Objectives: To assess the safety and effectiveness of early enteral feeding after gastrostomy to the clinical, blood pre-albumin index. Subjects and methods: An interventional, control and comparative study on 115 patients who were indicated gastrostomy from May 2011 to November 2013 at Abdominal Surgery Department, 103 Military Hospital.
Journal of military pharmaco-medicine n08-2017 ASSESSING THE EFFECTIVENESS OF FEEDING THE GUT EARLY AFTER STOMACH SURGERY Truong Thi Thu*; Nguyen Thanh Cho** Hoang Manh An**; Dang Viet Dung** SUMMARY Objectives: To assess the safety and effectiveness of early enteral feeding after gastrostomy to the clinical, blood pre-albumin index Subjects and methods: An interventional, control and comparative study on 115 patients who were indicated gastrostomy from May 2011 to November 2013 at Abdominal Surgery Department, 103 Military Hospital The patients were divided into groups: 58 patients in early enteral nutrition group (EEN) were started with Ensure formula within 24 - 48 hours after surgery, 57 patients in control group (late enteral nutrition: LEN) were fed as routine regimen of the hospital Results: 112 patients participated in the study, patients stopped the treatment There were significant differences both EEN groups and LEN ones (p < 0.05): the first enteral intake (27.2 ± 6.2 hours versus 124.6 ± 52.7 hours, time of the first bowel movement (54.6 ± 11.8 versus 82.1 ± 29 hours), time to sit up after surgery (1.53 ± 0.9 versus 3.5 ± 1.2 days), length of hospital stay after surgery (7.8 ± 1.9 days versus 9.6 ± 6.4 days), postoperative complications (1.8% versus 17.6%) and the level of pre-albumin after hospital discharge (0.28 ± 0.32 versus 0.14 ± 0.05) were recorded Absorption capacity after surgery (nausea, diarrhea, bloating) were equivalent in groups, p > 0.05 Conclusion: The results showed that early enteral feeding after stomach surgery was safe and feasible It helped patients recover sooner, reduce complications and the number of days in the hospital as well as improve pre-albumin index * Keywords: Early enteral feeding; Stomach surgery INTRODUCTION For many decades, a “nil-by-mouth” policy has been commonly applied as a surgical dogma after gastrointestinal procedures The long-held belief that nutritional interventions should be done until bowel function recovery [3, 4] The intestinal postoperative feeding in patients with gastrointestinal surgery was safe and patients were well-tolerated even when started within 12 hours after surgery, which that benefits the patient [3] It has been an important issue for clinicians to choose a proper nutrition therapy, which helps the patient recover quickly after the gastric surgery Early enteral nutrition (EEN) can improve the body nutrition and the mesenteric blood flow, maintain the mesentery permeability, repair and maintain the structure and function of gastrointestinal tracts [5] In Vietnam, there have been some early feeding studies in patients with liver surgery, pancreatitis and severe burns However, up to now, there has been no study mentioning early feeding problems in patients after gastric bypass surgery ** Haiduong Medical Technical University * 103 Military Hospital Corresponding author: Truong Thi Thu (truongthu16hd@gmail.com) Date received: 29/08/2017 Date accepted: 28/09/2017 244 Journal of military pharmaco-medicine n08-2017 In order to evaluate the differences between early enteral nutrition and late enteral nutrition after the gastric cancer surgery, the study was conducted: To assess the effectiveness of early enteral nutrition with improved clinical and pre-albumin index after gastric bypass surgery SUBJECTS AND METHODS Subjects Patients from 18 to 65 years old, without co-morbidities, were assigned to gastric bypass surgery - Time and place of the study: from May, 2011 to November, 2013 at Abdominal Surgery Department, 103 Military Hospital Methods * Study design: Interventional, control and comparison between the pre- and post-treatment was made * Sample size: Patients were at the age from 18 to 65 between May 2011 and November 2013 * Sampling method: From the checklist every Thursday, all eligible patients were included The was matche with the age, sex and surgical methods, then the subjects were randomly divided into two groups Patients number were put in the intervention group; The others number were put in the control group * Method of data collection: Interview, examination and measurement of anthropometric analysis according to