Effects of early enteral nutrition on patients after emergency gastrointestinal surgery: a propensity score matching analysis

An Elemental Diet Reduces Chylous Ascites of Patients Undergoing Pancreatoduodenectomy in the Setting of Early Enteral Feeding

OBJECTIVES

The elemental diet (ED) is a formula to support nutritional status without increasing chylous burden. This study evaluates the efficacy of early ED feeding after pancreatoduodenectomy (PD).

MATERIALS AND METHODS

A prospective phase II study of consecutive patients who underwent PD with early ED feeding was conducted. Patient backgrounds, surgical outcomes, and ED feeding tolerability were compared with a historical cohort of 74 PD patients with early enteral feeding of a low residue diet (LRD).

RESULTS

The ED group comprised 104 patients. No patient in the ED group discontinued enteral feeding because of chylous ascites (CAs), whereas 17.6% of the LRD group experienced refractory CAs that disrupted further enteral feeding. The CAs rate was significantly decreased in the ED group compared with the LRD group (3.9% and 48.7%, respectively; P < 0.001). There was no significant difference in the incidence of major complications (ED: 17.3%, LRD: 18.9%; P = 0.844). Postoperative prognostic nutritional index was similar between the 2 groups ( P = 0.764). In multivariate analysis, enteral feeding formula, and sex were independent risk factors for CAs (LRD: P < 0.001, odds ratio, 22.87; female: P = 0.019, odds ratio, 2.78).

CONCLUSIONS

An ED reduces postoperative CAs of patients undergoing PD in the setting of early enteral feeding.

Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 1: From Intestinal Resection to Home Discharge

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The mainstay of treatment for IF is parenteral nutrition (PN). The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their experience. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. The first part of this position paper focuses on the physiological mechanism of intestinal adaptation after surgical resection. It subsequently provides some clinical practice recommendations for the primary management of children with SBS from surgical resection until discharged home on PN.

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care

BACKGROUND

This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care.

METHODS

Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL.

RESULTS

Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process.

CONCLUSIONS

These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Enhanced Recovery After Surgery Protocol in Bariatric Surgery Leads to Decreased Complications and Shorter Length of Stay

PURPOSE

Enhanced recovery after surgery (ERAS) programs have been shown in some specialties to improve short-term outcomes following surgical procedures. There is no consensus regarding the optimal perioperative care for bariatric surgical patients. The purpose of this study was to develop a bariatric ERAS protocol and determine whether it improved outcomes following surgery.

MATERIALS AND METHODS

An IRB-approved prospectively maintained database was retrospectively reviewed for all patients undergoing bariatric surgery from October 2018 to January 2020. Propensity matching was used to compare post-ERAS implementation patients to pre-ERAS implementation.

RESULTS

There were 319 patients (87 ERAS, 232 pre-ERAS) who underwent bariatric operations between October 2018 and January 2020. Seventy-nine patients were kept on the ERAS protocol whereas 8 deviated. Patients who deviated from the ERAS protocol had a longer length of stay when compared to patients who completed the protocol. The use of any ERAS protocol (completed or deviated) reduced the odds of complications by 54% and decreased length of stay by 15%. Furthermore, patients who completed the ERAS protocol had an 83% reduction in odds of complications and 31% decrease in length of stay. Similar trends were observed in the matched cohort with 74% reduction in odds of complications and 26% reduction in length of stay when ERAS was used.

CONCLUSIONS

ERAS protocol decreases complications and reduces length of stay in bariatric patients.

Nutrition delivery after emergency laparotomy in surgical ward: a retrospective cohort study

PURPOSE

Adequate nutrition after major abdominal surgery is associated with less postoperative complications and shorter hospital length of stay (LOS) after elective procedures, but there is a lack of studies focusing on the adequacy of nutrition after emergency laparotomies (EL). The aim of the present study was to investigate nutrition adequacy after EL in surgical ward.

