Skip to main content
PMC home page
Annals of Surgery logoLink to Annals of Surgery
. 1992 Aug;216(2):172–183. doi: 10.1097/00000658-199208000-00008

Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis.

F A Moore 1, D V Feliciano 1, R J Andrassy 1, A H McArdle 1, F V Booth 1, T B Morgenstein-Wagner 1, J M Kellum Jr 1, R E Welling 1, E E Moore 1
PMCID: PMC1242589  PMID: 1386982

Abstract

This two-part meta-analysis combined data from eight prospective randomized trials designed to compare the nutritional efficacy of early enteral (TEN) and parenteral (TPN) nutrition in high-risk surgical patients. The combined data gave sufficient patient numbers (TEN, n = 118; TPN, n = 112) to adequately address whether route of substrate delivery affected septic complication incidence. Phase I (dropouts excluded) meta-analysis confirmed data homogeneity across study sites, that TEN and TPN groups were comparable, and that significantly fewer TEN patients experienced septic complications (TEN, 18%; TPN, 35%; p = 0.01). Phase II meta-analysis, an intent-to-treat analysis (dropouts included), confirmed that fewer TEN patients developed septic complications. Further breakdown by patient type showed that all trauma and blunt trauma subgroups had the most significant reduction in septic complications when fed enterally. In conclusion, this meta-analysis attests to the feasibility of early postoperative TEN in high-risk surgical patients and that these patients have reduced septic morbidity rates compared with those administered TPN.

