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Overviewofperioperativenutritionalsupport
OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate

Overviewofperioperativenutritionalsupport
Authors
KathleenMFairfield,MD,DrPH
RezaAskari,MD,FACS

SectionEditors
TimothyOLipman,MD
HilarySanfey,MD

DeputyEditor
KathrynACollins,MD,PhD,FACS

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jun2016.|Thistopiclastupdated:Apr05,2016.
INTRODUCTIONMalnutritioninhospitalizedpatientsiswelldocumentedwithratesupto50percentincertain
populations[1].Nutritionalsupportmaybeindicatedformalnourishedindividualsrequiringsurgicalintervention,orfor
healthyindividualsundergoingmajorsurgerywithananticipatedlengthyrecoverytimetoreturnofnormal
gastrointestinalfunctionhowever,itcanbeunclearwhenitisappropriatetointervene.Thenotionthatmalnutritioncan
affectoutcomesinsurgicalpatientswasfirstreportedin1936inastudyshowingthatmalnourishedpatients
undergoingulcersurgeryhada33percentmortalityratecomparedwith3.5percentinwellnourishedindividuals[2].A
prospectivestudyof500patients,including200surgicalpatients,admittedtoateachinghospitalinEnglandfoundthat
40percentofpatientswereundernourishedonpresentation,andpatientslostanaverageof5.4percentoftheirbody
weightduringtheirhospitalstay[3].
Thenutritionalassessmentofsurgicalpatients,optionsforandpotentialbenefitsofnutritionalsupportarereviewed
here.Anoverviewofparenteralandenteralnutritionandissuesrelatedtonutritionalsupportincriticallyillpatients,and
otherspecificpopulations(eg,cancer,burns,lungdisease)arediscussedinseparatetopicreviews.
CONSEQUENCESOFMALNUTRITIONINSURGICALPATIENTSReducedfoodintakeresultsinlossoffat,
muscle,skin,andultimatelyboneandviscera,withsubsequentweightloss,andexpansionoftheextracellularfluid
compartment[4].Nutritionalrequirementsfallasanindividual'sbodymassdecreases,probablyreflectingmore
efficientutilizationofingestedfoodandareductioninworkcapacityatthecellularlevel.However,thecombinationof
decreasedtissuemassandreducedworkcapacityimpedesnormalhomeostaticresponsestostressorssuchas
surgeryorcriticalillness[5].
Thestressofsurgeryortraumacreatesahypermetabolicstate,increasingproteinandenergyrequirements.
Macronutrients(fat,protein,andglycogen)fromthelabilereservesoffattissueandskeletalmuscleareredistributedto
moremetabolicallyactivetissuessuchastheliverandvisceralorgans.Thisresponsecanleadtotheonsetofprotein
caloriemalnutrition(definedasanegativebalanceof100gofnitrogenand10,000kcal)withinafewdays[6].Therate
ofdevelopmentofpostoperativemalnutritioninagivenindividualdependsupontheirpreexistingnutritionalstatus,
natureandcomplexityofthesurgicalprocedure,andthedegreeofhypermetabolism.
Malnutritioncausesanumberofnegativeconsequences,including[4,5,7,8]:

Increasedsusceptibilitytoinfection
Poorwoundhealing
Increasedfrequencyofdecubitusulcers
Overgrowthofbacteriainthegastrointestinaltract
Abnormalnutrientlossesthroughthestool

Ofparticularconcernforpatientsundergoingsurgeryaretherisksofpostoperativeinfectionandpoorwoundhealing.
Malnutritionleadstoimmunesystemdysfunctionbyimpairingcomplementactivationandproduction,bacterial
opsonization,andthefunctionofneutrophils,macrophages,andlymphocytes[8].Oneseriesofunderfedpatients
identifiedsubnormalskinreactionstoCandidaandlowlevelsofantibodiestovariousphytomitogens,suggestingthat
humoralandcellmediatedimmunityareaffected[9].(See"Secondaryimmunodeficiencyduetounderlyingdisease
states,environmentalexposures,andmiscellaneouscauses",sectionon'Malnutrition'.)
Patientswithproteinenergymalnutritionalsohaveslowerratesofwoundhealing[10],althoughmostwoundswill
eventuallyhealontheirown[11].Additionaladverseeffectsassociatedwithmalnutritionwereidentifiedinastudyof
2743patientsundergoingcardiothoracicsurgery[12].Patientswithpreoperativehypoalbuminemiaaloneorin
associationwithchronicliverdiseaseorheartfailureweremorelikelytohavepostoperativeorgandysfunction
(cardiac,pulmonary,renal,hepatic,neurologic),gastrointestinalbleeding,nosocomialinfections,increaseddayson
mechanicalventilationandlengthofstayintheintensivecareunit,andinpatientdeath.Abodymassindex(BMI)<20
kg/m2wasassociatedwithlowermorbidityandmortalitycomparedwithahigherBMIhowever,thisfindinginthis
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studycontrastswithotherstudies.BMIisanimperfectmeasureofnutritionalstatusandshouldbeusedinconjunction
withotherclinicalindicators.
NUTRITIONALASSESSMENTINTHESURGICALPATIENTThefirsttaskwhenconsideringperioperative
nutritionalrecommendationsistoassesswhetherornotthepatienthasmalnutrition.Thebasicprincipleofdietaryand
nutritionalassessmentinthegeneralpopulationisdiscussedelsewhere.Importantaspectsofnutritionalassessment
thatpertaintosurgicalpatientsarereviewedbelow.(See"Dietaryassessmentinadults".)
Baseduponexpertconsensus,adiagnosisofmalnutritionrequiresthatthepatientexhibittwoormoreofthefollowing
[13,14]:

Insufficientenergyintake
Weightloss
Lossofmusclemass
Lossofsubcutaneousfat
Localizedorgeneralizedfluidaccumulationthatmaysometimesmaskweightloss
Diminishedfunctionalstatusasmeasuredbyhandgripstrength

