Wcirld J. SuFK. 29. H)23-1028 (2()05| IM)I: H).

l7's(M)268-05-749l-z

WORLD
Journal ol

SURGERY
t> 211(15 by the .Sodete Inttrnarioiiale ile Chirurpie

Early Enteral Feeding by Nasoenteric Tubes in Patients with Perforation Peritonitis

Navneet Kaur, M.S., Manish K. Gupta, M.S., Vivek Ratan Minocha, M.S.
Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital. University of Delhi, Shahdara. Delhi 11009.5. ltidia Published Online: June 30. 2005 .Abstract. Malnutritiim is \vo)l rec(it;nized as a potential cause of incrt'iised niiirbidity find mnrtuiity in snrgiciil patients. Eiirly postoperative untLTui nutrition thniu^h a feeding Jejunostomy has been sbown to impniM.- reMilts in patients under(>oin)> nuijor resections for i^astrointestJnal ina)i}inanciL's, tratinia. iind pt^rfciration peritonitis. We conducted a prospective sdidy to assess tbe feasibility and sb<irt-lerm efficacy of early enteral feeding) tbront>b a na.soenterie tube plaet'd intraoperiitively in patients wKb nontraiimatic perforation peritonitis witb mal nutrition. One bnndred putii-nts witb nontrauniiitie perforation pL-ritcmitis wilh malnutrition undfr|>oin[> exploratory' lapanitoniy were randcmilv divided into a test grotip H'til and a control Kroup )CG) of 50 paiients each. TG patients bad a nasoenteric tube placed at tht time of surgerv and were started rm an enteral feeding regime 24 bours postoperalively. Patients in CG were allowed to eat orally once tbey passed flatus. Ibe differences hctwt't'n the two groups witb respect to nulritional intake in terms of energj and protein, cbanges in nutritional status as assessed by iintbropomctric. hiocbemical. and bematological \alues, amount of nasogastric aspirate, return of bowel motilit.v, and complication rates were analyzed. The nasoenleric feeding was well tolerated. Total calorie and protein intake in TCi was significantly bigber tbn in CG: 9SI vs. 50? kcal {p < t>.l)l). pnuein 24 vs. 0 g on day 3 and 1498 vs. 846 kcal (/? < tl.tlll, protein 44 vs. 2.^ g (/> < 0.01) on day 7, respectively. There was reduction in the amount of nasogastric aspirate in TG compared witb tbat in C(;: 431 vs. 545 ml/24 b on dav 2 and 301 vs. 440 mI/24 b on day 3, respectivelv. Tbere was mucb faster recoverv' of b(wel niotility in T(; than in C(; at 3.34 vs. 4.4 days ip < 0.01). Complications developed in 39 of 50 patients in TG and in 47 of 5(( in CG. Tbe major complications occurred in 6 patients in T(> and 12 patients in CG ip < 0.05). Patients with perforation peritonitis with malnutrition are likely to develop large energ> deficits postoperativelv, resulting in bigber incidence of infective complications. Early enlcral feeding tbrougb a nasoenteric tube is well tolerated by tbese patients and belps to improve energy and protein intake, reduces tbe amount of nasogastric aspirate. reduce.s tbe duration of postoperative ileus, and reduces the risk of serious complications.

