Immediate postoperative enteral feeding results in impaired respiratory mechanics and decreased mobility

Feeding jejunostomy: does the benefit overweight the risk (a retrospective study from a single centre)

BACKGROUND

The purpose of this study was to review the efficacy and safety of feeding jejunostomy in terms of achieving the nutritional goals in patients undergoing esophagectomy for carcinoma of oesophagus and complications associated hence with.

METHODS

A total of 463 patients underwent esophagogastrectomy for carcinoma oesophagus during this period. All these patients underwent Witzel feeding jejunostomy for post-operative enteral nutrition. Enteral feeding was started after 24 h of surgery and increased gradually till target caloric and protein value was achieved. Nutritional goals achieved were reviewed. All complications related to jejunostomy were recorded.

RESULTS

The study comprised of 463 patients who underwent elective esophagogastrectomy. Mean age was 58 +/- 8.4 in male patients and 55 +/- 4.2 years in female patients. Patients spend a mean of 19 +/- 8.4 (range 10-49) days on jejunostomy feed. The targeted calorie requirement was achieved by post-operative day 3 in 408 (88.12%) patients. The catheter blockage was one of the main complications during the course of feeding. Seven patients required relaparotomy for catheter blockage.

CONCLUSION

Feeding jejunostomy is an effective, safe, economic and well tolerated method of providing nutrition to the patients of esophagogastrectomy. Feeding jejunostomy should be done in every patient undergoing esophagectomy at the time of laparotomy.

Respiratory complications after oesophageal surgery

PURPOSE OF REVIEW

The most frequent complications of oesophageal surgery are respiratory and these are associated with increased critical care stay, hospital stay and mortality. This review focuses on the risk factors associated with the development of respiratory complications after oesophageal surgery.

RECENT FINDINGS

An acceptable operative mortality, increased and improved quality of life can be gained in appropriately selected patients. When induction therapy is scheduled, smoking cessation is advised. The preoperative treatment of airway pathogens can reduce postoperative complications and this may be particularly relevant in patients who have received induction chemoradiotherapy. Nonrandomized studies suggest that thoracic epidural analgesia improves outcome. Minimally invasive surgery is increasingly used and appears safe but direct comparisons to open surgery in terms of respiratory complications are awaited. Few randomized studies are available to guide anaesthetic management but anaesthetists should aim to avoid hypoxaemia, hypotension, aspiration and limit blood and fluid administration. Postoperative aspiration is common and steps to reduce it are recommended.

SUMMARY

The multifactorial nature of respiratory complications after oesophageal surgery may mean that a number of interventions are needed to have a detectable influence on outcome, much like a care bundle strategy.

Benefits versus risks: a prospective audit. Feeding jejunostomy during esophagectomy

BACKGROUND

The purpose of this prospectively collected database is to evaluate the safety, efficacy, and utility of postoperative jejunostomy feeding in terms of achieving nutritional goals and evaluating gastrointestinal and mechanical complications in patients undergoing esophagectomy.

METHODS

The study included 204 consecutive patients who underwent esophagectomy for various benign and malignant conditions. All patients underwent Witzel feeding jejunostomy at the time of laparotomy. Patients were followed prospectively to record nutritional intake, type of feed administered, rate progression, tolerance, and complications either mechanical or gastrointestinal.

RESULTS

Feeding jejunostomy could be performed in 99.5% patients; 6.0% of the patients had a blocked catheter during the course of feeding. The target calorie requirement could be achieved in 78% of patients by third day. In all, 95% of patients could be successfully fed exclusively by jejunostomy catheter during the postoperative period. Minor gastrointestinal complications developed in 15% of the patients and were managed by slowing the rate of infusion or administering medication. Patients spent a mean of 16.67 +/- 22.00 days (range 0-46 days) on jejunostomy feeding after surgery; however, 13% required prolonged jejunostomy feeding beyond 30 days. Altogether, 64% of the patients with an anastomotic leak and 50% of the patients with postoperative complications required catheter jejunostomy feeding beyond 30 days. The mean duration for which jejunostomy tube feeding was used was significantly higher for patients who developed anastomotic disruptions (33.05 +/- 16.24 vs. 14.69 +/- 19.04 days; p = 0.000) and postoperative complications (26.67 +/- 25.56 vs. 14.52 +/- 18.64 days; p = 0.000) when compared to those without disruption or complications. There were no serious complications related to the feeding catheter that required reintervention. There was no difference in the mean body weight or weight deficit at the end of 10 days and at 1 month in patients who developed complications or anastomotic disruption when compared to their counterparts. No patient died as a result of a complication related to the feeding jejunostomy.

CONCLUSIONS

Tube jejunostomy feeding is an effective method for providing nutritional support in patients undergoing esophagectomy, and it allows home support for the subset who fail to thrive. Prolonged tube feeding was continued in patients developing anastomotic disruptions and postoperative complications. Feeding jejunostomy has a definitive role to play in the management of the patients undergoing esophagectomy.

Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials

PURPOSE

To determine whether the provision of early standard enteral nutrition (EN) confers treatment benefits to critically ill patients.

METHODS

Medline and EMBASE were searched. Hand citation review of retrieved guidelines and systematic reviews were undertaken, and academic and industry experts were contacted. Methodologically sound randomised controlled trials (RCTs) conducted in critically ill patient populations that compared the delivery of standard EN, provided within 24 h of intensive care unit (ICU) admission or injury, to standard care were included. The primary analysis was conducted on clinically meaningful patient-oriented outcomes. Secondary analyses considered vomiting/regurgitation, pneumonia, bacteraemia, sepsis and multiple organ dysfunction syndrome. Meta-analyses were conducted using the odds ratio (OR) metric and a fixed effects model. The impact of heterogeneity was assessed using the I (2) metric.

RESULTS

Six RCTs with 234 participants were analysed. The provision of early EN was associated with a significant reduction in mortality [OR = 0.34, 95% confidence interval (CI) 0.14-0.85] and pneumonia (OR = 0.31, 95% CI 0.12-0.78). There were no other significant differences in outcomes. A sensitivity analysis and a simulation exercise confirmed the presence of a mortality reduction.

CONCLUSION

Although the detection of a statistically significant reduction in mortality is promising, overall trial quality was low, trial size was small, and the findings may be restricted to the patient groups enrolled into included trials. The results of this meta-analysis should be confirmed by the conduct of a large multi-centre trial enrolling diverse critically ill patient groups.

