Comparing efficacy of a jejunostomy tube vs a nasojejunal nutrient tube after pancreatectomy

Abstract

BACKGROUND

Pancreatic surgery is highly invasive and associated with prolonged postoperative recovery. Safe, effective postoperative nutritional support is essential for patient recovery. The impact of two modes of nutritional support-jejunostomy tube (JT) and nasojejunal tube (NJT), on recovery after resolution of novel coronavirus infection has been rarely reported.

AIM

To compare the effects of JT with those of NJT after pancreatectomy.

METHODS

We retrospectively analyzed clinical data from 60 patients who underwent pancreatic surgery between January 2023 and May 2025 and classified them into an NJT group (n = 39) and a JT group (n = 21) according to the nutritional method used. Postoperative nutritional status and related complication rates were compared between the two groups.

RESULTS

No statistically significant differences were observed in sex, age, body mass index, preoperative hemoglobin level, or preoperative jaundice status between the two groups; postoperative pathologic type, incidence of delayed gastric emptying, time to transoral feeding, and time to defecation also did not differ (P > 0.05). The postoperative albumin level in the JT group was higher than in the NJT group, whereas the incidences of vomiting, pharyngeal discomfort, and hypostatic pneumonia, as well as the postoperative length of stay, were significantly lower (P < 0.05).

CONCLUSION

The use of JT for nutritional support after pancreatectomy is safe and effective, significantly reducing complication incidence and shortening postoperative length of stay; therefore, it is worthy of clinical selection and standardized use.

Key Words: Enteral nutrition; Jejunostomy tube; Nasojejunostomy tube; Complication

Core Tip: This study compared the effects of different enteral nutrition methods in patients undergoing pancreatic surgery after coronavirus disease 2019 infection and found that a jejunostomy tube is safer and more effective than a nasojejunostomy tube, significantly reducing the incidence of postoperative vomiting, pharyngeal discomfort, hypostatic pneumonia, and postoperative hospitalization time while ensuring nutritional support. These findings have significant clinical value and warrant broader clinical application.

INTRODUCTION

Pancreatic diseases often have an insidious and heterogeneous onset and are commonly managed surgically with extensive resection, which carries a risk of postoperative complications. Malnutrition due to malignant disease or metabolic disorders, as well as major surgical trauma, can impede postoperative recovery[1]. Moreover, many individuals infected with the novel coronavirus exhibit residual pulmonary changes, including decreased diffusing capacity, ground-glass opacity infiltration, and fibrotic scar remodeling[2,3]. Patients undergoing pancreatic surgery typically require prolonged postoperative bed rest, and the slow, insidious development of lung injury is a potential risk factor that impedes recovery. Timely, safe, and effective postoperative nutritional support in this context may mitigate these risks. Current ESPEN and ERAS guidelines recommend enteral nutrition as the preferred option after major gastrointestinal surgery[4,5].

This study aimed to compare the effects of two enteral nutrition methods, jejunostomy tube (JT) and nasojejunal tube (NJT), on postoperative recovery in patients with pancreatic diseases following coronavirus disease 2019 (COVID-19) infection and to provide a reference for clinical selection and practice.

MATERIALS AND METHODS

General information

Clinical data were collected for 60 patients who underwent pancreatic surgery at the Affiliated Hospital of Inner Mongolia Medical University between January 2023 and May 2025. Patients were assigned to a JT group (n = 21) or an NJT group (n = 39) based on the postoperative nutritional method used. The cohort included 35 males and 25 females, aged 44-83 years. All patients met surgical indications. Based on medical history, nucleic acid or antigen testing, and preoperative lung computed tomography (CT) scans (which assess features of viral pneumonia such as pulmonary consolidation), a prior COVID-19 infection was confirmed. Patients with mild or moderate COVID-19 infection were included.

Patients with active infection (with or without physical symptoms), a positive test, or rapid deterioration of lung lesions over a short period were excluded. Patients with a history of severe or critical COVID-19 (e.g., shortness of breath, resting oxygen saturation ≤ 93%, severe pneumonia) were also excluded. In addition, patients with local or distant metastasis, prior radiotherapy or chemotherapy, or severe organ dysfunction were excluded. Patients were free of preoperative local or distant metastasis, had not received radiotherapy or chemotherapy, and had no severe organ insufficiency. All patients provided informed consent. There were no statistically significant differences in baseline characteristics between the two groups (P > 0.05).

