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Clinical Case Study

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Sanaa Bhatti

on 19 December 2014

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Transcript of Clinical Case Study

Clinical Case Study
Nutritional Management of Postoperative Complications of Nissen Fundoplication
By: Sanaa Bhatti
Describe the incidence and management of GERD

Identify potential long term and short term complications of Nissen fundoplication procedures

Analyze a patient’s clinical, social, and nutritional history

Determine a nutrition care plan for that patient based on their current health status

Evaluate alternative nutritional interventions based on the literature

20-40% of Americans report 1 episode of GERD per week (1)

2-20% of children experience GERD (1)

People with GERD report lower health-related quality of life (2)
80% - less enjoyment of food
60% - sleep problems
40% - difficulty at work
Pathophysiology (1)
Reflux in esophagus, results in erosion of the lining of the esophagus
Increased intraabdominal pressure (obesity, pregnancy, COPD)
Reduced LES strength (use of NSAIDS, Ca-channel blockers, anti-depressants, smoking, aggravation by certain foods)
Decreased gastric motility (hiatal hernia)
Symptoms (1)
Short Term:
Heartburn, substernal pain, belching, esophageal spasms
Symptoms worsen in evening

Long term:
Esophagitis, ulcerations, scarring, strictures, Barrett's esophagus, some cases dysphagia

Management (1)
Suppression of acid secretion
Use of PPIs or milder H2 receptor antagonists
Prokinetic agents for increased gastric emptying

Lifestyle changes:
Losing weight
Raising head of bed
Avoiding bending over
Quitting smoking

Nutritional Management:
Smaller, low-fat meals
Decrease caffeine, chocolate, alcohol
Avoid spicy, acidic foods
Surgical Management (3)
Indications for surgery:
Failure of medical/lifestyle management
Complications of GERD
Extra-esophageal manifestations of GERD

Nissen fundoplication is the most common surgical treatment for GERD (vs Toupet and others)

Laparoscopic Nissen fundoplication is associated with shorter length of hospital stay, lower immune response, and fewer complications than open surgery
Case Study
L. H.
Personal History
71 year old White female

Married, lives at home w/ husband
Middle socioeconomic class
3 children, 9 grandchildren
Previously worked in HR

Insurance: Medicare, Mutual of Omaha
No history of alcohol, drug, or tobacco use
Family Medical History
Mother: reflux disease, cancer, died at age 74
Father: cancer, died at age 81
Past Medical History
Previous Medical Encounters
Previous Medical Encounters
Uncomplicated laparoscopic Nissen fundoplication w/ hiatal hernia repair and cholecystectomy
Bravo pH monitoring study indicating insignificant acid reflux
24 hour ambulatory esophageal pH & impedance report indicating some insignificant nonacid reflux events
Laparoscopic repair of epigastric incisional hernia w/ placement of preperitoneal mesh
POD #2

Developed fever, tachycardia, high WBC count, noted to be in atrial fibrillation

Pt transferred to ICU, placed on CPAP, high dose O2, being diuresed
POD #3

JP drain output discoloration 2/2 possible leak

CT scan
Collection of fluid anterior to the liver confirming leak

Patient taken back to OR


Admitted for elective Nissen revision w/ repair of recurrent hiatal hernia

Recurrent GERD w/ relaxation of prior fundoplication and migration of fundoplication into lower mediastinum (chest)

2 JP drains placed

Timeline for Recent Hospital Stay
11/16/14 : POD # 5

Nutrition history:
Pt has been NPO/Clear Liquids for 5 days

Need to advance diet or initiate nutrition support when ordered, within 3-5 days (extended)
Nutrition Note
Lower Esophageal Sphincter
Hiatal Hernia
Complications of Nissen (4,5)
Recurrent symptoms such as abdominal fullness, mild dysphagia, continued acid reflux

Severe post-op pain, leukocytosis, tachycardia can be indications of surgical complications

Complications can include:
Gastroesophageal perforation
Inadvertent vagotomy
Migrated fundoplication
Recurrent hernia

Rate of Nissen re-surgery: up to 15% (6)
Chest X-ray
Left lower lobe infiltrate, pneumoperitoneum,and L>R pleural effusions
Laparoscopic Exploration: Findings
Reactive fluid in left chest (pneumonia vs. aspiration pneumonitis) - chest tube placed, leak appears contained

Findings consistent with infection (10,11)
Exudative peel across liver and stomach
Acute inflammatory changes in esophagus

