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Ljungqvist O, Weimann A, Sandini M, Baldini G, Gianotti L. Contemporary Perioperative Nutritional Care. Annu Rev Nutr 2024; 44:231-255. [PMID: 39207877 DOI: 10.1146/annurev-nutr-062222-021228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Over the last decades, surgical complication rates have fallen drastically. With the introduction of new surgical techniques coupled with specific evidence-based perioperative care protocols, patients today run half the risk of complications compared with traditional care. Many patients who in previous years needed weeks of hospital care now recover and can leave in days. These remarkable improvements are achieved by using nutritional stress-reducing care elements for the surgical patient that reduce metabolic stress and allow for the return of gut function. This new approach to nutritional care and how it is delivered as an integral part of enhancing recovery after surgery are outlined in this review. We also summarize the new and increased understanding of the effects of the routes of delivering nutrition and the role of the gut, as well as the current recommendations for artificial nutritional support.
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Affiliation(s)
- Olle Ljungqvist
- Department of Surgery, School of Medical Sciences, Orebro University Hospital and Orebro University, Orebro, Sweden;
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Arved Weimann
- Department of General, Visceral, and Oncologic Surgery, Saint George Hospital, Leipzig, Germany
| | - Marta Sandini
- Department of Medicine, Surgery, and Neuroscience and Unit of General and Oncologic Surgery, University of Siena, Siena, Italy
| | - Gabriele Baldini
- Section of Anesthesia and Critical Care, Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Florence, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- HPB Surgery, Foundation IRCCS San Gerardo Hospital, Monza, Italy
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2
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Gianotti L, Paiella S, Frigerio I, Pecorelli N, Capretti G, Sandini M, Bernasconi DP. ERAS with or without supplemental artificial nutrition in open pancreatoduodenectomy for cancer. A multicenter, randomized, open labeled trial (RASTA study protocol). Front Nutr 2023; 10:1113723. [PMID: 37051129 PMCID: PMC10083279 DOI: 10.3389/fnut.2023.1113723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/13/2023] [Indexed: 03/28/2023] Open
Abstract
PurposeThe role of supplemental artificial nutrition in patients perioperatively treated according to enhanced recovery programs (ERAS) on surgery-related morbidity is not known. Therefore, there is a need of a clinical trials specifically designed to explore whether given a full nutritional requirement by parenteral feeding after surgery coupled with oral food “at will” compared to oral food “at will” alone, within an established ERAS program, could achieve a reduction of the morbidity burden.Materials and analysisRASTA will be a multicenter, randomized, parallel-arm, open labeled, superiority trial. The trial will be conducted in five Italian Institutions with proven experience in pancreatic surgery and already applying an established ERAS program. Adult patients (age ≥ 18 and < 90 years of age) candidate to elective open pancreatoduodenectomy (PD) for any periampullary or pancreatic cancer will be randomized to receive a full ERAS protocol that establishes oral food “at will” plus parenteral nutrition (PN) from postoperative day 1 to day 5 (treatment arm), or to ERAS protocol without PN (control arm). The primary endpoint of the trial is the complication burden within 90 days after the day of surgery. The complication burden will be assessed by the Comprehensive Complication Index, that incorporates all complications and their severity as defined by the Clavien-Dindo classification, and summarizes postoperative morbidity with a numerical scale ranging from 0 to 100. The H0 hypothesis tested is that he administration of a parenteral nutrition added to the ERAS protocol will not affect the CCI as compared to standard of care (ERAS). The H1 hypothesis is that the administration of a parenteral nutrition added to the ERAS protocol will positively affect the CCI as compared to standard of care (ERAS). The trial has been registered at ClinicalTrials.gov (number: NCT04438447; date: 18/05/2020).ConclusionThis upcoming trial will permit to establish if early postoperative artificial nutritional support after PD may improve postoperative outcomes compared to oral nutrition alone within an established ERAS program.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- HPB Unit IRCCS San Gerardo Hospital, Monza, Italy
- *Correspondence: Luca Gianotti,
| | - Salvatore Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona Hospital, Verona, Italy
| | | | - Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Capretti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Marta Sandini
- Surgical Oncology Unit, Department of Medical, Surgical, and Neurologic Sciences, Policlinico Le Scotte, University of Siena, Siena, Italy
| | - Davide Paolo Bernasconi
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre - B4, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
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3
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Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale RG, Waitzberg D, Bischoff SC, Singer P. ESPEN practical guideline: Clinical nutrition in surgery. Clin Nutr 2021; 40:4745-4761. [PMID: 34242915 DOI: 10.1016/j.clnu.2021.03.031] [Citation(s) in RCA: 219] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 02/07/2023]
Abstract
Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.
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Affiliation(s)
- Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany.
| | - Marco Braga
- University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Franco Carli
- Department of Anesthesia of McGill University, School of Nutrition, Montreal General Hospital, Montreal, Canada
| | | | - Martin Hübner
- Service de chirurgie viscérale, Centre Hospitalier Universitaire de Lausanne, Lausanne, Switzerland
| | - Stanislaw Klek
- General Surgical Oncology Clinic, National Cancer Institute, Krakow, Poland
| | - Alessandro Laviano
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
| | | | - Dan Waitzberg
- University of Sao Paulo Medical School, Ganep, Human Nutrition, Sao Paulo, Brazil
| | - Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany
| | - Pierre Singer
- Institute for Nutrition Research, Rabin Medical Center, Beilison Hospital, Petah Tikva, Israel
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4
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Comparison of Perioperative Standard and Immunomodulating Enteral Nutrition in Patients Received Major Abdominal Cancer Surgery: a Prospective, Randomized, Controlled Clinical Trial. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02114-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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5
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Messiner R, Griffen M, Crass R. Small Bowel Necrosis Related to Enteral Nutrition after Duodenal Surgery. Am Surg 2020. [DOI: 10.1177/000313480507101201] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Nutritional support is the key to the successful recovery of any patient. Small bowel necrosis is described in patients being fed with enteral nutrition after surgery. Five patients with small bowel necrosis after surgery will be discussed and an etiology proposed. A retrospective review of patient data was performed. Data was collected on the type of surgical procedures performed, the enteral nutrition given to the patient, basic laboratory data, the length of stay, and discharge status. A total of five patients’ charts were reviewed. Three patients had pancreaticoduodenectomy for a pancreatic mass and two required pyloric exclusion secondary to gunshot wounds. All five patients were fed with a fiber-based enteral nutrition. All patients subsequently had small bowel necrosis requiring reoperation. Four of the five patients had inspissated tube feeding within the necrotic small bowel. Two patients died and three survived with prolonged hospital courses. We propose that the combination of duodenal surgery and fiber-based enteral nutrition contribute to the development of small bowel necrosis postoperatively.
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Affiliation(s)
- Ryan Messiner
- University of Florida Health Science Center, Jacksonville, Florida
| | - Margaret Griffen
- University of Florida Health Science Center, Jacksonville, Florida
| | - Richard Crass
- University of Florida Health Science Center, Jacksonville, Florida
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Bischoff SC, Escher J, Hébuterne X, Kłęk S, Krznaric Z, Schneider S, Shamir R, Stardelova K, Wierdsma N, Wiskin AE, Forbes A. ESPEN practical guideline: Clinical Nutrition in inflammatory bowel disease. Clin Nutr 2020; 39:632-653. [PMID: 32029281 DOI: 10.1016/j.clnu.2019.11.002] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/01/2019] [Indexed: 02/06/2023]
Abstract
The present guideline is the first of a new series of "practical guidelines" based on more detailed scientific guidelines produced by ESPEN during the last few years. The guidelines have been shortened and now include flow charts that connect the individual recommendations to logical care pathways and allow rapid navigation through the guideline. The purpose of the present practical guideline is to provide an easy-to-use tool to guide nutritional support and primary nutritional therapy in inflammatory bowel disease (IBD). The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. In 40 recommendations, general aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.
