Perioperative Nutrition Research Articles

Impact of early enteral nutrition on outcomes after chronic pancreatitis resectional surgery

Rationale: Malnutrition in patients with chronic pancreatitis (CP) affects the process of healing after surgery and number of postoperative complications. The aim of this study was to examine the efficiency of perioperative enteral nutrition (EN) in patients with CP, who were underwent the elective pancreatic resections.

Preoperative Testing and Planning for Safer Surgery

Consensus statements and regulatory guidelines endorse the process of identifying patients at increased risk for surgical morbidity and mortality. This is termed prognostic testing, and it identifies patients who are deemed to be too sick to benefit from the anticipated gain of surgery. However, much more valuable than prognostic testing is predictive, or directive, testing. A predictive test pinpoints the patient’s problem that will benefit from a specific available intervention. This review covers what is risk?, changing paradigms of surgical success, building a case for moderation, so, does anyone disagree?, timing, frailty and age (and the eyeball test), is the heart the only organ that counts?, changing paradigms, the enhanced importance of functional capacity, resting electrocardiogram, exercise stress testing, ventricular function testing, stair climbing: putting it all together, pulmonary function tests, obstructive airway disease, perioperative nutrition, how can we make surgery safer?, enhanced recovery after surgery, putting it all together, extended enhanced recovery after surgery, tight glucose control, smoking cessation, and timing of collaboration with anesthesia. Figures show routine preoperative tests for elective surgery (adapted from the National Institute for Health and Care Excellence clinical guideline 3, preoperative assessment strategies and recommended risk-reducing therapy relative to American Society of Anesthesiologists (ASA) classification performed by the surgeon and age, ASA Class I and II patients may be safely be evaluated by an anesthesiologist on the day of their scheduled surgery for a full preoperative history and physical examination, flow volume loop. Tables list ASA physical status classification, effect of abnormal screening results on physician behavior, and minimum preoperative test requirements at the Mayo Clinic (in 1997). This review contains 4 highly rendered figures, 3 tables, and 111 references

EXploring practice gaps to improve PERIoperativE Nutrition CarE (EXPERIENCE Study): a qualitative analysis of barriers to implementation of evidence-based practice guidelines.

Aligning care with best practice-such as Enhanced Recovery After Surgery (ERAS) guidelines-may improve patient outcomes. However, translating research into practice is challenging and implementation science literature emphasises the importance of understanding barriers and enablers specific to the local context and clinicians. This study aimed to explore staff perceptions about barriers and enablers to practice change aligning with nutrition-related recommendations from ERAS guidelines. A qualitative study using a maximum variation sampling method. Clinicians involved in care of patients admitted to two general surgical wards consented to participate in semi-structured interviews. Framework analysis was undertaken using the integrated Promoting Action on Research Implementation in Health Services framework to identify a priori and emergent themes. From interviews with 13 clinicians (two surgical consultants, one registrar, one intern; one anaesthetist; two nurse unit managers, one surgical nurse coordinator, three nurses; two dietitians), three major themes were identified: (a) complexity of the context (e.g., unpredictable theatre times, requirement for flexibility and large, multidisciplinary workforce); (b) strong decision-making hierarchy, combined with lack of knowledge, confidence or authority of junior and non-surgical staff to implement change; and (c) poor communication and teamwork (within and between disciplines). These barriers culminate in practice where default behaviours are habit, and the view that achieving clinical consensus is challenging. This study highlights the necessity for a multifaceted implementation approach that simplifies the process, flattens the power differential and facilitates communication and teamwork. Other facilities may consider these findings when implementing similar practice change interventions.

Energy and Protein Requirements in Children Undergoing Cardiopulmonary Bypass Surgery: Current Problems and Future Direction.

