Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery.
da Silva JSV, et al. ASPEN Consensus Recommendations for Refeeding Syndrome. Nutr Clin Pract. 2020 Apr;35(2):178-195.
Madsen H, Frankel EH. The hitchhiker’s guide to parenteral nutrition management for adult patients. Practical Gastroenterology. 2006 Jul;30(7):46.
Summary: This was discussed as a possible question on boards. Below are three tables, taken directly from the article referenced.
Taghavi S, et al. Comparison of open gastrostomy tube to percutaneous endoscopic gastrostomy tube in lung transplant patients. Ann Med Surg (Lond). 2015 Dec 23;5 :76-80.
Introduction: Lung transplant patients require a high degree of immunosuppression, which can impair wound healing when surgical procedures are required. We hypothesized that because of impaired healing, lung transplant patients requiring gastrostomy tubes would have better outcomes with open gastrostomy tube (OGT) as compared to percutaneous endoscopic gastrostomy tube (PEG).
Continue readingPatel JJ, et al. Phase 3 Pilot Randomized Controlled Trial Comparing Early Trophic Enteral Nutrition With “No Enteral Nutrition” in Mechanically Ventilated Patients With Septic Shock. JPEN J Parenter Enteral Nutr. 2020 Jul;44(5):866-873.
Full-text for Emory users.
Results: One hundred thirty-one patients were eligible for enrollment, and 49 were available for consent. Thirty-one (86%) consented and were randomized and 100% of patients in the early EN arm and 94% in the “no EN” arm completed their protocols. While on vasopressors, early EN group received median 384 kcal, and the “no EN” group received median 0 kcal. Contamination rate was 0 in the early trophic EN arm and 6% in the “no EN” arm. The early EN group had median 25 intensive care unit-free days, as compared with 12 in the “no EN” arm (P = .014). The early EN arm had median 27 ventilator-free days, compared with 14 in “no EN” arm (P = .009).
Conclusion: Our protocol comparing early trophic EN with “no EN” in septic shock was feasible. Early trophic EN may be beneficial, but a larger multicenter trial is warranted to confirm the observed clinical benefits seen in this trial.
Froghi F, et al. A randomised trial of post-discharge enteral feeding following surgical resection of an upper gastrointestinal malignancy. Clin Nutr. 2017 Dec;36(6):1516-1519.
Full-text for Emory users.
RESULTS: 44 patients (M:F, 29:15) were randomised, 23 received jejunal supplements. There were no differences between the groups. Percentage of calculated energy requirement received was greater in the supplemented group at weeks 3 and 6 (p < 0.0001). Oral energy intake was not different between the groups at any time period. After hospital discharge, there were no differences in MFI-20, EQ5D and QLQ-OES18 scores at any time point. From hospital discharge fatigue improved and plateaued at 6 weeks (p < 0.05 for both groups), independence at 12 weeks (p < 0.05 for both groups). No improvement was seen in quality of life until 24 weeks in the active group alone (p < 0.02) and not at all in the control group.
CONCLUSIONS: Addition of jejunal feeding is effective in providing patients with an adequate energy intake. Increased energy intake however, produced no obvious improvement in measures of fatigue, quality of life or health economics.
Kumpf VJ, et al. ASPEN-FELANPE Clinical Guidelines: Nutrition Support of Adult Patients With Enterocutaneous Fistula.JPEN J Parenter Enteral Nutr. 2017 Jan;41(1):104-112. doi: 10.1177/0148607116680792.
Questions addressed in these guidelines:
In adult patients with enterocutaneous fistula: (1) What factors best describe nutrition status? (2) What is the preferred route of nutrition therapy (oral diet, enteral nutrition, or parenteral nutrition)? (3) What protein and energy intake provide best clinical outcomes? (4) Is fistuloclysis associated with better outcomes than standard care? (5) Are immune-enhancing formulas associated with better outcomes than standard formulas?(6) Does the use of somatostatin or somatostatin analogue provide better outcomes than standard medical therapy? (7) When is home parenteral nutrition support indicated?
Surgical Focus 