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Affiliation(s)
- Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany.
| | - Johanna Escher
- Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Xavier Hébuterne
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France
| | - Stanisław Kłęk
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Krakow, Poland
| | - Zeljko Krznaric
- Clinical Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - Stéphane Schneider
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France
| | - Raanan Shamir
- Tel-Aviv University, Schneider Children's Medical Center of Israel, Petach-Tikva, Israel
| | - Kalina Stardelova
- University Clinic for Gasrtroenterohepatology, Clinal Centre "Mother Therese", Skopje, Macedonia
| | | | - Anthony E Wiskin
- Pediatric Gastroenterology & Nutrition Unit, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Alastair Forbes
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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Adithya GK, Madaan V, Gupta R, Jindal S, Govil D. Long term complication of feeding jejunostomy – small bowel volvulus. APOLLO MEDICINE 2020. [DOI: 10.4103/am.am_32_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Gannam‐Somri L, Matter I, Hadjittofi C, Vaida S, Khalaily H, Hossein J, Somri M. Combined epidural-general anaesthesia vs general anaesthesia in neonatal gastrointestinal surgery: A randomized controlled trial. Acta Anaesthesiol Scand 2020; 64:34-40. [PMID: 31506919 DOI: 10.1111/aas.13469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 08/26/2019] [Accepted: 09/01/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Post-operative ileus is a frequent complication of gastrointestinal surgery under general anaesthesia. The aim of this study was to investigate whether combined epidural-general anaesthesia is associated with expedited gastrointestinal function recovery in neonates undergoing elective gastrointestinal surgery. METHODS A randomized controlled trial including 60 neonates who underwent gastrointestinal surgery at a university hospital was performed. Thirty neonates received combined epidural-general anaesthesia (CEGA), and 30 neonates received general anaesthesia (GA) alone. The primary outcome was the post-operative time to tolerance of full enteral nutrition. The secondary outcomes were the post-operative time defaecation, the duration of nasogastric drainage, and infections. RESULTS After excluding two neonates from the CEGA group, where repeated attempts at epidural catheterization were unsuccessful, a total of 58 patients completed the study (CEGA: 28; GA: 30). Full enteral nutrition was tolerated earlier in CEGA vs the GA group (4.0 vs 8.0 days; P = .0001). Time to defaecation was shorter in the CEGA group (3.5 vs 5.0 days; P = .0001). Duration of nasogastric drainage was similar between groups (7.0 vs 7.0 days; P = .9502). Fewer patients in the CEGA group experienced post-operative infection (35.7% vs 60.0%; P = .038). CONCLUSION Combined epidural-general anaesthesia is associated with expedited gastrointestinal function recovery and a lower infection risk after gastrointestinal surgery in neonates.
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Affiliation(s)
- Lina Gannam‐Somri
- The Ruth and Bruce Rappaport Faculty of Medicine Technion—Israel Institute of Technology Haifa Israel
| | - Ibrahim Matter
- The Ruth and Bruce Rappaport Faculty of Medicine Technion—Israel Institute of Technology Haifa Israel
- Department of Surgery Bnei Zion Medical Center Haifa Israel
| | | | - Sonia Vaida
- Obstetric Anesthesia Department of Anesthesiology Penn State College of Medicine Penn State Milton S. Hershey Medical Center Hershey USA
| | - Husein Khalaily
- Department of Anaesthesia Bnei Zion Medical Center Haifa Israel
| | - Jalaa Hossein
- Department of Anaesthesia Bnei Zion Medical Center Haifa Israel
| | - Mostafa Somri
- The Ruth and Bruce Rappaport Faculty of Medicine Technion—Israel Institute of Technology Haifa Israel
- Department of Anaesthesia Bnei Zion Medical Center Haifa Israel
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9
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The effect of diets delivered into the gastrointestinal tract on gut motility after colorectal surgery-a systematic review and meta-analysis of randomised controlled trials. Eur J Clin Nutr 2019; 73:1331-1342. [PMID: 31366995 DOI: 10.1038/s41430-019-0474-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/25/2019] [Accepted: 07/12/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND/OBJECTIVES Despite best practice guidelines, feeding methods after colorectal surgery vary due to the difficulties translating evidence into practice. The aim was to determine the effectiveness of diets delivered into the gastrointestinal tract (GIT) on gut motility following colorectal surgery. SUBJECTS/METHODS EMBASE, MEDLINE, CINAHL, Web of Science and PubMed were systematically searched. Randomised controlled trials investigating effectiveness of a diet on gut motility after colorectal surgeries were included. Outcomes included postoperative ileus, length of stay, mortality, nausea and vomiting. RESULTS A total of 756 potential studies were identified; of these, 10 trials reporting on 1237 unique patients were included. There is evidence that early feeding reduces time (days) to first flatus (mean difference (MD):-0.64; 95% CI:-0.84 to -0.44) and bowel movements (MD:-0.64; 95% CI:-1.01 to -0.26), when compared to traditional postoperative fasting. Introducing solids versus the progression of fluids to solids had no effect on time (days) to first flatus (MD:0.13; 95% CI:-1.99 to 1.74) or bowel movement (MD:0.20; 95% CI:-0.50 to 0.98). Complete nutrition compared to hypocaloric nutrition had no effect on time to first flatus (MD:-0.60; 95% CI:-1.66 to 0.46) or bowel movement (MD:-0.20; 95% CI:-1.59 to 1.19), whereas coffee and diet compared to water and diet significantly decreased time (days) to first bowel movement (MD:-0.60; 95% CI:-0.97 to -0.19) but had no effect on time to first flatus (MD:-0.20; 95% CI:-0.57 to 0.09). CONCLUSIONS Any form of early postoperative diet provided into the GIT early after colorectal surgery is likely to stimulate gut motility, resulting in earlier return of bowel function and shorter length of stay.
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10
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Furness K, Huggins CE, Hanna L, Silvers MA, Cashin P, Low L, Croagh D, Haines TP. A process and mechanism of action evaluation of the effect of early and intensive nutrition care, delivered via telephone or mobile application, on quality of life in people with upper gastrointestinal cancer: a study protocol. BMC Cancer 2018; 18:1181. [PMID: 30486814 PMCID: PMC6262954 DOI: 10.1186/s12885-018-5089-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/13/2018] [Indexed: 12/21/2022] Open
Abstract
Background Cancers of the upper gastrointestinal tract commonly result in malnutrition, which increases morbidity and mortality. Current nutrition best practice lacks a mechanism to provide early and intensive nutrition support to these patients. A 3-arm parallel randomised controlled trial is testing the provision of a tailored, nutritional counselling intervention delivered using a synchronous, telephone-based approach or an asynchronous, mobile application-based approach to address this problem. This protocol outlines the design and methods that will be used to undertake an evaluation of the implementation process, which is imperative for successful replication and dissemination. Methods A concurrent triangulation mixed methods comparative analysis will be undertaken. The nutrition intervention will be provided using best practice behaviour change techniques and communicated either via telephone or via mHealth. The implementation outcomes that will be measured are: fidelity to the nutrition intervention protocol and to the delivery approach; engagement; acceptability and contextual factors. Qualitative data from recorded telephone consultations and written messages will be analysed through a coding matrix against the behaviour change techniques outlined in the standard operating procedure, and also thematically to determine barriers and enablers. Negative binomial regression will be used to test for predictive relationships between intervention components with health-related quality of life and nutrition outcomes. Post-intervention interviews with participants and health professionals will be thematically analysed to determine the acceptability of delivery approaches. NVivo 11 Pro software will be used to code for thematic analysis. STATA version 15 will be used to perform quantitative analysis. Discussion The findings of this process evaluation will provide evidence of the core active ingredients that enable the implementation of best practice nutrition intervention for people with upper gastrointestinal cancer. Elucidation of the causal pathways of successful implementation and the important relationship to contextual delivery are anticipated. With this information, a strategy for sustained implementation across broader settings will be developed which impact the quality of life and nutritional status of individuals with upper gastrointestinal cancer. Trial registration 27th January 2017 Australian and New Zealand Clinical Trial Registry (ACTRN12617000152325).
