Immediate postoperative enteral feeding results in impaired respiratory mechanics and decreased mobility

Immediate vs. gradual advancement to goal of enteral nutrition after elective abdominal surgery: A multicenter non-inferiority randomized trial

BACKGROUND & AIMS

The strategy of increasing the postoperative enteral nutrition dose to the target goal has not yet been clarified. This study aimed to determine whether an immediate goal-dose enteral nutrition (IGEN) strategy is non-inferior to a gradual goal-dose enteral nutrition (GGEN) strategy in reducing infections in patients undergoing abdominal surgery involving the organs of the digestive system.

METHODS

This randomized controlled trial enrolled postoperative patients with nutritional risk screening 2002 scores ≥3 from 11 Chinese hospitals. Energy targets were calculated as 25 kcal/kg and 30 kcal/kg of ideal body weight for women and men, respectively. Patients were randomly assigned 1:1 to IGEN or GGEN group after enteral tolerance was confirmed (30% of the target on day 2). The IGEN group immediately started receiving 100% of the caloric requirements on day 3, while the GGEN group received 40% progressing to 80% of target on day 7. The primary endpoint was the infection rate until discharge, based on the intention-to-treat population.

RESULTS

A total of 411 patients were enrolled and randomized to the IGEN and GGEN groups, and five patients did not receive the allocated intervention. A total of 406 patients were included in the primary analysis, with 199 and 207 in the IGEN and GGEN groups, respectively. Infection was observed in 17/199 (8.5%) in the IGEN group and 19/207 (9.2%) in the GGEN group, respectively (difference, -0.6%; [95% confidence interval (CI), -6.2%-4.9%]; P = 0.009 for non-inferiority test). There were significantly more gastrointestinal intolerance events with IGEN than with GGEN (58/199 [29.1%] vs. 32/207 [15.5%], P < 0.001). All other secondary endpoints were non-significant.

CONCLUSIONS

Among postoperative patients at nutritional risk, IGEN was non-inferior to GGEN in regards to infectious complications. IGEN was associated with more gastrointestinal intolerance events. It showed that IGEN cannot be considered to be clinically directive. ClinicalTrials.gov (#NCT03117348).

The Role of Chewing Gum on Post-operative Bowel Recovery after Gynecological Laparoscopic Surgery: A Short Report and Updated Review

BACKGROUND: Adverse post-operative complication of gynecological laparoscopic surgery, post-operative ileus, could be reduced by mimicking early post-operative oral feeding; however, the role of chewing gum is still lack evidence. AIM: This study was conducted to assess chewing gum’s role in post-operative bowel recovery after gynecological laparoscopic surgery. METHODS: This prospective clinical trial recruited 60 participants who had undergone gynecological laparoscopic surgery under general anesthesia. The study was conducted at Arifin Achmad Hospital, Riau Province, Indonesia, from January to April 2021. The patients were equally divided into two groups: Intervention (n = 30) and control (n = 30). They were asked to chew sugar-free gum every 2 h after the surgery (i.e. 5 times within 10 h post-surgery). Time of the first flatus and the first bowel sounds were recorded (i.e. 5 times of assessment within 10 h post-surgery). In addition, a literature review was conducted to add evidence of the role of chewing gum on postoperative bowel recovery after gynecological laparoscopic surgery. RESULTS: Patients from both groups had a close age range (23–44-year-old versus 21–42-year-old). Our data suggested a significant difference in the time of the first flatus between the treatment and control group (15.95 h vs. 45.05 h), p < 0.001. The length of stay in the hospital among those from the treatment group was also significantly shorter compared to controls (15.50 h vs. 45.50 h), p < 0.001. The literature review of four updated randomized clinical trials suggests chewing gum in the early onset of first flatus and bowel movement. CONCLUSION: Chewing gum following gynecological laparoscopic surgery could accelerate gastrointestinal recovery.

ESPEN practical guideline: Clinical nutrition in surgery

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.

Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications

BACKGROUND

This is an update of the review last published in 2011. It focuses on early postoperative enteral nutrition after lower gastrointestinal surgery. Traditional management consisted of 'nil by mouth', where patients receive fluids followed by solids after bowel function has returned. Although several trials have reported lower incidence of infectious complications and faster wound healing upon early feeding, other trials have shown no effect. The immediate advantage of energy intake (carbohydrates, protein or fat) could enhance recovery with fewer complications, and this warrants a systematic evaluation.

OBJECTIVES

To evaluate whether early commencement of postoperative enteral nutrition (within 24 hours), oral intake and any kind of tube feeding (gastric, duodenal or jejunal), compared with traditional management (delayed nutritional supply) is associated with a shorter length of hospital stay (LoS), fewer complications, mortality and adverse events in patients undergoing lower gastrointestinal surgery (distal to the ligament of Treitz).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library 2017, issue 10), Ovid MEDLINE (1950 to 15 November 2017), Ovid Embase (1974 to 15 November 2017). We also searched for ongoing trials in ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (15 November 2017). We handsearched reference lists of identified studies and previous systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCT) comparing early commencement of enteral nutrition (within 24 hours) with no feeding in adult participants undergoing lower gastrointestinal surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality using the Cochrane 'Risk of bias' tool tailored to this review and extracted data. Data analyses were conducted according to the Cochrane recommendations.We rated the quality of evidence according to GRADE.Primary outcomes were LoS and postoperative complications (wound infections, intraabdominal abscesses, anastomotic dehiscence, pneumonia).Secondary outcomes were: mortality, adverse events (nausea, vomiting), and quality of life (QoL).LoS was estimated using mean difference (MD (presented as mean +/- SD). For other outcomes we estimated the common risk ratio (RR) and calculated the associated 95% confidence intervals. For analysis, we used an inverse-variance random-effects model for the primary outcome (LoS) and Mantel-Haenszel random-effects models for the secondary outcomes. We also performed Trial Sequential Analyses (TSA).

MAIN RESULTS

We identified 17 RCTs with 1437 participants undergoing lower gastrointestinal surgery. Most studies were at high or unclear risk of bias in two or more domains. Six studies were judged as having low risk of selection bias for random sequence generation and insufficient details were provided for judgement on allocation concealment in all 17 studies. With regards to performance and deception bias; 14 studies reported no attempt to blind participants and blinding of personnel was not discussed either. Only one study was judged as low risk of bias for blinding of outcome assessor. With regards to incomplete outcome data, three studies were judged to be at high risk because they had more than 10% difference in missing data between groups. For selective reporting, nine studies were judged as unclear as protocols were not provided and eight studies had issues with either missing data or incomplete reporting of results.LOS was reported in 16 studies (1346 participants). The mean LoS ranged from four days to 16 days in the early feeding groups and from 6.6 days to 23.5 days in the control groups. Mean difference (MD) in LoS was 1.95 (95% CI, -2.99 to -0.91, P < 0.001) days shorter in the early feeding group. However, there was substantial heterogeneity between included studies (I² = 81, %, Chi² = 78.98, P < 0.00001), thus the overall quality of evidence for LoS is low. These results were confirmed by the TSA showing that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit.We found no differences in the incidence of postoperative complications: wound infection (12 studies, 1181 participants, RR 0.99, 95%CI 0.64 to 1.52, very low-quality evidence), intraabdominal abscesses (6 studies, 554 participants, RR 1.00, 95%CI 0.26 to 3.80, low-quality evidence), anastomotic leakage/dehiscence (13 studies, 1232 participants, RR 0.78, 95%CI 0.38 to 1.61, low-quality evidence; number needed to treat for an additional beneficial outcome (NNTB) = 100), and pneumonia (10 studies, 954 participants, RR 0.88, 95%CI 0.32 to 2.42, low-quality evidence; NNTB = 333).Mortality was reported in 12 studies (1179 participants), and showed no between-group differences (RR = 0.56, 95%CI, 0.21 to 1.52, P = 0.26, I² = 0%, Chi² = 3.08, P = 0.96, low-quality evidence). The most commonly reported cause of death was anastomotic leakage, sepsis and acute myocardial infarction.Seven studies (613 participants) reported vomiting (RR 1.23, 95%CI, 0.96 to 1.58, P = 0.10, I² = 0%, Chi² = 4.98, P = 0.55, low-quality evidence; number needed to treat for an additional harmful outcome (NNTH) = 19), and two studies (118 participants) reported nausea (RR 0.95, 0.71 to 1.26, low-quality evidence). Four studies reported combined nausea and vomiting (RR 0.94, 95%CI 0.51 to 1.74, very low-quality evidence). One study reported QoL assessment; the scores did not differ between groups at 30 days after discharge on either QoL scale EORTC QLQ-C30 or EORTC QlQ-OV28 (very low-quality evidence).

AUTHORS' CONCLUSIONS

This review suggests that early enteral feeding may lead to a reduced postoperative LoS, however cautious interpretation must be taken due to substantial heterogeneity and low-quality evidence. For all other outcomes (postoperative complications, mortality, adverse events, and QoL) the findings are inconclusive, and further trials are justified to enhance the understanding of early feeding for these. In this updated review, only a few additional studies have been included, and these were small and of poor quality.To improve the evidence, future trials should address quality issues and focus on clearly defining and measuring postoperative complications to allow for better comparison between studies. However due to the introduction of fast track protocols which already include an early feeding component, future trials may be challenging. A more feasible trial may be to investigate the effect of differing postoperative energy intake regimens on relevant outcomes.

