Abstract Background After major upper gastro-intestinal surgery, enteral feeding is often hampered. There is still no consensus on which route of nutrition is preferable in patients undergoing this type of surgery. Current ESPEN guidelines recommend parenteral nutrition in undernourished patients, if caloric requirements cannot be met orally/enterally within 7 days and enteral nutrition is contraindicated. Objective The current practice of systematic parenteral nutrition at the thoracic surgery ward of the University Hospitals Leuven was evaluated based on the ESPEN guidelines. Method This prospective observational study included patients undergoing upper gastro-intestinal surgery and receiving postoperative parenteral nutrition. Parenteral nutrition use was considered appropriate when patients were undernourished and unable to obtain adequate caloric requirements by oral or enteral feeding within 7 days. Results Twenty-five out of 35 patients were nutritionally at risk. In 9 of 25 patients, the indication for parenteral nutrition was considered justified. As the intestinal tract below the anastomosis site remains accessible in the total studied population, enteral nutrition might be an option. Unfortunately, an appropriate jejunostomy tube was not available at our institution. Conclusion In accordance to the ESPEN guidelines, enteral nutrition can replace parenteral nutrition in most thoracic surgery patients, but only if an appropriate enteral access is available

Barbara Deleenheer

Hans Van Veer

Isabel Spriet

Philippe Nafteux

• Peter Declercq

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SHORT RESEARCH REPORT
Evaluation of parenteral nutrition use in patients undergoing
major upper gastro-intestinal surgery
Barbara Deleenheer1 • Peter Declercq1 • Hans Van Veer1 •
Philippe Nafteux1 • Isabel Spriet1
Received: 27 August 2014 / Accepted: 10 March 2015 / Published online: 20 March 2015
 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015
Abstract Background After major upper gastro-intestinal
surgery, enteral feeding is often hampered. There is still
no consensus on which route of nutrition is preferable
in patients undergoing this type of surgery. Current
ESPEN guidelines recommend parenteral nutrition in
undernourished patients, if caloric requirements cannot be
met orally/enterally within 7 days and enteral nutrition is
contraindicated. Objective The current practice of system-
atic parenteral nutrition at the thoracic surgery ward of the
University Hospitals Leuven was evaluated based on the
ESPEN guidelines. Method This prospective observational
study included patients undergoing upper gastro-intestinal
surgery and receiving postoperative parenteral nutrition.
Parenteral nutrition use was considered appropriate when
patients were undernourished and unable to obtain ade-
quate caloric requirements by oral or enteral feeding within
7 days. Results Twenty-five out of 35 patients were nutri-
tionally at risk. In 9 of 25 patients, the indication for
parenteral nutrition was considered justified. As the
intestinal tract below the anastomosis site remains acces-
sible in the total studied population, enteral nutrition might
be an option. Unfortunately, an appropriate jejunostomy
tube was not available at our institution. Conclusion In
accordance to the ESPEN guidelines, enteral nutrition can
replace parenteral nutrition in most thoracic surgery
patients, but only if an appropriate enteral access is
available.
Keywords Enteral nutrition  Gastro-intestinal surgery 
Nutrition  Nutritional risk score  Parenteral nutrition
Impact of findings on practice statements
• A nutritional plan is mandatory for patients undergoing
thoracic surgery, as most of the patients are nutritionally
at risk.
• Most patients undergoing thoracic surgery can receive
enteral nutrition instead of parenteral nutrition, based
on the ESPEN guidelines. However, this is only
feasible if an appropriate jejunostomy tube is available.
• The administration of enteral instead of parenteral
nutrition to patients undergoing thoratic surgery
reduces the direct and indirect nutrition costs.
Introduction
