Intolerability to postoperative early oral nutrition in older patients (≥70 years) undergoing gastrectomy for gastric cancer: A case-control study.

BACKGROUND: Postoperative early oral nutrition has increasingly been adopted for patients undergoing gastrectomy. However, intolerability to early oral nutrition remains a major concern, especially in older patients. This study aimed to investigate early oral nutrition intolerability in older patients who had undergone gastrectomy. METHODS: We retrospectively reviewed 825 patients who had undergone gastrectomy for gastric carcinoma between 2017 and 2019. All patients received an oral diet on postoperative day 1. Patients were divided into older (≥70 years) and younger (<70 years) adult groups, and short-term outcomes and intolerability to oral nutrition were compared. Intolerability to early oral nutrition was defined as oral diet cessation due to adverse gastrointestinal symptoms. RESULTS: Among the 825 patients (≥70 years, n = 286; <70 years, n = 539), 151 (18.3%) developed intolerability to early oral nutrition, of whom 100 patients were < 70 years old and 51 were ≥70 years old. The most common symptom causing intolerability was abdominal distension. The mean duration of fasting after developing intolerability was 2.8 ± 2.4 days. The incidence of intolerability in the older and younger adult groups was 17.8% and 18.6%, respectively (p = 0.799). In terms of sex, operative approach, gastric resection, lymph node dissection, reconstruction, and tumor stage subgroups, the older adult group did not exhibit a significant increase in intolerability. Postoperatively, the older adult group showed a higher incidence of systemic complications; however, anastomotic complications did not significantly differ between the two groups. CONCLUSIONS: Postoperative early oral nutrition can safely be adopted for older patients undergoing gastrectomy, with acceptable intolerability and surgical outcomes.

Incidence and risk factors of oral feeding intolerance in acute pancreatitis: Results from an international, multicenter, prospective cohort study.

BACKGROUND: Inability to advance to an oral diet, or oral feeding intolerance, is a common complication in patients with acute pancreatitis associated with worse clinical outcomes. The factors related to oral feeding intolerance are not well studied. OBJECTIVE: We aimed to determine the incidence and risk factors of oral feeding intolerance in acute pancreatitis. METHODS: Patients were prospectively enrolled in the Acute Pancreatitis Patient Registry to Examine Novel Therapies in Clinical Experience, an international acute pancreatitis registry, between 2015 and 2018. Oral feeding intolerance was defined as worsening abdominal pain and/or vomiting after resumption of oral diet. The timing of the initial feeding attempt was stratified based on the day of hospitalization. Multivariable logistic regression was performed to assess for independent risk factors/predictors of oral feeding intolerance. RESULTS: Of 1233 acute pancreatitis patients included in the study, 160 (13%) experienced oral feeding intolerance. The incidence of oral feeding intolerance was similar irrespective of the timing of the initial feeding attempt relative to hospital admission day (p = 0.41). Patients with oral feeding intolerance were more likely to be younger (45 vs. 50 years of age), men (61% vs. 49%), and active alcohol users (44% vs. 36%). They also had higher blood urea nitrogen (20 vs. 15 mg/dl; p < 0.001) and hematocrit levels (41.7% vs. 40.5%; p = 0.017) on admission; were more likely to have a nonbiliary acute pancreatitis etiology (69% vs. 51%), systemic inflammatory response syndrome of 2 or greater on admission (49% vs. 35%) and at 48 h (50% vs. 26%), develop pancreatic necrosis (29% vs. 13%), moderate to severe acute pancreatitis (41% vs. 24%), and have a longer hospital stay (10 vs. 6 days; all p < 0.04). The adjusted analysis showed that systemic inflammatory response syndrome of 2 or greater at 48 h (odds ratio 3.10; 95% confidence interval 1.83-5.25) and a nonbiliary acute pancreatitis etiology (odds ratio 1.65; 95% confidence interval 1.01-2.69) were independent risk factors for oral feeding intolerance. CONCLUSION: Oral feeding intolerance occurs in 13% of acute pancreatitis patients and is independently associated with systemic inflammatory response syndrome at 48 h and a nonbiliary etiology.

A case of an absent gall bladder presenting as biliary colic in a tertiary care hospital in Karachi.