Clinical severity scores do not predict tolerance to enteral nutrition in critically ill children

The objective of the present study was to analyse whether there is a relationship between the clinical severity at the time of starting transpyloric enteral nutrition (TEN) and the onset of digestive tract complications in critically ill children. Between May 2005 and December 2007, we performed a prospective, observational study with the participation of 209 critically ill children aged between 3 d and 17 years and who received TEN. The characteristics of the nutrition and its tolerance were compared with the paediatric risk of mortality (PRISM), the paediatric index of mortality (PIM) and the paediatric logistic organ dysfunction index (PELOD) at the time of starting the nutrition. Higher PRISM and PELOD scores correlated with a later time of starting enteral nutrition, a longer time to reach the maximum daily energy delivery and a longer duration of the TEN. However, the severity scores did not correlate with the maximum energy delivery achieved. Abdominal distension or excessive gastric residues were observed in 4.7 % of the patients and diarrhoea in 4.3 %. The ability of the severity scores to predict diarrhoea was of 0.67 for PRISM, 0.63 for PELOD and 0.60 for PIM-2.The severity scores were not able to predict other digestive tract complications. Higher scores of clinical severity at the time of starting enteral nutrition correlate with a later initiation of the nutrition, a longer time to reach the maximum energy delivery and a longer duration of TEN. However, their ability to predict digestive tract complications is low.

ESPEN Guidelines on Parenteral Nutrition: surgery

In modern surgical practice it is advisable to manage patients within an enhanced recovery protocol and thereby have them eating normal food within 1-3 days. Consequently, there is little room for routine perioperative artificial nutrition. Only a minority of patients may benefit from such therapy. These are predominantly patients who are at risk of developing complications after surgery. The main goals of perioperative nutritional support are to minimize negative protein balance by avoiding starvation, with the purpose of maintaining muscle, immune, and cognitive function and to enhance postoperative recovery. Several studies have demonstrated that 7-10 days of preoperative parenteral nutrition improves postoperative outcome in patients with severe undernutrition who cannot be adequately orally or enterally fed. Conversely, its use in well-nourished or mildly undernourished patients is associated with either no benefit or with increased morbidity. Postoperative parenteral nutrition is recommended in patients who cannot meet their caloric requirements within 7-10 days orally or enterally. In patients who require postoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice. The main consideration when administering fat and carbohydrates in parenteral nutrition is not to overfeed the patient. The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements. Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weights. In those patients who are unable to be fed via the enteral route after surgery, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basis.

The etiology and prevention of feeding intolerance paralytic ileus--revisiting an old concept

Gastro-intestinal (G-I) motility is impaired ("paralytic ileus") after abdominal surgery. Premature feeding attempts delay recovery by inducing "feeding intolerance," especially abdominal distention that compromises respiration. Controlled studies (e.g., from Sloan-Kettering Memorial Hospital) have lead to recommendations that patients not be fed soon after major abdominal surgery to avoid this complication. We postulate that when total fluid inflow of feedings, digestive secretions, and swallowed air outstrip peristaltic outflow from the feeding site, fluid accumulates. This localized stagnation triggers G-I vagal reflexes that further slow the already sluggish gut, leading to generalized abdominal distention. Similarly, vagal cardiovascular reflexes in susceptible subjects could account for the 1:1,000 incidence of unexplained bowel necrosis reported with enteral feeding. We re-evaluated our data, which supports this postulated mechanism for the induction of "feeding intolerance." We had focused our efforts on postoperative enteral nutrition, with the largest reported series of immediate feeding of at least 100 kcal/hour after major surgery. We found that this complication can be avoided consistently by monitoring inflow versus peristaltic outflow, immediately removing any potential excess from the feeding site. We fed intraduodenally immediately following "open" surgery for 31 colectomy and 160 consecutive cholecystectomy patients. The duodenum was aspirated simultaneously just proximal to the feeding site, efficiently removing all swallowed air and excess feedings. To salvage digestive secretions, the degassed aspirate was re-introduced manually (and later automatically) via a separate feeding channel. Hourly assays were performed for nitrogen balance, serum amino acids, and for the presence of removed feedings in the aspirate. The colectomy patients had X-ray motility studies initiated 5-17 hours after surgery. Clinically normal motility and absorption resumed within two hours. Fed BaSO4 traversed secure anastomoses, to exit in bowel movements within 24-48 hours of colectomy. All patients were in positive protein balance within 2-24 hours, with elevated serum amino acids levels and without adverse G-I effects. Limiting inflow to match peristaltic outflow from the feeding site consistently prevented "feeding intolerance." These patients received immediate full enteral nutrition, with the most rapid resolution of postoperative paralytic ileus, to date.

Pilot postoperative ileus study of escin in cancer patients after colorectal surgery

BACKGROUND

Postoperative ileus, a common complication in patients after abdominal surgery, brings no benefit to the recovery of postoperative patients, and treatment targeted at restoring gastrointestinal motility may shorten the hospital stay. Studies have shown that escin accelerates gastrointestinal transit in mice and improves gastrointestinal motility in patients after abdominal surgery. A pilot study of escin's effect on the recovery of gastrointestinal motility was conducted in colorectal cancer patients in anticipation of a multiple-center randomized controlled trial.

METHODS

A total of 72 postoperative colorectal cancer patients were randomly assigned to four parallel groups on the basis of sealed envelopes-escin 5 mg group (E5 mg), escin 15 mg group (E15 mg), escin 25 mg group (E25 mg), and placebo group-with 18 patients in each group. Escin or placebo was diluted in 500 ml 5% dextrose injection, which was given once daily through the subclavian vein. The first injection took place 6 h after completion of the surgery. The treatment continued for 7 days or stopped at the time of the patient's first bowel movement. Time to recovery of passage of gas (TRPG), time to recovery of gastrointestinal sounds (TRGS), and time to recovery of bowel movements (TRBM) were recorded to evaluate the efficacy of escin.

RESULTS

The TRPGs of the three escin treatment groups were 76.78 + 28.81 h (E5 mg), 72.06 + 14.65 h (E15 mg), and 65.50 + 26.70 h (E25 mg), respectively, with differences of 6.03 +/- 7.64 h (p = 0.436; E5 mg), 10.75 +/- 4.92 h (p = 0.036; E15 mg), and 17.31 +/- 7.20 h (p = 0.022; E25 mg) compared with the placebo group. The TRGSs of the three escin treatment groups were 45.28 +/- 26.15 h (E5 mg), 41.22 +/- 16.98 h (E15 mg), and 40.33 +/- 14.09 h (E25 mg), respectively, with differences of 4.33 +/- 7.12 h (p = 0.547; E5 mg), 8.39 +/- 5.36 h (p = 0.127; E15 mg), and 9.28 +/- 4.87 h (p = 0.065; E25 mg) compared with the placebo group. The TRBMs of the three escin treatment groups were 89.25 +/- 23.77 h (E5 mg), 84.83 +/- 27.91 h (E15 mg), and 84.44 +/- 19.74 h (E25 mg), respectively, with differences of 19.03 +/- 10.13 h (p = 0.069; E5 mg), 23.44 +/- 10.70 h (p = 0.035; E15 mg), and 23.83 +/- 9.63 h (p = 0.019; E25 mg) compared with the placebo group.

