Perioperative Nutritional Management Research Articles

Perioperative glycemic and nutritional management of 32 patients undergoing total pancreatectomy

Perioperative glycemic and nutritional management of 32 patients undergoing total pancreatectomy

Carbohydrate loading and fluid management within enhanced recovery

Enhanced recovery pathways (ERP) are focused on improving perioperative patient care to reduce postoperative complications and improve outcomes. ERP includes elements of preoperative preparation, fluid management, anesthesia and analgesia, and perioperative nutrition and mobilization. Significant evidence suggests that traditional non-evidence-based perioperative nutritional and fluid management dogmas that prolong fasting and promote fluid overload should be abandoned. Carbohydrate loading has been shown to be safe in non-diabetic patients while also reducing postoperative insulin resistance. Evidence suggest that perioperative fluid overload and restriction should be avoided, and near-zero homeostasis should be the goal of perioperative fluid management. Goal-directed fluid therapy (GDFT) has shown to be safe in most patients and could be beneficial in high-risk patients.

Impact of a Geriatric Intervention to Improve Screening and Management of Undernutrition in Older Patients Undergoing Surgery for Colorectal Cancer: Results of the ANC Stepped-Wedge Trial

Almost two in three patients who are aged 75 years and older and scheduled for surgery for colorectal cancer (CRC) are undernourished. Despite evidence that perioperative nutritional management can improve patients outcomes, international guidelines are still insufficiently applied in current practice. In this stepped-wedge cluster-randomized study of five surgical hospitals, we included 147 patients aged 70 years or older with scheduled abdominal surgery for CRC between October 2013 and December 2016. In the intervention condition, an outreach team comprising a geriatrician and a dietician visited patients and staff in surgical wards to assist with the correct application of guidelines. Evaluation, diagnosis, and prescription (according to nutritional status) were considered appropriate and strictly consistent with guidelines in 39.2% of patients in the intervention group compared to only 1.4% in the control group (p = 0.0002). Prescription of oral nutritional supplements during the perioperative period was significantly improved (41.9% vs. 4.1%; p < 0.0001). However, there were no benefits of the intervention on surgical complications or adverse events. A possible benefit of hospital stay reduction will need to be confirmed in further studies. This study highlights the importance of the implementation of quality improvement interventions into current practice for the perioperative nutritional management of older patients with CRC.

Perioperative instrumental swallowing evaluation in adult airway reconstruction: A retrospective observational cohort study.

Airway reconstruction for laryngotracheal stenosis (LTS) encompasses several procedures. Dysphagia is a well-recognised sequela of LTS and airway surgery, however studies have employed mostly non-validated assessments post-operatively in small, heterogenous samples, perpetuating uncertainty around the contributions of LTS and its management to impaired deglutition. Consequently, considerable variation in LTS perioperative nutritional management exists. Our objective was to characterise baseline and post-operative dysphagia with instrumental assessment in an LTS cohort undergoing airway reconstruction and provide a gold-standard management framework for its management. We performed a retrospective cohort study of adult airway reconstruction procedures from 2016-2020 at our quaternary centre. Patient background, LTS aetiology, procedure type, tube feeding duration, length of stay and serial Functional Oral Intake Scale (FOIS) and International Dysphagia Diet Standardisation Initiative (IDDSI) scores were noted. Baseline, post-operative day one and post-stent removal Fibreoptic Endoscopic Evaluation of Swallow (FEES) generated Penetration Aspiration Scale (PAS) scores. Forty-four patients underwent forty-six reconstructions. Baseline incidence of penetration-aspiration was considerably higher than the general population and worsened in the immediate post-operative period, however FOIS and PAS scores generally returned to baseline by discharge. Post-operative FOIS correlated negatively with tracheostomy or airway stent placement. At discharge, 80% tolerated soft or normal diet and 93% were feeding tube independent. We present the largest adult airway reconstruction cohort with instrumental swallow assessment perioperatively. LTS patients have a higher incidence of underlying dysphagia but swallowing tends to return to baseline with appropriate postoperative rehabilitation. Such practice may avoid the complications, costs and morbidity of prolonged nutritional support.

Consensus guidelines are required for the peri-operative nutritional assessment and management of patients who undergo surgical resection for suspected pancreatic cancer

Surgical resection remains the only treatment option for patients with pancreatic cancer who wish to achieve long-term survival. Despite recent advances, this is associated with considerable morbidity and mortality. Surgical candidates are frequently malnourished, and this is known to negatively affect outcomes. Despite this, the nutritional assessment and management of pancreatic cancer patients remains highly variable and there is no consensus. We argue that a specialist nutrition professional should be involved pre-operatively to optimise outcomes and to identify patients who require additional support. Micronutrient deficiencies are common amongst surgical candidates; it is unknown whether this affects outcomes. Furthermore, it is unknown if correcting deficiencies is of benefit. Robust studies are required to investigate this. Finally, there is limited evidence to support the use of prehabilitation in pancreatic surgery, but this is starting to emerge. The present short communication aims to review the recent literature and comment on the above issues.

