Nutritional support in surgical practice: Part II

Early Versus Delayed (Traditional) Postoperative Oral Feeding in Patients Undergoing Colorectal Anastomosis

BACKGROUND

A period of starvation after colorectal anastomosis to permit for resolution of the clinical evidence of ileus has been an unchallenged surgical dogma until recent years. We intended to determine the safety and feasibility of an unconventional postoperative oral intake protocol in patients experiencing colorectal anastomosis.

MATERIALS AND METHODS

Between 2013 and 2015, sixty consecutive patients underwent colorectal anastomosis and they were randomized into two groups. The early feeding group began fluids on the first postoperative day while the regular feeding group was managed in the traditional way - nothing by mouth until the complete resolution of ileus.

RESULTS

The majority of patients (93%) tolerated the early feeding. The times to first passage of flatus (2.66 ± 0.71 days vs. 3.9 ± 0.071 days) and stool (3.9 ± 0.92 days vs. 5.4 ± 0.77 days) were significantly quicker in early feeding group. Hospital stay was also significantly shorter in the early feeding group (4 ± 0.64 days vs. 6.1 ± 0.84 days). Anastomosis leakage and abscess formation were not seen in early feeding group. The patient's satisfaction (visual analog scale) in the early feeding group was higher than delayed feeding group (8.56 ± 1.16 vs. 7.06 ± 1.59, P < 0.001).

CONCLUSIONS

Early oral feeding after colorectal surgeries is safe and tolerated by the majority of patients.

Early oral feeding vs. traditional feeding in patients undergoing elective open bowel surgery-a randomized controlled trial

OBJECTIVE

This prospective randomized controlled trial was conducted to compare the safety, tolerability and outcome of early oral feeding vs. traditional feeding in patients undergoing elective open bowel surgery.

METHODS

A total of 120 consecutive patients who underwent elective open bowel surgeries were randomized into either early feeding (n = 60) or traditional feeding group (n = 60). Patients in the early feeding group were started on oral fluids on post-operative day 1, while those in the traditional feeding group were started orals after the resolution of ileus. Patient characteristics, surgical procedures, co-morbidity, first flatus, first defecation, time of starting solid diet, complications and length of hospitalization were assessed between the two groups.

RESULTS

The two groups were similar in demographic and baseline data. The number of days to first flatus (p < 0.0001), first defecation (p < 0.0001), length of post-operative stay (p = 0.011) and time of starting solid diet (p < 0.0001) were significantly earlier in the early feeding group. Anastomotic leak, wound infection, fever, vomiting, abdominal distention and other complications were similar. Multivariate analysis showed that patients in the early oral feeding group were discharged 3.4 days earlier (p = 0.037).

CONCLUSION

In patients undergoing elective open bowel surgeries, early post-operative feeding is safe, is well tolerated and reduces the length of hospitalization.

Early oral feeding in patients undergoing elective colonic anastomosis

BACKGROUND

This study assesses the safety outcome of early oral feeding and reports on the factors affecting early postoperative feeding after colorectal procedures.

PATIENTS AND METHODS

Between June 2005 and April 2008, 120 consecutive patients underwent elective colonic anastomosis and were then randomized into two groups. The early feeding group began fluids on the first postoperative day while the regular feeding group was managed in the traditional way - nothing by mouth until the resolution of ileus.

RESULTS

The majority of patients (75%) tolerated the early feeding. The times to first passage of flatus (3.3+/-0.9 days vs 4.2+/-1.2 days) and stool (4.1+/-1.2 days vs 4.9+/-1.2 days) were significantly quicker in group 1. Hospital stay was also significantly shorter in the early feeding group (6.2+/-0.2 days vs 6.9+/-0.5 days). Operative time and amount of blood loss had an impact on the tolerability of early feeding while age, gender, type of operation and previous abdominal operation had no such impact.

