Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 4  |  Page : 469-477

Perioperative nutrition to enhance recovery after surgery


Department of Anesthesia, Intensive Care, and Pain Management, Ain Shams University, Cairo, Egypt

Date of Submission02-Oct-2016
Date of Acceptance05-Oct-2016
Date of Web Publication12-Jan-2017

Correspondence Address:
Dina Salah
8595, El Reda and Nour Street, Mokattam, Cairo, 11571
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.198247

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  Abstract 

Preoperative malnutrition is a major risk factor for increased postoperative morbidity and mortality. Patients at risk for malnutrition should be identified early. The Nutritional Risk Score is a validated tool to identify patients who should benefit from nutritional support. The adoption of total parenteral nutrition followed by the extraordinary progress in parenteral and enteral feedings, in addition to the increased knowledge of cellular biology and biochemistry, has allowed clinicians to treat malnutrition and improve surgical patient’s outcomes. Periods of prolonged fasting should be minimized and nutrition should be commenced as early as possible after surgery, preferably through the enteral route. The surgical patient with established malnutrition should begin aggressive nutrition at least 7–10 days before surgery. Those patients in whom eating is not anticipated beyond the first 5 days following surgery should receive the benefits of early enteral or parenteral feeding depending on whether the gut can be used. Many patients may benefit from newer enteral formulations, such as those designed to enhance immune function (immunonutrition).

Keywords: enteral nutrition, immunonutrition, total parenteral nutrition


How to cite this article:
Salah D. Perioperative nutrition to enhance recovery after surgery. Ain-Shams J Anaesthesiol 2016;9:469-77

How to cite this URL:
Salah D. Perioperative nutrition to enhance recovery after surgery. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2017 Aug 24];9:469-77. Available from: http://www.asja.eg.net/text.asp?2016/9/4/469/198247


  Introduction Top


Ever since 1936 when Studley [1] demonstrated a direct relationship between preoperative weight loss and operative mortality, nutritional support of surgical and critically ill patients has undergone significant advances. The WHO cites malnutrition as the greatest single threat to the world’s public health as the reported in-hospital prevalence of malnourished patients on admission ranges up to 50% [2],[3]. Malnutrition is considered a risk factor for impaired systemic and intestinal immune function, as well as decreased digestive and absorptive capacity due to the altered architecture of the gut barrier [4]. Perioperative nutrition has been convincingly shown to improve clinical outcome in patients undergoing major gastrointestinal surgery, to reduce costs, and to decrease length of hospital stay [5]. The mechanism of action seems to be not only an improved nutritional status by providing a higher caloric intake, but primarily a re-enforced immune response; nutritional formulas containing immunomodulating agents (glutamine, arginine, n-3 fatty acids, and RNAs) are particularly beneficial modulators of the acute stress response [6],[7].

Major stress, such as surgery, can subject a patient to a whole host of metabolic and physiologic changes. The body responds to such stress by increasing its basal metabolic rate, using up its nitrogen stores, and creating a negative nitrogen balance [8]. An increase in gluconeogenesis as well as the synthesis of acute phase proteins is also observed [9]. The body scavenges for the required nutrients during times of stress, which if continues undetected for prolonged periods of time could lead to adverse consequences. Perioperative nutritional supplementation, therefore, should blunt the catabolic effects of such a high-energy state [10]. Interestingly, there is an increase in intestinal permeability during periods of surgical stress, which can be as greater as four-fold in some patients, usually normalizing around fifth postoperative day [10],[11],[12]. Associated with this increase in permeability is a decrease in villous height, leading to malabsorption and an impaired ability of the gut to act as a barrier against endogenous bacteria and toxins [10],[13].

Malnutrition and surgery can also both present a stress on the heart. Patients undergoing cardiac surgery are frequently found to be malnourished, resulting in alteration in the structure of myocytes and depleting the substrates utilized by the heart for mechanical work. It is therefore hypothesized that, by addressing the undernourished state of the patient before surgical intervention, we can improve cardiovascular performance and decrease the incidence of cardiac complications after surgery as well as lower perioperative mortality [14].

The aim of this review was to focus on the advantages, limitations, and comparisons of both parenteral and enteral nutrition (EN) in the malnourished perioperative patient.


  Preoperative Top


Nutritional assessment and population at risk for perioperative malnutrition

Nutritional status is difficult to quantify accurately. A history of chronic disease, cancer, infection, surgery, recent reduced dietary intake, and weight loss help identify patients at risk for malnutrition. Assessment may include a calculation of BMI, an estimate of recent loss of subcutaneous fat and muscle mass, and signs of specific nutritional deficiencies [15]. Interestingly, malnutrition can occur in obese patients who have low muscle mass. This form of obesity, termed sarcopenic obesity, may be less recognizable in many cases [16]. In many patients, fat-free mass index may be a better predictor for mortality compared with BMI. Van Venrooij et al. [17] found that low fat-free mass index was associated with an increased occurrence of adverse outcomes after cardiac surgery. They advocate fat-free mass index as the leading parameter in classifying and treating malnourished cardiac surgical patients [17].

