Impact of nutritional support routes on mortality in acute pancreatitis: A network meta-analysis of randomized controlled trials.

BACKGROUND: Nutritional administration in acute pancreatitis (AP) management has sparked widespread discussion, yet contradictory mortality results across meta-analyses necessitate clarification. The optimal nutritional route in AP remains uncertain. Therefore, this study aimed to compare mortality among nutritional administration routes in patients with AP using consistency model. METHODS: This study searched four major databases for relevant randomized controlled trials (RCTs). Two authors independently extracted and checked data and quality. Network meta-analysis was conducted for estimating risk ratios (RRs) with 95% confidence interval (CI) based on random-effects model. Subgroup analyses accounted for AP severity and nutrition support initiation. RESULTS: A meticulous search yielded 1185 references, with 30 records meeting inclusion criteria from 27 RCTs (n = 1594). Pooled analyses showed the mortality risk reduction associated with nasogastric (NG) (RR = 0.34; 95%CI: 0.16-0.73) and nasojejunal (NJ) feeding (RR = 0.46; 95%CI: 0.25-0.84) in comparison to nil per os. Similarly, NG (RR = 0.45; 95%CI: 0.24-0.83) and NJ (RR = 0.60; 95%CI: 0.40-0.90) feeding also showed lower mortality risk than total parenteral nutrition. Subgroup analyses, stratified by severity, supported these findings. Notably, the timing of nutritional support initiation emerged as a significant factor, with NJ feeding demonstrating notable mortality reduction within 24 and 48 h, particularly in severe cases. CONCLUSION: For severe AP, both NG and NJ feeding appear optimal, with variations in initiation timings. NG feeding does not appear to merit recommendation within the initial 24 h, whereas NJ feeding is advisable within the corresponding timeframe following admission. These findings offer valuable insights for optimizing nutritional interventions in AP.

Bedside naso-jejunal placement is more difficult, but successful in patients with COVID-19 in critical care: A retrospective service evaluation of a dietitian-led service.

The COVID-19 pandemic presented clinical and logistical challenges in the delivery of adequate nutrition in the critical care setting. The use of neuromuscular-blocking drugs, presence of maxilla-facial oedema, strict infection control procedures, and patients placed in a prone position complicated feeding tube placement. We audited the outcomes of dietitian-led naso-jejunal tube (NJT) insertions using the IRIS® (Kangaroo, USA) device, before and during the COVID-19 pandemic. NJT placement was successful in 78% of all cases (n = 50), and 87% of COVID-19 cases. Anaesthetic support was only required in COVID-19 patients (53%). NJT placement using IRIS was more difficult but achievable in patients with COVID-19.

Complexities of Long-Term Care With Gastro-Jejunal (GJ) Feeding Tubes and Enteral Migration During COVID-19 Pandemic Times: A Case Report.

Gastro-jejunostomy tubes, or percutaneous endoscopic gastrostomy tubes with jejunal extension (PEG-J), hold a significant role in the long-term nutritional management of patients with poor oral intake. This can be for a variety of reasons; ranging from metabolic conditions, including diabetes mellitus, inherited or congenital conditions like Ehler Danlos syndrome, or patients with neurological disorders, such as stroke, advanced Parkinson's disease or multiple sclerosis. Although they are very helpful for the overall nutritional needs of such patients, they are associated with complications, including the dislodging of jejunal tubes. The need to promptly recognise, investigate and manage this, in a timely manner, is vital, particularly during the COVID-19 pandemic times, as such patients may be associated with multiple comorbidities.

Incidence and risk factors of nasogastric feeding intolerance in moderately-severe to severe acute pancreatitis.