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Affiliation(s)
- Kate Furness
- Nutrition and Dietetics, Monash Health, Monash Medical Centre, 246 Clayton Road, Clayton, VIC, 3168, Australia. .,Department of Physiotherapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, VIC, 3199, Australia. .,School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, VIC, 3199, Australia.
| | - Catherine E Huggins
- Department of Nutrition, Dietetics and Food, School of Clinical Sciences, Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, VIC, 3168, Australia
| | - Lauren Hanna
- Nutrition and Dietetics, Monash Health, Monash Medical Centre, 246 Clayton Road, Clayton, VIC, 3168, Australia.,Department of Nutrition, Dietetics and Food, School of Clinical Sciences, Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, VIC, 3168, Australia
| | - Mary Anne Silvers
- Nutrition and Dietetics, Monash Health, Monash Medical Centre, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Paul Cashin
- Upper Gastrointestinal and Hepatobiliary Surgery, Monash Medical Centre, Clayton, VIC, 3168, Australia.,Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, 3168, Australia
| | - Liang Low
- Upper Gastrointestinal and Hepatobiliary Surgery, Monash Medical Centre, Clayton, VIC, 3168, Australia.,Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, 3168, Australia
| | - Daniel Croagh
- Upper Gastrointestinal and Hepatobiliary Surgery, Monash Medical Centre, Clayton, VIC, 3168, Australia.,Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, 3168, Australia
| | - Terry P Haines
- Department of Physiotherapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, VIC, 3199, Australia.,School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, VIC, 3199, Australia
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11
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Minarich MJ, Schwarz RE. Experience with a simplified feeding jejunostomy technique for enteral nutrition following major visceral operations. Transl Gastroenterol Hepatol 2018; 3:44. [PMID: 30148229 DOI: 10.21037/tgh.2018.06.08] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/27/2018] [Indexed: 12/14/2022] Open
Abstract
Background Background: Perioperative nutrition support has been shown to impact on outcomes for patients with gastrointestinal cancer. Postoperative benefits of feeding tubes must be weighed against morbidity related to placement and use. A simplified jejunostomy tube technique was evaluated for outcomes. Methods A 16-Fr rubber tube is secured at the jejunal entry site without Witzel tunnel, followed by a continuous, circumferential and alternating suture between jejunal wall and parietal peritoneum. Prospectively collected data were analyzed. Results The technique was performed in 343 of 803 major hepatopancreatobiliary and upper gastrointestinal (GI) resections (43%). Of these patients (male =57%, median age: 65.8 years, range, 24.0-98.0 years), 89% had a cancer diagnosis. The procedures included pancreatectomy (n=189, 55%), gastrectomy (n=109, 32%), esophagectomy (n=19, 6%) and others (n=26, 7%). The operative intent was curative in 78%, palliative in 10%, or combined in 12% of patients. Postoperative morbidity rate was 40%, with 19 lethal events (5.5%), and a median length of stay of 10 days (range, 4-111 days). Tube feeds were administered in 139 patients (41%), and in 17% continued beyond discharge. Use of the feeding tube was linked to treatment interval, length of stay, major complication grade (all at P<0.0001), metastatic stage (P=0.0007) and noncurative intent (P=0.001). Tube feeds beyond discharge were associated with time interval (P<0.0001), length of stay (P=0.0006) and noncurative intent (P=0.014). Tube-specific events in 38 patients (11%) were all minor, without any intraabdominal leak, infection or obstruction. Conclusions The technique described is safe and expedient, and the overall tube-related morbidity is low. This procedure can be recommended in cases at risk for major morbidity and nutrition support needs.
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Affiliation(s)
| | - Roderich E Schwarz
- Goshen Center for Cancer Care, Goshen, IN, USA.,Department of Surgery, Indiana University School of Medicine, South Bend, IN, USA
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12
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Gianotti L, Besselink MG, Sandini M, Hackert T, Conlon K, Gerritsen A, Griffin O, Fingerhut A, Probst P, Abu Hilal M, Marchegiani G, Nappo G, Zerbi A, Amodio A, Perinel J, Adham M, Raimondo M, Asbun HJ, Sato A, Takaori K, Shrikhande SV, Del Chiaro M, Bockhorn M, Izbicki JR, Dervenis C, Charnley RM, Martignoni ME, Friess H, de Pretis N, Radenkovic D, Montorsi M, Sarr MG, Vollmer CM, Frulloni L, Büchler MW, Bassi C. Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS). Surgery 2018; 164:1035-1048. [PMID: 30029989 DOI: 10.1016/j.surg.2018.05.040] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal nutritional therapy in the field of pancreatic surgery is still debated. METHODS An international panel of recognized pancreatic surgeons and pancreatologists decided that the topic of nutritional support was of importance in pancreatic surgery. Thus, they reviewed the best contemporary literature and worked to develop a position paper to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection. Strength of recommendation and quality of evidence were based on the approach of the grading of recommendations assessment, development and evaluation Working Group. RESULTS The measurement of nutritional status should be part of routine preoperative assessment because malnutrition is a recognized risk factor for surgery-related complications. In addition to patient's weight loss and body mass index, measurement of sarcopenia and sarcopenic obesity should be considered in the preoperative evaluation because they are strong predictors of poor short-term and long-term outcomes. The available data do not show any definitive nutritional advantages for one specific type of gastrointestinal reconstruction technique after pancreatoduodenectomy over the others. Postoperative early resumption of oral intake is safe and should be encouraged within enhanced recovery protocols, but in the case of severe postoperative complications or poor tolerance of oral food after the operation, supplementary artificial nutrition should be started at once. At present, there is not enough evidence to show the benefit of avoiding oral intake in clinically stable patients who are complicated by a clinically irrelevant postoperative pancreatic fistula (a so-called biochemical leak), while special caution should be given to feeding patients with clinically relevant postoperative pancreatic fistula orally. When an artificial nutritional support is needed, enteral nutrition is preferred whenever possible over parenteral nutrition. After the operation, regardless of the type of pancreatic resection or technique of reconstruction, patients should be monitored carefully to assess for the presence of endocrine and exocrine pancreatic insufficiency. Although fecal elastase-1 is the most readily available clinical test for detection of pancreatic exocrine insufficiency, its sensitivity and specificity are low. Pancreatic enzyme replacement therapy should be initiated routinely after pancreatoduodenectomy and in patients with locally advanced disease and continued for at least 6 months after surgery, because untreated pancreatic exocrine insufficiency may result in severe nutritional derangement. CONCLUSION The importance of this position paper is the consensus reached on the topic. Concentrating on nutritional support and therapy is of utmost value in pancreatic surgery for both short- and long-term outcomes.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy.