Effect of age, stress and protein supply on plasma amino acids during continuous enteral nutrition; a pragmatic study in rats

As life expectancy increases, an increasing older population may require surgery with perioperative nutritional management. While little is known about the combined effect of age and stress on amino acid metabolism during enteral nutrition, we hypothesized that blood amino acid bioavailability may be influenced not only by the characteristics of the ingested protein but also by intestinal ageing and splanchnic sequestration of amino acids. Plasma amino acid kinetics were thus evaluated in aged and adult rats receiving continuous enteral nutrition before and after standardized surgical stress. Sixteen 5-month-old and sixteen 21-month-old male rats were used. After a gastrostomy, the insertion of a jugular vein catheter and a one-week recovery, the animals were enterally fed with commercially available formulas containing whole milk proteins or a whey hydrolysate for 24h before (healthy state) and 18h after a standardized laparotomy (surgical stress). Data were analyzed by 3-factor ANOVA. In all rats, enteral nutrition was associated with a marked increase in plasma alanine, threonine, lysine and proline (+50 to+150μmol/L; p<0.001), and a decrease in glycine (≈-80μmol/L; p<0.01). For most amino acids, their availability depended first on the amino acid composition of each protein and second on surgical stress. Aging was only associated with higher tyrosine and threonine availability (p<0.001). There was only limited statistical interaction between age and surgical stress. In rats, plasma amino acid availability during continuous enteral nutrition is determined by the nature of the protein source and the occurrence of stress. The effects of aging on plasma amino acid availability seem very limited. Commonly used formulas therefore appear to be as suitable for elderly patients as for adult patients.

Current situation, consensus and controversy of perioperative nutrition management in pancreatic surgery: A narrative review

Abstract Pancreatic surgery contains several major procedures of pancreatectomy. Surgical trauma, severe complications and preoperative nutritional disorders will affect postoperative recovery and clinical outcomes of patients. Perioperative whole-course nutrition management focus on rational nutritional care from admission to discharge even post-hospital follow-up, including preoperative nutritional screening, perioperative nutrition assessment and intervention. The whole-course strategy has been validated in some other fields by RCTs and is also seemed to be suitable for pancreatic surgery. However, few high-grade evidences have been published and controversy still exists. This review aims to reflect the current situation, consensus and controversy of perioperative nutrition management in pancreatic surgery, expecting to provide necessary guidance for clinical research and practice.

Current situation in postoperative adjuvant chemotherapy and perioperative nutritional management for the treatment of pancreatic cancer

Introduction: We have standardized the operative procedures and perioperative managements for pancreaticoduodenectomy(PD) and performed “Step-by-step” renovations to improve surgery-associated outcomes. In case of invasive pancreatic ductal carcinoma(IPDC), postoperative adjuvant chemotherapy with S-1 has been applied together with strengthened nutritional management. In this study, we examine the efficacy of our treatment and compare it with the results of JASPAC 01 trial (the induction within 70days after operation, completion rate:72%, no dose-reduction rate:59%).

A report of perioperative nutritional management using indirect calorimetry in severe anorexia nervosa

A report of perioperative nutritional management using indirect calorimetry in severe anorexia nervosa

Application of perioperative nutrition management strategy in patients with hepatic cystic echinococcosis