Gallbladder agenesis is a rare congenital anomaly occurring in 10-65 per 100,000 populations with the incidence being more common in females with a ratio of 3:1. Although asymptomatic, some patients present with symptoms like biliary colic and often indistinguishable from common conditions leading to unnecessary surgery. A 19-year old woman presented to the hospital with epigastric and right upper quadrant pain, other signs and symptoms consistent with biliary colic. However, on laparoscopy gall bladder was absent. Ultra-sound of the abdomen is the preferred for gallbladder diseases but due to scarcity of reports on gallbladder agenesis, it is often misread due to periportal tissue and sub-phrenic folds often reported as gallbladder or calculi leading to unnecessary surgery. Agenesis, a rare anomaly, poses a diagnostic dilemma to surgeons as it is usually diagnosed during a laparoscopic cholecystectomy. Clinicians should keep in mind this entity when the gallbladder is poorly visualized on ultrasound and think of more detailed investigations such as Magnetic resonance cholangiopancreatography.

Improvement in Food Intolerance Resulting from Roux-En-Y Gastric Bypass after Speech Therapy Intervention in Chewing.

INTRODUCTION: Food intolerance is expected during the postoperative period following gastric bypass and may be associated with inadequate chewing. OBJECTIVE: To evaluate chewing before and after speech therapy intervention in subjects undergoing Roux-en-Y gastric bypass who present with food intolerance. MATERIALS AND METHODS: This was a randomized controlled trial, approved by the Brazilian Ethics and Research Committee under n. 438,600. The study population was allocated into two groups: the study group (SG), who received speech therapy intervention, and the control group (CG), who did not receive any intervention, in six visits at 7, 15, 30, 60, and 90 days (v7, v15, v30, v60, and v90) after the initial visit (v0). During v0 and v90, a chewing evaluation was performed according to the MBGR protocol adapted. The significance level adopted was 5%. RESULTS: A total of 30 females (88%) and 4 males (12%) were analyzed. The SG had 18 subjects, and the CG had 16, with mean ages of 50.17 ± 12.28 years and 45.69 ± 9.78 years, respectively. The postoperative time ranged from 4 to19 months. In the SG, a marked improvement in the number of episodes of food intolerance was observed (p < 0.001), an improvement in the intake of cereals and meats (p = 0.004 and p < 0.001, respectively), and an improvement in chewing capacity and swallowing (p = 0.002 and p = 0.011, respectively). CONCLUSION: Speech therapy intervention in chewing led to a marked improvement of food acceptance and food intolerance resulting from Roux-en-Y gastric bypass.

Tolerance of Hydrolyzed Liquid Protein Fortified Human Milk and Effect on Growth in Premature Infants.

BACKGROUND: We evaluated tolerance of hydrolyzed liquid protein (LP) supplement added to fortified human milk (HM) to optimize protein intake in preterm infants. METHODS: A prospective observational study of 31 subjects compared with 31 historic controls, receiving mothers own milk (MOM) and/or donor milk (DM) to assess LP tolerance, growth, and risk for morbidities was conducted. Milk was analyzed for nutrient content. Feeding intolerance, defined as cessation of feedings for ≥48 hours, abdominal distension and/or residuals, necrotizing enterocolitis (NEC), and metabolic acidosis were used to assess safety, while weight and head circumference (HC) were used to evaluate growth. RESULTS: LP added to powder-fortified HM had no impact on feeding intolerance and NEC. Biochemical parameters showed no metabolic acidosis: blood urea nitrogen levels (first week: median, 13 mg/dL; interquartile range [IQR], 9-16; last week: median, 13 mg/dL; IQR, 10.3-14; P = .94), bicarbonate levels (first week: median, 26.3 mEq/L; IQR, 24-28; last week: median, 28 mEq/L; IQR, 26.3-29.8; P = .10), and pH levels (first week: median, 7.4; IQR, 7.3-7.4; last week: median, 7.4; IQR, 7.37-7.40; P = .5). Weight and HC were not statistically significant. HM analysis showed lower protein and caloric content, respectively (MOM: 0.88 vs DM: 0.77 g/100 mL; P < .0001 and MOM: 18.68 vs DM: 17.96 kcal/oz; P = .02). CONCLUSIONS: Hydrolyzed LP is well tolerated in preterm infants with no difference in growth rates. Clinicians should focus on the need to maximize both protein and energy to optimize growth.

