Arch Surg 2001; 136:933-6.

HYPOTHESIS: Immediate enteral feeding following major abdominal surgery reduces postoperative complications and mortality when compared with parenteral nutrition. DESIGN: A prospective multicenter randomized trial. SETTING: A university hospital department of digestive surgery. PATIENTS AND INTERVENTIONS: Two hundred forty-one malnourished patients undergoing major elective abdominal surgery were randomly assigned to receive, after surgery, either enteral (enteral nutrition group: 119 patients) or parenteral nutrition (total parenteral nutrition group: 122 patients). The patients were monitored for postoperative complications and mortality. RESULTS: The rate of major postoperative complications was similar in the enteral and parenteral groups (enteral nutrition group: 37.8%; total parenteral nutrition group: 39.3%; P was not significant), as were the overall postoperative mortality rates (5.9% and 2.5%, respectively; P was not significant). CONCLUSION: The present study failed to demonstrate that enteral feeding following major abdominal surgery reduces postoperative complications and mortality when compared with parenteral nutrition.

Vol: 359 Issue: 9318, May 11, 2002

Fabio Pacelli, , Maurizio Bossola, Valerio Papa, Antonio Sgadari, Giovanni Battista Doglietto

Department of Surgical Sciences, Digestive Surgery Unit, and Department of Internal Medicine, Catholic University School of Medicine, 00168 Rome , Italy
Sir—Federico Bozzetti and colleagues (Nov 3, p 1487)compare early postoperative enteral nutrition with parenteral nutrition in malnourished patients undergoing major surgical procedures for gastrointestinal cancer. They conclude that early enteral nutrition significantly reduces complication rates and duration of postoperative stay compared with parenteral nutrition, although parenteral nutrition is better tolerated.

We have done a prospective randomised study on the same topic, in which all patients underwent major abdominal surgery, mostly for gastrointestinal cancer. The preoperative weight loss was in all cases more than 10% of normal bodyweight. Parenteral supplementation was added during the first 3 days of enteral nutrition to achieve the same caloric intake as in the parenteral group. We classified postoperative complications as major and minor, infectious and non-infectious, according to precise criteria. All statistical analyses were two-tailed and based on intention to treat, the anticipated rate of postoperative complications and the statistical power being 40% and 90%, respectively.

We were unable to show that early enteral nutrition reduces the rate of postoperative complications compared with parenteral nutrition Bozzetti and colleagues show a significant number of patients (21%) did not tolerate postoperative enteral nutrition. Therefore, one in five patients did not receive, after major abdominal surgery, adequate nutritional therapy. This finding translates, in this subgroup of patients, into an increased rate of infectious and non-infectious complications.The frequency of postoperative major complications as well as complications requiring re-intervention was similar in the enteral and parenteral nutrition groups. Minor infectious and non-infectious complications were significantly fewer in patients who received postoperative enteral nutrition. Moreover, some complications seem to have been included in the non-infectious group (bleeding, deep-vein thrombosis, renal failure, arrhythmia, delayed gastric emptying) that are not strictly related to the nutritional status and to the route of feeding. Indeed, if these complications are not included in the analysis, the enteral and parenteral nutrition groups do not differ significantly. Duration of postoperative stay and postoperative mortality were also similar in the two groups: 15·2 days (SD 3·6) compared with 16·1 (4·5) days for the enteral and parenteral groups, respectively, for hospital stay, and 5·9% compared with 2·5% for mortality.Taking into account these considerations and the results of our study, we think, in accordance with other researchers,that early enteral nutrition with standard formulas should not currently be considered as the nutritional treatment of choice after major abdominal surgery.

Ann Surg 1996 ; 223 : 357-362

OBJECTIVE: A prospective multicenter randomized trial was designed to evaluate the clinical efficacy of postoperative protein-sparing therapy. SUMMARY BACKGROUND DATA: The metabolic effect of postoperative protein-sparing therapy has been shown by several studies, but the clinical utility of this treatment has not been investigated by large prospective trials. METHODS: Six hundred seventy-eight patients undergoing major elective abdominal surgery were randomly assigned to receive either protein-sparing therapy after surgery (protein-sparing therapy group) or conventional therapy (control group). The patients were monitored for postoperative complications and mortality. RESULTS: The rate of major postoperative complications was similar in both groups (protein-sparing therapy group, 19.5%; control group, 20.9%; p=0.66) as were the overall postoperative mortality rates (4.7% and 3.5%, respectively; p=0.43). CONCLUSIONS: The present study indicates that routine protein-sparing therapy for patients normonourished or mildly malnourished undergoing major abdominal surgery is not clinically justified.

JPEN J Parenter Enteral Nutr. 2008 Jan-Feb;32(1):94-7.

Pacelli F, Rotondi F, Rosa F, Bossola M, Papa V, Tortorelli AP, Sollazzi L, Doglietto GB.

Department of Surgical Sciences, Digestive Surgery Unit, Catholic University, School of Medicine, Rome, Italy. fpacelli@rm.unicatt.it

BACKGROUND: Emergency high-loop jejunostomies are seldom used for nutrition access in the clinical practice. METHODS: This paper describes the results of a simple and safe technique that uses emergency high-loop jejunostomy as an enteral feeding access. A feeding tube is inserted into the efferent loop of the jejunostomy and then subcutaneously tunneled. In this way, whenever it becomes necessary, the bag collecting fluids from the afferent loop can be changed without removing the tube, which remains permanently inserted into the efferent loop and secured to the skin in order to avoid displacements. RESULTS: Twenty-nine patients with high-loop jejunostomy were consecutively treated with the described technique during the period 2000-2006. The mean distance between the ligament of Treitz and tube was 38.3 +/- 16.2 cm. After an induction period, all patients received full-strength enteral nutrition and were discharged after a mean of 25.1 +/- 19.5 days of treatment. All patients were subsequently readmitted to our unit, and their ostomies were successfully closed. No major early and late complications were observed; particularly, no patient experienced local or systemic septic complications. Conclusion: From the analysis of our results, the described method for delivering enteral nutrition through an emergency high-loop ostomy proves easy to apply and clinically effective. Enteral nutrition can be started as soon as possible after operation through the efferent loop of the ostomy; the management of the jejunostomy is simple and safe, with no additional discomfort for the patients.