CONCLUSION

The results of this pilot Postoperative Ileus Study of Escin (PISE) showed that escin can shorten the time to recovery of gastrointestinal motility in cancer patients after colorectal surgery.

Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: a systematic review and meta-analysis

BACKGROUND

We set out to evaluate early commencement of post-operative enteral nutrition versus traditional management in patients undergoing gastrointestinal surgery.

METHODS

Electronic databases were searched, references lists were scanned and authors contacted for additional information. We looked for randomised controlled trials comparing early commencement of feeding (within 24 h) with no feeding in patients undergoing gastrointestinal surgery. Primary endpoints were wound infections, intra-abdominal abscesses, pneumonia, anastomotic leakage, mortality, length of hospital stay and complications of feeding. Data were combined to estimate the common relative risk of post-operative complications and associated 95% confidence intervals.

RESULTS

Thirteen trials, with a total of 1,173 patients, fulfilled our inclusion criteria. Mortality was reduced with early post-operative feeding. Early post-operative feeding increased vomiting. The direction of effect is suggestive of a reduction of risk of post-surgical complications and reduced length of hospital stay.

CONCLUSION

There is no obvious advantage in keeping patients 'nil by mouth' following gastrointestinal surgery. Early enteral nutrition is associated with reduced mortality, though the mechanism is not clear. This review supports the notion that early commencement of enteral feeding may be of benefit.

Interventions for preventing critical illness polyneuropathy and critical illness myopathy

BACKGROUND

Critical illness polyneuro-and/or myopathy (CIP/CIM) is an important and frequent complication in the intensive care unit (ICU), causing delayed weaning from mechanical ventilation. It may increase ICU stay and mortality.

OBJECTIVES

To examine the ability of any intervention to prevent the occurrence of CIP/CIM.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials Register (October 2007), MEDLINE (January 1950 to April 2008), EMBASE (January 1980 to October 2007), checked bibliographies and contacted trial authors and experts in the field.

SELECTION CRITERIA

All randomised controlled trials (RCTs), examining the effect of any intervention on the incidence of CIP/CIM in adult medical or surgical ICU patients. The primary outcome measure was the incidence of CIP/CIM after at least seven days in ICU, based on electrophysiological or clinical examination.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data.

MAIN RESULTS

Three out of nine identified trials, provided data on our primary outcome measure. Two trials examined the effects of intensive insulin therapy versus conventional insulin therapy. Eight hundred and twenty-five out of 2748 patients randomised, were included in the analysis. The incidence of CIP/CIM was significantly reduced with intensive insulin therapy in the population screened for CIP/CIM (relative risk (RR) 0.65, 95% confidence interval (CI) 0.55 to 0.78) and in the total population randomised (RR 0.60, 95% CI 0.49 to 0.74). Duration of mechanical ventilation, duration of ICU stay and 180-day mortality but not 30-day mortality, were significantly reduced with intensive insulin therapy, in both the total and the screened population. Intensive insulin therapy significantly increased hypoglycaemic events and recurrent hypoglycaemia. Death within 24 hours of the hypoglycaemic event was not different between groups. The third trial examined the effects of corticosteroids versus placebo in 180 patients with prolonged acute respiratory distress syndrome. No significant effect of corticosteroids on CIP/CIM was found (RR 1.09, 95% CI 0.53 to 2.26). No effect on 180-day mortality, new serious infections and glycaemia at day seven was found. A trend towards fewer episodes of pneumonia and reduction of new events of shock was shown.

AUTHORS' CONCLUSIONS

Substantial evidence shows that intensive insulin therapy reduces the incidence of CIP/CIM, the duration of mechanical ventilation, duration of ICU stay and 180-day mortality. There was a significant associated increase in hypoglycaemia. Further research needs to identify the clinical impact of this and strategies need to be developed to reduce the risk of hypoglycaemia. Limited evidence shows no significant effect of corticosteroids on the incidence of CIP/CIM, or on any of the other secondary outcome measures, except for a significant reduction of new episodes of shock. Strict diagnostic criteria for the purpose of research should be defined. Other interventions should be investigated in randomised controlled trials.

Chylous ascites after pancreaticoduodenectomy: introduction of a grading system

BACKGROUND

Chylous ascites (CA) is a complication that follows thoracic and abdominal surgery, recognized after provocation by enteral feeding and characterized by its milky appearance from an elevated triglyceride level. The aim of this study was to evaluate incidence, management, and predisposing factors of CA and its impact on outcomes after pancreaticoduodenectomy.

STUDY DESIGN

Between 1996 and 2007, 609 consecutive patients underwent pancreaticoduodenectomy. Patients having a drain output with a milky appearance, and with a triglyceride level greater than 1.2 mmol/L, were compared with patients without significant drain production or with a low triglyceride level. Management of CA was reviewed.

RESULTS

Sixty-six patients had isolated CA (11%) of any measurable volume, 440 patients (72%) had no CA, and 109 patients (16%) were excluded from analysis. CA was diagnosed on postoperative day 6 (median; interquartile range 5 to 8), generally after introduction of a normal (polymeric low-chain-triglyceride) diet. Female gender (odds ratio, 1.79; 95% CI, 1.05 to 3.03) and chronic pancreatitis at pathology (odds ratio, 2.52; 95% CI, 1.19 to 5.32) were independently associated with development of isolated CA. A low-chain-triglyceride-restricted diet was initiated in 47 patients, 3 were started on total parenteral nutrition, and an expectative approach was followed in 16 patients. CA resolved after 3.5 days (median; interquartile range, 2 to 5). Isolated CA was significantly associated with prolonged hospital stay (p=0.002).

CONCLUSIONS

We propose a novel definition and grading system for CA after pancreaticoduodenectomy, according to which the incidence is 9%, with clinically significant CA occurring in 4% (grades B and C). Although female gender and (focal) chronic pancreatitis were associated with development of isolated CA, no predisposing factors that could readily anticipate CA were identified. Isolated CA was associated with prolonged hospital stay.

Enteral versus parenteral nutrition after gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials in the English literature

BACKGROUND

Although previous studies recommend the use of enteral nutrition (EN), the benefit of EN after elective gastrointestinal surgery has not been comprehensively demonstrated as through a meta-analysis. Our aim is to determine whether enteral nutrition is more beneficial than parenteral nutrition.

METHODS

A search was conducted on Medline, Web of Science, the Cochrane Library electronic databases, and bibliographic reviews. The trials were based on randomization, gastrointestinal surgery, and the reporting of at least one of the following end points: any complication, any infectious complication, mortality, wound infection and dehiscence, anastomotic leak, intraabdominal abscess, pneumonia, respiratory failure, urinary tract infection, renal failure, any adverse effect, and duration of hospital stay.

