Impact of perioperative nutritional status on the outcome of abdominal surgery in a sub-Saharan Africa setting

Prevalence, impact, and management of adult disease-related malnutrition in African hospitals: A narrative review and insight from resource-limited clinical settings

Disease-related malnutrition (DRM) is a worldwide problem regarded as a global policy priority, but occurs on an exaggerated scale in Africa. While interpretation of studies is difficult due to the variety of nutrition assessment techniques, DRM in acute care in-patient African settings is commonly reported in the range of 45-75%, with nutritional risk reaching 84%. Challenges to the comprehensive management of DRM in the resource-limited clinical settings with few dietitians reviewed in this paper include the following: first, lack of routine nutrition screening resulting in more than 90% of malnourished or at-risk patients failing to receive nutrition support referrals, or receiving very delayed referrals. The result is worsening of nutritional status during hospital stay, clinical complications two to six times higher, up to a doubling of length of stay, and significantly higher mortality. Second, hospital structures are generally unsupportive of worthwhile nutritional care due to very poor or absent provision of nutritious oral diets, lack of multidisciplinary insight and collaboration, and the nonexistence of formalized nutrition support protocols and standards. Third, there is a grave lack of medical nutrition therapy (MNT) products and feeding pumps, forcing dietitians to improvise suboptimal formulations for enteral and parenteral feeding. Where MNT is available it is expensive and often not reimbursed, placing the responsibility for acquisition onto patients' families at their own expense. Urgent improvements in nutrition protocols adapted for resource-constrained contexts are needed, along with political commitment to facilitate the supply of suitable MNT products and equipment for use in hospitals.

Enhanced Surgical Recovery Nursing Program: A Multidisciplinary Approach to Optimize Postoperative Patient Recovery

Background

Enhanced recovery is currently considered to be the treatment of various elective major surgeries. Enhanced recovery after surgery (ERAS) includes applying various perioperative measures, strategies, and active participation of patients in the recovery process.

Materials and methods

A quasi-experimental study was conducted in the surgical units of a hospital in Karnataka, India. Data were collected from patients undergoing elective abdominal surgery (n = 142). Psychological (anxiety) and physiological outcomes (vital capacity, pulse, respiration, and blood pressure) were assessed in experimental and treatment-as-usual groups on preoperative day 1 (2 days before surgery) and preoperative day 2 (1 day before surgery).

Results

The results showed a significant decrease in the state-anxiety scores in the experimental group than in the treatment-as-usual group (p < 0.05). Physiological outcomes such as pain, pulse, respiration, and blood pressure showed a significant decrease in the experimental group than the treatment-as-usual group (p < 0.05). Vital capacity was significantly increased in the experimental group and decreased in the treatment-as-usual group in the postoperative days (p < 0.05). A significant decrease in the length of postoperative stay was seen in the experimental group than in the treatment-as-usual group (p = 0.001). In the experimental group, there were less postoperative complications than in the treatment-as-usual group.

Conclusion

Enhanced recovery is considered to be the treatment for various elective major surgeries. It is an essential responsibility of healthcare professionals to improve postoperative outcomes by reducing complications and length of postoperative hospital stay.

How to cite this article

Barboza HR, Dsilva F, Lobo AS, Moosabba MS, Gurmitkal B. Enhanced Surgical Recovery Nursing Program: A Multidisciplinary Approach to Optimize Postoperative Patient Recovery. Indian J Crit Care Med 2025;29(1):21-26.

Prevalence and related assessment practices of adult hospital malnutrition in Africa: A scoping review

BACKGROUND AND AIMS

Globally, hospital malnutrition prevalence is estimated at 20-50%, with little known about the situation in African hospitals. The aim of this scoping review was to appraise the current evidence base regarding the prevalence of adult hospital malnutrition and related assessment practices in an African context.

METHODS

A comprehensive and exhaustive search strategy was undertaken to search seven electronic bibliographic databases (including Africa-specific databases) from inception until August 2022 for articles/resources reporting on the prevalence of adult hospital malnutrition in an African setting. Two reviewers independently reviewed abstracts and full-text articles and data extraction was undertaken in duplicate.

