Parenteral Nutrition Support Research Articles

MON-P129: A Specialized Parenteral Nutrition Support in Surgical Patients Improves Clinical Results as Compared to Non-Specialized

MON-P129: A Specialized Parenteral Nutrition Support in Surgical Patients Improves Clinical Results as Compared to Non-Specialized

MON-P256: The Impact of Standardised Protocols to Guide Intravenous Magnesium and Phosphate Replacement in Non-Critically Ill Surgical Patients Requiring Parenteral Nutrition Support

MON-P256: The Impact of Standardised Protocols to Guide Intravenous Magnesium and Phosphate Replacement in Non-Critically Ill Surgical Patients Requiring Parenteral Nutrition Support

A Randomized Trial on the Efficacy of Prophylactic Active Drainage in Prevention of Complications after Pancreaticoduodenectomy.

This randomized controlled trial was conducted to examine whether prophylactic active drainage decreases morbidity associated with pancreati-coduodenectomy. A prospective, randomized controlled trial was conducted between April 2010 and May 2015 when 160 consecutive patients following elective pancreaticoduodenectomy were randomized intraoperatively to either prophylactic active drainage group or conventional passive drainage group. The main objectives were the incidence of postoperative pancreatic fistula and the associated clinical outcomes. There were 82 patients in the active drain group and 78 patients in the passive drain group. The overall pancreatic fistula rate occurred similarly in the two groups (11.0% (9/82) vs 14.1% (11/78), p = 0.360). Grade C pancreatic fistula in active drain group was significantly less than that in passive drain group (0% (0/82) vs 6.4% (5/78), p = 0.026). The mean postoperative hospital stay and parenteral nutrition support time in active drainage group were shorter than those in passive drainage group (12.6 days vs 14.5 days, p = 0.037; 6.9 days vs 8.6 days, p = 0.047, respectively). Prophylactic active drainage reveals significant reduction in severity of complications associated with pancreatic fistula and might be recommended as an alternative for patients with high risk of developing serious pancreatic fistula after pancreaticoduodenectomy.

Excessive Postoperative Fluid Administration in Infants with Gastroschisis

Careful fluid management is a cornerstone of neonatology because the cardiovascular, respiratory, and gastrointestinal systems in the newborn are sensitive to overhydration. Fluid management in gastroschisis is complicated by insensible fluid loss and postoperative third-space fluid shifts. Study of perioperative fluid management in gastroschisis is limited and has not undergone careful scrutiny. We reviewed perioperative fluid administration and urine output in all infants with gastroschisis over a 5-year period. Data included whether the patient underwent primary closure or staged repair, weight, and events during hospitalization (length of hospitalization and duration of gastric decompression, parenteral nutrition, and ventilator support). Paired t test gave statistical comparisons with significance at P < 0.05. From 2010 to 2014, 24 patients underwent abdominal closure, 17 had primary and 7 had staged closures. Fluid administration exceeded 100 mL/kg/d after primary closure, and was significantly higher (>150 mL/kg/d; P < 0.05) after staged closure on postoperative days 0 to 5. Postoperative urinary output exceeded 75 mL/kg/d for all patients, with higher volumes reaching 100 mL/kg/d after staged closure on postoperative days 4 to 6 (P < 0.05). Two patients died of sepsis. All survivors were discharged with intestinal continuity and gaining weight on oral feeding. Patients with gastroschisis received large volumes of fluid after operation despite similarly high urine output and positive daily fluid balances. The amounts of fluid administered after both primary and staged closure may be excessive and potentially deleterious.

Persistan plevral efüzyonu olan infant olgunun talk plörodezis ile tedavisi

Pleural effusion is excessive fluid that accumulates in the pleural cavity. It predominantly occurs by infectious agents. Other various causes include congestive heart diseases, malignancies, viral diseases, trauma, hypoalbuminemia, connective tissue diseases and chromosomal abnormalities. Treatment strategies should target the responsible cause. Herein, we present a 16-month old male infant with persistent pleural effusion occuring after uncomplicated Morgagni hernia surgery who had no response to antibiotics, parenteral nutritional support and octreotide therapy that was eventually treated by pediatric surgery with talc pleurodesis. No significant advers effect was observed after administration of talc as a sclerozing agent for pleurodesis. This procedure has been rarely reported at this age group.

Can We Rely on Predicted Basal Metabolic Rate in Patients With Intestinal Failure on Home Parenteral Nutrition?