Congenital heart disease (CHD) is 1 of the most common congenital malformations, and considerable numbers of infants and young children with CHD undergo cardiopulmonary bypass surgery. It has been increasingly realized that perioperative nutrition support plays an important role in improving clinical outcomes. The purpose of this review, by searching PubMed, was to examine the nutrition conditions in perioperative children with CHD and the main problems in nutrition management in the cardiac intensive care unit (CICU), based on which future directions were proposed. We found that preoperative poor nutrition status is common. This limited reserve of energy and protein is further compounded by the complex metabolic alterations with hypermetabolism, hypercatabolism, and hypoanabolism in the early postoperative course. Knowledge about energy and protein metabolism and requirements in children after cardiopulmonary bypass remains very limited. The current nutrition recommendations in the CICU are based on little evidence. Insufficient energy and protein supply to meet demands remains a norm in the immediate postoperative period. The commonly used predictive equations do not provide accurate estimate of energy requirement in individual patients during the highly dynamic postoperative course. Indirect calorimetry can provide the best estimate of energy requirements for children with CHD in the CICU. Measurement of nitrogen balance is the recommended method to determine the minimal protein requirement. During the early postoperative period, daily measurements of resting energy expenditure using indirect calorimetry and nitrogen balance in each individual child are essential to optimize energy and protein supply to meet requirements.

Implementation of an Enhanced Recovery After Surgery Program Can Change Nutrition Care Practice: A Multicenter Experience in Elective Colorectal Surgery.

Enhanced recovery after surgery (ERAS) programs are multimodal evidenced-based care pathways for optimal recovery. Central to ERAS is integration of perioperative nutrition care into the overall management of the patient. This study describes changes to perioperative nutrition care after implementation of an ERAS program, and identifies factors that affect compliance to ERAS care elements and short-term postoperative outcomes. Data were prospectively collected from patients undergoing elective colorectal surgery at 6 hospitals in Alberta, Canada, from 2013-2017. Compliance to nutrition care elements (nutrition risk screening, preoperative carbohydrate loading, early postoperative oral feeding, and mobilization) was recorded before ERAS implementation (pre-ERAS group, n=487) and with ERAS implementation (ERAS group, n=3536). Logistic regression identified factors that affect compliance to care elements, length of hospital stay (LOS), and postoperative complications. A total of 4023 patients were included. The rate of nutrition risk screening improved from 9% (pre-ERAS group) to 74% (ERAS group); 12% were at nutrition risk. Compliance increased for preoperative carbohydrate loading (4%-61%), early postoperative oral feeding (P<.001), and mobilization (P<.001). In multivariable logistic regression, nutrition risk independently predicted low overall compliance (<70%) to ERAS care elements (odds ratio [OR] 2.77; 95% CI, 2.11-3.64; P<.001) and a trend for LOS >5days (OR 1.40; 95%CI, 1.00-1.96; P=.052). Low compliance to ERAS (<70%) predicted postoperative complications (OR 2.69; 95% CI, 2.23-3.24; P<.001). ERAS implementation positively impacted the adoption of standardized perioperative nutrition care practices. Nutrition risk screening identified patients less able to comply with postoperative nutrition care elements and who had longer LOS.

Experience with a simplified feeding jejunostomy technique for enteral nutrition following major visceral operations

Background: Perioperative nutrition support has been shown to impact on outcomes for patients with gastrointestinal cancer. Postoperative benefits of feeding tubes must be weighed against morbidity related to placement and use. A simplified jejunostomy tube technique was evaluated for outcomes. A 16-Fr rubber tube is secured at the jejunal entry site without Witzel tunnel, followed by a continuous, circumferential and alternating suture between jejunal wall and parietal peritoneum. Prospectively collected data were analyzed. The technique was performed in 343 of 803 major hepatopancreatobiliary and upper gastrointestinal (GI) resections (43%). Of these patients (male =57%, median age: 65.8 years, range, 24.0-98.0 years), 89% had a cancer diagnosis. The procedures included pancreatectomy (n=189, 55%), gastrectomy (n=109, 32%), esophagectomy (n=19, 6%) and others (n=26, 7%). The operative intent was curative in 78%, palliative in 10%, or combined in 12% of patients. Postoperative morbidity rate was 40%, with 19 lethal events (5.5%), and a median length of stay of 10 days (range, 4-111 days). Tube feeds were administered in 139 patients (41%), and in 17% continued beyond discharge. Use of the feeding tube was linked to treatment interval, length of stay, major complication grade (all at P<0.0001), metastatic stage (P=0.0007) and noncurative intent (P=0.001). Tube feeds beyond discharge were associated with time interval (P<0.0001), length of stay (P=0.0006) and noncurative intent (P=0.014). Tube-specific events in 38 patients (11%) were all minor, without any intraabdominal leak, infection or obstruction. The technique described is safe and expedient, and the overall tube-related morbidity is low. This procedure can be recommended in cases at risk for major morbidity and nutrition support needs.

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.

