Perioperative Nutritional Supplementation Research Articles

Response to Letter to the Editor on "Other Factors that Can Affect Wound Healing with Elective Lumbar Spine Surgery and Perioperative Nutritional Supplementation in Patients".

Response to Letter to the Editor on "Other Factors that Can Affect Wound Healing with Elective Lumbar Spine Surgery and Perioperative Nutritional Supplementation in Patients".

Focused Perioperative Nutritional Supplementation Reduces Wound Complications in Patients Undergoing Spinal Fusion Surgery.

Retrospective cohort study. To evaluate intensive postoperative nutritional supplementation on wound healing complications and outcomes after spinal fusion surgery. Poor nutritional status leads to inferior postoperative outcomes by increasing mortality and predisposing patients to infection and wound healing complications. While perioperative nutritional supplementation has shown promise in mitigating these risks, there is a paucity of literature regarding specific nutritional routines in spinal fusion surgery. A retrospective analysis was conducted on patients who underwent spinal fusion surgery between 2019 and 2022. Demographic and nutritional data, including preoperative prealbumin levels (PAB) and postoperative supplemental diet, were examined. Primary endpoints included wound complications, with secondary outcomes assessing Oswestry Disability Index (ODI) and Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Health (PH) scores. Statistical analyses included unpaired t-tests and Chi-squared/Fischer's exact tests with significance set at P<0.05. Patients receiving the supplemental diet (n=229) demonstrated fewer wound complications (7% vs. 21%, P=0.004) and reoperations (3% vs. 11%, P=0.016) compared to those without supplementation (n=56). No significant differences were observed in preoperative or postoperative PROMIS PH or ODI scores. Patients with normal preoperative PAB had more wound complications without the supplemental diet (5% vs. 18%, P=0.025). A similar trend was seen in the patients with low preoperative PAB (12% vs. 26%, P=0.12). Postoperative nutritional supplementation significantly reduces wound complications after spinal fusion surgery in a cost-effective manner. This study underscores the modifiability of certain perioperative risk factors and suggests that nutritional strategies can mitigate potential complications.

Quality of life following perioperative optimization with nutritional supplements in patients undergoing gastrointestinal surgery for cancer: A randomized, placebo-controlled feasibility clinical trial.

Up to two thirds of patients presenting for abdominal cancer surgery are malnourished pre-operatively. Perioperative nutritional supplementation has been proposed to improve surgical outcomes, though its effect on quality of life (QoL) is not yet understood. A randomized controlled feasibility trial for perioperative nutrition among patients undergoing major abdominal cancer surgery was conducted. Participants in the intervention group received supplements for 30 days before surgery. Participants completed two QoL questionnaires (EORTC-QLQ-C-30 and FACT-G) at baseline, then 4 and 12 weeks postoperatively. Participants were compared between and within groups at baseline, Weeks 4,and 12 using ttests. Minimal clinically important differences (MCIDs) were considered as a 10-point worsening from baseline. Sixty-sixparticipants were available for analysis in this study, including 33 in the intervention and 30 in the control arms. Baseline demographics were balanced between groups except for different rates of pancreas cancer (36% intervention vs. 9% control) and colorectal cancer (19% intervention vs. 34% control). At baseline, participants in the intervention group had lower overall QoL (59% vs. 77%, p = 0.01), role functioning (72% vs 88%, p = 0.045), and cognitive functioning (79% vs 90%, p = 0.047). Following surgery, role and physical functioning worsened in the control group, without significant differences between groups. Role functioning was persistently worsened at 12 weeks in the control group. The rates of MCIDs were similar between both intervention and control groups. Perioperative nutrition was associated with preservation of QoL in the postoperative period following major abdominal cancer surgery compared to placebo. Among patients undergoing surgery for cancer, the majority present at high risk for malnutrition. In this placebo-controlled randomized trial among patients undergoing major abdominal surgery for cancer, preoperative nutrition supplementation was associated with the preservation of QoL in the postoperative period.

Why Wait Until After Surgery? The Case for Pre-habilitation in Head and Neck Cancer Care.