Intestinal failure (IF) is a serious and common complication of short bowel syndrome with patients depending on parenteral nutrition (PN) support. Effective nutrition management requires an accurate estimation of the patient's basal metabolic rate (BMR) to avoid underfeeding or overfeeding. However, indirect calorimetry, considered the gold standard for BMR assessment, is a time- and resource-consuming procedure. Consequently, several equations for prediction of BMR have been developed in different settings, but their accuracy in patients with IF are yet to be investigated. We evaluated the accuracy of predicted BMR in clinically stable patients with IF dependent on home parenteral nutrition (HPN). In total, 103 patients with IF were included. We used indirect calorimetry for assessment of BMR and calculated predicted BMR using different equations based on anthropometric and/or bioelectrical impedance parameters. The accuracy of predicted BMR was evaluated using Bland-Altman analysis with measured BMR as the gold standard. The average measured BMR was 1272 ± 245 kcal/d. The most accurate estimations of BMR were obtained using the Harris-Benedict equation (mean bias, 14 kcal/d [ P = .28]; limits of agreement [LoA], -238 to 266 kcal/d) and the Johnstone equation (mean bias, -16 kcal/d [ P = .24]; LoA, -285 to 253 kcal/d). For both equations, 67% of patients had a predicted BMR from 90%-110% All other equations demonstrated a statistically and clinically significant difference between measured and predicted BMR. The Harris-Benedict and Johnstone equations reliably predict BMR in two-thirds of clinically stable patients with IF on HPN.

Effectiveness of ω-3 Polyunsaturated Fatty Acids Based Lipid Emulsions for Treatment of Patients after Hepatectomy: A Prospective Clinical Trial.

Objective: The present study aimed to investigate the effectiveness of parenteral nutritional support with ω-3 PUFAs–based lipid emulsions in patients after liver resection. Methods: A total of 119 patients were randomly assigned to the immunonutrition (IM) group (n = 59) and control group (n = 60). The IM group was continuously given Omegaven® 10% 100 mL/day rather than regular nutrition for five days postoperatively. Venous blood samples were obtained from all subjects before surgery and D1, D3 and D7 after surgery. Results: No significant difference was found in baseline characteristics of the two groups. On D1 after surgery, no statistically significant differences were observed in the blood sample tests between the two groups. On D3 after surgery, the levels of white blood cell count (WBC), alanine aminotransferase (ALT), aspartate transaminase (AST) and total bilirubin (TBil) were dramatically decreased in the IM group (t = 3.065, p = 0.003; t = 2.149, p = 0.034; t = 5.313, p= 0.001; and t = 2.419, p = 0.017, respectively). Furthermore, on D7 after surgery, not only could a significant decrease be observed in the IM group concerning the levels of WBC, ALT and TBil (t = 3.025, p = 0.003; t = 2.094, p = 0.038; and t = 2.046, p = 0.043, respectively), but it was also seen in the level of Δprothrombintime (PT) (t = 2.450, p = 0.016). An increase in the level of prealbumin (Pre-Alb) in the IM group was observed on D7 after surgery (t = 2.237, p = 0.027). The frequency of total complications in the IM group were significantly lower than in the control group (χ2 = 4.225, p = 0.040 and χ2 = 3.174, p = 0.075). The trend favored the IM group in reducing the total infective complications rate (χ2 = 3.174, p = 0.075). A significant decrease in the duration of the hospital stay after surgery was also observed in the IM group (t = 2.012, p = 0.047).Conclusion: ω-3 PUFAs–based lipid emulsions for treatment of patients after hepatectomy are safe and effective in controlling inflammation, protecting liver function, and consequently reducing the rate of total complications and the duration of the hospital stay.