Finding the Whey to Improve Surgical Outcomes: Perioperative Nutrition Screening and Intervention.

While the majority of patients presenting for gastrointestinal surgery are malnourished and data have shown an associated increased risk for postoperative morbidity and mortality, only a small portion of patients receive any preoperative nutrition intervention, as few hospitals have a formal nutrition screening process. This is in spite of surgeons’ belief in adequate nutrition for outcome improvement and demonstrated cost savings for nutritional interventions. In this infographic, we review a novel perioperative nutrition screening tool and strategy for improving perioperative nutritional status, which optimally begins weeks before the planned surgery and extends months beyond hospital discharge until the patient has achieved full recovery. BMI indicates body mass index.

An observational study of perioperative nutrition and postoperative outcomes in patients undergoing laparotomy at Queen Elizabeth Central Hospital in Blantyre, Malawi.

Nutritional status in patients undergoing surgery can influence their immune function, tissue repair and, hence, clinical outcomes. This study aimed to assess the perioperative nutrition and postoperative outcome of patients undergoing laparotomy at a tertiary hospital in Malawi. A total of 25 patients were included in this prospective, observational study. The Subjective Global Assessment was used to classify each patient according to nutritional status. Handgrip strength was measured for each patient preoperatively and at day 3 postoperatively. Anthropometric measurements were also done. Protein and energy requirements for each participant were estimated and compared to the quantities provided by the hospital diet. Patients were followed up until discharge and outcome variables which included length of hospital stay and wound dehiscence or infectious complications were recorded. Of the study participants, 20% were well-nourished, 52% were moderately malnourished and 28% were severely malnourished. The median handgrip strength decreased at day 3 postoperatively from the preoperative handgrip strength. Well-nourished patients had higher handgrip strength than malnourished patients both preoperatively and postoperatively. Total energy and protein provided by the hospital diet were significantly lower than the estimated requirements for the patients. Severely malnourished patients had increased median length of hospital stay and increased rate of postoperative complications. Preoperative and postoperative day 3 handgrip strength correlated negatively with the number of postoperative complications and length of hospital stay. This study showed high rates of malnutrition and inadequate in-hospital nutritional support which were associated with poor clinical outcomes, especially in severely malnourished patients. Proper nutritional assessment and provision of adequate nutritional support should be reinforced in surgical patients to promote favourable clinical outcomes postoperatively. Further studies with larger sample sizes in other patient populations and hospitals in Malawi are required in this area.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway.

Perioperative malnutrition has proven to be challenging to define, diagnose, and treat. Despite these challenges, it is well known that suboptimal nutritional status is a strong independent predictor of poor postoperative outcomes. Although perioperative caregivers consistently express recognition of the importance of nutrition screening and optimization in the perioperative period, implementation of evidence-based perioperative nutrition guidelines and pathways in the United States has been quite limited and needs to be addressed in surgery-focused recommendations. The second Perioperative Quality Initiative brought together a group of international experts with the objective of providing consensus recommendations on this important topic with the goal of (1) developing guidelines for screening of nutritional status to identify patients at risk for adverse outcomes due to malnutrition; (2) address optimal methods of providing nutritional support and optimizing nutrition status preoperatively; and (3) identifying when and how to optimize nutrition delivery in the postoperative period. Discussion led to strong recommendations for implementation of routine preoperative nutrition screening to identify patients in need of preoperative nutrition optimization. Postoperatively, nutrition delivery should be restarted immediately after surgery. The key role of oral nutrition supplements, enteral nutrition, and parenteral nutrition (implemented in that order) in most perioperative patients was advocated for with protein delivery being more important than total calorie delivery. Finally, the role of often-inadequate nutrition intake in the posthospital setting was discussed, and the role of postdischarge oral nutrition supplements was emphasized.