RESULTS

Twenty-nine trials, which included 2,552 patients, met the criteria. EN was beneficial in the reduction of any complication (relative risk (RR), 0.85; 95% confidence interval (CI), 0.74-0.99; P = 0.04), any infectious complication (RR, 0.69; 95% CI, 0.56-0.86; P = 0.001), anastomotic leak (RR, 0.67; 95% CI, 0.47-0.95; P = 0.03), intraabdominal abscess (RR, 0.63; 95% CI, 0.41-0.95; P = 0.03), and duration of hospital stay (weighted mean difference, -0.81; 95% CI, -1.25-0.38; P = 0.02). There were no clear benefits in any of the other complications.

CONCLUSION

The present findings would lead us to recommend the use of EN rather than PN when possible and indicated.

Feeding critically ill patients: what is the optimal amount of energy?

Hypermetabolism and malnourishment are common in the intensive care unit. Malnutrition is associated with increased morbidity and mortality, and most intensive care unit patients receive specialized nutrition therapy to attenuate the effects of malnourishment. However, the optimal amount of energy to deliver is unknown, with some studies suggesting that full calorie feeding improves clinical outcomes but other studies concluding that caloric intake may not be important in determining outcome. In this narrative review, we discuss the studies of critically ill patients that examine the relationship between dose of nutrition and clinically important outcomes. Observational studies suggest that achieving targeted caloric intake might not be necessary since provision of approximately 25% to 66% of goal calories may be sufficient. Randomized controlled trials comparing early aggressive use of enteral nutrition compared with delayed, less aggressive use of enteral nutrition suggest that providing increased calories with early, aggressive enteral nutrition is associated with improved clinical outcomes. However, energy provision with parenteral nutrition, either instead of or supplemental to enteral nutrition, does not offer additional benefits. In summary, the optimal amount of calories to provide critically ill patients is unclear given the limitations of the existing data. However, evidence suggests that improving adequacy of enteral nutrition by moving intake closer to goal calories might be associated with a clinical benefit. There is no role for supplemental parenteral nutrition to increase caloric delivery in the early phase of critical illness. Further high-quality evidence from randomized trials investigating the optimal amount of energy intake in intensive care unit patients is needed.

Do Data Support Nutrition Support? Part II. Enteral Artificial Nutrition

Artificial nutrition is widely advocated as adjunctive care in patients with a variety of underlying diseases. In recent years more emphasis has been placed on delivering it directly into the gastrointestinal tract through tubes in the stomach or proximal small intestine (enteral nutrition). Because the efficacy of any therapeutic intervention is best established by demonstrating it in one or more randomized controlled trials, this review focuses on data from such studies. The specific issue to be assessed is the ability of enteral nutrition to influence the mortality and morbidity of various diseases, a question that was addressed in depth in a recent systematic review. This article presents the highlights of that systematic review and puts it in context with the perspective of a practicing food and nutrition professional. Using established search strategies, 30 randomized controlled trials were identified that compared enteral nutrition to no artificial nutrition. In addition, other randomized controlled trials were identified that did provide some insight into the clinical utility of enteral nutrition. The randomized controlled trials were stratified by the underlying disease state. No high-quality evidence indicated that enteral nutrition had any beneficial effect on clinical outcome. Low-quality evidence, which tends to overestimate the treatment effect, suggested that enteral nutrition may be useful in reducing the incidence of postoperative complications and infection rates in intensive care units, improving mortality in chronic liver disease, and reducing length of stay when provided as trophic feeding to low-birth-weight neonates who are also receiving intravenous artificial nutrition. Enteral nutrition was not helpful when given during the first week to patients with dysphagic strokes. Thus, the randomized controlled trials that have compared enteral nutrition to no artificial nutrition have only found benefit when the methodologic rigor of the studies is inadequate to prevent bias from interfering with the interpretation of the data. No high-quality data are available to prove that enteral nutrition is of benefit.

Gastrointestinal monitor: automatic titration of jejunal inflow to match peristaltic outflow

A peristaltic gradient insures that chyme normally removed from the jejunal feeding site continues to be propelled caudad. The trigger for iatrogenic "feeding intolerance" is the inadvertently overwhelming of the jejunum's peristaltic outflow, even momentarily. Even minimum local stasis can stimulate a vagal reflex response. Motility of the sluggish gut further slows, leading to generalized abdominal distention, malaise, immobility, and impaired respiratory mechanics. Vagal vascular reflexes could explain the 1:1000 incidence of bowel necrosis for jejunally fed patients. We developed a clinical regimen that continuously "checks for residual" at the enteral feeding site, monitoring the adequacy of emptying. The jejunal inflow automatically is titrated to match peristaltic outflow if the latter cannot keep up. Intermittent suction aspirates the feeding catheter into a plastic chamber for 30 s. All swallowed air is removed efficiently within the close confines of the jejunal segment, without wasting digestive juices. The degassed aspirate is returned by gravity with the feedings during the second half of the 1-min cycle, unless incipient excess (>or=20 mL) fluid overflows. Only this relatively small volume of potentially excess fluid is discarded, forestalling the local distention. All patients tolerated immediate feeding without discomfort or abdominal distention, including three that had esophageal resection (including vagotomy) for carcinoma. Postoperative full enteral nutrition can be achieved quickly and safely with minimum attention, despite initially marginal gastrointestinal function.

Who benefits from nutritional support: what is the evidence?

Nutritional support, including oral nutritional supplements, enteral tube feeding and parenteral nutrition, can be an important part of the management of any patient. Malnutrition is common and costly, clinically and financially, if left untreated. In patients with, or at risk of, malnutrition, the appropriate use of nutritional support can prevent complications arising, produce other clinical, functional and financial benefits, and can be life saving in some situations. This article discusses the evidence from systematic reviews and meta-analyses of the effectiveness of nutritional support.

Early transpyloric enteral nutrition in critically ill children

OBJECTIVE

We compared the tolerance of early (within the first 24 h after admission to the pediatric intensive care unit) and late transpyloric enteral nutrition in critically ill children.

METHODS

We performed a prospective observational study including all critically ill children fed using transpyloric enteral nutrition. The clinical characteristics, energy intake, tolerance, and complications of nutritional delivery between the children with early (first 24 h) and late (after 24 h, range 1-43 d) transpyloric enteral nutrition were compared.

RESULTS

Transpyloric nutrition was started within the first 24 h in 202 (38.5%) of the 526 children. There were no differences in the diagnoses, incidence of organ disturbances, doses of vasoactive drugs, or mortality between the two groups. There were no differences in the maximum number of calories delivered or in the duration of the nutrition between children with early and late transpyloric nutrition. The incidence of abdominal distention was lower in the children receiving early transpyloric nutrition (3.5%) than in those receiving nutrition at a later date (7.8%; P < 0.05). Moreover, 6.3% of patients presented diarrhea, with no difference being found between the two groups.

CONCLUSION

Early transpyloric enteral nutrition is well tolerated in critically ill children and is not associated with an increase in incidence of complications.

