Y. Song1, A. D. Tieniber1, C. M. Vollmer1, M. K. Lee1, R. E. Roses1, D. L. Fraker1, R. R. Kelz1, G. C. Karakousis1 1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA
Introduction: Pancreaticoduodenectomy (PD) has been associated with significant morbidity, including development of postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE). Jejunostomy tube (JT) placement has been used at time of surgery to mitigate the impact of these complications. We studied a national sample to determine whether the decision to place JT is predicated upon the risk of POPF and/or DGE and to evaluate the influence of this approach on postoperative outcomes after PD.
Methods: Patients undergoing PD were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and Procedure Targeted Pancreatectomy (2014-2015) databases. JT placement status at the time of PD and development of POPF and DGE were determined. Multivariate logistic regression analyses were used to identify pre- and intraoperative factors predicting JT placement, POPF, and DGE, as well as postoperative outcomes associated with JT placement. Statistical analyses were performed using R version 3.5.1.
Results: Of 3,600 patients who underwent PD, 322 (8.9%) underwent concurrent JT placement. The factors most strongly associated with JT placement included preoperative radiation (Odds Ratio (OR) 4.45, P<0.001), preoperative albumin < 3.5 g/dl (OR 2.43, P<0.001), and white race (OR 1.54, P=0.008). Notably, these were not associated with development of either POPF or DGE. Factors associated with POPF included soft pancreas texture (OR 2.65, P<0.001), pancreas duct size < 3mm (OR 2.15, P<0.001), and male sex (OR 1.41, P<0.001). Factors associated with DGE included preoperative admission (OR 1.56, P=0.004), preoperative bilirubin < 2mg/dl (OR 1.51, P=0.002), and male sex (OR 1.47, P<0.001). Rates of postoperative complications, including development of DGE (25.5% vs. 14.9%, P<0.001), return to the operating room (9.3% vs. 4.7%, P<0.001), and other medical complications (23.3% vs. 16.8%, P=0.004) were higher in the JT than non-JT group. In multivariate analyses, JT placement was associated with DGE (OR 1.92, P<0.001), return to the operating room (OR 1.92, P=0.004), other medical complications (OR 1.41, P=0.022), and increased length of stay (P<0.001), but not with mortality (P=0.14). Among 314 patients with low preoperative albumin (< 3g/dl), JT placement does not increase overall morbidity (P=0.88) or mortality (P=1.00). Additionally, among 967 patients who developed POPF or DGE, the development of other complications (P=0.36) and mortality (0.92) did not differ by JT status.
Conclusions: JT placement during PD is infrequent and not driven by clinical factors associated with POPF or DGE. Among patients with low preoperative nutritional parameters or who develop POPF or DGE, JT placement does not increase the immediate postoperative morbidity profile. If utilized during PD, efforts for more rational patient selection should be made.