Use Of Enteral Feeding Research Articles

Feeding practices and weight status of children with congenital Zika syndrome: A longitudinal study in Brazil.

The objective of this study was to describe feeding practices and weight status in a cohort of children with congenital Zika syndrome (CZS) in northeastern Brazil. This longitudinal study of children with CZS (N = 156) included data collection on child feeding practices and weight status at five timepoints between 2018 and 2022. The average age of the children was 32.1 months at enrollment and 76.6 months at the fifth assessment. Multilevel models, with repeated observations nested within children, were used to estimate time-related differences in each outcome. Use of enteral feeding, such as gastrostomy, increased from 19.2% to 33.3% over 4 years (p < .001). Among children who did not exclusively use an enteral feeding method, the percentage experiencing at least one dysphagia-associated behavior, such as coughing or gagging, increased from 73.9% to 85.3% (p = .030) while consuming liquids and from 36.2% to 73.5% (p = .001) while consuming solids. Based on weight-for-age z-scores, the percentage of children who were moderately or severely underweight increased from 42.5% to 46.1% over the 4 years but was not statistically significant. Children exclusively using an enteral feeding method had significantly decreased odds of being underweight at assessments 3, 4, and 5. These data highlight the ongoing and increasing challenges of feeding young children with CZS. Our findings elucidate the physiological reasons children with CZS may be underweight and point to intervention targets, such as enteral feeding, to improve their feeding practices.

Feeding Management and Palate Repair Timing in Infants with Cleft Palate with and without Pierre Robin Sequence: A Multisite Study.

Compare the feeding management practices in infants with cleft palate with and without Pierre Robin sequence (PRS) and determine if specific feeding difficulties or interventions predict delayed palate repair. Retrospective cross-sectional study. Seventeen cleft palate teams contributed data. 414 infants were included in this study: 268 infants with cleft palate only and 146 infants with cleft palate and PRS. Data were collected via parent interview and electronic health records. Outcomes for the primary objective included categorical data for: history of poor growth, feeding therapy, milk fortification, use of enteral feeding, and feeding difficulties. The outcome for the secondary objective was age in months at primary palate repair. Infants with PRS had a significantly higher prevalence of feeding difficulties (81% versus 61%) and poor growth (29% versus 15%) compared to infants with cleft palate only. Infants with PRS received all feeding interventions-including feeding therapy, milk fortification, and enteral feeding-at a significantly higher frequency. Infants with PRS underwent primary palate repair at a mean age of 13.55 months (SD = 3.29) which was significantly (P < .00001) later than infants with cleft palate only who underwent palate repair at a mean age of 12.05 months (SD = 2.36). Predictors of delayed palate repair included diagnosis of PRS as well as Hispanic ethnicity and a history of poor growth. These findings can be used to establish clinical directives focused on providing early, multimodal feeding interventions to promote optimal growth and timely palate repair for infants with PRS.

The effects of endovascular clot retrieval and thrombolysis on dysphagia in an Australian quaternary hospital: A retrospective review

To establish incidence rates and patterns of dysphagia following the administration of reperfusion therapies in acute ischaemic stroke management. A retrospective review of 193 patients admitted with acute ischaemic stroke to a quaternary stroke unit in Australia over a three year period was completed. Clinical information extracted included demographics, type (thrombolysis and/or endovascular clot retrieval) and success of reperfusion therapy, and the progression of dysphagia and related factors. Over half of all patients treated with reperfusion therapies presented with dysphagia on initial assessment by speech-language pathology (SLP). The type of reperfusion therapy administered was not significantly correlated with the presence of dysphagia. Dysphagia on initial assessment was significantly correlated with the presence of aphasia on initial assessment, the presence of haemorrhagic transformation, and the success of reperfusion. Increased rates of enteral feeding were also found in this study compared to figures reported in literature. This study identified ongoing high rates of dysphagia amongst this patient population regardless of treatment type, demonstrating the need for ongoing SLP management post stroke. Further research is required in this area to develop an evidence-base for SLPs and the wider medical team and to inform clinical practice guidelines. What is already known on the subject Stroke is one of the leading causes of disability and death internationally. Dysphagia (impaired swallowing), a common sequalae of stroke, is known to contribute to decreased quality of life, increased length of hospital stay and mortality. With advancements in technology, treatments for acute ischaemic stroke (endovascular clot retrieval and thrombolysis) are increasing in popularity. However, limited research exists exploring the impact of these therapies on dysphagia. What this paper adds Despite the advancements in stroke treatment, patients continue to present with high rates of dysphagia. Dysphagia following thrombolysis and/or ECR was found to be significantly correlated to the presence of aphasia, haemorrhagic transformation, and the success of reperfusion (regardless of treatment type). Additionally, increased rates of enteral feeding were found amongst this patient population compared to figures reported in the literature for patients following traditional stroke management. Clinical implications of this study Speech-language pathologists and the wider medical team should consider dysphagia as an ongoing consequence of stroke following reperfusion therapies, with consideration for success of reperfusion and adverse outcomes i.e., haemorrhagic transformation. Further research is required to provide an evidence-base and specific guidelines for the management of dysphagia post reperfusion therapies, including use of enteral feeding.