result of starvation, the stress of surgery, and a subsequent increase in their metabolie rate. Malnutrition is associated with tissue wasting and impaired organ tunction, which lead to increased morbidity and extended hospitalization [4, 5]. Impaired immune function eontribtites to an inereased risk of infection [6]. and muscle funetion is also adversely affeeted by nutrititmat depletion |7|. in response to the awareness of the deleterious effeets that malnutrition has on patients, significant advances have been made in the Held ()f enteral and parenteral nutritional support during the peri- and postoperative periods. Whenever safe and efiicicnt access to a functional gastrointestinal traet ean be achieved, gut feeding is preferred over total parenteral nutrition (TPN) |S|. F.arly postoperative feeding can be started because of the preservation of postoperative small bowel peristaltic aetivity and absorptive capacity. With gut feeding, the liver has the first opportunity to clear, process, and distribute the nutritional eoniponents. Also, the vital gut functions sueh as substrate traflic, the gut mucosal barrier, and immunoeompctencc are maintained. Early enteral feeding in the postoperative period has been to shown to reduce the number of septic complications in burn patients [9], trauma patients [10, II], and patients with major gastrointestinal resections for malignancies [12]. This route is also most economical. A large number of patients who present to our hospital for emergency surgery for perforation peritonitis arc malnourished at the time of admission. In peritonitis, enteral nutrition is nol routinely used beeause of the edematous and paralytic characteristics of the bowel. However, the role of early enteral nutrition (EEN) in peritonitis has been investigated by many workers. EEN by jejunostomy was found to reduce septic complications in patients with severe pancreatitis and secondary peritonitis [13[. Glutamine-enriched enteral diet was found to be well tolerated in patients with purulent peritonitis [14j. Singh et al. [15] reported that early enteral feeding through jejunostomy in patients with perforation peritonitis is feasible and tesults in reduced sepUe morbidity. However, sinee patients with perforation peritonitis require supplementation for only a short period, we evaluated the feasibility of EEN through a nasojejunal tube in patients presenting with nontraumatie perforation peritonitis with malnutrition.

There is an iitistispcctcd prevalence of malnutrition in hospitalized patients [1. 2). Up to A07c of patients are malnourished at the time of admission to the hospital [3]. Those patients who tindergo major surgery are at further risk of malnutrition as a

Correspondence to: Navtiect Kaur, M.S.. c-tiiail: tlr_niivkaur((i hotniail. com

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World .1. Surg. Vol. 29. No. 8. August 2005

Patients and Methods This prospective study was carried out in the Department of Surgery at the University College of Medical Sciences and the Guru Teg Bahadur Hospital. Delhi, frtim April 2000 to Mai'eh 2002, after approval from the local ethical coEiiniittee. The subjects were 100 patients aged 20-70 years who underwent emergency exploratory laparotomy for nontraumatie perforation peritonitis and were malnourished at presentation. Patients were required to give informed consent for inclusion in the study. Those with dementia, diabetes, renal failure, or hepatic failure were excluded from the study. Patients were eonsidered malnourished if they met any of the following eriteria of nutritional assessment: (I) Nutritional Risk Index (NRI) [16] < 100 [NRI = 1..519 X serum albumin (g/L) -I- 0.417 (current weight/ Ltsual weight) x 1(10] or (2) current weight < 957f of the ideal weight and serum albumin at 39.2g/L.

counts were reeorded. The postoperative course of each patient was monitored for the duration of postoperative ileus, amount of Ryles tube aspirate, sepsis score, and infeetious complications such as septiceniia, intra-abdoniinai sepsis, wound dehiseence, wound infection, and pneumonia. Objective eriteria were established for eaeh complication as defined by Mullen et al. [19]. The number of days in the hospital was recorded tor each patient. Statistical Analysis All results were subjected to statistical analysis. Demographic and clinical data from the two groups were compared and intergroup differences among the parameters reeorded were analyzed by analysis of variance and the Stitdent and chi-squared tests. Student's /-test was used for intergroup analyses and the ehi-squared test was used to analyze the level of significance or differences in the incidence of complications. All tests for significanee were twotailed. A p value of less than 0.05 was eonsidered statistically significant and p value of less than 0.001 was eonsidered highly signifieant. Results A total of 100 patients participated in the study. All the patients were between 18 and 70 years of age. Sixty-five percent of patients were between IS and 40 years old while 35'^' were between 41 and 70 years old. There were 79 males and 21 female patients. All these patients underwent emergency exploratory laparotomy for nontraumatie perforation peritonitis. Forty-four percent of patients had duodenal uleer perforation. 39*;^ had ileal perforation (20 tubereular and 19 typhoid perforation), 10 had appendieular. 4 had gastric ulcer, and 3 had ceeal perforation as a result of amoebic typhilitis. All patients with duodenal perforation underwent primary closure with Graham's patch. Of the 39 patients with ileal perforation, 20 undei'went primary elosure and in 19 patients an ileostomy was made. Patients with gastric and cecal perforation had primary elosure of perforation. Patients with appendieular perforation underwent appendectomy. The baseline characteristics in terms of age, gender, anthropometric. and biochemical parameters of nutritional status were eomparable in both test and eontrol groups (Table I).

