Limited efficacy of early postoperative jejunal feeding

Nutrition and Nutritional Support in Critically Ill Patients

The use of intravenous nutritional support has increased dramatically in the last 20 years. Although it is not without controversy, administration of nutritional support is common practice in hospitalized patients including critically ill patients. Malnutrition continues to be reported in a significant number of hospitalized patients. The incidence of malnutrition in critically ill patients may be even higher than that reported in hospitalized patients overall. The consequences of malnutrition in a critically ill patient may be severe. Nutritional assessment and nutritional support can present special challenges to the intensivist. Techniques of nutritional assessment in critically ill patients are evaluated. Guidelines for the determination of the nutritional needs of these patients are outlined. Methods of delivery of nutritional support in critically ill patients are reviewed. Complications of nutritional support are discussed.

Jejunostomy tube feeding in patients undergoing esophagectomy

BACKGROUND

Surgical jejunostomy tubes are a routine part of elective esophagectomies in patients with carcinomas and provide a route for nutritional support in those who experience complications. We wished to determine how frequently oral intake is delayed and the amount of nutrition delivered via the jejunostomy tube.

METHODS

We reviewed the charts of all adults undergoing esophagectomy for carcinoma between January 2000 and June 2008. We determined the proportion of patients unable to resume oral nutrition after 8 days and the amount of nutrition delivered in each of the 8 days.

RESULTS

In all, 111 patients underwent elective esophagectomy for carcinoma, and 103 had a jejunostomy tube placed. The mean age was 67 ± 10.8 years. The median time to oral intake was 7 (interquartile range 7-11) days. Seventy-four (67%) patients resumed oral intake within 8 days. The mean nutrition delivered by jejunostomy within the first 8 days as a percentage of the target was 45.6% (95% confidence interval 41.2%-49.9%). Six (5.4%) patients experienced complications attributable solely to the jejunostomy tube; 3 (2.9%) required surgery. Forty (38.8%) patients had abdominal issues serious enough to warrant delaying the progression of feeding.

CONCLUSION

Two-thirds of patients undergoing elective esophagectomy were tolerating oral intake by the end of the eighth postoperative day, and less than half of the target nutrition was delivered over the first 8 days. We now selectively place surgical jejunostomy tubes in patients undergoing elective esophagectomies.

Early enteral feeding by nasoenteric tubes in patients with perforation peritonitis

Malnutrition is well recognized as a potential cause of increased morbidity and mortality in surgical patients. Early postoperative enteral nutrition through a feeding jejunostomy has been shown to improve results in patients undergoing major resections for gastrointestinal malignancies, trauma, and perforation peritonitis. We conducted a prospective study to assess the feasibility and short-term efficacy of early enteral feeding through a nasoenteric tube placed intraoperatively in patients with nontraumatic perforation peritonitis with malnutrition. One hundred patients with nontraumatic perforation peritonitis with malnutrition undergoing exploratory laparotomy were randomly divided into a test group (TG) and a control group (CG) of 50 patients each. TG patients had a nasoenteric tube placed at the time of surgery and were started on an enteral feeding regime 24 hours postoperatively. Patients in CG were allowed to eat orally once they passed flatus. The differences between the two groups with respect to nutritional intake in terms of energy and protein, changes in nutritional status as assessed by anthropometric, biochemical, and hematological values, amount of nasogastric aspirate, return of bowel motility, and complication rates were analyzed. The nasoenteric feeding was well tolerated. Total calorie and protein intake in TG was significantly higher than in CG: 981 vs. 505 kcal (p < 0.01), protein 24 vs. 0 g on day 3 and 1498 vs. 846 kcal (p < 0.01), protein 44 vs. 23 g (p < 0.01) on day 7, respectively. There was reduction in the amount of nasogastric aspirate in TG compared with that in CG: 431 vs. 545 ml/24 h on day 2 and 301 vs. 440 ml/24 h on day 3, respectively. There was much faster recovery of bowel motility in TG than in CG at 3.34 vs. 4.4 days (p < 0.01). Complications developed in 39 of 50 patients in TG and in 47 of 50 in CG. The major complications occurred in 6 patients in TG and 12 patients in CG (p < 0.05). Patients with perforation peritonitis with malnutrition are likely to develop large energy deficits postoperatively, resulting in higher incidence of infective complications. Early enteral feeding through a nasoenteric tube is well tolerated by these patients and helps to improve energy and protein intake, reduces the amount of nasogastric aspirate, reduces the duration of postoperative ileus, and reduces the risk of serious complications.

