Extending the benefit of nutrition intervention beyond the operative setting.

PURPOSE OF REVIEW: To provide an update of the recent evidence on the potential of perioperative nutritional interventions to benefit adult patients undergoing head and neck and digestive procedures. RECENT FINDINGS: Perioperative nutrition within multimodal prehabilitation programs improve postoperative outcomes. Perioperative fasting time can be reduced with beverages containing carbohydrate alone or blended with a nitrogenous source such as whey protein; this approach seems to be safe and improve outcome. The choice of protein-containing formula, as well as diet composition to be recommended early during the postoperative refeeding, can be optimized to reduce complications. Sarcopenia is an important risk factor for surgical patients, as such, prehabilitation along with preoperative nutrition is strongly advised. Perioperative supplementation with ß-hydroxy ß-methylbutyrate to mitigate sarcopenia requires further investigation. Although perioperative nutritional interventions reduce healthcare costs, recent data suggest it has been scarcely prescribed. SUMMARY: Nutritional intervention is key in multimodal programs of enhanced recovery after surgery to ensure better outcomes. Perioperative fasting should be shortened, and include clear fluids containing carbohydrates and protein, especially in the early postoperative period. Multimodal prehabilitation is key to mitigate sarcopenia. Action to improve knowledge on the cost-effectiveness of nutritional interventions in the perioperative setting are needed.

Preoperative education in cholecystectomy in the context of a multimodal protocol of perioperative care: a randomized, controlled trial.

BACKGROUND: Preoperative education is a key point in multimodal protocols of perioperative care. We investigated whether preoperative education for patients undergoing open cholecystectomy would reduce the incidence of perioperative symptoms. METHODS: This was a randomized, single-blinded, clinical trial that included adult (18-65 years old) candidates for elective open cholecystectomy. All patients took part in the ERAS/ACERTO protocol of perioperative care except that only the intervention group received preoperative education. The main endpoints of the study were the presence and intensity of postoperative symptoms (e.g., nausea, vomiting, pain) measured by a visual analogue scale, 24 h after the operation. RESULTS: A total of 74 patients (34 in the intervention group, 40 in the control group) completed the study. The intervention group had significantly lower median (interquartile range) scores for nausea [0 (4) vs. 2.5 (5.8), p = 0.04] and pain [0.2 (2.3) vs. 3.1 (3.45), p < 0.01] than the controls. High well-being (score ≥ 6) was reported by 79.4 % (27 patients) of the intervention group in contrast to 57.5 % (23 patients) of the controls (p = 0.04). CONCLUSIONS: Preoperative education is highly effective in the context of a multimodal protocol for enhancing the recovery of patients submitted to open cholecystectomy.

Changes in body composition, hematologic parameters, and serum biochemistry after rapid intravenous infusion or oral intake of 2 liters of 0.9% saline solution in young healthy volunteers: randomized crossover study.

BACKGROUND: The perioperative infusion of 2 L of saline is associated with weight gain and decreased serum albumin and hematocrit. We hypothesized that these parameters would respond differently to oral administration and intravenous infusion of saline solution. METHODS: This was a crossover study that included 10 healthy young men (ages 18-26 years). At two times, 8 weeks apart, the participants were randomized to receive 2 L of 0.9% saline over 1 h by intravenous (IV) administration to a forearm vein or by oral intake. The participants were weighed and body masses were calculated. Bioelectrical impedance analysis was performed with a single-frequency device using tetrapolar distal limb electrodes. Blood samples were collected 1 h after the administration period for laboratory assays: hematocrit, hemoglobin, blood glucose, serum electrolytes, albumin, creatinine, osmolality. RESULTS: There was an increase in body weight (p<0.01), total body water (p<0.01), and lean body mass (p<0.01) after the experiment in both groups, with no difference between them. The volume of urine output was similar in the two experiments. The hemoglobin (oral group from 14.4±0.8 g/dl to 13.8±0.8 g/dl; IV group from 14.4±0.6 g/dl to 12.6±0.6 g/dl) and hematocrit (oral group from 43.2±1.8% to 43.2±2.8%; IV group from 43.6±2.2% to 40.0±2.6%) significantly decreased (p<0.01) with IV saline. Serum albumin remained stable after oral intake but significantly decreased (p=0.04) after IV infusion. CONCLUSIONS: Oral intake of 2 L of 0.9% saline results in minimal variations in serum albumin, hemoglobin, and hematocrit when compared to IV infusion of the same volume.