The Use of Parenteral Nutrition Support in an Acute Care Hospital and the Cost Implications of Short-term Parenteral Nutrition

Parenteral nutrition (PN) is indicated for patients who are unable to progress to oral or enteral nutrition. There are no local studies done on estimating the cost of PN in acute settings. The aims of this study are to describe the demographics, costs of PN and manpower required; and to determine the avoidable PN costs for patients and hospital on short-term PN. Patient data between October 2011 and December 2013 were reviewed. Data collected include demographics, length of stay (LOS), and the indication/duration of PN. PN administration cost was based on the cost of the PN bags, blood tests and miscellaneous items, adjusted to subsidy levels. Manpower costs were based on the average hourly rate. Costs for PN and manpower were approximately S$1.2 million for 2791 PN days. Thirty-six cases (18.8%) of 140 PN days were short-term and considered to be avoidable where patients progressed to oral/enteral diet within 5 days. These short-term cases totalled $59,154.42, where $42,183.15 was payable by the patients. The daily costs for PN is also significantly higher for patients on short-term PN (P <0.001). In our acute hospital, 90% of patients referred for PN were surgical patients. Majority of the cost comes from the direct daily cost of the bag and blood tests, while extensive manpower cost was borne by the hospital; 18.8% of our cohort had short-term avoidable PN. Daily PN may cost up to 60% more in patients receiving short-term PN. Clinicians should assess patient's suitability for oral/enteral feeding to limit the use of short-term PN.

Clinical application analysis of parenteral nutrition drugs

Objective To investigate the clinical application of parenteral nutrition drugs and promote the rational use of drugs. Methods The data of parenteral nutrition drugs used in our hospital were analyzed, including the quantity, the amount of money, the scope and purpose, etc.The rationality of drug use was reviewed by prescription comment simultaneously. Results On similar medicines comparison, the fat emulsion, amino acids(17) and glucose(11%) injection (1440mL) and fat emulsion and amino acids (18) injection (1 000mL), which were designed according to the basal metabolic rate in patients were far greater than the fat emulsion, amino acids(17) and glucose(11%) injection (1 920mL) of the added value of design.And the balanced amino acid preparations in compound amino acid in 18 AA-Ⅳ usage, was far greater than 18 AA-Ⅱ and 18 AA.Fat emulsion preparation with concentration of 20% dosage was bigger, because the price advantage, ordinary long-chain fat milk consumption was greater than the long chain fatty milk.In terms of drug use rationality, the usage, dosage, compatibility and adverse reactions of parenteral nutrition drugs were analyzed.The dosage, frequency and compatibility problems still needed to be improved. Conclusion The use of parenteral nutrition drugs were basic reasonable, but we should strictly control the indications for parenteral nutrition support, such as drug compatibility, using frequency to strengthen management and reasonable application of drugs to improve medication safety. Key words: Parenteral nutrition drugs; Prescription comment; Rational drug use

Comment: Leiomyosarcoma of the retrohepatic vena cava: Report of a case treated with resection and reconstruction with polytetrafluoroethylene vascular graft.

To the Editor, We read with interest the paper titled “Leiomyosarcoma of the retrohepatic vena cava: Report of a case treated with resection and reconstruction with polytetrafluoroethylene vascular graft” by Yankol et al. (1). In this case report, the authors describe a successful treatment of a retrohepatic vena cava leiomyosarcoma with resection and polytetrafluoroethylene vascular graft reconstruction. As mentioned in the manuscript surgical resection with negative margins is the gold standard treatment. But after resection, in conjunction with inferior vena cava (IVC) reconstruction options, there also stands another choice which is ligation without reconstruction, which is not discussed in the manuscript. Regarding to this case report, we aimed to present a patient (S.O,prot:806/59,F) from our clinic to whom we performed segmented IVC resection and ligation for diagnosed level 2 vena cava leiomyosarcoma. IVC was ligated above aortoiliac bifurcation and below renal veins. Because of the high graft thrombosis risk this approach was preferred instead of anastomosis. Intermittent pneumatic compression was applied and low dose fractioned heparin was given at therapeutic dosage in order to protect from deep venous thrombosis risk and lower-extremity edema. On postoperative day 3, the patient had underwent a second laparotomy because of intraabdominal bleeding. Perioperative exploration revealed an oozing type bleeding from the proximal caval stump. After hemostasis the patient sent to intensive care unit for close follow-up. On postoperative day 8, chylous drainage was encountered and oral feeding was stopped following total parenteral nutrition (TPN) support. 2 weeks after TPN treatment the drainage was turned to serous character and oral feeding was restarted with abolishment of TPN support. Finally the patient was discharged with compression stocking and 5-mg. coumadin tb./day orally one month after surgery and she did not suffer from renal failure or lower extremity edema during her hospitalization. Pathologic findings revealed a grade 2 leomyosarcoma with negative margins. Immunohistochemistry panel showed that SMA: (+), Desmin: (+), S-100: (−) CD117: (−) Ki-67 index: 30%. Six cycles of chemotherapy was given to the patient following discharge from our clinic. Now the patient is on postoperative 8th month and there is no documented recurrence or metastasis. The proper technique following IVC resection in the literature is lacking. Caval reconstruction is associated with longer operative time and has its own morbidity and mortality rates. On the other hand in the absence of sufficient collateral venous flow or in cases of interruption of vital organ vasculature, it is necessary to make a vascular reconstruction (2). Daylami et al. (3) claimed in their paper that reconstruction of the IVC was not necessary for resection of tumors below the level of the hepatic veins in most if not all cases. They also mentioned lower-extremity edema and acute renal failure as an albeit transient and early postoperative complication. According to their series with 6 patients, 2 of them developed chylous leak and 1 of them was treated with dietary modification and percutaneous drainage and the other with a Denver shunt. We wonder if the authors have checked the patency of graft during follow-up because as Hirohashi et al. (4) suggested in their case report, thrombosis may occur as a late complication in an inferior vena caval graft. In conclusion, we believe that whenever possible, primary IVC resection without reconstruction in the management of lower IVC leiomyosarcoma should be preferred due to its benefits by means of shorter operation time and acceptable morbidity and mortality rates.

