Small bowel necrosis in association with early postoperative enteral feeding after pancreatic resection

When can we start early enteral nutrition safely in patients with shock on vasopressors?

Shock is a common critical illness characterized by microcirculatory disorders and insufficient tissue perfusion. Patients with shock and hemodynamic instability generally require vasopressors to maintain the target mean arterial pressure. Enteral nutrition (EN) is an important therapeutic intervention in critically ill patients and has unique benefits for intestinal recovery. However, the initiation of early EN in patients with shock receiving vasopressors remains controversial. Current guidelines make conservative and vague recommendations regarding early EN support in patients with shock. Increasing studies demonstrates that early EN delivery is safe and feasible in patients with shock receiving vasopressors; however, this evidence is based on observational studies. Changes in gastrointestinal blood flow vary by vasopressor and inotrope and are complex. The risk of gastrointestinal complications, especially the life-threatening complications of non-occlusive mesenteric ischemia and non-occlusive bowel necrosis, cannot be ignored in patients with shock during early EN support. It remains a therapeutic challenge in critical care nutrition therapy to determine the initiation time of EN in patients with shock receiving vasopressors and the safe threshold region for initiating EN with vasopressors. Therefore, the current review aimed to summarize the evidence on the optimal and safe timing of early EN initiation in patients with shock receiving vasopressors to improve clinical practice.

Small bowel necrosis after esophagectomy

BACKGROUND

The study aimed to fully understand small bowel necrosis, a rare but fatal complication after esophagectomy.

METHODS

Patients who underwent esophagectomy for esophageal cancer at the Fudan University Shanghai Cancer Center from January 2013 to December 2021 were retrospectively reviewed. Clinical information on the demographics, presenting features, and outcomes of the cases were collected.

RESULTS

Of the 6607 patients during the study period, 11 (0.2%) underwent reoperation due to bowel necrosis, including nine males (81.8%) and two females (18.2%). Among them, eight cases (72.7%) had hypertension and seven (63.6%) suffered from lower thoracic esophageal cancer. Eight (72.7%) and three (27.3%) patients underwent the Ivor-Lewis and McKewon procedures, respectively. Jejunostomy was performed in nine patients (81.8%). The first signs of bowel necrosis appeared within 5 days after esophagectomy. Abdominal distension and deteriorating renal function were observed in seven patients (63.6%). There was no evidence of mesenteric vascular occlusion in any of the 11 cases, except for the hepatic portal venous gas found in seven patients on the computed tomography (CT) scan. Eight (72.7%) of the 11 patients underwent reoperation within 24 h due to the onset of the first symptoms. Eight (72.7%) had ileal necrosis, and three (27.3%) died.

CONCLUSION

Close attention should be paid to patients with abdominal distension, renal function damage, and portal hepatic venous gas after esophagectomy. These patients may suffer from small bowel necrosis, which may result in rapid disease progression. Exploratory laparotomy and bowel resection are effective treatments for such patients.

ESPEN practical guideline: Clinical nutrition in surgery

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. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.

Nonocclusive mesenteric ischemia associated with postoperative jejunal tube feeding: Indicators for clinical management

Postoperative nutrition via a jejunal tube after major abdominal surgery is usually well tolerated. However, some patients develop nonocclusive mesenteric ischemia (NOMI). This morbid complication has a grave prognosis with a mortality rate of 41% to 100%. Early symptoms are nonspecific, and no treatment guideline is available. We reviewed cases of NOMI at our institution and cases described in the literature to identify factors that impact the clinical course. Among five patients, three had no necrosis and one had segmental necrosis and perforation. These patients recovered with limited resection and decompression of the bowel and abdominal compartment. In one patient with extended bowel necrosis at the time of re-laparotomy, NOMI progressed and the patient died of multiple organ failure. The extent of small bowel necrosis at the time of re-laparotomy is a relevant prognostic factor. Therefore, early diagnosis and treatment of NOMI can improve the prognosis. Clinical symptoms of abdominal distension, cramps and high reflux plus paraclinical signs of leukocytosis, hypotension and computed tomography findings of a distended small bowel with pneumatosis intestinalis and portal venous gas can help to establish the diagnosis. We herein introduce an algorithm for the diagnosis and management of NOMI associated with jejunal tube feeding.

