This study aimed to describe the feeding practices and evaluate the dietary intake during the first 7 post-operative GI days of patients. Subjects (n = 82) were post-operative GI patients undergoing care by the Surgery department and Oncology and Palliative Care Department in Hanoi Medical Uninversity Hospital, from 2015 to 2016. The nutritional intake during the first 7 post-operative GI days, types, and routes of nutritional regimens, were assessed.
JOURNAL OF MEDICAL RESEARCH THE FEEDING PRACTICES OF POST - OPERATIVE GASTROINTESTINAL PATIENTS IN HANOI MEDICAL UNIVERSITY HOSPITAL, VIETNAM Linh Nguyen Thuy, Thao Tran Phuong, Phuong Duong Thi Hanoi Medical University In recent years, the feeding practices of post-operative gastrointestinal (GI) patients have begun to be examined more in-depth This study aimed to describe the feeding practices and evaluate the dietary intake during the first post-operative GI days of patients Subjects (n = 82) were post-operative GI patients undergoing care by the Surgery department and Oncology and Palliative Care Department in Hanoi Medical Uninversity Hospital, from 2015 to 2016 The nutritional intake during the first post-operative GI days, types, and routes of nutritional regimens, were assessed The average time of total parenteral nutrition was 83 hours (about 3.46 days) In which, minimum time was 24 hours (1 day) and maximum one was 168 hours (7 days) The mean calories and protein of TPN were 17.5 kcal/kg Ideal Body Weight/day and 0.5 g/kg IBW/ day, respectively The ratio of calories from carbohydrates, lipid and protein of TPN were 48.8; 39.3; 11.9%, respectively The energy consumption (kcal/kg IBW) had tended to rise in the following days They were 13.8 kcal/kg IBW (the 1st post-operative day), 20.3 kcal/kg IBW (the 3rd post-operative day) and 23.7 kcal/kg IBW (the 7th post-operative day) On the 7th post-operative day, the calories ratio of carbohydrates, lipid and protein were about 57; 30; 13, respectively Total calories and protein intake of post-operative GI patients were lower than the recommendation The calories ratio of protein, lipid and carbohydrates intake were suboptimal EN was used late for post-operative GI patients, TPN was quite popular and was held for a long time Keywords: Feeding practices, Post-operative gastrointestinal, Hanoi Medical University Hospital, Vietnam Abbreviations: OPCD = Oncology and Palliative Care Department, HMUH = Hanoi Medical University Hospital, GI = Gastrointestinal, EN = Enteral nutrition, PN = Parenteral nutrition, TPN = Total parenteral nutrition, ESPEN = The European Society for Clinical Nutrition and Metabolism I INTRODUCTION ods of starvation, the stress of surgery and Malnutrition is a common finding in patients subsequent increase in metabolic rate [2] The presenting for surgical management of upper prevalence of malnutrition depends on the gastrointestinal and colorectal malignancies, diseases type, surgery location and treatment with an estimated prevalence to be in the [3] range of 30% to 50% [1] Patients undergoing surgery are at risk of malnutrition due to peri- Recently, the maintenance of a trophic gut mucosa through enteral nutrition and the boost of the immune response through administra- Corresponding author: Nguyen Thuy Linh, Hanoi Medical University Email: nguyenthuylinh@hmu.edu.vn Received: 03/10/2018 Accepted: 18/11/2018 JMR 116 E3 (7) - 2018 tion of specialized nutrients became the main aim of perioperative nutrition (PN) even in well -nourished patients [4] Other strategies such as early enteral nutrition post-operation and 45 JOURNAL OF MEDICAL RESEARCH intravenous fluid restriction have proven have criteria for inclusion in the study: 1) ≥ 18 years adequate outcomes Meta-analysis has indi- old; 2) had undergone GI surgery Esophageal, cated that early enteral nutrition was associ- Gastric, Small intestinal and Colon-rectal ated with significant reductions in post- surgery) A convenience sampling technique operative complications, the length of hospital was used to recruit patients Patients who had stay, and resumption of bowel function com- GI surgery in HMUH were invited to enroll in pared with traditional postoperative feeding the study A total of 82 patients participated in practices In addition, data also demonstrated this research that there was no obvious benefit for keeping patients without