Start Of Oral Feeding Research Articles

The transition from tube feeding to oral feeding algorithm in preterm infants: case-control study

BackgroundOral feeding is a complex sensorimotor process influenced by many variables, making it challenging for healthcare providers to introduce and manage it. Feeding practice guided by tradition or a trial-and-error approach may be inconsistent and potentially delay the progression of oral feeding skills.AimTo apply a new feeding approach that assesses early oral feeding independence skills of preterm infants in the neonatal intensive care unit (NICU). To prove its effectiveness, compare two approaches of oral feeding progression based on clinical outcomes in preterm infants, the traditional approach used in the NICU of Mansoura University Children Hospital (MUCH) versus the newly applied approach.MethodsA quasi-experimental, exploratory, and analytical design was employed using two groups, control and intervention groups, with 40 infants for the first group and 41 infants for the second one. The first group (the control) was done first and included observation of the standard practice in the NICU of MUCH for preterm oral feeding, in which oral feeding was dependent on post-menstrual age (PMA) and weight for four months. The second group (the intervention) included early progression to oral feeding depending on early assessment of Oral Feeding Skills (OFS) and early supportive intervention and/or feeding therapy if needed using the newly developed scoring system, the Mansoura Early Feeding Skills Assessment “MEFSA” for the other four months. Infants in both groups were studied from the day of admission till discharge.ResultsIn addition to age and weight criteria, other indicators for oral feeding readiness and oral motor skills were respected, such as oral feeding readiness cues, feeding practice, feeding maintenance, and feeding techniques. By following this approach, preterm infants achieved earlier start oral feeding (SOF) and full oral feeding (FOF) and were discharged with shorter periods of tube feeding. Infants gained weight without increasing their workload to the NICU team.ConclusionThe newly applied approach proved to be a successful bedside scoring system scale for assessing preterm infants’ early oral feeding independence skills in the NICU. It offers an early individualized experience of oral feeding without clinical complications.

Safety and advantages of early oral feeding after intestinal anastomosis in children: Our experience

Background: Restoration of enteral feeding is believed to enhance recovery after surgery, but intestinal anastomosis is a matter of apprehension for surgeons to start enteral feeding early. Before 2022, our standard practice was to wait three to four days to begin oral feeding after intestinal anastomosis. Since 2022, we have allowed oral feeding to start within 24 hours of intestinal anastomosis. This study compares the safety and benefits of early oral feeding after intestinal anastomosis in children. Methods: This retrospective study was done in the neonatal and paediatric surgery department, BSH&I, from January 2021 to December 2022. Children who received early oral feeding in 2022 compared with children who received oral feeding after three days in 2021. Children with duodenal anastomosis and anastomosis with a covering stoma were excluded. Demographic and clinical data were extracted from hospital records using a predefined questionnaire. Data were analyzed in SPSS 26, and a p-value <0.05 was considered significant. Results: One hundred thirty-three children (90 in 2022 and 43 in 2021) underwent intestinal anastomosis. Fiftynine (44.4%) children had small gut anastomosis, 62 (46.6%) children had large gut anastomosis, and 12 (9%) children had ileocolic anastomosis. There was no difference in gender and mean age at the surgery between the two groups. The mean time to start oral feeding was 19.9±0.59 hours in the case group and 79.1±13.9 hours in the control group (p<0.001). The mean time to full oral feeding was 61.05±4.5 hours in the case group and 125.67±25.51 hours in the control group (p<0.001). The mean hospital stay was 4.16±1.18 days in the case group and 7.06±1.96 days in the control group (p<0.001). The two groups had no significant differences in anastomotic and wound complications. Conclusion: Early oral feeding after intestinal anastomosis is safe in children and reduces postoperative hospital stay without any added risk. Journal of Paediatric Surgeons of Bangladesh (2019) Vol. 10 (1 & 2): 22-25

Effects of implementing non-nutritive sucking on oral feeding progression and outcomes in preterm infants: A systematic review and meta-analysis.

