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Guenter P, Blackmer A, Malone A, Mirtallo JM, Phillips W, Tyler R, Barrocas A, Resnick HE, Anthony P, Abdelhadi R. Update on use of enteral and parenteral nutrition in hospitalized patients with a diagnosis of malnutrition in the United States. Nutr Clin Pract 2022; 37:94-101. [PMID: 35025121 DOI: 10.1002/ncp.10827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Malnutrition continues to be associated with outcomes in hospitalized patients. METHODS An updated review of national data in patients with a coded diagnosis of malnutrition (CDM) and the use of nutrition support (enteral nutrition [EN] and parenteral nutrition [PN]) was conducted using the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project and Medicare Claims data. RESULTS Results demonstrated a growing trend in CDM accompanied by continued low utilization of PN and EN. CONCLUSION Underutilization of nutrition support may be due to product shortages, reluctance of clinicians to use these therapies, undercoding of nutrition support, strict adherence to published guidelines, and other factors.
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Affiliation(s)
- Peggi Guenter
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, USA
| | - Allison Blackmer
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, USA
| | - Ainsley Malone
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, USA
| | - Jay M Mirtallo
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, USA
| | | | - Renay Tyler
- University of Maryland Medical Center, Baltimore, MD, USA
| | | | | | - Pat Anthony
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD, USA
| | - Ruba Abdelhadi
- University of Kansas School of Medicine, Kansas City, MO, USA
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2
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The Effect of Nutritional Status on Quality of Life in Palliative Care Patients. Indian J Surg 2020. [DOI: 10.1007/s12262-019-02013-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Harris JP, Parnell NK, Griffith EH, Saker KE. Retrospective evaluation of the impact of early enteral nutrition on clinical outcomes in dogs with pancreatitis: 34 cases (2010-2013). J Vet Emerg Crit Care (San Antonio) 2017; 27:425-433. [DOI: 10.1111/vec.12612] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 05/26/2016] [Accepted: 06/02/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Jessica P. Harris
- Departments of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University; Raleigh NC 27607
| | - Nolie K. Parnell
- the Department of Veterinary Clinical Sciences; College of Veterinary Medicine, Purdue University; West Lafayette IN 47906
| | - Emily H. Griffith
- Statistics; College of Veterinary Medicine, North Carolina State University; Raleigh NC 27607
| | - Korinn E. Saker
- Departments of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University; Raleigh NC 27607
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Stimac D, Poropat G, Hauser G, Licul V, Franjic N, Valkovic Zujic P, Milic S. Early nasojejunal tube feeding versus nil-by-mouth in acute pancreatitis: A randomized clinical trial. Pancreatology 2016; 16:523-8. [PMID: 27107634 DOI: 10.1016/j.pan.2016.04.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 03/28/2016] [Accepted: 04/02/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES There is substantial evidence of superiority of enteral nutrition (EN) to parenteral nutrition in acute pancreatitis (AP) treatment, but few studies evaluated its effectiveness compared to no intervention. The objective of our trial was to compare the effects of EN to a nil-by-mouth (NBM) regimen in patients with AP. METHODS Patients with AP were randomized to receive either EN via a nasojejunal tube initiated within 24 h of admission or no nutritional support. Systemic inflammatory response syndrome (SIRS) was assessed as the primary outcome. Secondary outcomes included mortality, organ failure, local complications, infected pancreatic necrosis, surgical interventions, length of hospital stay, adverse events and inflammatory response intensity. Outcomes were compared using Student's t-test and Mann-Whitney U test as appropriate. RESULTS 214 patients were randomized in total, 107 to each group. SIRS occurrence was similar between groups, with 48 (45%) versus 51 (48%), respectively (RR 0.94; 95% CI 0.71-1.26). No significant reduction of persistent organ failure (RR 0.81; 95% CI 0.52-1.27) and mortality (RR 0.59; 95% CI 0.28-1.23) was present in the EN group. There were no significant differences in other outcomes between the groups. When analyzing the occurrence of SIRS and mortality in subgroup of patients with severe disease no significant differences were noted. CONCLUSION Our results showed no significant reduction of persistent organ failure and mortality in patients with AP receiving early EN compared to patients treated with no nutritional support (NCT01965873).
