Malnourished Surgical Patients Research Articles

Effects of Postdischarge High-Protein Oral Nutritional Supplements and Resistance Training in Malnourished Surgical Patients: A Pilot Randomized Controlled Trial.

The presence of malnutrition is increasingly becoming a postdischarge problem in surgical patients. We aimed to investigate whether oral nutritional supplements combined with resistance training could minimize skeletal muscle atrophy in surgical patients after discharge. This randomized controlled study was conducted at the Department of Surgery, National Hospital of Faroe Islands from 2018 to 2020. A total of 45 patients aged 37–74 years participated and were allocated to one of three groups: diet (DI; n = 13), exercise and diet (EX + DI; n = 16), or control (CON; n = 16). The intervention period lasted 8 weeks. The intervention groups received individual dietary counselling and a protein-rich oral nutritional supplement twice a day containing 22 g of protein/day. Patients in the EX + DI group were assigned to resistance training sessions. Patients in the CON group received standard care. The primary outcome was change in lean body mass (LBM). Secondary outcomes were change in body weight, handgrip strength, quality of life, surgery-related side effects, energy and protein intake, length of stay and one-year mortality. To estimate within-group changes, linear mixed models including group–time interactions as fixed effects and patients as random effects were fitted. Within-group change in LBM was 233, 813 and 78 g in the DI, EX + DI and CON groups, respectively, with no significant between-group difference (p > 0.05). Pain score declined more (p = 0.04) in the EX + DI group compared with the CON group. Body weight, handgrip strength, quality of life and surgery-related side effects did not differ between groups. At the end of study, mean cumulative weight change in the DI and EX + DI groups was 0.4% and 1.6%, respectively, whereas the CON group experienced a weight loss of −0.6%. No significant difference in primary outcome between groups was noted. However, our results indicate some benefits from exercise and nutrition for malnourished surgical patients.

Study protocol for an open labelled randomised controlled trial of perioperative oral nutrition supplement in breast and colorectal cancer patients undergoing elective surgery

BackgroundWhile it is well established that perioperative use of oral nutrition supplement (ONS) improves nutrition status among severely malnourished surgical cancer patients, the evidence requires further substantiation for non-severely malnourished patients with cancer. This protocol paper presents the rationale and design of a randomised controlled trial to evaluate the effectiveness of preoperative as well as an extended 90-day postoperative use of ONS on nutritional and clinical outcomes among patients undergoing elective surgery for breast and colorectal cancer.MethodsPatients with primary breast and colorectal cancer undergoing elective surgery are recruited from two tertiary hospitals. Eligible patients are assigned into one of the three intervention arms: (i) Group SS will receive ONS in addition to their normal diet up to 14 days preoperatively and postoperatively up to discharge; (ii) Group SS-E will receive ONS in addition to their normal diet up to 14 days preoperatively, postoperatively up to discharge and for an extended 90 days after discharge; and (iii) Group DS will receive ONS in addition to their normal diet postoperatively up to discharge from the hospital. The ONS is a standard formula fortified with lactium to aid in sleep for recovery. The primary endpoints include changes in weight, body mass index (BMI), serum albumin and prealbumin levels, while secondary endpoints are body composition (muscle and fat mass), muscle strength (handgrip strength), energy and protein intake, sleep quality, haemoglobin, inflammatory markers (transferrin, high sensitivity C-reactive protein, interleukin-6), stress marker (saliva cortisol), length of hospital stay and postoperative complication rate.DiscussionThis trial is expected to provide evidence on whether perioperative supplementation in breast and colorectal cancer patients presenting with high BMI and not severely malnourished but undergoing the stress of surgery would be beneficial in terms of nutritional and clinical outcomes.Trial registrationClinicalTrial.gov NCT04400552. Registered on 22 May 2020, retrospectively registered

Impact of Artificial Nutrition on Postoperative Complications.

Malnutrition is common in surgical cancer patients and it is widely accepted that it can adversely affect their postoperative outcome. Assessing the nutritional status of every patient, in particular care of elderly and cancer patients, is a crucial feature of the therapeutic pathway in order to optimize every strategy. Evidence exists that the advantages of perioperative nutrition are more significant in malnourished patients submitted to major surgery. For patients recognized as malnourished, preoperative nutrition therapies are indicated; the choice between parenteral and enteral nutrition is still controversial in perioperative malnourished surgical cancer patients, although enteral nutrition seems to have the best risk–benefit ratio. Early oral nutrition after surgery is advisable, when feasible, and should be administered in all the patients undergoing elective major surgery, if compliant. In patients with high risk for postoperative infections, perioperative immunonutrition has been proved in some ways to be effective, even if operations including those for cancer have to be delayed.