Preterm infants have imperfect neurological development, uncoordinated sucking-swallowing-breathing, which makes it difficult to realize effective oral feeding after birth. How to help preterm infants achieve complete oral feeding as soon as possible has become an important issue in the management of preterm infants. Non-nutritive sucking (NNS), as a useful oral stimulation, can improve the effect of oral feeding in preterm infants. This review aimed to explore the effect of NNS on oral feeding progression through a meta-analysis. We systematically searched PubMed, CINHAL, Web of Science, Embase, Cochrane databases, China's National Knowledge Infrastructure (CNKI), Wanfang and VIP database from inception to January 20, 2024. Search terms included 'non-nutritive sucking' 'oral feeding' and 'premature.' Eligibility criteria involved randomized controlled studies in English or Chinese. Studies were excluded if they were reviews, case reports, or observational studies from which valid data could not be extracted or outcome indicators were poorly defined. The meta-analysis will utilize Review Manager 5.3 software, employing either random-effects or fixed-effects models based on observed heterogeneity. We calculated the mean difference (MD) and 95% confidence interval (CI) for continuous data, and estimated pooled odds ratios (ORs) for dichotomous data. Sensitivity and publication bias analyses were conducted to ensure robust and reliable findings. We evaluated the methodological quality of randomized controlled trials (RCTs) utilizing the assessment tool provided by the Cochrane Collaboration. A total of 23 randomized controlled trials with 1461 preterm infants were included. The results of the meta-analysis showed that NNS significantly shortened time taken to achieve exclusive oral feeding (MD = -5.37,95%CI = -7.48 to-3.26, p<0.001), length of hospital stay(MD = -4.92, 95% CI = -6.76 to -3.09, p<0.001), time to start oral feeding(MD = -1.41, 95% CI = -2.36 to -0.45, p = 0.004), time to return to birth weight(MD = -1.72, 95% CI = -2.54 to -0.91, p<0.001). Compared to the NNS group, the control group had significant weight gain in preterm infants, including weight of discharge (MD = -61.10, 95% CI = -94.97 to -27.23, p = 0.0004), weight at full oral feeding (MD = -86.21, 95% CI = -134.37 to -38.05, p = 0.0005). In addition, NNS reduced the incidence of feeding intolerance (OR = 0.22, 95% CI = 0.14 to 0.35, p<0.001) in preterm infants. NNS improves oral feeding outcomes in preterm infants and reduces the time to reach full oral feeding and hospitalization length. However, this study was limited by the relatively small sample size of included studies and did not account for potential confounding factors. There was some heterogeneity and bias between studies. More studies are needed in the future to validate the effects on weight gain and growth in preterm infants. Nevertheless, our meta-analysis provides valuable insights, updating existing evidence on NNS for improving oral feeding in preterm infants and promoting evidence-based feeding practices in this population.

СИСТЕМАТИЧЕСКИЙ ОБЗОР И МЕТААНАЛИЗ ТОРАКОСКОПИЧЕСКОГО И ОТКРЫТОГО ЛЕЧЕНИЯ АТРЕЗИИ ПИЩЕВОДА

Thoracoscopic reconstruction of esophageal atresia (EA) has become a standard procedure in many surgical centers Worldwide. The existing bibliographical reviews and meta-analyses have failed to demonstrate any significant difference in the immediate outcome of mini-aggressive treatment of EA. Authors had performed this truly systematic review and meta-analysis searching for the new evidence and confirmation of success of thoracoscopy in the treatment of EA. Materials and methods used: the systematic bibliographical review was prepared in accordance with the PRISMA 2020 statement guidelines. Thus, the scientific publications starting 1990 were searched in three major databases as follows: MEDLINE, PubMed and eLIBRARY.RU. Results: the included studies were published between 2008 and 2022 representing a total of 1958 cases that included 1369 (69.92%) open-surgery interventions and 589 (30.08%) thoracoscopic ones. Authors have found no significant difference between thoracoscopy and thoracotomy excluding an increased risk for esophageal anastomotic leak in the open-surgery treatment group (OR, 0.68; 95% CI, 0.46; 0.99; p = 0.04). A meta-analysis demonstrated that the thoracoscopy group had shorter time spent on lung ventilation (MD, -1.83; 95% CI, -3.02; -0.63; p = 0.003), shorter period to start oral feeding (MD, -1.34; 95% CI, -2.13; -0.56; p = 0.0008) and shorter hospital stay (MD, -4.26; 95% CI, -7.03; -1.49; p = 0.003). The data on the long-term outcomes of both thoracoscopic and open-surgery interventions were reported in a limited - insufficient number of observed cases and had demonstrated that gastroesophageal reflux was more common in the thoracoscopy group (OR, 2.82; 95% CI, 1.72; 4.61; p &lt; 0.0001). Conclusion: the meta-analysis had proved that, compared to open-surgery, thoracoscopy is associated with an almost comparable rate of postoperative complications coupled with the exception of anastomotic leaks. However, it is impossible to ignore the significant advantages of the modern method for treatment of EA which is characterized - among other things - by the more rapid recovery of patients after the surgical interventions.

Comparison between two minimally invasive techniques for Hirschsprung disease: transanal endorectal pull-through (TERPT) versus laparoscopic-TERPT.