BACKGROUND: The importance of enteral nutrition (EN) in acute pancreatitis (AP) has been emphasised. Nasogastric (NG) feeding has been the preferred route for EN delivery in most AP patients intolerant to oral intake. However, gastric feeding intolerance (GFI) was frequently reported, especially in patients with more severe diseases. This study aimed to investigate the incidence and risk factors for GFI in moderately-severe to severe AP. METHODS: This is a single-centre, retrospective study. All the data were extracted from an electronic database from April 2020 to May 2021. Data were prospectively collected during hospitalisation. Patients diagnosed with moderately-severe to severe AP and admitted within seven days from the onset of abdominal pain were assessed for eligibility. Patients who showed signs of intolerance to gastric feeding and required switching to nasojejunal (NJ) feeding were deemed GFI. Multivariable logistic regression was performed to assess potential risk factors of GFI. RESULTS: A total of 93 patients were analysed, of whom 24 were deemed GFI (25.8%), and the rest tolerated NG feeding well (n = 69). In patients with GFI, the median time of switching to NJ feeding was five days (interquartile range: 4-7 days) after admission. The multivariable analysis showed that respiratory failure (odds ratio = 3.135, 95% CI: 1.111-8.848, P = 0.031) was an independent risk factor for GFI.The mean daily energy delivery in the following three days after switching to NJ feeding was significantly higher than the first three days after initiation of NG feeding in patients with GFI [920.83 (493.33-1326) vs. 465 (252.25-556.67) kcal, P < 0.001]. CONCLUSION: GFI is common in moderately-severe to severe AP patients with an incidence of 25.8%, and the presence of respiratory failure may increase the risk of GFI.

Long-term outcomes following failure of Nissen fundoplication.

PURPOSE: To determine the management and outcomes of patients with gastro-oesophageal reflux (GOR) that requires further intervention following failure of Nissen fundoplication (NF). METHODS: After institutional audit department approval, a retrospective review of paediatric patients who had further intervention following failure of primary NF between January 2006 and December 2015 for GOR at our centre was performed. Data are presented as median (range). RESULTS: Of 820 patients who underwent NF, 190 (23%) received further procedures for GOR management at a median of 21 months of age (6-186); 90/190 (47%) had gastro-jejunal feeding (GJ). Of these, 67 (74%) remained on GJ feeds up to a median of 48 months and 23/90 (26%) had a second NF after GJ feeding. 97/190 (51%) had a redo fundoplication without having had a GJ; thus, 120/190 (63%) of patients having a further procedure went on to have a second NF after a median period of 15 months (1-70 months). Three patients (2%) had early emergency wrap revision 4 days after first fundoplication (we classed this as an 'early complication'). Of the seven patients who failed a 3rd NF, 4 continued GJ feeding, 2 of had oesophagogastric dissociation; 2 had 4th NF of which 1 was successful and 1 patient had gastric pacemaker and is successfully feeding orally. Patients who were finally successfully managed with GJ underwent 2 (2-5) tube changes/year. We found patients who had a previous GJ were more likely to have failure of the redo fundoplication than those who had not to have the GJ (16/24 vs. 30/90, p = 0.005). CONCLUSION: The chance of success decreases with every further attempt at fundoplication. The only factor significantly associated with failure of redo fundoplication was whether the patient previously had a GJ tube. In patients with failed fundoplications, when symptom free on jejunal feedings, further anti-reflux surgical intervention should be avoided. A randomized prospective study is needed for patient selection.

Hypothesis: Bolus jejunal feeding via an enteral feeding tube simulates key features of gastric bypass to initiate similar clinical benefits.

