- Email: [email protected]
P.29 More gastroesophageal reflux with percutaneousendoscopic gastrostomy tubes as compared to nasogastric tubes
4th S e s s i o n - E N T E R A L N U T R I T I O N tion + commercial swine chow 'ad Iibitum' in the postoperative period and no immunosuppression. Eight normal animals were used to obtain the standard reference of D-Xylose absorption test. On 28th postoperative day (pod) all the animals underwent an absorption test for D-Xylose (0.5 k/kg b.w. via the tube gastrostomy). Full thickness bioposies were taken from the graft at the transplant and on 29th pod for morphometric assessment of villi height and cryptae depth. Results: The area under the absorption curves of D-Xylose were 2777 in Group 1, 5304 in Group 2, 4976 in Group 3 and 5684 in normal animals. Two-way ANOVA test calculated a P value = 0.0001 between the absorption curves of Groups 1 and 2. Villi height increased in Group 3 only, but Group 2 showed a significantly lower reduction in comparison to Group 1. Neither histological signs of graft rejection nor graft versus host disease were detected in any of the animals. Postoperative enteral feeding limited the reduction in villi height and improved the absorption of D-Xylose from the intestinal allografts in pigs.
P.26 Metabolic and trophic effects of an enteral glutamate enriched-diet in endotoxemic rats C. S a v a n o v i t c h - C h a m b o n ~, M. C. Farges 1, M. P. Vasson ~, P.
Davot ~, F. Raul 2, E Blachier 3 and L. Cynober ~ ~Lab. Bioch., Biol. MoL et Nutr., Fac. Pharm. et CRNH, ClermontFerrand, 2IRCAD, Strasbourg, 31NRA, Jouy-en-Josas, France. Although glutamine (Gin) becomes a conditionally essential amino acid (AA) under catabolic conditions, it cannot be included in liquid enteral nutrition due to its instability. The use of a precursor-like glutamate (Glu), from which Gin can be synthesized, via Gin synthase, could be of interest. Aims: To evaluate whether a Glu enriched-diet is able to restore Gin tissue pools in endotoxemic rats. Methods: After acclimatization, young male Sprague-Dawley rats (123 + 1 g) received an injection of endotoxin (LPS E. coil serotype 0127: B8, 3 mg/kgb.w., i.p.). After 24-h fasting (d0-dl), animals were enterally refed for 48h (dl-d3), using Osmolite ® (Abbott-Ross, 210kcal/kg/d) without supplement (LPS, n = 14), or enriched with Glu at the dose of 4g/kg/d (LPS-GIn, n = 14), or with glycine isonitrogenous to Glu (LPSGly, n = 7). A control group of healthy rats (healthy, n = 7) was nourished ad libitum throughout the experiment. Urinary nitrogen balance was measured daily. AA concentrations and protein contents of plasma and tissues (intestine, EDL and tibialis muscles) and intestinal morphometry were determined at d3. Results: Tissue weight (in %) and protein content (in mg/g) were not significantly different among the three endotoxemic groups. At dl nitrogen balance became negative in these three groups and significantly lower than in the healthy (-153 + 210 vs 425 + 27 mg/N/d, P< 0.01). There was no difference between LPS and LPS-Gly for any parameters studied. Muscle alanine (Ala) concentrations were increased in LPS-Glu compared to LPS-Gly (EDL: 4.19 + 0.14 vs 2.46 _+0.08 i~mol/g, P < 0.01; tibialis: 4.34 + 0.12 vs 2.79 + 0.20 #mol/g, P< 0.01). Plasma and jejunal Gin concentrations were more elevated in LPS-Glu than in LPS-Gly (1155 + 31 vs 886 + 17 #mol/I, P < 0.01 ; 0.71 _+0.04 vs 0.49 + 0.03 #mol/g, P < 0.01, respectively). Moreover, ileal proline concentration was increased in LPS-Glu compared to LPS-GIy (0.51 _+0.02 vs 0.40 + 0.02 #mol/g, P < 0.05). In terms of intestinal morphometry, jejunal crypt depth was decreased in the three endotoxemic groups vs the healthy (155 _+ 4 vs 181 + 4pro, P< 0.01), without any difference between them. Conclusions: An enterally Glu enriched-diet administered in endotoxemic rats is able to counteract Gin depletion in intestine but not in muscles. However, Glu displayed no trophic effect in any tissue.