Surgical treatment for Hirschsprung disease (HD) has recently evolved into different minimally invasive techniques. The aim of the present study is to compare results from two different minimal invasive approaches, transanal endorectal pull-through (TERPT) and laparoscopic-assisted endorectal pull-through (LA-TERPT). Patients have been divided into two groups according to surgical technique. Data of HD patients treated by TERPT and those treated by LA-TERPT, respectively, performed at two different centers from January 2007 to December 2017, were retrospectively collected. Patients with aganglionosis confined to the recto-sigmoid colon with a minimum follow-up period of 4years have been included. Demographic, clinical, surgical and functional outcome data were reviewed for each group using Chi-square and Fisher tests (statistical differences were considered for p < 0.05). Among patients treated for HD in the two centers during the study period, 65 met the inclusion criteria (37 TERPT group and 28 LA-TERPT group). No differences regarding demographic and clinical data were observed between the two groups. Operative time was longer in the LA-TERPT group (p < 0.001). Time to start oral feeding was faster in the TERPT group while hospital stay was similar between the two groups. Three patients of the TERPT group required an additional abdominal approach. The rate of early complications was higher in the TERPT group. Long-term bowel function was assessed in 31 patients for the TERPT group and 24 patients for the LA-TERPT group. Outcomes showed that the bowel functional outcome was good (BFS ≥ 17) in 55% (n = 17) of TERPT group and 54% of LA-TERPT group (p = 0.97), moderate (BFS 12 to 16) in 16% (n = 5) and 33% (n = 8), respectively (p = 0.24), and poor in 29% (n = 9) and 13% (n = 3), respectively (p = 0.23). Both TERPT and LA-TERPT techniques should be considered safe and feasible for the treatment of HD patients. TERPT patients present faster time to return to normal bowel function while LA-TERPT patients have slightly lower incidence of postoperative complications. Long-term functional outcomes are similar between the two groups. III.

Characterization of feeding skills and clinical markers of preterm newborns with gastroschisis in a neonatal therapy unit.

To describe the clinical and feeding findings of premature infants with gastroschisis (GTQ) in a neonatal intensive care unit and compare them to preterm infants (NBs) without congenital anomalies. A retrospective case-control study was conducted with 50 premature NBs (25 with GTQ and 25 without comorbidities - control group). The NBs were compared regarding demographic and clinical data: risk of mortality and speech-language assessment (nonnutritive and nutritive sucking). Subsequently, a multiple logistic regression model was applied to determine the variables associated with the negative speech therapy outcome (speech therapy discharge after more than 7 days considering the first speech therapy evaluation). The results of the first analysis indicated that there was a difference between the GTQ and the CG for the following variables: total time in days of hospitalization; use of mechanical ventilation (invasive x noninvasive); days of life on the date of the first speech-language assessment; use of alternative feeding route; and the GTQ group had worse results. The results of the multiple logistic regression indicated that the diagnosis of GTQ, the use of invasive mechanical ventilation, and the absence of adequate intraoral pressure during the first speech-language evaluation were risk factors for a negative speech-language outcome. The feeding skills of preterm infants with QTG are related to the severity of the condition (gastrointestinal tract complications), requiring longer hospitalization, use of invasive mechanical ventilation, prolonged use of alternative feeding route and requiring more speech therapy to start oral feeding.

Risk Factors for Feeding and Swallowing Disorders in Very Low Birth Weight Infants in Their Second Year of Life.

Background and Objectives: This study aimed to identify the prevalence of feeding and swallowing disorders (FSD) in very low birth weight (VLBW, 1500 g or less) infants in the first two years after discharge from the maternity hospital, their possible risk factors, and the consequences of them. Materials and Methods: A total of 117 preterm children with VLBW born between 2013 and 2015 were included. The data concerning possible FSD after discharge from the hospital were obtained through accessible medical documentation for the child and a short parental questionnaire. Results: FSD was reported in 32 (27.4%) infants following discharge from the hospital but in only five children (4.3%) at a mean age of four years. Four variables (birth gestational age less than 28 weeks, birth weight equal to or less than 1000 g, birth length below 33 cm, and start of oral feeding after the 34th gestational week) were identified as risk factors for FSD after discharge. However, only birth length remained a significant predictor after being included in a binary logistic regression model (p = 0.000). Abnormal oral sensitivity and a decrease in weight to under the 10th percentile were significantly more common in the FSD group at follow-up visits at the age of about 2 years. Conclusions: FSD was still present in more than one-quarter of VLBW infants after discharge from the maternity hospital but mostly disappeared within four years. A birth gestational age under 28 weeks, weight up to 1000 g, the late beginning of per oral feeding, and a birth length below 33 cm were determined to be significant predictive factors for FSD. Having a birth length below 33 cm was associated with an almost 6.5-fold increase in the odds of having persistent FSD after discharge from the hospital. FSD in the first years of life may have an impact on the child's further growth and development.