The Role of Preoperative Parenteral Nutrition.

Malnutrition is associated with poor surgical outcomes, and therefore optimizing nutritional status preoperatively is very important. The purpose of this paper is to review the literature related to preoperative parenteral nutrition (PN) and to provide current evidence based guidance. A systemic online search of PubMed, Medline, and Cochrane Databases from January 1990 to February 2020 was done. Sixteen studies were included in this narrative review, including four meta-analyses and twelve clinical trials. The majority of studies have demonstrated benefits of preoperative PN on postoperative outcomes, including reduced postoperative complications (8/10 studies) and postoperative length of stay (3/4 studies). Preoperative PN is indicated in malnourished surgical patients who cannot achieve adequate nutrient intake by oral or enteral nutrition. It can be seen that most studies showing benefits of preoperative PN often included patients with upper gastrointestinal cancer and inflammatory bowel disease (10/12 studies), which gastrointestinal problems are commonly seen and enteral nutrition may be not feasible. When preoperative PN is indicated, adequate energy and protein should be provided, and patients should receive at least seven days of PN prior to surgery. The goal of preoperative PN is not weight regain, but rather repletion of energy, protein, micronutrients, and glycogen stores. Complications associated with preoperative PN are rarely seen in previous studies. In order to prevent and mitigate the potential complications such as refeeding syndrome, optimal monitoring and early management of micronutrient deficiencies is required.

Outpatient Preoperative Parenteral Nutrition in Malnourished Surgical Patients

Outpatient Preoperative Parenteral Nutrition in Malnourished Surgical Patients

Nutrition-Focused Quality Improvement Program Results in Significant Readmission and Length of Stay Reductions for Malnourished Surgical Patients.

Addressing nutrition needs of inpatients results in improved health outcomes. We conducted a post hoc analysis of previously published data. The aim of this analysis was to evaluate the clinical benefits of a nutrition quality improvement program (QIP) in surgical patients when compared with medical patients. Data were collected from 1269 QIP patients and 1319 historical controls. These combined 2588 patients were categorized into surgical (390, 15%) and medical (2198, 85%) patient subgroups. Readmission rate relative risk reductions were significantly higher among surgical patients when compared with the medical patients (46.9% vs 20.6%, P < .001). Average length of stay decreased significantly for both groups (29.0% and 29.6%, P = .8). Malnourished hospitalized surgical and medical patients experienced improved readmission rates and length of stay. However, surgical patients saw a significantly greater reduction in the readmission rate when compared with the medical patients, thus highlighting the importance of nutrition on surgical outcomes. The ClinicalTrials.gov Identifier for this study is NCT02262429.

Nutrition in the Post-surgical Patient: Myths and Misconceptions

Despite the large body of evidence supporting adequate early enteral nutrition (EN) in surgical patients, iatrogenic underfeeding is common. Myths and misconceptions persist and patients may receive suboptimal nutritional therapy as a result of outdated or uninformed practices. EN is safe and potentially beneficial in patients requiring vasopressor support. Early feeding proximal to a “fresh” anastomosis is safe. Routine monitoring of gastric residual volume (GRV) for tube feeding intolerance is no longer recommended, and routine post-pyloric feeding in patients without evidence of impaired gastric emptying does not lower the risk of aspiration. Awaiting the return of flatus before initiating post-operative feeding is not required. Albumin is not an accurate marker of nutritional adequacy in the hospital setting. Permissive underfeeding may not be beneficial for malnourished surgical patients. This article addresses myths and misconceptions of enteral nutrition in surgical patients.

