European Journal of Cardiovascular Medicine

Parenteral nutrition (PN) has been available for 30 years now and is an effective means of promoting recovery in critically ill patients incapable of ingesting, absorbing or assimilating nutrients, for non-critically ill patients who have preexisting malnutrition and for postoperative patients whoare unable to take orally for 7 or more days.[1]

PN has a mixture consists of various components containing lipid emulsions, amino acids, vitamins, dextrose, minerals, electrolytes, and trace elements. The three main macronutrients are lipids emulsions, proteins, and dextrose. It is advisable to begin parenteral nutrition as soon as one realizes that the patient is nutritionally compromised and requires parenteral nutrition.[2]The TPN itself comes in a 1-3 litre bag, and most patients are infused one bag per day. In this study we are using the peripheral route because of short duration of administration of parenteral nutrition.[3]Generally, patients are initially started on a continuous cycle and are given their TPN over a 24-hour period. As patients progress, it may be possible to move to an 18, 15, or even a 12-hour infusion cycle.

Perforation Peritonitis is one of the commonest surgical emergencies that surgeons have faced with in an emergency setting in the developing world.[4] Efforts are constantly being made for improving the prognosis of patients with perforation peritonitis pertaining to the management protocols, with regards to antimicrobial therapy, surgery and intensive care but it still continues to be complex and challenging problem as it brings along high morbidity and mortality rates. Patients undergoing exploratory laparotomy for perforation peritonitis are kept nil orally for 3-5 postoperative days in most cases and hence require tremendous nutritional support.[5]

As a result of inadequate nutritional intake, the patients undergoing gastrointestinal surgery are at risk of nutritional depletion.[6] Lately, perioperative care has placed a great deal of emphasis on ensuring surgical patients are getting enough nourishment. Research has concentrated on ways to provide nutritional support, their relative therapeutic benefits, and minimizing the metabolic changes associated with surgical trauma.[7] However, in India, there has still been a death of research studies and published work regarding its use. This project is an endeavor to assess the role of parenteral nutrition in Indian population in postoperative cases of exploratory laparotomy

for perforation peritonitis considering the cost of the same. This study is an attempt to conclude whether instituting parenteral nutrition in postoperative period has a role in reducing postoperative complications and in early recovery and discharge from hospital and thereby reducing mortality.

AIMS AND OBJECTIVES

The current study was conducted with an aim to establish the role of Parenteral Nutrition (PN) in reducing postoperative complications in perforation peritonitis cases. The outcome of the study is based on the following parameters:

• Incidence of postoperative complications
• Duration of hospital stay
• Mortality rate

The study was conducted on patients of either gender aged between 18 to 60 years, admitted at Rajindra Hospital Patiala, undergoing exploratory laparotomy for perforation peritonitis. Patients were allocated randomly to one of the two groups and either received PN postoperatively or not and outcome was compared in both the groups.

Our hospital caters to mainly poor subset of population, mostly daily wagers who depend on their daily wages to sustain their families. This study is an attempt to conclude whether instituting parenteral nutrition in postoperative period has a role in reducing postoperative complications and in early recovery and discharge from hospital.

This present study aims at establishing the role of Parenteral Nutrition (PN) in reducing postoperative complications, duration of hospital stay and 90 day mortality rate in postoperative cases of perforation peritonitis.

STUDY DESIGN

This study was a Prospective and Comparative control study.

STUDY SETTING and DURATION

Perforation peritonitis cases in the Department of General Surgery, Government Medical College & Rajindra Hospital, Patiala, Punjab and the study was conducted from November 2022 to October 2023.

STUDY TOOL

The data was collected in a pretested, pre-validated questionnaire which included patient data, clinical findings, lab investigations, postoperative outcomes.

SUBJECT SELECTION

The patients selected for this study were those who were diagnosed with perforation peritonitis in surgical emergency on the basis of thorough clinical examination and radiological investigations and underwent exploratory laparotomy for the same

Inclusion Criteria

1. Patients who have given informed and written consent.
2. Age of the patient->18 and <60 years.

Exclusion Criteria

• Patients with cardiac failure or liver failure.
• Patients who are hemodynamically unstable.
• Patients with severe metabolic derangement-severe hyperglycemia, azotemia, encephalopathy, hyperosmolality and fluid-electrolytedisturbances.