After major upper gastro-intestinal (GI) surgery, immediate
postoperative oral or enteral feeding is hampered by
common postoperative complications: swelling of the
anastomotic site, disability of safe swallowing due to neck
dissection, high risk for (micro) aspiration due to a
vagatomized stomach causing gastroparesis and pyloric
stenosis, and complications associated with surgically
placed jejunostomy tubes for enteral nutrition (EN) such as
leakage, infection, tube dislocation or obstruction [1, 2].
Although the gut remains accessible after major upper
GI surgery from below the anastomotic site, most patients
are systematically started on parenteral nutrition (PN) at
the thoracic surgery ward of the University Hospitals
Leuven. To the best of our knowledge, there is a paucity of
methodologically well conducted studies to conclude on
& Barbara Deleenheer
barbara.deleenheer@uzleuven.be
1 University Hospitals Leuven, Louvain, Belgium
123
Int J Clin Pharm (2015) 37:579–582
DOI 10.1007/s11096-015-0099-y
the best modality for delivering nutritional support to this
patient group [3–5].
According to the European Society for Clinical Nutri-
tion and Metabolism (ESPEN) guidelines, postoperative
PN is beneficial in undernourished patients (defined as an
Nutritional Risk Score (NRS) C3), if adequate caloric
requirements cannot be met by oral or enteral feeding
within 7 days and if EN is not feasible or not tolerated
[6, 7].
Aim of the study
The current practice of systematic PN at the thoracic sur-
gery ward was evaluated based on the ESPEN guidelines.
The primary objective was to report the proportion of
patients nutritionally at risk and the proportion of patients
with appropriate PN therapy.
Ethical approval
The study was approved by the Hospital’s Clinical Trial
Center and Ethical Board.
Method
A prospective observational study was carried out by a
clinical pharmacist at the 28-bed thoracic surgery ward of
the University Hospitals Leuven. Adult patients admitted
for an elective thoracic upper GI procedure (oesophagec-
tomy, laryngopharyngo-oesophagectomy or Belsey Mark
IV-procedure (i.e. an anti-reflux procedure)) and treated
with PN in the postoperative setting, were eligible.
Baseline demographic data and the NRSwere determined
for every included patient at time of PN initiation [7].
Duration (number of days) of PN therapy was registered
throughout the postoperative course and postoperative
weight loss was registered after 6–12 months. PN infusion
therapy consisted of OlimelN7E 1, 1.5 or 2 L; an emulsion
with a total energy of 1100 kcal/L and containing poly-
amino-acids (43.75 g/L), glucose (140 g/L), lipids (40 g/L)
and electrolytes. Cernevit, a multivitamin powder for in-
jection, and Addamel, a concentrate for injection con-
taining trace elements, were added daily to the PN.
ESPEN guidelines state that ‘‘postoperative PN is
beneficial in undernourished patients (interpreted as NRS
C3) in whom EN is not feasible or not tolerated’’ (grade A2
recommendation) and also ‘‘in patients with postoperative
complications impairing GI function who are unable to
receive and absorb adequate amounts of oral/enteral
feeding for at least 7 days (interpreted as a duration of PN
treatment of C7 days)’’ (grade A2 recommendation) [6].
Most of the patients of the studied population had no
postoperative complications (e.g. ileus) justifying PN use,
but didn’t have an appropriate jejunostomy tube for EN in
terms of avoiding the above mentioned complications.
Therefore, the criteria of NRS C 3 and PN C 7 days are
the criteria used in our study that had to be fulfilled to
justify the use of PN in this studied population (Fig. 1).
Based on NRS and duration of PN, patients were divided
into 4 groups: NRS\ 3 and PN\ 7 days, NRS\ 3 and
PN C 7 days, NRS C 3 and PN\ 7 days, and NRS C 3
and PN C 7 days.
Mean and median values are displayed for normal and
non-normal distributed continuous variables respectively.
Results
During the five-month study period between 2/2013 and
6/2013, 35 of the 400 hospitalized patients were included,
all fulfilling the above mentioned inclusion criteria. Base-
