Early Postoperative Enteral Feeding Research Articles

Endoskopische Unterdrucktherapie

Abstract Introduction Early postoperative reflux (PR) can compromise anastomotic healing after Ivor Lewis esophagectomy (ILE) and poses a risk for aspiration. Anastomotic insufficiency is the most threatening surgical complication. We present the protective method of pre-emptive active reflux drainage (PARD) with simultaneous enteral feeding. We report our experience with this new safety concept in esophageal surgery in a cohort of 43 patients. Materials and Methods For PARD we use a double lumen open porous film drainage (dOFD). To create the dOFD, the gastric tube of a Trelumina probe (Freka®Trelumina, Fresenius) is coated with a double-layered open-pore drainage film (Suprasorb®CNP drainage film, Lohmann & Rauscher) over a length of 25 cm. The dOFD is endoscopically inserted into the tubular stomach intraoperatively after completion of the anastomosis. Continuous negative pressure is applied with an electronic pump (−125 mm Hg). The PR is continuously aspirated completely and the stomach and anastomotic region are decompressed. At the same time, nutrition is delivered via an integrated intestinal tube. Depending on the results of the endoscopic control after 5 days, PARD is either continued or terminated. Results During the observation period (2017–2023), PARD was used in all patients (n = 43) with ILE. The healing rate under PARD was 100% and healing was observed in all anastomoses. No additional endoscopic procedures or surgical revisions of the anastomoses were required. The median duration of PARD was 8 days (range 4–21). We observed problems in the healing of the anastomosis in 20 of 43 patients (47%) for whom we defined endoscopic criteria for at-risk anastomosis. Conclusions Our results suggest that PARD has a strong protective effect on anastomotic healing and may reduce the risk of anastomotic insufficiency. The integrated feeding tube of the dOFD allows early postoperative enteral feeding while simultaneously applying negative pressure. PARD appears to prevent the negative consequences of impaired anastomotic healing.

Endoscopic negative pressure treatment : From management of complications to pre-emptive active reflux drainage in abdominothoracic esophageal resection-A new safety concept for esophageal surgery

Early postoperative reflux (PR) can compromise anastomotic healing after Ivor Lewis esophagectomy (ILE) and poses a risk for aspiration. Anastomotic insufficiency is the most threatening surgical complication. We present the protective method of pre-emptive active reflux drainage (PARD) with simultaneous enteral feeding. We report our experience with this new safety concept in esophageal surgery in a cohort of 43 patients. For PARD we use a double lumen open porous film drainage (dOFD). To create the dOFD, the gastric tube of a Trelumina probe (Freka®Trelumina, Fresenius) is coated with a double-layered open-pore drainage film (Suprasorb®CNP drainage film, Lohmann & Rauscher) over a length of 25 cm. The dOFD is endoscopically inserted into the tubular stomach intraoperatively after completion of the anastomosis. Continuous negative pressure is applied with an electronic pump (-125 mm Hg). The PR is continuously aspirated completely and the stomach and anastomotic region are decompressed. At the same time, nutrition is delivered via an integrated intestinal tube. Depending on the results of the endoscopic control after 5 days, PARD is either continued or terminated. During the observation period (2017-2023), PARD was used in all patients (n = 43) with ILE. The healing rate under PARD was 100% and healing was observed in all anastomoses. No additional endoscopic procedures or surgical revisions of the anastomoses were required. The median duration of PARD was 8 days (range 4-21). We observed problems in the healing of the anastomosis in 20 of 43 patients (47%) for whom we defined endoscopic criteria for at-risk anastomosis. Our results suggest that PARD has a strong protective effect on anastomotic healing and may reduce the risk of anastomotic insufficiency. The integrated feeding tube of the dOFD allows early postoperative enteral feeding while simultaneously applying negative pressure. PARD appears to prevent the negative consequences of impaired anastomotic healing.