Effects of preoperative feeding with a whey protein plus carbohydrate drink on the acute phase response and insulin resistance. A randomized trial.

BACKGROUND: Prolonged preoperative fasting increases insulin resistance and current evidence recommends carbohydrate (CHO) drinks 2 hours before surgery. Our hypothesis is that the addition of whey protein to a CHO-based drink not only reduces the inflammatory response but also diminish insulin resistance. METHODS: Seventeen patients scheduled to cholecystectomy or inguinal herniorraphy were randomized and given 474 ml and 237 ml of water (CO group) or a drink containing CHO and milk whey protein (CHO-P group) respectively, 6 and 3 hours before operation. Blood samples were collected before surgery and 24 hours afterwards for biochemical assays. The endpoints of the study were the insulin resistance (IR), the prognostic inflammatory and nutritional index (PINI) and the C-reactive protein (CRP)/albumin ratio. A 5% level for significance was established. RESULTS: There were no anesthetic or postoperative complications. The post-operative IR was lower in the CHO-P group when compared with the CO group (2.75 ± 0.72 vs 5.74 ± 1.16; p = 0.03). There was no difference between the two groups in relation to the PINI. The CHO-P group showed a decrease in the both CRP elevation and CRP/albumin ratio (p < 0.05). The proportion of patients who showed CRP/albumin ratio considered normal was significantly greater (p < 0.05) in the CHO-P group (87.5%) than in the CO group (33.3%). CONCLUSIONS: Shortening the pre-operative fasting using CHO and whey protein is safe and reduces insulin resistance and postoperative acute phase response in elective moderate operations. TRIAL REGISTRATION: ClinicalTrial.gov NCT01354249.

Preoperative fasting of 2 hours minimizes insulin resistance and organic response to trauma after video-cholecystectomy: a randomized, controlled, clinical trial.

BACKGROUND: Studies showing the improvement of insulin sensitivity by reducing the term of preoperative fasting are mostly done in patients undergoing major operations. More information about the role of shortened preoperative fasting in perioperative metabolism is needed for such elective minor/moderate abdominal procedures as laparoscopic cholecystectomy. We investigated the influence of a carbohydrate-rich drink given 2 h before laparoscopic cholecystectomy on insulin resistance and the metabolic response to trauma. METHODS: A group of 21 female candidates (18-65 years old) for elective laparoscopic cholecystectomy were randomized to either an 8 h fasting group (control group: n = 10) or to a group receiving 200 ml of a carbohydrate beverage containing 12.5% (25 g, 50 kcal per 100 ml and approximately 285 mOsm) of maltodextrin 2 h before operation (CHO group: n = 11). Blood samples for various biochemical assays were collected both at induction of anesthesia and after the 10th postoperative hour. Insulin resistance was assessed by the HOMA-IR equation (Insulin (microU/ml) x blood glucose (mg/dl)/405). RESULTS: There were no postoperative complications. Seventy percent (7/10) of the controls and 27.3% (3/11) of the CHO group experienced at least one episode of vomiting (RR = 2.42, 95% Confidence Interval [CI] = 0.88-6.68; P = 0.08). Biochemical analysis showed that serum glucose (P < 0.01), insulin (P < 0.01), lactate/pyruvate ratio (P = 0.03), and triglycerides (P < 0.01) for the control group were higher than for the CHO group. The value of HOMA-IR was significantly greater (P = 0.03) in the conventionally fasted patients than in the CHO group. CONCLUSIONS: Abbreviation of the period of preoperative fasting and administration of a carbohydrate beverage diminishes insulin resistance and the organic response to trauma.

Sleeve Gastrectomy With or Without a Multimodal Perioperative Care. A Randomized Pilot Study.