P,28 Safety and patient well-being after preoperative oral intake of carbohydrate rich beverage Nygren, A. Thorell, M. Lagerkranser 1, C. AlmstrSm, F. Hammarqvist 2 and O. Ljungqvist Depts of Surgery and ~Anesthesiology, Karolinska Hospital, 2Dept of Surgery, St GOrans Hospital, Stockholm, Sweden.
J.
Free intake of clear fluids up until 2h before anesthesia for elective surgery is becoming a new standard. Presently, we tested if it is safe to give an iso-osmolar carbohydrate rich drink (POC) in this situation and the effects on patient well-being. In a double-blind study, patients scheduled for elective surgery were randomized to the routine preoperative overnight fast (F), intake of placebo (PI) or a carbohydrate rich drink (POC, 12.5% carbohydrates) 800ml the evening before surgery and 400 ml 2 h before the initiation of anesthesia. Patient well-being (visual analogue scale, VAS, 14 different parameters) before and after surgery and postoperative activity levels were assessed. The sum of all 14 parameters of well-being are used to obtain a measurement of total patient well-being (index). Low values in VAS indicate increased wellbeing. Furthermore, the gastric residual volume (GRV) and pH (aspiration from naso-gastric tube) at the initiation of anesthesia was registered. A preliminary analysis has been performed (n = 87) in patients scheduled for elective laparoscopic cholecystectomy (n 49) or abdominal surgery (n = 38). Mean + SEM, P < 0.05 *POC vs F, 1-PI vs F, §POC vs PI, :I:POC vs F and PI, ANOVA. Results: Well-being was similar between the groups in a control situation. In the morning before surgery POC displayed reduced thirst (*), hunger (*:1:§), weakness (*:1:) and index (*:1:) while no difference was found between PI and F groups. Ninety minutes after intake of drink, POC displayed less weakness (:1:), thirst (*), hunger (*§:1:), nausea (:1:), index (*:1:) and increased fitness (*); PI displayed less thirst (1-), weakness (t), index (t) and increased fitness (t). On the first postoperative day, POC displayed decreased hunger (§$) while other parameters of well-being were not statistically different. In the patients undergoing abdominal surgery POC tended to improve weakness (:I:P = 0.15), thirst (:I:P = 0.10) and hunger (:I:P = 0.07) on the first postoperative day. No differences were found in GRV (35 -+ 4/29 _+4/37 _+8 ml, F/PI/POC, resp.) or pH at the initiation of surgery. Postoperative mobilization and outcome were similar in the two groups. Conclusions: The present data suggest that intake of an iso-osmolar carbohydrate rich beverage 2h before anesthesia for surgery is safe. POC improves Preoperative well-being, and tended to improve also postoperative well-being following abdominal surgery.
P.27 Enteral feeding significantly limits the reduction of villi height and improves the absorption of D-xylose by intestinal allografts in pigs R. Biffi*, B. Andreoni §, S. Pozzi*, L. Marzona*, F. Luca*, P. Velio t,
C. Robertson* and P. Maisonneuve* §lstituto di Chirurgia d'Urgenza, t di Scienze Mediche, Universita di Milano and *European Institute of Oncology, Divisions of Gastrointestinal Surgery and Epidemiology and Biostatistics, Milan, Italy. Absorption of D-Xylose and villi height have been reported to be considerably reduced 1 month after total orthotopic small bowel transplantation (TOSBT) in pigs as well as in humans, lacking any sign of graft rejection or graft versus host disease. The impact of postoperative enteral feeding has not been investigated. Aims: To evaluate changes in villi and eryptae height and to assess the intestinal absorption of D-Xylose in pigs given either a commercial chow 'ad libitum' or polymeric enteral feeding after TOSBT under cyelosporin-A (CsA). Methods: Seventeen large white female pigs weighing 30 _+ 7 kg were randomly allocated to one of the following experimental groups: Group 1 (n = 6): TOSBT + CsA 15 mg/kg body weight (b.w.)/day i.v. + commercial swine chow 'ad libitum' in the postoperative period. Group 2 (n = 6): TOSBT + CsA 15 mg/kg b.w./day i.v.+ defined enteral formula in the postoperative period via a tube-gastrostomy, consisting of 34.6 _+6.7 Kcal/kg b.w./day (51% carbohydates as dextrin, 15% proteins as casein and soya bean, 34% lipids as medium chain triglycerides, sunflower and coconut oils; osmolarity = ;245 mOsm/I). Group 3 (n = 5): TOSB autotransplanta-
P.29 More gastroesophageal reflux with percutaneous endoscopic gastrostomy tubes as compared to nasogastric tubes S.Aftahi and L. Howard Albany Medical College, Albany, New York, USA. One of the most life threatening complications of tube feeding (TF) is aspiration of formula. It is generally believed that endoscopically placed percutaneous gastrostomy (PEG) feedings are associated with less gas30