METHODS

The data from 405 adult patients who had undergone emergency laparotomy in Oulu University Hospital (OUH) between years 2015 and 2017 were analyzed retrospectively. Nutrition delivery and complications during first 10 days after the operation were evaluated.

RESULTS

There was a total of 218 (53.8%) patients who were able to reach cumulative 80% nutrition adequacy during the first 10 postoperative days. Patients with adequate nutrition (> 80% of calculated calories) met the nutritional goals by the second postoperative day, whereas patients with low nutrition delivery (< 80% of calculated calories) increased their caloric intake during the first 5 postoperative days without reaching the 80% level. In multivariate analysis, postoperative ileus [4.31 (2.15-8.62), P < 0.001], loss of appetite [3.59 (2.18-5.93), P < 0.001] and higher individual energy demand [1.004 (1.003-1.006), P = 0.001] were associated with not reaching the 80% nutrition adequacy.

CONCLUSIONS

Inadequate nutrition delivery is common during the immediate postoperative period after EL. Oral nutrition is the most efficient way to commence nutrition in this patient group in surgical ward. Nutritional support should be closely monitored for those patients unable to eat.

TRIAL REGISTRATION NUMBER

Not applicable.

The effects of early enteral nutrition on mortality after major emergency abdominal surgery: A systematic review and meta-analysis with Trial Sequential Analysis

BACKGROUND

Early oral or enteral nutrition (EEN) has been proven safe, tolerable, and beneficial in elective surgery. In emergency abdominal surgery no consensus exists regarding postoperative nutrition standard regimens. This review aimed to assess the safety and clinical outcomes of EEN compared to standard care after emergency abdominal surgery.

METHODS

The review protocol was performed according to the Cochrane Handbook and reported according to PRISMA. Clinical outcomes included mortality, specific complication rates, length of stay, and serious adverse events. Risk of bias was assessed by Cochrane risk of bias tool and Downs and Black. GRADE assessment of each outcome was performed, and Trial Sequential Analysis was completed to obtain the Required Information Size (RIS) of each outcome.

RESULTS

From a total of 4741 records screened, a total of five randomized controlled trials and two non-randomized controlled trials were included covering 1309 patients. The included studies reported no safety issues regarding the use of EEN. A significant reduction in the mortality rate of EEN compared with standard care was seen (OR 0.59 (CI 95% 0.34-1.00), I² = 0%). Meta-analyses on sepsis and postoperative pulmonary complications showed non-significant tendencies in favor of EEN compared with standard care. GRADE assessment of all outcomes was evaluated 'low' or 'very low'. Trial Sequential Analysis revealed that all outcomes had insufficient RIS to confirm the effects of EEN.

CONCLUSION

EEN after major emergency surgery is correlated with reduced mortality, however, more high-quality data regarding the optimal timing and composition of nutrition are needed before final conclusions regarding the effects of EEN can be made.

Patients' perceptions of barriers to enhanced recovery after emergency abdominal surgery

PURPOSE

The patient-perceived barriers towards an optimized short-term recovery after major emergency abdominal surgery are unknown. The purpose was to investigate which patient-perceived barriers dominated concerning nutrition, mobilization, and early discharge after major emergency abdominal surgery.

METHODS

An explorative study, which focused on patient-perceived barriers for early discharge, mobilization, and nutrition, was performed within an enhanced recovery perioperative setting in major emergency abdominal surgery. Patients were asked daily from postoperative day (POD) 1 to POD 7 of their self-perceived barriers towards getting fully mobilization and resuming normal oral intake. From POD 3 to POD 7, patients were asked regarding self-perceived barriers towards early discharge.

RESULTS

A total of 101 patients that underwent major emergency abdominal surgery were included for final analysis from March 2017 to August 2017. The main patient self-perceived barrier towards sufficient nutrition was dominated by food aversion (including loss of appetite). The main patient self-perceived barrier towards sufficient mobilization throughout the study period was fatigue. The patient self-perceived barriers towards early discharge were more diffuse and lacked a dominant variable throughout the study period; however, fatigue was the most pronounced barrier throughout the study period. The leading initial variables were postoperative ileus, insufficient nutrition, and epidural catheter. The leading later variables besides fatigue included awaiting normalization of biochemistry values, pain, and the perception of insufficient oral intake.