RESULTS

We screened the titles and abstracts of 7537 records and included 28 studies. Most of the included studies were conducted in the East African region (n = 12), with ten studies from South Africa. Most studies were single-centre studies (n = 22; 79%), including 23 to 2126 participants across all studies. A variety of study populations were investigated with most described as medical and surgical populations (n = 14; 50%). Malnutrition risk prevalence was reported to be between 23% and 74%, using a variety of nutritional screening tools (including MNA-SF/LF, NRS-2002, MUST, NRI, GNRI). Malnutrition prevalence was reported to be between 8% and 85%, using a variety of tools and parameters, including ASPEN and ESPEN guidelines, SGA, MNA-SF/LF, anthropometric and biochemical indices, with one study using the GLIM criteria to diagnose malnutrition.

CONCLUSIONS

Both malnutrition risk and malnutrition prevalence are alarmingly high in African adult hospitalised patients. The prevalence of malnutrition differs significantly among studies, owing in part to the variety of tools used and variability in cut-offs for measurements, underscoring the importance of adopting a standardised approach. Realities in the African context include limited nutritional screening and assessment, poor referral practices, and a unique disease burden. General awareness is needed, and routine nutritional screening practices with appropriate nutrition support action should be implemented as a matter of urgency in African hospitals.

Identifying malnutrition in emergency general surgery: systematic review

BACKGROUND

Emergency general surgery practice is high risk. Surgery is a key part of treatment, with resultant catabolic stress and frequent need for nutritional support. The aim of this study was to examine the current methods of defining and determining malnutrition in emergency general surgery. This included examining the use of nutrition screening and assessment tools and other measures of malnutrition.

METHODS

MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, trial registries, and relevant journals published between January 2000 and January 2022 were searched for studies of adult patients with any emergency general surgery diagnosis, managed conservatively or operatively, with an assessment of nutritional status. Mixed populations were included if more than 50 per cent of patients were emergency general surgery patients or emergency general surgery results could be separately extracted. Studies in which patients had received nutritional support were excluded. The protocol was registered with PROSPERO, the international prospective register of systematic reviews (CRD42021285897).

RESULTS

From 6700 studies screened, 324 full texts were retrieved and 31 were included in the analysis. A definition of malnutrition was provided in 23 studies (75 per cent), with nutritional status being determined by a variety of methods. A total of seven nutrition screening tools and a total of nine 'assessment' tools were reported. To define malnutrition, the most commonly used primary or secondary marker of nutritional status was BMI, followed by albumin level.

CONCLUSION

Wide variation exists in approaches to identify malnutrition risk in emergency general surgery patients, using a range of tools and nutrition markers. Future studies should seek to standardize nutrition screening and assessment in the emergency general surgery setting as two discrete processes. This will permit better understanding of malnutrition risk in surgical patients.

A Prospective Review of Preoperative Nutritional Status and Its Influence on the Outcome of Abdominal Surgery

Aim

To assess the incidence of malnutrition in a surgical gastroenterology unit and analyze its impact on postoperative complication rates.

Method

Data were prospectively accrued from patients admitted for emergency or elective surgery to the gastrointestinal surgery unit at Jaslok Hospital between May 2013 and May 2014. The nutritional status was preoperatively assessed by using anthropometric parameters like body mass index (BMI), midarm circumference (MAC), and tissue skinfold thickness (TSFT). In addition, a subjective global assessment scale (SGA), serum albumin, and absolute lymphocyte count (ALC) were used. Patients with BMI <18.5, MAC <24 cm in males and <22 cm in females, and TSFT <10 mm were considered malnourished. Patients with serum albumin between 3 and 3.5 g/dl were considered mild, 2.4-2.9 g/dl was moderate, and <2.4 g/dl were severely malnourished. Patients with ALC between 1200 and 2000/cm were labelled mild, between 800 and 1199/cm were moderate, and <800/cm were severely malnourished. As per SGA, well-nourished had less than 5% weight loss or if more than 5%, with recent gain and improved appetite, mild/moderately malnourished had 5% to 10% weight loss with no gain, mild subcutaneous fat loss, and those severely malnourished had more than 10% weight loss, severe subcutaneous fat loss, and muscle wasting. Postoperative complications were graded as per the Clavien-Dindo classification. Patients with grades 1 and 2 complications were labelled as minor and the rest as major.