Safety and Efficacy of Subcutaneous Parenteral Nutrition in Older Patients: A Prospective Randomized Multicenter Clinical Trial.

Many patients who cannot tolerate adequate enteral nutrition could benefit from parenteral nutrition support but fail to receive it due to difficult intravenous (IV) access. The objective of this study was to compare the safety and efficacy of subcutaneous (SC) administration of parenteral nutrition with the peripheral IV route. This was a prospective randomized multicenter study of 121 older hospitalized patients. The primary outcome was the composite end point of major local side effects, defined as local edema, blistering, erythema, phlebitis, cellulitis, unbearable pain, or route failure requiring a switch in route. Secondary outcomes were nutrition parameters, biochemical parameters, clinical outcomes, and safety. The SC route (n = 59) was noninferior to the IV route (n = 61) for major local side effects. Major local side effects trended higher in the IV group ( P = .059). Local edema was more common in the SC group ( P < .05), while route failure was more common in the IV group ( P < .001). Nutrition and biochemical parameters, safety, and clinical outcomes were similar between groups. The SC route of nutrient administration was better tolerated than the peripheral IV route. SC administration of parenteral nutrition represents a safe alternative to IV nutrition.

Normal Growth and Essential Fatty Acid Status in Children With Intestinal Failure on Lipid Limitation.

Lipid limitation, that is, ≤1 g · kg⁻¹ · day⁻¹ of soy oil lipid emulsion (SOLE), has been suggested as a method to reduce the risk of intestinal failure (IF)-associated liver disease (IFALD). There are limited data as to the effects of this strategy on growth and essential fatty acid (EFA) status. The aim of the study was to assess growth, prevalence of cholestasis, and EFA deficiency in patients with IF who were provided daily SOLE at a dose ≤1 g · kg⁻¹ · day⁻¹. Medical records were retrospectively reviewed from 9 patients age 16 months to 8 years who had IF requiring parenteral nutrition support for >12 months. Parenteral nutrition supplied a mean of 53% of total energy (range 24%-86%). Mean SOLE dose was 0.61 g · kg⁻¹ · day⁻¹ (range 0.4-0.81 g · kg⁻¹ · day⁻¹). After 1 month of lipid limitation between 2011 and 2014, no patient developed IFALD as defined by a direct bilirubin >2 mg/dL. The median direct bilirubin was 0.1 mg/dL (range 0.075-0.85 mg/dL). No patient developed EFA deficiency as defined by a triene-to-tetraene ratio >0.2 (median 0.026, range 0.017-0.076). Height z scores increased from mean of -2.568 (range -10.8 to 0.878) to -0.484 (range -3.546 to 0.822). Weight z scores increased from mean of -1.412 (range -5.871 to 0.906) to -0.595 (range -2.178 to 0.926). In this case series, lipid limitation allowed normal growth while preventing the development of cholestasis and EFA deficiency.

Parenteral nutrition support: Beyond gut feeling? Quality control study of parenteral nutrition practices in a Tertiary Care Hospital.