Enhanced Recovery after Surgery Implementation in a Cesarean Section Population in an Integrated Healthcare System [35B

INTRODUCTION: Enhanced Recovery After Surgery (ERAS) programs are evidence-based care pathways that focus on optimizing pain control, nutrition, fluids, and mobility. We evaluated implementation of a multi-faceted ERAS program among a cesarean section surgical population within Kaiser Permanente Northern California (KPNC), an integrated healthcare delivery system. We compared process measures before and after ERAS implementation at two pilot hospitals. METHODS: We evaluated changes in perioperative pain management (morphine equivalents and multimodal analgesics), mobility (early ambulation within 12 hours) and nutrition (early feeding within 12 hours), from pre-Implementation (March 2015-August 2015, n=1390 cesarean patients) to post-Implementation (March 2016-August 2016, n=1471 cesarean patients) of the multifaceted ERAS program. All urgent and elective cases were included. We quantified these metrics based on medication administration records, preoperative checklists, and/or nursing shift assessments recorded in the EMR. RESULTS: Process metrics among ERAS patients demonstrated significant changes between pre- and post-Implementation phases. The rate of early ambulation increased from 33% to 51% (p&lt;0.001), early postoperative resumption of nutrition increased from 17% to 57% (p&lt;0.001), and opioid consumption decreased significantly from 13.1 mg morphine equivalents to 7.7 mg (p&lt;0.001), while the use of multimodal analgesics increased from 5% to 87% (p&lt;0.001). CONCLUSION: ERAS program implementation successfully altered the process-of-care metrics for cesarean section surgical patients across two pilot hospitals. Further research is needed to determine the impact of ERAS implementation on complications and other outcomes following surgery among women undergoing cesarean sections.

SMJERNICE ZA KLINIČKU PREHRANU KOD UPALNIH BOLESTI CRIJEVA

Diet therapy and clinical nutrition have a significant place in the treatment of patients with inflammatory bowel disease (IBD). Nutritional support is an important component of medical therapy in patients with IBD, and in-cludes the prevention and treatment of all forms of malnutrition. Confirmed malnutrition in patients with in-flammatory bowel disease should be treated adequately as it exacerbates prognosis, degree of complications, mortality and quality of life of a patient. Enteral nutrition is an extremely important part of nutritional therapy in inflammatory bowel diseases, and in some situations it has the meaning of primary therapy. Parenteral nutri-tion has its place in nutrition therapy of inflammatory bowel disease, both in acute and chronic treatment of patients with short bowel syndrome. Representatives of the Croatian Society of Clinical Nutrition Croatian Medical Association, Croatian Society of Mucosal Immunology Croatian Medical Association, Croatian Socie-ty of Gastroenterology and Croatian Society of Nutritionists and Dietitians participated in the development of these guidelines. They are evidence-based, according to the GRADE (Grading of Recommendations, Assess-ment, Development and Evaluation) system which, with the strength of evidence, also describes the level of recommendation. The basic conclusions of these guidelines relate to the assessment of malnutrition in this group of patients, the determination of nutritional needs, the replacement of key nutrients and pharmaconutri-ents, the application of various artificial nutrition modalities and the specificities of perioperative nutrition.

A qualitative study on perioperative need recognition of elderly patients with lung cancer from the perspective of doctors and nurses

Objective To explore the recognition of perioperative needs of elderly lung cancer patients from the perspective of doctors and nurses and provide evidence for improving perioperative nursing measures in elderly patients with lung cancer. Methods Totally 17 doctors and nurses were selected by purposive sampling and received face-to-face semi-structural interview during June to September 2016. The data were analyzed with NVivo 8.0 according to Colaizzi's seven-step analysis method to refine the topic. Results The recognition of perioperative needs of elderly patients with lung cancer from the perspective of doctors and nurses could boil down to four topics: the urgent need for the patient's social support system, the need for perioperative nutrition screening, the need for self-care and assistance, and the need for improving doctor-patient communication skills. Conclusions Nursing managers should pay attention to meet the perioperative needs of elderly patients with lung cancer from the perspective of medical workers and put forward appropriate interventions based on their needs in order to improve the perioperative nursing quality of elderly patients with lung cancer. Key words: Aged; Lung neoplasms; Perioperative nursing; Nursing needs; Qualitative study

Perioperative lipid-enriched enteral nutrition versus standard care in patients undergoing elective colorectal surgery (SANICS II): a multicentre, double-blind, randomised controlled trial