Nutritional outcomes in patients undergoing transoral robotic surgery for head and neck cancers compared to conventional open surgery. Systematic review.

This systematic review examined nutritional outcomes in patients undergoing transoral robotic surgery (TORS), compared to open surgery (OS) for head and neck cancer. PUBMED, CINAHL, and Web of Science were systematically reviewed. Target nutritional outcomes included: weight, nutritional status, use of enteral feeding, swallowing function/ability, and time to oral diet. Risk of bias was assessed using the risk of bias in non-randomized studies tool, and certainty of evidence was assessed using grading of recommendations, assessment, development, and evaluation (GRADE). Eight studies were included (total n=608). Compared to OS, TORS probably reduces short- and long-term enteral feeding use or duration (GRADE "moderate" certainty), may reduce time to full swallow ability (GRADE "low" certainty), but it remains uncertain whether TORS reduces long-term patient reported swallowing function or time to oral feeding (GRADE "very-low" certainty). No studies examined nutritional status or weight. There is limited body of evidence examining nutrition outcomes following TORS. Further studies are warranted, which may improve the certainty of evidence and assist in determining the optimal nutrition care for these patients.

Enhancing shared and surrogate decision making for people living with dementia: A systematic review of the effectiveness of interventions.

BackgroundDementia can have a profound impact on decision making. People living with dementia (PLwD) often need to make decisions about health care, and, as dementia progresses, decisions may need to be made on their behalf. Specific interventions may support this process.Review QuestionWhat interventions are effective in improving shared decision making or surrogate decision making on the health care of PLwD?MethodsA narrative systematic review of existing literature was conducted. Seven databases, grey literature and key journals were searched. After exclusion by title, abstracts then full texts were reviewed collaboratively to manage any disagreements.ResultsEight studies met the inclusion criteria. Two articles, including one RCT, evaluated decision aids regarding the use of enteral feeding in advanced dementia. Six further articles, including five RCTs, were found which evaluated the effectiveness of interventions supporting patients or carers with advance care planning.ConclusionDecision‐making interventions typically consist of multiple components which aim to establish preferences for future health care. Advance care planning interventions supported aspects of the decision‐making processes but their impact on decision quality was rarely evaluated. Interventions did not increase the concordance of decisions with a person's values. The decision‐specific interventions are unlikely to produce benefit in other decision contexts.Patient InvolvementTwo caregivers, a public stakeholder group and a carer group were consulted in the design of the wider study to which this review relates. Six PLwD refined the research questions addressed in this paper.

Nutritional Management of Patients With Enterocutaneous Fistulas: Practice and Progression.

The management of enterocutaneous fistulas (ECF) can be challenging because of massive fluid loss, which can lead to electrolyte imbalance, severe dehydration, malnutrition and sepsis. Nutritional support plays a key role in the management and successful closure of ECF. The principle of nutritional support for patients with ECF should be giving enteral nutrition (EN) priority, supplemented by parenteral nutrition if necessary. Although total parenteral nutrition (TPN) may be indicated, use of enteral feeding should be advocated as early as possible if patients are tolerant to it, which can protect gut mucosal barrier and prevent bacterial translocation. A variety of methods of enteral nutrition have been developed such as fistuloclysis and relay perfusion. ECF can also be occluded by special devices and then EN can be implemented, including fibrin glue application, Over-The-Scope Clip placement and three-dimensional (3D)-printed patient-personalized fistula stent implantation. However, those above should not be conducted in acute fistulas, because tissues are edematous and perforation could easily occur.

