Perioperative nutrition in abdominal surgery: recommendations and reality

Yannick Cerantola, Fabian Grass, Alessandra Cristaudi, Nicolas Demartines, Markus Schäfer, Martin Hübner, Yannick Cerantola, Fabian Grass, Alessandra Cristaudi, Nicolas Demartines, Markus Schäfer, Martin Hübner

Abstract

Introduction. Preoperative malnutrition is a major risk factor for increased postoperative morbidity and mortality. Definition and diagnosis of malnutrition and its treatment is still subject for controversy. Furthermore, practical implementation of nutrition-related guidelines is unknown. Methods. A review of the available literature and of current guidelines on perioperative nutrition was conducted. We focused on nutritional screening and perioperative nutrition in patients undergoing digestive surgery, and we assessed translation of recent guidelines in clinical practice. Results and Conclusions. Malnutrition is a well-recognized risk factor for poor postoperative outcome. The prevalence of malnutrition depends largely on its definition; about 40% of patients undergoing major surgery fulfil current diagnostic criteria of being at nutritional risk. The Nutritional Risk Score is a pragmatic and validated tool to identify patients who should benefit from nutritional support. Adequate nutritional intervention entails reduced (infectious) complications, hospital stay, and costs. Preoperative oral supplementation of a minimum of five days is preferable; depending on the patient and the type of surgery, immune-enhancing formulas are recommended. However, surgeons' compliance with evidence-based guidelines remains poor and efforts are necessary to implement routine nutritional screening and nutritional support.

Figures

Figure 1
Figure 1
Pragmatic algorithm for preoperative nutritional screening and perioperative nutrition in digestive surgery. The algorithm resumes perioperative care in terms of nutrition in major abdominal surgery. It is largely based on recent systematic reviews and guidelines on perioperative nutrition [26, 27] and enhanced recovery [32]. aMajor abdominal surgery includes colorectal, gastric, liver, pancreatic, and esophageal resection for benign and malignant disease by either laparotomy or laparoscopic approach, lasting usually >2 h. bMajor upper GI surgery indicating preoperative IN regardless of nutritional status include oesophageal, gastric and pancreatic resection for cancer [26]. cdefined as anticipated perioperative starving >7 days and oral intake <60% of recommended for >10 days [26]. NRS: Nutritional Risk Score; pre-OP: pre-operative, IN: immunonutrition, SEN: standard enteral nutrition (usually whole protein formula). *currently evaluated by (http://www.clinicaltrial.gov; trial # NCT005122).