SAMPLE SIZE

The sample size for this study was calculated by using the formula: n= α2sd/(e)2

n = Sample size; α = 1.96 for 95% CI; SD=0.2; & e=0.04α2=3.8416, e2=0.016, SD2 =0.04

A minimum sample size required for the study of is 48. However, inorder to reduce the skewness, the sample size is taken as 60.

ETHICAL CONSIDERATIONS

Ethical consideration and clearance before data collection was obtained from the Institutional Ethical Committee. An informed written consent was taken from the patients. The study was granted permission by the Institutional Ethic Committee vide letter no. BFUHS/2K23p-TH/2040 dated – 02.02.2024.

CONDUCT OF THE STUDY

Patients were divided randomly into Group A, the study group and Group B, the control group. The study group was put on 3 planned parenteral nutrition infusions postoperatively on 1st, 3rd and 5th postoperative day while another group served as control and received only dextrose containing and electrolyte based intravenous fluids and received no parenteral nutrition. Postoperative outcomes were compared for both groups on the basis of complications such as surgical site infection, wound dehiscence, burst abdomen, anastomotic leak, intra-abdominal collection, septic shock and pleural effusion, duration of hospital stay and mortality rates.

The baseline demographic characteristics of the two groups were compared. Out of the 60 participants, mean age was 40.23±13.03 years in study group while it was 39.30±13.08 in control group. Majority belonged to the age group of 31-45 years in cases while 43% belonged to 18-30 years age group. In terms of gender, majority were males (Table 1 and 2). In terms of complications, majority developed surgical site infections (17%, 43%) followed by wound dehiscence (7%, 23%) and burst abdomen (10%, 20%) in cases and controls respectively (Figure 1). Mean hospital stay in the study group was 9.23±3.41 days while in control it was 10.97±2.43 days. In both cases of study and control, the 90-day mortality was 10% ((Table 3).

Table 1: Age-wise Distribution

Table 2: Gender-Wise Distribution

Figure 1: Distribution of Post-operative complications

Table 3: Duration of Hospital Stay & 90 Day Mortality

Parenteral nutrition is an essential component in the perioperative care of patients undergoing surgical procedures who have an inability to obtain adequate nutritional intake through the oral or enteral route. Parenteral nutrition can meet nutritional requirements and minimize the risk of complications related to malnutrition, such as decreased immune function, loss of muscle mass, delayed wound healing and infective complications.⁽⁸⁾

POSTOPERATIVE COMPLICATIONS

Results of the current study indicate that administration of 3 parenteral nutrition infusions postoperatively in patients undergoing exploratory laparotomy on 1st, 3rd and 5th postoperative days, is effective in reducing some of the postoperative infective and non-infective complications. .

In the study group, 5 patients (16.67%) developed surgical site infection, compared to 13 patients (43.33%) in the control group (p value< 0.05). Two patients (6.67%) in the study group developed wound dehiscence in comparison to 8 patients (23.33%) in the control group (p value <0.05) .In study group, 3 patients (10%) had burst abdomen postoperatively while in control group, 6 patients(20%) had burst abdomen (p value >0.05). One patient (3.33%) in the study group developed intra- abdominal collection in comparison to 4 patients (13.33%) in the control group (p value

>0.05). In the study group, 3 patients (10%) developed anastomotic leak compared to 5 patients (16.67%) in the control group (p value>0.05). None of the patients in the study group developed pleural effusion postoperatively while 2 patients (6.67%) in the control group did (p value>0.05). In the study group, 1 patient (3.33%) developed septic shock as comparedto 2 patients (6.67%) in the control group (p value>0.05). The overall comparison of all these outcome parameters suggested statistical significance (p value<0.05).

