1. Case Study P.L.
Gastrointestinal Surgery and Peri-Operative Nutrition Support
Salome P. Rao, Ph.D.
Raritan Bay Medical Center
Perth Amboy, NJ
May 26, 2015

2. P.L. 67-y.o-female; DOB 11/12/1947 Admitted 10/5/14-Discharged 2/12/15
Admit Dx:
Strangulated recurrent incisional ventral hernia
Small Bowel Obstruction
Ischemic Bowel
Perforated Bowel
Patient underwent incisional ventral hernia repair with diffuse peritoneal adhesions on exploratory laparotomy and small bowel perforation due to ischemia. Ended up with small bowel resection with anastomosis and ventral hernia repair.

3. Past Medical History 2009 Appendectomy and subsequent hernia repair
2012
Incarcerated ventral abdominal wall hernia
Partial small bowel obstruction
Hypertension
Hypothyroidism
GERD
Diabetes Type 2
Obesity –BMI 30
2013
Exploratory laparotomy, extensive enterolysis
4 abdominal wall hernias, dense peritoneal adhesions repaired

6. Small Bowel Obstruction
Causes
Signs and Symptoms
Intestinal adhesions
Hernias
Tumors in the small intestine
Inflammatory bowel diseases
Twisting of the intestine (volvulus)
Telescoping of the intestine (intussusception)
Crampy abdominal pain that comes and goes
Nausea
Vomiting
Diarrhea
Constipation
Inability to have a bowel movement or pass gas
Swelling of the abdomen (distention)
Intestinal adhesions — bands of fibrous tissue in the abdominal cavity that can form after abdominal or pelvic surgery
Hernias — portions of intestine that protrude into another part of your body
Tumors in the small intestine
Inflammatory bowel diseases, such as Crohn's disease
Twisting of the intestine (volvulus)
Telescoping of the intestine (intussusception)

7. Intussusception

8. Pt Surgeries-current admission
11/13/14
Enterocutaneous Fistulectomy
Oversewing of small bowel opening
12/4/14
Exploratory laparotomy
Enterorraphy
Closure of enterocutaneous fistula
Application of wound vac
1/6/15
Vac application
1/16/15
Leaking PICC line
10/6/14
Enterolysis
Small bowel resection with primary anastomosis
Strangulated Ventral Hernia Repair
Bowel Perforation
Sepsis from Peritonitis, Leukopenia
11/4/14
Fistulectomy
Small bowel repair
Explantation of Infected mesh

9. Adhesiolysis/Enterolysis

10. Intestinal Anastomosis

11. Intestinal Anastomosis

12. Intestinal Anastomosis

13. GI Surgery Complications
Wound Dehiscence
Ileus
Anastomotic Leaks
Fistulas

14. Postoperative Ileus (POI)
The transient cessation of coordinated bowel motility after surgical intervention, which prevents effective transit of intestinal contents or tolerance of oral intake.
Primary or Secondary
due to infection, anastomotic leak, obstruction
Prolonged if >5days

15. Risks for Anastomotic leak
Male
Renal Disease
Hx of Radiotherapy
Distal Site
Smoking
Obesity
Poor Nutrition

16. Patient Assessment
Pt appears well nourished. No pain reported. No n/v/d/c. Pt complains of taste changes during the short periods that she was PO. Estimated nutritional needs not being met with current TPN order. It is possible that inadequate protein infusion is contributing to poor wound healing. Pt weight stable. Edema noted. Weight fluctuations anticipated.
Age 67
Height 165 cm
Weight 84 Kg
BMI 30
BP /80
Braden 17
Sacrum 2
Edema +1 LArm

17. Medications Augmentin Synthroid Bacid Lovenox KCl Hydromorphone
Protonix
Vancomycin
Zofran
Amlodipine
Mag-Ox

18. Labs
10/5/14
11/9/14
12/28/14
1/21/15
2/10/15 Na
140
124L
138
141
136 K
2.9
5.8H
3.5L
2.3L
5.3H
BUN 13 18
<3 12 CR
0.6
1.1
1.1H
0.9
Glu
247 53
160H 89
115
HA1c
6.3H
6.5H
H/H
10.3/31.4
9.7L/29.6L
9.4L/29.4L
8.9L/28.7L Ca
9.4
8.5L
9.0 Cl
102 92
101
103
CO2 31 23 24
GFR
>60
53L

19. TPN prescription D20%, AA 8.5% @ 63 ml//hr plus 20% intralipids
@ 21 ml/hr, with MVI 10 ml/day and multitrace ml/day.
Provides 1361 kcal, 64 gm pro
Pt Requirements:
Calorie: 1,848-2,100 Kcal Kcal/kg)
Protein: gm gm/kg)
Fluid: 2,100-2,520 ml ml/kg)

20. Patient BMI Decreased During Hospital Stay

21. Nutrition Diagnosis
Inadequate oral intake related to Pt NPO as evidenced by Pt is on TPN
Increased energy and protein needs related to wound healing as evidenced by intestinal anastomosis, enterocutaneous fistula open wound, stage 2 pressure ulcer and sepsis.

