Table 54Enteral vs nil -- hepatobiliary surgery

Bibliographic referenceStudy
Evidence levelNo. of patientsPatients characteristicsInterventionComparisonLength of follow upOutcome measuresEffect sizeComments (including source of funding)
Frankel and Horowitz 1989117

This paper differs from several other papers here
RCT1+/1−?69 patients

(19 excluded) 50 randomised
Patients with chronic or acute cholecystitis undergoing op for cholecystectomy

Nasoduodenal group
Age (mean, range)
43.4 yrs (18–74)

No nasoduodenal group (NIL)
Age (mean, range)
40.4 yrs (18–61)
Nasoduodenal tube with esophagastric decompression
Timing of intervention:
Enteral feedings were initiated in the recovery room with an elemental feed (Viivonex T.E.N.) full strength, 40kcals per kg for 24 hours then stopped and then a clear liquid diet begun

No nasoduodenal tube but NG tube inserted for gastric decompression this was removed in recovery.
No enteral feeding allowed but sips of clear liquid diet on first post op night.

Until discharge from hospitalPost op diarrhoeaPost op diarrhoea
ND: 1
NIL: 0
The methods of randomisation, blinding are not clear and the sample size is small.

This study differs from the many other studies included in this review – since it is cholecystectomy patients and enteral feeding only lasted for 1 day.

However and ITT was done and it would seem that although probably not significant patients randomised to the not fed group, no intervention did better than those randomised to ND feeding.
Post op ileusPost op ileus
ND: 1
NIL: 0
Post op length of stayPost op length of stay days, (mean, sd)
ND: 2.0 +/−0.2
NIL: 1.7+/−0.1
Hasse et al 1995145RCT1−50 patientsLiver transplantImmediate post op naso jejunal feeding full-strength Reabilan HN (n=25) Timing of intervention:
Patients began to receive a continuous pump infusion of full- strength Reabilan HN 12 hrs after surgery. Infusion rate started at 20 mL/h and was increased to 40 mL/h 24 hrs after the initiation of the tube feeding. If the patient tolerated 40 mL/h, the tube feeding (TF) rate was increased to 60 mL/h 12 hrs after the previous rate increase. If patients required more than 60 mL/h, the TF rates were adjusted individually on the basis of measured energy and protein needs.
NG placed. Blue food colouring was added to TF formula. If the NG aspirate became blue or if patients showed other signs of intolerance the tube feeding was withheld for a few hours and then restarted. The NG tube was removed and diets were initiated when patient had bowel sounds. Diet progression followed the same pattern as for the control group. NJ tube remained in place until the patients were able to meet at least 66 % of nutritional needs by oral intake.
IV electrolyte fluid until oral feeding established (NG tubes placed but not used. NG tube removed when patients had bowel sounds. Clear liquid diets were initiated within 24 hrs of removal of the NG tube, and the diet was advanced to a general diet as tolerated) (n=25)12 days for some measures and until dischargeLength of stay after transplant:Length of stay after transplant mean +/− SD:
Int: 16 (17.3 +/− 5.4) (n=14)
Cont: 18 (27.1 +/37.1) (n=17) [not significant]
31 patients completed the study
Con (n=17)
An intention to treat analysis was not done.

The figures for the mean nitrogen balance figures were read from the graphs in the papers and should not be taken as exact values. However, the paper does report that there was a significant difference on day 4.

The figures for the mean daily total calorie intake at day 4 and day 12 were read from the graphs in the papers and should not be taken as exact values.

Funding: Nutrition Support Practice Group Member Research Award, Elan Pharma, Dallas Transplant Surgeons Associates
Mean nitrogen balance at 4 and 12 days post transplantApproximate mean nitrogen balance
Day 4:
Int: −5 grams (n=14)
Cont: −10 grams (n=17) [p<0.03]
Day 12:
Int: −6.5 grams (n=14)
Cont: −2.5 grams (n=17) (not significant)
Overall infection rate in the first 21 days after transplantationOverall infections in the first 21 days after transplantation
Int: 3 (21.4%) (n=14)
Cont: 8 (47.1%) (n=17) (not significant)
Mean daily total calorie intakeApproximate mean daily total calorie intake
Day 4
Int: 2,500 kcal (n=14)
Cont: 1,300 kcal (n=17)
Day 12
Int: 1,300 kcal (n=14)
Cont: 1,600kcal (n=17) ([p<0.05] days 1–6)
Cumulative mean total calorie intake at day 12Cumulative mean total calorie intake at day 12 (mean +/− range)
Int: 22,464 +/− 3,554 kcal (n=14)
Cont: 15,474 +/− 5,265 kcal (n=17) [p=0.0006]
Hwang et al 1991163RCT1+24 patientsPost-op biliary surgery (common bile duct or intrahepatic duct stones, treated by choledocholithotomy); uncomplicated surgeries sepsis, jaundice, or other complications excluded.

Nasoduodenal tubes inserted during the operation.

Mean age 52.
Nasodudonal tube feeding within 1 day of operation.

Blenderised diet (17% protein, 33% fat and 50% carbohydrate)
Nasodudonal feeding in day 4th of operation8 days

outcomes measured post-surgery days 1 and 8
No intended clinical outcome?Early vs lateNot all relevant outcomes are reported. Quality of life should have been considered.

Allocation procedure and also the total number of eligible patients unclear
Wound infection0/12 vs 1/12
Nutritional statusIncrease pre-albumin rate and lymphocyte count for early group. All others no difference
A range of outcomes

From: Appendix Four, Evidence Tables

Cover of Nutrition Support for Adults
Nutrition Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition.
NICE Clinical Guidelines, No. 32.
National Collaborating Centre for Acute Care (UK).
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