FRIEND OR FOE? FEEDING TUBE PLACEMENT AT TIME OF PANCREATODUODENECTOMY: PROPENSITY SCORE CASE-MATCHED ANALYSIS
Mohammed Al-Temimi*, Rachel Kim, E M. Kilbane, Trang K. Nguyen, Michael G. House, Nicholas J. Zyromski, C. Max Schmidt, Attila Nakeeb, Eugene P. Ceppa
General Surgery, Indiana University, Indianapolis, IN
Background: The role of concomitant gastrostomy or jejunostomy feeding tube (FT) placement during pancreatoduodenectomy (PD) and its impact on patient outcomes remains controversial.
Methods: The targeted pancreatectomy file of the NSQIP database (2014-2017) was surveyed for patients undergoing PD. FT placement was identified using CPT codes. Propensity scores were used to match the two groups (1:1) on baseline characteristics and intraoperative details (duct size, gland texture, underlying disease, wound class, use of wound protector, drain placement, type of pancreatic reconstruction and vascular reconstruction). Mortality, morbidity, length of hospital stay and readmission were compared between the two groups. Subset analyses in patients with delayed gastric emptying (DGE) or postoperative pancreatic fistula (POPF) were performed.
Results: Out of 15,224 PD, 1,104 (7.5%) had FT. POPF and DGE rates were 17% and 18% respectively for the entire cohort. Feeding jejunostomy was the most commonly placed FT (88.2%). Patients with FT placement were more likely to be older (mean, 65.8 vs. 64.6 y), smokers (22.6% vs. 17.8%) who had preoperative weight loss (22.5% vs. 15.3%), ASA≥3 (80.8% vs. 77.5%), preoperative transfusion (1.5% vs. 0.84%), chemotherapy (22.8% vs. 17.5%) and radiation (14.5% vs. 6.8%), P<0.05. The matched cohort included 880 patients in each group with completely balanced preoperative and intraoperative characteristics. In the matched cohort, patients with FT placement had higher overall morbidity (52.2% vs. 44.3%, p=0.001), major morbidity (28.4% vs. 22.5%, p=0.004), organ/space infection (14.4% vs. 10.9%, p=0.026), re-operation (8.6% vs. 5.1%, p=0.003), DGE (26.8% vs 16.4%, p<0.001) and longer mean hospital length of stay (12.9 vs. 11.2 days, p=0.001) than those without FT. There was no difference in mortality (1.7% vs. 2.2%, p=0.488) or readmission rate (20.2% vs. 17.2%, p=0.099). In patients with DGE and POPF, FT placement was not associated with morbidity, mortality, length of stay or readmission rate (P>0.05).
Conclusion:
Surgeons place feeding tubes in patients with higher risk profile as a mitigation strategy. However, in a balanced cohort, patients with feeding tube still had higher morbidity and longer hospital stay. These results do not support routine feeding tube placement at time of PD; selective placement may be reasonable in high-risk patients.
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