Early Enteral Feeding Reduces Complications After Whipple Surgery : JAMA Surg | Apr 2026

Introduction:

Pancreatoduodenectomy remains one of the most complex abdominal operations and is associated with substantial postoperative morbidity despite advances in surgical technique and perioperative care. Nutritional support is a critical component of recovery, particularly in patients who are malnourished or at increased nutritional risk before surgery. However, the optimal postoperative feeding strategy remains controversial, with uncertainty regarding whether early enteral nutrition offers advantages over standard oral feeding.

Problem Statement:

Patients undergoing pancreatoduodenectomy frequently experience delayed gastric emptying, pancreatic fistula, infections, and other complications that may impair nutritional intake and recovery. Although enteral nutrition is thought to preserve gut integrity and immune function, evidence supporting its routine use after pancreatoduodenectomy has been inconsistent. Determining the most effective nutritional approach is essential for improving postoperative outcomes.

Summary:

The NUTRIWHI randomized clinical trial evaluated the impact of early supplemental enteral nutrition (EEN) compared with oral nutrition alone in patients undergoing pancreatoduodenectomy who were identified as being at nutritional risk. Patients receiving EEN were fed immediately after surgery through a nasojejunal tube while also following the same oral feeding protocol as the control group. The study demonstrated that EEN significantly reduced the overall burden of postoperative complications during the first 90 days after surgery. Although rates of specific complications such as postoperative pancreatic fistula, delayed gastric emptying, hemorrhage, and surgical site infection were similar between groups, patients receiving enteral supplementation experienced a more favorable overall postoperative course. These findings suggest that the benefits of EEN extend beyond preventing individual complications and instead contribute to a broader improvement in postoperative recovery. Importantly, the intervention was targeted to patients with pre-existing nutritional risk, a population particularly vulnerable to adverse surgical outcomes. While nasojejunal tube displacement occurred in some patients, no major safety concerns were identified. This study provides strong evidence that early supplemental enteral nutrition should be considered as part of routine postoperative care in nutritionally at-risk patients undergoing pancreatoduodenectomy, with the potential to meaningfully reduce the overall burden of postoperative morbidity.