troesophageal reflux (GER) compared to nasogastric tube (NGT) feeding. This study compared GER in patients receiving continuous TF delivered first via an NGT and then by a PEG. Eight patients, (6M, 2F), mean age 69 years (range 27-98), who required TF because of a cerebrovascular accident (3), dementia (2) or short bowel syndrome (3) were studied. Twenty-four hour pH monitoring was performed twice on each patient; first on small bore NGT feeding and second after insertion of a PEG (_>5 days after insertion). All patients received the same polymeric formula delivered continuously and at the same rate on both occasions. Three pH monitoring parameters were compared and differences evaluated by the paired t-test. Number of reflux episodes with pH < 4 (mean 4- SD) was 23.4 _+22.5 with NGT and 48.3 _+28.9 with PEG (P < 0.05); % time pH < 4 was 3.7 _+7.5 with NGT and 17.2 4- 28.8 with PEG (NS); the number of episodes longer than 5 min was 1.6 _+ 3.5 with NGT and 5.4 4- 7.7 with PEG (NS). Two patients died in the following 6 months, one from aspiration (this patient was one of those experiencing the most reflux episodes with PEG). Conclusions: Reflux is more frequent with a PEG than NGT in patients on continuous TE This suggests a greater risk of aspiration with PEG compared to small bore NGT.
to receive a snack with 250 cc of one of these formulae at 09:00 after routine medications (insulin or suiphonylureas) had been taken. Venous blood samples were obtained during fasting and at 30 and 120 rnin after the snack. The significance of the difference for comparison of more than one group was calculated by analysis of variance for one or two factors. Results: The glycaemic and C-peptide response to the low fat diet was higher than to the high fat diet (P = 0.02, and P = 0.03 respectiw.Ny). On NIDDM (insulin-treated) the incremental glucose response at 0, 30 and 120 rain was lower with the high fat diet (P = 0.03, P = 0.002, P = 0.003 respectively). Two-factor analysis of variance on mean increments from basal levels of glucose and C-peptide show the type of enteral formulae as the main factor (P= 0.001 and P= 0.01 respectively). Variations of plasma acetoacetate and 3-hydroxybutyrate after tests with both enteral formulae were not statistically significant. We conclude that the partial replacement of carbohydrates with monounsaturated fatty acids in the enteral formulae, used for supplementation, may improve glycemic control in patients with NIDDM without adverse effects on ketone production.
1°.32 Tolerance and septic complications in surgical patients fed with different routes and composition of nutritional support
P.30 Evaluation of immune markers in asymptomatic AIDS patients receiving fish oil supplementation
A. Cestari, M. Braga, L. Gianotti, A. Vignali and V. Di Carlo
Dept of Surge04, Scientific Institute S. Raffaele Hospital, University of Milan, Italy.
N. Virgili*, M. Farriol, J. M. Castellanos, M. Gir6, D. Podzamczer and
A. M. Pita CSUB Bellvitge, Biochemistry Department and 'S. Grisolia' Research Unit, Barcelona, Spain.
The ability of specific nutrients to modulate the immune response has been repeatedly demonstrated. The aim of the present study was to evaluate the effect of the enteral administration of a diet supplemented in immunonutrients compared to a standard formula and total parenteral nutrition early after major surgery. One hundred and fifty patients with gastric or pancreatic cancer were randomized after surgery into three groups to receive a standard enteral formula (S) (n = 48), a formula enriched with arginine, RNA and omega-3 fatty acids (E), (n = 50) or total parenteral nutrition (TPN) (n = 52). The three treatments were isocaloric and isonitrogenous. The administration of both enteral formulas began within 12 h after surgery; the infusion rate was progressively increased and the full regimen (25 kcal/kg; 0.25 g nitrogen/kg) was reached on postoperative day 4. The clinical parameters were: length of postoperative stay, bowel movements, intolerance to enteral feeding, rate and severity of postoperative infections. Age, rate of malnutrition, duration of surgery, blood loss, transfusions and preoperative stay were similar in the three groups. The intolerance rate to enteral feeding was similar in both groups. Overall 22.4% (22/98) of patients complained of side effects but only in 5 of the 22 patients (22.7%) was it necessary to reduce or temporarily interrupt the enteral infusion to resolve the symptoms. In the enterally fed patients there was a quicker bowel canalization to gas and stools (2.9 4- 0.8 days and 5.4 _+ 1.4 days, respectively) than the TPN group (3.8 + 1.1 days and 6.9 _+1.5 days) (P < 0.05). Length of postoperative stagywas 15.1 _+7.7 days in the TPN group, 16.1 + 7.2 days in the S group and 13.7 _+5.7 days in the E group. Overall septic complication rate was 20.6% (31/150): 14.0% (7/50) in E group; 20.8% (10.48) in S group and 25.0% (13/52) in TPN group (P = 0.07 E vs TPN). The severity of septic complications (based on Sepsis Score) was 4.0 4- 2.6 in the E group versus 6.4 _+3.0 in S group and 7.5 + 4.8 in TPN group (P < 0.05 E vs TPN and S). Early enteral feeding after major abdominal surgery was well tolerated and permitted a quicker recovery of gut function. The use of the enriched enteral formula allowed a reduction of septic complications and their severity.
