The Lancet
Postoperative enteral versus parenteral nutrition

Vol: 359 Issue: 9318, May 11, 2002

Fabio Pacelli, Maurizio Bossola, Valerio Papa, Antonio Sgadari, Giovanni Battista Doglietto

Department of Surgical Sciences, Digestive Surgery Unit, and Department of Internal Medicine, Catholic University School of Medicine, 00168 Rome, Italy

Sir Federico Bozzetti and colleagues (Nov 3, p 1487)compare early postoperative enteral nutrition with parenteral nutrition in malnourished patients undergoing major surgical procedures for gastrointestinal cancer. They conclude that early enteral nutrition significantly reduces complication rates and duration of postoperative stay compared with parenteral nutrition, although parenteral nutrition is better tolerated.

We have done a prospective randomised study on the same topic, in which all patients underwent major abdominal surgery, mostly for gastrointestinal cancer. The preoperative weight loss was in all cases more than 10% of normal bodyweight. Parenteral supplementation was added during the first 3 days of enteral nutrition to achieve the same caloric intake as in the parenteral group. We classified postoperative complications as major and minor, infectious and non-infectious, according to precise criteria. All statistical analyses were two-tailed and based on intention to treat, the anticipated rate of postoperative complications and the statistical power being 40% and 90%, respectively.

We were unable to show that early enteral nutrition reduces the rate of postoperative complications compared with parenteral nutrition Bozzetti and colleagues show a significant number of patients (21%) did not tolerate postoperative enteral nutrition. Therefore, one in five patients did not receive, after major abdominal surgery, adequate nutritional therapy. This finding translates, in this subgroup of patients, into an increased rate of infectious and non-infectious complications.The frequency of postoperative major complications as well as complications requiring re-intervention was similar in the enteral and parenteral nutrition groups. Minor infectious and non-infectious complications were significantly fewer in patients who received postoperative enteral nutrition. Moreover, some complications seem to have been included in the non-infectious group (bleeding, deep-vein thrombosis, renal failure, arrhythmia, delayed gastric emptying) that are not strictly related to the nutritional status and to the route of feeding. Indeed, if these complications are not included in the analysis, the enteral and parenteral nutrition groups do not differ significantly. Duration of postoperative stay and postoperative mortality were also similar in the two groups: 15·2 days (SD 3·6) compared with 16·1 (4·5) days for the enteral and parenteral groups, respectively, for hospital stay, and 5·9% compared with 2·5% for mortality.Taking into account these considerations and the results of our study, we think, in accordance with other researchers,that early enteral nutrition with standard formulas should not currently be considered as the nutritional treatment of choice after major abdominal surgery.