Erythromycin accelerates gastric emptying of indigestible solids and transpyloric migration of the tip of an enteral feeding tube in fasting and fed states.
Keshavarzian A,Isaac R M
The American journal of gastroenterology
Erythromycin has been shown to initiate gastric interdigestive migrating motor complexes, which are the motor events responsible for gastric emptying of indigestible solids. Hence, erythromycin should also accelerate gastric emptying of indigestible particles and facilitate transpyloric migration of the tip of an enteral feeding tube. Accordingly, we assessed the effect of erythromycin on these events, using a single-blind crossover study. Healthy subjects were nasally intubated with an enteral feeding tube. For fasting studies, the subjects remained fasted; in the fed studies, the subjects were fed a cheeseburger and fries after placement of the feeding tube. Then, ten 1-cm radiopaque plastic segments were swallowed by each subject, followed by an iv infusion of either erythromycin (200 mg over 20 min) or saline. Abdominal x-rays were then taken at regular intervals to document the location of the tube tip and the plastic segments. Erythromycin significantly shortened gastric emptying time of the indigestible particles during both fasting and fed states. Erythromycin also accelerated transpyloric migration of the tip of the feeding tube in both fasting and fed states. Hence, erythromycin can be beneficial when placement of a feeding tube in the small intestine is clinically desired.
Minimizing respiratory complications of nasoenteric tube feedings: state of the science.
Metheny N
Heart & lung : the journal of critical care
This article summarizes research findings regarding ways to minimize the two most dreaded complications of tube feedings: (1) introduction of feedings through tubes positioned in the respiratory tract, and (2) pulmonary aspiration. Bedside methods that lack reliability in ruling out inadvertent respiratory placement of feeding tubes include the auscultatory method, the bubbling under water method, and observing for respiratory symptoms. Testing the pH of aspirates from feeding tubes can be of use in ruling out respiratory placement of newly inserted tubes when acidic values are properly obtained; further, this method can also be helpful in determining when a tube has migrated from the stomach to the intestine. Based on experience, the most frequently cited values for excessive gastric residuals are 100 to 150 ml. In a recent small study, researchers concluded that the residual volume that should raise concern in patients with nasogastric tubes is 200 ml and in patients with gastrostomy tubes the amount is 100 ml. Several recent studies indicate that although elevating the head of the bed 30 to 45 degrees does not prevent aspiration, it does reduce its frequency and severity. Because many studies described in this review have not been replicated, readiness of their findings for clinical application is variable. Many questions regarding methods to prevent respiratory complications in tube-fed patients remain unanswered, largely because it is difficult to design clinical studies with sufficient control of significant variables.
Nasoduodenal feeding tubes: prevention of occlusion.
Scanlan M,Frisch S
The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses
Blockage of nasoduodenal feeding tubes is costly in terms of materials and nursing time, and traumatic to the neuroscience patient. A laboratory experimental study explored ways to decrease obstruction of small bore nasoduodenal feeding tubes when medications are given concurrently with continuous tube feeding. The first part of the study examined type and form of 4 medications in relation to frequency and timing of tube blockage. Trimethoprim sulfamethoxazole (Septra) in dissolved pill form blocked tubes most frequently (F10,77 = 10.333, p < .001) and in the shortest time (F10,77 = 10.534, p < .001). The second part of the study examined different irrigation methods. Irrigation before and after administration of medication and irrigation after medication administration only were significantly better than no irrigation in preventing blockage, both in terms of number of occlusions (F2,87 = 5.486, p < .01) and time to occlusion (F2,87 = 4.556, p < .02). The fact the study was performed in vitro rather than in vivo was a limiting factor. However, results of the study suggest trimethoprim sulfamethoxazole forms occlusions, especially in dissolved form. Elixir of this medication should probably be used whenever available. This study also found that irrigating the tube before and after administration of medications was the most effective of the 3 options examined.
10.1097/01376517-199210000-00005
Early enteral feeding does not attenuate metabolic response after blunt trauma.
Eyer S D,Micon L T,Konstantinides F N,Edlund D A,Rooney K A,Luxenberg M G,Cerra F B
The Journal of trauma
Enteral feeding very early after trauma has been hypothesized to attenuate the stress response and to improve patient outcome. We tested this hypothesis in a prospective, randomized clinical trial in patients with blunt trauma. Following resuscitation and control of bleeding, 52 patients were randomized to receive early feedings (target, < 24 hours) or late feedings (target, 72 hours). Feeding was given via nasoduodenal feeding tubes. A rapid advance technique was used to achieve full volume and strength within 24 hours (goal, 1.5 g protein/kg.day). Patients who underwent at least 5 days of therapy were considered to have completed the study: 38 in all, 19 in each feeding group. Patients were similar in age, gender, Injury Severity Score, and mean PaO2/FiO2 ratio. The early group, however, had more patients with a PaO2/FiO2 < 150. After feeding began, the amount fed per day was the same in both groups. We found no significant differences in metabolic responses as measured by plasma lactate and urinary total nitrogen, catecholamines, and cortisol. Both groups achieved nitrogen retention. In addition, we found no significant differences in intensive care unit (ICU) days, ventilator days, organ system failure, specific types of infections, or mortality, although the early group had a greater number of total infections. In this study, early enteral feeding after blunt trauma neither attenuated the stress response nor altered patient outcome.
10.1097/00005373-199305000-00005
Using enteral nutrition formulas.
Culpepper-Morgan J A,Kim K,Floch M H
The Gastroenterologist
A review of enteral tube feeding formulations is presented. When choosing an enteral formula product for a patient one must first determine the calorie and protein needs of the patient. Then one must determine the level of gastrointestinal tract function. First ask, to what degree is the small bowel functioning: totally, partially, or not at all? Has the small bowel lost surface area because of atrophy, inflammation, or surgical removal? Is the gut edematous because of hypoalbuminemia or congestive heart failure? Is bowel motility impaired by opioids, anticholinergics, or mechanical ileus? Is digestion limited by pancreatic or bile acid insufficiency? Has absorption been decreased by intestinal ischemia or gastrointestinal bleeding? Decreased surface area, bowel edema, and diminished digestive juices are only partial losses of small bowel function. An elemental formula should be tried first in these situations. Any of the other problems alone or in combination probably preclude the use of the small bowel and the patient will need total parenteral nutrition. If gastrointestinal function is adequate, then other organ failures that result in specific nutrient intolerance must be ruled out. If gastrointestinal function is adequate and no other organ failures preclude the use of a polymeric formula, then one must decide if stress and hypermetabolism are present. Enteral feeding is the preferred method of providing specialized nutrition support. Bowel rest reduces the barrier functions of the gut and malnutrition reduces cell-mediated immunity. The indications and relative contraindications for enteral tube feeding are also reviewed. The rationale for the formula design and the evidence for formula efficacy are presented. Polymeric, elemental, organ-specific, and immune-modulating formulas are discussed. Guidelines for formula selection are suggested.
Laparoscopic placement of a percutaneous endoscopic gastrostomy (PEG) feeding tube.
Raaf J H,Manney M,Okafor E,Gray L,Chari V
Journal of laparoendoscopic surgery
Patients may have abnormal anatomic relationships between the stomach and adjacent organs, particularly when there is a history of abdominal surgery and adhesion formation. Routine placement of a percutaneous endoscopic gastrostomy tube can then be unsafe and result in inadvertent colon perforation, small bowel enterotomy, or injury to other structures. Described herein is a 94-year-old malnourished male in whom the colon lay directly anterior to the greater curvature of the stomach. A new technique was devised--laparoscopically-directed PEG placement--which proved to be a safer alternative approach in this patient.
10.1089/lps.1993.3.411
Success of immediate intragastric feeding of patients with burns.
Hansbrough W B,Hansbrough J F
The Journal of burn care & rehabilitation
We evaluated our attempts to aggressively feed 45 adult patients with burns with the use of intragastric tube feedings. Patients were divided into three burn sizes (20% to 30% total body surface area, 31% to 44% total body surface area, and > 44% total body surface area). No attempts were made to place feeding tubes across the pylorus. Patients were fed as early as possible after admission. Mean caloric intake met calculated nutritional goals beginning on the second day after burn injury, and in the severely burned group, mean caloric intake was 2500+ kcal by the second day. Initiation of intragastric feedings within hours of burn injury results in the provision of high daily levels of nutrition and may obviate the necessity of placing a transpyloric feeding tube in the majority of patients with burns.
Percutaneous gastrojejunostomy versus Nissen fundoplication for enteral feeding of the neurologically impaired child with gastroesophageal reflux.
Albanese C T,Towbin R B,Ulman I,Lewis J,Smith S D
The Journal of pediatrics
To determine the optimal method of providing enteral feeding to neurologically impaired children with gastroesophageal reflux, Nissen fundoplication with simultaneous gastrostomy tube placement (NGT) was compared with anterograde percutaneous gastrojejunostomy (APGJ), a nonsurgical procedure performed under fluoroscopic guidance. The records of 112 neurologically impaired children with gastroesophageal reflux were retrospectively reviewed; 68 had undergone NGT and 44 APGJ. Follow-up data were available for 45 NGT patients (mean age, 6.4 years) and 34 APGJ patients (mean age, 7.9 years). Mean follow-up was 1.8 years in the NGT group and 2.5 years in the APGJ group. Complications resulting from either procedure were classified either as major, which included treatment failures or morbidity resulting in prolonged hospitalization, or as minor, those requiring outpatient treatment only or not directly caused by the procedure. The NGT group had a significantly higher incidence of major complications in comparison with the APGJ group (33.3% vs 11.8%, p < 0.05). Ten patients (22.2%) in the NGT group required reoperation for complications; six required a second NGT for wrap hernia, failure, and continued gastroesophageal reflux. Two patients (5.9%) in the APGJ group required surgery for complications; one of these eventually required an NGT, and the other had an intussusception that necessitated a small-bowel resection. Minor complications were more common in the APGJ group than in the NGT group (44.1% vs 6.6%); the majority of complications were related to the jejunostomy tube. Premature replacement or reinsertion of the jejunostomy tube was necessary in 14 APGJ patients (32%). The mortality rate was 8.8% in the NGT group and 5.9% in the APGJ group (p = not significant). No death occurred within 30 days of either procedure. We conclude that APGJ is a safe alternative method for feeding the neurologically impaired child with gastroesophageal reflux.
10.1016/s0022-3476(05)81734-2
[ENT nosocomial infections in the intestinal care unit].
Alvarez Acevedo G,Carrillo Esper R,Hernández Palestina M,Volkow Fernández P
Anales otorrinolaringologicos ibero-americanos
This is a report about the outcome following a study of watchfullness on hospital acquired infections of the E.N.T.-area, during a 7 months term. In the study are included those internees admitted for more than 48 hours in the unit. In each case the clinical record comprises the infective risk factors, the follow-up and treatment, as well as a naso-pharyngo-laryngoscopy with cold light. If necessary cultures and imaging studies were done and even invasive procedures employed with diagnostical and/or therapeutical purposes (punction or surgery). In the whole, a collective of 24 patients, with an average attendance of 17.5 days (margin 3-60 days), average age 54.4 years (margin 22-85 years), 5 nosocomial E.N.T.-infections were detected: 2 pansinusitis, 2 bacterial otitis media and 1 case of infected tracheostome. This figures should be related with an incidence rate of 20.8 percent discharges. Cranio-encephalic traumata, the taken of antimycotics and either the simultaneous use of feeding tubes (naso-gastric, naso-jejunal) have had a statistical value as risk factors linked with ENT-area. Discussion on the need for establishing a permanent program of surveillance of ENT-infections in the ICU without missing a routine naso-pharyngolaryngoscopy.
Intraluminal "balloonless" air tonometry: a new method for determination of gastrointestinal mucosal carbon dioxide tension.
Salzman A L,Strong K E,Wang H,Wollert P S,Vandermeer T J,Fink M P
Critical care medicine
OBJECTIVE:To determine if air introduced directly into the lumen of a hollow viscus can be used instead of fluid in a Silastic balloon to estimate gastrointestinal mucosal PCO2. DESIGN:Prospective, unblinded comparison of two methods of mucosal PCO2 measurement. SETTING:Animal surgery suite at a large, university-affiliated medical center. INTERVENTIONS:Standard, commercially available, tonometric catheters were positioned in the ileum (n = 4) or the stomach and ileum (n = 12) of anesthetized, immature Yorkshire swine. Using gas-tight purse-string sutures, plastic cannulas were inserted into the lumen of the stomach (n = 12) and the lumen of a 10-cm isolated segment of ileum (n = 16). Data were collected after equilibration periods of 30 or 60 mins. Before each equilibration period, the "air tonometers" (i.e., the lumens of the stomach and/or the isolated ileal segment) were lavaged with 200 mL (stomach) or 20 mL (ileum) of air. In group 1 (n = 4) and group 2 (n = 3), graded degrees of mesenteric hypoperfusion were achieved by mechanical mesenteric occlusion or pericardial tamponade, respectively. In group 3 (n = 8), graded degrees of respiratory acidosis were induced. At various intervals, PCO2 was determined simultaneously in arterial blood, gastric air, saline from the gastric tonometric balloon, ileal air, and saline from the ileal tonometric balloon. MEASUREMENTS AND MAIN RESULTS:In pigs with ischemia created by mesenteric vascular occlusion (group 1), there was a moderate correlation between PCO2 values in air samples from the ileal lumen and samples of saline from the standard tonometer (r2 = .61, p < .001). In pigs with mesenteric ischemia secondary to pericardial tamponade (group 2), air and saline tonometry were well-correlated in the stomach (r2 = .71, p < .001) and ileum (r2 = .83, p < .001). In pigs with normal mesenteric perfusion (group 3) and PaCO2 > 40 torr (5.3 kPa), PaCO2 correlated with ileal mucosal PCO2, determined using air (r2 = .93, p < .001) or saline (r2 = .91, p < .001) tonometry, or gastric mucosal PCO2, determined using air (r2 = 1.00, p < .001) or saline (r2 = .97, p < .001) tonometry. Values obtained by air tonometry were highly correlated with values obtained using standard saline tonometry in the stomach (r2 = .98, p < .001; bias = -5 +/- 5 torr [-0.65 +/- 0.65 kPa]) or ileum (r2 = .96, p < .001; bias = 1 +/- 9 torr [0.13 +/- 1.17 kPa]). CONCLUSIONS:a) Under stable hemodynamic and respiratory conditions, air tonometry (which, in theory, can be performed using a conventional nasogastric or nasoenteric feeding tube) estimates gastrointestinal mucosal PCO2 as accurately as standard saline tonometry in the stomach or ileum; b) respiratory acidosis leads to tissue hypercarbia, a phenomenon that must be considered when tonometry is used to guide therapy in the clinical setting; c) under stable, nonischemic conditions, gastric or intestinal tonometry can be used to estimate PaCO2.
10.1097/00003246-199401000-00024
Fiber-containing formula and needle catheter jejunostomies: a clinical evaluation.
Collier P,Kudsk K A,Glezer J,Brown R O
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
Despite the high frequency of diarrhea, chemically defined diets have traditionally been used with needle catheter jejunostomies, a common form of postpyloric enteral access, to avoid tube occlusion. We reviewed our experience with 57 patients fed a fiber-containing diet to determine the incidence of catheter occlusion and diarrhea. Eight catheters temporarily occluded but were reopened and remained patent for an additional 6.3 +/- 3.1 days for an overall success rate of 91% (52 of 57). The five remaining occluded catheters were removed after 6.2 +/- 1.8 days. Four of the five patients with occluded catheters tolerated gastric feedings, but one required a permanent jejunostomy. Diarrhea occurred in six (10.5%) of the 57 patients given the fiber-containing formula. We concluded that a fiber-containing formula can be administered through needle catheter jejunostomies if the catheter is irrigated daily and if no medications are given via the catheter. A fiber-containing formula may reduce the incidence of diarrhea in jejunostomy-fed patients compared with patients fed chemically defined diets.
10.1177/0115426594009003101
Gastrostomy tubes after gynecologic oncologic surgery.
Gleeson N C,Hoffman M S,Fiorica J V,Roberts W S,Cavanagh D
Gynecologic oncology
In order to prevent the complications of long-term nasogastric suctioning and increase patient comfort, we have been using gastrostomy tubes (G-tubes) in gynecologic oncology patients who are deemed to be at risk for protracted postoperative bowel dysfunction. This study describes our patient selection criteria and evaluates the results with 35 MIC (Medical Innovation Corporation, Milpitas, CA) gastrostomy tubes inserted between September 1, 1992 and April 30, 1993. The procedure is technically easy and adds approximately 10 min to operating time. The tubes were well tolerated by the patients over periods ranging from 5 to 135 days. All tubes were used for postoperative gastric drainage and in addition, eight tubes were used for short-term enteral feeding. One patient with short bowel syndrome continued enteral nutritional supplementation at home. Twenty patients were discharged with their G-tubes in situ. Five of these patients required continuous gastric drainage because of obstruction of gastric emptying or small bowel by advanced tumor, and four of them were taking full liquids orally prior to discharge from the hospital. Gastrostomy tubes are convenient adjuncts to postoperative care of the gynecologic oncology patient and afford palliation with few complications to patients dying with bowel obstruction.
10.1006/gyno.1994.1159
Gut failure--predictor of or contributor to mortality in mechanically ventilated blunt trauma patients?
Dunham C M,Frankenfield D,Belzberg H,Wiles C,Cushing B,Grant Z
The Journal of trauma
UNLABELLED:Thirty-seven ventilator-dependent blunt trauma patients (ISS 36 +/- 15) were randomized at 24 hours after injury to receive parenteral (TPN) (n = 15), enteral (TEN) (n = 12), or parenteral plus enteral (PN/EN) (n = 10) nutrition. The TEN and PN/EN patients had endoscopically placed transpyloric feeding tubes. Patients who had nutritional complications were two TPN (13%), three TEN (25%), and five PN/EN (50%). Enteral complications were tube occlusion (two), failed duodenal intubation (one), patient extubation of feeding tube (one), gastric reflux (two), and abdominal distention (two). Mortality rates were not different between the groups, but were significantly related to the nutrition-associated complications (p = 0.01): four deaths in ten (40%) with complications and one death in 27 (3.7%) without complications. All four deaths associated with complications occurred in the four with gastric reflux or abdominal distention. No deaths occurred in the other 18 TEN or PN/EN patients (p = 0.0001). Of the four deaths, three were associated with ARDS and respiratory infection (75%). CONCLUSIONS:In mechanically ventilated blunt trauma patients, endoscopic transpyloric tube placement and feeding has a substantial failure rate (36%). Intolerance to duodenal feeding has a remarkably high mortality (100%) in patients in whom gut dysfunction may be a manifestation of injury severity or directly affect survival.
10.1097/00005373-199407000-00007
Direct endoscopic percutaneous jejunostomy (EPJ). Clinical results.
Mellert J,Naruhn M B,Grund K E,Becker H D
Surgical endoscopy
Direct puncture of the small bowel under endoscopic guidance (direct EPJ) is possible in patients whose stomach has been removed or whose small bowel cannot be punctured by other methods. From January 1990 to June 1992 a total of 39 patients underwent successful direct EPJ at our institution. The indications were malnutrition after partial or total gastrectomy (n = 19), insufficient anastomosis or a stenosis after esophageal resection and esophagojejunostomy (n = 13), esophageal perforation (n = 3), fistulas (n = 2), or severe trauma (n = 2). The tubes were inserted at the bedside under local anesthesia using the string pull-through technique. The procedure was attempted in five other patients but it was technically impossible to insert the tubes in these patients. Postoperative enteral feeding was possible in all 39 patients whose direct EPJ was successful. Complications included tube dysfunction due to plugging and fracture in five patients, pressure-induced enteric ulcers in two, and local infections in three patients. The ulcers and infections were managed conservatively. We conclude that direct EPJ is a safe, effective alternative to surgical catheter-jejunostomy.
pH measurements as guide for establishing short-term postpyloric enteral access.
Berry S,Schoettker P,Orr M
Nutrition (Burbank, Los Angeles County, Calif.)
Standard antiulcer regimens that use agents such as intravenous ranitidine (50 mg every 8 h) and/or intragastric antacids (30 ml every 4 h) do not seem to preclude use of pH-sensing feeding tubes in our patient population. The cost of placement ($174/successful tube) compared favorably (3-79% less) with the cost of other placement methods used at our institution. Immediate establishment of postpyloric access by this method can decrease delays in instituting nutritional support. Moreover, in patients at increased risk for aspiration, e.g., those with altered mental status, postpyloric tube placement may be beneficial in reducing aspiration occurrence. The equipment is portable and easy to operate, and the placement technique can be easily learned and performed at bedside by nurses and physicians. Whereas we feel that the sensitivity and specificity for intestinal placement are not sufficient to preclude a confirmatory radiograph, the sensitivity and specificity for intragastric placement in our study were both 100%. Our own policy is to obtain a confirmatory radiograph before institution of any nutritional therapy through a central access device (central venous catheter or feeding tube). However, depending on hospital or departmental policy, a radiograph may be unnecessary when intragastric placement is deemed adequate. Finally, this placement method may obviate the need for more intricate and expensive methods of feeding-tube placement.
Measurement of gastric and small bowel electrical activity at laparoscopy.
Familoni B O,Abell T L,Voeller G
Journal of laparoendoscopic surgery
Recordings of gastric electrical activity can be employed in the diagnosis of certain gastric motility disorders. Since the best recordings are obtained from electrodes implanted at laparotomy, the scope of application of this technique is limited. The current study details a method of measuring gastric electrical activity at laparoscopy. The patients were 3 Caucasian women whose age range was 16 to 30 years. Their pertinent history included symptoms of nausea, vomiting, constipation, and abdominal pain. Gastric and small bowel electrical activity was measured with stainless steel electrodes implanted into the serosa of the stomach and small bowel at laparoscopy. Laparoscopy was performed for small bowel biopsy, bowel resection, or feeding tube placement. The recorded signals were evaluated by manual analysis. Good quality gastric and small bowel electrical activities were obtained. Amplitude, frequency, rhythmicity, and direction of propagation information were readily obtained by visual inspection. Laparoscopic measurement of gastric electrical activity produces excellent quality recordings comparable with recordings from electrodes implanted at laparostomy. The technique combines the advantage of laparoscopy with the usefulness of serosal measurement of gastrointestinal electrical activity.
10.1089/lps.1994.4.325
Hold that x-ray: aspirate pH and auscultation prove enteral tube placement.
Neumann M J,Meyer C T,Dutton J L,Smith R
Journal of clinical gastroenterology
We report here a prospective study evaluating an alternative to the roentgenographic confirmation of "fine-bore" nasoenteral feeding tubes. Of 78 nasoenteral intubations in 46 patients using a Dobbhoff (Biosearch Medical Products) weighted enteral feeding tube, gastric aspirates were evaluated in 28. Auscultation was performed in all 78. Data was collected at initial placement prior to x-ray confirmation. Observers used color-coded pH paper to analyze gastric aspirate (pH < or = 4) and/or auscultation of the epigastrium to determine feeding tube position prior to x-rays. Auscultation alone was ineffective as a confirmatory test with only 6.3% specificity (p = 0.31). Aspiration to ascertain tube position was very accurate when pH < or = 4.0 (p = 0.0005) and when it was performed. A pH value of > 4 was not very helpful in predicting malposition (37%) especially when pH altering medications were used. Aspiration of contents was successful in 85% of patients. We conclude that when the pH of the nasogastric tube aspirate is < 4.0, x-ray films are not needed to prove the accuracy of tube placement. In other situations, a film is indicated since auscultation is inaccurate.
Use of a pressure gauge to differentiate gastric from pulmonary placement of nasoenteral feeding tubes.
Swiech K,Lancaster D R,Sheehan R
Applied nursing research : ANR
This study was conducted to determine the reliability and validity of using a pressure gauge to differentiate gastric from pulmonary placement of nasoenteral tubes in nonmechanically ventilated patients. It was anticipated that on inhalation, tubes properly placed in the gastric region would yield positive readings owing to positive gastric pressures. Conversely, tubes that were inadvertently placed in the pulmonary system should yield negative pressure readings owing to the negative pulmonary pressures that exist on inhalation. Forty-six subjects were enrolled in the study. Of those, 44 had positive gauge readings, and x-ray results showed that these nasoenteral tubes were in the gastric region. Two patients had negative gauge readings, and the x-rays for both of these subjects demonstrated that the nasoenteral tubes were in the pulmonary system. Thus, the findings were consistent with what was anticipated. Despite the small sample size, the results of this study indicate that this method of assessing nasoenteral tube placement may be a safe, reliable, and cost-effective method of differentiating gastric from pulmonary tube placement in this patient population.
10.1016/0897-1897(94)90025-6
[Pre- and post-operative enteral nutrition in elective surgery in adults. Techniques, advantages and adverse effects].
Beau P
Annales francaises d'anesthesie et de reanimation
This review examined the techniques for enteral nutrition (routes and methods of administration and choice of enteral diets) in the perioperative period of elective surgery in adults. Only few controlled studies have assessed the efficiency of techniques according to the indication of enteral feeding (pre or postoperative period, digestive or non-digestive surgery). The nasogastric tube remains the most appropriate method to deliver short-term enteral feeding during the preoperative period. Today percutaneous endoscopic gastrotomy is the preferred method of gastrostomy. It is indicated in long term enteral nutrition, for example in the perioperative period of cancer surgery of head and neck. In the postoperative period of digestive surgery, intrajejunal feeding is usually delivered by a surgical jejunostomy or by a nasojejunal tube. Controlled studies comparing these two methods are still lacking. An important limitation of intrajejunal feeding is the poor tolerance of enteral diet during the first postoperative days after major upper abdominal surgery. The choice of enteral diet in the perioperative period remains controversial. There is no clinical evidence to support the hypothesis that the use of pre-digested diets in jejunostomy feeding has a better nutritional benefit and a better tolerance than polymeric diets. Small peptides offer some metabolic advantages, however, the clinical superiority of these nutrients over polymeric diets is not definitively proven. Continuous administration of enteral nutrition is usually required in case of jejunal feeding. In the other cases, some data suggest that enteral nutrition is more efficient using an intermittent feeding regimen.
Small bowel necrosis associated with postoperative jejunal tube feeding.
Schunn C D,Daly J M
Journal of the American College of Surgeons
BACKGROUND:Postoperative enteral nutrition using jejunal tube feeding is widely practiced and usually well tolerated. Functional intestinal complaints occur frequently but generally respond to alteration of the infusion rate or tube feeding formula. Occasionally, however, nonspecific signs of intestinal disturbance progress to a syndrome of abdominal distention, hypotension, and hypovolemic shock resulting in extensive small bowel necrosis. STUDY DESIGN:During a six-year period, four patients have been identified retrospectively who had this complication among 1,359 patients receiving jejunal tube feeding. Their clinical course was evaluated critically and compared with 11 cases described in the literature. RESULTS:Small bowel necrosis is a rare but highly morbid complication associated with postoperative jejunal tube feeding. Of 14 patients who had small bowel necrosis develop, 12 succumbed to this complication. The causative mechanism remains unclear, but is most likely the result of several factors. CONCLUSIONS:Tube feeding should be discontinued immediately and total parenteral nutrition should be considered in patients who have abdominal pain, abdominal distention, increased nasogastric drainage, and signs of intestinal ileus.
Percutaneous endoscopic gastrojejunostomy: a dual center safety and efficacy trial.
DeLegge M H,Duckworth P F,McHenry L,Foxx-Orenstein A,Craig R M,Kirby D F
JPEN. Journal of parenteral and enteral nutrition
Although jejunal tube placement through a percutaneous endoscopic gastrostomy (PEG) has not been proven to be preferable to PEG feeding, it would be theoretically advantageous for those patients prone to gastrointestinal aspiration. However, reliable placement of a small bowel feeding tube through a PEG has been technically difficult. We have previously reported successful placement of a percutaneous endoscopic gastrojejunostomy (PEG/J) with minimal complications. These results are in contrast to other series that report technical difficulty, frequent tube dysfunction and gastric aspiration. We describe an over-the-wire PEG/J technique performed by multiple operators at two medical centers. Gastrostomy tube placement was successful in 94% of patients. Initial placement of the jejunal tube was successful in 88% of patients. Second attempts were 100% successful. The average procedure time was 36 minutes. The distal duodenal and jejunal placement of the jejunal tube resulted in no episodes of gastroduodenal reflux. Complications included jejunal tube migration (6%), clogging (18%), and unintentional removal (11%). The majority of patients were ultimately converted to either oral or intragastric feedings. We conclude that the PEG/J system is a reliable, reproducible method of small bowel feeding and is associated with no episodes of tube feeding reflux when the jejunal tube is positioned in the distal duodenum or beyond. Furthermore, it provides a temporary nutritional bridge for those patients who are later transitioned to either PEG or oral feeding.
10.1177/0148607195019003239
Tube jejunostomy in liver transplant recipients.
Pescovitz M D,Mehta P L,Leapman S B,Milgrom M L,Jindal R M,Filo R S
Surgery
BACKGROUND:Nutritional support after liver transplantation most often uses intravenous hyperalimentation followed by nasoduodenal tubes until adequate intake is achieved. Because of difficulties with nasoduodenal tubes, we place jejunostomy tubes (j-tube) at the time of the transplantation, allowing immediate postoperative enteral nutrition. This review analyzes the complications of this procedure in transplant recipients. METHODS:J-tubes were placed in 108 of 119 adults who underwent liver transplantation between October 1989 and June 6, 1994. These patients were retrospectively reviewed for the type and frequency of j-tube-related complications. J-tube feeds with a semielemental formula were started within 24 to 48 hours after transplantation. RESULTS:Eighteen complications occurred in 16 patients. Six were mechanical obstructions of the j-tube because of kinking by the fascia. Six exploratory laparotomies were required, two each for infection, small bowel obstruction, or catheter displacement. Four other infections were treated by local incision and drainage or percutaneous drainage. One tube required surgical removal in the operating room. CONCLUSIONS:Tube jejunostomies can be safely placed at the time of liver transplantation with a low risk of serious complications. We recommend the routine use of j-tubes in patients receiving a liver transplant for the immediate posttransplantation institution of enteral nutrition.
Is early oral feeding safe after elective colorectal surgery? A prospective randomized trial.
Reissman P,Teoh T A,Cohen S M,Weiss E G,Nogueras J J,Wexner S D
Annals of surgery
INTRODUCTION:The routine use of a nasogastric tube after elective colorectal surgery is no longer mandatory. More recently, early feeding after laparoscopic colectomy has been shown to be safe and well tolerated. Therefore, the aim of our study was to prospectively assess the safety and tolerability of early oral feeding after elective "open" abdominal colorectal operations. MATERIALS AND METHODS:All patients who underwent elective laparotomy with either colon or small bowel resection between November 1992 and April 1994 were prospectively randomized to one of the following two groups: group 1: early oral feeding--all patients received a clear liquid diet on the first postoperative day followed by a regular diet as tolerated; group 2: regular feeding--all patients were treated in the "traditional" way, with feeding only after the resolution of their postoperative ileus. The nasogastric tube was removed from all patients in both groups immediately after surgery. The patients were monitored for vomiting, bowel movements, nasogastric tube reinsertion, time of regular diet consumption, complications, and length of hospitalization. The nasogastric tube was reinserted if two or more episodes of vomiting of more than 100 mL occurred in the absence of bowel movement. Ileus was considered resolved after a bowel movement in the absence of abdominal distention or vomiting. RESULTS:One hundred sixty-one consecutive patients were studied, 80 patients in group 1 (34 males and 46 females, mean age 51 years [range 16-82 years]), and 81 patients in group 2 (43 males and 38 females, mean age 56 years [range 20-90 years]). Sixty-three patients (79%) in the early feeding group tolerated the early feeding schedule and were advanced to regular diet within the next 24 to 48 hours. There were no significant differences between the early and regular feeding groups in the rate of vomiting (21% vs. 14%), nasogastric tube reinsertion (11% vs. 10%), length of ileus (3.8 +/- 0.1 days vs. 4.1 +/- 0.1 days), length of hospitalization (6.2 +/- 0.2 days vs. 6.8 +/- 0.2 days), or overall complications (7.5% vs. 6.1%), respectively, (p = NS for all). However, the patients in the early feeding group tolerated a regular diet significantly earlier than did the patients in the regular feeding group (2.6 +/- 0.1 days vs. 5 +/- 0.1 days; p < 0.001). CONCLUSION:Early oral feeding after elective colorectal surgery is safe and can be tolerated by the majority of patients. Thus, it may become a routine feature of postoperative management in these patients.
10.1097/00000658-199507000-00012
Diagnostic and therapeutic push type enteroscopy in clinical use.
Davies G R,Benson M J,Gertner D J,Van Someren R M,Rampton D S,Swain C P
Gut
This study describes small bowel push enteroscopy in routine clinical practice, using a purpose designed instrument (Olympus SIF-10). Fifty six patients had a total of 60 procedures over a two and a half year period. The median (range) depth of small intestine intubated was 45 (15-90) cm. Procedure time varied from 10-45 minutes. Most enteroscopies were performed during routine gastroscopy lists. The technique was comparatively easy for experienced endoscopists to learn. Forty two procedures were for diagnostic purposes. Eleven patients had gastrointestinal bleeding where the source was obscure, or where early investigations had suggested a small bowel source: a specific diagnosis was made in 45% of these cases. Of seven iron deficient anaemic patients using non-steroidal anti-inflammatory drugs (NSAIDs), only one had a lesion detected in the upper small bowel. Nine patients had abnormal small bowel barium studies. Small bowel abnormalities were seen in six cases and were definitively diagnostic in three of these; in three patients the barium study appearances were confirmed as artefact. Fifteen patients were investigated for abdominal symptoms suggesting small bowel obstruction or malabsorption: a diagnosis was made in five cases. Fifteen patients underwent enteroscopy for therapeutic purposes, including successful treatment of difficult enteral feeding problems by nasojejunal tubes or by cutaneous endoscopic jejunostomies, polypectomy for Peutz-Jeghers syndrome, and dilatation of strictures. Additionally, bleeding lesions detected in patients during investigation of anaemia were successfully treated at the time by YAG laser or bipolar diathermy. In conclusion, push enteroscopy is a practical and valuable clinical service, which should probably become available on a subregional basis.