Comparative study between early versus late enteral nutrition after gastrointestinal anastomosis operations

Introduction An anastomosis of the digestive tract is a common operation, whether it be an unexpected medical crisis or a planned procedure. Feeding soon after gastrointestinal anastomosis is not only physiological, but also protects against morphologic and functional trauma-related modifications in the gut. Aim of work This research aimed to evaluate the advantages and disadvantages of initiating Enteral Nutrition immediately following gastrointestinal anastomosis surgery versus delaying it for a later time. Additionally, the frequency of Adverse Events. Patients and methods Thirty patients underwent abdominal surgery, with treatments ranging from small- to large-intestine anastomosis, for both urgent and elective reasons. Early postoperative enteral feeding in the early feeding group commenced within 24 h of surgery or immediately following nasogastric tube removal. The delayed feeding group began enteral feeding using the standard technique once bowel sounds were restored, distention was gone, and the patient passed flatus or stool. 14 patients were in the early enteral feeding group (A) while 16 patients were in the late enteral feeding group (B). Data regarding blood loss and transfusion, NGT removal time, time of intestinal sounds return, time of passage flatus and stool, hospital stay and postoperative complications were recorded. Results Among those who ate too early (46.6%), those who ate late (53.3%), abdominal distension was noted in 28.6%,in the early group and 43.8% in late feeding group and vomiting was reported in 50.0%, and 62.5%, respectively. In the first group, 57.1% of those who fed early experienced fever, while in the second group, 75.0% of those who fed late did so. Late feeding is associated with a statistically significant rise in both the Day of NGT removal and the Length of stay. When patients were admitted for early feeding, they stayed in the hospital for an average of 5.71 days. There was no statistically significant difference according serum albumin between the early feeding (3.79) and late feeding (3.50). There was a significantly higher concentration of potassium in the blood in the early feeding group (3.93) compared to the late feeding group (3.219). Anastomotic leaking, surgical site infection, and intensive care unit admission were not significantly different between early and late feeding. Conclusion Early enteral feeding has the upper hand on late enteral feeding as it goes with GIT physiology, we found that early postoperative feeding following gastrointestinal anastomosis surgery significantly reduced the day of NGT removal and the length of hospitalization, which may be attributable to fewer problems and better gut motility and healing.

AUDIT FOR ASSESSMENT OF THE FULFILLMENT OF CARDIAC ERAS GUIDELINES IN LOW EURO-SCORE II CARDIAC SURGICAL PATIENTS IN THE FREEMAN HOSPITAL.

<h3>Introduction</h3> Enhanced Recovery After Surgery (ERAS) is a multimodal, transdisciplinary care improvement initiative to promote recovery of patients undergoing surgery throughout their entire perioperative journey. These programs aim to reduce complications and promote an earlier return to normal activities. <h3>Aim</h3> Investigate the fulfilment of cardiac ERAS guidelines in low euro-score II cardiac surgical patients in the Freeman hospital in 2020. <h3>Patients & Methods</h3> A retrospective investigation of fulfillment of ERACS recommendations in patients with low euro-score II. - Data collected from the surgical data-base in 2020 and patients e-records. - The recommendations from the ERACS 2019 guidelines were used as a reference. Audit Results: The ERACS guidelines investigated included: - Preoperative data: - ALL patients had Pre-operative Albumin level done. - None of the patients had initiation of Preoperative multimodal analgesic. - None of the patients stopped smoking & hazardous alcohol 4 week before elective surgery. - None had preoperative CHO Loading. - Preoperative HbA1c in 69% of patients. - Clear liquids continued up to 2 to 4 hours before GA in 51% of patients. - Intraoperative data: - In ALL patients Hyperthermia was avoided while rewarming on CPB. - In ALL patients Tranexamic acid was given during on-pump. - Postoperative data: - All patients had Perioperative glycemic control. - ALL patients had an insulin infusion for hyperglycemia postoperatively. - In ALL patients a postoperative delirium screening tool used at least once per nursing shift . - In All patients persistent hypothermia after CPB was avoided. - The peri-operative, multimodal, opioid-sparing, pain management plan: Paracetamol: ALL Tramadol: None Dexmedetomidine: None Gabapentin: None Regional anaesthesia: None - ALL had thromboprophylaxis after surgery . - None had early detection of AKI. - All patients had early postoperative enteral feeding and mobilization. - 76% were extubated within 6 hrs. Audit Recommendations: - Initiate our own ERAS cardiac program. - Add engagement tools in pre-operative education. - Pre-habilitation and optimization for patients with multiple comorbidities. - Smoking and alcohol cessation. - Pre-operative HbA1C in all cases. - Preoperatrive correction of nutritional deficiency . - Clear liquids continued up to 2 to 4 hours before GA. - Oral CHO 2-4 h before surgery. - Pre-operative multimodal analgesic (Gabapentin 300 mg and Paracetamol 1000 mg given orally in preoperative holding area). - Minimal anxiolytics before surgery - Surgical site infection reduction care bundle. - Rigid sternal fixation. - Intraoperative multimodal analgesia. - Strategies to ensure early extubation within 6 h of surgery. - Avoid stripping or breaking the sterile field of chest tubes to remove clots. - Early detection of kidney stress - Goal-directed fluid therapy: - Early removal of Lines and drains - Management of pre-operative anaemia. - Goal directed perfusion strategies. - A protective lung ventilation strategy. ASSESSMENT OF THE FULFILLMENT OF CARDIAC ERAS GUIDELINES IN LOW EURO-SCORE II (<3) CARDIAC SURGICAL PATIENTS IN THE FREEMAN HOSPITAL, IN CALENDAR YEAR 2020.