Surgical methods

Patients in both groups underwent surgical procedures, including pancreaticoduodenectomy, pancreatic mid-section resection, pancreatic body-tail resection, and pancreatic enucleation. The two methods for placing the nutritional tube were as follows.

JT group: After completion of the Loux-en-Y jejunoileal anastomosis, a small hole was created in the jejunum at the proximal side of the enteroenteric anastomosis. A nutrient tube (T-drainage tube, 14F; Nantong Anqi Medical, China) was advanced into the distal limb, with the tip positioned 5 cm distal to the anastomosis. The external end was brought out through the left lower abdominal wall and secured to the skin surface after purse-string sutures were tightened.

NJT group: After reconstruction of the digestive tract, a jejunal nutrition tube (CH10-145; Nutricia Pharmaceuticals, China) was inserted through the nose to 10 cm distal to the flexor ligament, and the proximal end was secured to the nose and cheeks.

After tube placement, an abdominal drainage tube was routinely placed in both groups, and the incision was closed in layers to complete the operation.

Nutrition

Beginning on postoperative day 1, parenteral nutrition was administered according to the patient's weight to ensure an adequate energy supply. A mixture of electrolytes, vitamins, and trace elements was delivered through a central venous catheter. Parenteral nutrition was discontinued when the patient’s tolerance for enteral nutrition was established and energy requirements could be met.

Enteral nutrition was initiated on postoperative day 6 and provided continuously until the patients were able to receive a regular oral diet. In both groups, enteral nutrition suspensions (250 mL, 500 mL, 750 mL, and 1000 mL) were infused during the first four days to gradually increase tolerance. Afterward, 1000 mL/day was infused and adjusted according to patient weight as needed. The energy content of the enteral nutrition emulsion was 650 kcal/500 mL for patients without diabetes and 450 kcal/500 mL for patients with diabetes (Warren Pharmaceuticals Ltd., Germany).

The NJT was removed after resumption of normal transoral intake. The JT was clamped after the patient transitioned to normal transoral intake and removed at four weeks, after complete formation of the sinus tract.

Observation indicators

(1) General information: Sex, age, body mass index (BMI), hemoglobin level, preoperative jaundice, pathological type; and (2) Serum albumin level, vomiting, pharyngeal discomfort, hypostatic pneumonia, incidence of delayed gastric emptying (DGE), time to transoral feeding, time to defecation, and postoperative hospitalization time.

Statistical analysis

SPSS 26.0 was used for data analysis. The mean ± SD was used for quantitative data that met the normal distribution and homogeneity of variance; the median M (Q25, Q75) was used for quantitative data that did not meet the normal distribution. Between-group comparisons used the independent-samples t test or the rank-sum test. Qualitative data were expressed as n (%), and between-group comparisons were performed using the χ² test. The association between the two enteral nutrition methods and hypostatic pneumonia was analyzed by binary logistic regression. P < 0.05 was considered statistically significant.

RESULTS

Comparison of preoperative data

Thirty-nine patients in the NJT group and 21 patients in the JT group were included. There was no statistically significant difference in preoperative data between the two groups (P > 0.05) (Table 1).

Table 1 Comparison of general data between two groups of patients, n (%).

	JT (n = 21)	NJT (n = 39)	t/Z/χ2	P value
Age (years)	66 (61.5, 71.5)	66 (60, 72)	-0.241	0.810
Sex			0.471	0.493
Male	11 (52.4)	24 (61.5)
Female	10 (47.6)	15 (38.5)
BMI (kg/m2)	23.38 (19.36, 25.56)	22.57 (19.72, 23.43)	-0.969	0.333
Preoperative jaundice			1.316	0.251
Yes	7 (33.3)	19 (48.7)
No	14 (66.7)	20 (51.3)
Pathological classification			3.011	0.556
Malignant tumor of bile duct	4 (19.0)	5 (12.8)
Malignant tumor of pancreas	12 (57.1)	23 (59.0)
Benign pancreatic diseases	1 (4.8)	6 (15.4)
Duodenal malignant tumor	4 (19.0)	4 (10.3)
Benign diseases of duodenum	0 (0.0)	1 (2.6)
Hemoglobin (g/L)	129 (121, 139.5)	130 (118, 143)	-0.085	0.932

JT: Jejunostomy tube; BMI: Body mass index; NJT: Nasojejunal tube.

