Surgical nutrition &the management of gut failure                Marcel Gatt     Consultant General & Colorectal Surgeon  ...
Your mission; should you choose to accept it ...
Overview   I know how to feed my patients!        ... or do I?   I know when to feed my patients!       ... or do I?   ...
“The force is strong, Master”
Overview   I know how to feed my patients!        ... or do I?   I know when to feed my patients!       ... or do I?   ...
How should I feed my patients?
How to feed patients   Oral                   Oral diet                           Oral supplements   Enteral            ...
ASPEN 2009 guidelines                 Bankhead et al., JPEN 2009
Pre- vs. postpyloric feedingAim: “To establish whether the site of feed administration  influences the ability to achieve ...
Pre- vs. postpyloric feeding                    Prepyloric    Postpyloric                                              p-v...
Gut dysfunction in the critically illNormal volunteer       Critically ill patient                       Dive et al. Crit ...
Feeding in pancreatitis – oral vs. NJ    A randomized study of early nasogastric versus    nasojejunal feeding in severe a...
ESPEN guidelines – pancreatitis (2006)                           Meier et al., Clin Nutr 2006
How to feed patients   Oral                   PO                           Oral supplements   Enteral                Nas...
TPN versus EN:            septic morbidity                 230 patients          TPN                EN         (112)      ...
Myth about EN vs. PNIt used to be thought that :Parenteral nutrition is poison !! Enteral is betterthan parenteral. EN is ...
Enteral vs Parenteral Nutrition: a pragmatic study                             562 patients                      Assessmen...
Patients receiving less than 80% of                                                                                target ...
When to feed - ESPEN guidlines                   Weimann et al., Clin Nutr. 2006
Early feeding    Andersen HK et al. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD004080.   ... there is no obvious advan...
Overview   I know how to feed my patients!       ... or+ EN + PN                                          PO do I?   I k...
Overview   I know how to feed my patients!       PO + EN + PN   I know when to feed my patients!      Usually straight a...
Adequate gut function                            PubMed search   MeSH   “Renal function”           51881         18   “K...
Gut failure                           PubMed search   MeSH   “Renal failure”           69298         31   “Kidney failur...
Adequate gut function   What is “adequate” gut function?           No established and quantifiable definition.
The paradox of gut functionIGF is intuitively important to   But.. IGF is not acknowledged topatient outcome              ...
Adequate gut function   Cardiac function:        Adequate CO & end organ perfusion   Respiratory function:    Adequate o...
Adequate gut function                    NutritionMetabolic                             Excretion                  Intesti...
Adequate gut function    Oral/enteral tolerance of >80%of calculated nutritional requirements for a continuous period of >...
Adequacy of gut function on survival                                                                             MULTIVARI...
Overview   I know how to feed my patients!       PO + EN + PN   I know when to feed my patients!      Usually straight a...
Drip       Suck              Wait
Modulating gut function -          treatments in development-   Fluid restriction-   Early feeding-   Alvimopan®-   Cholec...
Alvimopan®peripheral μ-opioid receptor antagonistTraut U et al. Cochrane Database Syst Rev. 2008 23;(1): CD004930
Ghrelin agonists            (e.g. TZP-101 (ulimorelin)   GI motility co-ordinators   Strong antiemetic effect / promote ...
Gut specific nutrients                                                                              25                    ...
Enhanced recovery after surgery              Fearon K et al. Clin Nutr 2005 24: 466-477
Multimodal optimization                                                      Gatt M, et al. Br J Surg. 2005; 92: 1354-62  ...
Overview   I know how to feed my patients!      PO + EN + PN   I know when to feed my patients!     Usually straight awa...
Implications to daily practice   Gut function:        - is not a recognised condition        - can be defined by toleranc...
Implications to daily practice   Methods of curtailing post-op ileus:       - Opiate avoidance (NSAIDS/epidurals/TAP bloc...