Nutrición enteral con yeyunostomía con catéter de aguja en la anastomosis esofágica. Complicaciones de la técnica

OBJECTIVE

The aim of this study was to evaluate the presence of complications associated with the use of surgical needle catheter jejunostomy and tolerance to enteral nutrition.

PATIENTS AND METHOD

We performed a retrospective study of 58 consecutive patients, who underwent esophageal or gastric resection with esophageal anastomosis and needle catheter jejunostomy. The variables studied were initiation of enteral nutrition, duration of perfusion, complications associated with the use of jejunostomy, and tolerance to enteral nutrition.

RESULTS

Mortality in the series was 1.7%. Infusion of enteral nutrition was started at mean of 4.84+/-5.01 days and lasted for a mean of 7.9+/-7.5 days. In one patient the jejunostomy could not be used due to catheter obstruction and in another 2 patients some resistance to perfusion of nutrition was observed but these patients could be fed through the tube. One patient had to undergo reintervention due to peritonitis caused by extravasation of the enteral nutrition within the peritoneal cavity. Catheter withdrawal was difficult in 2 patients; of these, 1 patient required investigation of the skin wound under local anesthetic. The overall rate of jejunostomy-related complications was 10.3%. Tolerance of enteral nutrition was acceptable in 41 patients, the infusion rate was reduced in 6 patients and infusion was discontinued due to intolerance in 10.

CONCLUSIONS

Because needle catheter jejunostomy produces low morbidity and good tolerance to enteral nutrition, it is a valid alternative in patients with esophageal anastomosis.

Methods for decreasing postoperative gut dysmotility

Postoperative disturbances of gastrointestinal function (postoperative ileus) are among the most significant side-effects of abdominal surgery for cancer. Without specific treatment, major abdominal surgery causes a predictable gastrointestinal dysfunction which endures for 4-5 days and results in an average hospital stay of 7-8 days. Ileus occurs because of initially absent and subsequently abnormal motor function of the stomach, small bowel, and colon. This disruption results in delayed transit of gastrointestinal content, intolerance of food, and gas retention. The aetiology of ileus is multifactorial, and includes autonomic neural dysfunction, inflammatory mediators, narcotics, gastrointestinal hormone disruptions, and anaesthetics. In the past, treatment has consisted of nasogastric suction, intravenous fluids, correction of electrolyte abnormalities, and observation. Currently, the most effective treatment is a multimodal approach. Median stays of 2-3 days after removal of all or part of the colon (colectomy) are now achievable. Recent discoveries have the potential to significantly reduce postoperative ileus in patients with cancer who have had abdominal surgery.

Jejunal feeding, even when instituted late, improves outcomes in patients with severe pancreatitis and peritonitis

This study assessed the feasibility and effectiveness of jejunal feeding (JF) after surgery due to secondary peritonitis or failed conservative therapy of severe pancreatitis. Of 60 patients, 30 were randomly assigned to receive postoperative JF and the remaining 30 constituted the control group. Acute Physiology and Chronic Health Evaluation II, nutritional intake, systemic inflammatory response syndrome, and outcomes were measured. Patients in JF group received the daily mean of 1294.6 (362.6) kcal including 830.6 (372.7.0) kcal enterally, versus 472.8 (155.8) kcal daily in the control group (P < 0.0001). There were fewer complications in the JF patients, with no significant difference; length of stay in the intensive care unit and in the hospital did not differ. The frequency of systemic inflammatory response syndrome was similar in both groups, but outcomes differed. The first surgical intervention resulted in 3.3% of relaparotomies in JF patients, caused by unresolved peritonitis, versus 26.7% in the control subjects (P = 0.03). Recovery of bowel transit took significantly less time in the JF patients (mean: 54.6 h versus 76.8 h in control subjects, P = 0.01). JF resulted in 3.3% mortality as opposed to 23.3% in the control group (P = 0.05). In conclusion, JF is feasible and effective in postoperative treatment of patients due to secondary peritonitis or severe pancreatitis. Improved bowel and peritoneal function could be the main impact of JF.