line patient characteristics are shown in Table 1. The
majority of included patients underwent oesophagectomy
(n = 27; 77 %), followed by Belsey Mark IV in 14 % of
patients (n = 5) and laryngopharyngo-oesophagectomy
(n = 3; 9 %). The median NRS was 4 (IQR = 2–5). All
patients were treated with a total of 283 PN bags (median
of 6 per patient, IQR = 5–8) from the first postoperative
day per standard protocol. Almost every patient received a
dietary consultation during hospitalization, most of the
time in the last part of hospitalization (median time
69.23 % of the length of stay).
NRS≥3?
PN≥7 days?
Group 4: PN
indicated
Group 3: start IV
glucose, electrolytes
and minerals
Group 1 and 2: start
IV glucose,
electrolytes and
minerals
Yes No
Yes No
Fig. 1 Evaluation of the indication of PN- flowchart (IV = intra-
venous; NRS = nutritional risk score; PN = parenteral nutrition)
Group 1 = NRS\ 3 and PN\ 7 days. Group 2 = NRS\ 3 and
PN C 7 days. Group 3 = NRS C 3 and PN\ 7 days. Group
4 = NRS C 3 and PN C 7 days
580 Int J Clin Pharm (2015) 37:579–582
123
Twenty-five out of 35 patients were nutritionally at risk
(NRS C 3). In 9 out of 25 patients, the indication for PN
was considered justified, fulfilling both predefined criteria
(NRS C 3 and PN duration C 7 days). Additionally, 16
patients had a NRS C 3 but the duration of PN in this
cohort was less than 7 days. In those patients, oral feeding
was restarted within 7 days at a gradual increase and not to
the full caloric intake as intended by the ESPEN criteria
within the intended time frame [6–8]. The remaining 10
patients did not fulfill the NRS-criterion (Fig. 2).
Discussion
This observational study revealed that the majority (25/35
patients) of the studied population was nutritionally at risk
(NRS C 3) and that a nutritional plan is mandatory. There
are several strategies to improve nutritional management.
In order to identify those patients at risk for undernutrion, a
risk assessment for severe undernutrition according to the 4
criteria stated by the ESPEN working group should be
performed systematically upon admission [6]: weight loss
[10–15 % within 6 months; BMI\ 18 kg/m2; subjective
global assessment, Grade C; serum albumin\30 g/L (with
no evidence of hepatic or renal dysfunction). Conse-
quently, a nutritional plan can be installed for patients at
risk, preferably with EN because this has the advantage to
feed the patient on a more feasible way in comparison with
PN, even after discharge.
A comparison between the current ESPEN guidelines on
PN use after surgery and the actual practice at the thoracic
surgery ward of the University Hospitals Leuven, revealed
that in 9 out of 35 patients the indication for PN was jus-
tified because of the high risk for undernutrition
(NRS C 3) and the inability to receive and absorb adequate
amounts of oral/enteral feeding for at least 7 days
(PN C 7 days; Fig. 2). Although the study confirmed that a
high proportion of patients was nutritionally at risk
(NRS C 3 was detected in 25 out of 35 patients), oral
feeding was restarted within 7 days after surgery in 16 of
those 25 patients (NRS C 3 and PN\ 7 days), however
only at a gradual increase and not to the full caloric intake
as intended by the ESPEN criteria within the intended time
frame [6–8]. The remaining 10 patients did not fulfill the
NRS-criterion, but 3 of them received PN because of
postoperative complications such as pyloric stenosis
(ESPEN [6], grade A2 recommendation). In conclusion, if
an appropriate enteral feeding tube was present, 28 out of
35 patients could be fed by EN, including the 9 patients
with NRS C 3 and PN C 7 days.
Unfortunately, to date such a jejunostomy tube was not
available at our institution. The current available tubes are
considered to be too small, to cause too much side effects
or to get blocked too often. Therefore, as mentioned in the
Method, contraindications for EN as prerequisite to justify
Table 1 Baseline characteristics
Baseline characteristics
Type of surgery
Oesophagectomy (n) 27
Laryngopharyngectomy and oesophagectomy (n) 3
Belsey Mark IV-procedure (n) 5
Male/female ratio 26/9
Length (cm)a 169 ± 8