The LaryngoscopeEarly View Triological Society Best Practice Why Wait Until After Surgery? The Case for Pre-habilitation in Head and Neck Cancer Care Marna A. List MD, Marna A. List MD orcid.org/0000-0003-2742-7496 Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorJason P. Calligas MD, Jason P. Calligas MD Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorJohn Pang MD, John Pang MD orcid.org/0000-0002-4952-6711 Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorAmeya A. Asarkar MD, FACS, Ameya A. Asarkar MD, FACS Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorCherie-Ann O. Nathan MD, FACS, Corresponding Author Cherie-Ann O. Nathan MD, FACS [email protected] orcid.org/0000-0001-7386-318X Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USA Ochsner LSU Health- Feist-Weiller Cancer Center, Shreveport, Louisiana, USA Send correspondence to Cherie-Ann O. Nathan, Department of Otolaryngology/Head & Neck surgery, Louisiana State University Health Sciences Center, Shreveport. 1501 Kings Hwy, Shreveport, LA 71103, USA. Email: [email protected]Search for more papers by this author Marna A. List MD, Marna A. List MD orcid.org/0000-0003-2742-7496 Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorJason P. Calligas MD, Jason P. Calligas MD Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorJohn Pang MD, John Pang MD orcid.org/0000-0002-4952-6711 Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorAmeya A. Asarkar MD, FACS, Ameya A. Asarkar MD, FACS Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USASearch for more papers by this authorCherie-Ann O. Nathan MD, FACS, Corresponding Author Cherie-Ann O. Nathan MD, FACS [email protected] orcid.org/0000-0001-7386-318X Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Shreveport, Shreveport, Louisiana, USA Ochsner LSU Health- Feist-Weiller Cancer Center, Shreveport, Louisiana, USA Send correspondence to Cherie-Ann O. Nathan, Department of Otolaryngology/Head & Neck surgery, Louisiana State University Health Sciences Center, Shreveport. 1501 Kings Hwy, Shreveport, LA 71103, USA. Email: [email protected]Search for more papers by this author First published: 19 June 2023 https://doi.org/10.1002/lary.30827 Editor's Note: This Manuscript was accepted for publication on June 05, 2023. The authors have no funding, financial relationships, or conflicts of interest to disclose. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. BIBLIOGRAPHY 1Barberan-Garcia A, Ubré M, Roca J, et al. Personalised prehabilitation in high-risk patients undergoing elective major abdominal surgery: a randomized blinded controlled trial. Ann Surg. 2018; 267(1): 50- 56. 2Steegmann J, Bartella AK, Kloss-Brandstätter A, Kamal M, Hölzle F, Lethaus B. A randomized clinical trial on the efficacy of a patient-adapted autonomous exercise regime for patients with head and neck cancer. J Craniomaxillofac Surg. 2020; 48(3): 187- 192. 3Zhang B, Najarali Z, Ruo L, et al. Effect of perioperative nutritional supplementation on postoperative complications—systematic review and meta-analysis. J Gastrointest Surg. 2019; 23: 1682- 1693. 4Gillis C, Fenton TR, Sajobi TT, et al. Trimodal prehabilitation for colorectal surgery attenuates post-surgical losses in lean body mass: a pooled analysis of randomized controlled trials. Clin Nutr. 2018; 38: 1053- 1060. 5Nett H, Steegmann J, Tollkühn-Prott B, Hölzle F, Modabber A. A prospective randomized comparative trial evaluating postoperative nutritional intervention in patients with oral cancer. Sci Rep. 2022; 12:14213. Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation

Spine

The June 2023 Spine Roundup360 looks at: Characteristics and comparative study of thoracolumbar spine injury and dislocation fracture due to tertiary trauma; Sublingual sufentanil for postoperative pain management after lumbar spinal fusion surgery; Minimally invasive bipolar technique for adult neuromuscular scoliosis; Predictive factors for degenerative lumbar spinal stenosis; Lumbosacral transitional vertebrae and lumbar fusion surgery at level L4/5; Does recall of preoperative scores contaminate trial outcomes? A randomized controlled trial; Vancomycin in fibrin glue for prevention of SSI; Perioperative nutritional supplementation decreases wound healing complications following elective lumbar spine surgery: a randomized controlled trial.