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Affiliation(s)
- D Stimac
- Department of Gastroenterology, Faculty of Medicine Rijeka, University Hospital Rijeka, Rijeka, Croatia
| | - G Poropat
- Department of Gastroenterology, Faculty of Medicine Rijeka, University Hospital Rijeka, Rijeka, Croatia.
| | - G Hauser
- Department of Gastroenterology, Faculty of Medicine Rijeka, University Hospital Rijeka, Rijeka, Croatia
| | - V Licul
- Department of Gastroenterology, Faculty of Medicine Rijeka, University Hospital Rijeka, Rijeka, Croatia
| | - N Franjic
- Department of Gastroenterology, Faculty of Medicine Rijeka, University Hospital Rijeka, Rijeka, Croatia
| | - P Valkovic Zujic
- Department of Radiology, Faculty of Medicine Rijeka, University Hospital Rijeka, Rijeka, Croatia
| | - S Milic
- Department of Gastroenterology, Faculty of Medicine Rijeka, University Hospital Rijeka, Rijeka, Croatia
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Casaer MP, Ziegler TR. Nutritional support in critical illness and recovery. Lancet Diabetes Endocrinol 2015; 3:734-45. [PMID: 26071886 DOI: 10.1016/s2213-8587(15)00222-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/08/2014] [Accepted: 12/10/2014] [Indexed: 01/10/2023]
Abstract
An adequate nutritional status is crucial for optimum function of cells and organs, and for wound healing. Options for artificial nutrition have greatly expanded in the past few decades, but have concomitantly shown limitations and potential side-effects. Few rigorous randomised controlled trials (RCTs) have investigated enteral or parenteral nutritional support, and evidence-based clinical guidance is largely restricted to the first week of critical illness. In the early stages of critical illness, whether artificial feeding is better than no feeding intervention has been given little attention in existing RCTs. Expected beneficial effects of various forms of early feeding interventions on rates of morbidity or mortality have generally not been supported by results of recent high-quality RCTs. Thus, whether nutritional interventions early in an intensive care unit (ICU) stay improve outcomes remains unclear. Trials assessing feeding interventions that continue after the first week of critical illness and into the post-ICU and post-hospital settings are clearly needed. Although acute morbidity and mortality will remain important safety parameters in such trials, primary outcomes should perhaps, in view of the adjunctive nature of nutritional intervention in critical illness, be focused on physical function and assessed months or even years after patients are discharged from the ICU. This Series paper is based on results of high-quality RCTs and provides new perspectives on nutritional support during critical illness and recovery.
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Affiliation(s)
- Michael P Casaer
- Intensive Care Department and Laboratory of Intensive Care Medicine, Leuven University Hospitals, Leuven, Belgium.
| | - Thomas R Ziegler
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids and Center for Clinical and Molecular Nutrition, Emory University School of Medicine, Atlanta, GA, USA
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6
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Klek S, Hermanowicz A, Dziwiszek G, Matysiak K, Szczepanek K, Szybinski P, Galas A. Home enteral nutrition reduces complications, length of stay, and health care costs: results from a multicenter study. Am J Clin Nutr 2014; 100:609-15. [PMID: 24965306 DOI: 10.3945/ajcn.113.082842] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Home enteral nutrition (HEN) has always been recognized as a life-saving procedure, but with the ongoing economic crisis influencing health care, its cost-effectiveness has been questioned recently. OBJECTIVE The unique reimbursement situation in Poland enabled the otherwise ethically unacceptable, hence unavailable, comparison of the period of no-feeding and long-term feeding and the subsequent analyses of the clinical value of the latter and its cost-effectiveness. DESIGN The observational multicenter study in the group of 456 HEN patients [142 children: 55 girls and 87 boys, mean (±SD) age 8.7 ± 5.9 y; 314 adults: 151 women and 163 men, mean age 59.3 ± 19.8 y] was performed between January 2007 and July 2013. Two 12-mo periods were compared. During the first period, patients were tube fed a homemade diet and were not monitored; during the other period, patients received HEN. HEN included tube feeding and complex monitoring by a nutrition support team. The number of complications, hospital admissions, length of hospital stay, biochemical and anthropometric variables, and costs of hospitalization were compared. RESULTS Implementation of HEN enabled weight gain and stabilized liver function in both age groups, but it hardly influenced the other tests. HEN implementation reduced the incidence of infectious complications (37.4% compared with 14.9%; P < 0.001, McNemar test), the number of hospital admissions [1.98 ± 2.42 (mean ± SD) before and 1.26 ± 2.18 after EN; P < 0.001, Wilcoxon's signed-rank test], and length of hospital stay (39.7 ± 71.9 compared with 11.9 ± 28.5 d; P < 0.001, Wilcoxon's signed-rank test). The mean annual costs ($) of hospitalization were reduced from 6500.20 ± 10,402.69 to 2072.58 ± 5497.00. CONCLUSIONS The study showed that HEN improves clinical outcomes and decreases health care costs. It was impossible, however, to determine precisely which factor mattered more: the artificial diet itself or the introduction of complex care.