Appropriate use, complications and advantages demonstrated in 500 consecutive needle catheter jejunostomies

BACKGROUND

The ability to deliver nutrition enterally after operation has been a significant advance in managing patients after major intra-abdominal operations.

METHODS

The experience of a single surgeon at a tertiary referral hospital over a 10-year period with insertion and use of 500 consecutive needle catheter jejunostomies (NCJs) was reviewed critically from prospectively collected data.

RESULTS

The NCJ was used to deliver nutrition in 93 per cent, fluid and electrolytes in 95 per cent, and various medications in the postoperative period in the majority of patients. There were three major complications: small bowel obstruction and pneumatosis intestinalis in one and two patients respectively. Minor complications included diarrhoea (15 per cent), abdominal distension (15 per cent), abdominal cramps (3 per cent), subcutaneous infection at the insertion site (1 per cent) and catheter occlusion precluding use (1 per cent). In 16 patients, the NCJ was replaced percutaneously with a larger-bore catheter for more prolonged enteral feeding at home after discharge.

CONCLUSION

Through the experience gained, indications are offered for the placement of NCJs and cautions are provided concerning appropriate use of an NCJ to provide nutritional support, fluid and electrolyte replacement or maintenance, and safe enteral administration of medication. Overall, an NCJ appears to allow safer, cheaper and equally effective delivery of nutrition compared with total parenteral nutrition after major intra-abdominal operations.

The 1996 Nestlé International Clinical Nutrition Award for Enteral Nutrition. "Enteral versus parenteral nutrition: effects on gastrointestinal function and metabolism": background

Nutrition therapy for the critically ill patient is today an integral part of the treatment concept in intensive care medicine. Parenteral and enteral artificial nutrition are expensive, cost-intensive treatment procedures that are certainly not risk-free. For both ethical and economic reasons, the indications and principles of artificial nutrition must always be adapted to the latest knowledge.

A prospective, randomized trial of early enteral feeding after resection of upper gastrointestinal malignancy

OBJECTIVE

The purpose of the study was to determine whether early postoperative enteral feeding with an immune-enhancing formula (IEF) decreases morbidity, mortality, and length of hospital stay in patients with upper gastrointestinal (GI) cancer.

SUMMARY BACKGROUND DATA

Early enteral feeding with an IEF has been associated with improved outcome in trauma and critical care patients. Evaluable data documenting reduced complications after major upper GI surgery for malignancy with early enteral feeding are limited.

METHODS

Between March 1994 and August 1996, 195 patients with a preoperative diagnosis of esophageal (n = 23), gastric (n = 75), peripancreatic (n = 86), or bile duct (n = 11) cancer underwent resection and were randomized to IEF via jejunostomy tube or control (CNTL). Tube feedings were supplemented with arginine, RNA, and omega-3 fatty acids, begun on postoperative 1, and advanced to a goal of 25 kcal/kg per day. The CNTL involved intravenous crystalloid solutions. Statistical analysis was by t test, chi square, or logistic regression.

RESULTS

Patient demographics, nutritional status, and operative factors were similar between the groups. Caloric intake was 61% and 22% of goal for the IEF and CNTL groups, respectively. The IEF group received significantly more protein, carbohydrate, lipids and immune-enhancing nutrients than did the CNTL group. There were no significant differences in the number of minor, major, or infectious wound complications between the groups. There was one bowel necrosis associated with IEF requiring reoperation. Hospital mortality was 2.5% and median length of hospital stay was 11 days, which was not different between the groups.

CONCLUSION

Early enteral feeding with an IEF was not beneficial and should not be used in a routine fashion after surgery for upper GI malignancies.