Result

Men in the age group of 40-60 years comprised the majority of the study population. The most frequent reason for admission was cholelithiasis. The overall incidence of malnutrition was 22.16%. Out of the 96 patients who had complications, 45 had minor and 41 had significant complications. Amongst the well-nourished, the incidence of complications was 26.62% of which the majority were minor complications. Severely malnourished patients had a high complication rate (63.38%); 32% out of the 63.38% developed significant complications. The majority of the patients suffering from severe malnutrition belonged to the sub-group with chronic pancreatitis and carcinoma of the pancreas. According to the chi-square analysis of the data, ALC, serum albumin, and SGA correlate with the postoperative complication rate with a p-value <0.05 as significant. On the contrary, BMI, MAC, and TSFT did not correlate with postoperative complications.

Conclusion

Preoperative malnutrition is common among patients undergoing abdominal surgeries in the urban private health care sector. Although there have been studies that have analyzed the incidence of malnutrition in patients undergoing oncological surgeries, there is limited literature on malnutrition among patients subjected to gastrointestinal surgeries. We conclude that simple bedside nutritional assessment tools like serum albumin, absolute lymphocyte count, and SGA can accurately identify malnourished patients preoperatively and are good predictors of postoperative complications. Hence, it is imperative to assess and attempt to improve the nutritional status of the patients preoperatively.

Low Food Consumption Interferes with the Nutritional Status of Surgical Patients with Neoplasia of the Gastrointestinal Tract

Nutritional support strongly influence the nutritional status of the surgical neoplastic patients. This study aimed to evaluate the influence of food consumption on the perioperative nutritional status of hospitalized patients with neoplasia of the upper (UGIT) and lower (LGIT) gastrointestinal tract. Methods: Observational, longitudinal, and prospective study. Data collected: food consumption, Subjective Global Assessment, anthropometry, laboratory tests. Results: Eighty patients were followed up: 43 (54%) in the UGIT and 37 (46%) in the LGIT. The consumption in the perioperative period was lower than the usual consumption in the UGIT and LGIT groups, respectively, of energy (14.2 ± 6.5; 22.8 ± 11.2 Kcal/kg/d, p < 0.001; 13.6 ± 1.2; 19.0 ± 2.0 Kcal/kg/d; p = 0.014), protein (1.1 ± 0.7; 0.6 ± 0.3 g/kg/d, p < 0.001; 0.8 ± 0.1; 0.5 ± 0.1 g/kg/d; p = 0.058), selenium, zinc and copper. Most patients presented in the UGIT and LGIT groups, respectively, worsening malnutrition and muscle depletion according to the Subjective Global Assessment (61.9%; 51.4%) and hypoalbuminemia, mainly in the UGIT in the postoperative. Conclusion: Low food consumption during the perioperative period associated with prolongation of the postoperative fasting period worsens the nutritional status of patients undergoing surgery of the gastrointestinal tract for neoplasia, especially in the UGIT group.

Malnutrition in the Outcome of Wound Healing at Public Hospitals in Bahir Dar City, Northwest Ethiopia: A Prospective Cohort Study

Background

Poor nutritional status affects the normal process of the wound healing stage. There is limited evidence regarding the association between malnutrition and wound healing in Ethiopia.

Objective

To assess the association between nutritional status and wound healing progress among adult individuals who had undergone abdominal surgery at Public Hospitals, Ethiopia.