Study Design The patients who entered the study were randomly put into a control group (CG) or a test group (TG) of 50 patients each. After adequate resuseitation, all patients underwent emergeney laparotomy for peritonitis. At laparotomy the souree of peritoneal eontamination was eontrolled by simple closure, resection and anastomoses, or exteriorization of the bowel loop. A thorough peritoneal lavage was done at the end ol' the procedure. In the TG. at the end of surgery a nasoenteric tube was inserted by nasal route atid advanced into the dtiodenum or jejunum. A Ryles tube was also placed in the stoniaeh for decompression. In the postoperative period patients in the CG reeeived standard care while patients in the TG were given a hospital kitchen-prepared feed through the nasojejunal tube 24 h after surgery. The 500 ml of feed contained 375 ml milk. 12.5 g sugar. 12.5 g butter. 12.5 g starch. 125 ml rice water, and half an egg. The feed provided 500 kcal energy, 16.66 g protein, 43.5 g carbohydrate, and 30 g fat. The feed was started at a rate of 50 nil/h in the first 6 h and gradually was inereased to 10(1 ml/h by the third postoperative day. Our nutritional goal was to deliver 35-45 keal/kg/day and 1.5-2.0 g protein/kg/day. For those patients who developed abdominal distention, diarrhea, or vomiting, feeding was diseontinued for 6 h and than restarted at a slow rate. The nasogastric tube was taken out when gastric aspirate was minimal or nil and when patients started taking 2 L of feed per day, usually by the fourth or fifth postoperative day. All patients were assessed on the day of admission, on days 3 and 7, on the day of discharge for nutritional intake, nutritional status, sepsis seore [17]. eomplieations. and length of hospital stay. Energy and nutrient intake were calculated aeeording to tables supplied by the dietary department. Nutritional Status Nutritional status was documented by anthropometry. Weight (wt) was measured by scales, height (ht) was measured by stadiometer. and the midarm circumference (MAC) was measured with a nonstretchable plastic tape measure around the nondominant arm. The standards for comparing wt and ht were those proposed by Agarwal et al. [18]. The handgrip strength of the nondominant hand was assessed using a dynamometer. A random satnple was drawn and serum albumin and lytnphocyte

Ntitritional hitakc All patients remained on intravenous fluids for the first 24 hours. Patients in the TG tolerated tiasoenterie feeds well. Twenty-seven patients (5470 did not complain of any adverse effects. In these patients the full nutritional goal was aehieved by the fourth postoperative day. In 12 patients (24%) there were minor complications: Four developed diarrhea and eight developed abdominal eramps and distension. In these patients infusion was temporarily stopped and then restarted at a slower rate after 6-12 h. In these patients the nutritional goal was achieved by fifth postt)perative day. None of the patients developed any anastomotie leaks as a result of early entera! feeding. Tube intolerance was noted in 11 (22%) patients. Six patients pulled out their nasojejunal tube before the feeding eould be instituted. Five patients pulled out the tube by third or fourth day and they were switched to oral feeding. Total calorie and protein intake in the

Karii ct al.: Early Enteml Feeding in Perforation Peritonitis

1025 Table 5. Handgrip strength (in kg) in control and test groups

Table 1. Preoperative clinical characteristics Conirol group mean (SD) Age (vr) Gender (M/F) Preop weiglil (kg) P r e o p a l b i u n i n (g dl) Preop handgrip ^irengtli (kg) Preop lymphocyte count (eeM.cc)
[ reop JVI.AL (eni) TL'SI group

mean (SD) 35,76(14.94) 37 ; 13 49,34 (6,89) 2,40 (0,54) 10.S7 (1.82) 2200.00(1132,50)
1 Q 7 1 1 T 11 1 1 V . M I Z . J> 1 )

Dav Admission 3rd day 7ih day Diseharge

Control group (SD) 10,98(1,56) L3.64(l.98) 16,40(2,43) 17,42(2,47)

Tesl group mean (SD) 10,96(1,94) 15,26(2,63) 18,05(2,37) 18,49(2,15)

p Value 0.001 0.001

Signiticance NS S S NS

36,16 42 46.60 2.41

(14.61) / 8 (6.15) (0.40)

10.98 (1,56) 1508,42 (580.50)

1 U A l /I iii\ 1 V.D,' ( I . H / )

NS = not significant, S = significant.

