Enteral feeding and gut atrophy

Clinical benefits and controversies of jejunostomy feeding in patients undergoing gastrectomy for gastric cancer

Globally, gastric cancer ranks as the fifth most common malignancy and the third leading cause of cancer-related mortality. Gastrectomy combined with perioperative chemotherapy is currently the standard of care in locally advanced stages, but the completion rate of multimodal approach is influenced also by patient related factors. Malnutrition is a well-known risk factor associated with poor oncological outcomes. Its perioperative supplementation could lead to an improvement of the nutritional status. This article reviews and comments the retrospective study conducted by Jaquet et al, which evaluates the impact of enteral nutrition by jejunostomy feeding in patients undergoing gastrectomy for cancer. The authors included 172 patients, 35% of whom received jejunostomy. Patients with optimized biological nutritional parameters (body mass index, albumin, prealbumin) showed reduced major complications (> III), according to the Dindo-Clavien classification, 0 (0%) vs 8 (4.7%) (P = 0.05). In the era of multimodal treatment, optimization of nutritional and performance status is integral part of the therapeutic strategy.

Influence of Early Total Enteral Feeding in Preterm Infants with Respiratory Distress Syndrome

INTRODUCTION

Providing adequate nutrition in the management of preterm infants has been challenging. The objective of this secondary analysis of data from the randomized trial comparing "less invasive surfactant therapy (LISA) with InSurE method of surfactant administration" is to demonstrate the feasibility of early total enteral feeding (ETEF) in hemodynamically stable preterm neonates on respiratory support and to examine the factors associated with failure of ETEF.

METHODS

Secondary analysis of a randomized controlled trial comparing "LISA versus InSurE among preterm infants between 26 and 34 weeks of gestation" enrolled 150 infants with 117 being hemodynamically stable. ETEF without any parenteral supplementation was started on day 1 of life using the mother's own milk (MoM) or donor human milk (<32 weeks of GA) and MoM or preterm formula (33-34 weeks of GA). The data were analyzed to assess the proportion of babies developing feed intolerance and/or necrotizing enterocolitis (NEC) and factors associated with failure of ETEF. All Infants were assessed for the day of attainment of full enteral feeding defined as receiving and tolerating 150 mL/kg of enteral feeds per day.

RESULTS

Out of these 117 babies, 102 tolerated ETEF, and 15 had one or more episodes of FI requiring total parenteral nutrition, but none developed NEC till discharge or death. On the assessment of possible factors associated with ETEF failure, there were no differences in baseline characteristics but statistically significantly increased incidence of culture-positive sepsis as well as the requirement of antibiotic therapy for possible sepsis (early as well as late-onset sepsis) in babies with failure of ETEF. The babies who tolerated ETEF achieved full enteral feeding (150 mL/kg/day) significantly earlier (5.48 ± 1.1 days) compared to those with ETEF failure (7 ± 3.4 days) (p 0.001). The time to regain birth weight was earlier in the ETEF group without significant differences in growth parameters. There was also a reduction in the duration of hospital stay in babies who tolerated ETEF, but both these results were not statistically significant.

CONCLUSION

ETEF is feasible in preterm neonates with respiratory distress syndrome who are on respiratory support. It resulted in earlier attainment of full enteral feeds and decreased the incidence of sepsis with reduced antibiotic usage.

The Difference of Milk-Derived Extracellular Vesicles from Cow Colostrum and Mature Milk on miRNAs Expression and Protecting Intestinal Epithelial Cells against Lipopolysaccharide Damage

Intestinal epithelial cells (IECs) play crucial roles in forming an essential barrier, providing host defense against pathogens and regulating nutrients absorption. Milk-derived extracellular vesicles (EVs) within its miRNAs are capable of modulating the recipient cell function. However, the differences between colostrum and mature milk EVs and their biological function in attenuating intestinal epithelial cell injury remain poorly understood. Thus, we carried out the present study to characterize the difference between colostrum and mature milk-derived miRNA of EVs and the effect of colostrum and mature milk EVs on the proliferation, apoptosis, proinflammatory cytokines and intestinal epithelial barrier related genes in IEC-6 induced by LPS. Differential expression of 329 miRNAs was identified between colostrum and mature milk EVs, with 185 miRNAs being downregulated and 144 upregulated. In addition, colostrum contains a greater number and protein concentration of EVs than mature milk. Furthermore, compared to control, EVs derived from colostrum significantly inhibited the expression of apoptosis- (Bax, p53, and caspase-3) and proinflammatory-related genes (TNFα, IL6, and IL1β). EVs derived from mature milk did not affect expression of apoptosis-related genes (Bax, p53, bcl2, and caspase-3). The EVs derived from mature milk significantly inhibited the expression of proinflammatory-related genes (TNFα and IL6). Western blot analysis also indicated that colostrum and mature milk EVs significantly decreased the apoptosis of IEC-6 cells. The EdU assay results showed that colostrum and mature milk EVs significantly increased the proliferation of IEC-6 cells. The expression of intestinal barrier-related genes (TJP1, CLDN1, OCLN, CDX2, MUC2, and IGF1R) was significantly promoted in IEC-6 cells after colostrum and mature milk EVs addition. Importantly, colostrum and mature milk EVs significantly relieved the LPS-induced inhibition of proliferation and intestinal barrier-related genes expression and attenuated apoptosis and proinflammatory responses induced by LPS in IEC-6 cells. Flow cytometry and Western blot analysis also indicated that colostrum and mature milk EVs significantly affect the apoptosis of IEC-6 cells induced by LPS. The results also indicated that EVs derived from colostrum had better effects on inhibiting the apoptosis- and proinflammatory cytokines-related genes expression. However, the EVs derived from mature milk exhibited beneficial effects on intestinal epithelial barrier protection. The present study will provide a better understanding of the role of EVs derived from colostrum and milk in dairy cows with different responses in the regulation of intestinal cells function, and also presents new evidence for the change of EVs cargos during various stages of lactation.

Clinical impact of diarrhea during enteral feeding after esophagectomy

BACKGROUND

Enteral feeding (EF) is recommended to enhance nutritional status after esophagectomy; however, diarrhea is a common complication of EF. We investigated the clinical and prognostic impact of diarrhea during EF after esophagectomy.

METHODS

One hundred and fifty-two patients who underwent transthoracic esophagectomy were enrolled. The King's stool chart was used for stool characterization. The short- and long-term outcomes were compared between a non-diarrhea (Group N) and diarrhea group (Group D).

RESULTS

A higher dysphagia score (≥ 1) was observed more frequently in Group D than in Group N (45.7% vs. 19.8%, p = 0.002). Deterioration of serum total protein, serum albumin, serum cholinesterase, and the prognostic nutritional index after esophagectomy was greater in Group D than in Group N (p = 0.003, 0.004, 0.014, and 0.001, respectively). Patients in Group D had significantly worse overall survival (OS) and recurrence-free survival (RFS) than those in Group N (median survival time (MST): OS, 21.9 vs. 30.6 months, p = 0.001; RFS, 12.4 vs. 27.7 months, p < 0.001). In stratified analysis due to age, although there was no difference in OS with or without diarrhea in young patients (MST: 24.1 months in a diarrhea group vs. 33.6 months in a non-diarrhea group, p = 0.218), patients in a diarrhea group had significantly worse OS than those in a non-diarrhea group in elderly patients (MST: 17.8 months vs. 27.9 months, p < 0.001).

CONCLUSIONS

Diarrhea during EF can put elderly patients at risk of postoperative malnutrition and a poor prognosis after esophagectomy.