Evaluation of the effectiveness of early postoperative enteral feeding in patients undergoing upper gastrointestinal surgery and treated with an E.R.A.S. Regimen

Evaluation of the effectiveness of early postoperative enteral feeding in patients undergoing upper gastrointestinal surgery and treated with an E.R.A.S. Regimen

Intraluminal fluid infusion in a rat jejunum ischemia/reperfusion model is associated with improved tissue perfusion and less mucosal damage

This study used an experimental model mimicking early postoperative enteral feeding after the transfer of free jejunal flap and tested the hypothesis that jejunal infusion with dextrose or saline is associated with improved tissue perfusion and/or less mucosal damage after ischemia/reperfusion (IR) injury. Thirty-five male Sprague Dawley rats were randomly divided into five groups: sham group (no IR and no intraluminal infusion); IR control group (IR but not intraluminal infusion); IR plus intraluminal 0.9% NaCl infusion or 5% dextrose or 10% dextrose infusion groups. A jejunal segment of each rat was isolated. The animals had jejunal ischemia for 40min, reperfusion, and intestinal infusion on the basis of their allocation. Jejunal tissue perfusion was measured with laser Doppler flowmetry at one hour and two hours after reperfusion, after which the animals were sacrificed and tissue samples were obtained for the scoring of histological damage at superficial and cryptic epithelium, villus structure, and inflammatory cell infiltration and tissue nitric oxide (NO), interleukin (IL)-1, IL-6, and matrix metalloproteinase-1 (MMP) level measurements. At 1h of reperfusion, IR plus 5% dextrose and 10% dextrose groups both had significantly higher perfusion rates than the IR control group (384.8±26.7 and 462.4±44.7 versus 270.3±34.2 PU, respectively, p<0.05 for both). These differences were maintained at 2h of reperfusion (p<0.05 for both). Saline infusion, however, resulted in improved tissue perfusion only at the early phase of reperfusion. Intraluminal infusion with dextrose solution, either 5% or 10%, was associated with higher tissue NO, IL-1, and IL-6 levels than that in the sham group (p<0.05 for all). In addition, intraluminal infusion of any fluid resulted in less severe histological damage (8.1±0.9 versus 5.8±1.0, 5.4±0.9, and 5.2±1.9, for IR plus saline, 5% dextrose and 10% dextrose groups, respectively, p<0.05 for all). Intraluminal infusion of fluids, particularly dextrose solutions, may be protective against IR injury as demonstrated by improved tissue perfusion and less histological damage. In addition, increases in tissue NO, IL-1, and IL-6 levels in association with dextrose infusion may be explained by the activation of pro-inflammatory and anti-inflammatory protective pathways. These support early enteral feeding after free jejunum flap transfers; however, further studies are warranted.