Background:Enteral nutrition (EN) is preferred over parenteral nutrition (PN) in hospitalized patients based on International consensus guidelines. Practice patterns of PN in developing countries have not been documented.Objectives:To assess practice pattern and quality of PN support in a tertiary hospital setting in Chennai, India.Methods:Retrospective record review of patients admitted between February 2010 and February 2012.Results:About 351,008 patients were admitted to the hospital in the study period of whom 29,484 (8.4%) required nutritional support. About 70 patients (0.24%) received PN, of whom 54 (0.18%) received PN for at least three days. Common indications for PN were major gastrointestinal surgery (55.6%), intolerance to EN (25.9%), pancreatitis (5.6%), and gastrointestinal obstruction (3.7%).Conclusions:The proportion of patients receiving PN was very low. Quality issues were identified relating to appropriateness of indication and calories and proteins delivered. This study helps to introspect and improve the quality of nutrition support.

Differences in quality standards when prescribing nutritional support: Differences between specialist and non-specialist physicians

Abstract Adequate nutritional support includes many different aspects, but poor understanding of clinical nutrition by health care professionals often results in an inadequate prescription. Material and methods A study was conducted to compare enteral and parenteral nutritional support plans prescribed by specialist and non-specialist physicians. Results Non-specialist physicians recorded anthropometric data from only 13.3% of patients, and none of them performed nutritional assessments. Protein amounts provided by non-specialist physicians were lower than estimated based on ESPEN (10.29 g of nitrogen versus 14.62; p p = 0.072). Calorie and glutamine provision and laboratory controls prescribed by specialists were significantly closer to those recommended by clinical guidelines. Conclusion Nutritional support prescribed by specialists in endocrinology and nutrition at San Pedro de Alcantara Hospital was closer to clinical practice guideline standards and of higher quality as compared to that prescribed by non-specialists.

Catheter-related blood stream infection in patients receiving long-term home parenteral nutrition: Tertiary care hospital experience in Saudi Arabia.

Background/Aim:Parenteral nutrition (PN) is a lifesaving therapy for patients with many severe conditions, including intestinal failure. Some patients require long-term PN therapy, which makes home parenteral nutrition (HPN) an attractive option to improve the quality of life. Among the most common and serious complications observed in these patients are catheter-related blood stream infections (CRBSIs). The aim of our study is to determine the frequency of CRBSI among patients receiving long-term HPN.Patients and Methods:A retrospective chart review was conducted for patients enrolled in the HPN program between 2006 and 2012. Data on the demographic characteristics, indications and duration of PN therapy, catheter type, number of admissions because of CRBSI, and blood culture results were recorded.Results:Eight pediatric patients were included (mean age of 3.5 years at the start of HPN). Microvillus inclusive disease was noted in 50% of these patients, and 75% of them received HPN under parents' care. CRBSI resulted in 60 admissions with a median of 182 days of hospital stay and 74 changes of central venous catheters. The rate of CRBSI was 2.9 per 1000 catheter days. Staphylococcus species were the most prevalent pathogens (32%), followed by Klebsiella pneumoniae (5%).Conclusion:In this small group of HPN patients, the BSI rate was 2.9 infections per 1000 catheter days, and most common causative organisms were Staphylococcus species. We believe that a well-established training program for caregivers can reduce the rate of infectious complications associated with long-term PN support.

Amino acid dosing in parenteral nutrition for very low birth weight preterm neonates: an outcome assessment.

This study aimed to investigate the effects of parenteral nutrition (PN) administration of amino acids (AA) on physical changes among very low birth weight infants in a local hospital setting in Malaysia. A retrospective study was carried out at a hospital in Malaysia. Records of neonates prescribed PN in the neonatal unit in 2012 were screened for eligibility. A total of 199 premature neonates received PN support in the year 2012 and, of these, 100 fulfilled the inclusion criteria. The median value of AA intake on the first day of PN was 2.00 (<28 weeks group); 1.00 (28-31 weeks group) and 0.75 (>31 weeks group). Neonates in the <28 weeks group were more likely to receive AA at an earlier time and higher initial dose compared with the other age groups. The study also found that there was no statistically significant difference in the dose of AA on the first day of PN administration and that the significant variations in nutritional parameters among the subjects did not lead to differences in physical outcomes. This study identified that when PN is provided in the local hospital setting, it is likely that the current nutritional practices are inadequate to achieve the standard growth recommendations. Our findings call for a need to optimize AA and calorie intake since growth restriction is a morbidity which will affect the infants' growth and development. Current prescriptions for PN in this hospital need to be reviewed in order to improve patient outcomes.