References

    1. Correia MITD, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clinical Nutrition. 2003;22(3):235–239.
    1. Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related malnutrition. Clinical Nutrition. 2008;27(1):5–15.
    1. Waitzberg DL, Caiaffa WT, Correia MITD. Hospital malnutrition: the Brazilian national survey (IBRANUTRI): a study of 4000 patients. Nutrition. 2001;17(7-8):573–580.
    1. Wyszynski DF, Perman M, Crivelli A. Prevalence of hospital malnutrition in Argentina: preliminary results of a population-based study. Nutrition. 2003;19(2):115–119.
    1. Kyle UG, Pirlich M, Schuetz T, Luebke HJ, Lochs H, Pichard C. Prevalence of malnutrition in 1760 patients at hospital admission: a controlled population study of body composition. Clinical Nutrition. 2003;22(5):473–481.
    1. Bozzetti F, Gianotti L, Braga M, Di Carlo V, Mariani L. Postoperative complications in gastrointestinal cancer patients: the joint role of the nutritional status and the nutritional support. Clinical Nutrition. 2007;26(6):698–709.
    1. Schiesser M, Müller S, Kirchhoff P, Breitenstein S, Schäfer M, Clavien PA. Assessment of a novel screening score for nutritional risk in predicting complications in gastro-intestinal surgery. Clinical Nutrition. 2008;27(4):565–570.
    1. Sorensen J, Kondrup J, Prokopowicz J, et al. EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome. Clinical Nutrition. 2008;27(3):340–349.
    1. Griep MI, Mets TF, Collys K, Ponjaert-Kristoffersen I, Massart DL. Risk of malnutrition in retirement homes elderly persons measured by the ’mini-nutritional assessment’. Journals of Gerontology. 2000;55(2):M57–M63.
    1. Correia M, Cravo M, Marques-Vidal P, et al. Serum concentrations of TNF-alpha as a surrogate marker for malnutrition and worse quality of life in patients with gastric cancer. Clinical Nutrition. 2007;26(6):728–735.
    1. Hiesmayr M, Schindler K, Pernicka E, et al. Decreased food intake is a risk factor for mortality in hospitalised patients: the NutritionDay survey 2006. Clinical Nutrition. 2009;28(5):484–491.
    1. Bozzetti F, Braga M, Gianotti L, Gavazzi C, Mariani L. Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial. Lancet. 2001;358(9292):1487–1492.
    1. Braga M, Gianotti L, Vignali A, Di Carlo V. Preoperative oral arginine and n-3 fatty acid supplementation improves the immunometabolic host response and outcome after colorectal resection for cancer. Surgery. 2002;132(5):805–814.
    1. Zheng Y, Li F, Qi B, et al. Application of perioperative immunonutrition for gastrointestinal surgery: a meta-analysis of randomized controlled trials. Asia Pacific Journal of Clinical Nutrition. 2007;16(supplement 1):253–257.
    1. Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. ESPEN guidelines for nutrition screening 2002. Clinical Nutrition. 2003;22(4):415–421.
    1. Moher D, Pham B, Klassen TP, et al. What contributions do languages other than English make on the results of meta-analyses? Journal of Clinical Epidemiology. 2000;53(9):964–972.
    1. Kondrup J, Ramussen HH, Hamberg O, et al. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clinical Nutrition. 2003;22(3):321–336.
    1. Braga M, Gianotti L, Nespoli L, Radaelli G, Di Carlo V. Nutritional approach in malnourished surgical patients. A prospective randomized study. Archives of Surgery. 2002;137(2):174–180.
    1. Antoun S, Rey A, Béal J, et al. Nutritional risk factors in planned oncologic surgery: what clinical and biological parameters should be routinely used? World Journal of Surgery. 2009;33(8):1633–1640.
    1. Robinson MK, Trujillo EB, Mogensen KM, Rounds J, McManus K, Jacobs DO. Improving nutritional screening of hospitalized patients: the role of prealbumin. Journal of Parenteral and Enteral Nutrition. 2003;27(6):389–395.
    1. Buzby GP, Williford WO, Peterson OL, et al. A randomized clinical trial of total parenteral nutrition in malnourished surgical patients: the rationale and impact of previous clinical trials and pilot study on protocol design. American Journal of Clinical Nutrition. 1988;47(supplement 2):357–365.
    1. Hemphill DJ, Sniderman KW, Allard JP. Management of total parenteral nutrition-related superior vena cava obstruction with expandable metal stents. Journal of Parenteral and Enteral Nutrition. 1996;20(3):222–227.