Numerous laboratory indices have been proposed as markers of nutritional status. For example, low preoperative serum albumin concentrations are associated with delayed wound healing [18] and can be used to predict morbidity in patients undergoing elective operations [19],[20],[21]. However, as albumin concentration is suppressed by surgery and illness, its postoperative measurement is of limited value [19]. The perioperative measurements of serum transferrin and prealbumin have more potential, along with serum cholesterol and lymphocyte count, as their half-lives are shorter than that of albumin [22]. However, the clinical value of these markers is indicative rather than diagnostic, as they are not specific for malnutrition.

The European Society of Parenteral and Enteral Nutrition guidelines recommend the use of the Nutrition Risk Screening 2002 tool, along with subjective global assessment, and serum albumin less than 30 g/l in their evaluation of undernutrition [23],[24]. [Table 1] illustrates the components of the tool. In one study by Jie et al. [24], those patients scoring 5 or higher on the Nutrition Risk Screening 2002 malnutrition scale received the most benefit from perioperative nutritional support.
Table 1: Nutrition Risk Screening 2002 [23]

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Fasting

The most common surgical practice of making patients nil per os after midnight of the day of any planned surgical procedure has been recently questioned. Brady et al. [25] reviewed 38 randomized controlled trials on perioperative fasting and concluded that there was no evidence to suggest that overnight fasting for fluids results in a decrease in perioperative aspiration risk or related morbidities [25]. Evidence is emerging that overnight fasting is not only unnecessary but may also be harmful.

Gastric emptying is controlled by neural and hormonal pathways and is determined by a number of intraluminal and extraluminal factors. Intraluminal factors include meal composition (caloric load, volume, temperature, and nutrient type), the osmolality of small intestinal contents, and the length and the region of small intestine exposed to nutrient [26]. Extraluminal factors include glycemia, posture, pain, sex, and age [27],[28]. The optimal duration of fasting for a particular patient depends on numerous factors. The rate of emptying of nutrient from the stomach is linear, with emptying occurring more rapidly for liquids than for solids. In contrast, water is emptied from the stomach exponentially, with an approximate half-life of 10 min [29],[30],[31].

Gastroesophageal regurgitation and pulmonary aspiration is thought to be more likely in critically ill patients, due to disturbed gastric and esophageal motility [27]. Preoperative fasting, particularly when 6 or more hours in duration, will starve critically ill patients who require frequent operations [32],[33].

Factors associated with slower gastric emptying are as follows.

  1. Diseases affecting autonomic dysfunction, such as diabetes mellitus, amyloidosis, Parkinson’s disease, multiple sclerosis, HIV, and spinal injury.
  2. Other diseases such as hyperglycemia, alcoholism, hypothyroidism, malignancy, and critical illness.
  3. Gastrointestinal diseases such as gastric dysmotility, gastric outlet, or bowel obstruction.
  4. Surgical causes such as vagotomy, fundoplication, and Roux-en-Y anastomosis.
  5. Drugs such as opiates, tricyclic antidepressants, calcium channel blockers, dopamine agonists, α-2-adrenergic agonists, glucagon-like peptide-1 receptor agonists, muscarinic cholinergic receptor antagonists, catecholamines, cyclosporine, and somatostatin analogs (e.g. octreotide).
  6. In addition, composition of meal ingested, high caloric load, large lipid component, pregnancy or postpartum state, and advanced age [34].


Carbohydrate loading

Surgical stress causes postoperative insulin resistance, immunosuppression, and increased patient discomfort [35],[36]. Patient outcomes may be improved by a shorter fasting period preceded by prescribed carbohydrate intake [37]. Studies have reported that postoperative insulin sensitivity is preserved by carbohydrate drinks (100 g the night before surgery and 50 g 2 h before surgery) [38] or intravenous glucose (5 mg/kg/min) [39], possibly through suppression of fat and glucose oxidation and attenuation of pyruvate dehydrogenase kinase [40].

Preoperative nutritional support and immunonutrition

International guidelines recommend nutritional support for severely malnourished patients 7–14 days before elective major surgery. Severely malnourished patients have at least one of the following: weight loss more than 10–15% within 6 months; BMI less than 18.5 kg/m2; or serum albumin below 30 g/l without hepatic or renal dysfunction [41].

The optimal timing of nutritional intervention remains a controversial topic. Preoperative preparation of the patient gained support following several landmark studies by Gianotti et al. [42] and Braga et al. [43] demonstrating that major morbidity could be reduced by ∼50% in patients undergoing resection for malignancy of the esophagus, stomach, or pancreas. This benefit was noted in both the well-nourished and malnourished patient populations. They provided an immunomodulating formula given 5 days preoperatively, which included arginine, omega-3 (ω) fatty acids, and nucleic acids, and resulted in significant decreases in infectious morbidity, length of hospital stay, and hospital-related expenses.

In terms of nutritional support, it is generally accepted that earlier is better than later, that enteral is superior to parenteral, that the quality of nutrient appears more important than the quantity, and that select populations will show additional benefit from specific nutrient supplementation. Goals of nutritional support have changed in the past few years from attempts to preserve lean body mass following a surgical or traumatic stress to efforts to attenuate the hypermetabolic response, reverse loss of lean body mass, prevent oxidant stress, favorably modulate the immune response with early enteral feeding, attain meticulous glycemic control, and administer appropriate macronutrients and micronutrients [20].