Food Intolerance 1 Year After Banded Roux-En-Y Gastric Bypass.

The purpose of this study is to evaluate the food intolerance after banded Roux-en-Y gastric bypass (RYGB), correlating the data of food ingestion. METHODS: This is an observational prospective study, which evaluated the individuals before and 3, 6, and 12 months after banded RYGB. We performed an anthropometric evaluation and an assessment of the habitual food ingestion and applied a food tolerance questionnaire. RESULTS: The study group was comprised of 75 individuals, 89% of them female, with a percentual weight loss of 29.73 ± 6.79%. The observed results were that food intolerance increased over time and 1 year after surgery, only 2.7% reported to ingest any type of food, while the greatest difficulty was related to red meat (80%). Regarding vomits, after surgery, this proportion significantly increased after 3, 6, and 12 months. Preoperatively, the mean protein ingestion was 98 g, which decreased to 50 g after 3 and 6 months and to 51 g after 12 months. As a conclusion, food intolerance significantly increased following banded RYGB, leading to a crescent dissatisfaction regarding food and an increase in the vomits frequency.

Gastric Emptying and Food Tolerance Following Banded and Non-banded Roux-en-Y Gastric Bypass.

INTRODUCTION: Gastric emptying (GE) and food tolerance (FT) can be altered after Roux-en-Y gastric bypass (RYGB) has been performed, especially when it involved the use of a restrictive mechanism (such as a silastic ring). AIM: To assess GE and FT in patients who underwent banded (BRYGB) or non-banded Roux-en-Y gastric bypass (RYGB). METHODS: Forty-seven BRYGB patients and 47 RYGB patients underwent gastric emptying scintigraphy (GES) and FT assessment (by means of a questionnaire) between 6 months and 2 years postoperatively. RESULTS: GES was performed on average 11.7 ± 5.0 months (6 to 24) postoperatively. T½ medians (time taken for the gastric radioactivity to decrease to half of the original value in the gastric pouch) in the RYGB and BRYGB groups were 48.7 min (40.6-183.0 min) and 56.3 min (41.1-390.9 min), respectively (p = 0.031). The median of total questionnaire scores was 24 points (18-27) in the RYGB group and 20 points (13-27) in the BRYBG group (p < 0.001). CONCLUSIONS: The band (silastic ring) delays GE time and does not affect patient satisfaction or food tolerance to vegetables, bread, or rice, but does affect tolerance to the intake of meat, salad, and pasta. The best tolerated foods are vegetables, salad, and fish. Banded patients are more likely to regurgitate and vomit. Gastric emptying does not affect FT.

Diagnosis and treatment of chronic abdominal pain 5 years after Roux-en-Y gastric bypass.

BACKGROUND: Knowledge of optimal diagnostic workup, etiology, and response to treatment of chronic abdominal pain after Roux-en-Y gastric bypass (RYGB) is limited. OBJECTIVE: To define the etiology of chronic abdominal pain presenting at the 5-year follow-up after RYGB and to evaluate response to treatment. SETTING: Oslo University Hospital (tertiary referral center for obesity surgery). METHODS: Of 234 patients operated during a randomly selected 12-month period, 165 (71%) returned for 5-year follow-up, and 160 responded to study questionnaires. Of these, 54 (34%) reported chronic abdominal pain and were invited to participate in a structured diagnostic and treatment algorithm. These patients were contacted for the evaluation of their response to treatment. RESULTS: Fifty-one of 54 patients (94%) reporting chronic abdominal pain at the 5-year follow-up were included in the study. Of the 45 patients with onset of symptoms post-RYGB, 28 (62%) underwent one or more radiologic evaluations, 10 (22%) underwent endoscopy, and 13 (29%) underwent laparoscopy. Diagnosis and treatment were established for 34 patients (76%), whereas 11 (24%) had abdominal pain of unknown cause. The most common etiology was internal herniation (n = 6), dumping (n = 6), food intolerance (n = 6), gallstones (n = 5), and irritable bowel syndrome (n = 4). After a median follow-up of 13.0 months (standard deviation, 11.5), 37 (82%) patients reported remission or improvement of symptoms, 6 had unchanged symptoms, and 2 patients were lost to follow-up. CONCLUSIONS: The etiology of long-term chronic abdominal pain post-RYGB is diverse. A multidisciplinary team can help most patients with dedicated follow-up, but a subset of patients has symptoms of unknown etiology.