Diagnostic Stewardship Effectively Reduces Healthcare-Onset Clostridioides difficile Infections and Concurrent Laxative Use

Background:Clostridioides difficile infection (CDI) accounts for &gt;500,000 community-, nursing-, and hospital-acquired infections (HAIs), as well as 15,000–30,000 deaths, and =$4.8 billion in the United States annually. C. difficile toxin B gene nucleic acid amplification testing (NAAT) cannot distinguish between active CDI and colonization, particularly in the setting of laxative use or enteral feeding. Lack of judicious testing can result in the incorrect diagnosis of CDI, unnecessary CDI treatment, increased costs, and falsely augmented HAI rates. Like many healthcare facilities, the VA San Diego Healthcare System (VASDHS) solely utilizes C. difficile NAAT for CDI diagnosis. The aim of this study was to implement and evaluate a facility-wide initiative at the VASDHS to reduce healthcare onset, healthcare facility associated CDI (HO-HCFA CDI), including the use of a test ordering algorithm. Methods: From fiscal year (FY) 2015–2018, various measures were implemented including a hand hygiene initiative, reduction in fluoroquinolone usage, prompt isolation of patients with CDI, thorough terminal cleaning of rooms, and, lastly, a test-ordering algorithm starting FY2018. A retrospective study was performed to assess VASDHS HO-HCFA CDI case incidence, risk factors for infection, laxative or enteral feeding use at the time of testing, and CDI treatment. Results: Patient demographic data, medical history, CDI history, laxative use, treatment, and cost of CDI treatment were reviewed. From 2015 to 2018, 127 cases of HO-HCFA CDI were identified. The total number of HO-HCFA CDI cases and medication cost for CDI treatment were dramatically reduced from 2017 to 2018 following implementation of the test-ordering algorithm (Table 1, Fig. 1). This trend corresponded to a significant reduction in median HO-HCFA CDI cases per month (P = .02), medication cost of CDI treatment (P = .02), and proton pump inhibitor (PPI) use at the time of testing (P = .01). The number of positive HO-HCFA CDI cases associated with laxative use or escalation at the time of CDI testing (accounting for those on chronic laxatives) also decreased across the study period—most dramatically from 2015 vs 2016 (20 vs 14) and 2017 vs 2018 (11 vs 4) (Table 1). Conclusions: At the VASDHS, diagnostic stewardship of C. difficile NAAT with the use of a test-ordering algorithm significantly reduced HO-HCFA CDI incidence and treatment cost. This trend also corresponded with significantly less PPI use at the time of testing and reduced detection of colonization among patients with laxative-induced diarrhea. Diagnostic stewardship may serve as an effective tool to correctly diagnose and treat HO-HCFA CDI, while significantly reducing treatment costs.Funding: NoneDisclosures: None

Outcomes for Feeding Tube-Dependent Children With Oral Aversion in an Intensive Interdisciplinary Treatment Program

Purpose Feeding challenges in children are common, at times reaching a severity that requires the placement and long-term use of enteral feedings. A significant barrier to advancing the oral eating of some tube-dependent children is the presence of oral aversion. Although some research exists regarding the treatment of tube-dependent children who are averse to food or the process of eating, specifically, there has yet to be an examination of children who are truly "orally" averse-resisting not just the presentation of food or liquid but also nonnutritive stimuli presented extra- or intra-orally. Method Using a retrospective chart review, the current study aimed to examine the treatment outcomes of 18 feeding tube-dependent children with significant oral aversion (nine boys, nine girls; M age = 46.7 months, SD = 20.0 months, range: 11.4-89.3 months) as compared to 29 tube-dependent, but nonorally averse, clinical controls. Children completed approximately 6-8 weeks of intensive interdisciplinary feeding treatment. Results Analyses revealed significant improvements in all measured treatment outcomes for both patient groups, including children's rates of acceptance and maladaptive mealtime behavior. Significant reductions in tube use were also observed across both groups, with tube utilization decreasing, on average, by 76.2% for orally averse and by 64.3% for nonorally averse children by program discharge. Conclusion Results demonstrate the therapeutic benefits of intensive interdisciplinary intervention for both groups of tube-dependent children, highlighting that orally averse children, believed to be an especially challenging subset of pediatric feeding patients, demonstrate similarly positive treatment responses. Interestingly, in this preliminary examination, orally averse children demonstrated significantly greater reductions in tube utilization following discharge when compared with their nonorally averse clinical peers.