BACKGROUND: Therapy for obesity and related comorbidities should be clinically effective, widely available and acceptable, and used in conjunction with an optimized lifestyle. Dieting is widely available and acceptable but has poorly sustained clinical efficacy. By contrast, Roux-en-Y gastric bypass (GB) is highly effective but cost and safety concerns limit widespread use. In this article this we discuss the hypothesis that bolus jejunal feeding (BJ) via an enteral feeding tube simulates key features of GB with the potential for similar clinical benefits. We further hypothesize that a practical manner of providing BJ therapeutically is via an externally inapparent orojejunal feeding tube. RATIONALE: The first hypothesis is underpinned by the outcomes of research in three fields: 1) investigations into the mechanisms underlying the benefit of GB, 2) studies investigating gastrointestinal physiology and pathophysiology using enteral feeding tubes, and3) investigations into the mechanism underlying involuntary anorexia and weight loss in clinical situations that entail rapid nutrient delivery to the jejunum. There is compelling evidence that a supraphysiologic rate of delivery of nutrient to the jejunum suppresses appetite and energy intake and improves glucose homeostasis, and that these effects can be achieved non-surgically using an enteral feeding tube. The second hypothesis is supported by clinical demonstration of the feasibility of administering intermittent cycles of bolus feeds via an intraorally anchored feeding tube in ambulatory obese adults. CONCLUSION: The hypotheses are testable in clinical studies. If validated, BJ could be used to induce the clinical benefits of GB, but without its costs or safety concerns.

Top-ten tips for managing nutritional issues and gastrointestinal symptoms in children with neurological impairment.

The prevalence of children with neurological impairment (NI) presenting feeding difficulties and gastrointestinal symptoms is rising. The most recent guidelines recommend early nutritional assessment and intervention in order to prevent undernutrition and growth failure, along with the proper diagnosis and treatment of some frequent gastrointestinal symptoms, such as gastroesophageal reflux disease (GERD) and constipation, which can further worsen the feeding process and nutritional status. Nonetheless, the nutritional issues and growth deficits of children with NI are often considered to be of low priority or under recognised by healthcare providers. The present article proposes ten top tips that highlight the major points along the nutritional management pathway of NI children. The implementation of these tips in all healthcare settings could potentially improve patient outcomes and reduce morbidity and mortality.

A Comparison of Gastric and Jejunal Feeding in Hypercatabolism Associated With Hypothalamic AMPK-Autophagy-POMC in Endotoxemic Rats.

BACKGROUND: Hypercatabolism is associated with increased infectious rates and mortality in critically ill patients. Enteral nutrition (EN) is usually used to counteract hypercatabolism. However, the impact of different routes of EN on hypercatabolism remains unknown. Here, we compared the impact of gastric feeding (GF) and jejunal feeding (JF) on gastrointestinal hormones and hypercatabolism, which is associated with hypothalamic adenosine 5'-monophosphate-activated protein kinase (AMPK)-autophagy-proopiomelanocortin (POMC). METHODS: Sixty adult male Sprague-Dawley rats were divided into 5 groups: Sham and lipopolysaccharide (LPS) groups fed a standard chow diet, a pair-fed group that was a subset of saline-treated rats pair-fed with the LPS group, and LPS + JF and LPS + GF groups (received EN via jejunal and gastric tube, respectively, for 3 days [100 kcal/kg/d]). Hypercatabolism was measured by insulin resistance, muscle protein synthesis, and atrophy. Serum gastrointestinal hormones, hypothalamic ghrelin, growth hormone secretagogue receptor-1α (GHS-R1α), and AMPK-autophagy-POMC markers were also detected. RESULTS: GF increased serum total, acylated, desacylated, and hypothalamic ghrelin and decreased glucagon-like peptide-1 (GLP-1). But no effect on pancreatic polypeptide (PYY) and hypothalamic GHS-R1α was observed. JF showed no effect on hypothalamic ghrelin, GHS-R1α, and serum total, acylated, and desacylated ghrelin and even further aggravated GLP-1 and PYY. GF could effectively augment hypothalamic AMPK-autophagy-POMC and hypercatabolism. However, JF showed no effect on hypothalamic AMPK-autophagy-POMC and hypercatabolism. CONCLUSIONS: GF could activate hypothalamic AMPK-autophagy and suppress POMC expression via gastrointestinal hormones to ameliorate hypercatabolism compared with JF, which suggested that GF may be the preferred route of EN in endotoxemic rats.

Major complications of jejunal feeding in children.

