Digestive Diseases and Sciences, Vol. 44, No. 9 (September 1999), pp.

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Correction of Malnutrition Following Gastre ctomy with Cyclic Enteral Nutrition

XAVIER HE BUTERNE, MD, FRANCK V AILLON, MD, JEAN-LUC PEROUX, MD, and PATRICK RAMPAL, MD

This study was de signe d to evaluate the e f cacy and tole rance of cyclic e nte ral nutrition (CyEN) in gastre ctomized patie nts and to compare the nutritional response to refee ding of 28 gastre ctomized patie nts and 38 nongastre ctomized unde rnourishe d patie nts. Total (e nteral 1 oral) ene rgy intake (292% and 284% of re sting ene rgy e xpe nditure in gastre ctomized and nongastre ctomize d patie nts, respe ctively) and the duration of CyEN (27 days) were similar in both groups. Tole rance was good and not diffe rent in the two groups. In the gastre ctomize d patie nts, a global nutritional de cie ncy score base d on 10 biological and anthropome tric param eters signi cantly improve d (P , 0.0001) with six of the 10 nutritional parame te rs studie d being improve d by renutrition. Comparison of the two groups reve aled similar ef cacy of re fee ding; the global nutritional de cie ncy score improve d by 42.7 6 17.3% in group 1 and 40.0 6 17.4% in group 2. After one year, the probability of be ing alive without relapse was 77.8% in the gastre ctomize d and 72.2% in the nongastre ctomize d patie nts (P 5 0.70) . The ef cacy of re nutrition was similar re gardle ss of the type of gastre ctomy (eg, partial or total) . CyEN is a safe , e ffective and durable tre atme nt for unde rnutrition in gastre ctomized patie nts.
KEY WORDS: malnutrition; nutritional assessme nt; ente ral nutrition; stomach; gastric resection.

Protein e ne rgy malnutrition is fre que nt in gastre ctomize d patie nts (1 8). Six to 20 years after partial gastre ctomy for chronic pe ptic ulceration, 40% of patie nts have lost weight compare d to the ir pre ope rative weight, and 12.5% of patie nts show a weight loss greate r than 10% (1). In the study of Tove y e t al. (2), the ove rall incide nce of weight loss was 39% afte r Billroth I gastre ctomy and 35.5% afte r Billroth II, and 4.9% and 7.5% , re spective ly, of the patie nts suffere d se vere weight loss. Decreased fat and prote in store s have also bee n recently demonstrate d afte r total gastre ctomy (3), and malnutrition has bee n re porte d to
Manuscript receive d April 17, 1996; re vised manuscript re ce ive d Septe mber 22, 1996; acce pted January 31, 1997. From the Service de Gastroente rologie e t Nutrition, Centre agre e de Nutrition Arti cielle a Domicile, Ho pital de l Arche t, 06202 Nice Ce de x 03, France. Supported by the Ce ntre Hospitalo-Unive rsitaire de Nice . Address for re print requests: Dr. Xavier He buterne , Se rvice de Gastroe nte rologie et Nutrition, Ho pital de lArche t, 06202, Nice, Cedex 03, France.
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be an ine vitable conse que nce of total gastre ctomy (3, 4). Malnutrition afte r gastre ctomy may be relate d to inade quate ene rgy intake (5) and/or maldige stion of nutrie nts (9, 10) . Enteral nutrition is a wide ly used tre atme nt for unde rnourishe d patie nts, and it has bee n succe ssfully use d for gastre ctomize d patie nts (11) . Cyclic (nocturnal) enteral nutrition (CyEN) consists of continuous administration of nutrie nts with a pump during the nocturnal period, which allows the patie nts to eat normally and e ngage in physical activity during the day (12, 13) . The aim of this prospe ctive study was to assess the in uence of partial and total gastre ctomy on the tole rance and short- and long-te rm ef cacy of CyEN in unde rnourishe d patie nts. MATERIALS AND METHODS
Patients. Betwee n January 1989 and May 1993, 97 consecutive undernourished patie nts (54 females and 43 male s)