CONCLUSION

Early oral feeding after colorectal surgery is safe and tolerated by the majority of patients. Operative time and amount of blood loss do, however, have an impact on the tolerability of early feeding.

Resection and primary anastomosis with or without modified blow-hole colostomy for sigmoid volvulus

AIM: To evaluate the efficacy of resection and primary anastomosis (RPA) and RPA with modified blow-hole colostomy for sigmoid volvulus.

METHODS: From March 2000 to September 2007, 77 patients with acute sigmoid volvulus were treated. A total of 47 patients underwent RPA or RPA with modified blow-hole colostomy. Twenty-five patients received RPA (Group A), and the remaining 22 patients had RPA with modified blow-hole colostomy (Group B). The clinical course and postoperative complications of the two groups were compared.

RESULTS: The mean hospital stay, wound infection and mortality did not differ significantly between the groups. Superficial wound infection rate was higher in group A (32% vs 9.1%). Anastomotic leakage was observed only in group A, with a rate of 6.3%. The difference was numerically impressive but was statistically not significant.

CONCLUSION: RPA with modified blow-hole colostomy provides satisfactory results. It is easy to perform and may become a method of choice in patients with sigmoid volvulus. Further studies are required to further establish its role in the treatment of sigmoid volvulus.

Endoscopy or surgery for malignant GI outlet obstruction?

BACKGROUND

The treatment of gastroduodenal outflow obstruction (GOO) caused by malignant diseases represents a significant challenge. Open surgical gastrojejunostomy (GJ) has been the treatment of choice, but it has high morbidity and mortality rates. More recently, endoscopic placement of self-expanding metallic stents (SEMS) has been proposed and the results of small, preliminary studies are encouraging. This study compared technical and clinical success, morbidity, mortality, and hospital stay in patients undergoing endoscopic and surgical treatment of GOO.

METHODS

Medical records of 60 consecutive patients with GOO seen between April 1997 and November 2002 were retrospectively reviewed. Because of extremely short life expectancy, 13 patients were treated by insertion of a double-lumen nasogastric-jejunal tube. The remaining 47 patients (28 men, 19 women; mean age 73.5 years, range 48-92 years) with unresectable pancreatic (33), gastric (7), metastatic lymph nodal (4), papillary (2), and biliary (1) tumors were treated by placement of a SEMS (24) or open surgical GJ (23).

RESULTS

The technical success rates were similar, but clinical success was lower in the GJ group (92% vs. 56%, p = 0.0067). The SEMS group had a shorter length of hospital stay (3.0 [1.4] days vs. 24.1 [10.3], p < 0.001). Thirty-day mortality was 30% in the GJ group, and 0% in the SEMS group ( p = 0.004). Morbidity was higher in the GJ compared with the SEMS group (61% vs. 17%, p = 0.0021). Mean survival was longer in the SEMS group (96.1 [9.6] days vs. 70.2 [36.2] days, p = 0.0165 for a single test of hypothesis; Bonferroni correction for a multiple testing removes this significance), consequently, out-of-hospital survival was longer for the SEMS group (93.2 [9.3] days vs. 46.0 [31.5] days, p < 0.001). None of the endoscopic procedures required the assistance of an anesthesiologist or the use of an operating room.

CONCLUSIONS

The results of this retrospective study suggest that SEMS insertion is better than surgical GJ for palliation of patients with GOO in terms of clinical success, morbidity, and mortality. Technical success rates were similar. SEMS placement should be proposed as the first-line treatment for relief of GOO. However, a randomized, comparative, prospective study of SEMS vs. laparoscopic GJ is needed.