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Marta Sandini
- School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Thilo Hackert
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Kevin Conlon
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Arja Gerritsen
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Oonagh Griffin
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Abe Fingerhut
- University of Graz Hospital, Surgical Research Unit, Graz, Austria
| | - Pascal Probst
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Antonio Amodio
- Unit of Gastroenterology, University of Verona Hospital Trust, Verona, Italy
| | - Julie Perinel
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon-Sud Faculty of Medicine, Lyon, France
| | - Mustapha Adham
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon-Sud Faculty of Medicine, Lyon, France
| | - Massimo Raimondo
- Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL
| | - Horacio J Asbun
- Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL
| | - Asahi Sato
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kyoichi Takaori
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Marco Del Chiaro
- Pancreatic Surgery Unit - Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) - Karolinska Institutet at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christos Dervenis
- University of Cyprus and Department of Surgical Oncology and HPB Surgery Metropolitan Hospital, Athens, Greece
| | - Richard M Charnley
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marc E Martignoni
- Department of Surgery, Klinikum rechts der Isar, Technische Universität, München, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technische Universität, München, Germany
| | | | - Dejan Radenkovic
- Clinic for Digestive Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marco Montorsi
- Department of Surgery, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Michael G Sarr
- Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
| | - Markus W Büchler
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Mörgeli R, Scholtz K, Kurth J, Treskatsch S, Neuner B, Koch S, Kaufner L, Spies C. Perioperative Management of Elderly Patients with Gastrointestinal Malignancies: The Contribution of Anesthesia. Visc Med 2017; 33:267-274. [PMID: 29034255 DOI: 10.1159/000475611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Elderly patients suffering from gastrointestinal malignancies are particularly prone to perioperative complications. Elderly patients often present with reduced physiological reserves, and comorbidities can limit treatment options and promote complications. Surgeons and anesthesiologists must be aware of strategies required to deal with this vulnerable subgroup. METHODS We provide a brief review of current and emerging perioperative strategies for the treatment of elderly patients with gastrointestinal malignancies and frequent comorbidities. RESULTS Especially in combination with advanced age, the effects of malignancies can be devastating, bringing new health challenges, exacerbating preexisting conditions, and exerting severe psychological strain. An interdisciplinary assessment and process planning provide an ideal setting to identify and prevent potential complications, especially in regards to frailty and cardiovascular risk. In addition, important perioperative considerations are presented, such as malnutrition, fasting, intraoperative neuromonitoring, and hemodynamic control, as well as postoperative early mobilization, pain, and delirium management. CONCLUSION The decisions and interventions made in the perioperative stage can positively influence many intra- and postoperative factors, significantly improving the chances of successful treatment of elderly cancer patients. Appropriate management can help prevent or mitigate complications, secure a quick recovery, and improve short- and long-term outcomes.
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Affiliation(s)
- Rudolf Mörgeli
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Kathrin Scholtz
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johannes Kurth
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Bruno Neuner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Susanne Koch
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Lutz Kaufner
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale R, Waitzberg DL, Bischoff SC, Singer P. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr 2017; 36:623-650. [DOI: 10.1016/j.clnu.2017.02.013] [Citation(s) in RCA: 965] [Impact Index Per Article: 137.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 02/07/2023]
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Bercik P, Schlageter V, Mauro M, Rawlinson J, Kucera P, Armstrong D. Noninvasive Verification of Nasogastric Tube Placement Using a Magnet-Tracking System: A Pilot Study in Healthy Subjects. JPEN J Parenter Enteral Nutr 2017; 29:305-10. [PMID: 15961688 DOI: 10.1177/0148607105029004305] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Fluoroscopic verification of nasogastric (NG) feeding tube placement is inconvenient and involves radiation exposure. We tested whether the position of an NG tube can be assessed reliably by a recently introduced magnet-tracking system. METHODS A small permanent magnet was attached at the end of an NG tube and its position was monitored using an external sensor array connected to a computer. NG tube trajectory, spontaneous movements of the magnet, and its position relative to the lower esophageal sphincter (LES) and xiphisternum were assessed in 22 healthy subjects and compared with esophageal manometry. In 12 subjects, localization of the magnet was also compared with fluoroscopy. RESULTS Magnet-tracking displayed NG tube tip movement reproducibly as it moved vertically in the esophagus and then laterally into the stomach. Compared with manometry, the accuracy and sensitivity of magnet tracking for localization of the NG tube tip, above or below the diaphragm, were 100%. Compared with fluoroscopy, the accuracy of NG tube localization by magnet tracking was 100%. With the magnet in the stomach, but not in the esophagus or LES, low amplitude displacements at a frequency of 3 per minute, consistent with gastric slow wave activity, were observed. CONCLUSIONS Magnet tracking allows accurate, real-time, 3-dimensional localization of an NG tube with respect to anatomic landmarks. Recorded motor patterns are indicative of the position of the NG tube. Magnet tracking may be a useful tool for bedside placement of nasogastric and enteral feeding tubes.
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Affiliation(s)
- Premysl Bercik
- Division of Gastroenterology and Intestinal Disease Research Program, McMaster University Medical Center, Hamilton, Ontario, Canada
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Forbes A, Escher J, Hébuterne X, Kłęk S, Krznaric Z, Schneider S, Shamir R, Stardelova K, Wierdsma N, Wiskin AE, Bischoff SC. ESPEN guideline: Clinical nutrition in inflammatory bowel disease. Clin Nutr 2016; 36:321-347. [PMID: 28131521 DOI: 10.1016/j.clnu.2016.12.027] [Citation(s) in RCA: 395] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 12/28/2016] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The ESPEN guideline presents a multidisciplinary focus on clinical nutrition in inflammatory bowel disease (IBD). METHODOLOGY The guideline is based on extensive systematic review of the literature, but relies on expert opinion when objective data were lacking or inconclusive. The conclusions and 64 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required. RESULTS IBD is increasingly common and potential dietary factors in its aetiology are briefly reviewed. Malnutrition is highly prevalent in IBD - especially in Crohn's disease. Increased energy and protein requirements are observed in some patients. The management of malnutrition in IBD is considered within the general context of support for malnourished patients. Treatment of iron deficiency (parenterally if necessary) is strongly recommended. Routine provision of a special diet in IBD is not however supported. Parenteral nutrition is indicated only when enteral nutrition has failed or is impossible. The recommended perioperative management of patients with IBD undergoing surgery accords with general ESPEN guidance for patients having abdominal surgery. Probiotics may be helpful in UC but not Crohn's disease. Primary therapy using nutrition to treat IBD is not supported in ulcerative colitis, but is moderately well supported in Crohn's disease, especially in children where the adverse consequences of steroid therapy are proportionally greater. However, exclusion diets are generally not recommended and there is little evidence to support any particular formula feed when nutritional regimens are constructed. CONCLUSIONS Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 64 recommendations, of which 9 are very strong recommendations (grade A), 22 are strong recommendations (grade B) and 12 are based only on sparse evidence (grade 0); 21 recommendations are good practice points (GPP).
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Affiliation(s)
- Alastair Forbes
- Norwich Medical School, University of East Anglia, Bob Champion Building, James Watson Road, Norwich, NR4 7UQ, United Kingdom.
| | - Johanna Escher
- Erasmus Medical Center - Sophia Children's Hospital, Office Sp-3460, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands.
| | - Xavier Hébuterne
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France.
| | - Stanisław Kłęk
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, 15 Tyniecka Street, 32-050, Skawina, Krakau, Poland.
| | - Zeljko Krznaric
- Clinical Hospital Centre Zagreb, University of Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia.
| | - Stéphane Schneider
- Gastroentérologie et Nutrition Clinique, CHU de Nice, Université Côte d'Azur, Nice, France.
| | - Raanan Shamir
- Tel-Aviv University, Schneider Children's Medical Center of Israel, 14 Kaplan St., Petach-Tikva, 49202, Israel.
| | - Kalina Stardelova
- University Clinic for Gastroenterohepatology, Clinical Centre "Mother Therese", Mother Therese Str No 18, Skopje, Republic of Macedonia.
| | - Nicolette Wierdsma
- VU University Medical Center, Department of Nutrition and Dietetics, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Anthony E Wiskin
- Paediatric Gastroenterology & Nutrition Unit, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ, United Kingdom.
| | - Stephan C Bischoff
- Institut für Ernährungsmedizin (180) Universität Hohenheim, Fruwirthstr. 12, 70593 Stuttgart, Germany.
