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clinmed/2003040003v1 (February 26, 2004)
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EARLY    ENTERAL   NUTRITION    IN     CASES    OF    PERFORATION   OF THE GUT   WITH    PERITONITIS                                                                                    A study of 200 cases by Dr. Amber Malhotra (Resident) ,            Dr. A.K Mathur (Senior Consulting Surgeon & Associate Professor)    [Department Of Surgery, S.M.S Hospital, Jaipur.   India.]

Abstract:

Objective: To assess whether early postoperative nasogastric tube feeding in form of a balanced diet formula is safe and beneficial in patients of perforation of the gut (peptic ulcer perforations, enteric or typhoid perforations, traumatic perforations, tubercular and malignant perforations) even in presence of peritonitis.

 Design: A Randomized control study on operated patients of perforation of the gut with peritonitis. Nasogastric tube feeding of a balanced diet formula was begun on second postoperative day. Comparisons were made with randomly chosen patients kept post operatively nil by mouth for five to seven days in a conventional regimen of management.

Setting: The study was carried out in the one surgical unit of Medical College Hospital. Staff members of the unit following the same technique operated all the patients.

Subjects: 200 patients of perforation of the gut with peritonitis were admitted to our surgical unit.  The Patients under went emergency laparotomy. These patients were randomly chosen to receive either early postoperative enteral nutrition or conventional postoperative management.

Main outcome measures:                                                                                                          Incidence and duration of the following:  Wound infection, Wound dehiscence, Leakage of repaired perforation of the gut with peritonitis, Septicaemia, Intraabdominal sepsis, Pneumonia, Hospital stay & Mortality.

Tube feeding complications: Vomiting, Hiccough, Distension, Abdominal cramps, Diarrhoea, Leak of repaired perforation of the gut with peritonitis.

Biochemical measures: Haemoglobin, Serum albumin, Nitrogen balance, Blood urea, Serum creatinine. 

Others: General well being, Wt.gain/Wt.loss.

Results: Most of the patients in the enterally fed group tolerated post-operative nasogastric tube feeding successfully from second post-operative day. They received over 1800 Calories, enterally, from postoperative day 4 onwards and were averaging over 2500 Calories by day 8. The morbidity of wound complications, pneumonia, and septicaemia was significantly reduced in the enterally fed group. Though average hospital stay was no different from controls, the average loss of weight was minimal in the enterally fed patients who were also in a better nutritional state at the time of discharge.

Introduction:

After elective gastrointestinal surgery, the trend has been to keep the patient nil by mouth and decompress the stomach by nasogastric tube. There is a general consensus that gastric & colonic atony following laparotomy lasts 24-48 hrs and that small bowel recovers function within 4-6hrs (1). Over last few years great emphasis has been laid on early enteral feeding by nasojejunal tube or jejunostomy distal to the Anastomosis (2,3,4). There have been very few clinical trials of early enteral nutrition in patients of generalised peritonitis following perforation of the gut with peritonitis (5). Our contention is that even after repair of a perforation of the gut in presence of peritonitis the gastric atony recovers within 48hrs and the repaired perforation of the gut remains sealed and secure enough to cater to normal upper g.i.secretions as well as nasogastric feeding started after 48hrs. Small bowel function after proper peritoneal toilet & drainage recovers much before that.

         The present clinical trial was performed to assess safety and benefits of enteral feeding by nasogastic tube after 48hrs of surgery in a patient who is already in septicemia, with high post-operative risk of wound infection, dehiscence and pneumonia.

Materials and Methods:

 200 patients admitted to our surgical unit with perforation of the gut with peritonitis between May 2000 and February 2003. These included peptic ulcer perforations, enteric or typhoid perforations, traumatic perforations, tubercular and malignant perforations. After investigations they were prepared for emergency surgery by I.V fluids, I.Vantibiotics and N.G tube aspiration. The perforations were repaired appropriately by procedures ranging from ileostomy to simple repair by interrupted non-absorbable sutures to resections with anastomosis. After peritoneal toilet abdomen was closed with peritoneal drains. Post-operatively besides parenteral fluids, a broad-spectrum antibiotic combination of a cephalosporin, metronidazole, and an aminoglycoside was given. Continuous N.G. Tube aspiration was provided for 48 hours.