Methods

A prospective cohort study was conducted on 310 adult patients who had undergone abdominal surgery from August to December 2019. Data were collected using a standardized, structured, and pretested questionnaire. Anthropometric and serum albumin measurements were used to measure nutritional status. A multivariable Cox-regression analyses model was fitted to show the association between malnutrition and wound healing and p value < 0.05 was used to declare statistical significance value.

Results

The cumulative incidence rate of good wound healing was 65.5% (95% CI: 60.0–71.0). Patients who had normal preoperative body mass index (adjusted hazard ratio (AHR) = 2.22 (95% CI: 1.55–3.19)) and normal range of serum albumin level (≥3.5) (AHR = 1.56 (95% CI: 1.05–2.29)) were significantly associated with better wound healing outcomes.

Conclusion

Nutritional status had a strong association with good wound healing outcomes. Therefore, nutritional status screening should be done for all adult patients before undergoing abdominal surgery to improve wound healing outcomes and reduce hospital stays.

Malnutrition in Acute Care Surgery Patients in Rwanda

INTRODUCTION

Malnutrition is prevalent in hospitalized surgical patients and has been shown to significantly alter outcomes including length of hospital stay, complications, and mortality. Different tools for nutrition assessment were developed and are being used. The aim of this study was to characterize the nutritional status of acute care surgery patients, determine risk factors for malnutrition, and describe outcomes in patients with malnutrition.

METHODS

This was a prospective, descriptive study of malnutrition in acute care surgery patients at CHUK. Over a 6-month time period, we collected data on demographics, diagnosis, operation, and patient outcomes. We assessed the incidence of malnutrition using the American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines and Subjective Global Assessment (SGA). We reported frequencies and percentages for categorical variables and median and interquartile range (IQR) for continuous variables.

RESULTS

We analyzed data for 279 acute care surgery patients. Most (n = 209, 73%) patients were male. The median duration of symptoms was 5 days (IQR 2, 14). The most common diagnoses were trauma (n = 83, 30%), intestinal obstruction (n = 76, 27%), and peritonitis (n = 49, 18%). Most (n = 210, 73%) patients underwent operation. The median length of hospital stay was 6 days (IQR 4, 11). Using ASPEN guidelines, 99 (35%) patients had evidence of malnutrition on hospital admission and 76 (27%) had evidence of malnutrition using SGA. After 1 week of hospital stay, 48 (41%) patients had evidence of malnutrition. Overall mortality was 3%, with higher mortality seen in patients with malnutrition (8% vs. 0.6%, p = 0.001). The length of hospital stay was longer in patients with malnutrition on hospital admission (6 days vs. 5 days, p = 0.044).

CONCLUSIONS

Acute care surgical patients present to the hospital at high-risk for malnutrition. Efforts are needed to ensure that surgical patients receive adequate nutrition support to improve patient outcomes and minimize complications.

Postoperative Complications and Risk of Mortality after Laparotomy in a Resource-Limited Setting

BACKGROUND

Despite increases in surgical capacity in Malawi, minimal data exist on postoperative complications. Identifying surgical management gaps and targeting quality improvement requires detailed, longitudinal complications, and outcome data that assess surgical safety and efficacy.

METHODS

We conducted a 6-mo prospective, observational study of patients >12 y after laparotomy at a tertiary hospital in Lilongwe, Malawi. Outcomes included postoperative complications and mortality. The seniormost rounding physician determined complication diagnoses. Bivariate and Poisson regression analyses identified predictors of mortality.

RESULTS

Only patients undergoing emergent laparotomy (77.8%) died before discharge, so analysis excluded elective cases. Of 189 patients included, the median age was 33.5 y (IQR 22-50.5), 22 (12.2%) had prior abdominal surgery, and 11 (12.1%) were human immunodeficiency virus-positive. Gastrointestinal perforation was the most common diagnosis (35.5%). The most common procedures were primary gastrointestinal repair (24.9%), diverting ostomy (21.2%), and bowel resection with anastomosis (16.4%). Overall postoperative mortality was 14.8%. Intra-abdominal complication occurred in 17 (9.0%) patients, of whom 8 (47.1%) died. Older age (RR 1.05, 95% CI 1.02-1.08, P < 0.001) and intra-abdominal complication (RR 2.88, 95% CI 1.28-6.46, P = 0.01) increased the relative risk of mortality. Preoperative diagnosis, surgical intervention type, and symptom-to-surgery time did not increase the relative risk of mortality.

