Postoperative Tube Feeding Research Articles

Tattoo of Scheepers

Introduction: Following pancreaticoduodenectomy (PD) up to 40% of patients experience a degree of delayed gastric emptying (DGE). The role of intra-operative jejunal tube placement and direct post-operative tube feeding to prevent [LL1] DGE remains controversial. However, enteral jejunal feeding is preferred to total parental feeding. Endoscopic biliary intervention of the ascending loop of the gastro- or duodenal-jejunostomy, as well as endoscopic tube placement of the descending jejunal loop, is a technical challenge. To improve the endoscopic procedures after PD, a new technique has been developed. Methods: A simple guide [LL2] for post-operative endoscopic interventions is to tattoo the afferent jejunal loop 5 cm following the gastro- or duodeno-jejunostomy intra-operatively. A short video and endoscopic pictures will be shown. Conclusion: Intra-operative tattooing of the afferent jejunal loop provides guidance for post-operative endoscopic procedures. This will fasten endoscopic interventions and prevent misplacement of jejunal tubes.

Early Postoperative Tube Feeding in Liver Transplantation

We published one of the first prospective randomized controlled trials evaluating early postoperative tube feeding (TF) in liver transplant recipients nearly 20 years ago. That first study showed that early posttransplant TF was safe and well tolerated; the study results also suggested that early TF could reduce posttransplant infection rates. This Pivotal Paper review evaluates the past, present, and future of early postoperative TF in liver transplantation. This article identifies what nutrition support findings more than 2 decades ago were the basis for attempting postoperative TF in liver transplantation. The results of our study, its unique findings, and shortcomings are summarized. Other subsequent studies of post-liver transplant TF are evaluated with a focus on effects on posttransplant infection rates. Finally, current transplant challenges, including donor organ shortage, increased severity of patients' pretransplant condition, expansion of living donor options, changes in immunosuppression, and use of specialized nutrients, are discussed in the context of how and why these factors affect nutrition support.

Esophageal Guidewire-Assisted Nasogastric Tube Insertion in Anesthetized and Intubated Patients

Nasogastric tube (NGT) insertion is indicated almost routinely in patients undergoing abdominal surgery to decompress the stomach intraoperatively and postoperatively, and to allow postoperative tube feeding. NGTs are made of nonreinforced polymer plastic materials and are prone to kinking and coiling during insertion. This often poses difficulty in blind NGT placement or placement assisted by variously described techniques. We hypothesized that esophageal guidewire-assisted NGT insertion with manual forward laryngeal displacement can significantly improve the first-attempt success rate over the technique of head flexion and lateral neck pressure during its insertion in anesthetized and tracheally intubated patients. Four hundred eighty adult patients presenting for abdominal surgery under general anesthesia with neuromuscular relaxation were randomized to an experimental technique of esophageal guidewire with manual forward displacement of the larynx (group 1) or a control technique of head flexion and lateral neck pressure (group 2) for insertion of the NGT. The success rates (and failure rate) of the first and second attempts (and overall) were assessed along with the incidence of coiling and kinking of the NGT, procedure-related nasal bleeding and pharyngeal bleeding, and the incidence of moderate and life-threatening complications. The first-attempt success rate was 99.2% in group 1 compared with 56.7% in group 2 (P < 0.001). Thus, the first-attempt failure rate was 0.8% in group 1 compared with 43.3% in group 2 (P < 0.001, absolute risk reduction of first-attempt failure rate = 42.5%, 95% confidence interval [CI] = 36.0%-49.9%; numbers needed to treat = 2, 95% CI = 2-3; relative risk reduction of first-attempt failure rate = 98.1%, 95% CI = 92.3%-99.5%). The median time required to insert the NGT was significantly shorter in group 1 (55 vs 60 seconds); P < 0.001, 95% CI for the difference in means = 3.2 to 6.8 seconds. The incidences of kinking/coiling, bleeding, and moderate injuries were significantly lower in group 1. Esophageal guidewire-assisted insertion with manual forward laryngeal displacement technique most frequently resulted in correct positioning of the NGT in anesthetized and tracheally intubated patients after the first attempt. This technique is also associated with a lower incidence of procedure-related injuries and is less time-consuming than conventional insertion techniques.