  On 2^nd post-operative day patients were assigned randomly to enteral fed or conventionally managed group. In the enterally fed group NG tube was used for both feeding and aspiration. 100gms of a balanced diet formula (containing proteins, fats, carbohydrates, vitamins, minerals and fibre) dissolved in 500 ml of GDW 5 % (600Calories) was given slowly at the rate of 50 ml/hour by an I.V drip set connected to nasogastric tube. The feed was slowed/stopped, if patient developed intolerable distension, uneasiness, vomiting, heaviness, hiccough or crampy abdominal pain. The feeds were administered to an awake patient who was propped up at 30°. The patient received another 300-400Cals in the form of I.V Dextrose. The conventionally managed patients received the same management except that they received calories only in the form of I.V dextrose containing fluids which amounted to 600Calories on an average.

  On 3^rd post-operative day, 200gms of balanced diet formula dissolved in 1000ml of 5% GDW (1200Calories) was given at the rate of about 100ml/hour observing same precautions to the enterally fed group patients. The enterally fed patients received another 300-400Cals in the form of I.V Dextrose. The conventionally managed patients received calories only in the form of I.V dextrose containing fluids which amounted to 800Calories on an average.

  On 4^th post-operative day, 300gms of balanced diet formula in 1500ml of 5% GDW (1800Calories) was given. Throughout the post -operative period, patients received parenteral antibiotics and supportive I.V fluids providing additional 300-400Calories. Thus, after 4^th post-operative day patients received over 2000 Calories/day. The conventionally managed patients received 800 calories on an average in the form of I.V dextrose containing fluids.

  From 5^th post-operative day, 400gms of balanced diet formula were given in 2lts of 5%GDW.The patients were kept on I.V patency line. Between 8^th &10^th day the NG tube was removed and complete oral feeds in form of semi-solid diet was commenced. Patients were discharged on 10^th postoperative day in good nutritional state. 

  Patients were closely monitored and feeding slowed or stopped in case of tube feeding complications. The patients were watched closely for signs of a leak of repaired perforation of the gut. Post operatively the patient underwent certain investigations at regular intervals:                                                                             Weight:  Post-Operative Day 1, 7&10 and/or at the time of discharge.

 Biochemical Investigations:  Haemoglobin, Serum albumin, Serum Cholesterol Serum creatinine, Blood urea, Urinary urea on postoperative Day 3 &8.

 Nitrogen balance was calculated by estimating nitrogen input and output from urinary urea by the following formula:

Nitrogen Balance = (Protein intake/6.25)-(UUN + 4), where:
 6.25 grams of protein has 1gram of nitrogen UUN is urine urea nitrogen, or grams of nitrogen excreted in the urine over a 24-hour period of time
4 is 4 grams of nitrogen lost each day as “insensible losses” via the skin and GI tract.

Nitrogen input was calculated by dividing the protein intake (9.7gms in one 50gms sachet) by 6.25.

      The results were analysed using relative risk and c2 test (test of significance depicted by ‘P’ value).

 The major complications were measured in terms of MAN DAYS i.e. days spent by a man suffering from a particular complication which in turn depicts the time taken to control a particular complication and not its incidence. Relative Risk and ‘P’ value were calculated for Pneumonia, Septicaemia, Wound infection, Wound Dehiscence, Leak and Death.

The minor complications were measured as episodes. Relative Risk and ‘P’ value were calculated for Abdominal Distension, Diarrhoea, Vomiting.

Difference between values of serum albumin, serum cholesterol, and haemoglobin between days 3 and 8 were considered as markers of nutritional status along with weight (taken on days 1, 7&10 and/or at the time of discharge). These were expressed as % of patients showing an increase/decrease in value. Mean weight loss between days 1&7 and 7&10 was also calculated.

Calorie intake was calculated and to simplify matters broad categories of total calorie intake were developed and expressed as percentage of patients getting more than 1500 calories on day 4 and more than 2500 calories on day8 for enterally fed patients and half this amount for controls.