BACKGROUND: Multimodal protocols may enhance postoperative recovery. The aim of this study was to evaluate the influence of a multimodal protocol in the clinical results, insulin resistance, and inflammatory response to trauma in morbidly obese patients undergoing sleeve gastrectomy. METHODS: The population of the study consisted of morbidly obese patients, who were operated using sleeve gastrectomy, from Cuiaba, MT, Brazil, between April and October 2012. Twenty patients were divided into two groups whom received either traditional preoperative care or treatment following the Acerto (accelerating the total recovery of patients in the postoperative period) protocol. The study examined inflammatory response and insulin resistance by measuring levels of glucose, insulin, Homa-IR, reactive C protein, albumin, prealbumin, alpha 1 acid glycoprotein, interleukin 6, and glycosylated hemoglobin. In addition, the study investigated hydration levels, nausea and vomiting, hypertension, and length of hospital stay. RESULTS: Patients who followed the Acerto protocol showed no postoperative hypertensive crises (p = 0.03), and 30 % less vomiting (p = 0.35), and showed significant reductions in length of hospital stay, on average of 3 days versus 2 days (p = 0.02). There were not significant statistical differences between the two groups with respect to inflammatory response and insulin resistance (p > 0.05). CONCLUSION: This pilot study suggests that the prescription of the Acerto multimodal protocol for morbidly obese patients undergoing sleeve gastrectomy was safe, reduced the rate hypertensive complications, and the length of both ICU and hospital postoperative stay. However, there was no improvement in postoperative insulin resistance or inflammatory acute phase response.

Intraluminal irrigation with fibers improves mucosal inflammation and atrophy in diversion colitis.

OBJECTIVE: We investigated the effect of irrigating the colorectal mucosa of patients with a colostomy using a solution of fibers. METHODS: Eleven patients (10 male and 1 female; mean age, 34 y; age range, 16-49 y) with loop colostomy due to trauma underwent endoscopic evaluation of the rectum and the proximal and distal mucosa from the colostomy. An endoscopic score (range, 0-10) was used to quantify the intensity of the inflammation at the mucosa. Biopsies were taken from the colostomy border and from the rectum. The mean crypt depth of the five best-oriented glands was registered. Then the diverted colorectal segment was irrigated with a solution containing 5% fibers (10 g/d) for 7 d. The patients underwent repeated endoscopic and biopsy procedures, and then the colostomy was closed. RESULTS: The endoscopic score was higher (P < 0.01) at the distal border (2, 0-5) and the rectum (4, 1-10) when compared with the proximal border (0, 0-1). After treatment, the score at the diverted colon (1, 0-2) diminished (P = 0.03). The macroscopic score of the rectum also decreased after the infusion (4, 1-10, versus 3, 0-4; P = 0.03). Crypt depth at the proximal mucosa was higher than at the diverted mucosa (301 +/- 36 microm versus 205 +/- 76 microm; P < 0.01). After treatment, crypt depth at the diverted mucosa (280 +/- 64 microm) increased (P = 0.03). The rectum mucosa did not change before and after the treatment. CONCLUSION: Irrigation with fibers improves inflammation at the defunctionalized colon.

Gastric residual volume by magnetic ressonance after intake of maltodextrin and glutamine: a randomized double-blind, crossover study.

CONTEXT: The addition of glutamine in preoperative drinks may enhance the benefits of carbohydrate alone. OBJECTIVES: To evaluate the gastric residual volume after the intake of a beverage containing carbohydrate plus glutamine. METHODS: Eleven healthy volunteers (24-30 years-old) were randomized in a crossover fashion to intake 400 mL (4h before) and 200 mL (2h before) of a beverage containing either 12.5% maltodextrin (carbohydrate group) or 12.5% maltodextrin plus 15 g of glutamine (glutamine group) in two different moments 7 days apart. Magnetic ressonance was performed to measure the gastric residual volume (mL) 120 and 180 minutes after the last ingestion. RESULTS: Gastric residual volume similar to basal condition was found after 2h and 3h of the intake of beverages. There was no difference in the mean ±SD GRV (mL) found at 120 minutes (carbohydrate group: 22.9±16.6 and glutamine group: 19.7±10.7) and at 180 minutes (carbohydrate group: 21.5±24.1 and glutamine group: 15.1±10.1) between the two drinks. CONCLUSIONS: Gastric emptying is efficient, and occurs in up to two hours after the intake of a beverage containing either carbohydrate alone or carbohydrate associated with glutamine. The addition of glutamine to carbohydrate-enriched drink seems to be safe for the use up to 2h before an operation.

Actual preoperative fasting time in Brazilian hospitals: the BIGFAST multicenter study.