food, or “nil by mouth,” after gastrointestinal operation [4; 5] Variables Demographic characteristics A study in Bach Mai Hospital showed that The following demographics were recorded almost all patients (98%) were given PN post- for each subject: Gender (male and female), operatively, with oral feeding starting on an age group (< 60 and ≥ 60 years old) and mean average of postoperative day Mean daily age, type of surgery (esophageal, gastric, total calories intake was 15 kcal/kg/day and small intestinal and colorectal) protein intake was 0.61 g/kg/day during hospitalization [6] However, there is limited re- Feeding practices search focused on feeding practices of post- The number of days that patients received operative GI patients, especially in Vietnam TPN, PN and EN during the first post- Hence, the primary goal of this paper is to operative GI days explore information about the feeding practices of post-operative GI patients at Surgery department and OPCD of Hanoi Medical University Hospital (HMUH) with two objectives: To describe the feeding practices during the first post-operative GI days To evaluate energy and nutrients intake during the first post-operative GI days II METHODS Nutrients in each route The researcher recorded dietary intake (from fluid, soup sonde) of patients during the first post-operative GI days The researcher asked patients or relative of patients to record dietary intake (food and drink) of patients during this period Tools and information collection Data was collected on the day of study which was included general information, dis- Study setting and subjects ease status, feeding practices (EN and PN) A cross-sectional study of current feeding during the first post-operative GI days The practices during the first post-operative GI feeding practices were recorded, including the days was performed in Hanoi Medical Univer- number of days that patients received TPN, sity Hospital from August 2015 to October PN and EN; how much nutrient intake in each 2016 route The tool in order to conduct data was Participants had to meet the following 46 made by researcher JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH Study size Research ethics The following formula was used to estimate This was a descriptive study that the sample size for one average value s n = Z2(1- α/2) ( X ε)2 researcher only used the questionnaire to collect information and measurement without any intervention The participants were protected from harm by giving information n: sample size about the voluntariness to participate and data Z21-α/2: the value of z from the probability was be analyzed and presented anonymously tables Choosing α = 0.05 as confidence level All participants were informed about the is 95% The value of corresponding to this is purpose of the study through an open letter 1.96 and their right to decline participation or to s: the standard deviation Choosing s = 194 withdraw at any stage of the study Verbal (kcal) from the previous study [6] consent was obtained from all participants X : the mean value from the previous study, X = 680 (kcal) [6] The patients who refused participation in the ε = 0.07 From the formula, sample size was 64 pa- study were not be in any way discriminated against or treated differently III RESULTS tients By adding 25% participants who dropped, the sample size was 82 patients Statistical analysis The data analysis in this paper was performed using Stata 12.0 software Epi Data 3.1 was used for data input before analysis Data screening was done before analyzing the data Mean and proportion equations were General information of the participants Among the study participants, 51.2% of patients had underwent gastric surgery, 34.2% had colorectal surgery, with esophageal (9.8%) and small intestinal (4.9%) surgery accounting for the remaining participants (Table 1) used to analyze data Table Demographic characteristics of the study participants Characteristic (n = 82) Count (n) Percent (%) Male 51 62.2 Female 31 37.8 Gender Age group < 60 years old ≥ 60 years old Mean age: JMR 116 E3 (7) - 2018 46 56.1 36 43.9 57,6 ± 12,3 47 JOURNAL OF MEDICAL RESEARCH Characteristic (n = 82) Count (n) Percent (%) Esophageal 9.8 Gastric 42 51.2 Small intestinal 4.9 Colorectal 28 34.2 Type of surgery The feeding practices during the first post-operative GI days 2.1 The feeding practices during