Non-occlusive mesenteric ischemia associated with enteral feeding after esophagectomy for esophageal cancer: report of two cases and review of the literature

BackgroundNon-occlusive mesenteric ischemia (NOMI) is a rare but life-threatening complication of early postoperative enteral feeding. We herein report two patients who developed NOMI during enteral feeding after esophagectomy.Case presentationIn case 1, a 75-year-old man with no medical history was diagnosed with multiple primary cancers of the esophagus, stomach, and kidney. He underwent percutaneous endoscopic gastrostomy tube placement followed by thoracoscopic esophagectomy and cervical esophagostomy placement as the first-stage operation. Gastrostomy feeding was started on postoperative day (POD) 3 with a polymeric formula (ENSURE H®). On POD 7, he developed acute abdominal pain and distension with bloody drainage through the gastrostomy tube. Dynamic computed tomography showed massive hepatic portal venous gas and pneumatosis intestinalis. Angiography showed diffuse spasms in the branches of the superior mesenteric artery. Under a diagnosis of NOMI, we started intra-arterial infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 48.In case 2, a 68-year-old man with diabetes and atrial fibrillation was diagnosed with esophageal cancer. His medical history was significant for pylorus-preserving gastrectomy for gastric cancer and small bowel resection for trauma. He underwent thoracoscopic esophagectomy, open total gastrectomy, colonic reconstruction, and jejunostomy tube placement. Adhesiolysis for abdominal severe adhesions caused by previous operations was difficult. Jejunostomy feeding was started on POD 3 with a polymeric formula (Racol®). On POD 7, he developed persistent diarrhea and cervical anastomotic leakage. On POD 9, he developed acute abdominal pain and distension with bloody drainage through the jejunostomy tube. Dynamic computed tomography showed the same findings as in case 1. Under a diagnosis of NOMI, we started intravenous infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 28.ConclusionsThe causes of feeding-related NOMI may include the use of a high-osmolarity formula, preoperative malnutrition, abdominal adhesiolysis, systemic inflammation after anastomotic leakage, and a medical history of diabetes and atrial fibrillation. NOMI should be considered as a differential diagnosis in patients with these risk factors and clinical features such as acute abdominal pain and distension during enteral feeding.

Bowel necrosis associated with early postoperative enteral tube feeding: a case report

Bowel necrosis associated with early postoperative enteral tube feeding: a case report

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

Early postoperative enteral feeding has been demonstrated to improve the outcome of patients who underwent surgery for gastrointestinal (GI) malignancies, trauma, perforation, and/or obstruction. Thus, this study was conducted to assess the efficacy of early postoperative enteral nutrition (EN) after emergency surgery in patients with GI perforation or strangulation.The medical records of 484 patients, admitted between January 2007 and December 2012, were reviewed retrospectively. Patients were divided into 2 groups: the early EN (EEN, N = 77) group and the late EN (LEN, N = 407) group. The morbidity, mortality, length of hospital, and intensive care unit (ICU) stays were compared between the 2 groups. Propensity score matching was performed in order to adjust for any baseline differences.Patients receiving EEN had reduced in-hospital mortality rates (EEN 4.5% vs LEN 19.4%; P = 0.008), pulmonary complications (EEN 4.5% vs LEN 19.4%; P = 0.008), lengths of hospital stay (median: 14.0, interquartile range: 8.0–24.0 vs median: 17.0, interquartile range: 11.0–26.0, P = 0.048), and more 28-day ICU-free days (median: 27.0, interquartile range: 25.0–27.0 vs median: 25.0, interquartile range: 22.0–27.0, P = 0.042) than those receiving LEN in an analysis using propensity score matching. The significant difference in survival between the 2 groups was also shown in the Kaplan–Meier survival curve (P = 0.042). In a further analysis using the Cox proportional hazard ratio after matching on the propensity score, EEN was associated with reduced in-hospital mortality (hazard ratio, 0.03; 95% confidence interval, 0.01–0.49; P = 0.015).EEN is associated with beneficial effects, such as reduced in-hospital mortality rates, pulmonary complications, lengths of hospital stay, and more 28-day ICU-free days, after emergency GI surgery.

Jejunojejunal Intussusception after Feeding Jejunostomy: Rare Complication of a Common Surgery

Feeding jejunostomy is a very frequently performed procedure both for pre-operative feeding in carcinoma esophagus and also for early postoperative enteral feeding in major gastrointestinal surgeries. Feeding catheter induced jejunojejunal intussusceptions is an infrequent complication of feeding jejunostomy. We present a 34 year old female with carcinoma of upper third of esophagus with complete luminal obstruction who had jejunojejunal intussusception after feeding jejunostomy. Though, uncommon these complications should be reported in literature, as proactively managing these rare complications or preventing them will significantly improve outcomes in patients with feeding jejunostomy.

