Enteral nutrition best for postoperative pancreatic fistula
MedWire News: Enteral nutrition is superior to total parenteral nutrition (TPN) in patients who develop a postoperative pancreatic fistula (POPF), results from a randomized controlled trial show.
The study, which was undertaken by a Polish team, found that people who develop this life-threatening complication of pancreatic surgery are more likely to have recovered at 30 days if they receive enteral nutritional support rather than TPN.
Nutritional support is a key element of conservative therapy in patients with a POPF, but until now, the choice of enteral (via nasointestinal tube) versus parenteral therapy (via venous catheter) has been "essentially arbitrary," write Stanislaw Klek (Jagiellonian University Medical College, Krakow, Poland).
To help inform treatment decisions, Klek's team recruited 78 patients who developed POPF after undergoing pancreatic surgery. All were being treated conservatively and were randomly assigned to receive 30 days of either enteral nutrition) or parenteral nutrition.
The nutritional interventions provided a similar amount of kilocalories, protein, and nitrogen per day, and patients received nothing besides up to 500 ml water by mouth for 30 days or until day 5 after fistula closure.
At 30 days, fistula closure - the study's primary endpoint - had been reached by 60% of patients receiving enteral nutrition versus 37% of those receiving parenteral nutrition, a statistically significant difference.
This equated to an odds ratio of 2.57 for the likelihood of fistula closure with enteral versus parenteral nutrition, say the authors. Furthermore, in multivariate analysis, enteral nutrition was a significant independent predictor for fistula closure, with an odds ratio of 6.14.
There was just one other independent predictor of fistula closure, notes the team, namely, initial fistula output below 200 ml/day.
Writing in the journal Gastroenterology, Klek et al say that there has historically been concern about using the enteral route in POPF due to the possibility of increasing fistula output by stimulating pancreatic secretion.
"However, in this trial we demonstrated that enteral nutrition was effective for the treatment of POPF," they write. "Enteral nutritional support increased >2-fold the probability of fistula closure, shortened time to closure, and was associated with lower costs than TPN."
They add: "Future clinical trials should address the benefits of multidisciplinary therapy of pancreatic fistulas with enteral nutrition combined with other interventions, such as somatostatin analogs."
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By Joanna Lyford