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 HE BUTERNE ET AL
T ABLE 1. NORMAL V ALUES OF 10 NUTRITIONAL P ARAMETERS U SED G LOBAL NUTRITIONAL D EFICIENCY* Norm al value Weight TS MAC Se rum albumin Se rum pre albumin Se rum transfe rrin He moglobin Lymphocytes Se rum chole ste rol 24-hr urinary cre atinine Ide al body weight (Me tropolitan Life Insurance) 12.5 mm for male s; 16.5 mm for female s 25.3 cm for male s; 23.2 cm for fe males 35.0 g/liter 0.3 g/lite r 3.0 g/lite r 9.0 mmol/liter for male s, 8.0 mmol/liter for fe males 3 1200/mm 5.4 mmol/liter 23 mg/kg IBW for male s, 18 mg/kg IBW for fe males
TO

C ALCULATE

* IBW: ideal body weight, TS: triceps skinfold, MAC: mid-arm circumfere nce. From refe re nces 20 and 21.

speci cally referred to our nutritional support unit for refee ding we re tre ate d by CyEN for more than two wee ks and were prospective ly evaluate d. Patients we re included in the study if they had a we ight loss gre ate r than 20% , or gre ate r than 10% in three months or less (if necessary, the initial we ight was obtained afte r correction of dehydration). All patie nts were ambulatory (able to walk alone from the bed to the bathroom) and ate normally during the day. In all patients, active dietitian support included e ncourageme nt to eat and oral supplements, had bee n performed prior CyEN, and failed to improve oral intake and nutritional status. Patie nts with short bowel syndrome, gut obstruction, AIDS, neoplasic disease under chemothe rapy, in ammatory bowel disease with more than 10 mg prednisone per day, acute pancreatitis, or any kind of nonstabilized disease were not included in the study. The e thical committe e of the Unive rsity of Nice approved the protocol and, afte r being informed about the study, consent was obtained from all participants. During the study period, 107 patie nts we re e ligible according to the se criteria, but 10 declined to give the ir consent and we re not enrolled. The patie nts we re divided into two groups: group 1 consisted of all gastrectomized patie nts; group 2 consisted of patients with undernutrition secondary to anorexia without identi able disease ; others patients we re e xcluded from the present study. Cyclic Enteral Nutrition. Patie nts were intubated with a ne-bore polyurethane nasogastric fe eding tube (9F or 12F) . The tube was placed in the antrum in a prepyloric position in patie nts with anorexia or in the jejunum in gastre ctomized patients. The position of the tube was controlled by uoroscopic e xamination. The tube was xed by adhesion to the nose and the chee k. A permane nt mark was placed on the proximal e xtremity of the tube to e nsure the position of the probe. Infusion began betwe en 7 and 8 PM and laste d until 7 9 AM . A commercially available polyme ric diet, lactose-, glute n-, and ber-free, with a concentration of 1.33 kcal/ml (5.56 kJ/ml) (Sondalis HP, ClintecSopharga Laboratories, Pute aux, France) was used to provide 20% protein (50% from casein and 50% from soy protein), 45% carbohydrates (maltodextrin), and 35% fat (corn oil, me dium-chain triglycerides oil: 47% ). The ow rate was maintained constant at less than 3 ml/min with a pump ( Alaska, V ial me dical, Saint-E tie nne -de -Saint-