EComment. Enteral nutrition following oesophagectomy for oesophageal carcinoma 3 July 2012

The systemic effects of malignancy and obstruction caused by oesophageal strictures means patients with oesophageal carcinoma are frequently malnourished. Wheble and colleagues [1] point out there is a paucity of data to identify whether a routine early post-operative enteral feeding after oesophageal resection is beneficial. They correctly conclude none of the randomized studies show any mortality benefits. However none of trials quoted examined whether any preoperative predictors of nutrition status would affect the outcome (mortality). This information could be used to see if stratification of patients based on nutritional status resulted in any benefit of early enteral feeding. Larger sample sizes would be needed for such an analysis. A study not quoted by the authors compared the outcomes of 44 patients who underwent early enteral feeding in patients who underwent oesophageal resection to a historical cohort of patients who underwent parenteral feeding [2]. Although no difference in 30-day perioperative mortality was found, early enteral feeding compared to parenteral feeding reduced both the stay in the ICU and overall hospital stay. Therefore, until more robust data is available, routine early postoperative enteral feeding should not be abandoned. Conflict of Interest: None declared

Impact of Early Postoperative Enteral Feeding on Hospital Length of Stay in Patients Undergoing Colonic Surgery: Results of a Prospective Randomized Trial

Introduction: Early feeding within 24 hours of intestinal surgery seems advantageous in terms of reduction of wound infection, pneumonia and length of hospital stay. The aim of the study is to evaluate the impact of early enteral nutrition in length of hospital stay in comparison to traditional postoperative feeding regimen. Method: This prospective study enrolled 95 patients randomized in two groups: control group patients receive enteral feeding in absence of nausea or vomiting, abdominal distension and after passage of flatus or stools, while patients in experimental group were fed a liquid diet within 12 hours of surgery, followed by a regular diet at the next meal. The primary endpoint was the impact of early oral feeding on hospital length of stay. The secondary endpoint was to measure the impact of the diet reintroduction modality on the incidence of early postoperative morbidity and return of bowel function. Result: Length of hospital stay was slightly diminished in the experimental group compared to control (8.78 ± 3.85 versus 9.41 ± 5.22), but the difference was not statistically significant. Postoperative nausea and vomiting were reported in 24 (51.0%) patients in experimental group and 30 (62.5%) in control group. Only one patient required nasogastric tube insertion. The majority of patients did not demonstrate any postoperative morbidity in both groups. Conclusion: Early enteral nutrition is safe after intestinal surgery. However we did not demonstrate that early enteral feeding diminished length of hospital stay or hastened the return of bowel function.

Non-Occlusive Small Bowel Necrosis in Association with Feeding Jejunostomy After Elective Upper Gastrointestinal Surgery

Non-occlusive small bowel necrosis (NOSBN) has been associated with early postoperative enteral feeding. The purpose of this study was to determine the incidence of this complication in an elective upper gastrointestinal (GI) surgical patient population and the influence of both patient selection and type of feeding jejunostomy (FJ) inserted, based on the experience of two surgical units in affiliated hospitals. The records were reviewed of 524 consecutive patients who underwent elective upper GI operations with insertion of a FJ for benign or malignant disease between 1997 and 2006. One unit routinely inserted needle catheter jejunostomies (NCJ), whilst the other selectively inserted tube jejunostomies (TJ). Six cases of NOSBN were identified over 120 months in 524 patients (1.15%), with no difference in incidence between routine NCJ (n = 5; 1.16%) and selective TJ (n = 1; 1.06%). Median rate of feeding at time of diagnosis was 105 ml/h (range, 75-125 ml/h), and diagnosis was made at a median of 6 days (range, 4-18 days) postoperatively. All patients developed abdominal distension, hypotension and tachycardia in the 24 h before re-exploratory laparotomy. Five patients died and one patient survived. The understanding of the pathophysiology of NOSBN is still rudimentary; nevertheless, its 1% incidence in the present study does call into question its routine postoperative use especially in those at high risk with an open abdomen, planned repeat laparotomies or marked bowel oedema. Patients should be fully resuscitated before initiating any enteral feeding, and feeding should be interrupted if there is any evidence of feed intolerance.

