Assessing the effectiveness of feeding the gut early after stomach surgery

Nội dung text: Assessing the effectiveness of feeding the gut early after stomach surgery

1. Journal of military pharmaco-medicine n08-2017 ASSESSING THE EFFECTIVENESS OF FEEDING THE GUT EARLY AFTER STOMACH SURGERY Truong Thi Thu*; Nguyen Thanh Cho** Hoang Manh An**; Dang Viet Dung** SUMMARY Objectives: To assess the safety and effectiveness of early enteral feeding after gastrostomy to the clinical, blood pre-albumin index. Subjects and methods: An interventional, control and comparative study on 115 patients who were indicated gastrostomy from May 2011 to November 2013 at Abdominal Surgery Department, 103 Military Hospital. The patients were divided into 2 groups: 58 patients in early enteral nutrition group (EEN) were started with Ensure formula within 24 - 48 hours after surgery, 57 patients in control group (late enteral nutrition: LEN) were fed as routine regimen of the hospital. Results: 112 patients participated in the study, 3 patients stopped the treatment. There were significant differences both EEN groups and LEN ones (p < 0.05): the first enteral intake (27.2 ± 6.2 hours versus 124.6 ± 52.7 hours, time of the first bowel movement (54.6 ± 11.8 versus 82.1 ± 29 hours), time to sit up after surgery (1.53 ± 0.9 versus 3.5 ± 1.2 days), length of hospital stay after surgery (7.8 ± 1.9 days versus 9.6 ± 6.4 days), postoperative complications (1.8% versus 17.6%) and the level of pre-albumin after hospital discharge (0.28 ± 0.32 versus 0.14 ± 0.05) were recorded. Absorption capacity after surgery (nausea, diarrhea, bloating) were equivalent in 2 groups, p > 0.05. Conclusion: The results showed that early enteral feeding after stomach surgery was safe and feasible. It helped patients recover sooner, reduce complications and the number of days in the hospital as well as improve pre-albumin index. * Keywords: Early enteral feeding; Stomach surgery. INTRODUCTION therapy, which helps the patient recover For many decades, a “nil-by-mouth” quickly after the gastric surgery. Early policy has been commonly applied as a enteral nutrition (EEN) can improve the surgical dogma after gastrointestinal body nutrition and the mesenteric blood procedures. The long-held belief that flow, maintain the mesentery permeability, nutritional interventions should be done until repair and maintain the structure and bowel function recovery [3, 4]. The intestinal function of gastrointestinal tracts [5]. In postoperative feeding in patients with Vietnam, there have been some early gastrointestinal surgery was safe and patients feeding studies in patients with liver were well-tolerated even when started within surgery, pancreatitis and severe burns. 12 hours after surgery, which that benefits However, up to now, there has been no the patient [3]. It has been an important issue study mentioning early feeding problems for clinicians to choose a proper nutrition in patients after gastric bypass surgery. ơ ** Haiduong Medical Technical University * 103 Military Hospital Corresponding author: Truong Thi Thu (truongthu16hd@gmail.com) Date received: 29/08/2017 Date accepted: 28/09/2017 244
2. Journal of military pharmaco-medicine n08-2017 In order to evaluate the differences at the time of surgery and 1 day before between early enteral nutrition and late hospital discharge. enteral nutrition after the gastric cancer * Feeding method: surgery, the study was conducted: To assess the effectiveness of early - Intervention group: Early enteral enteral nutrition with improved clinical and nutrition within 12 - 48 hours after surgery pre-albumin index after gastric bypass (nourishment sutures placed deep through surgery. 15 - 20 cm intervals during surgery) using Ensure milk, nourished by 3 continuous SUBJECTS AND METHODS drops, slow speed interruptions usually 1. Subjects. 20 - 30 mL/hour or direct injection with the Patients from 18 to 65 years old, syringe at the beginning. It was increased without co-morbidities, were assigned to to 6 - 10 kcal/kg/day with the patients’ gastric bypass surgery. gradually increased tolerance. - Time and place of the study: from May, 2011 to November, 2013 at Abdominal - Control group: Carry out nutrition Surgery Department, 103 Military Hospital. regimen according to the current practice of the Department of Gastroenterology, 2. Methods. 