Geoirs, France), and the diet was continuously administered for 12 14 hr ove rnight. Diets we re syste matically supplemente d with e lectrolytes, vitamins, and trace metals. When the infusion was stopped, the probe was ushed with wate r to avoid obstruction. During the day, patients we re allowed and encouraged to e at normally at the usual times for breakfast, lunch, and dinner and to walk inside or outside their room, alone or with the help of a physiotherapist. During the rst wee k of CyEN, energy inputs we re progressively increased to ensure good digestive tolerance and to avoid refe eding syndrome. The minimal period of refee ding was two wee ks. The amount of e nergy administered and the duration of the tre atme nt we re not standardized, they we re decided by the physicians as a function of nutritional assessment, voluntary oral intake, and psychological tolerance to tube fee ding. Nu tritional Assessm ent. A nutritional assessment was performed in all patients before beginning tre atme nt (D0), afte r two wee ks (D15), and at the e nd of tube fe eding (Dn: 26.5 6 6.8 days in group 1 and 27.3 6 9.7 days in group 2; P 5 0.73) with 10 anthropometric and biological parameters: we ight, mid-arm circumference (MAC), triceps skinfold (TS), serum albumin, serum prealbumin, serum transferrin, hemoglobin, lymphocytes, serum choleste rol, and 24-hr urinary creatinine. Patie nts were we ighed at the same time of day. MAC and TS we re measured by the same operator (XH), under the same conditions. Fasting blood samples we re obtained at the same time of day (betwee n 6 and 7 AM ). Urinary collections were obtained on two consecutive days and the 24-hr urinary creatinine results of the me an of the data obtained. To calculate a global nutritional de ciency (GND) , we considered a paramete r to be in de cit when it was less than 90% of the normal value (Table 1) , as previously validate d (12 14) . The sum of the de cit of e ach parame te r divided by 10 gives the GND in percentage . The . 90% levels of the nutritional parame te rs we re added as zero into the de cit calculation and late r increases we re not factore d. Re sting energy expe nditure (REE) was calculate d using the Harris and Benedict e quations (15) . Observation an d Toleran ce. E nergy and protein intakes were me asured eve ry day by the dietitians of the te am, who calculated the quantity of diet administered during the night and the voluntary oral intake during the day. Formula
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TABLE 2. D AILY E NERGY AND P ROTEIN I NTAKES (M EAN 6 SE ) D URING C YCLIC E NTERAL NUTRITION IN 28 U NDERNOURISHED G ASTRECTOMIZED P ATIENTS (G ROUP 1) AND 38 U NDERNOURISHED NONGASTRECTOMIZED P ATIENTS (G ROUP 2) * G roup 1 Ente ral e nergy intake (kcal/kg IBW/24 hr) Ente ral protein intake (g/kg IBW/24 hr) Oral e nergy intake (kcal/kg IBW/24 hr) Oral protein intake (g/kg IBW/24 hr) Total e ne rgy intake (kcal/kg IBW/24 hr) Total protein intake (g/kg IBW/24 hr) Ente ral e nergy intake/REE (% ) Total e ne rgy intake/REE (% ) Ente ral/total ene rgy intake (% ) 29.7 1.46 20.6 0.67 50.2 2.13 171.8 291.8 59.7 G roup 2 30.8 1.51 19.8 0.63 49.9 2.14 174.2 284.2 62.6 P 0.34 0.36 0.67 0.59 0.90 0.87 0.70 0.52 0.29

6 6 6 6 6 6 6 6 6

3.7 0.21 6.5 0.29 7.5 0.34 22.6 42.6 9.2

6 6 6 6 6 6 6 6 6

5.1 0.19 8.2 0.27 8.8 0.27 25.7 49.2 11.2

* REE: resting ene rgy expe nditure, IBW: ideal body we ight. To convert values to kJ/kg IBW/24 hr, multiply by 4.18.

intake was calculated by subtracting the volume initially give n to the residual volume checked eve ry morning by the nursing staff. For oral intake, foods of known composition were selecte d for breakfast, lunch, and dinner and we re weighed before and afte r serving. The difference betwe en the serving weight and leftove r weight represente d consumption. Snack consumption was also taken into conside ration and was carefully recorded by the nursing staff. E very morning, the medical team questioned patie nts and noted any incidents that occurred during tube fe eding (e g, diarrhea, constipation, vomiting, abdominal pain, probe obstruction). Once a wee k, biological samples were obtained to measure sodium, potassium, chloride, phosphate, bicarbonates, alanine aminotransfe rase, aspartate aminotransferase, alkaline phosphatase, and bilirubin. Patients Outcom e. Patie nts we re followed-up for one ye ar afte r renutrition. Treatme nt failure was de ned by one or more of the following criteria: (1) voluntary oral intake less than the calculated REE for more than one month accompanied by a weight loss of 10% or more; (2) the need for nutritional support during the ye ar; and (3) death of the patient. Statis tical Analysis. All results are expressed as me ans 6 SE . Comparisons of the results obtained betwe en the beginning of tube fe eding and D15 or afte r completion (Dn ) in e ach group of patie nts were performed by analysis of variance and two-tailed paired t te st. Comparisons betwee n the two groups of patie nts were made by analysis of variance and two-taile d unpaired t te sts. The Bonferroni correction was used in case of multiple comparisons. Treatme nt failures were e stimated from Kaplan-Meier survival curves and compared by the log-rank te st. A difference was considered statistically signi cant for P , 0.05.

