|Year : 2016 | Volume
| Issue : 2 | Page : 689-692
Influencing factors and interventional strategies for early enteral nutrition after gastric carcinoma surgery
Nian-Mei Li1, Fei Liu1, Feng-Ying Lv2, Qi-Wen Zhang1
1 Department of General Surgery, Laiwu People's Hospital, Laiwu 271100, Shandong, China
2 Department of General Surgery, Laiwu Iron and Steel Group Hospital, Laiwu 271100, Shandong, China
|Date of Web Publication||25-Jul-2016|
Department of General Surgery, Laiwu People’s Hospital, No. 1 Wenhuabei Road, Laiwu 271100, Shandong
Source of Support: None, Conflict of Interest: None
Objective: The aim of this study is to investigate the factors influencing early enteral nutrition (EN) to develop guidelines after gastric carcinoma (GC) surgery, and to propose appropriate interventions.
Materials and Methods: A total of 118 GC patients have administrated EN 24 h after surgery and were divided into standard-achieving and nonstandard-achieving groups based on meeting 60% of energy needs. The clinical data of these two groups were retrospectively analyzed and compared.
Results: The intraoperative blood loss, proportion of those with body mass ≤60 kg, and those cases tolerating EN in the standard-achieving group were significantly greater than in the nonstandard-achieving group, and the differences were statistically significant (P < 0.05). Gender, age, operative time, catheter length, American Society of Anesthesiologists risk class, and postoperative exhaust time showed no statistically significant differences (P > 0.05). However, logistic regression analysis revealed that intraoperative blood loss, body mass, and EN tolerance were independent risk factors influencing achievement of standards for early postoperative EN in GC patients (P < 0.05).
Conclusions: Individual differences should be considered when performing EN, and individualized nutritional support should be provided to improve the standard-achieving rate.
Keywords: Gastric carcinoma, enteral nutrition, influencing factors, intervention
|How to cite this article:|
Li NM, Liu F, Lv FY, Zhang QW. Influencing factors and interventional strategies for early enteral nutrition after gastric carcinoma surgery. J Can Res Ther 2016;12:689-92
|How to cite this URL:|
Li NM, Liu F, Lv FY, Zhang QW. Influencing factors and interventional strategies for early enteral nutrition after gastric carcinoma surgery. J Can Res Ther [serial online] 2016 [cited 2019 Sep 20];12:689-92. Available from: http://www.cancerjournal.net/text.asp?2016/12/2/689/179179
| > Introduction|| |
Gastric carcinoma (GC) is a common malignant tumor  responsible for one-fourth of annual deaths among patients with malignant tumors. Patients in early stages can be surgically treated, but prognosis is not only related to disease conditions and extent of surgery but also related to postoperative nutritional status., The nutritional status of GC patients is poor after surgery, but the high catabolic state requires long-term fluid infusion, which also increases the risks of adverse reactions., Enteral nutrition (EN) utilizes the gastrointestinal tract to deliver nutrients to the body safely and economically and should easily meet the physical needs of patients., However, EN does not always fully meet these nutritional needs, and improvement of the effectiveness of EN is of increasing concern to health care workers. This study retrospectively analyzed the clinical data of 118 GC patients who received early postoperative EN and analyzed the factors that might affect achievement of standards for EN.
| > Materials and Methods|| |
A total 118 GC patients (83 males and 35 females) treated in our hospital from July 2011 to August 2013, aged 21–69 years old (mean 53.28 ± 3.83), were selected. The preoperative disease duration was 0.5–3 years (average 1.32 ± 0.41). Preoperative body weight was 36–84 kg (average 60.18 ± 8.37). All patients underwent total gastrectomy. All patients were pathologically diagnosed as GC, and patients with remnant gastric cancer, metastatic gastric cancer, and primary gastric cancer associated with metastasis were excluded from the study; the Acute Physiology and Chronic Health-II scores were >10 points. Patients with poor preoperative nutritional status were excluded, including those with body mass index >24 kg/m2 and <18.5 kg/m2. Patients with endocrine and metabolic diseases, as well as other serious chronic diseases, were also excluded. This study was conducted in accordance with the Declaration of Helsinki. This study was conducted with approval from the Ethics Committee of our Hospital. Written informed consent was obtained from all participants.
Early enteral nutrition support
All patients received EN 24 h after surgery. A nasointestinal tube was placed intraoperatively, and Kabiven PI (Fresenius Kabi AB, Sweden) and All-in-One nutrient solution (SINO-SWED Pharmaceutical Co., Jiangsu, China) were administered on the 1st postoperative day for parenteral nutrition: 250–500 ml 0.9% NaCl solution (SINO-SWED) was intravenously infused within 24 h after surgery, and vital signs and adverse events were monitored. If there was no contraindication, a nutritional formulation, Fresubin (SINO-SWED), was then administered. The temperature of the infusion was 39–40°C, and the infusion rate was controlled by an infusion pump according to principles of low to high concentration, less to more capacity, and lower to higher speed. All preparations were completely infused within 24 h and discarded if more than 24 h had passed to prevent bacterial infection.