Postoperative nutritional efficiency and complications

There was no significant difference in postoperative time to oral feeding, time to defecation, or DGE between the groups (P > 0.05). The incidences of postoperative vomiting (9.5% vs 33.3%), pharyngeal discomfort (4.8% vs 25.6%), hypostatic pneumonia (14.3% vs 43.6%), and postoperative hospitalization time [20 (17, 27) vs 21 (15, 37)] were lower in the JT group than in the NJT group. Serum albumin level was higher in the JT group than in the NJT group [33.4 (30.6, 37.35) vs 31.1 (29.5, 33.5)] (Table 2).

Table 2 Comparison of postoperative nutrition and complications between the two groups of patients, n (%).

	JT (n = 21)	NJT (n = 39)	t/Z/χ2	P value
Serum albumin (g/L)	33.4 (30.6, 37.35)	31.1 (29.5, 33.5)	-2.279	0.023
Oral feeding time (day)	13 (11, 17)	15 (9, 21)	-0.210	0.834
Postoperative hospitalization time (day)	20 (17, 27)	21 (15, 37)	-2.355	0.019
Postoperative defecation time (day)	6 (5, 8)	5 (3, 8)	-1.322	0.186
Postoperative vomiting			4.127	0.042
Yes	2 (9.5)	13 (33.3)
No	19 (90.5)	26 (66.7)
Pharyngeal discomfort			3.974	0.046
Yes	1 (4.8)	10 (25.6)
No	20 (95.2)	19 (74.4)
hypostatic pneumonia			5.275	0.022
Yes	3 (14.3)	17 (43.6)
No	18 (85.7)	22 (56.4)
Delayed gastric emptying			0.354	0.552
Yes	3 (14.3)	8 (20.5)
No	18 (85.7)	31 (79.5)

JT: Jejunostomy tube; NJT: Nasojejunal tube.

Univariate analysis revealed a statistically significant association between the enteral nutrition method and postoperative hypostatic pneumonia

The risk of hypostatic pneumonia in the NJT group was 4.636 times that in the JT group, and the difference was statistically significant (P < 0.05) (Table 3).

Table 3 Logistic regression analysis of the relationship between two groups of patients and hypostatic pneumonia.

Group	β	SD	Wald	OR	Binary logistic regression, objective risk (95%CI)	P value
JT	-	-	-	1	1	-
NJT	1.534	0.702	4.771	4.636	(1.171, 18.363)	0.029

JT: Jejunostomy tube; NJT: Nasojejunal tube.

Multivariate logistic regression analysis of the relationship between the two groups of patients and postoperative hypostatic pneumonia

In Model 1, controlling for age and sex, the risk of postoperative hypostatic pneumonia in the NJT group was 4.559 times that in the JT group (OR 4.559; 95%CI: 1.144-18.173). In Model 2, after additionally controlling for BMI and hemoglobin, the risk in the NJT group remained higher (OR 4.428; 95%CI: 1.071-18.309). In Model 3, after further controlling for preoperative jaundice and pathological types, the risk increased (OR 5.944; 95%CI: 1.200-29.450). The probability of postoperative hypostatic pneumonia was higher in the NJT group than in the JT group across all models, and the differences were statistically significant (P < 0.05) (Table 4).

Table 4 Multivariate logistic regression analysis of the relationship between the two groups of patients and postoperative hypostatic pneumonia.

Group	OR (95%CI)
	Model 1	Model 2	Model 3
JT	1	1	1
NJT	4.559 (1.144, 18.173)	4.428 (1.071, 18.309)	5.944 (1.200, 29.450)

JT: Jejunostomy tube; NJT: Nasojejunal tube.

DISCUSSION

Perioperative malnutrition is more prevalent in oncology patients owing to malignant disease and several days of postoperative fasting. Among patients with pancreatic disease, malnutrition is an independent risk factor for postoperative complications, significantly impairing wound healing, increasing infection risk, and leading to prolonged hospitalization and higher mortality[6]. Regarding nutritional support after pancreatic surgery, parenteral nutrition via mixed fluid infusion does not promote early food-related stimulation of gastrointestinal function, resulting in decreased cholecystokinin secretion and more adverse effects with prolonged use[7]. According to ERAS guidelines, an early oral diet plays a crucial role in reducing postoperative complications and accelerating the recovery of intestinal function[4]. Enteral nutrition is inexpensive, stimulates gastrointestinal motility, reduces metabolic complications, and aligns more closely with human physiology[8].

