Early nasojejunal feeding in older patients with biochemical leak after pancreaticoduodenectomy: A propensity-weighted cohort study of a nutrition-driven intervention.

BACKGROUND & AIMS: Biochemical leak (BL) after pancreaticoduodenectomy (PD) is common and may progress to clinically relevant postoperative pancreatic fistula (CR-POPF), especially in older patients with limited physiological reserve. Nutritional strategies specifically tailored to the BL phase are not well defined in current perioperative management protocols, leaving this vulnerable population without targeted support during the critical early postoperative period. We aimed to assess whether early nasojejunal feeding (ENJF) improves outcomes compared with conventional oral feeding (COF) in older patients with BL after PD.

METHODS

We conducted a two-center retrospective observational cohort study, designed to emulate a target-trial, among patients aged ≥65 years who developed BL by postoperative day (POD) 3 after PD (January 2022-December 2024). Patients received either ENJF (POD 3-6) or COF. Propensity scores based on 16 predefined fistula-risk factors were used for inverse-probability weighting. The primary endpoint was 30-day CR-POPF; secondary endpoints included general postoperative complications (POCs, Clavien-Dindo grade II), severe POCs (grade ≥ III), and 90-day mortality.

RESULTS

Among 933 screened patients, 348 BL-positive patients were included. ENJF was associated with lower CR-POPF incidence than COF (23.0 % vs 45.4 %; OR 0.36; 95 % CI 0.26-0.50; P < 0.001). General POCs were lower (62.4% vs 70.2%; OR 0.70; 95% CI 0.51-0.97; P = 0.029), as were severe POCs (13.8 % vs 30.7 %; OR 0.36; 95 % CI 0.25-0.53; P < 0.001); 90-day mortality was 0 % vs 4.6 % (P = 0.038). ENJF was associated with earlier fulfillment of ≥80 % caloric and protein targets, required less parenteral nutrition, and more favorable trajectories of hemoglobin, prealbumin, and inflammatory markers during PODs 7-14.

CONCLUSIONS

In older PD patients with BL, ENJF after BL detection was associated with improved nutritional recovery and fewer POCs. These findings support consideration of BL-guided nutritional reassessment within a risk-stratified perioperative nutritional strategy, pending prospective validation.