Early postoperative enteral feeding following major upper gastrointestinal surgery

For a variety of reasons, enteral feeding is frequently delayed following major abdominal surgery. The purpose of this study was to evaluate prospectively the feasibility and tolerance of early jejunal feeding following major upper gastrointestinal surgery. Beginning on postoperative day 1, patients (n = 167) received a full-strength enteral formula at the rate of 25 ml/hr through a jejunal feeding tube. Diets were advanced to the calculated target rate (25 kcal/kg/day) by postoperative day 4. Complications of tube feeding, calories received, and patient symptoms were recorded daily. There were no major complications or deaths resulting from placement of a jejunal tube or from early enteral feeding. Patients had abdominal symptoms such as cramping, distention, nausea, and diarrhea on 9%, 18%, 4%, and 24% of all feeding days, respectively. The majority of these symptoms, with the exception of diarrhea, were graded as mild. Patients undergoing surgery for pancreatic malignancy had significantly more diarrhea than patients undergoing esophagectomy or gastrectomy. Despite these differences in symptoms, patients received an average of 78% of their targeted caloric goal by postoperative day 4 and maintained this level throughout the study. Early enteral feeding for patients undergoing esophageal, gastric, or pancreatic resections is both safe and feasible despite the occurrence of predominantly mild gastrointestinal symptoms.

Immediately elevated postoperative serum branched-chain amino acids following effective GI decompression and enteral feeding

Postoperative patients are hypercatabolic. They also suffer a degree of gastrointestinal (GI) dysfunction impairing nutritional intake. Safe enteral absorption had been limited to a maximum of 500 kcal provided over the initial 24 h in all previously reported regimens. Several days of negative nitrogen balance and diminution of serum branched-chain amino acids (BCAA) result. Some data suggest an association with suboptimal wound healing, and immune competence. We tested the hypothesis that immediate exploitation of more effectively preserved GI function could prevent this depressed serum concentration within hours of surgery. Our study group consisted of 34 consecutive elective "open" cholecystectomy patients who had terminal esophageal, gastric, and proximal duodenal decompression. Simultaneous distal duodenal feeding of elemental diet began immediately in the Recovery Room at 300 mL/h for 8-16 h, providing 2,400-4,800 kcal and 100-200 g amino acids. We found that each serum BCAA concentration rose above basal by one hour. The differences reached statistical significance (p < or = 0.05) within 2 h after surgery, when leucine had risen above basal levels by 70%, isoleucine by 63%, and valine by 26%. Elevations in these BCAA serum concentrations persisted for the duration of feeding. GI function can be maintained and successfully utilized in the immediate postoperative period for absorption of 300 kcal/h. Postoperative depression of serum BCAA concentrations are prevented. The serum BCAA rise of these GI protected and immediately fed postoperative patients contrasts with the 48-72 h decline universally reported with conventional protein- and calorie-deficient regimens. The optimum nutritional regimen for achievement of clinically significant enhanced wound healing, sepsis resistance, and muscle sparing, remains to be determined.

Enteral versus parenteral nutrition: effects on gastrointestinal function and metabolism

The effects of total parenteral nutrition (TPN) versus enteral nutrition (TEN) were studied in 34 patients following major neurosurgery. Measurements were made of resting energy expenditure (REE), urea production rate (UPR), visceral proteins, parameters of liver and pancreas function, as well as gastrointestinal absorption. To predict nutritional status, nutritional index (NI) was calculated. UPR revealed no significant differences between the groups. After 12 days of TEN, however, synthesis of visceral proteins increased significantly. In addition, NI improved after TEN (p < 0.05), whereas it remained unchanged after TPN. Thrombocyte and lymphocyte counts rose predominately during enteral nutrition. Only in the TEN group was REE increased by 18% and Glasgow Coma Scale (GCS) enhanced from Day 6 on. Exogenous insulin demand was enhanced in the parenterally fed group, and bilirubin (p < 0.05), amylase (p < 0.05), and lipase (p < 0.01) rose significantly, as did gamma-glutamyl-transferase (p < 0.0005) and alkaline phosphatase (p < 0.0005). After 12 d of TPN, vitamin A absorption was significantly attenuated, indicating reduced fat absorption compared to TEN. Carbohydrate absorption did not show significant changes between the groups. Only during TPN did mean values of xylose absorption remain below the normal range. Therefore, enteral nutrition following neurosurgical procedures is associated with an accelerated normalization of nutritional status and an improved substrate tolerance. TEN opposes early postoperative absorption disturbances of the small intestine.