JT and NJT are the primary methods of enteral nutrition after pancreatectomy, providing adequate postoperative nutritional support and promoting the recovery of intestinal function. However, these two tube placement methods differ in clinical selection, which generally follows three principles: (1) Effective nutritional support therapy; (2) Convenient and straightforward tube placement; and (3) Minimal complications with maximal comfort, conducive to long-term placement[9]. In a study of 100 pancreatectomized patients, those with an NJT had fewer postoperative complications[10]. However, multiple studies report that patients with an NJT often experience discomfort from the nasal tube and nausea, depending on the tube material. Displacement of the NJT can trigger coughing and relax the lower esophageal sphincter, thereby increasing reflux and aspiration[11-13]. In this study, among postoperative complications, vomiting (9.5% vs 33.3%) and pharyngeal discomfort (4.8% vs 25.6%) were less frequent in the JT group than in the NJT group, which is closely related to the choice of tube placement. In addition, a retrospective analysis of 156 patients who underwent pancreaticoduodenectomy found that a JT improved nutritional status, and minor self-limiting complications were controllable with bedside treatment[14].

In addition, studies indicate that individuals infected with the novel coronavirus (COVID-19) experience long-term sequelae with diverse manifestations, including fatigue, dyspnea, chest pain, and cognitive impairment[15]. COVID-19 has a pronounced effect on the lungs, including interstitial pneumonitis, pulmonary fibrosis, and damage to the pulmonary vascular system. In a cohort study that included mild to moderate and severe cases, fibrotic changes on chest CT were observed in approximately 25% and 65% of patients, respectively, at 3 months after discharge, manifesting as bronchial dilatation and reticular degeneration of the lung tissue[16]. The incidence of hypostatic pneumonia was significantly higher in the NJT group than in the JT group (43.6% vs 14.3%), likely because patients in the JT group were able to ambulate early in the postoperative period, allowing them to receive nutritional support, which significantly reduced the incidence of pneumonia. This reduction, particularly in elderly patients, may decrease the risk of lung infection and shorten hospitalization.

In terms of nutritional support, patient tolerance was gradually increased by slowly escalating the dose of enteral nutrition during the first postoperative week, thereby avoiding gastrointestinal discomfort such as nausea, vomiting, abdominal distension, diarrhea, and other gastrointestinal symptoms. Moreover, this study showed that the postoperative albumin level was higher in the JT group than in the NJT group [33.4 (30.6, 37.35) vs 31.1(29.5, 33.5), P < 0.05], indicating that JT can provide adequate nutritional support.

Limitations and future directions

First, the total sample size of this study is small (n = 60), which may limit generalizability. The study may lack statistical power to detect small to medium true effects, as reflected by wide confidence intervals. Consequently, some postoperative complications after pancreatic surgery may not have been detected because of insufficient statistical power.

Second, due to recruitment constraints, group sizes were uneven (NJT group n = 39, JT group n = 21), which may affect the stability of the results. In addition, we examined the incidence of postoperative hypostatic pneumonia among patients with prior mild to moderate infection; with a sufficient number of cases, further classification could explore the specific influence of infection severity on postoperative complications. Although this study is a single-center observational study, strict standards for case collection, diagnosis, and treatment were applied to ensure internal validity. Our findings are consistent with reports from other centers[17], suggesting generalizability across populations. Finally, although the COVID-19 pandemic has ended, the occurrence of complications will not disappear with the end of the epidemic phase. The preventive implications identified in this study remain highly relevant for managing future public emergencies. We also anticipate large-scale, multicenter prospective research to determine generalizable patterns in an evolving pandemic context.

CONCLUSION

The use of JT is safer and more effective than NJT for enteral nutrition after pancreatic surgery. JT significantly reduce postoperative vomiting, adverse pharyngeal reactions and hypostatic pneumonia while providing adequate nutritional support and shortening hospital length of stay, it is worthy of clinical selection and standardized use.