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Affiliation(s)
- Stanislaw Klek
- From Stanley Dudrick's Memorial Hospital, General and Oncology Surgery Unit, Skawina, Poland (SK, KS, and PS); the Department of Pediatric Surgery, Medical University of Bialystok, Bialystok, Poland (AH); the Home Enteral Nutrition Unit, Stomed, Ostroleka, Poland (GD); Gastroenterology and Oncology and Plastic Surgery, Medical University of Poznan, Poznan, Poland (KM); and Jagiellonian University Medical College, Chair of Epidemiology and Preventive Medicine, Department of Epidemiology, Krakow, Poland (AG)
| | - Adam Hermanowicz
- From Stanley Dudrick's Memorial Hospital, General and Oncology Surgery Unit, Skawina, Poland (SK, KS, and PS); the Department of Pediatric Surgery, Medical University of Bialystok, Bialystok, Poland (AH); the Home Enteral Nutrition Unit, Stomed, Ostroleka, Poland (GD); Gastroenterology and Oncology and Plastic Surgery, Medical University of Poznan, Poznan, Poland (KM); and Jagiellonian University Medical College, Chair of Epidemiology and Preventive Medicine, Department of Epidemiology, Krakow, Poland (AG)
| | - Grzegorz Dziwiszek
- From Stanley Dudrick's Memorial Hospital, General and Oncology Surgery Unit, Skawina, Poland (SK, KS, and PS); the Department of Pediatric Surgery, Medical University of Bialystok, Bialystok, Poland (AH); the Home Enteral Nutrition Unit, Stomed, Ostroleka, Poland (GD); Gastroenterology and Oncology and Plastic Surgery, Medical University of Poznan, Poznan, Poland (KM); and Jagiellonian University Medical College, Chair of Epidemiology and Preventive Medicine, Department of Epidemiology, Krakow, Poland (AG)
| | - Konrad Matysiak
- From Stanley Dudrick's Memorial Hospital, General and Oncology Surgery Unit, Skawina, Poland (SK, KS, and PS); the Department of Pediatric Surgery, Medical University of Bialystok, Bialystok, Poland (AH); the Home Enteral Nutrition Unit, Stomed, Ostroleka, Poland (GD); Gastroenterology and Oncology and Plastic Surgery, Medical University of Poznan, Poznan, Poland (KM); and Jagiellonian University Medical College, Chair of Epidemiology and Preventive Medicine, Department of Epidemiology, Krakow, Poland (AG)
| | - Kinga Szczepanek
- From Stanley Dudrick's Memorial Hospital, General and Oncology Surgery Unit, Skawina, Poland (SK, KS, and PS); the Department of Pediatric Surgery, Medical University of Bialystok, Bialystok, Poland (AH); the Home Enteral Nutrition Unit, Stomed, Ostroleka, Poland (GD); Gastroenterology and Oncology and Plastic Surgery, Medical University of Poznan, Poznan, Poland (KM); and Jagiellonian University Medical College, Chair of Epidemiology and Preventive Medicine, Department of Epidemiology, Krakow, Poland (AG)
| | - Piotr Szybinski
- From Stanley Dudrick's Memorial Hospital, General and Oncology Surgery Unit, Skawina, Poland (SK, KS, and PS); the Department of Pediatric Surgery, Medical University of Bialystok, Bialystok, Poland (AH); the Home Enteral Nutrition Unit, Stomed, Ostroleka, Poland (GD); Gastroenterology and Oncology and Plastic Surgery, Medical University of Poznan, Poznan, Poland (KM); and Jagiellonian University Medical College, Chair of Epidemiology and Preventive Medicine, Department of Epidemiology, Krakow, Poland (AG)
| | - Aleksander Galas
- From Stanley Dudrick's Memorial Hospital, General and Oncology Surgery Unit, Skawina, Poland (SK, KS, and PS); the Department of Pediatric Surgery, Medical University of Bialystok, Bialystok, Poland (AH); the Home Enteral Nutrition Unit, Stomed, Ostroleka, Poland (GD); Gastroenterology and Oncology and Plastic Surgery, Medical University of Poznan, Poznan, Poland (KM); and Jagiellonian University Medical College, Chair of Epidemiology and Preventive Medicine, Department of Epidemiology, Krakow, Poland (AG)
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Affiliation(s)
- Michael P Casaer
- From the Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
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KRAG M, PERNER A, WETTERSLEV J, MØLLER MH. Stress ulcer prophylaxis in the intensive care unit: is it indicated? A topical systematic review. Acta Anaesthesiol Scand 2013; 57:835-47. [PMID: 23495933 DOI: 10.1111/aas.12099] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2013] [Indexed: 12/18/2022]
Abstract