Endoscopic Carbon Dioxide Laser Zenker's Diverticulotomy Revisited

We assessed the efficacy of endoscopic Zenker's diverticulotomy with the carbon dioxide (CO2) laser and Acuspot and compared it with the historical results of using a CO2 laser without Acuspot and electrocautery diverticulotomy. Between 1976 and 2005, a total of 229 endoscopic Zenker's diverticulotomies in 189 patients were performed in our institution. Since 1995, micro-endoscopic diverticulotomy with the CO2 laser and Acuspot (MEDCO2A) has been performed in 61 cases. Between 1984 and 1995, micro-endoscopic diverticulotomy with the CO2 laser (MEDCO2) was performed in 113 cases. Before 1984, endoscopic diverticulotomy with electrocautery (EDE) was performed in 55 cases. All patients had radiologically proven Zenker's diverticula. We recorded preoperative and postoperative complaints of dysphagia, the frequency of recurrence in long-term follow-up, postoperative tube feeding, non-oral intake, days of admission, and complications. After operation, dysphagia was absent in 84.6% of MEDCO2A cases, 78.4% of MEDCO2 cases, and 72.0% of EDE cases. Repeat surgery was required in 13.0% of MEDCO2A cases, 19.6% of MEDCO2 cases, and 24.3% of EDE cases. Five patients developed mediastinitis (2 MEDCO2 cases and 3 EDE cases); none died as a consequence. In 1 patient, squamous cell carcinoma was found in the diverticulum. The technological improvement of the CO2 laser with Acuspot has further increased the efficacy of its use over that of methods previously used in our institution. The results and complications rate are comparable to those reported for endoscopic stapler diverticulotomy in the literature.

Examining the Role of Tube Feeding After Liver Transplantation

The rates of morbidity and mortality after liver transplantation are related to the degree of malnutrition. Because malnutrition is prevalent among liver transplant recipients, nutrition care practitioners must be aggressive in providing nutrition support to these patients in the perioperative period. Postoperative tube feeding (TF) has been studied for its role in improving short-term posttransplant outcomes. This paper evaluates published research that studied postoperative TF in liver transplant recipients; the methodology and outcomes are reviewed and drawbacks of these studies are considered. Case studies of liver transplant patients who received postoperative TF illustrate the variability of patient profiles and posttransplant complications that influence the provision and duration of posttransplant TF.

Postoperative Jejunal Feeding and Outcome of Pancreaticoduodenectomy

Complications after pancreaticoduodenectomy are common, partly because of nutritional debilitation. The aim of this study was to evaluate the impact of early postoperative tube feeding on outcome of pancreaticoduodenectomy and determine the best method for delivering enteral feeding. A retrospective review of 180 consecutive patients undergoing Whipple operations from 1994 to 2000 was performed. Two nonrandomized patient groups were retrospectively studied: those with early postoperative tube feeding vs those with no planned feeding. Ninety‐eight patients (54%) received postoperative jejunal feeding, whereas 82 patients (46%) did not. Jejunal feeding was delivered via a bridled nasojejunal tube in 55 patients (56%) and a gastrojejunal tube in 43 (44%). Vomiting (10% vs 29%; p = .002) and use of total parenteral nutrition (TPN) (6% vs 27%; p &lt; .0001) were less in the jejunal feeding group and rates of readmission (12% vs 27%; p = .022), early (52% vs 62%; p = .223) and late (12% vs 31%, p = .005) complications and infections (13% vs 20%, p = .014). Tube‐related complications occurred in 6 of 98 patients, all of which were associated with gastrojejunal tubes (p = .021). Early postoperative tube feeding after pancreaticoduodenectomy is associated with significantly less use of TPN and lower rates of readmission and complications. A bridled nasojejunal feeding tube appears to be a safe and reliable method of short‐term enteral feeding.

Postoperative jejunal feeding and outcome of pancreaticoduodenectomy.

