Association for Academic Surgery
Feeding jejunostomy during Whipple is associated with increased morbidity

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Abstract

Background

Placement of a feeding jejunostomy tube (FJ) is often performed during pancreaticoduodenectomy (PD). Few studies, however, have sought to determine whether such placement affects postoperative outcomes after PD.

Materials and methods

This is a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database to determine the 30-d-postoperative mortality rate, major complication rate, and overall complication rate of jejunostomy tube placement at the time of PD. Univariate and multivariate comparison of postoperative outcomes between patients with and without FJ placement during PD was performed on a total of 4930 patients.

Results

Thirty-day-postoperative mortality did not differ between the two groups (4.0% for patients with FJ versus 2.7% without, P = 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) 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.

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 [1], [2], [3], [4]. 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.

Section snippets

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

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

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

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    Of note, DGE shared many of the same preoperative and intraoperative risk factors as CR-POPF, consistent with earlier findings of a strong association between intra-abdominal abscess or CR-POPF with the development of secondary DGE.4,6,34,37,38 Similar to findings from other studies, JT placement was associated with increased rates of postoperative complications after PD.36 In addition, tube-specific complications are well-known, including increased rates of abdominal wall infections at the site of JT insertion.10,20,36,39,40

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