Fístulas enterocutâneas pós-operatórias: análise de 39 pacientes

OBJETIVO: As fístulas enterocutâneas podem ocorrer de forma espontânea ou no período pós-operatório. A fístula pós-operatória representa mais de 90% de todas as fístulas intestinais e estão quase sempre relacionadas com alguma das principais complicações da cirurgia do aparelho digestivo. De acordo com os fatores de risco e as características destas fístulas, têm sido propostas diferentes classificações prognósticas. Este estudo tem por objetivo analisar o resultado do tratamento de pacientes portadores de fístulas enterocutâneas pós-operatórias. MÉTODO: Foram analisados 39 pacientes submetidos a tratamento cirúrgico que desenvolveram fístula enterocutânea. Havia 27 pacientes do sexo masculino (69,2%) e 12 do sexo feminino (30,8%) com média de idade de 45,8 anos. Os fatores de risco considerados foram sepse, nível da albumina sérica, débito da fístula, idade do paciente e cirurgia de emergência. RESULTADOS: Sepse esteve presente em 13 pacientes com 61,5% de mortalidade, fístula de alto débito em 23 pacientes com 30,4% de mortalidade, idade acima de 60 anos em 14 pacientes com 28,5% de mortalidade e a albumina sérica baixa na admissão também esteve relacionada com mortalidade. CONCLUSÃO: Os autores concluem que a presença de sepse não controlada foi o fator mais importante de mortalidade.

Translocação bacteriana: efeito de dieta imunoestimuladora em ratos com oclusão intestinal

Este estudo tem por objetivo avaliar a ocorrência de translocação bacteriana em ratos submetidos a oclusão intestinal e verificar a capacidade de uma dieta imunoestimuladora em reduzir a incidência de translocação bacteriana nestes animais. Foram utilizados 24 ratos da linhagem Wistar, adultos, machos, pesando entre 180 e 240g, que foram divididos em três grupos, contendo oito animais cada. Ao grupo C (Controle) foi oferecida uma ração padrão para ratos, ao grupo I (Imunomodulação), uma dieta imunoestimuladora, e ao grupo D (Desnutrição) foi oferecida uma dieta padrão com a metade da oferta. Após sete dias, todos os animais foram submetidos a oc1usão intestinal por ligadura do íleo terminal. Após 18 horas da operação, com técnica asséptica, o abdome foi aberto e foram retirados 6ml de sangue da veia cava inferior, para determinação da glicemia, albumina e contagem de leucócitos. O baço, fígado e linfonodo mesentérico foram removidos separadamente, para estudo rnicrobiológico, e segmento do jejuno proximal, para estudo histológico. A ingesta calórica foi semelhante nos grupos C e I e a metade no grupo D. A média de glicemia foi inferior no grupo D. As culturas do linfonodo mesentérico, baço e fígado foram positivas em todos os animais do grupo D, em 58,3% dos ratos do grupo I e em 66,6% dos ratos do grupo C. As alterações histológicas foram mínimas quando comparados os três grupos. Conclui-se que a translocação bacteriana ocorre em ratos submetidos a oclusão intestinal e que o suporte nutricional com dieta imunoestimuladora é capaz de reduzir a incidência de translocação bacteriana em ratos com oclusão intestinal.

Studies on the regulation of food intake using rat total parenteral nutrition as a model

Total parenteral nutrition (TPN) is essential for maintaining the nutritional status of patients who are unable to eat sufficiently to meet their metabolic needs. However, TPN suppresses appetite and ultimately diminishes food intake. Theories concerning the role(s) of peripheral metabolites as signals, acting via the liver and the hypothalamus, for the metabolic control of food intake, have been put forward to explain the anorectic effect of TPN. In addition, it is postulated that changes in peripheral metabolites during TPN may be translated into changes in the levels of brain neurotransmitters known to decrease food intake. This review summarizes studies concerning the effect of TPN on food intake. These studies have involved: (1) characterizing the changes in feeding activity due to TPN; (2) investigating the involvement of the central nervous system; and (3) investigating the role of the periphery and its metabolites in the regulation of food intake during TPN. Some insight into the mechanism of action of TPN on food intake is provided.