10.1136/gut.37.3.346
Early oral feeding after elective colorectal surgery: is it safe.
Seenu V,Goel A K
Tropical gastroenterology : official journal of the Digestive Diseases Foundation
The authors have carried out a prospective trial to assess the safety, tolerability and outcome of early resumption of oral feeding after elective abdominal surgery involving the small or the large bowel. Over the study period, 161 patients undergoing elective laparotomy and bowel resection were randomized to two groups. Patients undergoing laparoscopic surgery were not included. In both groups, the nasogastric tube was removed immediately after surgery. In group I, oral feeding was started on first postoperative day, beginning with clear fluids and gradually progressing to a normal diet over a period of 24 to 48 hours, as tolerated. In group II, oral feeding was started after resolution of postoperative ileus, starting again with clear fluids as in group I. The resolution of postoperative ileus was defined as having bowel movements with no abdominal distention or vomiting. In both groups, nasogastric tube was reinserted if the patient had two episodes of vomiting of more than 100 ml over 24 hours in the absence of bowel movements. Postoperative analgesia was similar in both groups and same criteria for discharge from the hospital were followed. Of the 161 patients, 80 were in the early feeding group and 81 in the other group. The age and sex distribution of the patients in both groups was similar. In both groups, segmental colonic, rectal or small bowel resection was the commonest surgery. In group I, 79% patients tolerated feeds compared to 86% in group II. The incidence of vomiting was thus 21% in group I and 14% in group II, the difference being statistically insignificant. Reinsertion of nasogastric tube was required only in 11% patients in group I and 10% patients in group II. Further, the length of postoperative ileus (3.8 + 0.1 vs 4.1 + 0.1 days), length of hospital stay (6.2 + 0.2 vs 6.8 + 0.2 days) and incidence of complications (7.5% vs 6.1%) were not significantly different between the two groups. However, regular diet was tolerated significantly earlier. (p <0.001) in group I as compared to group II (2.6 + 0.1 vs. 5.0 + 0.1 days). Further, there was no incidence of anastomotic leaks or aspiration pneumonia, complications which could be expected to occur secondary to early feeding. The authors have reviewed the literature which shows a trend towards decreasing use of routine postoperative nasogastric drainage. Based on the results of the current study, they suggest that there is no need to delay oral feeding till resolution of colonic ileus as early feeding is safe and well tolerated. They also suggest that early resumption of oral feeding may have a positive impact on the psychological state of the patient and may help the recovery.
Phenytoin malabsorption after jejunostomy tube delivery.
Rodman D P,Stevenson T L,Ray T R
Pharmacotherapy
The literature supports interactions between phenytoin and both enteral feeding products and nasogastric feeding tubes; however, no published reports exist regarding the interaction of phenytoin with jejunostomy feedings. A 29-year-old woman with cerebral palsy, mental retardation, and a history of seizures was treated with intravenous phenytoin, which yielded detectable therapeutic serum concentrations. After switching to a comparable phenytoin suspension administered by jejunostomy tube, her serum phenytoin concentrations fell to below assay sensitivity concentrations. This drop, nearly 100%, was the greatest that we found reported in the literature. Distal placement of the jejunostomy tube within the small bowel may augment potential phenytoin-tube-enteral product interactions. In addition, the possible decrease in gastrointestinal transit time because of anatomic placement may not allow for adequate drug absorption. Decreased phenytoin bioavailability may become more common with increased use of supplemental feeding tubes.
Enteral nutritional support in acute alcoholic pancreatitis.
Simpson W G,Marsano L,Gates L
Journal of the American College of Nutrition
BACKGROUND:The experience to date with total enteral nutritional (TEN) support in acute alcoholic pancreatitis patients admitted to the University of Kentucky affiliated hospitals was reviewed. METHODS:Standard enteral formulas sufficient to meet patient's needs were administered into the small bowel via endoscopically placed nasoenteric feeding tubes in five patients. Feedings were administered for a mean of 28.4 days. Pancreatitis was mild to moderate in severity by Ranson's criteria in four patients, and severe in one. RESULTS:Four patients developed complications of pancreatitis before initiation of TEN, representing the most common indication for nutritional support. Nutritional status was maintained by TEN with no significant complications from this nutritional support identified. Diarrhea that did not limit tube feeding developed in a single patient. CONCLUSIONS:This experience further supports the safety of TEN in acute pancreatitis and suggests that adequate nutritional support can be delivered by this route.
Analysis of complications and long-term outcome of trauma patients with needle catheter jejunostomy.
Eddy V A,Snell J E,Morris J A
The American surgeon
Enteral feedings demonstrably lower the risk of septic complications. However, complications associated with the specific method of enteral feeding may diminish the intended benefits. The objective was to determine the short and long-term complications associated with needle catheter jejunostomy (NCJ). All NCJs placed at a Level I trauma center over an 8-year period were reviewed. Short-term complications directly attributable to NCJ were defined as tube leakage with intraabdominal or intraparietal spillage, intraabdominal abscess, small bowel obstruction at the catheter site, tube blockage or dislodgement, or soft tissue infection. Telephone interviews were conducted to elicit long-term complications, including operations to correct a complication of the NCJ, chronic nausea, vomiting, diarrhea, bloating, hernia, or change in appetite. Of 122 study patients, short-term complications (N = 22) included two abscesses, one bowel obstruction, two abdominal wall infections, three leaks, one local soft tissue infection, one enterocutaneous fistula, three blocked catheters, and nine tube dislodgements. Fifty patients were contacted by telephone; 19 had long-term complications, including two operations for adhesions. Complications associated with NCJ are common, may be life-threatening, and may require surgical intervention. In many cases, other methods of enteral feeding access may be preferable to NCJ.
Prevalence of gastroesophageal reflux in patients who develop pneumonia following percutaneous endoscopic gastrostomy: a 24-hour pH monitoring study.
Short T P,Patel N R,Thomas E
Dysphagia
Percutaneous endoscopic placement of feeding gastrostomies (PEG) was pioneered by Gauderer et. al. in 1980 [1]. Since then, it has become the preferred method of providing enteral nutritional support in children and adults because of advantages in morbidity and cost [2,3]. Pneumonia is a known sequel of this procedure, occurring at different rates, depending on the length of follow-up. Some series have shown an incidence of 10% at 30 days and others 56% at 11 months [4,5]. It does not appear that PEG feeding offers an advantage over the more traditional naso-enteric tube feeding methods in this respect. To study the prevalence of gastroesophageal reflux (GER) in PEG-fed patients, we quantitated GER by 24-hour intraesophageal pH monitoring in a group of patients who developed post-PEG pneumonia and compared it with a control group. Our study demonstrates an increased prevalence of GER in the pneumonia group compared with the control group. However, the exact contribution of this observed increased GER to the development of pneumonia needs to be determined.
10.1007/bf00417895
[Total enteral nutrition versus mixed enteral and parenteral nutrition in patients at an intensive care unit].
Chiarelli A G,Ferrarello S,Piccioli A,Abate A,Chini G,Berioli M B,Peris A,Lippi R
Minerva anestesiologica
OBJECTIVE:To compare metabolic, nutritional and epidemiological data in two groups of patients, one receiving total enteral nutrition, via nasoenteric tube, and one receiving both enteral and parenteral nutrition. DESIGN:A prospective, randomized study. SETTING:A general ICU, with both medical and surgical patients, in a big regional University and National Health Service hospital. PATIENTS:24 patients requiring Intensive Care after major surgery or because suffering from severe head injury or major neurological impairment. INTERVENTIONS:All patients initially received total parenteral nutrition: after 4 days 12 patients were "weaned" to total enteral nutrition and 12 stayed on mixed parenteral and enteral nutrition. LABORATORY INVESTIGATIONS AND OBSERVATIONAL DATA: Blood levels of albumin, prealbumin, transferrin, ALT, AST, bilirubin, blood urea, blood glucose, total linfocite count, and nutritional and epidemiological data such as nitrogen balance, calorie intake, diarrhea incidence, blood and sputum cultures and radiologic evidence of pneumonia are analysed. RESULTS:At T1, NET patients were able to reduce their nitrogen losses (0.27.1 g/kg +/-0.12 vs 0.35 +/- 0.13 at TO; p < 0.05) and improve nitrogen balance (-9 +/- 7 vs -2 +/- 6 at T0; p < 0.05); they also had a better total linfocite count (2034 +/- 304 vs. 1413 +/- 360 of the MISTA group; p < 0.05), and a lower incidence of pneumonia as documented by sputum cultures and radiograms. CONCLUSIONS:Patients fed with both parenteral and enteral nutrition did no better than those on total enteral nutrition as far as nutritional and metabolic indices were concerned; they also seemed more prone to infections than those on total enteral nutrition, indicating that mixed nutrition may result in more stable feeding, but this does not seem to have any beneficial nutritional, immunological and metabolic effect.
Nasal bridle revisited: an improvement in the technique to prevent unintentional removal of small-bore nasoenteric feeding tubes.
Popovich M J,Lockrem J D,Zivot J B
Critical care medicine
OBJECTIVE:To demonstrate the efficacy and safety of an updated version of the nasal "bridle," which is used to prevent the accidental removal of small-bore nasoenteric feeding tubes. DESIGN:A descriptive study. SETTING:Surgical intensive care unit in a tertiary care hospital. PATIENTS:Twenty-six critically ill patients without nasotracheal tubes or facial trauma or fractures who received enteral nutrition and either had removed or were at risk for removing their properly positioned nasoenteric feeding tubes. INTERVENTIONS:A length of one-eighth inch (3.2 mm) umbilical tape is looped around the nasal septum and vomer by serially attaching the ends of the umbilical tape to a suction catheter, passing the catheter through the nostrils, into the oropharynx, and retrieving the ends from the oropharynx. The properly positioned umbilical tape loops into one nostril around the vomer, and out the other nostril. The feeding tube is then anchored to the umbilical tape with a central venous catheter fastener clamp. MEASUREMENTS AND RESULTS:Communicative patients denied discomfort, and there were no episodes of bleeding, infection, sinusitis, or nasal septal trauma caused by the umbilical tape bridle. Five patients had the bridle in place >30 days. There were only two cases in which the bridle failed to prevent removal of a feeding tube. One of these cases occurred because the fastener clamp anchor failed, but this patient had had the same bridle and feeding tube for 170 consecutive days. CONCLUSIONS:An umbilical tape bridle with a central venous catheter fastener clamp anchor is a safe and effective method to prevent the accidental removal of nasoenteric feeding tubes in critically ill patients. We recommend its use in confused or uncooperative patients, or when the risk of unintentional feeding tube removal is high.
10.1097/00003246-199603000-00011
Surgically placed gastro-jejunostomy tubes have fewer complications compared to feeding jejunostomy tubes.
Gore D C,DeLegge M,Gervin A,DeMaria E J
Journal of the American College of Nutrition
OBJECTIVE:During laparotomy, jejunostomy tubes (J tubes) are often placed to provide access for enteral nutrition in the immediate postoperative period. However, the placement of such tubes may be associated with potentially devastating intra-abdominal complications possibly related to the tenuous security of a tube through the small bowel wall. An alternative method for enteral nutrition access is to surgically place a "PEG-J" tube (i.e., surgical G/J tube) thus providing for jejunal feedings via a gastrotomy without a jejunotomy. The purpose of this study is to assess whether surgically placed G/J tubes reduce the postoperative complications in comparison to feeding J tubes. METHODS:Over the past 18 months, 92 J tubes and 56 G/J tubes were placed during laparotomy at a single institution and the method chosen by surgeons' preference. The frequency of complications associated with each tube was determined by review of the postoperative medical records. RESULTS:There was no enteric leakage in those patient given G/J tubes (p < 0.05). Furthermore 10% of the patients receiving J tubes required operative repair of a J tube complication while no patient with an access complication following G/J tube placement required surgical repair (p < 0.05). CONCLUSIONS:These results demonstrate that operative positioning of a jejunal feeding tube through a gastrostomy tube (surgical G/J tube) provides a safer route for enteral nutrition than does direct tube placement via the jejunal wall, by significantly reducing both the incidence of enteric leakage and the requirement for operative repair.
Randomised trial of safety and efficacy of immediate postoperative enteral feeding in patients undergoing gastrointestinal resection.
Carr C S,Ling K D,Boulos P,Singer M
BMJ (Clinical research ed.)
OBJECTIVES:To assess whether immediate post-operative enteral feeding in patients who have undergone gastrointestinal resection is safe and effective. DESIGN:Randomised trial of immediate post-operative enteral feeding through a nasojejunal tube v conventional postoperative intravenous fluids until the reintroduction of normal diet. SETTING:Teaching hospitals in London. SUBJECTS:30 patients under the care of the participating consultant surgeon who were undergoing elective laparotomies with a view to gastrointestinal resection for quiescent, chronic gastrointestinal disease. Two patients did not proceed to resection. MAIN OUTCOME MEASURES:Nutritional state, nutritional intake and nitrogen balance, gut mucosal permeability measured by lactulose-mannitol differential sugar absorption test, complications, and outcome. RESULTS:Successful immediate enteral feeding was established in all 14 patients with a mean (SD) daily intake of 6.78 (1.57)MJ (1622 (375) kcal before reintroduction of oral diet compared with 1.58 (0.14) MJ (377 (34) kcal) for those on intravenous fluids (P < 0.0001). Urinary nitrogen balance on the first postoperative day was negative in those on intravenous fluids but positive in all 14 enterally fed patients (mean (SD) - 13.2 (11.6) g v 5.3 (2.7) g; P < 0.005). There was no difference by day 5. There was no change in gut mucosal permeability in the enterally fed group but a significant increase from the test ratios seen before the operation in those on intravenous fluids (0.11(0.06) v 0.15 (0.12); P < 0.005). There were also fewer postoperative complications in the enterally fed group (P < 0.005). CONCLUSIONS:Immediate postoperative enteral feeding in patients undergoing intestinal resection seems to be safe, prevents an increase in gut mucosal permeability, and produces a positive nitrogen balance.
10.1136/bmj.312.7035.869
Endoscopic nasoenteral feeding tube placement following cardiothoracic surgery.
Vaswani S K,Clarkston W K
The American surgeon
UNLABELLED:Our purpose was to evaluate the safety and efficacy of nasoenteral feeding tube placement in the cardiothoracic surgery patients. This is a retrospective analysis of 15 critically ill cardiothoracic surgery patients who underwent endoscopic placement of an enteral feeding tube beyond the proximal duodenum for maintenance of nutrition. Twenty-five entriflex 10-F nasoenteral tubes were placed endoscopically using a modified technique far into the distal duodenum, and the placement was confirmed radiographically. Mean patient age was 71 years. Seven were males and 8 were females. Eleven had undergone coronary artery bypass surgery, two aortic valve replacement, and two aortic aneurysm repair. The mean duration of tube function was 8.5 days and mean duration of tube feeding was 15.7 days. Of the total 15 patients, 7 required replacement due to various reasons, the most common being self extubation by the patient and malpositioning after initial placement. No cardiac complications or any other complications were noted directly related to the endoscopic procedure. In eight patients, the mean serum albumin level did not change [before: 2.5mg/dL, after: 2.6mg/dL] for the short time (avg. 8.5 days) the tube was functional. CONCLUSIONS:1) Endoscopic placement of the nasoenteral tubes is a safe method of providing enteral nutrition in critically ill cardiothoracic surgery patients. 2) Benefits of nasoenteral tubes compared to nasogastric tubes remain unproven, and frequent repositioning of nasoenteral tubes is required. 3) A prospective comparison of nasoenteral and nasogastric tubes is warranted.
Gastrointestinal consequences of left ventricular assist device placement.
el-Amir N G,Gardocki M,Levin H R,Markowitz D D,Greenspan R L,Catanese K A,Rose E A,Oz M C
ASAIO journal (American Society for Artificial Internal Organs : 1992)
Left ventricular assist devices effectively improve hemodynamic function and reverse renal and hepatic dysfunction; however, their effects upon the gastrointestinal (Gl) system have not been addressed. We evaluated Gl function in 27 left ventricular assist device recipients using interviews, Gl contrast studies, endoscopy, and 99mTc sulfur colloid studies of esophageal transit and gastric emptying. While on left ventricular assist device support (mean duration of 84 days), 19 patients reported early satiety and/or nausea, and 1 was unable to tolerate oral intake. Esophageal transit time (normal, < 10 sec) was borderline slow at 14 +/- 4 (mean +/- standard error of the mean) and gastric emptying (normal < 90 min) was prolonged (range of 106-506 min, mean = 283 +/- 69 min). In a 1-38 month follow-up, gastric function subjectively improved in all. Six patients had intraperitoneal device placement. One died of aspiration pneumonia secondary to small bowel obstruction, and one had prolonged inability to tolerate oral intake, which required feeding jejunostomy tube placement. The 21 patients with pre peritoneal placement of the device did not require Gl operative interventions and had no catastrophic Gl events; they had mild to no Gl complaints. Pre peritoneal placement may mitigate early satiety and obviate serious Gl complications.
Percutaneous endoscopic gastrojejunostomy with a tapered tip, nonweighted jejunal feeding tube: improved placement success.
DeLegge M H,Patrick P,Gibbs R
The American journal of gastroenterology
OBJECTIVES:Gaining enteral access to the small bowel for patients unable to tolerate gastric feedings is a difficult challenge for today's endoscopist. A new over-the-guidewire method for placement of a percutaneous endoscopic gastrojejunostomy (PEG/J) is prospectively studied using a nonweighted, tapered tip, distal feed through jejunal tube (J-tube). METHODS:Twenty five hospitalized patients were referred to the nutrition service for enteral access. A Wilson-Cook 24/12-French PEG/J system was placed and followed until removal or patient death. RESULTS:The PEG/J system was placed in 25/25 patients in an average of 26 min and 45 s. The tip of the J-tube was in the distal duodenum in 52% of patients and in the jejunum in 48% of patients. J-tube complications occurred in 20% of patients and included one incidence of clogging (4%) and four cases of inadvertent removal (16%). Average longevity of the J-tube was 63.9 days, with most patients converted to either oral or gastric feedings. CONCLUSION:The use of an nonweighted, tapered tip J-tube and the over-the-guidewire placement technique has resulted in a reliable method of accessing the small bowel for enteral nutrition.
[Nasoenteral tube feeding in hyperemesis gravidarum. An alternative to parenteral nutrition].
Trovik J,Haram K,Berstad A,Flaatten H
Tidsskrift for den Norske laegeforening : tidsskrift for praktisk medicin, ny raekke
A severe form of hyperemesis gravidarum involving maternal weight loss greater than 5% of the prepregnant weight occurs in up to 0.1-0.2% of all pregnancies and may lead to retarded foetal growth. Treatment consists of hospitalisation, antiemetics and correction of fluid and electrolyte deficiencies. If severe vomiting and weight loss continues, the mother must receive supplementary nutrition, usually parenteral. Nasoenteral tube feeding is a well documented method of nutrition for other patients. A gastroscopically placed nasojejunal tube as part of the treatment of hyperemesis gravidarum has not been reviewed before. Seven women with severe hyperemesis gravidarum were treated with nasojejunal tube feeding. The tube was positioned gastroscopically. Enteral feeding continued for up to 41 days, leading to reasonable weight gain. The tube was tolerated well by most patients and no serious adverse effects were seen. Nasoenteral nutrition ought to be considered as an alternative to parenteral nutrition for treatment of hyperemesis gravidarum.
Influence of postoperative enteral nutrition on postsurgical infections.
Beier-Holgersen R,Boesby S
Gut
BACKGROUND:This study was undertaken to test the hypothesis that early enteral nutrition might reduce the incidence of serious complications after major abdominal surgery. METHODS:In a randomised double blind prospective trial 30 patients received Nutri-drink and 30 patients received placebo through a nasoduodenal feeding tube. On the day of operation the patients were given median 600 ml of either nutrition or placebo, 60 ml per hour. On the first postoperative day the patients received either 1000 ml (median) of nutrition or placebo, on day 2 1200 ml (median) nutrition, 1400 ml placebo, on day 3 1000 ml (median) nutrition, 1150 ml placebo, and on day 4 1000 ml (median) nutrition, 800 ml placebo. All patients were followed up for 30 days by the same investigator. RESULTS:The two groups were similar with regard to nutritional status and type of operation. The rate of postoperative infectious complications was significantly lower in the nutrition group, two of 30 compared with 14 of 30 in the placebo group (p = 0.0009). CONCLUSION:Early enteral nutrition given to patients after major abdominal surgery results in an important reduction in infectious complications.
10.1136/gut.39.6.833
Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis.
McClave S A,Greene L M,Snider H L,Makk L J,Cheadle W G,Owens N A,Dukes L G,Goldsmith L J
JPEN. Journal of parenteral and enteral nutrition
BACKGROUND:This prospective study was designed to compare the safety, efficacy, cost, and impact on patient outcome of early total enteral nutrition (TEN) vs total parenteral nutrition (TPN) in acute pancreatitis. METHODS:Patients admitted with acute pancreatitis or an acute flare of chronic pancreatitis, characterized by abdominal pain and elevated serum amylase and lipase, were randomized to receive either isocaloric and isonitrogenous TEN (via a nasojejunal feeding tube placed endoscopically) or TPN (via a central or peripheral line) started within 48 hours of admission. RESULTS:Thirty patients were studied over 32 admissions (TEN given on 16 and TPN on 16) for acute pancreatitis. There were no differences on admission in mean age, Ranson criteria, multiple organ failure score (MOF), or APACHE III score between TEN and TPN groups. Although slower to approach goal feeding over the first 72 hours of admission, TEN patients received 71.3% goal calories by day 4 vs 85.2% for TPN patients (not significant). There were no deaths and no differences between groups in serial pain scores, days to normalization of amylase, days to diet by mouth, serum albumin levels, or percent nosocomial infection. However, the mean cost of TPN per patient was over four times greater than that for TEN ($3294 vs $761, respectively, p < .001). Mean serial Ranson criteria, APACHE III, and MOF scores recorded every 2 to 3 days decreased in the TEN group, whereas those in the TPN group increased. Only the difference in the third Ranson criteria (mean 6.3 days after admission) for the TEN and TPN groups (0.5 vs 2.8, respectively) reached statistical significance (p = .002). Stress-induced hyperglycemia was worse in the TPN group, as serum glucose levels increased significantly over the first 5 days of hospitalization (p < .02), whereas those in the TEN group showed no significant change. An exacerbation of pancreatitis, occurring in one TEN patient when the nasojejunal tube was dislodged into the stomach, resolved after placement back in the jejunum. Three patients who became asymptomatic and normalized amylase on TEN flared upon advancing to diet by mouth. CONCLUSIONS:TEN for acute pancreatitis is as safe and effective, but is significantly less costly than TPN. Compared with TPN, TEN may promote more rapid resolution of the toxicity and stress response to pancreatitis. TEN via jejunal feeding should be used preferentially in this disease setting.
10.1177/014860719702100114
Nutritional management of the critically ill neurologic patient.
Twyman D
Critical care clinics
To summarize, the event of severe neurologic injury results in significant metabolic changes. These changes cause increased requirements for protein and nonprotein calories, micronutrients, and small bowel feedings or TPN. Early feeding has been shown to improve survival. Therefore, every effort should be made to provide aggressive nutritional support within the first 72 hours after injury. Specific guidelines are as follows: Provide full-strength, full-rate feedings within 72 hours. Provide enteral nutrients via nasojejunal or percutaneous endoscopic jejunostomy feeding tube if access is available; attempt gastric feedings if not. Provide TPN within 48 hours if enteral access is not available and begin enteral feeding as soon as possible. Provide 2 to 2.3 g protein/kg/d if renal function is normal. Provide 40% to 70% above basal needs as total calories, with 30% to 40% of calories as lipid to minimize hyperglycemia. Provide protein as small peptides to improve tolerance, absorption, utilization, and gut integrity. Provide a lipid source with 50% to 70% medium-chain triglycerides and an omega-6 to omega-3 ratio of 2:1 to 8:1 to minimize negative effects of omega-6 fatty acids and provide an easily absorbed and utilized source of lipid.
10.1016/s0749-0704(05)70295-5
Early enteral nutrition in gastrointestinal surgery: a pilot study.
Velez J P,Lince L F,Restrepo J I
Nutrition (Burbank, Los Angeles County, Calif.)
There is still some concern about the safety of early enteral nutrition (EN) to patients with recent anastomoses. A pilot trial was carried out on a prospective basis to evaluate the tolerance and clinical outcome of 56 patients who received early EN following gastrointestinal (GI) surgery. A continuous infusion of an elemental, peptide-based diet was administered using a nasointestinal feeding tube placed beyond the pylorus by the operating surgeon. Tube feeds were started at 6.07 +/- 4.99 h after surgery and advanced as tolerated to a rate of 60 mL/h on the third postoperative day. Patients received the diet either proximal or distal (in the case of gastrectomies) to their recent anastomosis. Forty-six patients met the inclusion criteria and were included in the analysis. EN was well tolerated with a low incidence of side effects (19.5%), nausea and vomiting being the most frequent. Oral feeding was started 2.89 +/- 1.28 d after surgery. There was one case of small bowel suture leakage, but no relationship to the tube feeding was established. Early EN appears to be a useful and safe therapeutic alternative for the postoperative management of patients undergoing GI surgery. It may contribute to faster recovery of bowel function and lead to a shorter hospital stay. Careful selection of patients is necessary in order to obtain the greatest benefit of early enteral feeding in this patient population.
Improved long-term outcome for patients with jejunoileal apple peel atresia.
Waldhausen J H,Sawin R S
Journal of pediatric surgery
BACKGROUND/PURPOSE:Although apple peel intestinal atresia is a rare lesion associated with significant morbidity and high mortality, the authors have seen no deaths since 1983. Similar success has rarely been reported, and there are no reports of long-term follow-up. This study examines the short-term and long-term complications and outcome for these children, critiques our evolution in care, and gives current recommendations for therapy. METHODS:A retrospective review of 12 patients over 11 years was conducted. Perinatal history and operative and perioperative management were examined and end results and complications using different management plans compared. Long-term outcome was determined through clinic follow-up. RESULTS:Mean follow-up was 5.1 years. Children had a mean 61.4 cm of total small bowel. Seven patients underwent a primary anastomosis and five had enterostomies. The proximal jejunum was tapered, plicated, resected or left intact. Eleven children required gastrostomy tubes. All children required total parenteral nutrition. Full enteral feeding was achieved in all children, but three required gastrostomy supplementation. Three patients who had enterostomies suffered bowel obstruction, two with dilated, dysmotile proximal jejunum required subsequent tapering. Eight children maintained a growth curve between the 5th and 50th percentile. None have short bowel physiology, and all have achieved acceptable bowel function. CONCLUSIONS:(1) Total parenteral nutrition is essential for initial nutritional management. (2) Use of an enterostomy leads to an increased incidence of complications. (3) The dilated proximal bowel should be resected, tapered, or plicated, and a primary anastomosis should be performed. (4) Gastrostomy tubes are necessary for initial management. (5) Early morbidity is common, though excellent long-term outcome and normal growth and development are expected.
10.1016/s0022-3468(97)90308-0
Prophylactic locking of enteral feeding tubes with pancreatic enzymes.
Sriram K,Jayanthi V,Lakshmi R G,George V S
JPEN. Journal of parenteral and enteral nutrition
BACKGROUND:Obstruction of feeding tubes is a common mechanical complication associated with enteral feeding. Standard methods of flushing are not always effective. METHODS:This study was conducted with patients receiving enteral feeding via nasogastric, nasoenteral, gastrostomy, or jejunostomy tubes to determine if prophylactic use of pancreatic enzymes would maintain patency of feeding tubes. Interrupted feeding regimens were used. Control patients (n = 24) received only water for flushing. After water flushing of the tube, study patients (n = 33) received a 5-mL suspension of pancreatic enzyme containing the following enzyme activity (in Federation Internationale Pharmaceutique [FIP] units): lipase, 2000; amylase, 1500; and protease, 100. The suspension also contained 90 mg of NaHCO3 to maintain a pH of 7.5. The mean duration of observation in the control and study groups was 25 and 48 days, respectively. RESULTS:Compared with eight episodes (23.5%) of tube occlusions in the control group (n = 34), there was only one episode (2.6%) in the study group (n = 38). This difference was significant by the test of proportions (z = 2.68, p = .01). CONCLUSIONS:In addition to routine water flushing, the routine prophylactic use of pancreatic enzyme-sodium bicarbonate suspension (pH 7.5) prevents occlusion of feeding tubes.
10.1177/0148607197021006353
Enteral or parenteral feeding after total gastrectomy: prospective randomised pilot study.
Sand J,Luostarinen M,Matikainen M
The European journal of surgery = Acta chirurgica
OBJECTIVE:To compare the efficacy and cost of enteral and parenteral feeding after total gastrectomy. DESIGN:Prospective randomised open study. SETTING:University hospital, Finland. SUBJECTS:29 patients undergoing curative total gastrectomy for gastric cancer. INTERVENTIONS:13 patients were given early enteral feeding by nasojejunal tube and 16 patients parenteral nutrition by central venous catheter. MAIN OUTCOME MEASURES:Postoperative complications, duration of hospital stay, serum CRP and albumin concentrations, cost, and postoperative abdominal symptoms. RESULTS:One patient in the enteral feeding group discontinued the study on day 1. Oesophagojejunal leaks developed in one patient in each group. Infective complications occurred in 3 (23%) in the enteral group and 5 (31%) in the parenteral group. Serum CRP concentration on day six was lower in the enteral feeding group than in the parenteral feeding group (32 (16) g/L compared with 61 (41) g/L; p = 0.02). Enteral feeding was well tolerated. Diarrhoea developed earlier in the enteral than in the parenteral group (days 3-5 compared with 5-7, respectively) but there was a tendency to an increased risk of diarrhoea in the parenteral group. Parenteral feeding was more than four times as expensive as enteral feeding. CONCLUSION:Enteral nasojejunal feeding is safe and well tolerated after total gastrectomy. It is also cheaper than parenteral nutrition.
Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial.
Kalfarentzos F,Kehagias J,Mead N,Kokkinis K,Gogos C A
The British journal of surgery
BACKGROUND:Parenteral nutrition is well established for providing nutritional support in acute pancreatitis while avoiding pancreatic stimulation. However, it is associated with complications and high cost. Benefits of enteral feeding in other disease states prompted a comparison of early enteral feeding with total parenteral nutrition in this clinical setting. METHODS:Thirty-eight patients with acute severe pancreatitis were randomized into two groups. The first (n = 18) received enteral nutrition through a nasoenteric tube with a semi-elemental diet, while the second group (n = 20) received parenteral nutrition through a central venous catheter. Safety was assessed by clinical course of disease, laboratory findings and incidence of complications. Efficacy was determined by nitrogen balance. The cost of nutritional support was calculated. RESULTS:Enteral feeding was well tolerated without adverse effects on the course of the disease. Patients who received enteral feeding experienced fewer total complications (P < 0.05) and were at lower risk of developing septic complications (P < 0.01) than those receiving parenteral nutrition. The cost of nutritional support was three times higher in patients who received parenteral nutrition. CONCLUSION:This study suggests that early enteral nutrition should be used preferentially in patients with severe acute pancreatitis.
An analysis of upper GI endoscopy done for patients in surgical intensive care: high incidence of, and morbidity from reflux oesophagitis.
Plaisier P W,van Buuren H R,Bruining H A
The European journal of surgery = Acta chirurgica
OBJECTIVE:To investigate the role of upper gastrointestinal (GI) endoscopy in a surgical intensive care unit [ICU]. DESIGN:Retrospective analysis. SETTING:University hospital, The Netherlands. SUBJECTS:87 Male and 42 female patients, mean age 62.0 years (range 14-86). INTERVENTIONS:198 Upper GI endoscopies. MAIN OUTCOME MEASURES:Incidence of, indication for, and abnormalities noted at upper GI endoscopy. RESULTS:52 (40%) and 18 (14%) patients underwent 82 and 27 upper GI endoscopies, respectively, for evaluation of upper GI haemorrhage and surgical anastomoses. 59 Patients (46%) underwent 89 endoscopies for placement of nasoduodenal feeding tubes (n = 86, 97%), biliary stents (n = 2, 2%) and gastrostomy cathether (n = 1, 1%). The causes of haemorrhage were: oesophagitis (n = 13, 25%), duodenal ulcer (n = 13, 25%), gastric ulcer (n = 7, 13%) and others (n = 14, 28%). In 6 cases (11%), no bleeding site was detected. As a coincidental finding, a third of all patients had oesophagitis. The incidence of haemorrhage in patients treated and not treated by mechanical ventilation was 43/1350 (3.2%) and 9/1470 (0.6%), respectively (p < 0.0001). CONCLUSIONS:Upper GI endoscopy is a common diagnostic and therapeutic procedure in a surgical ICU. Reflux oesphagitis is often found and is clinically important. Mechanical ventilation is a risk factor for upper GI haemorrhage.
Laparoscopic jejunostomy with an 18-mm trocar.
Gedaly R,Briceño P,Ravelo R,Weisinger K
Surgical laparoscopy & endoscopy
We describe our technique to perform laparoscopic jejunostomies with an 18-mm trocar. This procedure facilitates the exteriorization of the proximal bowel and construction of the jejunostomy. We describe our laparoscopic technique in nine patients with severe neurologic conditions (two in the postoperative period of a cerebral aneurysm in a coma, three patients with severe head injury, and four patients with cerebrovascular strokes). The operative time ranged from 20 to 75 min (average, 44.38 min). Nutrition was initiated 24 h after the placement of the jejunostomy. Tolerance of the enteral nutrition was excellent in all cases. One major complication occurred, minor leakage around the feeding tube 3 weeks after the jejunostomy was constructed. The jejunostomy was removed without further consequences. Laparoscopy is an effective technique for the creation of feeding jejunostomies. We believe that this minimally invasive approach is an alternative for patients requiring long-term postpyloric enteral feeding.
Syndrome of intractable diarrhoea with persistent villous atrophy in early childhood: a clinicopathological survey of 47 cases.
