0.31 0.21 0.2 0.02 0.43 0.06 0.001
between the two groups in the proportion of patients with preoperative weight loss or the overall operative time. When considering the entire NSQIP sample of patients, there was no significant difference on univariate analysis in the 30-d-postoperative mortality rate of FJ patients versus No FJ patients (4.0% versus 2.7%, P ¼ 0.09), although FJ patients did have a significantly higher incidence of major complications (29.5% versus 22.8%, P < 0.0001) and overall complications (43.3% versus 34.6%, P < 0.0001). To adjust for potentially important baseline differences between the No FJ and FJ groups from the entire NSQIP sample, we used propensity matching techniques to create a smaller cohort of patients in whom detectable baseline differences were minimized. As shown in Table 2, these techniques resulted in a smaller cohort of No FJ and FJ patients who were well matched for all of the preoperative and intraoperative variables that we included in our analysis. Table 3 shows the postoperative outcomes of No FJ and FJ patients in the propensity-matched cohort. The overall morbidity rate was significantly higher in FJ patients (43.3% versus 34.0%, odds ratio 1.46 [1.16e1.85], P ¼ 0.001), as was the major complication rate (29.5% versus 23.8%, 1.34 [1.04e1.75], P ¼ 0.03). There was no difference between the two groups,
however, in 30-d-postoperative mortality. A review of specific complications revealed the FJ group to have higher rates of postoperative deep surgical site infection, pneumonia, unplanned reintubation, acute renal failure, and sepsis (Table 3). The proportion of patients requiring reoperation did not differ significantly between the two groups, although patients in the FJ group did have a longer length of postoperative hospitalization.
4.
Discussion
In this analysis of 4930 patients with pancreatic neoplasms, we demonstrate that the concurrent placement of an FJ catheter during PD is associated with a significant increase in early postoperative morbidity and length of postoperative hospitalization. Although our use of ACS NSQIP subjects in our study has several important limitations, our findings nevertheless suggest that FJ catheters should be placed selectively, and not routinely, in patients who require PD for neoplastic disease. The fact that only 11.9% of PD patients in our analysis underwent concurrent FJ catheter placement during PD
364
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 3 6 1 e3 6 6
Table 2 e Preoperative and intraoperative characteristics for propensity-matched cohort of PD patients, stratified by FJ tube placement. Preoperative or intraoperative variable
Age, y (mean SD) Female White Body mass index, kg/m2 (mean SD) ASA classification 3 Diabetes mellitus Tobacco use Heavy ethanol use Dyspnea Nonindependent functional status On mechanical ventilation Chronic obstructive pulmonary disease Preoperative pneumonia Ascites Esophageal varices Congestive heart failure Coronary artery disease Peripheral vascular disease Hypertension Renal disease Neurologic disorder Disseminated cancer Preoperative infected wound Steroids Weight loss Bleeding disorder Preoperative transfusion Chemotherapy in past 30 d Radiotherapy in past 90 d Preoperative sepsis/SIRS/septic shock Malignant tumor Nonclean incisional wound Operative time, min (mean SD) Intraoperative packed red blood cell transfusion
Cohorts matched on propensity for FJ tube placement No FJ tube (n ¼ 623)
FJ tube (n ¼ 623)
P value