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Preoperative vitamin C supplementation improves colorectal anastomotic healing and biochemical parameters in malnourished rats. Int J Colorectal Dis 2016; 31:1759-1766. [PMID: 27614446 DOI: 10.1007/s00384-016-2647-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/30/2016] [Indexed: 02/06/2023]
Abstract
PURPOSES The objective of this study was to evaluate the effect of supplementation with vitamin C on intestinal anastomosis healing in malnourished rats. METHODS Male Wistar rats were divided into three groups: (1) sham, well-nourished rats that received vehicle; (2) FR+Veh, rats that were subjected to food restriction and received vehicle; and (3) FR+VC, rats that were subjected to food restriction and received vitamin C. Four days before surgery, the animals received vitamin C (100 mg/kg/day) via gavage and underwent colon resection with anastomosis in a single plane. The survival rate of rats was monitored until day 7 after surgery. Regarding anastomosis tissues, we examined intra-abdominal adhesion index, hydroxyproline content, collagen density, inflammatory parameters, and oxidative damage to proteins and lipids. RESULTS Malnutrition decreases body weight and increases mortality; the survival rate was 90 % in group 1, 60 % in group 2, and 80 % in group 3. Vitamin C was able to increase hydroxyproline concentration and density of collagen and decrease the intra-abdominal adhesion index, as well as the infiltration of neutrophils and oxidative damage to proteins in malnourished rats compared to group treated with vehicle. CONCLUSIONS Preoperative vitamin C supplementation can improve the intestinal anastomosis healing, biochemical alterations, and prolong survival in rats subjected to food restriction.
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Tsuruta K, Mann FA, Backus RC. Evaluation of jejunostomy tube feeding after abdominal surgery in dogs. J Vet Emerg Crit Care (San Antonio) 2016; 26:502-8. [DOI: 10.1111/vec.12494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 12/17/2014] [Accepted: 02/13/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Kaoru Tsuruta
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine; University of Missouri - Columbia; Columbia MO 65211
| | - F. A. Mann
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine; University of Missouri - Columbia; Columbia MO 65211
| | - Robert C. Backus
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine; University of Missouri - Columbia; Columbia MO 65211
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Braga M. The 2015 ESPEN Arvid Wretlind lecture. Evolving concepts on perioperative metabolism and support. Clin Nutr 2016; 35:7-11. [DOI: 10.1016/j.clnu.2015.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 10/26/2015] [Accepted: 12/15/2015] [Indexed: 12/16/2022]
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20
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Wang YF, Wu M, Ma BJ, Cai DA, Yin BB. Role of high mobility group box-1 and protection of growth hormone and somatostatin in severe acute pancreatitis. ACTA ACUST UNITED AC 2014; 47:1075-84. [PMID: 25387675 PMCID: PMC4244674 DOI: 10.1590/1414-431x20143165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 05/27/2014] [Indexed: 01/24/2023]
Abstract
In this study, we investigated the potential role of high-mobility group box 1
(HMGB1) in severe acute pancreatitis (SAP) and the effects of growth hormone (G) and
somatostatin (S) in SAP rats. The rats were randomly divided into 6 groups of 20
each: sham-operated, SAP, SAP+saline, SAP+G, SAP+S and SAP+G+S. Ileum and pancreas
tissues of rats in each group were evaluated histologically. HMGB1 mRNA expression
was measured by reverse transcription-PCR. Levels of circulating TNF-α, IL-1, IL-6,
and endotoxin were also measured. In the SAP group, interstitial congestion and
edema, inflammatory cell infiltration, and interstitial hemorrhage occurred in ileum
and pancreas tissues. The levels of HMGB1, TNF-α, IL-1, IL-6 and endotoxin were
significantly up-regulated in the SAP group compared with those in the sham-operated
group, and the 7-day survival rate was 0%. In the SAP+G and SAP+S groups, the
inflammatory response of the morphological structures was alleviated, the levels of
HMGB1, TNF-α, IL-1, IL-6, and endotoxin were significantly decreased compared with
those in the SAP group, and the survival rate was increased. Moreover, in the SAP+G+S
group, all histological scores were significantly improved and the survival rate was
significantly higher compared with the SAP group. In conclusion, HMGB1 might
participate in pancreas and ileum injury in SAP. Growth hormone and somatostatin
might play a therapeutic role in the inflammatory response of SAP.
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Affiliation(s)
- Y F Wang
- Department of Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - M Wu
- Department of Surgery, Jinshan Pavilion Forest Hospital, Shanghai, China
| | - B J Ma
- Department of Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - D A Cai
- Department of Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - B B Yin
- Department of Surgery, Huashan Hospital, Fudan University, Shanghai, China
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Lefrant JY, Hurel D, Cano N, Ichai C, Preiser JC, Tamion F. Nutrition artificielle en réanimation. NUTR CLIN METAB 2014. [DOI: 10.1016/j.nupar.2014.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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23
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Lefrant JY, Hurel D, Cano NJ, Ichai C, Preiser JC, Tamion F. [Guidelines for nutrition support in critically ill patient]. ACTA ACUST UNITED AC 2014; 33:202-18. [PMID: 24565944 DOI: 10.1016/j.annfar.2014.01.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- J-Y Lefrant
- Services des réanimations, division anesthésie réanimation douleur urgence, CHU de Nîmes, place du Pr-Robert-Debré, 30029 Nîmes cedex 9, France.
| | - D Hurel
- Service de réanimation médico-chirurgicale, centre hospitalier François-Quesnay, 2, boulevard Sully, 78201 Mantes-la-Jolie cedex, France
| | - N J Cano
- Service de nutrition, CHU de Clermont-Ferrand, 63003 Clermont-Ferrand cedex, France; Unité de nutrition humaine, Clermont université, université d'Auvergne, BP 10448, 63000 Clermont-Ferrand, France; Inra, UMR 1019, UNH, CRNH Auvergne, 63000 Clermont-Ferrand, France
| | - C Ichai
- Service de réanimation médico-chirurgicale, hôpital Saint-Roch, CHU de Nice, 5, rue Pierre-Dévoluy, 06006 Nice cedex 1, France
| | - J-C Preiser
- Service des soins intensifs, hôpital universitaire Erasme, 808, route de Lennik, 1070 Bruxelles, Belgique
| | - F Tamion
- Service de réanimation médicale, hôpital Charles-Nicolle, CHU de Rouen, 1, rue de Germont, 76081 Rouen cedex, France
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Saira Chowdhury, Orla Hynes. Nutrition in Upper Gastrointestinal Cancer. Nutr Cancer 2013. [DOI: 10.1002/9781118788707.ch12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Berry AJ. Pancreatic surgery: indications, complications, and implications for nutrition intervention. Nutr Clin Pract 2013; 28:330-57. [PMID: 23609476 DOI: 10.1177/0884533612470845] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Pancreatic surgery is a complicated procedure leaving postoperative patients with an altered gastrointestinal (GI) anatomy and a potential for further surgical complications such as leaks and fistulas. Beyond surgical complications, these patients are prone to delayed gastric emptying, fat malabsorption, and hyperglycemia, with early satiety and poor appetite further compromising nutrition status. Many of these patients are malnourished prior to this major surgical procedure, and significant weight loss is common postoperatively. Does this affect their outcome? There seems to be a lack of consensus in this patient population regarding how to optimize nutrition and limit potential deleterious effects of this surgery. It is important to first understand the underlying disease condition and the effects to the gland, different forms of surgery with subsequent GI alterations, and common surgical and digestive complications. Once this is reviewed, existing nutrition support literature will be explored in attempts to determine the best nutrition management in this patient population.