AIM OF THE STUDY: The aim of the study was to identify major gastrointestinal complications associated with direct jejunal feeding. We hypothesized that jejunal feeding may cause life-threatening surgical complications in a minority of patients. METHODS: All patients undergoing jejunal feeding between 1/2008 and 1/2018 at a pediatric surgical unit were identified retrospectively. Data sought from records included demographics, comorbidities, indications, feeding strategies, adverse events, and follow-up. Major surgical complications were defined by Clavien-Dindo grade ≥ IIIb and involving the GI tract (excluding changes of jejunal tube). MAIN RESULTS: 197 patients were identified (110 female). Median age (IQR) at initiation of jejunal feeding months was 5.6 (6-164) months. 122 were neurologically impaired. The most frequent indications were: GERD/gastroparesis (n = 114), prophylaxis/treatment of Superior Mesenteric Artery (SMA) syndrome (N.B. our center is a national spinal deformity unit) (n = 47), congenital anomalies of aerodigestive anatomy (n = 17), and malignancy (n = 7). 125 patients were managed with nasojejunal feeding alone: gastrojejunal tube (n = 51) and via Roux-en-Y jejunostomy (n = 21). There were 14 significant gastrointestinal complications (n = 11 grade > IIIb) identified among 12 patients, of whom 8 required bowel resections, and 2 died as a result: nonmechanical bowel ischemia (n = 7), intussusception (n = 4), and volvulus (n = 3). CONCLUSION: This series highlights the major complications of jejunal feeding, including a significant yet underreported risk of gut compromise. Patients undergoing jejunal feeding had a 6.1% risk of developing major surgical complications (of note, 3.6% developed bowel ischemia of unknown etiology). Susceptible children were comorbid, fragile, and neurologically impaired. These findings should influence parental discussions and informed consent before embarking upon jejunal feeding. LEVEL OF EVIDENCE: Level IV prognosis study.

Bedside electromagnetic-guided placement of nasoenteral feeding tubes among critically Ill patients: A single-centre randomized controlled trial.

PURPOSE: We aimed to compare the effectiveness of EM-guided and endoscopic nasoenteral feeding tube placement among critically ill patients. MATERIALS AND METHODS: We performed a single-center, randomized controlled trial among 161 adult patients admitted to intensive care units (ICUs) requiring nasoenteral feeding. Patients were randomly assigned to EM-guided or endoscopic nasoenteral feeding tube placement (1:1). The primary end point was the total success rate of correct jejunal placement. RESULTS: This was achieved in 74/81 and 76/80 patients who underwent EM-guided and endoscopic jejunal tube placements, respectively (91.4% vs. 95%; relative risk, 0.556; [CI], 0.156-1.980; P = 0.360). The EM-guided group had more placement attempts, longer placement time, and shorter inserted nasal intestinal tube length. However, they had shorter total placement procedure duration and physician's order-tube placement and order-start of feeding intervals. The EM-guided group had higher discomfort level and recommendation scores and lesser patient costs. This trial is registered at Chinese Clinical Trials Registry (ChiCTR-IOR-17011737). CONCLUSION: Bedside EM-guided placement is as fast, safe, and successful as endoscopic placement and may be considered the preferred technique in critically ill patients.

Placement of a Jejunal Feeding Tube via an Ultrasound-Guided Antral Progressive Water Injection Method.