Basics in clinical nutrition: Surgical access – Gastrostomy, needle catheter jejunostomy

Surgical techniques for enteral feeding are necessary when percutaneous endoscopic placement is not possible. This is most often the case when endoscopy is impossible due to tumor obstruction. However, the majority of surgical gastrostomies and jejunostomies that are currently performed are done as a concomitant procedure at the time of major surgery for trauma or upper gastrointestinal tract disease. More than 100 years ago Albert described the use of a catheter jejunostomy for postoperative alimentation. However, the use of the method has been limited by the mistaken belief in complete postoperative gastrointestinal atony. Since the end of 1960s the results of experimental and clinical studies have shown that postoperative atony primarily affects the stomach and the colon, but the digestive function of the small intestine is almost physiological a couple of hours after abdominal surgery. These observations gave new impetus for early postoperative enteral feeding. Surgical techniques to allow enteral feeding vary, but they can be classified as either temporary or permanent.

Jejunojejunal Intussusception: An Unusual Complication Of Feeding Jejunostomy.

BackgroundImportance of early postoperative enteral feeding by placement of feeding jejunostomy catheter is widely accepted after oesophagogastrectomy. However very little attention has been paid to the surgical complications and their consequences following feeding jejunostomy. Feeding jejunostomy can lead to serious surgical complications necessitating relaparotomy.Methods150 patients underwent oesophagogastrectomy for carcinoma oesophagus between Jan 2005 to Jan 2008.In all these patients feeding jejunostomy was done at the end of procedure for postoperative enteral feeding. All these patients were prospectively evaluated in the database for surgical complications related to feeding jejunostomy.ConclusionFeeding jejunostomy for enteral feeding after oesophagogastrectomy can lead to severe surgical complications sometimes necessitating relaparotomy. Modifying surgical technique does decrease the incidence of jejunojejunal intussusception. Relaparotomy lead to increased morbidity in these patients.

P124 UPSTREAM CHYME REINFUSION INCREASES PLASMA CITRULLINE IN PATIENTS WITH SHORT BOWEL SYNDROME

postoperative enteral feeding (EN) has been proposed as the novel method for nutritional support after surgery. Nevertheless, pancreatic surgeons often prefer postoperative TPN because of concerns about the possible adverse effects of early feeding and increased risk of anastomotic leak especially pancreaticojejunostomy site. The aim of this study was to evaluate whether early postoperative enteral feeding reduced the incidence of complications and length of hospital stay in patients following pancreaticoduodenectomy Methods: Between May 2007 and March 2008, 21 patients who underwent PD for a periamullary disease at Yongdong Severance Hospital of Yonsei University College of Medicine and randomized to enteral feeding or TPN. Enteral feeding and TPN begun on postoperative 1, and advanced to a goal of 25 kcal/kg per day. Both group started to have an oral diet after stool passing. Complications was diagnosed according to the criteria developed by the International Study Group Results: Patients demographics, nutritional state, and operative factors were similar between the groups. Comparison of length of hospital stay and time to normal intake of soft diet were shorter in the EN group, but there was no statistical significance. Postoperative surgery related complication (anastomosis leak, delated gastric empting) was similar between both group, however the rate of infections complications (wound infection, pneumonia, UTI, etc) was lower in EN group. Conclusion: The postoperative early enteral feeding is safe and well-tolerated and it s could give the beneficial opportunity for patients who have underwent PD for a periampullary disease.

ESPEN Guidelines on Enteral Nutrition: Intensive care

Enteral nutrition (EN) via tube feeding is, today, the preferred way of feeding the critically ill patient and an important means of counteracting for the catabolic state induced by severe diseases. These guidelines are intended to give evidence-based recommendations for the use of EN in patients who have a complicated course during their ICU stay, focusing particularly on those who develop a severe inflammatory response, i.e. patients who have failure of at least one organ during their ICU stay. These guidelines were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They were discussed and accepted in a consensus conference. EN should be given to all ICU patients who are not expected to be taking a full oral diet within three days. It should have begun during the first 24h using a standard high-protein formula. During the acute and initial phases of critical illness an exogenous energy supply in excess of 20-25 kcal/kg BW/day should be avoided, whereas, during recovery, the aim should be to provide values of 25-30 total kcal/kg BW/day. Supplementary parenteral nutrition remains a reserve tool and should be given only to those patients who do not reach their target nutrient intake on EN alone. There is no general indication for immune-modulating formulae in patients with severe illness or sepsis and an APACHE II Score >15. Glutamine should be supplemented in patients suffering from burns or trauma.