Thoracoscopic posterior tracheopexy during primary esophageal atresia repair ameliorate tracheomalacia in neonates: a single-center retrospective comparative cohort study

BackgroundEsophageal atresia (EA) is often associated with tracheomalacia (TM). The severity of TM symptoms varies widely, with serious cases requiring prolonged respiratory support and surgical treatment. Although we performed thoracoscopic posterior tracheopexy (TPT) during primary EA repair to prevent or reduce the symptoms of TM, few studies have investigated the safety and effectiveness of TPT during primary EA repair. Therefore, this study aimed to evaluate the safety and efficacy of TPT in neonates.MethodsWe retrospectively reviewed the records of all patients diagnosed with TM who underwent primary thoracoscopic EA repair between 2013 and 2020 at the Nagoya University Hospital. Patients were divided into two groups: TPT (TPT group) and without TPT (control group). TPT has been performed in all patients with EA complicated by TM since 2020. We compared patient backgrounds, surgical outcomes, postoperative complications, and treatment efficacy.ResultsOf the 22 patients reviewed, eight were in the TPT group and 14 were in the control group. There were no statistically significant differences in the surgical outcomes between the groups (operation time: p = 0.31; blood loss: p = 0.83; time to extubation: p = 0.30; time to start enteral feeding: p = 0.19; time to start oral feeding: p = 0.43). Conversion to open thoracotomy was not performed in any case. The median operative time required for posterior tracheopexy was 10 (8–15) min. There were no statistically significant differences in postoperative complications between the groups (chylothorax: p = 0.36; leakage: p = 1.00; stricture: p = 0.53). The respiratory dependence rate 30 days postoperative (2 [25%] vs. 11 [79%], p = 0.03) and the ratio of the lateral and anterior–posterior diameter of the trachea (LAR) were significantly lower in the TPT group (1.83 [1.66–2.78] vs. 3.59 [1.80–7.70], p = 0.01).ConclusionsTPT during primary EA repair for treatment of TM significantly lowered respiratory dependence rate at 30 days postoperative without increasing the risk of postoperative complications. This study suggested that TPT could improve TM associated with EA.

Surgical techniques and outcomes in patients with oral cavity cancer after induction chemotherapy

Objective: Locally advanced Oral squamous cell carcinoma OSCC has a poor prognosis, surgery is mainline for treatment. The role of induction chemotherapy is still controversial. Methodology: This is a prospective study that included 25 patients with locally advanced OSCC who received induction chemotherapy with cisplatin, docetaxel &amp; 5-FU (TPF) protocol regimen followed by surgical intervention. The epidemiological, surgical, and oncological outcomes of all the included patients were analyzed. Results: one patient showed no response, 18 patients had a partial response while 6 patients showed pathological complete response (pCR). Five out of the six patients who achieved pCR did not need reconstructive surgery and also five out of those 6 patients were operated on through a less destructive transoral approach. Consequently, those patients had less operative time, blood loss, hospital stay, and significantly less time to start oral feeding. The median disease-free survival was 15 (12-18) months in patients who attained pCR and 13 (5-24) months in the non pCR group. Conclusion: Pathological complete response after induction chemotherapy for locally advanced OSCC is associated with improvement in disease-free survival, less destructive surgery, and less need for flap reconstruction.

The Effect of Chitohem Bleeding Inhibitor Powder on Pain and Bleeding After Tonsillectomy by Suturing Method.

Study Design and Objectives: This study aimed to investigate Triamcinolone ointment's effect on pain and bleeding after tonsillectomy by suturing method. Methods: The present study was performed as a single-blind clinical trial on 200 patients who underwent a total tonsillectomy in the ENT department of Loghman Hakim Hospital in Tehran during 2016. Candidates for total tonsillectomy were randomized into 2 groups one by one. Participants were randomly divided into 2 groups. Both groups matched homologically. Patients in both groups (intervention and control) underwent cold dissection total tonsillectomy. In addition to suturing, in the intervention group, Triamcinolone ointment was used to control the local bleeding at the surgical site. In the control group, only sutures were used to control bleeding. The studied variables included: bleeding and pain 24 hours after surgery, Time to start oral feeding. Result: The frequency of bleeding cases in the first 24 hours are included: 4 patients (5.63%) in the intervention group and 6 patients (8.45%) in the control group (P = 0.01). The average time to start eating for patients who were treated with topical triamcinolone ointment was significantly less than those who were not treated with this ointment. Only 2 patients (2.77%) in the intervention group took analgesics in the first 24 hours after surgery, while and 11 patients (15.3%) in the control group received analgesics in the same time period. Conclusion: In general, the results of this study showed that the use of Triamcinolone ointment in total tonsillectomy could reduce bleeding, analgesics usage, and the time of feeding onset.