Early Initiation of Feeding and In-Hospital Outcomes in Patients Hospitalized for Acute Heart Failure

Extensive data on early nutrition support for patients requiring critical care are available. However, whether early initiation of feeding could be beneficial for patients hospitalized for acute heart failure (HF) remains unclear. We sought to compare outcomes of early and delayed initiation of feeding for hospitalized patients with acute HF using a nationwide inpatient database. We retrospectively analyzed data from the Diagnosis Procedure Combination database. We included patients hospitalized for HF between January 2010 and March 2018. We excluded patients with length of hospital stay ≤2 days, those patients who underwent major procedures under general anesthesia, and those requiring advanced mechanical supports within 2 days after admission including intubation, intra-aortic balloon pumping, and extracorporeal membrane oxygenation. Propensity score matching and instrumental variable analyses were conducted to compare in-hospital mortality, complications and length of stay between the early and delayed feeding groups. Among 432,620 eligible patients, 403,442 patients (93%) received early initiation of feeding (within 2 days after admission) and 29,178 patients (7%) received delayed initiation of feeding. Propensity score matching created 29,153 pairs and delayed initiation of feeding was associated with higher in-hospital mortality (odds ratio 1.32; 95% confidence interval 1.26 to 1.39), longer hospital stay and higher incidence of pneumonia and sepsis. The instrumental variable analysis also showed patients with delayed initiation of feeding had higher in-hospital mortality (odds ratio 1.34; 95% confidence interval 1.28 to 1.40). In conclusion, our analysis suggested a potential benefit of early initiation of feeding for in-hospital outcomes in hospitalized patients hospitalized for acute HF. Further investigations are required to confirm our results and to clarify the underlying mechanisms.

Enteral nutrition for intubated adults in the intensive care unit prior to general anesthesia: a scoping review

OBJECTIVE

The objective of this scoping review was to examine and map fasting times for intubated adult patients in the intensive care unit prior to general anesthesia, and patient outcomes following the cessation of enteral nutrition.

BACKGROUND

Malnutrition in critically ill patients in the intensive care unit has been associated with increased infectious morbidity, increased length of intensive care unit and hospital stay, increased rate of infections, increased number of ventilator days, and impaired wound healing. One potential contributor to malnutrition is prolonged fasting times prior to general anesthesia. The American Society of Parenteral and Enteral Nutrition and the Society of Critical Care Medicine recommend minimizing fasting times prior to surgery; however, neither gives guidelines for intubated patients in the intensive care unit. By limiting fasting times with cuffed endotracheal tubes, nutritional goals could be improved without additional complications.

INCLUSION CRITERIA

This scoping review considered studies that included patients in the intensive care unit who were 18 years and older possessing a cuffed endotracheal tube, requiring enteral nutrition, and undergoing surgery requiring general anesthesia. Specifically, fasting protocols, location of enteral nutrition being delivered, and patient outcomes were mapped for studies meeting these criteria. The review also looked at available protocols for preoperative fasting times for patients with cuffed endotracheal tubes prior to surgical procedures requiring anesthesia.

METHODS

The JBI methodology was followed to complete this scoping review. The objectives, inclusion criteria, and methods of analysis for this review were previously established and documented in an a priori protocol.

RESULTS

Three studies, one prospective observational study, and two retrospective chart reviews, with a total of 128 participants, were included in this review. Also, eight fasting protocols regarding adult intensive care unit patients with cuffed endotracheal tubes prior to general anesthesia were identified.

CONCLUSIONS

The identified studies and protocols conclude that institutions apply different fasting times depending on procedure types and feeding access for patients with cuffed endotracheal tubes. Some protocols require fasting to begin at midnight on the day of the procedure, while others allow enteral nutrition to be continued throughout the procedure. All identified protocols exclude some procedures from a reduced fast, typically airway procedures and abdominal surgeries. Each institution has specific requirements for patients that qualify for a reduced fast - such as feeding tube location, type of procedure, and positioning during the procedure - as well as specific times for enteral nutrition to be held. Following review of the studies, no aspiration events were witnessed during any operative procedure where a reduced fast was used.

Nutrition update in gastric cancer surgery

Patients with gastric cancer are often malnourished during tumor progression. Malnutrition is a risk factor for postoperative complications and a poor prognosis. Early evaluation and management of nutrition can improve these outcomes. Various combined indices in which albumin is the primary component are used to evaluate the nutritional status, including the Prognostic Nutritional Index, Glasgow Prognostic Score, and Controlling Nutritional Status score. Both the American Society for Parenteral and Enteral Nutrition and the European Society for Clinical Nutrition and Metabolism guidelines recommend immediate and early oral/enteral nutrition. However, few reports have described the additional effects of preoperative immunonutrition on clinical outcomes of gastric cancer surgery. Gastrectomy types and reconstruction methods that consider the postoperative nutritional status have been used when oncologically acceptable. Total gastrectomy has recently tended to be avoided because of its negative impact on nutritional status. New findings obtained from the emergence of continuous glucose measurement, such as glucose fluctuation and nocturnal hypoglycemia, may affect nutritional management after gastrectomy. Some prospective clinical studies on perioperative nutritional intervention have set postoperative body weight loss as a primary endpoint. It seems important to continue oral nutritional supplement, even in small doses, to reduce body weight loss after gastrectomy. Evidence generated by prospective, well-developed randomized controlled studies must be disseminated so that nutritional therapy is widely recognized as an important multimodal therapy in patients undergoing gastric cancer surgery.

Early enteral nutrition in patients with severe traumatic brain injury: a propensity score-matched analysis using a nationwide inpatient database in Japan

BACKGROUND

Whether enteral nutrition (EN) should be administered early in severe traumatic brain injury (TBI) patients has not been fully addressed.

OBJECTIVE

The present study aimed to evaluate whether early EN can reduce mortality or nosocomial pneumonia among severe TBI patients.

METHODS

Using the Japanese Diagnosis Procedure Combination inpatient database from April 2014 to March 2017 linked with the Survey for Medical Institutions, we identified patients admitted for intracranial injury with Japan Coma Scale scores ≥30 (corresponding to Glasgow Coma Scale scores ≤8) at admission. We designated patients who started EN within 2 d of admission as the early EN group, and those who started EN at 3-5 d after admission as the delayed EN group. The primary outcome was in-hospital mortality. The secondary outcome was nosocomial pneumonia. Propensity score-matched analyses were performed to compare the outcomes between the 2 groups.

RESULTS

We identified 3080 eligible patients during the 36-mo study period, comprising 1100 (36%) in the early EN group and 1980 (64%) in the delayed EN group. After propensity score matching, there was no significant difference in in-hospital mortality (difference: -0.3%; 95% CI: -3.7%, 3.1%) between the 2 groups. The proportion of nosocomial pneumonia was significantly lower in the early EN group than in the delayed EN group (difference: -3.2%; 95% CI: -5.9%, -0.4%).

CONCLUSIONS

Early EN may not reduce mortality, but may reduce nosocomial pneumonia in patients with severe TBI.

Insights into the role of intestinal microbiota in hematopoietic stem-cell transplantation

The gut microbiota (GM) is able to modulate the human immune system. The development of novel investigation methods has provided better characterization of the GM, increasing our knowledge of the role of GM in the context of hematopoietic stem-cell transplantation (HSCT). In particular, the GM influences the development of the major complications seen after HSCT, having an impact on overall survival. In fact, this evidence highlights the possible therapeutic implications of modulation of the GM during HSCT. Insights into the complex mechanisms and functions of the GM are essential for the rational design of these therapeutics. To date, preemptive and curative approaches have been tested. The current state of understanding of the impact of the GM on HSCT, and therapies targeting the GM balance is reviewed herein.

Combined epidural-general anaesthesia vs general anaesthesia in neonatal gastrointestinal surgery: A randomized controlled trial

BACKGROUND

Post-operative ileus is a frequent complication of gastrointestinal surgery under general anaesthesia. The aim of this study was to investigate whether combined epidural-general anaesthesia is associated with expedited gastrointestinal function recovery in neonates undergoing elective gastrointestinal surgery.