Goulet O J,Brousse N,Canioni D,Walker-Smith J A,Schmitz J,Phillips A D
Journal of pediatric gastroenterology and nutrition
BACKGROUND:The syndrome of intractable diarrhoea of infancy is heterogeneous and includes several diseases with diverse aetiologies. This study determines whether diagnostic categories can be defined on the basis of clinicopathological analysis. METHODS:European Society of Paediatric Gastroenterology, Hepatology and Nutrition members were surveyed to identify cases of intractable diarrhoea with persisting small intestinal enteropathy. A retrospective clinicopathological analysis was performed on cases showing life-threatening diarrhoea within the first 24 mo of life and requiring total parenteral nutrition, which were characterized by persistent villous atrophy, and resistance to therapy. RESULTS:Forty-seven infants were identified with intractable diarrhoea. Villous atrophy was of varying degrees with (group I, n = 24) or without (group II, n = 18) lamina propria mononuclear cell infiltration. Group I presented later, had gut autoantibodies, and a higher prevalence of protein-losing enteropathy; a subset (group Ia, n = 12) also had extraintestinal symptoms of autoimmunity associated with a later onset of larger volume diarrhoea. Group II presented early; 8 cases (group IIa) had phenotypic abnormalities and a low birth weight; the remaining 10 (group IIb) showed mild-to-moderate villous atrophy, epithelial tufting, and abnormal crypts. Group III included five patients in whom no specific features were recognised. Twenty-one (45%) died at a median age of 24 months, 20 (43%) remained dependent on parenteral (n = 16) or enteral tube (n = 4) feeding, 4 (9%) received elimination diets plus other therapies, and 2 (4%) were lost to follow-up. CONCLUSIONS:Clinicopathological analysis allowed distinct disease groups to be identified, allowing a provisional classification to be made. This straightforward approach forms a basis for future research in this exceptionally difficult paediatric condition.
Nightly enteral nutrition support of elderly hip fracture patients: a phase I trial.
Sullivan D H,Nelson C L,Bopp M M,Puskarich-May C L,Walls R C
Journal of the American College of Nutrition
OBJECTIVE:This non-blinded randomized controlled trial was the first phase of a planned series of investigations designed to test the efficacy of aggressive post-operative enteral nutrition support to decrease the rate of post-operative complications or improve long-term outcomes in specifically defined subgroups of elderly patients who have sustained a hip fracture requiring surgery. METHODS:Eighteen patients (17 males) were randomized to the treatment (eight male subjects) or control groups. The control group (mean age 76.5+/-6.1 years) received standard post-operative care. Subjects in the treatment group (mean age 74.5+/-2.1 years) received 125 cc/hour of nasoenteral tube feedings over 11 hours each night in addition to standard post-operative nutritional care. RESULTS:Both the treatment and control groups had reduced volitional nutrient intakes for the first 7 post-operative days (3,966+/-2,238 vs. 4,263+/-2,916 kJ/day [948+/-535 vs. 1019+/-697 kcal/day], p=0.815), but the treatment subjects had a greater total nutrient intake (7,719+/-2,109 vs. 4,301+/-2,858 kJ/day [1845+/-504 vs. 1028+/-683 kcal], p=0.012). On average, treatment subjects were tube fed for 15.8+/-16.4 days. There was no difference between the groups (treatment vs. controls) in the rate of post-operative life-threatening complications (25 vs. 30%, p=1.00) or in-hospital mortality (0 vs. 30%, p=0.216). Mortality within 6 months subsequent to surgery was lower in the treatment group compared to the controls (0 vs. 50%, p=0.036). DISCUSSION:We conclude that nightly enteral feedings are a safe and effective means of supplementing nutrient intake. The greatest impact of nutrition support may be to reduce mortality.
Jejunostomy tube failure: malnutrition caused by intraluminal antegrade jejunostomy tube migration.
Prahlow J A,Barnard J J
Archives of physical medicine and rehabilitation
Complications occurring with jejunostomy feeding tubes are common and sometimes life-threatening. We describe a case of peristalsis-induced intraluminal antegrade migration of a jejunostomy tube's distal end with concomitant retrograde movement of the small bowel over the tube, which was first discovered at autopsy. This ultimately resulted in the jejunostomy feedings entering the distal ileum, therefore bypassing most of the small intestine. Subsequent malnutrition was a contributing factor in the death of the patient, who had required tube feedings after suffering severe head trauma in a motor vehicle accident 29 months earlier. The only nutritional interventions attempted before death involved various attempts at controlling diarrhea. We discuss the incidence, cause, recognition, and prevention of this rarely reported complication of a "functioning" jejunostomy feeding tube.
[Clinical effects of supplemental enteral nutrition solution in severe polytrauma].
Bastian L,Weimann A,Bischoff W,Meier P N,Grotz M,Stan C,Regel G
Der Unfallchirurg
Previous studies in critically ill patients have shown the beneficial effects of early enteral nutrition supplemented with arginine, omega-3 fatty acids and nucleotides (Impact) on immunological response, infection rate and length of stay in hospital. No specific data exist for patients with severe multiple injury, who represent a high risk group for systemic inflammatory response syndrome (SIRS), septic complications and multiple organ failure (MOF). In this prospective, randomized, double-blind controlled clinical study on patients after severe trauma (ISS ca. 40) the primary study endpoints were incidence of SIRS and MOF [definitions according to Am Soc Crit Care Med (5) and Goris (23), Sauaia (43)]. Thirty-two patients enrolled in the study, and 29 were eligible for analysis: test (Impact) (n = 16), control (n = 13). Both groups were comparable according to age, body mass index and severity of trauma (PTS-test: 38.8 +/- 12.5, PTS-control: 40.8 +/- 15.5, ISS-test: 39.6 +/- 11.4, ISS-control: 40.5 +/- 9.2). Patients were randomized to receive either Impact (test) or an isonitrogenous isocaloric diet (control). Feeding was started on the 2nd day after trauma via endoscopically placed nasoduodenal or jejunal feeding tubes. The experimental diet was safe and well tolerated. During the 1st week the enteral feeding amount was about 2000 ml without significant difference. Test-fed patients developed SIRS significantly less frequently between day 1 and day 28 (8 vs 13.3; P < 0.05) and especially between day 8 and day 14 (3 vs 6.2; P < 0.001). In the control group the Goris score was significantly worse (P < 0.05) on days 3, 4, 6, 7, 10, 11, 16 and 17 and the Sauaia score on days 8, 9, 10 and 11 (P < 0.05; P < 0.01). Mortality rate did not significantly differ (test 2/16, control 4/13), nor did length of ICU or hospital stay. With regard to the acute-phase response, C-reactive protein was significantly lower on day 4 in the test group (test: 131 +/- 67 mg/l, control: 221 +/- 110 mg/l) as was fibrinogen on day 12 (6.6 +/- 1.4 vs 7.5 +/- 1.4 g/l) and day 14 (7.1 +/- 1.3 vs 7.8 +/- 0.8 g/l). No significant difference could be observed for CD4/CD8 ratio, CD45 isotope on activated T-cells and lymphocytic interleukin (II)-2-receptor- and II-6 level. However, HLA-DR antigen presentation on peripheral monocytes was significantly elevated on day 7 in the test group (P < 0.05). According to the results, arginine, omega-3 fatty acids and nucleotides-enriched diet during early enteral feeding leads to reduction of SIRS after severe multiple injury. There is evidence for improvement of post-traumatic immunological response which helps to overcome the immunological depression after trauma.
10.1007/s001130050242
Dietary peptides improve wound healing following surgery.
Roberts P R,Black K W,Santamauro J T,Zaloga G P
Nutrition (Burbank, Los Angeles County, Calif.)
To determine if peptide-based enteral diets improve wound healing when compared to amino acid-based diets, a prospective randomized study was conducted using 38 male Sprague-Dawley rats. Following placement of a standardized abdominal wound, 20 animals were randomized to an isonitrogenous peptide-based (PEP) versus amino acid-based diet (AA) for 10 d. In addition, 18 animals were randomized to an amino acid-based diet supplemented with the peptide carnosine (CARN) or its constituent amino acids (Control). Diets were administered through small bowel feeding tubes. Wound bursting pressure was significantly higher in the PEP animals compared to the AA animals (179+/-9 versus 138+/-12 mmHg; P=0.02). In addition, wound bursting pressure was significantly greater in the CARN animals compared to the Control animals (143+/-10 versus 116+/-8 mmHg; P=0.005). Peptide-based enteral diets improve wound healing when compared to nonpeptide generating amino acid-based diets. We also conclude that the dietary peptide carnosine represents a dietary peptide that improves wound healing when administered as part of a complete enteral formula. This effect on wound healing may be clinically relevant because carnosine is not found in most enteral formulas.
[The role of jejunal feeding in the treatment of acute necrotizing pancreatitis and in recurrence of chronic pancreatitis with severe necrosis].
Hamvas J,Pap A
Orvosi hetilap
Acute necrotising is the most serious form of pancreatic inflammatory diseases leading to multiorgan failure and high (15-20%) mortality. The poor nutritional and metabolic condition of the patient and secondary bacterial translocation further rise the mortality. A recently introduced method of continuous nasojejunal feeding putting the pancreas into rest with basal pattern of secretion resulted in lower mortality rate by using adequate nutrition into the second loop of jejunum bypassing duodenopancreatic stimulations via an endoscopically placed feeding tube. The better nutritional and immunological states of the patients, the restored absorption and intestinal motility promote the recovery of pancreatitis, prevent bacterial translocation, resulting in time and in financial spares. Although surgery is occasionally inevitable because of progression of pancreatitis, nasojejunal feeding improves the general condition of patients more efficiently than parenteral nutrition and makes the scheduling of the operation optimal. The authors retrospectively analyse the results of treatment in 56 patients suffering from acute necrotising pancreatitis, as well as in 30 patients with chronic pancreatitis accompanied with more than 20% of necrosis in the pancreas and admitted to their gastroenterological medical department during 5 years. The effect of parenteral nutrition were less beneficial than that of jejunal feeding regarding the mortality and the necessity of operative interventions. Chronic pancreatitis with severe necrosis behaved similarly to the acute necrotising pancreatitis. The continuous nasojejunal feeding seems to be a promising new method for acute necrotising pancreatitis preventing complications and severe catabolic state of the disease by a cost--effective manner.
Virtual endoscopy of the small bowel: phantom study and preliminary clinical results.
Rogalla P,Werner-Rustner M,Huitema A,van Est A,Meiri N,Hamm B
European radiology
The purpose of this study was to determine the optimal scanning technique for lesion detection in a small bowel phantom and to evaluate the virtual endoscopy (VE) technique in patients. A small bowel phantom with a fold thickness of 7 mm and length of 115 cm was prepared with nine round lesions (3 x 1 mm, 2 x 2 mm, 2 x 3 mm, 2 x 4 mm). Spiral CT parameters were 7/7/4, 3/5/2, 3/5/1, 1.5/3/1 (slice thickness/table feed/reconstruction interval). VE was done using volume rendering technique with 1 cm distance between images and 120 degrees viewing angle. Two masked readers were asked to determine the number and location of the lesions. Seven patients underwent an abdominal CT during one breathhold after placement of a duodenal tube and filling of the small bowel with methyl cellulose contrast solution. VE images were compared with the axial slices with respect to detectability of pathology. With the 7/7/4 protocol only the 4-mm lesions were visualised with fuzzy contours. The 3/5/2 protocol showed both 4-mm lesions, one 3-mm lesion and one false positive lesion. The 3/5/1 protocol showed both 4-mm and both 3-mm (one uncertain) lesions with improved sharpness, and no false positive lesions. One 2-mm and one 1-mm lesion were additionally seen with the 1.5/3/1 protocol. Path definition was difficult in sharp turns or kinks in the lumen. In all patients, no difference was found between VE and axial slices for bowel pathology; however, axial slices showed 'outside' information that was not included in VE. We conclude that the 3/5/2 protocol may be regarded as an optimal compromise between lesion detection, coverage during one breathhold, and number of reconstructed images in patients; round lesions of 4 mm in diameter can be detected with high certainty.
10.1007/s003300050434
[Effect of early postoperative enteral nutrition on postoperative infections].
Beier-Holgersen R,Boesby S
Ugeskrift for laeger
We undertook this study to test the hypothesis that early enteral nutrition might reduce the incidence of serious complications after major abdominal surgery. In a randomized double blind prospective trial 30 patients received Nutridrink and 30 patients received placebo through a nasoduodenal feeding tube. On the day of operation the patients were given median 600 ml nutrition/placebo, 60 ml/h. On the first postoperative day the patients received median 1000 ml nutrition/placebo, second day median 1200 ml nutrition, 1400 ml placebo, third postoperative day median 1000 ml nutrition, 1150 ml placebo and 4th postoperative day median 1000 ml nutrition, 800 ml placebo. All patients were followed for 30 days by the same investigator. The two groups were not different with regard to nutritional status and type of operation. The rate of postoperative infectious complications was significantly lower in the nutrition group, 2/30 compared to 14/30 in the placebo group (p = 0.0009). We conclude that early enteral nutrition given to patients after major abdominal surgery is followed by a major reduction in infectious complications.
Comparison of tacrolimus absorption in transplant patients receiving continuous versus interrupted enteral nutritional feeding.
Murray M,Grogan T A,Lever J,Warty V S,Fung J,Venkataramanan R
The Annals of pharmacotherapy
OBJECTIVE:To determine the effect of enteral nutritional feeding on the absorption of tacrolimus administered through a nasoduodenal tube to organ transplant patients. METHODS:A nonrandomized, prospective study of tacrolimus absorption was performed in 10 liver or lung transplant patients who received Osmolite enteral nutrition through a nasoduodenal feeding tube. Multiple blood samples were collected just prior to and at 30 minutes, 1, 2, 3, 4, 6, 8, 10, and 12 hours after nasoduodenal administration of tacrolimus on 2 consecutive days, once when tacrolimus was administered along with the continuous enteral feeding and the other time when the enteral feeding was withheld 1 hour prior to and 8 hours after tacrolimus administration, to assess tacrolimus absorption. The whole blood tacrolimus concentrations were measured by the microparticulate enzyme immunoassay method. Pharmacokinetic parameters between the two time periods were compared by using a paired t-test at a significance level of a p value of 0.05 or less. RESULTS:The time to reach peak blood concentrations (p = 0.055), dose-normalized trough concentrations (p = 0.617), maximum blood concentrations (p = 0.197), and dose-normalized AUC (p = 0.755) were not significantly different between two study periods. CONCLUSIONS:This study demonstrated that simultaneous administration of Osmolite enteral feedings with tacrolimus did not interfere with tacrolimus absorption in transplant patients.
10.1345/aph.17181
Treatment of diencephalic syndrome with chemotherapy: growth, tumor response, and long term control.
Gropman A L,Packer R J,Nicholson H S,Vezina L G,Jakacki R,Geyer R,Olson J M,Phillips P,Needle M,Broxson E H,Reaman G,Finlay J
Cancer
BACKGROUND:The diencephalic syndrome (DS), which is manifested by progressive emaciation and failure to thrive in an apparently alert, cheerful infant, usually is due to a low grade hypothalamic glioma. Treatment with aggressive surgery and/or radiotherapy is variably successful in controlling disease and may result in severe neurologic sequelae. Chemotherapy recently has been shown to be effective in patients with low grade gliomas of childhood, but it is used infrequently in those with DS. METHODS:The authors evaluated the efficacy of a regimen of carboplatin and vincristine on improving weight, causing tumor shrinkage, and delaying the need for alternative therapies in seven children (ages 9-20 months; median age, 11 months) with DS. Five patients weighed less than the 5th percentile for their age at the start of the study, one weighed within the 10th percentile, and one weighed within the 25th percentile. RESULTS:At follow-up (range, 6-54 months; median, 28 months), the patients' weights had increased by 66-95% (median, 80%). On magnetic resonance imaging, four patients had a >50% reduction in tumor mass, one had a 25-50% reduction, and two had stable disease. In those patients with radiographic response to treatment, weight gain was accomplished with oral feedings in four of five patients, whereas those with stable disease required nasogastric, nasojejunal, or gastrostomy tube supplementation to maintain weight. Disease progression occurred at a median of 24 months after initiation of chemotherapy, and two patients remained free of progressive disease at last follow-up. Five patients were alive a median of 59 months from diagnosis. The need for radiation or other therapies was delayed in six of seven children. Therapy was tolerated without significant toxicities. CONCLUSION:The authors conclude that treatment of DS with a carboplatin and vincristine regimen results in demonstrable weight gain, may result in tumor shrinkage, and in some cases, significantly delays the need for alternative therapies.
10.1002/(sici)1097-0142(19980701)83:1<166::aid-cncr22>3.0.co;2-u
Gastric pH control in critically ill children receiving intravenous ranitidine.
Harrison A M,Lugo R A,Vernon D D
Critical care medicine
OBJECTIVE:To determine whether the dose of ranitidine recommended in commonly used pediatric drug dosage handbooks (2 to 4 mg/kg/day i.v.) results in successful gastric pH control (pH of >4) in critically ill children. DESIGN:Prospective sample. SETTING:Pediatric intensive care unit in a tertiary care children's hospital. PATIENTS:Fifty consecutive patients who received >24 hrs of scheduled intermittent intravenous ranitidine for stress ulcer prophylaxis were enrolled in the study. Patients with renal or hepatic dysfunction and those who received enteral nutrition through the nasogastric tube were excluded from enrollment. INTERVENTION:Gastric pH was determined at the end of the ranitidine dosing interval, 1 hr after the dose, and at the midpoint between doses. All pH measurements were made from a sample of nasogastric aspirate, using pH sensitive paper. Gastric pH control with ranitidine was considered unsuccessful (poorly controlled) if the pH was <4 for any of the three measurements. MEASUREMENTS AND MAIN RESULTS:Forty-five patients (median age 36 mos; range 2 wks to 264 mos) were included in the analysis. Eighty-two percent of the patients were mechanically ventilated, 16% were pharmacologically paralyzed, 18% required vasoactive infusions, 36% were nourished via transpyloric feeding tubes, and 7% received total parenteral nutrition. Gastric pH was poorly controlled in 36% of patients. Among these patients, the pH at the end of the dosing interval was significantly lower than the pH measured at 1 hr or at the midpoint between doses (p < .05). Seventy-one percent of patients who received <3 mg/kg/day of ranitidine had poor gastric pH control as compared with 19% who received a minimum of 3 mg/kg/day (p< .05). Poor control of gastric pH was not associated with feeding, intubation status, presence of pharmacologic paralysis, use of vasoactive infusions, or age (p > .05). CONCLUSIONS:The minimum ranitidine dose recommended in commonly used pediatric drug references resulted in unsuccessful gastric pH control in a high percentage of pediatric intensive care unit patients. Critically ill children with normal renal and hepatic function should be treated with a minimum 3 mg/kg/day of intravenous ranitidine and the dose should be titrated to a gastric pH of > or =4.
10.1097/00003246-199808000-00032
Nosocomial sinusitis in patients in the medical intensive care unit: a prospective epidemiological study.
George D L,Falk P S,Umberto Meduri G,Leeper K V,Wunderink R G,Steere E L,Nunnally F K,Beckford N,Mayhall C G
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
A prospective observational cohort study of nosocomial sinusitis was carried out in two medical intensive care units. Sinusitis was diagnosed by computed tomographic scanning and the culture of sinus fluid obtained by puncture of a maxillary sinus. Clinical and epidemiological data were collected at the time of admission to the unit and daily thereafter. Specimens from the nares, oropharynx, trachea, and stomach were cultured on admission and daily thereafter. The cumulative incidence of nosocomial sinusitis was 7.7%, and the incidence rates were 12 cases per 1,000 patient-days and 19.8 cases per 1,000 nasoenteric tube-days. Risk factors for nosocomial sinusitis, as determined by multiple logistic regression analysis, included nasal colonization with enteric gram-negative bacilli (odds ratio [OR], 6.4; 95% confidence interval [95% CI], 2.2-18.8; P = .007), feeding via nasoenteric tube (OR, 14.1; 95% CI, 1.7-117.6; P = .015), sedation (OR, 15.9; 95% CI, 1.9-133.5; P = .011), and a Glasgow coma score of < or = 7 (OR, 9.1; 95% CI, 3.0-27.3; P = .0001).
10.1086/514711
Effect of intragastric or intraduodenal administration of a polymeric diet on gallbladder motility, small-bowel transit time, and hormone release.
Ledeboer M,Masclee A A,Biemond I,Lamers C B
The American journal of gastroenterology
OBJECTIVE:During postpyloric tube feeding, GI intolerance is observed more frequently than during prepyloric feeding, possibly by evoking a stronger GI response. METHODS:We investigated the effect of intragastric and intraduodenal administration of a polymeric diet (125 kcal/h) on gallbladder motility (by ultrasonography), duodeno-cecal transit time (by lactulose H2 breath test), and GI hormone release (including cholecystokinin, pancreatic polypeptide, and gastrin). Six healthy subjects (two male, four female; mean age 22 yr, range 18-27 yr) were studied on two separate occasions in random order during 6 h of continuous administration of the diet through either the gastric or duodenal port of a two-lumen tube. RESULTS:Intraduodenal feeding resulted in a more rapid contraction of the gallbladder, from 32 +/- 4 to 23 +/- 4 cm3 at 10 min (p < 0.05), reaching a minimum of 6 +/- 1 cm3, in contrast to intragastric feeding (31 +/- 4 to 19 +/- 3 cm3 at 60 min, p < 0.05; minimum 14 +/- 1 cm3). The gallbladder remained contracted during the 6-h study period during both intraduodenal and intragastric feeding. Small-bowel transit time was significantly accelerated during intraduodenal compared with intragastric feeding (51 +/- 12 vs 81 +/- 9 min; p = 0.003). Plasma cholecystokinin secretion was significantly (p < 0.05) increased during intraduodenal compared with intragastric feeding (848 +/- 107 vs 279 +/- 89 pmol x L(-1) x 360 min). The same was true for pancreatic polypeptide secretion. However, gastrin release was significantly (p < 0.05) higher during intragastric feeding. CONCLUSIONS:Intraduodenal feeding elicited a stronger GI response than intragastric feeding, as demonstrated by accelerated small-bowel transit time, more rapid and stronger gallbladder contractions, and increased cholecystokinin and pancreatic polypeptide release. Gastrin release, on the other hand, was stronger during intragastric feeding.
10.1111/j.1572-0241.1998.00599.x
Small-bowel necrosis associated with jejunal tube feeding.
Lawlor D K,Inculet R I,Malthaner R A
Canadian journal of surgery. Journal canadien de chirurgie
OBJECTIVES:To report 3 cases of small-bowel necrosis after jejunal tube feeding and to review the literature concerning this condition. DESIGN:A 5-year retrospective review. SETTING:A 560-bed university-affiliated tertiary-care teaching hospital. PATIENTS:Three patients who had bowel necrosis out of 386 who received jejunal tube feedings. RESULTS:The patients experienced small-bowel necrosis as a consequence of jejunal feeding. The ischemic necrosis was preceded by progressive abdominal pain, distension and high nasogastric output. All 3 patients required extensive small-bowel resection. Although survival was rare in previous reports, our 3 patients survived after prompt surgical intervention and small-bowel resection. CONCLUSIONS:Although the death rate for this condition approaches 70%, timely recognition and surgical intervention can save the patient's life.
Enteral glutamine does not enhance the effects of hepatocyte growth factor in short bowel syndrome.
Alavi K,Kato Y,Yu D,Schwartz M Z
Journal of pediatric surgery
PURPOSE:This study was designed to determine if luminally administered glutamine alone functions as a growth factor or is synergistic with hepatocyte growth factor (HGF) after massive small bowel resection (MSBR). METHODS:Twenty Sprague-Dawley rats underwent an 80% small bowel resection and jejunostomy tube placement. Seven days later the rats were divided into four groups: group 1, control, no further treatment (n = 5); group 2 received glutamine (4% of total food intake per day) via an orogastric tube (n = 5); group 3 received intraluminal HGF via a jejunostomy tube at 75 microg/kg/d (n = 5); and group 4 received glutamine and HGF at the same doses, respectively. After a 14-day HGF infusion, glutamine feeding, or both combined, [C14] glycine absorption (micromol/L/cm2 intestine) and mucosal DNA and protein content (microg/mg mucosa) were measured in the remaining small bowel. RESULTS:Glutamine alone had no effect on substrate absorption and protein or DNA content. HGF increased galactose absorption (106% increase over control, P<.01), glycine absorption (95% increase over control, P<.05), protein content (44% increase over control, P<.01), and DNA content (32% increase over control, P<.01). The combination of glutamine and HGF did not prove to be synergistic. CONCLUSIONS:These data demonstrate that in this short bowel model, glutamine alone did not enhance intestinal function. Furthermore, glutamine is not synergistic with HGF. This study suggests that glutamine alone may not be useful clinically in patients with inadequate intestinal function.
10.1016/s0022-3468(98)90605-4
Acquisition of Clostridium difficile and Clostridium difficile-associated diarrhea in hospitalized patients receiving tube feeding.
Bliss D Z,Johnson S,Savik K,Clabots C R,Willard K,Gerding D N
Annals of internal medicine
BACKGROUND:Clostridium difficile is the most common infectious cause of nosocomial diarrhea, but its role in diarrhea associated with tube feeding has not been rigorously investigated. OBJECTIVE:To determine the incidence of C. difficile acquisition and C. difficile-associated diarrhea in tube-fed and non-tube-fed patients. DESIGN:Prospective cohort study. SETTING:A university-affiliated Veterans Affairs Medical Center. PATIENTS:76 consecutive hospitalized, tube-fed patients and 76 hospitalized, non-tube-fed patients. The two cohorts were matched for age, unit location, duration of hospitalization before surveillance, and severity of illness. MEASUREMENTS:Incidence of C. difficile acquisition, incidence of C. difficile-associated diarrhea, and C. difficile restriction endonuclease analysis typing results. RESULTS:More tube-fed patients than non-tube-fed patients acquired C. difficile (15 of 76 patients [20%] compared with 6 of 76 patients [8%]; P=0.03) and developed C. difficile-associated diarrhea (7 of 76 patients [9%] compared with 1 of 76 patients [1%]; P=0.03). The mean proportion (+/-SD) of surveillance days with diarrhea was greater for tube-fed patients after the development of C. difficile-associated diarrhea than for tube-fed patients without this diarrhea (0.68+/-0.4 compared with 0.22+/-0.2 [95% CI for the mean difference, 0.08 to 0.84]). Postpyloric tube feeding (odds ratio, 3.14 [CI, 1.008 to 9.77]) and duration of surveillance (odds ratio, 1.08 [CI, 1.0009 to 1.16]) were risk factors for the acquisition of C. difficile. Nineteen restriction endonuclease analysis types of C. difficile were identified from 20 patients. CONCLUSIONS:Hospitalized, tube-fed patients, especially those receiving postpyloric tube feeding, are at greater risk for the acquisition of C. difficile and the development of C. difficile-associated diarrhea than are hospitalized, non-tube-fed patients. Clinicians should test for C. difficile in tube-fed patients with diarrhea.
10.7326/0003-4819-129-12-199812150-00004
Gastric versus duodenal feeding and gastric tonometric measurements.
Levy B,Perrigault P F,Gawalkiewicz P,Sebire F,Escriva M,Colson P,Wahl D,Frederic M,Bollaert P E,Larcan A
Critical care medicine
OBJECTIVE:To compare the influence of gastric and postpyloric enteral feeding on the gastric tonometric PCO2 gap (tonometric PCO2 - PaCO2). DESIGN:A prospective, clinical trial. SETTING:Two intensive care units in a university hospital. PATIENTS:Twenty patients undergoing mechanical ventilation and enteral feeding without catecholamines, sepsis, or sign of hypoxia. INTERVENTIONS:Patients were randomized to receive feeding through the tonometer (gastric group), or through a postpyloric tube (postpyloric group). MEASUREMENTS AND MAIN RESULTS:The patients received tube feeding at a rate of 50 mL/hr during 4 hrs. Baseline measurements included: mean arterial pressure, heart rate, tonometric parameters, arterial gases, and arterial lactate concentration. Except for lactate concentration, these measurements were repeated after 1 and 4 hrs of enteral feeding and 2 hrs after stopping enteral feeding. During the study, arterial pH and PaCO2 did not change. During enteral feeding, the PCO2 gap increased in the gastric group from a mean of 7+/-5 to 17+/-14 (SD) torr (0.9 0.7 to 2.3+/-1.9 kPa) (p< .O01) and did not change in the postpyloric group (5+/-5 to 3+/-1 torr [0.7+/-0.7 to 0.4+/-0.1 kPa]). Two hours after stopping enteral feeding, the PCO2 gap was still increased in the gastric group (15+/-9 vs. 7+/-5 torr [2.0+/-1.2 vs. 0.9+/-0.7 kPa]) (p < .01). CONCLUSION:The results indicate that gastric enteral feeding increased the PCO2 gap. However, postpyloric enteral feeding does not interact with gastric tonometric measurements and should be used when using gastric tonometry in enterally fed patients.
10.1097/00003246-199812000-00026
Influence of hyperglycemia on the satiating effect of CCK in humans.
Lam W F,Gielkens H A,de Boer S Y,Lamers C B,Masclee A A
Physiology & behavior
In the present study the effects of intraduodenal (i.d.) fat (endogenous CCK) and of CCK infusion on satiety were studied during normo-and hyperglycemic conditions. Eight healthy subjects participated in two protocols consisting of two experiments each. First protocol: (a) normoglycemia (control) with i.d. emulsified fat (i.d. fat) infusion, (b) acute hyperglycemia (HG) with plasma glucose levels stabilized at 15 mmol/L and i.d. fat infusion. In the second protocol the effect of exogenous cholecystokinin (CCK) on satiety was studied during normo- and hyperglycemia. Intraduodenal fat (Intralipid 10%) was infused at a dose of 1 g/h via a nasoduodenal tube in the first protocol, whereas in the second protocol CCK-33 was infused intravenously at a dose of 0.5 IDU/kg x h. Satiety was scored using visual analog scales (VAS). Plasma CCK levels were determined at regular intervals. During infusion of i.d. fat and i.v. CCK the VAS scores of wish to eat, hunger, and prospective feeding decreased significantly (p<0.05) in the normoglycemic experiments. During hyperglycemia satiety did not significantly change in the basal period; however, the scores of wish to eat, hunger, and prospective feeding increased significantly (p<0.05) when i.d. fat or i.v. CCK was administered. Plasma CCK levels in the basal and the stimulated period were not significantly different between normo- and hyperglycemia. In summary, the present study shows that in healthy humans volunteers 1) during normoglycemic conditions satiety can be induced by very low dose of i.d. fat and by CCK infusion, 2) during hyperglycemia the effect of i.d. fat and CCK on satiety are reversed, resulting in increased appetite.
10.1016/s0031-9384(98)00189-9
Insulin's anabolic effect is influenced by route of administration of nutrients.
Clements R H,Hayes C A,Gibbs E R,Geiger J,Laws H L,Long C L
Archives of surgery (Chicago, Ill. : 1960)
OBJECTIVE:To determine if the anabolic effects of intravenous insulin on protein kinetics could be exploited in the enterally fed trauma victim. DESIGN:Randomized, crossover control protocol. SETTING:Level I trauma center. PATIENTS:Ten trauma patients with an Injury Severity Score higher than 20. Exclusion criteria included diabetes mellitus, pregnancy, steroid use, and aged younger than 18 years or older than 65 years. INTERVENTIONS:Within the first 24 hours of admission to the intensive care unit, each patient had a transpyloric feeding tube inserted radiographically. Enteral nutrition was provided with a protein supplement (Ensure, Ross Laboratories, Columbus, Ohio) and Promod, supplemented with protein powder to supply 1.5 g/kg per day of protein and 156.9 kJ/kg per day. Intravenous insulin was provided at 0.043 U/kg per hour beginning on the second or fourth day. MAIN OUTCOME MEASURES:Urinary nitrogen balance and 3-methylhistidine excretion rates were measured at the end of the third and fifth days. Plasma glucose, insulin, and C-peptide levels were obtained at these same times. RESULTS:Urinary nitrogen balance was not significantly different with or without the administration of insulin (-4.58+/-50.1 mg/kg per day vs -9.38+/-50.9 mg/kg per day, respectively). 3-Methylhistidine excretion rates did not change significantly with or without the administration of insulin (5.77+/-0.67 micromol/kg per day vs 6.15+/-0.43 micromol/kg per day, respectively). Serum insulin levels did not differ significantly when exogenous infusions were added (57.8+/-17.9 microU/mL vs 82.1+/-44.9 microU/mL), but serum C-peptide levels did decrease significantly when exogenous insulin was added (5.11+/-3.2 microU/mL vs 10.28+/-3.5 microU/mL; P = .04). Serum glucose levels decreased significantly when insulin was administered (5.8+/-0.4 mmol/L [104.6+/-7.2 mg/dL] vs 7.7+/-0.4 mmol/L [138.1+/-7.4 mg/dL; P =.004). CONCLUSION:The anabolic effect of intravenous insulin on protein kinetics is not evident when nutrition is provided enterally in the trauma victim.
10.1001/archsurg.134.3.274
Effect of chain length on absorption of biologically active peptides from the gastrointestinal tract.
Roberts P R,Burney J D,Black K W,Zaloga G P
Digestion
OBJECTIVES:Protein digestion generates many peptides in the gut lumen. Some of these peptides possess biological effects when tested using in vitro systems. It is clear that dipeptides and tripeptides can be absorbed intact from the gastrointestinal tract. However, the fate of larger peptides and small proteins remains unclear. Equally unclear are the biologic potencies of absorbed peptides and the quantity of peptide that must be administered into the gut to produce a biologic effect. Thus, the purpose of this study was to determine the effect of amino acid chain length on the ability of enterally administered peptides to produce biologic effects. METHODS:Small bowel feeding tubes, jugular catheters, and arterial lines were placed into adult male Sprague-Dawley rats. Rats were administered intravenous (50 microg) and enteral (125 and 500 microg) thyrotropin-releasing hormone (TRH, a tripeptide), intravenous (100 microg) and enteral (100 and 500 microg) luteinizing hormone-releasing hormone (LHRH, a decapeptide), and intravenous (0.5 mg) and enteral (0.5 and 25 mg) insulin (a 51-amino acid polypeptide). The quantity of peptide administered represented less than 0.5% of a rat's normal daily protein intake. The biologic effect of TRH, LHRH, and insulin were assessed using thyroid-stimulating hormone (TSH) response, follicle-stimulating hormone (FSH) response, and glucose. We also measured serum levels of insulin in the rats following enteral insulin administration. RESULTS:The results indicate that enteral TRH (125 and 500 microg) produced the same TSH response as intravenous TRH. The response to 500 microg enteral LHRH was 50% of the response to intravenous LHRH and the response to 25 mg enteral insulin was 30% of the response to 0.5 mg intravenous insulin. Serum insulin levels increased significantly following both 0.5 and 25 mg enteral insulin. CONCLUSIONS:These results support the concept that small (di- and tripeptides) and large (10-51 amino acids) peptides generated in the diet can be absorbed intact through the intestines and produce biologic effects at the tissue level. The potency of the enterally administered peptides decreases as the chain length increases. We postulate that absorbed dietary peptides play a role in the modulation of organ function and disease progression.