103 Military Hospital (the patient was * Study design: Interventional, control offered internal jugular vein on the first and comparison between the pre- and post-operative day). After 4 - 5 days when post-treatment was made. the patient had first bowel movement, * Sample size: Patients were at the patients were fed under the guidance of a age from 18 to 65 between May 2011 and surgeon. It was increased to 2 - 3 kcal/kg/day November 2013. with the patients’ gradually increased * Sampling method: From the checklist tolerance. every Thursday, all eligible patients were included. The was matche with the age, - Assessing nutritional status: sex and surgical methods, then the BMI (Body Mass Index) = [weight (kg)]/ 2 subjects were randomly divided into two [high (m)] groups. Patients number 1 were put in the * Analysis on the effectiveness of intervention group; The others number 2 indexes: The first enteral intake time, were put in the control group. absorption capacity after surgery (nausea, * Method of data collection: Interview, diarrhea, bloating). Time of the first bowel examination and measurement of movement, time to sit up after surgery, anthropometric analysis according to the length of hospital stay after surgery, researches’s design, collecting general postoperative complications, the nutritive information and nutritional status, clinical index (the level of pre-albumin on the first manifestations, vital signs, absorption day before and after hospital discharge) capacity, number of days after the surgery were recorded. 245
3. Journal of military pharmaco-medicine n08-2017 * Statistics method: All data was * Research ethics: The study was analyzed by SPSS 16. software packet. approved by the Scientific Council and the The measurement data was described in Ethics Review Board in the biomedical the mean ± SD form. Comparisons research of 103 Military Hospital. The between the two groups were tested by subject is clearly stated in the purpose t-test, count data was measured by chi- and content of the study, is completely square test and p < 0.05 is considered to voluntary and can be withdrawn from the be statistically significant difference. study at any time. RESULTS One hundred and fifteen (115) patients enrolled in the study, 3 patients stopped the treatment. Therefore, there were 112 participants in the study. 1. Patient’s characteristics. Table 1: Comparison of data between the two groups (age, gender, BMI, weight loss). Characteristics Control group Intervention group p (n = 57) (n = 55) Age 53.2 ± 9,3 51.2 ± 8,4 0.187 Sex (male/female) 42/15 33/22 0.08 Weight loss in 2 months (kg) 2.1 ± 1,5 2.2 ± 1.2 0.746 Weight loss in 6 months (kg) 4.1 ± 2,7 4.3 ± 2.4 0.703 BMI 19.4 ± 2,7 18.7 ± 2,0 0.146 Age, sex ratio of male/female, weight loss in 2 months, 6 months, BMI before admission equivalent to 2 groups, the differences were not statistically significant (p > 0.05). Table 2: Comparison of data between the two groups (surgical type). Control group (n = 57) Intervention group (n = 55) p Surgical type n % n % Total gastrectomy 6 10.5 4 7.3 0.394 Partial gastrectomy 51 89.5 51 92.7 Type of surgery of 2 groups was similar, p > 0.05. Table 3: Comparison of the first enteral intake between the two groups. Control group (n = 57) Intervention group (n = 55) p Feeding time after Average Max Min Average Max Min < 0.001 surgery 124.6 ± 52.7 384 49 27.2 ± 6.2 45 16 Table 2 showed the average time to start feeding the gastrointestinal tract in the intervention group was 27.2 ± 6.2 hours, much earlier than that in the control group which was 124.6 ± 52.7 hours. The differences were statistically significant (p < 0.001). 246
4. Journal of military pharmaco-medicine n08-2017 2. Assess the effectiveness of early enteral nutrition with clinical improvement. Table 4: Clinical symptoms appear after surgery. Control group (n = 57) Intervention Group (n = 55) Symptoms p Number Percentage Number Percentage Nausea 20 35.1 26 47.3 0.190 Diarrhea 7 12.3 3 5.5 0.322 Bloating 28 49.1 30 54.5 0.161 Reflux 0 0 0 0 0.371 Gastrointestinal complications such as bloating, vomiting, nausea, reflux in the intervention group were more than those in the control group, the symptoms of diarrhea in the control group were more than those in the intervention group, there was no statistically significant difference (p > 0.05). Table 5: Comparison of flatus time, sit up, length of hospital stay after surgery. Control group Intervention group Targets p value (n = 57) (n = 55) 82.1 ± 29 54.6 ± 11.8 Flatus time (hours) (Min-max) 0.001 (40 - 230) (34 - 89) 3.5 ± 1.2 1.53 ± 0.9 Time to sit up after surgery (day) (Min-max) 0.001 (1 - 7) (1 - 6) Length of hospital stay after surgery. 