The NUTRIWHI randomised clinical trial evaluates whether early enteral nutrition delivered through a nasojejunal tube in addition to oral feeding offers clinical advantages over only early oral feeding following pancreatoduodenectomy, a procedure known for relevant postoperative morbidity and nutritional challenges. The investigators designed the study to address ongoing uncertainty about optimal postoperative nutritional strategies, as enhanced recovery protocols encourage early oral intake despite limited evidence in high‑risk pancreatic surgery populations. Adult patients at high nutritional risk undergoing elective pancreatoduodenectomy were randomised to receive either enteral tube feeding initiated within 24 hours in addition to oral nutrition or only structured early oral feeding guided by tolerance. The primary endpoint was the Comprehensive Complication Index (CCI) at 90 days, with secondary outcomes including specific postoperative complications, delayed gastric emptying, length of stay, and nutritional adequacy.
The trial found a significant difference in the CCI (mean difference (95% CI) of 90-d CCI, 10.3 (1.8 to 18.8)) and no significant difference in overall postoperative morbidity rates between the two groups. Patients in the oral feeding group achieved comparable caloric intake postoperatively and the number of patients requiring parenteral nutrition was comparable. Importantly, rates of delayed gastric emptying—a major concern after pancreatoduodenectomy—were similar between groups, suggesting that early enteral intake does not exacerbate this complication. Apart from lower infectious and pulmonary complications in the enteral feeding group, there were no differences in secondary outcomes. Exploratory subgroup analysis suggests a benefit of the use of enteral nutrition in older patients, patients with diabetes, after biliary drainage and a higher nutritional risk score.
The authors conclude that early enteral nutrition via nasojejunal tube decreases the burden and incidence of postoperative complications compared with an oral only approach. Clinically, the trial supports incorporating early enteral feeding into enhanced recovery pathways for pancreatic surgery patients at malnutrition risk, while balancing the logistical demands and tube‑related adverse events against the demonstrated reduction in overall morbidity burden."
Interview with Gaëtan-Romain Joliat
What inspired you to conduct this study?
We noticed that patients undergoing pancreas surgery were often malnourished. Moreover, the best postoperative nutrition route or regimen after pancreatoduodenectomy remained unclear in the literature, especially for patients at malnutrition risk. The idea was therefore to evaluate if adding enteral nutrition to oral nutrition early after pancreatoduodenectomy could improve the postoperative outcomes, as in our practice, patients routinely received oral nutrition and artificial nutrition was added only if the caloric needs were not covered by the oral nutrition. In addition, a previous international survey on perioperative nutrition after pancreas surgery conducted by our team showed heterogeneous practices worldwide. We therefore wanted to bring more robust data on that subject.
Were there any unexpected findings?
Yes, the main unexpected finding was the relatively high rate of involuntary removal of nasojejunal tubes during the postoperative period. 14 out of 59 patients (24%) removed their nasojejunal tube and had to have it replaced. This was not something we expected and all these patients needed a gastroscopy during the postoperative phase to put back their nasojejunal tube.
What is the direct impact on the surgeon’s work?
The findings of this study can be directly implemented into clinical practice. For patients with a nutritional risk score of 3 or higher, adding enteral nutrition early after pancreatoduodenectomy might improve postoperative morbidity.
What is your learning point from this project?
Performing a randomized controlled trial from the initial idea of the project to the final publication takes a long time and requires financial and logistical resources. Overall, while this project required a lot of work and energy, the findings were definitely worth the job. Moreover, I also learned that having a specific person to coordinate the study on a daily basis (e.g., identification of potential patients to include, prescription of study tests, or follow-up) is extremely important in such a long haul project.
Are there any subsequent projects planned?
As we have collected several nutritionally-focused data during this study, the next steps of this project will be to analyse in more detail the nutritional aspects (absorption, caloric needs, lean and fat masses) of patients undergoing pancreatoduodenectomy based on specific lab values, bioimpendancemetry and calorimetric data.