    1. Schiesser M, Kirchhoff P, Müller MK, Schäfer M, Clavien PA. The correlation of nutrition risk index, nutrition risk score, and bioimpedance analysis with postoperative complications in patients undergoing gastrointestinal surgery. Surgery. 2009;145(5):519–526.
    1. Korfali G, Gündoğdu H, Aydintuğ S, et al. Nutritional risk of hospitalized patients in Turkey. Clinical Nutrition. 2009;28(5):533–537.
    1. Gianotti L, Braga M, Nespoli L, Radaelli G, Beneduce A, Di Carlo V. A randomized controlled trial of preoperative oral supplementation with a specialized diet in patients with gastrointestinal cancer. Gastroenterology. 2002;122(7):1763–1770.
    1. Weimann A, Braga M, Harsanyi L, et al. ESPEN Guidelines on Enteral Nutrition: surgery including organ transplantation. Clinical Nutrition. 2006;25(2):224–244.
    1. Stratton RJ, Elia M. Who benefits from nutritional support: what is the evidence? European Journal of Gastroenterology and Hepatology. 2007;19(5):353–358.
    1. Akbarshahi H, Andersson B, Nordén M, Andersson R. Perioperative nutrition in elective gastrointestinal surgery—potential for improvement? Digestive Surgery. 2008;25(3):165–174.
    1. Senkal M, Zumtobel V, Bauer KH, et al. Outcome and cost-effectiveness of perioperative enteral immunonutrition in patients undergoing elective upper gastrointestinal tract surgery: a prospective randomized study. Archives of Surgery. 1999;134(12):1309–1316.
    1. Jeejeebhoy KN, Detsky AS, Baker JP. Assessment of nutritional status. Journal of Parenteral and Enteral Nutrition. 1990;14(5, supplement):193S–196S.
    1. Machado AN, Sitta MDC, Jacob Filho W, Garcez-Leme LE. Prognostic factors for mortality among patients above the 6TH decade undergoing non-cardiac surgery: (cares—clinical assessment and research in elderly surgical patients) Clinics. 2008;63(2):151–156.
    1. Lassen K, Soop M, Nygren J, et al. Consensus review of optimal perioperative care in colorectal surgery: enhanced Recovery after Surgery (ERAS) Group recommendations. Archives of Surgery. 2009;144(10):961–969.
    1. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database of Systematic Reviews. 2003;(4) Article ID CD004423.
    1. Lewis SJ, Andersen HK, Thomas S. Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: a systematic review and meta-analysis. Journal of Gastrointestinal Surgery. 2009;13(3):569–575.
    1. Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24 h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database of Systematic Reviews. 2006;(4) Article ID CD004080.
    1. El Nakeeb A, Fikry A, El Metwally T, et al. Early oral feeding in patients undergoing elective colonic anastomosis. International Journal of Surgery. 2009;7(3):206–209.
    1. Giger U, Büchler M, Farhadi J, et al. Preoperative immunonutrition suppresses perioperative inflammatory response in patients with major abdominal surgery—a randomized controlled pilot study. Annals of Surgical Oncology. 2007;14(10):2798–2806.
    1. Beattie AH, Prach AT, Baxter JP, Pennington CR. A randomised controlled trial evaluating the use of enteral nutritional supplements postoperatively in malnourished surgical patients. Gut. 2000;46(6):813–818.
    1. Smedley F, Bowling T, James M, et al. Randomized clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care. British Journal of Surgery. 2004;91(8):983–990.
    1. Finco C, Magnanini P, Sarzo G, et al. Prospective randomized study on perioperative enteral immunonutrition in laparoscopic colorectal surgery. Surgical Endoscopy and Other Interventional Techniques. 2007;21(7):1175–1179.
    1. Satinský I, Mitták M, Foltys A, Kretek J, Dostalík J. Comparison various types of artificial nutrition on postoperative complications after major surgery. Rozhledy v Chirurgii. 2005;84(3):134–141.
    1. Schilling J, Vranjes N, Fierz W, et al. Clinical outcome and immunology of postoperative arginine, ω-3 fatty acids, and nucleotide-enriched enteral feeding. A randomized prospective comparison with standard enteral and low calorie/low fat IV solutions. Nutrition. 1996;12(6):423–429.
    1. Daly JM, Lieberman MD, Goldfine J, et al. Enteral nutrition with supplemental arginine, RNA, and omega-3 fatty acids in patients after operation: immunologic, metabolic, and clinical outcome. Surgery. 1992;112(1):56–67.
    1. Daly JM, Weintraub FN, Shou J, Rosato EF, Lucia M. Enteral nutrition during multimodality therapy in upper gastrointestinal cancer patients. Annals of Surgery. 1995;221(4):327–338.