Interventions for the management and prevention of sarcopenia in the critically ill: A systematic review

PURPOSE

In the critically ill, sarcopenia is associated with a variety of adverse outcomes however there is no consensus regarding its management. This study aimed to systematically review the evidence for interventions for the management and prevention of sarcopenia in critically ill patients.

MATERIALS AND METHODS

Bibliographic databases were searched according to pre-specified criteria (PROSPERO-CRD42018086271). Randomised controlled trials (RCTs) investigating interventions to preserve muscle mass and/or function in critically ill patients were included. Two independent authors selected the articles and assessed bias using the Cochrane Risk of Bias Tool.

RESULTS

Twenty-two eligible RCTs were identified comprising 2792 patients. Three main groups of interventions were implemented in these trials: neuromuscular electrical stimulation (NMES), exercise-based and nutritional. Both the interventions and outcomes measured varied significantly between studies. NMES was most frequently studied as an intervention to preserve muscle mass whilst exercise-based treatments were evaluated as interventions to preserve muscle function. There was significant variation in the efficacy of the interventions on sarcopenia markers and secondary outcomes.

CONCLUSIONS

NMES and exercise-based interventions may preserve muscle mass and function in patients with critical illness. There is a lack of consistency seen in the effects of these interventions. Further, large, high quality RCTs are required.

Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications

BACKGROUND

This is an update of the review last published in 2011. It focuses on early postoperative enteral nutrition after lower gastrointestinal surgery. Traditional management consisted of 'nil by mouth', where patients receive fluids followed by solids after bowel function has returned. Although several trials have reported lower incidence of infectious complications and faster wound healing upon early feeding, other trials have shown no effect. The immediate advantage of energy intake (carbohydrates, protein or fat) could enhance recovery with fewer complications, and this warrants a systematic evaluation.

OBJECTIVES

To evaluate whether early commencement of postoperative enteral nutrition (within 24 hours), oral intake and any kind of tube feeding (gastric, duodenal or jejunal), compared with traditional management (delayed nutritional supply) is associated with a shorter length of hospital stay (LoS), fewer complications, mortality and adverse events in patients undergoing lower gastrointestinal surgery (distal to the ligament of Treitz).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library 2017, issue 10), Ovid MEDLINE (1950 to 15 November 2017), Ovid Embase (1974 to 15 November 2017). We also searched for ongoing trials in ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (15 November 2017). We handsearched reference lists of identified studies and previous systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCT) comparing early commencement of enteral nutrition (within 24 hours) with no feeding in adult participants undergoing lower gastrointestinal surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality using the Cochrane 'Risk of bias' tool tailored to this review and extracted data. Data analyses were conducted according to the Cochrane recommendations.We rated the quality of evidence according to GRADE.Primary outcomes were LoS and postoperative complications (wound infections, intraabdominal abscesses, anastomotic dehiscence, pneumonia).Secondary outcomes were: mortality, adverse events (nausea, vomiting), and quality of life (QoL).LoS was estimated using mean difference (MD (presented as mean +/- SD). For other outcomes we estimated the common risk ratio (RR) and calculated the associated 95% confidence intervals. For analysis, we used an inverse-variance random-effects model for the primary outcome (LoS) and Mantel-Haenszel random-effects models for the secondary outcomes. We also performed Trial Sequential Analyses (TSA).

MAIN RESULTS

We identified 17 RCTs with 1437 participants undergoing lower gastrointestinal surgery. Most studies were at high or unclear risk of bias in two or more domains. Six studies were judged as having low risk of selection bias for random sequence generation and insufficient details were provided for judgement on allocation concealment in all 17 studies. With regards to performance and deception bias; 14 studies reported no attempt to blind participants and blinding of personnel was not discussed either. Only one study was judged as low risk of bias for blinding of outcome assessor. With regards to incomplete outcome data, three studies were judged to be at high risk because they had more than 10% difference in missing data between groups. For selective reporting, nine studies were judged as unclear as protocols were not provided and eight studies had issues with either missing data or incomplete reporting of results.LOS was reported in 16 studies (1346 participants). The mean LoS ranged from four days to 16 days in the early feeding groups and from 6.6 days to 23.5 days in the control groups. Mean difference (MD) in LoS was 1.95 (95% CI, -2.99 to -0.91, P < 0.001) days shorter in the early feeding group. However, there was substantial heterogeneity between included studies (I² = 81, %, Chi² = 78.98, P < 0.00001), thus the overall quality of evidence for LoS is low. These results were confirmed by the TSA showing that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit.We found no differences in the incidence of postoperative complications: wound infection (12 studies, 1181 participants, RR 0.99, 95%CI 0.64 to 1.52, very low-quality evidence), intraabdominal abscesses (6 studies, 554 participants, RR 1.00, 95%CI 0.26 to 3.80, low-quality evidence), anastomotic leakage/dehiscence (13 studies, 1232 participants, RR 0.78, 95%CI 0.38 to 1.61, low-quality evidence; number needed to treat for an additional beneficial outcome (NNTB) = 100), and pneumonia (10 studies, 954 participants, RR 0.88, 95%CI 0.32 to 2.42, low-quality evidence; NNTB = 333).Mortality was reported in 12 studies (1179 participants), and showed no between-group differences (RR = 0.56, 95%CI, 0.21 to 1.52, P = 0.26, I² = 0%, Chi² = 3.08, P = 0.96, low-quality evidence). The most commonly reported cause of death was anastomotic leakage, sepsis and acute myocardial infarction.Seven studies (613 participants) reported vomiting (RR 1.23, 95%CI, 0.96 to 1.58, P = 0.10, I² = 0%, Chi² = 4.98, P = 0.55, low-quality evidence; number needed to treat for an additional harmful outcome (NNTH) = 19), and two studies (118 participants) reported nausea (RR 0.95, 0.71 to 1.26, low-quality evidence). Four studies reported combined nausea and vomiting (RR 0.94, 95%CI 0.51 to 1.74, very low-quality evidence). One study reported QoL assessment; the scores did not differ between groups at 30 days after discharge on either QoL scale EORTC QLQ-C30 or EORTC QlQ-OV28 (very low-quality evidence).

AUTHORS' CONCLUSIONS

This review suggests that early enteral feeding may lead to a reduced postoperative LoS, however cautious interpretation must be taken due to substantial heterogeneity and low-quality evidence. For all other outcomes (postoperative complications, mortality, adverse events, and QoL) the findings are inconclusive, and further trials are justified to enhance the understanding of early feeding for these. In this updated review, only a few additional studies have been included, and these were small and of poor quality.To improve the evidence, future trials should address quality issues and focus on clearly defining and measuring postoperative complications to allow for better comparison between studies. However due to the introduction of fast track protocols which already include an early feeding component, future trials may be challenging. A more feasible trial may be to investigate the effect of differing postoperative energy intake regimens on relevant outcomes.

Enhanced Recovery After Surgery (ERAS®) in thoracic surgical oncology

Enhanced recovery after surgery (ERAS®) is a strategy that seeks to reduce patients’ perioperative stress response, thereby reducing potential complications, decreasing hospital length of stay and enabling patients to return more quickly to their baseline functional status. The concept was introduced in the late 1990s and was first adopted for use with patients undergoing open colorectal surgery. Since that time, the concept of ERAS has spread to multiple surgical specialties. This article explores the key elements for patient care using an ERAS protocol applied to minimally invasive thoracic surgery.

Multicentre randomized clinical trial of the effect of chewing gum after abdominal surgery

Background

Postoperative ileus is a common complication of abdominal surgery, leading to patient discomfort, morbidity and prolonged postoperative length of hospital stay (LOS). Previous studies suggested that chewing gum stimulates bowel function after abdominal surgery, but were underpowered to evaluate its effect on LOS and did not include enhanced recovery after surgery (ERAS)-based perioperative care. This study evaluated whether chewing gum after elective abdominal surgery reduces LOS and time to bowel recovery in the setting of ERAS-based perioperative care.

Methods

A multicentre RCT was performed of patients over 18 years of age undergoing abdominal surgery in 12 hospitals. Standard postoperative care (control group) was compared with chewing gum three times a day for 30 min in addition to standard postoperative care. Randomization was computer-generated; allocation was concealed. The primary outcome was postoperative LOS. Secondary outcomes were time to bowel recovery and 30-day complications.

Results

Between 2011 to 2015, 1000 patients were assigned to chewing gum and 1000 to the control arm. Median LOS did not differ: 7 days in both arms (P = 0·364). Neither was any difference found in time to flatus (24 h in control group versus 23 h with chewing gum; P = 0·873) or time to defaecation (60 versus 52 h respectively; P = 0·562). The rate of 30-day complications was not significantly different either.

Conclusion

The addition of chewing gum to an ERAS postoperative care pathway after elective abdominal surgery does not reduce the LOS, time to bowel recovery or the rate of postoperative complications. Registration number: NTR2594 (Netherlands Trial Register).

Monitoring Nutrition in Critical Illness: What Can We Use?

BACKGROUND

Nutrition monitoring in the context of critical care presents unique challenges. Traditionally used anthropometric and biochemical markers may be difficult to obtain or confounded by factors such as fluid status and the inflammatory response. A previous survey identified 15 parameters in common use, all of which have confounding influences during critical illness.

MATERIALS AND METHODS

A literature search was conducted to assess current use of commonly used nutrition-monitoring parameters and to explore other possible methods that might be more useful. More than 1000 journal articles were reviewed to identify indicators of nutrition status or nutrition progress that have been used in ICU studies. The most recent 200 articles were examined to quantify the number of occurrences for each indicator. Each parameter was rated for availability and feasibility in the ICU.