Malnourished surgical patients undergoing major surgery: A preoperative multidisciplinary challenge

Pr. g/24h: LSG 109 20/ 62 7 Kcal tot/24h 2754 391/ 1359 189* Nonostante in entrambi i gruppi venga prescritta un’integrazione vitaminico-minerale con copertura totale delle RDA(3% BPG e 15% LSG ha sospeso multivitaminico), si determinano i seguenti stati carenziali: BPG0Fe:50%*;Mg:15%*; Vit.A:12%*;Vit.B1230%;Ac.Folico15%;Vit.D12%;Zn5% LSG0Fe:10%; Mg: 1%; Vit.A:1%; Vit.B1223%;Ac.Folico 25%;Vit.D 8%;Zn 5%. Conclusioni: Questo lavoro evidenzia un risultato sovrapponibile come riduzione del BMI a 2 anni tra BPG e LSG e conferma migliori risultati sugli indici metabolici nel BPG nonostante questo gruppo di pazienti abbia un apporto calorico significativamente superiore rispetto a LSG. Questo risultato pu o essere correlato al malassorbimento di nutrienti legato al BPG, che per o evidenzia una maggior presenza di stati carenziali, infatti e statisticamente significativo il deficit di Fe,Vit.A,Mg.E’ comunque presente uno stato carenziale di Vit.B12, Vit.D, Ac.Folico,Zn anche nel LSG. Probabilmente la copertura del 100% delle RDA non e sufficiente in alcuni casi e risulta comunque fondamentale un attento follow up per valutare la copertura dei fabbisogni e prevenire quindi stati carenziali che possono inficiare il risultato di questi interventi. Bibliografia: 1) Sj€ ostr€ om L, Lindroos AK, Peltonen M et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med 2004;351:268393. 2) Shah M, Simha V, Garg A. Review: long-term impact of bariatric surgery on body weight, comorbidities, and nutritional status. J Clin Endocrinol Metab. 2006;91(11):4223-31. 3) Sj€ ostr€ om L, Narbro K, Sj€ ostr€ om CD et al. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. N Engl J Med. 2007;23;357(8):741-52.

Could preoperative and postoperative optimal nutrition support modulate the inflammatory response and clinical outcome of severe malnourished surgical patients with gastrointestinal neoplasia?

Our aim was to assess whether perioperative and postoperative optimal 7-day nutrition support could modulate the inflammatory status and clinical outcome of severe malnourished patients with surgery for gastrointestinal neoplasia.

Percutaneous Endoscopic Gastrostomy in the Open Abdomen Patient

Nutrition support of critically ill patients is an integral element to their multimodal care. We describe the placement of a percutaneous endoscopic gastrostomy (PEG) for long-term enteral access in a patient with an open abdomen. To our knowledge, this is the third successfully reported case that demonstrates the viability of PEG in this uncommon population. In critically ill and malnourished surgical patients with contraindications for immediate abdominal closure, PEG should be strongly considered as a procedure for enteral feedings.

The Role of the Enteral Route and the Composition of Feeds in the Nutritional Support of Malnourished Surgical Patients

In surgical patients, malnutrition is an important risk factor for post-operative complications. In undernourished patients undergoing major gastrointestinal procedures, preoperative enteral nutrition (EN) should be preferred whenever feasible. It may be given either orally or by feeding tubes, depending on patient compliance. Early oral intake after surgery should be encouraged, but if an insufficient postoperative oral intake is anticipated, tube feeding should be initiated as soon as possible. The use of immunomodulating formulas offers significant advantages when compared to standard feeds and the positive results on postoperative complications seem independent from the baseline nutritional status. In malnourished patients, the optimal timing and dose of immunonutrition is unclear, but consistent data suggest that they should be treated peri-operatively for at least two weeks.

Perioperative nutrition in malnourished surgical cancer patients – A prospective, randomized, controlled clinical trial

Malnourished surgical patients are supposed to benefit from perioperative nutrition. It is unclear, however, whether enteral intervention really surpasses the parenteral one, and whether the modification of standard formula matters. The aim of the study was to evaluate the clinical value of the route and type of perioperative nutritional support. A group of 167 malnourished patients (91M, 76F, mean age 61.4 years) operated between June 2001 and December 2008 was randomly assigned during postoperative period to four groups according to nutritional intervention: enteral and parenteral, standard or immunomodulating. All patients received parenteral nutrition before surgery for 14 days, which provided homogenous groups for the postoperative evaluation. The trial was designed to test the hypothesis that enteral nutrition and/or immunonutrition can reduce the incidence of postoperative complications. The incidence of individual complications was comparable among all four groups (p>0.05). Infectious complications occurred in 23 of 84 patients with standard diets and in 20 of 83 patients receiving immunomodulatory formula (odds ratio 0.84; 95% CI 0.42 to 1.69). There were no significant differences in infectious complications' ratio in patients receiving enteral (24/84 patients) and parenteral formulas (19/83 patients). Neither immunomodulating formulas nor enteral feeding significantly affected the length of hospitalization, overall morbidity and mortality rates. Results demonstrated that postoperative nutritional intervention generates comparable results regardless of the route and formula used and that preoperative intervention is of the utmost importance. The study was registered in the Clinical Trials Database - number: NCT 00558155.