RESULTS Patien ts. Thirty-one of the 97 patie nts tre ated with CyEN for more than 15 days were e xclude d because unde rnutrition was secondary to a dige stive proble m othe r than gastre ctomy (eg, Crohn s dise ase , dige stive surge ry, chronic pancre atitis, e tc). The re maining 66 patie nts were include d in the prese nt study and were divide d into two groups. Group 1 consiste d of 28 gastre ctomized patie nts (11 fe males and 17 males,
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mean age 64.8 6 12.7 ye ars, range 37 85 ye ars). Group 2 consiste d of 38 patie nts with anore xia (23 fe males and 15 male s, mean age 55.4 6 21.4 ye ars, range 16 86 years). Unde rnutrition was the sole or main cause of current hospitalization for all 66 patie nts. In group 1, gastre ctomy was partial in 20 patie nts and total in e ight patie nts; the proce dure was pe rforme d for ne oplastic dise ase in 11 case s. The time interval since gastre ctomy was 3 300 months. In group 2, unde rnutrition was due to anore xia secondary to psychological proble ms, and none of the patie nts had active dise ase at the time of the study. Eight patie nts in group 1 and 16 in group 2 took antide pressants, and 12 patie nts in group 1 and 18 in group 2 took antianxie ty age nts. Treatments were not starte d or stoppe d during the re fe e ding pe riod, but dose s were modi e d when necessary. The calculate d REE was 1055 6 134 kcal/24 hr (4410 6 560 kJ/24 hr) in group 1 and 1045 6 144 kcal/24 hr (4368 6 602 kJ/24 hr) in group 2 (P 5 0.78) . Be fore initiation of CyEN, the GND was 20.5 6 7.3% in group 1 and 22.7 6 9.0% in group 2 (P 5 0.29) . Among the 10 nutritional param eters studie d, two were signi cantly lower in group 2 than in group 1 be fore initiation of CyEN: body weight (42.1 6 6.4 kg vs 37.4 6 7.5 kg) re prese nting 68.8 6 6.3% and 62.9 6 9.6% of the ideal body weight (IBW) in groups 1 and 2, respe ctive ly (P 5 0.01) , and the mid-arm circumfere nce (18.3 6 2.6 cm vs 16.6 6 2.7 cm in groups 1 and 2, re spective ly; P 5 0.02) . The othe r param eters were not signi cantly differe nt be twee n the two groups. Energy Intake. Ente ral ene rgy intake , voluntary oral intake , and total e nergy intake were similar in the two groups (Table 2). Ente ral e ne rgy re prese nte d 59.7 6 9.2% of the total e nergy intake in group 1 and 62.6 6 11.2% in group 2 (P 5 0.29) . A signi cant improve ment (P , 0.01) of voluntary e ne rgy oral intake be twee n the rst and the last week of CyE N

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Fig 1. Oral voluntary food intake (mean 6 SE) during the rst and the last week of cyclic e nteral nutrition in 28 gastrectomi ze d patie nts and 38 nongastrectomized patie nts.

was obse rved in both groups (Figure 1). This improve ment was not signi cantly differe nt be twee n group 1 and group 2 [ 1 3.3 6 5.5 kcal/kg IBW ( 1 13.8 6 22.9 kJ/kg IBW) vs 1 4.1 6 6.4 kcal/kg IBW ( 1 17.1 6 26.7 kJ/kg IBW), re spective ly; P 5 0.58]. In group 1, 77.7% of the patie nts had a be tter voluntary oral intake at the end of CyEN than at the be ginning ve rsus 78.4% in group 2. Toleran ce. The nutritional program was administe red as planne d and was well tole rate d in 27 of the 28 patie nts in group 1 and in 37 of the 38 patie nts in group 2. In e ach group, CyEN was stoppe d in one patie nt because of aspiration pne umonia; both patie nts re covere d while receiving pare nte ral antibiotics. CyEN neve r had to be stoppe d because of se vere diarrhe a. Howe ver, four patie nts in group 1 (14.8% ) and six patie nts in group 2 (16.2% ) complaine d of liquid bowe l move ments at the beginning of the tre atment. Five patie nts in group 1 (18.5% ) and seve n patie nts in group 2 (18.9% ) complaine d of vomiting during CyEN, which require d a de crease in the infusion rate. No major ele ctrolyte abnormalitie s were obse rved. Two patie nts in group 2 (but none in group 1) deve lope d a mild incre ase of alanine aminotransfe rase , aspartate aminotransfe rase, and phosphatase alkaline (less than two time s the normal value ). Evolu tion of Nu trition al Assessm ent. The GND improve d signi cantly (P , 0.0001) be twee n D0 and D15 and betwe en D0 and Dn in both groups of patie nts (Figure 2A). On D15, the GND had improve d by an ave rage of 25.6 6 16.8% in group 1 and 25.4 6 14.8% in group 2 (P 5 0.96) . O n Dn, the GND had improve d by 42.7 6 17.3% in group 1 and 40.0 6 17.4% in group 2 (P 5 0.55). On D15, six nutritional parame ters (weight, TS, MAC, se rum pre albumin, se rum transfe rrin, 24-hr urinary creatinine ) were sig-

