The feeding practices of post - Operative gastrointestinal patients in hanoi medical university hospital, Vietnam – Linh Nguyen Thuy

JMR 116 E3 (7) - 2018 45 JOURNAL OF MEDICAL RESEARCH THE FEEDING PRACTICES OF POST - OPERATIVE GASTROINTESTINAL PATIENTS IN HANOI MEDICAL UNIVERSITY HOSPITAL, VIETNAM Linh Nguyen Thuy, Thao Tran Phuong, Phuong Duong Thi Hanoi Medical University In recent years, the feeding practices of post-operative gastrointestinal (GI) patients have begun to be examined more in-depth. This study aimed to describe the feeding practices and evaluate the dietary intake during the first 7 post-operative GI days of patients. Subjects (n = 82) were post-operative GI patients undergoing care by the Surgery department and Oncology and Palliative Care Department in Hanoi Medical Uninversity Hospital, from 2015 to 2016. The nutritional intake during the first 7 post-operative GI days, types, and routes of nutritional regimens, were assessed. The average time of total parenteral nutrition was 83 hours (about 3.46 days). In which, minimum time was 24 hours (1 day) and maximum one was 168 hours (7 days). The mean calories and protein of TPN were 17.5 kcal/kg Ideal Body Weight/day and 0.5 g/kg IBW/ day, respectively. The ratio of calories from carbohydrates, lipid and protein of TPN were 48.8; 39.3; 11.9%, respectively. The energy consumption (kcal/kg IBW) had tended to rise in the following days. They were 13.8 kcal/kg IBW (the 1st post-operative day), 20.3 kcal/kg IBW (the 3rd post-operative day) and 23.7 kcal/kg IBW (the 7th post-operative day). On the 7th post-operative day, the calories ratio of carbohydrates, lipid and protein were about 57; 30; 13, respectively. Total calories and protein intake of post-operative GI patients were lower than the recommendation . The calories ratio of protein, lipid and carbohydrates intake were suboptimal. EN was used late for post-operative GI patients, TPN was quite popular and was held for a long time. Keywords: Feeding practices, Post-operative gastrointestinal, Hanoi Medical University Hospital, Vietnam Abbreviations: OPCD = Oncology and Palliative Care Department, HMUH = Hanoi Medical University Hospital, GI = Gastrointestinal, EN = Enteral nutrition, PN = Parenteral nutrition, TPN = Total parenteral nutrition, ESPEN = The European Society for Clinical Nutrition and Metabolism. I. INTRODUCTION Malnutrition is a common finding in patients presenting for surgical management of upper gastrointestinal and colorectal malignancies, with an estimated prevalence to be in the range of 30% to 50% [1]. Patients undergoing surgery are at risk of malnutrition due to peri- ods of starvation, the stress of surgery and subsequent increase in metabolic rate [2]. The prevalence of malnutrition depends on the diseases type, surgery location and treatment [3]. Recently, the maintenance of a trophic gut mucosa through enteral nutrition and the boost of the immune response through administra- tion of specialized nutrients became the main aim of perioperative nutrition (PN) even in well -nourished patients [4]. Other strategies such as early enteral nutrition post-operation and Corresponding author: Nguyen Thuy Linh, Hanoi Medical University Email: nguyenthuylinh@hmu.edu.vn Received: 03/10/2018 Accepted: 18/11/2018 46 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH intravenous fluid restriction have proven have adequate outcomes. Meta-analysis has indi- cated that early enteral nutrition was associ- ated with significant reductions in post- operative complications, the length of hospital stay, and resumption of bowel function com- pared with traditional postoperative feeding practices. In addition, data also demonstrated that there was no obvious benefit for keeping patients without food, or “nil by mouth,” after gastrointestinal operation [4; 5]. A study in Bach Mai Hospital showed that almost all patients (98%) were given PN post- operatively, with oral feeding starting on an average of postoperative day 4. Mean daily total calories intake was 15 kcal/kg/day and protein intake was 