Early Refeeding Research Articles

S170 Impact of Early Refeeding of Patients With Acute Non-Gallstone Pancreatitis: A Quality Assessment Study

S170 Impact of Early Refeeding of Patients With Acute Non-Gallstone Pancreatitis: A Quality Assessment Study

Pancreatitis in cystic fibrosis: Presentation, medical and surgical management, and the impact of modulator therapies.

Patients with Cystic Fibrosis (CF) are at increased risk of acute (AP) and chronic (CP) pancreatitis, and their complications. The extent of remaining healthy pancreatic parenchyma determines the risk of developing future episodes of pancreatitis, as well as pancreatic exocrine or endocrine insufficiency. Pancreatitis may be the presenting symptom of CF, and genetic testing is especially important in pediatrics. AP and recurrent AP are managed with intravenous fluid hydration and pain control, in addition to early refeeding and treatment of complications. With the use of modulator therapy in CF, pancreatic function may be restored to some extent. CP related pain is managed with analgesics and neuromodulators, with surgery if indicated in specific situations including TPIAT as a possible type of surgical intervention. Long-term sequelae of CP in patients with CF include exocrine pancreatic insufficiency treated with pancreatic enzyme replacement therapy, fat-soluble vitamin deficiencies and associated metabolic complications such as bone disease/osteoporosis, pancreatogenic diabetes, and less commonly, pancreatic cancer. We review the presentation and etiologies of pancreatitis in CF patients as well as the management of AP and CP primarily in children.

Expert recommendations on feeding practices of milk diets in acute infant diarrhea in India: a collaborative position statement Expert opinion on nutritional management in acute infant diarrhea

Acute infant diarrhea has a significant impact on India's public health landscape, which is characterized by regional disparities and predominantly viral causes that often resolve on their own. The primary management objective of acute infant diarrhea is to ensure quick recovery while maintaining the nutritional intake of affected infants, aiming to reduce weight loss, manage loose stools better, and reduce the duration of diarrhea. Early refeeding, oral rehydration solution (ORS), and zinc supplementation are critical strategies, according to international consensus and scientific validation. Milk-based diets practically form a key part of dietary choices in young children. There was a need to develop an expert position for the nutritional management of acute infant diarrhea in this aspect in the Indian context. Therefore, between July and September 2023, a series of expert meetings across India were dedicated to formulating an evidence-based position for the nutritional management of acute infant diarrhea. The emphasis was on the benefits of continuing feeding and early refeeding as appropriate, and promoting continued breastfeeding. For non-breastfed infants, a strategic approach to selecting suitable milk diets was deliberated, supporting rapid recovery without compromising nutrition. This strategy not only supports the overall developmental well-being of the infant but also addresses potential issues related to alternative diets, such as palatability, potential long-term effects, and the challenges of reverting to standard milk diets. Through these discussions, a comprehensive framework for managing nutrition in acute diarrhea in infants with milk-based diets was established, highlighting the importance of continued nutritional intake along with standard management guidelines.

Starvation hepatitis and refeeding-induced hepatitis: mechanism, diagnosis, and treatment.

Anorexia nervosa (AN) is one of the most common psychiatric disorders among young adults and is associated with a substantial risk of death from suicide and medical complications. Transaminase elevations are common in patients with AN at the time of hospital admission and have been associated with longer lengths of hospital stay. Multiple types of hepatitis may occur in these patients, including two types that occur only in patients with AN: starvation hepatitis and refeeding-induced hepatitis. Starvation hepatitis is characterized by severe transaminase elevation in patients in the advanced phase of protein-energy deprivation and is associated with complications of severe starvation, such as hypoglycaemia, hypothermia, and hypotension. Refeeding-induced hepatitis is characterized by a milder increase in transaminases that occurs in the early refeeding phase and is associated with hypophosphatemia, hypokalemia, and hypomagnesaemia. Among the most common forms of hepatitis, drug-induced liver injury is particularly relevant in this patient cohort, given the frequent use and abuse of methamphetamines, laxatives, antidepressants, and antipsychotics. In this review, we provided an overview of the different forms of anorexic-associated hepatitis, a diagnostic approach that can help the clinician to correctly frame the problem, and indications on their management and treatment.

American College of Gastroenterology Guidelines: Management of Acute Pancreatitis.

Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.

