Feeding the gut early after digestive surgery: results of a nine-year experience.

BACKGROUND AND AIMS: Early enteral nutrition (EEN) after surgery should be preferred to parenteral feeding, but its clinical use is limited for concerns about possible gastrointestinal (GI) adverse effects and feeding tube-related complications. Thus we evaluated our experience focusing on safety and tolerance of early postoperative jejunal feeding and possible risk factors for gastrointestinal adverse effects. METHODS: 650 subjects treated with EEN after major digestive surgery for cancer were prospectively studied. EEN was started within 12 hours after operation via a naso-jejunal (NJ) feeding tube or a catheter-feeding jejunostomy. The rate of infusion was progressively increased to reach the nutritional goal (25 kcal/kg/day) within the 4th postoperative day. Rigorous treatment protocols for diet delivery and EEN-related GI adverse effects were applied. RESULTS: 402 patients had a jejunostomy and 248 patients a NJ tube. EEN-related GI adverse effects were observed in 194/650 patients (29.8%). In 136/194 patients, these events were successfully handled by treatment protocols. Overall the nutritional goal was achieved in 592/650 patients (91.1%). Fifty-eight (8.9%) subjects had to be switched to parenteral feeding because of refractory intolerance to EEN. Intra-abdominal surgical complications and low serum albumin (<30 g/L) were the two major factors affecting tolerance. Severe jejunostomy-related complications occurred in 7/402 (1.7%) patients. EEN-related mortality was 0.1% (1/650). CONCLUSIONS: The use of the gut early after surgery is safe and well-tolerated and it should represent the first choice for nutritional support in this type of patients.

Percutaneous balloon mitral valvuloplasty: early and late results according to surgical risk and echocardiographic score.

OBJECTIVE AND DESIGN: Early results, complications and follow-up of 70 patients undergoing percutaneous balloon mitral valvuloplasty (BMV) were retrospectively analyzed to establish whether an increased surgical risk or an unfavourable echocardiographic score influenced the results. PATIENTS: The patients were divided into two groups according to the presence (group A, n = 31) or absence (group B, n = 38) of high surgical risk factors. The patients were also divided into two other groups according to the presence (group C, n = 46) or absence (group D, n = 20) of favourable mitral valve anatomy. Group A (high surgical risk) included patients fulfilling at least one of the following criteria: 65 years of age or older; previous surgical commissurotomy; depressed left ventricular function; respiratory or hepatic insufficiency; or previous aortic valve replacement. Mitral valve anatomy was classified as 4 to 16, according to the echocardiographic score established by Abascal et al. Group C patients had echocardiographic score below 8 and group D had echocardiographic scores of 8 or greater. INTERVENTIONS: Mean mitral valve gradient (MVG) and area (MVA) were Doppler-estimated immediately before and 48 h after the BMV. MAIN RESULTS: There were no differences in the early results and complications between groups A and B (MVA 1.8 +/- 0.5 versus 1.9 +/- 0.4 cm2). Final MVA was significantly greater in group C than in group D (MVA 1.9 +/- 0.4 versus 1.6 +/- 0.4 cm2; P = 0.03). There was no difference in the incidence of complications. Over a follow-up period averaging 19.1 months (range 1 to 55), 90.7% of the patients were in New York Heart Association functional class I or II. Four patients had a mitral valve replacement, one had a surgical commissurotomy and one had a second BMV. Two unrelated deaths occurred. There were no differences in the characteristics of the study population and the incidence of events in the follow-up period between groups. CONCLUSIONS: The results and outcome of BMV were unrelated to the general surgical risk, suggesting that this procedure may be used with particular benefit in this group of patients. In contrast, mitral valve anatomy must be considered as an important determinant of the results.