  Intraoperative Top


There are few randomized controlled trials assessing intraoperative enteral feeding. Studies are limited to surgery following burn injury and nongastrointestinal trauma [40]. Following burn injury, the small intestine can be fed during surgery, which reduces cumulative calorie deficits and does not appear to increase the risk for aspiration of gastric contents [44]. Intraoperative EN, except during surgery on the airway or gastrointestinal tract, can shorten the duration of fasting in mechanically ventilated critically ill patients.


  Postoperative Top


Optimal time to start nutrition

The optimal time to start postoperative nutritional intervention is significantly influenced by a host of factors such as age, premorbid conditions, route of delivery, metabolic state, organ involvement, etc. The reported benefits of early enteral feeding are prevention of adverse structural and functional alterations in the mucosal barrier, augmentation of visceral blood flow, and enhancement of local and systemic immune response [45].

Postoperatively, normal oral food intake or nutrition through feeding tube should start within the first 24 h. A meta-analysis evaluated early commencement of postoperative EN (within 24 h) versus traditional management in patients undergoing gastrointestinal surgery. It was in favor of early enteral feeding following gastrointestinal surgery to reduce morbidity and mortality rates [46]. The beneficial effect of early oral feeding was also shown by El Nakeeb et al. [47]. There is strong evidence that oral nutritional supplements (200 ml twice daily) given from the day of surgery until normal food intake is achieved are beneficial.

The optimal duration of nutritional support in the postoperative period remains unclear. Although using postoperative oral nutritional supplements for 8 weeks in malnourished patients enhances recovery of nutritional status and quality of life [11], benefits for well-nourished patients are less evident [48]. Concerning postoperative immunonutrition, duration of therapy varied from 3 [49] to more than 10 days [42],[43],[50], with the most common duration being 7 days [6],[51],[52].


  Route of administration Top


Enteral nutrition

Specific benefits to perioperative EN include a reduction in the incidence of postoperative infections and complications, and improved wound healing [8],[10]. This would also include fewer life-threatening surgical complications, such as anastomotic stenosis or leak, delayed gastric emptying, recurrent nerve palsy, and superficial or deep fascial surgical site infections [12],[53]. EN has been shown to be cost-effective by reducing the length of hospital stay [12]. These effects are thought to be due to EN capacity to maintain gastrointestinal integrity, thus preventing villous atrophy, to attenuate the body’s response to stress and maintain immunocompetency through IgA secretion [10],[4],[12]. EN contraindications include the presence of intestinal obstruction, malabsorption, multiple fistulas with high output, intestinal ischemia, severe shock with impaired splanchnic perfusion, and fulminant sepsis [54],[55].

Strategies used to reduce postoperative gastrointestinal dysmotility and increase success of postoperative enteral feeding include the following [34]:

  1. Correction of pH imbalance.
  2. Correction of electrolyte abnormalities (especially potassium and magnesium).
  3. Limiting excessive fluid administration.
  4. Minimization of exogenous opiates.
  5. Optimization of glycemic control to avoid hyperglycemia-induced slowing of gastric emptying.
  6. Early institution of enteral feeding.
  7. Use of prokinetic medications to treat established feed intolerance ([Table 2]).
    Table 2: Complications associated with enteral nutrition [34]

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Parenteral nutrition

Total parenteral nutrition (TPN) has been shown to significantly affect postoperative outcomes in the severely malnourished patient group [10],[56]. Because of its direct central venous administration, parenteral nutrition can rapidly improve nitrogen balance, which allows for quicker lymphocyte recovery and improved wound healing [8],[10]. Although TPN has many benefits, there are considerable risks to its use. Volume overload can cause respiratory compromise, particularly in individuals with marginal cardiopulmonary reserve [45]. Hyperglycemia, along with its metabolic consequences, can result in adverse outcomes if allowed to remain uncorrected.

Hyperglycemia is also associated with the dysfunction of the immune response. Abnormalities include affecting the granulocyte adhesion, chemotaxis, phagocytosis, complement function, and intracellular killing [53],[57]. Compher et al. [56] were able to demonstrate that tight glycemic control in ICU patients receiving TPN resulted in fewer infectious complications and a decrease in mortality. Overfeeding is another concern with TPN, especially in patients at extreme ages. Overfeeding can lead to azotemia, hypertonic dehydration, and metabolic acidosis. Excessive carbohydrate infusion results in hyperglycemia, hypertriglyceridemia, and hepatic steatosis. High lipid infusions can cause hypertriglyceridemia and fat-overload. Hypercapnia and refeeding syndrome may also result from aggressive feeding [58] ([Table 3]).
Table 3: Complications associated with total parenteral nutrition [15]

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  Optimum nutrition Top


As regards specific macronutrients, the requirement for carbohydrates is estimated at 3–6 mg/kg/min (roughly 200–300 g/day), for protein it is 1.25–2.0 g/kg/day, and for lipids it is 10–25% of total calories, depending on the route and lipid composition [59]. These figures vary depending on the specific patient condition. Ideally, one would like to provide sufficient nutrients to minimize the catabolic loss associated with stress, injury, and surgery while avoiding the problems associated with overfeeding, such as hyperglycemia, azotemia, excess CO2 production, etc.