Pt placed on antibiotics for pneumonia and leukocytosis

**G-tube placed for suctioning, decompression
**PICC line inserted
Post Surgical Progression of Diet (7)
Literature Review #1 : Early Oral Feeding vs Traditional Feeding in Patients Undergoing Elective Open Bowel Surgery - a Randomized Control Trial (9)
Initiation of TPN for Post-Operative Ileus
Nutrition Screen
11/12/14 Post Op Day 1: NPO
No BM, hypoactive bowel sounds

Negative screen - no nutrition risk factors identified on admission
136% IBW
No reports of significant weight loss PTA
Ht: 64 " or 5'4"
Wt: 70.3 kg

Ideal body weight
Hamwi equation: 100 + 5 (4) =
120 lbs or 54.5 kg

% IBW : actual weight/ideal weight ~
129% IBW

Wt (kg)/Ht (m2) = 70.3/(1.63 x 1.63) =
26.6 (pre-obese)

No significant weight changes PTA
Nutrition Assessment: NPO/Clear Liquids Diet Monitoring
Pt has been NPO/Clear Liquids for 3 days

: Inadequate oral food and beverage intake
related to
possible Nissen leak
as evidenced by
patient NPO with G-tube.

Initiate oral nutrition or nutrition support when ordered (within 3-5 days)
Pt has been NPO/Clear Liquids for 5 days
Abdominal distention/pain/nausea w/ oral intake of liquids
No flatus, hypoactive bowel sounds noted

G-tube for decompression, PICC line
Nutrition History
Aspirated barium - possible difficulty swallowing
Pleural effusion, pneumonia 2/2 to esophageal leak (contained)
No BS/BM and nausea w/ PO - postoperative ileus
Contraindications to Initiation of PO
Clinical Monitoring
Energy Needs and TPN Goal
Ht: 64"
Admit Wt: 70.3 kg
IBW: 54.5 kg
20-25 kcal/kg IBW =
1365-1635 kcal
1.2-1.5 g/kg IBW =
66-82 g Protein
Clinimix E 5/20 @ 65 mL/hr
1560 mL total volume
1373 kcal (25 kcal/kg IBW)
78 g Protein (1.4 g/kg IBW)
Literature Review #2: Reduction of Postoperative Ileus by Early Enteral Nutrition in Patients Undergoing Major Colorectal Surgery (16)
POD #6
Nutrition Assessment: Initiation of TPN
Refeeding Syndrome: Nutrition Support Guidelines
MD ordered TPN until ileus resolves
Inadequate oral food/beverage intake
related to
possible Nissen leak, post-operative ileus
as evidenced by
patient NPO with TPN order.
Goals: Tolerate TPN at goal within 3-5 days
TPN Goal Assessment
Energy needs:
20-25 kcal/kg ABW (70.3 kg) =
1406-1757 kcal
1-1.8 g/kg Protein ABW (70.3 kg) =
71-127 g Protein

Clinimix E 5/15
(maximize protein) w/ Lipids SWF
Rate: 2 L over 24 hours =
83 mL/hr
1632 kcal (23 kcal/kg ABW)
100 g Protein (1.4 g/kg ABW)
299 g dextrose
Ht: 64"
Admit Wt: 70.3 kg
IBW: 54.5 kg
126% IBW
Advancing TPN to Goal
Nutrition Monitoring: TPN
11/19 : TPN advanced to goal (Day 3)
d/c thiamine

11/20-11/22 (Days 4-6) :
TPN continues at goal, 20 units insulin
Patient is allowed meds, sips of water via G-tube
Patient c/o cramping in abdomen, some nausea

I/O - indicate positive fluid balance, urine output is good, minimal JP drain output, no G-tube output

Clinical Progress
Patient with peritonitis, left aspiration with pleural effusions, persistent leukocytosis, SIRS-like deterioration.

On 3-6 L O2 via NC, poor respiratory effort

11/18 - had thoracentesis pulling off 650 mL serosanguienous fluid

11/22 - pending UGI
Nutrition Monitoring: TPN Day 7
Na 131, trending down

MD order - RD to adjust Na in custom TPN

Custom TPN Order:
83 mL w/ 250 mL 20% IL 3x/week
1632 kcal (23 kcal/kg ABW)
100 g Protein (1.4 g/kg ABW)
299 g Dextrose
100 mEq Na
20 units insulin
Initial bag:
1 L Clinimix E 5/15 (41 mL/hr)
699 kcal (9.9 kcal/kg ABW)
50 g protein (0.7 g/kg ABW)
148 g dextrose
100 g thiamine
no insulin, no protonix