10.1159/000007679
Antroduodenal motility and small bowel transit during continuous intraduodenal or intragastric administration of enteral nutrition.
Ledeboer M,Masclee A A,Coenraad M,Vecht J,Biemond I,Lamers C B
European journal of clinical investigation
BACKGROUND:Gastrointestinal intolerance is observed more frequently during intraduodenal (ID) tube feeding than during intragastric (IG) feeding, possibly because it evokes a stronger gastrointestinal response and accelerates small bowel transit. We have investigated whether the accelerated small bowel transit during ID feeding results from alterations in antroduodenal motility pattern. DESIGN:The effect of IG and ID infusion of a polymeric diet (Nutrison, 125 kcal h-1) on antroduodenal motility, small bowel transit time (SBTT) and gastrointestinal hormone release was studied in nine healthy subjects. These subjects were studied on three occasions for 6 h during fasting, continuous IG or ID feeding. RESULTS:Phase III recurrence time was significantly prolonged during IG feeding compared with fasting (240 +/- 51 vs. 136 +/- 24 min; P < 0.05). None of the subjects had recurrence of phase III during ID feeding; the fed motor pattern remained present. Parameters of fed motility (mean amplitude and motility index) were not significantly different between IG and ID feeding, although the frequency of antral and duodenal contractions was lower during ID than during IG feeding. SBTT was significantly accelerated during ID compared with IG feeding and with fasting (58 +/- 8 vs. 73 +/- 9 and 83 +/- 10 min respectively; P < 0.05). Plasma cholecystokinin (CCK) and pancreatic polypeptide (PP) levels were significantly higher during ID than during IG feeding. Peptide YY (PYY) levels were significantly higher during ID than during fasting, but not during IG feeding CONCLUSIONS:During intraduodenal feeding, a fed motility pattern is preserved, whereas during intragastric feeding transition from a fed to a fasting motor pattern is observed in over 50% of the subjects. These differences may be related to augmented hormone release during intraduodenal feeding.
Gastric acidity and duodenogastric reflux during nasojejunal tube feeding in mechanically ventilated patients.
Dive A,Michel I,Galanti L,Jamart J,Vander Borght T,Installé E
Intensive care medicine
OBJECTIVE:In order to prevent gastric microbial overgrowth, which may complicate nasogastric feeding, administration of nutrients more distally into the gut has been advocated in intensive care patients, as it offers the advantage of keeping the stomach empty and acid. In this study, we assessed the impact of jejunal feeding upon gastic pH in a group of mechanically ventilated, critically ill patients, with special focus on duodenogastric reflux as a possible cause of gastric alkalinization during jejunal nutrition. DESIGN:Prospective experimental study. SETTING:Multidisciplinary intensive care unit of a university hospital. PATIENTS AND METHODS:Gastric pH was recorded by continuous pHmetry over a 4-h period of fasting followed by a 4-h period of nasojejunal feeding at 100 kcal/h in 21 mechanically ventilated, critically ill patients. To determine the contribution of duodenogastric reflux to modifications of gastric acidity, the diet was traced with [(111)In] DTPA (pentetic acid) in 11 of these 21 patients; gastric contents were aspirated every 30 min, then analysed for measurement of radioactivity, glucose, and bile acid concentration. MEASUREMENTS AND RESULTS:Median intragastric pH increased slightly from 1.59 (1.20-2.73; interquartile range) (fasting) to 2.33 (1.65-4.64) (feeding) (p = 0.013), and the length of time that the pH was 4 or above increased from 1 (0-24) to 9 (0-142) min (p = 0.026). The variability of pH values and the number of acute alkalinization episodes did not change between the two phases. In 10 of 11 patients in which the diet was labeled with [(111)In] DTPA, reflux was documented at a given time of the feeding period. Bile acid concentrations in the stomach increased from 392 (61-1076) (fasting) to 1446 (320-2770) micromol/l (feeding) (p = 0.010) and mean glucose concentration increased from 59 (28-95) to 164 (104-449) mg/dl (p = 0.006). CONCLUSION:Duodenogastric reflux is common in mechanically ventilated critically ill patients with nasojejunal feeding tubes. It occurs both during fasting and during nasojejunal feeding. During nasojejunal feeding, moderate alkalinization of the gastric contents occurs as a result of bile and nutrient reflux.
[The nasojejunal tube in early postoperative nutrition].
Monteferrante E,Mancini G,Pedrazzoli C,Rozzi F,Ciampaglia F,Manso L,Listorto G
Minerva chirurgica
BACKGROUND:To verify the effectiveness of the nasojejunal tube inserted during operation as an alternative to jejunostomy to perform early enteral feeding. METHODS: EXPERIMENTAL DESIGN:Prospective study. SETTING:Department of Surgery, General Hospital. PATIENTS:27 patients undergoing laparotomy because of a gastric pathology. INTERVENTIONS:In 18 patients before construction of the distal jejunum anastomosis the tube was inserted by nasal route and advanced into the jejunum ansa until the end reached 15 to 20 cm down the anastomosis (group A); 9 patients underwent a jejunostomy according to Delany (group B). All the patients started enteral feeding 24 hours after operation and had the same polymeric diet, given to them using the same procedures. MEASURES:postoperative complications, tube intolerance, intestinal tolerance. RESULTS:The degree of non-acceptance of the tube was: absent in 3 patients of group A and in 7 patients of group B (p > 0.05); slight in 6 patients of group A and in 2 patients of group B (p > 0.05); medium in 9 patients of group A and in no one of the group B (p no measurable); high in neither groups. The intestinal tolerance was similar in both groups. CONCLUSIONS:Nasojejunal tube is an effective alternative to jejunostomy to perform early postoperative enteral feeding.
Does jejunal feeding activate exocrine pancreatic secretion?
Vu M K,van der Veek P P,Frölich M,Souverijn J H,Biemond I,Lamers C B,Masclee A A
European journal of clinical investigation
BACKGROUND:The upper small bowel is of pivotal importance for the stimulation of exocrine pancreatic secretion in response to a meal. We hypothesize that more distal delivery of nutrients into the small intestine will result in less activation of pancreatic secretion. MATERIALS AND METHODS:Eight healthy subjects (3 male, 5 female; age 23 +/- 1 years) participated in two experiments, performed in random order. Subjects were intubated with a 4-lumen tube. Duodenal outputs of pancreatic enzymes and bilirubin were measured by aspiration using a recovery marker. The distal opening was used for continuous administration of a mixed liquid meal and located at either the ligament of Treitz or 60 cm further distally. Gallbladder volume was measured and blood samples were drawn for determination of gastrointestinal hormones. The duration of each experiment was 4 h; with 1 h fasting and 3 h continuous administration of nutrients. RESULTS:During proximal jejunal feeding, pancreatic enzyme output increased significantly over basal levels. No significant increase over basal levels was observed during distal jejunal feeding. Bilirubin output and gallbladder contraction were significantly (P < 0.05) reduced during distal compared to proximal jejunal feeding. No significant differences were found in plasma levels of CCK, PYY and neurotensin between proximal and distal jejunal feeding. CONCLUSION:Continuous feeding in the distal jejunum does not stimulate exocrine pancreatic secretion but maintains gallbladder contraction, although to a lesser extent. These effects are not related to hormonal changes but probably reduced activation of the enteropancreatic reflexes.
Bacterial contamination of ready-to-use 1-L feeding bottles and administration sets in severely compromised intensive care patients.
Mathus-Vliegen L M,Binnekade J M,de Haan R J
Critical care medicine
OBJECTIVE:In intensive care patients, enteral feeding requires sterile feedings because of infectious complications and adequate supplements to meet nutritional needs. Heretofore, prepacked, large-volume formula containers were developed, but bacterial contamination occurred in 4% to 15%. Our objective was to investigate the microbial contamination rate of 1-L feeding bottles and newly designed administration sets over hanging times of 24 hrs in the intensive care unit (ICU). DESIGN AND SETTING:A prospective observational cohort study of patients admitted to the ICU of a university hospital. PATIENTS:All consecutive patients fed via a nasojejunal tube for at least 4 days. MEASUREMENTS:Cultures of feeding bottles, administration sets, and gastric and tracheobronchial aspirates at day 0, 1, 2, 4, and 7. RESULTS:A total of 4% of feeding bottles and 74% of infusion sets contained >10(2) colony forming units (CFU)/mL. Gastric and bronchial aspirates were positive in 90% and 92%, respectively. Bacterial counts of feeding bottles were 10(2)-10(5) CFU/mL, and the main bacteria isolated included Enterobacter cloacae, Klebsiella oxytoca, and enterococci. One third of all cultured bacteria in feeding bottles, administration sets, stomach, and lungs belonged to the Enterobacteriaceae family, which was held responsible for the nosocomial infections in the ICU. None of the 1-L feeding bottles with a hanging time of 19-24 hrs was contaminated. Only bottles that had to be exchanged because of need for a faster rate of infusion proved to be contaminated, apparently without clinical consequences. With time and the increasing severity of disease, the administration sets became contaminated at an increasingly faster rate and with higher bacterial counts mainly through retrograde growth of endogenous bacteria. The final step of bottle contamination might have been the bacterial transfer by nurses' hands. CONCLUSION:Despite an almost ideal design of the enteral nutrition delivery system, a 4% contamination rate of initially sterile feedings with clinically relevant bacteria and the fact that only manipulated systems showed bacterial growth are of concern.
10.1097/00003246-200001000-00011
Enteral nutrition support in acute pancreatitis.
Erstad B L
The Annals of pharmacotherapy
OBJECTIVE:To review the controversies surrounding the use of nutritional interventions, particularly enteral support, in patients with acute pancreatitis. DATA SOURCES:Articles were obtained through a MEDLINE search (1966-June 1999). Additionally, several textbooks containing information on the diagnosis and management of acute pancreatitis were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references. STUDY SELECTION:All original investigations in humans pertaining to the use of enteral nutritional support in acute pancreatitis were reviewed for inclusion. Studies that investigated parenteral nutrition in acute pancreatitis were also reviewed, with preference given to controlled comparisons with enteral regimens or no nutritional support. DATA EXTRACTION:The primary outcomes extracted from the literature were time to oral feeding tolerance, complications (e.g., infection) associated with nutritional support, and length of stay. DATA SYNTHESIS:The duration of pancreatitis and time to oral feedings is similar whether patients receive enteral (i.e., jejunal tube feedings) or parenteral nutrition. Additionally, complications, length of stay, and costs are either similar or decreased with enteral versus parenteral nutrition. CONCLUSIONS:Current evidence suggests that the enteral rather than parenteral route should be used to provide nutrition to patients with acute pancreatitis. Parenteral nutrition should be reserved for patients in whom nasojejunal feeding is not possible.
10.1345/aph.19144
[Gastroplegia after elective intestinal surgery].
Matulíková A,Hoch J
Rozhledy v chirurgii : mesicnik Ceskoslovenske chirurgicke spolecnosti
The postoperative gastric atony presents a regular early complication after each laparotomy. The purpose of this study was to evaluate the impact of gastroduodenal decompression on the development of postoperative gastroplegia, the association of gastric atony with risk of other postoperative complications and the influence of nasogastric decompression on early postoperative feeding. 236 patients who underwent elective small bowel and colorectal surgery were evaluated according to the fact whether a prophylactic nasogastric tube was applied or not. Neither a higher incidence of gastric atony nor a rate of other postoperative complications in the patients with prophylactic gastroduodenal decompression was detected. The difference in the beginning of enteral feeding was statistically significant. The patients with gastroplegia had a higher incidence of the laparotomy wound dehiscence and of postoperative bronchopneumonia. The authors recommend a selective gastroduodenal decompression after elective bowel surgery only.
Early versus delayed feeding with an immune-enhancing diet in patients with severe head injuries.
Minard G,Kudsk K A,Melton S,Patton J H,Tolley E A
JPEN. Journal of parenteral and enteral nutrition
BACKGROUND:Although early enteral feeding clearly reduces septic morbidity after blunt and penetrating trauma, data for head-injured patients are conflicting. This study examines the effects of early vs delayed enteral feedings on outcome in patients with severe closed-head injuries with a Glasgow Coma Scale (GCS) score greater than 3 and less than 11. METHODS:Thirty patients were prospectively randomized to receive an immune-enhancing diet (Impact with fiber) early (initiated < 72 hours after trauma) delivered via an endoscopically placed nasoenteric tube (Stay-Put) or late (administered after gastric ileus resolved). This formula was continued for 14 days or until the patient tolerated oral feeding. Goal rate of nutrition was 21 nonprotein cal/kg/d and 0.3 g N/kg/d. RESULTS:Two patients in the early group were excluded due to inability to place the tube, and one patient in the late group died before 72 hours. Five of the remaining 27 died, 1 in the early group and 4 in the late group. There were no significant differences between the groups in length of stay, intensive care unit (ICU) days, significant infection, or GCS score. However, major infection correlated inversely with admission GCS score (R = -0.6, p < .003). Time to reach a GCS score of 14 was significantly longer in patients with significant infections compared with those without (p < .02). CONCLUSIONS:No difference in length of stay or infectious complications is shown in patients with severe closed-head injury when they are given early vs delayed feeding using an immune-enhancing formula. Severity of the head injury is closely associated with significant infection.
10.1177/0148607100024003145
The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical trial.
Kearns P J,Chin D,Mueller L,Wallace K,Jensen W A,Kirsch C M
Critical care medicine
BACKGROUND:Enteral feeding provides nutrients for patients who require endotracheal tubes and mechanical ventilation. There is a presumed increase in the risk of ventilator-associated pneumonia (VAP) with tube feeding. This has stimulated the development of procedures for duodenal intubation and small intestinal (SI) feeding as primary prophylaxes to prevent VAP. OBJECTIVE:To investigate the rate of VAP and adequacy of nutrient delivery with gastric (G) vs. SI feeding. DESIGN:A prospective, randomized, controlled trial. SETTING:A medical intensive care unit of a county hospital. PATIENTS:A total of 44 endotracheally intubated, mechanically ventilated patients requiring enteral nutrition. INTERVENTION:Subjects were randomized to receive enteral nutrition via G or SI feeding. Protocols directed the placement of the feeding tube and the infusion of enteral nutrition and defined the radiographic and clinical criteria for a diagnosis of VAP. MEASUREMENTS AND OUTCOMES:The incidence of VAP and the adequacy of nutritional supplementation were prospectively followed. The relative risk of VAP with SI was 1.1 (95% confidence interval 0.96-2.44) compared with G. The SI group received a greater percentage of their caloric requirements (SI 69 +/- 7% vs. G 47 +/- 7%, mean +/- SEM, p < .05). Mortality did not differ between G (26 +/- 9%) and SI (24 +/- 10, p = .86). CONCLUSIONS:There is no clear difference in the incidence of VAP in SI compared with G enteral nutrition. Patients given feeding into the SI do receive higher calorie and protein intakes.
10.1097/00003246-200006000-00007
Further report of small-bowel intussusceptions related to gastrojejunostomy tubes.
Hughes U M,Connolly B L,Chait P G,Muraca S
Pediatric radiology
BACKGROUND:The use of gastrojejunostomy (GJ) tubes for feeding pediatric patients who have inadequate oral intake, cannot tolerate gastric feeding, or have significant gastroesophageal reflux may present problems. OBJECTIVE:To report our experience of intussusception associated with GJ tubes, with emphasis on risk factors. MATERIALS AND METHODS:Clinical histories and imaging studies were reviewed for all patients with GJ tube-associated intussusceptions at our institution from January 1995 to March 1999. RESULTS:Of 251 GJ tubes inserted, 40 (16%) intussusceptions occurred in 30 patients (20 males). They ranged in age from 3 months to 17 years (mean 2.6 years) and in weight from 3 to 90 kg (mean 12.5 kg). The underlying diagnosis varied. The main symptom was bilious vomiting. The initial diagnosis was made by sonography in 19 cases and fluoroscopy in 21. Intussusceptions recurred eight times in patients with a distal pigtail (n = 17) but only twice in patients without the distal pigtail (n = 18). CONCLUSIONS:GJ-tube related intussusception is a common, easily diagnosed problem. Predisposing factors appear to be male sex, young children, and presence of a distal pigtail on the tube. Awareness of intussusception is imperative for prompt diagnosis to achieve feeding tolerance.
10.1007/s002470000260
Pancreaticoduodenal necrosis due to caustic burns.
Landen S,Wu M H,Jeng L B,Delugeau V,Launois B
Acta chirurgica Belgica
BACKGROUND AND METHODS:Fourteen patients with caustic necrosis of the digestive tract extending beyond the pylorus were included in a multicenter retrospective study to define a surgical strategy. Twelve patients underwent esophagogastrectomy. Two patients had total gastrectomy without esophagectomy. In addition, all patients underwent duodenal stripping (n = 7) or pancreaticoduodenectomy (n = 7). Immediate biliopancreatic reconnection was performed in ten patients. Four patients had biliary diversion and/or pancreatic duct ligation. RESULTS:Seven in-hospital deaths occurred after a mean delay of 27 days (range 16-45 days). There were two late deaths occurring 6 and 12 months postoperatively. Morbidity was noted in 86% of survivors. Acute or chronic airway tract injuries were incurred by 57% of patients. Among the five long-term survivors two were able to feed orally and had preserved voice function. One long-term survivor could resume oral feeding only, another was considered psychologically unfit for digestive reconstruction but had normal voice function and the last patient was deprived of oral feeding and phonation. CONCLUSIONS:Early radical debridement is capable of saving patients with gastrointestinal necrosis extending beyond the pylorus. Necrosis of the duodenum can be managed by pancreaticoduodenectomy or by duodenal stripping, with similar results. Immediate reconnection of the bile and pancreatic ducts to a small bowel Roux-en-Y loop appears preferable to biliary diversion and pancreatic duct ligation. Normal oral feeding and the preservation of voice function can sometimes be achieved but depends on late scarring of the airway-alimentary tract junction. Quality of life is often compromised by prolonged hospital stays, staged surgical procedures and the handicap of a feeding jejunostomy and tracheal tube.
Nasogastric feeding in severe acute pancreatitis may be practical and safe.
Eatock F C,Brombacher G D,Steven A,Imrie C W,McKay C J,Carter R
International journal of pancreatology : official journal of the International Association of Pancreatology
BACKGROUND:Severe acute pancreatitis may be protracted and some form of nutritional support is frequently required to maintain the patient's nutritional status. Recent work has suggested that enteral feeding via a jejunal route of delivery may reduce the magnitude of the inflammatory response. Insertion of nasojejunal (NJ) tubes in the patient with severe acute pancreatitis involves both delay and inconvenience. We undertook a prospective, feasibility study to assess the safety and practicability of nasogastric (NG) feeding in patients with severe acute pancreatitis. PATIENTS AND METHODS:Twenty-six patients with objective evidence of severe acute pancreatitis received nasogastric feeding within 48 h of admission to our unit. RESULTS:Etiology was identified as cholelithiasis (18 patients), ethanol (5), and miscellaneous (3). The median Glasgow score was 4 (range 2-7), APACHE II score 10 (4-28), and C-reactive protein concentration 286 mg/L (79-469). Fifteen patients had pancreatic and/or peripancreatic necrosis. Eleven patients developed severe organ failure, necessitating ventilatory support. Six developed multiple organ system failure, requiring inotropic support and/or renal dialysis. There were four deaths (15.3%). Nine patients underwent early, and nine late, ERCP, respectively; six necrosectomy (5 proven infected necrosis, 1 continued deterioration despite maximal support) and 4 patients internal drainage of a pseudocyst. The feed was well-tolerated in 22 patients. In 3 patients gastric stasis proved troublesome. There was no evidence of clinical or biochemical deterioration on commencing nasogastric feeding. CONCLUSION:It would appear that early NG feeding is usually possible in severe acute pancreatitis. In most patients it appears safe, well-tolerated, and worthy of further study.
10.1385/IJGC:28:1:23
Direct percutaneous endoscopic jejunostomy with small bowel enteroscopy and fluoroscopy.
Shetzline M A,Suhocki P V,Workman M J
Gastrointestinal endoscopy
BACKGROUND:Approaches to the creation of a percutaneous jejunostomy (PEJ) include enteroscopy with jejunal transillumination, fluoroscopy with small bowel distension and tract dilation, and jejunal enteral tube placement through a percutaneous endoscopic gastrostomy. Although all have been successful, the combination of enteroscopy and fluoroscopy may improve visualization and the success of PEJ placement. This is a description of such a technique and its successful use in 7 patients. METHODS:The procedure was performed with the patient under conscious sedation in a manner similar to standard PEG placement. The proximal jejunum was visualized and a standard snare was passed though the enteroscope and was opened. A needle and guidewire were directed percutaneously though the snare by using fluoroscopic guidance. Under direct endoscopic visualization the snare was closed around the guidewire. A standard 20F push-type "gastrostomy" tube was passed over the guidewire and through the mouth and the dome seated in the jejunum. A bumper was passed externally over the tube and tightened at the skin. RESULTS:PEJ placement was successful in all 7 patients. The average length of the procedure was 40 minutes (range 22-64 minutes). There were no major complications. Mean follow-up was 124 days (range 28-308 days). Feeding tubes remained functional until removal (2), death (1), or surgical removal for an unrelated reason (1). Three tubes are still in use. CONCLUSIONS:Percutaneous endoscopic jejunostomy tube placement can be performed successfully with enteroscopy and fluoroscopy. This technique is safe and efficient and provides distal enteral nutritional support for patients in whom PEG cannot be used.
10.1067/mge.2001.114420
[Endoscopic gastrostomy in patients with complicated heart diseases].
Cukier C,Magnoni C D,Poletti P,Tacla M
Arquivos de gastroenterologia
Complicated cardiologic patients with brain ischemia and heart failure need long term enteral nutrition. Long term nasoenteral tube feeding may cause complications that could be avoided with percutaneous endoscopic gastrostomy. The aim of this study was to evaluate the indications for percutaneous endoscopic gastrostomy and its main complications. Twelve patients were submitted to percutaneous endoscopic gastrostomy (eight male) with main age of 62.42 +/- 22.10 years old. Brain ischemia was the main indication of percutaneous endoscopic gastrostomy and occurred after 35.58 +/- 26.79 days, after initiated enteral nutrition. There were no complications during procedure. On late post operatory period there were local infection in one cases, treated with local care. In conclusion, percutaneous endoscopic gastrostomy is a secure technique with low incidence of complications and its indication should be earlier.
10.1590/s0004-28032000000400004
Gastric feeding with erythromycin is equivalent to transpyloric feeding in the critically ill.
Boivin M A,Levy H
Critical care medicine
OBJECTIVE:To determine whether adding erythromycin to a gastric feeding regimen could render it as effective in meeting nutritional needs as transpyloric feeding. DESIGN:Randomized, controlled study. SETTING:University hospital medical, surgical, and neurologic care intensive care units. PATIENTS:Critically ill patients, requiring a projected 96 hrs of enteral feeding, who had no specific indication for tube location (gastric or transpyloric). Eighty patients were randomized. INTERVENTIONS:Patients were randomized to gastric feeding with erythromycin (200 mg iv) given every 8 hrs or feeding through a transpylorically placed feeding tube. Goal rate and feeding advancement were determined by protocol. MEASUREMENTS AND MAIN RESULTS:During the 96-hr period, the gastric group received 74% of their goal calories and the transpyloric group received 67%. The only day on which gastric feedings were superior was the first study day, where the gastric group attained 55% of their goal, compared with 44% in the transpyloric group. This 1-day difference was the result of an initial failure of tube placement in some subjects. Exclusion of these patients did not change overall results. Nutritional indexes, length of stay in the intensive care unit, ventilator dependence, and survival were not different between the two groups. CONCLUSIONS:Gastric feeding with erythromycin as a prokinetic is equivalent to transpyloric feeding in meeting the nutritional goals of the critically ill.
10.1097/00003246-200110000-00011
[Endoscopic percutaneous gastrostomy with gastropexy: a safe technical choice].
Paganelli M T,Antonini G,Correnti F S,Mercati U
Chirurgia italiana
Percutaneous endoscopic gastrostomy is an interesting method of providing enteral nutrition or gastric decompression in patients who are candidates for operative gastrostomy or nasoenteric tube feeding. We report our experience with percutaneous endoscopic gastrostomy with gastropexy (Introducer T-Fastener) in 41 patients. This method uses a technique in which the anterior gastric wall is non-surgically sutured to the anterior abdominal wall before catheter insertion. This technique was successful in all patients, including one subject with a Billroth II hemigastrectomy. Enteral nutrition was started in all cases within 24 hours of the end of the procedure. The medium enteral nutrition period to date is 482.5 days. There were no deaths related to the procedure and no patients had major specific abdominal complications requiring urgent surgical repair. Eight patients complained of minor specific complications which were successfully resolved in all cases with simple conservative procedures and/or therapies. These results indicate that the Introducer T-Fastener method for performing percutaneous endoscopic gastrostomy is rapid, safe, and inexpensive.
[The effects of percutaneous endoscopic gastrostomy feeding in patients with swallowing disturbance].
Kawasaki Y,Nakayoshi T,Kuramochi A,Masuda K,Suzuki H,Suzuki Y,Ikegami M,Kawakami M
Gan to kagaku ryoho. Cancer & chemotherapy
BACKGROUND AND PURPOSE:Because the number of patients who need home healthcare has recently increased in Japan, Percutaneous endoscopic gastrostomy (PEG) will soon become more popular. This study aims to examine the effects of enteral alimentation via PEG. MATERIAL AND METHODS:The subjects were 18 patients who underwent PEG instead of receiving total parental nutrition (TPN) (TPN-to-PEG group), 13 patients who underwent PEG instead of receiving enteral nutrition through a naso gastric tube (NG-to-PEG group), and 11 healthy volunteers (control). Morphological changes of the small bowel mucosa and activities of daily life (ADL) after PEG were also investigated. RESULTS:In the TPN-to-PEG group, the serum level of total protein and albumin, length of duodenal villi, ration of positive proliferative cells, width of duodenal microvilli and ADL markedly increased. In the NG-to-PEG group, body weight and ADL were markedly improved after PEG. CONCLUSION:Nutrition via PEG is superior to TPN or enteral nutrition with an NG tube. I conclude that PEG will become the first choice for improving nutrition in patients with dysphasia and will contribute to continuous enteral nutrition for home care.
Bioavailability of gatifloxacin by gastric tube administration with and without concomitant enteral feeding in critically ill patients.
Kanji Salmaan,McKinnon Peggy S,Barletta Jeffrey F,Kruse James A,Devlin John W
Critical care medicine
OBJECTIVE:Sequential intravenous-to-oral antimicrobial therapy with highly bioavailable antiinfective agents such as the fluoroquinolones may improve patient safety and decrease cost of infection management. However, physiologic changes associated with critical illness may alter drug absorption, distribution, and clearance, and concomitant enteral feeding may decrease fluoroquinolone bioavailability. We evaluated the effect of critical illness and concomitant gastric tube feeding on gatifloxacin bioavailability. DESIGN:Prospective, randomized, single-dose, two-way crossover, pharmacokinetic study. SETTINGA tertiary, level-one, trauma center. PATIENTS:Sixteen critically ill patients (baseline Acute Physiology and Chronic Health Evaluation II score >or=16) tolerating enteral nutrition administered by gastric tube (NG) for >or=12 hrs were randomized to receive gatifloxacin concurrently with continuous tube feeding or with interrupted tube feeds. Patients with renal insufficiency or those receiving concomitant fluoroquinolone therapy or postpyloric feeding were excluded. Patients received gatifloxacin 400 mg either by the intravenous or NG route followed by the alternative dosage form after a 72-hr washout period. MEASUREMENTS AND MAIN RESULTS:Serial serum gatifloxacin concentrations (from 5 mins to 24 hrs) were analyzed using a validated high-performance liquid chromatography method. Bioavailability was determined as the ratio of NG/intravenous area under the concentration-time curve (AUC infinity ) measured by the trapezoidal method. Although there was no difference in the bioavailability between NG (AUC infinity : 38.0 [range 20.1 to 48.5] microg x h/mL) and intravenous (AUC infinity : 39.5 [range 24.1 to 63.1] microg x h/mL, p =.60) gatifloxacin (bioavailability: 98.5% [range 61.1% to 119.7%]), a wide variability was observed in three of eight patients (>30% reduction in bioavailability). Concomitant gastric tube feeding did not affect gatifloxacin bioavailability (interrupted tube feeds: 98.5% [range 61.1% to 119.7%]; continuous tube feeding: 109.0% [range 86.2% to 142.1%]; p =.42). Neither a period nor differential carryover effect was observed. CONCLUSIONS:Although concomitant tube feeding did not affect gatifloxacin bioavailability, critical illness resulted in significant variability that may complicate the role of gatifloxacin in sequential intravenous-to-oral therapy. More research is needed to identify those patients in whom gatifloxacin bioavailability is reduced and for whom an empirical increase in gatifloxacin dose should be considered.
10.1097/01.CCM.0000059317.75234.46
Naso-jejunal feeding in allogeneic bone marrow transplant recipients: results of a pilot study.
Sefcick A,Anderton D,Byrne J L,Teahon K,Russell N H
Bone marrow transplantation
Patients undergoing allogeneic bone marrow transplants (BMT) are often malnourished prior to commencing the procedure. They face intensive treatment with often marked nutritional consequences. There is no consensus on the optimal nutritional management of these patients. Elective parenteral nutrition (PN), beginning pre-transplant irrespective of the patients nutritional status, or the use of "salvage" PN, beginning during the post-transplant period if the patient fails to maintain nutritional status with oral diet, have been used. Enteral nutrition may benefit the patient by maintaining nutritional support throughout the transplant period, avoiding the complications and expense of PN and possibly, by using specific diets, protecting the gastrointestinal tract from the effects of chemoradiation. However, naso-gastric feeding during a transplant is not without risks, including the safe insertion of a tube in patients with mucositis and pan-cytopenias, tube displacement by vomiting and aspiration from gastro-oesophageal reflux. An alternative approach is to use naso-jejunal (NJ) feeding tubes which are associated with less risk of loss due to vomiting and less risk of aspiration. We report a pilot study of 15 allogeneic BMT patients who had elective NJ feeding initiated before conditioning therapy irrespective of perceived nutritional compromise. This was well tolerated and feasible with a motivated nutritional team.
10.1038/sj.bmt.1703301
Outcome of direct percutaneous endoscopic jejunostomy tube placement for nutritional support in critically ill, mechanically ventilated patients.
Barrera R,Schattner M,Nygard S,Ahdoot M,Ahdoot A,Adeyeye S,Groeger J,Shike M
Journal of critical care
PURPOSE:Gastrointestinal function is adversely affected in critically ill mechanically ventilated patients. The most common abnormality is delayed gastric emptying. Among the options for postpyloric feeds, direct percutaneous endoscopic jejunostomy (PEJ) provides a permanent, reliable, and direct access to the small bowel and can be used for full enteral feedings, thus eliminating the need for parenteral nutrition. PATIENTS AND METHODS:All patients who underwent direct PEJ tube placement while mechanically ventilated in the intensive care unit (ICU) were evaluated. For each patient the following factors were identified: age, indication for ICU admission and PEJ placement, nutritional support before and after PEJ placement, calories received, complications, and outcome. RESULTS:Seventeen patients underwent the procedure. All had successful placement of direct PEJ tube. There was a single complication. Within 24 hours of PEJ placement, 16 of 17 patients tolerated jejunal feedings. All patients progressed to their established nutritional goals. There were no cases of aspiration of enteral feedings. In the 16 patients, total parenteral nutrition (TPN) was not required once PEJ tubes were placed. Thirteen patients were discharged home or to a rehabilitation facility with jejunal feedings. CONCLUSIONS:Direct PEJ placement is a safe and reliable device that can be successfully placed in critically ill, mechanically ventilated patients. With this procedure, all patients can meet their nutritional requirements and eliminate the need for TPN.
10.1053/jcrc.2001.30667
Jejunal feeding in chronic pancreatitis with severe necrosis.
Hamvas J,Schwab R,Pap A
JOP : Journal of the pancreas
CONTEXT:Necrotizing pancreatitis is the most serious form of pancreatic inflammatory disease leading to multiorgan failure and a high (15-20%) mortality rate. The poor nutritional and metabolic conditions and secondary bacterial translocation raise the mortality rate even more. OBJECTIVE:The aim of the study was to evaluate the effect of jejunal feeding in cases of chronic pancreatitis with extended necrosis. PATIENTS:In our institution, over a five-year period, 86 patients with severe necrotizing pancreatitis were treated for extended necrosis. In 19 patients, chronic calcifying pancreatitis was demonstrated by computed tomography showing more than 20% necrosis in the residual pancreas as well. SETTING:In 12 cases, nutrition was provided by jejunal feeding using an endoscopically placed nasojejunal feeding tube, whereas in 7 cases, hypocaloric parenteral nutrition was used. DESIGN:Retrospective unicenter study. MAIN OUTCOME MEASURES:The rate of healing with conservative treatment. RESULTS:Two of the 12 jejunally fed patients were operated on because of complications of pancreatitis. Five patients required intervention in the hypocaloric parenteral nutrition group: 4 were operated on and one more needed endoscopic intervention. The healing rate was significantly higher (P=0.045) in the jejunal feeding group (83.3%) than in the parenteral nutrition (28.6%) patients. CONCLUSIONS:In cases of chronic calcifying pancreatitis serious necrosis can develop in the residual pancreas resulting in a severe acute pancreatitis-like disease. A better healing rate was achieved and less interventions became necessary using nasojejunal tube feeding than in the parenteral nutrition group and this was analogous to what was observed in severe necrotizing pancreatitis This form of pancreatitis has not yet been described in the literature in detail. The authors suggest that it be regarded as a separate entity.