Table 6. Comparison of number ot complicatiuns in conirol and lest groups Table 2. Caloric intake (in kcal) in control and test groups Da\
i
T

Control group (keal) mean (SD) 500,00 502,70 (28,74) 505,41 (46.82) 544.00(138.83) 551,00(226,11) 739,76(320.29) 846,59(360,51)

Test group (kca!) mean (SD) 510,87 (48,20) 912,6(248,66) 981,20 (388,78) 1075,13(506,22) 1263,07(531,73) 143y (,4,304,19) i498,74 (.545,64)

Complications p Value 0,00 0,00 0,00 0,00 0,00 0,00 Signitieaiiec NS

S

Conirol 8 4
14 13 8 47

Sludy

3 4

s
6 7

s s s s

Wound infeetion with dchiscence Complete wound dehiscence witli bowel loop prolapse Chest infeelion willi productive eougli Bronclio pneumonia, pleural effusion Scplisemia. lou UP. high-grade lever, ele. Tola I

7 3
17 9

3
39

s
in tbe TG [48.80 (7.39) kg on day of admission to 46.83 (7.31) kg on day of discharge] was signilieantly less tban in the CG group [46.60 (6.15) kg on day of admission to 43.SI (5.72) kg on day of discbarge]. Tbcrc was no significant cbange in MAC or absolute lymphocyte count in citber group. There was a statistically significant difference in serum albumin and handgrip strength (HGS) in TG vs CG. Serum albumin levels in patients in ihe TG showed an increase from 2.40 (0.47) g/'dl at admission to 2.41 (0.54) g/dl on day 3 to 2.56 (0.52) g/dl on day 7. Serum albumin levels in the CG showed a decrease from 2.41 (0.40) g/dl at admission to 2.29 (0,37) g/dl on day 3 to 2.20 ((1.35) g/dl on day 7. Tbe HGS also sbowed a significant improvement in the TG compared with the CG (Table 5). Scp.si.s Score and Complications

NS - not significant, S = significant.

Table 3. Protein intake (in g) in eontrol and lest groups

Days 1 2 3 4 5 6 7 S 19,13 (7.25) 25.60 (9.36) 21,5(9,845) 23,36(11,68) significant. Control/group (g day) mean (SD) Test group (g/day) mL'an^(SD) Significance

17.7 (6,802) 24,37 (9,34) 34,77(14,11) 43,90(18,57) 44,46(21,63) 44,48 (21,56)

S S

s s

Table 4. Ryle's lube aspirate (ml/24 h) in the conirol and Icsl groups Control group mean (SD) Tesl group mean (SD)

