Timing of nasogastric tube insertion and the risk of postoperative pneumonia: an international, prospective cohort study

Validating nasogastric tube placement with pH testing: A randomized controlled trial protocol

Background

Enteral nutrition (EN) is preferred when oral feeding is not possible. The use of the Nasogastric Tube (NGT) ensures rapid and low-risk nutrient administration. However, confirming the placement through chest radiography, besides delaying the initiation of nutritional therapy, exposes patients to radiation. The pH test of gastric aspirate provides a quicker check for NGT placement, but its reliability is compromised by challenges related to aspirating gastric secretions.

Study objective

The main objective of this study is to assess the high-performance placement of NGTs for nutritional purposes, optimizing the evaluation of correct insertion through pH testing using an electronic pH meter. Additionally, the study aims to evaluate patient tolerance to the intervention.

Materials and methods

This single-center RCT will include 150 EN candidate patients divided into three groups. Each group will use distinct NGTs, evaluating placement through pH testing and chest radiography for safety. Tolerance, complications related to NGT placement, and costs will be assessed, with data collected anonymously through a secure electronic database.

Ethical considerations

authorization no. 3624, Territorial Ethical Committee Lombardy 5, October 20, 2023.

Implications and perspectives

This protocol introduces innovative technologies, such as advanced NGTs and an electronic pH meter, aiming to optimize enteral nutrition management. This RCT focuses on replacing X-rays as the primary method for verifying NGT placement, thereby reducing costs, time, and patient exposure to radiation. Data analysis may provide insights into managing patients on pH-altering medication. Implementing innovative technologies has the potential to reduce errors and improve economic efficiency and process sustainability.

Pulmonary Fibrosis as a Result of Acute Lung Inflammation: Molecular Mechanisms, Relevant In Vivo Models, Prognostic and Therapeutic Approaches

Pulmonary fibrosis is a chronic progressive lung disease that steadily leads to lung architecture disruption and respiratory failure. The development of pulmonary fibrosis is mostly the result of previous acute lung inflammation, caused by a wide variety of etiological factors, not resolved over time and causing the deposition of fibrotic tissue in the lungs. Despite a long history of study and good coverage of the problem in the scientific literature, the effective therapeutic approaches for pulmonary fibrosis treatment are currently lacking. Thus, the study of the molecular mechanisms underlying the transition from acute lung inflammation to pulmonary fibrosis, and the search for new molecular markers and promising therapeutic targets to prevent pulmonary fibrosis development, remain highly relevant tasks. This review focuses on the etiology, pathogenesis, morphological characteristics and outcomes of acute lung inflammation as a precursor of pulmonary fibrosis; the pathomorphological changes in the lungs during fibrosis development; the known molecular mechanisms and key players of the signaling pathways mediating acute lung inflammation and pulmonary fibrosis, as well as the characteristics of the most common in vivo models of these processes. Moreover, the prognostic markers of acute lung injury severity and pulmonary fibrosis development as well as approved and potential therapeutic approaches suppressing the transition from acute lung inflammation to fibrosis are discussed.

Delayed return of gastrointestinal function after hepatectomy in an ERAS program: incidence and risk factors

BACKGROUND

Delayed return of gastrointestinal function (DGIF) after hepatectomy can involve increased morbidity and prolonged hospital stay. Yet, data on incidence and risks factors are lacking.

METHODS

All consecutive patients who underwent hepatectomy between June 2018 and December 2020 were included. All patients were included in an enhanced recovery after surgery (ERAS) program. DGIF was defined by the need for nasogastric tube (NGT) insertion after surgery. DGIF risk factors were identified.

RESULTS

Overall, 206 patients underwent hepatectomy. DGIF occurred in 41 patients (19.9%) after a median time of 2 days (range, 1-14). Among them, 6 patients (14.6%) developed aspiration pneumonia, of which one required ICU for mechanical ventilation. DGIF developed along with an intraabdominal complication in 7 patients (biliary fistula, n = 5; anastomotic fistula, n = 1; adhesive small bowel obstruction, n = 1). DGIF was associated with significantly increased severe morbidity rate (p = 0.001), prolonged time to normal food intake (p < 0.001) and hospital stay (p < 0.001) and significantly decreased overall compliance rate (p = 0.001). Independent risk factors of DGIF were age (p < 0.001), vascular reconstruction (p = 0.007), anaesthetic induction using volatiles (p = 0.003) and epidural analgesia (p = 0.004). Using these 4 variables, a simple DGIF risk score has been developed allowing patient stratification in low-, intermediate- and high-risk groups.

CONCLUSION

DGIF after hepatectomy was frequently observed and significantly impacted postoperative outcomes. Identifying risk factors remains critical for preventing its occurrence.

Collaboration in colorectal surgical research

Surgical research has been under-powered, under-funded and under-delivered for decades. A solution may be to form large research collaborations and thereby enable implementation of successful interventional trials as well as robust international observational studies with thousands of patients. There are many such research collaborations in colorectal surgery, and in this paper we have highlighted the experiences from the West Midlands Research Collaborative (WMRC), the Scandinavian Surgical Outcomes Research Group (SSORG) and the European Society of Coloproctology. With active research networks, it is possible to deliver large, high-quality studies and provide high-level evidence for solving important clinical questions in an efficient and timely manner.

Early enteral feeding is beneficial for patients after pelvic exenteration surgery: A randomized controlled trial

BACKGROUND

Postoperative feeding practices vary after pelvic exenteration surgery because of the lack of nutrition research in this specific surgical area. Postoperative ileus (POI) is common after pelvic exenteration surgery, and early enteral feeding is often avoided because of the lack of evidence and the belief that this may induce POI in this patient cohort. The aim of this study was to determine the effects of early enteral feeding after pelvic exenteration surgery on return of bowel movement and POI.

METHODS

A randomized controlled trial was conducted with patients undergoing pelvic exenteration surgery from November 2018 to June 2020. Forty participants received standard nutrition care (parenteral nutrition) and 47 participants received trophic enteral feeding (20 ml/h) via a nasogastric tube, in addition to standard care, until participants were upgraded to free fluids. Time to first bowel movement and rates of POI were the main outcome measures.

RESULTS

There was no significant difference between arms for time to first bowel movement; however, POI rates were significantly less in participants who were enterally fed (P = .036) in the per-protocol analysis. Regressions showed that the longer patients were restricted from an oral diet after surgery, the greater the time was to first bowel movement and the greater the postoperative complication rates (P < .0005).

CONCLUSIONS

Early enteral feeding can be commenced safely to improve gastrointestinal function after pelvic exenteration surgery.