Efficacy of Nasogastric and Nasojejunal Enteral Feeding in the Early Phase of Acute Pacreatitis

Enteral nutrition in the early phase of predicted severe acute pancreatitis can be administered via a nasogastric or nasojejunal tube. Finding the most effective method in terms of daily balance, the volume of feeding and residual gastric volume in the early period of moderate and severe acute pancreatitis is a current challenge.The aim of the study was to estimate the efficacy of nasogastric and nasojejunal early enteral feeding duringthe early phase of predicted severe acute pancreatitis.Material and methods. The study was prospective, single-center, and randomized. The data were collected from November 2012 to October 2018. The study included 64 ICU patients in the early period of acute pancreatitis exhibiting predictors of severity. During randomization, the patients were assigned to either nasogastric (group 1) or nasojejunal (group 2) feeding for the next four days. The volume of enteral feeding on Day 1 was 250 ml/day, and on each successive day it was increased by 250 ml/day. During group allocation, the disease severity and the way of nutrient administration were taken into account. Daily balance was calculated using the difference between enterally administered and residual gastric volume. Statistical analysis was performed using SPSS v.23 software package. The null hypothesis was rejected at P0.05.Results. The volume of enteral nutrition administered over 4 days did not differ between the study groups. Patients with severe acute pancreatitis had significantly better nutrient absorption over 4 days when the postpyloric route was used (1.63±0.98 l/d) vs the nasogastric one (0.55±0.29 l/d) (P=0.001). In moderate pancreatitis, the enteral nutrition absorption over 4 days did not differ (P=0.107) between the groups with nasogastric (2.06±0.87 l/day) and nasojejunal (2.6±0.45 l/day) feeding.Conclusion. Nasojejunal route is the preferred way to start enteral feeding in patients with severe acute pancreatitis. In moderate acute pancreatitis, feeding can be initiated via the gastric route and only in case of intolerance it should be switched to the nasojejunal one.

Effects of Preoperative Oral Carbohydrate on Cirrhotic Patients under Endoscopic Therapy with Anesthesia: A Randomized Controlled Trial

Preoperative fasting causes significant perioperative discomfort in patients. Preoperative oral carbohydrate (POC) is an important element of the enhanced recovery after surgery protocol, but its effect on cirrhotic patients who tend to have abnormal gastric emptying remains unclarified. We investigated the influence of POC on gastric emptying and preprocedural well-being in cirrhotic patients. A prospective, randomized, controlled study of cirrhotic patients with gastroesophageal varices scheduled for elective therapeutic endoscopy under intravenous anesthesia was conducted. We enrolled 180 patients and divided them into three groups: those not supplemented with carbohydrates for 8 h before therapeutic endoscopy (control group) and those administered a carbohydrate beverage 2 h (2 h group) and 4 h (4 h group) before endoscopy. The residual gastric volume was quantified before anesthesia, gastric emptying was evaluated using gastric ultrasonography, and preprocedural well-being was assessed using the visual analogue scale (VAS). Preanesthesia gastric sonography scores were similar among the three groups. No patient had residual gastric volume > 1.5 ml / kg in the control and 4 h groups, but six patients (11%) had a residual gastric volume of >1.5 ml/kg in the 2 h group, hence were at a risk of regurgitation and aspiration. Moreover, VAS scores for six parameters (thirst, hunger, mouth dryness, nausea, vomiting, and fatigue) in the 2 h group and three parameters (thirst, hunger, and mouth dryness) in the 4 h group were significantly lower than those in the control group, suggesting a beneficial effect on cirrhotic patients’ well-being. Preoperative gastric peristaltic and operation scores, postoperative complications, length of hospital stay, and in-hospital expenses were not significantly different among the three groups. Our study indicated that avoiding preoperative fasting with oral carbohydrates administered 4 h before anesthesia can be achieved in cirrhotic patients. Further studies to assess whether POC can help improve postoperative outcomes in cirrhotic patients are needed.

SHORTEN PREOPERATIVE FASTING AND INTRODUCING EARLY EATING ASSISTANCE IN RECOVERY AFTER GASTROJEJUNAL BYPASS?