Optimal Management of the Post–Intestinal Transplant Patient

The lack of controlled interventional studies limits the ability to assess optimal management of intestine transplant recipients. This report aims to examine factors that probably impact on the quality of patient care in the setting of intestine transplantation. The specific practice in the most experienced intestine transplant programs in the United States was surveyed with regard to immunosuppressive regimens, treatment of acute allograft rejection, feeding, and viral surveillance and treatment. The most striking finding was in the level of agreement between the centers, particularly with regard to use of tacrolimus for maintenance immunosuppression, methylprednisone boluses for treatment of acute rejection, early postoperative enteral feeding, and ganciclovir prophylaxis.

Early enteral feeding following major abdominal surgery for recurrent gynaecological cancer

SummaryWe studied the safety of early postoperative enteral feeding in 22 patients with recurrent gynaecological cancer who underwent major abdominal surgery including extensive adhesiolysis, bowel resection and bowel anastomosis. A total of 19 patients (86.4%) had been treated by both radical surgery and radiation therapy with curative intent. In 18 cases (81.8%), the indication for surgery was bowel obstruction. Preoperative total parenteral nutrition (TPN) was not used. Enteral feeding was given through a gastrostomy tube or a jejunal feeding tube and was commenced within 72 h of completion of surgery. The age range was 30 – 78 years with a median of 52.8 years. A total of 13 patients (59.1%) had a bowel resection and 17 patients (77.3%) had a bowel anastomosis, all stapled. The median maximum tolerated full strength feeding was 50 ml/h for 18 – 20 h in a 24 h period and maintained for a median of 9 days. In six patients the feeding was interrupted but was re-commenced in five, in four of whom there was no further interruption of feeding. There were no anastomotic leaks and no cases of aspiration. Postoperative enteral feeding was safe in patients with recurrent gynaecological cancer who had undergone major abdominal surgery and should be considered as an alternative to TPN.

Early enteral feeding after closure of colostomy in pediatric patients

Background/Purpose The aim of this study was to determine the benefits and adverse effects of protocolized early postoperative enteral feeding in pediatric patients undergoing a closure of colostomy. Methods Pediatric patients, completely treated for anorectal malformation, who underwent a closure of colostomy during September 2000 and May 2002 received early postoperative feeding according to the authors’ protocol (EF group). Retrospective data of consecutive patients operated on from March 1998 to August 2000 who received traditional feeding practice were used as a control (TF group). The protocol began with a small volume of formula or breast feeding within the first postoperative day. Volume allowance was advanced every 4 hours up to the daily maintenance volume. Full feeding was defined as when the patient was able to tolerate at least 80% of daily maintenance volume. TF group received nothing by mouth until documentation of bowel function. The groups were compared with regard to postoperative stay, postoperative hour of full feeding, first bowel movement, and adverse effects. Statistical analyses were performed with χ 2 test, Student’s t test, and Mann-Whitney U test. Results There were 34 and 30 patients in EF and TF groups, respectively. Median age of the patients was 13 months, and median weight was 8.39 kg. Except for the associated anomalies, which were found more in the EF group, there were no differences in the demographic characteristics of the 2 groups. On average, feeding was initiated at 19.7 (16 to 24) hours in the EF group and 51.7 (18 to 92) hours in the TF group ( P < .01). Median full feeding hours were 45.5 and 70.5 hours in the EF and TF group, respectively ( P < .01). First bowel movement in the EF group was recorded at the average of 4.14 postoperative nurse shifts, compared with 5.96 shifts in the TF group ( P < .01). Postoperative stay was significantly reduced from the average of 6.1 days to 4.5 days ( P < .01). The overall hospital expenses were not significantly different between the 2 groups. ($203.95 US in TF group and $198.50 US in EF group; P = .75) There was 1 vomiting case in the EF group that was temporary and resolved spontaneously. Septic complications were noted in 8 patients in the EF group and 6 patients in the TF group ( P = .27). The majority were uncomplicated urinary tract infections. Conclusions Early feeding after a closure of colostomy in pediatric patients stimulated early bowel movement and reduced hospital stay with no increased adverse effects.