Feeding the gut early after digestive surgery: results of a nine-year experience.
Braga M,Gianotti L,Gentilini O,Liotta S,Di Carlo V
Clinical nutrition (Edinburgh, Scotland)
BACKGROUND AND AIMS:Early enteral nutrition (EEN) after surgery should be preferred to parenteral feeding, but its clinical use is limited for concerns about possible gastrointestinal (GI) adverse effects and feeding tube-related complications. Thus we evaluated our experience focusing on safety and tolerance of early postoperative jejunal feeding and possible risk factors for gastrointestinal adverse effects. METHODS:650 subjects treated with EEN after major digestive surgery for cancer were prospectively studied. EEN was started within 12 hours after operation via a naso-jejunal (NJ) feeding tube or a catheter-feeding jejunostomy. The rate of infusion was progressively increased to reach the nutritional goal (25 kcal/kg/day) within the 4th postoperative day. Rigorous treatment protocols for diet delivery and EEN-related GI adverse effects were applied. RESULTS:402 patients had a jejunostomy and 248 patients a NJ tube. EEN-related GI adverse effects were observed in 194/650 patients (29.8%). In 136/194 patients, these events were successfully handled by treatment protocols. Overall the nutritional goal was achieved in 592/650 patients (91.1%). Fifty-eight (8.9%) subjects had to be switched to parenteral feeding because of refractory intolerance to EEN. Intra-abdominal surgical complications and low serum albumin (<30 g/L) were the two major factors affecting tolerance. Severe jejunostomy-related complications occurred in 7/402 (1.7%) patients. EEN-related mortality was 0.1% (1/650). CONCLUSIONS:The use of the gut early after surgery is safe and well-tolerated and it should represent the first choice for nutritional support in this type of patients.
10.1054/clnu.2001.0504
Early nasojejunal feeding in acute pancreatitis is associated with a lower complication rate.
Oláh Attila,Pardavi Gábor,Belágyi Tibor,Nagy Attila,Issekutz Akos,Mohamed Gamal E
Nutrition (Burbank, Los Angeles County, Calif.)
OBJECTIVE:We investigated the effect of early jejunal feeding on septic complications and mortality rate in patients with acute pancreatitis in a two-phase, prospective, controlled study. METHODS:In the first, randomized phase of the study, conventional parenteral nutrition was compared with early (within 24-72 h after the onset of symptoms) enteral nutrition. Of 89 patients admitted with acute pancreatitis, 48 patients were randomized into a parenteral group (Rindex 10, Infusamin S, Intralipid 10%; 30 kcal/kg) and 41 patients into an enteral group (jejunal tube feeding; Survimed OPD; 30 kcal/kg). RESULTS:The rate of septic complications (infected pancreatic necrosis, abscess) was lower in the enteral group (P = 0.08, chi(2) test). In the second phase of the study, early jejunal feeding was combined with prophylactic imipenem (Tienam, 500 mg intravenously twice each day) when necrosis of the pancreas was detected by abdominal computed tomography. When the outcomes of 92 patients in the third group were compared with those of patients in the parenteral group, the rate of septic complications decreased significantly (P = 0.03). Multiple organ failure (P = 0.14) and mortality (P = 0.13) tended to decrease. CONCLUSIONS:We believe that the combination of early enteral nutrition and selective, adequate antibiotic prophylaxis may prevent multiple organ failure in patients with acute pancreatitis.
Randomized comparison of nasojejunal and nasogastric feeding in critically ill patients.
Davies Andrew R,Froomes Paul R A,French Craig J,Bellomo Rinaldo,Gutteridge Geoffrey A,Nyulasi Ibolya,Walker Robyn,Sewell Richard B
Critical care medicine
OBJECTIVE:Critically ill patients often develop large gastric residual volumes during nasogastric feeding as a result of poor gastroduodenal motility. Nasojejunal feeding may decrease the severity of this complication. The aim of this study was to determine whether nasojejunal feeding improved tolerance of enteral nutrition by reducing gastric residual volumes. DESIGN:Randomized, prospective, clinical study. SETTING:Intensive care unit of a university-affiliated hospital. PATIENTS:Seventy-three intensive care unit patients expected to require nutritional support for at least 3 days. INTERVENTIONS:Patients were randomized to receive enteral nutrition via a nasojejunal tube (placed endoscopically) (34 patients) or a nasogastric tube (39 patients). A strict protocol was followed, which included regular gastric residual volume measurement (in both groups), the use of predetermined criteria for intolerance, and an attempt at nasojejunal feeding for those nasogastrically fed patients who were intolerant of enteral nutrition. MEASUREMENTS AND MAIN RESULTS:Endoscopic placement of nasojejunal tubes was successful in 98% with no complications of insertion. Patients fed via a nasojejunal tube had 1) a reduced total gastric residual volume in both the first 24 (197 vs. 491 mL, p = .02) and 48 hrs (517 vs. 975 mL, p = .02); 2) a reduced incidence of a single gastric residual volume >150 mL (32% vs. 74%, p = .001); and 3) a trend toward a reduced incidence of intolerance of enteral nutrition (13% vs. 31%, p = .09). Only 13% of those nasogastrically fed patients who were initially intolerant of enteral nutrition remained intolerant once fed via a nasojejunal tube, and only 1.4% of all patients met criteria for commencement of parenteral nutrition. CONCLUSIONS:Enteral nutrition delivered via a nasojejunal tube is associated with a significant reduction in gastric residual volume, a strong trend toward improved tolerance of enteral nutrition, and an extremely low requirement for parenteral nutrition.
10.1097/00003246-200203000-00016
Gastric versus small-bowel tube feeding in the intensive care unit: a prospective comparison of efficacy.
Neumann Daniel A,DeLegge Mark H
Critical care medicine
OBJECTIVE:To compare the outcomes of intensive care unit patients fed through a nasogastric vs. a nasal-small-bowel tube including the time from tube placement to feeding, time to reach goal rate, and adverse events. DESIGN:Sixty patients were prospectively randomized to receive gastric or small-bowel tube feedings. Nursing staff attempted to place a feeding tube in the desired position, and placement was confirmed radiographically after each bedside attempt. After two unsuccessful attempts, the feeding tube was placed under fluoroscopy. Feedings were started at 30 mL/hr and advanced to the patient's specific goal rate. SETTING:Twenty-bed medical intensive care unit. PATIENTS:Sixty medical patients admitted/transferred to the intensive care unit. INTERVENTIONS:Tube feeds were held for 2 hrs if any residual was >200 mL. MEASUREMENTS:Times were recorded at the initial tube insertion, onset of feeding, achievement of goal rate, and termination of feeding. Adverse outcomes included witnessed aspiration, vomiting, and clinical/radiographic evidence of aspiration. Patients were followed up for the duration of feeding, until leaving the intensive care unit, or for a maximum of 14 days. MAIN RESULTS:Patients fed in the stomach received nutrition sooner from initial placement attempt (11.2 hrs vs. 27.0 hrs) and with fewer attempts (one vs. two) than those fed in the small bowel. Patients achieve goal rate sooner (28.8 hrs vs. 43.0 hrs) with gastric feeding compared with small-bowel feeding. There was no difference in aspiration events. CONCLUSIONS:Gastric feeding demonstrates no increase in aspiration or other adverse outcomes compared with small-bowel feeding in the intensive care unit. Gastric feeding can be started and advanced to goal sooner with fewer placement attempts than small-bowel feeding.
10.1097/00003246-200207000-00006
Prevention of ventilator-associated pneumonia: current practice in Canadian intensive care units.
Heyland Daren K,Cook Deborah J,Dodek Peter M
Journal of critical care
OBJECTIVE:To evaluate the current use of strategies to prevent ventilator-associated pneumonia (VAP) and to identify interventions to target for quality-improvement initiatives. DESIGN:Cross-sectional national survey. SETTING:Canadian intensive care units (ICUs) with at least 8 beds. PATIENTS:Seven hundred and two patients in 66 ICUs in 10 provinces in Canada. INTERVENTIONS:None. MEASUREMENTS AND RESULTS:The Canadian Critical Care Trials Group recently developed VAP prevention guidelines. Before these guidelines were disseminated, we documented the extent to which these recommendations were followed in practice by using 3 methods: survey of ICU directors, prospective observation of patients on one day, and retrospective review of patient charts for a 12-day period. According to ICU directors, ventilator circuits were changed only for new patients or if the circuit was soiled in 7 of 66 ICUs (10%), heat and moisture exchangers were used routinely in 53 of 66 ICUs (80%), and closed-suction catheter systems were used in 58 of 66 ICUs (88%). Neither subglottic secretion drainage tubes nor prophylactic antibiotics for VAP were used at all. Of the entire cohort of 702 patients, the average degree of elevation of the head of the bed was 29.9 degrees (range, 0 degrees -90 degrees ) and 22 of 702 (3.1%) were observed to be on a kinetic bed. Of the 459 patients receiving any form of mechanical ventilation, 56 (12.2%) were receiving noninvasive or mask ventilation, 262 (57.1%) were orally intubated, 9 (1.9%) were nasally intubated, and 132 (28.8%) had received a tracheostomy. Of the 423 patients who received nutrition support, 373 (88.2%) received enteral nutrition. Small bowel feeding tubes were used during 16.4% of study days on enteral feeds and sucralfate was prescribed for 1.7% of study days. CONCLUSIONS:Significant opportunities exist to improve VAP prevention practices in Canada. These strategies include decreasing the frequency of ventilator circuit changes, and increasing the use of non-invasive ventilation, subglottic secretion drainage endotracheal tubes, kinetic bed therapy, small bowel feedings, and elevation of the head of the bed.
10.1053/jcrc.2002.35814
Intravenous hydration versus naso-jejunal enteral feeding after esophagectomy: a randomised study.
Page Richard D,Oo Aung Y,Russell Glen N,Pennefather Stephen H
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery
OBJECTIVE:Patients undergoing esophagectomy are typically nutritionally depleted and cannot establish oral feeding for up to a week after surgery. We have investigated the routine use of enteral feeding via a naso-jejunal tube. METHODS:Forty consecutive patients undergoing a transthoracic esophagectomy for cancer were randomised to receive enteral feeding or intravenous crystalloid fluids after surgery. Nutritional indices were obtained prior to surgery and on the 7th post-operative day. RESULTS:There were no post-operative deaths. Non-fatal complications occurred in 10 patients, without difference in morbidity between the two groups. Lean body mass did not change in either group over the study period. No differences in any other parameters were identified between the two groups. CONCLUSION:Enteral feeding via a naso-jejunal tube is safe and well tolerated after esophagectomy. It is a simple method of providing nutritional support prior to the re-introduction of oral feeding. However it provides no measurable benefit over intravenous hydration only for patients undergoing routine esophagectomy.
10.1016/s1010-7940(02)00489-x
Reconstruction of rabbit urethra with surgisis small intestinal submucosa.
Rotariu Paul,Yohannes Paulos,Alexianu Mihai,Gershbaum David,Pinkashov David,Morgenstern Nora,Smith Arthur D
Journal of endourology
PURPOSE:To evaluate the efficacy of Surgisis, porcine small intestinal submucosa, in the reconstruction of iatrogenic urethral defects in rabbits. MATERIALS AND METHODS:Eight male white rabbits were enrolled in this protocol. A 2.5-cm segment of urethra was excised. One control consisted of a normal urethra. The other rabbits underwent urethroplasty with Surgisis and 6-0 Vicryl running suture. An 8F feeding tube was left in place to divert urine for 2 weeks after surgery. Retrograde urethrograms were performed to assess the patency of the urethras and to rule out fistula formation prior to sacrifice of the animals. The sacrifice protocol began with the control and a urethroplasty animal 6 weeks after surgery. The other rabbits were euthanized at 2-week intervals thereafter. RESULTS:Surgisis promoted epithelial regeneration in all cases. One animal developed a wound infection; this was associated with a small fistula at the proximal end of the anastomosis. Good cosmetic and functional results were documented. Retrograde urethrograms showed no stricture formation at the site of the anastomosis in six rabbits. The histopathologic examination showed complete regeneration of all urethral layers, almost indistinguishable from the normal urethra. CONCLUSION:Surgisis is an excellent material for urethral reconstruction in rabbits. It promotes regeneration of all the components of the host urethral layers and is biodegradable.
10.1089/089277902320913332
Physiological effects of enteral and parenteral feeding on pancreaticobiliary secretion in humans.
O'Keefe Stephen J D,Lee Ronzo B,Anderson Frank P,Gennings Chris,Abou-Assi Souheil,Clore John,Heuman Douglas,Chey William
American journal of physiology. Gastrointestinal and liver physiology
In the nutritional management of digestive disorders, it is important to know the relative secretory and metabolic responses to enteral and parenteral feeding. Twenty-seven healthy volunteers were studied while receiving either oral drinks or duodenal infusions of a complex formula diet, duodenal or intravenous infusions of elemental (protein as free amino acids, low fat) formulae, or saline. Pancreaticobiliary secretory responses were measured by nasoduodenal polyethylene glycol perfusion and aspiration, while monitoring blood hormone and nutrient levels. Diets were matched for protein (1.5 g x kg(-1) x d(-1)) and energy (40 kcal x kg(-1) x d(-1)). Compared with placebo, all oroenteral diets stimulated amylase, lipase, trypsin, and bile acid secretion and increased plasma concentrations of gastrin and cholecystokinin, whereas intravenous feeding did not. The complex formula produced a similar response whether given as drinks or duodenal infusions. Changing the duodenal formula to elemental reduced enzyme secretion by 50%, independently of CCK. Higher increases in plasma insulin, glucose, and amino acids were noted with intravenous feeding. Delivering food directly to the intestine by a feeding tube does not reduce pancreaticobiliary secretion. Enteral "elemental" formulae diminish, but only intravenous feeding avoids pancreatic stimulation. Intravenous administration impairs metabolic clearance.
10.1152/ajpgi.00155.2002
[Early enteral nutrition in cancer patients subjected to a total gastrectomy].
Papapietro Karin,Díaz Emma,Csendes Attila,Díaz Juan C,Burdiles Patricio,Maluenda Fernando,Braghetto Italo,Llanos José L,D'Acuña Sonia,Rappoport Jaime
Revista medica de Chile
BACKGROUND:Total parenteral nutrition has a high cost and frequency of complications. Enteral feeding is a feasible alternative that can be started early in the postoperative period. AIM:To assess digestive tolerance to early enteral feeding in cancer patients undergoing total gastrectomy and to compare early enteral feeding (EEF) with total parenteral nutrition plus enteral feeding (TPN + EF), initiated after overcoming postoperative ileus. PATIENTS AND METHODS:Subjects with a resectable gastric cancer were considered eligible for the study. During surgery a nasoenteral tube was placed and patients were prospectively randomized to EEF or TPN + EF. Digestive tolerance, effectiveness, complications and costs between both modalities of nutritional support were compared. RESULTS:Twenty eight patients (15 male, aged 63 +/- 14 years old) were studied. Fourteen patients were randomized to EEF and 14 to TPN + EF. Diarrhea occurred in 14 and 29% of EEF and TPN + EF patients respectively, (p: NS). Patients with TPN + EF received an average of 28 Cal/kg/day and 1.1 g/kg/day proteins. Patients with EEF received an average of 29 Cal/kg/day and 0.8 g/kg/day proteins. At the eighth postoperative day, serum albumin was 3.9 +/- 0.7 and 3.2 +/- 0.5 g/dl in EEF and TPN + EF patients respectively (p < 0.05), serum prealbumin was 16.9 +/- 5 and 12.3 +/- 4.3 mg/dl in EEF and TPN + EF patients respectively (p < 0.05) and nitrogen balance was +2.4 +/- 1.5 and -1.6 +/- 0.6 g/24 h in EEF and TPN + EF patients respectively (p < 0.05). Postoperative hyperglycemia was observed with a lower frequency and nutritional support costs and length of hospital stay were significantly lower in the EEF group. CONCLUSIONS:After total gastrectomy EEF is well tolerated, safe and effective, even during the early postoperative ileus. This therapeutic modality could be the first choice for nutritional support in these patients.
Effects of duodenal seal oil administration in patients with inflammatory bowel disease.
Arslan Gülen,Brunborg Linn Anne,Frøyland Livar,Brun Johan G,Valen Merete,Berstad Arnold
Lipids
Long-chain n-3 PUFA in fish oil have modulating effects on inflammatory responses. The aim of this open pilot study was to investigate whether duodenal seal oil administration would benefit patients with inflammatory bowel disease (IBD). Seal oil (10 mL) was administered three times a day directly into the distal part of the duodenum via a nasoduodenal feeding tube for 10 d in 10 patients, 5 of whom had Crohn's disease and 5 ulcerative colitis. Nine of the 10 patients suffered from IBD-associated joint pain. Various parameters of disease activity and FA incorporation in tissues were analyzed before and after treatment. Following seal oil therapy, joint pain index, disease activity, and serum cholesterol level were significantly decreased, whereas the n-3 to n-6 ratio both in intestinal biopsies and blood was significantly increased. Measures of calprotectin concentration in gut lavage fluid, intestinal permeability, and lipid peroxidation were not significantly changed. The results suggest positive effects of seal oil in patients with IBD, especially on IBD-associated joint pain. Further controlled studies are warranted.
[Enteral nutrition at home: National register for the year 2000].
Planas M,Castellá M,García Luna P P,Chamorro J,Gómez Candela C,Carbonell M D,Irles J A,Jiménez M,Morejón E,Pérez de la Cruz A,Bobis M A,Rodríguez Pozo A,Adrio G,Salas J,Calañas A J,Gómez Enterría P,Mancha A,Martí Bonmatí E,Martínez I,Celador A,Camarero E,Tusón C,Carrera J A,
Nutricion hospitalaria
GOAL:Once again, the NADYA-SENPE Working Group analysed the registered data of Home Enteral Nutrition (HEN) in our country, during the year 2000. MATERIAL AND METHODS:The data were collected through a closed questionnaire included on our web site (www.nadya-senpe.com). Apart from epidemiological information, the form includes the indication to prescribe this treatment, the specific nutritional treatment used and its duration, access path, complications and readmission rate in hospital, follow-up of the treatment, patient's quality of life and progress. All data were processed and analysed by the co-ordinating team. RESULTS:Twenty two hospital participated and 2,986 patients, aged 65.1 +/- 19.7 years, were enrolled. Of these patients, 41.2% were diagnosed with neurological diseases and 33.3% with cancer. The mean time on HEN was 6.3 +/- 4.4 months. Oral nutrition was the preferential route (50.8%), followed by nasoenteral tube (30.5%), and in 17.4% ostomy tubes were placed. Polymeric was the formula composition mainly used (83.2%). Patients were followed (70.1%) by the hospital reference Nutritional Support Unit. The complications related to nutrition included the gastrointestinal (0.25 complications/patient), the mechanical one (0.19 complications/patient), and the metabolic (0.007 complications/patient). Feeding tube need to be replaced 0.3 times/patient/year. The readmission rate, for nutritional problems, was observed in 0.03 patients. At the end of the year, 54.9% of the patients were in the HEN program, and in 30.3% HEN was finish due to different reasons. In 21.9% of the patients no, o light, discapacity degree was found. CONCLUSIONS:Related to previous years, there is an increment in the number of enrolled patients. Neurological diseases and cancer were the more frequent diagnoses in HEN patients. Oral access was the higher feeding route due, probably, to the high prevalence of cancer patients. In spite of the elevated prevalence of neurological diseases, a few number of patients were feed with ostomy tube. Finally, due to the few readmission rate and complications, HEN is a safe treatment in our country.
Transient small-bowel intussusception in children on CT.
Strouse Peter J,DiPietro Michael A,Saez Fermin
Pediatric radiology
OBJECTIVE:To determine the frequency and significance of small-bowel intussusception identified in children on CT. MATERIALS AND METHODS:All abdomen CT reports between July 1995 and April 2002 were reviewed to identify patients with small-bowel intussusception. Intussusceptions were identified as an intraluminal mass with a characteristic layered appearance and/or continuity with adjacent mesenteric fat. Ileocolic intussusceptions and intussusceptions related to feeding tubes were excluded. Imaging studies and medical records were reviewed. RESULTS:Twenty-five pediatric patients (16 boys, 9 girls; mean age 11.2 years) were identified with small-bowel intussusception on CT. No patient had a persistent intussusception requiring surgery. Fourteen had limited immediate repeat CT images as part of the same examination, ten of which demonstrated resolution of the CT abnormality. Follow-up CT [ n=13 (6 within 24 h)], ultrasound ( n=3), small-bowel follow-through ( n=4) and surgery ( n=3) showed no intussusception. In four patients with persistent symptoms, underlying pathology was identified requiring treatment (giardiasis, 2; small-bowel inflammation/strictures, 1; abscess and partial small-bowel obstruction after perforated appendicitis, 1). In 21 other patients, direct correlation of symptoms to CT abnormality was absent or questionable, no treatment was required, and there was no clinical or imaging evidence of persistence or recurrence. CONCLUSION:Most small-bowel intussusceptions identified in children by CT are transient and of no clinical significance.
10.1007/s00247-003-0870-4
Use of a 19-gauge injection needle as a guide for direct percutaneous endoscopic jejunostomy tube placement.
Varadarajulu Shyam,Delegge Mark H
Gastrointestinal endoscopy
BACKGROUND:Direct percutaneous endoscopic jejunostomy (DPEJ) tube placement is becoming an accepted means of achieving enteral nutrition. However, during DPEJ placement it can be difficult to maintain the position of the small bowel for insertion of the plastic sheath with stylet, thus limiting the success of the procedure. The results of a technique designed to overcome this problem are presented. METHODS:During DPEJ placement, a 19-gauge injection needle was passed into the bowel at the site of transillumination. The needle was snared tightly, fixing the small bowel against the abdominal wall. The plastic sheath with stylet was then inserted adjacent to the 19-gauge needle and into the small bowel and was subsequently snared to facilitate guidewire passage. A 24F, pull-type PEJ tube was then placed in standard fashion. RESULTS:A DPEJ was placed successfully in 24 of 26 (92.3%) patients with this technique. There was one (4%) major complication: inadvertent small bowel perforation during DPEJ placement. The average time to complete a procedure was 23.3 minutes; the mean time to achieve the dietary goal after DPEJ placement was 39 hours. One patient died of an unrelated illness 6 days after DPEJ placement; 23 were discharged with jejunal feeding. CONCLUSIONS:A DPEJ can be performed successfully by using a 19-gauge injection needle as guide for tube placement.
10.1016/s0016-5107(03)70049-2
Nutrition support for the patient with an open abdomen after major abdominal trauma.
McKibbin Blake,Cresci Gail,Hawkins Michael
Nutrition (Burbank, Los Angeles County, Calif.)
OBJECTIVE:Nutrition support in the severely injured trauma patient is crucial to minimize the hypermetabolic stress response. Even though enteral nutrition is the preferred method of feeding, it is not always feasible after multiple trauma. We present a complex nutritional case in a patient who sustained severe abdominal trauma with a severe liver injury, rib fractures, and pulmonary contusion. METHODS:The patient required several repeat laparotomies, abdominal packing, and temporary abdominal closure. The clinical course was complicated by hypotension requiring multiple vasopressors; coagulopathy requiring more than 35 U of packed red cells, more than 50 U of fresh frozen plasma, and more than 80 U of platelets; acute renal failure requiring dialysis; and pneumonia and acute respiratory distress syndrome requiring intricate ventilator management. Nutrition intervention began on post-trauma day 4 with total parenteral nutrition due to hypotension, resuscitation, and massive bowel edema; by post-trauma day 8. the patient was receiving goal nutrients. RESULTS:On post-trauma day 27, bowel edema was significantly less, and a nasoenteric feeding tube was placed and enteral feeding initiated. By post-trauma day 31, full enteral feeds were tolerated, and total parenteral nutrition was stopped. Nutrient provision was adjusted daily to account for organ and metabolic changes including hepatic, pulmonary, and renal dysfunction. The patient did well and was eventually extubated and eating a regular diet. CONCLUSION:With careful monitoring and adjusting of the nutritional plan, a hypermetabolic complex trauma patient with an open abdomen can be fed optimally, safely, and successfully despite increased bowel edema and multiple organ dysfunction.
Imatinib (STI-571) heals a gastrocutaneous fistula resulting from a malignant gastric stromal tumor.
Ng Enders K W,Wong Simon K H,Mok Tony S K,Chan W Y,Chung S C Sydney
Gastric cancer : official journal of the International Gastric Cancer Association and the Japanese Gastric Cancer Association
The management of inoperable giant malignant gastrointestinal stromal tumor (GIST) of the stomach sed to be a formidable task. We report our success with the use of STI-571 in treating a patient with huge GIST of the stomach complicated by gastrocutaneous fistula after an unsuccessful laparotomy. The patient was a 49-year-old man who presented to our center with a painful epigastric mass in December 2001. Endoscopy, biopsy, and magnetic resonance scan confirmed that it was a malignant stromal tumor arising from the gastric fundus. Laparotomy with an intention to resect the tumor was performed in view of the obstructing symptoms. However, massive bleeding was encountered during dissection of the tumor and gastrectomy was abandoned. The case was further complicated with the development of a gastrocutaneous fistula in the early postoperative period. The patient ws then managed with naso-duodenal tube feeding and enteral STI-571 was prescribed. The fistula healed up in 20 days and the mass became impalpable 1 month afterwards. Follow-up computed tonography (CT) scan 3 months later confirmed significant tumor reduction, and the patient has experienced no side effects from the treatment
10.1007/s10120-003-0233-8
Clip-assisted endoscopic method for placement of a nasoenteric feeding tube into the distal duodenum.
Shie Chang-Bih,Hsu Ping-I,Lo Gin-Ho,Lin Chiun-Ku,Lo Ching-Chu,Cheng Jin-Shiung,Lin Chi-Pin,Chen Wen-Chi,Wang E-Ming,Chen I-Shu,Mok King-Tong,Lai Kwok-Hung
Journal of the Formosan Medical Association = Taiwan yi zhi
Gastroenterologists are often frustrated in their efforts to deliver a feeding tube by endoscopic guidance into the small bowel because of retrograde migration during the withdrawal of the endoscope. We describe a clip assisted endoscopic method whereby a nasoenteric feeding tube can be reliably delivered into the distal duodenum. A nasoduodenal tube with a 3-0 silk suture sewn on its distal tip is inserted into the stomach. The suture on the feeding tube is grasped by a clip-fixing device. Then, the endoscope with feeding tube is advanced into the distal duodenum and the tube is fixed on a mucosal fold by clipping. We used this technique to successfully place nasoenteric tubes into the distal duodenum in 9 patients. There were no procedure-related complications, and no bleeding or perforation due to removal of the feeding tubes was observed. We conclude that this clip-assisted endoscopic method is a reliable modality for placing nasoenteric tubes.
Mini-laparoscopically guided percutaneous gastrostomy and jejunostomy.
Denzer Ulrike,Mergener Klaus,Kanzler Stefan,Kiesslich Ralf,Helmreich-Becker Ilka,Galle Peter R,Lohse Ansgar W
Gastrointestinal endoscopy
BACKGROUND:Percutaneous endoscopic tube placement can be problematic under certain circumstances: absence of transillumination of the abdominal wall, percutaneous jejunostomy in patients with a PEG tube and recurrent aspiration, enteral feeding access after gastrectomy, and obstruction of the upper GI tract. As an alternative in these problematic situations, a technique was developed for placing feeding tubes under visual control by using mini-laparoscopy. METHODS:Placement of a feeding tube with mini-laparoscopy with the patient under conscious sedation was considered for 17 patients in whom standard PEG placement was impossible. Techniques used were the following: combined mini-laparoscopy/endoscopy for placement of a percutaneous gastrostomy or jejunostomy, and mini-laparoscopic-guided direct tube placement in cases of obstruction of the upper GI tract. OBSERVATIONS:In 13 patients, mini-laparoscopic-assisted tube placement was successful. In 4 patients, adhesions or peritoneal carcinomatosis prevented laparoscopic visualization of the stomach or small bowel. The combined mini-laparoscopic/endoscopic approach allowed a successful insertion of gastric tubes in 6 patients and jejunal tubes in 4 patients. Direct insertion of a percutaneous endoscopic jejunostomy tube without enteroscopy was feasible in all 3 patients with obstruction of the upper GI tract. No complication occurred. CONCLUSIONS:Mini-laparoscopy-assisted tube placement is a simple and safe alternative when endoscopic percutaneous tube placement is problematic or not feasible.
10.1067/s0016-5107(03)00024-5
Meeting the nutritional needs of patients with severe dysphagia following a stroke: an interdisciplinary approach.
Rodrigue Nathalie,Côté Robert,Kirsch Connie,Germain Chantal,Couturier Céline,Fraser Roxanne
Axone (Dartmouth, N.S.)
Dysphagia is a common problem with individuals who have experienced a stroke. The interdisciplinary stroke team noted delays in clinical decision-making, or in implementing plans for patients with severe dysphagia requiring an alternative method to oral feeding, such as enteral feeding via Dobhoff (naso-jejunum) or PEG (percutaneous endoscopic gastrostomy) tubes, occurred because protocols had not been established. This resulted in undernourishment, which in turn contributed to clinical problems, such as infections and confusion, which delayed rehabilitation and contributed to excess disability. The goal of the project was to improve quality of care and quality of life for stroke patients experiencing swallowing problems by creating a dysphagia management decision-making process. The project began with a retrospective chart review of 91 cases over a period of six months to describe the population characteristics, dysphagia frequency, stroke and dysphagia severity, and delays encountered with decision-making regarding dysphagia management. A literature search was conducted, and experts in the field were consulted to provide current knowledge prior to beginning the project. Using descriptive statistics, dysphagia was present in 44% of the stroke population and 69% had mild to moderate stroke severity deficit. Delays were found in the decision to insert a PEG (mean 10 days) and the time between decision and PEG insertion (mean 12 days). Critical periods were examined in order to speed up the process of decision-making and intervention. This resulted in the creation of a decision-making algorithm based on stroke and dysphagia severity that will be tested during winter 2002.
Small bowel obstruction from a dislodged feeding tube.
Kamar Moshe,Bar-Dayan Avner,Zmora Oded,Ayalon Amram
Age and ageing
Elderly nursing home patients may suffer from inadequate oral nutritional intake for a variety of reasons. In some of them, nutritional status cannot be maintained without the use of enteral feeding. Nasogastric tube feeding is associated with significant patient discomfort, and may lead to significant complications. Thus, in those who require long-term enteral tube feeding, a gastrostomy tube may be necessary. Although surgical insertion may occasionally be required, percutaneous insertion with upper endoscopy assistance is usually safe and feasible. This case represents an unusual complication of such a gastrostomy tube, which draws attention to the need for appropriate care of these tubes.
10.1093/ageing/afh012
Early enteral nutrition in mechanically ventilated patients in the prone position.
Reignier Jean,Thenoz-Jost Nathalie,Fiancette Maud,Legendre Eric,Lebert Christine,Bontemps Frederic,Clementi Eva,Martin-Lefevre Laurent
Critical care medicine
OBJECTIVE:To assess the tolerance of early enteral nutrition in critically ill patients receiving invasive mechanical ventilation in the prone position. DESIGN:Prospective, comparative study. SETTING:General intensive care unit in a university-affiliated hospital. PATIENTS:A total of 71 consecutive patients receiving invasive mechanical ventilation with early nasogastric enteral nutrition were studied for 5 days while being treated continuously in the supine position (supine position group, n = 37) or with intermittent prone positioning for severe hypoxemia (prone position group, n = 34). INTERVENTIONS:Inclusion occurred within 24 hrs of mechanical ventilation initiation. Daily 18-hr enteral nutrition via a 14F gastric tube was initiated. Prone position patients were turned every 6 hrs as long as PaO2/FiO2 remained at <150, with a FiO2 of 0.6 and positive end-expiratory pressure of 10; the head was slightly elevated. When supine, patients in both groups were semirecumbent. Residual gastric volume was measured every 6 hrs, and enteral nutrition was discontinued if it exceeded 250 mL or vomiting occurred. MEASUREMENTS AND MAIN RESULTS:The groups were similar for age, sex, Simplified Acute Physiology Score II, mortality, and risk factors for enteral nutrition intolerance. At baseline, PaO2/FiO2 was lower in prone position patients than in supine position patients (127 +/- 55 vs. 228 +/- 102; p <.001). As compared with supine position patients, prone position patients had significantly greater residual gastric volumes on days 1, 2, and 4 and experienced more vomiting episodes (median, 1 [interquartile range, 0-2] vs. 0 [interquartile range, 0-1]; p <.05). Enteral nutrition was stopped in 82% of prone position patients and 49% of supine position patients (p <.01) so that daily enteral nutrition volumes were lower with prone position patients. In the prone position group, vomiting occurred more frequently in the prone than in the supine position (relative risk, 2.5; 95% confidence interval, 1.5-4.0; p <.001). CONCLUSION:In critically ill patients receiving invasive mechanical ventilation in the prone position, early enteral nutrition is poorly tolerated. Prokinetic agents or transpyloric feeding and semirecumbency should be considered to enhance gastric emptying and to prevent vomiting in patients receiving mechanical ventilation in the prone position.
10.1097/01.CCM.0000104208.23542.A8
Nasojejunal feeding in hyperemesis gravidarum--a preliminary study.
Vaisman N,Kaidar R,Levin I,Lessing J B
Clinical nutrition (Edinburgh, Scotland)
Hyperemesis gravidarum is a severe form of nausea and vomiting during the first trimester of pregnancy. Our objective was to assess the feasibility of nasojejunal feeding in our patients. Eleven pregnant women aged 23-46 years with hyperemesis gravidarum, persisting in spite of an in-hospital treatment of 2-15 days by intravenous fluids and antiemetic drugs and accompanied by weight loss, consented to have a nasojejunal feeding tube inserted endoscopically. Mean in-hospital weight loss prior to tube insertion was 2.2+/-1.1 kg (range 0.9-5.1 kg). A clear reduction in the extent of vomiting was already apparent within the first 48 h after tube insertion, but vomiting ceased completely after a mean of 5+/-4 days (range 1-13 days). Weight gain was recorded in six patients who stayed on tube feeding for more than 4 days. Patients were encouraged to start drinking and eating along tube feeding after 3-4 days. Ceasing vomiting and a concomitant sufficient oral intake of at least 1000 kcal/day resulted in the decision to remove the tube after 4-21 days. In three cases, however, the tube was expelled by recurrent vomiting after 1-4 days, or was blocked as in one case. The tube was not reintroduced and patients did not resume vomiting. There were no complications associated with this feeding approach in this population. Only one patient was readmitted. None of the rest resumed vomiting after tube withdrawal.The above suggests that nasojejunal enteral feeding can be an effective option in hyperemesis gravidarum persisting despite intravenous fluids and antiemetic drugs.