Clinical application of enhanced recovery after surgery in thoracoscopic and laparoscopic esophagectomy for esophageal cancer

Objective To investigate the application value and feasibility of enhanced recovery after surgery (ERAS) in thoracoscopic and laparoscopic esophagectomy for esophageal cancer. Methods The clinical data of 304 patients with esophageal cancer who were admitted to the Affiliated Cancer Hospital of Zhengzhou University from December 2013 and July 2014 were retrospectively analyzed. All the patients underwent esophagogastric partial resection, esophagogastric cervical anastomosis and 2-field lymph node dissection under general anesthesia. The management of 195 patients guided by ERAS were allocated to the ERAS group and 109 patients receiving perioperative traditional treatments were allocated to the control group. Observing indicators included: (1) enteral and parenteral nutritional support treatments; (2) nutrient indexs: levels of serum albumin (Alb) and prealbumin; (3) the recovery of gastrointestinal function: time to anal exsufflation and defecation; (4) postoperative complications and the grading according to Clavien standard; (5) duration of postoperative hospital stay and treatment expenses; (6) risk factors affecting postoperative complications by multivariate analysis; (7) independent risk factors affecting occurrence rate of postoperative complications by univariate analysis. Measurement data with normal distribution were presented as ±s and analyzed using the t test. Non-normal distribution data were analyzed by the Wilcoxon rank sum test. Comparison of repeated data was analyzed by the repeated measures ANOVA. Categorical variables were analyzed using the chi-square test or Fisher's exact probability. The multiple linear regression analysis and Logistic regression were used to measure the multivariate analysis of continuous variables and binary variable, respectively. Results (1) During the enteral and parenteral nutritional support treatments, 11 patients with surgery-related complications in the ERAS group didn't receive oral intake at postoperative day 1, 26 proceeded the intravenous rehydration at postoperative day 4 due to calorie intake less than 80% of calorie requirement, and enteral nutritional support treatment was well-tolerated in the control group. (2) Comparison of nutrient indexs: the levels of serum Alb and prealbumin at postoperative day 1, 3 and 5 were (37.2±3.9)g/L, (39.1±3.5)g/L, (38.5±3.0)g/L and (0.20±0.06)g/L, (0.13±0.04)g/L, (0.13±0.04)g/L in the ERAS group, (37.7±2.8)g/L, (39.0±3.6)g/L, (38.4±3.8)g/L and (0.18±0.06)g/L, (0.13±0.04)g/L, (0.13±0.04)g/L in the control group, respectively, showing no significant difference in the postoperative changing trends between the 2 groups (F=0.357, 0.453, P>0.05). (3) The recovery of gastrointestinal function: time to first anal exsufflation and first defecation were (2.1±0.8)days and (3.4±1.2)days in the ERAS group, (3.2±0.9)days and (5.5±1.5)days in the control group, respectively, showing significant differences between the 2 groups (t=-10.505, -13.174, P 0.05). Eight and 10 patients in the ERAS and control groups underwent gastrointestinal decompression, 6 and 8 patients in the ERAS and control groups underwent retreatment in the intensive care unit (ICU), 3 and 2 patients in the ERAS and control groups were readmitted to the hospital at 3 weeks after discharge, with no significant difference in the above indexes (χ2=0.185, 2.892, P>0.05). (5)The duration of postoperative hospital stay and treatment expenses were (6.8±2.4)days and (25 088±10 336)yuan in the ERAS group, (11.1±3.4)days and (38 819±14 854)yuan in the control group, showing significant differences between the 2 groups (t=-12.782, -9.452, P 10%, tumor staging, tumor differentiation, neoadjuvant chemotherapy and time of food intake were risk factors affecting incidence of postoperative complication in patients with esophageal cancer by the univariate analysis (χ2=2.484, 2.333, 0.061, 8.553, 2.459, 0.163, 3.462, P 10%, tumor staging and neoadjuvant chemotherapy were independent risk factors affecting incidence of postoperative complication in patients with esophageal cancer by the multivariate analysis (OR=0.365, 10.761, 0.290, 8.140, 95% confidence interval : 0.198-0.671, 4.122-28.095, 0.130-0.645, 3.946-16.791, P 0.05). Conclusions ERAS in the esophageal minimally invasive surgery for esophageal cancer is safe and feasible, with the advantages of shorter recovery time of gastrointestinal function and duration of hospital stay, lower treatment expenses and a better application value compared with traditional treatment. Key words: Esophageal neoplasms; Thoracoscopic and laparoscopic esophagectomy; Enhanced recovery after surgery

