Perioperative nutrition: parenteral versus enteral

Effects of fasting and preoperative feeding in children

AIM: To investigate whether children should undergo surgery without a long period of fasting after feeding.

METHODS: Eighty children with inguinoscrotal disorders (aged 1-10 years) were studied prospectively. They were divided into eight groups that each contained 10 children who were fed normal liquid food (NLF) and a high-calorie diet (HCD) 2, 3, 4 and 5 h before surgery, in two doses at 6-h intervals. NLF was given to four groups and HCD to the other four. In all groups, glucose, prealbumin and cortisol levels in the blood were measured twice: just after oral feeding and just before the operation. After the establishment of adequate anesthesia, gastric residue liquid was measured with a syringe.

RESULTS: Blood glucose levels in all patients fed NLF and HCD were high, except in patients in the HCD-4 group. There was no significant difference in the blood prealbumin levels. There was a significant increase in the blood cortisol levels in the NLF-2 (14.4 ± 5.7), HCD-2 (13.2 ± 6.0), NLF-3 (10.9 ± 6.4), and HCD-5 (6.8 ± 5.7) groups (P < 0.05).

CONCLUSION: The stress of surgery may be tolerated by children when they are fed up to 2 h before elective surgery.

Oxidative stress due to anesthesia and surgical trauma: importance of early enteral nutrition

Anesthesia and surgical trauma are considered major oxidative and nitrosative stress effectors resulting in the development of SIRS. In this study we evaluated the usefulness of early enteral nutrition after surgical trauma. Sixty male Wistar rats were subjected to midline laparotomy and feeding-gastrostomy. Twenty of these rats served as controls after recovering from the operation stress. The remaining rats received, through gastrostomy, enteral nutrition or placebo-feeding for 24 h. Oxidative stress markers and CC chemokine production were evaluated in rat serum and liver tissue. The operation itself was found to increase nitric oxide (NO) and malondialdehyde (MDA) and to decrease superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px), as well as liver tissue energy charge (EC) in relation to controls. The rats receiving enteral feeding exhibited statistically significantly lower levels of NO and MDA, and higher levels of SOD, GSH-Px, and liver EC, in relation to placebo feeding rats. The operation significantly increased the chemokines monocyte chemoattractant protein (MCP)-1 and regulated upon activation, normal T-cell expressed, and secreted (RANTES) in rat serum, while enteral nutrition caused a further significant increase in chemokine levels in serum. mRNA chemokine expression in liver was increased in a similar pattern. These findings indicate that early enteral feeding might play an important role after surgery ameliorating oxidative stress, affecting positively the hepatic EC and regulating, via chemokine production, cell trafficking, and healing process.

Enteral versus parenteral nutrition after gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials in the English literature

BACKGROUND

Although previous studies recommend the use of enteral nutrition (EN), the benefit of EN after elective gastrointestinal surgery has not been comprehensively demonstrated as through a meta-analysis. Our aim is to determine whether enteral nutrition is more beneficial than parenteral nutrition.

METHODS

A search was conducted on Medline, Web of Science, the Cochrane Library electronic databases, and bibliographic reviews. The trials were based on randomization, gastrointestinal surgery, and the reporting of at least one of the following end points: any complication, any infectious complication, mortality, wound infection and dehiscence, anastomotic leak, intraabdominal abscess, pneumonia, respiratory failure, urinary tract infection, renal failure, any adverse effect, and duration of hospital stay.

RESULTS

Twenty-nine trials, which included 2,552 patients, met the criteria. EN was beneficial in the reduction of any complication (relative risk (RR), 0.85; 95% confidence interval (CI), 0.74-0.99; P = 0.04), any infectious complication (RR, 0.69; 95% CI, 0.56-0.86; P = 0.001), anastomotic leak (RR, 0.67; 95% CI, 0.47-0.95; P = 0.03), intraabdominal abscess (RR, 0.63; 95% CI, 0.41-0.95; P = 0.03), and duration of hospital stay (weighted mean difference, -0.81; 95% CI, -1.25-0.38; P = 0.02). There were no clear benefits in any of the other complications.

CONCLUSION

The present findings would lead us to recommend the use of EN rather than PN when possible and indicated.