BACKGROUND: Jejunal feeding tube allows the nutrition of critical care patients more easy and safe. However, its placement remains a challenge. This study aimed to introduce a jejunal feeding tube through an ultrasound-guided antral progressive water injection method and subsequently to examine its efficacy. METHODS: Between April 2016 and April 2017, 54 patients hospitalized in the Department of Critical Care Medicine, Peking Union Medical College Hospital, China who needed nutritional support through a jejunal feeding tube were recruited for this study. Patients who applied ultrasound-guided antral progressive water injection method were classified into the experimental group. Patients who applied conventional method were registered as control group. RESULTS: No significant differences were found in age, body mass index, and Acute Physiology and Chronic Health Evaluation score, but a significant difference in operation time was found between the experimental group and the control group. Of the 24 individuals in the control group, 17 displayed clear catheter sound shadows once the tube entered the esophagus. In comparison, of the 30 individuals in the experimental group, all harbored catheter sound shadows through the esophageal gas injection method. Subsequent observation revealed that in the control group (via ultrasonographic observation), 15 individuals underwent successful antral tube entry, for a success rate of 63%. In the experimental group (via antral progressive water injection), 27 individuals underwent successful antral tube entry, for a success rate of 90%. There was a significant difference between the success rates of the two groups (χ2 = 5.834, P = 0.022). CONCLUSION: The antral progressive water injection method for the placement of a jejunal feeding tube is more effective than the traditional ultrasonic placement method.

Two-tube method for treatment of spontaneous esophageal rupture and concomitant mediastinal infection.

Objective Spontaneous esophageal rupture (SER) is a rare but life-threatening condition with high mortality. The prognosis of patients with SER treated with surgical intervention or the traditional "three-tube" method is controversial. Thus, the aim of this study was to evaluate the clinical efficacy, feasibility, and safety of a new "two-tube" method involving a trans-fistula drainage tube and a three-lumen jejunal feeding tube for the treatment of SER without concomitant pleural rupture. Methods From January 2007 to June 2016, patients with SER and managed with the "two-tube" method or other methods were retrospectively analyzed. Data collected included initial presentation, procedure time, duration of treatment, numbers of patients with eventual healing of leaks, and complications. Results The average procedure time for the "two-tube" method was 22.1 ± 5.5 minutes. In comparison with the control method, the "two-tube" method had a similar diagnosis time (3.6 ± 1.4 vs. 3.4 ± 1.4 days) but a significantly higher successful closure rate (94.4% vs. 63.6%) and shorter treatment time (38.2 ± 5.6 vs. 53.6 ± 16.9 days). No complications associated with performance of the "two-tube" method occurred. Conclusion The "two-tube" method is an effective and safe approach for patients with SER.

The role of nutritional assessment and early enteral nutrition for combined pancreas and kidney transplant candidates.

BACKGROUND: Early post-operative enteral nutrition is an important part of perioperative management and is strongly supported by ESPEN Guidelines. However, there is limited evidence into the use of Early Enteral Nutrition (EEN) after combined Pancreas and Kidney Transplantation (PKT). We know malnutrition in type-1 diabetics with end stage renal failure (ESRF) is a common problem and a significant risk factor. Therefore, we introduced EEN in our patients. METHOD: We monitored and recorded nutritional data on 29 PKT recipients who underwent transplantation between Oct 2007 and Jan 2010 without a nutritional assessment or EEN [Monitored Group (MG)] and on 30 PKT recipients between Feb 2010 and Dec 2013 who received a nutritional assessment and EEN (Naso-jejunal feed or oral intake with supplementation, according to their nutritional status) [Fed Group (FG)]. The end-point was to assess patients' daily post-transplant nutritional intake. This was calculated as a percentage of estimated nutritional requirements using the Schofield equation with a 25% added stress factor and relevant activity factor. Following a literature search and realistic targets our aim was to reach >60% requirements: achievement of ≥60% energy requirements by day-7 (7d-60%) and at the time of discharge (total-60%) [13,14]. RESULTS: There was no significant difference between MG and FG patients in cold ischemic time (CIT), recipient-age and donor-age, Length of Stay and donor-creatinine. In contrast, FG patients were less frequently in predialysis status 41.4% vs. 26.7%, p = 0.001; and had higher incidence of BMI <22.5 kg/m2 63.3% vs. 48.3%, p = <0.005. In outcomes, FG patients more frequently achieved a higher average % of nutritional requirements in the first week 39.69% vs. 22.37%, p = <0.005; as well as during whole in-patient stay 57.24% vs. 44.43%, p = <0.005 (Table 3, Figs. 1 and 2). The FG spent a greater proportion during the first week 66.7% vs. 31%, p = <0.005; and of whole their admission 93.3% vs. 75.9%, p = <0.005; meeting more than 60% of nutritional requirements. Most important, the need for parenteral nutrition within the FG was significantly lower, 7.1% vs. 20.7%, p < 0.005 (Table 3). CONCLUSION: Our results show that these patients benefit from planned EEN and receive better nutritional support when compared to the patients managed with the historic, reactive approach to nutritional care. Nutritional intake in the first week as well as during the whole admission was superior in patients receiving active EEN despite a more difficult post-operative course due to higher incidence of re-operations compared to the control group. Also the need for parenteral nutrition was significantly lower in this group. In addition, pre-transplant nutritional assessment is beneficial and accurately highlights those who may be at risk of malnutrition pre and post-operatively.