METHODS

A randomized controlled trial including 60 neonates who underwent gastrointestinal surgery at a university hospital was performed. Thirty neonates received combined epidural-general anaesthesia (CEGA), and 30 neonates received general anaesthesia (GA) alone. The primary outcome was the post-operative time to tolerance of full enteral nutrition. The secondary outcomes were the post-operative time defaecation, the duration of nasogastric drainage, and infections.

RESULTS

After excluding two neonates from the CEGA group, where repeated attempts at epidural catheterization were unsuccessful, a total of 58 patients completed the study (CEGA: 28; GA: 30). Full enteral nutrition was tolerated earlier in CEGA vs the GA group (4.0 vs 8.0 days; P = .0001). Time to defaecation was shorter in the CEGA group (3.5 vs 5.0 days; P = .0001). Duration of nasogastric drainage was similar between groups (7.0 vs 7.0 days; P = .9502). Fewer patients in the CEGA group experienced post-operative infection (35.7% vs 60.0%; P = .038).

CONCLUSION

Combined epidural-general anaesthesia is associated with expedited gastrointestinal function recovery and a lower infection risk after gastrointestinal surgery in neonates.

Moderately high-protein enteral formula improved retinol-binding protein in tube-fed patients: A multicentre open study

Background:

Long-term inadequate dietary consumption may increase the possibility of malnutrition, morbidity and mortality. Enteral nutrition (EN) is a beneficial support that could help to maintain nutritional status and gut function.

Aim:

Our aim was to evaluate the effect of moderately high-protein enteral formula containing fibre on nutritional status, and its safety.

Method:

A total of 23 tube-feeding-dependent adult patients were included in this multicentre, open-label study. The patients were fed with the study formula for 7–12 days or equal to the required nutritional support period, during which we performed physical examinations and assessed nutritional status. The primary endpoint was the statistical difference in nutritional status after the treatment, and the secondary outcome was the desirable safety profile.

Results:

A significant improvement in cumulative energy balance after intervention was observed (p = 0.008). However, the differences in nutritional status, weight and BMI before and after the intervention do not reach statistical significance. Retinol-binding protein (RBP), a marker for nutritional status, increased from baseline levels. Few cases of diarrhoea and constipation had been reported during the study as a safety concern.

Conclusions:

This study investigated the efficacy and safety of an enteral feed formulation containing fibre. The patients were nourished with the studied formulation via tube feeding for a short period without serious adverse events. After the intervention, the significant increase in cumulative energy balance was observed. However, an extended period of the intervention may be required to attain the significance in other indicators for nutritional status.

High-fibre enteral feeding results in improved anthropometrics and favourable gastrointestinal tolerance in malnourished children with growth failure

Aim

The practical value of using fibre‐enriched enteral feeding regimens to rehabilitate malnourished children remains inconclusive. This study determined the usage patterns, gastrointestinal tolerance, anthropometrics and safety of high‐fibre enteral feeding in malnourished children with growth failure.

Methods

This Turkish observational study between February 2013 and June 2015 comprised 345 paediatric patients from 17 centres with malnutrition‐related growth failure, with a weight and height of <2 SD percentiles for their age. Changes in anthropometrics, gastrointestinal symptoms, defecation habits and safety data relating to adverse events were analysed during the six‐month follow‐up period.

Results

Most subjects (99.7%) were supplemented with enteral feeding. The absolute difference and 95% confidence interval values for the Z scores of height for age, weight for age, weight for height and body mass index for height increased significantly in four months to six months to 0.21 (0.09–0.32), 0.61 (0.51–0.70), 0.81 (0.56–1.06) and 0.70 (0.53–0.86), respectively (p < 0.001 for each). The percentage of patients with normal defecation frequency significantly increased from 70.3% to 92.8% at the four months to six months visit (p = 0.004). Adverse events occurred in 15 (4.3%) of patients.

Conclusion

Using a six‐month high‐fibre enteral feeding was associated with favourable outcomes in anthropometrics, appetite, gastrointestinal tolerance and safety in malnourished children.

Enteral nutrition for the intubated adult intensive care unit patient prior to general anesthesia: a scoping review protocol

REVIEW QUESTION

The objectives of this scoping review are to examine and map fasting times for adult intubated intensive care unit (ICU) patients prior to general anesthesia and patient outcomes following the cessation of enteral nutrition, to examine and conceptually map the evidence, and identify any gaps.Specifically, the review questions are.

Better early outcome with enteral rather than parenteral nutrition in children undergoing MAC allo-SCT

There is no consensus on the type of nutritional support to introduce in children undergoing allogeneic stem cell transplantation (allo-SCT) after myeloablative conditioning (MAC). This retrospective, multicenter, observational study compared the early administration of enteral nutrition (EN group, n = 97) versus parenteral nutrition (PN group, n = 97) in such patients with matching for important covariates. The primary endpoint was the study of day 100 overall mortality. The early outcome at day 100 was better in EN group regarding mortality rate (1% vs. 13%; p = 0.0127), non relapse mortality (1% vs. 7%; p = 0.066), acute GVHD grades II-IV (37% vs. 54%; p = 0.0127), III-IV (18% vs. 34%; p = 0.0333) and its gut localization (16% vs. 32%; p = 0.0136). Platelet engraftment was better in EN group than in PN group for the threshold of 20 G/L (97% vs. 80% p < 0.0001) and 50 G/L (92% vs. 78%, p < 0.0001). The length of stay was shorter in EN group (28 vs. 52 days, p < 0.0001). There were no differences between the two groups regarding the polynuclear neutrophil engraftment, infection rate or mucositis occurrence. These results suggest that, in children undergoing MAC allo-SCT, PN should be reserved to the only cases when up-front EN is insufficient or impossible to perform.

Porcine milk-derived exosomes promote proliferation of intestinal epithelial cells

Milk-derived exosomes were identified as a novel mechanism of mother-to-child transmission of regulatory molecules, but their functions in intestinal tissues of neonates are not well-studied. Here, we characterized potential roles of porcine milk-derived exosomes in the intestinal tract. In vitro, treatment with milk-derived exosomes (27 ± 3 ng and 55 ± 5 ng total RNA) significantly promoted IPEC-J2 cell proliferation by MTT, CCK8, EdU fluorescence and EdU flow cytometry assays. The qRT-PCR and Western blot analyses indicated milk-derived exosomes (0.27 ± 0.03 μg total RNA) significantly promoted expression of CDX2, IGF-1R and PCNA, and inhibited p53 gene expression involved in intestinal proliferation. Additionally, six detected miRNAs were significantly increased in IPEC-J2 cell, while FAS and SERPINE were significantly down-regulated relative to that in control. In vivo, treated groups (0.125 μg and 0.25 μg total RNA) significantly raised mice' villus height, crypt depth and ratio of villus length to crypt depth of intestinal tissues, significantly increased CDX2, PCNA and IGF-1R' expression and significantly inhibited p53' expression. Our study demonstrated that milk-derived exosomes can facilitate intestinal cell proliferation and intestinal tract development, thus giving a new insight for milk nutrition and newborn development and health.

Maintaining physical activity during refeeding improves body composition, intestinal hyperpermeability and behavior in anorectic mice

A role of gut-brain axis emerges in the pathophysiology of anorexia nervosa and maintaining adapted physical activity during refeeding remains discussed. We aimed to assess gastrointestinal protein metabolism and investigate the contribution of physical activity during refeeding in C57BL/6 mice with activity-based anorexia (ABA). ABA mice exhibited lower body weight and food intake with increase of lean mass/fat mass ratio and fat oxidation. Colonic permeability was increased in ABA. Ad libitum food access was then restored and ABA group was divided into two subgroups, with access to running wheel (ABA-PA) or not (ABA-NPA). After refeeding, fat free mass was completely restored only in ABA-PA. Colonic permeability was enhanced in ABA-NPA. Finally, muscle kynurenine conversion into kynurenic acid was lower in ABA-NPA who also exhibited altered behavior. Maintaining physical activity during refeeding may thus limit colonic hyperpermeability and improve behavior in anorectic mice.