Preoperative Nutritional Status Predicts the Severity of the Systemic Inflammatory Response Syndrome (SIRS) Following Major Vascular Surgery

OBJECTIVES

This study examined the relationship between pre-operative nutritional status and systemic inflammatory response syndrome (SIRS) or sepsis following major vascular surgery.

DESIGN AND METHODS

Subjects undergoing open AAA repair, EVAR or lower limb revascularisation were studied prospectively. Pre-operative nutrition was assessed clinically using Mini-Nutritional Assessment (MNA) and body composition was measured by dual energy X-ray absorptiometry (DEXA) scanning. SIRS severity was assessed for 5 post-operative days and sepsis noted within 30 days of surgery.

RESULTS

Using MNA, neither SIRS severity nor sepsis occurrence differed significantly between 'well-nourished' subjects and those 'at risk of malnutrition'. Using DEXA, negative associations existed between body mass index and both SIRS score and SIRS duration. Fat free mass (FFM) was negatively associated with SIRS score and duration. Negative associations also existed between skeletal muscle mass (SMM) and SIRS score and duration. SMM was also negatively correlated with post-operative length of stay in hospital. There were no significant correlations between sepsis and any nutritional indices.

CONCLUSIONS

Lower pre-operative nutritional indices, indicating protein energy malnutrition, were associated with more severe systemic inflammatory responses following major vascular surgery.

Supportive nutrition on recovery of metabolism, nutritional state, health-related quality of life, and exercise capacity after major surgery: a randomized study

BACKGROUND & AIMS

The aim of this study was to investigate whether specialized supportive enteral and parenteral feeding have superior effects compared to oral nutrition on recovery during long-term postoperative treatment of cancer patients with preoperative weight loss and reduced maximum exercise capacity.

METHODS

One hundred twenty-six patients referred for resection of the esophagus (n = 48), stomach (n = 28), or pancreas (n = 50) were considered to be included before operation. Included patients (n = 80) received supportive enteral or parenteral nutrition postoperatively at home corresponding to 1000 kcal/d until the patients did not wish to continue with artificial nutrition for any reason. Patients randomized to oral nutrition only served as control subjects. Caloric intake, body composition (dual-energy x-ray absorptiometry), and respiratory gas exchanges at rest and during exercise were measured including health-related quality of life.

RESULTS

Survival and hospital stay did not differ among the groups, whereas overall complications were higher on artificial nutrition (P < .05). Changes in resting energy expenditure and biochemical tests did not differ during follow-up among the groups. Body weight and whole body fat declined similarly over time in all groups (P < .005), whereas lean body mass was unchanged during follow-up compared to preoperative values. Maximum exercise capacity and maximum oxygen consumption were normalized within 6 months postoperatively in all groups. There was no difference in recovery of food intake among the groups. Parenteral feeding was associated with the highest rate of nutrition-related complications, whereas enteral feeding reduced quality of life most extensively.

CONCLUSION

After major surgery, specialized supportive enteral and parenteral nutrition are not superior to oral nutrition only when guided by a dietitian.

Randomized clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care

BACKGROUND

Postoperative oral nutritional supplementation has been shown to be of clinical benefit. This study examined the clinical effects and cost of administration of oral supplements both before and after surgery.

METHODS

This was a randomized clinical trial conducted in three centres. Patients undergoing lower gastrointestinal tract surgery were randomized to one of four groups: group CC received no nutritional supplements, group SS took supplements both before and after surgery, group CS received postoperative supplements only, and group SC were given supplements only before surgery. Preoperative supplements were given from the time it was decided to operate to 1 day before surgery. Postoperative supplements were started when the patient was able to take free fluids and continued for 4 weeks after discharge from hospital. Data collected included weight change, complications, length of stay, nutritional intake, anthropometrics, quality of life and detailed costings covering all aspects of care.

RESULTS

Some 179 patients were randomized, of whom 27 were withdrawn and 152 analysed (CC 44, SS 32, CS 35, SC 41). Dietary intake was similar in all four groups throughout the study. Mean energy intake from preoperative supplements was 536 and 542 kcal/day in the SS and SC groups respectively; that 2 weeks after discharge from hospital was 274 and 361 kcal/day in the SS and CS groups respectively. There was significantly less postoperative weight loss in the SS group than in the CC and CS groups (P < 0.050), and significantly fewer minor complications in the SS and CS groups than the CC group (P < 0.050). There were no differences in the rate of major complications, anthropometrics and quality of life. Mean overall costs were greatest in the CC group, although differences between groups were not significant.