Objective To explore the application of perioperative nutrition management strategy in patients with hepatic cystic echinococcosis. Methods From October 2017 to February 2019, 53 patients with hepatic cystic echinococcosis who met the inclusion criteria were selected as the control group. Another 53 patients from June 2018 to January 2019 were collected as the experimental group, the nutritional index, liver function, complication rate and postoperative recovery were compared between the two groups. Results The levels of retinol-binding protein, prealbumin and transferrin were (24.32 ± 3.76) μg/L, (167.00 ± 24.12) mg/L, (2.08 ± 0.43) μg/L on the day of admission in the experimental group, and one day before the operation were (27.78± 4.98) μg/L, (245.00 ± 22.02) mg/L,(2.47 ± 0.54)μ g/L, there was no significant difference (t=0.576-3.552, P < 0.05). The incidence of infection, biliary leakage and hemorrhage in the experimental group were 0, 1.89% (1/53) and 0 respectively, which were lower than 9.43% (5/53), 13.21% (7/53), 11.32% (6/53) in the control group (χ2 value was 4.867, P < 0.05). The aspartate aminotransferase and alanine aminotransferase of the experimental group on the 7th day after operation were (51.50 ± 6.30), (29.54 ± 2.03) U/L, which were significantly different from (69.53 ± 7.07), (43.72±3.67) U/L of the control group (t value was 2.032, 2.015, P<0.05). Anal exhaust, defecation time, hospitalization time and expenses in the experimental group were (15.89±8.34) h, (49.12±10.56) h, (8.69 ± 1.69) d, (2.84±1.37) thousand yuan, which were significantly different from (34.13±7.13) h, (63.45±11.03) h, (11.51±4.18) d, (3.76±1.53) thousand yuan in the control group. There was statistical significance (t values were 3.372-12.592, P<0.05). Conclusions The application of perioperative nutrition management strategy in patients with hepatic cystic echinococcosis can improve the nutritional status of patients during perioperative period, promote the recovery of liver function and reduce the occurrence of postoperative complications. Key words: Hepatic cystic echinococcosis; Perioperative period; Nutrition management

Optimizing perioperative nutrition management in enhanced recovery after surgery

As the concept of enhanced recovery after surgery (ERAS) have been widely promoted and applied in clinical practice,reasonable nutrition intervention strategy has been paid more and more attention. The whole-process nutrition management strategy has been optimized based on the ERAS concept,which mainly includes key points such as pre-operative nutrition screening and nutrition assessment,perioperative nutrition treatment,and post-discharge nutritional support. With more and more research evidences,the ERAS strategy would be more detailed and complete. Further nutrition-related high-quality researches is necessary to provide evidence support,aiming to establish a standardized,ERAS-optimized,whole-process nutrition management pathway.

Perioperative nutritional management of patients undergoing pancreatoduodenectomy: an international survey among surgeons

BackgroundThere is still a lack of good evidence regarding the optimal perioperative nutritional management for patients undergoing pancreatoduodenectomy (PD). The aim of this international survey was to assess the current practice among pancreatic surgeons. MethodsA web survey of 30 questions was sent to the members of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA). All members were invited by email to answer the online survey. A reminder was sent after 4 weeks. ResultsIn total 420 out of 2500 surgeons (17%) answered the survey. Almost half of the surgeons (44%) did not organize a preoperative nutritional consultation for their patients. Seventy-seven percent of the participants did not have specific nutritional thresholds before the operation. A majority (66%) routinely used biological parameters to detect or follow malnutrition. Regarding intraoperative details, 69% of the respondents routinely leaved a nasogastric tube at the end of PD for gastric drainage. Sixty-six percent of the participants reported a postoperative nutritional follow-up consultation during hospitalization, and 58% of them had established local standardized protocols for postoperative nutritional support. ConclusionManagement of perioperative nutrition in patients undergoing PD was very disparate internationally. No specific preoperative nutritional thresholds were used, and postoperative feeding routes and timing were diverse.

Perioperative serum and urine metabolome analyses in patients with hepatocellular carcinoma undergoing partial hepatectomy.

Perioperative nutritional management is essential for early recovery after liver surgery. The aim of this study was to assess changes in amino acid levels in serum and urine after hepatectomy. Serum samples were collected from 16 patients with hepatocellular carcinoma before and 1, 3, and 14 d after hepatectomy (S0, S1, S3, and S14, respectively). Spot urine samples were collected before and 3 d after the hepatectomy (U0 and U3). Metabolites in the serum and urine were analyzed. Compared with S0, insulin levels significantly increased in the S1 and S3 samples. Valine levels significantly decreased in S1 and S14, and leucine levels significantly decreased in S14. Phenylalanine levels significantly increased in S1 and S3, and tyrosine levels significantly increased in S1. The Fischer ratio (branched-chain/aromatic amino acids) significantly decreased in S1 and S3. In multiple regression analysis, changes in serum taurine levels were related to the white blood cell count in S1 and S3, and inversely related to alanine aminotransferase levels in S14. Changes in serum glutamine levels were negatively related to C-reactive protein levels in S3. Serum glutamine levels decreased in S3 and S14, and tended to increase in U3, suggesting a deficiency of glutamate resulting from the invasive surgical procedure. These findings highlight the usefulness of metabolome analysis for characterizing perioperative patterns after liver resection. The observed amino acid pattern, including the reduction in Fischer ratio, underscores the need for specialized nutritional support.

Risk analysis using the prognostic nutritional index in hemodialysis-dependent patients undergoing cardiac surgery.