    1. Di Carlo V, Gianotti L, Balzano G, Zerbi A, Braga M. Complications of pancreatic surgery and the role of perioperative nutrition. Digestive Surgery. 1999;16(4):320–326.
    1. Braga M, Gianotti L, Radaelli G, et al. Perioperative immunonutrition in patients undergoing cancer surgery: results of a randomized double-blind phase 3 trial. Archives of Surgery. 1999;134(4):428–433.
    1. Farreras N, Artigas V, Cardona D, Rius X, Trias M, González JA. Effect of early postoperative enteral immunonutrition on wound healing in patients undergoing surgery for gastric cancer. Clinical Nutrition. 2005;24(1):55–65.
    1. Gianotti L, Braga M, Vignali A, et al. Effect of route of delivery and formulation of postoperative nutritional support in patients undergoing major operations for malignant neoplasms. Archives of Surgery. 1997;132(11):1222–1230.
    1. Jiang XH, Li N, Zhu WM, Wu GH, Quan ZW, Li JS. Effects of postoperative immune-enhancing enteral nutrition on the immune system, inflammatory responses, and clinical outcome. Chinese Medical Journal. 2004;117(6):835–839.
    1. Klek S, Kulig J, Sierzega M, et al. Standard and immunomodulating enteral nutrition in patients after extended gastrointestinal surgery—a prospective, randomized, controlled clinical trial. Clinical Nutrition. 2008;27(4):504–512.
    1. Klek S, Kulig J, Sierzega M, et al. The impact of immunostimulating nutrition on infectious complications after upper gastrointestinal surgery: a prospective, randomized, clinical trial. Annals of Surgery. 2008;248(2):212–220.
    1. Lassen K, Kjæve J, Fetveit T, et al. Allowing normal food at will after major upper gastrointestinal surgery does not increase morbidity: a randomized multicenter trial. Annals of Surgery. 2008;247(5):721–729.
    1. Jiang ZM, Gu ZY, Chen FL, et al. The role of immune enhanced enteral nutrition on plasma amino acid, gut permeability and clinical outcome (a randomized, double blind, controlled, multi-center clinical trail with 120 cases) Acta Academiae Medicinae Sinicae. 2001;23(5):515–518.
    1. Senkal M, Mumme A, Eickhoff U, et al. Early postoperative enteral immunonutrition: clinical outcome and cost-comparison analysis in surgical patients. Critical Care Medicine. 1997;25(9):1489–1496.
    1. Gunerhan Y, Koksal N, Sahin UY, Uzun MA, Ekşioglu-Demiralp E. Effect of preoperative immunonutrition and other nutrition models on cellular immune parameters. World Journal of Gastroenterology. 2009;15(4):467–472.
    1. Okamoto Y, Okano K, Izuishi K, Usuki H, Wakabayashi H, Suzuki Y. Attenuation of the systemic inflammatory response and infectious complications after gastrectomy with preoperative oral arginine and ω-3 fatty acids supplemented immunonutrition. World Journal of Surgery. 2009;33(9):1815–1821.
    1. Xu J, Zhong Y, Jing D, Wu Z. Preoperative enteral immunonutrition improves postoperative outcome in patients with gastrointestinal cancer. World Journal of Surgery. 2006;30(7):1284–1289.
    1. Jiang ZM, Wilmore DW, Wang XR, et al. Randomized clinical trial of intravenous soybean oil alone versus soybean oil plus fish oil emulsion after gastrointestinal cancer surgery. British Journal of Surgery. 2010;97(6):804–809.
    1. Wei C, Hua J, Bin C, Klassen K. Impact of lipid emulsion containing fish oil on outcomes of surgical patients: systematic review of randomized controlled trials from Europe and Asia. Nutrition. 2010;26(5):474–481.
    1. Sun LC, Shih YL, Lu CY, et al. Randomized, controlled study of branched chain amino acid-enriched total parenteral nutrition in malnourished patients with gastrointestinal cancer undergoing surgery. American Surgeon. 2008;74(3):237–242.
    1. Gianotti L, Braga M, Biffi R, Bozzetti F, Mariani L. Perioperative intravenous glutamine supplemetation in major abdominal surgery for cancer: a randomized multicenter trial. Annals of Surgery. 2009;250(5):684–689.
    1. Asprer JM, Llido LO, Sinamban R, Schlotzer E, Kulkarni H. Effect on immune indices of preoperative intravenous glutamine dipeptide supplementation in malnourished abdominal surgery patients in the preoperative and postoperative periods. Nutrition. 2009;25(9):920–925.
    1. Schindler K, Pernicka E, Laviano A, et al. How nutritional risk is assessed and managed in European hospitals: a survey of 21,007 patients findings from the 2007-2008 cross-sectional nutritionDay survey. Clinical Nutrition. 2010;29(5):552–559.

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