Is routine postoperative enteral feeding after oesophagectomy worthwhile?
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A best evidence topic in surgery was written according to a structured protocol. The question addressed was whether, in patients undergoing an oesophagectomy for cancer, immediate postoperative enteral feeding (via percutaneous jejunostomy or nasojejunostomy) provides better patient outcomes as compared to waiting until oral feeding can be instituted. Four randomized controlled trials represented the best evidence to answer the clinical question. The first study randomized 25 patients into enteral feeding via jejunostomy (n = 13) versus a routine diet without jejunostomy (n = 12). The authors found no statistical difference in outcomes including length of stay, anastomotic complications and mortality. They did not report any catheter-related complications. A second study included patients undergoing an oesophagectomy or a pancreatodudenectomy, randomized to immediate postoperative jejunostomy feeding (n = 13) or remaining unfed for 6 days (n = 15). They reported one incident of detachment of the catheter from the abdominal wall. They also noted a statistically significant decrease in vital capacity and FEV1 in enterally fed patients. There was no difference in length of stay or anastomotic complications. They concluded that there was no indication for routine use of immediate postoperative enteral feeding in those patients without significant preoperative malnutrition. A third report randomized their post-oesophagectomy patients into enteral feeding via jejunostomy (n = 20) versus crystalloid only (n = 20). The also found no difference in length of stay, anastomotic leak rate or mortality. One catheter was removed due to concerns over respiratory function. They also concluded that there was no measurable benefit in early enteral feeding. The last of these 4 studies randomized patients into naso-duodenal feeding (n = 71) and jejunostomy feeding groups (n = 79). As in previous trials, they found no statistically significant difference between length of stay or anastomotic leak rates. Mortality was higher in the jejunostomy group, although the team did not attribute the deaths to the catheter. They found both methods equally effective in providing postoperative nutrition. In summary, all the trials concluded that routine postoperative enteral nutrition was feasible, but there was no evidence suggesting that it conferred any clinical benefits. (+info)
Fluoroscopically guided nose tube drainage of mediastinal abscesses in post-operative gastro-oesophageal anastomotic leakage.
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Protective ileostomy: complications and mortality associated with its closure.
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INTRODUCTION: diverting loop ileostomies are widely used in colorectal surgery to protect low rectal anastomoses. However, they may have various complications, among which are those associated with the subsequent stoma closure. The present study analyses our experience in a series of patients undergoing closure of loop ileostomies. METHOD: retrospective study of all the patients undergoing ileostomy closure at our hospital between 2006-2010. There were 89 patients: 56 males (63%) and 33 females (37%) with a mean age of 55 (38-71) years. The most common indication for ileostomy was protection of a low rectal anastomosis, 81 patients (91%). The waiting time until stoma closure, type and frequency of the complications, length of hospital stay and mortality rate are analysed. RESULTS: waiting time before surgery was 8 (1-25) months. Forty-one patients (45,9%) developed some type of complication, three were reoperated (3.37%) and one patient died (1.12%). The most important complications were intestinal obstruction (32.6%), diarrhoea(6%), surgical wound infection (6%), enterocutaneous fistula (4.5%), rectorrhagia (3.4%) and anastomotic leak (1.12%). The mean length of patient stay was 7.54 (2-23) days. CONCLUSIONS: protective ostomies in low rectal anastomoses have proved to be the only preventive measure for reducing the morbidity and mortality rates for anastomotic leakage. However, creation means subsequent closure, which must not be considered a minor procedure but an operation with possibly significant complications, including death, as has been shown in publications on the subject and in our own series. (+info)
Managing complications associated with laparoscopic Roux-en-Y gastric bypass for morbid obesity.
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Obesity has become a major health concern in Canada. This has resulted in a steady rise in the number of bariatric surgical procedures being performed nationwide. The laparoscopic Roux-en-Y gastric bypass (LRYGB) is not only the most common bariatric procedure, but also the gold standard to which all others are compared. With this in mind, it is imperative that all gastrointestinal surgeons understand the LRYGB and have a working knowledge of the common postoperative complications and their management. Early postoperative complications following LRYGB that demand immediate recognition include anastomotic or staple line leak, postoperative hemorrhage, bowel obstruction and incorrect Roux limb reconstructions. Later complications may be challenging to differentiate from other gastrointestinal disorders and include anastomotic stricture, marginal ulceration, fistula formation, weight gain and nutritional deficiencies. We discuss the principles involved in the management of each complication and the timing of referral to specialist bariatric centres. (+info)
Management of chest tubes after pulmonary resection: a systematic review and meta-analysis.
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