Abstract A36: Impact of feeding tube use on swallowing-related quality of life and weight in oropharyngeal cancer

Abstract Purpose: This study investigated differences in swallowing-related quality of life (QoL) and weight outcomes in patients treated for oropharyngeal cancer (OPC) based on feeding tube (FT) use. Methods: A retrospective chart review of OPC patients treated with definitive radiotherapy (± chemotherapy) was performed. Swallowing QoL and weight outcomes were collected from electronic medical records for patients seen at a single regional cancer center between January 2013 and December 2015. M.D. Anderson Dysphagia Inventory (MDADI) composite scores, Performance Status Scale for Head and Neck Cancer (PSS-HN) Normalcy of Diet scores, and weight measurements were gathered at baseline and at 3, 6, and 12 months post-treatment. Patients were grouped based on FT use. Bivariate associations were evaluated using the chi-square test and change over time was analyzed by group using a linear mixed effects analysis. The proportion of patients with clinically meaningful change was also determined. Results: Of 126 eligible patients, 46 (36.5%) received a reactive gastrostomy or gastro-jejunostomy FT (FT group). Compared to baseline, MDADI composite scores were significantly lower at 3 and 6 months (p &amp;lt; .001) for those who did not receive a FT (NFT group), while no significant change occurred in the FT group over time. No significant change was noted in PSS-HN scores for either group. Significant decreases in weight occurred in both groups at 3 and 6 months, and at 12 months for the NFT group alone (p &amp;lt; .001). Clinically meaningful decreases in MDADI composite scores at 3, 6, and 12 months were observed in 53%, 43%, and 29% of FT patients and 45%, 44%, and 33% of NFT patients, respectively. Clinically meaningful decreases in weight were observed at 3, 6, and 12 months in 30%, 23%, and 13% of FT patients and for 50%, 44%, and 40% of NFT patients, respectively. There was no significant association between FT use and clinically meaningful decreases in either MDADI composite scores or weight. Conclusions: Despite selective use of enteral feeding for nutritional support in patients at risk, the impact of FT utilization on functional outcomes is not well understood. Statistically significant decreases in short-term swallowing-related QoL were noted preferentially in patients without FTs, and there was a concerning trend for NFT patients to not return to baseline weight by 12 months post-treatment. However, this study also identified that patients in both groups experienced clinically meaningful decreases in swallowing-related QoL and weight in the first year post-treatment irrespective of FT use. Based on this evidence, it is prudent to monitor weight change closely, particularly in patients who do not meet initial risk criteria for reactive FT placement. Understanding the potential for clinically meaningful change in swallowing QOL and weight will contribute to improved patient monitoring and intervention, and may ultimately lead to better outcomes for those with OPC. Citation Format: Nedeljko Jovanovic, Colleen Dreyer, Sarah Hawkins, Kendra Thouless, David Palma, Philip C. Doyle, Julie A. Theurer. Impact of feeding tube use on swallowing-related quality of life and weight in oropharyngeal cancer [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; 2019 Apr 29-30; Austin, TX. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(12_Suppl_2):Abstract nr A36.

Factors associated with non-completion of radiation therapy (RT) or radiochemotherapy (RTCT) in head and neck squamous cell carcinoma (HNSCC): A prospective study.