ni cantly improve d in groups 1 and 2. O n Dn, he moglobin, lymphocyte s, se rum chole sterol, and se rum albumin were not signi cantly improve d in group 1, and hemoglobin, lymphocyte s, and serum chole ste rol were not signi cantly improve d in group 2 (Table 3). Comparison of the ne t improve ment in the 10 parame ters at D15 and Dn faile d to re ve al any statistically signi cant diffe rence s be twee n the two groups of patie nts. Com parison of Total Versus Partial Gastrectom y. Eight of the gastre ctomize d patie nts had had a total gastre ctomy, while 20 had a partial gastre ctomy. Duration of re fe e ding (29.3 6 5.8 vs 25.3 6 5.7 days, in groups 1 and 2, respe ctive ly) and ene rgy intake s (49.5 6 6.9 vs 50.4 6 7.9 kcal/kg IBW/24 hr, in groups 1 and 2, re spectively) were similar. In all of the gastre ctomized patie nts, the GND had improve d signi cantly (P , 0.001) on D15 and at the end of re fee ding (Figure 2B). At the e nd of refe eding, GND had improve d by 50.3 6 17.8% in the patie nts with total gastre ctomy ve rsus 39.4 6 16.5% in the patie nts with partial gastre ctomy (P 5 0.14) . Six nutritional parame ters were signi cantly improve d regardle ss of the type of gastre ctomy: weight, TS, MAC, se rum pre albumin, serum transfe rrin, and 24-hr urinary creatinine (Table 4). The ne t improve ments of the 10 nutritional parame ters were not signi cantly diffe rent betwee n the two groups on day 15 and at the e nd of re fee ding. Patien t Outcom e. The probability of being alive and in re mission at one ye ar was 77.8% (95% con de nce inte rval: 59.2 89.4% ) for the gastre ctomize d patie nts and 72.2% (56.0 84.2% ) for the nongastre ctomize d patie nts (P 5 0.70) (Figure 3). Two of the gastre ctomized patie nts died (one stroke , one relapse of gastric cancer), and four re quire d at le ast one new pe riod of nutritional support. In the nongastre ctomize d group, one patie nt died (myocardial infarction) and 10 ne e de d one or more additional pe riod of nutrition al support. Prolonge d tube fe e ding ( . 3 months) was ne ede d for thre e gastre ctomize d and six nongastre ctomize d patie nts. Among the patie nts who did not relapse , oral ene rgy supple ments were still being give n after one ye ar to 10 (48% ) gastre ctomize d and 8 (30% ) nongastre ctomized patie nts. Duration of re fee ding, ene rgy intake , and improve ment of the diffe rent nutritional parame te rs were not diffe rent betwee n the patie nts who faile d and those who did not fail during the follow-up pe riod.
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Fig 2. (A) The global nutritional de cie ncy (me an 6 SE) calculate d using 10 biological and anthropometric paramete rs during cyclic enteral nutrition in 28 gastrectomized patients and 38 nongastre ctomize d patie nts. D0: before renutrition, D15: afte r two we eks of refee ding, Dn at the end of cyclic e nteral nutrition. *Signi cantly different from D0 in the group conside red (P , 0.001) . (B) The global nutritional de ciency (me an 6 SE ) calculate d using 10 biological and anthropometric paramete rs during cyclic ente ral nutrition in eight patie nts with a total gastrectomy and 20 patients with a partial gastre ctomy. D0: before renutrition, D15: after two we eks of re fee ding, Dn at the end of cyclic enteral nutrition. *Signi cantly differe nt from D0 in the group considered (P , 0.001) .