The immunomodulating enteral nutrition in malnourished surgical patients – A prospective, randomized, double-blind clinical trial

The immunomodulating nutrition was supposed to reduce the incidence of complications in surgical patients, but many authors have questioned its value recently. The aim of the study was to assess the impact of enteral immunonutrition in postoperative period. Between January 2003 and December 2009, 305 malnourished patients (123 F, 182 M, m. age 60.8) undergoing resection for pancreatic or gastric cancer, after preoperative 14 days of parenteral feeding, were randomized in double-blind manner to receive either postoperative immunomodulating enteral diet (IMEN) or standard oligopeptide diet (SEN). Outcome measures of the intend-to-treat analysis were: number and type of complications, length of hospitalization, mortality, and vital organ function. Median postoperative hospital stay was 17.1 days in SEN and 13.1 days in IMEN group (p = 0.006). Infectious complications were observed in 60 patients (39.2%) in SEN and 43 (28.3%) in IMEN group (p = 0.04). Differences were also observed in overall morbidity (47.1 vs 33.5%, p = 0.01) and mortality (5.9 vs 1.3%, p = 0.03), but the ratio of surgical complications, organ function, and treatment tolerance did not differ. The study proved that postoperative immunomodulating enteral nutrition should be the treatment of choice in malnourished surgical cancer patients. The Clinical Trials Database registry number: NCT00576940.

British consensus guidelines on intravenous fluid therapy for adult surgical patients (GIFTASUP) – Cassandra’s view

British consensus guidelines on intravenous fluid therapy for adult surgical patients (GIFTASUP) – Cassandra’s view

Parenteral nutrition and urban legends

To assess the recent literature regarding parenteral nutrition to identify publications that have purported to support various beliefs about the utility of parenteral nutrition, and then to critically evaluate the data presented in those (as well as prior) publications. Artificial nutrition improves nutritional markers but not clinical outcomes, suggesting that malnutrition is not causatively associated with a poor outcome. There are no convincing data that parenteral nutrition is beneficial in severely malnourished surgical patients. Glutamine supplementation of parenteral nutrition solutions may reduce the infectious complication rate, but it is unknown if glutamine-supplemented parenteral nutrition is better than no parenteral nutrition. Most, but not all, systematic reviews have demonstrated that enteral nutrition produces fewer problems than parenteral nutrition; no data suggest that either modality is better than doing no artificial nutrition. Randomized trials have not uniformly been able to demonstrate that parenteral nutrition is efficacious in acute pancreatitis. There is some, but not convincing, data that a regimen of glutamine, growth hormone, and a specialized diet will reduce the need for parenteral nutrition in patients with short bowel syndrome. It is important for clinicians to be able to critically evaluate the medical literature.

Randomized, Controlled Study of Branched Chain Amino Acid-Enriched Total Parenteral Nutrition in Malnourished Patients with Gastrointestinal Cancer Undergoing Surgery

The objective of this study was to investigate the potential benefit of branched chain amino acid (BCAA)-enriched total parenteral nutrition (TPN) for malnourished surgical patients with gastrointestinal cancer. Sixty-four malnourished patients with gastrointestinal cancer with elective surgical intervention were equally allocated into two groups to receive isonitrogenous and isocaloric TPN. All of them must have received TPN soon after surgery and were subsequently randomized and divided into either BCAA-enriched TPN (30% BCAA; intervention group) or standard TPN (24% BCAA; control group). Patient biochemical data, nutritional parameters, and clinical outcome were collected to analyze the significance of BCAA-enriched TPN. After a period of TPN, laboratory data, including white blood cell (WBC), C-reactive protein (CRP), alkaline phosphatase (ALK-P), and gamma-glutamyltransferase (gamma-GT) levels, were significantly different between these two groups (all P < 0.05). Decreasing white blood cell and C-reactive protein levels were observed in the intervention group that might partially explain the reduced numbers of infectious complications. Furthermore, elevating alkaline phosphatase and gamma-glutamyltransferase levels being also less prominent might indicate a lesser hepatic burden by using BCAA-enriched TPN. The BCAA-enriched TPN can maintain a patient's serum visceral protein (albumin and prealbumin) and positive nitrogen balance better than standard TPN (all P < 0.05). Furthermore, a prominently decreased frequency of postoperative morbidity was also found in the BCAA-enriched TPN group (P = 0.021) despite no difference regarding surgical mortality. Our observations show that BCAA-enriched TPN may be beneficial in improving the nutritional status and reducing postoperative complications for malnourished patients with gastrointestinal cancer undergoing major surgery.

