NUTRITION
Nutrition’s impact on surgery
By Dr George Leow Chee Seng
Despite knowing that even a single vitamin deficiency can affect the immune
system compromised by surgery, a recent study has found that many patients
are still facing unnecessarily higher risks – because of their poor diets.
F or more than 40 years, we have known that
malnutrition greatly increases surgical
mortality – with malnourished patients being ten
times more likely to die soon after surgery.
Unfortunately, most of us are deluded into thinking
our bodies look alright and that a malnourished
person would look more like an Ethiopian refugee.
But the true fact is that you can be malnourished
and obese at the same time.
Taking a cue from the word “undernourished”, a new
term has been coined to describe this syndrome –
“under-nutritioned”. It is an important term that
has begun to gain medical attention because it has
been shown that people with even a single vitamin
deficiency can have a poorly functioning immune
system. Looks, indeed, can be deceiving.
58 MAR/APR 2009 • OH!
To illustrate the previously unrecognised prevalence
of this condition, it would be good to draw on the
conclusions of a most enlightening study done
some years ago.
The study included a careful survey of surgical
patients admitted to the hospital and found that
44% of the patients had general malnutrition
on admission. This means that the patients were
under-nutritioned long before needing surgery
and coming to the hospital.
Even worse, 75% of the patients admitted to
an intensive care unit were found to be under-
nutritioned. This put the patients in even greater
danger because their bodies and immune systems
were placed under much greater stress.
The sad irony is that such stress is a tremendous
drain on nutrition at a time when the patient’s
nutritional status needs to be better – to improve
the odds for survival and post-surgical recovery.
If such a prognosis wasn’t already bad enough,
the study also uncovered another even more
shocking finding – that 69% of the patients actually
experienced a deterioration in their nutritional
status while in the hospital; thus pointing to a
rather sad indictment of hospital nutrition.
Deficiency effects
Another study involving a number of hospitals
found that 38% of patients had obvious vitamin
deficiencies and even a larger percentage was
marginally deficient.
These statistics were worrying because patients
 NUTRITION

with marginal nutritional deficiencies are at a

significantly higher risk of complications, especially
in terms of poor wound healing and suffering
potentially higher rates of infections.

Most bleeding tendencies following surgery are

minimal two days after the operation. This means
you can safely resume taking your nutritional
supplements.

The only contraindication would be if you were

receiving blood-thinning medications. In that
case, I would avoid using vitamin E in doses over
200 international units (IUs), even though blood-
thinning effects are rare below 1,000 IUs.

Several supplements can thin the blood (and affect

coagulation) and they include ginkgo, garlic ex
tract, quercetin, curcumin, and high-dose vitamin
E (greater than 1,000 IUs). But this concern is more
apparent than real as, in general, the blood-thinning
effect of these supplements is no more than that of
taking one aspirin tablet a day.
Magnesium factor
Maintaining adequate magnesium levels is
especially important in preventing surgical and
post-surgical complications. Magnesium is one of
those nutrients that seem to have an unlimited list
of benefits.
In addition to playing a role in more than 300
enzymes, it regulates blood flow, protects brain
cells, protects the heart muscle, reduces the risk
of cardiac arrhythmia, improves lung function,
improves kidney function, and prevents one of the
most frightening complications of major surgery –
blood clots.
a stroke or myocardial infarction (heart attack).
Magnesium significantly protects against these
complications as well.
Several studies have shown that magnesium
infusions can reduce the severity of a stroke or
heart attack by 50%. What is important is that your
tissue magnesium level be normal before surgery.
An ounce of prevention is truly worth more than a
pound of cure.
People who take diuretics or birth control pills, or
whose diet is low in fruits and vegetables, are at a
very high risk of magnesium depletion. Teenagers
often drink large amounts of carbonated soft drinks
throughout the day. These drinks significantly
lower the tissue magnesium levels. All of these
individuals therefore have a higher risk of surgical
complications.