A prospective analysis of factors influencing outcome after fundoplication

Fundoplication remains a common operation in the brain-damaged pediatric patient, but recent reports suggest a poor outcome in these patients. The factors that might be associated with complications or recurrence after fundoplication have not been extensively examined. Fifty-six brain-damaged children, aged 6 months to 12 years, with documented gastroesophageal (GE) reflux underwent preoperative nutritional evaluations (percentage of ideal weight, albumin, nutrition risk index [NRI]) and documentation of medications (dexamethasone for bronchopulmonary dysplasia) before standard Nissen fundoplication. Hospital stay, intensive care unit (ICU) stay, and time on ventilator, as well as major postoperative complications (wound infection/dehiscence, pneumonia) were prospectively analyzed. Survival and recurrence rates 1 to 3 years postoperatively were also assessed. Eighty-two percent of patients were < 90% ideal weight, and 50% had NRI < 90 (normal = 100) and 29% had albumin < 3.5 g/dL. Albumin < 3.5 was significantly (P < .01) associated with prolonged hospitalization (26.8 + 2.2 versus 15.1 + 1.1 days) and ICU stay (13.8 + 1.0 versus 4.4 + .5 days) and time on ventilator (8.0 + 1.0 versus 1.8 + .4 days). NRI < 90 showed similar significant differences (P < .01). Ideal body weight < 90% was not significant. Major complications developed in 54% of patients; only two or more preoperative nutritional deficiencies, or a nutritional deficiency plus dexamethasone were significantly associated (P < .01). Recurrence occurred in 21% of patients and was significantly correlated with preoperative dexamethasone alone (P < .01), and especially when dexamethasone plus a nutritional deficit were present (low albumin, P < .001; low NRI, P < .005).(ABSTRACT TRUNCATED AT 250 WORDS)

Is early oral feeding safe after elective colorectal surgery? A prospective randomized trial

INTRODUCTION

The routine use of a nasogastric tube after elective colorectal surgery is no longer mandatory. More recently, early feeding after laparoscopic colectomy has been shown to be safe and well tolerated. Therefore, the aim of our study was to prospectively assess the safety and tolerability of early oral feeding after elective "open" abdominal colorectal operations.

MATERIALS AND METHODS

All patients who underwent elective laparotomy with either colon or small bowel resection between November 1992 and April 1994 were prospectively randomized to one of the following two groups: group 1: early oral feeding--all patients received a clear liquid diet on the first postoperative day followed by a regular diet as tolerated; group 2: regular feeding--all patients were treated in the "traditional" way, with feeding only after the resolution of their postoperative ileus. The nasogastric tube was removed from all patients in both groups immediately after surgery. The patients were monitored for vomiting, bowel movements, nasogastric tube reinsertion, time of regular diet consumption, complications, and length of hospitalization. The nasogastric tube was reinserted if two or more episodes of vomiting of more than 100 mL occurred in the absence of bowel movement. Ileus was considered resolved after a bowel movement in the absence of abdominal distention or vomiting.

RESULTS

One hundred sixty-one consecutive patients were studied, 80 patients in group 1 (34 males and 46 females, mean age 51 years [range 16-82 years]), and 81 patients in group 2 (43 males and 38 females, mean age 56 years [range 20-90 years]). Sixty-three patients (79%) in the early feeding group tolerated the early feeding schedule and were advanced to regular diet within the next 24 to 48 hours. There were no significant differences between the early and regular feeding groups in the rate of vomiting (21% vs. 14%), nasogastric tube reinsertion (11% vs. 10%), length of ileus (3.8 +/- 0.1 days vs. 4.1 +/- 0.1 days), length of hospitalization (6.2 +/- 0.2 days vs. 6.8 +/- 0.2 days), or overall complications (7.5% vs. 6.1%), respectively, (p = NS for all). However, the patients in the early feeding group tolerated a regular diet significantly earlier than did the patients in the regular feeding group (2.6 +/- 0.1 days vs. 5 +/- 0.1 days; p < 0.001).