The prognostic nutritional index is an effective prognostic tool used in gastrointestinal surgeries. However, its value has not been verified in cardiovascular surgeries. This study aimed to investigate its utility in hemodialysis-dependent patients undergoing cardiac surgery. We retrospectively reviewed data of 110 hemodialysis-dependent patients who underwent cardiac surgery between January 2006 and July 2016. 20 variables were evaluated for short- and long-term mortality prediction. Patients were divided into high and low prognostic nutritional index groups with values > 34 (n = 90) and ≤ 34 (n = 20), respectively. Preoperative characteristics and surgical outcomes were compared between both groups. Overall, the in-hospital mortality rate was 9% (n = 10) and the 1-, 3-, and 5-year actual survival rates were 69%, 58%, and 40%, respectively. Univariate analysis for hospital death revealed age ≥ 70years, body mass index ≤ 18kg/m2, total cholesterol ≤ 120mg/dl, concomitant procedures, albumin concentration ≤ 3.0g/dl, and prognostic nutritional index ≤ 34 as risk factors. Multivariate logistic regression analysis confirmed age ≥ 70years and concomitant procedures as independent risk factors. Whereas ejection fraction ≤ 30% and prognostic nutritional index ≤ 34 were strong independent predictors of long-term death. Patients in the low prognostic nutritional index group had significantly longer postoperative hospitalization, higher incidence of complications, significantly higher in-hospital mortality rate, and significantly lower actual survival rate. The low prognostic nutritional index affected surgical outcomes in hemodialysis-dependent patients undergoing cardiac surgery. Perioperative nutrition management based on the prognostic nutritional index may improve surgical outcomes.

Sarcopenia and Inflammatory Bowel Disease: A Systematic Review.

Sarcopenia is associated with increased morbidity and mortality in oncologic and transplant surgery. It has a high incidence in chronic inflammatory states including inflammatory bowel disease (IBD). The validity of existing data in IBD and of sarcopenia's correlation with surgical outcomes is limited. We performed a systematic review to assess the correlation of sarcopenia with the requirement for surgery and surgical outcomes in patients with IBD. Observational studies of patients with IBD in whom an assessment of sarcopenic status/skeletal muscle index was undertaken, a proportion of whom proceeded to surgical management, were selected. A total of 5 studies with a combined 658 IBD patients met the inclusion criteria. The majority (70%) had a diagnosis of Crohn's disease. Median (range) body mass index and skeletal muscle index were reported in 4 studies and were 16.58 (13.66-22.50) kg/m2 and 44.52 (42.90-50.64) cm2/m2, respectively. Forty-two percent of IBD patients had sarcopenia. Notably, none of the studies assessed both the anatomical and functional component required for a correct assessment of sarcopenia. Three studies noted that sarcopenic IBD patients had a higher probability of requiring surgery. The rate of major complications (Clavien-Dindo grade ≥IIIa) was significantly higher in patients with sarcopenia. Improved perioperative nutrition management may mitigate the risk of complications. Many IBD patients are young, may be malnourished, and commonly require emergent surgery. There is considerable heterogeneity in the assessment of sarcopenia. Sarcopenia is common in the IBD population and can predict the need for surgical intervention. Sarcopenia correlates with an increased rate of major postoperative complications. Improved perioperative intervention may diminish this risk. A formal assessment, screening by a dedicated IBD dietician, and preoperative physical therapy may facilitate early intervention.

Enhanced Recovery After Surgery Protocols in Major Urologic Surgery.

The analysis of the components of enhanced recovery after surgery (ERAS) protocols in urologic surgery. ERAS protocols has been studied for over 20 years in different surgical procedures, mostly in colorectal surgery. The concept of improving patient care and reducing postoperative complications was also applied to major urologic surgery and especially procedure of radical cystectomy. This procedure is technically challenging, due to a major surgical resection and high postoperative complication rate that may reach 65%. Several clinical pathways were introduced to improve perioperative course and reduce the length of hospital stay. These protocols differ from ERAS modalities in other surgeries. The reasons for this are longer operative time, increased risk of perioperative transfusion and infection, and urinary diversion achieved using transposed intestinal segments. Previous studies in this area analyzed the need for mechanical bowel preparation, postoperative nasogastric tube decompression, as well as the duration of urinary drainage. Furthermore, the attention has also been drawn to perioperative fluid optimization, pain management, and bowel function. Notwithstanding partial resemblance between the pathways in major urologic surgery and other pelvic surgeries, there are still scarce guidelines for ERAS protocols in urology, which is why further studies should assess the importance of preoperative medical optimization, implementation of thoracic epidural anesthesia and analgesia, and perioperative nutritional management.