I have used magnesium in my neurosurgical
patients for more than 15 years and I have never
had a patient develop post-operative blood clots
in the legs or lungs. In most cases, the blood clot
forms in the veins of the legs or pelvis – where it can
suddenly enter the bloodstream, producing a fatal
clot in the lungs called a pulmonary embolism.
Sudden cardiac arrest can be another catastrophic
event during surgery, leaving the patient with
Magnesium is also essential for normal immune
function. The bottom line is that the better your
nutrition is before surgery, the less likely it is that you
will have a major complication and the faster, and
more completely, you will recover from surgery.
Detection fallacies
Over the years, I have noticed that patients who
take these supplements regularly have significantly
less pain and fatigue after surgery as well. Post-

MAR/APR 2009 • OH! 59

NUTRITION
operative fatigue has always been a problem for
patients and one for which surgeons usually have
little to offer.
We are becoming increasingly aware of the fact that
even nutrient deficiencies too small to be recognised
by clinical examination can impair the body’s
functioning. We call these deficiencies subclinical.
A large number of people living in industrialised
countries suffer from these subclinical deficiencies,
and the number is continuing to grow.
When doctors want to know if you have adequate
amounts of a certain vitamin in your body, they
usually draw your blood and have it tested for the
vitamin in question. When they want to assess
the adequacy of your nutrition in general, they
frequently have your blood tested for your folate
and vitamin B12 levels.
Newer studies, however, have shown this method to
be very inaccurate. In one study, doctors compared
the usual blood levels of the vitamins folate, B6, and
B12 to the actual levels in the tissues as measured
biochemically. What they discovered was quite
shocking.
60 MAR/APR 2009 • OH!
When they measured the conventional vitamin
levels in a group of healthy elderly, they found
that approximately 19% of the study subjects had
deficiencies. Yet, when they used the more accurate
biochemical method, they found that 63% of these
same individuals were significantly deficient in one
or more of these critical vitamins.
A similar comparison of sick elderly subjects
found that 60% were deficient using conventional
measurement and a whopping 83% were deficient
when the biochemical method was used.
This study clearly demonstrates that measuring
vitamin blood levels by the conventional method
can result in a false assurance that all is well –
when in fact, severe deficiencies may exist. This is
especially true for the chronically ill.
Immunity suppression
It is well known that surgery and especially
anaesthesia are powerful suppressors of the
body’s immunity function. This is especially so for
surgeries lasting longer than two hours and in cases
where more than a unit of blood is lost during the
procedure.
 NUTRITION

This immunity suppression can last for several weeks

and can be made even worse if the patient has to
receive blood during or after the surgery. Immunity
suppression caused by blood transfusion, especially
multiple transfusions, can equal that caused by
acquired immune deficiency syndrome (AIDS).

A combination of poor nutrition, the trauma of

surgery, blood transfusion, and anaesthesia can
temporarily wipe out the immune system. It also
puts you at a much higher risk of postoperative
wound infection and pneumonia.

It has been shown that this immune suppression

caused by surgery, anaesthesia, and blood
transfusion can be reversed or even prevented by
proper nutrition. It will, of course, require special
immunity stimulants, but it can easily be done.

Cancer patients
Most cancer patients have as their primary treatment
the surgical removal of the tumour(s). Sometimes
this can be a relatively minor procedure, as with
a skin cancer. But it is often more complicated,
entailing the surgical removal of the cancer and any
surrounding lymph nodes.
The more complicated and prolonged surgeries
can be extremely stressful, both physically and
psychologically. For cancer patients, not only is
wound healing and avoiding all the complications
associated with surgery important, but so is making
sure the immune system is functioning at peak
activity.
The status of a person’s nutrition is critical to the
immune system. Again, I emphasise that even
a single nutrient deficiency can severely impair
the immune system. For example, a vitamin B6
deficiency alone can lower immunity, even when
the levels of all the other vitamins are perfectly
normal.
Of special concern are patients who undergo pre-
operative chemotherapy – that is, who receive a
dose of chemotherapy before surgery. It is well
recognised that most chemotherapy drugs cause
significant immunity suppression and interfere with
wound healing, thereby significantly increasing the
risk of infections after surgery.
This profound level of immunity suppression can
give cancer a chance to invade and spread.
Several studies have shown that nutritional
immune enhancement can significantly reduce
complications, especially infections, following
major surgeries. In one study, almost 70% of
immunity-deficient cancer patients undergoing
surgery developed post-operative complications
as compared to 25% with functioning immune
systems. This is a dramatic difference.
It should be appreciated that the patients in the
group with a functioning immune system did not
have specific nutritional immune stimulation. My
experience, as well as that of others, is that immunity
not only can be restored in patients, but can also be
maximised with special supplements. OH!

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