Enhancing adjuvant chemotherapy tolerance in pancreatic adenocarcinoma following pancreaticoduodenectomy: Insights from minimally invasive surgery and home enteral nutrition

Purpose: Adjuvant chemotherapy(AC) for pancreatic ductal adenocarcinoma(PDAC) following pancreaticoduodenectomy(PD) is essential yet often challenging to tolerate. This study aims to elucidate the patterns and determinants associated with the omission or completion of AC after minimally invasive PD(MI-PD) and to investigate the impact of home enteral nutrition(HEN) on AC tolerance. Methods: Patients underwent laparoscopic or robotic PD with PDAC between March 2020 and January 2023 in Zhejiang Provincial People’s Hospital were enrolled. HEN was routinely recommended for all patients and executed for 3-month after surgery with 780kcal/day(600ml). According to the recipient of HEN or not, patients were divided into HEN group and non-HEN group. The AC omission and completion after MI-PD were analyzed by uni-variate and multi-variate analysis, and the impacts of HEN on AC administration after MI-PD were analyzed. Results: A total of 95 patients met the inclusion criteria and 42 patients received the HEN. Only 4(9.5%) patients had the diarrhea after HEN and relieved after anti-diarrheal medication. All the patients tolerated the HEN well. 77(81.1%) patients started AC while 18(18.9%) patients never received any course of AC, only 26(27.4%) patients completed all the planned courses. The median chemotherapy initiation interval was 45 days after MI-PD. Uni-variate analysis revealed preoperative malnutrition(odds ratio (OR)=5.06; CI _95% [1.48 - 17.37]), postoperative complications(OR=3.5; CI _95% [1.18 - 10.35]) were the main risk factors for AC omission. HEN served as the only protective factor for AC omission(OR=0.29; CI _95% [0.09 - 0.97]). Preoperative nutritional support(OR=3.87; CI _95% [1.16 - 10.91]) and HEN (OR=20.18; CI _95% [5.42 - 75.07]) were the main protective factors for AC completion. However, on the multi-variate analysis the preoperative malnutrition and postoperative complications were independently associated with AC omission(OR=4.35; CI _95% [1.19 - 16.00];OR=3.56; CI _95% [1.11 - 11.39]). HEN remained the only factors independently related to the AC completion(OR=18.54; CI _95% [4.94 - 69.59]). Conclusions: For PDAC patients underwent upfront MI-PD, 18.9% patients failed to receive AC mainly because of the postoperative complication, and 27.4% patients completely tolerated the AC. HEN for 3-months after MI-PD was convenient and safe in practice, with promising efficacy in enhancing the tolerance of AC.