HistoryandphysicalSeveralaspectsofthepastmedicalhistoryareofparticularimportance,includingchronic
disease(particularlydiabetes),infection,recenthospitalization,andpriorsurgery(particularlygastrointestinalsurgery).
Onreviewofsystems,ahistoryofweightlossorgainisimportant.Anyrecentlossesorgains(andwhethertheywere
purposefulornot)priortothehospitalstayshouldbeassessed.Thedetailsofthecurrenthospitalizationalsoplaya
centralrole.Newlyadmittedtraumapatientswhoareotherwisewellhavedrasticallydifferentneedsfrompatientswho
havehadsurgeryseveralweeksinthepastbuthaveremainedhospitalizedduetocomplications.
Inadditiontocollectinginformationoncurrentmedications,nonprescriptionmedicinesandothersupplementsshould
benoted.Theuseofdietarysupplements,suchasproteinshakes,shouldalsobedetermined.Lastly,anyallergiesor
foodintolerancesshouldalsobenoted.Adiethistoryshouldbecollectedfromthepatient,family,orcarefacility.
Althoughthereareseveralmethodsofdietaryassessment,themostusefulandstraightforwardmaybetoassessthe
usualintakeonanaveragedaybeforehospitalizationorbeforetheonsetofthecurrentillness[15].
Inadditiontovitalsignsandageneralphysicalexamination,thefollowingshouldbenoted:
Heightandweight(calculatebodymassindex[BMI]usingweightinkgdividedbyheightinmeterssquared
(calculator1),orusinganomogram)(figure1)
General:Lossofsubcutaneousfat,anygeneralizedfluidaccumulation
Headandneckexam:Hairloss,bitemporalwasting,conjunctivalpallor,xerosis,glossitis,bleedingorsoreson
thegumsandoralmucosa,angularcheilosisorstomatitis,dentition
Cardiovascular:Evidenceofheartfailureorhighoutputstate
Neck:Thyromegaly
Extremities:Edema,lossofmusclemass
Neurologic:Evidenceofperipheralneuropathy,reflexes,tetany,mentalstatus,handgripstrength
Skin:Ecchymoses,petechiae,pallor,pressureulcers,assessmentofsurgicalwoundhealingandsignsof
surgicalsiteinfection(ifpostoperative).
Signsofspecificnutritionaldeficienciesshouldalsobesought.Someofthesearegiveninthetable(table1).
Appropriatemicronutrientlevelsshouldbeinvestigateddependingonclinicalexamfindings.(See'Otherlaboratory
studies'below.)
Severalclinicaltoolsareavailabletoquicklyassessandscorenutritionstatus.TheSubjectiveGlobalAssessmentof
NutritionalStatusisabrieftoolthatincludeshistoryandphysicalexaminationfindings,andallowsstandardized
assessment[16].TheNutritionalRiskScreeningtool(NRS2002)canbeappliedrapidlyandusedtoscreenforpoor
baselinenutritionalstatus[17].AstudythatassessedtheabilityoftheNRS2002scoretopredicttheincidenceand
severityofpostoperativecomplicationsfoundtheoverallincidenceofnutritionalriskwas14percentamong608
patientsundergoinggastrointestinalsurgery[18].Asignificantlyhigheroverallcomplicationratewasfoundinpatients
atnutritionalriskcomparedwiththosewithanormalNRS2002riskscore(40versus15percent).Severe
complicationswerealsosignificantlyhigherinpatientsatnutritionalrisk(54versus15percent).
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AssessingproteinstatusAssessingproteinstatusisparticularlyimportantinthesurgicalpatientbecauseofthe
closerelationshipbetweenproteinstatusandwoundhealing,andbecauseproteincaloriemalnutritioncanbetreated
withsupplementationasdiscussedbelow[19,20].Proteinstatusisaffectedbypreviousintake,musclemass,duration
ofcurrentillness,bloodloss,woundhealing,infections,andgastrointestinalabsorption.
Threeserummeasuresofproteinstatushavedifferinghalflives.Theseserumcomponentsdonotdirectlyindicate
nutritionalstatus,butratherreflecttheseverityofillnessandmustbeusedinconjunctionwithotherclinicaldatasuch
asthedurationofthecurrentsurgicalillnesstobeusefulindeterminingtherapy.Althoughdecreasedlevelsforthese
proteinmarkerscorrelatewithadverseoutcomes,improvementsinthesemarkerswithnutritionalsupplementationare
notreliablyassociatedwithaclinicalbenefit[21].(See'Outcomesfornutritionalintervention'below.)
Serumalbuminhasthelongesthalflifeat18to20daysandisthemostextensivelyusedparameter.Lowserum
albumin(<2.2g/dL)isamarkerofanegativecatabolicstate,andapredictorofpooroutcome[22].Surgical
stress,otheracutestresses,hepaticdisease,andrenaldiseasedecreaseserumalbuminlevels.
Serumtransferrinhasanintermediatehalflifeofeighttoninedays,reflectingproteinstatusoverthepasttwoto
fourweeks.Transferrinalsoreflectsironstatus,andlowtransferrinshouldbeconsideredanindicatorofprotein
statusonlyinthesettingofnormalserumiron.
Serumprealbumin(transthyretin)hastheshortesthalflifeattwotothreedays.Althoughprealbuminresponds
quicklytotheonsetofmalnutritionandrisesrapidlywithadequateproteinintake,thelevelcanbealteredinthe
acutephaseresponseduetoacuteorchronicinflammation.Ingeneral,inflammatorycytokinesreducethelevel
ofprealbuminsynthesisbytheliver,anditcanalsobereducedwithrenalandhepaticdisease.Therefore,serum
prealbuministheleasthelpfulofthethreeforassessingoverallnutritionalstatus.
OtherlaboratorystudiesInadditiontoassessingproteinstatus,afewotherlaboratorystudiesmaybehelpful.
Electrolytes,glucose,andBUN/creatininehelpassessoverallclinicalandfluidvolumestatusandneedtobeobtained
ifparenteral(intravenous)nutritionwillbeinstituted.Ironlevelsshouldbemeasuredinthesettingofunexplained
anemia,asshouldspecificvitaminlevelsifclinicallyindicated(eg,B12/folateinmacrocyticanemias,othersbased