Effect of rectus sheath anaesthesia versus thoracic epidural analgesia on postoperative recovery quality after elective open abdominal surgery in a French regional hospital: the study protocol of a randomised controlled QoR-RECT-CATH trial

IntroductionEnhanced recovery after surgery (ERAS) protocols increase patient well-being while significantly reducing mortality, costs and length-of-stay after surgery. A key component is multimodal analgesia that prevents postoperative pain and facilitates...

Benefits of fasting abbreviation and early refeeding of multimodal perioperative care protocols

The multimodal protocols of perioperative care, as a European project of ERAS-Enhanced Recovery After Surgery and, in Brazil, the project ACERTO (Acceleration of Total Post-Operative Recovery), emerged as relevant alternatives to reduce preoperative discomforts, including anxiety, thirst, hunger, and enhance the recovery of surgical patients. These initiatives, supported by scientific evidence, advocate the fasting abbreviation with the ingestion of clear liquids up to 2 hours before elective surgery, as a strategy to reduce insulin resistance, immunomodulation and for the purpose of anesthetic induction, without causing risks of aspiration of gastric contents, as well as early refeeding with a small volume of diet, capable of stimulating the gastrointestinal tract and reducing the period of postoperative ileus. In this way, the literature shows that such measures are safe and bring several benefits, such as reducing hospitalization time and reducing the number of complications.

Monitoring and treating hypoglycemia during meal-based rapid nutritional rehabilitation in patients with extreme anorexia nervosa.

Hypoglycemia, a complication of prolonged starvation, can be life-threatening and is presumed to contribute to the high mortality of anorexia nervosa. Furthermore, early refeeding in severe anorexia nervosa can precipitate paradoxical post-prandial hypoglycemia. Few studies have analyzed the course of hypoglycemia during nutritional rehabilitation in patients with extremely low-weight anorexia nervosa. No standard practice guidelines exist and recommended strategies for managing hypoglycemia (i.e., nasogastric feeds, high-fat diets) have limitations. This cohort study assessed prevalence and correlates of hypoglycemia in 34 individuals with very low body mass index (BMI < 14.5kg/m2) anorexia nervosa treated in an intensive eating disorders program with an exclusively meal-based rapid weight gain nutritional protocol. Hypoglycemia was monitored with frequent point of care (POC) glucose testing and treated with oral snacks and continuous slow intravenous 5% dextrose in 0.45% saline (IV D5 1/2 NS) infusion. POC hypoglycemia was detected in 50% of patients with highest prevalence noted on the day of admission. Hypoglycemia resolved during the first week of hospitalization in most cases and was generally asymptomatic. Seven patients (20.6%) experienced at least one episode of severe hypoglycemia with POC glucose < 50mg/dl. Lower admission BMI was associated with higher likelihood of developing hypoglycemia and longer duration of hypoglycemia. Meal-based management of hypoglycemia supplemented by continuous IV D5 1/2 NS appears a viable alternative to alternate strategies such as enteral tube feeding. We discuss recommendations for hypoglycemia monitoring during nutritional rehabilitation and directions for future research. Level III, retrospective cohort study.

Perioperative parameters to consider for enhanced recovery in surgery (ERS) in gynecology (excluding breast surgery)

The current review explores the Enhanced Rehabilitation in Surgery (ERS) approach in the specific context of gynecological surgery. Implementation of an ERS protocol in gynecological surgery reduces postoperative complications and length of stay without increasing morbidity.An ERS approach is based on maintaining an adequate diet and hydration before the operation, according to the recommended time frame, to reduce the phenomenon of insulin resistance, and to optimize patient comfort. On the other hand, the use of anxiolytic treatment as premedication is not recommended.Systematic preoperative digestive preparation, a source of patient discomfort, is not associated with an improvement in the postoperative functional outcome or with a reduction in the rate of complications. A minimally invasive surgical approach is preferrable in the context of ERS. Prevention of surgical site infection includes measures such as optimized antibiotic prophylaxis, skin disinfection with alcoholic chlorhexidine, reduction in the use of drainage of the surgical site, and prevention of hypothermia. Early removal of the bladder catheter is associated with a reduction in the risk of urinary tract infection and a reduction in the length of hospital stay. Prevention of postoperative ileus is based on early refeeding, and prevention of postoperative nausea-vomiting in a multimodal strategy to be initiated during the intraoperative period. Intraoperative hydration should be aimed at achieving euvolemia. Pain control is based on a multimodal strategy to spare morphine use and may include locoregional analgesia. Medicines should be administered orally during the postoperative period to hasten the resumption of the patient's autonomy.The prevention of thromboembolic risk is based on a strategy combining drug prophylaxis, when indicated, and mechanical restraint, as well as early mobilization.However, the eclectic nature of the implementation of these measures as reported in the literature renders their interpretation difficult. Furthermore, beyond the application of one of these measures in isolation, the best benefit on the postoperative outcome is achieved by a combination of measures which then constitutes a global strategy allowing the objectives of the ERS to be met.