Similar observations were seen in the study conducted by Collins et al. (1978)^[9], wherein postoperative patients undergoing proctocolectomy or rectal excision had faster wound-healing rates and a lower incidence of postoperative sepsis with TPN vs an amino acid solution or oral intake. Another study by Mullen et al. (1980)^[10] showed that TPN reduced postoperative complications 2.5-fold (p < 0.01), postoperative major sepsis six-fold (p < 0.005) and mortality five-fold (p <0.01) and these results are almost similar to the current study conducted. Ganaie et al. (2015)^[11] showed in the study that the TPN group experienced significantly fewer problems, including wound infections, sepsis, abscess development, anastomotic leak, and wound dehiscence, as well as a shorter time to resolve complications. In the study group, 5 patients (16.67%) developed an infection at the site of surgery compared to 13 patients (43.33%) in the control group and the variation was significant statistically (p value< 0.05). Two patients (6.67%) in the study group developed wound dehiscence in comparison to 8 patients (23.33%) in the control group and the difference was statistically significant (p value <0.05). The results of the quoted study are in concordance to the meta-analysis entitled "Perioperative Parenteral Nutrition" which was conducted by Detsky et al. ^[12] to assess the outcomes of eighteen controlled trials that assessed the efficacy of perioperative total parenteral nutrition and the randomized study by Sandstrom et al. (1993)^[13]. The latter study also concluded that total parenteral nutrition might reduce the complication rate, especially in malnourished patients. Bozzetti et al. (2000) ^[14] conducted a study on Perioperative TPN administration in Malnourished GI Cancer Patients. An occurrence of complications was observed in 37% patients receiving TPN. In comparison, the percentage of such an occurrence was noted as 57% of the control patients (p = 0.03). This difference was mainly due to non-infectious complications, with the difference being 12% vs. 34%, respectively (p = 0.02). The result however differs from the current study owing to administration of parenteral nutrition extended from pre-operative to post-operative while the current study was focused only on post-operative administration.

DURATION OF HOSPITAL STAY

The present study also demonstrates that immediate postoperative parenteral nutrition results in a reduced length of hospital stay (p value<0.05). Mean hospital stay in the study group was 9.23 while in the control group mean hospital stay was 10.97 days and the difference was statistically significant (p value< 0.05). The reduction in the hospital stay is likely due to reduced postoperative infective and non-infective complications due to administration of parenteral nutrition and reduced incidence of secondary suturing of the wounds and re-exploration as a result of reduced wound related complications and anastomotic leak, hence decreasing the duration of the stay at the hospital. These observations are supported by the study studies conducted by Ganaie et al. in their RCT and Askanazi et al.^[15] However, these results in the latter study underscored that in the aftermath of radical cystectomy, providing immediate postoperative nutritional support reduced the time span of hospitalization.

90 DAY MORTALITY

However, 90-day mortality rate was not modified through the administering of parenteral nutrition. There were three deaths in the study group. One of the patients was a known case of CAD, Second patient died of septicemia for anastomotic leak on 2nd postoperative day following revision surgery while the Third patient died of cardiopulmonary arrest on 8th postoperative day. Three deaths occurred in the control group of the study too. One patient died of septicemia on 4th post-operative day following laparotomy. Second patient died on 4th postoperative day as a consequence of multiorgan dysfunction due to sepsis while the Third patient died of cardiac arrest on 13th postoperative day. The difference in 90-day mortality in both the groups was statistically insignificant (p value>0.05). The same results were also found in a similar meta-analysis conducted by Lakananurak and Gramlich (2020)^[16] and Heyland et al^[17]. Similar to the current study, Sandstrom and colleagues (1993) studied the impact of postoperative intravenous feeding (TPN) on outcomes following major surgery in a randomized trial and concluded that TPN did not have a bearing on the overall mortality rate of surgical or critically ill patients.

Majority of the cases belonged to the age group 18-45 years while in terms of gender distribution, males had a higher percentage. Complications occurred in both the groups with surgical site infection and wound dehiscence taking the top spots. However, the incidence was less in cases as compared to the control group. Overall length of hospital stay was lesser in the study group while 90 day mortality was same in both groups.

STRENGTHS OF THE STUDY

The strength of this study lies in the fact that it attempted to explore whether instituting PN in postoperative period had a role in reducing postoperative complications and in early recovery and discharge of the patient.

LIMITATIONS OF THE STUDY

The study however is not without its limitations. The sample size chosen was small. Also, the duration of administration of PN was limited owing to the cost of the PN bags.

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