ASSESSING THE ROLE AND DANGERS OF TOTAL PARENTERAL NUTRITION AFTER PANCREATODUODENECTOMY
Alexandra M. Roch*, Kyle A. Lewellen, Thomas K. Maatman, Danielle K. DePeralta, Eugene P. Ceppa, Nicholas J. Zyromski, C. Max Schmidt, Attila Nakeeb, Michael G. House
Surgery, Indiana School of Medicine, Indianapolis, IN
Background: Although total parenteral nutrition (TPN) has facilitated nutritional therapy for patients undergoing pancreatoduodenectomy (PD), recent studies suggest that enteral nutrition should be preferred. This study examines the role of TPN in patients requiring nutritional therapy after PD.
Methods: All patients who underwent PD at a single tertiary medical center (2005-2016) were included in a prospective database which was retrospectively queried. Patients who received postoperative TPN were compared to patients who did not for preoperative demographic, clinical, laboratory data, and postoperative outcomes. Univariate and binary regression analyses were performed, with statistical significance set at p<0.05.
Results: 1451 patients had complete data for analysis. Postoperative TPN was initiated in 302 patients (20.8%) based on surgeon's decision at a median of 8.1 days [1-32]. TPN use was continued for a median of 20.6 days [1-16 months]. On multivariate analysis, only delayed gastric emptying was associated with TPN use (31.8% vs. 7.7%, p<0.001). Preoperative weight loss was not an independent predictor for postoperative TPN use (27.8% vs. 25.2%, p=0.37). Postoperative TPN use was associated with significantly increased 90-day mortality (10.6% vs. 2.6%, p<0.001), morbidity (76% vs. 36.8%, p<0.001) and length of stay (19.7 vs. 9.2 days, p<0.001). Postoperative TPN use was associated with complications in 51% of patients: line sepsis 25%, hyperglycemia 20%, transaminitis 5%, thromboembolism 5%. Compared to enteral tube feeding, TPN resulted in a slower rise in serum albumin levels.
Conclusion: TPN is still widely used in high volume centers, without downtrend, despite poorer outcomes and significant morbidity directly associated with its use. TPN should be reserved for very selected patients who are not eligible for enteral routes of nutrition.
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