CONCLUSIONS

The major patient-perceived factors that limited postoperative recovery after major emergency abdominal surgery included food aversion regarding normalization of oral intake and fatigue regarding mobilization and early discharge.

Association between parenteral nutrition in the early phase and outcomes in patients with abdominal trauma undergoing emergency laparotomy: A retrospective nationwide study

BACKGROUND & AIMS

Parenteral nutrition in the early phase is often performed for patients with trauma who have undergone laparotomy. However, the clinical benefits of parenteral nutrition in the early phase in this population remain unknown. We investigated the association of parenteral nutrition in the early phase with outcomes in patients with trauma who underwent emergency laparotomy.

METHODS

Using a Japanese nationwide database from July 2010 to March 2018, we identified patients with trauma who underwent emergency laparotomy on admission to the hospital, required mechanical ventilation on admission, and did not receive enteral nutrition within 2 days after admission. We performed an overlap weights analysis to compare in-hospital outcomes between patients with and without parenteral nutrition in the early phase. The primary outcome was the duration of mechanical ventilation. The secondary outcomes were the length of hospital stay, total hospitalization cost, tracheostomy, hospital-acquired pneumonia, and all-cause 28-day in-hospital mortality.

RESULTS

In total, 1700 adult patients were included. There were no significant associations between parenteral nutrition in the early phase and the duration of mechanical ventilation (difference, -0.4 days; 95% confidence interval, -2.9 to 2.2), length of hospital stay (difference, 1.3 days; 95% confidence interval, -5.0 to 7.5), total hospitalization cost (difference, US$ 730; 95% confidence interval, -2911 to 4370), tracheostomy (risk difference, 0.01; 95% confidence interval, -0.03 to 0.05), hospital-acquired pneumonia (risk difference, -0.01; 95% confidence interval, -0.05 to 0.03), or all-cause 28-day in-hospital mortality (risk difference, 0.02; 95% confidence interval, -0.01 to 0.06).

CONCLUSIONS

Parenteral nutrition in the early phase for patients with trauma undergoing emergency laparotomy was not associated with better in-hospital outcomes.

Perioperative nutrition: Recommendations from the ESPEN expert group

BACKGROUND & AIMS

Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14-15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients.

METHODS

This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art.

RESULTS

Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer.

CONCLUSIONS

Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient.

Effectiveness of a multidisciplinary team for nutrition support in a trauma intensive care unit

BACKGROUND

We evaluated clinical and nutritional outcomes according to multidisciplinary team involvement in nutrition support in a regional trauma intensive care unit (TICU).

METHODS

We retrospectively compared the outcomes for 339 patients admitted to the TICU for >5 days depending on nutrition support team (NST) involvement (n=176) and non-NST involvement (n=163).

RESULTS

The mean age and injury severity score (ISS) were 57.3±16.7 years and 18.6±9.7, respectively. Fifty-three patients (15.6%) had shock on admission and 182 (53.7%) underwent surgery during TICU admission. Some patients were admitted to neurosurgery (46%), general surgery (35.4%), and other (18.6%) departments. There were significant differences in the ISS, Acute Physiology and Chronic Health Evaluation (APACHE) II score, shock on TICU admission, and initial laboratory results. After propensity score matching, the total delivered/required caloric ratio and total delivered/required protein ratio were significantly higher in the NST group than in the non-NST group (calorie: 80.4% vs. 66.7%, P=0.007; protein: 93.1% vs. 68.3%, P<0.001). The NST group had an adequate protein supply more frequently than the non-NST group (protein: 48.0% vs. 25.8%, P=0.002). There was no significant difference in survival, even after adjustment for risk factors using Cox proportional hazard analysis.