Enhanced Lacto-Tri-Peptide Bio-Availability by Co-Ingestion of Macronutrients

Some food-derived peptides possess bioactive properties, and may affect health positively. For example, the C-terminal lacto-tri-peptides Ile-Pro-Pro (IPP), Leu-Pro-Pro (LPP) and Val-Pro-Pro (VPP) (together named here XPP) are described to lower blood pressure. The bioactivity depends on their availability at the site of action. Quantitative trans-organ availability/kinetic measurements will provide more insight in C-terminal tri-peptides behavior in the body. We hypothesize that the composition of the meal will modify their systemic availability. We studied trans-organ XPP fluxes in catheterized pigs (25 kg; n=10) to determine systemic and portal availability, as well as renal and hepatic uptake of a water-based single dose of synthetic XPP and a XPP containing protein matrix (casein hydrolyte, CasH). In a second experiment (n=10), we compared the CasH-containing protein matrix with a CasH-containing meal matrix and the modifying effects of macronutrients in a meal on the availability (high carbohydrates, low quality protein, high fat, and fiber). Portal availability of synthetic XPP was 0.08 ± 0.01% of intake and increased when a protein matrix was present (respectively 3.1, 1.8 and 83 times for IPP, LPP and VPP). Difference between individual XPP was probably due to release from longer peptides. CasH prolonged portal bioavailability with 18 min (absorption half-life, synthetic XPP: 15 ± 2 min, CasH: 33 ± 3 min, p<0.0001) and increased systemic elimination with 20 min (synthetic XPP: 12 ± 2 min; CasH: 32 ± 3 min, p<0.0001). Subsequent renal and hepatic uptake is about 75% of the portal release. A meal containing CasH, increased portal 1.8 and systemic bioavailability 1.2 times. Low protein quality and fiber increased XPP systemic bioavailability further (respectively 1.5 and 1.4 times). We conclude that the amount and quality of the protein, and the presence of fiber in a meal, are the main factors that increase the systemic bioavailability of food-derived XPP.

Meta-analysis of gut barrier dysfunction in patients with acute pancreatitis

BACKGROUND

The gut is implicated in the pathogenesis of acute pancreatitis but there is discrepancy between individual studies regarding the prevalence of gut barrier dysfunction in patients with acute pancreatitis. The aim of this study was to determine the prevalence of gut barrier dysfunction in acute pancreatitis, the effect of different co-variables, and changes in gut barrier function associated with the use of various therapeutic modalities.

METHODS

A literature search was performed using PRISMA and MOOSE guidelines. Summary estimates were presented as pooled prevalence of gut barrier dysfunction and the associated 95 per cent c.i.

RESULTS

A total of 44 prospective clinical studies were included in the systematic review, of which 18 studies were subjected to meta-analysis. The pooled prevalence of gut barrier dysfunction was 59 (95 per cent c.i. 48 to 70) per cent; the prevalence was not significantly affected by disease severity, timing of assessment after hospital admission or type of test used, but showed a statistically significant association with age. Overall, nine of 13 randomized clinical trials reported a significant improvement in gut barrier function following intervention compared with the control group, but only three of six studies that used standard enteral nutrition reported a statistically significant improvement in gut barrier function after intervention.

CONCLUSION

Gut barrier dysfunction is present in three of five patients with acute pancreatitis, and the prevalence is affected by patient age but not by disease severity. Clinical studies are needed to evaluate the effect of enteral nutrition on gut function in acute pancreatitis.

Enteral nutrition in critical care

There is a consensus that nutritional support, which must be provided to patients in intensive care, influences their clinical outcome. Malnutrition is associated in critically ill patients with impaired immune function and impaired ventilator drive, leading to prolonged ventilator dependence and increased infectious morbidity and mortality. Enteral nutrition is an active therapy that attenuates the metabolic response of the organism to stress and favorably modulates the immune system. It is less expensive than parenteral nutrition and is preferred in most cases because of less severe complications and better patient outcomes, including infections, and hospital cost and length of stay. The aim of this work was to perform a review of the use of enteral nutrition in critically ill patients.

Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patients

OBJECTIVES

Delay in initiating enteral nutrition has been reported to disrupt intestinal mucosal integrity in animals and to prolong the duration of mechanical ventilation in humans. However, its impact on intestinal absorptive function in critically ill patients is unknown. The aim of this study was to examine the impact of delayed enteral nutrition on small intestinal absorption of 3-O-methyl-glucose.

DESIGN

Prospective, randomized study.

SETTING

Tertiary critical care unit.

PATIENTS

Studies were performed in 28 critically ill patients.

INTERVENTIONS

Patients were randomized to either enteral nutrition within 24 hrs of admission (14 "early feeding": 8 males, 6 females, age 54.9 ± 3.3 yrs) or no enteral nutrition during the first 4 days of admission (14 "delayed feeding": 10 males, 4 females, age 56.1 ± 4.2 yrs).

MEASUREMENTS AND MAIN RESULTS

Gastric emptying (scintigraphy, 100 mL of Ensure (Abbott Australia, Kurnell, Australia) with 20 MBq Tc-suphur colloid), intestinal absorption of glucose (3 g of 3-O-methyl-glucose), and clinical outcomes were assessed 4 days after intensive care unit admission. Although there was no difference in gastric emptying, plasma 3-O-methyl-glucose concentrations were less in the patients with delayed feeding compared to those who were fed earlier (peak: 0.24 ± 0.04 mmol/L vs. 0.37 ± 0.04 mmol/L, p < .02) and integrated (area under the curve at 240 mins: 38.5 ± 7.0 mmol/min/L vs. 63.4 ± 8.3 mmol/min/L, p < .04). There was an inverse correlation between integrated plasma concentrations of 3-O-methyl-glucose (area under the curve at 240 mins) and the duration of ventilation (r = -.51; p = .006). In the delayed feeding group, both the duration of mechanical ventilation (13.7 ± 1.9 days vs. 9.2 ± 0.9 days; p = .049) and length of stay in the intensive care unit (15.9 ± 1.9 days vs. 11.3 ± 0.8 days; p = .048) were greater.

CONCLUSIONS

In critical illness, delaying enteral feeding is associated with a reduction in small intestinal glucose absorption, consistent with the reduction in mucosal integrity after nutrient deprivation evident in animal models. The duration of both mechanical ventilation and length of stay in the intensive care unit are prolonged. These observations support recommendations for "early" enteral nutrition in critically ill patients.

Glutamine therapy improves outcome of in vitro and in vivo experimental colitis models

BACKGROUND

Pharmacologic doses of glutamine (GLN) can improve clinical outcome following acute illness and injury. Recent studies indicate enhanced heat shock protein (HSP) expression is a key mechanism underlying GLN's protection. However, such a link has not yet been tested in chronic inflammatory states, such as experimental inflammatory bowel disease (IBD).

METHODS

Experimental colitis was induced in Sprague-Dawley rats via oral 5% dextran sulfate sodium (DSS) for 7 days. GLN (0.75 g/kg/d) or sham was administered to rats by oral gavage during 7-day DSS treatment. In vitro inflammatory injury was studied using YAMC colonic epithelial cells treated with varying concentrations of GLN and cytokines (tumor necrosis factor-α/interferon-γ).

