Early enteral nutrition in patients after laparoscopy sleeve gastrectomy

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State Scientific Institution "Center for Innovative Medical Technologies of the National Academy of Sciences of Ukraine"

Early enteral nutrition in patients after laparoscopy sleeve gastrectomy

Kalashnikov O.O.

Kyiv, Ukraine

Abstract

Obesity has become a worldwide pandemic, resulting in increased morbidity and mortality in young and elderly patients. Conservative methods of obesity treatment did not live up to expectations. It has been proven that bariatric surgery is a safe and effective method of treating obesity and compensating for obesity-related diseases. Sleeve gastrectomy confidently took the leading position as the most performed operation in the world. Most surgeons still adhere to the traditional principle of deciding when to start enteral nutrition after upper gastrointestinal surgery based on the onset of gas release. However, after the introduction of rapid recovery protocols, modern views on managing patients in the postoperative period have radically changed in all areas of gastrointestinal surgery, including major surgical interventions on the oesophagus and stomach. For a long time, it was believed that the use of nasogastric decompression and delayed enteral nutrition is one of the key points in the prevention of complications after surgery on the organs of the gastrointestinal tract, but in the literature, there are very few publications devoted to the study of the results of the use of these approaches in patients after laparoscopic sleeve gastrectomy. This problem became the goal of our research. This article presents an analysis of the results of patients' treatment after laparoscopic sleeve gastrectomy concerning the use of early enteral nutrition. The obtained results allow us to conclude that early enteral nutrition leads to a shorter stay in the hospital and does not affect the increase in the frequency of postoperative complications. Key words: obesity, bariatric surgery, laparoscopic sleeve gastrectomy, staple line failure, early enteral nutrition.

Connection of the publication with planned research works. The work is a fragment of the research work "Complex development of innovative minimally invasive techniques in surgery with use in practical and educational programs", state registration number 0120U105160.

Аннотация

Ожирение стало всемирной пандемией, что привело к росту заболеваемости и смертности среди молодых и пожилых пациентов. Консервативные методы лечения ожирения не оправдали ожиданий. Доказано, что бариатрическая хирургия является безопасным и эффективным методом лечения ожирения и компенсации заболеваний, связанных с ожирением. Рукавная резекция желудка уверенно заняла лидирующие позиции как самая выполняемая операция в мире. Большинство хирургов по-прежнему придерживаются традиционного принципа принятия решения о начале энтерального питания после операции на верхних отделах желудочно-кишечного тракта в зависимости от начала выделения газов. Однако после внедрения протоколов быстрого восстановления современные взгляды на ведение пациентов в послеоперационном периоде радикально изменились во всех областях желудочно-кишечной хирургии, включая крупные хирургические вмешательства на пищеводе и желудке. Долгое время считалось, что применение назогастральной декомпрессии и отсроченного энтерального питания является одним из ключевых моментов в профилактике осложнений после операций на органах желудочно-кишечного тракта, но в литературе очень мало публикаций, посвященных изучению результатов применения эти подходы применяются у пациентов после лапароскопической рукавной резекции желудка. Эта проблема стала целью нашего исследования. В данной статье представлен анализ результатов лечения пациентов после лапароскопической рукавной резекции желудка, касающихся применения раннего энтерального питания. Полученные результаты позволяют сделать вывод, что раннее энтеральное питание приводит к сокращению срока пребывания в стационаре и не влияет на увеличение частоты послеоперационных осложнений. Ключевые слова: ожирение, бариатрическая хирургия, лапароскопическая рукавная резекция желудка, несостоятельность скобок, раннее энтеральное питание.

Связь публикации с планируемыми исследовательскими работами. Работа является фрагментом научно-исследовательской работы "Комплексная разработка инновационных малоинвазивных методик в хирургии с использованием в практических и образовательных программах", государственный регистрационный номер 0120U105160.

Introduction

According to the World Health Organization, obesity has long been a worldwide epidemic that affects people regardless of age, gender, race, or geographic location. Numerous meta-analyses and randomized clinical trials have proven the advantages of bariatric surgery over conservative treatment methods for obesity and related metabolic disorders [1].

Bariatric surgery has made a radical breakthrough over the last decade, and its popularity grows yearly. The increase in operations on all continents confirms it. So, if in 2003 they performed all over the world 146 thousand, then already in 2016, their number reached the mark of more than 685 thousand [2].