22. Interventions
Recommend initially increasing TPN rate from 63 ml/hr to 84 ml/hr (1,520 Kcal, 84 gm Pro)
Recommend increasing Amino Acid concentration from 8.5% to 10 %, Dextrose from 20% to 50% (2,350 Kcal, 100 gm Pro) or
D20%, A 125 ml/hr plus 250 ml 20% lipid for: 2,302 Kcal, 128 gm protein

23. Interventions (continued)
Recommend wean off TPN when able to meet >50% estimated needs by PO intake.
Recommend add Gelatein 20 BID (160 Kcal, 40 gm protein)
Recommend advance diet to clear liquids, Vital AF1.2 supplement, Full Liquids to goal diet GI soft/Low Fiber, 4 GM Na.

24. Traditional GI Post-Op Management
Nil by mouth (NPO)
Nasogastric Decompression
Continue fasting until resolution of Post-op Ileus
Passage of flatus and bowel sounds return
To prevent nausea, vomiting and protect anastomosis. New Research: Early Post-Op feeding

25. J Gastrointest Surg. 2008 Apr;12(4):739-55. Epub 2007 Oct 16.
Enteral versus parenteral nutrition after gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials in the English literature. Mazaki T1, Ebisawa K
1Department of Surgery, Nihon University School of Medicine, Nihon University Nerima-Hikarigaoka Hospital, Hikarigaoka, Nerima-ku, Tokyo , Japan.
BACKGROUND:
Although previous studies recommend the use of enteral nutrition (EN), the benefit of EN after elective gastrointestinal surgery has not been comprehensively demonstrated as through a meta-analysis. Our aim is to determine whether enteral nutrition is more beneficial than parenteral nutrition.
METHODS:
A search was conducted on Medline, Web of Science, the Cochrane Library electronic databases, and bibliographic reviews. The trials were based on randomization, gastrointestinal surgery, and the reporting of at least one of the following end points: any complication, any infectious complication, mortality, wound infection and dehiscence, anastomotic leak, intraabdominal abscess, pneumonia, respiratory failure, urinary tract infection, renal failure, any adverse effect, and duration of hospital stay.
RESULTS:
Twenty-nine trials, which included 2,552 patients, met the criteria. EN was beneficial in the reduction of any complication (relative risk (RR), 0.85; 95% confidence interval (CI), ; P = 0.04), any infectious complication (RR, 0.69; 95% CI, ; P = 0.001), anastomotic leak (RR, 0.67; 95% CI, ; P = 0.03), intraabdominal abscess (RR, 0.63; 95% CI, ; P = 0.03), and duration of hospital stay (weighted mean difference, -0.81; 95% CI, ; P = 0.02). There were no clear benefits in any of the other complications.
CONCLUSION:
The present findings would lead us to recommend the use of EN rather than PN when possible and indicated.

26. Have you passed gas yet? Time for a New Approach to
Feeding Patients Postoperatively

27. Benefits of Early Oral or Enteral Feeding
Reduces weight loss; less protein catabolism; positive nitrogen balance
Decreased length of Ileus
Reduced infectious complications
Prevents increase in mucosal permeability
Reduced in-hospital mortality rates
Ameliorating Pt post-op experience
Decreased length of hospital stay
Early=within 24 hr

28. ImmunoNutrition and Gut Function
Reduced inflammation
Reduction of infection rates
Reduction of post-op complications such as fistula formation
Improved gas exchange
Improved post op gut mucosal oxygen metabolism
Reduction of length of hospital stay
Preoperative nutrition is recommended (ESPEN) in patients with elective GI cancer surgery
Oral Impact®

29. Immunomodulators Glutamine Arginine Omega-3 Fatty acids
RNA Nucleotides

30. Supplement Recommendations
Oral/Enteral Formulas
Modulars
Impact®
Pivot®
Vital 1.2 AF
AlitraQ (Ross-Sachets)
Optimental (now Vital)
Juven
Prosource

31. Impact®
IMPACT ADVANCED RECOVERY® Drink is the only beverage patented for the pre-surgical application of an immunonutrient blend (arginine, omega-3 fatty acids, nucleotides) to reduce the risk of infection after surgery

32. Impact® EPA/DHA Supplemental L-Arginine L-glutamine (inherent)
Dietary Nucleotides

33. Impact ®
Supports the immune system, helps reduce rates of infection, ventilator days and LOS in surgical and critically ill patients when used as part of an early enteral nutrition regimen
Recommended intake for 5 days pre-, peri-, or post-operatively 

34. Pivot® 1.5
Pivot® 1.5 Cal
Therapeutic, Peptide-Based, Very-High-Protein Nutrition for Metabolic Stress
PIVOT 1.5 CAL is designed for metabolically stressed surgical, trauma, burn, and head and neck cancer patients who could benefit from an immune modulating enteral formula.
For tube feeding.
For sole-source nutrition.