Apparent low frequency of undernutrition in Dublin hospital in-patients: should we review the anthropometric thresholds for clinical practice?

Protein–energy undernutrition, or the possibility of its development, has been documented to occur frequently in patients on admission to hospital. Deterioration in nutritional status is known to occur in hospital. In a prospective study of 594 sequential hospital admissions, we aimed to assess the prevalence of undernutrition among patients on admission to two acute teaching hospitals in Dublin, Republic of Ireland using the widely-accepted anthropometric criteria applied in a large study from Dundee, Scotland, UK () and to determine changes in nutritional status in hospital. The mean prevalence of undernutrition (11 %) was considerably lower than was reported from Dundee (40 %). Unintentional weight loss before admission and functional impairment on admission occurred to a similar extent in both centres. Weight loss in hospital occurred in the same proportion of patients, but less frequently among those undernourished on admission to hospital, in Dublin compared with Dundee. The patients found to be undernourished on admission in this study had a mortality rate in hospital (6·5 %) over three times that of the adequately nourished group (2 %). The magnitude of the difference in prevalence of undernutrition between the two centres cannot be explained by ethnicity, case-mix or age distribution. With the secular increase in BMI in the population, the thresholds for classifying patients as undernourished or at risk of nutritional deterioration may need to be reviewed. For clinical use, recent weight loss and functional status may be more appropriate variables to use in the evaluation of nutritional status on admission to hospital.

Nutrition Society Symposium on ‘End points in clinical nutrition trials’ Death, morbidity and economics are the only end points for trials

In order to determine whether surrogate markers predict clinical outcome, randomized controlled trials (RCT) of nutrition supportv. no nutrition support that have reported at least one clinical outcome (mortality, infections, total complications, or duration of hospitalization) and at least one nutritional outcome (energy or protein intake, weight gain, N balance, albumin, prealbumin, transferrin, three anthropometric measures, skin testing, lymphocyte count) were assessed for concordance. If changes in nutritional markers predict clinical outcome, changes in both outcomes should go in the same direction. Concordance is defined as both outcomes changing in the same direction or both outcomes showing no difference. Discordance is defined as one outcome changing and the other not (partial) or both outcomes changing in opposite directions (complete). Ninety-nine RCT were identified, of which most were underpowered to see statistically significant changes, especially in clinical outcomes. Thus, the results were analysed only in relation to the direction of the respective changes in outcomes. Forty-eight comparisons (4×12) were made. The rates of concordance were ≤50% in forty-one of forty-eight comparisons; the rate was never >75%. A complete discordance rate of ≥25% was present in forty-three (≥50% in thirteen) of the forty-eight comparisons. The discordance was usually a result of the nutritional outcome being better than the clinical outcome. Changes in nutritional markers do not predict clinical outcomes. Before adopting any surrogate marker as an end point for a clinical trial, it has to be known that improving it will result in patient benefit.

Risk factors of pancreatic fistula and delayed gastric emptying after pancreaticoduodenectomy with pancreaticogastrostomy

BACKGROUND

Pancreatic fistula (PF) and delayed gastric emptying (DGE) are, respectively, the most frightening and most frequent complications after pancreaticoduodenectomy (PD). This study was undertaken to determine which independent factors influence the development of PF and DGE after PD.

STUDY DESIGN

Between January 1996 and December 2005, 131 consecutive patients underwent a PD with pancreaticogastrostomy. A total of 22 items, entered prospectively, were examined with univariate and multivariate analysis. PF was defined as amylase-rich fluid collected by needle aspiration from an intraabdominal collection or from the drainage placed intraoperatively from day 3. DGE was defined as the need for nasogastric decompression beyond the 10(th) postoperative day.

RESULTS

PF occurred in 14 patients (10.7%), with a mean length of hospital stay of 40.1+/-16.6 days. DGE occurred in 41 patients (31.3%), with a mean length of hospital stay of 35.5+/-13.6 days. PF and DGE increased postoperative length of stay. Multivariate analysis identified two independent factors for PF: heart disease as a risk factor and arterial hypertension as a protective factor. According to these two predictive factors, the observed rates of PF ranged from 4.1% to 66.6%. Age and early enteral feeding with nasojejunal tube were independent risk factors for DGE. DGE was statistically more frequent when surgical complications occurred or when an intraabdominal collection was present.

CONCLUSIONS

Heart disease was a risk factor and arterial hypertension was a protective factor of PF. Age and early enteral feeding were independent risk factors for DGE. DGE is linked to the occurrence of other postoperative intraabdominal complications.

Does enteral nutrition affect clinical outcome? A systematic review of the randomized trials

BACKGROUND

Both parenteral nutrition (PN) and enteral nutrition (EN) are widely advocated as adjunctive care in patients with various diseases. A systematic review of 82 randomized controlled trials (RCTs) of PN published in 2001 found little, if any, effect on mortality, morbidity, or duration of hospital stay; in some situations, PN increased infectious complication rates.

OBJECTIVE

The objective was to assess the effect of EN or volitional nutrition support (VNS) in individual disease states from available RCTs.

DESIGN

We conducted a systematic review. RCTs comparing EN or VNS with untreated controls, or comparing EN with PN, were identified and separated according to the underlying disease state. Meta-analysis was performed when at least three RCTs provided data. The evidence from the RCTs was summarized into one of five grades. A or B, respectively, indicated the presence of strong or weak (low-quality RCTs) evidence supporting the use of the intervention. C indicated a lack of adequate evidence to make any decision about efficacy. D indicated that limited data could not support the intervention. E indicated either that strong data found no effect, or that either strong or weak data suggested that the intervention caused harm.

PATIENTS AND SETTINGS

RCTs could include either hospitalized or nonhospitalized patients. The EN or VNS had to be provided as part of a treatment plan for an underlying disease process.

INTERVENTIONS

The RCT had to compare recipients of either EN or VNS with controls not receiving any type of artificial nutrition or had to compare recipients of EN with recipients of PN.

OUTCOME MEASURES

These were mortality, morbidity (disease specific), duration of hospitalization, cost, or interventional complications. SUMMARY OF GRADING: A: No indication was identified. B: EN or VNS in the perioperative patient or in patients with chronic liver disease; EN in critically ill patients or low birth weight infants (trophic feeding); VNS in malnourished geriatric patients. (The low-quality trials found a significant difference in survival favoring the VNS recipients in the malnourished geriatric patient trials; two high-quality trials found nonsignificant differences that favored VNS as well.) C: EN or VNS in liver transplantation, cystic fibrosis, renal failure, pediatric conditions other than low birth weight infants, well-nourished geriatric patients, nonstroke neurologic conditions, AIDS; EN in acute pancreatitis, chronic obstructive pulmonary disease, nonmalnourished geriatric patients; VNS in inflammatory bowel disease, arthritis, cardiac disease, pregnancy, allergic patients, preoperative bowel preparation. D: EN or VNS in patients receiving nonsurgical cancer treatment or in patients with hip fractures; EN in patients with inflammatory bowel disease; VNS in patients with chronic obstructive pulmonary disease. E: EN in the first week in dysphagic, or VNS at any time in nondysphagic, stroke patients who are not malnourished; dysphagia persisting for weeks will presumably ultimately require EN.

