Invited Commentary
To Tube or Not to Tube—A Case for Early Enteral Nutrition
Yuqi Zhang, Krista Haines, Suresh Agarwal
JAMA Surg Published Online: April 22, 2026
doi: 10.1001/jamasurg.2026.1058
The early introduction of enteral feeding after surgery is well recognized as a cornerstone of Enhanced Recovery After Surgery (ERAS) protocols, consistently shown to reduce postoperative infections and mortality across multiple surgical domains. Although prior studies have compared total parenteral nutrition with enteral nutrition after pancreatoduodenectomy,1,2 the NUTRIWHI (Early Enteral vs Oral Nutrition After Whipple Procedure) randomized clinical trial evaluated the impact of supplementing standard oral nutrition with early enteral tube feeding (EEN).3 This effectively single-center, nonblinded, randomized clinical trial demonstrated a significantly lower 90-day Comprehensive Complication Index in the EEN group, suggesting that the early addition of tube feeds may reduce the overall burden of complications.
Closer examination reveals that this reduction was primarily driven by lower rates of pulmonary and infectious complications (excluding superficial surgical site infections). Although improved nutritional status may contribute to these findings, other factors—such as enhanced pulmonary hygiene and more vigilant aspiration monitoring among patients with feeding tubes—may also have played a role. Notably, delayed gastric emptying occurred in 45% of the cohort, necessitating nasogastric decompression in nearly half the study population. The duration of nasogastric tube use was not reported, but prolonged decompression transforms the study into a comparison of postpyloric feeding vs nothing by mouth, diverging from the original intent. Presumably, this is why patients requiring a nasogastric tube at the end of surgery were excluded. A subgroup analysis would have strengthened the conclusions, though at the cost of reduced statistical power. Lastly, it would be interesting to know what proportion of patients undergoing pancreatoduodenectomy during the study period had a nutritional risk screening score less than 3 and thus did not meet eligibility criteria, to better assess the generalizability of the findings.
Despite these limitations, the NUTRIWHI trial offers important practical insights. The addition of EEN to oral intake was safe, with no increase in major complications, and generally well tolerated, providing a dependable method for supplemental nutrition in high-risk patients. Tube dislodgement occurred in a minority of patients but did not compromise overall feasibility. Although the study’s 90-day follow-up period limits conclusions about long-term outcomes, future investigations can explore EEN’s effects on functional recovery, quality of life, and completion of adjuvant therapy.