Malnutrition in the critically ill children: the importance of enteral and parenteral nutrition

The incidence of malnutrition is high among critically ill children.Thus, nutritional support has a major influence on the prognosis of critically ill children.Appropriate nutritional support can not only correct the poor nutritional status of critically ill children, but also improve the clinical prognosis.Fortunately, there are enteral and parenteral nutrition support available, but both have advantages and disadvantages.How to combine enteral and parenteral nutrition for a better personalized nutrition support plan, has become the major focus of nutritional support.In this regard, the nutrition risk, malnutrition screening and the effect of enteral/ parenteral nutrition on the disease severity are summarized in this review. Key words: Critical illness; Malnutrition; Enteral nutrition; Parenteral nutrition

Application value of nutritional support therapy after resection of esophageal cancer

Objective To investigate the application value of nutritional support therapy after resection of esophageal cancer. Methods The clinical data of 125 patients with esophageal cancer who were admitted to the Shandong Provincial Hospital Affiliated to Shandong University between May and November 2013 were retrospectively analyzed. According to the Nutritional Risk Screening 2002 (NRS 2002), 58 patients with scores of NRS 2002≥3 were allocated to the A group including 43 receiving nutritional support therapy in the A1 group and 15 receiving no nutritional support therapy in the A2 group; 67 patients with scores of NRS 2002<3 were allocated to the B group including 29 receiving nutritional support therapy in the B1 group and 38 receiving no nutritional support therapy in the B2 group. The NRS 2002 was used as a screening tool of nutritional risk within 48 hours after admission. There was nutritional risk in patients with scores of NRS 2002≥3 and no nutritional risk in patients with scores of NRS 2002<3. Patients and their families would choose whether or not underwent nutritional support therapy after the risks being informed. Parenteral nutritional support therapy used any 2 kinds of intravenously infusions of glucose, fat emulsion and amino acid, and enteral nutritional support therapy included tube feeding enteral nutrition or oral nutriments. The calories≥10 kcal/(kg·d) were offered for more than 5 days. The incidence of malnutrition in patients with nutritional risk was calculated, and the level of serum Alb and prealbumin before operation, at postoperative day 3 and day 7, postoperative recovery time of gastrointestinal function and duration of hospital stay were detected. Count data were analyzed using the chi-square test. Measurement data with normal distribution were presented as ±s. Comparison among groups was analyzed using the LSD-t test, and repeated measures data were analyzed by the repeated measures ANOVA. Results Of 58 patients in the A group, 51 patients were complicated with malnutrition with a incidence of 87.9%, and nutritional support therapy in 43 patients was well tolerated without abdominal pain, distension and diarrhea. The level of serum Alb before operation, at postoperative day 3 and day 7 were (29.4±1.7)g/L, (29.8±1.5)g/L, (32.2±2.3)g/L in the A1 group, (28.5±1.9)g/L, (27.0±1.8)g/L, (28.3±1.7)g/L in the A2 group, (35.8±1.3)g/L, (36.0±1.4)g/L, (37.4±2.1)g/L in the B1 group and (34.5±1.3)g/L, (35.3±1.7)g/L, (36.3±1.5)g/L in the B2 group, showing a significant difference in the changing trends between the A1 and A2 groups (F=2.541, P 0.05). The number of patients with level of prealbumin 0.05). The postoperative recovery time of gastrointestinal function and duration of hospital stay were (3.2±0.8)days and (11.6±1.1)days in the A1 group, (3.8±1.0)days and (15.5±2.7)days in the A2 group, (2.7±1.0)days and (10.6±2.6)days in the B1 group and (3.2±0.8)days and (11.3±1.5)days in the B2 group, with significant differences between the A1 and A2 groups (t=0.921, 3.005, P 0.05). Conclusions Application of NRS 2002 for evaluating nutritional status and guiding nutritional support therapy in patients with esophageal cancer is accurate and trusted. The postoperative nutritional support therapy should be selectively and reasonably applied to patients with nutritional risk, and it can improve the nutritional status of patients with esopha-geal cancer, enhance postoperative recovery and reduce duration of hospital stay. Key words: Esophageal neoplasms; Nutritional support therapy; Nutritional Risk Screening 2002