CONCLUSION

Perioperative oral nutritional supplementation started before hospital admission for lower gastrointestinal tract surgery significantly diminished the degree of weight loss and incidence of minor complications, and was cost-effective.

Surgical Management of Infiltrating Bladder Cancer in Elderly Patients

OBJECTIVES

To review the surgical therapeutic options in elderly patients with infiltrating bladder cancer.

METHODS

A review of the literature relevant to cystectomy and transurethral resection for infiltrating bladder cancer in elderly patients was conducted using Medline Services.

RESULTS

Thanks to progress in anaesthesia, intensive care and surgery, cystectomy now forms part of the classical treatments for bladder cancer in elderly patients, with acceptable mortality and morbidity rates. The recent series of cystectomies performed in patients over 75 years old report a mortality rate associated with the procedure of less than 4.5%. The global mortality rate in the same population ranges from 10 to 50%. These rates are now similar to those reported in the general population. The mean survival after cystectomy in patients over 75 years old is more than 2 years. Global survival at 5 years is between 37 and 68%. It is acknowledged by most authors that resection alone is associated with higher relapse and progression rates than cystectomy.

CONCLUSIONS

Cystectomy appears to be reasonable in elderly people who have a life expectancy of more than 2 years, provided that a rigorous pre-operative assessment and anaesthetic management are performed. Transurethral resection alone should be proposed only to patients with poor health status and/or very advanced age.

Study of the clinical effects of postoperative parenteral nutrition in 15 horses

Several clinical variables were compared in two groups of 15 horses recovering from resection and anastomosis of a strangulated small intestine; 15 were treated with parenteral nutrition and 15 were starved routinely. There was some evidence that parenteral nutrition had a short-lived adverse effect on both the catheter sites and gastric emptying, but there were no marked adverse clinical effects and no evidence of any improvement in the horses' condition.

New developments facilitating nutritional intake after gastrointestinal surgery

PURPOSE OF REVIEW

Conventional perioperative care includes a period of semistarvation before bowel function returns and adequate oral intake is allowed. It has been clearly shown that there is no need for restriction in oral intake after, at least lower, gastrointestinal surgery, and that early oral feeding does not increase the risk for dehiscense of the anastomosis. In contrast, early feeding reduces postoperative complications. Even if early oral intake is allowed, however, it is common that side effects such as nausea and vomiting prevent patients from reaching the target energy intakes. Thus, developing routines and treatments that promote sufficient early oral intake after surgery and maintain adequate energy intake in the postoperative period are probably of great importance for the outcome from surgery.

RECENT FINDINGS

There are a number of factors which may facilitate early oral intake after gastrointestinal surgery including effective pain relief using epidural anaesthesia while avoiding opioids, minimizing sodium and fluid administration perioperatively and substantially reducing preoperative fasting. In addition, sufficient preoperative information, intensive mobilization, energy-dense hospital food and oral supplements may all contribute to improved energy intake after surgery.

SUMMARY

In general, there is a great need for randomized controlled trials examining factors important for the regulation of oral intake after surgery and also the effects of early oral intake after upper gastrointestinal surgery. Future areas of research may also include regulation of appetite and use of peripherally acting opioid antagonists.

Nutritional assessment and support during pregnancy

This article thoroughly updates the authors' previous review of nutritional assessment and support during pregnancy. After briefly reviewing nutrient metabolism and requirements, the authors discuss the nutritional assessment of the pregnant woman and review the nutritional support principles in hyperemesis gravidarum and other conditions that can compromise the nutritional health of mother or fetus.

Multimodal strategies to improve surgical outcome

OBJECTIVE

To evaluate the effect of modifying perioperative care in noncardiac surgical patients on morbidity, mortality, and other outcome measures.

BACKGROUND

New approaches in pain control, introduction of techniques that reduce the perioperative stress response, and the more frequent use of minimal invasive surgical access have been introduced over the past decade. The impact of these interventions, either alone or in combination, on perioperative outcome was evaluated.

