Surgery, Gastroenterology and Oncology

Background: Postoperative pancreatic fistula (POPF) remains a significant source of morbidity following pancreatic surgery. The most effective feeding route for the conservative management of POPF is currently unknown. We aimed to compare the efficacy of enteral to parenteral nutrition in the rate of POPF closure.

Methods: Medline, EMBASE, CENTRAL, and Web of Science were searched for randomized controlled trials (RCTs) comparing enteral to parenteral nutrition in the conservative management of POPF. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Quality of the evidence was assessed using GRADE. Random-effects meta-analysis was used to estimate time to POPF closure.

Results: From 2,682 citations, three RCTs (n=167) were included (enteral group, n=85; parenteral group, n=82). Mean time to POPF closure was 3.64 days shorter in the enteral than the parenteral group, which was not statistically significant (95% CI -3.22 to 10.49, P = 0.30). There were no significant differences in postoperative complication rate (OR 1.69, 95% CI 0.52 to 5.47, P = 0.38) or length of hospital stay between groups (mean difference: 0.76, 95% CI -9.21 to 10.74, P = 0.88). According to GRADE, the overall certainty of the evidence for the main outcome was very low.

Conclusions: There was no data to suggest that enteral nutrition is more effective than parenteral nutrition at enhancing the rate of POPF closure. However, the quality of evidence that currently exists is very low. Therefore, the decision between enteral and parenteral nutrition in this setting should still be based on physician preference and patient specific factors.

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