Mild nonocclusive mesenteric ischemia associated with syncope

Nonocclusive mesenteric ischemia (NOMI) is a life-threatening disease caused by a reduction in mesenteric blood supply without vascular occlusion. Early diagnosis of NOMI is often difficult because there are no specific findings suggesting NOMI. Here, we report a rare case of a very elderly patient with mild NOMI caused by dehydration due to short-term reduced oral intake and associated with syncope. A 90-year-old man was admitted to our hospital with syncope and melena. The syncope was thought to be caused by orthostatic hypotension due to dehydration owing to reduced oral intake for approximately 24 h. Abdominal computed tomography (CT) revealed marked bowel wall thickening with mesenteric stranding in the ileum and ascending colon, dilated small intestine with thinned bowel wall, collapsed superior mesenteric vein, hemorrhagic ascites, and absence of obvious vascular occlusion in the mesenteric vessels. Abdominal symptoms, laboratory abnormalities, and CT findings improved gradually with the correction of dehydration. Therefore, we diagnosed our patient with mild NOMI. NOMI can be associated with syncope and can occur even with dehydration due to short-term reduced oral intake. When examining elderly patients with hypovolemic signs, such as syncope, who exhibit abdominal symptoms, clinicians must keep in mind the possibility of NOMI.

Needle Catheter Jejunostomy in Patients Undergoing Surgery for Upper Gastrointestinal and Pancreato-Biliary Cancer-Impact on Nutritional and Clinical Outcome in the Early and Late Postoperative Period

The metabolic risk for patients undergoing abdominal cancer resection increases in the perioperative period and malnutrition may be observed. In order to prevent further weight loss, the guidelines recommend for high-risk patients the placement of a needle catheter jejunostomy (NCJ) for supplementing enteral feeding in the early and late postoperative period. Our aim was to evaluate the safety of NCJ placement and its potential benefits regarding the nutritional status in the postoperative course. We retrospectively analyzed patients undergoing surgery for upper gastrointestinal cancer, such as esophageal, gastric, and pancreato-biliary cancer, and NCJ placement during the operation. The nutritional parameters body mass index (BMI), perioperative weight loss, phase angle measured by bioelectrical impedance analysis (BIA) and the clinical outcome were assessed perioperatively and during follow-up visits 1 to 3 months and 4 to 6 months after surgery. In 102 patients a NCJ was placed between January 2006 and December 2016. Follow-up visits 1 to 3 months and 4 to 6 months after surgery were performed in 90 patients and 88 patients, respectively. No severe complications were seen after the NCJ placement. The supplementing enteral nutrition via NCJ did not improve the nutritional status of the patients postoperatively. There was a significant postoperative decline of weight and phase angle, especially in the first to third month after surgery, which could be stabilized until 4-6 months after surgery. Placement of NCJ is safe. In patients with upper gastrointestinal and pancreato-biliary cancer, supplementing enteral nutrition during the postoperative course and continued after discharge may attenuate unavoidable weight loss and a reduction of body cell mass within the first six months.

Small Bowel Necrosis Related to Enteral Nutrition after Duodenal Surgery

Nutritional support is the key to the successful recovery of any patient. Small bowel necrosis is described in patients being fed with enteral nutrition after surgery. Five patients with small bowel necrosis after surgery will be discussed and an etiology proposed. A retrospective review of patient data was performed. Data was collected on the type of surgical procedures performed, the enteral nutrition given to the patient, basic laboratory data, the length of stay, and discharge status. A total of five patients’ charts were reviewed. Three patients had pancreaticoduodenectomy for a pancreatic mass and two required pyloric exclusion secondary to gunshot wounds. All five patients were fed with a fiber-based enteral nutrition. All patients subsequently had small bowel necrosis requiring reoperation. Four of the five patients had inspissated tube feeding within the necrotic small bowel. Two patients died and three survived with prolonged hospital courses. We propose that the combination of duodenal surgery and fiber-based enteral nutrition contribute to the development of small bowel necrosis postoperatively.