Several trials suggest additional benefits with immunomodulation compared with the standard formulas when the appropriate population is chosen. More than 27 prospective randomized trials using immunomodulation formulas have resulted in very similar conclusions, demonstrating a decrease in infectious complications and shortened hospital stays with no change in overall mortality [60],[61]. Some editorials continue to support the use of immune formulas [62], whereas others report them as poison [63].

The greatest debate revolves around the pros and cons of additional arginine in the ICU setting. One school considers that arginine is potentially toxic [63], whereas another argument is that arginine is deficient in critical illness and should be supplemented. No prospective clinical data are currently available proving that arginine is harmful, whereas numerous prospective articles have demonstrated arginine to be beneficial, especially in the surgical and trauma population.

Glutamine is the other conditionally essential amino acid that has recently gained even greater support in the critical care setting. Glutamine has been reported to offer a myriad of benefits, including maintenance of acid/base balance, provision of primary fuel for rapidly proliferating cells (i.e. enterocytes and lymphocytes), synthesis of glutathione and arginine, and lowering of insulin resistance, and functions as a key substrate for gluconeogeneis [64]. Evidence that glutamine can induce heat-shock protein is yet another beneficial molecular effect of this amino acid [65]. The heat-shock proteins are a class of cellular chaperone proteins that support appropriate protein folding [66]. With glutamine enhancing heat-shock protein, the cell protects itself from subsequent stress.

The ω-3 fats in fish oil have multiple beneficial effects in the perioperative period, including modulation of leukcocyte function and regulation of cytokine release through nuclear signaling and gene expression [67]. The ω-3 lipids have recently been reported to enhance the production of a new group of prostaglandin derivatives called resolvins and neuroprotectins, which play a role in accelerating their solution of the proinflammatory state [68] ([Table 4]).
Table 4: The daily vitamins and trace element requirements for an adult receiving artificial nutrition [54]

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  How much to feed? Top


The caloric requirement for the perioperative and ICU patient is evolving as the concept of hypocaloric feeding, or so-called permissive underfeeding, in the early ICU and postoperative period. There is a relative anorexia that occurs from significant illness and the supply of nutrients during this period induces a proinflammatory state, which then exacerbates the condition. This concept has led several investigators to encourage hypocaloric feeding in the early phases of critical illness. Krishnan et al. [69] reported that underfeeding the septic medical ICU patient resulted in a small improvement in survival. In a study evaluating TPN and caloric delivery, McCowan et al. [70] demonstrated an interesting but not statistically significant trend in decreasing infectious complications. Several studies in critically ill obese patients use a hypocaloric high-protein regimen with excellent metabolic results [71],[72]. Although the optimal caloric load for the hypermetabolic (nonobese) patient remains in transition, the caloric delivery currently considered safe for the perioperative period is in the range of 20–30 kcal/kg/day (excluding the morbidly obese).


  Special patient groups Top


Obese patients

Despite a considerable fat store, obese patients are at risk of loss of lean body mass through gluconeogenesis and micronutrient deficiency during times of acute stress. Fasting insulin concentrations are increased, which suppress lipid mobilization from stores and result in accelerated protein breakdown to fuel gluconeogenesis [73]. These risks may be increased because of an incorrect assumption that obese patients have a greater ‘nutritional reserve’ compared with nonobese patients [74].

Screening and supplementation for micronutrient deficiency may be of benefit. For example, patients undergoing laparoscopic sleeve gastrectomy can be deficient in vitamin D, iron, thiamine, and vitamin B12 [75]. Postoperative nutrition should contain enough protein to minimize muscle loss and aid wound healing and should contain enough calories to prevent severe ketoacidosis [74]. High-protein hypocaloric feeding of critically ill obese patients has been evaluated with the aim of allowing fat stores to be utilized for energy and sparing muscle protein from excessive catabolism [76],[77],[78]. Suggested caloric requirements for this group of patients are 22–25 kcal/kg ideal body weight/day (or 11–14 kcal/kg actual body weight/day) with 2 g/kg/day of protein, but the evidence upon which the recommendation is based is weak [76].

The elderly

Aging is associated with a reduction in lean body mass, increase in body fat, decrease in total body water, and a reduction in bone density [73]. Advanced age is independently associated with poor nutritional status in hospitalized patients [77]. Deficiencies of vitamins B6, B12, C, D, folate, and calcium are prevalent in this group [73],[78]. Elderly patients who have experienced 10% or more weight loss in the previous 6 months, or who are hypoalbuminemic, experience more adverse postoperative outcomes [77]. Perioperative nutritional support is indicated in malnourished elderly patients, who are not in a terminal phase of illness, and the enteral route is preferred [79]. Although the evidence is limited, nutritional supplementation may reduce morbidity in elderly patients who suffer a hip fracture [80] or who undergo total hip or total knee arthroplasty [81].

The critically ill

Critically ill surgical patients often do not receive adequate nutrition [19], although only two specific situations arise where concerns about the safety of EN may be valid − namely, for patients receiving vasopressor drugs and those with laparostomies. The rationale for avoiding EN is that it might exacerbate subclinical gut ischemia in patients receiving vasoconstrictor agents. However, in health, mesenteric artery blood flow increases with nutrient load [82]. Retrospective observational data have suggested that enteral feeding during shock is safe and may be associated with reduced mortality [83]. A recent large multicenter cohort study conducted in France reported that nutrition within 48 h of intubation in shocked patients was associated with reduced mortality, irrespective of the route of feeding [84]. Similarly, EN does not appear to delay closure of laparostomies and has been associated with a reduction in the frequency of both fistulae formation and pneumonia [85].

