EARLY ENTERAL FEEDING VERSUS

1
EARLY ENTERAL FEEDING VERSUS NIL BY MOUTH

• Journal Club Presentation
• December 2001
• Presenter Jui Tham
• Mentor Dr G Keogh

2
BACKGROUND

• Many patients are relatively undernourished prior
  to surgery.
• Physiological response to starvation glycogen,
  proteins, fats as energy sources.
• Nutritional depletion is an independent
  determinant of serious complications post major
  GI surgery.
• Enteral nutrition versus TPN
• Is early enteral nutrition safe? If so, could it
  be clinically beneficial?

3
SEARCH

• Medline search.
• Keywords enteral nutrition and randomized
  controlled trials (limited to english and human)
• Results 8 articles (7 reviews and 1
  meta-analysis.

4
Early enteral feeding versus nil by mouth after
gastrointestinal surgery systematic review and
meta-analysis of controlled trials

• Authors SJ Lewis, M Egger, PA Sylvester, S
  Thomas.
• Objective To determine if a period of starvation
  post GI surgery is beneficial.
• Rationale of NBM post GI surgery is to prevent
  post-op NV and to protect an anastomosis.
• Post-op dysmotility predominantly affects stomach
  and colon the small bowel recovers function 4-8
  hours post-laporotomy.

5
Method of Selection

• Eligibility criteria Elective GI surgery with
  patients randomly allocated to receive either
  enteral feeding (within 24 hrs of surgery) or
  NBM/IV fluids with introduction of enteral fluids
  and diet as tolerated.
• Searches were made of PubMed, Embase and Cochrane
  databases and further unpublished data was sought
  with letters sent to pharmaceutical companies and
  authors of the trials included in the study.

6
Outcomes Analysed

• Anastomotic dehiscence
• Infection of any type
• Wound infection
• Pneumonia
• Intra-abdominal abscess
• Vomiting
• Mortality
• Length of hospital stay

7
Results

• 13 randomised controlled trials were found. 2
  were excluded as no information on relevant
  outcomes was given.
• Additional unpublished data was obtained for 6 of
  the remaining 11 studies.

8
Characteristics of the 11 trials
9
Comment on Quality of Trials

• Only 4 of the trials outlined the exact method of
  randomisation.
• Only 1 study had blinded outcome assessments.

10
(No Transcript)
11
(No Transcript)
12
Length of hospital stay

• Reported in all 11 studies.
• Mean length of stay 6.2 to 14.0 days in early
  feeding groups and 6.8 to 19.0 days in control
  groups.
• Significant reduction by 0.84 day (P0.001).

13
Summary of Authors Findings

• No clear advantage in keeping pts NBM after
  elective GI surgery.
• Early enteral feeding may be beneficial
  (decreased risk of infection of any type and
  length of hospital stay).
• Suggested an adequately powered clinical trial.

14
A Prospective, Randomized Trial of Early Enteral
Feeding After Resection of Upper Gastrointestinal
Malignancy MJ Heslin, et al. Annals of Surgery
226 4 567-80. 1997.

• 195 patients undergoing resection of neoplasms of
  the oesophagus, stomach, pancreas and distal bile
  duct were randomised to receive either
  intravenous crystalloid post-op (control) or
  enteral feeding via jejunostomy tube.
• Feed consisted of supplemented Impact (boosted
  with arginine, RNA, omega-3 fatty acids, vitamins
  and minerals).
• Feed commenced within 24 hours of operation.
• Advanced to 25kcal/kg/day.

15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
Early Feeding After Elective Open Colorectal
Resections A Prospective Randomized Trial. BT
Stewart et al. ANZ J Surg. 1998. 68 125-8.

• 80 patients who underwent elective colorectal
  resection with anastomosis and without stoma
  formation.
• Randomised to early feeding group (free fluids
  from 4 hrs post-op to solid diet day one post-op)
  or control group (NBM until passage of flatus or
  bowel motion).

22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
Strengths and Weaknesses

• Heterogeneity of studies.
• Doubtful methodological qualities of many of the
  studies.
• Incomplete outcomes for many of the studies.
• Acknowledgement of limitations of analysis and
  need for further adequately powered trials.