e17568 Background: Although numerous factors have been reported to increase RT/RTCT toxicity, identification of patients with high risk of toxicities is lacking. Methods: The monocentric NutriNeck study (NCT02900963) recruited all HNSCC patients between 2014 and 2018 treated by RT or RTCT. Patients fed by enteral nutrition before RT initiation were excluded. All clinical and biological, planned RT or RTCT parameters were collected at baseline. A daily monitoring of the weight and a weekly evaluation of clinical, biological and food intake during RT/RTCT were performed. A nutritional intervention by enteral feeding was systematically proposed in case of 2 kg weight loss under treatment. Complete treatment was defined as full planned RT doses without more than 3 days interruption, and full planned doses of cisplatin and cetuximab if indicated. Primary endpoint assessed factors associated with non-completion of the planned treatment. Secondary endpoint assessed factors associated with use of enteral nutrition during treatment. A p value &lt; 0.01 was considered significant. Results: Among the 249 HNSCC patients included, 118 (47%) were treated by RT and 131 (53%) by RTCT. 63 patients (25%) did not complete treatment: 3/118 (2.5%) in the RT group compared to 60/131 (45.8%) the RTCT group, p &lt; 0.0001. Median weight lost during treatment (7 vs 3.8 kg, p &lt; 0.0001) and grade 3 toxicities (53 vs 33%, p = 0.006) were more frequent in patients with incomplete RT/RTCT. Nutritional intervention was performed in 111 patients: 28 (23.7%) with RT and 83 (62.6%) with RTCT (p &lt; 0.0001). Week 4 was associated with the higher rate of enteral nutrition initiation in both RT and RTCT groups. Among RTCT group, weight loss during treatment (OR 1.2 for each kg, p &lt; 0.0001) and use of enteral feeding (OR 2.7, p = 0.005) were associated with incomplete treatment in multivariate analysis. Of note, 48 patients refused enteral nutrition while indicated, they had comparable grade 3 toxicities and weight loss during treatment compared to the 111 patients who accepted enteral nutrition. Conclusions: Incomplete treatment is overwhelmingly associated with RTCT rather than RT. Baseline clinical, biological features or treatment volume/dose are not associated with incomplete treatment. Enteral nutrition initiated during treatment is poorly efficient.

Long term patient reported swallowing function following chemoradiotherapy for oropharyngeal carcinoma

Background and purposeLimited data are available to inform on long term swallowing outcomes following concurrent chemoradiotherapy for oropharyngeal carcinoma. The aims of this study are to determine long term patient-reported swallowing outcomes across two large UK centres in routine clinical practice and identify associated factors. Material and methodsAll patients treated for oropharyngeal squamous cell carcinoma with concurrent chemoradiotherapy, and irradiation of the bilateral neck, between 2011 and 2013 were identified. Those requiring therapeutic enteral feeding prior to treatment, or having subsequent disease relapse, were excluded from the study. Patients were sent postal invitations to complete the MD Anderson Dysphagia Inventory (MDADI), at least two years following completion of treatment. ResultsCompleted MDADI were received from 201/242 eligible patients (83%) at a median of 3.4 years (range 2–5) post treatment. Median composite MDADI score was 68.4. 64 (32%) had composite MDADI <60 classed as ‘poor’ function, 76 (38%) scores ≥60–<80 classed as adequate function, and 61 (31%) had scores ≥80 classed as optimal function. Patients with normal and abnormal pre-treatment diet had median composite MDADI scores of 70.5 versus 47.4 respectively. Patients who did not require enteral feeding during treatment and those who did had median composite MDADI scores of 76.3 versus 65.3 respectively. On multivariate analysis poorer performance status, abnormal pre-treatment diet, and use of enteral feeding during radiotherapy were all significantly associated with lower composite, global and subscale MDADI scores. ConclusionsPatient reported swallowing dysfunction remains common in the long term post-chemoradiotherapy. Impaired pre-treatment diet and use of enteral feeding during treatment are key factors associated with poorer swallowing outcomes.

Acute Pancreatitis: Landmark Studies, Management Decisions, and the Future.

A great deal of progress has been made in the last 50 years in the diagnosis and treatment of acute pancreatitis. Many landmark studies have been published and have focused on the classification of acute pancreatitis, markers of severity, important roles of imaging and endoscopy, and improvements in our treatment. This report will review several landmark studies, describe ongoing controversies in management decisions including standards of early fluid resuscitation and appropriate use of enteral feeding, and outline what will be required in the future to improve the care of patients with acute pancreatitis.

Is Total Parenteral Nutrition (TPN) an Evil in Trauma Patients?

The use of parenteral nutrition has been progressively decreasing over the past 30 years, and it has been considered as harmful while enteral feeding has been preferred for critically ill trauma patients, including for head trauma patients. However, the use of enteral feeding is associated with underfeeding while the use of parenteral nutrition can create complications due to overfeeding (infections, increased length of stay, length of ventilation, increased liver tests). Measuring energy expenditure by indirect calorimetry enables more accurate energy needs and calorie targets can be optimized. Formulas with higher protein content allow increased protein administration. In case of gastrointestinal intolerance, parenteral nutrition is an efficient alternative route to reach optimal targets. This route may improve clinical outcome. The use of parenteral nutrition has recently been shown to be safe if not given in excess, challenging the theory that TPN should be avoided. A reevaluation of the use of parenteral nutrition has to be performed to decrease calorie and nitrogen deficits in critically ill trauma patients.

