Several studies have reported that gastrointestinal (GI) intolerance symptoms are the limiting factor to enteral alimentation in the immediate postoperative period and often the reason for resorting to total parenteral nutrition (TPN). We postulated that Reabilan HN (a recently developed small peptide-based formula, in part obtained by enzyme hydrolysis of proteins) might be better absorbed and better tolerated so as to avoid the need for TPN. Accordingly, 19 patients undergoing major abdominal surgery were randomly assigned to receive Reabilan HN via jejunostomy or an equicaloric isonitrogenous TPN regimen. Both were begun 6 hr postoperatively at 25 ml/hr and increased by 25 ml/hr at 12-hr intervals up to the rate providing 1.5 times the calculated REE. GI tolerance to enteral feeding was excellent during the first three postoperative days, allowing the progression of the feeding rate to 99% of goal. During the next 3 days (starting on average 1.7 days after the return of bowel sounds), GI intolerance symptoms required a reduction in feeding rate to 52% on average. Subsequently, the symptoms resolved and the feeding rate reached 96% of goal. Although overall mean daily calorie and nitrogen intakes were lower for the enteral than for the TPN group (79.6 +/- 10.2% vs 94.6 +/- 3.8% of goal; p less than 0.01), the enteral group was nevertheless in positive caloric and nitrogen balance, and maintained similar serum albumin, prealbumin, and plasma transferrin levels. Average daily cost of supplies was $44.36 for enteral vs $102.10 for parenteral nutrition (p less than 0.001). We conclude that enteral feeding using this formula is well tolerated and cost-effective in the immediate postoperative period.(ABSTRACT TRUNCATED AT 250 WORDS)

This article thoroughly updates the authors' previous review of nutritional assessment and support during pregnancy. After briefly reviewing nutrient metabolism and requirements, the authors discuss the nutritional assessment of the pregnant woman and review the nutritional support principles in hyperemesis gravidarum and other conditions that can compromise the nutritional health of mother or fetus.

The development of clinical nutrition in the past few years has occasioned a rapid proliferation of hundreds of nutrition support teams across the country. Data available in several surveys of these teams suggest that they are so likely to differ from one another that they scarcely merit a common name. Some standard is clearly needed. A formulation of the essential features that should be found in every NST is presented. In light of this conceptual framework, data on the efficacy of NSTs are discussed. It is suggested that, although there is enough favorable evidence in cost-effectiveness for a hospital to establish an NST, the full potential of the NST as the proper repositor of a new branch of medicine (Clinical Nutrition) has yet to be widely recognized and properly tested.

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To investigate the pathophysiology of aspiration pneumonia in patients fed via gastrostomy tube, the authors measured lower esophageal sphincter pressure in 10 patients 1 before and 24 hours after percutaneous endoscopic gastrostomy tube placement and also during bolus vs continuous feeding. 2 In five of these patients, gastroesophageal reflux scintigrams were obtained (using technetium-99-labeled feeding) comparing bolus and continuous feeding. Bolus feeding consisted of 250 mL of Jevity, an isotonic formula (310 mOsm/kg), followed by 100 mL of water, all given within 20 seconds; continuous feeding consisted of the same formula infused at 80 mL/h without added water. Lower esophageal sphincter pressure was measured continuously during the 15 minutes immediately after a feeding bolus and for another 15 minutes after initiation of continuous feeding 2 hours later. The scintigrams were obtained every 10 seconds during similar 15-minute periods. Basal lower esophageal sphincter pressure was not affected by percutaneous endoscopic gastrostomy tube placement or by continuous intragastric feeding. In contrast, bolus feeding was associated with marked relaxation of the lower esophageal sphincter to incompetent levels (16.6 ± 4.6 mm Hg to 2.1 ± 2.0 mm Hg, p < .001). The scintigrams revealed gastroesophageal reflux to the sternal notch after bolus infusion but not during continuous feeding. The authors concluded that gastroesophageal reflux associated with lower esophageal sphincter relaxation occurs in response to bolus feeding but not in response to continuous feeding, presumably a result of gastric distention by the bolus. Continuous feeding is therefore recommended for reducing the risk of aspiration pneumonia.Comments:Aspiration pneumonia is one of the most dreaded complications of intragastric tube feeding. Recommendations for reducing this risk have included raising the head of the bed during feeding to minimize gravity-driven gastroesophageal reflux and using slow continuous feeding instead of intermittent bolus feeding in order to avoid gastric distention that results in pressure-driven gastroesophageal reflux. Although reasonable, these precautions have not been of proven efficacy, yet they remain widely practiced. This study examined lower esophageal sphincter (LES) function as it relates to gastroesophageal reflux during feeding via percutaneous endoscopic gastrostomy tube. Although this study is limited both in the number of patients studied (a total of 10 patients, only five of whom were studied by scintigraphy) and in the length of follow-up, the results are nevertheless significant, and they are of particular interest when compared with those obtained by Kocan and Hickisch2 in neurosurgical intensive care unit patients. In the latter study, which comprised 34 patients randomly assigned to continuous or intermittent feeding who were followed for an average of 7.6 days, there was no significant difference in prevalence of aspiration (as evidenced by the presence in pulmonary secretions of the b...