CONCLUSIONS

There is strong evidence for not using EN in the first week in dysphagic, and not using VNS at all in nondysphagic, stroke patients who are not malnourished. There is reasonable evidence for using VNS in malnourished geriatric patients. The recommendations to consider EN/VNS in perioperative/liver/critically ill/low birth weight patients are limited by the low quality of the RCTs. No evidence could be identified to justify the use of EN/VNS in other disease states.

Anaesthesia for oesophagectomy

PURPOSE OF REVIEW

To review the current anaesthetic management of patients undergoing transthoracic oesophagectomy.

RECENT FINDINGS

Oesophageal adenocarcinoma is increasing rapidly in the West. The perioperative mortality for oesophagectomy remains high. A relationship has been established between volume and outcome for oesophageal surgery. There is little evidence from randomized clinical studies to guide the management of patients undergoing oesophagectomy. The profile of patients presenting for oesophagectomy is changing. There is emerging evidence that anaesthetic management influences outcome. At present there are no clear advantages for minimal access surgery.

SUMMARY

Although nonsurgical treatments are being developed, at present surgery remains the mainstay of potentially curative treatment. Accurate risk stratification would greatly facilitate the assessment of strategies to reduce operative mortality. Anaesthetic research has the potential to further improve the safety of patients undergoing oesophageal surgery.

Acute Abdominal Pain among Elderly Patients

BACKGROUND

Diagnosis of acute abdominal pain in older persons is a challenge, with the age-related increase in concurrent diseases. In most western countries the number of elderly people is constantly rising, which means that an increasing proportion of patients admitted for abdominal pain at the emergency department are elderly.

OBJECTIVE

To characterize differences in clinical presentation and diagnostic accuracy between younger and more elderly patients with acute abdominal pain.

METHODS

Patients admitted to Mora Hospital with abdominal pain of up to seven days' duration were registered according to a detailed schedule. From 1st February 1997 to 1st June 2000, 557 patients aged 65-79 years and 274 patients aged > or = 80 years were registered. Patients aged 20-64 years (n = 1,458) served as a control group.

RESULTS

A specific diagnosis, i.e. other than 'nonspecific abdominal pain', was established in 76 and 78% of the patients aged 65-79 and > or = 80 years respectively, and in 64% of those aged 20-64 (p < 0.001). Pain duration before admission increased with age (p < 0.003), as did frequency and duration of hospitalization (p < 0.0001). Hospital stay increased from 170 days per 100 emergency admissions in the control group to 320 and 458 days in the younger and older study groups, respectively. At the emergency department, older patients were more often misdiagnosed than control patients (52 vs. 45%; p = 0.002). At discharge the diagnosis was more accurate in the control group (86 vs. 77%; p < 0.0001). Hospital mortality was higher among older patients (23/831 vs. 2/1,458; p < 0.001). The admission-to-surgery interval was increased (1.8 vs. 0.9 days, p < 0.0001) in patients > or = 65 years. Rebound tenderness (p < 0.0001), local rigidity (p = 0.003) and rectal tenderness (p = 0.004) were less common in the older than in the control patients with peritonitis. In patients > or = 65 years, C-reactive protein did not differ between patients operated on and those not, contrary to the finding in patients < 65 years (p < 0.0001).

CONCLUSION

Both the preliminary diagnosis at the emergency department and the discharge diagnosis were less reliable in elderly than in younger patients. Elderly patients more often had specific organic disease and arrived at the emergency department after a longer history of abdominal pain compared to younger patients.

Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications

BACKGROUND

The role of early postoperative enteral nutrition after gastrointestinal surgery is controversial. Traditional management consist of 'nil by mouth', where patients receive fluids followed by solids when tolerated. Although several trials have implicated lower incidence of septic complications and faster wound healing upon early enteral feeding, other trials have shown opposite results. The immediate advantage of caloric intake could be a faster recovery with fewer complications, to be evaluated systematically.

OBJECTIVES

To evaluate whether early commencement of postoperative enteral nutrition compared to traditional management (no nutritional supply) is associated with fewer complications in patients undergoing gastrointestinal surgery

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, PUBMED, EMBASE, and LILACS from 1979 (first RCT published) to March 2006. We manually scanned the references from the relevant articles, and consulted primary authors for additional information.

SELECTION CRITERIA

We looked for randomised controlled trials (RCT's) comparing early commencement of feeding (within 24 hours) with no feeding in patients undergoing gastrointestinal surgery. Early enteral nutrition is defined as all oral intakes (i.e. registered oral intake, supplemented oral feeding) and any kind of tube feeding (gastric, duodenal or jejunal) containing caloric content. No feeding is traditional management, defined as none caloric oral intake or any kind of tube feeding before bowel function. The definition 'no nutrition' includes non caloric placebo and water.

DATA COLLECTION AND ANALYSIS

The three authors independently assessed the identified trials, and extracted the relevant data using a specifically developed data extraction sheet. Primary end points of interest were: Wound infections and intraabdominal abscesses, postoperative complications such as acute myocardial infarction, postoperative thrombosis or pneumonia, anastomotic leakages, mortality, length of hospital stay, and significant adverse effects. We combined data to estimate the common relative risk of postoperative complications, and calculated the associated 95% confidence intervals. For analysis, we used fixed effects model (risk ratios to summarise the treatment effect) whenever feasible. The treatment effect on length of stay was estimated using effect size (presented as mean +/- SD). Some outcomes were not analysed but presented in a descriptive way. We used a random effects model to estimate overall risk ratio and effect size.

MAIN RESULTS

We identified thirteen randomised controlled trials, with a total of 1173 patients, all undergoing gastrointestinal surgery. Individual clinical complications failed to reach statistical significance, but the direction of effect indicates that earlier feeding may reduce the risk of post surgical complications. Mortality was the only outcome showing a significant benefit, but not necessarily associated with early commencement of feeding, as the reported cause of death was anastomotic leakage, reoperation, and acute myocardial infarction.

AUTHORS' CONCLUSIONS

Although non-significant results, there is no obvious advantage in keeping patients 'nil by mouth' following gastrointestinal surgery, and this review support the notion on early commencement of enteral feeding.