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Studley HO. Percentage of weight loss: a basic indicator of surgical risk in patients with chronic peptic ulcer. Nutr Hosp 2001; 16:141–143.  Back to cited text no. 1
    
2.
Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related malnutrition. Clin Nutr 2008; 27:5–15.  Back to cited text no. 2
    
3.
Kyle UG, Pirlich M, Schuetz T, Luebke HJ, Lochs H, Pichard C. Prevalence of malnutrition in 1760 patients at hospital admission: a controlled population study of body composition. Clin Nutr 2003; 22:473–481.  Back to cited text no. 3
    
4.
Braga M, Gianotti L, Gentilini O, Parisi V, Salis C, Di Carlo V. Early postoperative enteral nutrition improves gut oxygenation and reduces costs compared with total parenteral nutrition. Crit Care Med 2001; 29:242–248.  Back to cited text no. 4
    
5.
Bozzetti F, Braga M, Gianotti L, Gavazzi C, Mariani L. Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomized multicentre trial. Lancet. 2001; 358:1487–1492.  Back to cited text no. 5
    
6.
Braga M, Gianotti L, Vignali A, di Carlo V. Preoperative oral arginine and n-3 fatty acid supplementation improves the immunometabolic host response and outcome after colorectal resection for cancer. Surgery 2002; 132:805–814.  Back to cited text no. 6
    
7.
Zheng YM, Li F, Qi BJ, Wang XH, Sun HC, Liu S, Ai Zheng. Application of perioperative immunonutrition for gastrointestinal surgery: a meta-analysis of randomized controlled trials. Asia Pac J Clin Nutr 2007; 16:253–257.  Back to cited text no. 7
    
8.
Bozzetti F. Nutritional support in oncologic patients: where we are and where we are going. Clin Nutr 2011; 30:714–717.  Back to cited text no. 8
    
9.
Bozzetti F. Perioperative nutritional management. Proc Nutr Soc 2011; 70:305–310.  Back to cited text no. 9
    
10.
Ward N. Nutrition support to patients undergoing gastrointestinal surgery. Nutr J 2003; 2:18.  Back to cited text no. 10
    
11.
Beattie AH, Prach AT, Baxter JP, Pennington CR. A randomised controlled trial evaluating the use of enteral nutritional supplements postoperatively in malnourished surgical patients. Gut 2000; 46:813–818.  Back to cited text no. 11
    
12.
Fujita T, Daiko H, Nishimura M. Early enteral nutrition reduces the rate of life-threatening complications after thoracic esophagectomy in patients with esophageal cancer. Eur Surg Res 2012; 48:79–84.  Back to cited text no. 12
    
13.
van der Hulst RR, von Meyenfeldt MF, van Kreel BK, Thunnissen FB, Brummer RJ, Arends JW, Soeters PB. Gut permeability, intestinal morphology, and nutritional depletion. Nutrition 1998; 14:1–6.  Back to cited text no. 13
    
14.
Visser M, Davids M, Verberne HJ, Kok WE, Niessen HW, van Venrooij LM, Cocchieri R, Wisselink W, de Mol BA, van Leeuwen PA. Rationale and design of a proof-of-concept trial investigating the effect of uninterrupted perioperative (par)enteral nutrition on amino acid profile, cardiomyocytes structure, and cardiac perfusion and metabolism of patients undergoing coronary artery bypass grafting. J Cardiothorac Surg 2011; 6:36.  Back to cited text no. 14
    
15.
Klein S, Kinney J, Jeejeebhoy K, Alpers D, Hellerstein M, Murray M, Twomey P. Nutrition support in clinical practice: review of published data and recommendations for future research directions. National Institutes of Health, American Society for Parenteral and Enteral Nutrition, and American Society for Clinical Nutrition. J Parenter Enteral Nutr 1997; 21:133–156.  Back to cited text no. 15
    
16.
Stenholm S, Harris TB, Rantanen T, Visser M, Kritchevsky SB, Ferrucci L. Sarcopenic obesity: definition, cause and consequences. Curr Opin Clin Nutr Metab Care 2008; 11:693–700.  Back to cited text no. 16
    
17.
Van Venrooij LM, de Vos R, Zijlstra E, Borgmeijer-Hoelen MM, van Leeuwen PA, de Mol BA. The impact of low preoperative fat-free body mass on infections and length of stay after cardiac surgery: a prospective cohort study. J Thorac Cardiovasc Surg 2011; 142:1263–1269.  Back to cited text no. 17
    
18.
Makelka JT, Kiviniemi H, Juvonen T, Laitinen S. Factors influencing wound dehiscence after midline laparotomy. Am J Surg 1995; 170:387–390.  Back to cited text no. 18
    
19.
Martindale RG, McClave SA, Taylor B, Lawson CM. Perioperative nutrition: what is the current landscape? J Parenter Enteral Nutr 2013; 37(Suppl):5S–20S.  Back to cited text no. 19
    