METHODS

We searched Medline for the period of 1980 to the present using the key terms fast track surgery, accelerated care programs, postoperative complications and preoperative patient preparation; and we examined and discussed the articles that were identified to include in this review. This information was supplemented with our own research on the mediators of the stress response in surgical patients, the use of epidural anesthesia in elective operations, and pilot studies of fast track surgical procedures using the multimodality approach.

RESULTS

The introduction of newer approaches to perioperative care has reduced both morbidity and mortality in surgical patients. In the future, most elective operations will become day surgical procedures or require only 1 to 2 days of postoperative hospitalization. Reorganization of the perioperative team (anesthesiologists, surgeons, nurses, and physical therapists) will be essential to achieve successful fast track surgical programs.

CONCLUSIONS

Understanding perioperative pathophysiology and implementation of care regimes to reduce the stress of an operation, will continue to accelerate rehabilitation associated with decreased hospitalization and increased satisfaction and safety after discharge. Developments and improvements of multimodal interventions within the context of "fast track" surgery programs represents the major challenge for the medical professionals working to achieve a "pain and risk free" perioperative course.

Nutritional support in the postoperative period

Nutritional support is used frequently as a treatment modality in the postoperative patient. Indications for nutrition support, patient selection, mode of administration, contents of solutions and complications of therapy are issues that the consulting internist must address. The role of a nutrition support team and optimal communication between the consultant and members of the surgical staff are emphasized.

Malnutrition in liver transplant patients: preoperative subjective global assessment is predictive of outcome after liver transplantation

BACKGROUND

Malnutrition is a common complication of end-stage liver disease. It is frequently not a priority of treatment before liver transplantation. The purpose of this study was to examine whether prospective preoperative nutritional assessment could predict resource utilization and outcome after liver transplantation.

METHODS

We retrospectively reviewed 109 sequential orthotopic liver transplants performed at our center between July 1996 and May 1999. Ten patients with fulminant hepatic failure were excluded from the study, leaving 99 patients. Nutritional status was determined at the time of transplantation using subjective global assessment. Wilcoxon rank sum test and rank analysis of variance were used to analyze the data. Results are reported as median (interquartile range). A P value <0.05 was considered significant.

RESULTS

Intraoperative transfusion requirements of packed red blood cells and cryoprecipitate was higher in the patients with severe malnutrition in comparison to the mild and moderate groups (severe vs. moderate, 5.5+/-5.5 vs. 3.0+/-6, P=0.026; vs. mild, 1.5+/-3, P<0.0001). The severe group required more fresh-frozen plasma intraoperatively than the mild group (mild vs. severe, 0+/-2 vs. 2+/-6, P=0.0007; vs. moderate, 1+/-4, P=0.071). Patients in the severe group had longer postoperative lengths of stay compared with patients in the moderate and mild groups (severe vs. moderate, 16+/-9 days vs. 10+/-5 days, P=0.0027; vs. mild, 9+/-8 days, P=0.0006).

CONCLUSIONS

Subjective global assessment is an excellent independent predictor of outcome in patients undergoing liver transplantation. Severely malnourished patients require more blood products during surgery and have prolonged postoperative length of stay in hospital. Our data suggest that if nutritional repletion is possible in patients with end-stage liver disease before transplantation, patient outcomes could be improved.

Effect of perioperative nutrition, with and without arginine supplementation, on nutritional status, immune function, postoperative morbidity, and survival in severely malnourished head and neck cancer patients

BACKGROUND

Malnourished head and neck cancer patients are at increased risk of postoperative complications.

OBJECTIVE

We studied the effect of perioperative, arginine-supplemented nutritional support on nutritional status, immune status, postoperative outcome, and survival in severely malnourished (weight loss >10% of body weight) head and neck cancer patients undergoing major surgery.

DESIGN

Forty-nine patients were randomly assigned to receive 1) no preoperative and standard postoperative tube feeding, 2) standard preoperative and postoperative tube feeding, or 3) arginine-supplemented preoperative and postoperative tube feeding.

RESULTS

Patients in both prefed groups received approximately 9 d of preoperative tube feeding, resulting in energy intakes of 110% and 113% of calculated needs (compared with 79% in the control group; P = 0.007). Compared with no preoperative feeding, preoperative enteral nutrition did not significantly improve nutritional status or any of the studied biochemical or immunologic indexes. Major postoperative complications occurred in 53%, 47%, and 59% of patients in study groups 1, 2, and 3 (NS). A trend was seen toward better survival in the arginine-supplemented group (P = 0.15). Secondary analysis showed that survivors had better human leukocyte antigen-DR expression on monocytes (P = 0.05) and higher endotoxin-induced cytokine production (P = 0.010 for tumor necrosis factor alpha and P = 0.042 for interleukin 6) at the start of the study than did patients who died.