RESULTS

Pharmacologic dose, bolus GLN attenuated DSS-induced colitis in vivo with decreased area under curve for bleeding (8.06 ± 0.87 vs 10.38 ± 0.79, P < .05) and diarrhea (6.97 ± 0.46 vs 8.53 ± 0.39, P < .05). This was associated with enhanced HSP25 and HSP70 in colonic mucosa. In vitro, GLN enhanced cell survival and reduced proapoptotic caspase3 and poly(ADP-ribose) polymerase cleavage postcytokine injury. Cytokine-induced inducible nitric oxide synthase expression and nuclear translocation of nuclear factor-κB p65 subunit were markedly attenuated at GLN concentrations above 0.5 mmol/L. GLN increased cellular HSP25 and HSP70 in a dose-dependent manner.

CONCLUSIONS

These data demonstrate the therapeutic potential of GLN as a "pharmacologically acting nutrient" in the setting of experimental IBD. GLN sufficiency is crucial for the colonic epithelium to mount a cell-protective, antiapoptotic, and anti-inflammatory response against inflammatory injury. The enhanced HSP expression observed following GLN treatment may be responsible for this protective effect.

Effects of enteral immunonutrition on the maintenance of gut barrier function and immune function in pigs with severe acute pancreatitis

BACKGROUND

This study evaluated the effects of enteral immunonutrition (EIN) supplemented with glutamine, arginine, and probiotics on gut barrier function and immune function in pigs with severe acute pancreatitis (SAP).

METHODS

The model was induced by retrograde injection of 5% sodium taurocholate and trypsin via the pancreatic duct. After induction of SAP, 18 pigs were randomly divided into 3 groups, in which either parenteral nutrition (PN), control enteral nutrition (CEN), or EIN was applied for 8 days. Serum and pancreatic fluid amylase concentration was determined. Intestinal permeability (lactulose to mannitol ratio) was measured by high-performance liquid chromatography, and plasma endotoxin was quantified by the chromogenic limulus amebocyte lysate technique. Samples of venous blood and organs were cultured using standard techniques. Pancreatitis severity and villi of ileum were scored according to histopathologic grading. Plasma T-lymphocyte subsets were measured by flow cytometry, and immunoglobulins (Igs) were determined via enzyme-linked immunosorbent assay.

RESULTS

There were no significant differences in serum and pancreatic fluid amylases concentrations or in pancreatitis severity between any 2 of the 3 groups. Compared with PN and CEN, EIN significantly decreased intestinal permeability, plasma endotoxin concentration, and the incidence and magnitudes of bacterial translocation, but increased ileal mucosal thickness, villous height, crypt depth, and percentage of normal intestinal villi. Significant differences were found in CD3+, CD4+ lymphocyte subsets, the ratio of CD4+: CD8+ lymphocyte subsets, and serum IgA and IgG, but not IgM, between any 2 of the 3 groups.

CONCLUSIONS

EIN maintained gut barrier function and immune function in pigs with SAP.

Parenteral nutrition: a clear and present danger unabated by tight glucose control

BACKGROUND

The infectious risks of parenteral nutrition (PN) in critical illness are well described, although most literature predates tight glucose control (TGC) practice. The authors hypothesized that PN-related complications are ameliorated by TGC and are equivalent to those in enteral nutrition (EN) patients.

METHODS

A prospective cohort study of patients admitted to the surgical intensive care unit was conducted, comparing PN and EN patients. TGC target was 80 to 110 mg/dL. Univariate and multivariate logistic regression was used to explore the association between infectious outcomes and PN use.

RESULTS

One hundred fifty-five patients were studied. Mean daily glucose values were lower for the PN group than for the EN patients (118.2 vs 125.6 mg/dL, P = .002). Nonetheless, the incidence of bloodstream infection and catheter-related bloodstream infection was significantly associated with the administration of PN. In a multivariate logistic regression model, PN was associated with a >4-fold increase in the odds of having a catheter-related bloodstream infection (odds ratio, 4.48; 95% confidence interval, 1.14-17.49; P = .03).

CONCLUSIONS

Despite the successful implementation of TGC, PN is still a significant risk factor for infectious complications among surgical intensive care unit patients.

Nutritional programming of gastrointestinal tract development. Is the pig a good model for man?

The consequences of early-life nutritional programming in man and other mammalian species have been studied chiefly at the metabolic level. Very few studies, if any, have been performed in the gastrointestinal tract (GIT) as the target organ, but extensive GIT studies are needed since the GIT plays a key role in nutrient supply and has an impact on functions of the entire organism. The possible deleterious effects of nutritional programming at the metabolic level were discovered following epidemiological studies in human subjects, and confirmed in animal models. Investigating the impact of programming on GIT structure and function would need appropriate animal models due to ethical restrictions in the use of human subjects. The aim of the present review is to discuss the use of pigs as an animal model as a compromise between ethically acceptable animal studies and the requirement of data which can be interpolated to the human situation. In nutritional programming studies, rodents are the most frequently used model for man, but GIT development and digestive function in rodents are considerably different from those in man. In that aspect, the pig GIT is much closer to the human than that of rodents. The swine species is closely comparable with man in many nutritional and digestive aspects, and thus provides ample opportunity to be used in investigations on the consequences of nutritional programming for the GIT. In particular, the 'sow-piglets' dyad could be a useful tool to simulate the 'human mother-infant' dyad in studies which examine short-, middle- and long-term effects and is suggested as the reference model.

Exogenous ghrelin regulates proliferation and apoptosis in the hypotrophic gut mucosa of the rat

Ghrelin is the natural endogenous ligand for growth hormone secretagogue receptors. This peptide regulates energy homeostasis and expenditure and is a potential link between gut absorptive function and growth. We hypothesized that ghrelin may induce a proliferative and antiapoptotic action promoting the recovery of the hypotrophic gut mucosa. Therefore, the aim of the study was to determine the action of exogenous ghrelin following gut mucosal hypotrophia in rats fed an elemental diet. An elemental diet provides readily absorbable simple nutrients and is usually given to patients with absorptive dysfunction. Male Wistar rats ( n = 48) were fed the elemental diet for one week to induce mucosal hypotrophy and then treated for another week with systemic ghrelin and pair-fed with either a normoproteic or hyperproteic isocaloric liquid diet. Another group received a standard diet instead of the elemental diet and served as control (normotrophy). The elemental diet induced intestinal hypotrophia characterized by decreased proliferation in the ileum and increased apoptosis in jejunum and ileum. Ghrelin administration restored normal levels of proliferation in the ileum and apoptosis in the jejunum, with partial apoptosis restoration in the ileum. Ghrelin levels in plasma and fundus were increased in all groups, although the highest levels were found in rats treated with exogenous ghrelin. Ghrelin administration has a positive effect in the hypotrophic gut, regulating both proliferation and apoptosis towards a physiological balance counteracting the negative changes induced by an elemental diet in the intestines.

Complications and monitoring - Guidelines on Parenteral Nutrition, Chapter 11

Compared to enteral or hypocaloric oral nutrition, the use of PN (parenteral nutrition) is not associated with increased mortality, overall frequency of complications, or longer length of hospital stay (LOS). The risk of PN complications (e.g. refeeding-syndrome, hyperglycaemia, bone demineralisation, catheter infections) can be minimised by carefully monitoring patients and the use of nutrition support teams particularly during long-term PN. Occuring complications are e.g. the refeeding-syndrome in patients suffering from severe malnutrition with the initiation of refeeding or metabolic, hypertriglyceridemia, hyperglycaemia, osteomalacia and osteoporosis, and hepatic complications including fatty liver, non-alcoholic fatty liver disease, cholestasis, cholecystitis, and cholelithiasis. Efficient monitoring in all types of PN can result in reduced PN-associated complications and reduced costs. Water and electrolyte balance, blood sugar, and cardiovascular function should regularly be monitored during PN. Regular checks of serum electrolytes and triglycerides as well as additional monitoring measures are necessary in patients with altered renal function, electrolyte-free substrate intake, lipid infusions, and in intensive care patients. The metabolic monitoring of patients under long-term PN should be carried out according to standardised procedures. Monitoring metabolic determinants of bone metabolism is particularly important in patients receiving long-term PN. Markers of intermediary, electrolyte and trace element metabolism require regular checks.