CONCLUSIONS

The results of our study suggest that multidisciplinary team involvement in nutrition support in TICU patients may improve nutritional, but not clinical, outcomes.

Epidemiological Study on the Status of Nutrition-Support Therapies by Emergency Physicians in China

Objectives

This study aimed to investigate the current status of nutrition-support therapies by emergency physicians in China and to provide an evidence-based case to improve the regulation of enteral and parenteral nutrition-support therapies.

Methods

Physicians from the Emergency Branch of the China Geriatrics Society were enrolled in the present survey. A questionnaire related to nutrition-support therapy, including the time, location, ways, indications, complications, and nutrition-support training for physicians was answered.

Results

527 questionnaires were collected from over 300 hospitals in 25 provinces of China. The time to initiation of emergency nutrition support was often delayed. Furthermore, the treatment intensity and standardized training of physicians are weaknesses concerning nutrition support. Treatment standardization has been significantly improved, including blood glucose monitoring, precaution and management of complications, and the use of immunomodulators.

Conclusions

Emergency physicians should pay attention to early identifying and providing nutrition support to those patients who need it. Finally, standardized training should be developed for emergency nutrition-support therapy.

Effect of early enteral nutrition on laparoscopic common bile duct exploration with enhanced recovery after surgery protocols

BACKGROUND/OBJECTIVES

Protocols for enhanced recovery after surgery (ERAS) provide comprehensive and evidence-based guidelines to improve perioperative care. It remains elusive whether early enteral nutrition (EEN) will play an active role in the ERAS protocols. Laparoscopic common bile duct exploration (LCBDE) is a safe and efficient method to treat patients with bile duct stones. This study aims to assess the safety, tolerability, and outcomes of EEN after LCBDE.

SUBJECTS /METHODS

From January 2014 to April 2017, a total of 100 patients with postoperative LCBDE were chosen and randomly divided into control group and EEN group. Patients in the control group were treated with traditional management with regular diet when tolerated, while patients in the EEN group were fed with EEN 3 h after LCBDE. The patients' characteristics, time to first flatus, complications, hospitalization stay, and hospitalization expenses were assessed and compared between patients in these two groups.

RESULTS

EEN accelerated the recovery of gastrointestinal function, being indicated by reduced time to first flatus when compared with control group (P = 0.00). In accordance, the quick recovery of gastrointestinal function resulted in shorter hospitalization stay for the EEN group (P = 0.00); however, no significant difference was shown when comparing the hospitalization expenses. On another hand, early oral feeding increased the occurrence of abdominal distension and diarrhea complications (P = 0.00 and P = 0.03).

CONCLUSIONS

EEN effectively improves gastrointestinal function, but raises complications such as abdominal distension and diarrhea after LCBDE. It is recommended to implement the EEN as early as possible if the patients are reasonably expected to have high compliance.

Effects of Prostaglandin E1 on Patients Undergoing Major Gastrointestinal Surgery

OBJECTIVE

The aim of this study was to investigate the clinical effects of prostaglandin E1 (PGE1) in patients who underwent surgery for gastrointestinal (GI) trauma, perforation, or obstruction.

BACKGROUND

PGE1 is thought to enhance intestinal blood supply and reduce GI complications during the postoperative period.

METHODS

The medical records of 889 patients undergoing major GI surgery were reviewed retrospectively. Propensity score matching was performed to adjust for any baseline differences. Clinical outcomes, including early GI function recovery, postoperative complications, and length of hospital stay, were evaluated in all patients. In 278 paired patients, selected nutritional, immunologic, and inflammatory variables were compared based on PGE1 administration.