Other Factors that Can Affect Wound Healing With Elective Lumbar Spine Surgery and Perioperative Nutritional Supplementation in Patients.

Department of Medicine, Rowan University School of Osteopathic Medicine, Stratford, NJ Funding: No funding was received for this study/paper. Competing interests: The authors declare that they have no competing interests. Address correspondence and reprint requests to Ajani Morgan, MS, Department of Medicine, Rowan School of Osteopathic Medicine, 1 Medical Center Dr, Stratford, NJ 08084; E-mail: [email protected]

Perioperative optimization with nutritional supplements in patients undergoing gastrointestinal surgery for cancer: A randomized, placebo-controlled feasibility clinical trial

BackgroundPerioperative nutritional supplementation may improve outcomes. Trials have not investigated the role of combination strategy using different types of nutritional supplements. MethodsWe conducted a single-site randomized pilot trial, among gastrointestinal cancer patients undergoing surgery, comparing perioperative nutritional supplements versus placebo (1 placebo to each supplement), to determine feasibility of a larger trial. Intervention, administered in sequence, included: protein supplementation (preoperative day 30–6), protein supplementation rich in arginine and omega-6 (preoperative day 5–1, and postoperative day 1–5), and carbohydrate loading (surgery day). Primary outcome was enrollment. Secondary outcomes included participant compliance with study supplements (target ≥70% of total packets). We planned protocol modifications to improve enrollment and compliance. Postoperative complications were described. ResultsOver 18 months, 495 patients were screened, 144 were deemed eligible, and 71 consented to participate, resulting in an enrollment fraction of 71/144 (49%, 95% confidence interval: 41%–57%). ‘Too much burden’ was the most common reason for refusal to participate (34%). Participants’ median overall compliance with study packets was 80%. Protocol modifications (decreasing the interval from enrollment to surgery from 4 to 2 weeks and decreasing length of baseline assessment) did not impact enrollment or compliance. Postoperative complications were similar between control (18/31 [58%, 95% confidence interval: 4–74]), and intervention (22/34 [65%, 95% confidence interval: 48–79]) arms, with a higher proportion of infectious complications in the control arm (16/31, 52% vs 12/34, 35%). ConclusionResults from this pilot suggest a larger phase III trial is feasible. Postoperative infectious complications were common, making this a suitable outcome of interest.

Perioperative optimization with nutritional supplements in patients undergoing gastrointestinal surgery for cancer: A randomized, placebo controlled feasibility clinical trial.

482 Background: Nutritional status is a major determinant of outcomes following surgery. Perioperative nutritional supplementation may improve postoperative outcomes, however, studies on the topic have led to controversial results. Methods: Single-centre, feasibility randomized trial among gastrointestinal cancer patients undergoing surgery, comparing perioperative nutritional supplements versus placebo. The supplements included: protein supplementation (preoperative day 30-6), “immunonutrition” (preoperative day 5-1 and postoperative day 1-5), and carbohydrate loading (surgery day). Primary outcome was enrollment fraction (i.e., enrolled/eligible patients). Secondary outcomes were patient compliance with study packages (target &gt; 70% of total packages provided) and 90-day postoperative complication rate, including postoperative infectious complications. A priori, we considered protocol modifications to improve enrollment fraction and compliance. Results: From October 2018 to March 2020, 495 patients were screened, of which, 144 were eligible and 71 were enrolled (enrollment fraction: 49%, 95%CI, 41-57%). Patients did not enroll for various reasons including refusal without reason (n = 33) and too much burden (n = 25). Protocol modifications did not impact enrollment fraction or compliance. Modifications included decreasing the interval from enrollment to surgery from 4 weeks to 2 weeks, and decreasing the complexity and length of the baseline assessment. Median overall compliance was 80%, lower for intervention versus control arm (67% and 87%, respectively). Postoperative complication rates were similar between control (18/31 (58%, 95% CI: 41-74)) and intervention (22/34 (65%, 95%CI 48-79)) arms. There was a trend for lower postoperative infectious rates in the intervention arm (12/34 (35%, 95%CI 22-52)) compared to control (16/31 (52%, 95%CI 35-68)). Conclusions: A trial like this is feasible, with an enrollment fraction of 49% and an overall patient compliance with study packages of 80%. Pilot trial protocol modifications did not increase these proportions. Clinical trial information: NCT03445260.