the first post-operative GI days Table Average time of total parenteral nutrition Type of surgery Mean ± SD (hours) Min (hours) Max (hours) 66 ± 24.8 24 96 82.3 ± 27.6 24 168 84 ± 24 72 120 Colorectal 89.1 ± 34.5 48 168 Total 83.1 ± 29.99 24 168 Esophageal Gastric Small intestinal The average time of TPN was 83.1 hours (3.46 days) The minimum time was 24 hours (1 day) and maximum one was 168 hours (7 days) The longest mean time of TPN was 89.1 hours (colorectal surgery) and the shortest one was 66 hours (esophageal surgery) 2.2 Energy and nutrients of feeding practices during the first post-operative GI days 2.2.1 Energy and nutrients of total parenteral nutrition Table Energy and nutrients of total parenteral nutrition Post-operative day Total parenteral Esophageal Gastric Small intestinal Colorectal Total (n = 8) (n = 42) (n = 4) (n = 28) (n = 82) 1167.3 ± 349.1 942.3 ± 364.6 1066.7 ± 409.2 936.2 ± 392.2 968.2 ± 374.7 19.0 ± 5.3 16.9 ± 6.9 21.7 ± 8.6 17.2 ± 7.3 17.5 ± 7.0 Carbohydrates (g/d) 160.1 ± 84.2 115.0 ± 51.5 105.6 ± 42.7 116.4 ± 53.2 Protein (g/kg IBW/d) 0.6 ± 0.47 0.5 ± 0.41 0.7 ± 0.16 0.48 ± 0.24 0.5 ± 0.4 42.8 ± 26.4 35.7 ± 21.7 41.3 ± 21.7 41.6 ± 26.0 nutrition Total Energy (kcal/d) Energy (kcal/kg IBW/d) Lipid (g/d) 39.9 ± 39.5 119.3 ± 29.6 Regarding TPN, the mean total energy was 968.2 kcal/day or 17.5 kcal/kg IBW/day The mean 48 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH of protein, lipid and carbohydrates of TPN were 0.5 g/kg IBW/day, 41.6 g/day and 116.4 g/day, respectively Figure The rate of energy substances for total parenteral nutrition Figure shows that the calories ratio of protein, lipid and carbohydrates of TPN were 11.9: 39.3: 48.8%, respectively 2.2.2 Energy and nutrients of parenteral nutrition and enteral nutrition Table Enteral and parenteral nutrition during the first post-operative GI days (Mean ± SD) Vari- The 1st postoperative day The 3rd post-operative day The 7th post-operative day ables PN Energy (kcal/d) Energy (kcal/kg IBW/d) 760.3 ± 454.9 EN Total PN EN Total PN EN Total 0.0 760.3 ± 454.9 1089.1 ± 450 37.8 ± 162.5 1126.9 ± 470.2 921.6 ± 371 394.4 ± 306.4 1315.9 ± 509.4 13.8 ± 8.6 20.3 ± 8.8 23.7 ± 9.4 The mean total energy of the first, the third and the seventh post-operative days were 760.3 kcal, 1126.9 kcal and 1315.9 kcal, respectively The energy consumption (kcal/kg IBW) had tended to rise in the following days They were 13.8 ± 8.6 kcal/kg IBW (the 1st post-operative day), 20.3 ± 8.8 kcal/kg IBW (the 3rd post-operative day) and 23.7 ± 9.4 kcal/kg IBW (the 7th postoperative day) The average energy of PN increased from 760.3 kcal (the 1st post-operative day) to 1089.1 kcal (the 3rd post-operative day) and decreased to 921.6 kcal on the 7th post-operative day There was an increase in the mean energy of EN , which were kcal (the 1st post-operative day), 37.8 kcal (the 3rd post-operative day) and 394.4 kcal (the 7th post-operative day) JMR 116 E3 (7) - 2018 49 JOURNAL OF MEDICAL RESEARCH Figure The rate of energy substances of EN and PN on the 7th post-operative day The pie chart illustrated that the ratio of macronutrients (protein: lipid: carbohydrates) of PN and EN was 12.9: 30: 57.1% on the 7th post-operative day Table Energy and nutrients of PN and EN on the 7th post-operative day Post-operative day PN and EN Esophageal (n = 8) Gastric (n = 42) Small intestinal (n = 4) Colorectal (n = 28) Total (n = 82) Energy (kcal) 1791.3 ± 501.8 1300 ± 505.1 1165 ± 547.9 1225 ± 461.8 1315 ± 509.4 Energy (kcal/ 29.2 ± 7.6 23.4 ± 9.9 23.9 ± 13.3 22.4 ± 8.4 23.7 ± 9.4 Carbohydrates (g/d) 236.4 ± 62,4 196.5 ± 92.0 185.9 ± 87.0 165.8 ± 189.4 ± 86.2 Protein (g/kg 0.95 ± 0,47 0.85 ± 0,6 1.2 ± 0.8 0.7 ± 0.45 0.82 ± 0.55 Lipid (g/d) 67.8 ± 45.3 43.4 ± 26.8 35.7 ± 27.1 45.3 ± 22.4 46.0 ± 28.1 The mean energy of PN and EN was 1315 kcal/day or 23.7 kcal/kg IBW on the 7th postoperative day Esophageal operative patients received the highest amount of calories (1791.3 ± 501.8 kcal) while small intestine patients received the lowest amount of calories (1165 ± 547.9 kcal) The amount of protein, lipid and carbohydrates were 0.82 ± 0.55 (g/kg IBW/d), 46.0 ± 28.1 (g/d) and 189.4 ± 86.2 (g/d), respectively IV DISCUSSION among post- ated with worse clinical outcomes The study operative GI patients Poor nutritional status aimed to explore information about feeding and feeding practices