Immediately elevated postoperative serum branched-chain amino acids following effective GI decompression and enteral feeding

Nassif, Anthony C.; Naylor, Edwin W.

doi:10.1016/s0899-9007(96)91119-3

Cited by 5 publications

(3 citation statements)

References 16 publications

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“…This was confirmed by a surgical team in Cleveland in 34 consecutive "open" cholecystectomy patients fed with our regimen. Branched chain amino acids, essential for protein preservation and synthesis, rose above basal within one hour, and was sustained for the duration of feeding [ 20 ].…”

Section: Discussionmentioning

confidence: 99%

The etiology and prevention of feeding intolerance paralytic ileus – revisiting an old concept

Moss

2009

Ann Surg Innov Res

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Gastro-intestinal (G-I) motility is impaired ("paralytic ileus") after abdominal surgery. Premature feeding attempts delay recovery by inducing "feeding intolerance," especially abdominal distention that compromises respiration. Controlled studies (e.g., from Sloan-Kettering Memorial Hospital) have lead to recommendations that patients not be fed soon after major abdominal surgery to avoid this complication.We postulate that when total fluid inflow of feedings, digestive secretions, and swallowed air outstrip peristaltic outflow from the feeding site, fluid accumulates. This localized stagnation triggers G-I vagal reflexes that further slow the already sluggish gut, leading to generalized abdominal distention. Similarly, vagal cardiovascular reflexes in susceptible subjects could account for the 1:1,000 incidence of unexplained bowel necrosis reported with enteral feeding.We re-evaluated our data, which supports this postulated mechanism for the induction of "feeding intolerance." We had focused our efforts on postoperative enteral nutrition, with the largest reported series of immediate feeding of at least 100 kcal/hour after major surgery. We found that this complication can be avoided consistently by monitoring inflow versus peristaltic outflow, immediately removing any potential excess from the feeding site.We fed intraduodenally immediately following "open" surgery for 31 colectomy and 160 consecutive cholecystectomy patients. The duodenum was aspirated simultaneously just proximal to the feeding site, efficiently removing all swallowed air and excess feedings. To salvage digestive secretions, the degassed aspirate was re-introduced manually (and later automatically) via a separate feeding channel.Hourly assays were performed for nitrogen balance, serum amino acids, and for the presence of removed feedings in the aspirate. The colectomy patients had X-ray motility studies initiated 5 -17 hours after surgery.Clinically normal motility and absorption resumed within two hours. Fed BaSO 4 traversed secure anastomoses, to exit in bowel movements within 24-48 hours of colectomy. All patients were in positive protein balance within 2 -24 hours, with elevated serum amino acids levels and without adverse G-I effects.Limiting inflow to match peristaltic outflow from the feeding site consistently prevented "feeding intolerance." These patients received immediate full enteral nutrition, with the most rapid resolution of postoperative paralytic ileus, to date.

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Section: Discussionmentioning

confidence: 99%

The etiology and prevention of feeding intolerance paralytic ileus – revisiting an old concept

Moss

2009

Ann Surg Innov Res

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“…All the feedings had been propelled downstream to be completely digested. Absorption and X-ray motility studies confirmed the rapid recovery of G-I function [ 7 – 9 ] (Figs. 4 , 5 ).…”

Section: Introductionmentioning

confidence: 88%

Development of automated postoperative enteral nutrition: restricting feeding site inflow to match peristaltic outflow

Moss

2015

Ann Surg Innov Res

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BackgroundSurgical stress accelerates postoperative metabolism, while simultaneously compromising gut activity. The dysfunction may be worsened by early feeding. These patients are not expected to fully meet their optimum metabolic requirements using current nutritional regimens. For optimum postoperative enteral nutrition, we must automatically match the patients’ feeding site inflows to their impaired peristaltic outflows. An essential adjunct is virtually complete exclusion of swallowed air. The small diameter post-pyloric duodenum is an efficient site for both aspiration and feeding.MethodA multi-lumen feeding-decompression tube is utilized to feed an “elemental diet” (1 kcal/ml) at the rate of 3000–5000 ml/day immediately postoperatively. Outflow from the feeding site, relative to inflow, is monitored. Excess aspirate is discarded automatically, so that the re-fed inflow exactly matches the peristaltic outflow. The aspirate (digestive secretions, feedings, and swallowed air) is degassed. The aspirate is then directed by one-way valves alternately, every 30 s, into a pair of 30 ml collection chambers for re-feeding. Simultaneously, the previously collected aspirate (less discarded volume, if required) is delivered by gravity into the slightly more distal duodenum.ResultsWithin 2 h, the return of the entire aspirate volume is tolerated. The patients’ increased metabolic demands are met early on the initial day of surgery. They achieve positive protein balance, with documented enhanced healing (experimentally) and immune globulin synthesis (clinically). Breakfast is tolerated the morning following operation, with discharge soon thereafter. X-ray motility and nutrient absorption studies document the more rapid return of clinically normal peristalsis.ConclusionAutomatically keeping the proximal duodenum and stomach continuously decompressed, while simultaneously re-feeding tolerated degassed duodenal aspirate, leads to more rapid return of clinically adequate G-I function postoperatively. In addition to maximizing immediately postoperative nourishment, the secretory globulins are salvaged, and spontaneously delivered into the colon, where they provide natural antimicrobial protection.

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“… 63 More recently, in 34 elective ‘open’ cholecystectomy patients early enteral feeding was found to result in an elevation in BCAA serum concentrations that persisted for the duration of feeding. 64 However, despite these apparent advantages, none of these earlier studies demonstrated a clinical advantage in terms of morbidity and mortality in catabolic patients.…”

Section: Metabolismmentioning

confidence: 98%

Branched‐chain amino acids

Platell

Kong

Mccauley³

et al. 2000

J of Gastro and Hepatol

123

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The branched‐chain amino acids (BCAA), isoleucine, leucine and valine, are unique in that they are principally metabolized extrahepatically in the skeletal muscle. This observation led to the investigation of these nutrients in a number of clinical scenarios. By far the most intensively studied applications for BCAA have been in patients with liver failure and/or patients in catabolic disease states. However, the resulting studies have not demonstrated a clear clinical benefit for BCAA nutritional supplements. In patients with liver failure, the BCAA did improve nitrogen retention and protein synthesis, but their effect on patient outcome was less clear. Similarly, in critically ill septic patients, BCAA did not improve either survival or morbidity. The BCAA are important nutrients, and it seems that any specific benefits associated with their use will be based upon a greater understanding of the underlying cellular biology. Potential areas of further research may include the combination of BCAA supplements with other anabolic factors (e.g. growth hormone) in managing patients with catabolic disease states.

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Immediately elevated postoperative serum branched-chain amino acids following effective GI decompression and enteral feeding

Cited by 5 publications

References 16 publications

The etiology and prevention of feeding intolerance paralytic ileus – revisiting an old concept

The etiology and prevention of feeding intolerance paralytic ileus – revisiting an old concept

Development of automated postoperative enteral nutrition: restricting feeding site inflow to match peristaltic outflow

Branched‐chain amino acids

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