Aim: To evalute the effect of oral fish oil (FO) supplementation on selected immune markers in asymptomatic HIV-infected patients. Material and methods: Nine asymptomatic, A2 clinical category (CD4 count 290 4- 123cells/mm3), HIV-infected male subjects receiving AZT retroviral treatment, were studied. A 24-h dietary recall and food frequency questionnaire were used. Eight 0.5 mg capsules of FO (Pulse, Grifols), containing co-3 fatty acids: 70 mg of EPA and 45 mg of DHA were administered twice a day (8 g) over 6 weeks. Biochemistry studied at zero time (To) and 6 weeks of treatment (T6) were: leucocyte and lymphocyte counts, CD4/CD8 ratio, prealbumin, uric acid, cholesterol and triglycerides and erythrocyte malondialdehyde (MDA). IL-lJ3 levels after LPS (10#g/ml) exposure were determined in whole blood culture supernatants. Dehydroepiandrosterone-sulphate (DHEA-S) was analysed by radioimmunoassay (112s). Statistics: Mann-Whitney U-test. Results: Patients were well-nourished (mean BMI = 23.8 4- 4.9 kg/m2). There were some small, beneficial tendencies after treatment shown in the following results: erythrocytes (3.97 4- 0.6 vs 4.16 _+0.6 x 102), lymphocytes (1.70 _+0.58 vs 1.84 4- 0.40 x 109), CD4/CD8 ratio (0.26 _+0.08 vs 0.28 _+0.08), and triglycerides (2.03 _+0.87 vs 1.87 _+0.57 mmol/I). After stimulation there was a statistically significant increase in MDA release (To: 350.9 _+79.8 vs T6:614.1 _+ 106.4 nmol/g b). IL-I~ at To and T 6 was increased with respect to normal range (NR), with a slight decrease at T 6 (49.8 vs 40.9; NR: 1-8.4). After stimulation, significant decreases in IL-1 were observed after treatment (To: 797.7 vs m6: 535.6pg/ml; NR: 471-1820 pg/ml). Mean DEAH-S values decreased after FO supplementation: 1134.1 vs 637.6 ng/ml (NR: 800-5600 ng/ml). Conclusions: Taken collectively, these results suggest a tendency toward improvement in immune function and nutritional status. The trends observed lead us to think that FO administration at other dosing regimens merits further study.
P.31 High-fat versus high-carbohydrate enteral formulae: effect on blood glucose, C-peptide and ketones
P.33 The quantitative effect of nutrition support on quality of life in outpatients
A. Sanz, M. Guallar, I. Salazar, A. B. Cortes, R. Albero and S. Celaya
Endocrinology and RIA Laboratory, Miguel Servet Hospital, Zaragoza, Spain.
C. P. J a m i e s o n , B. Norton, T. Day, M. Lakeman and J. Powefl- Tuck
Rank Dept of Human Nutrition, Royal London Hospital, Whitechapel, London, UK.