Postoperative ileus and anastomotic leakage severely impair recovery after colorectal resection. We investigated the effect of perioperative lipid-enriched enteral nutrition versus standard care on the risk of postoperative ileus, anastomotic leakage, and other clinical outcomes. We did an international, multicentre, double-blind, randomised, controlled trial of patients (≥18 years) undergoing elective colorectal surgery with primary anastomosis at six clinical centres in the Netherlands and Denmark. Patients were randomly assigned (1:1), stratified by location (colonic and rectal) and type of surgery (laparoscopic and open), via online randomisation software, with block sizes of six, to receive either continuous lipid-enriched enteral tube feeding from 3 h before until 6 h after surgery (intervention) or no perioperative nutrition (control). Surgeons, patients, and researchers were masked to treatment allocation for the entire study period. The primary outcome was postoperative ileus. Secondary outcomes included anastomotic leakage, pneumonia, preoperative gastric volumes, time to functional recovery, length of hospital stay, the need for additional interventions, intensive care unit admission, postoperative inflammatory response, and surgical complications. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT02175979, and trialregister.nl, number NTR4670. Between July 28, 2014, and February 20, 2017, 280 patients were randomly assigned, 15 of whom were excluded after random allocation because they fulfilled one or more exclusion criteria. 265 patients received perioperative nutrition (n=132) or standard care (n=133) and were included in the analyses. A postoperative ileus occurred in 37 (28%) patients in the intervention group versus 29 (22%) in the control group (risk ratio [RR] 1·09, 95% CI 0·95-1·25; p=0·24). Anastomotic leakage occurred in 12 (9%) patients in the intervention group versus 11 (8%) in the control group (RR 1·01, 95% CI 0·94-1·09; p=0·81). Pneumonia occurred in ten (8%) patients in the intervention group versus three (2%) in the control group (RR 1·06, 95% CI 1·00-1·12; p=0·051). All other secondary outcomes were similar between groups (all p>0·05). Perioperative lipid-enriched enteral nutrition in patients undergoing elective colorectal surgery has no advantage over standard care in terms of postoperative complications. Netherlands Organisation for Health Research and Development (ZonMW), Fonds NutsOhra, and Danone Research.

Perioperative nutrition and enhanced recovery after surgery in gastrointestinal cancer patients. A position paper by the ESSO task force in collaboration with the ERAS society (ERAS coalition)

Malnutrition in cancer patients – in both prevalence and degree – depends primarily on tumor stage and site. Preoperative malnutrition in surgical patients is a frequent problem and is associated with prolonged hospital stay, a higher rate of postoperative complications, higher re-admission rates, and a higher incidence of postoperative death. Given the focus on the cancer and its cure, nutrition is often neglected or under-evaluated, and this despite the availability of international guidelines for nutritional care in cancer patients and the evidence that nutritional deterioration negatively affects survival. Inadequate nutritional support for cancer patients should be considered ethically unacceptable; prompt nutritional support must be guaranteed to all cancer patients, as it can have many clinical and economic advantages. Patients undergoing multimodal oncological care are at particular risk of progressive nutritional decline, and it is essential to minimize the nutritional/metabolic impact of oncological treatments and to manage each surgical episode within the context of an enhanced recovery pathway. In Europe, enhanced recovery after surgery (ERAS) and routine nutritional assessment are only partially implemented because of insufficient awareness among health professionals of nutritional problems, a lack of structured collaboration between surgeons and clinical nutrition specialists, old dogmas, and the absence of dedicated resources. Collaboration between opinion leaders dedicated to ERAS from both the European Society of Surgical Oncology (ESSO) and the ERAS Society was born with the aim of promoting nutritional assessment and perioperative nutrition with and without an enhanced recovery program. The goal will be to improve awareness in the surgical oncology community and at institutional level to modify current clinical practice and identify optimal treatment options.

Combination of arginine, glutamine, and omega-3 fatty acid supplements for perioperative enteral nutrition in surgical patients with gastric adenocarcinoma or gastrointestinal stromal tumor (GIST): A prospective, randomized, double-blind study.

Background:Perioperative enteral nutrition (EN) enriched with immune-modulating substrates is preferable for patients undergoing major abdominal cancer surgery. In this study, perioperative EN enriched with immune-modulating nutrients such as arginine, glutamine, and omega-3 fatty acids was evaluated for its anti-inflammatory efficacy in patients with gastric adenocarcinoma or gastrointestinal stromal tumor (GIST) receiving curative surgery.Materials and Methods:This prospective, randomized, double-blind study recruited 34 patients with gastric adenocarcinoma or gastric GIST undergoing elective curative surgery. These patients were randomly assigned to the study group, receiving immune-modulating nutrient-enriched EN, or the control group, receiving standard EN from 3 days before surgery (preoperative day 3) to up to postoperative day 14 or discharge. Laboratory and inflammatory parameters were assessed on preoperative day 3 and postoperative day 14 or at discharge. Adverse events (AEs) and clinical outcomes were documented daily and compared between groups.Results:No significant differences were observed between the two groups in selected laboratory and inflammatory parameters, or in their net change, before and after treatment. AEs and clinical outcomes, including infectious complications, overall complications, time to first bowel action, and length of hospital stay after surgery, were comparable between treatment groups (all P > 0.05).Conclusion:Immune-modulating nutrient-enriched EN had no prominent immunomodulation effect compared with that of standard EN.