Sepsis score in tbe TG was 11.58 (1.8(1) compared witb Il.(i7 {1.28) in tbe CG at the time of admission, so the two groups were comparable. On the tbird day, tbe sepsis score in the TG was 4.76 p Value Davs (1.30) compared wilb 5.60 (1.15) in CG and the difference was 1 503,06 (230,35) 465 (265.49) NS significant (/? < 0.05). On day 7, tbe sepsis score in tbe TG was 2 585,56 (272.99) 431.14(244,15) NS 3.58 (1.05) compared with ,3.71 (1.49) in tbe CG. 3 674,25(751.27) 426,58 (309,74) NS 4 440,9] (286,53) 301,52 (215,64) NS The number of complications in the TG was 39 compared witb 47 in the CG. Major complications like septicemia, low hlood NS - not significant. pressure, bigh-grade fever dessiminalcd intravascular coagulation (DlC), and burst abdomen were seen in 6 patients in tbe TG TG was significantly higher than in Ibe CG (Tables 2 and 3) compared witb 12 patients in tbe CG: the difference was statisTbere was reduction in the amount of nasogastric aspirate in the tically significant (j> < 0.05). The details of complications in tbe TG compared witb the CG (Table 4), Tbere was much faster CG and TG are given in Table 6. The abdominal wound dchisrecovery of bowel motility in the TG tban in tbe CG at 3.36 (0.75) cence and severe chest infections mostly occurred together. However, upper respiratory tract infections were seen more frevs. 4.4 (1.02) days {p = ().()()()). quently in the TG and were probably related to ineffective cougbing resulting from tbe presence of two tubes in the esopbNittiitional Stattis agus. Tbere were a total of seven deaths, three in the TG and four Tbe effect on nutritional status was assessed by measuring the in the CG, Tbe cause of deatb was septicemia in six cases and change in wcigbt. albumin, bandgrip strength, MAC, and lym- myocardial infarction in one case. The mean length of hospital phocyte citunl from the day of admission tii the day of discbarge. stay In the TG was 12.48 days compared witb 14.44 days in the There was loss of weight in both groups. Tlie mean loss in weight CG,

1026

World J. Surg. Vol. 29, No. 8, August 2005 EEN allowed a significantly greater amount of protejn and ealorie intake in the TG than in the C'G. Reeenlly reported results have demonstrated the same outcome with enteral feeding regimes that provide 8H7 (4S8) and 830.6 (372.7) keal/day. whieh. however, is less than the supplementation aehieved in our paiients [13. 30]. Assessment of nutritional status showed that paiients had weight loss in the immediate postoperative period. However, the mean weight loss in patients in the TG was significantly less than that in patienls in the CG (4.1I6%' vs. 6.0%). This concurs with other studies that also found that a ehange in weight in the postoperative period is a good parameter for assessment of nutritional supplementation [10. 15. 31]. An aeute weight loss of 25%'-3O% is associated with a high mortality rate of 90%. in postoperative paiients [32[. It has been shown that malnutrition ean begin to have detrimental effects on function, ineluding surgieal wound healing, when individuals lose only5%-10% of body weight. In eatabolic surgical patients, this degree of loss ean oeeur in only 5-10 days of slai^valion. even if starting fri>m a good nutritional status [33]. Therefore, it seems appropriate Ihal nutritional support is considered with in 5 days if a patient is eompletely starving. We also found an increase in serum albumin levels in the TG (2.40 g on day I to 2.36 on day 7) compared with a decrease in serum albumin levels in CG (2.41 g on day 1 to 2.20 g on day 7). However, the status of the serum albumin level as a tool for assessment of nutritional support is eontroversial. Serum albumin has a long half-life of 20 days, and the early postoperative period may be too short to demonstrate ehanges in tbe serum albumin level after supplementation. Other proteins sueh as retinal binding prolejn and iransferrin and thyroxine-binding protein have a short half-life and should be more sensjljve parameters to demonstrate the effect of supplementation on the nutritional status. Other anthropometric parameters, sueh as MAC or absolute lymphoeyte eount in either group, did not show any significant change. Impairment in muscle function as measured by handgrip strength has been found to be a sensitive parameter to demonstrate the effeet of supplementation on nutritional status [34]. In our study HGS showed a statistieally significant improvement in patients with EEN. Protein depletion is more important than energy depletion in predisposing patients to postoperative morbidity. As skeletal museles are used as an important reserve of aminc) aeids and ean be assessed by HGS the use of HGS is recommended to deleci postoperative protein depletion. In our study there was a high ineidenee of inieetious eomplieations in both groups. However, there was a signifieanl reduetion in major septie complications in the TG than in the CG. A similar outeome has been observed in many other studies as well. Early enteral nutrition after major abdominal surgei^ for gastrointestinal traet eaneers was found to reduee the severity of infections[12. 27]. EEN after surgery for peritonitis has also been reported to reduee septie morbidity [18, 23]. Saisi et al. [35] assessed the effieaey of EEN after major urologic surgery and found a lower ineidenee of eomplieations. mainly infeetious. and a shorter length of hospital stay. Moore and Moore [lU] found that blunt trauma patients fed enterally experieneed more significant reduction in septic complications than patienls reeeiving TPN. Though various studies have shown a reduction in mortality as welt as a shorter length of hospital slay in patients reeeiving EEN [36, 37] no sueh benefit was seen in our study. Length of hospital stay is not eonsidered a good parameter since the actual day of