102: EFFECT OF A MULTIMODAL PREHABILITATION PROGRAM ON POSTOPERATIVE RECOVERY AND MORBIDITY IN PATIENTS UNDERGOING A MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Background and aim Despite recent advancements in perioperative care, postoperative morbidity following an esophagectomy remains substantial. Studies in other major abdominal surgery, have shown that prehabilitation can improve short-term outcomes. This single-center cohort study investigated the effect of prehabilitation in patients undergoing minimally invasive Ivor-Lewis esophagectomy (MIE-IL). Methods Data were collected on consecutive patients receiving a standardized ERAS program that included direct start of oral feeding following MIE-IL (from postoperative day one), between October 2015 and February 2020. The intervention group comprised patients enrolled in the PREPARE prehabilitation program that was implemented in 2018 as the standard care pathway for all patients. The control group comprised a retrospective cohort prior to implementation of PREPARE. Postoperative outcomes included (functional) recovery, length of hospital stay (LOHS), cardiopulmonary complications (CPC) and other predefined outcomes. Results The PREPARE group comprised 52 patients and control group 43 patients. Median time to functional recovery was 6 vs. 7 days (P = 0.074) and LOHS 7 vs. 8 days (P = 0.039) in the PREPARE and control group, respectively. Hospital readmission rate was 9.6% vs. 14.3% (P = 0.484). Although thirty-day overall postoperative complication rate did not differ statistically significantly (P = 0.106), a clinically relevant reduction of 17% was observed in PREPARE patients. Similarly, CPC rate was 14% lower in the PREPARE group (P = 0.190). Anastomotic leakage rate was similar (9.6% vs 14.0%; P = 0.511). Despite no difference in severity (Clavien-Dindo) of complications (P = 0.311), ICU readmission rate was lower in PREPARE patients (3.8% vs. 16.3%, P = 0.039). In the PREPARE group wherein maximum oxygen uptake capacity (VO2max) was assessed preoperatively during a Steep Ramp Test, VO2max was lower at baseline in patients diagnosed with postoperative complications (P = 0.011). There were no data on VO2max in the control group. Conclusion Prehabilitating patients prior to a MIE-IL led to a shorter LOHS and reduced ICU readmission rate. Additionally, a clinically relevant improvement in (functional) recovery and reduction in postoperative morbidity was observed in patients that were prehabilitated.

Abstract WMP34: Early Oral Feeding Following Removal Of Feeding Tube In Stroke Patients Based On The Modified Volume-viscosity Swallow Test

Objective: Dysphagia is common in patients with acute ischemic stroke patients (AIS). Feeding tubes are often placed to prevent aspiration pneumonia and supply nutrition when swallow function impaired are detected. However, little is known about when and how to start oral feeding in AIS. The purpose of this study is to establish a feasibility and effective intervention for early oral feeding following removal of feeding tube in patients with AIS. Methods: A total of 37 patients with AIS who were removed feeding tubes and start oral feeding in our hospital from 2017 to 2021 were retrospectively analyzed. An intervention program for early oral feeding, which consisted of the modified volume-viscosity swallow test (V-VST) and mechanical soft diet, was fully operationalized from October 2020 to July 2021. Outcomes were compared between an early oral feeding intervention group of 17 patients and a historical control group of 20 patients from July 2017 to September 2020. We compared the baseline characteristics between the groups. To analyze aspiration pneumonia probability, the Kaplan-Meier method were used. Results: The length of stay in hospital was significantly longer in the control group compared with the early oral feeding group (16.70±5.24 vs 12.88±4.46; P=0.024). Patients in the control group tolerated tube feeding longer days ( 9.45±2.93 vs 6.59±3.57; P=0.011 ). A log-rank test found no significant difference in aspiration pneumonia between the two groups ( P =0.111). Conclusions: Our data suggest that the intervention for early oral feeding can be used safely and possibly.

Videoendoscopic evaluation of swallowing using normal saline in NICU infants.

Videoendoscopic evaluation (VE) of swallowing involves inserting a small flexible endoscope transnasally to allow direct observation of pharyngeal and laryngeal structures and swallowing functions. In our neonatal intensive care unit (NICU) VE is performed in infants suspected of severe swallowing dysfunction, using normal saline (NS) with the aim of minimizing the detrimental effect of aspiration on respiration caused by VE. This retrospective study was conducted to evaluate the usefulness of VE using NS in NICU infants. We enrolled 28 infants who demonstrated clinical signs of swallowing dysfunction or who were ready to start oral feeding. Swallowing evaluations were completed using flexible fiberoptic laryngobronchoscopy (FLB). While observing the pharyngeal and laryngeal cavity with FLB, NS was gradually increased by 1 mL and injected up to a maximum of 3 mL, and the swallowing reflex, tracheal aspiration, and pharyngeal residue were observed. Median gestational age was 37 weeks 6 days, median birthweight 2,539 g, and median age at first examination was 107.5 days. Abnormalities in VE were observed in 20 cases, most of which were upper airway lesions. Most of these upper airway abnormalities were pharyngeal lesions. In two pharyngeal lesion cases, swallowing function improved using positive airway pressure. Infants with pharyngeal lesions demonstrated abnormal VE findings. Furthermore, positive airway pressure improved swallowing in some cases, suggesting that narrowing of the pharyngeal cavity may affect swallowing function. In addition, results suggest that VE using NS is a safe and useful method for evaluating swallowing function and determining countermeasures in NICU infants.