RESULTS

There were 53 parameters found, including the 15 already identified as commonly used; 27 were used in ≥3 recent studies. Less-well-established nutrition indicators with potential for use in the ICU (moderate or high feasibility and availability) included ultrasound measurement of arm or leg muscle thickness, fatigue scoring with the Chalder scale, urinary creatinine assay, and serum insulin-like growth factor 1 level. None of these was among the commonly used indicators in recent studies.

CONCLUSION

This study identifies commonly used nutrition-monitoring parameters and discusses their feasibility and availability in the critical care setting. Further investigation of nutrition indicators in ICU is needed, ideally as part of a randomized trial to reduce the effect of the many possible confounding factors.

Routine jejunostomy tube feeding following esophagectomy

BACKGROUND

Malnutrition is an important problem following esophagectomy. A surgically placed jejunostomy secures an enteral feeding route, facilitating discharge with home-tube feeding and long-term nutritional support. However, specific complications occur, and data are lacking that support its use over other enteral feeding routes. Therefore routine jejunostomy tube feeding and discharge with home-tube feeding was evaluated, with emphasis on weight loss, length of stay and re-admissions.

METHODS

Consecutive patients undergoing esophagectomy for cancer, with gastric tube reconstruction and jejunostomy creation, were analyzed. Two different regimens were compared. Before January 07, 2011 patients were discharged when oral intake was sufficient, without tube feeding. After that discharge with home-tube feeding was routinely performed. Logistic regression analysis corrected for confounders.

RESULTS

Some 236 patients were included. The median duration of tube feeding was 35 days. Reoperation for a jejunostomy-related complication was needed in 2%. The median body mass index (BMI) remained stable during tube feeding. The BMI decreased significantly after stopping tube feeding: from 25.6 (1st-3rd quartile 23.0-28.6) kg/m² to 24.4 (22.0-27.1) kg/m² at 30 days later [median weight loss: 3.0 (1.0-5.3) kg; 3.9% (1.5-6.3%)]. Weight loss was not affected by the duration of tube feeding duration. Routine home-tube feeding did not affect weight loss, admission time or the readmission rate.

CONCLUSIONS

Weight loss following esophagectomy occurs once that tube feeding is stopped, independently from the time interval after esophagectomy. Moreover routine discharge with home-tube feeding does not reduce length of stay or readmissions. These findings question the value of routine jejunostomy placement and emphasize the need for further research.

Nutrition support in hospitalised adults at nutritional risk

BACKGROUND

The prevalence of disease-related malnutrition in Western European hospitals is estimated to be about 30%. There is no consensus whether poor nutritional status causes poorer clinical outcome or if it is merely associated with it. The intention with all forms of nutrition support is to increase uptake of essential nutrients and improve clinical outcome. Previous reviews have shown conflicting results with regard to the effects of nutrition support.

OBJECTIVES

To assess the benefits and harms of nutrition support versus no intervention, treatment as usual, or placebo in hospitalised adults at nutritional risk.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE (Ovid SP), Embase (Ovid SP), LILACS (BIREME), and Science Citation Index Expanded (Web of Science). We also searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp); ClinicalTrials.gov; Turning Research Into Practice (TRIP); Google Scholar; and BIOSIS, as well as relevant bibliographies of review articles and personal files. All searches are current to February 2016.

SELECTION CRITERIA

We include randomised clinical trials, irrespective of publication type, publication date, and language, comparing nutrition support versus control in hospitalised adults at nutritional risk. We exclude trials assessing non-standard nutrition support.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and the Cochrane Hepato-Biliary Group. We used trial domains to assess the risks of systematic error (bias). We conducted Trial Sequential Analyses to control for the risks of random errors. We considered a P value of 0.025 or less as statistically significant. We used GRADE methodology. Our primary outcomes were all-cause mortality, serious adverse events, and health-related quality of life.

MAIN RESULTS

We included 244 randomised clinical trials with 28,619 participants that met our inclusion criteria. We considered all trials to be at high risk of bias. Two trials accounted for one-third of all included participants. The included participants were heterogenous with regard to disease (20 different medical specialties). The experimental interventions were parenteral nutrition (86 trials); enteral nutrition (tube-feeding) (80 trials); oral nutrition support (55 trials); mixed experimental intervention (12 trials); general nutrition support (9 trials); and fortified food (2 trials). The control interventions were treatment as usual (122 trials); no intervention (107 trials); and placebo (15 trials). In 204/244 trials, the intervention lasted three days or more.We found no evidence of a difference between nutrition support and control for short-term mortality (end of intervention). The absolute risk was 8.3% across the control groups compared with 7.8% (7.1% to 8.5%) in the intervention groups, based on the risk ratio (RR) of 0.94 (95% confidence interval (CI) 0.86 to 1.03, P = 0.16, 21,758 participants, 114 trials, low quality of evidence). We found no evidence of a difference between nutrition support and control for long-term mortality (maximum follow-up). The absolute risk was 13.2% in the control group compared with 12.2% (11.6% to 13%) following nutritional interventions based on a RR of 0.93 (95% CI 0.88 to 0.99, P = 0.03, 23,170 participants, 127 trials, low quality of evidence). Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.We found no evidence of a difference between nutrition support and control for short-term serious adverse events. The absolute risk was 9.9% in the control groups versus 9.2% (8.5% to 10%), with nutrition based on the RR of 0.93 (95% CI 0.86 to 1.01, P = 0.07, 22,087 participants, 123 trials, low quality of evidence). At long-term follow-up, the reduction in the risk of serious adverse events was 1.5%, from 15.2% in control groups to 13.8% (12.9% to 14.7%) following nutritional support (RR 0.91, 95% CI 0.85 to 0.97, P = 0.004, 23,413 participants, 137 trials, low quality of evidence). However, the Trial Sequential Analysis showed we only had enough information to assess a risk ratio reduction of approximately 10% or more. A risk ratio reduction of 10% or more could be rejected.Trial Sequential Analysis of enteral nutrition alone showed that enteral nutrition might reduce serious adverse events at maximum follow-up in people with different diseases. We could find no beneficial effect of oral nutrition support or parenteral nutrition support on all-cause mortality and serious adverse events in any subgroup.Only 16 trials assessed health-related quality of life. We performed a meta-analysis of two trials reporting EuroQoL utility score at long-term follow-up and found very low quality of evidence for effects of nutritional support on quality of life (mean difference (MD) -0.01, 95% CI -0.03 to 0.01; 3961 participants, two trials). Trial Sequential Analyses showed that we did not have enough information to confirm or reject clinically relevant intervention effects on quality of life.Nutrition support may increase weight at short-term follow-up (MD 1.32 kg, 95% CI 0.65 to 2.00, 5445 participants, 68 trials, very low quality of evidence).

AUTHORS' CONCLUSIONS

There is low-quality evidence for the effects of nutrition support on mortality and serious adverse events. Based on the results of our review, it does not appear to lead to a risk ratio reduction of approximately 10% or more in either all-cause mortality or serious adverse events at short-term and long-term follow-up.There is very low-quality evidence for an increase in weight with nutrition support at the end of treatment in hospitalised adults determined to be at nutritional risk. The effects of nutrition support on all remaining outcomes are unclear.Despite the clinically heterogenous population and the high risk of bias of all included trials, our analyses showed limited signs of statistical heterogeneity. Further trials may be warranted, assessing enteral nutrition (tube-feeding) for different patient groups. Future trials ought to be conducted with low risks of systematic errors and low risks of random errors, and they also ought to assess health-related quality of life.

ESPEN guideline: Clinical nutrition in inflammatory bowel disease

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).

Nutritional route in oesophageal resection trial II (NUTRIENT II): study protocol for a multicentre open-label randomised controlled trial

INTRODUCTION

Early start of an oral diet is safe and beneficial in most types of gastrointestinal surgery and is a crucial part of fast track or enhanced recovery protocols. However, the feasibility and safety of oral intake directly following oesophagectomy remain unclear. The aim of this study is to investigate the effects of early versus delayed start of oral intake on postoperative recovery following oesophagectomy.

METHODS AND ANALYSIS

This is an open-label multicentre randomised controlled trial. Patients undergoing elective minimally invasive or hybrid oesophagectomy for cancer are eligible. Further inclusion criteria are intrathoracic anastomosis, written informed consent and age 18 years or older. Inability for oral intake, inability to place a feeding jejunostomy, inability to provide written consent, swallowing disorder, achalasia, Karnofsky Performance Status <80 and malnutrition are exclusion criteria. Patients will be randomised using online randomisation software. The intervention group (direct oral feeding) will receive a liquid oral diet for 2 weeks with gradually expanding daily maximums. The control group (delayed oral feeding) will receive enteral feeding via a jejunostomy during 5 days and then start the same liquid oral diet. The primary outcome measure is functional recovery. Secondary outcome measures are 30-day surgical complications; nutritional status; need for artificial nutrition; need for additional interventions; health-related quality of life. We aim to recruit 148 patients. Statistical analysis will be performed according to an intention to treat principle. Results are presented as risk ratios with corresponding 95% CIs. A two-tailed p<0.05 is considered statistically significant.

ETHICS AND DISSEMINATION

Our study protocol has received ethical approval from the Medical research Ethics Committees United (MEC-U). This study is conducted according to the principles of Good Clinical Practice. Verbal and written informed consent is required before randomisation. All data will be collected using an online database with adequate security measures.

TRIAL REGISTRATION NUMBERS

NCT02378948 and Dutch trial registry: NTR4972; Pre-results.