T ABLE 3. E VOLUTION OF 10 NUTRITIONAL P ARAMETERS (MEAN 6 SE) B ETWEEN S TART (D0) , D15, AND COMPLETION (Dn) OF C YCLIC E NTERAL NUTRITION FOR 28 G ASTRECTOMIZED (G ROUP 1) AND 38 NONGASTRECTOMIZED (G ROUP 2) U NDERNOURISHED P ATIENTS G astrectom ized patients D0 We ight (kg) Triceps skinfold (mm) Mid-arm circumfere nce (cm) Serum albumin (g/lite r) Serum prealbumin (g/liter) Serum transferrin (g/lite r) 24-hr urinary Creatinine (mmol/liter) Hemoglobin (mmol/lite r) 3 Lymphocyte s (/mm ) Serum cholesterol (mmol/lite r) 42.2 6.8 18.3 34.3 0.19 2.19 4.81 7.34 1769 4.33 D15 6.4 2.7 2.6 7.8 0.07 0.68 2.49 0.94 738 1.57 45.6 8.4 18.7 33.9 0.24 2.79 5.59 6.93 1890 4.32 Dn 47.2 9.4 19.4 35.6 0.28 3.09 6.29 7.09 2007 4.50 D0 37.4 6.1 16.6 33.8 0.22 1.94 4.09 7.24 1684 4.61 Non-gastrectom ized patients D15 7.5 3.4 2.7 6.1 0.09 0.73 2.49 1.08 805 1.50 41.5 7.2 17.4 35.0 0.27 2.44 5.05 6.82 1861 4.51 Dn 43.4 8.3 18.1 37.9 0.29 2.78 6.14 7.23 1881 4.61

6 6 6 6 6 6 6 6 6 6

6 6 6 6 6 6 6 6 6 6

6.9* 3.1* 2.6* 4.7 0.07* 0.78* 3.00 0.64* 813 0.92 0.01) . 0.05) .

6 6 6 6 6 6 6 6 6 6

6.7* 3.2* 2.8* 4.3 0.07* 0.80* 2.33* 0.72 893 0.87

6 6 6 6 6 6 6 6 6 6

6 6 6 6 6 6 6 6 6 6

7.5* 3.5* 2.7* 5.9 0.06* 0.78* 2.98* 1.23* 633 0.93

6 6 6 6 6 6 6 6 6 6

7.0* 3.7* 2.7* 6.4* 0.07* 0.89* 3.93* 0.85 630 0.83

* Signi cantly different from D0 in the group considered (P , Signi cantly different from D0 in the group considered (P ,
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T ABLE 4. E VOLUTION OF 10 NUTRITIONAL P ARAMETERS (M EAN 6 SE) B ETWEEN S TART (D0) , D15, AND COMPLETION (Dn) OF C YCLIC E NTERAL NUTRITION FOR 8 P ATIENTS WITH T OTAL G ASTRECTOMY (G ROUP 1) AND 20 P ATIENTS WITH P ARTIAL G ASTRECTOMY (G ROUP 2) Total gastrectom y D0 We ight (kg) Triceps skinfold (mm) Mid-arm circumfere nce (cm) Serum albumin (g/lite r) Serum prealbumin (g/liter) Serum transferrin (g/lite r) 24-hr urinary creatinine (mmol/liter) Hemoglobulin (mmol/liter) 3 Lymphocyte s (/mm ) Serum cholesterol (mmol/lite r) 43.9 8.0 19.4 33.2 0.17 2.11 4.47 7.26 1711 4.19 D15 7.1 2.2 2.9 11.3 0.10 0.80 2.15 1.28 892 1.70 46.9 9.2 19.5 32.0 0.22 2.56 4.48 6.68 1945 4.23 Dn 48.9 10.4 20.3 34.8 0.27 2.99 6.20 6.85 2181 4.35 D0 41.4 6.2 17.9 34.8 0.20 2.22 4.96 7.38 1793 4.39 Partial gastrectom y D15 6.2 2.7 2.4 6.2 0.05 0.65 2.66 0.79 689 1.56 45.0 8.0 18.5 34.8 0.26 2.88 6.05 7.04 1866 4.36 Dn 46.4 9.0 19.1 35.9 0.28 3.13 6.32 7.20 1934 4.57

6 6 6 6 6 6 6 6 6 6

6 6 6 6 6 6 6 6 6 6

7.7 2.3* 2.6 5.9 0.09 0.83 1.96 0.43 930 0.81 0.01) . 0.05) .