Immediate enteral nutrition can accelerate recovery and be safe in mild acute pancreatitis: A meta-analysis of randomized controlled trials

ObjectivesThe effect of early enteral nutrition (EN) in patients with acute pancreatitis (AP) has been confirmed. In recent years, some researchers provided new strategy that immediate EN was offered after admission. The effect and safety of immediate EN was unclear because of the different results among studies. The study aimed to implement the meta analysis of randomized controlled trials (RCT) to confirm the effect and safety between the immediate EN group and the early refeeding group. MethodsFour electronic databases including PubMed, EMBASE, the Cochrane Library and China National Knowledge Internet (CNKI) were searched from inception to July 2021. Endnote X7.0 software was used to manage all the relevant citations. Then data extraction and evaluation of risk of bias for included studies were performed after initial selection and full-text selection. All statistical analyses were performed by Review Manager 5.3 version software. Results5 randomized controlled trials (RCT) involving 372 patients were included in the present study. The meta analysis revealed that immediate EN after admission in patients with AP could significantly decrease the length of hospital stay (LOHS) (Mean difference [MD] = 2.57, 95% confidence interval [CI] = 0.41–4.72) and the intolerance of feeding (risk ratio [RR] = 0.78, 95%CI = 0.63–0.95), compared with early refeeding. But immediate EN couldn't significantly decrease the incidence of readmission after discharging (RR = 0.51, 95%CI = 0.12–2.27), the incidence of progression to severe pancreatitis (RR = 0.76, 95%CI = 0.15–3.76), the incidence of complications (RR = 1.12, 95%CI = 0.50–2.49) and the values of C-reactive protein (CRP) and leukocyte counts (MD = 1.05, 95%CI = 0.15–2.26 and MD = 0.11, 95%CI = 0.59–0.80), compared with early refeeding. ConclusionsCompared with early refeeding, immediate EN after admission could safely reduce LOHS and intolerance of feeding in patients with AP.

Understanding implicit and explicit learning in adolescents with and without anorexia nervosa

BackgroundCognitive disturbances such as impairments in learning are thought to play a role in adult Anorexia Nervosa (AN). It is remains unclear to what extent these disturbances result from starvation of the brain, or relate to an abnormal premorbid cognitive profile. This study investigates learning processes in adolescents with AN, hypothesizing that implicit learning is intact, as found previously in explicit learning tasks. Secondly, we hypothesized that anxiety and depression symptoms, inherent to AN, are associated to learning processes in AN.MethodsIn total 46 adolescents diagnosed with AN and 44 control participants were administered an implicit category learning task in which they were asked to categorize simple perceptual stimuli (Gabor patches) based on a linear integration (i.e., an implicit task) of orientation and spatial frequency of the stimulus. A subgroup of adolescents (n = 38) also completed a task assessing explicit learning.ResultsModel-based analyses indicated that adolescents with AN performed significantly more accurately compared to their healthy peers regardless of whether they used the optimal strategy or not. Depression and anxiety did not relate to learning performance in the AN group.ConclusionsOverall, our findings of augmented implicit and explicit learning in adolescents with AN corroborate recent studies that suggested higher stimulus-response learning during prediction error paradigms. Learning disturbances in adult AN may then be at least partly due to long-term malnourishment, highlighting the importance of early recognition and refeeding in treatments for AN.

NUTRITIONAL MANAGEMENT OF PANCREATIC FISTULA POST SPLENECTOMY DURING CYTOREDUCTIVE SURGERY FOR OVARIAN CANCER

This study aimed to evaluate the safety and efficacy of a specified nutritional planning after a pancreatic fistula (PF) diagnosis (1). Patients with clinical or laboratory diagnosis of PF after cytoreductive surgery (CRS) for ovarian cancer at the Fondazione Policlinico “A. Gemelli” – IRCCS in Rome, were enrolled in this study. Each patient started parenteral nutrition from the 1st postoperative day (POD) and a specific diet with increasing food texture and caloric intake (mean from 600 to 1500 kcal) was decided case-by-case, according to surgeon decision. Here we present the first data from the first ten patients enrolled. Data are presented as median (IQR). Ten patients [age: 63 (49-66), BMI: 24.2 (20.4-25.0)] were enrolled between January and June 2020. The median of starting oral nutrition was 4 days [median: 4 (3-8)]. Both the abdominal drainages output and amylases level were reduced in all patients. Early oral feeding, with increasing food texture and calories, seems to be a safe and efficint procedure in nutritional management of PF, aiming to reduce PF output. Therefore, a personalized early refeeding should be encouraged, aiming to reduce the PF-related complications.