Determining the Independent Risk Factors and Mortality Rate of Nosocomial Infections in Pediatric Patients.

The objective of this study was to determine the rate, independent risk factors, and outcomes of healthcare-associated infections in pediatric patients. This study was performed between 2011 and 2014 in pediatric clinic and intensive care unit. 86 patients and 86 control subjects were included in the study. Of 86 patients with nosocomial infections (NIs), there were 100 NIs episodes and 90 culture growths. The median age was 32.0 months. The median duration of hospital stay of the patients was 30.0 days. The most frequent pathogens were Coagulase-negative Staphylococcus, Acinetobacter spp., Klebsiella spp., and Candida spp. Unconsciousness, prolonged hospitalization, transfusion, mechanical ventilation, use of central venous catheter, enteral feeding via a nasogastric tube, urinary catheter, and receiving carbapenems and glycopeptides were found to be significantly higher in NIs patients. Multivariate logistic regression analysis showed prolonged hospitalization, neutropenia, and use of central venous catheter and carbapenems as the independent risk factors for NIs. In the univariate analysis, unconsciousness, mechanical ventilation, enteral feeding, use of enteral feeding via a nasogastric tube, H2 receptor blockers, and port and urinary catheter were significantly associated with mortality. In the multiple logistic regression analysis, only mechanical ventilation was found as an independent predictor of mortality in patients with NIs.

PP12.4 – 2816: Status dystonicus: Is it a gut feeling?

Objective Status dystonicus (SD) is a life-threatening movement disorder. We report nine severely disabled children with SD and gut motility problems managed by the paediatric neurology and gastroenterology teams at the Sheffield Children's Hospital U.K. Methods Retrospective case notes review of nine children admitted with SD at our tertiary paediatric centre looking at underlying neurological diagnoses, age of onset of dystonia, concomitant anti-dystonia medication, intrathecal baclofen pump with rate of daily infusion, anti-reflux medication, gastroenterological investigations, use of enteral feeding (oral, gastrostomy and jejunal feeds) and parental nutrition (PN). Results Nine children, mean age 8.43 years (range 5 months to 15.2 years) presented with SD. Pain, pallor, sweating and spasms were precipitated by enteral feeding. All had multiple, independently observed time points where stopping feeds resulted in resolution of symptoms and recommencement of enteral feeds even at 5 ml per hour lead to the return of dystonic spasms and pain. All showed no evidence of reflux disease on pH impedance studies and gastroscopy and did not show peptic oesophagitis on oesophageal biopsies. All nine had jejunal feeding tubes (jejunal extensions to the PEG) with confirmed tip position in the first loop of the jejunum or close to the duodenojejunal flexure by fluoroscopic placement. Barium studies and plain films ruled out intestinal obstruction or sub-acute obstruction. Five of nine patients with severe feed induced pain and dystonia were treated with PN (3 long term and 2 short term). There was objective evidence of substantial pain resolution in all five. Conclusion Children with SD can be at risk of enteral feed induced abdominal pain and small bowel (foregut) dysmotility with some needing PN. The severity of the neurological condition seems to correlate with the severity of gastrointestinal problems raising the need for an ethical frame work and greater understanding of neuro-gastroenterological relationship.

Age most significant predictor of requiring enteral feeding in head-and-neck cancer patients.