RESULTS

After propensity score 1:1 matching, the baseline characteristics were similar for both groups. PGE1 was associated with prompt postoperative GI function recovery, including first bowel movement [2.6 ± 0.9 vs 3.1 ± 1.0 days after surgery in patients with and without PGE1 treatment, risk ratio 0.51, 95% confidence interval (CI) 0.41-0.65, P < 0.001] and first feeding within postoperative day 3 [179 (64.39%) vs 152 (54.68%); risk ratio 0.61, 95% CI 0.42-0.90, P = 0.012]. A lower overall postoperative complication rate, including infectious complications [45 (16.2%) vs 68 (24.5%); odds ratio 0.60, 95% CI 0.39-0.91, P = 0.010] and major complications [23 (8.3%) vs 48 (17.3%); odds ratio 0.43, 95% CI 0.26-0.73, P = 0.001], was noted in patients with PGE1 treatment than in patients without PGE1 treatment. Furthermore, the immunologic and inflammatory variable C-reactive protein on postoperative day 3 was reduced by PGE1 treatment (52.5 ± 36.4 vs 89.6 ± 42.4 mg/L; P = 0.037, t test).

CONCLUSIONS

PGE1 is associated with beneficial clinical effects, such as prompt postoperative GI function recovery and reduced overall postoperative complications after emergency GI surgery, which may be attributed to a reduced inflammatory response.

Association of Inadequate Caloric Supplementation with 30-Day Mortality in Critically Ill Postoperative Patients with High Modified NUTRIC Score

Modified NUTRIC (mNUTRIC) score is a useful assessment tool to determine the risk of malnutrition in patients on mechanical ventilation (MV). We identified associations between postoperative calorie adequacy, 30-day mortality, and surgical outcomes in patients with high mNUTRIC scores. Medical records of 272 patients in the intensive care unit who required MV support for >24 h after emergency gastro-intestinal (GI) surgery between January 2007 and December 2017 were reviewed. Calorie adequacy in percentage (Calorie intake in 5 days ÷ Calorie requirement for 5 days × 100) was assessed in patients with high (5–9) and low (0–4) mNUTRIC scores. In the high mNUTRIC score group, patients with inadequate calorie supplementation (calorie adequacy <70%) had higher 30-day mortality than those with adequate supplementation (31.5% vs. 11.1%; p = 0.010); this was not observed in patients with low mNUTRIC scores. This result was also confirmed through Kaplan–Meier survival curve (p = 0.022). Inadequate calorie supplementation in the high mNUTRIC score group was not associated with Intra-abdominal infection (p = 1.000), pulmonary complication (p = 0.695), wound complication (p = 0.407), postoperative leakage (p = 1.000), or infections (p = 0.847). Inadequate calorie supplementation after GI surgery was associated with higher 30-day mortality in patients with high mNUTRIC scores. Therefore, adequate calorie supplementation could contribute to improved survival of critically ill postoperative patients with high risk of malnutrition.

Current management of small bowel obstruction in the UK: results from the National Audit of Small Bowel Obstruction clinical practice survey

AIM

Small bowel obstruction (SBO) is associated with high rates of morbidity and mortality. The National Audit of Small Bowel Obstruction (NASBO) is a collaboration between trainees and specialty associations to improve the care of patients with SBO through national clinical audit. The aim of this study was to define current consultant practice preferences in the management of SBO in the UK.

METHOD

A survey was designed to assess practice preferences of consultant surgeons. The anonymous survey captured demographics, indications for surgery or conservative management, use of investigations including water-soluble contrast agents (WSCA), use of laparoscopy and nutritional support strategies. The questionnaire underwent two pilot rounds prior to dissemination via the NASBO network.

RESULTS

A total of 384 responses were received from 131 NASBO participating units (overall response rate 29.2%). Abdominal CT and serum urea and electrolytes were considered essential initial investigations by more than 80% of consultants. Consensus was demonstrated on indications for early surgery and conservative management. Three hundred and thirty-eight (88%) respondents would consider use of WSCA; of these, 328 (97.1%) would use it in adhesive SBO. Two hundred (52.1%) consultants considered a laparoscopic approach when operating for SBO. Oral nutritional supplements were favoured in operatively managed patients by 259 (67.4%) respondents compared with conservatively managed patients (186 respondents, 48.4%).