Take home message 1                  How to feed   It‟s about the nutrition not the route of    administration!
Take home message 2                When to feed   Starving people is cruelty in 3rd world    countries, so why do it in 1...
Take home message 3                Gut failure / ileus   If it works, use it.                                     Drip,  ...
Take home message 4           Gut function & gut failure   There are exciting times ahead
Surgical Nutrition and Management of Gut Failure- Marcel Gatt
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Surgical Nutrition and Management of Gut Failure- Marcel Gatt

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Presentation given by Marcel Gatt, Scarborough Hospital, at the Dukes' Club AGM 2012

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Surgical Nutrition and Management of Gut Failure- Marcel Gatt

  1. 1. Surgical nutrition &the management of gut failure Marcel Gatt Consultant General & Colorectal Surgeon Combined Gastroenterology Research Unit Scarborough Hospital, UK marcelgatt@gmail.com
  2. 2. Your mission; should you choose to accept it ...
  3. 3. Overview I know how to feed my patients! ... or do I? I know when to feed my patients! ... or do I? Who decides how to feed patients? ... Me after bedside assessment (duh)! Is the gut ok & what is gut failure? ... err I’m not sure? I cant do much about ileus. ... or can I?
  4. 4. “The force is strong, Master”
  5. 5. Overview I know how to feed my patients! ... or do I? I know when to feed my patients! ... or do I? Who decides how to feed patients? ... Me after bedside assessment (duh)! Is the gut ok & what is gut failure? ... err I’m not sure? I cant do much about ileus. ... or can I?
  6. 6. How should I feed my patients?
  7. 7. How to feed patients Oral Oral diet Oral supplements Enteral Nasogastric Nasojejunal PEG / RIG/ PEGJ Feeding jejunostomy Parenteral Peripheral PN Central PN Other Enteroclysis Combination Optimal feeding
  8. 8. ASPEN 2009 guidelines Bankhead et al., JPEN 2009
  9. 9. Pre- vs. postpyloric feedingAim: “To establish whether the site of feed administration influences the ability to achieve enteral feed tolerance.” All patients needing enteral nutrition Randomized Prepyloric feeding: Postpyloric feeding: NG / PEG NJ / PEGJ F/U till discharge Gatt et al., Clin Nutr. 2005
  10. 10. Pre- vs. postpyloric feeding Prepyloric Postpyloric p-value feeding feedingRecruited 33 32Enteral tolerance 23 (70) 20 (63) 0.539(%) Gatt et al., Clin Nutr. 2005
  11. 11. Gut dysfunction in the critically illNormal volunteer Critically ill patient Dive et al. Crit Care Med. 1994 Dive et al. Clin Nutr. 1994 Dive et al. Intensive Care Med. 1999
  12. 12. Feeding in pancreatitis – oral vs. NJ A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis. CONCLUSION: “The simpler, cheaper, and more easily used NG feeding is as good as NJ feeding in patients with objectively graded severe AP...” Eatock et al., Am J Gastroenterol. 2005 Feb;100(2):432-9.
  13. 13. ESPEN guidelines – pancreatitis (2006) Meier et al., Clin Nutr 2006
  14. 14. How to feed patients Oral PO Oral supplements Enteral Nasogastric Naso-jejunal PEG / RIG/ PEGJ Feeding jejunostomy Parenteral Peripheral PN Central PN Other Enteroclysis Combination Optimal feeding
  15. 15. TPN versus EN: septic morbidity 230 patients TPN EN (112) (118)Sepsis 35% 18% p=0.01 Moore et al 1992
  16. 16. Myth about EN vs. PNIt used to be thought that :Parenteral nutrition is poison !! Enteral is betterthan parenteral. EN is associated with reducedseptic morbidity and fewer complications. Am J Clin Nutr. 2001; 74: 160-3.