Full text

PDF
180

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Abel R. M., Grimes J. B., Alonso D., Alonso M., Gay W. A., Jr Adverse hemodynamic and ultrastructural changes in dog hearts subjected to protein-calorie malnutrition. Am Heart J. 1979 Jun;97(6):733–744. doi: 10.1016/0002-8703(79)90008-5. [DOI] [PubMed] [Google Scholar]
  2. Adams S., Dellinger E. P., Wertz M. J., Oreskovich M. R., Simonowitz D., Johansen K. Enteral versus parenteral nutritional support following laparotomy for trauma: a randomized prospective trial. J Trauma. 1986 Oct;26(10):882–891. doi: 10.1097/00005373-198610000-00004. [DOI] [PubMed] [Google Scholar]
  3. Alexander J. W., MacMillan B. G., Stinnett J. D., Ogle C. K., Bozian R. C., Fischer J. E., Oakes J. B., Morris M. J., Krummel R. Beneficial effects of aggressive protein feeding in severely burned children. Ann Surg. 1980;192(4):505–517. doi: 10.1097/00000658-198010000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Alverdy J. C., Aoys E., Moss G. S. Total parenteral nutrition promotes bacterial translocation from the gut. Surgery. 1988 Aug;104(2):185–190. [PubMed] [Google Scholar]
  5. Alverdy J., Chi H. S., Sheldon G. F. The effect of parenteral nutrition on gastrointestinal immunity. The importance of enteral stimulation. Ann Surg. 1985 Dec;202(6):681–684. doi: 10.1097/00000658-198512000-00003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Arora N. S., Rochester D. F. Respiratory muscle strength and maximal voluntary ventilation in undernourished patients. Am Rev Respir Dis. 1982 Jul;126(1):5–8. doi: 10.1164/arrd.1982.126.1.5. [DOI] [PubMed] [Google Scholar]
  7. Bessey P. Q., Jiang Z. M., Johnson D. J., Smith R. J., Wilmore D. W. Posttraumatic skeletal muscle proteolysis: the role of the hormonal environment. World J Surg. 1989 Jul-Aug;13(4):465–471. doi: 10.1007/BF01660758. [DOI] [PubMed] [Google Scholar]
  8. Birkhahn R. H., Renk C. M. Immune response and leucine oxidation in oral and intravenous fed rats. Am J Clin Nutr. 1984 Jan;39(1):45–53. doi: 10.1093/ajcn/39.1.45. [DOI] [PubMed] [Google Scholar]
  9. Blair P., Rowlands B. J., Lowry K., Webb H., Armstrong P., Smilie J. Selective decontamination of the digestive tract: a stratified, randomized, prospective study in a mixed intensive care unit. Surgery. 1991 Aug;110(2):303–310. [PubMed] [Google Scholar]
  10. Border J. R., Chenier R., McManamy R. H., La Duca J., Seibel R., Birkhahn R., Yu L. Multiple systems organ failure: muscle fuel deficit with visceral protein malnutrition. Surg Clin North Am. 1976 Oct;56(5):1147–1167. doi: 10.1016/s0039-6109(16)41035-2. [DOI] [PubMed] [Google Scholar]
  11. Border J. R., Hassett J., LaDuca J., Seibel R., Steinberg S., Mills B., Losi P., Border D. The gut origin septic states in blunt multiple trauma (ISS = 40) in the ICU. Ann Surg. 1987 Oct;206(4):427–448. doi: 10.1097/00000658-198710000-00004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Bower R. H., Talamini M. A., Sax H. C., Hamilton F., Fischer J. E. Postoperative enteral vs parenteral nutrition. A randomized controlled trial. Arch Surg. 1986 Sep;121(9):1040–1045. doi: 10.1001/archsurg.1986.01400090070011. [DOI] [PubMed] [Google Scholar]
  13. Burke D. J., Alverdy J. C., Aoys E., Moss G. S. Glutamine-supplemented total parenteral nutrition improves gut immune function. Arch Surg. 1989 Dec;124(12):1396–1399. doi: 10.1001/archsurg.1989.01410120042009. [DOI] [PubMed] [Google Scholar]
  14. Cerra F. B. Hypermetabolism, organ failure, and metabolic support. Surgery. 1987 Jan;101(1):1–14. [PubMed] [Google Scholar]
  15. Cerra F. B., McPherson J. P., Konstantinides F. N., Konstantinides N. N., Teasley K. M. Enteral nutrition does not prevent multiple organ failure syndrome (MOFS) after sepsis. Surgery. 1988 Oct;104(4):727–733. [PubMed] [Google Scholar]
  16. Cerra F. B., Shronts E. P., Konstantinides N. N., Thoele S., Konstantinides F. N., Teasley K., Lysne J. Enteral feeding in sepsis: a prospective, randomized, double-blind trial. Surgery. 1985 Oct;98(4):632–639. [PubMed] [Google Scholar]
  17. Christou N. V., McLean A. P., Meakins J. L. Host defense in blunt trauma: interrelationships of kinetics of anergy and depressed neutrophil function, nutritional status, and sepsis. J Trauma. 1980 Oct;20(10):833–841. doi: 10.1097/00005373-198010000-00003. [DOI] [PubMed] [Google Scholar]
  18. Clarke R. M. The time-course of changes in mucosal architecture and epithelial cell production and cell shedding in the small intestine of the rat fed after fasting. J Anat. 1975 Nov;120(Pt 2):321–327. [PMC free article] [PubMed] [Google Scholar]