[Respective indications of enteral or parenteral nutrition during pre- and post-operative periods]

Denutrition is often associated with poor postoperative outcome. However, a large body of evidence, from studies comparing perioperative parenteral (PN) or enteral (EN) nutrition to the absence of perioperative nutrition, suggests that perioperative nutritional support provides significant improvements in both nutritional status and postoperative clinical outcome in selected patients who are or will become malnourished. The aim of this study was to select and review all relevant articles comparing perioperative parenteral and enteral nutritional support, either in terms of clinical outcome, or risks and costs, or in pathophysiological terms. Twelve clinical reports were reviewed. All contained methodological flaws, mainly type II statistical error due to an insufficient number of patients, inaccurate primary diagnosis, absence of blinding, and lack of objective criteria of judgement. These concerns warrant caution in interpreting the results. Moderately strong (grade B) recommendations can only be drawn from these studies: PN (compared to early EN) is associated with a higher rate of sepsis in patients following abdominal trauma; EN is as efficient as PN in patients following surgery; EN is safe and cheaper than PN. PN formulae lack many important nutrients (glutamine, arginine, cysteine, peptides, fibers, n-3 polyunsaturated fatty acids, and nucleotides). Many experimental (animal) and some clinical (in non surgical patients) studies showed that PN (compared to EN) induces gut mucosal atrophy, liver dysfunction, gut bacterial translocation and immune dysfunction. The final aim of PN and EN would therefore strikingly differ. The qualitatively imperfect PN would only supply the fasting patient with quantitative amounts of calories and proteins. Due to initially limited digestive tolerance, EN provides less nutrition than PN does, but would finally lead to the same or even better outcome, due to its ability to counteract stress induced gut and immune dysfunction. Current evidence therefore suggests that early EN is superior to PN in trauma patients, and not different from but cheaper (and therefore more cost-effective) than PN in surgical patients. Further controlled, randomised, and blinded studies including sufficient sizes of groups are required, especially in the surgical setting, to address a large number of still unanswered questions.

[Pre- and post-operative enteral nutrition in elective surgery in adults. Techniques, advantages and adverse effects]

This review examined the techniques for enteral nutrition (routes and methods of administration and choice of enteral diets) in the perioperative period of elective surgery in adults. Only few controlled studies have assessed the efficiency of techniques according to the indication of enteral feeding (pre or postoperative period, digestive or non-digestive surgery). The nasogastric tube remains the most appropriate method to deliver short-term enteral feeding during the preoperative period. Today percutaneous endoscopic gastrotomy is the preferred method of gastrostomy. It is indicated in long term enteral nutrition, for example in the perioperative period of cancer surgery of head and neck. In the postoperative period of digestive surgery, intrajejunal feeding is usually delivered by a surgical jejunostomy or by a nasojejunal tube. Controlled studies comparing these two methods are still lacking. An important limitation of intrajejunal feeding is the poor tolerance of enteral diet during the first postoperative days after major upper abdominal surgery. The choice of enteral diet in the perioperative period remains controversial. There is no clinical evidence to support the hypothesis that the use of pre-digested diets in jejunostomy feeding has a better nutritional benefit and a better tolerance than polymeric diets. Small peptides offer some metabolic advantages, however, the clinical superiority of these nutrients over polymeric diets is not definitively proven. Continuous administration of enteral nutrition is usually required in case of jejunal feeding. In the other cases, some data suggest that enteral nutrition is more efficient using an intermittent feeding regimen.

Effects of enteral infusion of hypertonic saline and nutrients on canine jejunal motor patterns