Robotic pancreatic surgery: minimally invasive approach to challenging operations.

Pancreatic surgery is still associated with high perioperative morbidity and mortality. The purpose of this study was to present the short-term outcomes of robot-assisted pancreatic surgery, including pancreaticoduodenectomy (RAPD), distal pancreatectomy (RDP) with or without splenectomy, enucleation (REN), and atypical resection (RAR), for benign, borderline, and malignant lesions at a high-volume center. A single-center, prospective database was used to retrospectively analyze the early outcomes of robotic pancreatic procedures completed between 2014 and 2020. Out of 124 attempted operations, 3 patients received palliative robotic surgery (2.4%). Of the remaining 121, 14 (11.6%) were converted to open surgery. The robotic procedures included 107 patients: 56 underwent RAPD, 31 underwent RDP (28 with and 3 without splenectomy), 16 underwent REN, and 4 underwent RAR (2 central and 2 total pancreatectomies). The preoperative baseline characteristics and comorbidities were consistent with those of a Western population. The overall incidence of complications was 43.9%, with the more severe (Clavien-Dindo III-IV) occurring after RAPD (19.6%). We collected 7 (13.1%) postoperative pancreatic fistulae after RAPD, 5 (16.1%) after RADP, and 2 (12.5%) after REN. The two central pancreatectomies developed a biochemical leak without sequelae. Three patients (2.8%) died within 90 days after surgery. Early refeeding was achieved in those who did not experience severe complications, while the median hospital stay was 8 days. The median number of harvested lymph nodes was 22, with non-R1 microscopic residual tumors found. Robotic pancreatic surgery is a safe and oncologically adequate technique to manage benign and malignant diseases arising from the head, body, and tail of the pancreas.

Prise en charge de la pancréatite aiguë. Revue de la littérature

The management of acute pancreatitis is now fairly codified, with specific recommendations developed by expert groups. These recommendations deal in particular with the minimum initial assessment, recognized severity scores, initial medical management with hyperhydration, preventive anticoagulation, early refeeding, delays in imaging and management of complications. In this work, we have tried to bring together the various recommendations, articles and studies dealing with this subject, based more particularly on European recommendations, in order to guide the management of acute pancreatitis in current practice.

Non-inferiority comparative clinical trial between early oral REFEEDING and usual oral REFEEDING in predicted mild acute biliary pancreatitis

BackgroundThe aim of the study was to compare the onset of oral feeding in the first 24 h after hospital admission with usual oral refeeding and determine whether the timing of the onset of oral feeding influences the recurrence of pain or alters the blood levels of pancreatic enzymes in patients with predicted mild acute biliary pancreatitis.MethodsThis non-inferiority randomized controlled trial was carried out between September 2018 and June 2019 after receiving authorization from the ethics committee for health research. Patients with a diagnosis of predicted mild acute biliary pancreatitis were divided into Group A (early oral refeeding, EOR) and Group B (usual oral refeeding, UOR). Outcome measures included pancreatic lipase levels, the systemic inflammatory response (concentrations of leukocytes), feasibility (evaluated by abdominal pain recurrence), the presence and recurrence of gastrointestinal symptoms and the length of hospital stay.ResultsTwo patients in the EOR group experienced pain relapse (3.2%), and four patients in the UOR group experienced pain relapse (6.77%) after oral refeeding (p = 0.379). The presence of nausea or vomiting after the onset of oral refeeding was not different between the two groups (p = 0.293). The onset of oral refeeding was approximately 48 h later in the UOR group. The length of hospital stay was 5 days in the EOR group and 8 days in the UOR group (p = 0.042), and this difference was also manifested in higher hospital costs in the UOR group (p = 0.0235).ConclusionCompared with usual oral refeeding, early oral refeeding is safe in predicted mild acute biliary pancreatitis patients, does not cause adverse gastrointestinal events, and reduces the length of hospital stay and costs.Trial registrationEarly oral refeeding in mild acute pancreatitis (EORVsUOR). NCT04168801, retrospectively registered (November 19, 2019).

