The impact of postoperative enteral nutrition on duodenal injury outcomes: A post hoc analysis of an Eastern Association for the Surgery of Trauma multicenter trial
Authors: Choron Rachel L. , Rallo Michael , Piplani Charoo , Youssef Sara , Teichman Amanda L. , Bargoud Christopher G. , Sciarretta Jason D. , Smith Randi N. , Hanos Dustin S. , Afif Iman N. , Beard Jessica H. , Dhillon Navpreet K. , Zhang Ashling , Ghneim Mira , Devasahayam Rebekah J. , Gunter Oliver L. , Smith Alison A. , Sun Brandi L. , Cao Chloe S. , Reynolds Jessica K. , Hilt Lauren A. , Holena Daniel N. , Chang Grace , Jonikas Meghan , Echeverria-Rosario Karla , Fung Nathaniel S. , Anderson Aaron , Dumas Ryan P. , Fitzgerald Caitlin A. , Levin Jeremy H. , Trankiem Christine T. , Yoon JaeHee Jane , Blank Jacqueline , Hazelton Joshua P. , McLaughlin Christopher J. , Al-Aref Rami , Kirsch Jordan M. , Howard Daniel S. , Scantling Dane R. , Dellonte Kate , Vella Michael , Hopkins Brent , Shell Chloe , Udekwu Pascal O. , Wong Evan G. , Joseph Bellal A. , Lieberman Howard , Ramsey Walter A. , Stewart Collin , Alvarez Claudia , Berne John D. , Nahmias Jeffry , Puente Ivan , Patton Joe H. , Rakitin Ilya , Perea Lindsey L. , Pulido Odessa R. , Ahmed Hashim , Keating Jane , Kodadek Lisa M. , Wade Jason , Henry Reynold , Schreiber Martin A. , Benjamin Andrew J. , Khan Abid , Mann Laura K. , Mentzer Caleb J. , Mousafeiris Vasileios , Mulita Francesk , Reid-Gruner Shari , Sais Erica , Foote Christopher , Palacio Carlos H. , Argandykov Dias , Kaafarani Haytham , Bover Manderski Michelle T. , Narayan Mayur , Seamon Mark J. 
Published: May 2024

BACKGROUND
Leak following surgical repair of traumatic duodenal injuries results in prolonged hospitalization and oftentimes nil per os treatment. Parenteral nutrition (PN) has known morbidity; however, duodenal leak patients often have complex injuries and hospital courses resulting in barriers to enteral nutrition (EN). We hypothesized that EN alone would be associated with (1) shorter duration until leak closure and (2) less infectious complications and shorter hospital length of stay compared with PN.

METHODS
This was a post hoc analysis of a retrospective, multicenter study from 35 level 1 trauma centers, including patients older than 14 years who underwent surgery for duodenal injuries (January 2010 to December 2020) and endured postoperative duodenal leak. The study compared nutrition strategies: EN versus PN versus EN-PN using χ2 and Kruskal-Wallis tests; if significance was found, pairwise comparison or Dunn's test were performed.

RESULTS
There were 113 patients with duodenal leak: 43 EN, 22 PN, and 48 EN-PN. Patients were young (median age, 28 years) males (83.2%) with penetrating injuries (81.4%). There was no difference in injury severity or critical illness among the groups; however, there were more pancreatic injuries among PN groups. Enteral nutrition patients had less days nil per os compared with both PN groups (12 days [interquartile range, 23 days] vs. 40 [54] days vs. 33 [32] days, p = <0.001). Time until leak closure was less in EN patients when comparing the three groups (7 days [interquartile range, 14.5 days] vs. 15 [20.5] days vs. 25.5 [55.8] days, p = 0.008). Enteral nutrition patients had less intra-abdominal abscesses, bacteremia, and days with drains than the PN groups (all p < 0.05). Hospital length of stay was shorter among EN patients versus both PN groups (27 days [24] vs. 44 [62] days vs. 45 [31] days, p = 0.001). When controlling for predictors of leak, regression analysis demonstrated that EN was associated with shorter hospital length of stay (β = −24.9; 95% confidence interval, −39.0 to −10.7; p < 0.001).

CONCLUSION
Enteral nutrition was associated with a shorter duration until leak closure, less infectious complications, and shorter length of stay. Contrary to some conventional thought, PN was not associated with decreased time until leak closure. We therefore suggest that EN should be the preferred choice of nutrition in patients with duodenal leaks whenever feasible.

LEVEL OF EVIDENCE
Therapeutic/Care Management; Level IV.