the researches’s design, collecting general information and nutritional status, clinical manifestations, vital signs, absorption capacity, number of days after the surgery at the time of surgery and day before hospital discharge * Feeding method: - Intervention group: Early enteral nutrition within 12 - 48 hours after surgery (nourishment sutures placed deep through 15 - 20 cm intervals during surgery) using Ensure milk, nourished by continuous drops, slow speed interruptions usually 20 - 30 mL/hour or direct injection with the syringe at the beginning It was increased to - 10 kcal/kg/day with the patients’ gradually increased tolerance - Control group: Carry out nutrition regimen according to the current practice of the Department of Gastroenterology, 103 Military Hospital (the patient was offered internal jugular vein on the first post-operative day) After - days when the patient had first bowel movement, patients were fed under the guidance of a surgeon It was increased to - kcal/kg/day with the patients’ gradually increased tolerance - Assessing nutritional status: BMI (Body Mass Index) = [weight (kg)]/ [high (m)] * Analysis on the effectiveness of indexes: The first enteral intake time, absorption capacity after surgery (nausea, diarrhea, bloating) Time of the first bowel movement, time to sit up after surgery, length of hospital stay after surgery, postoperative complications, the nutritive index (the level of pre-albumin on the first day before and after hospital discharge) were recorded 245 Journal of military pharmaco-medicine n08-2017 * Statistics method: All data was analyzed by SPSS 16 software packet The measurement data was described in the mean ± SD form Comparisons between the two groups were tested by t-test, count data was measured by chisquare test and p < 0.05 is considered to be statistically significant difference * Research ethics: The study was approved by the Scientific Council and the Ethics Review Board in the biomedical research of 103 Military Hospital The subject is clearly stated in the purpose and content of the study, is completely voluntary and can be withdrawn from the study at any time RESULTS One hundred and fifteen (115) patients enrolled in the study, patients stopped the treatment Therefore, there were 112 participants in the study Patient’s characteristics Table 1: Comparison of data between the two groups (age, gender, BMI, weight loss) Characteristics Age Control group (n = 57) Intervention group (n = 55) p 53.2 ± 9,3 51.2 ± 8,4 0.187 42/15 33/22 0.08 2.1 ± 1,5 2.2 ± 1.2 0.746 Sex (male/female) Weight loss in months (kg) Weight loss in months (kg) 4.1 ± 2,7 4.3 ± 2.4 0.703 BMI 19.4 ± 2,7 18.7 ± 2,0 0.146 Age, sex ratio of male/female, weight loss in months, months, BMI before admission equivalent to groups, the differences were not statistically significant (p > 0.05) Table 2: Comparison of data between the two groups (surgical type) Surgical type Control group (n = 57) Intervention group (n = 55) n % n % Total gastrectomy 10.5 7.3 Partial gastrectomy 51 89.5 51 92.7 p 0.394 Type of surgery of groups was similar, p > 0.05 Table 3: Comparison of the first enteral intake between the two groups Control group (n = 57) Feeding time after surgery Intervention group (n = 55) Average Max Min Average Max Min 124.6 ± 52.7 384 49 27.2 ± 6.2 45 16 p < 0.001 Table showed the average time to start feeding the gastrointestinal tract in the intervention group was 27.2 ± 6.2 hours, much earlier than that in the control group which was 124.6 ± 52.7 hours The differences were statistically significant (p < 0.001) 246 Journal of military pharmaco-medicine n08-2017 Assess the effectiveness of early enteral nutrition with clinical improvement Table 4: Clinical symptoms appear after surgery Control group (n = 57) Symptoms Intervention Group (n = 55) p Number Percentage Number Percentage 20 35.1 26 47.3 0.190 Diarrhea 12.3 5.5 0.322 Bloating 28 49.1 30 54.5 0.161 Reflux 0 0 0.371 Nausea Gastrointestinal complications such as bloating, vomiting, nausea, reflux in the intervention group were more than those in the control group, the symptoms of diarrhea in the control group were more than those in the intervention group, there was no statistically significant difference (p > 0.05) Table 5: Comparison of flatus time, sit up, length of hospital stay after surgery Control group (n = 57) Intervention group (n = 55) p value Flatus time (hours) (Min-max) 82.1 ± 29 (40 - 230) 54.6 ± 11.8 (34 - 89) 0.001 Time to sit up after surgery (day) (Min-max) 3.5 ± 1.2 (1 - 7) 1.53 ± 0.9 (1 - 6) 0.001 9.6 ± 6.4 (4 - 46) 7.8 ± 1.9 (4 - 15) 0.04 Targets Length of hospital stay after surgery Time flatus present in the intervention group was shorter than that in the control group (54.6 versus 82.1 hours) (p < 0.05), while sitting up light exercise, the tube was removed earlier as well The duration of hospitalization for the intervention group was shorter than that of the control group (7.8 versus 9.6 days), the difference was statistically significant (p < 0.05) Table 6: Complications after surgery Complications Control group (n = 57) Intervention group (n = 55) Number Rate Number Anastomotic leakage 1.8 Duodenal leakage 3.5 Infections 3.5 Abscess 3.5 Septicemia 0 ICU Operation again 3.5 Mortality 1.8 Total 10 17.6 Rate 1.8 1.8 247 Journal of military pharmaco-medicine n08-2017 The overall rate of complications in the late-fed group was higher than that of the early feeding group (17.6% vs 1.8%), with the complication rate of 3.5% versus 8%, abscess 1.8%, surgery 3.5%; death 1.8% Early intervention group had no case Assess the effectiveness of early enteral nutrition with improved blood prealbumin index Table Comparison of pre-albumin levels before and after intervention of each group and two groups Pre-albumin Control group (n = 57) Intervention group (n = 55) p Before the intervention 0.18 ± 0.15 0.19 ± 0.11 0.504 After the intervention 0.14 ± 0.05 0.28 ± 0.32 0.009 p 0.09 0.103 The blood pre-albumin level of the two groups before the intervention was equivalent After the intervention, the blood pre-albumin level of intervention group was higher than that of the control group (0.28 vs 0.14) The difference was statistically significant, p < 0.05 The prealbumin blood concentration of intervention group after intervention increased meanwhile decreased in the control group, but no statistically significant difference was observed DISCUSSIONS Assess the effectiveness of early enteral nutrition with improved clinical, average early feeding time was at 27.2 ± 6.6 hours, the earliest was 16 hours after surgery, the latest was 45 hours after surgery, the patient was fully awake, spontaneously breathing well Drainage anesthesia, hemodynamic stability can be fed through the intestinal tract For the patients who are fed with no bowel syndrome, this time is longer than that in some other authors’ studies in the world In Vietnam, it is a new intervention, changing the surgeon's habit of feeding time is very difficult, often the surgeon feeds the patient when it has been inflamed (usually to days after surgery), our result was 124.6 ± 52.7 hours According to Lewis, after to 12 hours, 248 the patient was completely awake, wellventilated, the respiratory status and hemodynamic stability can be fed to through the intestinal tract [4] * Clinical symptoms after surgery: Early feeding did not increase postoperative morbidity, including compromised integrity of an anastomosis Therefore, such nutritional intervention can be safely adapted to accelerated patients Although the patients were yet not able to eat, the secretion of bile, pancreas, gastric fluid, intestinal fluid secretes, which will be absorbed by the intestinal mucosa Intestinal mucosa without altering intestinal pressure much [3, 5, 6] Our results of these gastrointestinal complications after the onset of treatment in the intervention group and the control group were not statistically significant (p > 0.05) Journal of military pharmaco-medicine n08-2017 * Reflux: It is a potential danger Some risk factors included stomach full of fluid and vapor, because some drugs reduce gastrointestinal motility, so reflux may occur in any patient [4, 6] The authors agreed that close monitoring of the gastrointestinal tract, position of the nasal duct, position of the patient when feeding, was necessary to ensure that the intestinal was safe and successful Our results did not have any reflux patients [3, 4, 5] * Diarrhea: The diarrhea rate in the intervention group was 5.5% (which is less than that of the control group 12.3%), similar to Nguyen Nhu Lam’s research on the incidence of diarrhea increased with time [1] Feeding the intestines, according to research by Braga M, Gianotti L of the feeding time of the intestines, as well as the diarrhea rate, may be reduced as early as possible due to early feeding of structural disorders and atrophy of intestinal mucosa [5] Assessment of postoperative recovery and postoperative fluid flow was found to be active