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Affiliation(s)
- Amy J Berry
- University of Virginia Health System, Surgical Nutrition Support/Nutrition Services, Charlottesville, VA 22908-0673, USA.
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The role of the enteral route and the composition of feeds in the nutritional support of malnourished surgical patients. Nutrients 2012; 4:1230-6. [PMID: 23112911 PMCID: PMC3475233 DOI: 10.3390/nu4091230] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 08/21/2012] [Accepted: 08/27/2012] [Indexed: 12/22/2022] Open
Abstract
In surgical patients, malnutrition is an important risk factor for post-operative complications. In undernourished patients undergoing major gastrointestinal procedures, preoperative enteral nutrition (EN) should be preferred whenever feasible. It may be given either orally or by feeding tubes, depending on patient compliance. Early oral intake after surgery should be encouraged, but if an insufficient postoperative oral intake is anticipated, tube feeding should be initiated as soon as possible. The use of immunomodulating formulas offers significant advantages when compared to standard feeds and the positive results on postoperative complications seem independent from the baseline nutritional status. In malnourished patients, the optimal timing and dose of immunonutrition is unclear, but consistent data suggest that they should be treated peri-operatively for at least two weeks.
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Walczewski MDRM, Justino AZ, Walczewski EAB, Coan T. [Evaluation of changes made in the peri-operative care in patients submitted to elective abdominal surgery]. Rev Col Bras Cir 2012; 39:119-25. [PMID: 22664518 DOI: 10.1590/s0100-69912012000200007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 08/18/2011] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To evaluate the results of the introduction of new measures to accelerate the postoperative recovery of patients undergoing elective abdominal surgery. METHODS We observed 162 patients and interviewed them on two distinct periods: the first between October to December 2009 (n = 81) comprised patients who underwent conventional perioperative monitoring (pre-intervention) and the second between March and May 2010 (n = 81), formed by a new group of patients, submitted to the new protocol of perioperative monitoring. Data collection in the two periods occurred without the knowledge of the professionals in the service. The variables were: indication for preoperative nutritional support, duration of fasting, post-operative volume of hydration, use of catheters and drains, length of stay and postoperative morbidity. RESULTS when comparing the two periods we observed a decrease of 2.5 hours in the time of preoperative fasting (p = 0.0002) in the post-intervention group. As for the reintroduction of oral diet, there was no difference between the two periods (p = 0.0007). When considering the patients without postoperative complications, there was a significantly decreased length of stay (p = 0.001325). There was a reduction of approximately 50% in antibiotic use in the post-intervention group (p = 0.00001). CONCLUSION The adoption of multidisciplinary perioperative measures is feasible within our reality, and although there was no statistically significant changes in the present study, it may improve morbidity and reduce length of stay in general surgery.
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Sánchez Álvarez C, Zabarte Martínez de Aguirre M, Bordejé Laguna L. Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Cirugía del aparato digestivo. Med Intensiva 2011; 35 Suppl 1:42-7. [DOI: 10.1016/s0210-5691(11)70009-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Abstract
Postoperative Ileus (POI) is a frequent, frustrating occurrence for patients and surgeons after abdominal surgery. Despite significant research investigating how to reduce this multi-factorial phenomenon, a single strategy has not been shown to reduce POI's significant effects on length of stay (LOS) and hospital costs. Perhaps the most significant cause of POI is the use of narcotics for analgesia. Strategies that target inflammation and pain reduction such as NSAID use, epidural analgesia, and laparoscopic techniques will reduce POI but are accompanied by a simultaneous reduction in opioid use. Pharmacologic means of stimulating gut motility have not shown a positive effect, and the routine use of nasogastric tubes only increases morbidity. Recent multi-site phase III trials with alvimopan, a peripherally acting mu-antagonist, have shown significant reductions in POI and LOS by 12 and 16 hours, respectively, by blunting the effects of narcotics on gut motility while sparing centrally mediated analgesia. Use of alvimopan, along with a multi-modal postoperative treatment plan involving early ambulation, feeding, and avoiding nasogastric tubes, will likely be the crux of POI treatment and prevention.
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Affiliation(s)
- James Lubawski
- Section of Colon and Rectal Surgery, Rush University Medical Center, Chicago, IL, USA
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Gianotti L, Nespoli L, Torselli L, Panelli M, Nespoli A. Safety, feasibility, and tolerance of early oral feeding after colorectal resection outside an enhanced recovery after surgery (ERAS) program. Int J Colorectal Dis 2011; 26:747-53. [PMID: 21286920 DOI: 10.1007/s00384-011-1138-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2011] [Indexed: 02/04/2023]
Abstract
INTRODUCTION It is generally believed that resumption of feeding after colorectal resection is indicated only after recovery of bowel function. This study was designed to verify safety, feasibility, and tolerance of early oral postoperative feeding (EOF) outside an enhanced recovery after surgery (ERAS) program. MATERIALS AND METHODS One hundred patient candidates to elective colorectal resection were prospectively enrolled in an EOF program. Feeding was started on postoperative day (POD) 1 with oral nutritional supplement (ONS). On POD 2, patients had normal food plus ONS to reach 1,000-1,200 kcal/day with progressive increase until 1,800-2,000 kcal/day. Results were compared with historical controls (n = 100) in whom oral feeding was allowed only after full bowel function recovery. The ERAS program was not applied in both groups. RESULTS The EOF group had a better recovery of short half-life protein synthesis compared with the control group (P < 0.001). Stool canalization occurred after a median of 3 days (range, 1-6 days) in the EOF group versus 5 days (range, 2-8 days) in the control group (P = 0.001). The feeding protocol was completed in 89 patients within POD 5. Tolerance to resumption of feeding was similar in the two groups. The overall rate of postoperative complication was 22% in the EOF group vs. 27% in the control group (P = 0.51). The median length of hospitalization was 9 days (range, 6-25 days) in the EOF group vs. 12 days (range, 6-31 days) in controls (P = 0.01). CONCLUSIONS EOF after colorectal operations is feasible and safe outside an ERAS program.
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Affiliation(s)
- Luca Gianotti
- Department of Surgery, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy.
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Chaufour-André C, Bajard A, Fingal C, Roux P, Fiorletta I, Gertych W, Rivoire M, Bonnefoy M, Bachmann P. Conséquences nutritionnelles de la chirurgie en oncogériatrie. Étude descriptive et prospective. NUTR CLIN METAB 2011. [DOI: 10.1016/j.nupar.2010.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Zhu XH, Qiu YD, Wu YF, Zhou JX, Jiang CP, Ding YT. Value of early enteral nutrition through Freka Trelumina in patients after pancreaticoduodenectomy. Shijie Huaren Xiaohua Zazhi 2010; 18:3026-3030. [DOI: 10.11569/wcjd.v18.i28.3026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the value of early enteral nutrition (EEN) through Freka Trelumina (FT), a new three-lumen gastrojejunal tube, in patients after pancreaticoduodenectomy.
METHODS: Eighty-nine patients undergoing pancreaticoduodenectomy were divided into three groups: total parenteral nutrition (TPN) group (n = 31), one-lumen tube group (nasojejunal or nasogastric tube, n = 30) and FT group (n = 28). Parenteral nutrition were given to the TPN group patients by superior vena cava catheterization before the operation, while the patients in the two EN groups were given EEN from the first day after the operation.