ABSTRACT Rational: The metabolic response to surgical trauma is enhanced by prolonged preoperative fasting, contributing to increased insulin resistance. This manifestation is more intense on the 1st and 2nd postoperative days and is directly proportional to the size of the operation. Aim: To compare whether preoperative fasting abbreviation and early postoperative refeeding associated with intraoperative and postoperative fluid restriction interfere in the evolution of patients undergoing gastrojejunal bypass. Methods: Eighty patients indicated for Roux-en-Y gastrojejunal bypass were selected. They were randomly divided into two groups: Ringer Lactate (RL) group, who underwent a 6 hours solids fasting, with the administration of 50 g of maltodextrin in 100 ml of mineral water 2 hours before the beginning of anesthesia; and Physiologic Solution (PS) group, who underwent a 12 hours solids and liquids fasting. Anesthesia was standardized for both groups. During the surgical procedure, 1500 ml of ringer lactate solution was administered in the RL and 2500 ml of physiological solution (0.9% sodium chloride) in the PS. In both groups, the occurrence of bronchoaspiration was analyzed during intubation, and the residual gastric volume was measured after opening the abdominal cavity. In the postoperative period in Group RL, patients started a liquid diet 24 hours after the end of the operative procedure; whilst for PS group, fasting was maintained for the first 24 hours, it was prescripted 2000 ml of physiological solution and a restricted liquid diet after 36 hours. Each patient underwent CPK, insulin, sodium, potassium, urea, creatinine, PaCO2, pH and bicarbonate dosage in the immediate postoperative period, and 48 hours later, the exams were repeated. Results: There were no episodes of bronchoaspiration and gastrojejunal fistulas in either group. In the analysis of the residual gastric volume of the PS and RL groups, the mean volumes were respectively 16.5 and 8.8, which shows statistical significance between the groups. In laboratory tests, there was no difference between groups in sodium; PS group showed a higher level of serum potassium (p=0.029); whilst RL group showed a higher urea and creatinine values; CPK values were even for both; PS group demonstrated a higher insulin level; pH was higher in PS group; sodium bicarbonate showed a significant difference at all times; PaCO2 values in RL group was higher than in PS. In the analysis of the incidence of nausea and flatus, no statistical significance was observed between the groups. Conclusions: The abbreviation of preoperative fasting and early postoperative refeeding of Roux-en-Y gastrojejunal bypass with the application of ERAS or ACERTO Project accelerated the patient’s recovery, reducing residual gastric volume and insulin level, and do not predispose to complications.

Successful Laparoscopic Resection of Gastric Lymphangioma Under the Intraoperative Guidance of Indocyanine Green Fluorescence Imaging: A Case Report

Background: Gastric lymphangioma (GLA) is an extremely rare tumor without an established therapeutic strategy. Surgical resection is considered the mainstay of treatment, although there is a high risk of local recurrence if negative margins are not achieved. Thus, it would be useful to develop tools and strategies to achieve safe and complete resection. We describe our experience with the first case involving GLA resection under the intraoperative guidance of indocyanine green (ICG) fluorescence imaging, which allowed us to achieve limited but complete resection with negative margins.Case Presentation: A 51-year-old Japanese man with a history of alcoholic liver disease underwent routine abdominal ultrasonography, which incidentally detected a 20-mm tumor adjacent to the lesser curvature of the stomach. The mass was suspected to be GLA based on its polycystic appearance. After a 16-month monitoring period, the patient was referred to our hospital for further assessment because of tumor growth and involvement of the left gastric artery. We selected surgical resection to facilitate a pathological diagnosis and treatment of potential invasion to the surrounding organs. Intraoperative use of a ICG navigation system revealed lymphatic drainage from the tumor, which we used to help determine the optimal excision line and minimize the loss of gastric volume. Pathological examination confirmed complete resection with negative margins and supported a diagnosis of lymphangioma.Conclusions: We performed laparoscopic radical resection of GLA under guidance from intraoperative ICG fluorescence imaging, which allowed us to maximize residual gastric volume. Although further cases are needed to validate this strategy, it may be useful for guiding the resection of GLA.

Effects of Preoperative Oral Carbohydrate on Cirrhotic Patients Under Endoscopic Therapy with Anesthesia: A Randomized Controlled Trial

Background: Preoperative fasting is a major cause of perioperative discomfort in patients. Addressing this problem by preoperative oral carbohydrate (POC) has been recommended as an important element of the enhanced recovery after surgery (ERAS) protocol, but its effect on cirrhotic patients who tend to show abnormalities in gastric emptying function has not yet been clarified. Our study aims to investigate the influence of POC on gastric empting and preoperative well-being in cirrhotic patients. Methods: A prospective, randomized and controlled study of cirrhotic patients with gastroesophageal varices scheduled for elective endoscopic therapy under intravenous anesthesia was conducted. 180 patients were enrolled in this study. Patients were divided into three groups: those not supplement with carbohydrate for 8h prior to endoscopic therapy (Control group), those given a carbohydrate beverage 2h (2h group) or 4h (4h group) prior to endoscopy. Gastric emptying was evaluated by gastric sonography score and collecting gastric content aspirated endoscopically before anesthesia. Stresses caused by examination associated fasting were evaluated by visual analogue scale (VAS) scores for six parameters (thirst, hunger, mouth dryness, nausea, vomit and weakness) preoperatively. Hemodynamic changes, peristole and postoperative complications were also recorded. Results: Before anesthesia, gastric sonography score was similar among three groups. In addition, no patient had residual gastric volume more than 1.5ml/kg in control and 4h group, but six patients (11%) reached a residual gastric volume of more than 1.5ml/kg in 2h group. Moreover, compared with control fasting, VAS scores for six parameters (thirst, hunger, mouth dryness, nausea, vomiting and fatigue) in 2h group and for three parameters (thirst, hunger and mouth dryness) in 4h group were both significantly lower. Gastric peristaltic score and operation score before operation, postoperative complication, lengths of hospital stay and in-hospital expense were not significantly different among three groups.Conclusions: For the first time, we demonstrate that avoiding preoperative fasting with oral carbohydrates given 4h prior to anesthesia can improve preoperative well-being feelings, without enhancing the risk of aspiration and regurgitation in cirrhotic patients. Our study adds knowledge for preoperative fasting guidelines in anesthesia for cirrhotic patients. Trial registration: This trial was registered at Clinicaltrials.gov under the number ChiCTR2000032394.