Immunonutrition in surgery and critical care

The benefits of specialty supplemented enteral diets administered to critically ill and critically injured patients and those undergoing major surgical procedures have been documented in a number of randomized prospective studies. It is unclear which nutrient or combination of nutrients causes the beneficial effects, but there are significant reductions in infectious complications depending upon the patient populations studied. It is imperative that the data be interpreted in the context of individual patient risk since specialty formulas appear most beneficial in patients at risk of subsequent complications or in those with significant pre-existing malnutrition. Although controversy exists regarding the use of specialty supplemented enteral diets in critically ill patients, they have been administered safely with minimal risk of adverse outcome in malnourished patients and in the critically ill and critically injured.

Recent randomized controlled trials in pancreaticoduodenectomy

OBJECTIVES

To analyze and summarize the recent randomized controlled trials (RCTs) investigating pancreaticoduodenectomy (PD).

METHODS

A MEDLINE search was performed to identify prospective RCTs on PD published during the last decade. Eligible RCTs were analyzed using the following items: publication year, geographical area, study theme, sample size, and multicenter study. Moreover, the quality of each RCT was evaluated.

RESULTS

Thirty-four articles were eligible for review. One to 6 RCTs have been carried out annually during the recent 10 years. Geographically, 15 trials were performed in Europe, 10 trials in North America, and 9 in Asia. Studies concerning postoperative complications in the early postoperative period such as pancreatic fistula and delayed gastric emptying have been most frequent. Randomized controlled trials comparing anastomotic procedures for the remnant pancreas, standard PD versus PD with extended lymphadenectomy, and PD versus pylorus-preserving PD follow in descending order. The average sample size has been 117, and 10 RCTs had sample size less than 50. The rate of multicenter studies among all RCTs is 21%, with the rate in the most recent 5 years having increased 2-fold compared with that in the earlier period. Concerning the quality of RCTs, calculation of sample size was described in only 14 RCTs and intention to treat analysis was performed in 26 RCTs.

CONCLUSIONS

This study reviewed 34 RCTs on PD performed all over the world. Although the quality of every RCT was not satisfactory, high-grade evidence obtained by these RCTs should be applied in clinical settings to improve surgical quality and quality of life for each patient.

An investigation into the current peri-operative nutritional management of oesophageal carcinoma patients in major carcinoma centres in England

INTRODUCTION

Patients with oesophageal carcinoma are at high risk of malnutrition. The aim of this study was to assess current practice for the nutritional management of patients following surgery for oesophageal carcinoma.

PATIENTS AND METHODS

A postal questionnaire was sent to 82 dietetic departments of those hospitals in England identified as major centres for upper gastrointestinal surgery.

RESULTS

Of the 66 (80%) responses received, 22 (33%) centres routinely perform pre-operative nutritional screening/assessment on oesophageal carcinoma patients. Centres with dietetic support dedicated to these patients are more likely to perform a pre-operative nutritional assessment (n = 17; 55%) than those without (n = 5; 14%; P < 0.001; chi(2) = 12.17). Pre-operative nutritional support is routinely provided in only 11 (17%) centres with the majority of centres (n = 50; 75%), providing it if patients are considered malnourished only. A total of 47 (70%) centres routinely provide postoperative nutritional support with jejunal feeding being the most commonly chosen route. Dedicated dietetic support is provided at 31 (47%) centres. Those centres with a dedicated dietitian are more likely to provide early postoperative nutritional support (n = 27; 87%) than those without (n = 20; 57%; P = 0.007; chi(2) = 7.195) and more likely to review patients routinely following discharge from hospital (n = 25 [81%] with a dietitian versus n = 17 [49%] without; P = 0.007; chi(2) = 7.2).

CONCLUSIONS

The nutritional management of patients following surgery for upper gastrointestinal carcinoma is not uniform with practice varying considerably between centres. Those centres with a dedicated dietitian are more likely to assess patients' nutritional status and provide nutritional support.

Transpyloric enteral feeding in the postoperative of cardiac surgery in children

PURPOSE

The aim of this study is to assess the utility of transpyloric enteral nutrition in the postoperative period of cardiac surgery in children.

METHODS

A prospective, observational study was performed on children receiving transpyloric enteral nutrition in the postoperative period of cardiac surgery. The type of nutrition, duration, tolerance, and complications were studied.

RESULTS

Children (212) between the ages of 3 days and 17 years received transpyloric enteral nutrition in the postoperative period of cardiac surgery. The duration of the transpyloric feeding was 16 +/- 23.8 days, and the maximum calorie delivery was 85.1 +/- 25.7 kcal/kg/d. Tolerance to nutrition was good and was not affected by the infusion of vasoactive drugs, sedatives, or muscle relaxants. Of the study population, 14.6% presented with gastrointestinal complications, 9.4% with abdominal distension and/or excessive gastric residue, and 7.5% with diarrhea. Nutrition was withdrawn in 2.4% of the patients because of gastrointestinal complications. Mortality was not related to any characteristic of the nutrition or to gastrointestinal complications.

CONCLUSIONS

Transpyloric enteral nutrition is useful and is a simple feeding method that enables a high calorie delivery to be provided with few complications in the postoperative period of cardiac surgery in children, including those receiving high doses of sedatives and muscle relaxants.

ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation

Enhanced recovery of patients after surgery ("ERAS") has become an important focus of perioperative management. From a metabolic and nutritional point of view, the key aspects of perioperative care include: Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and if necessary tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in surgical patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1980. The guideline was discussed and accepted in a consensus conference. EN is indicated even in patients without obvious undernutrition, if it is anticipated that the patient will be unable to eat for more than 7 days perioperatively. It is also indicated in patients who cannot maintain oral intake above 60% of recommended intake for more than 10 days. In these situations nutritional support should be initiated without delay. Delay of surgery for preoperative EN is recommended for patients at severe nutritional risk, defined by the presence of at least one of the following criteria: weight loss >10-15% within 6 months, BMI<18.5 kg/m(2), Subjective Global Assessment Grade C, serum albumin <30 g/l (with no evidence of hepatic or renal dysfunction). Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Does gum chewing reduce postoperative ileus following open colectomy for left-sided colon and rectal cancer? A prospective randomized controlled trial

OBJECTIVE

Postoperative ileus is common after colorectal resection and can prolong hospital stay. Gum chewing, a type of sham feeding, may to stimulate gut motility via cephalic-vagal stimulation, and thereby reduce the length of ileus. This study aimed to determine whether gum chewing in the immediate postoperative period facilitated recovery from ileus following resection for left-sided colorectal cancer.

METHODS

In a prospective randomized control trial, 38 patients undergoing open surgery for left-sided colorectal cancer were allocated to standard postoperative care (control group, n = 19) or to standard postoperative care plus the immediate use of chewing gum (treatment group, n = 19).

RESULT

Control patients passed flatus by mean of 2.7 days (SD 1.0) and faeces by 3.9 days (SD 1.5); for the treatment group, this was 2.4 days (SD 1.0) and 3.2 days (SD 1.5) respectively, (NS, P = 0.56 and P = 0.38). Length of hospital stay was 11.1 days (SD 7.3) in control group and 9.4 days (SD 2.5) in the treatment group (NS, P = 0.75).