RESULTS: Nutritional parameters were improved postoperatively in patients receiving EN through FT and decompression of the stomach. Compared with the one-lumen tube group, the incidence of complications (lung infection: 7.1% vs 20.0, P < 0.05) and nausea/vomiting was significantly lower (10.7% vs 30.0%, P < 0.05) in the FT group. Compared with the TPN group, the time required to restore anal exhaust, the duration of postoperative hospitalization, and the cost were significantly lower in the FT group (91.2 d ± 12.0 d vs 146.1 d ± 19.2 d, 14.3 d ± 2.5 d vs 18.5 d ± 3.6 d; 4.1 million yuan ± 1.5 million yuan vs 5.8 million yuan ± 1.3 million yuan, all P < 0.05).
CONCLUSION: EEN through FT is feasible and safe in patients after pancreaticoduodenectomy.
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Garth AK, Newsome CM, Simmance N, Crowe TC. Nutritional status, nutrition practices and post-operative complications in patients with gastrointestinal cancer. J Hum Nutr Diet 2010; 23:393-401. [PMID: 20337847 DOI: 10.1111/j.1365-277x.2010.01058.x] [Citation(s) in RCA: 171] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Malnutrition and its associated complications are a considerable issue for surgical patients with upper gastrointestinal and colorectal cancer. The present study aimed to determine whether specific perioperative nutritional practices and protocols are associated with improved patient outcomes in this group. METHODS Patients admitted for elective upper gastrointestinal or colorectal cancer surgery (n = 95) over a 19-month period underwent a medical history audit assessing weight changes, nutritional intake, biochemistry, post-operative complications and length of stay. A subset of patients (n = 25) underwent nutritional assessment by subjective global assessment prior to surgery in addition to assessment of post-operative medical outcomes, nutritional intake and timing of dietetic intervention. RESULTS Mean (SD) length of stay for patients was 14.0 (12.2) days, with complication rates at 35%. Length of stay was significantly longer in patients who experienced significant preoperative weight loss compared to those who did not [17.0 (15.8) days versus 10.0 (6.8) days, respectively; P < 0.05]. Low albumin and post-operative weight loss were also predictive of increased length of stay. Of patients who underwent nutritional assessment, 32% were classified as mild-moderately malnourished and 16% severely malnourished. Malnourished patients were hospitalised twice as long as well-nourished patients [15.8 (12.8) days versus 7.6 (3.5) days; P < 0.05]. Time taken [6.9 (3.6) days] to achieve adequate nutrition post surgery was a factor in post-operative outcomes, with a positive correlation with length of stay (r = 0.493; P < 0.01), a negative correlation with post-operative weight change (r = -0.417; P < 0.05) and a greater risk of complications (52% versus 13%; P < 0.01). CONCLUSIONS Malnutrition is prevalent among surgical patients with gastrointestinal cancer. Poor nutritional status coupled with delayed and inadequate post-operative nutrition practices are associated with worse clinical outcomes.
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Affiliation(s)
- A K Garth
- School of Exercise and Nutrition Sciences, Deakin University, Melbourne, Victoria, Australia
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Luan ZG, Zhang H, Ma XC, Zhang C, Guo RX. Role of high-mobility group box 1 protein in the pathogenesis of intestinal barrier injury in rats with severe acute pancreatitis. Pancreas 2010; 39:216-23. [PMID: 19786932 DOI: 10.1097/mpa.0b013e3181bab5c5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the role of high-mobility group box 1 (HMGB1) in the development of intestinal barrier injury of severe acute pancreatitis (SAP) and to examine the effect of ethyl pyruvate (EP) on intestinal inflammation in rats with SAP. METHODS Rats were randomly divided into the following experimental groups: control, SAP, and EP treated. Then, the distal ileum was harvested for morphological studies, streptavidin-peroxidase immunohistochemistry examination, and Western blot analysis. The concentrations of plasma amylase, endotoxin, and diamine oxidase (DAO) and the activity of myeloperoxidase (MPO) in the intestine were determined. RESULTS We found that the expression of HMGB1 was up-regulated in the ileal mucosa within 6 hours and then remained elevated for more than 48 hours after SAP. Meanwhile, the levels of plasma amylase, endotoxin, and DAO and the activity of MPO in the intestinal mucosa were rapidly increased after SAP. Whereas treatment with EP significantly decreased the expression of intestinal HMGB1, the levels of plasma amylase, endotoxin, and DAO ameliorated the activity of MPO in the intestine in SAP rats. CONCLUSIONS Our results demonstrate that HMGB1 participates in intestinal barrier injury in SAP and EP might play a therapeutic role in intestinal inflammation in this SAP model.
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Affiliation(s)
- Zheng-Gang Luan
- Department of Intensive Care Unit, The First Affiliated Hospital of China Medical University, Shenyang, China
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Guinvarch A. Mise en œuvre de la nutrition entérale précoce en réanimation : pourquoi et à quel prix ? NUTR CLIN METAB 2009. [DOI: 10.1016/j.nupar.2009.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Kotzampassi K, Kolios G, Manousou P, Kazamias P, Paramythiotis D, Papavramidis TS, Heliadis S, Kouroumalis E, Eleftheriadis E. Oxidative stress due to anesthesia and surgical trauma: Importance of early enteral nutrition. Mol Nutr Food Res 2009; 53:770-9. [DOI: 10.1002/mnfr.200800166] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Stylianides NA, Date RS, Pursnani KG, Ward JB. Jejunal perforation caused by a feeding jejunostomy tube: a case report. J Med Case Rep 2008; 2:224. [PMID: 18590544 PMCID: PMC2443370 DOI: 10.1186/1752-1947-2-224] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2007] [Accepted: 06/30/2008] [Indexed: 11/10/2022] Open
Abstract
Introduction Percutaneous endoscopic gastrostomy and feeding jejunostomy are used for providing long-term nutritional support to patients with neurological disorders. Various mechanical complications of these procedures are described. Case presentation We report a case of a 17-year-old boy with cerebral injury who had a percutaneous endoscopic gastrostomy tube changed to a feeding jejunostomy tube. Twenty-four hours later he developed abdominal pain and became clinically septic. A contrast study through the feeding tube and a subsequent computed tomography scan did not reveal any intra-abdominal pathology. At laparotomy it was discovered that the tip of the feeding tube had perforated through the jejunal wall and was lying outside the lumen. This was successfully treated by re-inserting a feeding jejunostomy tube distally and closure of the perforation and previous FJ site Conclusion We suggest that the threshold for contrast studies and operative intervention should be low in neurologically impaired patients to avoid the delay in treatment of tube-related complications.
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Affiliation(s)
- Nicholas A Stylianides
- Department of Gastrointestinal Surgery, Lancashire Teaching Hospital NHS Foundation Trust, Preston Road, Chorley, Lancashire, UK.
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Tight Energy Balance Control for Preventing Complications in the ICU. Intensive Care Med 2007. [DOI: 10.1007/0-387-35096-9_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Malnutrition in acute care patients: A narrative review. Int J Nurs Stud 2007; 44:1036-54. [DOI: 10.1016/j.ijnurstu.2006.07.015] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2006] [Revised: 07/12/2006] [Accepted: 07/13/2006] [Indexed: 01/15/2023]
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Martin L, Lagergren J, Jia C, Lindblad M, Rouvelas I, Viklund P. The influence of needle catheter jejunostomy on weight development after oesophageal cancer surgery in a population-based study. Eur J Surg Oncol 2007; 33:713-7. [PMID: 17321099 DOI: 10.1016/j.ejso.2007.01.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Accepted: 01/09/2007] [Indexed: 12/17/2022] Open
Abstract
AIMS We aimed to assess whether needle catheter jejunostomy (NCJ) influences the weight development or discharge from hospital after oesophageal cancer surgery in an unselected and prospectively collected series of patients. METHODS Data regarding patients who underwent oesophageal cancer surgery between April 2001 and October 2004 and were followed up until April 2005 were collected from the Swedish Esophageal and Cardia Cancer Register. Details of patient characteristics, including preoperative body weight and length, tumour characteristics, surgical procedures, including NCJ insertion, complications and ward time were obtained. Six months postoperatively the patients responded to a questionnaire that gave information about postoperative weight development. Relative risks were estimated as odds ratios (ORs) calculated with 95% confidence intervals (CIs) using multinomial logistic regression, adjusted for patient and tumour characteristics, type of treatment, type of hospital and occurrence of complications. RESULTS A total of 233 patients participated, among whom 48% received NCJ. Patients with NCJ had a 42% statistically non-significantly decreased risk of weight loss compared to those without NCJ after adjustment for covariates (OR 0.58; 95% CI 0.25-1.39). Patients with NCJ had a non-statistically significantly longer hospital stay than patients without NCJ, but were seemingly less often discharged to other care homes than their own home compare to the group without NCJ (OR 0.62; 95% CI 0.28-1.38). CONCLUSION Use of needle catheter jejunostomy might counteract weight loss and facilitate discharge to home after oesophageal cancer resection.