10.1016/s0261-5614(03)00088-8
Bowel necrosis caused by water in jejunal feeding.
Schloerb Paul R,Wood John G,Casillan Alfred J,Tawfik Ossama,Udobi Kahdi
JPEN. Journal of parenteral and enteral nutrition
BACKGROUND:Fifteen reports of bowel necrosis in patients receiving jejunal feeding have been reported. Etiology remains unexplained. METHODS:A patient with a 60% burn receiving jejunostomy tube feeding developed hypernatremia and was given distilled water in the jejunum, 400 mL every 2 hours. One week later, he developed an acute abdomen with abdominal distention. At operation, he had 4 L of cloudy fluid containing jejunal feeding. Three large duodenal perforations were present. The jejunostomy site was normal. In an animal study, water or normal saline (0.85% NaCl) were infused into the mid small bowel, and sections of bowel were taken 5 minutes later for histologic study. RESULTS:Animal study of the effect of water in the rat intestine revealed disruption of intestinal epithelium. It is suggested that disruption of epithelium by electrolyte-free water may permit digestion of the bowel wall and result in perforation, as was observed in this patient. This mechanism may have been responsible for some of the cases reported in the literature. CONCLUSIONS:Tap or distilled water may injure intestinal epithelium and should not be infused directly into the small bowel as jejunal feeding.
10.1177/014860710402800127
Survival rate and prognostic factors in patients with intestinal failure.
Vantini I,Benini L,Bonfante F,Talamini G,Sembenini C,Chiarioni G,Maragnolli O,Benini F,Capra F
Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver
BACKGROUND:Intestinal failure impairs nutritional status and survival expectance. Though intestinal adaptation and enteral independence may be achieved, artificial nutrition is needed in about half of the patients. AIMS:This study is aimed at assessing the causes of death, survival rate, enteral independence in time, and factors affecting the clinical outcome in a group of patients with intestinal insufficiency. PATIENTS:Sixty-eight patients with intestinal insufficiency, due to major intestinal resection in 60 cases (short bowel syndrome) (remnant intestine length 101-150 cm in 31 cases, 50-100 cm in 23 cases, <50 cm in 6 cases), and due to chronic idiopathic pseudo-obstruction in 8 cases, were enrolled and followed-up for (median) 36 months (25th and 75th percentile in 12 and 60 months, respectively). In 60 short bowel syndrome patients, the main conditions that led to intestinal failure were ischemic bowel (28), major surgery complications or severe adhesions (17), radiation enteritis (10), Chron's disease, intestinal tuberculosis, small bowel lymphoma and trauma (others). METHODS:Seventeen variables age, underlying disorders, length of remnant bowel, type of surgery, hospital stay, type of nutrition (hospital and home) and its variations in time, causes of death, survival rate and time were considered. Statistical analysis was carried out by Mann-Whitney U-test, Pearson chi2, Spearman correlation test, Kaplan-Meyer method and Cox's proportion hazards regression model. RESULTS:At the time of admission to the hospital, none of the patients had nutritional independence, 54 (79.4%) were on parenteral nutrition and 14 (20.6%) were on enteral nutrition. At the time of discharge, 23 (33.8%) patients showed enteral independence, 39 were on home parenteral nutrition, 3 on enteral nutrition + i.v. feeding, 1 on enteral nutrition, and 2 needed oral supplementation with hydroelectrolyte solutions only. After a median value of 36 months, 30 and 2 patients were on home parenteral nutrition and enteral nutrition + i.v. feeding, respectively, 2 on enteral nutrition, 2 on oral supplementation with hydroelectrolyte solutions, and 26 cases reached enteral independence. A significant relationship was detected between the length of remnant bowel and types of nutrition at both admission (r = 0.38; P = 0.001) and discharge (r = 0.48; P = 0.001), parenteral nutrition being more frequent in patients with very short bowel. Twenty-two patients (32.4%) died (4 from newly occurring malignancies), 40 (58.8%) survived, and 6 (8.8%) were lost to the follow-up. Eleven of 22 patients died from conditions related to intestinal failure (8 cases) and/or home parenteral nutrition complications (3 cases). At 12, 24, 36, 48, 60 and 72 months, survival rates were 95.4, 93.3, 88.1, 78.6, 78.6 and 65.5%, respectively, but it was significantly lower for patients with <50 cm of remnant bowel than those with longer residual intestine (P < 0.05), and in patients who started home parenteral nutrition above the age of 45 years (P < 0.02). Survival rate was higher in patients with enteral independence than those with enteral dependence (P < 0.05). Better survival rates were registered in patients with chronic obstructive intestinal pseudo-obstruction and major surgery complications, whereas ischemic bowel and even more radiation enteritis were associated with a lower survival expectance. CONCLUSIONS:Actuarial survival rate of patients with intestinal failure quotes 88 and 78% at 3 and 5 years, respectively. It is influenced by the length of remnant intestine, age at the start of home parenteral nutrition, enteral independence and, to some extent at least, by the primary disorder. Enteral independence can be achieved in time by about 40% of the patients with intestinal insufficiency, but for home parenteral nutrition-dependent cases, intravenous feeding can be stopped in less than one out of five patients during a median 3-year period.
10.1016/j.dld.2003.09.015
A multidisciplinary approach to the focal form of congenital hyperinsulinism leads to successful treatment by partial pancreatectomy.
Adzick N Scott,Thornton Paul S,Stanley Charles A,Kaye Robin D,Ruchelli Eduardo
Journal of pediatric surgery
BACKGROUND/PURPOSE:Congenital hyperinsulinism (HI) causes severe hypoglycemia in neonates and infants. Recessive mutations of the beta-cell K(ATP) channel genes cause diffuse HI, whereas loss of heterozygosity together with inheritance of a paternal mutation cause focal adenomatous HI. Although these 2 forms of HI are clinically identical, focal HI can be cured surgically. The authors reviewed their experience with partial pancreatectomy for focal HI. METHODS:From December 1998 to January 2003, 38 patients (ages 2 weeks to 14 months; median age, 10 weeks) were treated with partial pancreatectomy for focal HI. Before surgery, patients had localization studies using selective arterial calcium stimulation with venous sampling or transhepatic portal venous sampling. At operation, the focal lesion was found using the preoperative localization data and multiple pancreatic biopsies with frozen section analysis, followed by partial pancreatectomy. A complete response at follow-up was defined as no requirement for glycemic medications, no continuous tube feedings, and no diabetes mellitus. RESULTS:Nineteen pancreatic focal lesions were in the head; 15 were in the neck, body, or tail; and 4 had more extensive involvement. Lesions that required substantial resection of the pancreatic head underwent Roux-en-Y pancreaticojejunostomy to preserve the normal body and tail. Lesions of the body or tail were usually treated with partial distal pancreatectomy. Ninety-two percent (35 of 38) of patients had a complete response to surgery. Three patients have required glycemic medications. No patient is diabetic. Surgical complications included additional resection for residual disease (3), small bowel obstruction requiring laparotomy and enterolysis (2), and chylous ascites (3) that resolved with medical management. CONCLUSIONS:A multidisciplinary approach to patients with the focal form of congenital hyperinsulinism can distinguish focal from diffuse disease, localize focal lesions, and permit partial pancreatectomy with cure in most patients.
10.1016/j.jpedsurg.2003.11.019
Postoperative jejunal feeding and outcome of pancreaticoduodenectomy.
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract
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.
10.1016/j.gassur.2004.01.007
Is early enteral feeding safe in patients who have suffered spinal cord injury?
Rowan C J,Gillanders L K,Paice R L,Judson J A
Injury
OBJECTIVE:To examine whether enteral feeding is a safe technique to use in the acute stage of spinal cord injury. METHODS:We searched the departmental computerised patient database and clinical records for all patients with spinal cord injuries admitted to the Auckland Hospital Intensive Care Unit (ICU), known as the Department of Critical Care Medicine (DCCM), between January 1988 and December 2000. Patients were included in the study if they had suffered complete spinal cord transection resulting in either paraplegia or quadriplegia. Data was collected for the following variables: length of time to commence enteral feeding, type of enteral feeding, duration of enteral feeding and reasons for interrupting the feed. RESULTS:Thirty-three patients were found and were included in the study. Twenty-seven (82%) of the patients commenced enteral feeding in the DCCM, 25 by nasogastric (NG) and 2 by nasojejunal (NJ) tube. Feeding was commenced a median of 2 days after admission and the median length of enteral feeding was 7.7 days. The main feeding complications that resulted in interrupting the feed were high gastric aspirates. One patient commenced on enteral feeding developed medical complications that prevented continuation. Two patients on NG feeding converted to NJ feeding. CONCLUSION:No major complications associated with enteral feeding were seen in this study. This would indicate that enteral feeding can be safely administered in the acute stage of spinal cord injury provided complications are monitored for daily.
[Home Enteral Nutrition: National Registry 2001].
Planas M,Castellà M,García Luna P P,Parés R M,Chamorro J,Camarero E,Calañas A J,Bonada A,Irles J A,Adrio G,Jiménez M,Bobis M A,Rodríguez A,Pérez de la Cruz A,Gómez Enterría P,Zamarrón I,Cos A,Mancha A,Martínez I,Martí E,de Luis D,Virgili N,Moreno J M,Luengo L M,de la Cuerda C,Forga M T,Goenaga M A,Carrera J A,Garde C,Ordóñez J,Pedrón C
Nutricion hospitalaria
GOAL:The NADYA-SENPE Working Group analyzed the registered data of patients on Home Enteral Nutrition (HEN) in our country, during year 2001. MATERIAL AND METHODS:The data were collected through a closed questionnaire included on our web site (www.nadya-senpe.com). Apart from epidemiological information, the form includes the indication to prescribe this treatment, the specific nutritional treatment used and its duration, access path, complications and readmission rate in hospital, follow-up of the treatment, patient's quality of life and progress. All data were processed and analyzed by the coordinating team. RESULTS:Twenty two hospitals participated and 3,458 patients, aged 5.6 +/- 4.0 y for those younger than 14 y, and 67.1 +/- 19.5 y for those older than 14 y, were enrolled. Of these patients, 43.4% were diagnosed with neurological diseases and 33.5% with cancer. The mean time on HEN was 6.5 +/- 4.5 months. Oral nutrition was the preferential route (54.5%), followed by nasoenteral tube (32.3%), and in 13.3% ostomy tubes were placed. Polymeric was the formula composition mainly used (85.9%). Patients were followed (71.1%) by the hospital reference Nutritional Support Unit. The complications related to nutrition included mainly the gastrointestinal (0.16 complications/patient), and the mechanical one (0.15 complications/patient). At the end for the year, 48.3% of the patients were in the HEN program, and in 33.3% HEN was finish due to different reasons. In 22.9% of the patients no, o light, discapacity degree was found. CONCLUSIONS:Neurological diseases and cancer were the more frequent diagnoses in HEN patients. Oral access was the higher feeding route due, probably, to the high prevalence of cancer patients. In spite of the elevated prevalence of neurological diseases, a few number of patients, as previous years, were feed with ostomy tube. Due to the few complications observed, HEN is a safe treatment in our country.
Patient safety: effect of institutional protocols on adverse events related to feeding tube placement in the critically ill.
Marderstein Eric L,Simmons Richard L,Ochoa Juan B
Journal of the American College of Surgeons
BACKGROUND:Inadvertent passage of a nasoenteric feeding tube into the tracheobronchial tree can result in pneumothorax. Measures requiring feeding tube passage to 35 cm only followed by a radiograph to verify intraesophageal placement and creation of a specialized placement team were implemented to decrease the incidence of procedure-related pneumothorax. This study evaluates the effectiveness of our safety measures. STUDY DESIGN:Radiology reports from January 2000 through July 2003 were searched by computer with an algorithm designed to detect feeding tube placements possibly associated with the complication of intrabronchial placement or pneumothorax. Results were manually examined to eliminate false positives and verify causality. RESULTS:Feeding tubes were placed in 4,190 unique patients during the study period; 87 patients had an intrabronchial malposition, and 9 experienced a pneumothorax caused by their feeding tube. The safety measures resulted in a significant decrease in procedure-related pneumothorax (0.09% versus 0.38%, p < 0.05), and a decrease in pneumothorax among patients with an intrabronchial placement (3% versus 27%, p < 0.05). More than two-thirds of patients with a misplaced tube had an endotracheal tube or tracheostomy, illustrating that such patients are not protected. Repeated malposition in the same patient was surprisingly common; 32% of patients with one intrabronchial misplacement ultimately had multiple misplacements. The risk of pneumothorax increased with misplacement at night (p < 0.05) and increased exponentially with each additional misplacement (p < 0.05). CONCLUSIONS:Creating a specialized placement team, and initiating the safety measure of limiting feeding tube placement to 35 cm and obtaining a radiograph before full advancement reduced the incidence of procedure-related pneumothorax.
10.1016/j.jamcollsurg.2004.03.011
Appropriateness of the use of parenteral nutrition in a local tertiary-care hospital.
Chan S L,Luman W
Annals of the Academy of Medicine, Singapore
INTRODUCTION:Parenteral nutrition (PN) is an important supportive therapy for critically ill patients who have non-functioning gut. However, it is an expensive therapy and carries significant complications. The objective of our audit was to determine the appropriateness of prescription of PN in our hospital, based on the American Society for Parenteral and Enteral Nutrition (ASPEN) 2002 guidelines. In our hospital, the prescription of PN is managed by the Nutrition Support Team. MATERIALS AND METHODS:A retrospective review of adult patients prescribed with PN in 2001 was undertaken. Data on patient demographics, underlying diagnoses, indications, duration and routes administration were collected. The use of PN was classified as "appropriate", "inappropriate" or "indeterminate" by the authors based on the above guidelines. RESULTS:145 patients were prescribed PN in 2002. We were able to review the case notes for 137 patients. One patient received PN on 2 separate admissions. Of the 138 courses of PN (in 137 patients) reviewed, there were 88 males with the median age of 61 years (range, 16 to 91 years). 81.2% were surgical patients and of the remaining patients, 10.1% had haematological malignancies. The 2 most common indications were postoperative ileus (37.0%) and post-surgical complications (14.5%). The median duration of PN prescription was 9 days (range, 1 to 175 days). 109 (78.3%) courses of PN were classified as "appropriate", 22 (15.9%) courses as "inappropriate" and 7 (5.8%) courses as "indeterminate". Patients from the postoperative ileus group contributed to 10 (45.5%) patients with "inappropriate" indications; the main reason was premature initiation of PN. Of the patients considered to show "inappropriate" indications, 15 courses (68.1%) were prescribed for less than 7 days. PN was discontinued in 78% of courses due to satisfactory resumption of oral or enteral intake. The mean duration of PN use for patients with "inappropriate" indication was significantly shorter than for patients with "appropriate" indication (7.7 +/- 5.3 days versus 15.8 +/- 20.0 days, P = 0.002). 99.3% of PN courses were given via the central routes (with central vein cannulation or PICC). These lines were specifically inserted for PN in 60.14% of the cases. CONCLUSION:Our audit showed that 15.9% of PN prescriptions were inappropriate according to the ASPEN guidelines. This was largely attributed to premature initiation of PN for postoperative ileus. We believe that these PN courses could have been avoided if these patients had been tried on naso-jejunal tube feeding, or oral nutrition with the use of prokinetics during the postoperative period.
Reduced joint pain after short-term duodenal administration of seal oil in patients with inflammatory bowel disease: comparison with soy oil.
Bjørkkjaer T,Brunborg L A,Arslan G,Lind R A,Brun J G,Valen M,Klementsen B,Berstad A,Frøyland L
Scandinavian journal of gastroenterology
BACKGROUND:Rheumatic joint pain is a common extra-intestinal complication of inflammatory bowel disease (IBD). Because the high ratio of n-6 to n-3 fatty acids (FAs) of the Western diet might promote rheumatic disorders, we sought to compare the effects of short-term duodenal administration of n-3-rich seal oil and n-6-rich soy oil on IBD-related joint pain. METHODS:Nineteen patients with IBD-related joint pain were included in the study; 9 had Crohn disease and 10 had ulcerative colitis. Ten millilitres seal oil (n = 10) or soy oil (n = 9) was self-administered through a nasoduodenal feeding tube 3 times daily for 10 days. RESULTS:Compared with soy oil treatment, seal oil significantly reduced the duration of morning stiffness (P = 0.024), number of tender joints (P = 0.035), intensity of pain (P = 0.025) and the doctor's scoring of rheumatic disease activity (P = 0.025) at the end of the 10-day treatment period. Analysis of the effects as area under the curve (area between the curve and baseline, zero) for the entire period from start of treatment until 6 months' post-treatment suggested a long-lasting beneficial effect of seal oil administration on joint pain, whereas soy oil tended (not significantly) to aggravate the condition. Consistently, the serum ratios of n-6 to n-3 FAs (P < 0.01) and arachidonic acid to eicosapentaenoic acid (P < 0.01) were reduced after treatment with seal oil. CONCLUSION:The results suggest distinctive, differential prolonged effects on IBD-related joint pain of short-term duodenal administration of n-3-rich seal oil (significant improvement) and n-6-rich soy oil (tendency to exacerbation).
10.1080/00365520410009429
Gastric intubation: assessment and intervention.
Cottrell Damon B,Asturi Elizabeth
Critical care nursing clinics of North America
When gastric intubation is the chosen method of providing enteral nutrition, a variety of factors must be considered. To choose the proper tube, whether it resides in the gastric area or is postpyloric, it is important to consider the patient's level of consciousness, the duration of feeding, and the patient's overall status. Proper assessment, confirmation of tube placement, and nursing vigilance greatly reduce the likelihood of complications.
10.1016/j.ccell.2004.06.001
Extemporaneous procedures for dissolving risedronate tablets for oral administration and for feeding tubes.
Dansereau Richard J,Crail Debbie J
The Annals of pharmacotherapy
BACKGROUND:Risedronate (Actonel, Procter & Gamble Pharmaceuticals) is commercially available only as film-coated tablets. Extemporaneous procedures for dissolving tablets for feeding tubes and for preparation of an oral liquid have not previously been evaluated. OBJECTIVE:To evaluate procedures for dissolving risedronate sodium tablets for administration in liquid form and drug recovery following dissolution in cups and following passage through different types of feeding tubes. METHODS:Tablets (5 and 35 mg) were individually dispersed in 2 oz of water. After 2 minutes, the solution was stirred for 30 seconds, dispensed, and rinsed with an additional 4 oz of water. The sample was filtered and analyzed by HPLC. Ten replicates were performed using the various cups. Gastrostomy and nasoenteric tubes were flushed with 1 oz of water. Individual tablets were dispersed in 2 oz of water; after 2 minutes, the solution was stirred for 30 seconds and poured through the tube and flushed with 1 oz of water. Samples were filtered and analyzed by HPLC. Ten replicates were performed for each type of feeding tube. RESULTS:For cups, the mean amount of drug recovered ranged from 95.7% to 100.5% of the label claim, with a relative standard deviation (RSD) range of 1.1-6.3%. For gastrostomy and nasoenteric tubes, the mean amount of drug recovered ranged from 98.3% to 101.9% of label claim, with an RSD range of 0.9-3.3%. CONCLUSIONS:A simple and accurate procedure was developed for dissolving risedronate tablets in water to prepare a liquid formulation for administration orally or through feeding tubes.
10.1345/aph.1E299
Nightly enteral nutrition support of elderly hip fracture patients: a pilot study.
Sullivan Dennis H,Nelson Carl L,Klimberg V Suzanne,Bopp Melinda M
Journal of the American College of Nutrition
OBJECTIVES:Assess whether postoperative nightly enteral nutrition support improves outcomes of elderly patients with an acute hip fracture DESIGN:Randomized controlled trial. SETTING:A University and a Department of Veteran's Affairs Hospital SUBJECTS:Adults >64 years of age who underwent surgical repair of an acute hip fracture. INTERVENTIONS:Subjects randomized to the control (Ctrl) group received standard care while the treatment (Tx) group received standard care plus up to 1,375 Kcal [5,755 kJ/d] of nasoenteral tube feedings each night. When tube feedings had to be discontinued, Tx subjects were asked to drink an equivalent amount of the nutritional supplement each night. MEASURES OF OUTCOME:Rate of postoperative complications and 6-month postoperative survival. RESULTS:Fifty-seven patients were randomized to the Tx (n = 27, mean age 75.9 +/- 7.4 yrs) or Ctrl groups (age 81.7 +/- 7.7 yrs). All subjects had reduced volitional nutrient intakes after surgery. During the first week subsequent to surgery, there was no difference between the treatment and control groups in the amount of nutrients that they volitionally consumed during the day. However, the treatment subjects had a greater total daily nutrient intake (Median 5,866 (IQR 5,024 to 7,335) kJ/d vs. 3,965 (IQR 2,968 to 4,664) kJ/d, p < 0.001). However, by the second postoperative week this difference was no longer statistically significant. Intolerance to the tube feedings developed commonly. There was no difference between the groups in the rate of postoperative life-threatening complications or mortality within six months subsequent to surgery. CONCLUSIONS:This study failed to confirm findings from a prior study of improved postoperative survival with nutrition support. However, it was conducted on multiple hospital wards which may have contributed to the higher rate of tube-related problems and less nutrient delivery signifying the need for further study.
A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis.
Eatock F C,Chong P,Menezes N,Murray L,McKay C J,Carter C R,Imrie C W
The American journal of gastroenterology
BACKGROUND:After 50 yr in which nasoenteric feeding was considered contraindicated in acute pancreatitis (AP), several clinical studies have shown that early nasojejunal (NJ) feeding can be achieved in most patients. A pilot study of early nasogastric (NG) feeding in patients with objectively graded severe AP proved that this approach was also feasible. A randomized study comparing NG versus NJ feeding has been performed. METHODS:A total of 50 consecutive patients with objectively graded severe AP were randomized to receive either NG or NJ feeding via a fine bore feeding tube. The end points were markers of the acute phase response APACHE II scores and C-reactive protein (CRP) measurements, and pain patterns by visual analogue score (VAS) and analgesic requirements. Complications were monitored and comparisons made of both total hospital and intensive-care stays. RESULTS:A total of 27 patients were randomized to NG feeding and 23 to NJ. One of those in the NJ group had a false diagnosis, thereby reducing the number to 22. Demographics were similar between the groups and no significant differences were found between the groups in APACHE II score, CRP measurement, VAS, or analgesic requirement. Clinical differences between the two groups were not significant. Overall mortality was 24.5% with five deaths in the NG group and seven in the NJ group. CONCLUSIONS:The simpler, cheaper, and more easily used NG feeding is as good as NJ feeding in patients with objectively graded severe AP. This appears to be a useful and practical therapeutic approach to enteral feeding in the early management of patients with severe AP.
10.1111/j.1572-0241.2005.40587.x
Effect of jejunal long-term feeding in chronic pancreatitis.
Stanga Zeno,Giger Urs,Marx Arthur,DeLegge Mark H
JPEN. Journal of parenteral and enteral nutrition
BACKGROUND:In the late course of chronic pancreatitis (CP), weight loss is often seen because of reduced caloric intake and a reduction of pancreatic enzyme secretion, resulting in maldigestion. Most of these patients can be managed by dietary recommendations and pancreatic enzyme supplementation. However, approximately 5% of these patients are reported to be candidates for enteral nutrition support during their course of CP. Although small bowel access for enteral feeding can be easily obtained by percutaneous endoscopic gastrojejunostomy (PEG/J) or direct percutaneous endoscopic jejunostomy (DPEJ), to date there are no data regarding clinical outcome and safety of long-term jejunal feeding in CP. METHODS:From January 1999 to October 2002, 57 patients receiving enteral nutrition by PEG/J or DPEJ were retrospectively analyzed during a follow-up period of 6 months. There were 38 females and 19 males, with an average age of 46.6 years. RESULTS:Small-bowel access was obtained by PEG/J in 53 patients and by DPEJ in 4. Duration of enteral feeding was 113 days. Average body weight significantly increased from 64.8 kg at day 1 to 69.1 kg at day 180 (p < .001). The percentage of patients with abdominal pain decreased from 96% to 23%. One patient sustained a colon mesentery injury after DPEJ tube placement. CONCLUSIONS:Long-term nutrition support by PEG/J or DPEJ in patients with symptomatic, chronic pancreatitis increases patients' body weight and decreases the degree of malnutrition, abdominal pain, and other gastrointestinal symptoms. The underlying mechanisms for these observations are unclear and require further investigation. Small-bowel rest with reduced pancreatic gland stimulation might be a key component. Moderately to severely malnourished patients who do not respond to oral dietary interventions and who are candidates for elective pancreatic surgery might also be candidates for long-term preoperative jejunal feeding to reduce malnutrition-associated perioperative complications. In experienced hands, we feel that long-term jejunal feeding is safe, with minimal major complications.
10.1177/014860710502900112
Laparoscopic Roux-en-Y feeding jejunostomy: a new minimally invasive surgical procedure for permanent feeding access in children with gastric dysfunction.
Neuman Heather B,Phillips J Duncan
Journal of laparoendoscopic & advanced surgical techniques. Part A
Long-term feeding access in children with foregut dysfunction has traditionally been achieved by gastrostomy tube placement with or without fundoplication. Alternatives after failed procedures have included re-do fundoplication, transpyloric gastrojejunal tube placement, loop jejunostomy (open or laparoscopic), and open Roux-en-Y jejunostomy. We describe a new technique, laparoscopic Roux-en-Y feeding jejunostomy (LRFJ), which offers a minimally invasive option in providing long-term enteral access to these children. Five children, ages 10 months to 9 years (mean age, 3.4 years), weighing 8.8 to 15.2 kilograms (mean weight, 12.3 kg), underwent LRFJ. Four children had mental retardation/cerebral palsy. In 3 children, LRFJ was the only intra-abdominal procedure performed. No technical complications related to the procedure were observed. Mean operative time was 98 minutes in the children in which LRFJ was the only procedure performed. Enteral feeds were typically begun by postoperative day (POD) 5. Follow-up has ranged from 12 to 30 months (mean follow-up, 23 months). All 4 survivors remain on full jejunal feedings and are doing well. One child developed stomal stenosis requiring dilatation. In summary, LRFJ can be performed safely in children with gastric dysfunction, may be performed in conjunction with a variety of other laparoscopic procedures, and offers a new option for nutritional access in this challenging pediatric population.
10.1089/lap.2005.15.71
Effect of feeding-tube properties on residual volume measurements in tube-fed patients.
Metheny Norma A,Stewart Jena,Nuetzel Gretel,Oliver Dana,Clouse Ray E
JPEN. Journal of parenteral and enteral nutrition
BACKGROUND:The effect of feeding tube size and port configuration on the ability to measure gastric residual volume (GRV) is poorly understood. In addition, there is confusion about the need to measure GRVs during feedings into the small bowel. This study sought to (1) compare the volume of gastric contents obtained from small-diameter feeding tubes and large-diameter sump tubes concurrently positioned in the stomach and (2) describe the distribution of GRVs during small-bowel feedings. METHODS:For the first objective, GRV measurements were made from 10-Fr tubes (n = 645) and 14-Fr or 18-Fr sump tubes (n = 645) concurrently present in 62 critically ill patients. Sixty-milliliter syringes were used to measure GRVs from the 10-Fr tubes; the fluid was returned to the stomach and measurements were repeated from the large-diameter sump tubes. To address the second research objective, 890 GRV measurements were made from 14-Fr or 18-Fr gastric sump tubes (not connected to suction) in 75 critically ill patients who were receiving small-bowel feedings. RESULTS:When GRVs were >50 mL, a linear regression equation indicated that volumes obtained from the large-diameter sump tubes were about 1.5 times greater than those obtained from the small-diameter tubes concurrently present in the stomach, p < .001. Gastric volumes > or =100 mL were found in 11.6% of the 890 measurements made in patients receiving small-bowel feedings; volumes > or =150 mL were found in 5.4% of the measurements. CONCLUSIONS:The findings suggest that GRVs obtained from large-diameter sump tubes are about 1.5 times greater than those obtained from 10-Fr tubes. Large GRVs occur in at least 5% of patients receiving postpyloric feedings.
10.1177/0148607105029003192
The economic impact of early enteral feeding in gastrointestinal surgery: a prospective survey of 51 consecutive patients.
Lucha Paul A,Butler Ralph,Plichta Jessica,Francis Michael
The American surgeon
Early postoperative oral feeding has been demonstrated to be safe and not increase postoperative morbidity. There are conflicting reports about its effect on postoperative length of stay. Some patients will fail attempts at early postoperative feeding and may be relegated to a longer postoperative course. Few studies to date have attempted to identify cost savings associated with early oral support, and those identified address nasoenteric support only. Fifty-one consecutive patients were randomized into either a traditional postoperative feeding group or an early postoperative feeding group after their gastrointestinal surgery. Length of hospital stay, hospital costs (excluding operating room costs), morbidity, and time to tolerance of a diet were compared. There was a tendency toward increased nasogastric tube use in the early feeding arm, but the morbidity rates were similar. Length of hospital stay and costs were similar in both arms. Early postoperative enteral support does not reduce hospital stay, nursing workload, or costs. It may come at a cost of higher nasogastric tube use, however, without an increase in postoperative morbidity.
Early enteral feeding compared with parenteral nutrition after oesophageal or oesophagogastric resection and reconstruction.
Gabor S,Renner H,Matzi V,Ratzenhofer B,Lindenmann J,Sankin O,Pinter H,Maier A,Smolle J,Smolle-Jüttner F M
The British journal of nutrition
After resective and reconstructive surgery in the gastrointestinal tract, oral feeding is traditionally avoided in order to minimize strain to the anastomoses and to reduce the inherent risks of the postoperatively impaired gastrointestinal motility. However, studies have given evidence that the small bowel recovers its ability to absorb nutrients almost immediately following surgery, even in the absence of peristalsis, and that early enteral feeding would preserve both the integrity of gut mucosa and its immunological function. The aim of this study was to investigate the impact of early enteral feeding on the postoperative course following oesophagectomy or oesophagogastrectomy, and reconstruction. Between May 1999 and November 2002, forty-four consecutive patients (thirty-eight males and six females; mean age 62, range 30-82) with oesophageal carcinoma (stages I-III), who had undergone radical resection and reconstruction, entered this study (early enteral feeding group; EEF). A historical group of forty-four patients (thirty-seven males and seven females; mean age 64, range 41-79; stages I-III) resected between January 1997 and March 1999 served as control (parenteral feeding group; PF). The duration of both postoperative stay in the Intensive Care Unit (ICU) and the total hospital stay, perioperative complications and the overall mortality were compared. Early enteral feeding was administered over the jejunal line of a Dobhoff tube. It started 6 h postoperatively at a rate of 10 ml/h for 6 h with stepwise increase until total enteral nutrition was achieved on day 6. In the controls oral enteral feeding was begun on day 7. If compared to the PF group, EEF patients recovered faster considering the duration of both stay in the ICU and in the hospital. There was a significant difference in the interval until the first bowel movements. No difference in overall 30 d mortality was identified. A poor nutritional status was a significant prognostic factor for an increased mortality. Early enteral feeding significantly reduces the duration of ICU treatment and total hospital stay in patients who undergo oesophagectomy or oesophagogastrectomy for oesophageal carcinoma. The mortality rate is not affected.
10.1079/bjn20041383
Clinical application of clip-assisted endoscopic method for nasoenteric feeding in patients with gastroparesis and gastroesophageal wounds.
Wu Chung-Jen,Hsu Ping-I,Lo Gin-Ho,Shie Chang-Bih,Lo Ching-Chu,Wang E-Ming,Lin Chiun-Ku,Chen Wen-Chi,Cheng Lung-Chih,Yu Hsien-Chung,Chan Yi-Chun,Lai Kwok-Hung
World journal of gastroenterology
AIM:To report the clinical experiences in the application of clip-assisted endoscopic method for nasoenteric feeding in patients with gastroparesis and patients with gastroesophageal wounds, and to compare the efficacy of nasoenteric feeding in these two indications. METHODS:From April 2002 to January 2004, 21 consecutive patients with gastroparesis or gastroesophageal wounds were enrolled and received nasoenteric feeding for nutritional support. A clip-assisted method was used to place the nasoenteric tubes. Outcomes in the two groups were compared with respect to the successful rate of enteral feeding, percentage of recommended energy intake (REI), and complication rates. RESULTS:The gastroparesis group included 13 patients with major burns (n = 7), trauma (n = 2), congestive heart failure (n = 2) and post-surgery gastric stasis syndrome (n = 2). The esophageogastric wound group included eight patients with tracheoesophageal fistula (n = 2) and wound leakage following gastric surgery (n = 6). Two study groups were similar in feeding successful rates (84.6% vs 75.0%). There were also no differences in the percentage of REI between groups (79.4% vs 78.6%). Additionally, no complications occurred in any of the study groups. CONCLUSION:Nasoenteric feeding is a useful method to provide nutritional support to most of the patients with gastroparesis who cannot tolerate nasogastric tube feeding and to the cases who need bypass feeding for esophageogastric wounds.
10.3748/wjg.v11.i24.3714
Early enteral feeding by nasoenteric tubes in patients with perforation peritonitis.