uponspecificphysicalsigns).Serumcalcium,magnesium,andphosphorousshouldalsobeassessedperiodically,
particularlyinthesettingofpoororalintakeordiarrhea[23].
NUTRITIONALINTERVENTIONSOncethepresenceofmalnutritionisestablished,oritbecomesclearthatthe
patientwillnotbeabletomaintainadequatenutrition,nutritionalinterventionmayincludeoralsupplementation,enteral
(tube)feeding,orparenteral(intravenous)feeding.Enteralsupportisrecommendedoverparenteralsupportbecauseof
itsrelativesimplicity,safety,reducedcomplications,andlowercost,aswellasitsabilitytomaintainmucosalbarrier
function.
EnteralnutritionEnteralnutritionsupportreferstotheprovisionofcalories,protein,electrolytes,vitamins,
minerals,traceelements,andfluidsviaanintestinalroute,eitherorallyorviaafeedingtube.
OralsupplementationThereisawidevarietyofsupplementsavailablefororalsupplementationinawide
rangeofstyles(juice,yogurt,milkshakes),formats(liquid,powder,pudding,prethickened),types(high
protein,fibercontaining,lowvolume),energydensities(1to2.4Kcal/mL),andflavors.Mostoral
supplementsprovide300Kcal,12gprotein,andafullrangeofvitaminsandminerals.Specifictypesoforal
supplementsmaybenefitcertaingroups.Ingeneral,highproteinoralsupplementsaremostsuitablefor
patientswithwounds,andthosewithmalignancy.Prethickenedsupplementsandpuddingsarehelpfulfor
providingnutritionalsupporttoindividualswithdysphagiaandthosewithneurologicalconditions.
TubefeedingEnteralnutritionmaybedeliveredinagastricorpostpyloricfashion.Theavailable
formulations,components,anddeliveryofenteralnutritionarereviewedelsewhere.(See"Nutritionsupport
incriticallyillpatients:Anoverview"and"Nutritionsupportincriticallyillpatients:Enteralnutrition".)
ParenteralnutritionParenteralnutritionisanintravenoussolutionthatcontainsdextrose,aminoacids,
electrolytes,vitamins,minerals,andtraceelements.Theavailableformulations,components,anddeliveryof
parenteralnutritionarereviewedelsewhere.(See"Nutritionsupportincriticallyillpatients:Anoverview"and
"Nutritionsupportincriticallyillpatients:Parenteralnutrition".)
Asthecomplexinteractionsbetweennutrition,mucosalbarrierfunction,immunoregulation,andsevereillnesshave
becomeclearer,tailoredformsofenteralnutritionalsupportforspecificdiseasestateshavebeendeveloped.Many
enteralandparenteralformulascontainnutrientspreviouslyconsiderednonessential,suchasarginine,glutamine,RNA
nucleotides,andomega3fattyacids.Duringanepisodeofcriticalillness,thesenutrientsmaybecome"conditionally
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essential."Formulasthataresupplementedwiththesecomponentsareoftenreferredtoasimmuneenhancing
nutritionalsupplements,orsimplyimmunonutrition.(See"Nutritionsupportincriticallyillpatients:Anoverview"and
'Immuneenhancingnutritionalsupplements'below.)
INDICATIONSThegeneralindicationsfornutritionalsupportincludepreexistingnutritionaldeprivation,anticipated
oractualinadequateenergyintakebymouth,andsignificantmultiorgansystemdisease.Amongpatientsundergoing
surgery,patientswhoundergogastrointestinalsurgerymaybeatagreaternutritionaldisadvantageifthereturnof
intestinalfunctionissignificantlydelayed[2430].
Earlyenteralfeeding(oral,tubefeeding)canbeinstitutedfollowingmanytypesofsurgery[30,31].ACochranereview
andmetaanalysisupdatedin2011identifiednoobviousadvantagetotheroutinepracticeofmaintainingpatientsnil
peros(ie,NPO)postoperatively[32].Thereviewidentified14trialsthatincluded1224patientsundergoing
predominantlycolorectalsurgery.Nosignificantdifferenceswereidentifiedintheriskofintraabdominalabscess,
anastomoticleak/dehiscence,orpneumoniaforpatientsstartedonearlyoralnutrition(initiatedwithin24hoursof
surgery)comparedwithtraditionalsurgicalcare(ie,nonutritionororalnutritionwhentolerated).Lengthofhospitalstay
andtheincidenceofpostoperativewoundinfectionwerealsosimilar.Ametaanalysisofsixofthetrialsfoundaslightly
increasedriskofvomiting(riskratio1.27,95%CI,1.011.61).Thehigherincidenceofvomitingreportedintheearly
feedinggroupdidnotappeartoberelatedtooralintakecomparedwithtubefeeding.Noadditionalinformationwas
givenregardingthetypeofsurgery(openversuslaparoscopic),orperioperativepainmanagement(eg,opioidor
antiemeticuse).Alatersystematicreviewandmetaanalysisthatfocusedoncolorectalsurgeryfoundsimilarresults
therewasareducedlengthofhospitalstay,butnosignificantdifferenceintherateofvomitingbetweenthosewho
receivedearlyoralfeedingcomparedwiththosewhodidnot[33].
Somepatients,suchasthosewithinflammatoryboweldisease,haveanincreasedriskofbeingmalnourishedwhen
undergoingsurgicalprocedures.Aperiodofbowelrest(nilperos)maybeappropriateforpatientswithdiseasethatis
severeenoughtorequiresurgicalintervention.(See"Nutritionanddietaryinterventionsinadultswithinflammatory
boweldisease".)
Parenteralsupportisindicatedinpostoperativepatientswhoareunabletoreceiveadequateenteralnutritionby
postoperativedays10to14[26,34].Earlierenteralsupportmaybeappropriateinpatientswhoaremalnourishedat
baseline,orwhohaveacomplicatedpostoperativecourse[23,35].Inpatientsundergoingbowelsurgeryfor
gastrointestinalmalignancy,malignancyrelatedmetabolicchangesmayalsosuggesttheneedforearlierintervention.