The aim of the study was to clarify the effects of hypertonic solutions on jejunal motility. The study focused on differential effects of hypertonic saline and nutrients. Motility of the canine proximal jejunum was recorded with closely spaced strain-gauge transducers. During fasting, hyperosmotic solutions (up to 1520 mosmol/liter) of saline or nutrients (1 kcal/ml) were infused into the proximal jejunum (0.5-1.5 ml/min) up to 6 hr. The hyperosmotic solutions stimulated jejunal motility. With both increasing osmolarity of saline or increasing energy load of nutrients, jejunal motility linearly declined. The reduction of motility was associated with a change in motor pattern from a propulsive to a more segmenting one. Hypertonic glucose evoked a significantly smaller level of motor activity compared with both saline (at given osmolarities) and an elemental diet (at given energy loads). Motility parameters were not different between glucose and maltose, although osmolarity of maltose was less than half (760 vs 1520 mosmol/liter). In contrast, a mixture of glucose-fructose exerted a smaller inhibition of jejunal motility than glucose. The hypertonic solutions of saline or nutrients were tolerated over 2 hr; with hypertonic saline retrograde power contractions with or without vomiting occurred, whereas with hypertonic nutrients vomiting was preceded by strong inhibition of jejunal motility. Three conclusions can be derived from the present results: (1) The behavior of jejunal motility suggested that the motor activity was the result of both a local stimulation and an inhibitory feedback mechanism. (2) The different degree of inhibition between glucose and saline indicated that the nutrient itself played a major role in the inhibitory feedback regulation, whereas osmolarity was of minor importance. (3) Comparisons between different nutrients suggested a linkage between inhibitory control of motility and the absorptive capacity of the gut for the single nutrient.

Percutaneous endoscopic gastrostomy

Over the past 5 to 7 years, the veterinary profession has benefitted from our increased ability to provide nutrition to the small animal patient who cannot or will not eat. The adaptation of the percutaneous endoscopic gastrostomy (PEG) for use in the dog and cat deserves a great deal of credit in advancing the level of care we can now give to the chronically ill or critical care patient. The PEG is a relatively simple technique that has proved to be a very cost-efficient way to maintain the nutritional status of the small animal patient. In the author's experience, owner acceptance of using the PEG in the home environment on a chronic basis has been excellent.

Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma

To investigate the importance of route of nutrient administration on septic complications after blunt and penetrating trauma, 98 patients with an abdominal trauma index of at least 15 were randomized to either enteral or parenteral feeding within 24 hours of injury. Septic morbidity was defined as pneumonia, intra-abdominal abscess, empyema, line sepsis, or fasciitis with wound dehiscence. Patients were fed formulas with almost identical amounts of fat, carbohydrate, and protein. Two patients died early in the study. The enteral group sustained significantly fewer pneumonias (11.8% versus total parenteral nutrition 31.%, p less than 0.02), intra-abdominal abscess (1.9% versus total parenteral nutrition 13.3%, p less than 0.04), and line sepsis (1.9% versus total parenteral nutrition 13.3%, p less than 0.04), and sustained significantly fewer infections per patient (p less than 0.03), as well as significantly fewer infections per infected patient (p less than 0.05). Although there were no differences in infection rates in patients with injury severity score less than 20 or abdominal trauma index less than or equal to 24, there were significantly fewer infections in patients with an injury severity score greater than 20 (p less than 0.002) and abdominal trauma index greater than 24 (p less than 0.005). Enteral feeding produced significantly fewer infections in the penetrating group (p less than 0.05) and barely missed the statistical significance in the blunt-injured patients (p = 0.08). In the subpopulation of patients requiring more than 20 units of blood, sustaining an abdominal trauma index greater than 40 or requiring reoperation within 72 hours, there were significantly fewer infections per patient (p = 0.03) and significantly fewer infections per infected patient (p less than 0.01). There is a significantly lower incidence of septic morbidity in patients fed enterally after blunt and penetrating trauma, with most of the significant changes occurring in the more severely injured patients. The authors recommend that the surgeon obtain enteral access at the time of initial celiotomy to assure an opportunity for enteral delivery of nutrients, particularly in the most severely injured patients.

Enteral nutrition in the early postoperative period: a new semi-elemental formula versus total parenteral nutrition