Use of enteral nutritional supplementation in elderly nursing home patients with type 2 diabetes (NIDDM) tends to exacerbate hyperglycemia and require initiation or increase of insulin therapy. Two commercial enteral diets for diabetic patients are available: low fat (15% protein P, 31% fat F and 54% carbohydrates CHO) and low CHO (16.7% protein, 50% fat: 35.5% monounsaturated, 33% carbohydrates). We compared the effects of two enteral diets on glycemic, C-peptide and ketones response in NIDDM treated with insulin or sulphonylureas. Patients and methods: Forty NIDDM patients were randomly assigned
Aim: To compare gains in body weight and lean body mass with changes in quality of life in an undernourished outpatient population. Methods: One hundred and thirty-one poorly rehabilitated patients with chronic disease (19 short bowel, 18 neoplasia, 13 inflammatory bowel disease, 12 pseudoobstruction, 9 neurological dysphagia, 3 chronic pancreatitis, 33 poor intake, 24 others), presenting sequentially to a nutrition support clinic, were divided into those with a body mass index (IBMI) of less than the desirable range of 20-25 (group 1) and those with an index 31
P.26 Metabolic and trophic effects of an enteral glutamate enriched-diet in endotoxemic rats C. S a v a n o v i t c h - C h a m b o n ~, M. C. Farges 1, M. P. Vasson ~, P.
Davot ~, F. Raul 2, E Blachier 3 and L. Cynober ~ ~Lab. Bioch., Biol. MoL et Nutr., Fac. Pharm. et CRNH, ClermontFerrand, 2IRCAD, Strasbourg, 31NRA, Jouy-en-Josas, France. Although glutamine (Gin) becomes a conditionally essential amino acid (AA) under catabolic conditions, it cannot be included in liquid enteral nutrition due to its instability. The use of a precursor-like glutamate (Glu), from which Gin can be synthesized, via Gin synthase, could be of interest. Aims: To evaluate whether a Glu enriched-diet is able to restore Gin tissue pools in endotoxemic rats. Methods: After acclimatization, young male Sprague-Dawley rats (123 + 1 g) received an injection of endotoxin (LPS E. coil serotype 0127: B8, 3 mg/kgb.w., i.p.). After 24-h fasting (d0-dl), animals were enterally refed for 48h (dl-d3), using Osmolite ® (Abbott-Ross, 210kcal/kg/d) without supplement (LPS, n = 14), or enriched with Glu at the dose of 4g/kg/d (LPS-GIn, n = 14), or with glycine isonitrogenous to Glu (LPSGly, n = 7). A control group of healthy rats (healthy, n = 7) was nourished ad libitum throughout the experiment. Urinary nitrogen balance was measured daily. AA concentrations and protein contents of plasma and tissues (intestine, EDL and tibialis muscles) and intestinal morphometry were determined at d3. Results: Tissue weight (in %) and protein content (in mg/g) were not significantly different among the three endotoxemic groups. At dl nitrogen balance became negative in these three groups and significantly lower than in the healthy (-153 + 210 vs 425 + 27 mg/N/d, P< 0.01). There was no difference between LPS and LPS-Gly for any parameters studied. Muscle alanine (Ala) concentrations were increased in LPS-Glu compared to LPS-Gly (EDL: 4.19 + 0.14 vs 2.46 _+0.08 i~mol/g, P < 0.01; tibialis: 4.34 + 0.12 vs 2.79 + 0.20 #mol/g, P< 0.01). Plasma and jejunal Gin concentrations were more elevated in LPS-Glu than in LPS-Gly (1155 + 31 vs 886 + 17 #mol/I, P < 0.01 ; 0.71 _+0.04 vs 0.49 + 0.03 #mol/g, P < 0.01, respectively). Moreover, ileal proline concentration was increased in LPS-Glu compared to LPS-GIy (0.51 _+0.02 vs 0.40 + 0.02 #mol/g, P < 0.05). In terms of intestinal morphometry, jejunal crypt depth was decreased in the three endotoxemic groups vs the healthy (155 _+ 4 vs 181 + 4pro, P< 0.01), without any difference between them. Conclusions: An enterally Glu enriched-diet administered in endotoxemic rats is able to counteract Gin depletion in intestine but not in muscles. However, Glu displayed no trophic effect in any tissue.
P,28 Safety and patient well-being after preoperative oral intake of carbohydrate rich beverage Nygren, A. Thorell, M. Lagerkranser 1, C. AlmstrSm, F. Hammarqvist 2 and O. Ljungqvist Depts of Surgery and ~Anesthesiology, Karolinska Hospital, 2Dept of Surgery, St GOrans Hospital, Stockholm, Sweden.
J.