and passive Post-operative recovery is the occurrence of bowel motility and time of movement Patients in the early feeding group had an earlier fart (54.6 hours versus 82.1 hours) (p < 0.01) This result was similar to raga M’s, Gianotti L’s study (2002) (35 hours and 67 hours) [6] The time to sit up, gentle movement in the intervention group was also earlier than in the control group Mean duration of hospital stay was shorter than that of the control group (7.8 days and 9.6 days) the difference was statistically significant (p < 0.05) After gastrointestinal surgery, the most frightening complication is duodenal fistula, leakage, which is the main reason why the surgeon delays early feeding, but both complications occur; one in the control group, but not in the early feeding group Lewis has synthesized 13 studies from various authors around the world and concluded that early intestinal feeding after surgery was safe [4] In our results, the overall complication rate in the late breeding group was higher than that of the early feeding group (17.6% vs 1.8%) This is similar to Sanjay Marwa's study, where the prevalence of early feeding was 4% compared to 20% Late feeding groups also included two patients (6%) with abscess and none of the patients in early feeding group However, this difference was not significant at p > 0.05 This is similar to the Lewis’s study that was higher in the late feeding group, with a 3% of oral leakage rate (the only patient) in the late feeding group and none in the intervention group [4] Early feeding can improve health, as early feeding increases collagen deposition and reduces mucosal shrinkage, thus speeding up wound healing [4] Assess the effectiveness of early enteral nutrition with improved clinical and prealbumin index of patients after gastric bypass surgery Effects of early intestinal feeding on prealbumin index, the prevalence of the prevalence is days This is a marker used to assess malnutrition in patients who are hypersensitive to albumin After intervention, the prealbumin concentration in the intervention group was significantly higher than in the control group 249 Journal of military pharmaco-medicine n08-2017 CONCLUSION Early gastrointestinal uptake after postoperative gastric bypass surgery was safe, feasible with shorter hospital stay (7.8 days with 9.6 days) and less complication rate (1.8% with 17.6%) Early feeding improved the maintenance of nutritional index, prealbumin blood concentration of intervention group after intervention increased (0.19 and 0.28); the control group was lower than before intervention (0.14 g/L and 0.18 g/L) and lower than intervention group (0.14 g/L versus 0.28 g/L) p < 0.05 Larger scale research is needed and early postnatal feeding regimen is necessary REFERENCES Lam N.N Effect of early feeding severe burn patients PhD thesis Military Medical University 2006 Tuyet C.T Effective comprehensive nutrition for patients with abdominal surgery Digestive open gastroenterology prepared at 250 Bachmai hospital in 2013 PhD thesis, Institute of Hygiene and Epidemiology 2015 Lassen K, Revhaug A Early oral nutrition after major upper gastro- intestinal surgery: why not? Curr Opin Clin Nutr Metab Care 2006, 9, pp.613-617 Lewis S.J Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials 2001, 323 (7316), p.773 Braga M., Gianotti L., Gentilini O et al Early postoperative enteral nutrition improves gut oxygennation and reduces costs compared with total parenteral nutrition 2001 Braga M, Gianotti L, Gentilini S, Liotta S, Di Carlo V Feeding the gut early after digestive surgery: results of a nine-year experience Clinical Nutrition 2002, 21, pp.5965 doi: 10.1054/clnu.2001.0504 ASPEN Board of Directors and the Clinical Guidelines Task Force Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients JPEN Journal of Parenteral and Enteral Nutrition 2002, 26 (1 Suppl):1SA-138SA ... capacity, number of days after the surgery at the time of surgery and day before hospital discharge * Feeding method: - Intervention group: Early enteral nutrition within 12 - 48 hours after surgery (nourishment... Assess the effectiveness of early enteral nutrition with improved clinical, average early feeding time was at 27.2 ± 6.6 hours, the earliest was 16 hours after surgery, the latest was 45 hours after. .. [1] Feeding the intestines, according to research by Braga M, Gianotti L of the feeding time of the intestines, as well as the diarrhea rate, may be reduced as early as possible due to early feeding