Kaur Navneet,Gupta Manish K,Minocha Vivek Ratan
World journal of surgery
Malnutrition is well recognized as a potential cause of increased morbidity and mortality in surgical patients. Early postoperative enteral nutrition through a feeding jejunostomy has been shown to improve results in patients undergoing major resections for gastrointestinal malignancies, trauma, and perforation peritonitis. We conducted a prospective study to assess the feasibility and short-term efficacy of early enteral feeding through a nasoenteric tube placed intraoperatively in patients with nontraumatic perforation peritonitis with malnutrition. One hundred patients with nontraumatic perforation peritonitis with malnutrition undergoing exploratory laparotomy were randomly divided into a test group (TG) and a control group (CG) of 50 patients each. TG patients had a nasoenteric tube placed at the time of surgery and were started on an enteral feeding regime 24 hours postoperatively. Patients in CG were allowed to eat orally once they passed flatus. The differences between the two groups with respect to nutritional intake in terms of energy and protein, changes in nutritional status as assessed by anthropometric, biochemical, and hematological values, amount of nasogastric aspirate, return of bowel motility, and complication rates were analyzed. The nasoenteric feeding was well tolerated. Total calorie and protein intake in TG was significantly higher than in CG: 981 vs. 505 kcal (p < 0.01), protein 24 vs. 0 g on day 3 and 1498 vs. 846 kcal (p < 0.01), protein 44 vs. 23 g (p < 0.01) on day 7, respectively. There was reduction in the amount of nasogastric aspirate in TG compared with that in CG: 431 vs. 545 ml/24 h on day 2 and 301 vs. 440 ml/24 h on day 3, respectively. There was much faster recovery of bowel motility in TG than in CG at 3.34 vs. 4.4 days (p < 0.01). Complications developed in 39 of 50 patients in TG and in 47 of 50 in CG. The major complications occurred in 6 patients in TG and 12 patients in CG (p < 0.05). Patients with perforation peritonitis with malnutrition are likely to develop large energy deficits postoperatively, resulting in higher incidence of infective complications. Early enteral feeding through a nasoenteric tube is well tolerated by these patients and helps to improve energy and protein intake, reduces the amount of nasogastric aspirate, reduces the duration of postoperative ileus, and reduces the risk of serious complications.
10.1007/s00268-005-7491-z
Effect of peptide YY on pancreatico-biliary secretion in humans.
Symersky Tomas,Biemond Izak,Frolich Marijke,Masclee Ad A M
Scandinavian journal of gastroenterology
OBJECTIVE:The negative feedback on pancreatico-biliary secretion induced by ileal nutrients has been well documented but the role of the distal gut peptide YY (PYY) as mediator is less well defined. We determined the effect of PYY on basal, sham feeding and feeding-stimulated pancreatico-biliary secretion in humans. MATERIAL AND METHODS:Eight healthy volunteers participated in a placebo-controlled, double-blind, randomized study with intravenous infusion of a physiological dose of PYY. Subjects were intubated with a naso-jejunal tube. Duodenal samples were aspirated continuously while a recovery marker perfused the duodenum. Outputs were measured in the basal state, in response to modified sham feeding (MSF) and during jejunal perfusion with a liquid meal. Blood samples were drawn for plasma cholecystokinin (CCK) and PYY measurements. RESULTS:PYY infusion significantly (p<0.01) increased plasma PYY, from 16+/-2 to 55+/-6 pM. Basal outputs of amylase, lipase, trypsin and bilirubin were not affected by PYY. In the placebo experiment, MSF significantly increased amylase, lipase, trypsin and bilirubin outputs. However, during PYY infusion lipase, trypsin and bilirubin outputs did not significantly increase in response to MSF. Jejunal feeding, however, significantly (p<0.01) increased the outputs of bilirubin and enzymes equally during both the placebo and PYY infusions. CONCLUSIONS:Infusion of PYY to physiological plasma levels exerts an inhibitory effect on pancreatico-biliary secretion during the cephalic phase of digestion, but not in the basal state or during the intestinal phase. PYY suppresses pancreatico-biliary secretion during the cephalic phase but not during the intestinal phase of nutrient digestion.
Comparison of continuous vs intermittent nasogastric enteral feeding in trauma patients: perceptions and practice.
Steevens Emmy C,Lipscomb A F,Poole Galen V,Sacks Gordon S
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
Enteral nutrition support (ENS) may be administered by continuous administration or by intermittent bolus, but few studies have compared the advantages and limitations associated with these methods in the trauma patient population. The purpose of this prospective randomized study was to evaluate the impact of continuous vs intermittent nasogastric enteral feeding on gastrointestinal tolerance, pulmonary aspiration, and nutritional indices. A survey of medical and surgical intensive care unit nursing staff was performed to assess perceptions and attitudes toward these 2 delivery methods. Eighteen trauma patients [Injury Severity Score (ISS) > or = 20] were enrolled in the study; 9 received continuous ENS (CENS) and 9 received intermittent bolus ENS (IENS). Interruption of ENS delivery occurred in more IENS than CENS patients due to elevated residuals and emesis. Diarrhea occurred in more patients (5/9 vs 2/9) and for a longer duration (14/65 vs 6/49 ENS days) in the IENS group compared with the CENS group. Aspiration was detected in 1 IENS patient. Method of nutrient delivery did not seem to influence urine urea nitrogen (UUN) measurements or prealbumin concentrations. Nurses surveyed in the study (n = 25) preferred CENS (84%) compared with IENS (12%). Data from this study suggest that CENS through a nasoenteric feeding tube may facilitate nutrient intake with less gastrointestinal complications in severely injured trauma patients compared with IENS. In addition, the majority of nurses surveyed preferred the continuous method for nutrient delivery.
10.1177/0115426502017002118
A retrospective review of the course of patients with pancreatitis discharged on jejunal feedings.
Yoder Andrea J,Parrish Carol Rees,Yeaton Paul
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
INTRODUCTION:Although parenteral nutrition (PN) has been the standard nutrition therapy in patients with pancreatitis requiring nutrition support, it is associated with a higher rate of catheter-related sepsis and gut atrophy. Research suggests enteral nutrition (EN) is possible in patients with pancreatitis without exacerbating symptoms when infused jejunally. The purpose of this study was to review the course of patients with resolving pancreatitis discharged to home on EN. METHODS:The medical records of 33 patients with a percutaneous endoscopic gastrostomy tube with jejunal extension (PEG-J) or nasojejunal tube (NJ) who received home EN were reviewed. The data collected included duration of EN, formula used, goal and maximum tolerated flow rates, anthropometric measures, and gastrointestinal complications. RESULTS:Ninety-seven percent of patients received a standard polymeric formula providing an average of 1845 +/- 421 kcal/d. Forty-two percent of patients took pancreatic enzyme supplements. Complications occurring in patients included nausea and vomiting (42%), feeding rate intolerance (18%), diarrhea (12%), and PEG site infection (27%). Seventy-seven percent of patients achieved nutritional goals. CONCLUSION:Standard polymeric EN seems to be safe and efficacious in the home setting for patients with resolving pancreatitis.
10.1177/0115426502017005314
Benefits of postpyloric enteral access placement by a nutrition support dietitian.
Jimenez L Lee,Ramage James E
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
BACKGROUND:Although enteral nutrition is considered the preferred strategy for nutrition support, it is often precluded by nasogastric feeding intolerance or the inability to place feeding access into the postpyloric position. In an effort to improve enteral nutrition (EN) outcomes at our institution, the nutrition support dietitian (NSD) began placing postpyloric feeding tubes (PPFT) in intensive care unit patients. METHODS:Intensive care unit patients who received blind, bedside PPFT placements by the NSD (n = 18) were compared with a concurrent age- and diagnosis-matched control group that received standard nutritional care without NSD intervention (n = 18). Interruption of EN infusion, appropriateness of parenteral nutrition (PN) prescription (based on American Society of Parenteral and Enteral Nutrition guidelines), and incidence of ventilator-associated pneumonia (VAP), as defined by the American College of Chest Physicians practice guidelines, were determined in each group. RESULTS:The NSD was successful in positioning the PPFT at or distal to the third portion of the duodenum in 83% of attempts. The PPFT group demonstrated no interruption of enteral feeding compared with 56% in the control group (p < .01) and required 1 (6%) PN initiation in contrast to 8 (44%) in the control group (p < .01). There was a trend toward reduced VAP in the PPFT group (6% vs 28%, p = .07). Of the PN initiations in the control group, 88% were deemed to be potentially avoidable; 6 of 8 PNs were initiated because of gastric residuals. CONCLUSIONS:Enteral nutrition facilitated by NSD placement of postpyloric feeding access is associated with improved tube feeding tolerance and reduced PN use. Further studies are needed to evaluate a possible effect of postpyloric feeding on the incidence of VAP.
10.1177/0115426504019005518
The impact of implementing an enteral tube feeding protocol on caloric and protein delivery in intensive care unit patients.
Arabi Yaseen,Haddad Samir,Sakkijha Maram,Al Shimemeri Abdullah
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition
BACKGROUND:The purpose of this study was to determine the effect of an enteral tube feeding protocol on caloric and protein delivery to intensive care unit (ICU) patients. METHODS:This prospective study consisted of 2 phases: before and after the implementation on an enteral-feeding protocol. The following data were collected: demographics, Acute Physiology and Chronic Health Evaluation II score and Simplified Acute Physiology Score II, caloric and protein requirements, the location of the feeding tube tip, and prokinetic agents use. The primary endpoint was caloric and protein intake as a percentage of the requirement. Secondary endpoints were gastric residuals >150 mL, vomiting episodes, ICU and hospital lengths of stay, mechanical ventilation duration, and ICU and hospital mortality. RESULTS:There were no significant differences between the control (n = 100) and protocol groups (n = 103) in baseline characteristics. The protocol was associated with significant improvement in the 7-day average of caloric intake/requirement (53.9 +/- 2.3% vs 64.5 +/- 2.2%, p = .001) and protein intake/requirement (56.7 +/- 2.6% vs 67.4% +/- 2.7%, p = .005). Caloric and protein intake improved whether the patient was receiving prokinetic agent or not. There was a trend toward lower gastric residual volumes and vomiting episodes in the protocol group. Patients receiving gastric feeding showed significant improvement in caloric intake to levels comparable to patients with postpyloric feeding. CONCLUSIONS:Enteral tube feeding protocol is effective in improving feeding delivery in ICU patients independent of prokinetic agent use. Protocol for enteral tube feeding should be considered in the management of ICU patients, given the positive impact of this nonpharmacologic, non-interventional tool.
10.1177/0115426504019005523
Nutritional intervention improves the caloric and proteic ingestion of head and neck cancer patients under radiotherapy.
Gonçalves Dias M C,de Fátima Nunes Marucci M,Nadalin W,Waitzberg D L
Nutricion hospitalaria
Malnutrition is commonly associated with head and neck cancer, due especially to anorexia, which is aggravated by radiotherapy. The objective of this study was to evaluate modifications to nutritional ingestion following three types of nutritional intervention. Sixty-four male out-patients (62.1 +/- 1.5 years) were divided into three groups: oral group, (n=32) that received an adapted oral diet; feeding tube group, (n=16) under home enteral nutrition via a nasoenteral feeding tube (6x/day); and supplement group, (n=16) with oral diet associated to oral alimentary supplement between meals (3x/day). The groups were homogeneous and counseled to maintain a caloric ingestion of 40 kcal/kg. The diet for the oral group was adapted to the age and to the side effects of radiotherapyThe nutritional state of the three groups was evaluated for the caloric-proteic ingestion, anthropometric indicators (body weight, body mass index, triceps skinfold thickness, midarm muscle area), laboratorial indicators (total proteins, albumin, hematocrit, hemoglobin and total lymphocytes count), The results showed that all of the groups presented an increase in the ingestion of calories and proteins (p < 0.001). The nutritional therapy support for patients with head and neck cancer under radiotherapy, whether exclusive oral diet, enteral through a feeding tube, or with alimentary supplement associated to an oral diet achieved a significant increase in the total caloric ingestion. It is recommended that programs be implemented-to improve the ingestion of foods among these patients.
Indicators of tubesite during feedings.
Metheny Norma A,Schnelker Renée,McGinnis Joan,Zimmerman Georgia,Duke Carolyn,Merritt Barbara,Banotai Mary,Oliver Dana A
The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses
Nurses are forced to make decisions about feeding tube position at regular intervals during the delivery of tube feedings; failure to detect an improperly positioned feeding tube can have serious consequences. This study was designed to determine the extent to which specific indicators could singularly and collectively differentiate between gastric and small-bowel placement in patients with nasally or orally inserted small-bore feeding tubes. Indicators were the length of tubing extending from the tube's insertion site as well characteristics of aspirates withdrawn from the feeding tube (volume, appearance, and pH). A total of 201 critically ill tube-fed patients participated in the study for a period of 2-3 days. Among the inclusion criteria were an order for the blind insertion of a small-bore feeding tube, orders to start continuous feedings, and radiographic confirmation of tube location. Five times daily, the following variables were measured: (a) length of tubing extending from the insertion site, (b) volume of aspirate from the feeding tube, (c) appearance of the aspirate, and (d) pH of the aspirate. At the time of entry into the study, 85 patients had gastric feeding tubes and 116 patients had small-bowel feeding tubes. A total of 2,754 concurrent measurements of the variables were attempted; sufficient fluid for pH testing and color description was obtained in 74.2% of the attempts from gastric tubes and in 62.2% of the attempts from small-bowel tubes. Univariate analysis showed that all four of the variables described above were able to differentiate between gastric and small bowel tube sites. A multivariate, forced entry, logistic regression model was able to correctly classify tube site in 81% of the predictions. A variety of easy-to-use bedside methods can be used with a moderate degree of confidence to distinguish between gastric and small-bowel tube placement during continuous feedings.
10.1097/01376517-200512000-00004
Non-occlusive small bowel necrosis during enteral feeding after pancreaticoduodenectomy.
Thaler K,Garreau J,Hansen P D
Digestive surgery
BACKGROUND:Early enteral tube feeding is widely used after major surgery and trauma. This article is intended to alert surgeons to the possibility of small bowel necrosis following enteral refeeding and to discuss etiology and clinical features. METHODS:A case series from a single surgeon's database at a Tertiary Care Center is reported. Cases were drawnfrom a consecutive series of patients undergoing pylorus-preserving pancreaticoduodenectomy and placement of a needle catheter jejunostomy between January 1998 and June 2004. RESULTS:Two patients receiving early postoperative tube feeding developed sepsis with subsequent small bowel necrosis. Abdominal distension and signs of sepsis developed early postoperatively. Diagnosis was made based on characteristic computed tomography findings. Both patients underwent laparotomy with segmental bowel resection and survived. CONCLUSION:Non-specific septic symptoms associated with recurrent abdominal distension are ominous signs in patients receiving early postoperative enteral tube feeding and should prompt discontinuation of enteral nutrition. Within this scenario, CT imaging represents a valuable adjunct in the early assessment of these patients.
10.1159/000090997
Small bowel necrosis related to enteral nutrition after duodenal surgery.
Messiner Ryan,Griffen Margaret,Crass Richard
The American surgeon
Nutritional support is the key to the successful recovery of any patient. Small bowel necrosis is described in patients being fed with enteral nutrition after surgery. Five patients with small bowel necrosis after surgery will be discussed and an etiology proposed. A retrospective review of patient data was performed. Data was collected on the type of surgical procedures performed, the enteral nutrition given to the patient, basic laboratory data, the length of stay, and discharge status. A total of five patients' charts were reviewed. Three patients had pancreaticoduodenectomy for a pancreatic mass and two required pyloric exclusion secondary to gunshot wounds. All five patients were fed with a fiber-based enteral nutrition. All patients subsequently had small bowel necrosis requiring reoperation. Four of the five patients had inspissated tube feeding within the necrotic small bowel. Two patients died and three survived with prolonged hospital courses. We propose that the combination of duodenal surgery and fiber-based enteral nutrition contribute to the development of small bowel necrosis postoperatively.
Impact of a computerized information system on quality of nutritional support in the ICU.
Berger Mette M,Revelly Jean-Pierre,Wasserfallen Jean-Blaise,Schmid Aline,Bouvry Sylvie,Cayeux Marie-Christine,Musset Myriam,Maravic Philippe,Chiolero René L
Nutrition (Burbank, Los Angeles County, Calif.)
OBJECTIVE:In intensive care units (ICUs), patient outcome depends on quality of nutritional support. We investigated the effect of computerized information systems (CISs) on quality of nutritional support by comparing two ICUs with or without CIS and burned patients before and after CIS implementation. METHODS:Part 1 was a 2-wk prospective survey in two units of a surgical ICU: unit A (11 beds) without CIS and unit B (four beds) with CIS. Part 2 consisted of two 18-mo periods in burn patients before and after CIS implementation. Nurses and doctors belonged to the same team; procedures were identical. A computer page was configured to retrieve data related to nutritional support. RESULTS:A total of 1313 ICU days were analyzed in 109 patients. Patients' characteristics were similar in parts 1 and 2. In part 1, nutritional support was required 38% of days. Nutritional route was similar but data were more frequently missing in unit A. Energy delivery was higher with CIS but below target values in both units (31+/-11% of target in unit A, 77+/-4% in unit B). Computations were incomplete and time consuming for unit A versus B (11+/-2 versus 2+/-1 min/patient, P<0.0001). In part 2, in the 54 burn patients, use of postpyloric feeding tubes and energy delivery increased with CIS, resulting in less weight loss. CONCLUSION:Computerized information systems favored standardization of nutritional care and monitoring, thus decreasing time required for writing and computations. Follow-up was improved and nutrient delivery was closer to target values, thus increasing quality of care. In burn patients, the better data visibility was associated with a significant improvement in nutrient delivery.
10.1016/j.nut.2005.04.017
External duodenal fistula following closure of duodenal perforation.
Verma G R,Kaman Lileshwar,Singh Gurpreet,Singh Rajinder,Behera Arunanshu,Bose Shashank Mohan
Indian journal of gastroenterology : official journal of the Indian Society of Gastroenterology
AIM:Retrospective analysis of experience with management of external duodenal fistula (EDF) without using total parenteral nutrition (TPN). METHOD:Medical records of 31 patients with EDF following closure of duodenal ulcer perforation, treated over a 7-year period (1994-2001), were studied. Twenty-one patients (68%) had evidence of sepsis at presentation or during the course of treatment. None could afford TPN for optimum time. All patients received hospital-based enteral nutrition through nasojejunal tube, besides supportive medical treatment and/or surgery. Peritonitis or failure to insert nasojejunal tube for enteric alimentation led to early surgery. RESULTS:Two patients died of septicemia and multi-organ failure within 48 hours of admission. Fourteen patients (48.3%) initially received conservative treatment (Group I); six of them later required surgery. Fifteen patients (51.7%) underwent early surgery due to peritonitis (n=9) or failure to establish enteral feeding (n=6) (Group II); wound infection, intra-abdominal abscess and septicemia were more common in these patients than those in Group I. Survival rate was higher in Group I than in Group II (86% versus 40%; p< 0.05). Septicemia and gastrectomy were the independent factors associated with high mortality. CONCLUSIONS:EDF can be satisfactorily managed without TPN. Successful placement of enteral feeding line, supportive treatment and delayed surgery can achieve survival in 85% of patients. Minimum intervention is recommended when early surgery is performed in peritonitis or to establish enteral feeding line.
A comparison of early gastric and post-pyloric feeding in critically ill patients: a meta-analysis.
Ho Kwok M,Dobb Geoffrey J,Webb Steven A R
Intensive care medicine
OBJECTIVE:To investigate the potential beneficial and adverse effects of early post-pyloric feeding compared with gastric feeding in critically ill adult patients with no evidence of impaired gastric emptying. DESIGN:Randomised controlled studies comparing gastric and post-pyloric feeding in critically ill adult patients from Cochrane Controlled Trial Register (2005 issue 3), EMBASE and MEDLINE databases (1966 to 1 October 2005) without any language restriction were included. Two reviewers reviewed the quality of the studies and performed data extraction independently. MEASUREMENTS AND RESULTS:Eleven randomised controlled studies with a total of 637 critically ill adult patients were considered. The mortality (relative risk [RR] 1.01, 95% CI 0.76-1.36, p=0.93; I2=0%) and risk of aspiration or pneumonia (RR 1.28, 95% CI 0.91-1.80, p=0.15; I2=0%) were not significantly different between patients treated with gastric or post-pyloric feeding. The effect of post-pyloric feeding on the risk of pneumonia or aspiration was similar when studies were stratified into those with and those without the use of concurrent gastric decompression (RR ratio 0.95, 95% CI 0.48-1.91, p=0.89). The risk of diarrhoea and the length of intensive care unit stay (weighted mean difference in days -1.46, 95% CI -3.74 to 0.82, p=0.21; I2=24.6%) were not statistically different. The gastric feeding group had a much lower risk of experiencing feeding tube placement difficulties or blockage (0 vs 9.6%, RR 0.13, 95% CI 0.04-0.44, p=0.001; I2=0%). CONCLUSIONS:Early use of post-pyloric feeding instead of gastric feeding in critically ill adult patients with no evidence of impaired gastric emptying was not associated with significant clinical benefits.
10.1007/s00134-006-0128-3
Temporary esophageal stenting allows healing of esophageal perforations following atrial fibrillation ablation procedures.
Bunch T Jared,Nelson Jennifer,Foley Tom,Allison Scott,Crandall Brian G,Osborn Jeffrey S,Weiss J Peter,Anderson Jeffrey L,Nielsen Peter,Anderson Lars,Lappe Donald L,Day John D
Journal of cardiovascular electrophysiology
BACKGROUND:Left atrial catheter ablation (LACA) has emerged as a successful method to eliminate atrial fibrillation (AF). Recent reports have described atrio-esophageal fistulas, often resulting in death, from this procedure. Temporary esophageal stenting is an established therapy for malignant esophageal disease. We describe the first case of successful temporary esophageal stenting for an esophageal perforation following LACA. CASE:A 48-year-old man with symptomatic drug refractory lone AF underwent an uneventful LACA. Fifty-nine ablations with an 8-mm tip ablation catheter (30 seconds, 70 Watts, 55 degrees C), as guided by 3-D NavX mapping, were performed in the left atrium to isolate the pulmonary veins as well as a left atrial flutter and roof ablation line. In addition, complex atrial electrograms in AF and sites of vagal innervation were ablated. Two weeks later, he presented with sub-sternal chest pain, fever, and dysphagia. A chest CT showed a 3-mm esophageal perforation at the level of the left atrium with mediastinal soiling and no pericardial effusion. An urgent upper endoscopy with placement of a PolyFlex removable esophageal stent to seal off the esophago-mediastinal fistula was performed. After 3 weeks of i.v. antibiotics, naso-jejunal tube feedings, and esophageal stenting, the perforation resolved and the stent was removed. Over 18 months of follow-up, there have been no other complications, and he has returned to a physically active life and remains free from AF on previously ineffective anti-arrhythmic drugs. CONCLUSION:Early diagnosis of esophageal perforations following LACA may allow temporary esophageal stenting with successful esophageal healing. Prompt chest CT scans with oral and i.v. contrast should be considered in any patient with sub-sternal chest pain or dysphagia following LACA.
10.1111/j.1540-8167.2006.00464.x
Total esophagogastric dissociation: 10 years' review.
Morabito Antonio,Lall Anupam,Lo Piccolo R,McCarthy Helen,Kauffmann Lisa,Ahmed Shiban,Bianchi Adrian
Journal of pediatric surgery
PURPOSE:Neurologically impaired children run a 12% to 45% risk of recurrent gastroesophageal reflux (GER) after fundoplication. Elimination of the reflux by "rescue" total esophagogastric dissociation (TEGD) encouraged us to use it also as a "primary" form of antireflux surgery in this group of patients. METHODS:Twenty-six (14 male, 12 female) patients underwent TEGD between 1994 and 2004, of which 16 were primary and 10 were rescue procedures for failed fundoplication. RESULTS:There was no operative mortality and postoperative complications were limited to one subphrenic collection, one esophagojejunal dehiscence, and one small bowel hernia beneath the jejunal Roux loop. Gastrostomy feeding was usually established by 3 to 5 days and the mean hospital stay was 10.2 days (range, 6-18 days). At follow-up of 7 months to 11 years, there was no recurrence of GER. Four late deaths were unrelated to the surgery. The children's nutritional status improved with the mean weight standard deviation score showing a statistically significant increase from -2.63 preoperatively to -0.96 postoperatively (Wilcoxon's signed rank P value < or =.005). CONCLUSIONS:Total esophagogastric dissociation is a safe definitive solution for GER because it eliminates all risk of recurrent reflux. We therefore feel that TEGD can be used as a primary treatment of choice for severely neurologically impaired patients who are experiencing GER and are completely dependant on tube feeds.
10.1016/j.jpedsurg.2006.01.013
Comparison of tolerance and change of intragastric pH between early nasogastric and nasojejunal feeding following resection of colorectal cancer.
Hsu Tzu-Chi,Su Chiu-Feng,Huang Pi-Chen,Lu Shu-Ching,Tsai Shu-Ling
Clinical nutrition (Edinburgh, Scotland)
BACKGROUND:Early feeding after injury has been suggested to decrease morbidity and mortality in many studies. Intrajejunal feeding has been preferred over intragastric feeding due to earlier return of peristalsis following laparotomy. Few reports, however, have focused on the tolerance and change in pH inside the stomach after intragastric and intrajejunal feeding. The aim of the present study was the assessment of (1) the postoperative tolerance of intragastric and intrajejunal feeding, and (2) the effect of intragastric and intrajejunal feeding on intragastric pH value. MATERIALS AND METHODS:From April 1998 to October 2002, 140 patients underwent colon resection for colorectal cancer entered the study. The patients were divided into seven groups of 20 patients each. Group I was kept on NPO for 1 week. Groups II, III, and IV were fed through a nasogastric (NG) tube from the second to the sixth postoperative day (POD) with low residual (Osmolite-HN), high-fat (Pulmocare), and glutamine-containing (AlitraQ) enteral formulas, respectively. Groups V, VI, and VII were fed through a nasojejunal (NJ) tube from the second to the sixth POD with Osmolite-HN, Pulmocare, and AlitraQ, respectively. Feeding started at 500 kcal/500 cm(3)/d. If the patient tolerated the formula well, feeding increased to 1,500 kcal/1,500 cm(3)/d the following day. Intragastric pH was measured preoperatively and then twice daily until the sixth POD. RESULTS:Poor tolerance occurred in 14 patients (23%) with NG tube feeding and 18 patients (30%) with NJ tube feeding. The pH value of intragastric juice increased significantly once NG feeding started (3.67+/-1.33 on the third POD; 4.28+/-1.26 on the sixth POD). However, the pH value remained low after NJ feeding was started (2.09+/-1.46 on the third POD; 2.14+/-1.49 on the sixth POD). CONCLUSIONS:This series suggests that (1) the majority of patients can tolerate early feeding well following resection of colorectal cancer, and NJ feeding is not necessarily better tolerated than NG feeding; (2) early NG, but not the NJ feeding, can significantly elevate the intragastric pH value in patients who underwent resection of colorectal cancer. NG may be more effective than NJ feeding in preventing stress-induced gastropathy by elevating the pH value of intragastric juice.
10.1016/j.clnu.2005.12.011
Early enteral nutrition in severe acute pancreatitis: a prospective randomized controlled trial comparing nasojejunal and nasogastric routes.
Kumar Ajay,Singh Namrata,Prakash Shyam,Saraya Anoop,Joshi Yogendra Kumar
Journal of clinical gastroenterology
PURPOSE:Enteral nutrition (EN) is effective, easy to provide, cheaper, and associated with fewer complications in comparison with parenteral nutrition in severe acute pancreatitis (SAP). However, the nasogastric (NG) route for enteral supplements still remains to be established, and most studies have used the nasojejunal (NJ) route. The purpose of this study was to compare early NJ with NG feeding in SAP. PATIENTS AND METHODS:A total of 31 patients with SAP were randomized to feeding by either NG (15 patients) or NJ (16 patients). A semi-elemental formula was used through an enteral tube in both groups. Nutritional parameters (anthropometry, serum prealbumin and albumin levels) were recorded at baseline and after 7 days. Recurrence of pain and tolerance of feeding was noted. RESULTS:Recurrence of pain occurred in only 1 patient each in the 2 groups. Diarrhea occurred in 3 and 4 patients in the NJ and NG groups, respectively. There were 4 deaths in the NJ group and 5 in the NG group. Two patients in the NJ group and 1 in the NG group underwent surgery. There was no difference in the outcome measures (ie, discharge, surgery, and death). There was a decline in nutritional parameters in both groups. CONCLUSIONS:EN at a slow infusion is well tolerated by both NJ and NG routes in patients with SAP. Neither NJ nor NG feeding leads to recurrence or worsening of pain in SAP. Nutritional parameters remained unaffected because of inadequate calorie intake during the first week of feeding.
A double-blind, randomised, controlled trial to study the effects of an enteral feed supplemented with glutamine, arginine, and omega-3 fatty acid in predicted acute severe pancreatitis.
Pearce Callum B,Sadek Sami A,Walters A Marisia,Goggin Patrick M,Somers Shaw S,Toh Simon K,Johns Tim,Duncan Hamish D
JOP : Journal of the pancreas
CONTEXT:Current best evidence is in favour of early institution of enteral feeding in acute severe pancreatitis with promising results from trials in immunonutrition on other patient groups. OBJECTIVE:To identify which groups of patients and products are associated with benefit, we investigated immunonutrition in patients with predicted acute severe pancreatitis. DESIGN:A randomised trial of a study feed containing glutamine, arginine, tributyrin and antioxidants versus an isocaloric isonitrogenous control feed was undertaken. PATIENTS:Thirty-one patients with a diagnosis of acute pancreatitis predicted to develop severe disease: 15 study feeds and 16 control feeds. INTERVENTIONS:Enteral feeding via nasojejunal tube for 3 days. If patients required further feeding the study was continued up to 15 days. MAIN OUTCOME MEASURES:Reduction in C-reactive protein (CRP) by 40 mg/L after 3 days of enteral feeding was the primary endpoint. Carboxypeptidase B activation peptide (CAPAP) levels were taken at regular intervals. RESULTS:After 3 days of feeding, in the study group 2/15 (13%) of patients had reduced their CRP by 40 mg/L or more. In the control group 6/16 (38%) of patients had reduced their CRP by this amount. This difference was found to be near the statistical significant limit (P=0.220). CONCLUSIONS:The cause of the unexpectedly higher CRP values in the study group is unclear. The rise in CRP was without a commensurate rise in CAPAP or outcome measures so there was no evidence that this represented pancreatic necrosis. The contrast between the CRP and CAPAP results is of interest and we believe that specific pancreatic indices such as CAPAP should be considered in larger future studies.
Gastrotracheal and gastrobronchial fistulas: management with covered expandable metallic stents.
Li Yong-Dong,Li Ming-Hua,Han Xin-Wei,Wu Gang,Li Wen-Bin
Journal of vascular and interventional radiology : JVIR
PURPOSE:The present study evaluated the clinical results of covered tracheobronchial metallic stent placement in the management of gastrotracheal fistulas (GTFs) and gastrobronchial fistulas (GBFs). MATERIALS AND METHODS:Sixteen patients with GTFs or GBFs after esophagogastrectomy were treated with one of two types of covered tracheobronchial metallic stents: a hinged stent or a straight stent. These included 12 GTFs and four GBFs. Thirteen hinged stents and three straight stents were placed during the initial procedure. Data regarding the technical success of stent placement, initial clinical success and failure, fistula reopening, and complications were obtained. RESULTS:Stent placement was technically successful in all patients. The stent completely sealed off the fistula in 12 of 16 patients (75% initial clinical success rate), whereas the remaining four patients (25%) had persistent aspiration symptoms as a result of incomplete GTF or GBF closure (ie, initial clinical failure). During follow-up, the fistula reopened in three of the 12 patients in whom initial clinical success was achieved (25%). Two reopened fistulas were sealed off with stent placement, and one was treated with a nasoenteric feeding tube and a nasogastric decompression tube. All patients died during the 1-year follow-up period; mean survival time was 17 +/- 3.02 weeks (range, 1-42 weeks) after stent placement. Mean survival in patients in whom initial clinical success was achieved was significantly longer than in patients with initial clinical failure (P = .003; log-rank test). CONCLUSION:Use of covered metallic stents appears to be a safe and moderately effective procedure to occlude GTFs and GBFs.
10.1097/01.RVI.0000236609.33842.50
Tolerance and efficacy of enteral nutrition in traumatic brain-injured patients induced into barbiturate coma.
Bochicchio Grant V,Bochicchio Kelly,Nehman Shelley,Casey Colleen,Andrews Penny,Scalea Thomas M
JPEN. Journal of parenteral and enteral nutrition
BACKGROUND:There is a paucity of data evaluating the efficacy of nutrition support in traumatic brain-injured patients induced into barbiturate coma for refractory intracranial hypertension. Our objective was to evaluate the efficacy of enteral nutrition in a select group of trauma patients. METHODS:Prospective data were collected on severe traumatic brain-injured patients over a 4-year period. Patients were stratified by whether or not they were induced into a barbiturate coma. Barbiturate coma was defined as per American Association of Neurological Surgeons (AANS) guidelines. All patients were initially fed via the enteral route via a nasogastric feeding tube. Patients who did not tolerate feedings within 48 hours started receiving prokinetic agents. Feeding tolerance was defined as ability to tolerate enteral feedings with <150 mL of gastric residuals every 6 hours for >72 hours. RESULTS:Fifty-seven patients were induced into a barbiturate coma. All were victims of blunt-force trauma. Forty-two of 57 (74%) patients were men, with a mean age of 37+/-12 years and a mean injury severity score of 24+/-10. Thirty-eight of the 57 (67%) patients had an isolated traumatic brain injury. All 57 patients failed enteral nutrition via the nasogastric route after the first 48 hours of nutrition initiation after barbiturate coma was fully achieved by protocol criteria. Prokinetic agents demonstrated no improvement in feeding tolerance after the subsequent 48-72 hours. Of the 12 patients who had a postpyloric feeding tube placed, only 25% tolerated enteral nutrition for >48 hours. CONCLUSIONS:Patients with traumatic brain injury induced into barbiturate coma develop a significant ileus that is refractory to prokinetic agents. Only a marginal improvement is seen when the postpyloric route is obtained. Early parenteral nutrition should be considered in this patient population.
10.1177/0148607106030006503
[Nutrition support in an intensive care unit: delivery versus requirements].