BackgroundA significant number of patients treated for head and neck squamous cell cancer (HNSCC) undergo enteral tube feeding. Data suggest that avoiding enteral feeding can prevent long-term tube dependence and disuse of the swallowing mechanism which has been linked to complications such as prolonged dysphagia and esophageal constriction. We examined detailed dosimetric and clinical parameters to better identify those at risk of requiring enteral feeding.MethodsOne hundred patients with advanced stage HNSCC were retrospectively analyzed after intensity-modulated radiation therapy (IMRT) to a median dose of 70 Gy (range: 60-75 Gy) with concurrent chemotherapy in nearly all cases (97%). Patients with significant weight loss (>10%) in the setting of severely reduced oral intake were referred for placement of a percutaneous endoscopic gastrostomy (PEG) tube. Detailed DVH parameters were collected for several structures. Univariate and multivariate analyses using logistic regression were used to determine clinical and dosimetric factors associated with needing enteral feeding. Dichotomous outcomes were tested using Fisher’s exact test and continuous variables between groups using the Wilcoxon rank-sum test.ResultsThirty-three percent of patients required placement of an enteral feeding tube. The median time to tube placement was 25 days from start of treatment, after a median dose of 38 Gy. On univariate analysis, age (p = 0.0008), the DFH (Docetaxel/5-FU/Hydroxyurea) chemotherapy regimen (p = .042) and b.i.d treatment (P = 0.040) (used in limited cases on protocol) predicted need for enteral feeding. On multivariate analysis, age remained the single statistically significant factor (p = 0.003) regardless of other clinical features (e.g. BMI) and all radiation planning parameters. For patients 60 or older compared to younger adults, the odds ratio for needing enteral feeding was 4.188 (p = 0.0019).ConclusionsOlder age was found to be the most significant risk factor for needing enteral feeding in patients with locally advanced HNSCC treated with multimodal treatment. Pending further validation, this would support maximizing early nutritional guidance, targeted supplementation, and symptomatic support for older adults (>60) undergoing chemoradiation. Such interventions and others (e.g. swallowing therapy) could possibly delay or minimize the use of enteral feeding, thereby helping avoid tube dependence and tube-associated long-term physiologic consequences.

Low level laser therapy against radiation induced oral mucositis in elderly head and neck cancer patients-a randomized placebo controlled trial

ObjectivesRadiotherapy (RT) is treatment of choice for Elderly Head and Neck Cancer (HNC) patients. Oral mucositis (OM) during RT affects patient’s routine oral activities and overall health. Low Level Laser Therapy (LLLT) provided some promising results against cancer therapy induced OM in children and adults. No study specifically evaluated effects of LLLT against RT induced OM in elderly HNC patients until date, hence we did this study. Material and methodsThis double blinded study randomized 46 elderly HNC patients scheduled for RT [Dosage=66 Gray (2Gy/fraction), 5 fractions/week, total 33 fractions for 6.5weeks], into laser (22) and placebo (24) groups. Laser group patients received LLLT [Helium–Neon, λ=632.8nm, power density=0.024W/cm2, dosage=3.0J/point at six anatomical sites bilaterally i.e. 12 locations, total dose/session=36J, beam aperture diameter=0.6mm, beam spot size=1cm2, irradiated area diameter=1cm2, irradiation time/point=125s, 5 sessions/week, non-contact method-distance between probe and irradiated tissues <1cm, whereas placebo group did not receive laser. OM grades (RTOG/EORTC Scale), oral pain, weight loss, need for morphine analgesics and tube feeding, and RT break were recorded by a blinded assessor. Descriptive statistics and repeated measures ANOVA were used for analysis keeping p<0.05. ResultsSignificant reduction in the incidence and duration of severe OM (p=0.016) and severe pain (p=0.023) and weight loss (p=0.004) was observed in laser than placebo group. No difference was found for enteral feeding use (p=0.667) between two groups. ConclusionsLLLT decreased the severity of OM and oral pain in elderly HNC patients. Also, lesser weight loss, morphine analgesic use and radiation break happened in laser group.

Enteral nutrition in acute pancreatitis: a review of the current evidence.

The use of enteral feeding as part of the management of acute pancreatitis dates back almost two decades. This review describes the indications for and limitations of enteral feeding for the treatment of acute pancreatitis using up-to-date evidence-based data. A systematic review was carried out to analyse current data on the use of enteral nutrition in the management of acute pancreatitis. Relevant literature was analysed from the viewpoints of enteral vs parenteral feeding, early vs delayed enteral nutrition, nasogastric vs nasojejunal feeding, and early oral diet and immunonutrition, particularly glutamine and probiotic supplementation. Finally, current applicable guidelines and the effects of these guidelines on clinical practice are discussed. The latest meta-analyses suggest that enteral nutrition significantly reduces the mortality rate of severe acute pancreatitis compared to parenteral feeding. To maintain gut barrier function and prevent early bacterial translocation, enteral feeding should be commenced within the first 24 h of hospital admission. Also, the safety of nasogastric feeding, which eases the administration of enteral nutrients in the clinical setting, is likely equal to nasojejunal feeding. Furthermore, an early low-fat oral diet is potentially beneficial in patients with mild pancreatitis. Despite the initial encouraging results, the current evidence does not support the use of immunoenhanced nutrients or probiotics in patients with acute pancreatitis.