Perioperative artificial nutrition in malnourished gastroin-testinal cancer patients

To investigate the potential role of perioperative nutrition in reducing complications and mortality in malnourished gastrointestinal cancer patients. Four hundred and sixty-eight elective moderately or severely malnourished surgical patients with gastric or colorectal cancers defined by the subjective global assessment (SGA) were randomly assigned to 7 d preoperative and 7 d postoperative parenteral or enteral nutrition vs a simple control group. The nutrition regimen included 24.6+/-5.2 kcal /kg per d non-protein and 0.23+/-0.04 g nitrogen /kg per d. Control patients did not receive preoperative nutrition but received 600+/-100 kcal non-protein plus or not plus 62+/-16 g crystalline amino acids postoperatively. Complications occurred in 18.3% of the patients receiving nutrition and in 33.5% of the control patients (P=0.012). Fourteen patients died in the control group and 5 in those receiving nutrition. There were significant differences in the mortality between the two groups (2.1% vs 6.0%, P=0.003). The total length of hospitalization and postoperative stay of control patients were significantly longer (29 vs 22 d, P=0.014) than those of the studied patients (23 vs 12 d, P=0.000). Perioperative nutrition support is beneficial for moderately or severely malnourished gastrointestinal cancer patients and can reduce surgical complications and mortality.

Rationale and indications for preoperative feeding of malnourished surgical cancer patients

involving 3047 patients with 11 different tumor types 3 found that patients with favorable subtypes of non-Hodgkin’s lymphomas, breast cancer, acute non-lymphocytic leukemia, and sarcomas had the lowest prevalence of weight loss (31% to 41%), whereas patients with unfavorable non-Hodgkin’s lymphoma, colon cancer, prostate cancer, and lung cancer had a 48% to 61% prevalence of weight loss. Patients with pancreatic or gastric cancer had the highest prevalence of weight loss (83% to 87%). Several studies have reported that patients with upper gastrointestinal malignancy and especially cancer of the esophagus are frequently affected by malnutrition, 11,18 ‐21 whereas 43% to 61% of patients with lung cancer have weight loss, depending on the stage of the disease. 22 In the ECOG study, 3 a positive relation was also demonstrated between these types of cancer and the prevalence and severity of weight loss.

Nutritional Approach in Malnourished Surgical Patients: A Prospective Randomized Study

Hypothesis: Perioperative administration of a supplemented enteral formula may decrease postoperative morbidity. Design: Randomized clinical trial. Setting: Department of surgery at a university hospital. Patients: One hundred ninety‐six registered malnourished patients (weight loss &gt; or = 10%) who were candidates for major elective surgery for malignancy of the gastrointestinal tract. Intervention: After randomization (n = 150), one group received postoperative enteral feeding with a standard diet within 12 hours of surgery (control group; n = 50). Another group orally received 1 L/d for 7 consecutive days of a liquid diet enriched with arginine, omega‐3 fatty acids, and RNA (preoperative group; n = 50). After surgery, patients were given the same standard enteral formula as the control group. A third group orally received 1 L/d for 7 consecutive days of the enriched liquid diet. After surgery, patients were given enteral feeding with the same enriched formula (perioperative group; n = 50). Main Outcome Measures: Postoperative complications and length of hospital stay. Results: The 3 groups were comparable for baseline demographics, biochemical markers, comorbidity factors, and surgical variables. The intent‐to‐treat analysis showed that the total number of patients with complications was 24 in the control group, 14 in the preoperative group, and 9 in the perioperative group (p = .02, control group versus perioperative group). Postoperative length of stay was significantly shorter in the preoperative (13.2 days) and perioperative (12.0 days) groups than in the control group (15.3 days) (p = .01 and p = .001, respectively, versus the control group). Conclusion: Perioperative immunonutrition seems to be the best approach to support malnourished patients with cancer.

A randomised controlled trial evaluating the use of enteral nutritional supplements postoperatively in malnourished surgical patients

BACKGROUNDPatients who undergo surgery are at risk of malnutrition due to periods of starvation, the stress of surgery, and subsequent increase in metabolic rate. There are limited data on nutritional...