Lianne Latkany

A prospective, randomized trial of early enteral feeding after resection of upper gastrointestinal malignancy

OBJECTIVE The purpose of the study was to determine whether early postoperative enteral feeding with an immune-enhancing formula (IEF) decreases morbidity, mortality, and length of hospital stay in patients with upper gastrointestinal (GI) cancer. SUMMARY BACKGROUND DATA Early enteral feeding with an IEF has been associated with improved outcome in trauma and critical care patients. Evaluable data documenting reduced complications after major upper GI surgery for malignancy with early enteral feeding are limited. METHODS Between March 1994 and August 1996, 195 patients with a preoperative diagnosis of esophageal (n = 23), gastric (n = 75), peripancreatic (n = 86), or bile duct (n = 11) cancer underwent resection and were randomized to IEF via jejunostomy tube or control (CNTL). Tube feedings were supplemented with arginine, RNA, and omega-3 fatty acids, begun on postoperative 1, and advanced to a goal of 25 kcal/kg per day. The CNTL involved intravenous crystalloid solutions. Statistical analysis was by t test, chi square, or logistic regression. RESULTS Patient demographics, nutritional status, and operative factors were similar between the groups. Caloric intake was 61% and 22% of goal for the IEF and CNTL groups, respectively. The IEF group received significantly more protein, carbohydrate, lipids and immune-enhancing nutrients than did the CNTL group. There were no significant differences in the number of minor, major, or infectious wound complications between the groups. There was one bowel necrosis associated with IEF requiring reoperation. Hospital mortality was 2.5% and median length of hospital stay was 11 days, which was not different between the groups. CONCLUSION Early enteral feeding with an IEF was not beneficial and should not be used in a routine fashion after surgery for upper GI malignancies.

Direct percutaneous endoscopic jejunostomies for enteral feeding

Abstract Background: Enteral feeding through percutaneous endoscopic gastrostomy (PEG) is increasingly utilized in hospitals, homes, and institutions. However, PEGs have two major limitations: (1) risk for aspiration, which occurs in up to 30% of patients, and (2) it does not allow enteral feeding in patients with gastric outlet obstruction, gastroparesis, or gastric resection. Methods: A new endoscopic method for placement of direct percutaneous endoscopic jejunostomy (DPEJ) was attempted in 150 patients with or without a history of major abdominal surgery. Patients were followed-up until tube utilization ceased because of death or resumption of oral feeding. Results: There were 129 (86%) successful procedures and 21 (14%) unsuccessful attempts. Procedure-related complications included nine (6%) incisional infections. Bleeding, abscess, and colonic perforation each occurred in one patient (.6%), and all required surgical intervention. On long-term follow-up (n = 97), tube malfunction occurred in 3 patients (3%) and aspiration in 3 (3%). Duration of tube use in this population was 113 ± 173 days. Conclusions: DPEJs can be performed successfully with a low complication rate. Enteral feeding through DPEJs drastically reduces aspiration, which commonly occurs with PEG feeding. DPEJs allow feeding and hydration of patients with gastric outlet obstruction due to cancer who are not surgical candidates, eliminate the need for intravenous hydration and feeding, and can cut costs of hospitalization and treatment. (Gastrointest Endosc 1996;44:536-40.)

Lack of Effect of a Low-Fat, High-Fruit, -Vegetable, and -Fiber Diet on Serum Prostate-Specific Antigen of Men Without Prostate Cancer: Results From a Randomized Trial

PURPOSE To determine whether a diet low in fat and high in fruits, vegetables, and fiber may be protective against prostate cancer by having an impact on serial levels of serum prostate-specific antigen (PSA). METHODS Six hundred eighty-nine men were randomized to the intervention arm and 661 to the control arm. The intervention group received intensive counseling to consume a diet low in fat and high in fiber, fruits, and vegetables. The control group received a standard brochure on a healthy diet. PSA in serum was measured at baseline and annually thereafter for 4 years, and newly diagnosed prostate cancers were recorded. RESULTS The individual PSA slope for each participant was calculated, and the distributions of slopes were compared between the two groups. There was no significant difference in distributions of the slopes (P =.99). The two groups were identical in the proportions of participants with elevated PSA at each time point. There was no difference in the PSA slopes between the two groups (P =.34) and in the frequencies of elevated PSA values for those with elevated PSA at baseline. Incidence of prostate cancer during the 4 years was similar in the two groups (19 and 22 in the control and intervention arms, respectively). CONCLUSION Dietary intervention over a 4-year period with reduced fat and increased consumption of fruits, vegetables, and fiber has no impact on serum PSA levels in men. The study also offers no evidence that this dietary intervention over a 4-year period affects the incidence of prostate cancer during the 4 years.