Adequacy of Rifampin Absorption after Jejunostomy Tube Administration.

It is not always possible to administer antituberculosis pharmacotherapy orally for reasons that may be a direct consequence of tuberculosis itself. To our knowledge, no published literature is available regarding antituberculosis drug absorption via feeding tube. We present the case of a patient with tuberculosis meningitis who required medication administration via percutaneous endoscopic jejunostomy (PEJ) tube. Blood samples were collected during the continuation phase of antituberculosis therapy, immediately before dose administration, and then at 1, 2, 4, and 6 hours after dose administration for quantification of serum rifampin concentrations. Assaying these concentrations by high-pressure liquid chromatography demonstrated a peak serum rifampin level (C(max)) of 18 µg/ml and total rifampin exposure (area under the curve from 0-6 hours [AUC(0-6)]) of 50.1 µg/ml. These are high compared with rifampin C(max) and AUC(0-6) values reported in patients after oral rifampin administration; C(max) tends to range between 4.0-10.5 µg/ml and AUC(0-6) 7.0-52.9 µg/ml after oral administration of 600 mg at steady state. Based on our patient's results, therefore, rifampin administered by PEJ tube appears to be well absorbed, with preservation of adequate C(max) and AUC values. It is worth noting that this was in the context of drug administration in the fasted state. In the absence of any published evidence of adequate absorption via jejunal feeding tube in the nonfasted state, it would seem prudent to ensure that patients are fasted when rifampin is administered via PEJ tube, just as patients are when oral rifampin is administered. This report represents the first documented evidence, to our knowledge, of adequate rifampin absorption when administered via PEJ tube and provides important reassurance for health care providers, patients, and families facing similar clinical scenarios.

Jejunal feeding is followed by a greater rise in plasma cholecystokinin, peptide YY, glucagon-like peptide 1, and glucagon-like peptide 2 concentrations compared with gastric feeding in vivo in humans: a randomized trial.

BACKGROUND: Jejunal feeding is preferred instead of gastric feeding in patients who are intolerant to gastric feeding or at risk of aspiration. However, the impact of gastric feeding compared with that of jejunal feeding on postprandial circulating plasma glucose and amino acid concentrations and the associated endocrine response in vivo in humans remains largely unexplored. OBJECTIVE: We compared the impact of administering enteral nutrition as either gastric feeding or jejunal feeding on endocrine responses in vivo in humans. DESIGN: In a randomized, crossover study design, 12 healthy young men (mean ± SD age: 21 ± 2 y) received continuous enteral nutrition that contained noncoagulating proteins for 12 h via a nasogastric tube or a nasojejunal tube placed 30-40 cm distal to the ligament of Treitz. Blood samples were collected during the 12-h postprandial period to assess the rise in plasma glucose, amino acid, and gastrointestinal hormone concentrations. RESULTS: No differences were observed in the postprandial rise in circulating plasma amino acid and glucose concentrations between regimens. Jejunal feeding resulted in higher peak plasma insulin concentrations than did gastric feeding (392 ± 53 compared with 326 ± 54 pmol/L, respectively; P < 0.05). The postprandial rise in plasma cholecystokinin, peptide YY (PYY), glucagon-like peptide 1 (GLP-1), and glucagon-like peptide 2 (GLP-2) concentrations was greater after jejunal feeding than after gastric feeding, with higher peak concentrations and a greater postprandial incremental AUC for GLP-1 and cholecystokinin (all P < 0.05). Plasma ghrelin concentrations did not differ between regimens. CONCLUSIONS: Enteral nutrition with gastric or jejunal feeding in healthy young men results in similar postprandial plasma amino acid and glucose concentrations. However, the endocrine response differs substantially, with higher peak plasma cholecystokinin, PYY, GLP-1, and GLP-2 concentrations being attained after jejunal feeding. This effect may result in an improved anabolic response, greater insulin sensitivity, and an improved intestinotropic effect. Nevertheless, it may also lead to delayed gastric emptying. This trial was registered at trialregister.nl as NTR2801.

