Nutritional support in the critically ill surgical patient

Percutaneous endoscopic gastrostomy: a safe and effective bridge for enteral nutrition in neurological or non-neurological conditions

Percutaneous endoscopic gastrostomy (PEG) is one of the most commonly used methods for nutritional support in patients who are unable to take food orally. Traditional surgical gastrostomy, percutaneous radiologic gastrostomy, and laparoscopic gastrostomy are the alternatives. The most common indication is neurogenic dysphagia followed by obstructive causes such as head and neck tumors. Ethically justified and clinically comprehensive guidelines should be followed during the decision-making process for PEG tube placement. A limited life expectancy; technical difficulties, such as the inability to bring the anterior gastric wall in apposition to the abdominal wall; or pharyngeal/esophageal obstruction, which compromise tube insertion, peritonitis, and uncorrectable coagulopathy are absolute contraindications. The "pull method" is the first described and still the most performed technique of PEG tube placement. The procedure is simple, safe, and effective and fulfills all requirements to provide an ideal route for nutritional support. This article summarizes the reported experience on PEG in the current literature and discusses its utility in patients with neurological conditions.

Evaluation of laparoscopic-assisted placement of jejunostomy feeding tubes in dogs

OBJECTIVE

To evaluate feasibility of performing laparoscopic-assisted placement of a jejunostomy feeding tube (J-tube) and compare complications associated with placement, short-term feedings, and medium-term healing with surgically placed tubes in dogs.

DESIGN

Prospective study.

ANIMALS

15 healthy mixed-breed dogs.

PROCEDURES

Dogs were randomly allocated to undergo open surgical or laparoscopic-assisted J-tube placement. Required nutrients were administered by a combination of enteric and oral feeding while monitoring for complications. Radiographic contrast studies documented tube direction and location, altered motility, or evidence of stricture.

RESULTS

Jejunostomy tubes were successfully placed in the correct location and direction in all dogs. In the laparoscopic group, the ileum was initially selected in 2 dogs, 2 dogs developed moderate hemorrhage at a portal site, and 2 J-tubes kinked during placement but were successfully readjusted postoperatively. All dogs tolerated postoperative feedings. All dogs developed minor ostomy site inflammation, and 1 dog developed bile-induced dermatitis at the ostomy site. Despite mild, transient neutrophilia, no significant difference was noted in WBC counts between groups. No dog had altered gastric motility or evidence of stricture, although the jejunopexy site remained identifiable in several dogs at 30 days.

CONCLUSIONS AND CLINICAL RELEVANCE

Requirements for successful J-tube placement were met by use of a laparoscopic-assisted technique, and postoperative complications were mild and comparable to those seen with surgical placement. Laparoscopic-assisted J-tube placement compares favorably to surgical placement in healthy dogs and should be considered as an option for dogs requiring enterostomy feeding but not requiring a celiotomy for other reasons.

Controlled study of early postoperative parenteral nutrition in children

BACKGROUND/PURPOSE

Nutritional support of surgical patients has improved in recent years because of the possibility of modulating catabolism and anabolism, thus enhancing the immune response and repair processes. The objective of this study was to evaluate metabolic effects of early parenteral nutrition (PN) after major surgery.

METHODS

The authors studied 63 children aged 4 to 14 years with diffuse peritonitis caused by perforated-suppurative appendicitis. They were assigned randomly to a study group (SG, n = 31), which received PN for 5 days, starting 24 to 48 hours after surgery or to a control group (CG, n = 32), that received standard treatment (fluids). Weight, C-reactive protein (CRP), albumin, prealbumin, glycemia, nitrogen balance (NB), and insulinlike growth factor (IGF-I), were evaluated on postoperative days 1, 4, and 6.

RESULTS

Early nutritional support was associated with a significant improvement in NB and IGF-I (Repeat measures analysis of variance IGF-I, P<.001 and NB P<.01).

CONCLUSIONS

The authors conclude that early parenteral nutrition has a positive effect on the anabolic response as shown by improved NB and higher IGF-I levels in pediatric patients after major surgery.

TOTAL PARENTERAL NUTRITION

Total parenteral nutrition has been used in clinical practice for over a quarter of a century. It has revolutionized the management of potentially fatal condition like the short bowel syndrome in infants as well as adults. Refinements in techniques have led to development of sophisticated catheters and delivery systems. Better understanding of human nutrition and metabolic processes has lead to formulation of scientific parenteral solutions to suit specific situations. This article addresses the role of total parenteral nutrition in modern surgical practice.

Resting energy expenditure and nitrogen loss after surgery in chronically undernourished patients

Chronically undernourished patients (n = 10) undergoing elective abdominal surgery were assessed with regard to their energy expenditure and urinary nitrogen loss. These measurements were made for 1 week after the surgery, and stress factors for each parameter were computed. The responses of the chronically undernourished patients were compared to those of relatively well nourished patients (n = 10) undergoing comparable surgeries. It was found that the postoperative resting energy expenditure (REE) of the chronically undernourished patients was not significantly elevated when compared to their preoperative values (mean +/- SEM): 1210.66 +/- 88.13, 1354.91 +/- 86.61, 1215.09 +/- 89.68, and 1188.23 +/- 86.61 kcal/day preoperatively and on postoperative days 1, 4, and 8, respectively. On the other hand, the postoperative REE of the controls was significantly elevated (p < 0.05) over their baseline values: 1357.18 +/- 70.81, 1574.66 +/- 100.35, 1502.89 +/- 109.44, and 1477.23 +/- 83.52; kcal/day, respectively, for the same days. The stress factors for the controls were higher than those for the undernourished (1.16 versus 1.12, 1.11 versus 1.00, and 1.09 versus 0.98 on postoperative days 1, 4, and 8, respectively). The urinary nitrogen excretion in both groups (for the 4 days) was not significantly elevated over baseline (6.23 +/- 0.87, 7.72 +/- 0.71, 8.36 +/- 0.87, and 8.04 +/- 1.56 grams/day in the undernourished; and 7.59 +/- 1.03, 9.57 +/- 1.33, 9.49 +/- 1.03, and 8.67 +/- 0.76 grams/day in the controls. The stress factors for nitrogen excretion were slightly higher in the undernourished group.(ABSTRACT TRUNCATED AT 250 WORDS)