In 2002, M. Gagner proposed laparoscopic sleeve gastrectomy (LSG) as the first stage of the biliopancre- atic bypass with duodenal bypass, according to Hess- Marceau, in morbidly super-obese patients to reduce the operative risk. However, it soon demonstrated a powerful effect in reducing excess weight and compensating for accompanying pathology and began to be considered as an independent bariatric surgery [3].

The issue of starting enteral nutrition after operations on the gastrointestinal tract remains debatable. Numerous meta-analyses and randomized clinical trials are devoted to early or delayed enteral nutrition after various surgical interventions on the organs of the gastrointestinal tract [4, 5].

At the same time, even though the results of the application of rapid recovery protocols, which include early enteral nutrition (EEN), have proven their advantages over the traditional management of patients in many areas of gastrointestinal surgery [6] in the literature and still with there are publications in which the start of enteral nutrition is advocated no earlier than on the 6th postoperative day [7]. So far, in the modern literature, it was impossible to find publications in which the influence of EEN on the course of the early postoperative period and the impact on the development of staple line failure in patients after laparoscopic sleeve gastrectomy (LSG) were analyzed.

The aim of the study. To analyze the effectiveness and safety of early enteral nutrition in patients after laparoscopic sleeve gastrectomy.

Object and research methods. The basis of this retrospective study was analyzing the results of 64 patients' treatment who underwent LSG.

The patients in this study were divided into two groups: the 1st group included 39 patients in whom enteral nutrition was started from the zero day of the postoperative period, and the 2nd group included 25 patients in whom enteral nutrition was started on the fifth postoperative day.

Data evaluated (in addition to age and gender) included: body weight (kg), body mass index (BMI) (kg/ m²), excess body weight (kg), complications and bed days (days).

The technique of performing LSG. The traditional arrangement of trocars was used to operate. After the pneumoperitoneum was formed, the first stage was a mobilization of the stomach. With the help of LigaSure electrosurgical instruments, a 12 mm (36 Fr) calibration probe was used to mobilize the greater curvature and the fundus of the stomach with electrical ligation of the gastric branches of the right and left gastro-omental vessels, short vessels and the posterior gastric artery with a mandatory crossing of the gastro-diaphragmatic ligament and visualization of the left crus of the diaphragm. The last one is a criterion for the adequacy of mobilization in the fundus area of the stomach. The initial level of mobilization of the greater curvature was at a distance of 4 cm from the pylorus of the stomach. After that, the calibration probe was inserted into the duodenum, and its position was ensured along the lesser curvature. With the help of linear staplers Echelon Flex from Ethi- con, or Endo GIA from Medtronic staged vertical resection of the stomach was performed on a 12 mm (36 Fr) calibration probe from the level of 4 cm from the pylorus of the stomach (the starting point of mobilization) to the angle of His, ensuring the width of the gastric tube up to 2 cm and a controlled retreat of the stapler suture line from the oesophagal-gastric transition by 1 cm. The resection stage of the operation was performed under moderate lateral traction by the assistant of the greater curvature of the stomach strictly behind the line of its mobilization. The stapler suture line was peritonized on the calibration probe with a continuous sero-serous suture. During the operation, each patient underwent a gastric tube leak test with a methylene blue solution through a nasogastric tube, and the operation was completed by draining the abdominal cavity.

Statistical processing methods. Statistical processing of the data was carried out using the methods of variation and descriptive statistics using the statistical analysis package SPSS Statistics: An IBM Company, version 23. Before starting the data analysis, all indicators were checked for normality of distribution using the Shapiro- Wilcoxon test. Statistical indicators of descriptive statistics average value (М) and average square deviation (SD) for normal distribution are used in work. To assess statistically significant differences in average values of quantitative traits subject to the law of normal distribution, parametric assessment methods were used in independent groups (Student's t-test). For the probability of differences in relative indicators - according to Pearson's Chi-square test (x²) with Yates correction. Differences in the obtained results were considered statistically significant at p<0.05, which provides a 95% probability level.

Research results

The patients included in the study ranged from 17 to 68 years.

In the first group, the average value was 38.9±12.5 years, and in the second - 41±11. The ratio of males to females was almost the same, 20 to 19 in the first group and 9 to 16 in the second group, respectively. Anthropometric indicators in the groups: the average value of body weight, BMI and excess body weight in the first - 143.1±22.9 kg, 48.2±7.4 kg/m² and 76.3±20.7 kg and the second - 137.9±20.1 kg, 47.2±5.7 kg/m² and 74.2±16.8 kg, respectively.