Free intake of clear fluids up until 2h before anesthesia for elective surgery is becoming a new standard. Presently, we tested if it is safe to give an iso-osmolar carbohydrate rich drink (POC) in this situation and the effects on patient well-being. In a double-blind study, patients scheduled for elective surgery were randomized to the routine preoperative overnight fast (F), intake of placebo (PI) or a carbohydrate rich drink (POC, 12.5% carbohydrates) 800ml the evening before surgery and 400 ml 2 h before the initiation of anesthesia. Patient well-being (visual analogue scale, VAS, 14 different parameters) before and after surgery and postoperative activity levels were assessed. The sum of all 14 parameters of well-being are used to obtain a measurement of total patient well-being (index). Low values in VAS indicate increased wellbeing. Furthermore, the gastric residual volume (GRV) and pH (aspiration from naso-gastric tube) at the initiation of anesthesia was registered. A preliminary analysis has been performed (n = 87) in patients scheduled for elective laparoscopic cholecystectomy (n 49) or abdominal surgery (n = 38). Mean + SEM, P < 0.05 *POC vs F, 1-PI vs F, §POC vs PI, :I:POC vs F and PI, ANOVA. Results: Well-being was similar between the groups in a control situation. In the morning before surgery POC displayed reduced thirst (*), hunger (*:1:§), weakness (*:1:) and index (*:1:) while no difference was found between PI and F groups. Ninety minutes after intake of drink, POC displayed less weakness (:1:), thirst (*), hunger (*§:1:), nausea (:1:), index (*:1:) and increased fitness (*); PI displayed less thirst (1-), weakness (t), index (t) and increased fitness (t). On the first postoperative day, POC displayed decreased hunger (§$) while other parameters of well-being were not statistically different. In the patients undergoing abdominal surgery POC tended to improve weakness (:I:P = 0.15), thirst (:I:P = 0.10) and hunger (:I:P = 0.07) on the first postoperative day. No differences were found in GRV (35 -+ 4/29 _+4/37 _+8 ml, F/PI/POC, resp.) or pH at the initiation of surgery. Postoperative mobilization and outcome were similar in the two groups. Conclusions: The present data suggest that intake of an iso-osmolar carbohydrate rich beverage 2h before anesthesia for surgery is safe. POC improves Preoperative well-being, and tended to improve also postoperative well-being following abdominal surgery.
P.27 Enteral feeding significantly limits the reduction of villi height and improves the absorption of D-xylose by intestinal allografts in pigs R. Biffi*, B. Andreoni §, S. Pozzi*, L. Marzona*, F. Luca*, P. Velio t,
C. Robertson* and P. Maisonneuve* §lstituto di Chirurgia d'Urgenza, t di Scienze Mediche, Universita di Milano and *European Institute of Oncology, Divisions of Gastrointestinal Surgery and Epidemiology and Biostatistics, Milan, Italy. Absorption of D-Xylose and villi height have been reported to be considerably reduced 1 month after total orthotopic small bowel transplantation (TOSBT) in pigs as well as in humans, lacking any sign of graft rejection or graft versus host disease. The impact of postoperative enteral feeding has not been investigated. Aims: To evaluate changes in villi and eryptae height and to assess the intestinal absorption of D-Xylose in pigs given either a commercial chow 'ad libitum' or polymeric enteral feeding after TOSBT under cyelosporin-A (CsA). Methods: Seventeen large white female pigs weighing 30 _+ 7 kg were randomly allocated to one of the following experimental groups: Group 1 (n = 6): TOSBT + CsA 15 mg/kg body weight (b.w.)/day i.v. + commercial swine chow 'ad libitum' in the postoperative period. Group 2 (n = 6): TOSBT + CsA 15 mg/kg b.w./day i.v.+ defined enteral formula in the postoperative period via a tube-gastrostomy, consisting of 34.6 _+6.7 Kcal/kg b.w./day (51% carbohydates as dextrin, 15% proteins as casein and soya bean, 34% lipids as medium chain triglycerides, sunflower and coconut oils; osmolarity = ;245 mOsm/I). Group 3 (n = 5): TOSB autotransplanta-
P.29 More gastroesophageal reflux with percutaneous endoscopic gastrostomy tubes as compared to nasogastric tubes S.Aftahi and L. Howard Albany Medical College, Albany, New York, USA. One of the most life threatening complications of tube feeding (TF) is aspiration of formula. It is generally believed that endoscopically placed percutaneous gastrostomy (PEG) feedings are associated with less gas30
troesophageal reflux (GER) compared to nasogastric tube (NGT) feeding. This study compared GER in patients receiving continuous TF delivered first via an NGT and then by a PEG. Eight patients, (6M, 2F), mean age 69 years (range 27-98), who required TF because of a cerebrovascular accident (3), dementia (2) or short bowel syndrome (3) were studied. Twenty-four hour pH monitoring was performed twice on each patient; first on small bore NGT feeding and second after insertion of a PEG (_>5 days after insertion). All patients received the same polymeric formula delivered continuously and at the same rate on both occasions. Three pH monitoring parameters were compared and differences evaluated by the paired t-test. Number of reflux episodes with pH < 4 (mean 4- SD) was 23.4 _+22.5 with NGT and 48.3 _+28.9 with PEG (P < 0.05); % time pH < 4 was 3.7 _+7.5 with NGT and 17.2 4- 28.8 with PEG (NS); the number of episodes longer than 5 min was 1.6 _+ 3.5 with NGT and 5.4 4- 7.7 with PEG (NS). Two patients died in the following 6 months, one from aspiration (this patient was one of those experiencing the most reflux episodes with PEG). Conclusions: Reflux is more frequent with a PEG than NGT in patients on continuous TE This suggests a greater risk of aspiration with PEG compared to small bore NGT.
