University of Virginia Health System
Nutrition Support E-Journal Club
We had a great Weekend Warrior program on 5/31 - 6/1 with participants from across the country, and a wonderful traineeship session June 2nd to 6th with trainees from New Mexico, Missouri, Michigan and Vancouver Canada. Interacting with the participants of these programs, who share our passion for nutrition support and continued learning is always a joy, and makes us optimistic about where our field is headed.
Our journal article for June deals with the feasibility of early oral intake after GI surgery.
June Citation 1:
Lassen K, Kjaeve J, Fetveit T, et al. Allowing normal food at will after major upper gastrointestinal surgery does not increase morbidity: a randomized multicenter trial. Ann Surg 2008;247(5):721-9.
This study was a randomized, multicenter (5 facilities), unblinded study that compared early oral intake with enteral tube feeding via needle-catheter jejunostomy after major GI surgery.
Patients were either allowed to take "ordinary hospital food" as desired from POD#1 (n = 227), or a needle catheter jejunostomy was inserted in surgery (n = 220) and they received isotonic saline infusion until POD#1 and then a 1 cal/mL polymeric formula at 20 mL/hr and advancing by 20mL/hr increments each day to goal of 80mL/hr.
The primary outcomes measured were major complications or death during the hospital stay up to 8 weeks. The secondary endpoints measured were length of stay after surgery, minor complications, gut-recovery indicators (time to bowel movement, need for NG suction), and indicators of inadequate nutrition (weight loss, need for parenteral nutrition). All hospitals in the trial utilized a multimodal post-op care regimen that included N-G removal at the end of surgery, thoracic epidural analgesia, avoidance of parenteral opioids, and early mobilization of the patient.
Inclusion and Exclusion Criteria were:
The inclusion criteria were adult patients that could give written informed consent and required either scheduled or emergency major surgery of the upper GI tract, including hepatic, pancreatic, esophageal, gastric, biliary or small bowel procedures.
Exclusion criteria were severe extra-abdominal disease or trauma, life expectancy less than 3 months, and short bowel or other overt need for parenteral nutrition.
Major Results reported by authors:
There were no significant differences between the two groups in the primary outcomes of death or major complications. Major complications were not significant: 76/227 patients in the early tube feed group (ETF) and 62/220 patients in the normal food ad lib group (33.5% vs 28.2% respectively, p= 0.46). Thirty-day mortality also did not reach significance at 4.4% in the ETF group and 5.0% in the early food at will (p= 0.36).
A subgroup analysis of the 19 different operations revealed significantly more intra-abdominal abscess in the ETF group compared to the normal food group (15.8% versus 0%, respectively, p= 0.012).
The rates of minor complications and adverse events were not significantly different between the groups, and there were no significant differences in the need for parenteral nutrition or nasogastric suction.
Average time to flatus was significantly longer in the ETF group compared to the normal food group (3.0 days vs 2.6 days, respectively p = 0.01). This difference remained significant when adjusted for factors such as age, gender, emergency or high-risk procedures and facility (p = 0.03). The length of stay was longer in the ETF group (16.7 days) compared to the normal food group (13.5 days) (p = 0.046).
Results at the 8-week follow-up demonstrated that significantly more of the ETF group discharged alive were found to have suffered a late complication (40/211 patients in the ETF (19.0%) compared with 24/209 (11.4%) in the normal food group (11.5%) P = 0.04). There were also significantly more wound infections in the ETF group, 17/211 (8%) vs 5/209 (2.4%) patients in the normal food group (p = 0.01). The patients in the ETF group had a higher postoperative weight loss (mean 5.2 kg reduction in 144 patients) than those in the group allowed normal food ad lib (mean 4.0 kg reduction in 152 patients, p = 0.06). One of the patients in the ETF group developed a fistula at the site of the catheter insertion.
"Allowing patients to eat normal food at will from the first day after major upper GI surgery does not increase morbidity compared with traditional care with nil-by-mouth and enteral feeding."
This was a well designed study, with random assignment, multiple centers, and adequate size. There is, of course, no way to hide the treatment group allocation (blinding) from the caregiver or patient in a study of this nature.
One point that we noted was that the incidence of nausea/emesis, and the need for anti-emetic medication was not directly reported. The requirement for N-G suction and time to first bowel movement served as indicators of gut recovery, but it would be valuable to know if early food increased requirement for anti-emetic medication.
Several factors of the study differed from our practice, including the use of needle-catheter jejunostomies. Our current surgical jejunostomy (14 Fr) results in less clogging and complications than occurred when we utilized needle-catheter jejunostomies.
Additionally, the study protocol primarily used epidural analgesia and avoidance of systemic narcotics in the peri- and postoperative period; they also removed nasogastric suction tubes at the end of the surgical procedure. Patients that receive parenteral and/or oral narcotics for pain control may have a slower resumption of GI motility or increased nausea/emesis with oral intake.
Our Take Home message:
Oral intake as desired appears to be well tolerated in patients after major GI surgery when systemic narcotics are avoided. Routine use of needle-catheter jejunostomy feeding in the average GI surgery patient does not appear to offer net benefit, and may have net disadvantages compared to normal food ad lib. Further studies are required to determine if there are specific surgeries or patient populations (such as those with severe malnutrition on admission) that may benefit from routine jejunal (non needle catheter?) tube placement.
Check out the latest Practical Gastroenterology articles/info at:
1) O'Donnell K. Small but Mighty: Selected Micronutrient Issues in Gastric Bypass Patients. Practical Gastroenterology 2008;XXXII(5):37.
2) Lord LM, Pelletier K. Nutritional Management of Hyperemesis Gravidarum. Practical Gastroenterology 2008;XXXII(6):15.
Joe Krenitsky MS, RD
Carol Parrish RD, MS
PS - Please feel free to forward this on to friends and colleagues.