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Wcirld J. SuFK. 29. H)23-1028 (2()05|IM)I: H).l7's(M)268-05-749l-z W OR L D

Journal o lSURGERYt> 211(15 by the .Sodete

In ttrnar io iiale i le Chirurp i

Early Enteral Feeding by Nasoenteric Tubes in Patients with Perforation PeritonitiNavneet K aur, M.S., Manish K. Gupta, M.S., Vivek R atan Minocha, M .S.Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital. University of Delhi, Shahdara. Delhi 11009.5.ltidiaPublished Online: June 30. 2005.Abstract. Malnutritiim is \vo)l rec(it;nized as a potential cause of in-crt'iised niiirbidity find mnrtuiity in snrgiciil patients. Eiirly postoperativeuntLTui nutrition thniu^h a feeding Jejunostomy has been sbown to im-pniM.- reMilts in patients under(>oin)> nuijor resections for i^astrointestJnalina)i}inanciL's, tratinia. iind pt^rfciration peritonitis. We conducted a pro-spective sdidy to assess tbe feasibility and sbb a na.soenterie tube plaet'd intraoperiitively inpatients wKb nontraiim atic perforation peritonitis witb mal nutri t ion.One bnndred putii-nts witb nontrauniiitie perforation pL-ritcmitis wilhmalnutrition undfr|>oin[> exploratory' lapanitoniy were randcmilv dividedinto a test grotip H'til and a control Kroup )CG) of 50 paiients each. TGpatients bad a nasoenteric tube placed at tht time of surgerv and werestarted rm an enteral feeding regime 24 bours postoperalively. Patients inCG were allowed to eat orally once tbey passed flatus. Ibe differenceshctwt't 'n the two groups witb respect to nulritional intake in terms ofenergj and protein, cbanges in nutri t ional status as assessed byiintbropomctric. hiocbemical. and bematological \alues, amount ofnasogastric aspirate, return of bowel motilit.v, and complication rateswere analyzed. The nasoenleric feeding was well tolerated. Total calorieand protein intake in TCi was significantly bigber tbn in CG: 9SI vs. 50?kcal {p < t>.l)l). pn ue in 24 vs. 0 g on day 3 an d 1498 vs. 846 kcal (/? < 0.01) on day 7, respectively. There wasreduction in the amount of nasogastric aspirate in TG compared witb tbatin 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(; thanin C(; at 3.34 vs. 4.4 days ip < 0.01). Complications developed in 39 of 50patients in TG and in 47 of 5(( in CG. Tbe major complications occurredin 6 patients in T(> and 12 patients in CG ip < 0.05). Patients withperforation peritonitis with malnutrition are likely to develop large en-erg> deficits postoperativelv, resulting in bigber incidence of infectivecomplications. Early enlcral feeding tbrougb a nasoenteric tube is welltolerated by tbese patients and belps to improve energy and protein in-take, reduces tbe amount of nasogastric aspirate. reduce.s tbe duration ofpostoperative i leus, and reduces the risk of serious complications.

Th ere is an iitistispcctcd prevalence of m alnutrition in hospi-talized p atients [1. 2). Up to A07c of patients are malnourishedat the time of admission to the hospital [3]. Thos e pat ients w hotinderg o major surgery are at further risk of malnu trition as a

Correspondence to: Navtiect K aur, M.S.. c-tiiail: tlr_niivkaur((i hotnia il.co m

result of starvation, the stress of surgery, and a subsequeincrease in their metabolie rate. Malnutrition is associated witissue wasting and impaired organ tunction, which lead to icreased m orbidity and extended ho spitalization [4, 5]. Impa irimmune function eontribtites to an inereased risk of infectio[6]. and m uscle funetion is also adversely affeeted by nutrititmdepletion |7 |.

in response to the awareness of the deleterious effeets thmalnutrition has on patients, significant advances have been main the Held ()f enteral and parenteral nutritional support durithe peri- and postoperative periods. Whenever safe and efiicicaccess to a functional gastrointestinal traet ean be achieved, gfeeding is preferred over total parenteral nutrition (TPN) |F.arly postoperative feeding can be started because of the preervation of postoperative small bowel peristaltic aetivity anabsorptive capacity. With gut feeding, the liver has the firopportunity to clear, process, and distribute the nutritioneoniponents. Also, the vital gut functions sueh as substrate traflthe gut mucosal barrier, and immunoeompctencc are maintaineEarly enteral feeding in the postoperative period has been shown to reduce the number of septic complications in burn ptients [9], traum a patien ts [10, II ], and patients with major gatrointestin al resections for malignancies [12]. This route is almost economical.

