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RICHARD M. SALVINO, MD ROBERT S. DECHICCO, MS, RD, LD, CNSD DOUGLAS L. SEIDNER, MD, CNSP
Department of Gastroenterology, MetroHealth Manager, Nutrition Support Dietetics, Department of Nutrition Support Director, Department of Nutrition Support and Vascular
Medical Center, Cleveland, OH and Vascular Access, The Cleveland Clinic Foundation Access; Program Director, Fellowship in Clinical Nutrition,
Department of Gastroenterology and Hepatology,
The Cleveland Clinic Foundation
CME
CREDIT
Nutrition support should be considered in postoperative Malnutrition is associated with adverse out-
patients who cannot eat within 7 to 10 days after comes in surgical patients. Although it is diffi-
surgery. cult to establish a causal relationship, it is
known that malnutrition can impair wound
Whenever possible, enteral nutrition is preferred over healing and immunocompetence and decrease
parenteral nutrition, as it is safer and more cost-effective. cardiac and respiratory muscle function.
Furthermore, malnourished patients undergo-
Immune-enhancing enteral formulas are intended to ing surgery have higher rates of morbidity and
mortality as well as longer hospital stays com-
bolster the function of the immune system in stressed pared with adequately nourished patients.510
patients.
STUDIES OF PREOPERATIVE TPN
The Veterans Affairs Total Parenteral Koretz et al13 reached contrary conclu-
Nutrition Cooperative Study2 included 395 sions in a meta-analysis for the American
malnourished patients who required nonemer- Gastroenterological Association Position
gency laparotomies or thoracotomies, but not Paper on TPN, finding that preoperative TPN
vascular or cardiac procedures. Patients were did not have any effect on perioperative com-
randomly assigned to receive either TPN for 7 plications.
to 15 days before surgery and 3 days after Comment. The reason for the differing
surgery or no perioperative TPN. findings among the three meta-analyses is that
At 90 days, there were more infectious Koretz et al combined studies using TPN with
complications in the TPN group than in the studies using only protein-sparing therapy
control group (14.1% vs 6.4%; P = .01), but (< 10 kcal/kg/day of nonprotein energy).
more noninfectious complications in the con- Furthermore, despite using similar inclusion
trol group (22.2% vs 16.7%; P = .2). The most criteria, Koretz et al included 23 studies in
common infectious complications were pneu- their analysis that the other meta-analyses did
monia and bacteremia, and the most common not. Some of these 23 studies were not ran-
noninfectious complications were cardiovas- domized controlled trials, and others were
cular events and respiratory failure. repeat presentations of the same data.
A possible explanation for the greater These meta-analyses, moreover, point
number of infectious complications in the out an inherent weakness and limitation of
TPN group may be that these patients all meta-analyses: differences among the
received a high-calorie regimennearly 45 studies in patient populations and treat-
kcal/kg/day, which led in some cases to hyper- ments. Only Heyland et al11 attempted to
glycemia, a known risk factor for infections. account for such heterogeneity in their sub-
Furthermore, the excess of infections in the group analyses (ie, by grouping studies con-
TPN group was all in the subgroups with taining only malnourished patients and com-
either borderline or mild malnutrition. In con- paring these trials with other trials). These
trast, severely malnourished patients receiving investigators also developed a scoring system
Well- TPN had fewer noninfectious complications to assess the methodologic quality of the
nourished than controls (5% vs 43%; P = .03) and no individual studies, and used it to adjust the
increase in infectious complications. The results in their analysis.
patients may severely malnourished subgroup also had fewer
overall major complications with TPN than STUDIES OF PREOPERATIVE
do worse the subgroup without (21% vs 47%; P = .12). ENTERAL NUTRITION
with TPN Heyland et al11 did a meta-analysis of 27
randomized studies of perioperative TPN and Few studies examined enteral nutrition in pre-
concluded that TPN had no effect on mortal- operative patients.
ity but was associated with fewer major com- Lim et al14 found lower morbidity and
plications. mortality rates in patients receiving TPN vs
Subgroup analysis showed a trend toward enteral nutrition, but the differences were not
fewer deaths and complications in TPN statistically significant.
patients in studies published before 1988 (the Sako et al15 found no differences in rates
halfway point of the analysis) but not later. of postoperative complications and mortality
Although the reason for the difference in in patients who received preoperative TPN vs
results before and after this time was not those who received enteral nutrition.
entirely evident to the authors, they speculat-
ed that it was because the later studies were of STUDIES OF POSTOPERATIVE TPN
higher quality.