CONCLUSION

This survey demonstrates consensus on imaging requirements and indications for early surgery in the management of SBO. Significant variation exists around awareness of the need for nutritional support in patients with SBO, and on strategies to achieve this support.

Early Enteral Nutrition is Associated with Reduced Morbidity in Critically Ill Soft Tissue Patients

Soft tissue diseases including necrotizing soft tissue infections are associated with high mortality and morbidity with hospital-acquired infection rates up to 76 per cent. Critically ill patients with soft tissue infections have increased metabolic requirements; however, the effect of early nutrition on inhospital morbidity including nosocomial infection rates remains unclear. We hypothesized that enteral nutrition within 48 hours of intensive care unit admission would be associated with fewer hospital-acquired infections. We conducted a retrospective review of patients with soft tissue infection requiring intensive care unit admission for >72 hours from January 2013 through December 2014 to a high-volume, dedicated soft tissue service. Variables were compared using chisquared, Student's t test, linear regression, and binary logistic regression analysis. Eighty-five patients met inclusion criteria; 80 per cent started enteral nutrition within 48 hours. Twenty-six per cent had a hospital-acquired infection postadmission requiring treatment. Patients started on enteral nutrition within 48 hours had fewer ventilator days (mean 5 vs 12) and shorter hospital length of stay (mean 18 vs 40 days) when adjusted for age, gender, and confounding variables present on admission. Patients receiving early nutrition also had fewer hospital-acquired infections (18 vs 59%) when adjusted for confounding factors (aOR 0.15, P = 0.045). No significant difference in mortality (13.2% early vs 5.9% late, P = 0.4) or for inhospital morbidity when evaluating percentage of goal calories or protein received or time to goal tube feed rate was found. Early enteral feeding is associated with reduced inhospital morbidity in critically ill soft tissue patients, including fewer hospital-acquired infections and ventilator days, and shorter total length of stay.

The impact of early enteral nutrition on pediatric patients undergoing gastrointestinal anastomosis a propensity score matching analysis

This study was conducted to assess the clinical advantages of early enteral nutrition (EEN) in pediatric patients who underwent surgery with gastrointestinal (GI) anastomosis.EEN has been associated with clinical benefits in various aspect of surgical intervention, including GI function recovery and postoperative complications reduction. Evaluable data documenting clinical advantages with EEN for pediatric patients after surgery with GI anastomosis are limited.We retrospectively reviewed the medical records of 575 pediatric patients undergoing surgical intervention with GI anastomosis. Among them, 278 cases were managed with EEN and the remaining cases were set as late enteral nutrition (LEN) group. Propensity score (PS) matching was conducted to adjust biases in patient selection. Enteral feeding related complications were evaluated with symptoms, including serum electrolyte abnormalities, abdominal distention, abdominal cramps, and diarrhea. Clinical outcomes, including GI function recovery, postoperative complications, length of hospital stay, and postoperative follow-up, were assessed according to EEN or LEN.Following PS matching, the baseline variables of the 2 groups were more comparable. There were no differences in the incidence of enteral feeding-related complications. EEN was associated with postoperative GI function recovery, including time to first defecation (3.1 ± 1.4 days for EEN vs 3.8 ± 1.0 days for LEN, risk ratio [RR], 0.62; 95% confidence interval [CI] 0.43-1.08, P = .042). A lower total episodes of complication, including infectious complications and major complications were noted in patients with EEN than in patients with LEN (117 [45.9%] vs 137 [53.7%]; OR, 0.73, 95% CI 0.52-1.03, P = .046). Mean postoperative length of stay in the EEN group was 7.4 ± 1.8 days versus 9.2 ± 1.4 days in the LEN group (P = .007). Furthermore, the incidence of adhesive small bowel obstruction was lower for patients with laxative administration compared with control, but no significant difference was attained (P = .092)EEN was safe and associated with clinical benefits, including shorten hospital stay, and reduced overall postoperative complications on pediatric patients undergoing GI anastomosis.