Complications following pancreaticoduodenectomy are common, partly because of nutritional debilitation. The aim of this study was to evaluate the impact of early postoperative tube feeding on outcome of pancreaticoduodenectomy and determine the best method for delivering enteral feeding. A retrospective review of 180 consecutive patients undergoing Whipple operations from 1994 to 2000 was performed. Two nonrandomized patient groups were retrospectively studied: those with early postoperative tube feeding vs. those with no planned feeding. Ninety-eight patients (54%) received postoperative jejunal feeding, whereas 82 patients (46%) did not. Jejunal feeding was delivered via a bridled nasojejunal tube in 55 patients (56%) and a gastrojejunal tube in 43 (44%). Vomiting (10% vs. 29%; P=0.002) and use of total parenteral nutrition (6% vs. 27%; P < 0.0001) were less in the jejunal feeding group as well as rates of readmission (12% vs. 27%; P=0.022), early (52% vs. 62%; P=0.223) and late (12% vs. 31%, P=0.005) complications, and infections (13% vs. 20%, P=0.014). Tube-related complications occurred in 6 of 98 patients, all of which were associated with gastrojejunal tubes (P=0.021). Early postoperative tube feeding after pancreaticoduodenectomy is associated with significantly less use of total parenteral nutrition and lower rates of readmission and complications. A bridled nasojejunal feeding tube appears to be a safe and reliable method of short-term enteral feeding.

Postoperative jejunal feeding and outcome of pancreaticoduodenectomy

Complications following pancreaticoduodenectomy are common, partly because of nutritional debilitation. The aim of this study was to evaluate the impact of early postoperative tube feeding on outcome of pancreaticoduodenectomy and determine the best method for delivering enteral feeding. A retrospective review of 180 consecutive patients undergoing Whipple operations from 1994 to 2000 was performed. Two nonrandomized patient groups were retrospectively studied: those with early postoperative tube feeding vs. those with no planned feeding. Ninety-eight patients (54%) received postoperative jejunal feeding, whereas 82 patients (46%) did not. Jejunal feeding was delivered via a bridled nasojejunal tube in 55 patients (56%) and a gastrojejunal tube in 43 (44%). Vomiting (10% vs. 29%; P = 0.002) and use of total parenteral nutrition (6% vs. 27%; P < 0.0001) were less in the jejunal feeding group as well as rates of readmission (12% vs. 27%; P = 0.022), early (52% vs. 62%; P = 0.223) and late (12% vs. 31%, P = 0.005) complications, and infections (13% vs. 20%, P = 0.014). Tube-related complications occurred in 6 of 98 patients, all of which were associated with gastrojejunal tubes (P = 0.021). Early postoperative tube feeding after pancreaticoduodenectomy is associated with significantly less use of total parenteral nutrition and lower rates of readmission and complications. A bridled nasojejunal feeding tube appears to be a safe and reliable method of short-term enteral feeding.

Effect of perioperative nutrition, with and without arginine supplementation, on nutritional status, immune function, postoperative morbidity, and survival in severely malnourished head and neck cancer patients

Malnourished head and neck cancer patients are at increased risk of postoperative complications. We studied the effect of perioperative, arginine-supplemented nutritional support on nutritional status, immune status, postoperative outcome, and survival in severely malnourished (weight loss >10% of body weight) head and neck cancer patients undergoing major surgery. Forty-nine patients were randomly assigned to receive 1) no preoperative and standard postoperative tube feeding, 2) standard preoperative and postoperative tube feeding, or 3) arginine-supplemented preoperative and postoperative tube feeding. Patients in both prefed groups received approximately 9 d of preoperative tube feeding, resulting in energy intakes of 110% and 113% of calculated needs (compared with 79% in the control group; P = 0.007). Compared with no preoperative feeding, preoperative enteral nutrition did not significantly improve nutritional status or any of the studied biochemical or immunologic indexes. Major postoperative complications occurred in 53%, 47%, and 59% of patients in study groups 1, 2, and 3 (NS). A trend was seen toward better survival in the arginine-supplemented group (P = 0.15). Secondary analysis showed that survivors had better human leukocyte antigen-DR expression on monocytes (P = 0.05) and higher endotoxin-induced cytokine production (P = 0.010 for tumor necrosis factor alpha and P = 0.042 for interleukin 6) at the start of the study than did patients who died. Nine days of preoperative tube feeding, with or without arginine, did not significantly improve nutritional status, reduce the surgery-induced immune suppression, or affect clinical outcome in severely malnourished head and neck cancer patients. Patients supplemented with arginine-enriched nutrition tended to live longer. Some markers of immune function may distinguish patients with good or bad prognoses.