Factors associated with adjuvant chemotherapy tolerance in pancreatic adenocarcinoma following pancreaticoduodenectomy: insights from minimally invasive surgery and home enteral nutrition

Adjuvant chemotherapy (AC) for pancreatic ductal adenocarcinoma (PDAC) following pancreaticoduodenectomy (PD) is essential yet often difficult to tolerate. This study aimed to elucidate the patterns and determinants associated with AC omission or completion after minimally invasive PD (MI-PD) and to investigate the impact of home enteral nutrition (HEN) on AC tolerance. Patients who underwent laparoscopic or robotic PD with PDAC between March 2020 and January 2023 at Zhejiang Provincial People’s Hospital were enrolled. HEN was routinely recommended for all patients and consisted of 780 kcal/day (600 mL) of an oral nutritional supplement (TPF-T, Fresenius Kabi) administered for 3 months after surgery. Patients were divided into HEN group and non-HEN group based on whether they received HEN. The AC omission and completion after MI-PD were analyzed by univariate and multivariate analysis, and the impacts of HEN on AC tolerance after MI-PD were analyzed. A total of 95 patients met the inclusion criteria and 42 patients received the HEN. The primary reasons for HEN non-adherence were perceived burden on caregivers or patients ( n = 28, 52.8%), insurance-related costs ( n = 15, 28.3%), and personal refusal ( n = 10, 18.9%). Only 4 patients (9.5%) experienced diarrhea after HEN, which resolved with anti-diarrheal medication. All patients tolerated the HEN well. AC was initiated in 77 patients (81.1%), while 18 patients (18.9%) never received any chemotherapy; only 26 patients (27.4%) completed all planned courses. The median chemotherapy initiation interval was 45 days after MI-PD. Propensity score matching (PSM) analysis confirmed that HEN remained significantly associated with AC completion in the matched cohort. Uni-variate analysis identified preoperative malnutrition (OR = 5.06; 95%CI: 1.48–17.37), postoperative complications (OR = 3.50; 95%CI: 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; 95%CI: 0.09–0.97). Preoperative nutritional support (OR = 3.87; 95%CI: 1.16–10.91) and HEN (OR = 20.18; 95%CI: 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; 95%CI: 1.19-16.00; OR = 3.56; 95%CI: 1.11–11.39). HEN remained the only factor independently associated with the AC completion (OR = 18.54; 95%CI: 4.94–69.59). Among PDAC patients who underwent upfront MI-PD, 18.9% failed to receive AC mainly due to postoperative complications, while 27.4% successfully completed all planned AC cycles. HEN for 3 months after MI-PD was convenient and safe in practice, and was associated with improved tolerance of AC.