UNLABELLED Stress ulcer prophylaxis (SUP) is regarded as standard of care in the intensive care unit (ICU). However, recent randomized, clinical trials (RCTs) and meta-analyses have questioned the rationale and level of evidence for this recommendation. The aim of the present systematic review was to evaluate if SUP in the critically ill patients is indicated. DATA SOURCES MEDLINE including MeSH, EMBASE, and the Cochrane Library. PARTICIPANTS patients in the ICU. INTERVENTIONS pharmacological and non-pharmacological SUP. STUDY APPRAISAL AND SYNTHESIS METHODS Risk of bias was assessed according to Grading of Recommendations Assessment, Development, and Evaluation, and risk of random errors in cumulative meta-analyses was assessed with trial sequential analysis. A total of 57 studies were included in the review. The literature on SUP in the ICU includes limited trial data and methodological weak studies. The reported incidence of gastrointestinal (GI) bleeding varies considerably. Data on the incidence and severity of GI bleeding in general ICUs in the developed world as of today are lacking. The best intervention for SUP is yet to be settled by balancing efficacy and harm. In essence, it is unresolved if intensive care patients benefit overall from SUP. The following clinically research questions are unanswered: (1) What is the incidence of GI bleeding, and which interventions are used for SUP in general ICUs today?; (2) Which criteria are used to prescribe SUP?; (3) What is the best SUP intervention?; (4) Do intensive care patients benefit from SUP with proton pump inhibitors as compared with other SUP interventions? Systematic reviews of possible interventions and well-powered observational studies and RCTs are needed.
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Affiliation(s)
- M. KRAG
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Denmark
| | - A. PERNER
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Denmark
| | - J. WETTERSLEV
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen University Hospital; Rigshospitalet; Denmark
| | - M. H. MØLLER
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Denmark
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Hoffer LJ, Bistrian BR. Why critically ill patients are protein deprived. JPEN J Parenter Enteral Nutr 2013; 37:300-9. [PMID: 23459750 DOI: 10.1177/0148607113478192] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Critical illness dramatically increases muscle proteolysis and more than doubles the dietary protein requirement. Yet surprisingly, most critically ill patients receive less than half the recommended amount of protein during their stay in a modern intensive care unit. What could explain the wide gap between the recommendations in clinical care guidelines and actual clinical practice? We suggest that an important aspect of the problem is the failure of guidelines to explain the pathophysiology of protein-energy malnutrition and the ways critical illness modifies protein metabolism. The difficulty created by the lack of a framework for reasoning about appropriate protein provision in critical illness is compounded by the many ambiguous and often contradictory ways the word malnutrition is used in the critical care literature. Failing to elucidate these matters, the recommendations for protein provision in the guidelines are incoherent, unconvincing, and easy to ignore.
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Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
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Schetz M, Casaer MP, Van den Berghe G. Does artificial nutrition improve outcome of critical illness? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:302. [PMID: 23375069 PMCID: PMC4056754 DOI: 10.1186/cc11828] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Nutritional support is generally considered an essential component in the management of critically ill patients. The existing guidelines advocate early enteral nutrition, with the optimal timing for the addition of parenteral nutrition to insufficient enteral feeding being the subject of transatlantic controversy. The unphysiologic intervention of artificial nutrition in critically ill patients, however, may evoke complications and side effects. Besides the classically described complications, suppression of autophagy, potentially important for cellular repair and organ recovery, was elucidated only recently. The question whether artificial nutrition in critical illness improves or worsens outcome as compared with starvation has so far not been adequately addressed. This paper provides a critical analysis of the existing literature on ICU nutrition, highlighting important methodological shortcomings of many trials and meta-analyses and underlining the urgent need for high-quality research in this field. Recent adequately designed randomized controlled trials suggest that trophic enteral feeding during the first week of critical illness is as good as full enteral feeding and that early addition of parenteral nutrition to insufficient enteral nutrition does not provide any benefit and worsens morbidity.