OUTCOMESFORNUTRITIONALINTERVENTIONThemajorityoftrialsevaluatingthepotentialbenefitsof
perioperativenutritionalsupportaresmall,andcomparisonsaredifficultduetothewidevarietyofsurgeriesstudied,
variabilityinmethodology,andalackofstandarddefinitionsandmeasuresofmalnutritionused.Therisksassociated
witheachrouteofnutritionalsupport,plustheaddedcost,needtobetakenintoaccount,alongwiththepotential
benefits,whenassessingtheneedforperioperativenutritionalsupport.
PreoperativenutritionalsupportPatientswithseveremalnutritionmayderivesomebenefitfromdelayingsurgery
tobefed,butareatanincreasedriskforinfectiouscomplicationsiftreatedwithtotalparenteralnutrition.Patientswill
benefitmorefromenteralfeedingwheneveritispossible.Forpatientswhoareadequatelynourishedorwhohavemild
tomoderatemalnutrition,surgeryneednotbedelayedforpreoperativeparenteralorenteralsupplementation[24,25,35].
(See'Indications'above.)
Amulticentercohortstudyevaluatedtheeffectofpreoperativenutritionalsupportin512patientsundergoingabdominal
surgerywhowereatnutritionalriskasdefinedbytheNutritionalRiskScreeningTool2002(NRS2002)[35].Ofthe120
patientswithanNRSscore5,thecomplicationratewassignificantlylowerinthepreoperativenutritiongroup
comparedwiththecontrolgroup(25.6versus50.6percent).Thelengthofhospitalstaywassignificantlyshorterinthe
preoperativenutritiongroupthaninthecontrolgroup(13.7versus17.911.3days).Nosignificantdifferenceswere
seenforlesserNRSscores.
OralsupplementationAsystematicreviewthatfocusedonpreoperativenutritioninpatientsundergoing
gastrointestinalsurgeryincludedthreestudiescomparingpreoperativeliquidoralsupplementationwithusualcareor
dietaryadvice[36].Nosignificantdifferenceswerefoundintheoverallincidenceofcomplications,infectious
complications,orlengthofstay.Eachofthetrialsevaluatedadifferentoralsupplement.
ParenteralfeedingSeveralmetaanalyseshaveevaluatedpreoperativeparenteralnutrition,buthavereached
inconsistentconclusions[3739].
Onesystematicreviewfoundthatpreoperativeparenteralnutrition(13randomizedtrials)decreasedpostoperative
complicationsby10percent,whilepostoperativeparenteralnutritionalone(8randomizedtrials)resultedina10percent
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increaseincomplicationrates[39].Thesefindingswerenotverifiedbyasubsequentlargermetaanalysisthatincluded
41trialsofparenteralnutritionprovidedbeforeand/oraftersurgery[38].Parenteralnutritionhadnoeffecton
postoperativemortalityandtherewasnosignificanteffectonpostoperativecomplicationrates,althoughtrendsforall
evaluatedoutcomesfavoredparenteralnutritionovernonutrition.
Anothermetaanalysis(26randomizedtrials,although3werenotinsurgicalpatients)foundthatparenteralnutrition
decreasedhospitalcomplicationsinstudieswherelipidfreesolutionswereused,andforpatientswhowere
malnourished(notconsistentlydefined)[37].Thesefindingswerealsonotconfirmedinthelargermetaanalysis,which
foundgreaterbenefitfortotalparenteralnutritionintrialswherelipidswereused,andintrialsevaluatingwellnourished
patients[38].
Studieshavealsofocusedonwhetherparticularsubgroupsmightbenefitfrompreoperativeparenteralfeeding.
Anearlystudysuggestedthatparenteralnutritionwasbeneficialinpatientswithuppergastrointestinal
malignancies[40,41].Mortalityandpostoperativecomplicationsweredecreasedinagroupofpatientswith
gastrointestinalmalignanciesandweightloss(minimum10percent)whoreceived10daysofpreoperative
parenteralnutritionand9daysofpostoperativetotalparenteralnutrition,comparedwithcontrolpatientswhodid
notreceivepreoperativeparenteralnutritionandwereonlypartiallysupplementedpostoperatively[42].
Preoperativetreatmentwithparenteralnutritionalsodecreasedmorbidityinagroupofpatientsundergoing
resectionforhepatocellularcancer[43].(See"Theroleofparenteralandenteral/oralnutritionalsupportinpatients
withcancer".)
TheVACooperativestudyrandomlyassignedpatientstoparenteralnutritionforsevendayspreoperativelyand
threedayspostoperativelyortocontrolgroupswhoeitherreceivednonutritionorwerefedenterally[44].Overall,
patientswhoreceivedparenteralnutritionhadahigherrateofinfectiouscomplications(14.1versus6.4percent),
butmortalityrateswerenotsignificantlydifferent(7.3and4.9percentat30days).However,intheseverely
malnourishedsubgroup,thosetreatedwithparenteralnutritionhadfewermajorpostoperativecomplicationsthan
controls(20to25percentversus40to50percent).
Inalatersystematicreview(discussedabove)thatfocusedonpatientsundergoinggastrointestinalsurgery,
preoperativeparenteralnutritionsignificantlyreducedtheriskformajorcomplications(relativerisk0.64,95%CI
0.46087).However,nodifferencewasobservedforinfectiouscomplications[36].
PostoperativenutritionalsupportFormanypostoperativepatients,earlyenteralnutrition(<24hours)ispossible
andisassociatedwithbeneficialeffects.Enteralnutrition(oralortubefeeds)ratherthanparenteralnutritionshouldbe
institutedwheneverpossible.Forpatientswithadelayedreturnofintestinalfunction,postoperativeparenteralnutrition
isindicatedonlyifreturnofbowelfunctionisnotanticipatedformorethan10days.Earlierinterventionmaybe
appropriateinpatientswhoareseverelymalnourishedatbaseline,orwhohaveacomplicatedpostoperativecourse.
(See'Indications'above.)