  17. 17. Enteral vs Parenteral Nutrition: a pragmatic study 562 patients Assessment of GI function Clinically certain Clinically uncertain n = 498 n = 64 (88.6%) (11.4%) Inadequate Adequate Randomised GI function GI function TPN (Group1) EN (Group 2) rTPN (Group 3) rEN (Group 4) n = 267 n = 231 n = 32 n = 32 N P Woodcock et al. Nutrition 2001; 17: 1-12
  18. 18. Patients receiving less than 80% of target intakeClinicians are poor at assessing 70% 60%intestinal function 50% P<0.001 P<0.001 40% 30%Inadequate gut function is a predictor of 20%poor prognosis 10% 0% Group 1 (TPN) Group 2 (EN) Group 3 (rTPN) Group 4 (rEN) N P Woodcock et al. Nutrition 2001; 17: 1-12 1- Enteral vs Parenteral Nutrition: a pragmatic study Overall mortality 562 patients 40% 35% Assessment of GI function 30% P < 0.001 P = 0.17, NS Clinically certain Clinically uncertain 25% n = 498 n = 64 (88.6%) (11.4%) 20% 15% Inadequate Adequate Randomised GI function GI function 10% 5% TPN (Group1) EN (Group 2) rTPN (Group 3) rEN (Group 4) n = 267 n = 231 n = 32 n = 32 0% Group 1 (TPN) Group 2 (EN) Group 3 (rTPN) Group 4 (rEN) N P Woodcock et al. Nutrition 2001; 17: 1 -12
  19. 19. When to feed - ESPEN guidlines Weimann et al., Clin Nutr. 2006
  20. 20. Early feeding Andersen HK et al. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD004080. ... there is no obvious advantage in keeping patients „nil by mouth‟ following gastrointestinal surgery ... this review support the notion on early commencement of enteral feeding.
  21. 21. Overview I know how to feed my patients! ... or+ EN + PN PO do I? I know when to feed my patients! ... or do I? Usually straight away Who decides how to feed patients? ... Me after bedside Like everyone else, I’m not good at it! assessment (duh)! Is the gut ok & what is gut failure? ... err I’m not sure? I cant do much about ileus. ... or can I?
  22. 22. Overview I know how to feed my patients! PO + EN + PN I know when to feed my patients! Usually straight away Who decides how to feed patients? Like everyone else, I’m not good at it! Is the gut ok & what is gut failure? ... err I’m not sure? I cant do much about ileus. ... or can I?
  23. 23. Adequate gut function PubMed search MeSH “Renal function” 51881 18 “Kidney function” 26764 8 “Intestinal function” 1076 0 “Gut function” 412 0 “Interleukin 12” 11776 22
  24. 24. Gut failure PubMed search MeSH “Renal failure” 69298 31 “Kidney failure” 72801 18 “Intestinal failure” 736 0 “Gut failure” 53 0 “Ingrown toenails” 781 1
  25. 25. Adequate gut function What is “adequate” gut function? No established and quantifiable definition.
  26. 26. The paradox of gut functionIGF is intuitively important to But.. IGF is not acknowledged topatient outcome relate to outcome Many homeostatic functions  No quantifiable definition  Assessment of gut function is difficult  Assessment is subjective - Bowel sounds - Passage of flatus - Passage of faeces
  27. 27. Adequate gut function Cardiac function: Adequate CO & end organ perfusion Respiratory function: Adequate oxygenation / ventilation Renal function: Adequate clearance & urine output RAS Erythropoetin Organ function is described by its primary function
  28. 28. Adequate gut function NutritionMetabolic Excretion Intestinal functionHormonal Immunological Barrier
  29. 29. Adequate gut function Oral/enteral tolerance of >80%of calculated nutritional requirements for a continuous period of >48 hours Gatt M, Doctoral Thesis, University of Hull, 2008
  30. 30. Adequacy of gut function on survival MULTIVARIATE 1.2 ANALYSIS 1.0 .8 Adequate gut function (n=265) .6 Gut Failure P<0.001 P<0.001 .4 Yes Yes-censored .2 No Inadequate gut function(n=50) 0.0 No-censored 0 30 60 90 120 150 180 210 Time (days) Gatt M et al. Clin Nutr 2007 Sept; Suppl 2: 108CONCLUSION Inadequate gut function (IGF) is an independent indicator of outcome.