Management of upper gastrointestinal bleeding in neonates admitted at Neonatal Intensive Care Unit of Assiut University Children's Hospital: A clinical audit

BackgroundUpper gastrointestinal bleeding (UGIB) is an uncommon but potentially serious, life-threatening condition in neonates. Rapid assessment, stabilization, and resuscitation should precede all diagnostic modalities in unstable neonates. The diagnostic approach includes history, examination, laboratory evaluation, endoscopic procedures, and imaging studies. The clinician needs to determine carefully whether any blood or possible blood reported represents true UGIB because most neonates with true UGIB require admission to a neonatal intensive care unit (NICU).ObjectiveThe aim of this clinical audit study is to assess how much the adapted protocols of diagnosis and management of UGIB were applied in NICU in Assiut University Children Hospital.Patients and methodsThe present study was conducted in Assiut University Children's Hospital and included 100 neonates with UGIB who were admitted to NICU of Assiut University Children's Hospital over a 1-year period from the 1st of January 2017 to 31st of December 2017.ResultsComplete history was fulfilled in 100% of cases including the type of delivery, way of nutrition, history of maternal drug use, family history of bleeding, and vitamin K prophylaxis. Data of examination was fulfilled in 100% of cases including vital sign, hepatosplenomegaly, jaundice, bowel sound, and passing of stool. Data of investigations was fulfilled in 100% of cases except for Alkali denaturation test (Apt–Downey test) and upper endoscopy for ulcer evaluation was recorded in 0% of cases. Data about management was fulfilled in 100% of cases regarding secure airway, prophylaxis vitamin K, antibiotic therapy, and gastric lavage with normal saline; obtain two intravenous line was done in 18% of cases; replace blood loss with saline was done in 96% of cases; Foley catheter placement in shocked patient was done in 12% of cases; epinephrine lavage was done in 37% of cases; administration of H2 blockers was done in 13% of cases; administration of PPIs was done in 46% of cases; blood transfusion was done in 72% of cases; and plasma transfusion was done in 79%.ConclusionThe international guidelines for the management of UGIB had been followed by personnel working at NICU of Assiut University Children's Hospital regarding treatment lines and that some of the default is due to poor resources and lack of medication.RecommendationsInfection control measures must be appropriately done, this can be achieved by training nurses and resident doctors on infection control program continuously and also by staff members' supervision.Prolonged use of total parenteral nutrition increases the incidence of neonatal sepsis, this can be prevented by start of oral feeding as early as possible and proper infection control. Early weaning from ventilation as much as possible as prolonged use of mechanical ventilation to newborn predisposes them to develop sepsis and stress ulcer; this can be prevented by early weaning from ventilation. Evaluation and stabilization with airway management, intravenous fluids, or blood transfusion is essential before and during diagnostic evaluation. Gastric lavage with normal saline and epinephrine lavage should be done for all cases with UGIB. Complete laboratory investigations such as complete blood count, type and cross-match blood and coagulation profile should be done for all cases. Mother should be examined for cracked nipples as a source of swallowed blood, blood is usually apparent on examination.

The effects of swallowing exercise and non-nutritive sucking exercise on oral feeding readiness in preterm infants: A randomized controlled trial