Efficacy of Early Enteral Immunonutrition on Immune Function and Clinical Outcome for Postoperative Patients With Gastrointestinal Cancer

BACKGROUND

Nutrition support is crucial for patients with gastrointestinal (GI) cancer after the operation. However, the controversy over the application of parenteral nutrition (PN) and early enteral immunonutrition (EEIN) has no determinate conclusion.

MATERIALS AND METHODS

We compared the effects of PN and EEIN on the postoperative nutrition condition, immune status, inflammation level, long-term survival, and quality of life of the patients with GI cancer. Seventy-eight patients were randomly divided into the PN group (n = 44) or EEIN group (n = 34). After an 8-day nutrition treatment, clinical and immunological parameters were evaluated.

RESULTS

The EEIN group had a significantly shorter hospital stay and higher body mass index level on postoperative day 30 than those in the PN group (P < .05). However, total hospital cost and incidences of short-term postoperative complications had no significant difference (P > .05). The percentages of CD4⁺ , natural killer, and natural killer T lymphocyte cells and the ratio of CD4⁺ /CD8⁺ in peripheral blood were significantly increased. Compared with the PN group, the EEIN group had a higher expression of activated cell surface markers such as CD27 and CD28. In addition, the secretion of interleukin (IL)-2 and interferon-γ was significantly higher, and the secretion of tumor necrosis factor-α and IL-10 was lower. Complication-free survival in the EEIN group were longer than those in the PN group (P = .04).

CONCLUSION

EEIN is superior to PN in improving nutrition status, enhancing immune function, and elevating quality of life.

Impact of hypertonic saline on postoperative complications for patients undergoing upper gastrointestinal surgery

The aim of this study was to explore the impact of 3% hypertonic saline (HS) intragastric administration for patients who underwent upper gastrointestinal surgery.During the postoperative period, 3% HS has been suggested as a means to improve the intestinal edema and reduce gastrointestinal complications.The medical records of 111 patients with HS intragastric administration following upper gastrointestinal surgery and 268 patients, served as control, were reviewed retrospectively. Propensity score matching was performed to adjust for selected baseline variables. Clinical outcomes, including early gastrointestinal function recovery, postoperative complications, and length of hospital stay, were compared according to the HS intragastric administration or not.HS intragastric administration was associated with prompt postoperative gastrointestinal function recovery, including first flatus (risk ratio [RR], 1.32; 95% confidence interval [CI], 0.89-1.65; P = 0.048) and feeding within 3 postoperative days (RR (95% CI), 0.57 (0.49-0.77); P = 0.036). Early ileus occurred in 25 of 108 patients with HS treatment versus 36 of 108 patients without HS treatment (RR (95% CI), 1.43 (0.63-2.15); P = 0.065). The patients with HS experienced a lower overall postoperative complication (odds ratio [OD] 0.57; 95% CI, 0.33-1.09; P = 0.063), including trend toward a decrease for infectious complications (15[13.9] vs 23[21.3]; P = 0.11; OD, 0.59; 95% CI, 0.29-1.22). There was a decreased incidence of anastomotic leakage (1[0.9] vs 7[6.5]; P = 0.033) and postoperative ileuas (5[4.6%] vs 11[10.2%]; P = 0.096) in the HS administration patients.Our study demonstrated beneficial postoperative clinical effects of HS intragastric administration in patients who had undergone upper gastrointestinal surgery, such as prompt postoperative gastrointestinal function recovery and reduced overall postoperative complications, which may be attributed to a reduced intestinal edema.

Use of a Novel Pathway for Early Discharge Was Associated With a 48% Shorter Length of Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

INTRODUCTION

Hospital stay after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) has decreased only modestly over time despite a healthy patient population. The purpose of this study was to evaluate the impact of a novel postoperative pathway on length of stay (LOS) and complications.