Protective effect of galactooligosaccharide-supplemented enteral nutrition on intestinal barrier function in rats with severe acute pancreatitis

BACKGROUND & AIMS

Intestinal barrier dysfunction may play an important role in the secondary infectious complications associated with severe acute pancreatitis (SAP). We aimed to investigate the protective effect of enteral nutrition supplemented with prebiotics, namely, galactooligosaccharides (GOS), on intestinal barrier function in SAP rats.

METHODS

We randomly divided 60 Sprague-Dawley (SD) rats into 6 groups: sham operation 4-d and 7-d groups, SAP with standard enteral nutrition (EN) 4-d and 7-d groups, and SAP with GOS-supplemented EN (PRE-EN) 4-d and 7-d groups (n = 10 in each group). The intestinal barrier function was assessed on the basis of several aspects, including the number of colonic bifidobacteria and lactobacilli, sIgA concentration in intestinal mucus, extent of apoptosis in intestinal epithelial cells, and the protein expression and mRNA of the intestinal tight junction protein occludin. The results for groups at the same time points were compared with each other.

RESULTS

We observed that the intestinal barrier function was impaired after the establishment of the SAP model, in comparison with the sham control group. In the PRE-EN groups, the number of fecal bifidobacteria, sIgA level in intestinal mucus, intestinal occludin mRNA level at both day 4 and day 7, and extent of intestinal epithelial apoptosis at day 7 were significantly higher than the corresponding values in the standard EN groups (P < 0.05).

CONCLUSION

Supplementation of the prebiotic GOS in EN can significantly improve intestinal barrier function in SAP rats.

Neonatal outcome of gastroschisis is mainly influenced by nutritional management

OBJECTIVE

The aim of the study was to evaluate early minimal enteral feeding (MEF) and gradual enteral nutrition increment on neonatal outcome of gastroschisis.

PATIENTS AND METHODS

An intervention group was prospectively assessed and compared with an observational historical control group. The prospective study relied on a new protocol of enteral nutrition. According to the new protocol, MEF was initiated 5 days after bowel reintegration and milk amounts were increased 12 mL/kg/day. In the control group, enteral nutrition was delayed until resolution of postoperative ileus, and increment of feeding was not systematized.

RESULTS

Twenty-two patients were included in the MEF group and compared with 51 control patients. Infants in the control group had lower gestational age (36 vs 35 gestational weeks [GW], P=0.03) and birth weight (2465 vs 2200 g, P=0.05). Time to first enteral nutrition (5 vs 11.5 days, P=0.0005) was significantly shorter in the MEF group. All patients in this group were fully enteral fed at day 60, though 30.4% of patients in the control group still needed parenteral nutrition at day 60 (P=0.004). Incidence of nosocomial infection was reduced (9% of patients vs 40%, P=0.016) and hospital stay tended to be shorter in the MEF group (40 vs 54.5 days, P=0.08). In the univariate analysis, factors influencing the length of parenteral nutrition during the 2 periods were the severity of perivisceritis and new nutritional protocol. In the multivariate analysis, only nutritional protocol was significantly associated with the length of parenteral nutrition (P=0.038).

CONCLUSIONS

Early MEF and controlled increase of nutritional elements after bowel reintegration significantly improved outcome of gastroschisis in newborns.

The impact of delaying enteral feeding on gastric emptying, plasma cholecystokinin, and peptide YY concentrations in critically ill patients

BACKGROUND

Enteral nutrient (EN) deprivation slows gastric emptying (GE) and increases plasma cholecystokinin (CCK) concentrations in healthy humans and may potentially contribute to the delayed GE in the critically ill. This study examined the impact of delayed feeding on GE, plasma CCK, and peptide YY (PYY) concentrations in the critically ill.

DESIGN

Randomized controlled trial.

SETTING

Mixed medical and surgical intensive care unit (ICU).

INTERVENTIONS

Twenty-eight critically ill patients were randomized to receive EN either within 24 hrs of admission ("early feeding": 54.9 +/- 3.3 yrs; Acute Physiology and Chronic Health Evaluation (APACHE) II = 23.0 +/- 1.8) or on day 4 of admission after GE assessment ("delayed feeding": 56.1 +/- 4.2 yrs, APACHE II = 21.7 +/- 1.8). GE of 100 ml of Ensure was measured using scintigraphy on day 4 of admission. Blood was sampled for measurement of plasma CCK, PYY, and glucose concentrations.

RESULTS

Demographics, APACHE II score, use of inotrope and morphine sedation were similar between the groups. The mean administered/prescribed caloric ratio in the "early feeding" group was 72 +/- 4%. There were no differences in the retention of meal, intragastric meal distribution, proportion of patients with delayed GE (9/14 vs. 9/14), and plasma CCK and PYY concentrations during fasting and postprandially between the two groups. There was no relationship between the number of calories received and percentage of meal retention at 240 min (p > .05). However, delayed feeding was associated with longer duration of mechanical ventilations (13.7 +/- 1.9 vs. 9.2 +/- .9 days, p = .049) and length of stay in ICU (15.9 +/- 1.9 vs. 11.3 +/- 0.8 days, p = .048), but no difference in mortality.

CONCLUSIONS

In critical illness, delayed enteral feeding appears to have little impact on either GE or the enterogastric feedback hormones. However, the association between delayed feeding and increased duration of ventilation and length of stay in the ICU supports the current recommendation that enteral nutrition should be commenced early.

Effect of Enteral Versus Parenteral Nutrition on LPS-Induced Sepsis in a Rat Model

BACKGROUND

The purpose of the present study was to determine whether total enteral nutrition (TEN) or total parenteral nutrition (TPN) differ in their modulation of ghrelin production and cardiac dysfunction induced by lipopolysaccharide (LPS).

MATERIALS AND METHODS

Vascular catheters or gastrostomy tubes were surgically placed into rats who received isocaloric parenteral or enteral nutrition postoperatively. After 7 d, the rats were injected intravenously with LPS (2.5 mg/kg). Serum ghrelin levels were determined by enzyme-linked immunosorbent assay and myocardiac function was assessed via the Langendorff isolated heart technique.

RESULTS

Before and after the administration of LPS, TEN was found to be more effective at increasing the plasma ghrelin levels than TPN. After LPS administration, left-ventricular developed pressure decreased in animals receiving TPN when compared with animals receiving TEN. Animals receiving TPN also had significant reductions in their maximal rates of increase (+dp/dt max) and decrease (-dp/dt max) in left ventricular pressure when compared with animals receiving TEN (unpaired t-test, P < 0.05). Upon reperfusion after 30 min of ischemia, the left ventricular resting tension decreased in animals receiving TPN compared with animals receiving TEN. Thereafter, left-ventricular developed pressure, +dp/dt max, and -dp/dt max decreased in the TEN recipients in comparison to the TPN-receiving animals.

CONCLUSIONS

We conclude that TEN more effectively increases plasma ghrelin levels than TPN. The maintenance of higher ghrelin levels in TEN-fed rats is associated with maintaining cardiac function during LPS-induced septic shock.