Intermediate goal:
Clinimix E 5/15 @ 65 mL/hr w/ Lipids SWF
1322 kcal (18 kcal/kg ABW)
78 g protein (1.1 g/kg ABW)
234 g dextrose
100 mg thiamine, 15 units insulin
Nutrition Update
11/22 - Patient has BM
11/23 - UGI confirms no leak
11/24 - Diet advanced to mechanical soft, continue custom TPN until PO improves

Patient is tolerating clear and full liquids, no N/V

D/C lipids with TPN as diet is advanced, consider re-adding lipids if PO is poor
Nutrition Monitoring
TPN Day 9 : Continue Custom TPN

PO (Day 2)
Mechanical soft diet, PO is poor
Patient "does not feel like eating"
Added Ensure clears, encouraged patient to drink in between meals, and drink Ensure in preference to other fluids

Initiate EN
Spoke with PA, plan to check residuals and initiate EN if <100 mL (Q4h x 3)
Tube Feeding Goal
Promote @ 70 mL/hr (infusion over 22 hours)
Total volume - 1540 mL
1540 kcal (22 kcal/kg ABW)
97 gm Protein (1.4 g/kg ABW)
Na Lab Trends
Nutrition Monitoring
TPN Day 10: Continue custom TPN
restart lipids

PO Day 3
Mechanical soft, PO remains very poor
Patient c/o nausea, abdominal cramps
Admits to mostly wasting Ensure, only drinking a few sips, reduce Ensure from BID to 1x
Last BM 11/25

No plans to initiate EN at this time
Nutrition Monitoring: TPN Days 11-13

PO improving on day 13 (11/29) : 80%
Decrease dextrose in TPN to 200 g (down from 299 g)
TPN provides 1294 kcal (18 kcal/kg)

Regular BMs
Nutrition Monitoring
PO 100% in AM

? D/C TPN soon
Nutrition Update
PO 70%


Switched Ensure clears to Ensure Plus vanilla, per patient preference
Clinical Update
Patient is discharged to skilled nursing facility
Recommendations for Initiating Nutrition Support (18)
Energy: hypocaloric feeds (20 kcal/kg or less)
Protein: full goal okay (1.2-1.5 g/kg)
Restrict fluid & sodium (1000 mL or less in volume)
supplement thiamine and vitamins

Parenteral Nutrition:
Adults - limit dextrose to 100-150 g
Limit 1 L w/ mag K, Phos, Mg
Addition of lipids for calories
Traditionally, post-surgical GI patients are kept NPO and a NGT is placed for decompression

Typical signs of bowel function (bowel sounds, flatus, bowel movements) are measured before NGT is removed and PO initiated
NGT helps to alleviate gas, bloating, nausea (8)

While placement of NGT is not as common anymore, most surgeons still wait to hear bowel sounds before advancing diet

New evidence indicates that bowel sounds may not be a reliable marker of bowel motility -- BS simply may not be present with normal bowel activity

Additionally, waiting for BM may not be timely. Studies show that early post-op feeding can be safe and well-tolerated even before flatus or BMs occur; in fact, can even result in faster return of bowel activity

Pragastheewarane M, Muthukumarassamy R, Kadambari D, Kate V. Early oral feeding versus traditional feeding in patient undergoing elective open bowel surgery. J Gastrointest Surg. 2014; 18(5): 1017-23.
Early oral feedings are often withheld after surgery due to post-operative ileus

New evidence shows early feeding after lap colectomy is well-tolerated

Starting oral feedings within 24 hours after surgery can decrease LOS and complications such as wound infection

Early enteral nutrition also shown to reduce septic complication as compared to parenteral nutrition
Evaluate safety, tolerability, and outcome of early oral feeding vs traditional feeding in patients w/ open bowel surgery
120 patients randomized into 2 groups
60 = early feeding
60 = traditional feeding

Early feeding group started oral fluids POD # 1
Traditional feeding group started orals after ileus resolved
ie. after BM occurred, no abdominal distention

Diets were advanced as tolerated
Full liquids within 48 hours
Regular diet within next 24 hours

Outcomes were monitored
Primary: LOH
Secondary: BM, advance to solid diet,
NGT insertion
Early Feeding Group :
Shorter time to 1st flatus, BM
Started solid diet earlier
Short length of post-op stay (discharged 3.4 days earlier)

Complications were similar between both groups.
Anastomotic leak
Wound infection
Pros/Cons of Study
Demographic and baseline data distributed equally between both groups
Mean age: 46 +/- 17 years

