Pre-operative Nutrition Support in Patients Undergoing Gastrointestinal Surgery

School of Nursing, Midwifery and Social Work, University of Manchester, Room 6.32, Jean McFarlane Building, Oxford Road, Manchester, UK, M13 9PL.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 11/2012; 11(11):CD008879. DOI: 10.1002/14651858.CD008879.pub2
Source: PubMed


BACKGROUND: Post-operative management in gastrointestinal (GI) surgery is becoming well established with 'Enhanced Recovery After Surgery' protocols starting 24 hours prior to surgery with carbohydrate loading and early oral or enteral feeding given to patients the first day following surgery. However, whether or not nutritional intervention should be initiated earlier in the preoperative period remains unclear. Poor pre-operative nutritional status has been linked consistently to an increase in post-operative complications and poorer surgical outcome. OBJECTIVES: To review the literature on preoperative nutritional support in patients undergoing gastrointestinal surgery (GI). SEARCH METHODS: The searches were initially run in March 2011 and subsequently updated in February 2012. Databases including all EBM Reviews (Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA and NHSEED) MEDLINE, EMBASE, AMED, British Nursing Index Archive using OvidSP were included and a search was run on each database separately after which duplicates were excluded. SELECTION CRITERIA: The inclusion criteria were randomised controlled trials that evaluated pre-operative nutritional support in GI surgical participants using a nutritional formula delivered by a parenteral, enteral or oral route. The primary outcomes included post-operative complications and length of hospital stay. DATA COLLECTION AND ANALYSIS: Two observers screened the abstracts for inclusion in the review and performed data extraction. Bias was assessed for each of the included studies using the bias assessment tables in the Cochrane Software Review Manager (version 5.1, Cochrane Collaboration). The trials were analysed using risk ratios with Mantel-Haenszel in fixed effects methods displayed with heterogeneity. Meta-analyses were undertaken on trials evaluating immune enhancing (IE) nutrition, standard oral supplements, enteral and parenteral nutrition (PN) which were administered pre-operatively.Study characteristics were summarised in tables. Dichotomous and ratio data were entered into meta-analyses for the primary outcomes. These were then summarised in tables with assumed and corresponding risk with relative effect giving 95% confidence intervals. MAIN RESULTS: The searches identified 9900 titles and, after excluding duplicates, 6433 titles were initially screened. After the initial title screen, 6266 were excluded. Abstracts were screened for 167 studies and 33 articles were identified as meeting the inclusion criteria, of which 13 were included in the review after an assessment of the complete manuscripts.Seven trials evaluating IE nutrition were included in the review, of which 6 were combined in a meta-analysis. These studies showed a low to moderate level of heterogeneity and significantly reduced total post-operative complications (risk ratio (RR) 0.67 CI 0.53 to 0.84). Three trials evaluating PN were included in a meta-analysis and a significant reduction in post-operative complications was demonstrated (RR 0.64 95% CI 0.46 to 0.87) with low heterogeneity, in predominantly malnourished participants. Two trials evaluating enteral nutrition (RR 0.79, 95% CI 0.56 to 1.10) and 3 trials evaluating standard oral supplements (RR 1.01 95% CI 0.56 to 1.10) were included, neither of which showed any difference in the primary outcomes. AUTHORS' CONCLUSIONS: There have been significant benefits demonstrated with pre-operative administration of IE nutrition in some high quality trials. However, bias was identified which may limit the generalizability of these results to all GI surgical candidates and the data needs to be placed in context with other recent innovations in surgical management (eg-ERAS). Some unwanted effects have also been reported with components of IE nutrition in critical care patients and it is unknown whether there would be detrimental effects by administering IE nutrition to patients who could require critical care support after their surgery. The studies evaluating PN demonstrated that the provision of PN to predominantly malnourished surgical candidates reduced post-operative complications; however, these data may not be applicable to current clinical practice, not least because they have involved a high degree of 'hyperalimentation'. Trials evaluating enteral or oral nutrition were inconclusive and further studies are required to select GI surgical patients for these nutritional interventions.

