# Impact of feeding strategy after pancreatoduodenectomy on delayed gastric emptying and hospital stay: nationwide study

## TL;DR

A nationwide study found that feeding strategies after pancreatoduodenectomy do not affect delayed gastric emptying or hospital stay, but pancreatic fistulas are a major cause of this complication.

## Contribution

This study provides evidence from a large nationwide cohort that feeding strategies post-pancreatoduodenectomy do not influence delayed gastric emptying rates or hospital length of stay.

## Key findings

- No association was found between feeding strategies (unrestricted, step-up, artificial) and delayed gastric emptying.
- Pancreatic fistula was identified as the strongest predictor of delayed gastric emptying.
- Patients with delayed gastric emptying had a median hospital stay 13 days longer than those without.

## Abstract

Delayed gastric emptying is a major contributor to prolonged hospital stay following pancreatoduodenectomy. Although enhanced recovery after surgery guidelines recommend unrestricted feeding after pancreatoduodenectomy, nationwide studies evaluating the impact of different feeding strategies after surgery on delayed gastric emptying and length of hospital stay are limited. This study aimed to identify the use and impact of different feeding strategies after pancreatoduodenectomy on delayed gastric emptying and length of hospital stay.

This nationwide cohort study included consecutive patients after pancreatoduodenectomy from the Dutch Pancreatic Cancer Audit (2021–2023). Primary endpoints were delayed gastric emptying grade B/C and length of hospital stay. Feeding strategies were categorized based on structured interviews with representatives from 15 centres. Multilevel analysis was used to assess associations between feeding strategy, delayed gastric emptying, and length of hospital stay. Predictors of delayed gastric emptying were determined.

Overall, 2354 patients undergoing pancreatoduodenectomy were included, of whom 526 (23%) developed delayed gastric emptying grade B/C. Median length of hospital stay was 13 days longer in patients with delayed gastric emptying (23 versus 10 days; P < 0.001). Feeding strategies were: unrestricted feeding (3 centres, 637 patients; delayed gastric emptying 18%); step-up feeding (9 centres, 1462 patients; delayed gastric emptying 24%); and artificial feeding (3 centres, 255 patients; delayed gastric emptying 25%). No association was observed between feeding strategy and delayed gastric emptying: step-up versus unrestricted feeding (odds ratio 1.14, 95% confidence interval 0.53 to 2.47) and artificial versus unrestricted feeding (odds ratio 1.76, 0.65 to 4.73). Similarly, no association was found between feeding strategy and length of hospital stay. The strongest predictor of delayed gastric emptying was pancreatic fistula after surgery (odds ratio 3.16, 2.47 to 4.05).

This study found no significant association between feeding strategy and incidence of delayed gastric emptying or length of hospital stay after pancreatoduodenectomy. Efforts to reduce delayed gastric emptying should focus on reducing pancreatic fistula after surgery.

Delayed gastric emptying significantly prolongs hospital stay after pancreatoduodenectomy; there is much debate as to whether feeding strategy affects this. This nationwide study found no association between feeding strategies (unrestricted, step-up, or artificial feeding) and the rate of delayed gastric emptying or length of hospital stay; however, pancreatic fistula emerged as the strongest predictor of delayed gastric emptying. Efforts to reduce delayed gastric emptying should focus on reducing pancreatic fistula after surgery.