after surgery are associ- practices of postoperative GI patients Malnutrition is 50 prevalent JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH The average time of TPN was about 83 kg IBW was given for patient, which is an ap- hours (3.46 days) In which, minimum time proximate estimate of daily energy expendi- was 24 hours (1 day) and maximum one was ture and requirements; protein intake recom- 168 hours (7 days) According to the study in mendation is 1.5 g/kg IBW [8] So the energy Bach Mai hospital (2016), EN started on an and protein intake of patients in this study average of post-operative day so mean time were less than the ESPEN guideline After of TPN was days (72 hours) [6] Both stud- surgery, patients were unable to be fed by EN, ies’ mean TPN time were longer than ESPEN TPN was required [8] recommendation which starting EN for pa- The protein: lipid: carbohydrates calories tients in need within 24h after surgery (grade ratio should approximate to 20: 30: 50% [8] In A) [7] this study, the rate of P: L: C were 11.9: 39.3: The mean total energy and protein of TPN 48.8% So the energy from carbohydrates were 17.5 kcal/kg IBW/day and 0.5 g/kg IBW, reached the recommendation, protein was not respectively In the ESPEN guideline on Par- enough and lipid was higher than ESPEN enteral nutrition, the recommendation based guidelines on evidence (grade B) indicated that 25 kcal/ Table Com parison between HMUH and Bach Mai Hospital on EN and PN during the first post-operative GI days (Mean ± SD) Variables Energy (kcal) Energy (kcal) of Bach Mai Hospital`s Study (2016) [6] The 1st postoperative day The 3rd post operative day The 7th post operative day PN EN Total PN EN Total PN EN Total 760.3 ± 454.9 760.3 ± 454.9 1089.1 ± 450 37.8 ± 162.5 1126.9 ± 470.2 921.6 ± 371 394.4 ± 306.4 1315.9 ± 509.4 598 ± 288 598 ± 288 750 ± 352 152 ± 132 757 ± 367 531 ± 91 370 ± 234 674 ± 356 The table showed that the differences in energy and protein intake during the first postoperative GI days in patients between this study and Bach Mai Hospital`s study (2016) On the first post-operative day, the energy intake (23.7 ± 9.4 kcal/kg IBW) on the 7th post- intake of two studies were similar (13.8 and 13 operative day were more than Bach Mai Hos- kcal/kg IBW/day) And they also had no EN on pital`s study (17 ± 10 kcal/kg IBW, 0.76 ± 0.47 this day g/kg IBW, 15 ± kcal/kg IBW) In this study, the calories intake on the 3rd On the 7th post-operative day, the calories post-operative day (20.3 ± 8.8 kcal/kg IBW), ratio of P: L: C was 12.9: 30: 57.1%, respec- protein (0.82 ± 0.55 g/kg IBW) and energy tively In the comparison, the proportion of lipid JMR 116 E3 (7) - 2018 51 JOURNAL OF MEDICAL RESEARCH intake was higher and of carbohydrates and Postoperative Feeding in Patients Undergoing protein intake were lower than recommenda- Resectional Gastrointestinal Surgery: A Meta- tion (14: 20: 66) [9] Analysis J Parenter Enter Nutr 35, 473 487 V CONCLUSION Lewis SJ., Andersen HK., Thomas S EN was used late for post-operative GI pa- (2009) Early Enteral Nutrition Within 24 h of tients, PN was quite popular and was held for Intestinal Surgery Versus Later Commence- a long time Total energy and protein intake of ment of Feeding: A Systematic review and post-operative GI patients were lower than the Meta-analysis J Gastrointest Surg 13, 569 - recommendation The calories ratio of protein, 575 lipid and carbohydrates intake were suboptimal Young LS., Huong PTT., Lam NT., Thu NN et al (2016) Nutritional status and feeding REFERENCES practices in gastrointestinal surgery patients at Bach Mai Hospital, Hanoi, Vietnam Asia Pac Hébuterne X., Lemarié E., Michallet M J Clin Nutr 25, 513 - 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2018 ... first post- operative GI days The practices during the first post- operative GI feeding practices were recorded, including the days was performed in Hanoi Medical Univer- number of days that patients. .. about the feeding practices of post- operative GI patients at Surgery department and OPCD of Hanoi Medical University Hospital (HMUH) with two objectives: To describe the feeding practices during the. .. sonde) of patients during the first post- operative GI days The researcher asked patients or relative of patients to record dietary intake (food and drink) of patients during this period Tools and information