Managing liver dysfunction in parenteral nutrition

Parenteral nutrition is life saving in patients with intestinal failure but liver dysfunction is commonly encountered, especially in neonates. Although abnormal liver function tests associated with short-term parenteral nutrition are usually benign and transient, liver dysfunction in both children and adults receiving long-term parenteral nutrition can progress to end-stage liver disease and liver failure. The aetiology of parenteral nutrition-associated liver disease is complex and multifactorial, with a range of patient, disease and nutrition-related factors implicated. Sepsis is of particular importance, as is the lack of enteral nutrition and overfeeding with intravenous glucose and/or lipid. Deficiencies of a number of amino acids including choline and taurine have also been implicated. Management of hepatic dysfunction in parenteral nutrition should initially focus on preventing its occurrence. Sepsis should be managed appropriately, enteral nutrition should be encouraged and maximised where possible and parenteral overfeeding should be avoided. Provision of parenteral lipid should be optimised to prevent the adverse effects of both deficiency and excess, and cyclical rather than continuous parenteral feeding should be administered. There is some evidence of benefit in neonates from oral antibiotics to prevent intestinal bacterial overgrowth and from oral ursodeoxycholic acid, but less to support their use in adults. Similarly, data to support widespread use of parenteral choline or taurine supplementation are lacking at present. Ultimately, severe parenteral nutrition-associated liver disease may necessitate referral for small intestine and/or liver transplantation.

Fasting induces a biphasic adaptive metabolic response in murine small intestine

BACKGROUND

The gut is a major energy consumer, but a comprehensive overview of the adaptive response to fasting is lacking. Gene-expression profiling, pathway analysis, and immunohistochemistry were therefore carried out on mouse small intestine after 0, 12, 24, and 72 hours of fasting.

RESULTS

Intestinal weight declined to 50% of control, but this loss of tissue mass was distributed proportionally among the gut's structural components, so that the microarrays' tissue base remained unaffected. Unsupervised hierarchical clustering of the microarrays revealed that the successive time points separated into distinct branches. Pathway analysis depicted a pronounced, but transient early response that peaked at 12 hours, and a late response that became progressively more pronounced with continued fasting. Early changes in gene expression were compatible with a cellular deficiency in glutamine, and metabolic adaptations directed at glutamine conservation, inhibition of pyruvate oxidation, stimulation of glutamate catabolism via aspartate and phosphoenolpyruvate to lactate, and enhanced fatty-acid oxidation and ketone-body synthesis. In addition, the expression of key genes involved in cell cycling and apoptosis was suppressed. At 24 hours of fasting, many of the early adaptive changes abated. Major changes upon continued fasting implied the production of glucose rather than lactate from carbohydrate backbones, a downregulation of fatty-acid oxidation and a very strong downregulation of the electron-transport chain. Cell cycling and apoptosis remained suppressed.

CONCLUSION

The changes in gene expression indicate that the small intestine rapidly looses mass during fasting to generate lactate or glucose and ketone bodies. Meanwhile, intestinal architecture is maintained by downregulation of cell turnover.

Review article: bacterial translocation in the critically ill--evidence and methods of prevention

BACKGROUND

Delayed sepsis, systemic inflammatory response syndrome (SIRS) and multiorgan failure remain major causes of morbidity and mortality on intensive care units. One factor thought to be important in the aetiology of SIRS is failure of the intestinal barrier resulting in bacterial translocation and subsequent sepsis.

AIM

This review summarizes the current knowledge about bacterial translocation and methods to prevent it.

METHODS

Relevant studies during 1966-2006 were identified from a literature search. Factors, which detrimentally affect intestinal barrier function, are discussed, as are methods that may attenuate bacterial translocation in the critically ill patient.

RESULTS

Methodological problems in confirming bacterial translocation have restricted investigations to patients undergoing laparotomy. There are only limited data available relating to specific interventions that might preserve intestinal barrier function or limit bacterial translocation in the intensive care setting. These can be categorized broadly into pre-epithelial, epithelial and post-epithelial interventions.

CONCLUSIONS

A better understanding of factors that influence translocation could result in the implementation of interventions which contribute to improved patient outcomes. Glutamine supplementation, targeted nutritional intervention, maintaining splanchnic flow, the judicious use of antibiotics and directed selective gut decontamination regimens hold some promise of limiting bacterial translocation. Further research is required.

N-acetyl-L-glutamine, a liquid-stable source of glutamine, partially prevents changes in body weight and on intestinal immunity induced by protein energy malnutrition in pigs

The goal of this study was to evaluate the preventive effect of free glutamine versus N-acetyl-L-glutamine, a liquid-stable source of glutamine, on gut damage induced by protein energy malnutrition in pigs. Healthy pigs (n = 6) were fed a liquid formula for 30 days. Three subgroups of malnourished pigs (n = 6) received daily 20% of the food intake recorded in control group, supplemented with calcium caseinate, glutamine, or N-acetyl-L-glutamine. Body weight was recorded, and small intestinal samples were evaluated for biochemical and immunologic parameters. Suppression in body weight gain was significantly lower in pigs fed with N-acetyl-L-glutamine than in the rest of malnourished pigs. Total number of lymphocytes, CD21+ B cells and CD4+ T cells in ileal Peyer patches were not significantly different in malnourished pigs fed with N-acetyl-L-glutamine and in healthy pigs. In conclusion, N-acetyl-L-glutamine has a moderate protective effect, partially preventing changes induced by protein energy malnutrition.

Effect of severe undernutrition and subsequent refeeding on gut mucosal protein fractional synthesis in human subjects

OBJECTIVE

Undernutrition has been associated with gut mucosal atrophy, impaired absorption, and increased permeability. This study investigated the effect of severe undernutrition and subsequent refeeding on gastric and duodenal mucosal protein fractional syntheses (MPFS).

METHODS

MPFS was investigated in the gastric body, antrum, and duodenum of 23 severely undernourished patients by means of (14)C-leucine incorporation into tissue protein and repeated after a period of refeeding. Results were evaluated in comparison with a group of 22 healthy controls and presented as mean +/- standard error of the mean.

RESULTS

The mean body index of the undernourished patients was 13.29 +/- 0.33 kg/m(2) versus 22.67 +/- 0.63 kg/m(2) in the controls (P < 0.001). MPFS in the controls and undernourished patients were similar (gastric body, 36.49 +/- 2.88 versus 33.41 +/- 3.08%/d; gastric antrum, 25.51 +/- 2.20 versus 24.95 +/- 2.32%/d; duodenum, 25.90 +/- 2.58 versus 25.49 +/- 1.99%/d). After refeeding, the body mass index of the undernourished patients increased to 15.87 +/- 0.44 kg/m(2) (P < 0.001). The MPFS increased significantly (gastric body, 51.80 +/- 8.12%/d, P < 0.05; gastric antrum, 33.44 +/- 3.66%/d, P < 0.05; duodenum, 46.27 +/- 8.02%/d, P < 0.01), with the MPFS of the duodenum significantly greater than the control values (P = 0.01).

CONCLUSION

Despite severe undernutrition, MPFS of the gastric body, antrum, and duodenum remained similar to control values. Enteral feeding resulted in a significant increase in MPFS, indicating a trophic response.

Nutrition and management of enterocutaneous fistula

BACKGROUND

The management of enterocutaneous fistula is challenging, with significant associated morbidity and mortality. This article reviews treatment, with emphasis on the provision and optimal route of nutritional support.

METHODS

Relevant articles were identified using Medline searches. Secondary articles were identified from the reference lists of key papers.

RESULTS AND CONCLUSION

Management of enterocutaneous fistula should initially concentrate on correction of fluid and electrolyte imbalances, drainage of collections, treatment of sepsis and control of fistula output. The routine use of somatostatin infusion and somatostatin analogues remains controversial; although there are data suggesting reduced time to fistula closure, there is little evidence of increased probability of spontaneous closure. Malnutrition is common and adequate nutritional provision is essential, enteral where possible, although supplemental parenteral nutrition is often required for high-output small bowel fistulas. The role of immunonutrition is unknown. Surgical repair should be attempted when spontaneous fistula closure does not occur, but it should be delayed for at least 3 months.