BACKGROUND: Prolonged fasting increases organic response to trauma. This multicenter study investigated the gap between the prescribed and the actual preoperative fasting times in Brazilian hospitals and factors associated with this gap. METHODS: Patients (18-90-years-old) who underwent elective operations between August 2011 and September 2012 were included in the study. The actual and prescribed times for fasting were collected and correlated with sex, age, surgical disease (malignancies or benign disease), operation type, American Society of Anesthesiologists score, type of hospital (public or private), and nutritional status. RESULTS: A total of 3,715 patients (58.1% females) with a median age of 49 (18-94) years from 16 Brazilian hospitals entered the study. The median (range) preoperative fasting time was 12 (2-216) hours, and fasting time was longer (P<0.001) in hospitals using a traditional fasting protocol (13 [6-216] hours) than in others that had adopted new guidelines (8 [2-48] hours). Almost 80% (n=2,962) of the patients were operated on after 8 or more hours of fasting and 46.2% (n=1,718) after more than 12 hours. Prolonged fasting was not associated with physical score, age, sex, type of surgery, or type of hospital. Patients operated on due to a benign disease had an extended duration of preoperative fasting. CONCLUSION: Actual preoperative fasting time is significantly longer than prescribed fasting time in Brazilian hospitals. Most of these hospitals still adopt traditional rather than modern fasting guidelines. All patients are at risk of long periods of fasting, especially those in hospitals that follow traditional practices.

The combination of haloperidol, dexamethasone, and ondansetron for prevention of postoperative nausea and vomiting in laparoscopic sleeve gastrectomy: a randomized double-blind trial.

BACKGROUND: Many patients may experience postoperative nausea and vomiting (PONV) following laparoscopic sleeve gastrectomy (LSG). We evaluated the efficacy of the combination of haloperidol, dexamethasone, and ondansetron for prevention of PONV after LSG. METHODS: Ninety patients were included in this prospective, randomized, double-blinded, three-arm study (group O: ondansetron 8 mg; group DO: dexamethasone 8 mg and ondansetron 8 mg; group HDO: haloperidol 2 mg, dexamethasone 8 mg, and ondansetron). Nausea, vomiting, rescue antiemetic use, morphine consumption, adverse events, and volume of intravenous fluids infused were recorded at regular intervals for 36 h postoperatively. RESULTS: The incidence of nausea was lower 0-2 h postoperatively in group HDO compared to group O (23.7 versus 56.7 %, p = 0.016) and at 12-24 h postoperatively was lower in group HDO (23.3 %) and group DO (26.7 %) compared to group O (60 %) (p = 0.008 and p = 0.009, respectively). At 0-36 h postoperatively, nausea was lower in group HDO compared to group O (53.3 versus 86.7 %, p = 0.013). Vomiting at 0-36 h postoperatively was lower in group HDO compared to group O (20 versus 53.3 %, p = 0.015). Rescue antiemetic drug and morphine consumption were less used in group HDO compared to group O (p <0.01). The volume of fluids infused in group O was approximately 1 l greater than in group HDO (p = 0.026). CONCLUSION: The combination of haloperidol, dexamethasone, and ondansetron reduced PONV and the necessity of rescue antiemetics and also reduced morphine consumption and the volume of fluids infused postoperatively.

Optimal timing for the initiation of enteral and parenteral nutrition in critical medical and surgical conditions.

The early provision of nutrients as part of specialized therapy for critically ill patients admitted for critical medical and surgical conditions is recommended by various international guidelines. Enteral nutrition is the first option and should be initiated 24-48 h after admission to an intensive care unit. Even after gastrointestinal anastomosis, early oral or enteral feeding is not only safe but also associated with enhanced recovery and fewer complications. Recent studies showed that the use of an enteral diet or parenteral nutrition that contains immune nutrients enhances the recovery of critically ill patients. Although the precise caloric target remains controversial, the general consensus advocates the avoidance of prolonged hypocaloric or hypercaloric feeding. However, there is still debate about the timing of the initiation of parenteral nutrition when enteral nutrition either is impossible or does not meet the nutritional goals. Although controversy remains, two recent studies showed that when enteral feeding is not feasible the early initiation of parenteral nutrition was not associated with palpable benefit.

Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations.

BACKGROUND & AIMS: Protocols for enhanced recovery provide comprehensive and evidence-based guidelines for best perioperative care. Protocol implementation may reduce complication rates and enhance functional recovery and, as a result of this, also reduce length-of-stay in hospital. There is no comprehensive framework available for pancreaticoduodenectomy. METHODS: An international working group constructed within the Enhanced Recovery After Surgery (ERAS®) Society constructed a comprehensive and evidence-based framework for best perioperative care for pancreaticoduodenectomy patients. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group. The quality of evidence was rated "high", "moderate", "low" or "very low". Recommendations were graded as "strong" or "weak". RESULTS: Comprehensive guidelines are presented. Available evidence is summarised and recommendations given for 27 care items. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations. CONCLUSIONS: The present evidence-based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy. A unified protocol allows for comparison between centres and across national borders. It facilitates multi-institutional prospective cohort registries and adequately powered randomised trials.