65.9 11.4 299 (48.0%) 475 (76.2%) 26.9 6.7 34 (5.5%) 173 (27.8%) 124 (19.9%) 22 (3.5%) 64 (10.3%) 0 (0%) 1 (0.2%) 34 (5.5%) 2 (0.3%) 1 (0.2%) 0 (0%) 4 (0.6%) 78 (12.5%) 5 (0.8%) 348 (55.9%) 4 (0.6%) 35 (5.6%) 6 (1.0%) 4 (0.6%) 21 (3.4%) 153 (24.6%) 15 (2.4%) 2 (0.3%) 17 (2.7%) 31 (5.0%) 17 (2.7%) 244 (39.2%) 55 (8.8%) 368 120 246 (39.5%)
66.1 11.5 306 (49.1%) 467 (75.0%) 26.7 5.7 38 (6.1%) 163 (26.2%) 118 (18.9%) 19 (3.1%) 64 (10.3%) 2 (0.3%) 1 (0.2%) 32 (5.1%) 1 (0.2%) 2 (0.3%) 0 (0%) 3 (0.5%) 81 (13.0%) 6 (1.0%) 352 (56.5%) 6 (1.0%) 36 (5.8%) 9 (1.4%) 4 (0.6%) 16 (2.6%) 132 (21.2%) 17 (2.7%) 1 (0.2%) 13 (2.1%) 22 (3.5%) 19 (3.1%) 245 (39.3%) 63 (10.1%) 366 115 229 (36.8%)
0.91 0.73 0.63 0.57 0.72 0.57 0.72 0.75 0.99 0.5 0.99 0.90 0.99 0.99 0.99 0.99 0.86 0.99 0.86 0.75 0.99 0.61 0.99 0.51 0.2 0.86 0.99 0.58 0.26 0.87 0.99 0.51 0.94 0.32
suggests that the practice of routinely placing these catheters is not pervasive, although previous investigators have found the incidence of concurrent feeding catheter placement to be more common [7]. For example, Yermilov et al. found that 23% of 1873 PD patients from the 1994e2003 California Cancer Registry underwent concurrent enterostomy tube placement [8]. Other single-center studies, meanwhile, have shown the incidence of concurrent jejunostomy tube placement during pancreatic resections to be as high as 48%e57% [7,9,10]. Potential reasons for the seemingly low rate of concurrent FJ catheter placement in our study are that our data source contains information from over 250 participating hospitals and encompasses a later time period than previous studies. The relatively low rate of FJ catheter placement in our analysis may reflect a temporal trend toward less frequent use of these catheters nationwide, although the ACS NSQIP database is not population based and therefore is not appropriate for temporal analyses. Comparing a propensity-matched cohort of FJ and No FJ patients who were well matched for all of the preoperative and intraoperative variables included in our analysis demonstrated that FJ catheter placement during PD was associated with a 27.3% increase in the overall incidence of
postoperative morbidity and a 23.9% increase in the rate of major complications. The specific complications tracked by ACS NSQIP that occurred more frequently in FJ patients than in No FJ patients included deep space surgical site infection, pneumonia, unplanned reintubation, acute renal failure, and sepsis. Although it is not possible to prove causality between FJ catheter placement/utilization and the increased incidence of these complications among patients in whom FJ catheters were placed, there is at least a theoretical basis for concluding that the FJ catheters might be implicated. For example, abdominal wall infection at the site of catheter insertion has been shown to occur in up to 16% of esophagectomy patients in whom FJ catheters were placed [11]. Similarly, the availability of FJ catheter tubes after PD allows enteral nutrition to be started early in the postoperative course. While early enteral nutrition has clear benefit with regard to restoration of nutrition, it has also been shown to adversely impact gastric emptying and respiratory mechanics, which may explain the higher rate of pneumonia and unplanned reintubation among the FJ patients in our analysis [9,12]. The benefits of enteral postoperative nutrition over total parenteral nutrition in patients undergoing major abdominal procedures such as PD have been clearly established [1,2,13,14].