9.6 ± 6.4 7.8 ± 1.9 0.04 (4 - 46) (4 - 15) Time flatus present in the intervention group was shorter than that in the control group (54.6 versus 82.1 hours) (p < 0.05), while sitting up light exercise, the tube was removed earlier as well. The duration of hospitalization for the intervention group was shorter than that of the control group (7.8 versus 9.6 days), the difference was statistically significant (p < 0.05). Table 6: Complications after surgery. Control group (n = 57) Intervention group (n = 55) Complications Number Rate Number Rate Anastomotic leakage 1 1.8 0 Duodenal leakage 2 3.5 0 Infections 2 3.5 0 Abscess 2 3.5 0 Septicemia 0 0 ICU 0 1 1.8 Operation again 2 3.5 0 Mortality 1 1.8 0 Total 10 17.6 1 1.8 247
5. Journal of military pharmaco-medicine n08-2017 The overall rate of complications in the late-fed group was higher than that of the early feeding group (17.6% vs. 1.8%), with the complication rate of 3.5% versus 8%, abscess 1.8%, surgery 3.5%; death 1.8%. Early intervention group had no case. 3. Assess the effectiveness of early enteral nutrition with improved blood pre- albumin index. Table 7. Comparison of pre-albumin levels before and after intervention of each group and two groups. Control group Intervention group p (n = 57) (n = 55) Before the intervention 0.18 ± 0.15 0.19 ± 0.11 0.504 Pre-albumin After the intervention 0.14 ± 0.05 0.28 ± 0.32 0.009 p 0.09 0.103 The blood pre-albumin level of the two groups before the intervention was equivalent. After the intervention, the blood pre-albumin level of intervention group was higher than that of the control group (0.28 vs. 0.14). The difference was statistically significant, p < 0.05. The prealbumin blood concentration of intervention group after intervention increased meanwhile decreased in the control group, but no statistically significant difference was observed. DISCUSSIONS the patient was completely awake, well- Assess the effectiveness of early ventilated, the respiratory status and enteral nutrition with improved clinical, hemodynamic stability can be fed to through average early feeding time was at 27.2 ± the intestinal tract [4]. 6.6 hours, the earliest was 16 hours after * Clinical symptoms after surgery: surgery, the latest was 45 hours after Early feeding did not increase surgery, the patient was fully awake, postoperative morbidity, including spontaneously breathing well. Drainage compromised integrity of an anastomosis. anesthesia, hemodynamic stability can be Therefore, such nutritional intervention fed through the intestinal tract. For the can be safely adapted to accelerated patients who are fed with no bowel patients. Although the patients were yet syndrome, this time is longer than that in not able to eat, the secretion of bile, pancreas, gastric fluid, intestinal fluid some other authors’ studies in the world. secretes, which will be absorbed by the In Vietnam, it is a new intervention, intestinal mucosa. Intestinal mucosa changing the surgeon's habit of feeding without altering intestinal pressure much time is very difficult, often the surgeon [3, 5, 6]. Our results of these gastrointestinal feeds the patient when it has been complications after the onset of treatment inflamed (usually 3 to 4 days after surgery), in the intervention group and the control our result was 124.6 ± 52.7 hours. group were not statistically significant According to Lewis, after 6 to 12 hours, (p > 0.05). 248
6. Journal of military pharmaco-medicine n08-2017 * Reflux: It is a potential danger. Some fistula, leakage, which is the main reason risk factors included stomach full of fluid why the surgeon delays early feeding, but and vapor, because some drugs reduce both complications occur; one in the gastrointestinal motility, so reflux may control group, but not in the early feeding occur in any patient [4, 6]. The authors group. Lewis has synthesized 13 studies agreed that close monitoring of the from various authors around the world gastrointestinal tract, position of the nasal and concluded that early intestinal feeding duct, position of the patient when feeding, after surgery was safe [4]. In our results, was necessary