Currently submitted to: JMIR Perioperative Medicine
Date Submitted: Jul 11, 2026
Open Peer Review Period: Jul 22, 2026 - Sep 16, 2026
(currently open for review)
Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.
Optimal Postoperative Nutrition After Pancreatoduodenectomy: A Network Meta-Analysis of Randomized Trials
ABSTRACT
Background:
The optimal postoperative nutritional strategy after pancreatoduodenectomy (PD) remains uncertain, as available randomized controlled trials (RCTs) compare heterogeneous feeding routes, formulas, and perioperative pathways.
Objective:
We aimed to compare the efficacy and safety of postoperative nutritional interventions using network meta-analysis (NMA).
Methods:
We systematically searched PubMed, the Cochrane Library, Web of Science, and Scopus from inception to May 2026 for RCTs evaluating postoperative nutritional strategies in adults undergoing PD. Interventions were classified into nine network nodes: total parenteral nutrition (PN), nasojejunal tube standard enteral nutrition (NJT-SEN), feeding jejunostomy tube standard enteral nutrition (FJT-SEN), enteral immunonutrition (IN), early oral feeding (Early OF), supplemental PN, EN + PN, ERAS Protocol, and usual care. A frequentist NMA was performed, ranking the interventions by SUCRA.
Results:
Eighteen RCTs, including 1,932 patients, were included. For delayed gastric emptying, no pairwise comparison was significant; early oral feeding ranked highest (SUCRA=0.801), followed by supplemental parenteral nutrition and enteral immunonutrition. For overall postoperative complications, usual care increased risk versus feeding jejunostomy-based standard enteral nutrition (RR=2.37, 95% CI 1.17–4.83), while enteral immunonutrition ranked highest (SUCRA=0.889). Most secondary comparisons were not significant. Early oral feeding was associated with higher infectious complications (RR=2.11, 95% CI 1.17–3.81) and pulmonary complications (RR=2.86, 95% CI 1.07–7.63) versus FJT-SEN. Combined EN+PN prolonged hospital stay (MD=16.80 days, 95% CI 2.08–31.52).
Conclusions:
Postoperative nutrition after PD should be individualized. Enteral IN and FJT-SEN showed favorable comparative profiles, whereas early OF may be appropriate for selected patients but requires caution due to higher infectious and pulmonary complications in this network.
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