6 6 6 6 6 6 6 6 6 6

7.8* 2.7 2.6 3.7 0.07* 0.81 2.43* 0.86 1162 0.77

6 6 6 6 6 6 6 6 6 6

6 6 6 6 6 6 6 6 6 6

6.6* 3.4* 2.6* 3.9 0.07* 0.75* 3.28 0.70 784 0.98

6 6 6 6 6 6 6 6 6 6

6.2* 3.4* 2.8* 4.6* 0.07* 0.82* 2.36* 0.66 780 0.92

* Signi cantly different from D0 in the group considered (P , Signi cantly different from D0 in the group considered (P ,

DISCUSSION This study was conducte d in a group of se vere ly unde rnourishe d, but ambulatory patie nts and de monstrate s that CyEN is as safe and e ffective in gastre ctomize d patie nts as in nongastre ctomize d patie nts. Cyclic e nte ral nutrition plus ad libitu m intake was well tole rated by most of the gastre ctomize d patie nts, eve n whe n ene rgy rate s were high, and tolerance was similar to that of nongastre ctomized patie nts. The low rate of aspiration pne umonia in this study (3.7% in the gastre ctomize d patie nts and 2.6% in the nongastre ctomized patie nts) is consiste nt with the re sults commonly obse rved in nonsurgical patie nts (16) . To pre vent aspiration, we used only ne-bore nasogastric tube s, the position of the probe was checke d be fore infusion, and die ts were administe red in a semirecumbent position using a pump to assure a regular ow rate, which se ems to diminish aspiration (17) . O nly a fe w patie nts in the two groups complaine d of liquid

Fig 3. Kaplan-Me ier analysis of re curre nce or de ath after cyclic e nteral nutrition betwee n gastre ctomize d patients (solid line) and nongastre ctomize d patie nts (dashed line): P 5 0.70 (log-rank test).