CONCLUSION

Early oral feeding after elective colorectal surgery is safe and can be tolerated by the majority of patients. Thus, it may become a routine feature of postoperative management in these patients.

Underweight patients and the risks of major surgery

The relation between weight loss and the risks of major surgery have been investigated for more than 50 years. It can now be said, with some confidence, that the underweight patient has an increased risk of complications following major surgery. This understanding, however, is based on methods of nutritional assessment that are of limited relevance to hospitalized patients whose malnutrition might be due to sepsis, neoplasia, trauma, or starvation. A consequence is the widespread belief that protein-energy malnutrition (PEM) has been overemphasized as a surgical risk factor, and that the many nonnutritional risk factors ought to be implicated more often. An argument is made for a fresh approach to nutritional assessment in order to better identify the individual patient who, by virtue of PEM, stands an increased risk of a complicated postoperative course. It is suggested that an evaluation of the impact PEM has on vital physiologic function provides a clinically relevant defect to identify and treat and a means of monitoring response to nutritional intervention.

The current role of small-bowel transplantation in intestinal failure

Short bowel syndrome is the clinical manifestation of a fundamental reduction in the functional intestinal absorptive surface area and malabsorption. The development of total parenteral nutrition has improved the natural course of this disease. Home parenteral nutrition-related complications continue to generate significant morbidity and mortality for these patients. Small-bowel transplantation is an alternative to home parenteral nutrition. There are significant risks of graft rejection and the potential complications of long-term immunosuppression. Small-bowel transplantation is an option, but it should be reserved for patients no longer considered candidates for continued home parenteral nutrition.

The comparative effects of abrupt vs. stepwise discontinuation of TPN in rats

The comparative effects of discontinuing total parenteral nutrition (TPN: caloric ratio of glucose:fat:amino acid = 50:30:20) abruptly or in a stepwise manner on spontaneous food intake were investigated in two studies. Study 1: In 16 rats, TPN was given for 4 days, then stopped abruptly in eight rats. In the other eight rats, TPN was tapered; they received TPN at 75%, 50%, and 25% of their mean daily energy requirements per day for 3 consecutive days, and then switched to normal saline. Total parenteral nutrition induced a significant 60% reduction in spontaneous food intake (SFI) in both groups during the first TPN day. After 4 days of TPN, an 80% decrease in SFI had occurred in both groups. Resumption of SFI was significantly sooner in the abruptly-stopping group than in the stepwise-stopping group. But, in the latter group, there was a significantly greater cumulative caloric intake during the entire study. Study 2: In 32 rats, TPN providing either 100%, 50%, or 25% of their mean daily caloric requirements was given to three groups each of eight rats, for 3 days, then abruptly changed to normal saline; control rats received normal saline throughout. The TPN-induced decrease in SFI was proportional to the caloric density of the solution infused. Three days of 100%, 50%, or 25% TPN infusion led to an approximate 85%, 60%, or 35% decrease in SFI, respectively. Spontaneous food intake recovery was independent of the caloric density of TPN.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of anterior subdiaphragmatic vagotomy and TPN on rat feeding behavior

Total parenteral nutrition (TPN) inhibits food intake and feeding behavior. Whether caloric sensory function of the liver contributes to this food intake and feeding behavior regulation via vagal-afferent innervation was tested after performing anterior hepatic vagotomy or sham operation in rats infused with a TPN solution providing 100% of daily energy needs, given continuously for 4 days. Food intake, meal number, size, duration, meal and intermeal sniffs, and eating activity were measured using an automated computerized rat eater meter (ACREM). TPN infusion resulted in a significant decrease of food intake and feeding indexes in both groups. The vagotomized rats showed a significantly higher food consumption, achieved by greater meal frequency, larger meal size, and longer meal duration. Thus, vagotomized rats consumed more than their controls by eating larger meals more often and of longer duration. Data suggest that anterior hepatic vagotomy interrupts hepatic caloric sensory feedback loop, diminishing inhibitory vagal effects on food intake with TPN, leading to an overall increase in food intake.