Effect of early enteral nutrition on patients with digestive tract surgery: A meta-analysis of randomized controlled trials

Postoperative early enteral nutrition (EEN) is useful for the effective recovery of patients that have undergone surgery. However, the feasibility and efficacy of EEN in patients with digestive tract surgery remain inconclusive. In the present meta-analysis, the PubMed, EMBASE, Web of Science, The Cochrane Library, China National Knowledge Infrastructure and VIP databases were searched to identify controlled trials of patients with and without EEN following digestive tract surgery between October, 1966 and December, 2014. Methodological quality assessment was carried out for each of the included studies. For estimation of the analysis indexes, relative risk (RR) was used as the effect size of the the categorical variable, while the weighted mean difference (MD) was used as the effect size of the continuous variable. The meta-analysis was conducted using RevMan 5.2 software. Eleven randomized controlled trials involving 1,095 patients were included in the meta-analysis. The results revealed that, EEN in patients with digestive tract surgery was more effective in decreasing the incidence of infectious [RR=0.50, 95% confidence interval (CI): 0.38, 0.67; P<0.01] and non-infectious complications (RR=0.72, 95% CI: 0.43, 1.22; P<0.05) and shortening the length of first bowel action (MD=−4.10, 95% CI: −5.38, −2.82; P<0.05). It also had a significant influence on increasing the serum albumin (MD=2.87, 95% CI: 1.03, 4.71; P<0.05) and serum prealbumin (MD=0.04, 95% CI: 0.02, 0.05; P<0.05) levels. In conclusion, the results of the study have shown that EEN in patients with digestive tract surgery improved the nutritional status, reduced the risk of postoperative complications, shortened the length of hospital stay and promoted the functional recovery of the digestive system.

Immediate Postoperative Oral Nutrition Following Esophagectomy: A Multicenter Clinical Trial

BACKGROUND

Immediate start of oral intake is beneficial following colorectal surgery. However, following esophagectomy the safety and feasibility of immediate oral intake is unclear, thus these patients are still kept nil by mouth. This study therefore aimed to determine the feasibility and safety of oral nutrition immediately after esophagectomy.

METHODS

A multicenter, prospective trial was conducted in 3 referral centers between August 2013 and May 2014, including 50 patients undergoing a minimally invasive esophagectomy. Oral nutrition was started postoperatively immediately (clear liquids on postoperative day [POD] 0, liquid nutrition on POD 1 to 6, solid food from POD 7). Nonoral enteral nutrition was started when <50% of caloric need was met on postoperative day POD 5 or when oral intake was impossible. A comparison was made with a retrospective cohort (n = 50) with a per-protocol delayed start of oral intake until POD 4 to 7.

RESULTS

The median caloric intake at POD 5 was 58% of required. In 38% of the patients nonoral nutrition was started, mainly due to complications (36%). The pneumonia rate was 28% following immediate oral intake and 40% following delayed oral intake (p = 0.202). The aspiration pneumonia rate was 4% in both groups. The anastomotic leakage rate was 14% after immediate oral intake versus 24% following delayed oral intake (p = 0.202). The 90-day mortality rate was 2% in both groups. Hospital stay and intensive care unit stay were significantly shorter following immediate oral intake.

CONCLUSIONS

Immediate start of oral nutrition following esophagectomy seems to be feasible and does not increase complications compared to a retrospective cohort and literature. However, if complications arise an alternative nutritional route is required. This explorative study shows that a randomized controlled trial is needed.

Early enteral nutrition compared with parenteral nutrition for esophageal cancer patients after esophagectomy: a meta-analysis

Early postoperative enteral nutrition (EN) after esophagectomy in esophageal cancer patient has been reported to be correlated with a better rehabilitation than parenteral nutrition (PN). However, a robust conclusion has not been achieved. Therefore, we performed a meta-analysis to compare the postoperative EN and PN in patients with esophageal cancer undergoing esophagectomy. Three electronic databases were searched for eligible studies to be included in the meta-analysis. The summary relative risk/weighted mean difference (RR/WMD) estimates and corresponding 95% confidence interval (CI) were calculated using fixed- and random-effects models. Ten studies met the inclusion criteria. The analysis demonstrated that the early postoperative EN could significantly decrease the pulmonary complications (RR = 0.37, 95% CI = 0.22-0.62, P = 0.00, test for heterogeneity: I(2) = 0.0%, P = 0.89) and anastomotic leakage (RR = 0.46, 95% CI = 0.22-0.96, P = 0.04, test for heterogeneity: I(2) = 0.0%, P = 0.66) compared with PN. On the eighth postoperative day, the EN group had a higher levels of albumin (WMD = 1.84, 95% CI = 0.47-3.21, P = 0.01, test for heterogeneity: I(2) = 84.5%, P = 0.00) and prealbumin (WMD = 12.96, 95% CI = 3.63-22.29, P = 0.01, test for heterogeneity: I(2) = 0.0%, P = 0.63) compared with the PN group. However, there was no difference in digestive complications between these two approaches (RR = 1.30, 95% CI = 0.79-2.13, P = 0.30, test for heterogeneity: I(2) = 0.0%, P = 0.97). For patients with esophageal cancer following esophagectomy, the early postoperative EN support could decrease the morbidity of severe complications, such as pulmonary complications and anastomotic leakage, and maintain patients at a better nutritional status than parenteral nutrion support.

Early enteral nutrition vs parenteral nutrition following pancreaticoduodenectomy: Experience from a single center

AIM: To analyze and compare postoperative morbidity between patients receiving total parenteral nutrition (TPN) and early enteral nutrition supplemented with parenteral nutrition (EEN + PN).

METHODS: Three hundred and forty patients receiving pancreaticoduodenectomy (PD) from 2009 to 2013 at our center were enrolled retrospectively. Patients were divided into two groups depending on postoperative nutrition support scheme: an EEN + PN group (n = 87) and a TPN group (n = 253). Demographic characteristics, comorbidities, preoperative biochemical parameters, pathological diagnosis, intraoperative information, and postoperative complications of the two groups were analyzed.

RESULTS: The two groups did not differ in demographic characteristics, preoperative comorbidities, preoperative biochemical parameters or pathological findings (P > 0.05 for all). However, patients with EEN + PN following PD had a higher incidence of delayed gastric emptying (16.1% vs 6.7%, P = 0.016), pulmonary infection (10.3% vs 3.6%, P = 0.024), and probably intraperitoneal infection (18.4% vs 10.3%, P = 0.059), which might account for their longer nasogastric tube retention time (9 d vs 5 d, P = 0.006), postoperative hospital stay (25 d vs 20 d, P = 0.055) and higher hospitalization expenses (USD10397 vs USD8663.9, P = 0.008), compared to those with TPN.

CONCLUSION: Our study suggests that TPN might be safe and sufficient for patient recovery after PD. Postoperative EEN should only be performed scrupulously and selectively.

Low fat-containing elemental formula is effective for postoperative recovery and potentially useful for preventing chyle leak during postoperative early enteral nutrition after esophagectomy

BACKGROUND AND AIMS

Transthoracic esophagectomy using 3-field lymphadenectomy (TTE-3FL) for esophageal cancer is one of the most aggressive gastrointestinal surgeries. Early enteral nutrition (EN) for TTE-3FL patients is useful and valid for early recovery; however, EN using a fat-containing formula risks inducing chyle leak. In the present study, we retrospectively examined esophageal cancer patients treated byTTE-3FL and administered postoperative EN to elucidate the validity of lowering the fat levels in elemental formulas to prevent postoperative chyle leak and improve postoperative recovery.

METHODS

A total of 74 patients who received TTE-3FL for esophageal cancer were retrospectively examined. Patients were classified into two groups according to the type of postoperative EN: Group LF patients received a low-fat elemental formula, and Group F patients received a standard fat-containing polymeric formula. The following clinical factors were compared between the groups: EN start day, maximum EN calories administered, duration of respirator use, length of ICU stay, incidence of postoperative infectious complications, use of parenteral nutrition (PN), and incidence of postoperative chyle leak.

RESULTS

Patients in Group LF were started on EN significantly earlier after surgery and they consumed significantly higher maximum EN calories compared to Group F patients (P < 0.01). Duration of respirator use and length of ICU stay were also significantly shorter, and TPN was used significantly less in Group LF compared to Group F (P < 0.05). Postoperative chyle leak was observed in six patients in total (8.1%); five patients in Group F and one patient in Group LF, although there was no significant difference in frequency of chyle leak per patient between Group LF and Group F.

CONCLUSIONS

Early EN using low-fat elemental formula after esophagectomy with three-field lymphadenectomy was safe and valid for postoperative recovery and potentially useful in preventing chyle leak.

Enhanced Recovery After Surgery: It's Time to Change Practice!

Perioperative surgical care is undergoing a paradigm shift. Traditional practices such as prolonged preoperative fasting (nil by mouth from midnight), bowel cleaning, and reintroduction of oral nutrition 3-5 days after surgery are being shunned. These and other similar changes have been formulated into a protocol called Enhanced Recovery After Surgery (ERAS) pathway. It is a multimodal perioperative care pathway designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of an ERAS protocol include preoperative counseling, optimization of nutrition, standardized analgesic and anesthetic regimes, and early mobilization. The recent literature is heavily influenced by colorectal surgery, but the principles are now being applied to a wide range of disciplines. As they challenge traditional surgical doctrine, the implementation of ERAS guidelines has been slow, despite the significant body of evidence indicating that ERAS guidelines may lead to improved outcomes.

