Presentation given by Marcel Gatt, Scarborough Hospital, at the Dukes' Club AGM 2012

1. Surgical nutrition &
the management of gut failure
Marcel Gatt
Consultant General & Colorectal Surgeon
Combined Gastroenterology Research Unit
Scarborough Hospital, UK
marcelgatt@gmail.com

2. Your mission; should you choose to accept it ...

3. Overview
 I know how to feed my patients! ... or do I?
 I know when to feed my patients! ... or do I?
 Who decides how to feed patients? ... Me after bedside
assessment (duh)!
 Is the gut ok & what is gut failure? ... err I’m not sure?
 I can't do much about ileus. ... or can I?

4. “The force is strong, Master”

6. Overview
 I know how to feed my patients! ... or do I?
 I know when to feed my patients! ... or do I?
 Who decides how to feed patients? ... Me after bedside
assessment (duh)!
 Is the gut ok & what is gut failure? ... err I’m not sure?
 I can't do much about ileus. ... or can I?

7. How should I feed my patients?

8. How to feed patients
 Oral Oral diet
Oral supplements
 Enteral Nasogastric
Nasojejunal
PEG / RIG/ PEGJ
Feeding jejunostomy
 Parenteral Peripheral PN
Central PN
 Other Enteroclysis
 Combination Optimal feeding

9. ASPEN 2009 guidelines
Bankhead et al., JPEN 2009

10. Pre- vs. postpyloric feeding
Aim: “To establish whether the site of feed administration
influences the ability to achieve enteral feed tolerance.”
All patients needing
enteral nutrition
Randomized
Prepyloric feeding: Postpyloric feeding:
NG / PEG NJ / PEGJ
F/U till discharge
Gatt et al., Clin Nutr. 2005

11. Pre- vs. postpyloric feeding
Prepyloric Postpyloric
p-value
feeding feeding
Recruited 33 32
Enteral tolerance
23 (70) 20 (63) 0.539
(%)
Gatt et al., Clin Nutr. 2005

12. Gut dysfunction in the critically ill
Normal volunteer Critically ill patient
Dive et al. Crit Care Med. 1994
Dive et al. Clin Nutr. 1994
Dive et al. Intensive Care Med. 1999

13. Feeding in pancreatitis – oral vs. NJ
A randomized study of early nasogastric versus
nasojejunal feeding in severe acute pancreatitis.
 CONCLUSION:
“The simpler, cheaper, and more easily used NG
feeding is as good as NJ feeding in patients with
objectively graded severe AP...”
Eatock et al., Am J Gastroenterol. 2005 Feb;100(2):432-9.

14. ESPEN guidelines – pancreatitis (2006)
Meier et al., Clin Nutr 2006

15. How to feed patients
 Oral PO
Oral supplements
 Enteral Nasogastric
Naso-jejunal
PEG / RIG/ PEGJ
Feeding jejunostomy
 Parenteral Peripheral PN
Central PN
 Other Enteroclysis
 Combination Optimal feeding

16. TPN versus EN:
septic morbidity
230 patients
TPN EN
(112) (118)
Sepsis 35% 18% p=0.01
Moore et al 1992

17. Myth about EN vs. PN
It used to be thought that :
Parenteral nutrition is poison !! Enteral is better
than parenteral. EN is associated with reduced
septic morbidity and fewer complications.
Am J Clin Nutr. 2001; 74: 160-3.

18. Enteral vs Parenteral Nutrition: a pragmatic study
562 patients
Assessment of GI function
Clinically certain Clinically uncertain
n = 498 n = 64
(88.6%) (11.4%)
Inadequate Adequate Randomised
GI function GI function
TPN (Group1) EN (Group 2) rTPN (Group 3) rEN (Group 4)
n = 267 n = 231 n = 32 n = 32
N P Woodcock et al. Nutrition 2001; 17: 1-12

19. Patients receiving less than 80% of
target intake
Clinicians are poor at assessing 70%
60%
intestinal function
50%
P<0.001 P<0.001
40%
30%
Inadequate gut function is a predictor of 20%
poor prognosis 10%
0%
Group 1 (TPN) Group 2 (EN) Group 3 (rTPN) Group 4 (rEN)
N P Woodcock et al. Nutrition 2001; 17: 1-12
1-
Enteral vs Parenteral Nutrition: a pragmatic study
Overall mortality
562 patients 40%
35%
Assessment of GI function
30% P < 0.001 P = 0.17, NS
Clinically certain Clinically uncertain
25%
n = 498 n = 64
(88.6%) (11.4%) 20%
15%
Inadequate Adequate Randomised
GI function GI function 10%
5%
TPN (Group1) EN (Group 2) rTPN (Group 3) rEN (Group 4)
n = 267 n = 231 n = 32 n = 32 0%
Group 1 (TPN) Group 2 (EN) Group 3 (rTPN) Group 4 (rEN)
N P Woodcock et al. Nutrition 2001; 17: 1 -12

20. When to feed - ESPEN guidlines
Weimann et al., Clin Nutr. 2006

21. Early feeding
Andersen HK et al. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD004080.
 ... there is no obvious advantage in keeping patients „nil by
mouth‟ following gastrointestinal surgery
 ... this review support the notion on early commencement
of enteral feeding.

22. Overview
 I know how to feed my patients! ... or+ EN + PN
PO do I?
 I know when to feed my patients! ... or do I?
Usually straight away
 Who decides how to feed patients? ... Me after bedside
Like everyone else,
I’m not good at it!
assessment (duh)!
 Is the gut ok & what is gut failure? ... err I’m not sure?
 I can't do much about ileus. ... or can I?