Several studies have reported that gastrointestinal (GI) intolerance symptoms are the limiting factor to enteral alimentation in the immediate postoperative period and often the reason for resorting to total parenteral nutrition (TPN). We postulated that Reabilan HN (a recently developed small peptide-based formula, in part obtained by enzyme hydrolysis of proteins) might be better absorbed and better tolerated so as to avoid the need for TPN. Accordingly, 19 patients undergoing major abdominal surgery were randomly assigned to receive Reabilan HN via jejunostomy or an equicaloric isonitrogenous TPN regimen. Both were begun 6 hr postoperatively at 25 ml/hr and increased by 25 ml/hr at 12-hr intervals up to the rate providing 1.5 times the calculated REE. GI tolerance to enteral feeding was excellent during the first three postoperative days, allowing the progression of the feeding rate to 99% of goal. During the next 3 days (starting on average 1.7 days after the return of bowel sounds), GI intolerance symptoms required a reduction in feeding rate to 52% on average. Subsequently, the symptoms resolved and the feeding rate reached 96% of goal. Although overall mean daily calorie and nitrogen intakes were lower for the enteral than for the TPN group (79.6 +/- 10.2% vs 94.6 +/- 3.8% of goal; p less than 0.01), the enteral group was nevertheless in positive caloric and nitrogen balance, and maintained similar serum albumin, prealbumin, and plasma transferrin levels. Average daily cost of supplies was $44.36 for enteral vs $102.10 for parenteral nutrition (p less than 0.001). We conclude that enteral feeding using this formula is well tolerated and cost-effective in the immediate postoperative period.(ABSTRACT TRUNCATED AT 250 WORDS)

Enteral versus parenteral glucose as the sole nutritional support after colorectal resection. A prospective, randomized comparison

Twenty consecutive patients undergoing resection for colorectal carcinoma were randomized to receive either a glucose polymer by nasojejunal tube or glucose by intravenous infusion as the sole postoperative nutritional support for 4 days. Identical amounts of glucose were given by the two routes. Brief infusions of insulin (10 mU kg-1) and glucose (25 g) were given before and 4 days after surgery for the purpose of metabolic evaluation. Blood glucose was consistently lower in the enteral than in the parenteral group (p less than 0.05). Glucose tolerance and the hypoglycemic response to insulin were impaired after surgery in the parenteral group (p less than 0.01 in both cases) but not in the enteral group. Clearance and release of insulin were similar before and after surgery and were similar in both groups. Patients receiving enteral glucose had less postoperative distress and required fewer doses of analgesic drug (p less than 0.05 in both cases). It is concluded that enteral infusion of glucose preserves insulin action and glucose tolerance after colorectal resection, whereas intravenous infusion of glucose does not. The favorable metabolic effects seen after enteral infusion are accompanied by a reduction of postoperative discomfort.

Microbial contamination of continuous drip feedings

We evaluated the extent and effects of bacterial contamination of an open continuous enteral feeding system. Eighty-two quantitative enteral feeding cultures and clinical data were obtained during 8 days of observation on each of 33 patients. Cultures of appropriate sites were obtained on febrile patients and compared to the enteral feeding culture. Gram negative bacilli (GNB) in the enteral feeding correlated with abdominal distension in the patients (10 of 12 patients with GNB compared to 5 of 21 without GNB; p less than 0.01). Nine of the 10 patients with GNB and distension were receiving systemic antimicrobics to which the organism was resistant. Contamination of feeding with Serratia marcescens correlated with cultures for the same organism in patients' other body sites (p less than 0.01). The feeding contaminant may have been the source of sepsis in one patient who expired from septic shock. No relationship was demonstrated between contamination and liquid stools or fever. Undiluted, canned feedings were significantly less contaminated at 24 hr (15%) than those requiring mixing of powder (94%) (p less than 0.0001). The canned feedings grew primarily enteric organisms, whereas the powder feedings grew flora typically resident on the skin. Mixing or diluting feedings appears to represent an increased risk of contamination. Growth of GNB may produce adverse effects. Further investigation into methods to limit contamination and growth is warranted.

Needle catheter jejunostomy: a controlled, prospective, randomized trial in patients with gynecologic malignancy

Sixty patients with gynecologic cancer entered a prospective, randomized study of immediate postoperative feeding. Thirty-three women in the study group received an elemental diet (Vivonex HN) delivered through a needle catheter jejunostomy. Twenty-seven patients in the control group were given standard 5% dextrose and electrolyte solutions. Patients in both groups were stratified according to nutritional status as determined by anthropometric evaluation and levels of serum albumin, total protein, and transferrin. These parameters also were measured at intervals throughout the study. Only one catheter-related complication occurred. Patients in the study group received significantly more calories (p = 0.01) and were better able to maintain serum levels of transferrin (p = 0.05) than those in the control group. An elemental diet administered through the needle catheter jejunostomy effectively maintains postoperative nutrition and is associated with few complications.