Stay of each patient in the hospital was noted and general condition at the time of discharge recorded.

Results:

The effect of early nasogastric enteral nutrition in 100 operated patients of perforation of the gut with peritonitis was studied. The results were compared with 100 control patients operated for perforation of the gut with peritonitis who were kept nil by mouth for 5-7days with continuous NG tube aspiration, I.V fluids (Dextrose based) and I.V antibiotics. The results were analysed using relative risk and c²   test (test of significance).

 The main outcome measures are shown in the table below. The relative risk of major complications like leaking of repaired perforation, wound dehiscence, wound infection, septicemia, pneumonia, and mortality was significantly lower than the control cases. The duration in which the major complications were controlled was significantly lower in the patients receiving EARLY ENTERAL NUTRITION (6,7). 

The major complications were measured in terms of MAN DAYS i.e. days spent by a man suffering from a particular complication which in turn depicts the time taken to control a particular complication and not its incidence. These were all relatively in favour of case study.  Pneumonia had a R.R of 0.702 the ‘P’ value calculated by c²   test was <0.005 (significant), Septicaemia: R.R - 0.668, P <0.001 (significant), Wound infection: R.R – 0.66, P<0.005 (significant), Wound Dehiscence: R.R - 0.45, P<0.005 (significant), Leak: R.R - 0.125, P=0.22 (not significant), Death: R.R - 0.66, P=0.10 (not significant).

The minor complications were measured as episodes. These were all relatively in favour of control cases but on c²  test they proved to be insignificant. Abdominal Distension: R.R – 0.904, Diarrhoea: R.R – 0.687, Vomiting: R.R - 0.57.

Biochemical and other parameters were also significantly in favour of the study group.

 Discussion: The analyses of the results strongly indicate that even after generalised peritonitis the GI tract recovers tone and function within 48hrs.The perforation of the gut after repair remains secure, and is not put to any risk of leakage by enteral nutrition started after 48hrs by NG tube. The already proven advantages of early enteral nutrition (8,9) after elective GI surgery are clearly seen in patients of peritonitis also. The control of major complications is much earlier in patients receiving enteral nutrition hence the total morbidity is much reduced.

     Bibliography: 

 1.        Charles Wells, Laurence Tinckler, Keith Rawlinson, Howell Jones and John Saunders: Postoperative gastrointestinal motility. Lancet 1964; 1:4-10.

 2.        Silk DBA, Rees RG, Keohane PP, Attrill H. Clinical efficacy and design changes of "fine bore" nasogastric feeding tubes: a seven-year experience involving 809 intubations in 403 patients. JPEN 1987; 11:378-383.

 3.        Carr CS, Ling KDE, Boulos P, Singer M. Randomized trial of safety and efficacy of immediate postoperative enteral feeding in patients undergoing  gastrointestinal resection. BMJ 1996; 312:869-71.

 4.        Hoover HC, Ryan JA, Anderson EJ, Fischer JE. Nutritional benefits of immediate postoperative jejunal feeding of an elemental diet. Am J Surg 1980; 139:153-9.

 5.        Singh G, Ram R P, Khanna S K : Early postoperative feeding in patients with nontraumatic intestinal perforation and peritonitis. J Am ColI Surg 1998 Aug; 187(2): 142-6.

 6.        Boesby S, Beier-Hogersen R (1998): Effect of early post-operative enteral nutrition on post-operative infections. Ugeskr Laeger 1998 May 25: 160 (22):3223-6.

 7.        Stephen J Lewis, Matthias Egger, Paul A Sylvester. Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systemic review and metaanalysis of     controlled trials. BMJ vol.323, 6 Oct 2001, 773-776.

 8.        Heslin MJ, Latkany L, Leung D, Brooks AD, Hochwald SN, Pisters PWT,et al. A prospective, randomizedtrial of early enteral feeding after resection of upper GI malignancy. Ann Surg1997; 226:567-680.

9.   Silk DBA, Green CJ. Peri-operative nutrition: parenteral versus enteral. Curr Opin Clin Nutr Metab Care 1998; i: 21-27.

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