Early Oral Refeeding in Mild Acute Pancreatitis

Early Oral Refeeding in Mild Acute Pancreatitis

Prospective Analysis of an Acoustic Biomarker for Successful Early Oral Re-Feeding after Major Abdominal Surgery

Prospective Analysis of an Acoustic Biomarker for Successful Early Oral Re-Feeding after Major Abdominal Surgery

Primary Posterior Sagittal Anorectoplasty Outcomes for Rectovestibular and Perineal Fistulas Using an Accelerated Pathway: a Single Institution Study

BackgroundPosterior sagittal anorectoplasty (PSARP) is the most common surgical treatment for patients with anorectal malformations. Such patients are often subjected to prolonged nil per os (NPO), antibiotic use, and use of parenteral nutrition. Our aim was to review our institutional experience with patients undergoing PSARP using an accelerated standardized postoperative pathway. MethodsOur hospital database was queried from 2004 to 2016 for patients diagnosed with imperforate anus who underwent a surgical procedure. Short term outcomes, hospital length of stay (LOS), and cost were evaluated. ResultsSixty-three patients were identified during the study period. Of these patients, 34 (54.0%) had a fistula to the urogenital tract or had no demonstrable fistula and one cloaca and 29 (46.0%) had a fistula in the perineum. Approximately half of patients underwent primary PSARP, including 8 patients with fistulas located in the vestibule and vagina in girls and two with no apparent fistulas (12.7% of total cohort). Only two postoperative complications occurred: one superficial surgical site infection and one perineal wound dehiscence. Among the whole cohort, median LOS was 3 days. Median time to PO intake was 2 days, and median cost was $11,532. No complications occurred among the subset of 8 patients undergoing primary PSARP. ConclusionPatients undergoing PSARP experienced similar outcomes compared to historical series, suggesting that the accelerated pathway for early refeeding and reduced use of antibiotics may be beneficial in appropriately selected patients. Type of studyCase series with no comparison groupLevel of evidenceLevel IV.

Timing and method of oral refeeding in mild acute pancreatitis: a systematic review

Background: Optimal timing and method of oral refeeding in mild acute pancreatitis (AP) is unclear. Aims: To identify the optimal timing and method of oral refeeding in patients with mild AP. Methods: PubMed and CINAHL were searched to identify randomised control trials (RCTs) for inclusion, and risk of bias was assessed with the Cochrane Collaboration Tool. Results: A total of 10 RCTs were included, six trials assessing timing of oral refeeding and five trials assessing method of oral refeeding. Early refeeding was associated with reduced length of hospital stay (LoHS) in five out of six trials. An immediate full caloric diet was associated with reduced LoHS in two out of five trials. There was a statistical increase in calories consumed in the group receiving immediate full caloric diets in three trials. There were no adverse events. Conclusion: Early oral refeeding can safely reduce LoHS in patients with mild AP. Refeeding with an immediate full caloric diet is safe and can increase calories consumed, but it does not decrease LoHS.

Survey of nil per os duration of patients admitted to the emergency department due to vomiting.

During the acute phase of vomiting, even a small amount of water may not be tolerated by mouth. Early refeeding may cause re-vomiting in patients, whereas late refeeding may result in dehydration and hypoglycemia. Nil per os (NPO) may be generally recommended by primary physicians, but the appropriate NPO duration for these patients is still unclear.The study aimed to identify the ideal NPO duration for patients with acute vomiting.We prospectively recruited patients with vomiting who underwent NPO management and were administered antiemetic agents in the emergency department (ED) and the pediatric ED. The demographics, final diagnosis, clinical manifestations, medical management, NPO duration, and laboratory data were collected and analyzed to identify the ideal NPO durationA total of 304 patients with vomiting who were admitted in the ED were enrolled. The major diagnosis was acute gastroenteritis (AGE) (82.9%), followed by acute gastritis and colitis. Most patients were younger than 6 years (43.8%). Apart from abdominal pain and vomiting, nausea was the most common symptom (93.1%). NPO duration of 4 to 6 hours had the lowest rate of refeeding failure (3.7%) compared to the other NPO durations.For patients with acute vomiting who are admitted to the ED, NPO duration of 4 to 6 hours may be necessary and should be recommended by primary ED physicians.