Perioperative nutritional supplementation-what is really evidence based?

For patients undergoing major surgery, perioperative management according to an early recovery after surgery (ERAS) protocol focusing on early oral food intake is the strategy of choice. So-called perioperative nutritional (artificial) support now seems to be very traditional and outdated. Nevertheless, even in an overweight and obese society the prevalence of combined malnutrition and/or sarcopenia should not be underestimated. This results in the necessity for identification of patients at metabolic risk and the indications for nutritional therapy. This article provides a review of the current concepts of perioperative nutritional supplementation and discusses the available evidence and guideline recommendations.

Risk factors for gastrointestinal complications after spinal fusion in children with cerebral palsy.

Prospective cerebral palsy (CP) registry review. (1) Evaluate the incidence/risk factors of gastrointestinal (GI) complications in CP patients after spinal fusion (SF); and (2) investigate the validity of the modified Clavien-Dindo-Sink classification. Perioperative GI complications result in increased length of stay (LOS) and patient morbidity/mortality. However, none have analyzed the outcomes of GI complications using an objective classification system. A prospective/multicenter CP database identified 425 children (mean, 14.4 ± 2.9 years; range, 7.9-21 years) who underwent SF. GI complications were categorized using the modified Clavien-Dindo-Sink classification. Grades I-II were minor complications and grades III-V major. Patients with and without GI complications were compared. 87 GI complications developed in 69 patients (16.2%): 39 minor (57%) and 30 major (43%). Most common were pancreatitis (n = 45) and ileus (n = 22). Patients with preoperative G-tubes had 2.2 × odds of developing a GI complication compared to oral-only feeders (OR 2.2; 95% CI 0.98-4.78; p = 0.006). Similarly, combined G-tube/oral feeders had 6.7 × odds compared to oral-only (OR 6.7; 95% CI 3.10-14.66; p < 0.001). The likelihood of developing a GI complication was 3.4 × with normalized estimated blood loss (nEBL) ≥ 3ml/kg/level fused (OR 3.41; 95% CI 1.95-5.95; p < 0.001). Patients with GI complications had more fundoplications (29% vs. 17%; p = 0.03) and longer G-tube fasting periods (3days vs. 2days; p < 0.001), oral fasting periods (5 days vs. 2 days; p < 0.001), ICU admissions (6 days vs. 3 days; p = 0.002), and LOS (15 days vs. 8 days; p < 0.001). LOS correlated with the Clavien-Dino-Sink classification. Gastrointestinal complications such as pancreatitis and ileus are not uncommon after SF in children with CP. This is the first study to investigate the validity of the modified Clavien-Dindo-Sink classification in GI complications after SF. Our results suggest a correlation between complication severity grade and LOS. The complexity of perioperative enteral nutritional supplementation requires prospective studies dedicated to enteral feeding protocols. Therapeutic-level III.

Reducing venous deep trombosis with immunonutrition in perioperative of total knee and hip arthroplasty

Rationale: total arthroplasties are surgeries to improve quality of life in elderly with severe osteoarthritis. Perioperative oral nutritional supplements (ONS) with specific nutrients can improve nutritional status, metabolic response to surgery and prevent postoperative complications. The aim is to evaluate whether ONS with immunomodulatory agents (arginine, omega-3 fatty acids and nucleotides) can reduce venous deep thrombosis (VDT) after total knee (TKA) and hip arthroplasty (THA) in elderly.