Weight (kg)a 71 ± 17
BMI (kg/m2)a 25 ± 5
Age (year)a 63 ± 10
NRSb 4 (2–5)
Ideal amount kilocalories (kcal)a 1623 ± 274
Ideal amount nitrogen (g)a 15.7 ± 2.6
Hospital mortality rate 0 %
Number of fasting days (days)b 1 (1–2)
Postoperative start PN (days)b 2 (1–2)
Postoperative LOS (days)b 13 (10–19)
Number of days PN/LOS (%)a 51.74 ± 20.07
Total fluid volume per day (mL)b 1637.5
(1500–1820)
Daily residual stomach volume (mL)b 100 (10–200)
Number of dietary consultations per patient during hospitalizationb
Oesophagectomy 1 (1–2)
Belsey Mark IV-procedure 0 (0–1)
Laryngopharyngectomy and oesophagectomy 4 (2.5–4)
Percentage of LOS when first dietary consultation
takes placeb
69.23
(52.88–83.33)
a = Mean and standard deviation, b = median and IQR, IQR = in-
terquartile range, LOS = length of stay, NRS = nutritional risk score,
PN = parenteral nutrition
0
2
4
6
8
10
12
14
16
NRS <3 and
PN <7days
NRS <3 and 
PN ≥7days
NRS ≥3 and 
PN <7days
NRS ≥3 and 
PN ≥7days
7
3
16
9
N
um
be
r o
f p
a
en
ts
Fig. 2 Indication for parenteral nutrition (NRS = nutritional risk
score, PN = duration of parenteral nutrition)
Int J Clin Pharm (2015) 37:579–582 581
123
the initiation of PN were not taken into account, despite the
fact that this is recommended in the ESPEN guidelines [6].
If these would have been considered, PN was not first
choice in the entire study population. However, to date, it is
still not conclusive whether PN or EN should be the first
choice of nutrition in this selected group of patients [3–5].
Nevertheless, this study has some limitations. First, the
duration of PN treatment was used as surrogate marker for
estimating the duration of the inability of adequate oral/
enteral caloric intake. The ESPEN guidelines state that one
of the criteria that have to be fulfilled to justify PN, is the
inability to receive and absorb adequate amounts of oral or
enteral feeding for at least 7 days [6]. Estimating the
duration of inability to receive adequate amounts of oral or
enteral feeding is very difficult, especially in the immediate
postoperative phase. Therefore, calculating retrospectively
the duration of PN seemed a more objective criterion.
Second, we are aware of the small amount of patients,
especially the number of patients undergoing Belsey Mark
IV-procedure or laryngopharyngectomy with oesophagec-
tomy, being the main limitation of this study.
Critical appraisal of recommendations concerning ini-
tiation of PN in surgical patients is an ideal task for the
clinical pharmacist, as this leads to an objective assessment
of how many patients really need PN versus EN. However,
the clinical setting confronts the team also with limitations
or unexplored areas of the intended populations of these
specific guidelines.
Conclusion
The majority of the population in our study was
nutritionally at risk, so a nutritional plan is mandatory.
According to the current ESPEN guidelines, PN was
justified in 9 of 35 patients. However, PN could only be
replaced by EN if an appropriate jejunostomy tube would
be found. Specific problems rise in thoracic surgical
patients where a continuous risk analysis should be made to
avoid pulmonary complications and aspiration, whichever
route for nutritional support is chosen. Methodologically
well conducted studies that compare the efficacy, safety
and tolerability of EN via jejunostomy tube versus PN in
this specific patient population are needed. Whether EN,
compared with PN, has an effect on the overall survival,
will be the subject of further research in the near future.
Funding No special funding was received for this study.
Conflicts of interest None of the authors have financial or personal
relationships with other people or organizations that could inappro-
priately influence (bias) their work.
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Evaluation of parenteral nutrition use in patients undergoing major upper gastro-intestinal surgery

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Evaluation of parenteral nutrition use in patients undergoing major upper gastro-intestinal surgery

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