  19. Deitch E. A., Winterton J., Li M., Berg R. The gut as a portal of entry for bacteremia. Role of protein malnutrition. Ann Surg. 1987 Jun;205(6):681–692. doi: 10.1097/00000658-198706000-00010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Detsky A. S., Baker J. P., O'Rourke K., Goel V. Perioperative parenteral nutrition: a meta-analysis. Ann Intern Med. 1987 Aug;107(2):195–203. doi: 10.7326/0003-4819-107-2-195. [DOI] [PubMed] [Google Scholar]
  21. Drabik M. D., Schnure F. C., Mok K. T., Moldawer L. L., Dinarello C. A., Blackburn G. L., Bistrian B. R. Effect of protein depletion and short-term parenteral refeeding on the host response to interleukin 1 administration. J Lab Clin Med. 1987 Apr;109(4):509–516. [PubMed] [Google Scholar]
  22. Driks M. R., Craven D. E., Celli B. R., Manning M., Burke R. A., Garvin G. M., Kunches L. M., Farber H. W., Wedel S. A., McCabe W. R. Nosocomial pneumonia in intubated patients given sucralfate as compared with antacids or histamine type 2 blockers. The role of gastric colonization. N Engl J Med. 1987 Nov 26;317(22):1376–1382. doi: 10.1056/NEJM198711263172204. [DOI] [PubMed] [Google Scholar]
  23. Enrione E. B., Gelfand M. J., Morgan D., Sperling M., Wagner S. C., Popp M. B. The effects of rate and route of nutrient intake on protein metabolism. J Surg Res. 1986 Apr;40(4):320–325. doi: 10.1016/0022-4804(86)90194-0. [DOI] [PubMed] [Google Scholar]
  24. Freiman J. A., Chalmers T. C., Smith H., Jr, Kuebler R. R. The importance of beta, the type II error and sample size in the design and interpretation of the randomized control trial. Survey of 71 "negative" trials. N Engl J Med. 1978 Sep 28;299(13):690–694. doi: 10.1056/NEJM197809282991304. [DOI] [PubMed] [Google Scholar]
  25. Fry D. E., Pearlstein L., Fulton R. L., Polk H. C., Jr Multiple system organ failure. The role of uncontrolled infection. Arch Surg. 1980 Feb;115(2):136–140. doi: 10.1001/archsurg.1980.01380020006003. [DOI] [PubMed] [Google Scholar]
  26. Goris R. J., te Boekhorst T. P., Nuytinck J. K., Gimbrère J. S. Multiple-organ failure. Generalized autodestructive inflammation? Arch Surg. 1985 Oct;120(10):1109–1115. doi: 10.1001/archsurg.1985.01390340007001. [DOI] [PubMed] [Google Scholar]
  27. Horwitz R. I. Complexity and contradiction in clinical trial research. Am J Med. 1987 Mar;82(3):498–510. doi: 10.1016/0002-9343(87)90450-5. [DOI] [PubMed] [Google Scholar]
  28. Kudsk K. A., Carpenter G., Petersen S., Sheldon G. F. Effect of enteral and parenteral feeding in malnourished rats with E. coli-hemoglobin adjuvant peritonitis. J Surg Res. 1981 Aug;31(2):105–110. doi: 10.1016/0022-4804(81)90037-8. [DOI] [PubMed] [Google Scholar]
  29. Kudsk K. A., Stone J. M., Carpenter G., Sheldon G. F. Enteral and parenteral feeding influences mortality after hemoglobin-E. coli peritonitis in normal rats. J Trauma. 1983 Jul;23(7):605–609. doi: 10.1097/00005373-198307000-00010. [DOI] [PubMed] [Google Scholar]
  30. L'Abbé K. A., Detsky A. S., O'Rourke K. Meta-analysis in clinical research. Ann Intern Med. 1987 Aug;107(2):224–233. doi: 10.7326/0003-4819-107-2-224. [DOI] [PubMed] [Google Scholar]
  31. Law D. K., Dudrick S. J., Abdou N. I. Immunocompetence of patients with protein-calorie malnutrition. The effects of nutritional repletion. Ann Intern Med. 1973 Oct;79(4):545–550. doi: 10.7326/0003-4819-79-4-545. [DOI] [PubMed] [Google Scholar]
  32. Law N. W., Ellis H. The effect of parenteral nutrition on the healing of abdominal wall wounds and colonic anastomoses in protein-malnourished rats. Surgery. 1990 Apr;107(4):449–454. [PubMed] [Google Scholar]
  33. Lickley H. L., Track N. S., Vranic M., Bury K. D. Metabolic responses to enteral and parenteral nutrition. Am J Surg. 1978 Feb;135(2):172–176. doi: 10.1016/0002-9610(78)90092-2. [DOI] [PubMed] [Google Scholar]
  34. Marshall J. C., Christou N. V., Horn R., Meakins J. L. The microbiology of multiple organ failure. The proximal gastrointestinal tract as an occult reservoir of pathogens. Arch Surg. 1988 Mar;123(3):309–315. doi: 10.1001/archsurg.1988.01400270043006. [DOI] [PubMed] [Google Scholar]
  35. McArdle A. H., Palmason C., Morency I., Brown R. A. A rationale for enteral feeding as the preferable route for hyperalimentation. Surgery. 1981 Oct;90(4):616–623. [PubMed] [Google Scholar]
  36. Meyer J., Yurt R. W., Duhaney R., Hesse D. G., Tracey K. J., Fong Y., Richardson D., Calvano S., Dineen P., Shires G. T. Differential neutrophil activation before and after endotoxin infusion in enterally versus parenterally fed volunteers. Surg Gynecol Obstet. 1988 Dec;167(6):501–509. [PubMed] [Google Scholar]