CONCLUSIONS

The incidence of complications and mortality after laparotomy at a large referral hospital in Malawi is high. Older age and intra-abdominal complications increase the risk of death. Strategies to improve operative mortality in Malawi should prioritize postoperative surveillance and management and continued outcomes reporting.

Perioperative mortality as a meaningful indicator: Challenges and solutions for measurement, interpretation, and health system improvement

Expanding global access to safe surgical and anaesthesia care is crucial to meet the health targets of the Sustainable Development Goals (SDGs). As global surgical volume increases, improving safety throughout the patient care pathway is a public health priority. At present, an estimated 4.2 million individuals die within 30 days of surgery each year, and many of these deaths are preventable. Important considerations for the collection and reporting of perioperative mortality data have been identified in the literature, but consensus has not been established on the best methodology for the quantification of excess surgical mortality at a hospital or health system level. In this narrative review, we address challenges in the use of perioperative mortality rates (POMR) for improving patient safety. First, we discuss controversies in the use of POMR as a health system indicator and suggest advantages for using a "basket" of procedure-specific mortality rates as an adjunct to gross POMR. We offer then solutions to challenges in the collection and reporting of POMR data, and propose interventions for improving care in the preoperative, operative, and postoperative periods. Finally, we discuss how health systems leaders and frontline clinicians can integrate surgical safety into both national health plans and patient care pathways to drive a sustainable safety revolution in perioperative care.

Preoperative Nutritional Status and Its Consequences on Abdominal Surgery in Wolaita Zone, Southern Ethiopia: An Institution-Based Observational Study

This study aimed to determine the prevalence of malnutrition and its association with wound healing and length of hospitalization among patients undergoing abdominal surgery admitted to hospitals in the Wolaita zone in southern Ethiopia. Methods. An institution-based prospective observational study was conducted in three hospitals in the Wolaita zone from August to October 2016. All eligible individuals aged between 19 and 55 years were recruited in this study. Anthropometric and biochemical analyses, such as serum albumin (Alb) and total lymphocyte count (TLC), were taken for nutritional assessment during the preoperative period. Quantitative variables were compared using Student's t test. Cox's regression was employed to determine which variables were possible risk factors for poor wound healing. Results. A total of 105 patients aged 19 to 55 with a mean age (±SD) of 34 ± 9.6 years were included, and the prevalence of preoperative malnutrition was 27.6%, 87%, according to BMI and nutritional risk index, respectively. Poor wound healing was significantly associated with underweight patients (BMI < 18.5 kg/m²) (AHR: 6.5 : 95%CI: 3.312.9), postoperative weight loss (AHR: 4.9; 95%CI: 2.8–8.5), and nutritional risk index (NRI) less than 97.5 (AHR 1.8; 95% CI: 1.09–3.1). Conclusion. The prevalence of malnutrition is high in our study setup; this is associated with an increased risk of adverse postoperative outcomes. Therefore, our results emphasize the need of routine preoperative nutritional assessment, optimizing nutritional status of patients and postoperative nutritional support.

Perioperative management of gastrointestinal surgery in a resource-limited hospital in Niger: Cross-sectional study

Background

Perioperative management in digestive surgery is a challenge in sub-Saharan Africa. Objective: To describe the process and outcomes of perioperative management in gastrointestinal surgery.

Materials and methods

This was a single center cross-sectional study over a 4-month period from June 1 to September 30, 2017, in a Nigerien hospital (West Africa). This study included caregivers and patients operated on gastrointestinal surgery.

