Mattias Soop, MD PhD

Centre for Gastrointestinal Disease, Ersta Hospital and Centre for Surgical Sciences, Karolinska Institute, Stockholm, Sweden

M62 Coloproctology Course Huddersfield 1-2 April 2004

The uncomplicated patient

In the uncomplicated surgical patient, the aim of perioperative nutrition is primarily to avoid prolonged semi-starvation rather than to prevent malnutrition. Over the last decade, oral intake of clear fluids hours before surgery and feeding immediately following surgery have been shown not only to be safe but also beneficial. These findings challenge the traditional routines of preoperative overnight fasting and the postoperative reintroduction of oral diet only upon return of bowel function.

Preoperative oral carbohydrate treatment

Oral intake of clear fluids up to two to three hours before anaesthesia has been shown to be

safe in patients with normal gastric emptying1, and is now advocated by most national

anaesthetic professional organisations. For example, The Royal College of Anaesthesia of

England recommends a three-hour interval between intake of clear fluids and anaesthesia2.

Preoperative treatment with a carbohydrate-rich beverage two to three hours before

anaesthesia has been shown to blunt catabolic responses to surgery such as insulin resistance3

and accelerated nitrogen losses4. Preoperative carbohydrate treatment has also been associated

with an attenuation of postoperative muscle weakness5 and a reduction in postoperative

hospital stay6 although these findings remains to be confirmed in larger trials.

Postoperative oral nutrition

Contrary to traditional belief, early (<24 h postop) feeding above a bowel anastomosis has not

been associated with an increased risk of anastomotic dehiscence; indeed there was a near

significant risk reduction in a recent meta-analysis of trials comparing early feeding with late

reintroduction of oral diet after gastrointestinal surgery7. Significant reductions of

postoperative infectious complication rates and lengths of hospital stay were found with early

feeding7. While postoperative gastrointestinal paralysis has traditionally limited early

feeding8, modern perioperative enhanced-recovery protocols including thoracic epidural

analgesia, opioid-sparing analgesia, early mobilization and postoperative laxatives completely

eliminates gastrointestinal paralysis after open colonic resection9, 10. Such protocols thus allow

for immediate postoperative oral intake of significant amounts of nutrients11, making artificial

intravenous or enteral tube feeding superfluous in patients undergoing uncomplicated

colorectal surgery today. Furthermore, enhanced-recovery protocols including preoperative

carbohydrate treatment markedly blunt the catabolic response to surgery and allows for

immediate, complete feeding without hyperglycaemia and with nitrogen balance12.

The malnourished patient

Diagnosing malnutrition before surgery

Approximately 25 % of surgical patients have been reported to be malnourished on

admission13. There is little doubt that malnutrition adversely affects outcome from surgery14,

and it is therefore important to diagnose malnutrition before surgery. A simple and highly

predictive test is the subjective global assessment (SGA), which is based on a careful history

and physical examination15.

Nutritional support in the malnourished surgical patient

Many trials have assessed the efficacy of perioperative nutritional support on outcome in

malnourished patients. There is good evidence that five to ten days of total parenteral nutrition

(TPN) at 30-35 kcal•kg–1•day–1 and 0.16-0.20 g nitrogen•kg–1•day–1 before major abdominal

surgery decreases overall postoperative morbidity in malnourished patients 16-18. Although

similar beneficial effects would be expected from preoperative oral nutritional support in

patients who tolerate it, no trials testing this hypothesis have been reported. Routine TPN in

the postoperative phase, in contrast to preoperative TPN, was reported to significantly

increase postoperative morbidity in a meta-analysis19, perhaps due to access complications20.

However, oral so-called sip feeds supplementing oral diet during the postoperative hospital

stay has been associated with decreased complication rates in mildly malnourished patients

undergoing gastrointestinal surgery21, 22.

The patient with a postoperative complication

Prolonged postoperative ileus

Although postoperative gastrointestinal paralysis can be avoided in most patients after

colorectal surgery with enhanced-recovery protocols9, ileus still occurs in some patients.

Although no data has been reported on the effects of delayed TPN in prolonged postoperative

ileus, an American consensus conference advocates starting TPN after five to ten days of

postoperative ileus19 to avoid prolonged starvation. With modern perioperative care, the

caloric demands after elective surgery are little increased above basal needs; a rough guide is

25-30 kcal•kg–1•day–1 12.

Infectious complications

Serious infectious complications after surgery result in progressively increasing caloric

demands23, aggravated insulin resistance resulting in hyperglycaemia24, and often

gastrointestinal paralysis. The enteral route should be used for total or partial nutritional

support as tolerated25, with additional caloric needs covered via the parenteral route. Most

investigators recommend that caloric supply be tailored to meet measured caloric demands

(indirect calorimetry) with 30–40% of total calories from fat and intakes of

0.15–0.2 g nitrogen•kg–1•day–1. Lacking indirect calorimetry equipment, empiric estimates of

the increases in caloric demands above basal may be used, such as +25 % during the first

week of severe sepsis, and +100 % from the second week23. Treatment of insulin resistance

by aggressive intravenous insulin therapy, keeping blood glucose concentrations at 4.4-

6.1 mmol•l–1, drastically reduces morbidity and mortality in postoperative patients in the

intensive care unit26. Critical illness is one condition where so-called immuno-nutrition may

be beneficial27. Provision of supplemental arginine27 and glutamine28 has been associated with improved outcomes, although this is a field of current controversy.

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