23. Overview
 I know how to feed my patients! PO + EN + PN
 I know when to feed my patients! Usually straight away
 Who decides how to feed patients? Like everyone else,
I’m not good at it!
 Is the gut ok & what is gut failure? ... err I’m not sure?
 I can't do much about ileus. ... or can I?

24. Adequate gut function
PubMed search MeSH
 “Renal function” 51881 18
 “Kidney function” 26764 8
 “Intestinal function” 1076 0
 “Gut function” 412 0
 “Interleukin 12” 11776 22

25. Gut failure
PubMed search MeSH
 “Renal failure” 69298 31
 “Kidney failure” 72801 18
 “Intestinal failure” 736 0
 “Gut failure” 53 0
 “Ingrown toenails” 781 1

26. Adequate gut function
 What is “adequate” gut function?
No established and quantifiable definition.

27. The paradox of gut function
IGF is intuitively important to But.. IGF is not acknowledged to
patient outcome relate to outcome
 Many homeostatic functions  No quantifiable definition
 Assessment of gut function is
difficult
 Assessment is subjective
- Bowel sounds
- Passage of flatus
- Passage of faeces

28. Adequate gut function
 Cardiac function: Adequate CO & end organ perfusion
 Respiratory function: Adequate oxygenation / ventilation
 Renal function: Adequate clearance & urine output
RAS
Erythropoetin
Organ function is described by its primary function

29. Adequate gut function
Nutrition
Metabolic Excretion
Intestinal
function
Hormonal Immunological
Barrier

30. Adequate gut function
Oral/enteral tolerance of >80%
of calculated nutritional requirements
for a continuous period of >48 hours
Gatt M, Doctoral Thesis, University of Hull, 2008

31. Adequacy of gut function on survival
MULTIVARIATE
1.2
ANALYSIS
1.0
.8
Adequate gut function (n=265)
.6
Gut Failure
P<0.001 P<0.001
.4
Yes
Yes-censored
.2
No
Inadequate gut function(n=50)
0.0 No-censored
0 30 60 90 120 150 180 210
Time (days)
Gatt M et al. Clin Nutr 2007 Sept; Suppl 2: 108
CONCLUSION
 Inadequate gut function (IGF) is an independent
indicator of outcome.

32. Overview
 I know how to feed my patients! PO + EN + PN
 I know when to feed my patients! Usually straight away
 Who decides how to feed patients? Like everyone else,
I’m not good at it!
 Is the gut ok & what is gut failure? Relates to not sure?
... err I’m tolerance
 I can't do much about ileus. ... or can I?

33. Drip
Suck
Wait

34. Modulating gut function -
treatments in development
- Fluid restriction
- Early feeding
- Alvimopan®
- Cholecystokinin-like acting drugs
- Ghrelin agonists
- Gut specific nutrients
- Synbiotics (pro- & prebiotics)
- Modulation of gut microflora (SGD)
- Immunomodulation
- Laparoscopic / robotic surgery
- Combined approaches (ERAS)

35. Alvimopan®
peripheral μ-opioid receptor antagonist
Traut U et al. Cochrane Database Syst Rev. 2008 23;(1): CD004930

36. Ghrelin agonists
(e.g. TZP-101 (ulimorelin)
 GI motility co-ordinators
 Strong antiemetic effect / promote gastric emptying
 May improve recovery of GI motility following bowel
resection.
Popescu I et al. Dis Colon Rectum. 2010 Feb;53(2):126-34.

37. Gut specific nutrients
25
Time to return of gut function (days)
Time to return of gut function (hrs)
P=0.016
20
15
10
GSN cocktail
5
0
Glutamine
Control GSN
Multivitamins
Group
8.9 days 6.8 days
Probiotics
(214 hours) (164 hours)
Prebiotics
Gatt M et al. BJS, 2010 Nov; 97(11):1629-36

38. Enhanced recovery after surgery
Fearon K et al. Clin Nutr 2005 24: 466-477

39. Multimodal optimization
Gatt M, et al. Br J Surg. 2005; 92: 1354-62
p = 0.007 p = 0.042
Return of Gut Function (hours)
Duration of IV fluids (hours)
N = 20 19
N = 20 19
Control Optimisation Control Optimisation
Group Group
Duration of IV Fluids Return of Gut Function

40. Overview
 I know how to feed my patients! PO + EN + PN
 I know when to feed my patients! Usually straight away
 Who decides how to feed patients? Like everyone else,
I’m not good at it!
 Is the gut ok & what is gut failure? Relates to tolerance
 I can't do much about ileus. ... or can yes I can!
Actually I?

41. Implications to daily practice
 Gut function:
- is not a recognised condition
- can be defined by tolerance to oral/enteral nutrition
- is an independent prognostic indicator
- using time to passage of flatus/faeces is wrong
 Feed patients early post-operatively:
- safe
- only way of assessing gut function
- may enhance recovery of GI function ... ???
- Aim to provide calorie requirements

42. Implications to daily practice
 Methods of curtailing post-op ileus:
- Opiate avoidance (NSAIDS/epidurals/TAP blocks)
- Early mobilization
- IV fluid optimization
- Many others
 Treatments in development:
- GSN‟s
- Cholecystokinin-like acting drugs
- Peripheral μ-opioid receptor antagonist
- Ghrelin agonists
- Many others

43. Take home message 1
How to feed
 It‟s about the nutrition not the route of
administration!

44. Take home message 2
When to feed
 Starving people is cruelty in 3rd world
countries, so why do it in 1st world ones?

45. Take home message 3
Gut failure / ileus
 If it works, use it.
Drip,
If it doesn‟t, loose it. & Suck,
& Wait.
If it works, use it.
If it doesn‟t, do something about it. .

46. Take home message 4
Gut function & gut failure
 There are exciting times ahead