to receive a snack with 250 cc of one of these formulae at 09:00 after routine medications (insulin or suiphonylureas) had been taken. Venous blood samples were obtained during fasting and at 30 and 120 rnin after the snack. The significance of the difference for comparison of more than one group was calculated by analysis of variance for one or two factors. Results: The glycaemic and C-peptide response to the low fat diet was higher than to the high fat diet (P = 0.02, and P = 0.03 respectiw.Ny). On NIDDM (insulin-treated) the incremental glucose response at 0, 30 and 120 rain was lower with the high fat diet (P = 0.03, P = 0.002, P = 0.003 respectively). Two-factor analysis of variance on mean increments from basal levels of glucose and C-peptide show the type of enteral formulae as the main factor (P= 0.001 and P= 0.01 respectively). Variations of plasma acetoacetate and 3-hydroxybutyrate after tests with both enteral formulae were not statistically significant. We conclude that the partial replacement of carbohydrates with monounsaturated fatty acids in the enteral formulae, used for supplementation, may improve glycemic control in patients with NIDDM without adverse effects on ketone production.
1°.32 Tolerance and septic complications in surgical patients fed with different routes and composition of nutritional support
P.30 Evaluation of immune markers in asymptomatic AIDS patients receiving fish oil supplementation
A. Cestari, M. Braga, L. Gianotti, A. Vignali and V. Di Carlo
Dept of Surge04, Scientific Institute S. Raffaele Hospital, University of Milan, Italy.
N. Virgili*, M. Farriol, J. M. Castellanos, M. Gir6, D. Podzamczer and
A. M. Pita CSUB Bellvitge, Biochemistry Department and 'S. Grisolia' Research Unit, Barcelona, Spain.
The ability of specific nutrients to modulate the immune response has been repeatedly demonstrated. The aim of the present study was to evaluate the effect of the enteral administration of a diet supplemented in immunonutrients compared to a standard formula and total parenteral nutrition early after major surgery. One hundred and fifty patients with gastric or pancreatic cancer were randomized after surgery into three groups to receive a standard enteral formula (S) (n = 48), a formula enriched with arginine, RNA and omega-3 fatty acids (E), (n = 50) or total parenteral nutrition (TPN) (n = 52). The three treatments were isocaloric and isonitrogenous. The administration of both enteral formulas began within 12 h after surgery; the infusion rate was progressively increased and the full regimen (25 kcal/kg; 0.25 g nitrogen/kg) was reached on postoperative day 4. The clinical parameters were: length of postoperative stay, bowel movements, intolerance to enteral feeding, rate and severity of postoperative infections. Age, rate of malnutrition, duration of surgery, blood loss, transfusions and preoperative stay were similar in the three groups. The intolerance rate to enteral feeding was similar in both groups. Overall 22.4% (22/98) of patients complained of side effects but only in 5 of the 22 patients (22.7%) was it necessary to reduce or temporarily interrupt the enteral infusion to resolve the symptoms. In the enterally fed patients there was a quicker bowel canalization to gas and stools (2.9 4- 0.8 days and 5.4 _+ 1.4 days, respectively) than the TPN group (3.8 + 1.1 days and 6.9 _+1.5 days) (P < 0.05). Length of postoperative stagywas 15.1 _+7.7 days in the TPN group, 16.1 + 7.2 days in the S group and 13.7 _+5.7 days in the E group. Overall septic complication rate was 20.6% (31/150): 14.0% (7/50) in E group; 20.8% (10.48) in S group and 25.0% (13/52) in TPN group (P = 0.07 E vs TPN). The severity of septic complications (based on Sepsis Score) was 4.0 4- 2.6 in the E group versus 6.4 _+3.0 in S group and 7.5 + 4.8 in TPN group (P < 0.05 E vs TPN and S). Early enteral feeding after major abdominal surgery was well tolerated and permitted a quicker recovery of gut function. The use of the enriched enteral formula allowed a reduction of septic complications and their severity.