Abstract B02: Efficacy of EPA-enriched supplement compared with standard formula on body weight changes in malnourished head and neck cancer patients undergoing surgery: A randomized study

Abstract Background: Eicosapentaenoic acid (EPA) containing nutritional supplement can reverse weight loss and increase lean body mass in a perioperative period of head and neck cancer patients. There is no randomized study to clinically compare an EPA-enriched supplement over a conventional supplement in head and neck cancer patients. Thus the aim of this study was to compare an EPA-enriched supplement with a conventional supplement in malnourished head and neck cancer patients following surgery. The primary outcome of this study was defined as perioperative weight changes, with postoperative complications a secondary outcome. Methods: The patients were stratified into 4 groups based on the extent of their surgery: primary tumor resection or neck dissection, primary tumor resection and neck dissection, primary tumor resection and flap reconstruction, and primary tumor resection and neck dissection and flap reconstruction. Pretreatment randomization was conducted in each stratified group for the selection of nutritional supplement, whether EPA-enriched or standard formula. The supplements were prescribed 7 days preoperative through 14 days postoperative. Body weight and composition including serum parameters were measured from 7 days preoperative until 4 months postoperative. The hospitalized courses were recorded. Results: Thirty-one patients in each group consumed EPA-enriched and standard formula supplements. There were no significant body weight or composition changes perioperatively. From 7 days before surgery to 4 months after surgery, mean body weight reduced by 2.95 (SD 4.70) kg and 2.82 (SD 4.78) kg in the EPA-enriched and standard formula groups, respectively. The mean overall patient weight loss was 2.89 kg or 5% throughout the period of study. No significant differences in lean body mass and body composition changes from the beginning to the end of the study were observed between the groups. No significant differences in the hospitalized days and postoperative complications were observed. Conclusions: Body weight changes in malnourished head and neck cancer patients following surgery were not influenced by EPA additives to perioperative nutritional supplements. Citation Format: Kitti Jantharapattana, Orachat Orapipatpong. Efficacy of EPA-enriched supplement compared with standard formula on body weight changes in malnourished head and neck cancer patients undergoing surgery: A randomized study [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; 2019 Apr 29-30; Austin, TX. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(12_Suppl_2):Abstract nr B02.

Efficacy of EPA-enriched supplement compared with standard formula on body weight changes in malnourished patients with head and neck cancer undergone surgery: a randomized study.

Eicosapentaenoic acid (EPA) containing nutritional supplement can reverse weight loss and increase lean body mass in a perioperative period of patients with head and neck cancer. To study effects of an EPA-enriched supplement compared with a conventional supplement in malnourished patients with head and neck cancer following surgery is primary objective. The patients were randomized into EPA-enriched and standard formula group. The supplements were prescribed 7 days preoperative through 14 days postoperative. Body weight and composition including serum parameters were measured from 7 days preoperative until 4 months postoperative. The hospitalized courses were recorded. Thirty-one patients in each group consumed EPA-enriched and standard formula supplements. There was no significant body weight or composition changes perioperative. No significant differences in the hospitalized days and postoperative complications was observed. Body weight changes in malnourished patients with head and neck cancer following surgery were not influenced by EPA additives to perioperative nutritional supplements.

Perioperative nutrition for the treatment of bladder cancer by radical cystectomy.