0.61 g/kg/day during hospi- talization [6]. However, there is limited re- search focused on feeding practices of post- operative GI patients, especially in Vietnam. Hence, the primary goal of this paper is to explore information about the feeding prac- tices of post-operative GI patients at Surgery department and OPCD of Hanoi Medical University Hospital (HMUH) with two objectives: 1. To describe the feeding practices during the first 7 post-operative GI days. 2. To evaluate energy and nutrients intake during the first 7 post-operative GI days. II. METHODS 1. Study setting and subjects A cross-sectional study of current feeding practices during the first 7 post-operative GI days was performed in Hanoi Medical Univer- sity Hospital from August 2015 to October 2016. Participants had to meet the following criteria for inclusion in the study: 1) ≥ 18 years old; 2) had undergone GI surgery Esophageal, Gastric, Small intestinal and Colon-rectal surgery). A convenience sampling technique was used to recruit patients. Patients who had GI surgery in HMUH were invited to enroll in the study. A total of 82 patients participated in this research. Variables Demographic characteristics The following demographics were recorded for each subject: Gender (male and female), age group (< 60 and ≥ 60 years old) and mean age, type of surgery (esophageal, gastric, small intestinal and colorectal) Feeding practices The number of days that patients received TPN, PN and EN during the first post- operative GI days. Nutrients in each route The researcher recorded dietary intake (from fluid, soup sonde) of patients during the first 7 post-operative GI days. The researcher asked patients or relative of patients to record dietary intake (food and drink) of patients dur- ing this period. 2. Tools and information collection Data was collected on the day of study which was included general information, dis- ease status, feeding practices (EN and PN) during the first 7 post-operative GI days. The feeding practices were recorded, including the number of days that patients received TPN, PN and EN; how much nutrient intake in each route. The tool in order to conduct data was made by researcher. JMR 116 E3 (7) - 2018 47 JOURNAL OF MEDICAL RESEARCH 3. Study size The following formula was used to estimate sample size for one average value . n: sample size Z 2 1-α/2: the value of z from the probability tables. Choosing α = 0.05 as confidence level is 95%. The value of corresponding to this is 1.96. s: the standard deviation. Choosing s = 194 (kcal) from the previous study [6]. : the mean value from the previous study, = 680 (kcal) [6]. ε = 0.07. From the formula, sample size was 64 pa- tients. By adding 25% participants who dropped, the sample size was 82 patients 4. Statistical analysis The data analysis in this paper was per- formed using Stata 12.0 software. Epi Data 3.1 was used for data input before analysis. Data screening was done before analyzing the data. Mean and proportion equations were used to analyze data. 5. Research ethics This was a descriptive study that the researcher only used the questionnaire to collect information and measurement without any intervention. The participants were protected from harm by giving information about the voluntariness to participate and data was be analyzed and presented anonymously. All participants were informed about the purpose of the study through an open letter and their right to decline participation or to withdraw at any stage of the study. Verbal consent was obtained from all participants. The patients who refused participation in the study were not be in any way discriminated against or treated differently. III. RESULTS 1. General information of the partici- pants Among the study participants, 51.2% of patients had underwent gastric surgery, 34.2% had colorectal surgery, with esophageal (9.8%) and small intestinal (4.9%) surgery accounting for the remaining participants (Table 1). n = Z 2 (1- α/2) s 2 ( .