Aim: To evalute the effect of oral fish oil (FO) supplementation on selected immune markers in asymptomatic HIV-infected patients. Material and methods: Nine asymptomatic, A2 clinical category (CD4 count 290 4- 123cells/mm3), HIV-infected male subjects receiving AZT retroviral treatment, were studied. A 24-h dietary recall and food frequency questionnaire were used. Eight 0.5 mg capsules of FO (Pulse, Grifols), containing co-3 fatty acids: 70 mg of EPA and 45 mg of DHA were administered twice a day (8 g) over 6 weeks. Biochemistry studied at zero time (To) and 6 weeks of treatment (T6) were: leucocyte and lymphocyte counts, CD4/CD8 ratio, prealbumin, uric acid, cholesterol and triglycerides and erythrocyte malondialdehyde (MDA). IL-lJ3 levels after LPS (10#g/ml) exposure were determined in whole blood culture supernatants. Dehydroepiandrosterone-sulphate (DHEA-S) was analysed by radioimmunoassay (112s). Statistics: Mann-Whitney U-test. Results: Patients were well-nourished (mean BMI = 23.8 4- 4.9 kg/m2). There were some small, beneficial tendencies after treatment shown in the following results: erythrocytes (3.97 4- 0.6 vs 4.16 _+0.6 x 102), lymphocytes (1.70 _+0.58 vs 1.84 4- 0.40 x 109), CD4/CD8 ratio (0.26 _+0.08 vs 0.28 _+0.08), and triglycerides (2.03 _+0.87 vs 1.87 _+0.57 mmol/I). After stimulation there was a statistically significant increase in MDA release (To: 350.9 _+79.8 vs T6:614.1 _+ 106.4 nmol/g b). IL-I~ at To and T 6 was increased with respect to normal range (NR), with a slight decrease at T 6 (49.8 vs 40.9; NR: 1-8.4). After stimulation, significant decreases in IL-1 were observed after treatment (To: 797.7 vs m6: 535.6pg/ml; NR: 471-1820 pg/ml). Mean DEAH-S values decreased after FO supplementation: 1134.1 vs 637.6 ng/ml (NR: 800-5600 ng/ml). Conclusions: Taken collectively, these results suggest a tendency toward improvement in immune function and nutritional status. The trends observed lead us to think that FO administration at other dosing regimens merits further study.
P.31 High-fat versus high-carbohydrate enteral formulae: effect on blood glucose, C-peptide and ketones
P.33 The quantitative effect of nutrition support on quality of life in outpatients
A. Sanz, M. Guallar, I. Salazar, A. B. Cortes, R. Albero and S. Celaya
Endocrinology and RIA Laboratory, Miguel Servet Hospital, Zaragoza, Spain.
C. P. J a m i e s o n , B. Norton, T. Day, M. Lakeman and J. Powefl- Tuck
Rank Dept of Human Nutrition, Royal London Hospital, Whitechapel, London, UK.
Use of enteral nutritional supplementation in elderly nursing home patients with type 2 diabetes (NIDDM) tends to exacerbate hyperglycemia and require initiation or increase of insulin therapy. Two commercial enteral diets for diabetic patients are available: low fat (15% protein P, 31% fat F and 54% carbohydrates CHO) and low CHO (16.7% protein, 50% fat: 35.5% monounsaturated, 33% carbohydrates). We compared the effects of two enteral diets on glycemic, C-peptide and ketones response in NIDDM treated with insulin or sulphonylureas. Patients and methods: Forty NIDDM patients were randomly assigned
Aim: To compare gains in body weight and lean body mass with changes in quality of life in an undernourished outpatient population. Methods: One hundred and thirty-one poorly rehabilitated patients with chronic disease (19 short bowel, 18 neoplasia, 13 inflammatory bowel disease, 12 pseudoobstruction, 9 neurological dysphagia, 3 chronic pancreatitis, 33 poor intake, 24 others), presenting sequentially to a nutrition support clinic, were divided into those with a body mass index (IBMI) of less than the desirable range of 20-25 (group 1) and those with an index 31