Development of automated postoperative enteral nutrition: restricting feeding site inflow to match peristaltic outflow

BACKGROUND

Surgical stress accelerates postoperative metabolism, while simultaneously compromising gut activity. The dysfunction may be worsened by early feeding. These patients are not expected to fully meet their optimum metabolic requirements using current nutritional regimens. For optimum postoperative enteral nutrition, we must automatically match the patients' feeding site inflows to their impaired peristaltic outflows. An essential adjunct is virtually complete exclusion of swallowed air. The small diameter post-pyloric duodenum is an efficient site for both aspiration and feeding.

METHOD

A multi-lumen feeding-decompression tube is utilized to feed an "elemental diet" (1 kcal/ml) at the rate of 3000-5000 ml/day immediately postoperatively. Outflow from the feeding site, relative to inflow, is monitored. Excess aspirate is discarded automatically, so that the re-fed inflow exactly matches the peristaltic outflow. The aspirate (digestive secretions, feedings, and swallowed air) is degassed. The aspirate is then directed by one-way valves alternately, every 30 s, into a pair of 30 ml collection chambers for re-feeding. Simultaneously, the previously collected aspirate (less discarded volume, if required) is delivered by gravity into the slightly more distal duodenum.

RESULTS

Within 2 h, the return of the entire aspirate volume is tolerated. The patients' increased metabolic demands are met early on the initial day of surgery. They achieve positive protein balance, with documented enhanced healing (experimentally) and immune globulin synthesis (clinically). Breakfast is tolerated the morning following operation, with discharge soon thereafter. X-ray motility and nutrient absorption studies document the more rapid return of clinically normal peristalsis.

CONCLUSION

Automatically keeping the proximal duodenum and stomach continuously decompressed, while simultaneously re-feeding tolerated degassed duodenal aspirate, leads to more rapid return of clinically adequate G-I function postoperatively. In addition to maximizing immediately postoperative nourishment, the secretory globulins are salvaged, and spontaneously delivered into the colon, where they provide natural antimicrobial protection.

Early Enteral Nutrition Versus Parenteral Nutrition After Resection of Esophageal Cancer: a Retrospective Analysis

This study aimed to compare the clinical outcomes and hospitalization cost between early enteral nutrition (EEN) and parenteral nutrition (PN) after resection of esophageal cancer. A total of 79 patients with esophageal cancer who underwent surgical treatment in our hospital from July 2010 to July 2013 were enrolled in this study. They were divided into EEN group (n = 39) and PN group (n = 40) based on the nutrition support modes. The clinical factors such as time to first fecal passage, postoperative albumin infusion, differences of serum albumin value, hospital stay, systematic inflammatory response syndrome (SIRS) duration, complications, initial hospitalization cost, and mortality were retrospectively compared. The EEN group had a significantly shorter hospital stay, lower initial hospitalization cost, earlier first fecal passage, and shorter duration of SIRS than PN group (P < 0.05). The dose of albumin infusion was significantly smaller in EEN group (P < 0.05) and the decreased value of serum albumin (Δalb) was more prominent in PN group compared with EEN group (P < 0.05). The percentage of patients having any postoperative complication was much higher in PN group than EEN group (P < 0.05), but there was no significant difference in in-hospital morbidity between two groups. Pneumonia was found significantly more frequent in PN group compared with EEN group (P < 0.05). Early EN started within 48 h after esophagectomy is safe, economic, and superior for reduction of postoperative complication, for promoting early recovery of intestinal movement, and for early recovery from systemic inflammation.

A Prospective Randomized Trial of Enteral Nutrition After Thoracoscopic Esophagectomy for Esophageal Cancer

BACKGROUND

Several studies have reported that postoperative enteral nutrition (EN) reduced complications and decreased weight loss and hospital stay periods; however, the majority of patients analyzed in these studies underwent open thoracic surgery. No studies have been conducted regarding EN in patients after thoracoscopic esophagectomy as a less invasive surgery. The aim of this study was to investigate the efficacy of EN after thoracoscopic esophagectomy.

METHODS

Fifty patients who underwent thoracoscopic esophagectomy for esophageal cancer were divided into two groups: parenteral nutrition (PN; n = 25) and EN (n = 25). The rate of weight loss at postoperative day (POD) 14, levels of prealbumin at POD 10, postoperative complications until POD 14, and other perioperative data were collected for each group.

RESULTS

This study analyzed data for 47 patients. The rate of weight loss at POD 14 was significantly lower in the EN group (3.0 ± 3.2 %) than in the PN group (5.1 ± 3.7 %; p = 0.020). Prealbumin levels were 21.0 ± 7.5 mg/dL in the PN group and 18.4 ± 5.8 mg/dL in the EN group at POD 10, with no significant differences between the groups. However, the incidence of postoperative pneumonia was higher in the PN group (30.4 %) than in the EN group (12.5 %).

CONCLUSIONS

EN could suppress weight loss and reduce the incidence of pneumonia after thoracoscopic esophagectomy.

The Sick and the Weak: Neuropathies/Myopathies in the Critically Ill

Critical illness polyneuropathies (CIP) and myopathies (CIM) are common complications of critical illness. Several weakness syndromes are summarized under the term intensive care unit-acquired weakness (ICUAW). We propose a classification of different ICUAW forms (CIM, CIP, sepsis-induced, steroid-denervation myopathy) and pathophysiological mechanisms from clinical and animal model data. Triggers include sepsis, mechanical ventilation, muscle unloading, steroid treatment, or denervation. Some ICUAW forms require stringent diagnostic features; CIM is marked by membrane hypoexcitability, severe atrophy, preferential myosin loss, ultrastructural alterations, and inadequate autophagy activation while myopathies in pure sepsis do not reproduce marked myosin loss. Reduced membrane excitability results from depolarization and ion channel dysfunction. Mitochondrial dysfunction contributes to energy-dependent processes. Ubiquitin proteasome and calpain activation trigger muscle proteolysis and atrophy while protein synthesis is impaired. Myosin loss is more pronounced than actin loss in CIM. Protein quality control is altered by inadequate autophagy. Ca(2+) dysregulation is present through altered Ca(2+) homeostasis. We highlight clinical hallmarks, trigger factors, and potential mechanisms from human studies and animal models that allow separation of risk factors that may trigger distinct mechanisms contributing to weakness. During critical illness, altered inflammatory (cytokines) and metabolic pathways deteriorate muscle function. ICUAW prevention/treatment is limited, e.g., tight glycemic control, delaying nutrition, and early mobilization. Future challenges include identification of primary/secondary events during the time course of critical illness, the interplay between membrane excitability, bioenergetic failure and differential proteolysis, and finding new therapeutic targets by help of tailored animal models.

Treatment options for chylous ascites after major abdominal surgery: a systematic review

BACKGROUND

Chylous leakage is a relevant clinical problem after major abdominal surgery leading to an increased length of stay.

DATA SOURCES

A systematic search of MEDLINE/PubMed and the Cochrane Library was performed according to the PRISMA statement. The search for the MeSH terms "chylous ascites" and/or "lymphatic fistula" retrieved a total of 2,348 articles, of which 36 full-text articles were reviewed by 2 independent investigators.

RESULTS

Chylous ascites is described with an incidence of up to 11%, especially after pancreatic surgery. The incidence is increasing with the number of lymph nodes harvested. In patients treated with total parenteral nutrition, conservative treatment is demonstrated to be effective in up to 100% of cases.

CONCLUSIONS

The extent of abdominal surgery mainly predicts the risk of chylous ascites. Conservative treatment has been shown to be effective in almost all cases and is the treatment of choice.

Pancreatic cancer surgery and nutrition management: a review of the current literature

Surgery remains the only curative treatment for pancreaticobiliary tumors. These patients typically present in a malnourished state. Various screening tools have been employed to help with preoperative risk stratification. Examples include the subjective global assessment (SGA), malnutrition universal screening tool (MUST), and nutritional risk index (NRI). Adequate studies have not been performed to determine if perioperative interventions, based on nutrition risk assessment, result in less morbidity and mortality. The routine use of gastric decompression with nasogastric sump tubes may be unnecessary following elective pancreatic resections. Instead, placement should be selective and employed on a case-by-case basis. A wide variety of feeding modalities are available, oral nutrition being the most effective. Artificial nutrition may be provided by temporary nasal tube (nasogastric, nasojejunal, or combined nasogastrojejunal tube) or surgically placed tube [gastrostomy (GT), jejunostomy (JT), gastrojejunostomy tubes (GJT)], and intravenously (parenteral nutrition, PN). The optimal tube for enteral feeding cannot be determined based on current data. Each is associated with a specific set of complications. Dual lumen tubes may be useful in the presence of delayed gastric emptying (DGE) as the stomach may be decompressed while feeds are delivered to the jejunum. However, all feeding tubes placed in the small intestine, except direct jejunostomies, commonly dislodge and retroflex into the stomach. Jejunostomies are associated with less frequent, but more serious complications. These include intestinal torsion and bowel necrosis. PN is associated with septic, metabolic, and access-related complications and should be the feeding strategy of last-resort. Enteral feeds are clearly preferred over parental nutrition. A sound understanding of perioperative nutrition may improve patient outcomes. Patients undergoing pancreatic cancer surgery should undergo multidisciplinary nutrition screening and intervention, and the surgical/oncological team should include nutrition professionals in managing these patients in the perioperative period.