EarlyenteralfeedingEarlypostoperativeenteralnutritionalsupportmaydecreasetheincidenceofinfectious
complications,butdoesnotimpactotheroutcomes.Earlynutritionisacomponentofmostenhancedrecoveryafter
surgeryprotocols(ERAS)[4547].
Ametaanalysisevaluated44randomizedtrialsofperioperativeenteralnutrition(predominantlypostoperative
support)[48].Trialsweregroupedintothreecomparisons:enteralnutritionversusnoartificialnutrition,enteral
nutritionversusparenteralnutrition,andvolitionalnutritionalsupplements(oralsupplementalfeeding)versusno
artificialnutrition.Therewerenomortalitydifferencesforanyofthecomparatorgroups.Comparedwithno
artificialnutrition,patientsreceivingenteralnutritionhadfewerinfections(absoluterisk11percent,95%CI20to
1percent),buttherewasnosignificantimpactondurationofhospitalizationortheincidenceofwound
complications.Patientswhoreceivedpostoperativeoralnutritionalsupplements,comparedwithnosupplements,
alsohadadecreasedinfectionrate(absoluteriskdifference10percent95%CI19to1),andashorterlengthof
hospitalstaybytwodays(95%CI3.37to0.72).
Anothermetaanalysiscomparingenteralnutritionwithin24hoursofgastrointestinalsurgerywithtraditional
postoperativemanagementshoweda45percentdecreaseintheriskofoverallpostoperativecomplicationsin
thosepatientsreceivingearlypostoperativefeeding.Therewerenodifferencesintheincidenceofanastomotic
dehiscence,lengthofstay,ormortality[49].
TotalparenteralnutritionPatientswhoareunabletotolerateenteralnutritionalsupportwillrequireintravenous
fluidandtotalparenteralnutritionatthediscretionofthetreatingteamuntilsuchtimeastheycanbetransitionedto
enteralnutrition.Theoutcomesoftotalparenteralnutritionincriticallyillpostoperativepatients,andfollowingburnand
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cancersurgery,arediscussedelsewhere.(See"Nutritionsupportincriticallyillpatients:Anoverview"and"Overview
ofnutritionalsupportformoderatetosevereburnpatients"and"Theroleofparenteralandenteral/oralnutritional
supportinpatientswithcancer".)
ImmuneenhancingnutritionalsupplementsTheroleforimmuneenhancingnutritionalsupplements,alsoreferred
toasimmunonutrition,remainsunclear.Thereisinsufficienthighqualityevidencetosuggestanyspecificaminoacid
orothersupplementationforallsurgicalpatients.(See'Nutritionalinterventions'above.)
Severalmetaanalyseshaveevaluatedimmunonutrition(ie,enteralorparenteralsupplementationwitharginine,
glutamine,nonessentialfattyacids,branchedchainfattyacids,orRNA)insurgicalpatients[36,5052].Reductionsin
infectiouscomplicationsandlengthofhospitalstayhavebeenfound,butwithoutaneffectonmortality.A2012
Cochranereviewandmetaanalysisofpreoperativenutritionalsupportfoundthatimmunonutrition(sixtrials)
significantlydecreasedtheriskofcomplications(noninfectiousandinfectious)(relativerisk0.67,95%CI0.530.84)
[36].Thevariousmetaanalyseshavebeeninconsistentintheirresultsandarewithoutsufficientstrengthtomake
clinicalrecommendations[50,51,53,54].Theauthorsofthesemetaanalyseshavenotedmethodologicalflawsinthe
individualstudies.Itisworthnotingthatsurgicalpatientsatthehighestriskforpostoperativecomplicationshavebeen
excludedfromthemajorityofstudiesonimmunonutrition.Thus,untilhigherqualitydatademonstratingunequivocal
benefitareavailable,immunonutritioncannotberecommendedasaroutineadditiontonutritionalsupplementationin
surgicalpatients.
Studiesofindividualandcombinationsofcomponentsofimmunonutritionhavedemonstratedsomebenefitbutno
effectonsurvivalinsurgicalpatients[15,50,51,5465].Separatemetaanalyseshavefoundasignificantlyreduced
incidenceofinfectiouscomplicationsandreducedlengthofhospitalstayforpatientsreceivingsupplementalglutamine
[51],orarginine[50].However,alatermulticentertrialrandomlyassigned150intensivecareunitpatientsrequiring
parenteralnutritionaftergastrointestinal,vascular,orcardiacsurgerytoreceivestandardglutaminefreeparenteral
nutritionoralanylglutaminedipeptideparenteralnutrition[66].Therewerenosignificantdifferencesbetweenthe
groupsforcumulativemortalityatsixmonths,theincidenceofbloodstreaminfection,oranyotheradverseevent.
However,thisstudywaslikelyunderpoweredtofullyassesstheseoutcomes.
SUMMARYANDRECOMMENDATIONS
Malnutritionisaprevalentconditionwithimportantimplicationsforpatientsundergoingsurgery.Whenevaluating
thepatientforpossibleintervention,thepatient'snutritionalstatusshouldbeassessedbyperformingahistory
andphysicalexamination.Judicioususeoflaboratorytestsaimedatassessingproteinstatusisuseful.(See
'Consequencesofmalnutritioninsurgicalpatients'aboveand'Nutritionalassessmentinthesurgicalpatient'
aboveand"Dietaryassessmentinadults".)
Studiesregardingoutcomesofnutritionalinterventionsintheperioperativeperiodarenumerousbutareoftenof
lowquality,andcomparisonsaredifficultgiventhebroadrangeofsurgicalsettingsandinterventions.However,
ourgeneralrecommendationsareasfollows:(see'Nutritionalinterventions'aboveand'Outcomesfornutritional
intervention'above)
Forpatientswhoarenotmalnourishedorwhohavemildtomoderatemalnutrition,surgeryshouldnotbe
delayedforpreoperativeenteralorparenteralfeeding.
Patientswithseveremalnutritionmayderivesomebenefitfromdelayingsurgerytobefed.
Patientsclearlybenefitmorefromenteralfeeding,wheneverpossible,ratherthantotalparenteralnutrition