Discussion Peritonitis after bowel perforation is one of the most common .septic states. The anatomical site and cause of perforation is an important faetor determining outeome. The spectrum of peritonitis seen in India is different from that seen in the West, with more of entcrie and tubercular perforations involving small intestines, mainly ileum, and less of eolonie perforations [20]. However, in our study the duodenum was the most eommon site of perforation (44%). followed hy the ileum which accounted lor 39% of the perforation cases. Enteric perforations are reported to have a mortality rate of l8%-2()9'( and eomplieation rales of around 66% [21, 22]. The most frequent eomplieation is wound infection. Tubercular perforations are reported to have higher mortality figures of 42%-57% [23, 24j. Poor outeome in patients with tubercular and typhoid perforations has been attributed to the overall poor condition of the patients prior to the development of peritonitis. This poor general condition results frt)m mulliple-organ involvement by the disease process as well as malnutrition. As per traditional eustom in India, patients with a painful abdomen and fever are allowed only clear liquids orally. Inadequate oral intake eontributes to malnutrition. The problem is eompounded by the presenee of sepsis and its related metabolie alterations such as an increase in energy demands and ehanges in substrate utilization. All these faetors combine to increase the patient's risk for morbidity and mortality. Various studies on EEN in patients undergoing major abdominal surgery have shown good tolerance to entcral feeding and reduetion in septic morbidity. A nasojejunal route for tube feeding in patients undergoing laparotomy for gastric pathology was used and found to have good lube toieranee and good intestinal toieranee [25]. A nasojejunal tube feeding regime providing from 30(1 to 11)00 ml/day of enteral feed was well tolerated in patients of peritonitis [13]. Our patients also tolerated enteral feeds well and we were able lo infuse 2 L of enteral feed by the fourth postoperative day. Twenty-four pereent of the patients developed abdominal distension and cramps at the start of tbe cnleral feed for which feeding had to be stopped and restarted after 6-12 h. This led to some dekiy in achieving lhe goal of 2000 ml of enteral feed per day. Not being able to deliver the actually required amount of energy and prolein is considered to be an important drawbaek of enteral nutrition. Two major faetors affecting intestinal toieranee have been found to be intraabdominal surgieal eomplieations and low serum albumin (< 30 g/ L) [26]. However, positive effects of enterai feeds have been shown even in patients with redueed protein ealorie supply [13, 27]. This beneficial effect has been attributed to a possible immunomodulatory effect of the EEN by promoting reeonditioning and reeovery ofthe gnt [13]. Another important problem eneountered in these patients was "tube intoleranee" which was seen in II patients. A nasogastric tube for aspiration and a nasojejunal tube for feeding are sourees of signifieant discomfort to these patients. Double-lumen tube designed to aspirate gastrie contents and to provide feed into lhe jejunum may obviate this problem eonsiderably. EEN leads to earlier canalization of gas and feees [2S. 29]. This fact was conlirmed in our sludy as well. Pupelis et al. [ 13] reported that the appearance of the hrst audible bowel sound after surgery did not differ in TG and the CG, but the passage of lhe first stool was signifieantly earlier in the TG.