to ensure that the intestinal the overall complication rate in the late was safe and successful. Our results did breeding group was higher than that of not have any reflux patients [3, 4, 5]. the early feeding group (17.6% vs. 1.8%). * Diarrhea: The diarrhea rate in the This is similar to Sanjay Marwa's study, intervention group was 5.5% (which is where the prevalence of early feeding less than that of the control group 12.3%), was 4% compared to 20%. Late feeding similar to Nguyen Nhu Lam’s research on groups also included two patients (6%) the incidence of diarrhea increased with with abscess and none of the patients in time [1]. Feeding the intestines, according early feeding group. However, this to research by Braga M, Gianotti L of the difference was not significant at p > 0.05. feeding time of the intestines, as well as This is similar to the Lewis’s study that the diarrhea rate, may be reduced as was higher in the late feeding group, with early as possible due to early feeding of a 3% of oral leakage rate (the only structural disorders and atrophy of patient) in the late feeding group and intestinal mucosa [5]. none in the intervention group [4]. Assessment of postoperative recovery Early feeding can improve health, and postoperative fluid flow was found to as early feeding increases collagen be active and passive. Post-operative deposition and reduces mucosal shrinkage, recovery is the occurrence of bowel motility and time of movement. Patients in thus speeding up wound healing [4]. the early feeding group had an earlier fart Assess the effectiveness of early (54.6 hours versus 82.1 hours) (p < 0.01). enteral nutrition with improved clinical and This result was similar to raga M’s, prealbumin index of patients after gastric Gianotti L’s study (2002) (35 hours and 67 bypass surgery. hours) [6]. The time to sit up, gentle Effects of early intestinal feeding on movement in the intervention group was also earlier than in the control group. prealbumin index, the prevalence of the Mean duration of hospital stay was prevalence is 2 days. This is a marker shorter than that of the control group (7.8 used to assess malnutrition in patients days and 9.6 days) the difference was who are hypersensitive to albumin. After statistically significant (p < 0.05). intervention, the prealbumin concentration After gastrointestinal surgery, the most in the intervention group was significantly frightening complication is duodenal higher than in the control group. 249
7. Journal of military pharmaco-medicine n08-2017 CONCLUSION Bachmai hospital in 2013. PhD thesis, Institute of Hygiene and Epidemiology. 2015. Early gastrointestinal uptake after postoperative gastric bypass surgery was 3. Lassen K, Revhaug. A Early oral nutrition after major upper gastro- intestinal safe, feasible with shorter hospital stay surgery: why not?. Curr Opin Clin Nutr Metab (7.8 days with 9.6 days) and less Care. 2006, 9, pp.613-617. complication rate (1.8% with 17.6%). 4. Lewis S.J. Early enteral feeding versus Early feeding improved the maintenance “nil by mouth” after gastrointestinal surgery: of nutritional index, prealbumin blood systematic review and meta-analysis of concentration of intervention group after controlled trials. 2001, 323 (7316), p.773. intervention increased (0.19 and 0.28); 5. Braga M., Gianotti L., Gentilini O. et al. the control group was lower than before Early postoperative enteral nutrition improves intervention (0.14 g/L and 0.18 g/L) and gut oxygennation and reduces costs lower than intervention group (0.14 g/L compared with total parenteral nutrition. 2001. versus 0.28 g/L) p < 0.05. 6. Braga M, Gianotti L, Gentilini S, Liotta S, Larger scale research is needed and Di Carlo V. Feeding the gut early after early postnatal feeding regimen is necessary. digestive surgery: results of a nine-year experience. Clinical Nutrition. 2002, 21, pp.59- REFERENCES 65. doi: 10.1054/clnu.2001.0504. 1. Lam N.N. Effect of early feeding severe 7. ASPEN Board of Directors and the burn patients. PhD thesis. Military Medical Clinical Guidelines Task Force. Guidelines for University. 2006. the use of parenteral and enteral nutrition in 2. Tuyet C.T. Effective comprehensive adult and pediatric patients. JPEN Journal of nutrition for patients with abdominal surgery - Parenteral and Enteral Nutrition. 2002, 26 Digestive open gastroenterology prepared at (1 Suppl):1SA-138SA. 250