The comparison groups were homogeneous regarding age, gender and anthropometric parameters (Р> 0,05). The main characteristics of patients by the group are presented in table 1.

Table 1 - Main characteristics of patients by group

Among patients included in the study, 37.6% were morbidly super-obese (BMI over 50 kg/m²). The distribution of patients by BMI was as follows: in 7 patients (10.9%), BMI was in the range of 36.5-39.9 kg/m²; in 15 (23.4%) - 40-44.6 kg/m²; in 18 (28.1%) -45.3-49.2 kg/m², 22 (34.4%) 50-59.5 kg/m² and 2 patients (3.1%) over 60 kg/m². The technical execution of the LSG was the same. Except for the use of linear stapling devices Echelon Flex by Ethicon or Endo GIA by Medtronic during the gastric tube formation. The main intraoperative indicators are presented in table 2.

Table 2 - Main intraoperative indicators by groups

There were no cases of intraoperative complications among the patients included in the study. There was no statistically significant difference in the volume of intraoperative blood loss and the time of LSG performance (Р>0.05).

After forming the gastric tube and performing a leak test with methylene blue solution in the second group, the calibration probe was replaced with a nasogastric decompression probe with a diameter of 4 mm (12 Fr).

Patient management tactics in the first two days of the postoperative period differed. While the patients of the first group were allowed to consume liquid from the zero day of the postoperative period with a gradual increase (the zero day - 200 ml of liquid, the first day - 500 ml, the second day - 800 ml of liquid + 1 jar of baby food). Thus, the second group of patients underwent nasogastric decompression of the stomach tube for 2 days and were prohibited from consuming liquids by mouth until the fifth postoperative day.

Due to the limited mode of oral liquid intake in the patients of the second group, the period of intravenous infusion therapy was more prolonged than that of the first group. Which, in turn, on the third postoperative day, were fully independent enteral support.

All patients included in the study underwent the same prevention of nausea and vomiting according to the protocol of rapid recovery of patients after bariatric surgery [6]. Despite this, cases of nausea and vomit-ing occurred in both groups. Thus, in the second group, where nasogastric probe decompression of the stomach tube was performed, more cases of nausea were recorded compared to the first group (x²=4,75; Р=0.03) (table 3).

The staple line failure (SLF) occurred in one patient of the second group on the 5th postoperative day, while in the first group of cases, this complication was not recorded (x²=0.051; Р=0.82). Although there was no statistically significant difference in the SLF occurrence in the groups, the very fact of the specified complication in the group of patients who underwent nasogastric probe decompression of the stomach tube testifies to the ineffectiveness of the specified method of SLF prevention.

Table 3 - Complications and length of hospital stay by group

Discussion of research results

Energy support in the postoperative period is an essential component since the body experiences stress after surgery. Lack of energy can lead to deterioration of health, delayed recovery of the body, increased risk of complications and lengthening of the period of stay in the hospital.

Most surgeons still adhere to the traditional principle of deciding when to start enteral nutrition after upper gastrointestinal surgery based on the onset of gas release. invasive laparoscopic gastrectomy nutrition

This flawed approach is based on preventing complications caused by excessive volume or early stimulation of the gastrointestinal tract, including nausea, vomiting, aspiration pneumonia, and anastomotic failure [8].

In this regard, patients who have restrictions on the use of food by mouth in the early postoperative period require total parenteral nutrition (PN) to ensure full energy support.

PN was developed in the late 1960s by Dr Stanley Dudrick to provide nutritional support via central venous catheterization when patients, for various reasons, could not absorb nutrients through the gastrointestinal tract [9].

PN has been shown in numerous publications to influence postoperative outcomes in patients with severe metabolic disorders significantly. By direct central venous administration, parenteral nutrition can rapidly improve nitrogen balance, which promotes active lymphocyte recovery and improved tissue healing. In addition, there is a quick opportunity to ensure a sufficient amount of liquid in the body, preventing dehydration and ensuring the normal functioning of the kidneys and other organs. The addition of vitamins and trace elements leads to a decrease in both infectious and non- infectious complications [10].