53 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: To evaluate preoperative albumin levels as a marker for comparing survival outcomes after cystectomy in patients with bladder cancer. Materials and methods: We performed a retrospective record review using our bladder cancer database of 238 patients from 2004 to 2011. Of these, we included 187 patients with sufficient data for analysis, aged 35 years or older, who survived to undergo cystectomy. Serum albumin levels were routinely checked the day before cystectomy. Overall survival and cancer-specific survival by albumin levels were compared using Kaplan-Meier and Cox proportional hazards regression models. Complication rates between albumin groups were compared by a 2-sample test of proportions. Results: Thirty-one patients (16.5%) were in the low-albumin cohort (defined as albumin <3.5 g/dL), and 156 patients had albumin levels within normal reference ranges. Multivariable analysis showed overall survival at 3 years was 41% and 56% (adjusted hazard ratio, 1.76; P = .04) and cancer-specific survival was 57% and 72% (hazard ratio, 1.57; P = .22) in the low- and normal-albumin groups, respectively. Overall complication rates were significantly higher in the cohort with low albumin than in those with normal albumin (87% vs 65%; P = .014). Conclusion: Our single-institution retrospective study demonstrates that patients with low preoperative albumin levels had an increased overall mortality and cancer-specific mortality risk than those with normal albumin levels. Albumin may therefore be a reflection of disease state as well as nutritional status.
    Urology 01/2013; 81(3). DOI:10.1016/j.urology.2012.10.055 · 2.19 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The current era of health care delivery, with its focus on providing high-quality, affordable care, presents many challenges to hospital-based health professionals. The prevention and treatment of hospital malnutrition offers a tremendous opportunity to optimize the overall quality of patient care, improve clinical outcomes, and reduce costs. Unfortunately, malnutrition continues to go unrecognized and untreated in many hospitalized patients. This article represents a call to action from the interdisciplinary Alliance to Advance Patient Nutrition to highlight the critical role of nutrition intervention in clinical care and suggest practical ways for prompt diagosis and treatment of malnourished patients and those at risk for malnutrition. We underscore the importance of an interdisciplinary approach to addressing malnutrition both in the hospital and in the acute post-hospital phase. It is well recognized that malnutrition is associated with adverse clinical outcomes. Although data vary across studies, available evidence shows early nutrition intervention can reduce complication rates, length of hospital stay, re-admission rates, mortality, and cost of care. The key is to identify patients systematically who are malnourished or at risk and to promptly intervene. We present a novel care model to drive improvement, emphasizing the following six principles: (1) create an institutional culture where all stakeholders value nutrition; (2) redefine clinicians' roles to include nutrition care; (3) recognize and diagnose all malnourished patients and those at risk; (4) rapidly implement comprehensive nutrition interventions and continued monitoring; (5) communicate nutrition care plans; and (6) develop a comprehensive discharge nutrition care and education plan.
    Medsurg nursing: official journal of the Academy of Medical-Surgical Nurses 06/2013; 22(3):147-65. DOI:10.1177/0148607113484066
  • [Show abstract] [Hide abstract]
    ABSTRACT: The success of hernia repair is measured by absence of recurrence, appearance of the surgical scar, and perioperative morbidity. Perioperative surgical site occurrence (SSO), defined as infection, seroma, wound ischemia, and dehiscence, increases the risk of recurrent hernia by at least 3-fold. The surgeon should optimize all measures that promote healing, reduce infection, and enhance early postoperative recovery. In the population with ventral hernia, the most common complication in the immediate perioperative period is surgical site infection. This article reviews several preoperative measures that have been reported to decrease SSOs and shorten length of hospital stay.
    Surgical Clinics of North America 10/2013; 93(5):1041-55. DOI:10.1016/j.suc.2013.06.015 · 1.88 Impact Factor
Show more

Similar Publications