Enteral Feeding and Early Outcomes of Patients Undergoing Allogeneic Stem Cell Transplantation Following Myeloablative Conditioning

The purpose of this study was to evaluate the impact of enteral nutrition on early outcome of patients after myeloablative allogeneic stem cell transplantation (allo-SCT). From January 2001 to January 2003, 22 patients agreed to receive enteral nutrition via a nasogastric feeding tube; the remaining 23 patients received parenteral nutrition (n=22) or standard oral feeding (n=1). Early complications and factors influencing 100-day overall survival (OS) were investigated. Patients who received enteral nutrition developed less often acute-grade III/IV graft-versus-host disease (18%) than those who did not (35%) (P=0.011). In addition, this group showed lower mortality from infection during the first 100 days after transplantation. In multivariate analyses, only the absence of enteral nutrition was found to adversely influence 100-day OS with a hazard ratio of 8.3. Enteral nutrition is a safe and effective method for feeding allo-SCT patients. A randomized trial is warranted to confirm its advantage on early patient outcome.

Hypertonic saline enhances host defense to bacterial challenge by augmenting Toll-like receptors*

OBJECTIVE

To determine whether hypertonic saline infusion modulates thermal injury-induced bacterial translocation and host response to bacterial challenge through the augmentation of Toll-like receptors (TLRs).

DESIGN

Prospective, experimental study.

SETTING

Research laboratory at a university hospital.

SUBJECTS

Thermal injury models in the mice.

INTERVENTIONS

In experiment 1, mice underwent burn were given with 10 mL/kg hypertonic saline (7.5% NaCl), 10 mg/kg saline (N/S1), or 80 mL/kg saline (N/S2) at 4 or 8 hrs after burn. At 24 hrs after burn, mesenteric lymph nodes were harvested for bacterial translocation assay. In experiment 2, mice receiving hypertonic saline or saline after thermal injury received peritoneal challenge with Escherichia coli, and bacterial clearance was measured. In experiment 3, peritoneal cells from mice receiving hypertonic saline or saline after thermal injury were incubated with E. coli, and bacterial count, TLR2, TLR4, MIP2, CXCR2, pp38, and ERK expression were evaluated. In experiment 4, reactive oxygen species production, CXCR2, MIP2, TLR2, and TLR4 expression of bone marrow neutrophil from mice receiving hypertonic saline or saline treatment after thermal injury were evaluated. In experiment 5, neutrophil were cultured with hypertonic saline or N/S and incubated with E. coli. TLR2 and TLR4 expression and bacterial count were evaluated. In experiment 6, mice were fed with oral antibiotics with or without lipopolysaccharide, a TLR ligand, supplements. At 24 hrs after burn, mesenteric lymph nodes were harvested for bacterial translocation assay, and neutrophils were harvested for TLR2 and TLR4 protein assay.

MEASUREMENTS AND MAIN RESULTS

Hypertonic saline decreased thermal injury-induced bacterial translocation. Hypertonic saline increased bacterial clearance, phagocytic activity, and TLR2, TLR4, CXCR2, pp38, and p44/42 expression of peritoneal cells. Hypertonic saline treatment at 4 or 8 hrs after thermal injury decreased reactive oxygen species production of neutrophil. Hypertonic saline injection increased TLR2, TLR4, and pp38 expression of neutrophil. In vitro treatment of neutrophil with hypertonic saline increased phagocytic activity and TLR2 and TLR4 expression. Commensal depletion with oral antibiotics decreased TLR2 and TLR4 expression of neutrophil; lipopolysaccharide increased TLR4 expression of neutrophil and decreased thermal injury-induced bacterial translocation.

CONCLUSIONS

Restoration of extracellular fluid in burn shock with hypertonic saline decreased thermal injury-induced bacterial translocation. Hypertonic saline increased the phagocytic activity and TLR2, TLR4, CXCR2, pp38, and P44/42 expression of peritoneal cells. Hypertonic saline decreased reactive oxygen species but increased TLR2, TLR4, and pp38 expression and phagocytic activity of bone marrow neutrophil. Stimulation of the TLRs with lipopolysaccharide in commensal depleted mice increased TLRs expression of neutrophil and decreased thermal injury-induced bacterial translocation. Taken together with the fact that stimulation of TLRs with hypertonic saline increases phagocytic activity of systemic inflammatory cells, we conclude that TLRs play a critical role in the innate immunity by recognizing bacteria and that hypertonic saline enhances host response to bacterial challenge by increasing TLRs of inflammatory cells.

Early enteral feeding in newborn surgical patients

OBJECTIVE

We report the results of a multicenter prospective trial of early enteral trophic feeding in a group of 56 neonates who required abdominal surgery for a variety of congenital anomalies.

METHODS

In this clinical study, 33 neonates were fed in the early postoperative period (early enteral nutrition [EEN] group), and the remaining 23 (control [C] group) were fasted until resolution of postoperative ileus. Patients in the EEN group (Kocaeli feeding protocol) received 3 to 5 mL of breast milk every hour through a nasogastric feeding tube, starting a mean of 12 h (8 to 20 h) after surgery. The nasogastric tube was clamped for 40 min after each infusion and then opened for drainage. Groups were further divided into two subgroups according to whether an intestinal anastomosis or laparotomy was performed. The change in daily gastric drainage, time to first stool, day of toleration to full oral feeding, and length of hospital stay were compared. Blood bilirubin levels, white blood cell count, and C-reactive protein levels were monitored.

RESULTS

The time to first stool and day of toleration to full oral feeding occurred significantly sooner, whereas nasogastric tube drainage duration and hospital stay were significantly shorter in the EEN-anastomosis group than in the C-anastomosis group. Time to first stool occurred significantly sooner in the EEN-laparotomy group than in the C-laparotomy group, although other parameters did not differ. Neither anastomotic leakage nor dehiscence was observed in any group. There were two cases of wound infection and two of exitus among patients in the C group.

CONCLUSION

Postoperative, early intragastric, small-volume breast milk feeding is well tolerated by newborns. It is a reliable and feasible approach in neonates even in the presence of an intestinal anastomosis after abdominal surgery.

Effects of hyperosmolar agents--lactulose, lactitol, sodium phosphate and polyethylene glycol--on cecal coliform bacteria during traditional bowel cleansing: an experimental study in rats

Mechanical bowel cleansing is considered to be necessary prior to colorectal surgery, some radiological or endoscopic procedures, and for fecal disimpaction. Traditional bowel cleansing (TBC) with cathartics and enemas is a method of mechanical bowel cleansing for patients who have restrictive factors for whole-bowel irrigation (WBI), such as excessive fecal impaction, cardiac, hepatic or renal disorders. In this experimental study, TBC with hyperosmolar agents was evaluated in terms of their effects on colonic flora and bacterial translocation (BT). Sprague-Dawley rats were divided into 6 groups. The animals, except controls, were not fed for 72 h but received tap water ad libitum. During this period, lactulose, lactitol, sodium phosphate (NaP), polyethylene glycol 3350 (PEG3350) and physiological saline gavages were administered to the rats in groups 1-5, respectively, once a day. All animals except controls (group 6) received enemas with 15 ml of warm saline twice a day. The cecum, mesenteric lymph nodes (MLNs) and portal vein blood were sampled for microbiological and histopathological analysis. The highest level of coliform bacterial overgrowth and BT to MLNs were observed in the lactulose group, although the others, except the saline and control groups, also caused some degree of BT. Portal vein cultures were negative for all groups. Histopathological damage was not associated with cecal bacterial count and BT. As a result of this study, PEG3350 seems to be safer and more effective than lactulose, lactitol and NaP during TBC.