(TPN),asTPNisassociatedwithanincreasedriskforinfectiouscomplications.
Formanypatientsundergoingsurgery,earlyenteralnutrition(<24hours)ispossibleandisassociatedwith
beneficialeffects.Wheneverpossible,enteralnutrition(oralortubefeeds)shouldbeinstituted,unlessthere
isaspecificcontraindication.
Forpatientswithadelayedreturnofgutfunction,postoperativeparenteralnutritionisnotindicatedunless
bowelfunctionisnotanticipatedtoreturnformorethan10days.Earlierinterventionmaybeappropriatein
patientswhoareseverelymalnourishedatbaseline,orwhohaveacomplicatedpostoperativecourse.
Theroleforimmunonutritionisunclear.Thusfar,thereisinsufficienthighqualityevidencetosuggestany
specificaminoacidorothersupplementationforsurgicalpatients.
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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REFERENCES
1.BruunLI,BosaeusI,BergstadI,NygaardK.Prevalenceofmalnutritioninsurgicalpatients:evaluationof
nutritionalsupportanddocumentation.ClinNutr199918:141.
2.Studley,HO.Percentageofweightloss:Abasicindicatorofsurgicalriskinpatientswithchronicpepticulcer.
JAMA1936106:458.
3.McWhirterJP,PenningtonCR.Incidenceandrecognitionofmalnutritioninhospital.BMJ1994308:945.
4.ElwynDH,BryanBrownCW,ShoemakerWC.Nutritionalaspectsofbodywaterdislocationsinpostoperative
anddepletedpatients.AnnSurg1975182:76.
5.KinneyJM,WeissmanC.Formsofmalnutritioninstressedandunstressedpatients.ClinChestMed19867:19.
6.BabineauTJ,BorlaseBC,BlackburnGL.AppliedTotalParentalNutritionintheCriticallyIll.In:IntensiveCare
Medicine,RippeJM,IrwinRS,AlpertJS,FinkMP(Eds),Little,BrownandCo,Boston1991.p.1675.
7.SantosJI.Nutrition,infection,andimmunocompetence.InfectDisClinNorthAm19948:243.
8.MainousMR,DeitchEA.Nutritionandinfection.SurgClinNorthAm199474:659.
9.LawDK,DudrickSJ,AbdouNI.Immunocompetenceofpatientswithproteincaloriemalnutrition.Theeffectsof
nutritionalrepletion.AnnInternMed197379:545.
10.HaydockDA,HillGL.Impairedwoundhealinginsurgicalpatientswithvaryingdegreesofmalnutrition.JPENJ
ParenterEnteralNutr198610:550.
11.AlbinaJE.Nutritionandwoundhealing.JPENJParenterEnteralNutr199418:367.
12.RadyMY,RyanT,StarrNJ.Clinicalcharacteristicsofpreoperativehypoalbuminemiapredictoutcomeof
cardiovascularsurgery.JPENJParenterEnteralNutr199721:81.
13.WhiteJV,GuenterP,JensenG,etal.Consensusstatement:AcademyofNutritionandDieteticsandAmerican
SocietyforParenteralandEnteralNutrition:characteristicsrecommendedfortheidentificationand
documentationofadultmalnutrition(undernutrition).JPENJParenterEnteralNutr201236:275.
14.MuellerC,CompherC,DruyanMD.AmericanSocietyforParenteralandEnteralNutritionASPENclinical
guidelines:nutritionscreening,assessment,andinterventioninadults.JPEN201135:16.
15.KuppingerD,HartlWH,BertokM,etal.Nutritionalscreeningforriskpredictioninpatientsscheduledfor
abdominaloperations.BrJSurg201299:728.
16.DetskyAS,McLaughlinJR,BakerJP,etal.Whatissubjectiveglobalassessmentofnutritionalstatus?JPENJ
ParenterEnteralNutr198711:8.
17.KondrupJ,RasmussenHH,HambergO,etal.Nutritionalriskscreening(NRS2002):anewmethodbasedon
ananalysisofcontrolledclinicaltrials.ClinNutr200322:321.
18.SchiesserM,MllerS,KirchhoffP,etal.Assessmentofanovelscreeningscorefornutritionalriskinpredicting
complicationsingastrointestinalsurgery.ClinNutr200827:565.
19.ReinhardtGF,MyscofskiJW,WilkensDB,etal.Incidenceandmortalityofhypoalbuminemicpatientsin
hospitalizedveterans.JPENJParenterEnteralNutr19804:357.
20.McClaveSA,SniderHL,SpainDA.Preoperativeissuesinclinicalnutrition.Chest1999115:64S.
21.SeresDS.Surrogatenutritionmarkers,malnutrition,andadequacyofnutritionsupport.NutrClinPract2005
20:308.
22.vanStijnMF,KorkicHalilovicI,BakkerMS,etal.Preoperativenutritionstatusandpostoperativeoutcomein
elderlygeneralsurgerypatients:asystematicreview.JPENJParenterEnteralNutr201337:37.
23.KleinS,KinneyJ,JeejeebhoyK,etal.Nutritionsupportinclinicalpractice:reviewofpublisheddataand
recommendationsforfutureresearchdirections.SummaryofaconferencesponsoredbytheNationalInstitutes
ofHealth,AmericanSocietyforParenteralandEnteralNutrition,andAmericanSocietyforClinicalNutrition.Am
JClinNutr199766:683.
24.BragaM,LjungqvistO,SoetersP,etal.ESPENGuidelinesonParenteralNutrition:surgery.ClinNutr2009
28:378.
25.MartindaleRG,McClaveSA,VanekVW,etal.Guidelinesfortheprovisionandassessmentofnutritionsupport
therapyintheadultcriticallyillpatient:SocietyofCriticalCareMedicineandAmericanSocietyforParenteral
andEnteralNutrition:ExecutiveSummary.CritCareMed200937:1757.
26.SoubaWW.Nutritionalsupport.NEnglJMed1997336:41.
27.MooreFA,FelicianoDV,AndrassyRJ,etal.Earlyenteralfeeding,comparedwithparenteral,reduces
postoperativesepticcomplications.Theresultsofametaanalysis.AnnSurg1992216:172.
28.BowerRH,TalaminiMA,SaxHC,etal.Postoperativeenteralvsparenteralnutrition.Arandomizedcontrolled
trial.ArchSurg1986121:1040.
29.KudskKA,CroceMA,FabianTC,etal.Enteralversusparenteralfeeding.Effectsonsepticmorbidityafterblunt
andpenetratingabdominaltrauma.AnnSurg1992215:503.
http://www.uptodate.com/contents/overviewofperioperativenutritionalsupport?topicKey=SURG%2F2880&elapsedTimeMs=3&source=search_result&s 7/12

