Nonocclusive mesenteric ischemia associated with postoperative jejunal tube feeding: Indicators for clinical management

Abstract

Postoperative nutrition via a jejunal tube after major abdominal surgery is usually well tolerated. However, some patients develop nonocclusive mesenteric ischemia (NOMI). This morbid complication has a grave prognosis with a mortality rate of 41% to 100%. Early symptoms are nonspecific, and no treatment guideline is available. We reviewed cases of NOMI at our institution and cases described in the literature to identify factors that impact the clinical course. Among five patients, three had no necrosis and one had segmental necrosis and perforation. These patients recovered with limited resection and decompression of the bowel and abdominal compartment. In one patient with extended bowel necrosis at the time of re-laparotomy, NOMI progressed and the patient died of multiple organ failure. The extent of small bowel necrosis at the time of re-laparotomy is a relevant prognostic factor. Therefore, early diagnosis and treatment of NOMI can improve the prognosis. Clinical symptoms of abdominal distension, cramps and high reflux plus paraclinical signs of leukocytosis, hypotension and computed tomography findings of a distended small bowel with pneumatosis intestinalis and portal venous gas can help to establish the diagnosis. We herein introduce an algorithm for the diagnosis and management of NOMI associated with jejunal tube feeding.

Improving nutrition practices for postoperative high‐risk heart transplant and ventricular assist device implant patients in circulatory compromise: A quality improvement pre– and post–protocol intervention outcome study

“…Identifying NOBI early after EN introduction can be difficult in the postoperative setting given that GI intolerance symptoms are already common in critical care settings. Furthermore, the variable onset timing of NOBI diagnosis (3–15 days) after EN initiation 82 also contributes to challenges with early NOBI identification. For example, it is challenging to determine whether a patient simply has a temporary, reversible GI dysfunction such as common bowel ileus or whether the bowel ileus represents the first stages of gut mucosal ischemic injury or necrotic damage.…”

Recent Advances in Pancreatic Ductal Adenocarcinoma: Strategies to Optimise the Perioperative Nutritional Status in Pancreatoduodenectomy Patients

“…Recent evidence, including a systematic review and meta-analysis [69,71], shows that EN is associated with fewer complications and reduced length of stay compared to PN after PD. Some reasons behind these clinical benefits are thought to be improved immunological function due to stimulation of enterocyte growth, stabilisation of the mucosal barrier, and a decrease in bacterial translocation [72][73][74]. In addition to this, cyclical NJ feeding, whereby feed is stopped for a period each day, has been shown to lead to faster recovery and progression to normal diet after PD compared to continuous feeding (RCT), likely due to more physiological cholecystokinin (CCK) levels [70].…”

“…However, one important complication to be aware of in postoperative enteral tube feeding is small bowel ischaemia. The exact mechanism for this is still not fully understood, but it is likely to involve large fluid shifts and osmotic changes [74][75][76]. To reduce the chances of this, the feeding rate should be increased slowly, and caution should be applied in patients who are hypotensive and requiring inotropic or vasopressor support [74,77].…”

“…The exact mechanism for this is still not fully understood, but it is likely to involve large fluid shifts and osmotic changes [74][75][76]. To reduce the chances of this, the feeding rate should be increased slowly, and caution should be applied in patients who are hypotensive and requiring inotropic or vasopressor support [74,77]. Patients receiving small bowel feeding should be adequately hydrated prior to initiation of feeds, and EN should be discontinued if the patient becomes haemodynamically unstable.…”

Gastrointestinal function in critically ill patients

“…Indeed, it may lead to further complications if a hypo-motile or paralyzed intestine receives a large nutrient load. Of note, postoperative nonocclusive mesenteric ischemia is frequently attributed to post-pyloric feeding [43].…”