CONCLUSION

The addition of gum chewing to a standardized postoperative regimen did not reduce the period of postoperative ileus or shorten length of stay following open surgery for left-sided colorectal cancer.

Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection

BACKGROUND & AIMS

Clinical care of patients undergoing colonic surgery differs between hospitals and countries. In addition, there is considerable variation in rates of recovery and length of hospital stay following major abdominal surgery. There is a need to develop a consensus on key elements of perioperative care for inclusion in enhanced recovery programmes so that these can be widely adopted and refined further in future clinical trials.

METHODS

Medline database was searched for all clinical studies/trials relating to enhanced recovery after colorectal resection. Relevant papers from the reference lists of these articles and from the authors' personal collections were also reviewed. A combination of evidence-based and consensus methodology was used to develop the resulting enhanced recovery after surgery (ERAS) clinical care protocol.

RESULTS AND CONCLUSIONS

Within traditional perioperative practice there is considerable evidence supporting a range of manoeuvres which, in isolation, may improve individual aspects of recovery after colonic surgery. The present manuscript reviews these issues in detail. There is also growing evidence that an integrated multimodal approach to perioperative care can result in an overall enhancement of recovery. However, effects on major morbidity and mortality remain to be determined. A protocol is presented which is in current use by the ERAS Group and may provide a standard of care against which either current or future novel elements of an enhanced recovery approach can be tested for their effect on outcome.

The impact of early nutrition on metabolic response and postoperative ileus

PURPOSE OF REVIEW

Early nutrition has been evaluated and used as a possible strategy to decrease the negative impact of the metabolic response to injury and postoperative ileus. The metabolic response to injury, be it surgical or traumatic, is a physiological mechanism that, according to the magnitude and duration of the event, can impact on the patient's morbidity and survival. The adequate initial approach is a determinant factor that might influence its outcome. Simultaneously, gastrointestinal tract motility is transiently impaired, leading to the so-called postoperative ileus. The latter not only causes patient discomfort, but is also related to abdominal complications and worsening of the nutritional status, as well as increased length of hospital stay and costs.

RECENT FINDINGS

Multimodal surgical strategies such as preoperative intake of a carbohydrate drink, together with patient education of the postoperative care plan, efficacious analgesia and early nutrition have been described to significantly decrease the stress response and improve the ileus. Therefore, these strategies accelerate rehabilitation and, as a consequence, decrease complications and length of hospital stay and its related costs.

SUMMARY

Understanding perioperative pathophysiology and implementing care regimes through a multimodal approach in order to reduce the stress of the operation and the related postoperative ileus are major challenges. These factors will certainly impact on patient outcomes.

Randomized clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care

BACKGROUND

Postoperative oral nutritional supplementation has been shown to be of clinical benefit. This study examined the clinical effects and cost of administration of oral supplements both before and after surgery.

METHODS

This was a randomized clinical trial conducted in three centres. Patients undergoing lower gastrointestinal tract surgery were randomized to one of four groups: group CC received no nutritional supplements, group SS took supplements both before and after surgery, group CS received postoperative supplements only, and group SC were given supplements only before surgery. Preoperative supplements were given from the time it was decided to operate to 1 day before surgery. Postoperative supplements were started when the patient was able to take free fluids and continued for 4 weeks after discharge from hospital. Data collected included weight change, complications, length of stay, nutritional intake, anthropometrics, quality of life and detailed costings covering all aspects of care.

RESULTS

Some 179 patients were randomized, of whom 27 were withdrawn and 152 analysed (CC 44, SS 32, CS 35, SC 41). Dietary intake was similar in all four groups throughout the study. Mean energy intake from preoperative supplements was 536 and 542 kcal/day in the SS and SC groups respectively; that 2 weeks after discharge from hospital was 274 and 361 kcal/day in the SS and CS groups respectively. There was significantly less postoperative weight loss in the SS group than in the CC and CS groups (P < 0.050), and significantly fewer minor complications in the SS and CS groups than the CC group (P < 0.050). There were no differences in the rate of major complications, anthropometrics and quality of life. Mean overall costs were greatest in the CC group, although differences between groups were not significant.

CONCLUSION

Perioperative oral nutritional supplementation started before hospital admission for lower gastrointestinal tract surgery significantly diminished the degree of weight loss and incidence of minor complications, and was cost-effective.

A prospective cohort study of feeding needle catheter jejunostomy in an upper gastrointestinal surgical unit

BACKGROUND & AIM

Feeding jejunostomy is recommended to facilitate early enteral nutrition after major upper gastrointestinal surgery. We aimed to determine the benefits and risks associated with routine practice of feeding needle catheter jejunostomy (NCJ) in high-risk upper gastrointestinal surgery.

METHOD

This is a prospective consecutive cohort study of 84 patients underwent feeding NCJ over a 3 years period in an Upper Gastrointestinal Surgical Unit.

RESULTS

Feeding NCJ was placed after two-stage oesophago-gastrectomy in 24 patients (28.6%), after gastrectomy in 29 patients (34.5%), after liver resections in 7 patients (8.3%), pancreatic resection in 6 patients (7.1%), bile duct reconstruction in 8 patients (9.5%) and other operations in 10 patients (12%). The mean (SE) estimated nutritional requirement per 24 h was 1791 (31)kcal. Eighty-two patients (98%) started enteral feed on day 1 after surgery. Fifty-seven patients (68%) achieved the target nutritional requirements in 3 days. Four patients were discharged home on jejunal feed whilst only two patients required parenteral nutrition support. The rest tolerated full oral diet. There was no procedure related mortality. The morbidity related to feeding tube and feeding were 12.9% and 20%, respectively.

CONCLUSIONS

Routine practice of feeding NCJ is safe. Their benefits outweigh the risks in a specialist centre.

The nutritional management of surgical patients: enhanced recovery after surgery

Malnutrition has long been recognised as a risk factor for post-operative morbidity and mortality. Traditional metabolic and nutritional care of patients undergoing major elective surgery has emphasised pre-operative fasting and re-introduction of oral nutrition 3-5 d after surgery. Attempts to attenuate the consequent nutritional deficit and to influence post-operative morbidity and mortality have included parenteral, enteral and oral sip feeding. Recent studies have emphasised that an enhanced rate of recovery can be achieved by a multi-modal approach focused on modulating the metabolic status of the patient before (e.g. carbohydrate and fluid loading), during (e.g. epidural anaesthesia) and after (e.g. early oral feeding) surgery. Using such an approach preliminary results on patients undergoing elective colo-rectal surgery indicate a significant reduction in hospital stay (traditional care, n 48, median stay 10 d v. enhanced recovery programme, n 33, median stay 7d; P<0.01) can be achieved. Such findings emphasise the potential role of multi-modal care programmes in the promotion of early recovery from major surgical trauma.