Relationship between duration of preoperative symptoms and postoperative ileus for small bowel obstruction.

BACKGROUND: Factors associated with postoperative ileus and increased resource utilization for patients who undergo operative intervention for small-bowel obstruction are not extensively studied. We evaluated the association between total duration of preoperative symptoms and postoperative outcomes in this population. MATERIALS AND METHODS: We performed a retrospective review of patients who underwent surgery for small-bowel obstruction (2013-2016). Clinical data were recorded. Total duration of preoperative symptoms included all symptoms before operation, including those before presentation. Primary endpoint was time to tolerance of diet. Secondary endpoints included length of stay, total parenteral nutrition use, and intensive care unit admission. Association between variables and outcomes was analyzed using univariable analysis, multivariable Poisson modeling, and t-test to compare groups. RESULTS: Sixty-seven patients were included. On presentation, the median duration of symptoms before hospitalization was 2 d (range 0-18 d). Total duration of preoperative symptoms was associated with time to tolerance of diet on univariable analysis (Pearson's moment correlation: 0.28, 95% confidence interval: 0.028-0.5, P = 0.03). On multivariable analysis, ascites was correlated with time to tolerance of diet (P < 0.01), but total duration of preoperative symptoms (P = 0.07) was not. Length of stay (Pearson's correlation: 0.24, 95% confidence interval: -0.02 to 0.47, P = 0.07) was not statistically different in patients with longer preoperative symptoms. Symptom duration was not statistically associated with intensive care unit (P = 0.18) or total parenteral nutrition (P = 0.3) utilization. CONCLUSIONS: Our findings demonstrate that preoperative ascites correlated with increased time to tolerance of diet, and duration of preoperative symptoms may be related to postoperative ileus.

Postoperative Outcomes, Weight Loss Predictors, and Late Gastrointestinal Symptoms Following Laparoscopic Sleeve Gastrectomy.

OBJECTIVE: To evaluate the outcomes, weight loss predictors, and gastrointestinal symptoms of patients after laparoscopic sleeve gastrectomy (LSG). METHODS: The postoperative medical status of the patients was obtained retrospectively using a questionnaire and was compared to existing medical data before the surgery. RESULTS: We included 201 candidates, 178 patients completed mean of 3 years of follow-up. Mean excess body weight loss (%EWL) was 65.14% ± 15.74 at 6 months, 78.53% ± 20.28 at 12 months, and 74.32% ± 23.92 at 3 years after LSG. Older age (P = 0.018), higher baseline BMI (P = 0.003), and higher number of medications (P < 0.001) were negative predictors for EWL%. Total weekly hours of physical activity was found to be a positive predictor for EWL% (P = 0.008). Remission rates of co-morbidities were 83.5% for dyslipidemia (P < 0.001), 65.8% for hypertension (P < 0.001), 62.1% for type 2 diabetes mellitus (T2DM) (P < 0.001), and 60.7% for gastroesophageal reflux (GERD) (P < 0.001). Late gastrointestinal symptoms were as follows: emesis in 25.9%, constipation in 24.7%, diarrhea in 4.5%, food intolerance in 22.5% and alopecia in 42.7% of the patients. CONCLUSION: Our study shows LSG as a potential tool in achieving almost 75% of EWL% with significant remission of co-morbidities, along with various late gastrointestinal symptoms.