METHODS

A retrospective review of patients undergoing PSF for AIS in 2011 to 2012 was performed at 2 institutions evaluating demographics, preoperative Cobb angles, surgical duration, blood loss, LOS, and postoperative complications. Patients at one center were managed using an accelerated discharge (AD) pathway emphasizing early transition to oral pain medications mobilization with physical therapy 2 to 3 times/d, and discharge regardless of return of bowel function. Expectations were set with the family before surgery for early discharge. Patients at the other center were managed without a standardized pathway.

RESULTS

One hundred five patients underwent PSF and were treated by an AD pathway, whereas 45 patients were managed using a traditional discharge (TD) pathway. There was no difference in proximal thoracic and main thoracic Cobb magnitudes and a small difference in thoracolumbar curve magnitudes (35.2±13.0 degrees AD vs. 40.6±11.4 degrees TD, P=0.004) between groups. Surgical time was slightly shorter in AD patients (median 3.1 vs. 3.9 h, P=0.0003) with no difference in estimated blood loss. LOS was 48% shorter in the AD group (2.2 vs. 4.2 d, P<0.0001). There was no difference in readmissions or wound complications between groups.

CONCLUSIONS

Hospital stay was nearly 50% shorter in patients managed by the AD pathway without any increase in readmissions or early complications.

SIGNIFICANCE

Discharge after PSF for AIS may be expedited using a coordinated postoperative pathway. No increase in complications was seen using the AD pathway. Earlier discharge may reduce health care costs and allow an earlier return to normalcy for families.

LEVEL OF EVIDENCE

Level III-case control study.

Effectiveness of postoperative elemental diet (Elental®) in elderly patients after gastrectomy

Background

We aimed to investigate the efficacy of postoperative early intervention with an elemental diet to reduce weight loss and enhance recovery after gastrectomy. Nutritional status and gastrointestinal immune function tend to worsen, and postoperative weight loss is inevitable in these patients; therefore, improvement in their postoperative condition is important, especially in gastric cancer patients aged ≥80 years.

Methods

Clinical outcomes and postoperative nutritional status were compared between 21 and 22 consecutive elderly patients aged ≥80 years who underwent distal gastrectomy before and after the introduction of postoperative oral elemental diet (Elental®, 300 kcal/day), respectively, between October 2011 and June 2016.

Results

A significant reduction in postoperative complications was noted in the nutrition support group (N-group) as compared with the control group (C-group). In particular, the prevalence of systemic complications was significantly lower in the N-group (33.3 vs. 4.5 %, p = 0.015), whereas no significant difference was observed in the prevalence of locoregional complications. The percentage of weight loss and reduction in BMI from 1 month to 1 year after surgery was significantly lower in the N-group (p = 0.012 each). The nutrition status (albumin, total protein, hemoglobin, and C-reactive protein levels) at 1 month after surgery showed improvements (p = 0.005, p = 0.048), and hospital stay was decreased in the N-group as compared to the C-group (16.0 vs. 12.5 days, p = 0.041).

Conclusions

Early intervention with an elemental diet after distal gastrectomy is valuable for reducing perioperative weight loss and improving nutritional management and may be associated with enhanced postoperative recovery in elderly patients.

Feeding the Postoperative Patient on Vasopressor Support: Feeding and Pressor Support

Initiating enteral nutrition in the postoperative patient can be challenging. Postoperative ileus and bowel edema, bowel anastomosis, and intra-abdominal pathology contribute to the reluctance and inability to achieve adequate nutrition in this patient population. The addition of vasopressors confounds the difficulties. Clinical data are sparse but suggest that most postoperative patients requiring vasopressor therapy can be safely initiated and advanced on enteral nutrition. Consideration of the vasopressor agent being utilized and its dose is imperative, as are individual patient characteristics. Temporal changes in the dosage should be closely monitored, as increasing doses may reflect worsening clinical status that can be due to intestinal ischemia. Well-designed prospective trials are clearly necessary to address this controversial topic.