Thybout M. Moojen

Prospective, randomized trial on the effect of cyclic versus continuous enteral nutrition on postoperative gastric function after pylorus-preserving pancreatoduodenectomy.

OBJECTIVE The effect of a cyclic versus a continuous enteral feeding protocol on postoperative delayed gastric emptying, start of normal diet, and hospital stay was assessed in patients undergoing pylorus-preserving pancreatoduodenectomy (PPPD). SUMMARY BACKGROUND DATA Delayed gastric emptying occurs in approximately 30% of patients after PPPD and causes prolonged hospital stay. Enteral nutrition through a catheter jejunostomy is used to provide postoperative nutritional support. Enteral infusion of fats and proteins activates neurohumoral feedback mechanisms and therefore can potentially impair gastric emptying and prolong postoperative gastroparesis. METHODS From September 1995 to December 1996, 72 consecutive patients underwent PPPD at the Academic Medical Center, Amsterdam. Fifty-seven patients were included and randomized for either continuous (CON) jejunal nutrition (0-24 hr; 1500 kCal/24 hr) or cyclic (CYC) enteral nutrition (6-24 hr; 1125 kCal/18 hr). Both groups had an equal caloric load of 1 kCal/min. The following parameters were assessed: days of nasogastric intubation, days of enteral nutrition, days until normal diet was tolerated orally, and hospital stay. On postoperative day 10, plasma cholecystokinin (CCK) levels were measured during both feeding protocols. RESULTS Nasogastric intubation was 9.1 days in the CON group (n = 30) and 6.7 days in the CYC group (n = 27) (not statistically significant). First day of normal diet was earlier for the CYC group (15.7 vs. 12.2 days, p < 0.05). Hospital stay was shorter in the CYC group (21.4 vs. 17.5 days, p < 0.05). CCK levels were lower in CYC patients, before and after feeding, compared with CON patients (p < 0.05). CONCLUSIONS Cyclic enteral feeding after PPPD is associated with a shorter period of enteral nutrition, a faster return to a normal diet, and a shorter hospital stay. Continuously high CCK levels could be a cause of prolonged time until normal diet is tolerated in patients on continuous enteral nutrition. Cyclic enteral nutrition is therefore the feeding regimen of choice in patients after PPPD.

Gastrointestinal Motility after Pancreatoduodenectomy

Pancreatoduodenectomy (PD) is a major surgical procedure which is accompanied by a high morbidity of between 30 and 50%. A large part of this morbidity is caused by delayed gastric emptying (DGE), which is reported to have an incidence of between 30 and 40% and is associated with prolonged hospital stay. Several pathophysiological mechanisms are thought to cause this complication. Peroperative trauma of the pylorus and the occurrence of intra-abdominal abscesses play a role. Neuronal changes and disruption of the gastrointestinal (GI) intramural nervous plexus may be especially important regarding the pivotal role of the duodenum in the initiation and coordination of antroduodenal motor activity. Another important factor is the postoperative administration of enteral nutrition. Recently, it was demonstrated that cyclic enteral nutrition through a catheter jejunostomy led to a faster return to normal diet and shorter hospital stay than patients on continuous enteral nutrition; this might be partly caused by continuously elevated cholecystokinin levels. The effect of prokinetic agents has not been studied extensively, but a beneficial action on the return of postoperative gastric function after gastrointestinal surgery seems limited.