  31. 31. Overview I know how to feed my patients! PO + EN + PN I know when to feed my patients! Usually straight away Who decides how to feed patients? Like everyone else, I’m not good at it! Is the gut ok & what is gut failure? Relates to not sure? ... err I’m tolerance I cant do much about ileus. ... or can I?
  32. 32. Drip Suck Wait
  33. 33. Modulating gut function - treatments in development- Fluid restriction- Early feeding- Alvimopan®- Cholecystokinin-like acting drugs- Ghrelin agonists- Gut specific nutrients- Synbiotics (pro- & prebiotics)- Modulation of gut microflora (SGD)- Immunomodulation- Laparoscopic / robotic surgery- Combined approaches (ERAS)
  34. 34. Alvimopan®peripheral μ-opioid receptor antagonistTraut U et al. Cochrane Database Syst Rev. 2008 23;(1): CD004930
  35. 35. Ghrelin agonists (e.g. TZP-101 (ulimorelin) GI motility co-ordinators Strong antiemetic effect / promote gastric emptying May improve recovery of GI motility following bowel resection. Popescu I et al. Dis Colon Rectum. 2010 Feb;53(2):126-34.
  36. 36. Gut specific nutrients 25 Time to return of gut function (days)Time to return of gut function (hrs) P=0.016 20 15 10 GSN cocktail 5 0 Glutamine Control GSN Multivitamins Group 8.9 days 6.8 days Probiotics (214 hours) (164 hours) Prebiotics Gatt M et al. BJS, 2010 Nov; 97(11):1629-36
  37. 37. Enhanced recovery after surgery Fearon K et al. Clin Nutr 2005 24: 466-477
  38. 38. Multimodal optimization Gatt M, et al. Br J Surg. 2005; 92: 1354-62 p = 0.007 p = 0.042 Return of Gut Function (hours)Duration of IV fluids (hours) N = 20 19 N = 20 19 Control Optimisation Control Optimisation Group Group Duration of IV Fluids Return of Gut Function
  39. 39. Overview I know how to feed my patients! PO + EN + PN I know when to feed my patients! Usually straight away Who decides how to feed patients? Like everyone else, I’m not good at it! Is the gut ok & what is gut failure? Relates to tolerance I cant do much about ileus. ... or can yes I can! Actually I?
  40. 40. Implications to daily practice Gut function: - is not a recognised condition - can be defined by tolerance to oral/enteral nutrition - is an independent prognostic indicator - using time to passage of flatus/faeces is wrong Feed patients early post-operatively: - safe - only way of assessing gut function - may enhance recovery of GI function ... ??? - Aim to provide calorie requirements
  41. 41. Implications to daily practice Methods of curtailing post-op ileus: - Opiate avoidance (NSAIDS/epidurals/TAP blocks) - Early mobilization - IV fluid optimization - Many others Treatments in development: - GSN‟s - Cholecystokinin-like acting drugs - Peripheral μ-opioid receptor antagonist - Ghrelin agonists - Many others
  42. 42. Take home message 1 How to feed It‟s about the nutrition not the route of administration!
  43. 43. Take home message 2 When to feed Starving people is cruelty in 3rd world countries, so why do it in 1st world ones?
  44. 44. Take home message 3 Gut failure / ileus If it works, use it. Drip, If it doesn‟t, loose it. & Suck, & Wait. If it works, use it. If it doesn‟t, do something about it. .
  45. 45. Take home message 4 Gut function & gut failure There are exciting times ahead

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