The role of fast-track surgery in pancreaticoduodenectomy: a retrospective cohort study of 635 consecutive resections

BACKGROUND

Pancreaticoduodenectomy (PD) is one of the most difficult and dangerous operations in general surgery. This study used the concept of fast-track surgery (FTS) technique, which involves pain control, early enteral nutrition and other measures during the preoperative period, to evaluate the rate of complications and shorter hospitalization.

METHODS

This retrospective, observational study was conducted between January 2009 and January 2013. A total of 635 patients underwent PD in the Department of Pancreatic Surgery at ChangHai Hospital (Shanghai, China). 325 patients had FTS and 310 patients received the traditional pathway of treatment. The incidence of postoperative complications, the serum albumin level, expenses, postoperative hospitalization, and readmission rates were compared.

RESULTS

There were no significant differences in the blood transfusion volume, nasogastric intubation, and readmission rates (p > 0.05). However, the FTS group had less postoperative hospitalization, fewer expenses and a lower incidence of postoperative complications compared with the control group (p<0.05).

CONCLUSION

Pancreaticoduodenectomy can be further optimized by the use of FTS methods, which can reduce the incidence of in hospital postoperative complications and expenses without increasing the risk of readmission.

Perioperative Enteral Immunonutrition Modulates Systemic and Mucosal Immunity and the Inflammatory Response in Patients With Periampullary Cancer Scheduled for Pancreaticoduodenectomy: A Randomized Clinical Trial

OBJECTIVES

Nutritional deficiencies and immune dysfunction in cancer patients may contribute to postoperative septic morbidity. This trial compared the effects of perioperative enteral immunonutrition (EIN) versus standard enteral nutrition (SEN) on systemic and mucosal immunity in patients undergoing pancreaticoduodenectomy for periampullary cancer.

METHODS

Thirty-seven patients were randomized (EIN, n = 17; SEN, n = 20) to receive feed for 14 days preoperatively and 7 days postoperatively. Mediators of systemic immunity (interleukin 1α, tumor necrosis factor α, lymphocytes subsets, and complement components) and of mucosal immunity in duodenal biopsies, nutritional markers and parameters were evaluated.

RESULTS

The groups were comparable for demographics, the concentrations of mediators of systemic and mucosal immunity at time of recruitment, and for the duration and amount of feed received. Preoperative EIN rather than SEN was associated with significant reductions in plasma tumor necrosis factor α and total hemolytic complement. Enteral immunonutrition-fed patients had significantly higher total lymphocyte count on the third postoperative day and significantly greater rise in CD4/CD8 ratio from day 3 to day 7 postoperatively compared with SEN-fed patients.

CONCLUSIONS

The perioperative administration of EIN rather than SEN is associated with a favorable modulation of the inflammatory response and enhancement of systemic immunity in patients undergoing pancreaticoduodenectomy for periampullary cancer.

The Evidence against Prophylactic Nasogastric Intubation and Oral Restriction

Evidence-based perioperative care plans after colorectal surgery serve to improve quality outcome, decrease complications, and reduce medical cost. The benefits of routine nasogastric decompression and prolonged enteral restriction after bowel resection are not supported in this new era of evidence-based surgical care. Prophylactic nasogastric decompression fails to improve bowel function, length of stay, and prevent anastomotic leak, wound complications (infection, fascial dehiscence, incisional hernia), pulmonary complications (atelectasis, aspiration, pneumonia, fever, pharyngolaryngitis), and abdominal discomfort (distension, nausea, vomiting). Patients have earlier return of bowel function without the use of a nasogastric tube (NGT). Early refeeding within 24 hours after bowel resection is well tolerated in 80 to 90% of patients, and associated with earlier hospital discharge, decreased risk of infection, and improved postoperative hyperglycemic control. Abdominal discomfort is the most common complication observed in patients treated with early feeding and without a NGT, but does not result in higher therapeutic nasogastric intubation, postoperative ileus, aspiration, or other complications. The use of multimodal adjuncts in combination with these guidelines should be considered to improve outcome. The current literature is reviewed with suggestions for achieving better outcomes after colorectal resection.

Interventions for preventing critical illness polyneuropathy and critical illness myopathy

BACKGROUND

Critical illness polyneuropathy or myopathy (CIP/CIM) is a frequent complication in the intensive care unit (ICU) and is associated with prolonged mechanical ventilation, longer ICU stay and increased mortality. This is an interim update of a review first published in 2009 (Hermans 2009). It has been updated to October 2011, with further potentially eligible studies from a December 2013 search characterised as awaiting assessment.

OBJECTIVES

To systematically review the evidence from RCTs concerning the ability of any intervention to reduce the incidence of CIP or CIM in critically ill individuals.

SEARCH METHODS

On 4 October 2011, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, and EMBASE. We checked the bibliographies of identified trials and contacted trial authors and experts in the field. We carried out an additional search of these databases on 6 December 2013 to identify recent studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs), examining the effect of any intervention on the incidence of CIP/CIM in people admitted to adult medical or surgical ICUs. The primary outcome was the incidence of CIP/CIM in ICU, based on electrophysiological or clinical examination. Secondary outcomes included duration of mechanical ventilation, duration of ICU stay, death at 30 and 180 days after ICU admission and serious adverse events from the treatment regimens.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data and assessed the risk of bias in included studies.

MAIN RESULTS

We identified five trials that met our inclusion criteria. Two trials compared intensive insulin therapy (IIT) to conventional insulin therapy (CIT). IIT significantly reduced CIP/CIM in the screened (n = 825; risk ratio (RR) 0.65, 95% confidence interval (CI) 0.55 to 0.77) and total (n = 2748; RR 0.70, 95% CI 0.60 to 0.82) population randomised. IIT reduced duration of mechanical ventilation, ICU stay and 180-day mortality, but not 30-day mortality compared with CIT. Hypoglycaemia increased with IIT but did not cause early deaths.One trial compared corticosteroids with placebo (n = 180). The trial found no effect of treatment on CIP/CIM (RR 1.27, 95% CI 0.77 to 2.08), 180-day mortality, new infections, glycaemia at day seven, or episodes of pneumonia, but did show a reduction of new shock events.In the fourth trial, early physical therapy reduced CIP/CIM in 82/104 evaluable participants in ICU (RR 0.62. 95% CI 0.39 to 0.96). Statistical significance was lost when we performed a full intention-to-treat analysis (RR 0.81, 95% CI 0.60 to 1.08). Duration of mechanical ventilation but not ICU stay was significantly shorter in the intervention group. Hospital mortality was not affected but 30- and 180-day mortality results were not available. No adverse effects were noticed.The last trial found a reduced incidence of CIP/CIM in 52 evaluable participants out of a total of 140 who were randomised to electrical muscle stimulation (EMS) versus no stimulation (RR 0.32, 95% CI 0.10 to 1.01). These data were prone to bias due to imbalances between treatment groups in this subgroup of participants. After we imputed missing data and performed an intention-to-treat analysis, there was still no significant effect (RR 0.94, 95% CI 0.78 to 1.15). The investigators found no effect on duration of mechanical ventilation and noted no difference in ICU mortality, but did not report 30- and 180-day mortality.We updated the searches in December 2013 and identified nine potentially eligible studies that will be assessed for inclusion in the next update of the review.

AUTHORS' CONCLUSIONS

There is moderate quality evidence from two large trials that intensive insulin therapy reduces CIP/CIM, and high quality evidence that it reduces duration of mechanical ventilation, ICU stay and 180-day mortality, at the expense of hypoglycaemia. Consequences and prevention of hypoglycaemia need further study. There is moderate quality evidence which suggests no effect of corticosteroids on CIP/CIM and high quality evidence that steroids do not affect secondary outcomes, except for fewer new shock episodes. Moderate quality evidence suggests a potential benefit of early rehabilitation on CIP/CIM which is accompanied by a shorter duration of mechanical ventilation but without an effect on ICU stay. Very low quality evidence suggests no effect of EMS, although data are prone to bias. Strict diagnostic criteria for CIP/CIM are urgently needed for research purposes. Large RCTs need to be conducted to further explore the role of early rehabilitation and EMS and to develop new preventive strategies.

Interventions for preventing critical illness polyneuropathy and critical illness myopathy

BACKGROUND

Critical illness polyneuropathy or myopathy (CIP/CIM) is a frequent complication in the intensive care unit (ICU) and is associated with prolonged mechanical ventilation, longer ICU stay and increased mortality. This is an interim update of a review first published in 2009 (Hermans 2009). It has been updated to October 2011, with further potentially eligible studies from a December 2013 search characterised as awaiting assessment.

OBJECTIVES

To systematically review the evidence from RCTs concerning the ability of any intervention to reduce the incidence of CIP or CIM in critically ill individuals.

SEARCH METHODS

On 4 October 2011, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE, and EMBASE. We checked the bibliographies of identified trials and contacted trial authors and experts in the field. We carried out an additional search of these databases on 6 December 2013 to identify recent studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs), examining the effect of any intervention on the incidence of CIP/CIM in people admitted to adult medical or surgical ICUs. The primary outcome was the incidence of CIP/CIM in ICU, based on electrophysiological or clinical examination. Secondary outcomes included duration of mechanical ventilation, duration of ICU stay, death at 30 and 180 days after ICU admission and serious adverse events from the treatment regimens.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data and assessed the risk of bias in included studies.