Results specific to open colonic resection surgery
Comparative Standards
ESPEN Perioperative Nutrition Guidelines (12)
25-30 kcal/kg IBW
1.5 g/kg IBW
*IBW to prevent overfeeding in obese patients
ASPEN Perioperative Nutrition Guidelines (13)
30-40 kcal/kg, unless on ventilator (20-25 kcal/kg)
Protein 1-1.8 kcal/kg
*Use adjusted body weight for obese patients
ESPEN and ASPEN recommend initiation of PN after 7 days of inadequate oral intake, such as with an ongoing post-operative ileus (14)

PN is indicated in patients with post-operative complications who are unable to receive and absorb enteral feeding to meet energy needs within 7 days (15ESPEN article surgery)

Traditionally, PO & EN is held until bowel sounds are heard
Lack of BS, nausea, abdominal distention are signs of post-op ileus
However, in patients not taking PO and with G-tube, air is sucked out of abdomen -- no air or fluid in abdomen = no bowel sounds (medscape)

Studies show that an ileus may not be an indication of intestinal failure; EN may actually help resolve ileus
Boeiens P, Heesakkers F, Luyer M, et al. Reduction of Postoperative ileus by early enteral nutrition in patients undergoing major rectal surgery: Prospective, randomized, controlled trial. Annals Surg. 2014; 259 (4) : 649-55.
Post-operative ileus is a common complication of surgery (more extensive the surgery, higher chance for POI)

Most patients with POI are offered total PN to reach nutrition goals, as oral nutrition fails in first week

EN is associated with improved immune function
To examine whether early (post-pyloric) enteral feeding can be beneficial after major rectal surgery in reducing POI

Bypassing impaired gastric function
Restore intestinal function
Stimulate bowel movement
123 patients randomly assigned to 2 groups:
61 - early postoperative enteral nutrition
62 - early parenteral nutrition
Both groups started nutrition support 8 hours after surgery, gradually increased to goal, both also stimulated to progress to oral diet

Outcomes monitored:
Time to first BM
Ileus symptoms

Enteral nutrition group:
Shorter time to defecation
Less anastomotic leakage
LOS - 3.4 days shorter than control group
Early EN is safe and associated with significantly less ileus in patients undergoing extensive rectal surgery
Patients who have been NPO for 7-10 days or have had prolonged IV hydration days are at risk of refeeding (17)

Biochemical Abnormalities:
Hypophosphatemia, Hypokalemia, Hypomagnesemia
Fluid overload/sodium retention
Thiamine Deficiency

TPN started
no insulin
TPN intermediate goal
Add 15 units insulin
TPN at goal
20 units insulin
Initiate cyclic or bolus feedings, if tolerated
Literature Review #3: Standardized Versus Custom Parenteral Nutrition: Impact on Clinical and Cost Related Outcomes (19)
Blanchette LM, Huiras P, Papadopoulas S. Standardized versus custom parenteral nutrition: Impact on clinical and cost related outcomes.
Am J Health-Syst Pharm.
2014; 71: 114-21.
Compare the clinical and cost outcomes with the use of standardized versus custom PN in an acute care setting
Retrospective pre-post analysis of patients ages 15+ receiving PN for at least 72 hours

Large medical center over a 13 month period

Nutritional target attainment
Electrolyte abnormalities

Custom PN - 49 patients
Standardized PN - 57 patients
No significant differences:
Achieving estimated caloric requirements

Standardized TPN patients:
Less likely to achieve highest protein intake goal
More likely to develop hyponatremia
(only electrolyte disturbance with significant diff)

Preparation time/cost:
Standard TPN: 20 minutes/$61.06
Custom: 80 minutes/$57.84

Facilities compounding <6 TPN per day:
Purchasing standard < Per unit cost of custom

Standardized PN products may be more cost effective in facilities producing
< 6 PN orders/day
Standardized PN as effective as Custom in achieving energy goals, less effective in achieving 90% of protein goals, and is associated with higher frequency of hyponatremia
150 mEq
200 mEq

220 mEq

250 mEq

Chest X-ray indicates no pneumonia, however, some bilateral effusions

Patient encouraged to increase spirometer use and activity

Tolerating PO, regular BM

Stable for discharge
What Could Have Been Done Differently?
PN/EN combined nutrition support
Better outcomes - immunity, gut function

EN initated to resolve ileus (better immunity, shorter LOS)
Combined double-lumen G-J tube for simultaneous suction from gastrostomy tube and feeding via jejunostomy tube (20)

