Enteral Nutrition in the Treatment of Crohn's Disease: Overlooked and Underutilized

Nomogram to Predict Postoperative Intra-abdominal Septic Complications After Bowel Resection and Primary Anastomosis for Crohn's Disease

BACKGROUND

Postoperative intra-abdominal septic complications of Crohn's disease substantially increase the healthcare expenditure and prolong hospitalization.

OBJECTIVE

We aimed to develop and validate a prediction model for intra-abdominal septic complications after bowel resection and primary anastomosis for Crohn's disease.

DESIGN

This was a retrospective cohort study.

SETTINGS

This study was conducted in a tertiary center.

PATIENTS

Data of 949 Crohn's disease-related primary bowel resections and anastomosis from January 2011 to December 2017 were collected.

MAIN OUTCOME MEASURES

Primary outcomes were prevalence of intra-abdominal septic complications.

RESULTS

Overall prevalence of intra-abdominal septic complications after Crohn's disease surgery was 11.6%. Predictors included preoperative C-reactive protein level ≥40 mg/L (OR = 3.545), preoperative glucocorticoids (OR = 1.829) and infliximab use (OR = 3.365), upper GI involvement (OR = 2.072), and hypoalbuminemia (albumin level <30 g/L, OR = 2.406). Preoperative exclusive enteral nutrition was a protector for postoperative septic complications (OR = 0.192) compared with partial enteral nutrition/parenteral nutrition/straight to surgery. A nomogram was computed to facilitate risk calculation; this had a predictive discrimination, measured as area under the receiver operating characteristic curve, of 0.823.

LIMITATIONS

This model is generated from retrospective data. A major limitation of this model is the lack of external validation.

CONCLUSIONS

A new model to predict postoperative intra-abdominal septic complications was developed, which may guide preoperative optimization and candidate selection for primary anastomosis after bowel resection for Crohn's disease. See Video Abstract at http://links.lww.com/DCR/B178. NOMOGRAMA PARA PREDECIR COMPLICACIONES SéPTICAS INTRAABDOMINALES POSTOPERATORIAS DESPUéS DE RESECCIóN INTESTINAL Y ANASTOMOSIS PRIMARIA EN ENFERMEDAD DE CROHN: Las complicaciones sépticas intraabdominales postoperatorias en la enfermedad de Crohn aumentan sustancialmente los costos de atención médica y prolongan la hospitalización.Nuestro objetivo fue desarrollar y validar un modelo de predicción para las complicaciones sépticas intraabdominales después de resección intestinal y anastomosis primaria en enfermedad de Crohn.Este fue un estudio de cohorte retrospectivo.Este estudio se realizó en un centro de tercer nivel.Se recopilaron datos de 949 resecciones intestinales primarias con anastomosis por enfermedad de Crohn de enero de 2011 a diciembre de 2017.El resultado primario fue la prevalencia de complicaciones sépticas intraabdominales.La prevalencia general de complicaciones sépticas intraabdominales después de cirugía por enfermedad de Crohn fue 11.6%. Los predictores incluyeron un nivel preoperatorio de proteína C reactiva ≥ 40 mg / L (odds ratio = 3.545), glucocorticoides preoperatorios (odds ratio = 1.829) y uso de infliximab (odds ratio = 3.365), compromiso gastrointestinal superior (odds ratio = 2.072) e hipoalbuminemia (albúmina <30g / L, odds ratio = 2.406). La nutrición enteral exclusiva preoperatoria fue un protector para las complicaciones sépticas postoperatorias (odds ratio = 0.192, en comparación con la nutrición enteral parcial / nutrición parenteral / envío directo a cirugía. Se calculó un nomograma para facilitar el cálculo del riesgo; esto tuvo una discriminación predictiva, medida como área bajo la curva de la característica de operación del receptor, de 0.823.Este modelo se generó a partir de datos retrospectivos. Una limitación importante de este modelo es la falta de validación externa.Se desarrolló un nuevo modelo para predecir complicaciones sépticas intraabdominales postoperatorias, que puede guiar la optimización preoperatoria y la selección de candidatos para anastomosis primaria después de resección intestinal en enfermedad de Crohn. Consulte Video Resumen en http://links.lww.com/DCR/B178. (Traducción-Dr. Jorge Silva Velazco).

Is discard better than return gastric residual aspirates: a systematic review and meta-analysis

BACKGROUND

The assessment of residual gastric volume is common practice in critical care units. However, the effects and safety of discarding or returning gastric aspirates remain uncertain. Therefore, we aimed to evaluate the role of discarding or returning gastric aspirates on the gastric residual volumes in critically ill patients.

METHODS

A comprehensive, systematic meta-analysis of randomized controlled trials (RCTs) on the efficacy and safety of discarding or returning gastric aspirates in critical ill patients was performed. Studies were identified by searching Pubmed and other databases (from inception to 31 Sept 2018). Summary odd ratios (ORs) or mean differences (MDs) with 95% confidence intervals were calculated using fixed- or random-effects model for outcome assessment.

RESULTS

Four RCTs, with a total number of 314 adult patients, were included in the analysis. No significant differences were found in the 48th hour residual volume (MD = 8.89, 95% CI: 11.97 to 29.74), the average potassium level (MD = 0.00, 95% CI: - 0.16 to 0.16), the episodes of gastric emptying delay (OR = 0.98, 95% CI: 0.35 to 2.80), the incidence of aspiration pneumonia (OR = 0.93, 95% CI: 0.14 to 6.17), the episodes of nausea or vomiting (OR = 0.53, 95% CI: 0.07 to 4.13) and diarrhea (OR = 0.99, 95% CI: 0.58 to 1.70).

CONCLUSIONS

No evidence confirms that returning residual gastric aspirates provides more benefits than discarding them without increasing potential complications. Rigorously designed, multi-center, large-sample randomized controlled trials must be further conducted to validate the role of discarding or returning residual gastric aspirates.