Klein et al12 analyzed 22 studies and Numerous small studies examined the effects
found that malnourished patients receiving of postoperative TPN.
TPN for 7 to 10 days before surgery had a 10% Yamada et al16 found that cancer patients
absolute reduction in postoperative complica- receiving postoperative TPN vs oral intake
tions. had fewer postoperative complications, a
346 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71 NUMBER 4 APRIL 2004
higher survival rate, and higher body weights, WHO SHOULD RECEIVE
serum albumin levels, and total lymphocyte NUTRITION SUPPORT?
counts. The likely reason for the better sur-
vival rate was that TPN allowed the patients Nutrition support is indicated in patients who
to tolerate more chemotherapy. are unable or unwilling to consume, digest,
Collins et al17 found that postoperative and assimilate adequate nutrients orally.
patients had faster wound-healing rates and a However, not all patients who cannot eat for
lower incidence of postoperative sepsis with a few days are candidatesonly those in
TPN vs an amino acid solution or oral intake. whom the benefits outweigh the risks.
However, both of these studies, while sta- How long a patient can go without ade-
tistically significant, were quite small (23 and quate nutritional intake without increasing
30 patients, respectively). surgical risk is unknown. Most well-nourished
Preshaw et al,18 on the other hand, found patients recover well without nutrition for
no reduction in the rate of colonic fistulas several days after surgery while receiving stan-
after colonic anastomosis with 6 days of post- dard intravenous fluids and then slowly rein-
operative TPN vs oral intake alone. troducing an oral diet. Moreover, some surgi-
Woolfson and Smith19 found no differ- cal patients do worse with TPN than with
ence in morbidity and mortality rates after standard care.2,3 This is likely because nutri-
major thoracoabdominal procedures in tion support carries inherent risks such as
patients treated with 7 days of postoperative catheter sepsis, hyperglycemia, electrolyte
TPN vs controls who received the standard abnormalities, and liver dysfunction.
postoperative fluid regimen.
Unlike the Veterans Affairs Group, which Who should receive
stratified patients on the basis of nutritional preoperative nutrition support?
status, these latter two studies looked at There are three main criteria in determining if
patients who were well-nourished or whose a patient should receive preoperative nutri-
nutritional status was unspecified. tion support:
Torosian20 reviewed eight prospective The patient must be severely malnour- Overfeeding
randomized trials of postoperative TPN. ished.28
Pooled analysis showed an overall 10% The procedure should be one in which
may be worse
greater incidence of complications in patients nutrition support has been shown to than
receiving TPN. improve clinical outcome, eg, a major
Klein et al,12 in another meta-analysis, thoracoabdominal procedure
malnutrition
also found a 10% greater incidence of compli- The surgery should be elective and safe to
cations in patients receiving routine postoper- delay for 7 to 10 daysthe length of time
ative TPN. that preoperative nutrition support
should be given.
STUDIES OF POSTOPERATIVE Enteral or parenteral? Nutrition support
ENTERAL NUTRITION should preferably be given through the enter-
al route if reliable access to the gastrointesti-
Few studies examined the use of postoperative nal tract can be obtained and formula toler-
enteral nutrition. Some found that it improved ance is demonstrated. If this is not possible,
wound healing, reduced septic complications, TPN is the preferred route of feeding.
reduced length of stay, and reduced the hyper-
metabolic responseenergy requirements that Who should receive
exceed the patients usual basal energy expen- postoperative nutrition support?
diture.2126 Candidates for postoperative nutrition sup-
However, a review of five studies that port are not always obvious at the time of
prospectively compared postoperative enter- surgery. Often, the patients postoperative
al and parenteral nutrition head-to-head recovery needs to be monitored for several
reported similar rates of morbidity and mor- days before the need for nutrition support
tality.27 becomes apparent.
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71 NUMBER 4 APRIL 2004 347
PERIOPERATIVE NUTRITION SUPPORT SALVINO AND COLLEAGUES
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