Jejunal Casein Feeding Is Followed by More Rapid Protein Digestion and Amino Acid Absorption When Compared with Gastric Feeding in Healthy Young Men.

BACKGROUND: Dietary protein is required to attenuate the loss of muscle mass and to support recovery during a period of hospitalization. Jejunal feeding is preferred over gastric feeding in patients who are intolerant of gastric feeding. However, the impact of gastric vs. jejunal feeding on postprandial dietary protein digestion and absorption kinetics in vivo in humans remains largely unexplored. OBJECTIVE: We compared the impact of gastric vs. jejunal feeding on subsequent dietary protein digestion and amino acid (AA) absorption in vivo in healthy young men. METHODS: In a randomized crossover study design, 11 healthy young men (aged 21 ± 2 y) were administered 25 g specifically produced intrinsically l-[1-(13)C]phenylalanine-labeled intact casein via a nasogastric and a nasojejunal tube placed ~30 cm distal to the ligament of Treitz. Protein was provided in a 240-mL solution administered over a 65-min period in both feeding regimens. Blood samples were collected during the 7-h postprandial period to assess the increase in plasma AA concentrations and dietary protein-derived plasma l-[1-(13)C]phenylalanine enrichment. RESULTS: Jejunal feeding compared with gastric feeding resulted in higher peak plasma phenylalanine, leucine, total essential AA (EAA), and total AA concentrations (all P < 0.05). This was attributed to a more rapid release of dietary protein-derived AAs into the circulation, as evidenced by a higher peak plasma l-[1-(13)C]phenylalanine enrichment concentration (2.9 ± 0.2 vs. 2.2 ± 0.2 mole percent excess; P < 0.05). The total postprandial plasma AA incremental area under the curve and time to peak did not differ after jejunal vs. gastric feeding. Plasma insulin concentrations increased to a greater extent after jejunal feeding when compared with gastric feeding (275 ± 38 vs. 178 ± 38 pmol/L; P < 0.05). CONCLUSIONS: Jejunal feeding of intact casein is followed by more rapid protein digestion and AA absorption when compared with gastric feeding in healthy young men. The greater postprandial increase in circulating EAA concentrations may allow a more robust increase in muscle protein synthesis rate after jejunal vs. gastric casein feeding. This trial was registered at trialregister.nl as NTR2801.

Clinical management of post-pyloric enteral feeding in children.

Post-pyloric feeding (PF) allows the administration of enteral nutrition beyond the pylorus, either into the duodenum or, ideally, into the jejunum. The main indications of PF are: upper gastrointestinal tract obstructions, pancreatic rest (e.g., acute pancreatitis), gastric dysmotility (e.g., critically ill patients and chronic intestinal pseudo-obstruction) or severe gastroesophageal reflux with risk of aspiration (e.g., neurological disability). Physiological and clinical evidence derives from adults, but can also be pertinent to children. This review will discuss the practical management and potential clinical applications of PF in pediatric patients. Some key studies pertaining to the physiological changes during PF will also be considered because they support the strategy of PF management.