Meta-analysis on the prognosis of preoperative glucose pretreatment in patients with digestive tract malignant tumor

Objective The clinical benefits of carbohydrate intake 2-3 h before surgery in patients with digestive tract malignant tumor without diabetes mellitus have been confirmed by foreign experts, the High level evidence for perioperative nutrition support were also written in Guidelines for perioperative nutritional support in adults . However, there are few hospitals in China that prefer preoperative glucose pretreatment, taking into account the differences between domestic and foreign data.In this paper, the clinical randomly controlled experimental data about the effect of preoperative glucose pretreatment on the prognosis of patients with malignant tumor of digestive tract was analyzed by Meta analysis, in order to evaluate the efficacy and safety of preoperative glucose pretreatment in Chinese patients, and to achieve the clinical significance. Methods Retrieving the database from establishment to March 2017, the related literatures about preoperative glucose pretreatment and prognosis of patients with digestive tract malignant tumor were collected.Revman5.3 software was used to perform Meta analysis of 10 randomized controlled trials (606 patients) who met the inclusion criteria. Results Compared with the traditional fasting and non drinking group, the preoperative subjective discomfort of the preoperative group was significantly reduced (SMD=-1.29, 95%CI=-2.00--0.59, P=0.000 3), postoperative insulin resistance was significantly reduced (SMD=-1.92, 95%CI=-2.68--1.16, P<0.01), postoperative blood glucose concentration, insulin concentration increased, and no vomiting and aspiration occur in any patient as shown by the literature. Conclusion In the patients with malignant tumor of digestive tract, perioperative nutrition support and pretreatment show significant clinical benefits, preoperative subjective comfort improves, the risk of aspiration does not increase significantly, postoperative insulin resistance decreases.It is proved that preoperative carbohydrate pretreatment is effective and safe in the operation of domestic digestive tract cancer. Key words: Malignant tumor of digestive tract; Perioperative period; Glucose pretreatment; Meta analysis; Accelerated rehabilitation surgery

Enhanced Recovery After Surgery as an auditing framework for identifying improvements to perioperative nutrition care of older surgical patients.

Older patients are at increased risk of malnutrition and reduced physical function. Using Enhanced Recovery After Surgery (ERAS) guidelines as an auditing framework, this study aimed to determine adherence of nutrition care to perioperative best practice in older patients. A single researcher retrieved data via chart review. Seventy-five consenting patients ≥65 years (median 72 (range 65-95) years, 61% male) admitted postoperatively to general surgical wards were recruited. Sixty per cent had a primary diagnosis of cancer and 51% underwent colorectal resection. Seventeen per cent and 4% of patients met fasting targets of 2-4 h for fluid and 6-8 h for food, respectively. Fifty-five per cent were upgraded to full diet by first postoperative day. Nil received preoperative carbohydrate loading. Minimally invasive surgery (p = 0.01) and no anastomosis formation (p = 0.05) were associated with receiving ERAS-concordant nutrition care. This study highlights areas for improvement in perioperative nutrition care of older patients at our facility.

Influence of nutritional status on postoperative outcome in patients with colorectal cancer - the emerging role of the microbiome.

Many patients with colorectal cancer are overweight. Even then, nutritional status is a frequently underestimated risk factor for perioperative complications. Enhanced Recovery after Surgery is the goal for perioperative management, and preoperative nutritional risk screening should be a standard. In case of nutritional risk, perioperative nutrition therapy should be started without delay and should follow recent guideline recommendations. The preservation of the microbiome has an emerging role in preventing postoperative anastomotic leakage and septic complications. The time window for recovery after neoadjuvant treatment for rectal cancer may be used for conditioning appropriate-risk patients in a “prehabilitation” program. In order to assess metabolic recovery and the prognosis for long-term survival, C-reactive protein/albumin ratio may be a promising parameter, which has to be validated in the future. This narrative review summarizes recent strategies and guideline recommendations.