Custom TPN
Withhold for a few more days

1. Mahan K, Escott-Stump S, Raymond J. Krause's Food and the Nutrition Care Process. St Louis: Elsevier Saunders; 2012.
2. Liker H, Hungin P, Wiklund I. Managing Gastroesophageal Reflux Disease in Primary Care: The Patient Perspective. J Am Board of Fam Med. 2005; 18(5): 393-400.
3. Guidelines for the Surgica Treatment of Gastroesophageal Reflux Disease. Society of American Gastrointesinal and Endoscopic Surgeons. http://www.sages.org/publications/guidelines/guidelines-for-surgical-treatment-of-gastroesophageal-reflux-disease-gerd/. Accessed 10 Dec 2014.
4. Hahnloser D, Schumacher M, Cavin R, Cosendey B, Petropoulos P. Risk factors for complications of laparoscopic Nissen fundoplication. Surg Endosc. 2002;16(1):43-7.
5. Richter J. Gastroesophageal Reflux Disease Treatment. Clin Gastroenter Hepatology. 2013; 11(5): 465-471.
6. Agency for Healthcare Research and Quality–the Effective Healthcare Program. Comparative effectiveness of management strategies for gastroesophageal reflux disease: an update to the 2005 report 2011. Washington, DC: Agency for Healthcare Research and Quality, 2011.
7. Wilcutts K. Pre-op NPO and traditional post-op diet advancement: time to move on. Practical Gastroenter. 2010: 16-27.
8 Medical Nutrition Therapy: Gastrostomy Tube for Decompression: Health Facts for You publication. The University of Washington School of Medicine and Public Health. http://www.uwhealth.org/healthfacts/nutrition/6434.html. Accessed 12 Dec 2014.
9. Pragastheewarane M, Muthukumarassamy R, Kadambari D, Kate V. Early oral feeding versus traditional feeding in patient undergoing elective open bowel surgery. J Gastrointest Surg. 2014; 18(5): 1017-23.
10. Pleural effusion definition. The Free Dictionary by Farlex. http://medical-dictionary.thefreedictionary.com/pleural+effusion. Accessed 8 Dec 2014.
11. Understanding Your Pathology Report: Esophagus with Reactive or Reflux. The American Cancer Society website. http://www.cancer.org/treatment/understandingyourdiagnosis/understandingyourpathologyreport/esophaguspathology/esophagus-with-reactive-or-reflux-changes. Reviewed 14 Oct 2014. Accessed 8 Dec 2014.
12. Singer P, Berger NM, Van den Berghe G, et al. ESPEN guidelines on parenteral nutrition: intensive care. Clin Nutr. 2009;28(4):387-400.
13. American Society for Parenteral and Enteral Nutrition. The Science and Practice of Nutrition Support. USA: ASPEN; 2001. 14. Vather R, Bisset I. Management of prolonged post-operative ileus: evidence-based recommendations. ANZ J Surg. 2013; 83: 319-324.
15. Braga M, Ljungqvist O, Soeters P, et al. ESPEN guidelines on parenteral nutrition: surgery. Clin Nut. 2009; 28: 378-86.
16. Boeiens P, Heesakkers F, Luyer M, et al. Reduction of Postoperative ileus by early enteral nutrition in patients undergoing major rectal surgery: Prospective, randomized, controlled trial. Annals Surg. 2014; 259 (4) : 649-55.
17. Boateng AA, Sriram K, Meguid MM, Crook M. Refeeding syndrome: treatment considerations based on collective analysis of literature case reports. Nutrition. 2010 Feb;26(2):156-67.
18. Rees Parrish; Nutrition Issues in Gastroenterology, Series #23; 2005Fuentebella et al; Pediatric Clin N Am; 2009
19. Blanchette LM, Huiras P, Papadopoulas S. Standardized versus custom parenteral nutrition: Impact on clinical and cost related outcomes. Am J Health-Syst Pharm. 2014; 71: 114-21.
20. O’Keefe S. A guide to enteral access procedures and enteral nutrition: enteral access to avoid TPN. Nature Reviews Gastroenter Hepatology. 2009; 6: 207-15.

Patient presented w/ Nissen revision
-possible esophageal/gastric leak
-developed post-operative ileus

Day 3 Post-op :
Had exp lap; PICC line and G-tube inserted

NPO 5 days

Was on TPN 14 days
7 days standardized, had BM day 6
7 days custom

Day 2 of custom - advanced to PO

Never initiated EN, despite being a candidate
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