Dietary manipulation, ethnicity, and serum PSA levels

OBJECTIVES To examine whether a diet low in fat and high in fiber, fruits, and vegetables and ethnicity had any influence on serum prostate-specific antigen (PSA) levels, because serum PSA is a marker for the presence of prostate cancer. The incidence of prostate cancer increases with age, varies by ethnicity, and is greater among men with a first-degree relative who has had the disease. Large international variations in the rates of prostate cancer incidence and mortality, as well as the incidence changes in migrants and their offspring, also suggest that exogenous factors, including diet, have a strong influence on the development of this disease. METHODS We used data and blood samples from the Polyp Prevention Trial, a multicenter randomized trial designed to evaluate the impact of a diet low in fat and high in fiber, fruits, and vegetables on the recurrence of colorectal adenomas. Recruitment was from 1991 through 1994. Participants were followed up from their baseline recruitment date for 4 years. From this group, we identified 1100 white men and 97 black men who were 35 years of age or older, did not have prostate cancer, and had serum samples available for study. RESULTS At baseline, no difference was present in the fat intake for the black and white men (mean +/- SE, 90 +/- 3.6 g/day and 84 +/- 1.0 g/day, respectively; P = 0.15). The baseline serum PSA levels did not vary by ethnicity. For black men, the mean serum PSA level was 2.2 +/- 0.36 ng/mL compared with 2.0 +/- 0.07 ng/mL for white men (P = 0.64). Although all men assigned to the intervention group markedly reduced their fat intake by approximately 15% and increased their fruit and vegetable intake by approximately 2.25 servings per day, no difference was noted in the kinetics of the serum PSA levels by dietary intervention or race. CONCLUSIONS Although ethnic differences in the incidence of prostate cancer are well defined, we found no difference in the baseline fat intake among black and white men that might have contributed to this difference. Serum PSA, a marker often used in early detection programs for prostate cancer, was not associated with manipulation of the amount of fat in the diet, regardless of ethnicity.

Direct percutaneous endoscopic jejunostomies for enteral feeding.

BACKGROUND Enteral feeding through percutaneous endoscopic gastrostomy (PEG) is increasingly utilized in hospitals, homes, and institutions. However, PEGs have two major limitations: (1) risk for aspiration, which occurs in up to 30% of patients, and (2) it does not allow enteral feeding in patients with gastric outlet obstruction, gastroparesis, or gastric resection. METHODS A new endoscopic method for placement of direct percutaneous endoscopic jejunostomy (DPEJ) was attempted in 150 patients with or without a history of major abdominal surgery. Patients were followed-up until tube utilization ceased because of death or resumption of oral feeding. RESULTS There were 129 (86%) successful procedures and 21 (14%) unsuccessful attempts. Procedure-related complications included nine (6%) incisional infections. Bleeding, abscess, and colonic perforation each occurred in one patient (.6%), and all required surgical intervention. On long-term follow-up (n = 97), tube malfunction occurred in 3 patients (3%) and aspiration in 3 (3%). Duration of tube use in this population was 113 +/- 173 days. CONCLUSIONS DPEJs can be performed successfully with a low complication rate. Enteral feeding through DPEJs drastically reduces aspiration, which commonly occurs with PEG feeding. DPEJs allow feeding and hydration of patients with gastric outlet obstruction due to cancer who are not surgical candidates, eliminate the need for intravenous hydration and feeding, and can cut costs of hospitalization and treatment.

The Use Of Direct Percutaneous Endoscopic Jejunostomies

Abstract Direct percutaneous endoscopic jejunostomies (DPEJ) were evaluated to determine feasibility of technique, nutrition related outcomes and length of tube use in a cancer population. DPEJ is a technique using a tube placed directly into a proximal jejunual loop, pulling anteriorly with the endoscope and discreetly transluminating the jejunum. Patients were followed for duration of tube use. Results for the period of 1991–1995 follow: In 127 patients, (103 inpatients, 24 outpatients), in whom the technique was attempted, DPEJs were successfully placed in 122 (96%), while 5 (4%) could not be placed for technical reasons. Of the successful placements 115 were used for feeding and 7 for drainage. Indications for the procedure were: gastric outlet obstruction (37%), recurrent or potential aspiration (35%), anorexia (12%), small bowel obstruction (9%), gastroesophageal anastomotic leak (4%), and gastroparesis (3%). There were 4 severe complications (abdominal bleeding, abdominal abscess, jejunal perforation, and colonic perforation), but no deaths occurred as a result of the procedure. Eighty-two males and 45 females, with a mean age of 64 ± 12 years were given DPEJs. At the time of procedure mean weight loss was 15% of usual body weight and mean po intake was approximately 370 Kcal. In the 92 patients for which follow-up data was available, the mean period of DPEJ utilization was 114 ± 169 days: reasons for ending tube utilization were death (78%) or adequate po intake (22%). Method of feeding delivery was predominantly by pump (97%), with (3%) using gravity. Mean formula caloric intake at follow-up was 89% of the caloric goal determined by 30–40 Kcal/kg of baseline weight. An increase of 2% mean body weight and 33% mean po intake occurred in this DPEJ population. These results suggest that DPEJ can be placed safely and may be a viable procedure for achieving nutritional goals in patients where jejunal feedings are indicated.