35. Arginine to support proliferation and function of immune cells.
Pivot® 1.5
Provides 1.5 Cal/mL—concentrated calories for fluid-restricted patients.
Very high protein (93.8 g/L, 25% of calories) to support protein synthesis, tissue repair and wound healing.
Immune support:
Arginine to support proliferation and function of immune cells.
Glutamine (inherent) for GI-tract integrity and energy for immune cells.
Omega-3 fatty acids (EPA,DHA) to help modulate inflammation and support immune function

36. Pivot 1.5
Advanced blend of hydrolyzed protein, structured lipid, and prebiotic to promote absorption and tolerance.
MCT/fish oil structured lipid, a well-tolerated and absorbed next generation fat to promote absorption of fatty acids.
NutraFlora scFOS: prebiotic soluble fibers that stimulate the growth of beneficial bacteria in the colon.
Elevated antioxidants vitamin C, vitamin E and beta- carotene to help reduce free radical damage.

37. AlitraQ® Specialized Elemental Nutrition
With Glutamine
ALITRAQ is an elemental formula specifically designed for metabolically stressed patients with impaired GI function.
supplemented with glutamine to nourish the GI tract and to help restore glutamine depleted during catabolic states.
Supplemented Arginine--a conditionally essential amino acid that supports wound healing
For oral or tube feeding.

38. For tube or oral feeding .
Vital AF 1.2 Cal™
Therapeutic Elemental Nutrition to Help Manage Inflammation and Symptoms of GI Intolerance
For tube or oral feeding .
MCT/fish oil structured lipid, a well-tolerated1,2 and absorbed1 next generation fat to promote absorption of fatty acids.
NutraFlora® scFOS®: prebiotic fibers that stimulate the growth of beneficial bacteria in the colon.
EPA (2.7 g/L) and DHA (1.1 g/L) from fish oil (10.8 g/L) to help modulate inflammation and support immune function.
Elevated antioxidants vitamins C and E to help reduce free radical damage.

39. More Recent Approaches
Pre-operative Nutrition
Fasting vs.Carbohydrate loading
Intra-operative feeding
Fast track Perioperative programs
Enhanced/Early Recovery After surgery (ERAS) protocols
Gum Chewing

41. Our Patient however…
developed more complications..

42. Pt Surgeries-current admission
11/13/14
Enterocutaneous Fistulectomy
Oversewing of small bowel opening
12/4/14
Exploratory laparotomy
Enterorraphy
Closure of enterocutaneous fistula
Application of wound vac
1/6/15
Vac application
1/16/15
Leaking PICC line
10/6/14
Enterolysis
Small bowel resection with primary anastomosis
Strangulated Ventral Hernia Repair
Bowel Perforation
Sepsis from Peritonitis, Leukopenia
11/4/14
Fistulectomy
Small bowel repair
Explantation of Infected mesh

43. Enterocutaneous Fistula

44. Entero-Cutaneous Fistula (ECF)
An abnormal communication between the bowel lumen and skin
Most occur after an operative or intervention procedure
Physiologic classification is based on volume of output
A deep entero-abdominal fistula drains content into the peritoneum, causing Peritonitis
Procedure esp lysis of adhesions, bowel resection, cancer, panceratitis

45. Classification of EAF Fistulas
Deep or Superficial
Segment of GI involved
(Gastro/Entero/Colo-atmospheric)
High Output: over 500 ml effluent per day
Moderate: ml
Low output: less than 200 ml

46. P.L. Fistula 24 hr Output 11/30-12/3: 500ml, 650ml, 250ml, 300ml
12/27-31: No output noted

47. Fistula Management Fluid and electrolyte repletion Skin care
Control of Sepsis
Nutritional Support
Somatostatin, Octreotide, Loperamide
Vacuum assisted wound management

48. Wound Vac

49. Wound Vac

50. Nutrition Management of ECF
Enteral: Preferred route of nutrition
Oral: High Sodium, Low residue diet
Fistuloclysis: Delivering feed through the fistula
Parenteral: Moderate or high output may require TPN
Combination: PN, EN, Oral

51. Nutritional Management of ECF
Calories Kcal/Kg
Protein gm/Kg
Fish Oil or Omega-3 supplementation
B-12, Zn, Mg, Selenium. 5XDRI Vit C and Zinc
Glutamine-
the primary source of N and pro for enterocyte (reduction of infections, no effect on mortality).
Positive effects of glutamine more pronounced when administered parenterally

52. Enteral Feeding
Benefits: preservation of mucosal barrier, lower infectious complications
Begin with Standard polymeric formula
Less than 120 cm, or high output >500 ml, then elemental or semi-elemental
Contraindication <75 cm usable bowel or bowel discontinuity

53. Oral Intake? Yes! Do allow for some oral intake
Choose solids vs. liquids
Advise against oral hydration
Goal to control fistula output
Oral intake should be abandoned only if it increases fistula output to “unmanageable” or from electrolyte abnormalities

54. Before discharge Pt was advanced to full liquid
followed by Low Fiber/ GI Soft diet and discharged Feb 2015

55. Update on P.L.
April 2015
ER Dx facial and hand paresthesias x 2 weeks; numbness of the jaw and right arm
Final Dx: Transient Ischemic Attack, small meningioma of the brain
Hypokalemia, Hyperchol, Obesity, HTN
Cardiac, 2 GM Sodium diet
Condition improved and discharged x1 day

56. !Thank you!
?Questions?