A large number of patients who present to our hospital femergency surgery for perforation peritonitis arc malnourished the time of admission. In peritonitis, enteral nutrition is nroutinely used beeause of the edematous and paralytic charateristics of the bowel. However, the role of early enteral nutriti(EEN) in peritonitis has been investigated by many workers. EEby jejunostom y w as found to reduce sep tic complications in ptients with severe pancreatitis and secondary peritonitis [1Glutamine-enriched enteral diet was found to be well tolerated patients with purulent peritonitis [14j. Singh et al. [15] reportthat early enteral feeding through jejunostomy in patients wiperfora tion peritonitis is feasible and tesults in reduc ed sepmorbidity. However, sinee patients with perforation peritonirequire su pplemen tation for only a short period, we evaluated tfeasibility of EEN through a nasojejunal tube in patients prsenting with nontraumatie perforation peritonitis with malnuttion.


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Karii ct al.: Early Enteml Feeding inPerforation Peritonitis 10

Table 1. Preoperative clinical characteristics Table 5. Handgrip strength (in kg) in control andtest groupsConirol groupmean (SD) TL'SI groupmean (SD) Da v

Control group Tesl group(SD) mean (SD) p Value Signitican

Age (vr)Gender (M/F)Preop weiglil (kg)P r e o p a l b i u n i n ( g d l )[ reop JVI.AL (eni)Preop handgrip ^irengtliPreop lymphocyte count (kg)(eeM.cc)

36,164246.602.411 U Al1 V . D , '10.981508,42

(14.61)/ 8(6.15)(0.40)/I iii\( I . H / )(1,56)(580.50)

35,76(14.94)37 ; 1349,34 (6,89)2,40 (0,54)1 Q 7 1 1 T 1 1 11 V . M I Z . J> 1 )10.S7 (1.82)2200.00(1132,50)

Admission3rd day7ih dayDiseharge

NS = not

10,98(1,56)L3.64(l .98)16,40(2,43)17,42(2,47)significant, S

10,96(1,94)15,26(2,63)18,05(2,37)18,49(2,15)

= significant.

0.0010.001NSSSNS

Table 2. Caloric intake (in kcal) in control and test groupsTable 6. Comparison of number ot complicatiuns in conirol and lgroups

Da\iT34s67

Control group(keal) mean (SD)500,00502,70 (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)

p Value0,000,000,000,000,000,00

SignitieaiiecNSSsssss

NS - not significant, S = significant.

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

Days1234567

S

C o n t r o l / g r o u p (g day)mean (SD)

19,13 (7.25)25.60 (9.36)2 1 ,5 (9 ,8 4 5 )23,36(11,68)

- signif icant.

Test g rou p (g /day)mL'an^(SD)

17.7 (6,802)24,37 (9,34)34,77(14,11)43,90(18,57)4 4 ,4 6 (2 1 ,6 3 )44,48 (21,56)

Signif icance

SSss

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

DavsControl groupmean (SD) Tesl groupmean (SD) p Value

1234

503,06 (230,35)585,56 (272.99)674,25(751.27)440,9] (286,53)

465 (265.49)431.14(244,15)426,58 (309,74)301,52 (215,64)

NSNSNSNSNS - not significant.

T G was significantly higher than in Ibe CG (Tables 2 and 3)Tbere was reduction in the amount of nasogastric aspirate in theTG compared witb the CG (Table 4), Tbere was much fasterrecovery of bowel motility in th e TG tban in tbe CG at 3.36 (0.75)v s. 4.4 (1.02) days {p = ().()()()).

Nittiitional StattisTbe effect on nutritional status was assessed by measuring thechange in wcigbt. albumin, bandgrip strength, MAC, and lym-phocyte citunl from theday of admission tii the day of discbarge.There was loss of weight in both groups. Tlie mean loss in weight

Complications Conirol SluWound infeetion with dchiscenceComplete wound dehiscence witlibowel loop prolapseChest infeelion willi productive eougliBronclio pneumonia, pleural effusionScplisemia. lou UP. high-grade lever, ele.Tola I

8414138

4 7

73179339

in tbe TG [48.80 (7.39) kg on day of admission to 46.83 (7.31) kon day of discharge] was signilieantly less tban in the CG gro[46.60 (6.15) kg onda y of admission to 43.SI (5.72) kg on day odiscbarge]. Tbcrc was nosignificant cbange in M AC or absolulymphocyte count in citber group.There was a statistically significant difference in serum albumand handgrip strength (HGS) inTG vs CG . Serum album in levein patients in ihe TG showed an increase from 2.40 (0.47) g/'dladmission to 2.41 (0.54) g/dl onday 3 to 2.56 (0.52) g/dl ondaySerum albumin levels in the CG showed a decrease from 2.4

(0.40) g/dl at admission to 2.29 (0,37) g/dl onday 3 to 2.20 ((1.3g/dl on day 7. Tbe HGS also sbowed a significant improvementth e TGcompared with the CG (Table 5).

Scp.si.s Score and ComplicationsSepsis score in tbe TG was 11.58 (1.8(1) compared witb Il.({1.28) in tbe CG at the time of admission, so the two groups wecomparable. On the tbird day, tbe sepsis score in the TG was 4.(1.30) compared wilb 5.60 (1.15) in CG and the difference wsignificant (/? < 0.05). On day 7, tbe sepsis score in tbe TG w3.58 (1.05) compared with ,3.71 (1.49) in tbe CG.

The number of complications in the TG was 39 compared wi47 in the CG. Major complications like septicemia, low hloopressure, bigh-grade fever dessiminalcd intravascular coagulatio(D l C ) , and burst abdomen were seen in 6 patients in tbe Tcompared witb 12 patients in tbe C G : the difference was statitically significant ( j> < 0.05). The details of complications in tCG and TG are given in Table 6. The abdominal wound dchicence and severe chest infections mostly occurred togetheHowever, upper respiratory tract infections were seen more frquently in the TG and were probably related to ineffecticougbing resulting from tbe presence of two tubes in the esopagus. Tbere were a total of seven de aths, three inthe TG and foin the CG, Tbe cause of deatb was septicemia in six cases anmyocardial infarction in one case. The mean length of hospitstay In the TG was 12.48 days compared witb 14.44 days in tCG ,


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1026 World J. Surg. Vol. 29, No. 8, August 2005

DiscussionPeritonitis after bowel perforation is one of the most common.septic states. The a natomica l site and c ause of perforation is animportant faetor determining outeome. The spectrum of perito-nitis seen in India is different from tha t seen in the West, withmore of entcrie and tubercular perforations involving smallintestines, mainly ileum, and less of eolonie perforations [20].However, in our study the duodenum was the most eommon siteof perforation (44%). followed hy the ileum which accounted lor39 % of the perforation cases. Enteric perforations are reported tohave a mortality rate of l8%-2()9'( and eomplieation rales ofaroun d 66% [21, 22]. Th e most freque nt eomplieation is woundinfection. Tubercular perforations are reported to have highermortality figures of 42%-57% [23, 24j. Poor outeome in patientswith tubercular and typhoid perforations has been attributed tothe overall poor condition of the patients prior to the develop-ment of peritonitis. This poor general condition results frt)mmulliple-organ involvement by the disease process as well asmalnutrition. As per traditional eustom in India, patients with apainful abdomen and fever are allowed only clear liquids orally.Inadequate oral intake eontributes to malnutrition. The problemis eompounded by the presenee of sepsis and its related metaboliealterations such as an increase in energy demands and ehanges insubstrate utilization. All these faetors combine to increase thepatient's risk for morbidity and mortality.

Various studies on EEN in patients undergoing majorabdominal surgery have shown good tolerance to entcral feedingand reduetion in septic morbidity. A nasojejunal route for tubefeeding in patients undergoing laparotomy for gastric pathologywas used and found to have good lube toieranee and goodintestinal toierane e [25]. A nasojejunal tub e feeding regime pro -viding from 30(1 to 11)00 ml/day of en tera l feed was well tole rate din patien ts of peritonitis [13]. Ou r patien ts also tolerate d enter alfeeds well and we were able lo infuse 2 L of enteral feed by thefourth postoperative day. Twenty-four pereent of the patientsdeveloped abdominal distension and cramps at the start of tbecnleral feed for which feeding had to be stopped and restartedafter 6-12 h. This led to some dekiy in achieving lhe goal of 2000ml of enteral feed per day. Not being able to deliver the actuallyrequire d am ount of energy and prolein is consid ered to be animportant drawbaek of enteral nutrition. Two major faetorsaffecting intestinal toieranee have been found to be intra-abdominal surgieal eomplieations and low serum albumin (< 30 g/L) [26]. However, positive effects of enterai feeds have beenshown even in patients with redueed protein ealorie supply [13,27]. This beneficial effect has been attributed to a possibleimmunomodulatory effect of the EEN by promoting reeondi-tioning and reeovery ofthe gnt [13].

Another important problem eneountered in these patients was"tube intoleranee" which was seen in II patients. A nasogastrictube for aspiration and a nasojejunal tube for feeding are soureesof signifieant discomfort to these patients. Double-lumen tubedesigned to aspirate gastrie contents and to provide feed into lhejejunum may obviate this problem eonsiderably.EE N leads to earlier canalization of gas and feees [2S. 29]. Thisfact was conlirmed in our sludy as well. Pupelis et al. [ 13] reporte dthat the appearance of the hrst audible bowel sound after surgery

did not differ in TG and the CG, but the passage of lhe first stoolwas signifieantly earlier in the TG.

EE N allowed a significantly grea ter am ount of protejn andealorie intake in the TG than in the C'G. Reeenlly reported resultshave demonstrated the same outcome with enteral feeding re-gimes 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 hadweight loss in the immediate postoperative period. However, themean weight loss in patients in the TG was significantly less thantha t in pat ien ls in the CG (4.1I6%' vs. 6.0%). Th is conc urs withother studies that also found that a ehange in weight in thepostoperative period is a good parameter for assessment ofnutritional supp lem entat ion [10. 15. 31]. An a eute weight loss of25%'-3O% is assoc iated with a high m ortality rate of 90%. inpostoperative paiients [32[. It has been shown that malnutritionean begin to have detrimental effects on function, ineluding sur-gieal wound healing, when individuals lose only5%-10% of bodyweight. In eatabolic surgical patients, this degree of loss ean oeeurin only 5-10 days of slai^valion. even if starting fri>m a goodnutritional status [33]. There fore, it seems appr opriate Ihalnutritional support is considered with in 5 days if a patient iseompletely 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 inserum 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 forassessme nt of nutrition al supp ort is eontrove rsial. Serum album inhas a long half-life of 20 days, and the early postoperative periodmay be too short to demonstrate ehanges in tbe serum albuminlevel after supplementation. Other proteins sueh as retinal bind-ing prolejn and iransferrin and thyroxine-binding protein have ashort half-life and should be more sensjljve parameters to dem-onstrate the effect of supplementation on the nutritional status.Other anthropometric parameters, sueh as MAC or absolutelymphoeyte eount in either group, did not show any significantchange. Impairment in muscle function as measured by handgripstrength has been found to be a sensitive parameter to demon-strate the effeet of supplem enta tion on nu tritional sta tus [34]. Inour study HGS showed a statistieally significant improvement inpatients with EEN. Protein depletion is more important thanenergy depletion in predisposing patients to postoperative mor-bidity. As skeletal museles are used as an important reserve ofaminc) aeids and ean be assessed by HGS the use of HGS isrecom mend ed to deleci postoperative protein depletion.In our study there was a high ineidenee of inieetious eompli-eations in both grou ps. How ever, there was a signifieanl reduetio n

in major septie complications in the TG than in the CG. A similarouteome has been observed in many other studies as well. Earlyenteral nutrition after major abdominal surgei^ for gastrointes-tinal traet eaneers was found to reduee the severity of infec-tions[12. 27]. EEN after surgery for peritonitis has also beenreported to reduee septie morbidity [18, 23]. Saisi et al. [35] as-sessed the effieaey of EEN after major urologic surgery and founda lower ineidenee of eomplieations. mainly infeetious. and ashorter length of hospital stay. Moore and Moore [lU] found thatblunt trauma patients fed enterally experieneed more significantreduction in septic complications than patienls reeeiving TPN.Though various studies have shown a reduction in mortality aswelt as a shorter length of hospital slay in patients reeeiving EEN[36, 37] no sueh benefit was seen in our study. Length of hospitalstay is not eonsidered a good pa ram ete r since the actual day of


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Kuril et al.: Early Enleral Feeding in Perforation Peritonitis

discharge is dependent on the availability of social and commu-nity services than on the actual clinical condition of the patient.

Thus, from above data it can be safely concluded that EEN bythe NJ route is effective when used for the short term and leads toa reduetion in seplic complications in patients with perforationperitonitis with malnutrition.

References1. liislsriaii BR. Bkickhiiin GL. Vilale J. el al, PrcvaL-nut; of niahiutri-tion in gcncriil medical pati ents . JA M A I'J76;235:I567 15702. Hill GL. Pickford I, Y(tunii GA. ct al. MahiLitrition in surgical pa-tients: an unrecognized pro bk'm . Lancet l')77:l;68y 6923. McWhirler JP. Penningion CR. Incidence and reeognition of mal-nu iri tio n in ho sp ita l. BM j iy'-M;3()S:')45--9484. Giner M. In ]W 5 a eorrelation siill e.xisis heiwccn mahiuirition andpoor outcome in eritically ill patienls. Nulrilion I996;12;23 295. Pennington C. Review article: artificial nutritional support for im-proved patienl care. Alitnenl, Phariuaeol. Ther. 1995:9:471 4SI(). Winsdor JA. Hill CiL. Risk factors lor post operative pneumonia: theimpo rtance of protein depletion. Ann. Surg. l98K:17:lf^l-I857. Jeejcchhoy KN. Muscle fmiction and nutrition. Gut 1986:27:25-39X. Bower RH. Talamini MA. Sa,\ HC. el al. Post-operative enteral vsparcnleral ntttrition, Areh, Surg. I9S6:I21:IO4O 10459. Ale xand er JW . Macm illan BG . Stintiett JD . Beneficial effect ofaggressive protein feeding in severely burned children. Ann Surgt%(J:lK2(4):505 517

1(1. Moore TiL. Moore FA. Immediate enterai nutrition following multi-system traunia: a decade perspective. J. Am. Coll. Nutr. 199I;IO:633648IL Kudsk KA . Croce M A. Fabian TC . et al. Enteral versus parentera lfeeding. Effect on septic morbidity alter hluiit and penetratingabdoniinal trauma. Ann. Surg. i992:215(5):503 51312. Braga M. Vignali A, Gianotti L. et al. Immune and nutritional effectsof early enteral nutrition after tnajor abdominal operations, F.ur. J.Surg. 1996;lf.2:105- 1121.3. Pupelis Cl. Selga G. Fdmunds A. et al. Jejuiial feeding, even wheninstituted late, improves outcomes in patients v-ith severe patiereatitisand peritonitis. Nutrition 2U01:17)2):91 9414. Furukawa S. Hidcaki S. Ming-tsan L. et al. Fnteral administration ofglutamine in purulent peritonitis. Nutrition I999;I5(1):29 3115. Singh G. Ram RP. Khanna SK. Early postoperative enteral feeding inpatients with nontraumatic intestinal perforation and peritonitis. J.Am . Coll. Surg. 1998:1.34:142 146Ifi. Veterans Affairs Total Parenteral Nutiitioii Study Group, Perioper-ative total parenleral nutrition in surgical patients. N. Fni;l, J. Med.lWl;325:535-54517. Elebiite EA. Stoner MB. The grading of sepsis. Br. J- Stirg,1983:70:29 31