Non-occlusive mesenteric ischemia associated with enteral feeding after esophagectomy for esophageal cancer: report of two cases and review of the literature

Background

Non-occlusive mesenteric ischemia (NOMI) is a rare but life-threatening complication of early postoperative enteral feeding. We herein report two patients who developed NOMI during enteral feeding after esophagectomy.

Case presentation

In case 1, a 75-year-old man with no medical history was diagnosed with multiple primary cancers of the esophagus, stomach, and kidney. He underwent percutaneous endoscopic gastrostomy tube placement followed by thoracoscopic esophagectomy and cervical esophagostomy placement as the first-stage operation. Gastrostomy feeding was started on postoperative day (POD) 3 with a polymeric formula (ENSURE H®). On POD 7, he developed acute abdominal pain and distension with bloody drainage through the gastrostomy tube. Dynamic computed tomography showed massive hepatic portal venous gas and pneumatosis intestinalis. Angiography showed diffuse spasms in the branches of the superior mesenteric artery. Under a diagnosis of NOMI, we started intra-arterial infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 48.

In case 2, a 68-year-old man with diabetes and atrial fibrillation was diagnosed with esophageal cancer. His medical history was significant for pylorus-preserving gastrectomy for gastric cancer and small bowel resection for trauma. He underwent thoracoscopic esophagectomy, open total gastrectomy, colonic reconstruction, and jejunostomy tube placement. Adhesiolysis for abdominal severe adhesions caused by previous operations was difficult. Jejunostomy feeding was started on POD 3 with a polymeric formula (Racol®). On POD 7, he developed persistent diarrhea and cervical anastomotic leakage. On POD 9, he developed acute abdominal pain and distension with bloody drainage through the jejunostomy tube. Dynamic computed tomography showed the same findings as in case 1. Under a diagnosis of NOMI, we started intravenous infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 28.

Conclusions

The causes of feeding-related NOMI may include the use of a high-osmolarity formula, preoperative malnutrition, abdominal adhesiolysis, systemic inflammation after anastomotic leakage, and a medical history of diabetes and atrial fibrillation. NOMI should be considered as a differential diagnosis in patients with these risk factors and clinical features such as acute abdominal pain and distension during enteral feeding.

Feeding Jejunostomy-Associated Small Bowel Necrosis After Elective Esophago-Gastric Resection

BACKGROUND

Feeding jejunostomy has increasingly become a standard adjunctive procedure during major esophago-gastric resections. They provide nutritional support during the post-operative period as required. However, significant early complications have been reported, most notably small bowel necrosis. Literature reports have been restricted to case reports or series. This study aims to determine the frequency of this complication in a cohort of patients undergoing esophago-gastric resection, and identify any difference in the risk of this complication between patients undergoing esophagectomy and gastrectomy.

METHODS

Consecutive patients who had esophago-gastric resections for malignancy and who had a feeding jejunostomy placed were identified from a prospectively maintained database at Leicester Royal Infirmary during the years 2009-2015. Case notes were reviewed to extract information relating to demographics, presenting features and clinical outcome.

RESULTS

The study included 360 patients, 285 of which had esophagectomy and 75 had gastrectomy. There were no small bowel complications among esophagectomy patients (0%), while six patients who had total gastrectomy developed small bowel ischemia or necrosis (8%), p = 0.05, in spite of an identical feeding regimen. Every patient that developed the complication underwent surgery with five out six having resection of the infarcted segment and double-barrel stoma formation. A 6-8-week period of parenteral nutrition was required before stoma reversal. One patient had leucocytosis on the day of diagnosis. The other five patients showed no derangements in biochemical or clinical parameters in the preceding 48 h. Five of the six patients survived.

CONCLUSIONS

Small bowel necrosis and perforation is a life-threatening complication of feeding jejunostomy. In our cohort, it happened exclusively in total gastrectomy patients. Antecedent signs were lacking. The condition requires prompt attention with earlier use of CT scanning and a return to the operating room. The presence of pneumatosis intestinalis on CT scan should prompt surgical intervention that improves survival.