Nutritional status of premature neonates fed with extensively hydrolyzed protein formula

Objective To analyze the nutritional status of premature neonates first fed with extensively hydrolyzed protein formula. Methods From January 2013 to December 2014, 157 premature neonates hospitalized in Neonatal Intensive Care Unit of Shanghai Children's Medical Center who were first fed with extensively hydrolyzed protein formula were enrolled. Clinical data were recorded, including related diseases, birth weight and gestational age, nutrients intake, and growth charts. Two groups were divided according to the existence or absence of feeding intolerance, and three groups were divided based on birth weight (<1 500 g, 1 500~2 500 g, and ≥2 500 g). Results A total of 60 (38.2%) premature infants had feeding intolerance. The lower the birth weight and gestational age, the higher the frequency of feeding intolerance, and the incidence of feeding intolerance in <1 500 g group was 71.1%. Compared with the feeding tolerance group, the feeding intolerance group had significantly smaller birth weight [(1 620±440)g vs. (1 980±421)g, P=0.000], gestational age [ (31.3±2.6)weeks vs. (33.0±2.1)weeks, P=0.000], birth head circumference [(28.9±2.2)cm vs. (30.4±1.9)cm, P=0.000], and birth length [(41.1±3.9)cm vs. (43.2±3.4)cm, P=0.000], but significantly longer time before transfer formula [(26.4±17.6)d vs. (7.9±5.3)d, P=0.000] and time before reaching sufficient feeding [(21.5±10.0)d vs. (13.8±6.2)d, P=0.000]. The time of first feeding [<1 500 g group (6.1±5.1)d, 1 500~2 500 g group (3.8±2.5)d, ≥2 500 g group (3.3±1.2)d, P=0.002], time before transfer formula [<1 500 g group (28.7±18.3)d, 1 500~2 500 g group (9.7±8.1)d, ≥2 500 g group (7.0±3.8)d, P=0.000] and time before reaching sufficient feeding [<1 500 g group (24.0±10.4)d, 1 500~2 500 g group (14.3±6.0)d, ≥2 500 g group (11.4±3.5)d, P=0.000] increased along with the decrease of birth weight. The proportions of infants receiving parenteral nutrition in the feeding intolerance group (93.3%) and <1 500 g group (97.8%) were higher, with more calorie intake from parenteral nutrition [<1 500 g group (325.9±59.4)kJ/(kg·d), 1 500~2 500 g group (281.2±64.8)kJ/(kg·d), ≥2 500 g group (269.9±43.9)kJ/(kg·d), P=0.001] and longer duration [<1 500 g group (27.1±14.5)d, 1 500~2 500 g group (13.0±7.0)d, ≥2 500 g group (8.7±3.4)d, P=0.000]. In terms of growth indicators, the increase in head circumference was significantly higher in the feeding intolerance group than in the feeding tolerance group [(0.7±0.6)cm/week vs. (0.6±0.5)cm/week, P=0.045]. The increases in body weight and head circumference in the <1 500 g group were significantly higher than in the other 2 birth weight groups [body weight: <1 500 g group (21.8±9.5)g/d, 1 500~2 500 g group (4.2±7.6)g/d, ≥2 500 g group (4.9±11.9)g/d, P=0.000; head circumference: <1 500 g group (0.8±0.4)cm/week, 1 500~2 500 g group (0.5±0.4)cm/week, ≥2 500 g group (0.6±0.8)cm/week, P=0.005]. After controlling the variable of feeding intolerance, weight gain was negatively associated with gestational age (r=-0.666, P=0.035), birth weight (r=-0.700, P=0.024), head circumference (r=-0.846, P=0.002), and the day of returning to birth weight (r=-0.697, P=0.025), while positively associated with head circumference gain (r=0.672, P=0.033). There were no relationship between weight gain and birth length, the day of first feeding, time before transfer formula, time before reaching sufficient feeding, parenteral nutrition calorie and duration, days of hospital stay and complications. Conclusions First fed with extensively hydrolyzed protein formula, the growth in feeding intolerant premature infants may be similar to the feeding tolerant ones, which is associated with parenteral nutrition support. Premature infants with lower gestational age, birth weight, and head circumference may be more suitable for extensively hydrolyzed protein formula feeding. Key words: Extensively hydrolyzed protein formula; Premature; Nutrition