ESPEN practical guideline: Clinical nutrition in surgery.

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.

Enhanced recovery programs in gastrointestinal surgery: Actions to promote optimal perioperative nutritional and metabolic care.

The enhanced recovery after surgery (ERAS) pathway is an evidence-based approach to the use of care elements along the patient perioperative pathway. All care elements that may impact on clinically relevant outcomes have been considered and reviewed. The combined ERAS actions allow a quicker return to bowel function, oral feeding, nutritional and metabolic equilibrium, normal activity and ultimately to achieve better outcomes. Because of the multi factorial approach and the commitment of all the professionals caring for the patient, it is necessary to have the engagement of all disciplines, such as surgery, anesthesiology, clinical nutrition, nursing, physiatry, involved. ERAS is a dynamic process and new evidence are constantly integrated into the program. The primary endpoint of this review is to give updated information on the key ERAS actions to achieve optimal perioperative nutritional and metabolic care.

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

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

Pearls of optimizing nutrition and physical performance of older adults undergoing cancer therapy.

As the global population continues to age, the prevalence of cancer is increasing, with more than half of new cancer diagnoses occurring in those aged 65years and older. As a result of improved oncological care, a greater number of older patients undergo treatment, either chemoradiotherapy or surgery or both. The older oncology patient is not part of a homogenous group; chronological age poorly describes the health status of an individual. Comprehensive geriatric assessment (CGA) identifies domains, assessed by a multidisciplinary team, that should be considered to guide appropriate oncological treatment decisions. This paper will focus on two aspects of the CGA: the assessment of nutrition and functional status of the older patient with cancer. Optimization of both diet and physical activity may help patients improve their tolerance to oncological treatments and health-related quality of life (HRQOL). Beginning with definitions of frailty, sarcopenia, cachexia, and malnutrition, this paper will suggest standardized screening, diagnostic and interventional procedures to identify and treat these conditions in the older oncology patient.

An integrated multidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal surgery.

BACKGROUND: Enhanced perioperative care programs have been developed in order to attenuate the impact of surgical stress on organ dysfunction, thereby accelerating hospital discharge and reducing morbidity. The implementation of a fast-track program for laparoscopic colorectal surgery is reported. METHODS: We report on a series of patients who entered a coordinated program based on preoperative patient education and counseling, a laparoscopic approach, provision of postoperative epidural analgesia, early food intake and mobilization, and structured surgical and nursing care practices. The program was introduced in September 2006 and adapted to our institutional needs. Outcome measures included length of hospital stay, return of bowel function, incidences of postoperative complications, and rate of readmission to hospital. RESULTS: Twenty-five patients were selected by the surgeons for the accelerated laparoscopic colorectal pathway. The median duration of hospital stay was 3 (95% confidence interval, 3-4) days. Sixteen patients (64%) were discharged from hospital on day 3. Nine patients failed the pathway for various reasons (social indications, poor pain relief, wound infection, anemia, urinary retention) and were discharged later (six patients on day 4, two patients on day 5, and one patient on day 6). Times to recover bowel function and to resume a full diet were all within the first 36 hr from time of surgery. There were two readmissions. CONCLUSION: This early clinical experience demonstrates the feasibility of a fast-track program for colonic surgery and the requirement for an integrated multidisciplinary approach to perioperative care.

Perioperative amino acid supplementation of hypocaloric glucose does not impair glucose metabolism after surgery.

We tested the hypothesis that perioperative amino acid supplementation of hypocaloric dextrose would attenuate the inhibitory effect of glucose on endogenous glucose production after surgery. Sixteen patients undergoing colorectal cancer surgery were randomly assigned to receive intravenous glucose either with or without amino acids. Nutrition was administered over 48 hours from surgical skin incision until the second postoperative day. Glucose provided 50% and amino acids 20% of the patient's measured resting energy expenditure. Glucose rate of appearance was assessed by [6,6-2H2]glucose before and after surgery. Circulating concentrations of glucose, lactate, insulin, and glucagon were also determined. Hypocaloric glucose suppressed postoperative endogenous glucose production to a similar degree in both groups. The circulating concentrations of glucose increased to the same extent, whereas there was no significant change in plasma concentrations of lactate, glucagon, and cortisol. Postoperative plasma levels of insulin were significantly higher in patients receiving amino acids (P = .009). Perioperative amino acid administration does not mitigate the inhibitory effect of glucose on glucose production or aggravate hyperglycemia after colorectal surgery.

Parenteral nutrition and protein sparing after surgery: do we need glucose?

Although capable of inducing an anabolic state after surgery, parenteral nutrition, including glucose, leads to hyperglycemia. Even moderate increases in blood glucose are associated with poor surgical outcome. We examined the hypothesis that amino acids, in the absence of glucose supply, spare protein while preventing hyperglycemia. In this prospective study, 14 patients with colonic cancer were randomly assigned to undergo a 6-hour stable isotope infusion study (3 hours of fasting followed by 3-hour infusions of amino acids, Travasol [Baxter, Montreal, Canada] 10% at 0.02 mL.kg(-1).min(-1), with or without glucose at 4 mg.kg(-1).min(-1)) on the second day after colorectal surgery. Protein breakdown, protein oxidation, protein balance, and glucose production were assessed by stable isotope tracer kinetics using l-[1-(13)C]leucine and [6,6-(2)H2]glucose. Circulating concentrations of glucose, cortisol, insulin, and glucagon were determined. The administration of amino acids increased protein balance from -16+/-4 micromol.kg(-1).h(-1) in the fasted state to 16+/-3 micromol.kg(-1).h(-1). Combined infusion of amino acids and glucose increased protein balance from -17+/-7 to 7+/-5 micromol.kg(-1).h(-1). The increase in protein balance during nutrition was comparable in the 2 groups (P=.07). Combined administration of amino acids and glucose decreased endogenous glucose production (P=.001) and stimulated insulin secretion (P=.001) to a greater extent than the administration of amino acids alone. Hyperglycemia (blood glucose, 10.1+/-1.9 micromol/L) occurred only in the presence of glucose infusion. In summary, excluding glucose from a short-term feeding protocol does not diminish the protein-sparing effect of amino acids and avoids hyperglycemia.

Intraoperative infusion of amino acids induces anabolism independent of the type of anesthesia.

BACKGROUND: The infusion of dextrose in patients receiving epidural and light general anesthesia or general anesthesia alone failed to achieve a positive protein balance. We sought to verify the hypothesis that nutritional supplementation with i.v. amino acids induced a greater protein balance in patients receiving epidural blockade compared with those receiving general anesthesia. METHODS: Sixteen patients were randomly assigned to receive either general anesthesia with desflurane (control group) or general anesthesia combined with epidural analgesia (EDA group). A primed constant infusion of stable isotope tracers L-[1-(13)C]leucine and [6,6-(2)H2]glucose was started after a 32-h fast before surgery, (3 h of fasted state), and continued for 3 h during surgery during which amino acids were infused i.v. (fed state). RESULTS: Compared with the fasted state, the endogenous rate of appearance of leucine decreased to a similar extent in both groups, and protein synthesis increased, with no difference between the two groups. Leucine oxidation did not change in either group. After amino acids infusion, endogenous glucose production remained unchanged and glucose clearance decreased in both groups. Blood glucose, plasma cortisol, serum insulin, and glucagon concentrations increased to the same extent in both groups. CONCLUSIONS: Epidural anesthesia provided no additional benefit beyond the anabolism obtained with amino acids.