Although PN has many advantages, its use has significant risks. Hyperglycemia and its metabolic consequences can lead to adverse outcomes if left uncorrected. In addition, volume overload can cause oedema, especially in individuals with cardiovascular failure [11]. Therefore, it is not surprising that Compher C.W. and co-authors proved in their study that tight control of glucose levels in patients in the intensive care unit receiving PN leads to fewer infectious complications and a decrease in mortality [12]. At the same time, excessive carbohydrate infusion leads to hyperglycemia, hypertriglyceridemia, and hepatic steatosis. Infusions with a high lipid content can cause hypertriglyceridemia, fat overload syndrome, and thromboembolic complications, which can be life-threatening for patients [13].

Traditionally, postoperative nutritional support was recommended when patients, after extensive surgical interventions on the organs of the gastrointestinal tract, could not consume food orally for 5-7 days after the operation [14, 15]. However, the results of studies on the use of PN in patients after surgical interventions remain controversial. Thus, in his meta-analysis, Heyland D.K. and co-authors stated that studies published before 1988 show decreased mortality rates when using PN. At the same time, studies published after 1989 do not statistically significantly affect the risk of complications and the mortality rate. Thus, the authors concluded that routine PN use after surgery has no positive clinical effects and may be associated with a 10% increase in the frequency of postoperative complications. Considering the risk-benefit ratio, PN is not recommended for routine use in patients after surgical interventions on the organs of the gastrointestinal tract [16].

For a long time after operations on the gastrointestinal tract, the tactic was "zero through the mouth". And despite the implementation of rapid recovery protocols [6], which emphasize EEN, there are works in which the start of nutrition is advocated no earlier than on the 6th postoperative day [7].

Fasting, even for 24 hours, leads to metabolic changes in the human body. More profound knowledge in physiology, which was devoted to studying the effect of hunger on the patients' body after surgical interventions, radically changed views on the possibilities of using EEN.

As it is known, the intestine is a multifunctional organ that takes an active part in many body homeostasis processes. In addition to digesting food and absorbing nutrients, the intestine is a powerful endocrine organ. At the same time, it is essential to maintain the body's immune response since most of the immune cells are located in the intestine. The intestine also produces many different proteins and other molecules involved in the body's normal functioning [17]. That is why restoring its normal functioning in patients after operations significantly affects the course of the postoperative period.

The use of EEN leads to the initiation of a cascade of reactions that positively affect the rapid recovery of the body, primarily early activation of the intestine and reducing the risk of developing intestinal distress syndrome. The first stage begins when, after ingestion of food mass, hydrochloric acid is released and enters the intestine from the stomach, which in turn stimulates the release of the cholecystokinin hormone. This hormone increases the tone of Oddi's sphincter and increases the bile content in the intestine, which improves digestion and absorption of fats. The second stage of the cascade is an increase in the production of the hormone glucagon-like peptide-1 (GLP-1), which stimulates the synthesis and release of insulin and lowers blood glucose levels. In addition, GLP-1 helps increase energy metabolism and reduce appetite. The third stage of the cascade is the production and release of pancreatic hormones (pancreatic polypeptides), which stimulate the production of enzymes for food digestion and ensure the normalization of intestinal peristalsis [17].

After implementing the rapid recovery protocol, which Kehlet first described in 1997 in elective colorectal surgery, the modern views on managing patients in the postoperative period have changed radically in all areas of gastrointestinal surgery, including significant surgical interventions on the oesophagus and stomach [18]. Thus, Ashok A., in his literature review, which included an analysis of 115 sources, found that due to the use of rapid recovery protocols in patients after esophagectomy for oesophagal cancer, it was possible to reduce the percentage of postoperative complications and shorten the length of patients stay in the hospital [19].

One of the key positions of the rapid recovery protocol is to reduce the trauma of surgical intervention, primarily due to the wide use of laparoscopic access, early activation of patients and a set of measures aimed at restoring the normal function of the gastrointestinal tract [6].

Thus, according to the protocols of rapid recovery in colorectal surgery, it is recommended to start taking liquid food during the first postoperative day with a gradual transition to semi-liquid and solid food [20]. Traditional approaches are to restrict oral intake until bowel function is restored naturally. It is due to the fear of complications in the postoperative period, primarily a failure of anastomoses and aspiration pneumonia [21].

To date, there are several meta-analyses in which the effectiveness and safety of EEN use in patients after surgical interventions on the upper parts of the gastrointestinal tract were studied.