  37. Mochizuki H., Trocki O., Dominioni L., Brackett K. A., Joffe S. N., Alexander J. W. Mechanism of prevention of postburn hypermetabolism and catabolism by early enteral feeding. Ann Surg. 1984 Sep;200(3):297–310. doi: 10.1097/00000658-198409000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Moore E. E., Jones T. N. Benefits of immediate jejunostomy feeding after major abdominal trauma--a prospective, randomized study. J Trauma. 1986 Oct;26(10):874–881. doi: 10.1097/00005373-198610000-00003. [DOI] [PubMed] [Google Scholar]
  39. Moore E. E., Moore F. A. Immediate enteral nutrition following multisystem trauma: a decade perspective. J Am Coll Nutr. 1991 Dec;10(6):633–648. doi: 10.1080/07315724.1991.10718183. [DOI] [PubMed] [Google Scholar]
  40. Moore F. A., Moore E. E., Jones T. N., McCroskey B. L., Peterson V. M. TEN versus TPN following major abdominal trauma--reduced septic morbidity. J Trauma. 1989 Jul;29(7):916–923. doi: 10.1097/00005373-198907000-00003. [DOI] [PubMed] [Google Scholar]
  41. Moore F. A., Moore E. E., Poggetti R., McAnena O. J., Peterson V. M., Abernathy C. M., Parsons P. E. Gut bacterial translocation via the portal vein: a clinical perspective with major torso trauma. J Trauma. 1991 May;31(5):629–638. doi: 10.1097/00005373-199105000-00006. [DOI] [PubMed] [Google Scholar]
  42. Moore F. A., Peterson V. M., Moore E. E., Rundus C., Poggetti R. Inadequate granulopoiesis after major torso trauma: a hematopoietic regulatory paradox. Surgery. 1990 Oct;108(4):667–675. [PubMed] [Google Scholar]
  43. Naylor C. D., Detsky A. S., O'Rourke K., Fonberg E. Does treatment with essential amino acids and hypertonic glucose improve survival in acute renal failure?: A meta-analysis. Ren Fail. 1987;10(3-4):141–152. doi: 10.3109/08860228709047649. [DOI] [PubMed] [Google Scholar]
  44. Naylor C. D., O'Rourke K., Detsky A. S., Baker J. P. Parenteral nutrition with branched-chain amino acids in hepatic encephalopathy. A meta-analysis. Gastroenterology. 1989 Oct;97(4):1033–1042. doi: 10.1016/0016-5085(89)91517-5. [DOI] [PubMed] [Google Scholar]
  45. Page C. P. Edgar J. Poth lecture. The surgeon and gut maintenance. Am J Surg. 1989 Dec;158(6):485–490. doi: 10.1016/0002-9610(89)90176-1. [DOI] [PubMed] [Google Scholar]
  46. Peterson V. M., Moore E. E., Jones T. N., Rundus C., Emmett M., Moore F. A., McCroskey B. L., Haddix T., Parsons P. E. Total enteral nutrition versus total parenteral nutrition after major torso injury: attenuation of hepatic protein reprioritization. Surgery. 1988 Aug;104(2):199–207. [PubMed] [Google Scholar]
  47. Piccone V. A., LeVeen H. H., Glass P., Berlyne G., Lundin A. P. Prehepatic hyperalimentation. Surgery. 1980 Mar;87(3):263–270. [PubMed] [Google Scholar]
  48. Rush B. F., Jr, Sori A. J., Murphy T. F., Smith S., Flanagan J. J., Jr, Machiedo G. W. Endotoxemia and bacteremia during hemorrhagic shock. The link between trauma and sepsis? Ann Surg. 1988 May;207(5):549–554. doi: 10.1097/00000658-198805000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. SCHWEINBURG F. B., SELIGMAN A. M., FINE J. Transmural migration of intestinal bacteria; a study based on the use of radioactive Escherichia coli. N Engl J Med. 1950 May 11;242(19):747–751. doi: 10.1056/NEJM195005112421903. [DOI] [PubMed] [Google Scholar]
  50. Sacks H. S., Berrier J., Reitman D., Ancona-Berk V. A., Chalmers T. C. Meta-analyses of randomized controlled trials. N Engl J Med. 1987 Feb 19;316(8):450–455. doi: 10.1056/NEJM198702193160806. [DOI] [PubMed] [Google Scholar]
  51. Saito H., Trocki O., Alexander J. W., Kopcha R., Heyd T., Joffe S. N. The effect of route of nutrient administration on the nutritional state, catabolic hormone secretion, and gut mucosal integrity after burn injury. JPEN J Parenter Enteral Nutr. 1987 Jan-Feb;11(1):1–7. doi: 10.1177/014860718701100101. [DOI] [PubMed] [Google Scholar]
  52. Souba W. W., Smith R. J., Wilmore D. W. Glutamine metabolism by the intestinal tract. JPEN J Parenter Enteral Nutr. 1985 Sep-Oct;9(5):608–617. doi: 10.1177/0148607185009005608. [DOI] [PubMed] [Google Scholar]
  53. Wells C. L., Maddaus M. A., Simmons R. L. Proposed mechanisms for the translocation of intestinal bacteria. Rev Infect Dis. 1988 Sep-Oct;10(5):958–979. doi: 10.1093/clinids/10.5.958. [DOI] [PubMed] [Google Scholar]
  54. Wilmore D. W., Smith R. J., O'Dwyer S. T., Jacobs D. O., Ziegler T. R., Wang X. D. The gut: a central organ after surgical stress. Surgery. 1988 Nov;104(5):917–923. [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES