Nutrition in Clinical Practice http://ncp.sagepub.com/

Early Postoperative Tube Feeding in Liver Transplantation Jeanette M. Hasse Nutr Clin Pract 2014 29: 222 originally published online 13 February 2014 DOI: 10.1177/0884533614522653 The online version of this article can be found at: http://ncp.sagepub.com/content/29/2/222

Published by: http://www.sagepublications.com

On behalf of:

The American Society for Parenteral & Enteral Nutrition

Additional services and information for Nutrition in Clinical Practice can be found at: Email Alerts: http://ncp.sagepub.com/cgi/alerts Subscriptions: http://ncp.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav

>> Version of Record - Mar 13, 2014 OnlineFirst Version of Record - Feb 13, 2014 What is This?

Downloaded from ncp.sagepub.com at NATIONAL CHUNG HSING UNIV on March 16, 2014

522653

research-article2014

NCPXXX10.1177/0884533614522653Nutrition in Clinical PracticeHasse

Pivotal Paper

Early Postoperative Tube Feeding in Liver Transplantation Jeanette M. Hasse, PhD, RD, LD, FADA, CNSC1

Nutrition in Clinical Practice Volume 29 Number 2 April 2014 222­–228 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614522653 ncp.sagepub.com hosted at online.sagepub.com

Abstract We published one of the first prospective randomized controlled trials evaluating early postoperative tube feeding (TF) in liver transplant recipients nearly 20 years ago. That first study showed that early posttransplant TF was safe and well tolerated; the study results also suggested that early TF could reduce posttransplant infection rates. This Pivotal Paper review evaluates the past, present, and future of early postoperative TF in liver transplantation. This article identifies what nutrition support findings more than 2 decades ago were the basis for attempting postoperative TF in liver transplantation. The results of our study, its unique findings, and shortcomings are summarized. Other subsequent studies of post–liver transplant TF are evaluated with a focus on effects on posttransplant infection rates. Finally, current transplant challenges, including donor organ shortage, increased severity of patients’ pretransplant condition, expansion of living donor options, changes in immunosuppression, and use of specialized nutrients, are discussed in the context of how and why these factors affect nutrition support. (Nutr Clin Pract. 2014;29:222-228)

Keywords enteral nutrition; nutritional support; liver transplantation; infection; probiotics

In 1995, our center published results of a study evaluating the effect of early postoperative tube feeding (TF) on the outcomes following liver transplantation (Figure 1).1 This was the one of the first prospective randomized controlled studies in liver transplant patients to evaluate the effects of early enteral nutrition (EN) on posttransplant outcomes. The purpose of this Pivotal Paper review is to discuss the past, present, and future of postoperative TF in liver transplantation and evaluate whether the findings in this study almost 20 years ago still apply today.

Prevailing Belief System—2 Decades Ago Nutrition Support After Liver Transplantation In the 1980s, liver transplantation was being established as a viable option for patients with end-stage organ disease. By the early 1990s, there were a growing number of liver transplant centers being established in the United States and around the world. There was tremendous growth and learning in transplant organ preservation, surgical techniques, immunosuppressive medications, and medical management of patients. However, the field of transplant nutrition was largely undeveloped. During the early era of liver transplantation, it was not unusual for liver transplant recipients to require hospitalization for several weeks after surgery. During the initial postoperative phase, patients remained nil per os (NPO) with nasogastric tubes in place for several days. Some centers administered parenteral nutrition (PN) to their patients often in doses that today we would consider excessive. Diets were initiated when

nasogastric tubes were removed. A few liver transplant centers were just starting to evaluate and implement nutrition practices and protocols for their programs. The first study evaluating nutrition support in liver transplant recipients was published in 1994 by Wicks et al.2 In this prospective randomized controlled trial, 14 liver transplant patients received TF via a nasojejunal tube within 17 hours of surgery. Ten patients received PN that was initiated within 60 hours postoperatively. There were no differences between the groups with regard to rate of diarrhea or aspiration, nor was there a difference between the groups with regard to time elapsed between surgery and ability for the patients to consume at least 70% of their nutrition needs by oral diet (about 4 days). Bacterial infection occurred at about the same rate in the TF (71%) and the PN groups (70%); most of the infections were gut related. One of the greatest contributions of this study was to show that early posttransplant TF was possible and safe and that TF was a viable alternative for PN in liver transplant recipients.

From the 1Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas. Financial disclosure: None declared. This article originally appeared online on February 13, 2014. Corresponding Author: Jeanette M. Hasse, PhD, RD, LD, FADA, CNSC, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, 3410 Worth St, Suite 950, Dallas, TX 75246, USA. Email: [email protected]

Downloaded from ncp.sagepub.com at NATIONAL CHUNG HSING UNIV on March 16, 2014

Hasse

223

Figure 1.  First page of Pivotal Paper as published in Journal of Parenteral and Enteral Nutrition in 1995. Reprinted with permission from: Hasse JM, Blue LS, Liepa GU, et al. Early enteral nutrition support in patients undergoing liver transplantation. JPEN J Parenter Enteral Nutr. 1995;19:437-443.

Downloaded from ncp.sagepub.com at NATIONAL CHUNG HSING UNIV on March 16, 2014

224

Nutrition in Clinical Practice 29(2)

Nutrition Support After Surgery It was during this same time period (1980s–1990s) that the concept of “bacterial translocation” was being introduced in the general surgical and critical care literature. Moore et al3 randomized patients with an abdominal trauma index (ATI) score from 15–40 and provided early nutrition support either as TF or PN within 12 hours of surgery. The regimens were equal in calories and protein (with a calorie to nitrogen ratio of 150:1). Postoperative infections were reduced significantly in the TF (17%) vs PN group (37%). TF was not only well tolerated but resulted in improvements in outcomes. Shortly thereafter, Kudsk and colleagues4 published their pivotal paper on early postoperative TF in patients who had blunt and penetrating abdominal trauma. In this study, 98 patients with an ATI >15 (no upper limit) were randomized to receive TF (n = 51) vs PN (n = 45) within 24 hours of surgery. Rates of pneumonia, intra-abdominal abscesses, and line sepsis were all significantly lower in the TF vs the PN group. The TF group had 0.25 ± 0.06 infections per patient compared with 0.71 ± 0.14 infections per patient in the PN group (P < .03). In addition, 31% of the PN patients had more than 1 infectious complication compared with 6% of the TF patients (P = .02). These studies were the inspiration for evaluating early TF in liver transplantation.

Unique Scientific Contribution Our study was the first prospective randomized controlled trial to compare outcomes between liver transplant recipients receiving early postoperative TF vs no nutrition support (which was the standard at the time). Fifty patients were randomized to 1 of 2 groups: the experimental group received TF 12 hours postoperatively via a nasointestinal tube placed during surgery; the control group was NPO until diet was initiated. Nasogastric tubes were placed during surgery in both patient groups for gastric suctioning and medication administration as needed. There were a number of dropouts (a major shortcoming of this study) due to the surgeons forgetting to place the feeding tubes in the operating room since this was a new procedure (n = 7), the need to start nutrition support for various reasons in control patients (n = 4), and the transplant surgery being aborted due to discovery of metastatic cancer during the procedure (n = 3). Patients in the TF group received a peptide-based formula dosed at a level determined by indirect calorimetry. The TF was initiated 12 hours after liver transplantation and advanced every 12 hours to goal rate. Patients in both groups started to eat when the nasogastric tube was removed. The nasointestinal tube and TF was discontinued only when the patients in the TF group were able to eat at least two-thirds of their nutrient needs. As expected, 12-day average cumulative calorie and protein intakes were higher in the TF group (22,464 ± 3554 kcal, 927 ± 122 g protein) than in the control group (15,474 ± 5265 kcal,

637 ± 238 g protein) (P < .002). There were no significant differences between the 2 groups with regard to intensive care unit (ICU) stay, hospital stay, or hospital charges. TF did not influence rejection rates. There was a trend toward reduced overall infections (21.4% in TF patients, 47.2% in control patients), but it was not statistically significant. There was, however, a reduction in viral infections in the TF patients (0%) vs the control patients (17.7%) (P < .05).

Validation Since our article was published in 1995, there have been several subsequent published studies evaluating posttransplant TF as a therapeutic treatment.5-11 Some studies evaluated effects of TF on metabolic parameters or hospital stay, but most studies also looked at effects of TF on infection rates. Table 1 summarizes the studies’ findings on TF and infections; further detail on each of the studies is included below.

Subsequent Studies Evaluating Posttransplant TF Mehta et al5 published a retrospective evaluation comparing outcomes from 63 patients who received posttransplant TF via a jejunostomy with outcomes of 21 historical control patients who had received PN. While the median days to initiate nutrition and reach a nutrition support goal did not differ between the TF group (2 and 5.5 days, respectively) and the PN group (2 and 5 days, respectively), achieving adequate oral intake occurred more quickly in the TF group (median, 15.5 days) than in the PN group (median, 25 days). In addition, the prevalence of ileus was reduced in patients who received TF (8.3%) vs those who received PN (33.3%). Infection outcomes were not reported. The biggest drawback of this study was its retrospective design and lack of a control group who did not receive nutrition support at all. In 2012, a study from Ikegami and colleagues6 evaluated risk factors for bacterial sepsis after liver transplantation and assessed how early postoperative TF affected bacterial sepsis. The 2-year graft survival rate in their patients with bacterial sepsis was significantly lower (45.7%) than in patients with local infection only (79.8%) or no infection (88.7%, P < .001). In a multivariate analysis, intraoperative blood loss of >10 L and absence of TF within 48 hours of liver transplantation were found to be independent risk factors for bacterial sepsis after liver transplantation. Bacterial sepsis occurred in 5.9% of patients who received TF within 48 hours of surgery vs 21% in patients who started TF after 48 hours (P = .002) (Figure 2). In addition, when patients did not get TF within 48 hours of surgery and had >10-L blood loss, bacterial sepsis was 8-fold higher than in patients with low blood loss and early TF (P < .001) (Figure 3). A major shortcoming of this study is its retrospective design.

Downloaded from ncp.sagepub.com at NATIONAL CHUNG HSING UNIV on March 16, 2014

Hasse

225

Table 1.  Summary of Studies Evaluating Effect of Early Post Liver Transplant Tube Feeding on Infection Rates. Year

Authors 2

1994 Wicks et al

1995 Hasse et al1

1995 Mehta et al5 2002 Rayes et al7

2005 Rayes et al8

2005 Plank et al9

2012 Ikegami et al6

2012 Yoshida et al10

2012 Kaido et al11

Type of Study

Subject Assignment

Prospective randomized 14 patients received postoperative TF via controlled trial nasojejunal route 10 patients received PN Prospective randomized 14 patients received standard postoperative controlled trial TF via nasointestinal tube 17 control patients received IVF only before diet initiation Retrospective review 63 patients received TF via a jejunostomy 21 historical control patients received PN Prospective randomized 32 patients received standard TF and controlled trial selective bowel decontamination 31 patients received fiber-containing TF plus a probiotic (Lactobacillus plantarum 299) 32 patients received fiber-containing TF plus heat-killed probiotic Prospective randomized 33 patients received standard postoperative double-blind TF via nasointestinal tube plus synbiotic controlled trial containing 4 lactobacillus organisms and 4 fibers 33 patients received standard postoperative TF plus 4 fibers Retrospective review 15 patients received preoperative oral supplementation and postoperative TF with an immune-enhancing formula 17 historical control patients received standard postoperative TF with or without standard oral preoperative supplementation Retrospective review 136 living donor transplant recipients received standard postoperative TF within 48 hours of surgery 57 living donor transplant recipients received postoperative TF more than 48 hours of surgery Prospective randomized 12 living donor transplant recipients controlled trial received a BCAA supplement pre- and postoperatively; no TF 12 living donor liver transplant recipients received diet only; no TF

Retrospective review

40 living donor liver transplant recipients received postoperative TF with an HWP formula (containing ω-3 fatty acids) plus synbiotics 36 living donor liver transplant recipients received postoperative TF with an elemental TF formula (containing glutamine and arginine) plus synbiotics

Infection Rate Results 71% of TF group had bacterial infection vs 70% of PN group (NS) 21.4% of TF group had infection vs 47.2% of control group (NS) 0% of TF group had a viral infection vs 17.7% of control group (P < .05) Infectious outcomes not reported 48% of TF + bowel contamination group had an infection 3% of TF + probiotic group had an infection (P = .017 vs first group) 34% of TF + heat-killed probiotic group had an infection 3% of TF + synbiotic group had an infection vs 48% of TF + fiber group (P < .05)

33% of immune-enhancing formula group had an infection vs 71% of standard formula group (P = .074)

5.9% of early TF group had bacterial sepsis vs 21% of the late TF group (P = .002)

25% of BCAA group had a bacterial infection vs 33% of control group (NS) 38% of both groups had cytomegalovirus infection (NS) 0% of BCAA group vs 8% control group had fungal infection (NS) 15% of HWP TF group had a bacterial infection vs 74% of elemental TF group (P = .002)

BCAA, branched-chain amino acid; HWP, hydrolyzed whey protein; IVF, intravenous fluid; NS, not significant; PN, parenteral nutrition; TF, tube feeding. Adapted with permission from: Hasse JM. Examining the role of tube feeding after liver transplantation. Nutr Clin Pract. 2006;21:299-311.

Downloaded from ncp.sagepub.com at NATIONAL CHUNG HSING UNIV on March 16, 2014

226

Nutrition in Clinical Practice 29(2)

Figure 2.  Incidence of bacterial sepsis in liver transplant patients starting enteral nutrition within 48 hours (n = 135) or later than 48 hours (n = 57) after operation. Reprinted with permission from: Ikegami T, Shirabe K, Yoshiya S, et al. Bacterial sepsis after living donor liver transplantation: the impact of early enteral nutrition. J Am Coll Surg. 2012;214:288-295.

Figure 3.  The incidence of bacterial sepsis in liver transplant recipients with or without early enteral nutrition within 48 hours after operation and/or intraoperative blood loss >10 L. Reprinted with permission from: Ikegami T, Shirabe K, Yoshiya S, et al. Bacterial sepsis after living donor liver transplantation: the impact of early enteral nutrition. J Am Coll Surg. 2012;214:288-295.

Subsequent Studies Evaluating Posttransplant TF and Probiotics Rayes et al7,8 conducted 2 studies in which they evaluated the combination of early postoperative TF with probiotics in liver transplant recipients. In the first study,7 liver transplant recipients were randomized to 1 of 3 groups. Group 1 (n = 32) received standard TF formula and underwent selective bowel

decontamination. Group 2 (n = 31) received a fiber-containing TF formula and a probiotic (Lactobacillus plantarum 299) for 12 days. Group 3 (n = 32) received a fiber-containing TF formula with heat-killed probiotic for 12 days. Postoperative infection rate was lowest in group 2 (13%), followed by group 3 (34%) and group 1 (48%). There was a statistically significant difference in infection rates between groups 1 and 2 (P = .017). The second study by the same researchers compared 2 TF regimens.8 The experimental group (n = 33) received postoperative TF via a nasointestinal tube with a high-nitrogen formula and a synbiotic containing 4 lactobacillus organisms plus 4 fibers. The control group received the same TF formula but just the 4 fibers. Hospital and ICU stay were not significantly different between the 2 groups. However, bacterial infection occurred in 48% of the control patients and only 3% in the experimental group (P < .05). Reduction in bacterial infections also translated into reduced duration of antibiotic therapy in the group who received TF and the synbiotic.

Subsequent Studies Evaluating Posttransplant TF or Oral Supplementation With Specialty Enteral Formulas A few studies have evaluated different types of nutrition formulas or supplements in patients after liver transplantation. The first study by Plank et al9 was a pilot study using historical controls. Fifteen liver transplant candidates received an oral immune-enhancing supplement (Impact; Nestle Healthcare Nutrition, Florham Park, NJ) for a median of 54 days pretransplant. They were fed with the same formula after transplant via nasojejunal or nasogastric tubes after surgery. TF was discontinued when patients were eating at more than 50% of their needs. The outcomes of these patients were compared with outcomes of 17 historical controls, some of whom received standard oral nutrition supplementation pretransplant while others did not receive any preoperative supplementation. All patients received TF after transplantation until oral intake was adequate. Infectious complications (bacterial, fungal, or viral) occurred in 33% of the patients receiving the immune-enhancing formula vs 71% of historical controls, but the difference was not significantly different (P = .074). Inherent to the retrospective design of this study, the patient groups were not equal with regard to both pre- and postoperative nutrition regimens. A prospective controlled trial is needed to truly evaluate effects of an immune-enhancing diet on posttransplant outcomes. Two studies evaluated specialized nutrition formulas in living donor liver transplant recipients.10,11 The first study evaluated the effectiveness of an oral branched-chain amino acid (BCAA) supplement during the perioperative period on outcomes after living donor liver transplant.10 A BCAA supplement was provided to 12 patients prior to living donor liver transplantation and again from postoperative days 3–28. The oral diet was started 1 week posttransplant. The control patients

Downloaded from ncp.sagepub.com at NATIONAL CHUNG HSING UNIV on March 16, 2014

Hasse

227

(n = 12) received diet only. Early postoperative TF was not used in this study. The primary outcomes being measured were metabolic changes (nonprotein respiratory quotient, amino acids, and serum proteins). However, secondary outcomes such as liver regeneration rate, surgical outcomes, and infection rates were also measured. There were no differences between the groups with regard to any of these outcomes. Therefore, there appeared to be no significant clinical benefits of an oral BCAA supplement in living donor recipients. Kaido et al11 performed a retrospective review comparing results of living donor liver transplant recipients who received 1 of 2 types of specialized enteral TF formulas postoperatively. One group received a diet containing hydrolyzed whey protein (HWP) as the protein source, isomaltulose and dextrin as the carbohydrate source, and medium-chain triglyceride as well as eicosapentaenoic acid and docosahexaenoic acid as part of the lipid content (MHN-02, MEIN; Meiji Dairies Co, Tokyo, Japan). The HWP formula was started with 24 hours of surgery and administered via a jejunostomy tube. The TF formula initial rate provided 10–15 kcal/kg for 3 days and then increased to 25–35 kcal/kg. The other group was a historical control group that received TF with an elemental formula containing L-glutamine, L-serine, and L-arginine as well as carbohydrate mainly in the form of dextrin. It was a low-fat formula containing only 0.17 g lipid per 100 kcal (Elental; Ajinomotos Pharmac Co, Tokyo, Japan). The elemental TF was dosed at an initial rate of 20 mL/h and increased to 40 mL/h by the fifth postoperative day. Oral diets were initiated around the fifth postoperative day in both groups. EN was adjusted based on oral intake and discontinued when oral intake was tolerated (about 10–14 days after transplantation). All patients in both groups also received synbiotics consisting of a supplement containing glutamine, fiber, and oligosaccharides (FGO; Otsuka Pharmaceutical Factory, Tokushima, Japan) and a beverage containing Lacobacillus casei Shirota (Yakult 400; Yakult Honsha Co, Tokyo, Japan). The synbiotics were given orally or via feeding tube daily until discharge. The primary outcome of this study was 30-day postoperative bacteremia incidence. Secondary outcomes were hospital mortality, rejection, and fasting glucose on the postoperative day 7. Bacteremia occurred in 15% of the HWP group and 47% of the elemental group (P = .002). Hospital mortality and rejection rates were not different between the groups. There are many confounding factors in this study. It was not a prospective study, and both groups used specialized formulas and synbiotics. The TF advancement was different between the groups, and patients received TF over a longer period than some of the other studies. One would like to know if reduction of infection can be achieved with standard TF for a shorter period or if it would differ from a group that was not given TF at all.

Future Considerations Liver transplantation today provides additional challenges that were not present 20 years ago. Some of those challenges

include the increased demand for liver transplants with a limited donor pool, increased severity of illness before transplantation due to limited donor availability, expansion of living donors for transplantation, changes in immunosuppression regimens, and advances in nutrition support such as using specific nutrients or protocols to achieve specific clinical outcomes rather than providing nutrition just as a calorie and protein source. The number of transplant candidates has risen exponentially over the years, but the number of available donors has not risen to the same extent. In 1992, 3064 liver transplants were performed in the United States compared with 6256 in 2012. However based on Organ Procurement and Transplantation Network (OPTN) data as of January 14, 2014, there were 15,716 transplant candidates on the waiting list for a liver transplant. Since 2002, liver transplant patients are listed and transplanted based on a calculated model of end-stage liver disease (MELD) score. Because organs from deceased donors are relatively scarce, only the sickest patients with the highest MELD scores receive transplants. Often the sickest patients are significantly malnourished and physically deconditioned; they are frequently hospital or ICU bound. These conditions create additional nutrition challenges in patients’ postoperative recovery. Because patients undergoing transplantation today are generally sicker than those who were undergoing transplantation 20 years ago, it could be hypothesized that nutrition could play a more significant role today than in the past. With a limited number of deceased donors available, some transplant centers are turning to living donors as a source for transplantable organs. This offers new opportunities for nutrition support. In deceased donor transplantation, no one can predict when a patient will receive a transplant. With living donation, the transplant surgery is scheduled; this allows the transplant team to provide preoperative nutrition supplementation to recipients and donors alike. There is a lack of research on this topic. The first question that must be evaluated is if preoperative nutrition supplementation in either (or both) the donor or recipient can improve posttransplant outcomes such as liver function as well as reduce infection and rejection rates. Second, there is an opportunity to study if any specific nutrients can contribute to postoperative recovery. Can specific nutrients such as ω-3 fatty acids or arginine reduce inflammation or infection without increasing rejection rates? Can simple carbohydrate loading of the donor the day before surgery have potential benefits on the recipient’s recovery? Transplant immunosuppression regimens have also changed over the past 2 decades. There are medications available today that were not available more than 10 or 15 years ago. Transplant centers have altered their immunosuppression regimens to help reduce rejection rates and recurrent liver disease while trying to minimize potential side effects such as infection or nephrotoxicity. Results from TF studies in the past performed under specific immunosuppression and antimicrobial prophylaxis may not translate into the same results with patients who are treated with today’s current regimens.

Downloaded from ncp.sagepub.com at NATIONAL CHUNG HSING UNIV on March 16, 2014

228

Nutrition in Clinical Practice 29(2)

There are still many questions and opportunities for additional research to verify or refute benefits of posttransplant TF and supplementation of specific nutrients to liver transplant recipients. What types of formulas are likely to be the most beneficial? Are there any patient groups in whom posttransplant TF does not confer a benefit in reducing infections? What is the optimal dose or duration of postoperative TF? What probiotics are available today that could confer benefits in the transplant population? What immunomodulating nutrients or formulas could reduce infection and inflammation without increasing rejection? What benefits can be conferred to the recipients by providing nutrition to donors? The current published literature does not answer these questions.

Conclusion The study we published in 19951 was just the beginning of evaluating effects of early postoperative TF on liver transplant outcomes. Some subsequent studies6-8 support the premise that posttransplant TF (with or without probiotics) can improve posttransplant outcomes, specifically in reducing posttransplant infections. There are shortcomings to many of the studies reviewed, including lack of prospective controlled trials, small numbers of patients in the studies, lack of control groups without nutrition support, and varying types and duration of postoperative nutrition support. However, these studies are just a start and likely raise more questions than answer them. Transplant nutrition specialists must continue to study and evaluate the role of nutrition in transplantation, including the effectiveness of postoperative TF in liver transplant recipients. The potential for research and growth in transplant nutrition is greater than ever.

References 1. Hasse JM, Blue LS, Liepa GU, et al. Early enteral nutrition support in patients undergoing liver transplantation. JPEN J Parenter Enteral Nutr. 1995;19:437-443. 2. Wicks C, Somasaundarm S, Bjarnason I, et al. Comparison of enteral feeding and total parenteral nutrition after liver transplantation. Lancet. 1994;344:837-840. 3. Moore FA, Moore EE, Jones TN, McCroskey BL, Peterson VM. TEN versus TPN following major abdominal trauma: reduced septic morbidity. J Trauma. 1989;29:916-922. 4. Kudsk KA, Croce MA, Fabien TC, et al. Enteral versus Parenteral feeding: effects of septic morbidity after blunt and penetrating abdominal trauma. Ann Surg. 1992;5:503-511. 5. Mehta PL, Alaka KJ, Filo RS, Leaman SB, Milgrom ML, Pescovitz MD. Nutrition support following liver transplantation: comparison of jejunal versus parenteral routes. Clin Transplant. 1995;9:364-369. 6. Ikegami T, Shirabe K, Yoshiya S, et al. Bacterial sepsis after living donor liver transplantation: the impact of early enteral nutrition. J Am Coll Surg. 2012;214:288-295. 7. Rayes N, Seehofer D, Hansen S, et al. Early enteral supply of lactobacillus and fiber versus selective bowel decontamination: a controlled trial in liver transplant recipients. Transplantation. 2002;74: 123-128. 8. Rayes N, Seehofer D, Theruvath T, et al. Supply of pre- and probiotics reduces bacterial infection rates after liver transplantation: a randomized, double-blind trial. Am J Transplant. 2005;5:125-130. 9. Plank LD, McCall JL, Gane EJ, et al. Pre-and postoperative immunonutrition in patients undergoing liver transplantation: a pilot study of safety and efficacy. Clin Nutr. 2005;24:288-296. 10. Yoshida R, Yagi T, Sadamori H, et al. Branched-chain amino acidenriched nutrients improve nutritional and metabolic abnormalities in the early post-transplant period after living donor liver transplantation. JHepatobiliary Pancreat Sci. 2012;19:438-448. 11. Kaido T, Ogura Y, Ogawa K, et al. Effect of post-transplant enteral nutrition with an immunomodulating diet containing hydrolyzed whey peptide after liver transplantation. World J Surg.2012;36: 1666-1671.

Downloaded from ncp.sagepub.com at NATIONAL CHUNG HSING UNIV on March 16, 2014

Early postoperative tube feeding in liver transplantation.

We published one of the first prospective randomized controlled trials evaluating early postoperative tube feeding (TF) in liver transplant recipients...
954KB Sizes 2 Downloads 3 Views