Early enteral nutrition vs parenteral nutrition following pancreaticoduodenectomy: Experience from a single center

AIM: To analyze and compare postoperative morbidity between patients receiving total parenteral nutrition (TPN) and early enteral nutrition supplemented with parenteral nutrition (EEN + PN).

METHODS: Three hundred and forty patients receiving pancreaticoduodenectomy (PD) from 2009 to 2013 at our center were enrolled retrospectively. Patients were divided into two groups depending on postoperative nutrition support scheme: an EEN + PN group (n = 87) and a TPN group (n = 253). Demographic characteristics, comorbidities, preoperative biochemical parameters, pathological diagnosis, intraoperative information, and postoperative complications of the two groups were analyzed.

RESULTS: The two groups did not differ in demographic characteristics, preoperative comorbidities, preoperative biochemical parameters or pathological findings (P > 0.05 for all). However, patients with EEN + PN following PD had a higher incidence of delayed gastric emptying (16.1% vs 6.7%, P = 0.016), pulmonary infection (10.3% vs 3.6%, P = 0.024), and probably intraperitoneal infection (18.4% vs 10.3%, P = 0.059), which might account for their longer nasogastric tube retention time (9 d vs 5 d, P = 0.006), postoperative hospital stay (25 d vs 20 d, P = 0.055) and higher hospitalization expenses (USD10397 vs USD8663.9, P = 0.008), compared to those with TPN.

CONCLUSION: Our study suggests that TPN might be safe and sufficient for patient recovery after PD. Postoperative EEN should only be performed scrupulously and selectively.

Small bowel necrosis in association with jejunal tube feeding

Early recognition and appropriate treatment of bowel ischemia is imperative to reduce morbidity and mortality in any situation, including in conjunction with enteral tube feeding. GI intolerance can manifest as increased nasogastric tube output, unexplained abdominal pain/distension, and pneumatosis intestinalis in critically ill patients who are on tube feedings and may be experiencing periods of splanchnic hypotension. Recommendations are to immediately cease tube feedings when these signs and symptoms are recognized, and total parenteral nutrition should be considered. Surgical exploration during the early stages should be considered to prevent the usual and fatal catastrophic cascade of widespread bowl infarction.

Non-occlusive small bowel necrosis in association with feeding jejunostomy after elective upper gastrointestinal surgery

INTRODUCTION

Non-occlusive small bowel necrosis (NOSBN) has been associated with early postoperative enteral feeding. The purpose of this study was to determine the incidence of this complication in an elective upper gastrointestinal (GI) surgical patient population and the influence of both patient selection and type of feeding jejunostomy (FJ) inserted, based on the experience of two surgical units in affiliated hospitals.

PATIENTS AND METHODS

The records were reviewed of 524 consecutive patients who underwent elective upper GI operations with insertion of a FJ for benign or malignant disease between 1997 and 2006. One unit routinely inserted needle catheter jejunostomies (NCJ), whilst the other selectively inserted tube jejunostomies (TJ).

RESULTS

Six cases of NOSBN were identified over 120 months in 524 patients (1.15%), with no difference in incidence between routine NCJ (n = 5; 1.16%) and selective TJ (n = 1; 1.06%). Median rate of feeding at time of diagnosis was 105 ml/h (range, 75-125 ml/h), and diagnosis was made at a median of 6 days (range, 4-18 days) postoperatively. All patients developed abdominal distension, hypotension and tachycardia in the 24 h before re-exploratory laparotomy. Five patients died and one patient survived.

CONCLUSIONS

The understanding of the pathophysiology of NOSBN is still rudimentary; nevertheless, its 1% incidence in the present study does call into question its routine postoperative use especially in those at high risk with an open abdomen, planned repeat laparotomies or marked bowel oedema. Patients should be fully resuscitated before initiating any enteral feeding, and feeding should be interrupted if there is any evidence of feed intolerance.

ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation

Enhanced recovery of patients after surgery ("ERAS") has become an important focus of perioperative management. From a metabolic and nutritional point of view, the key aspects of perioperative care include: Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and if necessary tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in surgical patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1980. The guideline was discussed and accepted in a consensus conference. EN is indicated even in patients without obvious undernutrition, if it is anticipated that the patient will be unable to eat for more than 7 days perioperatively. It is also indicated in patients who cannot maintain oral intake above 60% of recommended intake for more than 10 days. In these situations nutritional support should be initiated without delay. Delay of surgery for preoperative EN is recommended for patients at severe nutritional risk, defined by the presence of at least one of the following criteria: weight loss >10-15% within 6 months, BMI<18.5 kg/m(2), Subjective Global Assessment Grade C, serum albumin <30 g/l (with no evidence of hepatic or renal dysfunction). Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

The role of macronutrients in gastrointestinal blood flow

PURPOSE OF REVIEW

The presence of luminal nutrients after a meal increases gastrointestinal blood flow in a phenomenon called postprandial hyperemia. In many conditions related to splanchnic hypoperfusion, enteral nutrition may play a role in counterbalancing the installed splanchnic low-flow state by producing intestinal hyperemia. However, when the gut is hypoperfused there is a chance of enteral nutrition producing a mismatch of the oxygen demand: supply ratio with subsequence gut ischemia. This article aims to review the effects of macronutrients on gastrointestinal blood flow in both health and critical conditions, especially those related to hepatosplanchnic hypoperfusion.

RECENT FINDINGS

Splanchnic blood flow is related not only to the route (intravenous or enteral) and timing of nutritional support (during the course of the insult) but also to the composition of the formula. Critically ill patients with gut hypoperfusion may tolerate enteral nutrition, but this effect may be restricted to the early post-injury phase. During ischaemia reperfusion injury, immune nutrients may promote different outcomes: glutamine may protect whereas arginine may deteriorate the mucosal barrier and enhance permeability.

SUMMARY

Understanding the relationship between macronutrients and gastrointestinal blood flow is a major challenge. Ongoing research in nutritional support in hypoperfused, catecholamine-dependent patients will open the door to optimize the recovery of patients in critical care.

Severe jejunoileitis after placement of a feeding jejunostomy: a series of four cases and a review of the literature

Feeding jejunostomy is a recognized method of managing feeding difficulties and failure to thrive in neurologically impaired children. There are, however, significant associated complications. The authors report 4 cases of the potentially fatal complication of severe jejunoileitis, which has not been reported previously in children. The possible underlying mechanisms are discussed.

When is the seriously ill patient ready to be fed?

BACKGROUND

After assessing the critically ill patient for risk of aspiration, the clinician still must decide if the patient is ready to be fed. The goal is to identify critically ill patients who are likely to tolerate enteral nutrition and attempt to minimize complications.

METHODS

A synthesis of the both clinical and animal studies to identify factors related to patient readiness for enteral nutrition.

RESULTS

The key issue to be resolved is adequacy of resuscitation and restoration of mesenteric perfusion. Currently, there is no reliable clinical tool to measure gut perfusion. The best indicators currently are stabilization of vital signs, decreasing fluid and blood requirements, normalization of the base deficit, and lactate and removal of inotropic or vasopressor support.

CONCLUSIONS

Most critically ill patients should be ready for enteral nutrition within 24 to 48 hours of intensive care unit admission. Critically ill patients who need catecholamine support, heavy sedation, or therapeutic neuromuscular blockade should probably not receive enteral nutrition until they have been stabilized.

Feeding the intensive care patient

The present review highlights recent findings (focusing on papers published between October 1999 and December 2000) in nutritional support of intensive care unit patients. During the past year, research focused on the use of enteral nutrition versus parenteral nutrition, and on the best composition of enteral nutrition and parenteral nutrition according to the clinical condition of the patient. With regard to enteral nutrition, the pH of nutritional support, the timing of administration and the technique of tube placement were debated. Immunomodulating agents and hormonal manipulations may improve outcomes of critically ill patients, but still warrant further research before they can be recommended for routine clinical use.