365
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 3 6 1 e3 6 6
Table 3 e Postoperative outcomes for propensity-matched cohort of PD patients, stratified by FJ tube placement. Outcome measure
Cohorts matched on propensity for FJ tube placement No FJ tube (n ¼ 623)
FJ tube (n ¼ 623)
P value
34.0% 23.8% 2.4%
43.3% 29.5% 3.9%
0.001 0.03 0.2
60 (9.6%) 7 (1.1%) 64 (10.3%) 16 (2.6%) 24 (3.9%) 25 (4.0%) 10 (1.6%) 35 (5.6%) 7 (1.1%) 4 (0.6%) 37 (5.9%) 2 (0.3%) 0 (0%) 0 (0%) 6 (1.0%) 1 (0.2%) 11 (1.8%) 1 (0.2%) 11 (1.8%) 61 (9.8%) 32 (5.1%) 56 (9.0%) 9 (7e14) and 13.0 d
74 (11.9%) 21 (3.4%) 62 (10.0%) 19 (3.1%) 49 (7.9%) 43 (6.9%) 7 (1.1%) 44 (7.1%) 5 (0.8%) 15 (2.4%) 38 (6.1%) 4 (0.6%) 2 (0.3%) 0 (0%) 8 (1.3%) 6 (1.0%) 10 (1.6%) 1 (0.2%) 17 (2.7%) 90 (14.5%) 37 (5.9%) 60 (9.6%) 12 (9e18) and 15.1 d
0.24 0.01 0.93 0.74 0.004 0.03 0.63 0.36 0.77 0.02 0.99 0.69 0.5 0.99 0.79 0.13 0.99 0.99 0.34 0.02 0.62 0.78 48 h) Progressive renal insufficiency Acute renal failure Urinary tract infection Stroke Coma >24 h Peripheral nerve injury Cardiac arrest Myocardial infarction Bleeding within 72 h of procedure Graft/prosthetic failure Deep venous thrombosis Sepsis Septic shock Return to operating room Median (interquartile range) and mean length of stay
Furthermore, there is general but not uniform consensus that the establishment of early postoperative nutrition using some type of feeding tube will result in a lower incidence of postoperative morbidity than if enteral nutrition is delayed until PD patients can take nutrition orally [2,5,13,14]. The available adjuncts for providing enteric feeds include nasoenteric tubes (either nasoduodenal or nasojejunal), double-lumen gastrojejunostomy tubes, or FJ catheters. Each of these feeding routes is associated with its own constellation of potential complications. Although several single-center studies have compared the outcomes associated with these various adjunctive routes for enteral nutrition, none has been conclusively demonstrated as superior to the others [10,11,15,16]. As a result, there is no solid evidence to guide pancreatic surgeons in deciding whether or not to use a feeding tube or which type of tube to use. By demonstrating that concurrent FJ catheter placement during PD appears to significantly increase the risk of major postoperative complications, the findings of our analysis support the conclusions of other investigators who recommend only selective use of FJ catheters in patients who are severely malnourished preoperatively or who seem at highest risk for postoperative delayed gastric emptying or pancreatic fistula [8,9]. Our analysis has several important limitations. First, we compare only patients with and without FJ catheters and do not consider other potential enteral feeding adjuncts such as nasoenteric or gastrojejunal feeding tubes. We are therefore unable to reach any conclusions about the comparative
efficacy of these other types of tubes based on our analysis. Second, our data source does not include hospital or surgeon identifiers. We are therefore not able to determine what percentage of hospitals/surgeons employ a strategy of routine FJ catheter placement during Whipple procedures, and whether those hospitals/surgeons that do place FJ catheters routinely might have lower catheter-related complication rates compared with hospitals/surgeons that employ a selective FJ catheter placement strategy. Third, although our use of propensity score matching techniques was successful in creating a cohort of patients with and without FJ catheter placement who were well matched with respect to known patient- and procedure-related characteristics, this statistical approach is not without inherent limitations. Namely, we are unable to account for variables that might influence the decision to place an FJ catheter or contribute to the risk of postoperative morbidity (for example, tumor stage, preoperative nutritional status, and/or the occurrence of adverse intraoperative events) but that are not available in the NSQIP database. Thus, propensity score matching techniques cannot completely account for unmeasured variation across study groups, and therefore cannot be considered an adequate substitute for prospective randomized analysis. Fourth, NSQIP lacks information on procedure-specific complications such as pancreatic fistula and/or delayed gastric emptying. Whether or not FJ catheter placement might obviate the need for parenteral nutrition or otherwise mitigate the overall clinical impact of these specific complications cannot be
366
j o u r n a l o f s u r g i c a l r e s e a r c h 1 8 7 ( 2 0 1 4 ) 3 6 1 e3 6 6
ascertained from our data. Because of this limitation and the lack of information about other important outcome parameters (postoperative nutritional status, quality of life, delay in adjuvant therapy), our findings should not be interpreted as arguing against FJ catheter placement in individual patients. Despite these limitations, our analysis demonstrates that concurrent FJ catheter placement during PD is associated with a significant increase in the incidence of major postoperative complications and the length of postoperative hospitalization. Although the findings of this study cannot be used to guide the clinical decision making in individual patients, our analysis does suggest that FJ catheters should be placed selectively and not routinely during PD. Future research should focus on which patients are most likely to benefit from FJ catheter placement.