Needle catheter jejunostomy: an unappreciated and misunderstood advance in the care of patients after major abdominal operations

We evaluated the use of a needle catheter jejunostomy in 83 consecutive patients who underwent complicated abdominal operations. We used the needle catheter jejunostomy to deliver immediate postoperative nutrition (mean, 1,700 kcal/day) in 66 patients for a range of 4 to 80 days. In addition, the needle catheter jejunostomy was used to provide all maintenance fluid and electrolyte needs and to administer almost all required medications. No serious complications were related to use of the needle catheter jejunostomy, although easily controlled diarrhea occurred in 16 patients (19%). We concluded that the needle catheter jejunostomy is a safe and cost-effective means of delivering postoperative nutrition, fluid and electrolytes, and most medications in selected patients undergoing high-risk abdominal operations.

Immediate postoperative jejunostomy feeding. Clinical and metabolic results in a prospective trial

A prospective clinical trial was designed to evaluate the efficacy of postoperative jejunostomy feedings using high (44 percent) and low (15 percent) branched-chain amino acid elemental diet formulations compared with no jejunostomy feedings in a homogeneous surgical population. Twenty-eight patients undergoing radical cystectomy and ileal diversion were randomized to the high branched-chain amino acid formula (11 patients) or the low branched-chain amino acid formula (9 patients). Eight patients received a 5 percent dextrose in water solution intravenously and served as a control group. Mean caloric intake per day in each group was 1,543 calories, 1,697 calories, and 550 calories, respectively; whereas the mean nitrogen intake of each group was 6.5 +/- 2.1 g/day, 8.2 +/- 2.4 g/day, and 0 g/day, respectively. Mean weight changes were minus 0.7 percent, 0.7 percent, and minus 0.3 percent, respectively. The mean daily nitrogen balance was minus 1.6 +/- 3.5 g/day, minus 1.1 +/- 4.4 g/day, and minus 6.6 +/- 1 g/day (p less than 0.001). Five patients (25 percent) in the jejunostomy groups progressed to an oral diet more rapidly than the control group, but gastrointestinal complications occurred in 11 patients (55 percent). Immediate postoperative jejunostomy feedings resulted in improved nitrogen balance compared with the control group values, but no metabolic advantage was noted by infusing a high branched-chain amino acid formula. Improved return to normal gastrointestinal function was noted in 25 percent of jejunostomy patients, but the gastrointestinal complications noted limited the overall usefulness of this technique.

Perioperative nutritional support in the cancer patient

Cancer patients in whom elective surgical intervention is planned are frequently malnourished. Moreover, the tumor itself may be responsible for additionally altering metabolism in the host, although the mechanisms by which this occurs are not clear. All preoperative cancer patients should be carefully surveyed for indices of malnutrition. Patients with a history of inadequate oral protein and calorie intake, an unintentional weight loss of greater than 10 pounds, or a serum albumin level of less than 3.5 gm per dl should undergo a thorough nutritional assessment, including anthropometric measurements, 24-hour urinary urea nitrogen and creatinine measurements, and recall skin antigen testing. Surgical risk may be predicted by using indices that are sensitive and specific in assessing preoperative parameters of malnutrition. Adequate nutritional support for 7 to 10 days prior to surgery should be provided to all patients falling into the high-risk category and has been shown to significantly reduce the rate of postoperative complications and death in this group. Generally, a serum albumin of less than 3 gm per dl, a recent unintentional weight loss of greater than 10 to 15 per cent of normal body weight, and/or skin test anergy should be considered to designate high risk. In the formulation of a nutritional plan, estimates of daily energy requirements are essential and can be made by use of the Harris-Benedict equation, metabolic cart measurements, and perhaps 24-hour urinary creatinine values. Generally, 30 to 45 kcal per kg of body weight with 1.2 to 1.5 gm of protein per kg of body weight daily, regardless of the route of delivery, will provide adequate nutritional support. Patients should be fed by the enteral route if possible. Although oral intake is preferable, many malnourished cancer patients will be unable to achieve necessary protein and calorie requirements in this manner.(ABSTRACT TRUNCATED AT 250 WORDS)