IntroductionPreterm infants demonstrate problems with pharyngeal swallowing in addition to sucking problems. Oral motor intervention and nonnutritive sucking (NNS) were introduced for promoting oral feeding skills in preterm infants. NNS cannot cover all the components of oral feeding. In another hand, the swallowing exercise (SE) can accelerate the attainment of independent oral feeding in the preterm infants. The current study sought to examine if a combined program of NNS and SE compared with a program that only involves NNS would be more effective on oral feeding readiness of premature infants. Material and methodsThis randomized controlled trial was conducted in a neonatal intensive care unit (NICU). 45 preterm infants were recruited in three groups. In the group I, infants were provided with NNS twice a day. The group II received a program that involved 15 min of NNS and 15 min of SE, daily. Both interventions were provided 10 days during two consecutive weeks. The group III, control group, just received the routine NICU care. All infants were assessed by functional oral feeding outcome measures including postmenstrual age (PMA) at the start of oral feeding, PMA at full oral feeding, transition time (days from start to full oral feeding), PMA at discharge time and also the infant's dependency on tube-feeding at discharge time after interventions. Also, all infants were assessed via Preterm Oral Feeding Readiness Scale (POFRAS) before and after intervention. ResultsNo significant differences were observed in the PMA mean at start of oral-feeding (P = 0.29), full oral-feeding (P = 0.13), discharge time (P = 0.45) and the mean of transition time (P = 0.14). Compared to the control group, more infants in the group II were discharged without tube-feeding (P = 0.01). The mean of POFRAS was significantly higher in both groups I and II compared to the group III (P = 0.02 and P = 0.01, respectively). This score was, however, not statistically different between the groups I and II (P = 0.98). ConclusionsBoth studied interventions were superior to routine NICU care in enhancing the oral feeding readiness of preterm infants based on the POFRAS score. The studied combined program of NNS and SE, and not NNS program, could significantly increase the number of discharged infants without tube-feeding compared to control group.

77 CUTOFF VALUE OF SERUM C-REACTIVE PROTEIN ON THE FIFTH POSTOPERATIVE DAY IS EFFECTIVE TO RULE OUT ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY

Abstract Anastomotic leakage is one of most severe complications after esophagectomy. There is no consensus on the best method of identification of such complications. Serum C-reactive protein measurement on postoperative day 5 (POD) has been reported to be reliable to rule-out leakage. Methods We prospectively assessed the medical records of consecutive post-esophagectomy patients from January 2019 to January 2020. We analyzed serum CRP and complete blood cell counts from the day before surgery to the POD5. A CRP level ≤ 150 mg/l at POD5 was considered sufficient to start oral feeding. In contrast a CRP level &amp;gt; 150 mg/l at POD5 lead to a computed tomography (CT) with oral contrast to rule-out the presence of an anastomotic leakage. Anastomotic leakage was classified according to ECCG classification. Sensibility, sensitivity, positive and negative predictive value of CRP were calculated. Results Over a 12-month period, 52 patients were included (Figure 1). Measurement of CRP on POD5 was ≤150 mg/l in 34 (64%) patients (32 without fistula and 2 with fistula diagnosed after POD5) and &amp;gt; 150 mg/L in 18 (36%) patients (8 without fistula and 10 with fistula). Twelve (23%) patients developed anastomotic fistula. The cutoff value of CRP ≤150 mg/l on the POD5 was associated with sensitivity 83%, specificity 80%, positive predictive value 56% and negative predictive value 94%. The CRP protocol allowed to avoid 30/52 (57%) unnecessary postoperative CT-scan. Conclusion On the basis of a high negative predictive value, a CRP level at POD5 ≤ 150 mg/l can be effective to eliminate an anastomotic leakage and to start oral feeding without any further exams. This information is useful in the context of ERAS protocols to reduce hospital discharge and decrease hospital costs.

Vacuum assisted closure system in the management of postoperative complex enterocutaneous fistulae: Postoperative Cohort Study‎

Background: There is controversy in the use of vacuum assisted closure therapy (VAC) in management of enterocutaneous fistula (ECF). Due to the increased risk of new fistula formation, its use was contraindicated, but then several studies reported successful closure, fistula effluent control and healing of excoriated skin by keeping it dry. Objectives: The aim of this study is to evaluate the efficacy of VAC in treatment of the complex postoperative ECF. Patient and Methods: Patients with postoperative ECF were enrolled in this prospective study in the period from January 2018 to June 2019. Full history, examination and investigations were done for all patients. Patients had VAC. After one month, responses to VAC in terms of time from fistula to VAC, general condition, fistula output, fistula closure, wound size, skin condition, time to start oral feeding, need to segregate, complications and mortality were recorded. On follow-up, time to complete closure, type of closure and cost were recorded. Results were then analyzed. Results: 60 patients with ECF were enrolled. General condition was improved in 32 patients while ECF output was improved in 52 patients. Early start of Oral feeding had occurred with the use of VAC. Complications as pain, new fistula formation, pulmonary embolism or ongoing sepsis occurred in 40 patients while mortality occurred in 12 patients. Conclusion: VAC is feasible in complex postoperative enterocutaneous fistulae. It enhances the survival, improves the general condition and the perifistular skin and reduces the fistula output and wound size.

Stapler Use in Salvage Total Laryngectomy: A Useful Tool?