MAIN RESULTS

We identified five trials that met our inclusion criteria. Two trials compared intensive insulin therapy (IIT) to conventional insulin therapy (CIT). IIT significantly reduced CIP/CIM in the screened (n = 825; risk ratio (RR) 0.65, 95% confidence interval (CI) 0.55 to 0.77) and total (n = 2748; RR 0.70, 95% CI 0.60 to 0.82) population randomised. IIT reduced duration of mechanical ventilation, ICU stay and 180-day mortality, but not 30-day mortality compared with CIT. Hypoglycaemia increased with IIT but did not cause early deaths.One trial compared corticosteroids with placebo (n = 180). The trial found no effect of treatment on CIP/CIM (RR 1.27, 95% CI 0.77 to 2.08), 180-day mortality, new infections, glycaemia at day seven, or episodes of pneumonia, but did show a reduction of new shock events.In the fourth trial, early physical therapy reduced CIP/CIM in 82/104 evaluable participants in ICU (RR 0.62. 95% CI 0.39 to 0.96). Statistical significance was lost when we performed a full intention-to-treat analysis (RR 0.81, 95% CI 0.60 to 1.08). Duration of mechanical ventilation but not ICU stay was significantly shorter in the intervention group. Hospital mortality was not affected but 30- and 180-day mortality results were not available. No adverse effects were noticed.The last trial found a reduced incidence of CIP/CIM in 52 evaluable participants out of a total of 140 who were randomised to electrical muscle stimulation (EMS) versus no stimulation (RR 0.32, 95% CI 0.10 to 1.01). These data were prone to bias due to imbalances between treatment groups in this subgroup of participants. After we imputed missing data and performed an intention-to-treat analysis, there was still no significant effect (RR 0.94, 95% CI 0.78 to 1.15). The investigators found no effect on duration of mechanical ventilation and noted no difference in ICU mortality, but did not report 30- and 180-day mortality.We updated the searches in December 2013 and identified nine potentially eligible studies that will be assessed for inclusion in the next update of the review.

AUTHORS' CONCLUSIONS

There is moderate quality evidence from two large trials that intensive insulin therapy reduces CIP/CIM, and high quality evidence that it reduces duration of mechanical ventilation, ICU stay and 180-day mortality, at the expense of hypoglycaemia. Consequences and prevention of hypoglycaemia need further study. There is moderate quality evidence which suggests no effect of corticosteroids on CIP/CIM and high quality evidence that steroids do not affect secondary outcomes, except for fewer new shock episodes. Moderate quality evidence suggests a potential benefit of early rehabilitation on CIP/CIM which is accompanied by a shorter duration of mechanical ventilation but without an effect on ICU stay. Very low quality evidence suggests no effect of EMS, although data are prone to bias. Strict diagnostic criteria for CIP/CIM are urgently needed for research purposes. Large RCTs need to be conducted to further explore the role of early rehabilitation and EMS and to develop new preventive strategies.

Jejunostomy tube feeding in patients undergoing esophagectomy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is early enteral nutrition initiated within 24 hours better for the postoperative course in esophageal cancer surgery?

BACKGROUND

Early enteral nutrition within 24 h after surgery has become a recommended procedure. In the present study, we retrospectively examined whether initiating EN within 24 h after esophagectomy improves the postoperative course.

METHODS

Among 103 patients who underwent thoracic esophagectomy for esophageal cancer, we enrolled the cases in which EN was initiated within 72 h after surgery. The patients were divided into two groups: EN started within 24 h (Group D1) and EN started at 24 - 72 h (Group D2-3). Clinical factors including days for first fecal passage, dose of postoperative albumin infusion, difference in serum albumin between pre- and postoperation, incidence of postoperative infection, and use of total parenteral nutrition were compared. Statistical analyses were performed by the Mann-Whitney U test and Chi square test, with significance defined as P < 0.05.

RESULTS

There was no significant difference between the groups in clinical factors. While pneumonia was significantly more frequent in Group D1 than in Group D2-3 (P = 0.0308), the frequency of infectious complications was comparable between the groups.

CONCLUSION

Initiating EN within 24 h showed no advantage for the postoperative course in esophageal cancer, and thus EN should be scheduled within 24 - 72 h, based on the patient condition.

Is early enteral nutrition better for postoperative course in esophageal cancer patients?

We retrospectively examined esophageal cancer patients who received enteral nutrition (EN) to clarify the validity of early EN compared with delayed EN. A total of 103 patients who underwent transthoracic esophagectomy with three-field lymphadenectomy for esophageal cancer were entered. Patients were divided into two groups; Group E received EN within postoperative day 3, and Group L received EN after postoperative day 3. The clinical factors such as days for first fecal passage, the dose of postoperative albumin infusion, differences of serum albumin value between pre- and postoperation, duration of systematic inflammatory response syndrome (SIRS), incidence of postoperative infectious complication, and use of total parenteral nutrition (TPN) were compared between the groups. The statistical analyses were performed using Mann-Whitney U test and Chi square test. The statistical significance was defined as p < 0.05. Group E showed fewer days for the first fecal passage (p < 0.01), lesser dose of postoperative albumin infusion (p < 0.01), less use of TPN (p < 0.01), and shorter duration of SIRS (p < 0.01). However, there was no significant difference in postoperative complications between the two groups. Early EN started within 3 days after esophagectomy. It is safe and valid for reduction of albumin infusion and TPN, for promoting early recovery of intestinal movement, and for early recovery from systemic inflammation.

A randomized controlled trial comparing a standard postoperative diet with low-volume high-calorie oral supplements following colorectal surgery

AIM

Postoperative oral nutritional supplementation is becoming a part of most patient care pathways. This study examined the effects of low-volume high-calorie prescribed supplemental nutrition on patient outcome following elective colorectal surgery.

METHOD

Patients undergoing elective colorectal resections were randomized to a prescribed nutritional supplementation group (SG) [standard diet + 6 × 60 ml/day of Pro-Cal (60 ml = 200 kcal + 4 g protein)] or conventional postoperative diet group (CG) (standard diet alone). Preoperative and daily postoperative hand-grip strengths were measured using a grip dynamometer after randomization. Daily food intake, return of bowel activity, nausea score for the first 3 days and postoperative length of hospital stay (LOS) were prospectively recorded. Micro-diet standardized software was used to analyse food diaries. Nonparametric tests were used to analyse the data.

RESULTS

Fifty-five patients were analysed (SG 28, CG 27). There was no difference in median preoperative and postoperative handgrip strengths at discharge within each group (SG 31.7 vs 31.7 kPa, P = 0.932; CG 28 vs 28.1 kPa, P = 0.374). The total median daily calorie intake was higher in SG than CG (SG 818.5 kcal vs CG 528 kcal; P = 0.002). There was no difference in median number of days to first bowel movement (SG 3 days vs CG 4 days, P = 0.096). The median LOS was significantly shorter in SG than CG (6.5 vs 9 days; P = 0.037).

CONCLUSION

Prescribed postoperative high-calorie, low-volume oral supplements in addition to the normal dietary intake are associated with significantly better total daily oral calorie intake and may contribute to a reduced postoperative hospital stay.

Complications after pancreatic resection: diagnosis, prevention and management

BACKGROUND

Although mortality after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) has decreased, morbidity still remains high. The aim of this review article is to present, define, predict, prevent, and manage the main complications after pancreatic resection (PR).

METHODS

A non-systematic literature search on morbidity and mortality after PR was undertaken using the PubMed/MEDLINE and Embase databases.

RESULTS

The main complications after PR are delayed gastric emptying (DGE), pancreatic fistula (PF), and bleeding, as defined by the International Study Group on Pancreatic Surgery. PF occurs in 10% to 15% of patients after PD and in 10% to 30% of patients after DP. The different techniques of pancreatic anastomosis and pancreatic remnant closure do not show significant advantages in the prevention of PF, nor does the perioperative use of somatostatin and its analogues. The trend is for conservative or interventional radiology therapy for PF (with enteral nutrition), which achieves a success rate of approximately 80%. DGE after PD occurs in 20% to 50% of patients. Prophylactic erythromycin may reduce the incidence of DGE. Gastric aspiration with erythromycin is usually effective in one to three weeks. Bleeding (gastrointestinal and intraabdominal) occurs in 4% to 16% of patients after PD and in 2% to 3% of patients after DP. Endovascular treatment can only be used for a haemodynamically stable patient. In cases of haemodynamic instability or associated septic complications, surgical treatment is necessary. In expert centres, the mortality rates can be less than 1% after DP and less than 3% after PD.

CONCLUSION

There is a need for improved strategies to prevent and treat complications after PR.

Pulmonary function and physical performance outcomes with preoperative physical therapy in upper abdominal surgery: a randomized controlled trial

OBJECTIVE

Investigation of the effects of preoperative physical therapy on pulmonary function and physical performance before and after upper abdominal surgery.

DESIGN

Non-blind randomized controlled trial.

SETTING

Tertiary public hospital and private university, São Paulo state, Brazil.

SUBJECTS

Thirty-two patients undergoing abdominal surgery.

INTERVENTIONS

Patients were randomly assigned to receive physical therapy, with respiratory and global exercises, 2-3 weeks before surgery (treatment group; n = 16) or await operation without engaging in practicing (control group; n = 16). After surgery, a physical therapy protocol was administered to all subjects until the seventh postoperative day.

MAIN MEASURES

Pulmonary function outcome variables were inspiratory and expiratory strength, respiratory muscle endurance and spirometry, and physical performance outcome variables were the functional independence measure and 6-minute walk test distance. Any postoperative pulmonary complications were recorded.