18. Agarwai DK. Agarwal KN. Upadhay SK. Physical and sexual growot afllueiit In dian children from 5 to IS years of age. Indian Pae dia1992:29:12tl3-128219. Mullen JJ. Gertner MH. Bii^by GP. et al. Implications of malnutritiin the surgieal patien t. Arch. Surg, 1979:114:121 12520 . Sharma LK. Gu pta S. Soin AS. et al. Generalized peritonitis in Indifhe tropical spectrum. Jpn. J. of Surg. 1991:21:272 27721 . Gupta V. Gupta SK. Shukla VK. et al. Perforated typhoid enteritis children. Postgrad. Med, J. 1994:70:19 2222 . Nyguyen VS, Typiioid perforation in tropics. J. Clin\ (Par1994:131:90 9523 . Dhar A. Bagga D. Taneja SB, Perforated tubercular enteritis childhood: a ten year study. Indian J Pediatr 1990:57:71.3-71624 . Cha /ecet C . Dci,\onnc B. Eklejam JJ. et al. A case ofperitonitis due perforation of lhe small intestines of tubercular etiology: review literature. Ann. Gastroenterol. Hepatol. (Paris) l9SS:24:243-24725 . Monteferrante E. Maiicini G. Pcdra//oli C. et al. The nasojejunlube in early postoperative nutrition. Minerva Chir, 1999:54(7 551 55526 . Braga M. Gianotti L. Gentilini O. et al. Feeding the gut early aldigestive surgery: results of a nine year experience. Clin. Nu2()02:21(l):59-65'27 . Hayashi JT. Wolfe BM. Calvert CC. Limited efHcacy of early pooperative jejunal feeding. Am. J. Surg. 19S5;15O:522X. Weinstein M D. D yne PL . Duerbeck NB . The Proef diet- A nepostoperative regimen for early oral feeding. Am. J, Obstet. (iynec1993:168:12S-13129 . Basse L. Hjort JD. Billesbolle P. et al. A clinical pathway to accelerrecovery after colonic resections. Ann. Surg. 2000:232(1): 15 1730 . AdamS. Batson S. A study of problems associated with the delivery enteral feed in critically ill patients in live ICHs in the UK. IntensiCare Med. 1997:23:261

31 . Herbert HC. Ryan JA. Anderson AJ. et al. Ntnritional benefits immediate postoperative jejuna! feeding of an elemental diet. Am,Surg. 19SO:I39:I53 15932 . Seltzer MH. Slocum BA. Cataldi-Belcher EL. Instant nutritionassessment. JPEN J Parentcr Enteral Nutr 1979:3:157-15933 . Haydock DA. Hill GL. Impaired wound heafing in surgical patiewith varying degrees of malnutrition. JPEN J Paronter Enter N1986:10:550 55434 . Klidjian AM. I-oster KJ. Kammerliiig RM. et al. Relation of athropometeric and dynamomcterie variables to serious postoperatcomplications. BMJ 1980:281:899-90135 . SaIsi P. Cortellini P. Simonazzi M. et al. The use of early entenutrition (EEN) after major urologic surgery. Aeta Biomed. ,AtenParmensc 1998:69(1 2):61 6536. Tucker HN. Miguel SG. Cost containment through nutrition intvention. Nutr, R^ev. 1996:54:111-12137. Neumaycr LA. Smout RJ. Horn HG. et al. Early and sufiicifeeding reduces length of stay and ch arges in surgical patients. J. SuRes. 2001:95:73-77

Invited CommentaryD O I : 10. l()07/s00268-U05-1119-1Bruce M. Wolfe, M.D., Ncclufar Ghaderi , B.S.Sacramento Barialric Medical Association, Carmichael, California, USAPublished On line: June 30. 2005

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

The feeding was eomposcd of everyday foods, including miblenderized in the hospital kitchen. The feeding was well tolated in approximately 80% of patients and ultimately was tolated in essentially all of the tube-fed patients. Benefits of the ealube feeding included an earlier return of gastrointestinal motii


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