Nutrition and Surgery: What You Need to Know

The evolution of modern nutrition therapy (NT) began in the mid-1940’s as physicians managed a large number of wounded soldiers and civilians. Over time, they noticed a correlation between patient outcomes and perioperative nutrition. In the 1950’s and 60’s, clinicians advanced their investigation of NT’s role in critically ill patients by varying the Nil Per Os (NPO) status of patients while attempting to optimize patient outcomes.1 In 1986, a trauma group at the University of Washington in Seattle issued a randomized clinical trial comparing parenteral nutrition (PN) and enteral nutrition (EN), confirming the importance of EN as an integral component of medical management. Recently there has been debate whether it is safe and beneficial to provide nutrition support by tube feedings immediately after surgery of the gastrointestinal tract. Traditionally, dietician waited for several days after surgery to begin feeding into the gastrointestinal tract. More recently, dietitians and some doctors have questioned whether waiting is necessary. They have also been concerned about the lack of nutrition for someone who has undergone a metabolically stressful surgery. It is important to

Background 1 

Osland, E., Hossain, M. B., Khan, S., & Memon, M. A. (2014). Effect of Timing of Pharmaconutrition (Immunonutrition) Administration on Outcomes of Elective Surgery for Gastrointestinal Malignancies: A Systematic Review and Meta-Analysis. Journal of Parenteral and Enteral Nutrition, 38, 1, 53-69. 

In this article, Osland et al. 2014 observed that Nutrition is very crucial amongst patients that have undergone elective gastrointestinal (GI) surgery. However, Osland et al. 2014 elaborate the circumstances that will ensure nutrition is effective when administered to a patient that has undergone elective gastrointestinal (GI) surgery. The authors depict that the provision of nutrition is only effective if it is administered promptly (Osland, Hossain, Khan, & Memon, 2014). The correct timing when administering nutrition is associated with an improved prospect in the health of patients who have undergone elective gastrointestinal (GI) surgery.

The benefit of administering nutrients to patients that have undergone surgery are conventionally understood to arise from administering micronutrients like calories for protein and energy for healing the wound. Also, it helps in reducing the effect of catabolism in the forthcoming period. However, it is in theory that because of oxidative stress, immune and complex inflammatory which is experienced prospectively, administering precise nutrients in supraphysiologic amounts can provide vivacious substrates which assist in modulating metabolic responses and immune, therefore improving outcomes of clinics.

To determine the impact of administering nutrients to patients that have undergone surgery, a research was conducted by Osland and his colleagues. Various reliable Electronic databases (Science Citation Index, Cochrane Register of Systematic Reviews, Medline, PubMed, CINAHL and EMBASE) were cross-searched for RCTs printed between 1980 and 2011 (Osland et al. 2014). The research aims to analyze the electronic database to find the efficiency of administering nutrients to patients. Twenty-one electronic databases were randomly picked to aid in the research.

About the result from the article, there were no significant benefits of administering solid nutrition and liquid nation. Both had the same effect when they were admitted to the parents who have undergone surgery. However, it is important for a person with diabetes at a time when to administer food to the patients since the body needs food to enable them to gain energy and heal the wound.

Background 2 

Shrikhande, Shailesh V., Shetty, Guruprasad S., Singh, Kailash, & Ingle, Sachin. (2010). Is early feeding after major gastrointestinal surgery a fashion or an advance? Evidence-based review of the literature. Journal of Cancer Research and Therapeutics, 5, 4, 232-239. 

The NBM (nil by mouth) is an approach used for many years after major surgery of gastrointestinal (GI). More devotion has been accorded to the early enteral Nutrition (EN) in the recent years, unlike the Intravenous Fluids (IVF) and the EN which have been on conventional. There has been no clarity of the advantages which are propounded linked to the evidence. This paper comprehensively combines all the evidence-based review that will be used in the determination of advancement and genuinely of the fashion presented by the EN.

To determine if early administering of food to patients that have undergone surgery is safe or not the traditional method is safe research was conducted. Since there is less evidence that on the efficiency of early administering of food too, the PubMed research was conducted on articles that were explaining nil by mouth method after a main gastrointestinal. 31 articles were selected to be studied; the articles should be with a range of 1979-2009 (Shrikhande, Shailesh, Shetty, Guruprasad, Singh, Kailash, & Ingle, Sachin, 2010). 14 articles were left out due to several motives, and 17 papers were designated for a comprehensive assessment.

After analyzing the PubMed on the publication that its research was concluded. It was evident that solid diet after main GI surgery is not recommended because it had its implication. According to an article that was picked randomly solid and liquid nutrition was fed to 9 patients that underwent surgery for each category. Out of 9 people who were feed solid diet after major GI surgery they experienced some side effect such as acute gastric dilatation, abdominal distension and vomiting (Shrikhande et al. 2010). Whereas the group that was administered liquid oral intake seven patients out of 9 experienced side effect such as acute gastric dilatation, abdominal distension, and vomiting. All the two groups were administered with the nutrients 4 hours after nasogastric tube removal. It is evident that timing is important for the administering of liquid oral intake, the probability of the patient responding to oral intake is 22.22 percent meaning compared to the solid intake. If the timing of administering oral intake is correct, the probability of it yielding positive result is high.

Primary 1: 

Kslenski, M. R., Fenton, T. R., Eliasziw, M., Zuege, D. J., Petrasek, P., Shahport, R., & Kaupland, K. B. (2013). A cohort study of nutrition in the intensive care unit following abdominal aortic aneurysm repair. Journal of Perenteral and Enteral Nutrition, 37 (2), 261-267. 