7/25/2016

Overviewofperioperativenutritionalsupport

30.ShrikhandeSV,ShettyGS,SinghK,IngleS.Isearlyfeedingaftermajorgastrointestinalsurgeryafashionoran
advance?Evidencebasedreviewofliterature.JCancerResTher20095:232.
31.LewisSJ,AndersenHK,ThomasS.Earlyenteralnutritionwithin24hofintestinalsurgeryversuslater
commencementoffeeding:asystematicreviewandmetaanalysis.JGastrointestSurg200913:569.
32.AndersenHK,LewisSJ,ThomasS.Earlyenteralnutritionwithin24hofcolorectalsurgeryversuslater
commencementoffeedingforpostoperativecomplications.CochraneDatabaseSystRev2006:CD004080.
33.ZhuangCL,YeXZ,ZhangCJ,etal.Earlyversustraditionalpostoperativeoralfeedinginpatientsundergoing
electivecolorectalsurgery:ametaanalysisofrandomizedclinicaltrials.DigSurg201330:225.
34.SandstrmR,DrottC,HyltanderA,etal.Theeffectofpostoperativeintravenousfeeding(TPN)onoutcome
followingmajorsurgeryevaluatedinarandomizedstudy.AnnSurg1993217:185.
35.JieB,JiangZM,NolanMT,etal.Impactofpreoperativenutritionalsupportonclinicaloutcomeinabdominal
surgicalpatientsatnutritionalrisk.Nutrition201228:1022.
36.BurdenS,ToddC,HillJ,LalS.Preoperativenutritionsupportinpatientsundergoinggastrointestinalsurgery.
CochraneDatabaseSystRev201211:CD008879.
37.HeylandDK,MontalvoM,MacDonaldS,etal.Totalparenteralnutritioninthesurgicalpatient:ametaanalysis.
CanJSurg200144:102.
38.KoretzRL,LipmanTO,KleinS,AmericanGastroenterologicalAssociation.AGAtechnicalreviewonparenteral
nutrition.Gastroenterology2001121:970.
39.KleinS,KinneyJ,JeejeebhoyK,etal.Nutritionsupportinclinicalpractice:reviewofpublisheddataand
recommendationsforfutureresearchdirections.ClinNutr199716:193.
40.MllerJM,BrennerU,DienstC,PichlmaierH.Preoperativeparenteralfeedinginpatientswithgastrointestinal
carcinoma.Lancet19821:68.
41.MllerJM,KellerHW,BrennerU,etal.Indicationsandeffectsofpreoperativeparenteralnutrition.WorldJSurg
198610:53.
42.BozzettiF,GavazziC,MiceliR,etal.Perioperativetotalparenteralnutritioninmalnourished,gastrointestinal
cancerpatients:arandomized,clinicaltrial.JPENJParenterEnteralNutr200024:7.
43.FanST,LoCM,LaiEC,etal.Perioperativenutritionalsupportinpatientsundergoinghepatectomyfor
hepatocellularcarcinoma.NEnglJMed1994331:1547.
44.Perioperativetotalparenteralnutritioninsurgicalpatients.TheVeteransAffairsTotalParenteralNutrition
CooperativeStudyGroup.NEnglJMed1991325:525.
45.AartsMA,OkrainecA,GlicksmanA,etal.Adoptionofenhancedrecoveryaftersurgery(ERAS)strategiesfor
colorectalsurgeryatacademicteachinghospitalsandimpactontotallengthofhospitalstay.SurgEndosc2012
26:442.
46.RawlinsonA,KangP,EvansJ,KhannaA.Asystematicreviewofenhancedrecoveryprotocolsincolorectal
surgery.AnnRCollSurgEngl201193:583.
47.VaradhanKK,NealKR,DejongCH,etal.Theenhancedrecoveryaftersurgery(ERAS)pathwayforpatients
undergoingmajorelectiveopencolorectalsurgery:ametaanalysisofrandomizedcontrolledtrials.ClinNutr
201029:434.
48.KoretzRL,AvenellA,LipmanTO,etal.Doesenteralnutritionaffectclinicaloutcome?Asystematicreviewof
therandomizedtrials.AmJGastroenterol2007102:412.
49.OslandE,YunusRM,KhanS,MemonMA.Earlyversustraditionalpostoperativefeedinginpatientsundergoing
resectionalgastrointestinalsurgery:ametaanalysis.JPENJParenterEnteralNutr201135:473.
50.DroverJW,DhaliwalR,WeitzelL,etal.Perioperativeuseofargininesupplementeddiets:asystematicreview
oftheevidence.JAmCollSurg2011212:385.
51.ZhengYM,LiF,ZhangMM,WuXT.Glutaminedipeptideforparenteralnutritioninabdominalsurgery:ameta
analysisofrandomizedcontrolledtrials.WorldJGastroenterol200612:7537.
52.MazakiT,IshiiY,MuraiI.Immunoenhancingenteralandparenteralnutritionforgastrointestinalsurgery:a
multipletreatmentsmetaanalysis.AnnSurg2015261:662.
53.MarikPE,ZalogaGP.Immunonutritionincriticallyillpatients:asystematicreviewandanalysisoftheliterature.
IntensiveCareMed200834:1980.
54.MarimuthuK,VaradhanKK,LjungqvistO,LoboDN.Ametaanalysisoftheeffectofcombinationsofimmune
modulatingnutrientsonoutcomeinpatientsundergoingmajoropengastrointestinalsurgery.AnnSurg2012
255:1060.
55.BealeRJ,BrygDJ,BihariDJ.Immunonutritioninthecriticallyill:asystematicreviewofclinicaloutcome.Crit
CareMed199927:2799.
56.HeylandDK,NovakF,DroverJW,etal.Shouldimmunonutritionbecomeroutineincriticallyillpatients?A
systematicreviewoftheevidence.JAMA2001286:944.
57.HegaziRA,HusteadDS,EvansDC.Preoperativestandardoralnutritionsupplementsvsimmunonutrition:
http://www.uptodate.com/contents/overviewofperioperativenutritionalsupport?topicKey=SURG%2F2880&elapsedTimeMs=3&source=search_result&s 8/12