Results

We collected data for 56 caregivers and 253 patients underwent gastrointestinal surgery. The average age of caregivers was 38.6 ± 8.7. The median length of professional practice was 9 years. Almost 52% of caregivers (n = 29) did not know the standards of perioperative care. The median age of patients was 24 years, and male gender constituted 70% of cases (n = 177) with a sex ratio of 2.32. Patients came from rural areas in 78.2% (n = 198). Emergency surgery accounted for 60% (n = 152). The most surgical procedure was digestive ostomies performed in 28.9% (n = 73), followed by hernia repair and appendectomy in 24.5% (n = 62) and 13.9% (n = 35) respectively. The postoperative course was complicated in 28.1% (n = 71) among which 13 deaths. In the group of caregivers, the poor practice of perioperative management was associated with poor professional qualification, insufficient equipment, insufficient motivation (p < 0.05). The ASA3&ASA4 score, undernutrition, emergency surgery, poor postoperative monitoring, and poor psychological preparation were associated with complicated postoperative outcomes (p < 0.05).

Conclusion

The inadequacy of the technical platform and the lack of continuous training for healthcare staff represented the main dysfunctions of our hospital. The risk factors for complications found in this study need appropriate perioperative management to improve prognosis in gastrointestinal surgery.

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Perioperative care in gastrointestinal surgery in a challenge in Sub-Saharan countries.

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This setting is characterised by the difficulty of geographical access to hospital, lack of equipment.

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Risk factors for complications are multifactorial.

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This study can be a draft for improvement the quality of care in low resource settings.

Pharmacist-driven multidisciplinary initiative continuously improves postoperative nausea and vomiting in female patients undergoing abdominal surgery

WHAT IS KNOWN AND OBJECTIVE

The incorrect or insufficient prophylaxis of postoperative nausea and vomiting (PONV) is common in practice. A clinical pharmacist-led guidance team (CPGT) was established and included in general surgery teams.

OBJECTIVE

This study aimed to evaluate the effects of the CPGT on the improvement of PONV and prophylaxis administration.

METHODS

A prospective before-after study was conducted on 156 female patients undergoing abdominal surgery at a Chinese tertiary teaching hospital from December 2016 to December 2017. A total of 82 patients were enrolled in the preintervention period, and 74 patients were included in the post-intervention period. The CPGT established the evidence-based criteria for prophylactic anti-emetic administration and conducted interventions, including a review of medical records, provision of feedback, educational outreach, and dedicated support. Primary outcomes included the incidence of PONV within 24 hours of surgery, administered number of prophylactic anti-emetics, and accuracy of the timing for prophylactic anti-emetics. Outcomes were analysed by logistic regression or multivariable linear regression.

RESULTS AND DISCUSSION

After intervention, patients reported significantly less PONV (33.78% vs 56.10%; odds ratio [OR]: 0.29; numbers needed to treat [NNT]: 3.47), vomiting (29.73% vs 45.12%; OR: 0.42; NNT: 5.16) and nausea (31.08% vs 56.10%; OR: 0.24; NNT: 3.19) within 24 hours of surgery. The accuracy of the timing for prophylactic anti-emetics significantly increased (OR: 3.66; P: .003). Anaesthesiologists administered increased numbers of prophylactic anti-emetics (OR: 5.82; P < .001). The improvement of PONV did not decrease during the four-month period after intervention (P: .639).

WHAT IS NEW AND CONCLUSION

The CPGT is a valuable service model to continuously improve PONV and optimize prophylaxis administration.

Ethics in Global Surgery

As the population increases in the world's poorest countries, the need for surgical interventions will increase. Short-term surgical missions can play an important role in increasing access to solve this disparity by providing much-needed surgical services to vulnerable populations in low-income and middle-income countries. As short-term surgical missions increase, it is important that basic ethical principles are a foundation in service delivery. By following ethical principles outlined in this article, abiding by common moral language, and establishing long-term relationships, a significant contribution can be made to global surgery to increase access and deliver high-quality surgery.