The AAA (Abdominal Aortic Aneurysm) it’s involved in the repairing of the postoperative morbidity substantially, the long stays in hospital and finally admission into the ICU. And several studies reveal that patients with main vascular surgery have an advanced probability of post and preoperative malnutrition, unlike the normal surgical group. The slower feeds resumption is a result of the postoperative malnutrition faced by one party.

To determine if Enteral nutrition administered within 48 hours is effective retroactive cohort research was carried out among 145 postsurgical AAA amend patients who are admitted to the ICU within 48 hours after surgery being conducted on them. Cox proportional hazard multiple regression and Kaplan-Meier procedures were employed to analyze the data. Based on the result it was evident that only 35 (24%) patients were able to be fed early. If a patients was a male, they are more probable to be fed first (adjusted hazard ratio [aHR] = 2.3; 95% sureness break [CI], 0.8–6.7; P = .13), had endovascular AAA reparation (aHR = 2.9; 95% CI, 1.4–6.2; P = .006), had less blood loss (80% EN goal) when being admitted to the ICU (Kslenski, Fenton, Eliasziw, Zuege, Petrasek, Shahport, & Kaupland, 2013). After regulatory for other factors, 14-day death had no relation to feeding time (aHR = 1.1; P = .88).

From the result, we can conclude that early nourishing was attained in sectional patients ensuring the repair of AAA, was correlated to the type of period of mechanical ventilation and surgery and was endured as well as later introduced feedings (Kslenski et al. 2013).

Primary 2 

Simoes, P. K., Woo, K. M., Shike, M., Mendelsohn, R. B., Gerdes, H., Markowitz, A. J., . . . Schattner, M. A. (2017). Direct percutaneous endoscopic jejunostomy: Procedural and nutrition outcomes in a large patient cohort. Journal of Parenteral and Enteral Nutrition , 1-9. 

Over one-third of the population with cancer face common malnutrition which is active with cancer. The Parental nutrition (PN) is less preferred to enteral feeding since they have a risk of multiple infections like liver dysfunction and hyperglycemia. For patient how have gone through UGI surgery, their only option is enteral feeding which is limited to them because of their postsurgical anatomy located in the upper DPEJ (Simoes, Woo, Shike, Mendelsohn, Gerdes, Markowitz, Schattner, 2017). Also, leaks might occur after UGI surgery with high aspiration risk, gastric dysmotility and duodenal obstruction.

To determine if technical achievement, technical and nutrition results and adverse events of a huge cohort of patients undertaking DPEJ insertion is success research was conducted. Patients who underwent DPEJ insertion between January 2009 and March 2015 were recognized from a recognized endoscopy database. Procedural, demographic, and nutrition result data were gathered from a medical report that is strode electronically. Regression analyses were used to identify predictors of adverse events and procedural success.

A total of 452 patients underwent 480 attempts at DPEJ insertion. Signs included preoperative or postoperative weight loss (64%), postoperative upper gastrointestinal (UGI) anastomotic drip (13%), aspiration deterrence (10%), and other (13%). Of attempted procedures, 398 (83%) were fruitful (Simoes et al. 2017). Feeding was introduced in 389 (98%) of patients; a median of 1775 calorie was delivered daily. Median body mass index (BMI) at baseline was 22.9 (11.4–44.7) and did not change over follow-up. Median change in BMI after DPEJ was similar in groups that received EN with palliative and curative intent. Adverse events following 480 attempted DPEJ insertions included 13 (3%) immediate and 74 (15%) delayed, 13 (3%) of which were serious. Patients with head and neck cancer had more adverse events than those with esophageal cancer (P = .020).

From the result, it is evident that DPEJ is a success and innocuous procedure which efficiently provides access for EN support in patients who are malnourished and patients with postoperative UGI cancer.

In conclusion, there is a lot of research that needs to be done to determine if it early enteral feeding is effective compared to the traditional plan which required dieticians to wait for a few days after surgery to begin feeding into the gastrointestinal tract. However, the articles depict that it is important to time nutrition for patients who are critically ill. The study of when to administer nutrients to patients that have undergone surgery has been done to close to a decade. Nowadays, the trend is to administration 48 hours after surgical operations. To minimalize the use of parenteral nutrition and to use some enteral nutrition. Nevertheless, full caloric enteral feedings for at least the first six days do not deliberate on a notable advantage over low-dose trophic enteral feedings. More study needs to be done because the success rate of enteral nutrition and supplementation is very low.

References

Kslenski, M. R., Fenton, T. R., Eliasziw, M., Zuege, D. J., Petrasek, P., Shahport, R., & Kaupland, K. B. (2013). A cohort study of nutrition in the intensive care unit following abdominal aortic aneurysm repair. Journal of Perenteral and Enteral Nutrition, 37 (2), 261-267.

Osland, E., Hossain, M. B., Khan, S., & Memon, M. A. (2014). Effect of Timing of Pharmaconutrition (Immunonutrition) Administration on Outcomes of Elective Surgery for Gastrointestinal Malignancies: A Systematic Review and Meta-Analysis. Journal of Parenteral and Enteral Nutrition, 38, 1, 53-69.

Shrikhande, Shailesh V., Shetty, Guruprasad S., Singh, Kailash, & Ingle, Sachin. (2010). Is early feeding after major gastrointestinal surgery a fashion or an advance? Evidence-based review of the literature. Journal of Cancer Research and Therapeutics, 5, 4, 232-239.

Simoes, P. K., Woo, K. M., Shike, M., Mendelsohn, R. B., Gerdes, H., Markowitz, A. J., . . . Schattner, M. A. (2017). Direct percutaneous endoscopic jejunostomy: Procedural and nutrition outcomes in a large patient cohort. Journal of Parenteral and Enteral Nutrition , 1-9.