ε)2 X X X Table 1. Demographic characteristics of the study participants Characteristic (n = 82) Count (n) Percent (%) Gender Male 51 62.2 Female 31 37.8 Age group < 60 years old 46 56.1 ≥ 60 years old 36 43.9 Mean age: 57,6 ± 12,3 48 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH Characteristic (n = 82) Count (n) Percent (%) Type of surgery Esophageal 8 9.8 Gastric 42 51.2 Small intestinal 4 4.9 Colorectal 28 34.2 2. The feeding practices during the first 7 post-operative GI days 2.1. The feeding practices during the first 7 post-operative GI days Table 2. Average time of total parenteral nutrition Type of surgery Mean ± SD (hours) Min (hours) Max (hours) Esophageal 66 ± 24.8 24 96 Gastric 82.3 ± 27.6 24 168 Small intestinal 84 ± 24 72 120 Colorectal 89.1 ± 34.5 48 168 Total 83.1 ± 29.99 24 168 The average time of TPN was 83.1 hours (3.46 days). The minimum time was 24 hours (1 day) and maximum one was 168 hours (7 days). The longest mean time of TPN was 89.1 hours (colorectal surgery) and the shortest one was 66 hours (esophageal surgery). 2.2. Energy and nutrients of feeding practices during the first 7 post-operative GI days 2.2.1. Energy and nutrients of total parenteral nutrition Table 3. Energy and nutrients of total parenteral nutrition Total parenteral nutrition Post-operative day Esophageal (n = 8) Gastric (n = 42) Small intestinal (n = 4) Colorectal (n = 28) Total (n = 82) Total Energy (kcal/d) 1167.3 ± 349.1 942.3 ± 364.6 1066.7 ± 409.2 936.2 ± 392.2 968.2 ± 374.7 Energy (kcal/kg IBW/d) 19.0 ± 5.3 16.9 ± 6.9 21.7 ± 8.6 17.2 ± 7.3 17.5 ± 7.0 Carbohydrates (g/d) 160.1 ± 84.2 115.0 ± 51.5 119.3 ± 29.6 105.6 ± 42.7 116.4 ± 53.2 Protein (g/kg IBW/d) 0.6 ± 0.47 0.5 ± 0.41 0.7 ± 0.16 0.48 ± 0.24 0.5 ± 0.4 Lipid (g/d) 39.9 ± 39.5 42.8 ± 26.4 35.7 ± 21.7 41.3 ± 21.7 41.6 ± 26.0 Regarding TPN, the mean total energy was 968.2 kcal/day or 17.5 kcal/kg IBW/day. The mean JMR 116 E3 (7) - 2018 49 JOURNAL OF MEDICAL RESEARCH of protein, lipid and carbohydrates of TPN were 0.5 g/kg IBW/day, 41.6 g/day and 116.4 g/day, respectively. Figure 1. The rate of energy substances for total parenteral nutrition Figure 1 shows that the calories ratio of protein, lipid and carbohydrates of TPN were 11.9: 39.3: 48.8%, respectively. 2.2.2. Energy and nutrients of parenteral nutrition and enteral nutrition Table 4. Enteral and parenteral nutrition during the first 7 post-operative GI days (Mean ± SD) Vari- ables The 1 st post- operative day The 3 rd post-operative day The 7 th post-operative day PN EN Total PN EN Total PN EN Total Energy (kcal/d) 760.3 ± 454.9 0.0 760.3 ± 454.9 1089.1 ± 450 37.8 ± 162.5 1126.9 ± 470.2 921.6 ± 371 394.4 ± 306.4 1315.9 ± 509.4 Energy (kcal/kg IBW/d) 13.8 ± 8.6 20.3 ± 8.8 23.7 ± 9.4 The mean total energy of the first, the third and the seventh post-operative days were 760.3 kcal, 1126.9 kcal and 1315.9 kcal, respectively. The energy consumption (kcal/kg IBW) had tended to rise in the following days. They were 13.8 ± 8.6 kcal/kg IBW (the 1 st post-operative day), 20.3 ± 8.8 kcal/kg IBW (the 3 rd post-operative day) and 23.7 ± 9.4 kcal/kg IBW (the 7 th post- operative day). The average energy of PN increased from 760.3 kcal (the 1 st post-operative day) to 1089.1 kcal (the 3 rd post-operative day) and decreased to 921.6 kcal on the 7 th post-operative day. There was an increase in the mean energy of EN , which were 0 kcal (the 1 st post-operative day), 37.8 kcal (the 3 rd post-operative day) and 394.4 kcal (the 7 th post-operative day). 50 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH Figure 2. The rate of energy substances of EN and PN on the 7 th post-operative day The pie chart 2 illustrated that the ratio of macronutrients (protein: lipid: carbohydrates) of PN and EN was 12.9: 30: 57.1% on the 7 th post-operative day. Table 5. Energy and nutrients of PN and EN on the 7 th post-operative day PN and EN Post-operative day Esophageal (n = 8) Gastric (n = 42) Small intestinal (n = 4) Colorectal (n = 28) Total (n = 82) Energy (kcal) 1791.3 ± 501.8 1300 ± 505.1 1165 ± 547.9 1225 ± 461.8 1315 ± 509.4 Energy (kcal/ 29.2 ± 7.6 23.4 ± 9.9 23.9 ± 13.3 22.4 ± 8.4 23.7 ± 9.4 Carbohy- drates (g/d) 236.4 ± 62,4 196.5 ± 92.0 185.9 ± 87.0 165.8 ± 4 189.4 ± 86.2 Protein (g/kg 0.95 ± 0,47 0.85 ± 0,6 1.2 ± 0.8 0.7 ± 0.45 0.82 ± 0.55 Lipid (g/d) 67.8 ± 45.3 43.4 ± 26.8 35.7 ± 27.1 45.3 ± 22.4 46.0 ± 28.1 The mean energy of PN and EN was 1315 kcal/day or 23.7 kcal/kg IBW on the 7 th post- operative day. Esophageal operative patients received the highest amount of calories (1791.3 ± 501.8 kcal) while small intestine patients received the lowest amount of calories (1165 ± 547.9 kcal). The amount of protein, lipid and carbohydrates were 0.82 ± 0.55 (g/kg IBW/d), 46.0 ± 28.1 (g/d) and 189.4 ± 86.2 (g/d), respectively. IV. DISCUSSION Malnutrition is prevalent among post- operative GI patients. Poor nutritional status and feeding practices after surgery are associ- ated with worse clinical outcomes. The study aimed to explore information about feeding practices of postoperative GI patients. JMR 116 E3 (7) - 2018 51 JOURNAL OF MEDICAL RESEARCH The average time of TPN was about 83 hours (3.46 days). In which, minimum time was 24 hours (1 day) and maximum one was 168 hours (7 days). According to the study in Bach Mai hospital (2016), EN started on an average of post-operative day 4 so mean time of TPN was 3 days (72 hours) [6]. Both stud- ies’ mean TPN time were longer than ESPEN recommendation which starting EN for pa- tients in need within 24h after surgery (grade A) [7]. The mean total energy and protein of TPN were 17.5 kcal/kg IBW/day and 0.5 g/kg IBW, respectively. In the ESPEN guideline on Par- enteral nutrition, the recommendation based on evidence (grade B) indicated that 25 kcal/ kg IBW was given for patient, which is an ap- proximate estimate of daily energy expendi- ture and requirements; protein intake recom- mendation is 1.5 g/kg IBW [8]. So the energy and protein intake of patients in this study were less than the ESPEN guideline. After surgery, patients were unable to be fed by EN, TPN was required [8]. The protein: lipid: carbohydrates calories ratio should approximate to 20: 30: 50% [8]. In this study, the rate of P: L: C were 11.9: 39.3: 48.8%. So the energy from carbohydrates reached the recommendation, protein was not enough and lipid was higher than ESPEN guidelines. Table 6. Com parison between HMUH and Bach Mai Hospital on EN and PN during the first 7 post-operative GI days (Mean ± SD) Variables The 1 st post- operative day The 3 rd post - operative day The 7 th post - operative day PN EN Total PN EN Total PN EN Total Energy (kcal) 760.3 ± 454.9 0 760.3 ± 454.9 1089.1 ± 450 37.8 ± 162.5 1126.9 ± 470.2 921.6 ± 371 394.4 ± 306.4 1315.9 ± 509.4 Energy (kcal) of Bach Mai Hospi- tal`s Study (2016) [6] 598 ± 288 0 598 ± 288 750 ± 352 152 ± 132 757 ± 367 531 ± 91 370 ± 234 674 ± 356 The table showed that the differences in energy and protein intake during the first 7 post- operative GI days in patients between this study and Bach Mai Hospital`s study (2016). On the first post-operative day, the energy intake of two studies were similar (13.8 and 13 kcal/kg IBW/day). And they also had no EN on this day. In this study, the calories intake on the 3 rd post-operative day (20.3 ± 8.8 kcal/kg IBW), protein (0.82 ± 0.55 g/kg IBW) and energy intake (23.7 ± 9.4 kcal/kg IBW) on the 7 th post- operative day were more than Bach Mai Hos- pital`s study (17 ± 10 kcal/kg IBW, 0.76 ± 0.47 g/kg IBW, 15 ± 9 kcal/kg IBW). On the 7 th post-operative day, the calories ratio of P: L: C was 12.9: 30: 57.1%, respec- tively. In the comparison, the proportion of lipid 52 JMR 116 E3 (7) - 2018 JOURNAL OF MEDICAL RESEARCH intake was higher and of carbohydrates and protein intake were lower than recommenda- tion (14: 20: 66) [9]. V. CONCLUSION EN was used late for post-operative GI pa- tients, PN was quite popular and was held for a long time. Total energy and protein intake of post-operative GI patients were lower than the recommendation. The calories ratio of protein, lipid and carbohydrates intake were suboptimal. REFERENCES 1. Hộbuterne X., Lemariộ E., Michallet M et al (2014). 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