Teixeira Ana Carolina de Castro,Caruso Lúcia,Soriano Francisco G
Revista Brasileira de terapia intensiva
BACKGROUND AND OBJECTIVES:In critically ill patients nutritional deficiency is common. Considering this fact, the diary monitoring of energy delivered is extremely important. The objective of this study is to assess the adequacy of enteral nutrition (EN) in an Intensive Care Unit (ICU) and identify the reasons for interruptions in feeding. METHODS:Prospective study of adult patients admitted to ICU in period of 53 days. Patients receiving continuous enteral tube feeding (22 hours/day) exclusively and post-pyloric tube feeding position were followed. The feeding volume started at 25 mL/h and was increased until nutritional goal, guided by a feeding protocol. RESULTS:33 patients between 18 and 85 years old were studied. 58% were male. The main admission diagnoses were cardiovascular diseases (27%) and septic shock (21%). The mean time to feeding was 25.3 hours after the patient admission and nutritional goal was achieved in a mean time of 32 hours. The total volume prescribed per day was sufficient to guarantee a mean of 26.1 kcal/kg of body weight and 1.04 g of protein/kg of body weight. Patients received a mean of 19.5 kcal/kg of body weight and 0.8 g of protein/kg of body weight, which correspond a 74% of adequacy. Interruptions of feeding for routine procedures related to patients accounted for 40.6% of the total reasons. CONCLUSIONS:The nutritional support is adequate considering the literature for these patients, who clinical instability causes gastrointestinal intolerance. The effective participation of the Nutrition Therapy Team can contribute positively on nutritional therapy.
Complications related to feeding tube placement.
Metheny Norma A,Meert Kathleen L,Clouse Ray E
Current opinion in gastroenterology
PURPOSE OF REVIEW:Blind placement of a feeding tube can result in serious complications. Given the widespread use of tube feedings, even a small percentage of such problems can affect a significant number of people. The purpose of this review is to describe recent reports of feeding tube placement problems and to examine possible solutions. RECENT FINDINGS:Multiple case reports of complications of malpositioned feeding tubes continue to surface; most are due to inadvertent placement in the respiratory tract. A tube with feeding ports in the esophagus significantly increases risk for aspiration, as does the displacement of a small bowel tube into the stomach of a patient with significantly slowed gastric motility. Isolated reports of a nasally placed tube entering the brain following head injury continue to occur, as do reports of esophageal and gastric perforation in neonates. A recent study showed that malpositioned tubes are not routinely recorded in risk management databases; it further demonstrated that a comprehensive intervention to reduce complications from small-bore nasogastric feeding tubes was effective. SUMMARY:Complications related to malpositioned feeding tubes are usually preventable. Poor reporting of feeding tube placement errors hinders the adoption of effective protocols to prevent such errors.
10.1097/MOG.0b013e3280287a0f
[Artificial nutrition in severe acute pancreatitis: an evolving concept].
Mangiante Gerardo,Zugni Chiara,Chimetto Andrea,Rossi Michele,Campagnaro Tommaso,Biasiutti Carlo
Chirurgia italiana
We reviewed our series of consecutive cases of severe pancreatitis observed from 2002 to 2004, in order to verify how our actual therapeutic strategy improved prognosis. Seventeen patients with diagnosis of severe pancreatitis (SP) were admitted. On presumption of SP we inserted a naso-jejunal self-propelling feeding tube (SPT) in all but one patients, and an early enteral nutrition ( EEN ) was started. Severity of pancreatitis has been scored by APACHE II (> 8), IMRIE (> or = 3), and Balthazar Computed Tomography findings (> 30% necrosis). We always used a polymeric diet added with glutamine and fibres at initial rate of 20-30 ml/h until achievement of a full regimen of EEN, based on Harris-Benedict formula but no more than 30 kcal/kg/day. Only one patient has been submitted to surgical removal of infected necrosis. A patient died (5.8%) by dis-metabolic and septic state. From our experience we can state EEN is safe and useful to determine a favourable outcome on this dismal pathology, preserving the patient from infection, without significative alterations of nutritional index.
Nutrition and quality of life following small intestinal transplantation.
O'Keefe Stephen J D,Emerling Maureen,Koritsky Darlene,Martin Dolly,Stamos June,Kandil Hossam,Matarese Laura,Bond Geoffrey,Abu-Elmagd Kareem
The American journal of gastroenterology
BACKGROUND:The outcome from small bowel transplantation (SBTx) has improved progressively over the past decade raising questions as to whether indications should be broadened from those currently followed based on "TPN (total parenteral nutrition) failure." OBJECTIVE AND METHODS:To assess current outcome, we studied the effect of transplantation on nutritional autonomy, organ function, and quality of life (QoL) measured by a validated self-administered questionnaire containing 26 domains and 130 questions, for a minimum of 12 months in a cohort of 46 consecutively transplanted patients between June 2003 and July 2004. The majority of transplanted patients (76%) had intestinal failure because of extreme short bowel, the remainder having either chronic pseudo-obstruction or porto-mesenteric vein thrombosis (PMVT). All but the PMVT patients were dependent on home TPN (HPN) (median 2, range 0-25 yr) and had developed serious recurrent infective complications with (25%) or without central vein thrombosis and liver failure. Sixty-one percent received a liver in addition to a small intestine. RESULTS:Follow-up was for a mean of 21 (range 12-36) months. Five patients died, two with chronic graft rejection. All the remaining patients have graft survival with an average of 1.2 (range 0-5) episodes of acute rejection. All patients were weaned from TPN by a median of 18 days (range 1-117 days) and from tube feeding by day 69 (range 22-272 days). There was a significant improvement in overall assessment of QoL and in 13 of 26 of the specific domains examined. CONCLUSION:Our results confirm the claim that a new era has dawned for SBTx, such that, with continued progress, it can potentially become an alternative to HPN for the management of permanent intestinal failure, rather than a last-chance treatment for "TPN failure."
10.1111/j.1572-0241.2007.01125.x
Risk factors of pancreatic fistula and delayed gastric emptying after pancreaticoduodenectomy with pancreaticogastrostomy.
Lermite Emilie,Pessaux Patrick,Brehant Olivier,Teyssedou Carlos,Pelletier Isabelle,Etienne Sandrine,Arnaud Jean-Pierre
Journal of the American College of Surgeons
BACKGROUND:Pancreatic fistula (PF) and delayed gastric emptying (DGE) are, respectively, the most frightening and most frequent complications after pancreaticoduodenectomy (PD). This study was undertaken to determine which independent factors influence the development of PF and DGE after PD. STUDY DESIGN:Between January 1996 and December 2005, 131 consecutive patients underwent a PD with pancreaticogastrostomy. A total of 22 items, entered prospectively, were examined with univariate and multivariate analysis. PF was defined as amylase-rich fluid collected by needle aspiration from an intraabdominal collection or from the drainage placed intraoperatively from day 3. DGE was defined as the need for nasogastric decompression beyond the 10(th) postoperative day. RESULTS:PF occurred in 14 patients (10.7%), with a mean length of hospital stay of 40.1+/-16.6 days. DGE occurred in 41 patients (31.3%), with a mean length of hospital stay of 35.5+/-13.6 days. PF and DGE increased postoperative length of stay. Multivariate analysis identified two independent factors for PF: heart disease as a risk factor and arterial hypertension as a protective factor. According to these two predictive factors, the observed rates of PF ranged from 4.1% to 66.6%. Age and early enteral feeding with nasojejunal tube were independent risk factors for DGE. DGE was statistically more frequent when surgical complications occurred or when an intraabdominal collection was present. CONCLUSIONS:Heart disease was a risk factor and arterial hypertension was a protective factor of PF. Age and early enteral feeding were independent risk factors for DGE. DGE is linked to the occurrence of other postoperative intraabdominal complications.
10.1016/j.jamcollsurg.2007.01.018
Use of small-bore feeding tubes: successes and failures.
de Aguilar-Nascimento José Eduardo,Kudsk Kenneth A
Current opinion in clinical nutrition and metabolic care
PURPOSE OF REVIEW:Early enteral nutrition is the preferred option for feeding patients who cannot meet their nutrient requirements orally. This article reviews complications associated with small-bore feeding tube insertion and potential methods to promote safe gastric or postpyloric placement. We review the available bedside methods to check the position of the feeding tube and identify inadvertent misplacements. RECENT FINDINGS:Airway misplacement rates of small feeding tubes are considerable. Bedside methods (auscultation, pH, aspirate appearance, air bubbling, external length of the tube, etc.) to confirm the position of a newly inserted small-bore feeding tube have limited scientific basis. Radiographic confirmation therefore continues to be the most accurate method to ascertain tube position. Fluoroscopic and endoscopic methods are reliable but costly and are not available in many hospitals. Rigid protocols to place feeding tubes along with new emerging technology such as CO2 colorimetric paper and tubes coupled with signaling devices are promising candidates to substitute for the blind placement method. SUMMARY:The risk of misplacement with blind bedside methods for small-bore feeding tube insertion requires a change in hospital protocols.
10.1097/MCO.0b013e3280d64a1d
Vacuum assisted closure system in the management of cervical anastomotic leakage after gastric pull-up.
Schintler M,Maier A,Matzi V,Smolle-Jüttner F M
Interactive cardiovascular and thoracic surgery
We propose the use of the vacuum assisted closure (VAC) system for the management of cervical anastomotic leakage after esophagectomy and reconstruction by gastric pull-up. The VAC system converts the open cervical wound into a controlled closed wound with major advantages: No need of a nasogastric tube for decompression, no need of a nasoenteric tube for feeding because of the possibility to maintain a semisolid oral diet and no need of frequent daily changes of dressings.
10.1016/S1569-9293(03)00212-3
["Fast-track" and elective, laparoscopic colo-rectal surgery].
Widmaier U,Karrer M,Schoenberg M H
Zentralblatt fur Chirurgie
UNLABELLED:The aim of this prospective clinical evaluation was to investigate the influence of "Fast-track"-treatment in patients undergoing laparoscopic colorectal operations and its effect on morbidity, hospital stay and recovery. PATIENTS AND METHODS:Bowel cleaning under enteral hypercaloric nutrition (Biosorb Energie, Fa. Nutricia, Germany) was achieved with Fleet (Ferring Arzneimittel, Germany) one day prior to surgery. A peridural catheter was placed preoperatively. Intraoperative electrolyte substitution should not exceed 12 ml/kg KG/h. In case of decreasing intraoperative blood pressure hydroxyethylstarch 6% was substituted. The nasogastric tube was removed immediately after the operation, the urinary catheter was removed on the first postoperative day. The patients stayed on the intermediate care department for one night and started already there with oral feeding and mobilisation (for 2 h). The following days mobilisation increased to 4 h daily under normal enteral nutrition without infusions. RESULTS:Between June 2003 and January 2006, 147 patients undergoing elective colorectal surgery were included in this study. Diverticulitis (n = 114), malignant tumors of the sigmoid colon (n = 6) or rectal cancer (n = 13), colonic adenomas (n = 5), stenotic Crohn's disease (n = 4) and small bowel carcinoid (n = 1), rectal prolaps (n = 1) and elongated colon sigmoideum (n = 4) were indications for surgical treatment. Laparoscopic sigmoid resection (n = 117), left hemicolectomy (n = 11), ileocecal resection (n = 8), anterior resection with total mesorectal excision (n = 9), abdomino-perineal exstirpation (n = 1) and anterior-segmental resection of the rectum (n = 1) were performed. Drainages were removed on the 2nd, peridural catheter on the 3rd postoperative day. Defecation occurred in all patients until the 2 (nd) postop. day. Early postoperative complication rate was 15% (22/147 patients) without mortality. 8 patients (5%) with anastomotic leakage were reoperated. The mean hospital stay was 6 days. The re-admission rate was 3% (4/147 patients) and included one patient with anastomotic leakage. CONCLUSION:"Fast-track"-treatment in combination with minimal-invasive surgery is a safe and comfortable perioperative treatment for patients with elective colorectal operations.
10.1055/s-2007-981204
Stepped assessment of gastric emptying of a solid meal using the (13)C-octanoic acid breath test.
Kusunoki Hiroaki,Hata Jiro,Aoki Shinya,Kamada Tomoari,Ishii Manabu,Sato Motonori,Tanaka Toshiaki,Manabe Noriaki,Shiotani Akiko,Yoshida Shigeto,Tanaka Shinji,Chayama Kazuaki,Haruma Ken
Journal of smooth muscle research = Nihon Heikatsukin Gakkai kikanshi
The (13)C-octanoic acid breath test is widely used for evaluating gastric emptying of solids. Since the results of this test are influenced by multiple factors such as the time required to grind the solid meal into smaller particles, the gastroduodenal transport time of the ground meal, and the time required for bowel drug absorption and drug dispersion, the administration of a test meal by the oral route alone cannot result in an accurate measurement of the complicated process of emptying the stomach of solids. The aim of the present study was to evaluate each phase of gastric emptying of solids by varying the administration route of the test meal. Six healthy male volunteers (mean age: 33.2 yr) participated in the study. The test meal consisted of a bowl of rice topped with a mixture of boiled chicken and eggs admixed with 100 mg of (13)C-octanoic acid (total: 273 kcal). All subjects were given the test meal by each of the following three methods: 1. Normal oral intake of the test meal, 2. Feeding of the ground test meal through a nasogastric tube, 3. Feeding of the ground test meal through a duodenal tube. For each set of examinations, the mean residence time (MRT), half-emptying time (T(1/2)), gastric emptying coefficient (GEC), lag phase (L-breath), and measured maximum (13)C excretion time (Tmax-measured) were calculated. The data was analyzed to determine the time for each phase of gastric emptying as follows: mean grinding time (MGT) = MRT(oral) - MRT(nasogastric), mean gastroduodenal transport time (MGDTT) = MRT(nasogastric) - MRT (nasoduodenal). Data was expressed as the mean +/- SE. The values of the parameters of MGT were 0.82 +/- 0.50 hr (MRT), 0.64 +/- 0.18 hr (T(1/2)), 0.51 +/- 0.24 hr (L-breath), -0.45 +/- 0.30 hr (GEC), and 49.2 +/- 8.0 min (Tmax-measured). The values of the parameters of MGDTT were 0.87 +/- 0.38 hr (MRT), 0.26 +/- 0.29 hr (T(1/2)), 0.92 +/- 0.36 hr (L-breath), 0.55 +/- 0.23 hr (GEC), and 63.33 +/- 8.16 min (Tmax-measured). The times required for the drug absorption and disposition were 1.60 0.20 hr (MRT), 1.03 +/- 0.24 hr (T(1/2)), 0.10 +/- 0.08 hr (L-breath), 3.72 +/- 0.46 hr (GEC), and 19.67 +/- 2.11 min (Tmax-measured). By varying the administration route of a test meal containing (13)C-octanoic acid, we may be able to assess each phase of the emptying of gastric solids in detail, thus leading to a better understanding of gastroduodenal motility.
10.1540/jsmr.43.99
Development and evaluation of standardized protocol to prevent nasoenteral tube obstruction in cardiac patients requiring enteral nutrition with restricted fluid volumes.
Matsuba Claudia St,De Gutiérrez Maria Gr,Whitaker Iveth Y
Journal of clinical nursing
AIMS AND OBJECTIVES:This study sought to assess the impact of a standardized protocol to maintain nasoenteral tube (NET) patency in patients requiring fluid restriction and identify factors associated with tube patency. BACKGROUND:Nasoenteral tube obstruction may interrupt nutritional support and prohibit drug administration. Balancing NET patency in the context of fluid restriction can be a challenge. DESIGN AND METHODS:The impact of the standardized protocol was assessed by using a quasi-experimental design and an historical control. RESULTS:Sixty patients receiving nasoenteral feeding as part of their clinical management were enrolled in the study. Nasoenteral obstruction was 8.3%, showing a reduction from the 17.4% observed in the baseline data collection. A key factor associated with tube obstruction was sounding of an infusion pump alarm reflecting the tube patency issues. CONCLUSIONS:While mindful of the limitations of probability sampling, the implementation of a standardized protocol accompanied by staff training reduced the rates of NET obstruction. RELEVANCE TO CLINICAL PRACTICE:On the basis of these findings, we conclude that it is possible to maintain the patency of small bore tubes, even in the presence of fluid restriction, with a standardized protocol to guide clinical management.
10.1111/j.1365-2702.2007.01793.x
Successful tubes treatment of esophageal fistula.
Zhou Ning,Chen Wei-xing,Li You-ming,Xiang Zhun,Gao Ping,Fang Ying
Journal of Zhejiang University. Science. B
AIM:To discuss the merits of "tubes treatment" for esophageal fistula (EF). METHODS:A 66-year-old female who suffered from a bronchoesophageal and esophagothoratic fistula underwent a successful "three tubes treatment" (close chest drainage, negative pressure suction at the leak, and nasojejunal feeding tube), combination of antibiotics, antacid drugs and nutritional support. Another 55-year-old male patient developed an esophagopleural fistula (EPF) after esophageal carcinoma operation. He too was treated conservatively with the three tubes strategy as mentioned above towards a favorable outcome. RESULTS:The two patients recovered with the tubes treatment, felt well and became able to eat and drink, presenting no complaint. CONCLUSION:Tubes treatment is an effective basic way for EF. It may be an alternative treatment option.
10.1631/jzus.2007.B0709
Exocrine pancreas disfunction in severely traumatised patients and early enteral nutrition.
Senkal Metin,Ceylan Bülent,Deska Thomas,Marpe Barbara,Geier Bruno
Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery : TJTES
BACKGROUND:We investigated exocrine pancreatic insufficiency in severely traumatised patients with enteral nutrition using the fecal elastase-1 concentration. METHODS:The fecal elastase-1 levels of critically ill patients after major trauma (n=18) were determined in a prospective study. Early enteral nutrition was started with a high molecular diet via a naso-duodenal tube, starting 24-36 hours after admission to the intensive care unit. Enteral feeding was administered continuously starting with 20 mL/h (1 kcal/mL) and advanced gradually to 80 mL/h in the next days. Stool samples from the first and second stool after beginning of the enteral nutrition were taken for determination of the fecal elastase-1. For elastase-1 analysis in a sandwich-type enzyme immunoassay (ELISA), a sample of approximately 1 g stool was taken from the first and second stool after beginning of the enteral nutrition. Elastase-1 concentration of >200 microg/g was considered as normal, whereas <100 microg/g elastase-1 was significantly low indicating a severe exocrine pancreas dysfunction. RESULTS:All patients were fed enterally without relevant feeding-associated complications and no diarrhoea occurred in any patient. In the initial stool passage, 55.6% of the patients had moderately or severely decreased elastase-1 concentrations. In the second stool passage, only 38.9% of the patients showed a decrease in the elastase-1 concentration (p<0.01). The average elastase-concentration in the first stool sample was 268.4 microg/g (median: 162.1 microg/g) and in the second sample 333.8 microg/g (median: 520.2 microg/g). CONCLUSION:The data of this study suggests that initial exocrine pancreas insufficiency may occur in severely traumatised and critically ill patients, which improves under early enteral nutrition with polymeric enteral diets. The clinical consequences of exocrine pancreatic dysfunction in the early posttraumatic situation have to be defined.
A critical appraisal of indications for endoscopic placement of nasojejunal feeding tubes.
Bouman G,van Achterberg T,Wanten G
The Netherlands journal of medicine
BACKGROUND:Postpyloric feeding is indicated whenever nutritional intake is compromised because of impaired gastric emptying. Although guidelines concerning this feeding modality are available it remains unclear whether these are applied in clinical practice. We therefore evaluated the indications provided by applicants for endoscopic placement of nasojejunal feeding tubes at our centre. METHODS:A prospective study was conducted in patients who were referred for endoscopic nasojejunal-feeding tube placement in a 950-bed Dutch university hospital. State-of-the-art criteria for nasojejunal tube placement comprised severe gastro-oesophageal reflux, gastroparesis leading to aspiration, gastric stasis not responding to prokinetics, gastroduodenal obstruction or proximal enteric fistulae. The study endpoint was met if the feeding tube was no longer needed or had to be replaced, or if the patient was discharged from the hospital or died. RESULTS:During a four-month observation period, 131 patients were enrolled, of whom 57% came from intensive care units. Tube placement only met at least one of the mentioned criteria in the hospital protocol in 59% of all cases, while in intensive care patients a lower proportion was observed (50%, p. <0.05). In the latter group, in 35% of all cases no increased gastric residues had been measured at all. CONCLUSION:Although directives are at hand that provide clear indications for endoscopic placement of nasojejunal feeding tubes, our data show that these guidelines are frequently not followed in clinical practice. These findings suggest that supervised implementation of established guidelines might reduce the strain on both patients and the hospital's resources.
Lessons learned: optimization of a murine small bowel resection model.
Taylor Janice A,Martin Colin A,Nair Rajalakshmi,Guo Jun,Erwin Christopher R,Warner Brad W
Journal of pediatric surgery
PURPOSE:Central to the use of murine models of disease is the ability to derive reproducible data. The purpose of this study was to determine factors contributing to variability in our murine model of small bowel resection (SBR). METHODS:Male C57Bl/6 mice were randomized to sham or 50% SBR. The effect of housing type (pathogen-free vs standard housing), nutrition (reconstituted powder vs tube feeding formulation), and correlates of intestinal morphology with gene expression changes were investigated. Multiple linear regression modeling or 1-way analysis of variance was used for data analysis. RESULTS:Pathogen-free mice had significantly shorter ileal villi at baseline and demonstrated greater villus growth after SBR compared to mice housed in standard rooms. Food type did not affect adaptation. Gene expression changes were more consistent and significant in isolated crypt cells that demonstrated adaptive growth when compared with crypts that did not deepen after SBR. CONCLUSION:Maintenance of mice in pathogen-free conditions and restricting gene expression analysis to individual animals exhibiting morphologic adaptation enhances sensitivity and specificity of data derived from this model. These refinements will minimize experimental variability and lead to improved understanding of the complex process of intestinal adaptation.
10.1016/j.jpedsurg.2008.02.025
[Red peony root decoction in treatment of severe acute pancreatitis: a randomized controlled trial].
Zhang Min,Zhu De-zeng,Li Zhao-shen,Zhan Xian-bao
Zhong xi yi jie he xue bao = Journal of Chinese integrative medicine
OBJECTIVE:To compare the therapeutic effects of red peony root decoction, a compound traditional Chinese herbal medicine, and rhubarb in treating severe acute pancreatitis (SAP). METHODS:A total of 96 consecutive patients with objectively-graded SAP were randomly divided into treatment and control groups. There were 48 cases in each group. The patients in the treatment and control groups were assigned to receive red peony root decoction and rhubarb treatment 1-2 times a day via a gastric tube respectively. Comparisons in the time needed for the disappearance of abdominal tenderness, fever and abdominal distension were made between the two groups. The total days of using antibiotics, enzyme inhibitor, protease inhibitor, and nasojejunal feeding start, nasojejunal feeding, gastrointestinal decompression, fasting diet were also compared. And comparison also included hospital stays and hospitalization costs. RESULTS:The durations of abdominal tenderness, fever and abdominal distension in the treatment group were less than those in the control group (P<0.05). Compared with the control group, the time length for antibiotics (including anti-bacteria drug and antifungal agent) use, nasojejunal feeding start, nasojejunal feeding, gastrointestinal decompression, fasting diet, hospital stays and hospitalization costs were decreased in the treatment group (P<0.05). There were no significant differences between the two groups in enzyme inhibitor and protease inhibitor requirement, mortality and adverse reactions. CONCLUSION:Red peony root decoction is more effective than rhubarb alone for SAP patients.
10.3736/jcim20080605
Temporary abdominal closure techniques: a prospective randomized trial comparing polyglactin 910 mesh and vacuum-assisted closure.
Bee Tiffany K,Croce Martin A,Magnotti Louis J,Zarzaur Ben L,Maish George O,Minard Gayle,Schroeppel Thomas J,Fabian Timothy C
The Journal of trauma
OBJECTIVE:The options for abdominal coverage after damage control laparotomy or abdominal compartment syndrome vary by institution, surgeon preference, and type of patient. Some advocate polyglactin mesh (MESH), while others favor vacuum-assisted closure (VAC). We performed a single institution prospective randomized trial comparing morbidity and mortality differences between MESH and VAC. METHODS:Patients expected to survive and requiring open abdomen management were prospectively randomized to either MESH or VAC. After randomization, an enteral feeding tube was inserted and the closure device placed. VAC patients returned to the operating room every 3 days for a total of three changes at which time polyglactin mesh was placed if closure was not possible. The MESH group had twice daily assessments for the possibility of bedside mesh cinching and closure. Both groups underwent split thickness skin grafting when granulation tissue was evident, if delayed primary closure was not possible. RESULTS:Fifty-one patients were randomized. Both cohorts were matched for Injury Severity Scale score, gender, blunt/penetrating/abdominal compartment syndrome and age. Three patients died within 7 days and were excluded from closure rate calculation. There were no differences between delayed primary fascial closure rates in the VAC (31%) or MESH (26%) groups. The fistula rate in the VAC group was 21% but not statistically different from the 5% rate for MESH. Intraabdominal rates were not statistically different. All VAC fistulas were related to feeding tubes and suture line areas; the MESH fistula followed a retroperitoneal colon leak remote from the mesh. CONCLUSIONS:MESH and VAC are both useful methods for abdominal coverage, and are equally likely to produce delayed primary closure. The fistula rate for VAC is most likely due to continued bowel manipulation with VAC changes with a feeding tube in place-enteral feeds should be administered via nasojejunal tube. Neither method precludes secondary abdominal wall reconstruction.
10.1097/TA.0b013e31817fa451
Reversal of parenteral nutrition-induced gut mucosal immunity impairment with small amounts of a complex enteral diet.
Ikezawa Fumie,Fukatsu Kazuhiko,Moriya Tomoyuki,Ueno Chikara,Maeshima Yoshinori,Okamoto Koichi,Hara Etsuko,Saitoh Daizoh
The Journal of trauma
BACKGROUND:Although parenteral nutrition (PN) prevents progressive malnutrition, lack of enteral nutrition (EN) during PN leads to gut associated lymphoid tissue (GALT) atrophy and dysfunction. Administering a small amount of EN with PN reportedly prevents increases in intestinal permeability. However, its effects on GALT remain unclear. We analyzed the minimum amount of EN required to preserve gut immunity during PN. METHODS:Male Institute of Cancer Research mice underwent jugular vein catheter insertion and tube gastrostomy. They were randomized into four groups to receive isocaloric and isonitrogenous nutritional support with variable EN to PN ratios (EN 0, EN 33, EN 66, and EN 100). EN was provided with a complex enteral diet. After 5 days of feeding, the mice were killed and whole small intestines were harvested. GALT lymphocytes were isolated and counted. Their phenotypes were analyzed by flow cytometry. IgA levels of small intestinal washings were analyzed with enzyme-linked immunosorbent assay. RESULTS:Body weight changes did not differ between any two of the groups. Peyer's patch lymphocyte numbers increased in proportion to EN amount, whereas lamina propria lymphocyte numbers were significantly higher in the EN 100 than in the EN 0 group, with no marked increases in the EN 33 and EN 66 groups. Small intestinal IgA levels increased EN amount-dependently and reached a plateau at EN 66. CONCLUSIONS:A small amount of EN partially reverses PN-induced GALT changes, suggesting beneficial but limited effects on gut mucosal immunity.
10.1097/TA.0b013e31817c9711
Effect of intestinal pacing on small bowel transit and nutrient absorption in healthy volunteers.
Liu Jinsong,Qiao Xian,Hou Xiaohua,Chen J D Z
Obesity surgery
BACKGROUND:Intestinal pacing (IP) has been previously shown to delay gastric emptying and reduce food intake in animals. The aims of this study were to investigate the effect and mechanism of IP on nutrient absorption in healthy volunteers. METHODS:Twelve healthy volunteers (six men, six women) were involved in a two-session (one session without IP and one with IP) study. At the beginning of each session, a nasal-duodenal feeding tube, with two ring electrodes (used for IP) on the tip of the tube, was incubated into the duodenum under endoscopy. After a complete recovery from the incubation, the duodenum was infused via the feeding tube with 150 ml 30% intralipid + 25 g D-xylose within 30 min, and the stool was collected for 24 h for the analysis of fecal lipid during which a controlled meal was taken. Then 100 ml 1mCi(99)Tc-labeled non-absorbable solution was infused within 3 min. The subject was asked to lie under a gamma camera for at least 1 h for the measurement of small bowel transit. The movement of isotopes was monitored by gamma camera at an interval of 10 s. The first appearance of isotopes in the cecum was considered as small intestinal transit time. The order of the two sessions was randomized and 1 week apart. In the IP session, intestinal pacing was performed via the pair of the ring electrodes for 2 h initiated at the beginning of infusion with a pacing frequency of 13 pulses/min, pulse width of 300 ms and amplitude of 5 mA. RESULTS:(1) IP significantly reduced lipid and D-xylose absorption. The fecal lipid was 6.6 +/- 4.6 g without IP and almost doubled with IP (11.1 +/- 6.5 g, P = 0.047). Similarly, the D-xylose in urine was 3.46 +/- 2.22 g with IP, which was significantly lower than that without IP (6.63 +/- 5.06 g, p = 0.049). (2) IP accelerated intestinal transit. The transit time was 39 +/- 17 min in the control session and reduced to 28 +/- 10 min in the IP session (p < 0.03). (3) Diarrhea was reported in one subject without IP but in six subjects with IP (p < 0.05). CONCLUSIONS:The increased fecal lipid and induction of diarrhea with intestinal pacing suggest that intestinal pacing is capable of inducing malabsorption. This effect maybe contributed to the acceleration of intestinal transit.
10.1007/s11695-008-9533-8
Use of three lumen catheter facilitates bowel movement after pancreato-duodenectomy.
Hallay Judit,Micskei Cs,Fülesdi B,Kovács G,Szentkereszty Zs,Takács I,Sipka S,Bodolay E,Sápy P
Hepato-gastroenterology
BACKGROUND/AIMS:The advantages of jejunal nutrition in postoperative bowel paralysis following pancreato-duodenectomy were analyzed. METHODOLOGY:Patients resected for pancreatic cancer received 25 kcal/kg/day and were followed up for 10 days postoperatively. Nasojejunal tube ensured enteral feeding in 16 patients (Gr. I), 6 patients (Gr. II) were nourished parenterally. Laboratory parameters, outcome were compared. Bowel movements were registered. Patients of Gr.1 received 25 kcal/kg parenterally. Jejunal nutriment (1.5 cal/mL) followed gradually up to 1500mL. Parenteral nutriment decreased reflecting enteral intake. Patients of Gr. II were nourished parenterally only for 8 days. Laboratory data were measured preoperatively, on the 1st, 4th, 10th days. RESULTS:The first stool appeared on the 4th day in Gr. I In Gr. II the bowel movement was delayed by 8 days. Laboratory data from the 1st, and 10th days were compared. In Gr. I serum total protein increased from 48.06 to 58.7g/L (p<0.001), serum albumin from 27.5 to 32.2g/L (p<0.02), CRP decreased from 117.8 to 74.1mg/L (p<0.035). No changes were significant in Gr. II. Length of hospitalization, weight loss did not differ between the 2 groups. CONCLUSIONS:Immediately postoperative use of a three-luminal tube ensured early enteral nutrition, improved serum total protein, albumin values and facilitated bowel movements.
Use of a nasal bridle prevents accidental nasoenteral feeding tube removal.
Gunn Scott R,Early Barbara J,Zenati Mazen S,Ochoa Juan B
JPEN. Journal of parenteral and enteral nutrition
Reinserting feeding tubes that are accidentally removed exposes patients to risk and consumes hospital resources. We were interested to know if using a bridle to secure tubes would be more effective than tape at preventing accidental tube removal. This was a quality improvement project with a before-and-after design. Between May 2007 and August 2007, we prospectively followed 90 tubes (50 tape, 40 bridle). Tubes were followed up daily until accidental tube removal, ICU discharge, or planned tube removal. Our primary endpoint was accidental tube removal. We compared the 2 groups on the following: (1) proportion of tubes accidentally removed; (2) rate of accidental tube removal (per 100 tube-days); and (3) Kaplan-Meier survival analysis. Survival analysis data were right-censored at ICU discharge or planned tube removal. There were no significant differences between groups in any demographics. The proportion of tubes accidentally removed was 36% (18 of 50) in the tape group and 10% (4 of 40) in the bridle group; P<.05. The rate of accidental tube removal (per 100 tube-days) was 6.4 (18 in 281 tube-days) in the tape group and 1.6 (4 in 248 tube-days) in the bridle group; P<.05. Survival analysis showed a significant difference between the groups with a log-rank test for equality of survivor function of P<.05. Using a bridle to secure feeding tubes significantly reduces the proportion and rate of accidental tube removal and results in increased tube survival by Kaplan-Meier analysis.
10.1177/0148607108321704
Effect of early enteral feeding after upper gastrointestinal surgery.
Vaithiswaran V,Srinivasan K,Kadambari D
Tropical gastroenterology : official journal of the Digestive Diseases Foundation
BACKGROUND AND AIMS:The impact of early enteral nutrition in elective upper gastrointestinal surgery was the focus of this study, with particular reference to its feasibility and benefits. METHOD:This prospective study was carried out over 2 years. The study group included 30 patients and the control group had 31patients. Twenty-two patients in each group underwent truncal vagotomy and gastrojejunostomy for chronic duodenal ulcer and gastric outlet obstruction. Eight patients in the study group and nine in the control group underwent gastrectomy for carcinoma stomach. A standard milk-based diet was initiated 12 hours after surgery through a nasojejunal tube. The patients were monitored for side effects of enteral feeding and postoperative infective complications. Nitrogen balance and nutritional parameters like the body weight, serum albumin, and serum transferrin were measured pre and postoperatively. RESULTS:The groups were comparable with respect to age, sex, and preoperative nutritional factors like body weight, serum albumin, and serum transferrin. The return of bowel sounds and passage of flatus took place significantly earlier in the study group (1.43 vs. 2.81 days). Diarrhoea and abdominal cramps were the significant complications noted in the study group in relation to early enteral feeding. No patient required withdrawal of enteral feeds. They showed a positive nitrogen balance on the fourth postoperative day. The patients in the study group showed significant increase in the serum transferrin level compared with the preoperative level but the serum albumin level was not significantly altered. CONCLUSION:Early enteral feeding through the nasojejunal tube following elective upper gastrointestinal surgery is feasible, safe and improves the nutritional status.