Clinical data including sex, age, body mass, American Society of Anesthesiologists (ASA) risk class, intraoperative blood loss, nasal catheter length, operative time, postoperative exhaust time, and EN tolerance were retrospectively analyzed. The absence of adverse reactions such as nausea, vomiting, bloating, diarrhea, and others was considered to represent good EN tolerance. Each patient needed 10.46 kJ cal/kg body weight per day, and the achievement standard was set so that the calories supplied by 3 h of EN could supply 60% of the calories required. According to whether, EN could achieve the standard, patients were divided into standard-achieving and nonstandard-achieving groups, and the data for the two groups were compared.
SPSS 13.0 software (SPSS Inc., Chicago, IL) was used for the analysis. Measured data were analyzed with t-tests, counted data used the Chi-square test, and multivariate analysis used logistic regression, with P < 0.05 considered statistically significant.
| > Results|| |
Univariate analysis of measured data
Intraoperative blood loss in the standard-achieving group was significantly less than in the nonstandard-achieving group, and the drop ratio of Hemoglobin of the standard-reaching group was significantly smaller than the non-standard-reaching group, and the difference was statistically significant (P < 0.05). The age, operative time, catheter length, ASA risk class, and postoperative exhaust time showed no statistically significant difference between the two groups (P > 0.05) [Table 1].
|Table 1: Early gastric cancer may affect compliance status of enteral nutrition univariate analysis of measurement data|
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Univariate analysis of counted data
Cases with body mass ≤60 kg and EN tolerance in the standard-achieving group were significantly more than those in the nonstandard-achieving group, and the difference was statistically significant (P < 0.05). The gender comparison between the two groups showed no statistically significant difference (P > 0.05) [Table 2].
|Table 2: Univariate analysis of counting data that might affect the early postoperative enteral nutrition status|
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Logistic regression analysis showed that intraoperative blood loss, body mass, and EN tolerance were independent risk factors that would affect the standard-achieving status of early EN GC patients (P < 0.05) [Table 3].
| > Discussion|| |
Gastrectomy is currently the most effective surgical treatment for GC. Early postoperative EN support can provide the patient with certain amounts of calories and nutrients, could improve the function of the intestinal mucosal barrier, promote gastrointestinal peristalsis and blood supply, reduce the displacement of intestinal pathogens, and therefore effectively promote the recovery of gastrointestinal function. EN has advantages of safety, easy absorption, nutritional balance, etc., and is the preferred nutritional support method after GC.,
Before early postoperative EN is administered, optimal nutritional indicators for the patient should be determined, and continuous evaluation of the patient's condition should be performed during clinical implementation, with gradual increases in the amount of feeding based on the patient's tolerance. If the patient can achieve the optimal target during the early EN stage, follow-up treatment could simply maintain the EN program and could also appropriately increase the dose of EN while concurrently reducing parenteral nutrition., In patients who cannot achieve the desired goals, excessive increases in the dose might cause EN intolerance; therefore, treatment should ensure the premise of EN implementation as much as possible and should be properly combined with parenteral nutrition. Studies showed that when the energy provided by EN reached 50–65% or more, EN could play a role in protecting intestinal function.,
In this study, patients with lighter body mass more easily achieved the standards because the calories required were relatively low; the same EN dose would account for a higher proportion of total calories required by a patient with lighter body mass. As for patients with greater intraoperative blood loss, even though there are no significant nutrients within the systemic circulation, the level of perfusion in the gastrointestinal tract is still relatively low and requires a relatively long time for recovery, approximately 72 h in one study. Decreased intestinal mucosal perfusion would cause lasting damage to the intestinal mucous membranes, thus affecting intestinal motility and absorption; nutrients administered through the intestinal approach would not be absorbed, thus affecting standard-achieving for EN. Therefore, in addition to minimizing intraoperative bleeding, the application of early postoperative EN in these patients should start with small doses, and the dose and infusion rate should gradually be increased to assist in rapid adaptation. Surgery damages the normal anatomic structure of the gastrointestinal tract in some patients, combined with surgical manipulation and the use of proton pump inhibitors and other drugs, these patients may not tolerate EN and will have abdominal distention and pain, thus affecting implementation and standard-achieving for EN. These patients should receive a warmed nutrient solution, and the infusion rate should be strictly controlled to increase tolerance, thus maximizing the effects of EN.
In this study, the standard-achieving status of early postoperative EN was affected by body mass, intraoperative blood loss, and EN tolerance; staff should fully consider individual differences before implementing EN and provide individualized nutritional support, thus improving standard-achieving rates for EN.
| > Conclusions|| |
The individual differences should be considered when performing enteral nutrition, the individualized nutritional support should be performed to improve the standard-reaching rate.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Ryu SW, Kim IH. Comparison of different nutritional assessments in detecting malnutrition among gastric cancer patients. World J Gastroenterol 2010;16:3310-7.
Barlow R, Price P, Reid TD, Hunt S, Clark GW, Havard TJ, et al.
Prospective multicentre randomised controlled trial of early enteral nutrition for patients undergoing major upper gastrointestinal surgical resection. Clin Nutr 2011;30:560-6.
Heighes PT, Doig GS, Sweetman EA, Simpson F. An overview of evidence from systematic reviews evaluating early enteral nutrition in critically ill patients: More convincing evidence is needed. Anaesth Intensive Care 2010;38:167-74.
Carter J, Szabo R, Sim WW, Pather S, Philp S, Nattress K, et al.
Fast track surgery: A clinical audit. Aust N
Z J Obstet Gynaecol 2010;50:159-63.
Migita K, Takayama T, Saeki K, Matsumoto S, Wakatsuki K, Enomoto K, et al.
The prognostic nutritional index predicts long-term outcomes of gastric cancer patients independent of tumor stage. Ann Surg Oncol 2013;20:2647-54.
Sultan J, Griffin SM, Di Franco F, Kirby JA, Shenton BK, Seal CJ, et al.
Randomized clinical trial of omega-3 fatty acid-supplemented enteral nutrition versus standard enteral nutrition in patients undergoing oesophagogastric cancer surgery. Br J Surg 2012;99:346-55.
Mohri Y, Inoue Y, Tanaka K, Hiro J, Uchida K, Kusunoki M. Prognostic nutritional index predicts postoperative outcome in colorectal cancer. World J Surg 2013;37:2688-92.
Pinato DJ, North BV, Sharma R. A novel, externally validated inflammation-based prognostic algorithm in hepatocellular carcinoma: The prognostic nutritional index (PNI). Br J Cancer 2012;106:1439-45.
Lee DY, Hong SW, Chang YG, Lee WY, Lee B. Clinical significance of preoperative inflammatory parameters in gastric cancer patients. J Gastric Cancer 2013;13:111-6.
Jie B, Jiang ZM, Nolan MT, Efron DT, Zhu SN, Yu K, et al.
Impact of nutritional support on clinical outcome in patients at nutritional risk: A multicenter, prospective cohort study in Baltimore and Beijing teaching hospitals. Nutrition 2010;26:1088-93.
Schiesser M, Müller S, Kirchhoff P, Breitenstein S, Schäfer M, Clavien PA. Assessment of a novel screening score for nutritional risk in predicting complications in gastro-intestinal surgery. Clin Nutr 2008;27:565-70.
Amaral TF, Matos LC, Tavares MM, Subtil A, Martins R, Nazaré M, et al.
The economic impact of disease-related malnutrition at hospital admission. Clin Nutr 2007;26:778-84.
Chen K, Xu XW, Mou YP, Pan Y, Zhou YC, Zhang RC, et al.
Systematic review and meta-analysis of laparoscopic and open gastrectomy for advanced gastric cancer. World J Surg Oncol 2013;11:182.
Chien LC, Chiang YC, Lin SW, Huang CK, Ren D. Reduction in nausea and vomiting in children undergoing cancer chemotherapy by either appropriate or sham auricular acupuncture points with standard care. J Altern Complement Med 2012;18:334-40.
He W, Wang X, Shi H, Shang H, Li L, Jing X, et al.
Auricular acupuncture and vagal regulation. Evid Based Complement Alternat Med 2012;2012:786839.
Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, et al.
Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS ®
) Society recommendations. Clin Nutr 2012;31:817-30.
Yang H, Feng Y, Sun X, Teitelbaum DH. Enteral versus parenteral nutrition: Effect on intestinal barrier function. Ann N
Y Acad Sci 2009;1165:338-46.
Yu G, Chen G, Huang B, Shao W, Zeng G. Effect of early enteral nutrition on postoperative nutritional status and immune function in elderly patients with esophageal cancer or cardiac cancer. Chin J Cancer Res 2013;25:299-305.
Mazaki T, Ebisawa K. Enteral versus parenteral nutrition after gastrointestinal surgery: A systematic review and meta-analysis of randomized controlled trials in the English literature. J Gastrointest Surg 2008;12:739-55.
Wang J, Yu JC, Kang WM, Ma ZQ. Superiority of a fish oil-enriched emulsion to medium-chain triacylglycerols/long-chain triacylglycerols in gastrointestinal surgery patients: A randomized clinical trial. Nutrition 2012;28:623-9.
[Table 1], [Table 2], [Table 3]