Postoperative Chyle Leak After Major Pancreatic Resections in Patients Who Receive Enteral Feed: Risk Factors and Management Options

Chyle leak complicates 1.3-10.8 % of pancreatic resections. Universal use of parenteral nutrition following pancreatic resection may reduce the incidence of chyle leak. However, this denies the majority of patients who do not develop chyle leak the benefits of enteral nutrition (EN). The present study aimed to identify risk factors for chyle leak following pancreatic resection within a single institution where EN was used universally. All patients who underwent pancreatic resection between January 2007 and December 2010 were identified retrospectively. The patients had been treated according to a common unit protocol of enteral feeding; those developing chyle leak were switched to a medium-chain triglyceride (MCT) regimen. Clinical progress and recovery after surgery was evaluated. Multivariate analysis was performed to identify factors associated with chyle leak. A total of 245 patients underwent major pancreatic resection (231 pancreatoduodenectomy, 14 total pancreatectomy). Chyle leak complicated 40 cases (16.3 %). After multivariate analysis, both extensive lymphadenectomy (P = 0.002) and postoperative portal/mesenteric venous thrombosis (PVT) (P = 0.009) were independently linked with a higher incidence of chyle leak. The development of chyle leak was not associated with poorer survival or prolonged duration of hospital stay. It was associated with a significantly increased duration of abdominal drainage and reduced likelihood of early hospital discharge (P = 0.026). Universal use of enteral feeding is associated with a high rate of chyle leak following pancreatic resection. Patients undergoing extensive lymphadenectomy or those who develop PVT postoperatively are at increased risk. Development of chyle leak was not associated with additional morbidity or mortality following implementation of an MCT regimen. The implication is that reactive management of chyle leak with conversion to a MCT predominant diet is safe.

Efficacy and Complications of Nasojejunal, Jejunostomy and Parenteral Feeding After Pancreaticoduodenectomy

BackgroundEuropean nutritional guidelines recommend routine use of enteral feeding after pancreaticoduodenectomy (PD) whereas American guidelines do not. Data on the efficacy and, especially, complications of the various feeding strategies after PD are scarce. MethodsRetrospective monocenter cohort study in 144 consecutive patients who underwent PD during a period wherein the routine post-PD feeding strategy changed twice. Patients not receiving nutritional support (n=15) were excluded. Complications were graded according to the Clavien-Dindo classification and the International Study Group of Pancreatic Surgery (ISGPS) definitions. Analysis was by intention-to-treat. Primary endpoint was the time to resumption of normal oral intake. Results129 patients undergoing PD (111 pylorus preserving) were included. 44 patients (34%) received enteral nutrition via nasojejunal tube (NJT), 48 patients (37%) via jejunostomy tube (JT) and 37 patients (29%) received total parenteral nutrition (TPN). Groups were comparable with respect to baseline characteristics, Clavien ≥II complications (P=0.99), in-hospital stay (P=0.83) and mortality (P=0.21). There were no differences in time to resumption of normal oral intake (primary endpoint; NJT/JT/TPN: median 13, 16 and 14 days, P=0.15) and incidence of delayed gastric emptying (P=0.30). Duration of enteral nutrition was shorter in the NJT- compared to the JT- group (median 8 vs. 12 days, P=0.02). Tube related complications occurred mainly in the NJT-group (34% dislodgement). In the JT-group, relaparotomy was performed in three patients (6%) because of JT-leakage or strangulation leading to death in one patient (2%). Wound infections were most common in the TPN group (NJT/JT/TPN: 16%, 6% and 30%, P=0.02). ConclusionNone of the analysed feeding strategies was found superior with respect to time to resumption of normal oral intake, morbidity and mortality. Each strategy was associated with specific complications. Nasojejunal tubes dislodged in a third of patients, jejunostomy tubes caused few but potentially life-threatening bowel strangulation and TPN doubled the risk of infections.