Radical cystectomy (RC) is the primary surgical treatment for muscle-invasive urothelial carcinoma of the bladder. This major operation is typically associated with an extended hospital stay, a prolonged recovery period and potentially major complications. Nutritional interventions are beneficial in some people with other types of cancer and may be of value in this setting too.To assess the effects of perioperative nutrition in people undergoing radical cystectomy for the treatment of bladder cancer.We performed a comprehensive search using multiple databases (Evidence Based Medicine Reviews, MEDLINE, Embase, AMED, CINAHL), trials registries, other sources of grey literature, and conference proceedings published up to 22 February 2019, with no restrictions on the language or status of publication.We included parallel-group randomised controlled trials (RCTs) of adults undergoing RC for bladder cancer. The intervention was any perioperative nutrition support.Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias and the quality of evidence using GRADE. Primary outcomes were postoperative complications at 90 days and length of hospital stay. The secondary outcome was mortality up to 90 days after surgery. When 90-day outcome data were not available, we reported 30-day data.The search identified eight trials including 500 participants. Six trials were conducted in the USA and two in Europe.1. Parenteral nutrition (PN) versus oral nutrition: based on one study with 157 participants, PN may increase postoperative complications within 30 days (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.07 to 1.82; low-quality evidence). We downgraded the quality of evidence for serious study limitations (unclear risk of selection, performance and selective reporting bias) and serious imprecision. This corresponds to 198 more complications per 1000 participants (95% CI 35 more to 405 more). Length of hospital stay may be similar (mean difference (MD) 0.5 days higher, CI not reported; low-quality evidence).2. Immuno-enhancing nutrition versus standard nutrition: based on one study including 29 participants, immuno-enhancing nutrition may reduce 90-day postoperative complications (RR 0.31, 95% CI 0.08 to 1.23; low-quality evidence). These findings correspond to 322 fewer complications per 1000 participants (95% CI 429 fewer to 107 more). Length of hospital stay may be similar (MD 0.20 days, 95% CI 1.69 lower to 2.09 higher; low-quality evidence). We downgraded the quality of evidence of both outcomes for very serious imprecision.3. Preoperative oral nutritional support versus normal diet: based on one study including 28 participants, we are very uncertain if preoperative oral supplements reduces postoperative complications. We downgraded quality for serious study limitations (unclear risk of selection, performance, attrition and selective reporting bias) and very serious imprecision. The study did not report on length of hospital stay.4. Early postoperative feeding versus standard postoperative management: based on one study with 102 participants, early postoperative feeding may increase postoperative complications (very low-quality evidence) but we are very uncertain of this finding. We downgraded the quality of evidence for serious study limitations (unclear risk of selection and performance bias) and very serious imprecision. Length of hospital stay may be similar (MD 0.95 days less, CI not reported; low-quality evidence). We downgraded the quality of evidence for serious study limitations (unclear risk of selection and performance bias) and serious imprecision.5. Amino acid with dextrose versus dextrose: based on two studies with 104 participants, we are very uncertain whether amino acids reduce postoperative complications (very low-quality evidence). We are also very uncertain whether length of hospital stay is similar (very low-quality evidence). We downgraded the quality of evidence for both outcomes for serious study limitations (unclear and high risk of selection bias; unclear risk of performance, detection and selective reporting bias), serious indirectness related to the patient population and very serious imprecision.6. Branch chain amino acids versus dextrose only: based on one study including 19 participants, we are very uncertain whether complication rates are similar (very low-quality evidence). We downgraded the quality of evidence for serious study limitations (unclear risk of selection, performance, detection, attrition and selective reporting bias), serious indirectness related to the patient population and very serious imprecision. The study did not report on length of hospital stay.7. Perioperative oral nutritional supplements versus oral multivitamin and mineral supplement: based on one study with 61 participants, oral supplements compared to a multivitamin and mineral supplement may slightly decrease postoperative complications (low-quality evidence). These findings correspond to 135 fewer occurrences per 1000 participants (95% CI 256 fewer to 65 more). Length of hospital stay may be similar (low-quality evidence). We downgraded the quality of evidence of both outcomes for study limitations and imprecision.Based on few, small and dated studies, with serious methodological limitations, we found limited evidence for a benefit of perioperative nutrition interventions. We rated the quality of evidence as low or very low, which underscores the urgent need for high-quality research studies to better inform nutritional support interventions for people undergoing surgery for bladder cancer.

Perioperative nutritional supplementation and skeletal muscle mass in older hip-fracture patients.

Older people with hip fractures are often malnourished at the time of fracture, which can have substantial influence on mortality and clinical outcomes, as well as functional outcome and quality of life. A close relationship between protein intake and muscle maintenance has been demonstrated. Skeletal muscle weakness is an independent risk factor for falls and fall-related injuries in the elderly and is an independent marker of prognosis. However, the effect of perioperative nutritional interventions on outcomes in elderly hip-fracture patients remains controversial. In this narrative review, an overview is presented of the existing literature on nutritional status and sarcopenia in elderly hip-fracture patients, clinical outcomes, and the effects of nutritional intervention on outcome and rehabilitation in this patient group.