20.
Martindale RG, Maerz LL. Management of perioperative nutrition support. Curr Opin Crit Care 2006; 12:290–294.  Back to cited text no. 20
    
21.
Kudsk KA, Tolley EA, DeWitt RC, Janu PG, Blackwell AP, Yeary S, King BK. Preoperative albumin and surgical site identify surgical risk for major postoperative complications. J Parenter Enteral Nutr 2003; 27:1–9.  Back to cited text no. 21
    
22.
Mueller C, Compher C, Ellen DM. A.S.P.E.N. clinical guidelines: nutrition screening, assessment, and intervention in adults. J Parenter Enteral Nutr 2011; 35:16–24.  Back to cited text no. 22
    
23.
Kondrup J, Allison SP, Elia M, Vellas zB, Plauth M. ESPEN guidelines for nutrition screening 2002. Clin Nutr 2003; 22:415–421.  Back to cited text no. 23
    
24.
Jie B, Jiang ZM, Nolan MT, Zhu SN, Yu K, Kondrup J. Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk. Nutrition 2012; 28:1022–1027.  Back to cited text no. 24
    
25.
Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003; 4:CD004423.  Back to cited text no. 25
    
26.
Chapman MJ, Deane AM. Gastrointestinal dysfunction relating to the provision of nutrition in the critically-ill. Curr Opin Clin Nutr Metab Care 2015; 18:207–212.  Back to cited text no. 26
    
27.
Kar P, Jones KL, Horowitz M, Chapman MJ, Deane AM. Measurement of gastric emptying in the critically-ill. Clin Nutr 2015; 34:557–564.  Back to cited text no. 27
    
28.
Shin AS, Camilleri M. Diagnostic assessment of diabetic gastroparesis. Diabetes 2013; 62:2667–2673.  Back to cited text no. 28
    
29.
Read NW, Houghton LA. Physiology of gastric emptying and pathophysiology of gastroparesis. Gastroenterol Clin North Am 1989; 18:359–373.  Back to cited text no. 29
    
30.
Nygren J, Thorell A, Jacobsson H, Larsson S, Schnell PO, Hylén L, Ljungqvist O. Preoperative gastric emptying. Effects of anxiety and oral carbohydrate administration. Ann Surg 1995; 222:728–734.  Back to cited text no. 30
    
31.
Søreide E, Eriksson LI, Hirlekar G, Eriksson H, Henneberg SW, Sandin R, Raeder J. Pre-operative fasting guidelines: an update. Acta Anaesthesiol Scand 2005; 49:1041–1047.  Back to cited text no. 31
    
32.
Pousman RM, Pepper C, Pandharipande P, Ayers GD, Mills B, Diaz J et al. Feasibility of implementing a reduced fasting protocol for critically-ill trauma patients undergoing operative and nonoperative procedures. J Parenter Enteral Nutr 2009; 33:176–180.  Back to cited text no. 32
    
33.
Passier RH, Davies AR, Ridley E, McClure J, Murphy D, Scheinkestel CD. Periprocedural cessation of nutrition in the intensive care unit: opportunities for improvement. Intensive Care Med 2013; 39:1221–1226.  Back to cited text no. 33
    
34.
Ali Abdelhamid Y, Chapman MJ, Deane AM. Perioperative nutrition. Anaesthesia 2016; 71(Suppl 1):9–18.  Back to cited text no. 34
    
35.
Lennard TW, Shenton BK, Borzotta A et al. The influence of surgical operations on components of the human immune system. Br J Surg 1985; 72:771–776.  Back to cited text no. 35
    
36.
Thorell A, Nygren J, Ljungqvist O. Insulin resistance: a marker of surgical stress. Curr Opin Clin Nutr Metab Care. 1999; 2:69–78.  Back to cited text no. 36
    
37.
Nygren J, Thorell A, Ljungqvist O. Are there any benefits from minimizing fasting and optimization of nutrition and fluid management for patients undergoing day surgery? Curr Opin Anaesthesiol 2007; 20:540–544.  Back to cited text no. 37
    
38.
Nygren J, Soop M, Thorell A, Efendic S, Nair KS, Ljungqvist O. Preoperative oral carbohydrate administration reduces postoperative insulin resistance. Clin Nutr 1998; 17:65–71.  Back to cited text no. 38
    
39.
Ljungqvist O, Thorell A, Gutniak M, Häggmark T, Efendic S. Glucose infusion instead of preoperative fasting reduces postoperative insulin resistance. J Am Coll Surg 1994; 178:329–336.  Back to cited text no. 39
    
40.
Evans DC, Martindale RG, Kiraly LN, Jones CM. Nutrition optimization prior to surgery. Nutr Clin Pract 2014; 29:10–21.  Back to cited text no. 40
    
41.
Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P. ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr 2006; 25:224–244.  Back to cited text no. 41
    
42.
Gianotti L, Braga M, Nespoli L, Radaelli G, Beneduce A, Di Carlo V. A randomized controlled trial of preoperative oral supplementation with a specialized diet in patients with gastrointestinal cancer. Gastroenterology 2002; 122:1763–1770.  Back to cited text no. 42
    