Kuril et al.: Early Enleral Feeding in Perforation Peritonitis 18. Agarwai DK. Agarwal KN. Upadhay SK. Physical and sexual growth ot afllueiit Indian children from 5 to IS years of age. Indian Paediatr, 1992:29:12tl3-1282 19. Mullen JJ. Gertner MH. Bii^by GP. et al. Implications of malnutrition in the surgieal patient. Arch. Surg, 1979:114:121 125 20. Sharma LK. Gupta S. Soin AS. et al. Generalized peritonitis in India fhe tropical spectrum. Jpn. J. of Surg. 1991:21:272 277 21. Gupta V. Gupta SK. Shukla VK. et al. Perforated typhoid enteritis in children. Postgrad. Med, J. 1994:70:19 22 22. Nyguyen VS, Typiioid perforation in tropics. J. Clin\ (Paris) 1994:131:90 95 23. Dhar A. Bagga D. Taneja SB, Perforated tubercular enteritis of childhood: a ten year study. Indian J Pediatr 1990:57:71.3-716 24. Cha/ecet C. Dci,\onnc B. Eklejam JJ. et al. A case ofperitonitis due to perforation of lhe small intestines of tubercular etiology: review of literature. Ann. Gastroenterol. Hepatol. (Paris) l9SS:24:243-247 25. Monteferrante E. Maiicini G. Pcdra//oli C. et al. The nasojejunal lube in early postoperative nutrition. Minerva Chir, 1999:54(7 S): 551 555 26. Braga M. Gianotti L. Gentilini O. et al. Feeding the gut early alter digestive surgery: results of a nine year experience. Clin. Nutr. 2()02:21(l):59-65' 27. Hayashi JT. Wolfe BM. Calvert CC. Limited efHcacy of early postoperative jejunal feeding. Am. J. Surg. 19S5;15O:52 2X. Weinstein MD. Dyne PL. Duerbeck NB. The Proef diet- A new postoperative regimen for early oral feeding. Am. J, Obstet. (iynecol. 1993:168:12S-131 29. Basse L. Hjort JD. Billesbolle P. et al. A clinical pathway to accelerate recovery after colonic resections. Ann. Surg. 2000:232(1): 15 17 30. AdamS. Batson S. A study of problems associated with the delivery of enteral feed in critically ill patients in live ICHs in the UK. Intensive Care Med. 1997:23:261 31. Herbert HC. Ryan JA. Anderson AJ. et al. Ntnritional benefits of immediate postoperative jejuna! feeding of an elemental diet. Am, J. Surg. 19SO:I39:I53 159 32. Seltzer MH. Slocum BA. Cataldi-Belcher EL. Instant nutritional assessment. JPEN J Parentcr Enteral Nutr 1979:3:157-159 33. Haydock DA. Hill GL. Impaired wound heafing in surgical patients with varying degrees of malnutrition. JPEN J Paronter Enter Nutr 1986:10:550 554 34. Klidjian AM. I-oster KJ. Kammerliiig RM. et al. Relation of anthropometeric and dynamomcterie variables to serious postoperative complications. BMJ 1980:281:899-901 35. SaIsi P. Cortellini P. Simonazzi M. et al. The use of early enteral nutrition (EEN) after major urologic surgery. Aeta Biomed. ,Ateneo Parmensc 1998:69(1 2):61 65 36. Tucker HN. Miguel SG. Cost containment through nutrition intervention. Nutr, R^ev. 1996:54:111-121 37. Neumaycr LA. Smout RJ. Horn HG. et al. Early and sufiicient feeding reduces length of stay and charges in surgical patients. J. Surg. Res. 2001:95:73-77

discharge is dependent on the availability of social and community services than on the actual clinical condition of the patient. Thus, from above data it can be safely concluded that EEN by the NJ route is effective when used for the short term and leads to a reduetion in seplic complications in patients with perforation peritonitis with malnutrition. References
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Invited Commentary
DOI: 10. l()07/s00268-U05-1119-1 Bruce M. Wolfe, M.D., Ncclufar Ghaderi, B.S.
Sacramento Barialric Medical Association, Carmichael, California, USA Published Online: June 30. 2005

Kaur et al. (DOI: l().10()7/s()()26K-005-7491-z) report the results of a earefully conducted prospective randomized irial comparing early enteral feeding in patients with peritonitis seeondary to gastrointestinal perforation with patients who resumed liquid oral feedings following return of elinical indicators of bowel molility.

The feeding was eomposcd of everyday foods, including milk. blenderized in the hospital kitchen. The feeding was well tolerated in approximately 80% of patients and ultimately was tolerated in essentially all of the tube-fed patients. Benefits of the early lube feeding included an earlier return of gastrointestinal motiiity