bowe l movements at the be ginning of treatment. Diarrhe a is a commonly cite d complication of tube fe eding, but its incide nce varie s among studie s, probably due to diffe rence s in patie nts condition, the de nition of diarrhe a, the te chnology of tube fee ding, and any associate d tre atment (18) . In our study, fe ces were not weighe d, but tube fee ding was ne ver stoppe d because of diarrhe a. Malabsorption of nutrie nts has bee n clearly demonstrate d in gastre ctomized patie nts (3, 4, 9, 10) , and ste atorrhe a occurs in 37% of patie nts afte r Billroth II, in 24% afte r Billroth I (2), and in almost 100% afte r total gastre ctomy (3). Malabsorption of fat afte r gastre ctomy is due to appare nt pancreatic e nzyme insuf cie ncy because of the dilution of pancre atic e nzymes cause d by rapid gastric e mptying (7). The continuous and slow administration of nutrie nts by CyEN at night may incre ase the inte stinal transit time compare d to normal oral nutrition and mimics pyloric function. This may improve dige stion of nutrie nts. Twenty-se ve n days of intensive refe eding plus ad libitum intake dramatically improve d biological and anthropom etric parame te rs of the se ve re ly unde rnourishe d gastre ctomize d and anore xic patie nts. The e f cacy of re fee ding was similar in the gastre ctomize d and nongastre ctomize d patie nts; we ight gain was about 1.3 kg/we ek of tube fe eding in group 1 and 1.5 kg/we e k in group 2. As the re is no ideal nutritional parame ter, we use d a pre viously validate d score (12 14) base d on 10 parame te rs. Results of the GND are give n as a percentage of de ciency that se e ms a be tte r assessment of unde rnutrition. If a param eter is arti cially high (because of dehydration, for e xample ), it is scored as zero, and not as a false incre ment of the mean. The pe rcentage of improve ment of the GND at the e nd of refee ding was about 40% in both groups.
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It should be note d that the two groups of patie nts we re not totally hom oge ne ous. The majority of the patie nts in group 1 we re male and in group 2 fe male . More ove r, me an age was highe r in group 1 than in group 2, and this must be take n into conside ration for inte rpre tation of the re sults. Howe ve r, nutriti onal state s we re ve ry similar, and on D0 the GND was not diffe re nt be twe e n the two groups. He moglobin, lymphocyte s, and se rum chole ste rol we re the only nutriti onal param e te rs that we re not signi cantly improve d in e ithe r group. The lack of improve me nt of the se param e te rs was not surprising, having be e n pre viously de scribe d in short-te rm re fe e ding ( 13, 14, 19) . Se rum album in signi cantly improve d in group 2 but not in group 1, but the ne t improve me nt was not signi cantly diffe re nt be twe e n the two groups. Se rum album in should be inte rpre te d care fully be cause uid ove rload, live r dysfunction, and the pre se nce of in ammation or infe ction may inte rfe re with the value . The lowe r e f cacy of re nutrition for corre cting se rum album in in gastre ctomize d patie nts may be due to age re late d diffe re nce s ( 13) . O the r nutritio nal param e te rs improve d e qually in the two groups. De spite the small numbe r of patie nts who had unde rgone total gastre ctomy, re nutriti on had a similar e ffe ct in both the total and partial gastre ctomy patie nts, again sugge sting that gastre ctomy has no conse que nce on the e ffe ct of CyE N. O ne inte re sting nding of the pre se nt study conce rne d the longte rm follow-up. O ne ye ar afte r the re fe e ding pe riod, more than 75% of the gastre ctomize d patie nts maintaine d the ir nutritio nal status, re ve aling the continue d be ne ts of re nutritio n. It should be note d that a control group of malnourished gastre ctomy patie nts not receiving tube fee dings would be he lpful to de ne the long-te rm e f cacy of cyclic tube fee ding in this population. Howeve r, in the patie nts studie d, active dietitian support include d e ncourage ment to eat and oral supple ments pe rforme d prior CyEN faile d to improve oral intake and nutritional status. The refore, these patie nts had bee n spe ci cally re fe rred to our nutritional support unit for re fee ding, and a control group have not bee n possible. Whe n prolonge d tube fe e ding is nee ded in gastre ctomized patie nts, pe rcutane ous endoscopic je junostomy may be use ful (20) . We did not compare CyEN to the traditional continuous e nte ral nutrition in this study. Howe ve r, using 24-hr continuous e nte ral nutrition with a similar e ne rgy supply, Kornowsky e t al. (11) re porte d weight gains of 0.9 kg/we ek and 1.3 kg/we ek in totally and
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partially gastre ctomize d patie nts, respe ctively, which is very close to our re sults (1.2 kg/we e k and 1.4 kg/we e k in total and partial gastre ctomy patie nts, re spe ctive ly) . CyE N appe ars to be partic ularly adapte d to the renutrition of unde rnourishe d patie nts because it allows regular oral fe eding and physical activitie s during the day. During tube fee ding, continuous infusion of nutrie nts re duces oral intake (21) . In CyEN, ove rnight administration of nutrie nts favors food intake during the day (22, 23) , and we observe d an incre ase in voluntary oral intake betwee n the rst and last week of renutrition. Drugs such as antide pre ssants, use d e qually in the two groups of patie nts, may also affe ct appe tite . The continuation of physical activitie s during the day may improve psychological tole rance of tube fe eding and have positive metabolic e ffects. The psychological tolerance to tube fe eding was not teste d in this study but, e xcept for the two patie nts who de velope d aspiration pne umonia, no patie nt stoppe d CyEN be fore 15 days. This is probably the re sult of se le ction of the patie nts speci cally assigne d to our unit for refee ding and the ge ntle care of the te am. Allowing the patie nts to walk during the day and to e at normally may also have bee n ve ry important. The bene cial e ffe cts of physical activity on e nergy and prote in metabolism are well known (24, 25) and discontinuous adm inistration of nutrie nts could be be ne cial in itself (26, 27) . In conclusion, this study demonstrate s that cyclic (nocturnal) e nte ral nutrition is a safe, effective, and durable tre atme nt for unde rnutrition in gastre ctomize d patie nts suitable for more widespre ad utilization. REFERENCES
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