Clinical benefits after the implementation of a protocol of restricted perioperative intravenous crystalloid fluids in major abdominal operations.

BACKGROUND: Perioperative fluid replacement is a challenging issue in surgical care. The purpose of the present study was to investigate the effect of two different perioperative hydration protocols on the outcome in patients undergoing major abdominal operations. METHODS: This was a prospective study involving 61 patients (42 men/19 women; mean age: 52 years; age range: 18-81 years) who underwent major abdominal operations. The study had two distinct phases: before (conventional group; administered 30-50 ml/kg per day of crystalloid fluids; n = 33) and after the implementation of a protocol of restricted use of intravenous fluids (restricted group; administered less than 30 ml/kg per day of crystalloid fluids; n = 28). The total volume of intravenous crystalloid fluids infused was recorded until postoperative day (POD) 4. Morbidity, mortality, and the length of postoperative hospital stay were the main clinical variables. RESULTS: Mortality was 4.9% (p > 0.05 between groups). Intravenous therapy in the restricted group was terminated earlier (p < 0.001) and the patients received 2.4 l less crystalloid fluid than did those in the conventional group from POD 1 through POD 4 (p < 0.001). The adoption of the restricted protocol shortened the postoperative hospital stay by 2 days (p = 0.02) and diminished the morbidity by 25% (p = 0.04). CONCLUSIONS: Restriction of perioperative intravenous crystalloid fluid is associated with reductions in morbidity and length of postoperative hospital stay after major abdominal operations.

Early nutritional therapy: the role of enteral and parenteral routes.

PURPOSE OF REVIEW: Early nutrition is defined as the initiation of nutritional therapy within 48 h of either hospital admission or surgery. However, optimal timing for initiation of nutritional therapy through either enteral or parenteral routes remains poorly defined with the existing data. We reviewed the recent literature investigating the role of early enteral and parenteral nutrition in critical illness and perioperative care. RECENT FINDINGS: Recent studies in both trauma/surgical and nonsurgical patients support the superiority of early enteral over early parenteral nutrition. However, late commencement of enteral feeding should be avoided if the gastrointestinal tract is functional. Both prolonged hypocaloric enteral feeding and hypercaloric parenteral nutrition should be avoided, although the precise caloric target remains controversial. SUMMARY: Early enteral nutrition remains the first option for the critically ill patient. However, there seems to be increased favor for combined enteral-parenteral therapy in cases of sustained hypocaloric enteral nutrition. The key issue is when the dual regimen should be initiated. Although more study is required to determine the optimal timing to initiate a combined enteral-parenteral approach, enteral nutrition should be initiated early and parenteral nutrition added if caloric-protein targets cannot be achieved after a few days.

Benefits of early enteral nutrition with glutamine and probiotics in brain injury patients.

Brain injury patients have higher energy and protein expenditures and are prone to infections. The aim of the present study was to evaluate the results of early enteral feeding with glutamine and probiotics in brain injury patients. Twenty-three brain injury patients (Glasgow score between 5-12 and therapeutic intervention scoring system>20) were studied. Three patients were excluded to leave 20 remaining patients. Patients were randomized to receive either an early enteral diet (control group, n=10) or the same formula with glutamine and probiotics added (study group, n=10) for a minimum of 5 days (range, 5-14 days). The diets were isocaloric and isonitrogenous [35 kcal.kg(-1).day(-1) (where 1 kcal approximately 4.184 kJ) and 1.5 g of protein.kg(-1).day(-1)]. Main outcome measures were the incidence of infection, the length of stay in the intensive care unit and the number of days requiring mechanical ventilation. The two groups were homogeneous in gender, age, nutritional status and severity of trauma. There was no mortality during the study period. The infection rate was higher in controls (100%) when compared with the study group (50%; P=0.03) and the median (range) number of infections per patient was significantly greater (P<0.01) in the control group [3 (1-5)] compared with the study group [1 (0-3)]. Both the critical care unit stay [22 (7-57) compared with 10 (5-20) days; P<0.01; median (range)] and days of mechanical ventilation [14 (3-53) compared with 7 (1-15) days; P=0.04; median (range)] were higher in the patients in the control group than in the study group. We conclude that the enteral formula containing glutamine and probiotics decreased the infection rate and shortened the stay in the intensive care unit of brain injury patients.