To analyze stapler benefits in salvage total laryngectomy in terms of surgical time, hospitalization length, oral feeding time, and occurrence of pharyngocutaneous fistula, and to evaluate risk factors for its onset. Retrospective analysis. One hundred fourteen patients affected by endolaryngeal squamous cell carcinoma who underwent salvage total laryngectomy following primary treatment failure were reviewed. We divided patients into two groups based on type of pharyngeal suture performed: mechanical suture with stapler (group A) and manual suture (group B). These two groups were compared for surgical time, start of oral feeding, hospitalization length, surgical margins and pharyngocutaneous fistula incidence considering its relationship with diabetes mellitus, nutritional status, primary treatment, and neck dissection. In group A and group B, oral feeding restarting time was 15 ± 9.33 versus 20.03 ± 13.81 days, hospitalization was 17.63 ± 10.08 versus 23.72 ± 14.29 days, and surgery lasted 268.39 ± 76.93 versus 294.26 ± 140.58 minutes, respectively (P < .05). Surgical margins resulted infiltrated in two patients (4.3%) in group A and 12 patients in group B (17.6%) (P = .03). Twenty-one patients (18.4%) presented with pharyngocutanoeus fistula. In group A and group B the incidence of fistula was 15.2% and 20.6%, respectively (P = .468). Fistula occurred in 7 of 18 diabetic patients (38.9%) and 14 of 96 (14.6%) nondiabetic patients (P = .015). Nineteen fistulas (90.5%) occurred in patients who had undergone previous radiation treatment (P = .013). Using a stapler shortened operative time and hospitalization, while also providing a faster restart of oral feeding. Moreover, mechanical pharyngeal suture seems to decrease fistula rate even though its prevention role in salvage laryngectomy should be confirmed by further studies. 4 Laryngoscope, 131:E473-E478, 2021.

The Interrater and Intrarater Reliability of the Preterm Infant Oral Feeding Readiness Assessment Scale

Introduction: One of the most challenging decisions is to assess the preterm infant’s transition from tube feeding to oral feeding. Thus, we require a reliable tool for determining the time to start oral feeding. This study aimed to measure the interrater and intrarater reliability of the Preterm Infant Oral Feeding Readiness Assessment scale (PIOFRA).&#x0D; Materials and Methods: This study was an observational, cross-sectional study. The study participants were preterm infants who had been hospitalized in the Neonatal Intensive Care Unit of Shariati Hospital affiliated to Tehran University of Medical Sciences, between December 2017 and February 2018. The inclusion criteria were absence of neurological and gastrointestinal disorders or major congenital anomalies, Apgar score 3 or more in the first 1 minute, and 5 or more in the first 5 minutes. The exclusion criteria included family’s unwillingness to participate in the study, infant’s death, or a sudden change that affects neonates’ nutritional status, like cerebral hemorrhage or intestinal problems.&#x0D; Results: The interrater and intrarater reliability of the total PIOFRA scale was good Intraclass Correlation Coefficients (ICC˃0.75). The interrater and intrarater reliability of most items were good and excellent, with weighted kappa more than 0.50, with the exception of lip posture and especially stress sign, with weighted kappa less than 0.40.&#x0D; Conclusion: Generally, most items of the PIOFRA scale had acceptable interrater and intrarater reliability. Also, the interrater and intrarater reliabilities of the total POFRAs score was good.

O3 DIRECT ORAL FEEDING FOLLOWING MINIMALLY INVASIVE ESOPHAGECTOMY (NUTRIENT II TRIAL): AN INTERNATIONAL, MULTICENTER, OPEN-LABEL RANDOMIZED CONTROLLED TRIAL

Abstract Aim Patients undergoing an esophagectomy are often kept nil-by-mouth postoperatively out of fear for increasing anastomotic leakage and pulmonary complications. This study investigates the effect of direct start of oral feeding following minimally invasive esophagectomy (MIE) compared to standard of care. Background &amp; Methods Elements of enhanced recovery after surgery (ERAS) protocols have been successfully introduced in patients undergoing an esophagectomy. However, start of oral intake, which is an essential part of the ERAS protocols, remains a matter of debate. Patients in this multicenter, international randomized controlled trial were randomized to directly start oral feeding (intervention) after a MIE with intrathoracic anastomosis or to receive nil-by-mouth and tube feeding for five days postoperative (control group). Primary outcome was time to functional recovery. Secondary outcome parameters included anastomotic leakage, pneumonia rate and other surgical complications scored by predefined definitions. Results Baseline characteristics were similar in the intervention (n=65) and control (n=67) group. Functional recovery was seven days for patients receiving direct oral feeding compared to eight days in the control group (p-value 0.436). Anastomotic leakage rate did not differ in the intervention (18.5%) and control group (16.4%, p-value 0.757). Pneumonia rates were comparable between the intervention (24.6%) and control group (34.3%, p-value 0.221). Other morbidity rates were similar, except for chyle leakage which was more prevalent in the standard of care group (p-value 0.032). Conclusions Direct oral feeding after an esophagectomy does not affect functional recovery and did not increase incidence or severity of postoperative complications.