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Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KC, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CH. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012; 31:817-30. [DOI: 10.1016/j.clnu.2012.08.011] [Citation(s) in RCA: 357] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 08/19/2012] [Indexed: 02/06/2023]
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Lassen K, Coolsen MME, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KCH, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CHC. Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg 2012; 37:240-58. [DOI: 10.1007/s00268-012-1771-1] [Citation(s) in RCA: 276] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Guillaume A, Seres DS. Safety of Enteral Feeding in Patients With Open Abdomen, Upper Gastrointestinal Bleed, and Perforation Peritonitis. Nutr Clin Pract 2012; 27:513-20. [DOI: 10.1177/0884533612450919] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Barlow R, Price P, Reid TD, Hunt S, Clark GWB, Havard TJ, Puntis MCA, Lewis WG. Prospective multicentre randomised controlled trial of early enteral nutrition for patients undergoing major upper gastrointestinal surgical resection. Clin Nutr 2011; 30:560-6. [PMID: 21601319 DOI: 10.1016/j.clnu.2011.02.006] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 01/25/2011] [Accepted: 02/23/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The evidence in support of Early Enteral Nutrition (EEN) after upper gastrointestinal surgery is inconclusive. The aim of this study was to determine if EEN improved clinical outcomes and shortened length of hospital stay. METHODS Open, prospective multicentre randomised controlled trial within a regional UK Cancer Network. One hundred and twenty-one patients with suspected operable upper gastrointestinal cancer (54 oesophageal, 38 gastric, 29 pancreatic) were studied. Patients were randomised to receive EEN (n = 64) or Control management postoperatively (nil by mouth and IV fluid, n = 57). Analysis was based on intention-to-treat and the primary outcome measure was length of hospital stay. RESULTS Operative morbidity was less common after EEN (32.8%) than Control management (50.9%, p = 0.044), due to fewer wound infections (p = 0.017), chest infections (p = 0.036) and anastomotic leaks (p = 0.055). Median length of hospital stay was 16 days (IQ = 9) after EEN compared with 19 (IQ = 11) days after Control management (p = 0.023). CONCLUSIONS EEN was associated with significantly shortened length of hospital stay and improved clinical outcomes. These findings reinforce the potential benefit of early oral nutrition in principle and as championed within enhanced recovery after surgery programmes, and such strategies deserve further research in the arena of upper GI surgery.
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Abstract
OBJECTIVES The aim of this study was to compare 2 protocols regarding the initiation of oral nutrition in patients with mild acute pancreatitis. METHODS We randomized 143 patients to the Lipase directed (LIP) (n = 74) and the self selected PAT (n = 69) group. In the (PAT) group, the patients restarted eating through self-selection. In the LIP group, serum lipase had to normalize before eating. RESULTS The mean time between admission and oral nutrition was 2 days (interquartile range [IQR], 1-3) in the PAT group and 3 days (IQR, 2-4) in the LIP group (P < 0.005). Before and after the first meal, the mean Δ visual analogue scale (VAS) was +3.14 mm (±11.5 mm) in the PAT group and +2.85 mm (±16.4) in the LIP group (P = 0.597). The length of hospital stay was 7 days (median; IQR, 5-10.5) in the PAT group and 8 days (median; IQR, 5.75-12) in the LIP group (P = 0.315). CONCLUSIONS We were not able to demonstrate a difference in postprandial abdominal pain or in the length of hospital stay. Patients with self-selected eating, however, were able to restart eating 1 day earlier, and this difference was found to be significant. Our data suggest that normalization of serum lipase is not obligatory for enteral nutrition in mild acute pancreatitis.
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Affiliation(s)
- Ronald Lee Koretz
- Department of Medicine, Olive View-UCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342 USA
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Abstract
Patients with gastrointestinal anastomoses are treated by physicians of multiple specialties, including gastroenterologists, radiologists and surgeons. This Review provides an overview of the surgical principles and techniques involved in the creation of lower intestinal anastomoses, including some of the mechanisms of healing. Anatomical configurations of small and large bowel anastomoses are illustrated. Stapled, hand-sewn, and sutureless anstomotic techniques are also discussed. Laparoscopy has revolutionized our approach to surgery of the gastrointestinal tract and we describe some of the current and future minimally invasive techniques for creating anastomoses. The article also highlights principles important in minimizing potential short-term and long-term complications such as anastomotic leaks and strictures. Common risk factors for dehiscence include poor nutrition, immunosuppression, microvascular disease, obesity and technical errors. An evidence-based review of perioperative and postoperative management of intestinal anastomoses is provided to help optimize patient care. The routine use of nasogastric tubes and mechanical bowel preparation has no documented benefits and could contribute to postoperative complications. Upcoming strategies that might prove useful to reinforce anastomoses are also reviewed.
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Affiliation(s)
- Govind Nandakumar
- Department of Surgery, Weill Cornell Medical College, 525 East 68th Street, New York, NY 10021, USA. doctorgovind@ gmail.com
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