CONCLUSIONS

Nine days of preoperative tube feeding, with or without arginine, did not significantly improve nutritional status, reduce the surgery-induced immune suppression, or affect clinical outcome in severely malnourished head and neck cancer patients. Patients supplemented with arginine-enriched nutrition tended to live longer. Some markers of immune function may distinguish patients with good or bad prognoses.

Enteral versus parenteral nutrition: a pragmatic study

Controversy persists as to the optimal means of providing adjuvant nutritional support. The aim of this study was to compare enteral nutrition (EN) and parenteral nutrition (TPN) in terms of adequacy of nutritional intake, septic and nonseptic morbidity, and mortality. This was a prospective pragmatic study, whereby the route of delivery of nutritional support was determined by the attending clinician's assessment of gastrointestinal function. Patients considered to have inadequate gastrointestinal function were given TPN (group 1), while those deemed to have a functioning gastrointestinal tract received EN (group 2). Patients in whom there was reasonable doubt as to the adequacy of intestinal function were randomized to receive either TPN (group 3) or EN (group 4). The trial setting was a large district general hospital with a dedicated nutrition team. A total of 562 patients were included in the study (331 males; median age 67 y). Gastrointestinal function on entry into the study was considered inadequate in 267 patients who were given TPN (group 1) and adequate in 231 whom received EN (group 2). There was clinical uncertainty about the adequacy of gut function in 64 patients (11.4%) who were randomized to receive either TPN (group 3, 32 patients) or EN (group 4, 32 patients). The incidence of inadequate nutritional intake was significantly higher in group 4 compared with group 3 (78.1% versus 25%, P < 0.001). Complications related to the delivery system and other feed-related morbidity were significantly more frequent in both EN groups compared with the respective TPN groups. EN was associated with a higher overall mortality in both nonrandomized and randomized patients. There were no significant differences observed in the incidences of septic morbidity between patients receiving TPN and those given EN. EN is associated with a higher incidence of inadequate nutritional intake, complications related to the delivery system, and other feed-related morbidity than TPN. There is no evidence from this study to support a difference between the two modalities in terms of septic morbidity. Patients in whom there is reasonable doubt as to the adequacy of gastrointestinal function should be fed by the parenteral route.

Nutrition support for individuals with liver failure

The prevalence of liver diseases is increasing in the United States, particularly as a result of the recent hepatitis C epidemic. In the past, patients who developed fulminant hepatic failure or cirrhosis owing to a chronic liver disease were likely to expire. During the last 15-20 years, liver transplantation has given these patients a chance at survival. Progressive nutrition deficiencies and muscle wasting are universal problems in these patients. Left untreated, the progressive wasting of liver disease leads to infection and an increased risk of death owing to infection both before and after transplantation. Aggressive nutritional support is essential to optimize the care of these patients and to enable them to obtain and survive a liver transplant and gain access to a new life following a successful liver engraftment.

Gut microenvironment and immune function

Overreaction of the acute phase response is responsible for the two major complications to surgery, sepsis and thrombosis, but also most likely for the leading sequela to surgery, adhesion formation. The gastrointestinal tract, especially the colon, is a major player in the acute phase response and responsible for important immune functions with important interactions between the commensal flora, mucosal cells and the mucosa/gut associated lymphoid tissues. These responses can effectively be modulated by enteral nutrition, provided it is properly composed and administered. There is increasing evidence that the important clinical effects sometimes observed in enteral nutrition are more related to immunostimulatory effects than to reduction in microbial translocation. It is suggested that in order to be effective enteral nutrition should be instituted if possible before the operation, but always at least immediately after. Furthermore, much supports that the formula given should contain what has been called colonic food, e.g. plant fibres, and have a low content of saturated fat. Use of antibiotics with deleterious effects on the commensal flora should also be limited as much as possible. Lack of compliance with these requests seems to explain the lack of consistency in clinical experience of enteral nutrition, when tried in connection with trauma and clinical surgery.