So, Stephen J. Lewis and co-authors, in their metaanalysis, based on 30 studies, which included 1173 patients, analyzed the EEN effect on the course of the postoperative period after surgical interventions on organs of the gastrointestinal tract. Enteral nutrition in the first 24 hours after surgery did not statistically significantly increase the risk of wound infections (RR=0.77; 95% CI 0.48-1.22; Z=1.13; P=0.26), pneumonia (RR 0.76; 95% CI 0.36-1.58; Z=0.75; P=0.46) and failure of anastomoses on the gastrointestinal tract (RR 0.69; 95% CI 0.36-1.32; Z=1.11; P=0.27). However, it statistically significantly reduces the risk of mortality (RR 0.41; 95% CI 0.18-0.93; Z=2.13; P=0.03) [4].

In 2020, Zhang S. and co-authors published their study evaluating the EEN effect on the incidence of anastomotic failure after esophagectomy. This meta-analysis included five randomized clinical studies and six observational studies. The authors established that using EEN does not increase the frequency of anastomotic failure. However, in this meta-analysis, significant heterogeneity and small sample sizes of these studies are observed, which leads to misleading information. In addition, the study compared different regimens of enteral nutrition [22].

Liu H. and co-authors conducted another study based on six randomized clinical trials, which included 454 patients after gastrectomy and gastric resection for gastric cancer. The authors concluded that EEN after gastric cancer surgery is effective and safe, even starting on the zero day of surgery and independent of the extent of gastric resection and the type of surgery. However, this study included only patients from China and Korea, so it does not represent the general population [23].

However, not everything is so clear-cut. Some studies state the negative impact of using EEN. Thus, Li H. and coauthors, in their meta-analysis, analyzed the frequency of development of anastomosis failure after esophagectomy in 1595 patients depending on the time of onset of enteral nutrition. The authors found that delayed enteral nutrition reduced the failure rate after open esophagectomy (OR=2.89; 95% CI 1.56-5.34). However, when using a miniinvasive approach, no statistically significant difference between similar indicators was found (OR=0.48; 95% CI 0.22-1.02) [24]. These conclusions contradict the majority of meta-analyses [4, 19, 22]. Perhaps because most of the studies included in this meta-analysis are retrospective studies of low quality, leading to low confidence in the results.

Willcutts K.F. et al. also conducted a meta-analysis comparing EEN's effect on patients' outcomes after upper gastrointestinal surgery. The authors concluded that the use of EEN allows for a statistically significant reduction in the length of stay in the hospital (Weighted mean difference (WMD) = - 1.72; 95% CI - 1.25 to 2.20) and does not lead to an increase in the risks of failure, pneumonia, reoperation, and mortality (р>0,05). However, clinical heterogeneity was inherent in their meta-analysis, as studies of several types of upper gastrointestinal surgery were included, which were grouped (gastrectomy, esophagectomy, hepatobiliary, and others) [5].

Deng H. and co-authors conducted a deeper study. Their meta-analysis was based on 12 randomized clinical trials, which included 1,771 patients after oesophagal, gastric, and duodenal surgery. All patients in this study were randomly divided into two groups: the 1st group included 887 (50.1%) people who used EEN, and the 2nd group included 884 (49.9%) people in which enteral nutrition was started with a delay.

The results showed that the 1st group had a statistically significantly shorter time to restore normal bowel function (WMD=- 0.39, 95% CI - 0.58 to - 0.20, I²=62.1%) and a shorter length of stay in the hospital (WMD = - 1.30; 95% CI - 1.79 to - 0.80, I²=0.0%). The EEN use reduces the risk of pneumonia (RR=0.74, 95% CI 0.55-0.99, I²=0.0%) compared to patients in whom enteral nutrition was started with a delay. At the same time, the authors emphasized the absence of a statistically significant difference in the risk of anastomosis failure (RR= 0.91, 95% CI 0.60-1.38, I²=0.0%), bleeding from anastomosis (RR=1.47, 95% CI 0.53-4.03, I²=0.0%), intra-abdominal abscess (RR=0.54, 95% CI 0.27-1.07, I²=0.0%), reoperation (RR=0.81, 95% CI 0.53-1.26, I2=0.0%) and mortality (RR =0.71, 95% CI 0.361.39, I²=0.0%) [25].

In our study, using EEN led to a statistically significant reduction in the length of patients' stay in the hospital. At the same time, without increasing the level of complications in the postoperative period.

Thus, abandoning the routine use of nasogastric tube decompression and EEN after LSG are integral components of rapid recovery protocols, leading to improved treatment outcomes.

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