43.
Braga M, Gianotti L, Nespoli L, Radaelli G, Di Carlo V. Nutritional approach in malnourished surgical patients: a prospective randomized study. Arch Surg 2002; 137:174–180.  Back to cited text no. 43
    
44.
Jenkins ME, Gottschlich MM, Warden GD. Enteral feeding during operative procedures in thermal injuries. J Burn Care Rehabil 1994; 15:199–205.  Back to cited text no. 44
    
45.
Sacks GS, Kudsk KA. Maintaining mucosal immunity during parenteral feeding with surrogates to enteral nutrition. Nutr Clin Prac 2003; 18:483–488.  Back to cited text no. 45
    
46.
Lewis SJ, Andersen HK, Thomas S. Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: a systematic review and meta-analysis. J Gastrointest Surg 2009; 13:569–575.  Back to cited text no. 46
    
47.
El Nakeeb A, Fikry A, El Metwally T, Elyamani Fouda, Mohamed Youssef, Hosam Ghazy et al. Early oral feeding in patients undergoing elective colonic anastomosis. Int J Surg 2009; 7:206–209.  Back to cited text no. 47
    
48.
Smedley F, Bowling T, James M, Stokes E, Goodger C, O’Connor O et al. Randomized clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care. Br J Surg 2004; 91:983–990.  Back to cited text no. 48
    
49.
Finco C, Magnanini P, Sarzo G, Vecchiato M, Luongo B, Savastano S et al. Prospective randomized study on perioperative enteral immunonutrition in laparoscopic colorectal surgery. Surg Endosc 2007; 21:1175–1179.  Back to cited text no. 49
    
50.
Satinský I, Mitták M, Foltys A, Kretek J, Dostalík J. Comparison various types of artificial nutrition on postoperative complications after major surgery. Rozhl Chir 2005; 84:134–141.  Back to cited text no. 50
    
51.
Klek V, Kulig J, Sierzega M, Szczepanek K, Szybiński P, Scislo L et al. Standard and immunomodulating enteral nutrition in patients after extended gastrointestinal surgery − a prospective, randomized, controlled clinical trial. Clin Nutr 2008; 27:504–512.  Back to cited text no. 51
    
52.
Klek S, Kulig J, Sierzega M, Szybinski P, Szczepanek K, Kubisz A et al. The impact of immunostimulating nutrition on infectious complications after upper gastrointestinal surgery: a prospective, randomized, clinical trial. Ann Surg 2008; 248:212–220.  Back to cited text no. 52
    
53.
Braunschweig CL, Levy P, Sheean PM, Wang X. Enteral compared with parenteral nutrition: a meta-analysis. Am J Clin Nutr 2001; 74:534–542.  Back to cited text no. 53
    
54.
Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F et al. ESPEN Guidelines on Parenteral Nutrition: surgery. Clin Nutr 2009; 28:378–386.  Back to cited text no. 54
    
55.
Gustafsson UO, Ljungqvist O. Perioperative nutritional management in digestive tract surgery. Curr Opin Clin Nutr Metab Care 2011; 14:504–509.  Back to cited text no. 55
    
56.
Compher CW, Spencer C, Kinosian BP. Perioperative parenteral nutrition: impact on morbidity and mortality in surgical patients. Nutr Clin Pract 2005; 20:460–467.  Back to cited text no. 56
    
57.
Bozzetti F, Gavazzi C, Miceli R, Rossi N, Mariani L, Cozzaglio L et al. Perioperative total parenteral nutrition in malnourished, gastrointestinal cancer patients: a randomized, clinical trial. J Parenter Enteral Nutr. 2000; 24:7–14.  Back to cited text no. 57
    
58.
Klein CJ, Stanek GS, Wiles CE. Overfeeding macronutrients to critically ill adults: metabolic complications. J Am Diet Assoc 1998; 98:795–806.  Back to cited text no. 58
    
59.
Jacobs DG, Jacobs DO, Kudsk KA, Moore FA, Oswanski MF, Poole GV et al. Practice management guidelines for the nutritional support of the trauma patient. J Trauma 2004; 57:660–678.  Back to cited text no. 59
    
60.
Beale RJ, Bryg DJ, Bihari DJ. Immunonutrition in the critically ill: a systematic review of clinical outcome. Crit Care Med 1999; 27:2799–2805.  Back to cited text no. 60
    
61.
Heyland DK, Novak F, Drover JW, Jain M, Su X, Suchner U. Should immunonutrition become routine in critically ill patients? A systematic review of the evidence. JAMA 2001; 286:944–953.  Back to cited text no. 61
    
62.
Luiking YC, Poeze M, Ramsay G, Deutz NE. The role of arginine in infection and sepsis. J Parenter Enteral Nutr 2005; 29:S70–S74.  Back to cited text no. 62
    
63.
Suchner U, Heyland DK, Peter K. Immune-modulatory actions of arginine in the critically ill. Br J Nutr 2002; 87(Suppl 1):S121–S132.  Back to cited text no. 63
    
64.
Coeffier M, Dechelotte P. The role of glutamine in intensive care unit patients: mechanisms of action and clinical outcome. Nutr Rev 2005; 63:65–69.  Back to cited text no. 64
    