Effect of perioperative oral nutritional supplementation in malnourished patients who undergo gastrectomy: A prospective randomized trial

The aim of this study was to examine the effect of a perioperative oral nutritional supplement in malnourished patients who undergo gastrectomy. Patients who were determined as being moderately or severely malnourished according to a patient-generated subjective global assessment or who had a body mass index <18.5, were enrolled. The oral nutritional supplement group received 500 mL/d of standard oral nutritional supplement for 2 weeks before gastrectomy and for 4 weeks postoperatively. The primary endpoint was postoperative complications (Clavien-Dindo classification ≥II). The secondary endpoints included body weight changes, biochemical parameters, and quality of life survey results. A total of 127 patients (65 in the oral nutritional supplement group and 62 in the control group) were enrolled. The complication rates were not significantly different (29.2% versus 37.1%, P = .346). However, the incidences of overall complications, complications persisting until postoperative week 3 or 5, and severe complications (grade ≥IIIa) were significantly lower in the oral nutritional supplement group for patients with patient-generated subjective global assessment grade C. Total lymphocyte counts were significantly higher in the oral nutritional supplement group at postoperative weeks 3 and 5. For most patients, oral nutritional supplement was well tolerated preoperatively. However, only 26.2% and 50.8% of the patients in the oral nutritional supplement group could consume >250 mL/d of oral nutritional supplement postoperatively during the 2nd and 4th weeks, respectively. The routine application of perioperative oral nutritional supplement is not recommended for malnourished patients receiving gastrectomy. However, perioperative standard oral nutritional supplement administration may reduce the incidence, severity, and duration of complications after gastrectomy in severely malnourished patients (patient-generated subjective global assessment grade C).

Should patients with hypoalbuminemia undergo LVAD implantation?

Serum albumin is an independent predictor of morbidity, including deep sternal wound infections, and mortality following cardiac surgery and left ventricular assist device (LVAD) implantation.1, 2 Preoperative hypoalbuminemia in patients being evaluated for LVAD implementation may be due to malnutrition and frailty, hepatic dysfunction due to both right and left heart failure, the cardiorenal syndrome, and systemic inflammation. Patients with hypoalbuminemia may potentially benefit from LVAD implantation since the combination of nutritional support and the reversal of heart failure may restore serum albumin to normal levels. On the other hand, the co-morbidities associated with hypoalbuminemia may increase perioperative morbidity and mortality and decrease long-term survival. Furthermore, patients with hypoalbuminemia undergoing LVAD implantation may not recover sufficiently to be considered candidates for heart transplantation. In view of the increasing costs associated with LVAD therapy,3 the known increased morbidity and mortality in patients with hypoalbuminemia, and the uncertainty of the option for heart transplantation, should patients with moderate and severe serum hypoalbuminemia undergo LVAD therapy? In this edition of the Journal, Critsinelis et al4 sought to determine short- and-long term survival in patients with low preoperative serum albumin levels who underwent continuous-flow LVAD implantation. In 526 patients who had undergone LVAD implantation at their center, 186 patients (35.4%) had moderate hypoalbuminemia (2.5-3.5 g/dL) and 18 (3.4%) had severe hypoalbuminemia (<2.5 g/dL). Patients with preoperative hypoalbuminemia were more likely to receive LVAD implementation for destination therapy, were more likely to have required preoperative circulatory support, had significantly lower preoperative hemoglobin levels and platelet counts, significantly higher white blood cell counts, and higher liver function enzyme levels. Hypoalbuminemia patients also had a higher incidence of postoperative morbidity, including infections and sepsis, gastrointestinal bleeding, neurological dysfunction, acute kidney injury, and an increased incidence of hospital readmissions. Preoperative hypoalbuminemia was also associated with significantly decreased early and long-term survival following LVAD implementation. However, hypoalbuminemia prior to LVAD implementation did not affect the success of bridge to transplantation and did not significantly affect survival after heart transplantation. Furthermore, there was no association between body mass index (BMI) and outcomes with LVAD implantation which suggests that the co-morbidities associated with hypoalbuminemia, and not preoperative BMI, are responsible for the increased morbidity and mortality associated with hypoalbuminemia. Patients with hypoalbuminemia, but with normal pre-albumin levels and a normal central venous pressure, had no difference in survival compared to patients with normal albumin levels. Should LVAD therapy be denied to patients with preoperative hypoalbuminemia? The answer lies in what co-morbidities responsible for preoperative hypoalbuminemia can be reversed following initiation of LVAD therapy. Reversing the sequelae of low cardiac output may improve appetite and absorption of nutrients, improve hepatic function, and reduce systemic inflammation. Critsinelis et al did not assess the effects of perioperative nutritional supplementation on perioperative morbidity and mortality in their patients. Furthermore, they limited their assessment to measuring only preoperative serum albumin levels. Hence, we do not know whether patients who had a significant increase in serum albumin levels post LVAD implantation had better short- and long-term survival. While deceased preoperative serum albumin levels are a marker for increased perioperative morbidity and decreased short- and long-term survival following LVAD implantation, the data from this study suggest that serum albumIn alone cannot be used to exclude patients for LVAD support who may be potential candidates for heart transplantation. These patients will require more aggressive perioperative nutritional supplementation and continued therapy for underlying co-morbidities in addition to LVAD support. Only then can we determine whether LVAD implementation can improve long- and short-time survival in patients with hypoalbuminemia.