7/25/2016

Overviewofperioperativenutritionalsupport

resultsofasystematicreviewandmetaanalysis.JAmCollSurg2014219:1078.
58.SenkalM,MummeA,EickhoffU,etal.Earlypostoperativeenteralimmunonutrition:clinicaloutcomeandcost
comparisonanalysisinsurgicalpatients.CritCareMed199725:1489.
59.SenkalM,ZumtobelV,BauerKH,etal.Outcomeandcosteffectivenessofperioperativeenteralimmunonutrition
inpatientsundergoingelectiveuppergastrointestinaltractsurgery:aprospectiverandomizedstudy.ArchSurg
1999134:1309.
60.GianottiL,BragaM,NespoliL,etal.Arandomizedcontrolledtrialofpreoperativeoralsupplementationwitha
specializeddietinpatientswithgastrointestinalcancer.Gastroenterology2002122:1763.
61.BragaM,GianottiL,NespoliL,etal.Nutritionalapproachinmalnourishedsurgicalpatients:aprospective
randomizedstudy.ArchSurg2002137:174.
62.Okabayashi,T,Nishimori,I,Sugimoto,T,etal.Thebenefitofthesupplementationofperioperativebranched
chainaminoacidsinpatientswithsurgicalmanagementforhepatocellularcarcinoma:apreliminarystudy.Dig
DisSci2007May18[Epubaheadofprint].
63.MorlionBJ,StehleP,WachtlerP,etal.Totalparenteralnutritionwithglutaminedipeptideaftermajorabdominal
surgery:arandomized,doubleblind,controlledstudy.AnnSurg1998227:302.
64.PowellTuckJ,JamiesonCP,BettanyGE,etal.Adoubleblind,randomised,controlledtrialofglutamine
supplementationinparenteralnutrition.Gut199945:82.
65.FujitaniK,TsujinakaT,FujitaJ,etal.Prospectiverandomizedtrialofpreoperativeenteralimmunonutrition
followedbyelectivetotalgastrectomyforgastriccancer.BrJSurg201299:621.
66.ZieglerTR,MayAK,HebbarG,etal.EfficacyandSafetyofGlutaminesupplementedParenteralNutritionin
SurgicalICUPatients:AnAmericanMulticenterRandomizedControlledTrial.AnnSurg2016263:646.
Topic2880Version12.0

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GRAPHICS
Nomogramfordeterminingbodymassindex

Thenomogramisusedbyplacingarulerorotherstraightedge
betweenthebodyweightinkilogramsorpounds(thelefthandline)
andtheheightincentimetersorinches(therighthandline).Thebody
massindexisreadfromthemiddleofthescale,inmetricunits.
Graphic65305Version1.0

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Physicalsignsofselectednutritionaldeficiencystates

Hair

Skin

Signs

Deficiencies

Alopecia

Proteinenergymalnutrition

Brittle

Biotin,Proteinenergymalnutrition

Colorchange

Proteinenergymalnutrition

Dryness

VitaminsEandA

Easypluckability

Proteinenergymalnutrition

Acneiformlesions

VitaminA

Follicularkeratosis

VitaminA

Xerosis(dryskin)

VitaminA

Ecchymosis

VitaminCorK

Intradermalpetechia

VitaminCorK

Erythema(especiallywhereexposedto

Niacin

sunlight)
Hyperpigmentation

Niacin

Seborrheicdermatitis(nose,eyebrows,

VitaminB2,VitaminB6,Niacin

eyes)

Eyes

Mouth

Extremities

Scrotaldermatitis

Niacin,VitaminB2,VitaminB6

Angularpalpebritis

VitaminB2

Cornealrevascularization

VitaminB2

Bitot'sspots

VitaminA

Conjunctivalxerosis,keratomalacia

VitaminA

Angularstomatitis

VitaminB12,VitaminB2,VitaminB6

Atrophicpapillae

Niacin

Bleedinggums

VitaminC

Cheilosis

VitaminB2,VitaminB6

Glossitis

Niacin,folate,vitaminB12,VitaminB2,
VitaminB6

Magentatongue

VitaminB2

Genuvalgumorvarum,metaphyseal

VitaminD

widening
Lossofdeeptendonreflexesofthelower

VitaminsB1andB12

extremities
VitaminB1:thiamineVitaminB2:riboflavinVitaminB3:niacinVitaminB6:pyridoxineVitaminB12:
cyanocobalamin.
Adaptedfrom:BernardMA,JacobsDO,RombeauJL.NutritionandMetabolicSupportofHospitalizedPatients.
WBSaunders,Philadelphia1986.
Graphic78426Version2.0

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ContributorDisclosures
KathleenMFairfield,MD,DrPHNothingtodisclose.RezaAskari,MD,FACSNothingtodisclose.TimothyO
Lipman,MDNothingtodisclose.HilarySanfey,MDNothingtodisclose.KathrynACollins,MD,PhD,FACS
Nothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressed
byvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthe
content.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsof
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