Change in meal size, number and duration after neural isolation of liver and with TPN

The abundant neural connections between the liver and hypothalamus suggest that the liver contributes to spontaneous food intake (SFI) regulation. This hypothesis was tested in rats after total liver denervation (TLD) and infusing TPN. A sham operation (SO) or TLD was performed in Fischer rats, placed in metabolic cages fitted with an Eater Meter to measure SFI, meal number (MN), size (MZ), and duration (MD). Rats had free access to chow and water. After 22 days, a jugular catheter was placed and normal saline continuously infused for 10 days (days 22-32). Then TPN-100, providing 100% of rats daily energy needs, was infused for 3 days (days 32-35). During the post-SO/TLD and postjugular catheterization periods and during TPN-100, SFI was the same in SO controls and TLD group. However, TLD rats had decreased MZ and MD (interpreted as early satiety) and increased MN (interpreted as increased hunger) to maintain the same SFI as control rats. Although total SFI was not influenced by TLD, it significantly affected feeding pattern, suggesting that the neural isolation of the liver from the brain produces altered hypothalamic regulation of not only the onset of feeding, but also satiety.

Effects of continuous graded total parenteral nutrition on feeding indexes and metabolic concomitants in rats

The influence of graded amounts of total parenteral nutrition (TPN) on food intake and feeding indexes was investigated in 90 rats housed in Automated Computerized Rat Eater Meter metabolic cages with free access to water and chow. When food intake was stable after catheter placement, 10 control rats continued with the 3 ml/h normal saline used for catheter patency, whereas study rats were given graded TPN continuously for 3 days, amounting to the equivalent of 26% (TPN-26), 53% (TPN-53), 81% (TPN-81), or 114% (TPN-114) of their daily caloric needs. TPN consisted of glucose, fat, and amino acids in the caloric ratio of 50:30:20. In study rats, the graded TPN depressed food intake, meal number, meal size, and eventually food consumption rate, meal sniffs, and intermeal sniffs in a dose- and time-dependent manner. During graded TPN, rats decreased total food intake by eating fewer, smaller, shorter meals at a decreasing consumption rate; sniffing activities were correspondingly curtailed. Stopping TPN led to normalization of feeding indexes. Blood glucose did not change while plasma insulin rose with graded TPN. A decrease in hepatic glycogen and an increase in hepatic triglycerides occurred. Plasma valine, phenylalanine, and methionine rose in a TPN dose-dependent manner. TPN-26 and TPN-53 significantly decreased whole brain amino acids; with TPN-114 no change occurred. Brain influx of tryptophan remained unchanged, but a progressive decrease in brain influx of tyrosine occurred. Whole brain dopamine and serotonin were depressed with TPN-26 and TPN-81 but were normal with TPN-114.(ABSTRACT TRUNCATED AT 250 WORDS)

Automated computerized rat eater meter: description and application

A real-time Automated Computerized Rat Eater Meter was developed by modifying commercially available metabolic cages. Food access via a feeding tunnel was monitored by photocells. Food consumption was measured by an electronic scale. The signals thus generated were processed by a computer. This allowed us to continuously measure the spontaneous feeding behavior of free-feeding nondeprived Fischer rats for a sum total of 35 study days. Based on our data, we defined a meal as an episode of food consumption preceded and followed by at least 5 minutes of no feeding. Fischer rats showed periodic nychthemeral eating behavior. Food consumption, number of meals, meal sniffs, intermeal sniffs, and, consequently, eating activity were greater during the dark cycle than the light cycle. Meal duration, meal size, and thus food consumption rates remained constant throughout both cycles. Our modification of commercially available metabolic cages provides unique data for continuously monitoring rat feeding patterns over prolonged periods of time.