Perioperative nutritional status, supplementation and monitoring in patients referred for bariatric surgery: Closing the audit loop

Perioperative nutritional status, supplementation and monitoring in patients referred for bariatric surgery: Closing the audit loop

Effect of a Perioperative Nutritional Supplementation with Oral Impact® in Patients undergoing Hepatic Surgery for Liver Cancer: A Prospective, Placebo-Controlled, Randomized, Double-Blind Study

ABSTRACTPerioperative nutrition with supplements containing l-arginine, ω3-polyunsaturated fatty acids, and nucleotides could boost liver function recovery, immune response, and resistance to infection after hepatic resection. We conducted a placebo-controlled, randomized, double-blind study to assess the effect of a perioperative nutritional supplementation with Oral Impact® in patients undergoing hepatic surgery for liver cancer. Treatment was given three times daily for 7 days before and 3 days after surgery. Primary outcome was factor V, 3 days after surgery. Thirty-five patients (placebo: 17; Oral Impact: 18) were included. Five patients (placebo: three; Oral Impact: two) were not operated and five (placebo: two; Oral Impact: three) did not undergo hepatic resection. Factor V (mean ± SD) was 70 ± 27% and 79 ± 25% (P = 0.409) 3 days after surgery and 90 ± 30% and 106 ± 16% (P = 0.066) 5 days after surgery, in placebo and Oral Impact groups, respectively. There were no significant differences between groups on other outcomes assessing liver function recovery (bile production, γ-glutamyl transferase, α-fetoprotein), immune response (CD3, CD4, CD8 cells, CD4/CD8 ratio, natural killer cells, B lymphocytes), number of infections, and tolerance. A 10-day perioperative nutritional supplementation with Oral Impact does not improve hepatic function, immune response, and resistance to infection in patients undergoing hepatic surgery for liver cancer.

Utility of a perioperative nutritional intervention on postoperative outcomes in high-risk head & neck cancer patients

Investigate both the utility and feasibility of perioperative nutritional supplementation with an arginine-enriched immunonutrition formula to high-risk head and neck cancer surgical patients and examine its effects on acute post-operative clinical outcomes. This prospective, non-randomized, interventional cohort study compared high-risk head and neck cancer surgical patients who consumed a pre- and post-operative arginine-based nutritional supplement to those that did not. Outcome measures included post-operative complications, length of hospitalization, readmission rates and measurement of nutritional biomarkers. 195 high-risk head and neck cancer surgical patients were enrolled. 59% of the patients used the nutritional supplement, 41% did not. Of the 80 patients who did not receive the immunonutrition formula, 38 (47.5%) experienced post-operative complications of all types as compared to 29 of the 115 (25.2%) patients who did consume the product (p=0.0021). Pharyngeal leaks or fistulas were the most common post-operative complications in both groups and more common in patients who did not receive supplementation (p=0.007). Length of stay was on average 2.8 days longer in patients who did not have enhanced nutrition (p=0.02), while readmission rates between the two groups were similar (p=0.91). Measurements of nutritional biomarkers were not reported secondary to low collection rates. Enhanced perioperative nutrition may result in significant reductions of post-operative fistula formations and decreased length of stay in a high-risk head and neck cancer population, even in the setting of poor compliance. The potential quality improvement in both patient care and healthcare cost is both real and significant.