65.
Ziegler TR, Ogden LG, Singleton KD, Luo M, Fernandez-Estivariz C, Griffith DP et al. Parenteral glutamine increases serum heat shock protein 70 in critically ill patients. Intensive Care Med 2005; 31:1079–1086.  Back to cited text no. 65
    
66.
Macario AJ, Conway de Macario E. Sick chaperones, cellular stress, and disease. N Engl J Med 2005; 353:1489–1501.  Back to cited text no. 66
    
67.
Calder PC. Fatty acids and gene expression related to inflammation. Nestle Nutr Workshop Ser Clin Perform Programme 2002; 7:19–36 discussion 36–40.  Back to cited text no. 67
    
68.
Serhan CN. Novel eicosanoid and docosanoid mediators: resolvins, docosatrienes, and neuroprotectins. Curr Opin Clin Nutr Metab Care 2005; 8:115–121.  Back to cited text no. 68
    
69.
Krishnan JA, Parce PB, Martinez A, Diette GB, Brower RG. Caloric intake in medical ICU patients: consistency of care with guidelines and relationships of clinical outcome. Chest 2003; 124:297–305.  Back to cited text no. 69
    
70.
McCowan KC, Friel C, Sternbert J, Chan S, Forse RA, Burke PA, Bistrian BR. Hypocaloric total parenteral nutrition: effectiveness in prevention of hyperglycemia and infectious complications − a randomized clinical trial. Crit Care Med 2000; 28:3606–3611.  Back to cited text no. 70
    
71.
Dickerson RN, Boschert KJ, Kudsk KA, Brown RO. Hypocaloric enteral tube feeding in critically ill obese patients. Nutrition 2002; 18:241–246.  Back to cited text no. 71
    
72.
Flancbaum L, Choban PS, Sambucco S, Verducci J, Burge JC. Comparison of indirect calorimetry, the Fick method, and prediction in estimating the energy requirements of critically ill patients. Am J Clin Nutr 1999; 69:461–463.  Back to cited text no. 72
    
73.
Lugli AK, Wykes L, Carli F. Strategies for perioperative nutrition support in obese, diabetic and geriatric patients. Clin Nutr 2008; 27:16–24.  Back to cited text no. 73
    
74.
Cullen A, Ferguson A. Perioperative management of the severely obese patient: a selective pathophysiological review. Can J Anesth 2012; 59:974–996.  Back to cited text no. 74
    
75.
Damms-Machado A, Friedrich A, Kramer KM, Stingel K, Meile T, Küper MA et al. Pre- and postoperative nutritional deficiencies in obese patients undergoing laparoscopic sleeve gastrectomy. Obes Surg 2012; 22:881–889.  Back to cited text no. 75
    
76.
McClave SA, Kushner R, Van Way CW 3rd, Cave M, DeLegge M, Dibaise J et al. Nutrition therapy of the severely obese, critically-ill patient: summation of conclusions and recommendations. J Parenter Enteral Nutr 2011; 35(Suppl):88S–96S.  Back to cited text no. 76
    
77.
Kaafarani HM, Shikora SA. Nutritional support of the obese and critically-ill obese patient. Surg Clin North Am 2011; 91:837–855.  Back to cited text no. 77
    
78.
van Stijn MF, Korkic-Halilovic I, Bakker MS, van der Ploeg T, van Leeuwen PA, Houdijk AP. Preoperative nutrition status and postoperative outcome in elderly general surgery patients: a systematic review. J Parenter Enteral Nutr 2013; 37:37–43.  Back to cited text no. 78
    
79.
Rosenberg IH, Miller JW. Nutritional factors in physical and cognitive functions of elderly people. Am J Clin Nutr 1992; 55(Suppl 6):1237S–1243S.  Back to cited text no. 79
    
80.
Volkert D, Berner YN, Berry E, Cederholm T, Coti Bertrand P, Milne A et al. ESPEN guidelines on enteral nutrition: geriatrics. Clin Nutr 2006; 25:330–360.  Back to cited text no. 80
    
81.
Berend KR, Lombardi AV Jr, Mallory TH. Rapid recovery protocol for peri-operative care of total hip and total knee arthroplasty patients. Surg Technol Int 2004; 13:239–247.  Back to cited text no. 81
    
82.
Gentilcore D, Hausken T, Meyer JH, Chapman IM, Horowitz M, Jones KL. Effects of intraduodenal glucose, fat, and protein on blood pressure, heart rate, and splanchnic blood flow in healthy older subjects. Am J Clin Nutr 2008; 87:156–161.  Back to cited text no. 82
    
83.
Khalid I, Doshi P, diGiovine B. Early enteral nutrition and outcomes of critically-ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care 2010; 19:261–268.  Back to cited text no. 83
    
84.
Reignier J, Darmon M, Sonneville R, Borel AL, Garrouste-Orgeas M, Ruckly S et al. Impact of early nutrition and feeding route on outcomes of mechanically ventilated patients with shock: a post hoc marginal structural model study. Intensive Care Med 2015; 41:875–878.  Back to cited text no. 84
    
85.
Dissanaike S, Pham T, Shalhub S, Warner K, Hennessy L, Moore EE et al. Effect of immediate enteral feeding on trauma patients with an open abdomen: protection from nosocomial infections. J Am Coll Surg 2008; 207:690–697.  Back to cited text no. 85
    



 
 
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