references
[1] Brennan MF, Pisters PWT, Posner M, Quesada O, Shike M. A prospective randomized trial of total parenteral nutrition after major pancreatic resection for malignancy. Ann Surg 1994;220:436. [2] Braunschweig CI, Levy P, Sheean PM, Wang X. Enteral compared with parenteral nutrition: a meta-analysis. Am J Clin Nutr 2001;74:534. [3] van Berge Henegouwen MI, van Gulik TM, DeWit LT, et al. Delayed gastric emptying after standard pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: an analysis of 200 consecutive patients. J Am Coll Surg 1997;185:373. [4] Winter JM, Cameron JL, Campbell KA, et al. 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg 2006;10:1199. discussion 1210. [5] Baradi H, Walsh RM, Henderson JM, Vogt D, Popovich M. Postoperative jejunal feeding and outcome of pancreaticoduodenectomy. J Gastrointest Surg 2004;8:428.
[6] Sarr MG. Appropriate use, complications and advantages demonstrated in 500 consecutive needle catheter jejunostomies. Br J Surg 1999;86:557. [7] Myers JG, Page CP, Stewart RM, Schwesinger WH, Sirinek KR, Aust JB. Complications of needle catheter jejunostomy in 2,022 consecutive applications. Am J Surg 1995;170:547. [8] Yemilov I, Sekeris E, Bentrem DJ, et al. Utilization of parenteral nutrition following pancreaticoduodenectomy: is routine jejunostomy tube placement warranted? Dig Dis Sci 2009;54:1582. [9] Martignoni ME, Friess H, Sell F, et al. Enteral nutrition prolongs delayed gastric emptying in patients after whipple resection. Am J Surg 2000;180:18. [10] Gerritsen A, Besselink MG, Cieslak KP, et al. Efficacy and complications of nasojejunal, jejunostomy and parenteral feeding after pancreaticoduodenectomy. J Gastrointest Surg 2012;16:1144. [11] Han-Geurts IJM, Hop WC, Verhoef C, Tran KTC, Tilanus HW. Randomized clinical trial comparing feeding jejunostomy with nasoduodenal tube placement in patients undergoing oesophagectomy. Br J Surg 2007;94:31. [12] Watters JM, Kirkpatrick SM, Norris DB, Shamji FM, Wells GA. Immediate postoperative enteral feeding results in impaired respiratory mechanics and decreased mobility. Ann Surg 1997;226:369. discussion 377. [13] Moore FA, Feliciano DV, Andrassy RJ, et al. Early enteral feeding, compared with parenteral, reduces postopertative septic complications. Ann Surg 1992;216:172. [14] Okabayashi T, Kobayashi M, Nishimori I, et al. Benefits of early postoperative jejunal feeding in patients undergoing duodenohemipancreatectomy. World J Gastroenterol 2006;12:89. [15] Mack LA, Kaklamanos IG, Livingstone AS, et al. Gastric decompression and enteral feeding through a double-lumen gastrojejunostomy tube improves outcomes after pancreaticoduodenectomy. Ann Surg 2004;240:845. [16] Abu-Hilal M, Hemandas AK, McPhail M, et al. A comparative analysis of safety and efficacy of different methods of tube placement for enteral feeding following major pancreatic resection. A non-randomized study. J Pancreas 2010;11:8.