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Affiliation(s)
- L Martin
- Unit of Esophageal and Gastric Research (ESOGAR), Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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Hachemi M, Attof Y, Flamens C, Bastien O, Boulétreau P, Chambrier C, Lehot JJ. [Impact of the guidelines on clinical practice of artificial nutrition in intensive care unit after cardiovascular and thoracic surgery]. ACTA ACUST UNITED AC 2006; 25:1034-40. [PMID: 17005359 DOI: 10.1016/j.annfar.2006.07.081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2005] [Accepted: 07/17/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To analyze the impact of an artificial nutrition program in post-anaesthesia intensive care unit. STUDY DESIGN Observational study. PATIENTS AND METHODS Patients with length of stay greater than 8 days after cardiovascular and thoracic surgery: Group 1: 34 patients (4-month period in 2000); group 2: 15 patients (2-month period in 2001); group 3: 40 patients (4-month period in 2003). Between these 3 periods, informations of physicians and written protocol in order to improve their nutritional knowledge. After analysis of variance (P<0.05). Newman-Keuls tests to compare themselves each groups. RESULTS Anthropometric, demographic and clinical parameters were similar in the 3 groups. Energic intakes were less than 80% of basal energetic expenditures in 33%, 33 and 22% of patient, respectively (NS). Caloric and nitrogen intakes were less than recommended, respectively 19+/-6 (mean+/-SD), 21+/-7 and 21+/-8 kcal/kg/24 h and 102+/-32, 111+/-31 and 92+/-40 mg/kg/24 h (NS). However enteral nutrition was administered in 49, 40 and 100% of patients respectively (P<0.001). The glucid/lipid ratio improved from 0.47 in group 1 up to 0.68 in group 3 (P<0.0001). Vitamins, oligoelements and clinical and biological monitoring of artificial nutrition improved (P<0.001). CONCLUSION A clinical audit demonstrated an improvement in artificial nutrition parameters but no significant change in others.
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Affiliation(s)
- M Hachemi
- Service d'anesthésie-réanimation, hôpital cardiovasculaire et pneumologique Louis-Pradel, BP Lyon-Montchat, 69394 Lyon cedex 03, France.
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Frizzell E, Darwin P. Endoscopic placement of jejunal feeding tubes by using the Resolution clip: report of 2 cases. Gastrointest Endosc 2006; 64:454-6. [PMID: 16923504 DOI: 10.1016/j.gie.2006.02.051] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2005] [Accepted: 02/28/2006] [Indexed: 12/10/2022]
Affiliation(s)
- Eric Frizzell
- Division of Gastroenterology, Department of Medicine, Walter Reed Army Medical Center, Washington, DC 20307, USA
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Slappy ALJ, Odell JA, Hinder RA, McKinney JM. Jejunopexy for Selectively Placed Fluoroscopically Guided Percutaneous Jejunal Feeding Tubes. Ann Thorac Surg 2006; 82:756-8. [PMID: 16863814 DOI: 10.1016/j.athoracsur.2005.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2005] [Revised: 06/30/2005] [Accepted: 07/06/2005] [Indexed: 11/28/2022]
Abstract
Prophylactic placement of feeding jejunostomy tubes in patients undergoing esophagectomy or gastrectomy continues to be a common practice. The aim of jejunostomy is to maintain nutrition, especially with an anastomotic leak. Frequently total or supplemental nutrition through a jejunostomy is not required, rendering prophylactic placement unnecessary. In addition, feeding jejunostomy tubes have potentially serious complications.
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Affiliation(s)
- A L Jackson Slappy
- Department of Surgery, Section of General Surgery, Mayo Clinic Jacksonville, Florida 32224, USA.
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Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P, Jauch KW, Kemen M, Hiesmayr JM, Horbach T, Kuse ER, Vestweber KH. ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation. Clin Nutr 2006; 25:224-44. [PMID: 16698152 DOI: 10.1016/j.clnu.2006.01.015] [Citation(s) in RCA: 645] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Accepted: 01/20/2006] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- A Weimann
- Klinik f. Allgemein- und Visceralchirurgie, Klinikum "St. Georg", Leipzig, Germany.
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Abstract
Enteral nutrition (EN) is the mainstay of nutrition delivery within intensive care seeking to capitalise on its benefits for the gastrointestinal tract and associated immune system, but this has brought new challenges in delivery to the sick. The hoped for benefit has led to the mistaken belief by some that parenteral nutrition (PN) is no longer required. However, a greater appreciation of the risks of EN delivery in the sick patient combined with improvements in PN formulation and use help explain why PN is not as risky as some have believed. Real outcome benefits have been described with the new glutamine containing PN formulations. PN remains important in the presence of gastrointestinal feed intolerance or failure.
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Affiliation(s)
- R D Griffiths
- Division of Metabolic and Cellular Medicine, School of Clinical Sciences, University of Liverpool, Whiston Hospital, Merseyside, UK.
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Affiliation(s)
- Benjamin Person
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
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Dedes KJ, Schiesser M, Schäfer M, Clavien PA. Postoperative bezoar ileus after early enteral feeding. J Gastrointest Surg 2006; 10:123-7. [PMID: 16368501 DOI: 10.1016/j.gassur.2005.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2005] [Revised: 04/08/2005] [Accepted: 04/11/2005] [Indexed: 01/31/2023]
Abstract
Postoperative enteral nutrition is a widely accepted route of application for nutrition formulas due to a low complication rate, a good acceptance by patients. and a favorable cost-effectiveness. We report three cases of bezoar ileus after early postoperative enteral nutrition, using a fine needle jejunostomy (FNJ) in two cases and a nasoduodenal tube in one case. A male patient who underwent gastric resection for a gastrointestinal stroma tumor and was nourished through an fine needle jejunostomy developed an acute abdomen on the seventh postoperative day. Surgical exploration revealed a mechanical ileus caused by denaturated nutrition formula distal to the catheter tip. The second case, a female patient, underwent gastric resection for a gastric cancer and on the fourth postoperative day developed acute onset of abdominal pain. Intraoperative findings were the same as described in the first case. The third case, a male patient with necrotizing cholecystitis, underwent open cholecystectomy. Postoperative enteral feeding was performed using a nasoduodenal tube. He developed a small bowel obstruction on the 17th postoperative day that was caused by an intraluminal bezoar. In conclusion, bezoar formation represents an underestimated complication of postoperative enteral feeding. Acute onset of abdominal pain and the development of small bowel obstruction are the main clinical symptoms of this severe complication. The pathogenesis of bezoar formation remains unclear.
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Affiliation(s)
- Konstantin J Dedes
- Department of Visceral and Transplantation Surgery, University Hospital of Zurich, Switzerland
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