Perioperative nutrition in ERAS Protocols

The trauma involved in any surgical procedure, even if elective, causes a metabolic stress response characterized by postoperative insulin resistance (PIR). PIR is considered a surgical stress marker and is associated with increased morbidity and postoperative length of stay. PIR worsens when the patient is operated in a state of prolonged preoperative fasting or when postoperative feeding is delayed. The ERAS Protocols (Enhanced Recovery After Surgery) includes anesthetic, surgical, kinesiology, nutritional and nursing interventions aimed to modulate PIR. The nutritional perioperative interventions in the ERAS protocols, focus on avoiding prolonged preoperative fasting by oral carbohydrate loading up to two hours before surgery, accompanied by early postoperative feeding through the digestive tube. These nutritional perioperative interventions are safe and effective to reduce complications and postoperative stay, even in patients with well controlled type 2 diabetes. Nevertheless, their implementation and compliance are rather low, therefore, we must continue to make efforts in order to change perioperative nutritional management of our patients to achieve the best possible postoperative recovery.

Perioperative nutrition management as an important component of surgical capacity in low‐ and middle‐income countries

Needs for surgical care are growing in low- and middle-income countries. Existing surgical care capacity indicators, focusing on the availability of equipment, personnel, and operation and anaesthetic skills, are not intended to evaluate perioperative nutrition management, which influences surgical outcomes. In this narrative review, we describe the prevalence of malnutrition and its clinical consequences among surgical patients in low- and middle-income countries, suggest potential measures to improve nutrition management and discuss the necessity of considering nutrition management as a component of surgical care capacity.

Results of a nationwide questionnaire-based survey on nutrition management following gastric cancer resection in Japan.

A study was conducted to clarify the actual status of nutrition management after gastric cancer surgery in Japan and obtain basic data for optimizing perioperative nutrition management. A questionnaire was sent to 354 hospitals with at least 50 cases of gastric cancer surgery per year. Questions included the perioperative nutrition management and length of hospital stay for patients who underwent gastric cancer surgery within three months of the survey. Responses were obtained from 242 hospitals (68%; 20,858 patients). Nutrition management was consistent between laparotomy and laparoscopic surgery for 84% of respondents. The number of postoperative days was the most commonly chosen index for starting oral feeding. The most commonly chosen index for hospital dischargeability was diet composition/amount consumed in 182 hospitals (44%), followed by laboratory data stabilization in 106 hospitals (26%), and the number of postoperative days in 87 hospitals (21%). A positive correlation was found between the mean length of postoperative hospital stay and starting oral feeding (r=0.23 for distal gastrectomy; r=0.34 for total gastrectomy). The length of hospital stay tended to be shorter with an earlier start of oral feeding (p<0.01). Early postoperative oral feeding may be a factor in reducing the length of hospital stay after gastric cancer surgery.

Age Nutrition Chirurgie (ANC) study: impact of a geriatric intervention on the screening and management of undernutrition in elderly patients operated on for colon cancer, a stepped wedge controlled trial

BackgroundUndernutrition prior to major abdominal surgery is frequent and increases morbidity and mortality, especially in older patients. The management of undernutrition reduces postoperative complications. Nutritional management should be a priority in patient care during the preoperative period. However undernutrition is rarely detected and the guidelines are infrequently followed. Preoperative undernutrition screening should allow a better implementation of the guidelines.Methods/designThe ANC (“Age Nutrition Chirurgie”) study is an interventional, comparative, prospective, multicenter, randomized protocol based on the stepped wedge trial design. For the intervention, the surgeon will inform the patient of the establishment of a systematic preoperative geriatric assessment that will allow the preoperative diagnosis of the nutritional status and the implementation of an adjusted nutritional support in accordance with the nutritional guidelines. The primary outcome measure is to determine the impact of the geriatric intervention on the level of perioperative nutritional management, in accordance with the current European guidelines. The implementation of the intervention in the five participating centers will be rolled-out sequentially over six time periods (every six months). Investigators must recommend that all patients aged 70 years or over and who are consulting for a surgery for a colorectal cancer should consider participating in this study.DiscussionThe ANC study is based on an original methodology, the stepped wedge trial design, which is appropriate for evaluating the implementation of a geriatric and nutritional assessment during the perioperative period. We describe the purpose of this geriatric intervention, which is expected to apply the ESPEN and SFNEP recommendations through the establishment of an undernutrition screening and a management program for patients with cancer. This intervention should allow a decrease in patient morbidity and mortality due to undernutrition.Trial registrationThis study is registered in ClinicalTrials.gov NCT02084524 on March 11, 2014 (retrospectively registered).