Fatores associados à intolerância alimentar em pacientes no pós-operatório de cirurgia bariátrica / Associated factors with food intolerance in patients after bariatric surgery

Introdução: Um dos efeitos colaterais da cirurgia bariátrica, a intolerância alimentar, é uma das causas dos sintomas comuns do pós-operatório, como vômito, diarreia, e síndrome de dumping. Objetivo: Este trabalho objetivou avaliar os fatores que estão relacionados com a ocorrência da intolerância alimentar em pacientes de pós-operatório de cirurgia bariátrica. Método: Trata-se de um estudo observacional transversal, no qual foram analisados 37 pacientes, no período de 8 meses. Os dados foram coletados em prontuário, sendo obtidas informações antropométricas, socioeconômicas e relacionadas à intolerância alimentar. Para identificar os fatores que estão associados com a intolerância alimentar no pós-operatório de cirurgia bariátrica, utilizou-se o teste qui-quadrado. A magnitude da associação entre os fatores de risco e a ocorrência do agravo foi expressa em Odds Ratio e respectivos intervalos de 95% de confiança. Resultados: Dos 37 pacientes, 86,5% são do sexo feminino e 56,8% apresentaram intolerância alimentar. O grupo alimentar menos tolerado foi dos cereais (47,6%), seguido do grupo das carnes (38%). Observou-se que 36,1% dos pacientes apresentaram episódio de vômito, 30,6% tiveram síndrome de dumping e 37,8% relataram entalação ao deglutir algum líquido ou alimento. Constatou-se associação positiva entre tempo de cirurgia (OR=0,08; IC=0,01-0,49), %PEP (OR=0,21; IC=0,46-0,95) e excesso de peso em kg (OR=0,22; IC=0,05-0,91) com a presença de intolerância alimentar. Conclusões: Observou-se que o tempo de cirurgia, percentual da perda do excesso de peso e excesso de peso estiveram associados com o desenvolvimento da intolerância alimentar. São necessários mais estudos, a fim de predizer os mecanismos de ação pelo qual se desenvolve essa intolerância.

Introduction: One of the side effects of bariatric surgery, food intolerance, is one cause of the common postoperative symptoms such as vomiting, diarrhea, and dumping syndrome. Objective: This study aimed to evaluate the factors or are related to the occurrence of food intolerance in post-operative bariatric surgery patients. Methods: This was a cross-sectional observational study, which analyzed 37 patients within 8 months. Data were collected from medical records and were obtained anthropometric, socioeconomic and related to food intolerance. To identify factors that are associated with food intolerance in post-bariatric surgery, we used the chi-square test. The magnitude of the association between risk factors and the occurrence of the injury was expressed as odds ratios and respective intervals of 95% confidence. Results: Of the 37 patients, 86.5% were female and 56.8% had food intolerance. The least tolerated food group was cereals (47.6%) followed by the meat of the group (38%). It was observed that 36.1% of patients had vomiting episode, 30.6% were dumping syndrome and 37.8% reported pinch to swallow any liquid or food. Found a positive association between time of surgery (OR=0.08, CI=.0.01 - 0.49), %PEP (OR=0.21, CI=0.46 to 0.95) and overweight in kg (OR=0.22, CI=0.05 to 0.91) with the presence of food intolerance. Conclusions: It was found that the time of surgery, loss of excess weight percentage of overweight and have been associated with the development of food intolerance. Make more research is necessary in order to predict the mechanisms of action by which develop this intolerance.

Gastric feeding intolerance is not caused by mucosal ischemia measured by intragastric air tonometry in the critically ill.

BACKGROUND: Gastric mucosal ischemia may be a risk factor for gastrointestinal intolerance to early feeding in the critically ill. AIMS: To study intragastric PCO2 air tonometry and gastric residual volumes (GRV) before and after the start of gastric feeding. METHODS: This is a two-center study in intensive care units of a university and teaching hospital. Twenty-nine critically ill, consecutive and consenting patients scheduled to start gastric feeding were studied after insertion of a gastric tonometry catheter and prior to and after start of gastric feeding (500 ml over 1 h), when clinically indicated. RESULTS: Blood gasometry and intragastric tonometry were performed prior to and 2 h after gastric feeding. The intragastric to arterial PCO2 gap (normal <8 mm Hg) was elevated in 41% of patients prior to feeding and measured (mean ± standard deviation) 13 ± 20 and 16 ± 23 mm Hg in patients with normal (<100 ml, 42 ± 34 ml, n = 19) and elevated GRV (250 ± 141 ml, n = 10, P = 0.75), respectively. After feeding, the gradient did not increase and measured 27 ± 25 and 23 ± 34 mm Hg, respectively (P = 0.80). CONCLUSION: Gastric mucosal ischemia is not a major risk factor for intolerance to early gastric feeding in the critically ill.