RESULTS

There were no between-group differences at randomization. In the preoperative period, patients in the intervention group had higher inspiratory strength and respiratory muscle endurance than controls (88 cmH(2)O versus 64 cmH(2)O and 28 cmH(2)O versus 23 cmH(2)O, respectively; P <0 0.05). On the seventh postoperative day, in addition to inspiratory force and respiratory muscle endurance, the intervention group showed better results than controls in the functional independence measure score (118 versus 95) and 6-minute walk test distance (368.5 m versus 223 m), all P <0 0.05. Postoperative pulmonary complications occurred in 11 patients in the control group and five in the intervention group (P = 0.03).

CONCLUSION

Preoperative physical therapy improved pulmonary function and physical performance in the pre- and postoperative periods among patients undergoing upper abdominal surgery.

Feeding jejunostomy during Whipple is associated with increased morbidity

BACKGROUND

Placement of a feeding jejunostomy tube (FJ) is often performed during pancreaticoduodenectomy (PD). Few studies, however, have sought to determine whether such placement affects postoperative outcomes after PD.

MATERIALS AND METHODS

This is a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database to determine the 30-d-postoperative mortality rate, major complication rate, and overall complication rate of jejunostomy tube placement at the time of PD. Univariate and multivariate comparison of postoperative outcomes between patients with and without FJ placement during PD was performed on a total of 4930 patients.

RESULTS

Thirty-day-postoperative mortality did not differ between the two groups (4.0% for patients with FJ versus 2.7% without, P = 0.13), whereas overall morbidity (43.3% with FJ versus 34.6% without, P < 0.0001) and serious morbidity (29.5% with FJ versus 22.8% without, P < 0.0001) were significantly higher in patients undergoing FJ placement during PD. The specific complications that occurred more frequently in FJ patients than patients without FJ included deep space surgical site infection, pneumonia, unplanned reintubation, acute renal failure, and sepsis.

CONCLUSION

Although FJ placement during PD is considered to be routine at many institutions, our analysis of data from NSQIP suggest that FJ placement may be associated with increased postoperative morbidity.

Is routine postoperative enteral feeding after oesophagectomy worthwhile?

A best evidence topic in surgery was written according to a structured protocol. The question addressed was whether, in patients undergoing an oesophagectomy for cancer, immediate postoperative enteral feeding (via percutaneous jejunostomy or nasojejunostomy) provides better patient outcomes as compared to waiting until oral feeding can be instituted. Four randomized controlled trials represented the best evidence to answer the clinical question. The first study randomized 25 patients into enteral feeding via jejunostomy (n = 13) versus a routine diet without jejunostomy (n = 12). The authors found no statistical difference in outcomes including length of stay, anastomotic complications and mortality. They did not report any catheter-related complications. A second study included patients undergoing an oesophagectomy or a pancreatodudenectomy, randomized to immediate postoperative jejunostomy feeding (n = 13) or remaining unfed for 6 days (n = 15). They reported one incident of detachment of the catheter from the abdominal wall. They also noted a statistically significant decrease in vital capacity and FEV1 in enterally fed patients. There was no difference in length of stay or anastomotic complications. They concluded that there was no indication for routine use of immediate postoperative enteral feeding in those patients without significant preoperative malnutrition. A third report randomized their post-oesophagectomy patients into enteral feeding via jejunostomy (n = 20) versus crystalloid only (n = 20). The also found no difference in length of stay, anastomotic leak rate or mortality. One catheter was removed due to concerns over respiratory function. They also concluded that there was no measurable benefit in early enteral feeding. The last of these 4 studies randomized patients into naso-duodenal feeding (n = 71) and jejunostomy feeding groups (n = 79). As in previous trials, they found no statistically significant difference between length of stay or anastomotic leak rates. Mortality was higher in the jejunostomy group, although the team did not attribute the deaths to the catheter. They found both methods equally effective in providing postoperative nutrition. In summary, all the trials concluded that routine postoperative enteral nutrition was feasible, but there was no evidence suggesting that it conferred any clinical benefits.

Postoperative nutritional effects of early enteral feeding compared with total parental nutrition in pancreaticoduodectomy patients: a prosepective, randomized study

The benefits of early enteral feeding (EEN) have been demonstrated in gastrointestinal surgery. But, the impact of EEN has not been elucidated yet. We assessed the postoperative nutritional status of patients who had undergone pancreaticoduodenectomy (PD) according to the postoperative nutritional method and compared the clinical outcomes of two methods. A prospective randomized trial was undertaken following PD. Patients were randomly divided into two groups; the EEN group received the postoperative enteral feed and the control group received the postoperative total parenteral nutrition (TPN) management. Thirty-eight patients were included in our analyses. The first day of bowel movement and time to take a normal soft diet was significantly shorter in EEN group than in TPN group. Prealbumin and transferrin were significantly reduced on post-operative day (POD) 7 and were slowly recovered until POD 90 in the TPN group than in the EEN group. EEN group rapidly recovered weight after POD 21 whereas it was gradually decreased in TPN group until POD 90. EEN after PD is associated with preservation of weight compared with TPN and impact on recovery of digestive function after PD.

Jejunostomy after oesophagectomy: a review of evidence and current practice

Patients undergoing oesophagectomy often have nutritional needs at the time of diagnosis and in the post-operative period. The aim of this article is to review the current literature and report on the author's experience of routine feeding jejunostomy insertion following oesophagectomy. The records of forty-eight consecutive patients undergoing oesphagectomy under the author's care were reviewed. Although the evidence of benefit of peri-operative feeding in patients undergoing oesophagectomy is limited, there is a clear need to establish a feeding route at the time of surgery. Oesophagectomy is associated with a mortality rate of 5-10% and a morbidity rate of 30-40% even in high-volume specialist centres. Over 50% of patients developing complications will require an alternative to oral feeding beyond 30 d. The enteral route is preferred in terms of safety and cost. A surgical feeding jejunostomy is associated with a low complication rate and a mortality rate of less than 1%. In forty-eight patients undergoing oesophagectomy the average weight loss at 6 months was 8·4 kg with only 8% regaining their pre-operative weight. Large reductions in weight at 6 months post-operatively were recorded irrespective of the development of post-operative complications or early recurrent disease. Routine jejunostomy insertion is recommended to ensure adequate nutrition in patients who develop post-operative complications and for those patients with long-term reduced appetite and poor oral intake.

Nutritional management of critically ill trauma patients in the deployed military setting

The role of nutritional support in critical illness is well established. This article reviews the nutritional management of military trauma patients in the deployed setting, which poses special challenges for the surgeon and intensivist. There is little direct evidence relating to the nutritional management of trauma patients in general, and military trauma patients in particular, but much of the evidence accrued in the civilian and non-trauma critical care setting can be extrapolated to military practice. There is strong consensus that feeding should be commenced as soon possible after injury. Enteral nutrition should be used in preference to parenteral nutrition whenever possible. If available, supplemental parenteral feeding can be considered if enteral delivery is insufficient. Gastrointestinal anastomoses and repairs, including those in the upper gastrointestinal tract, are not a contraindication to early enteral feeding. Intragastric delivery is more physiological and usually more convenient than postpyloric feeding, and thus the preferred route for the initiation of nutritional support. Feeding gastrostomies or jejunostomies should not be used for short-term nutritional support. Enteral feeding of patients with an open abdomen does not delay closure and may reduce the incidence of pneumonia, and enteral nutrition should be continued for scheduled relook surgery not involving hollow viscera or airway. Glutamine supplementation may improve outcome in trauma patients, but fish-oil containing feeds, while showing some promise, should be reserved for subgroups of patients with ARDS.

The relationships of nutrients, routes of delivery, and immunocompetence

Malnutrition has marked consequences on surgical outcomes. Adequate nutrition is important for the proper functioning of all organ systems, particularly the immune system. Determination of the type and amount of nutrient supplementation and the appropriate route of nutrient delivery is essential to bolster the immune system and enhance the host's response to stress. Correct administration of immunonutrients could lead to reductions in patient morbidity following major surgery, trauma, and critical illness.

A clinical and economic evaluation of enteral nutrition

MOTIVATION

The American Society of Parenteral and Enteral Nutrition (ASPEN) guidelines advise use of enteral nutrition (EN) for critically ill hospital patients requiring nutritional support, but no studies have comprehensively estimated economic benefits from adherence to this recommendation.

METHODS

We systematically reviewed studies comparing EN to alternative nutritional support therapies among adult, critically ill patients. We reviewed 1200 abstracts, selected 243 for further review, and included 48 studies in our analysis. Most retained studies compared EN and parenteral nutrition (PN). Using meta-analysis, we estimated the absolute impact of EN on adverse event risk and its impact on treatment duration and length of stay. These estimates were converted to population economic impacts by assuming 10% of PN patients are suitable candidates for EN.

RESULTS

Compared to PN, EN reduces the risk of major, potentially life-threatening infections (RR = 0.58, 95% confidence interval [CI] 0.44 to 0.77), the risk of major, potentially life-threatening non-infection events (RR = 0.73, CI 0.59 to 0.91), and suggests a reduction in mortality, although this result did not achieve statistical significance (RR = 0.70, CI 0.45 to 1.09). EN also reduces inpatient length of stay, time in the ICU, and length of nutritional treatment. Compared to PN, EN savings from reduced adverse event risks average nearly $1500 per patient; savings from reduced hospital length of stay amount to nearly $2500 per patient. Shifting 10% of parenterally treated adult patients in the U.S. to EN would save $35 million annually due to reduced adverse events and another $57 million due to shorter hospital stays.

CONCLUSION

The evidence of both clinical and economic gains from EN is consistent with ASPEN guidelines recommending use of EN in critically ill hospital patients when possible.