ESPEN guideline: Clinical nutrition in surgery

Abstract

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include: • integration of nutrition into the overall management of the patient • avoidance of long periods of preoperative fasting • re-establishment of oral feeding as early as possible after surgery • start of nutritional therapy early, as soon as a nutritional risk becomes apparent • metabolic control e.g. of blood glucose • reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function • minimized time on paralytic agents for ventilator management in the postoperative period • early mobilisation to facilitate protein synthesis and muscle function The guideline presents 37 recommendations for clinical practice.

Nutrition and the Elderly Surgical Patients

“…The rationale for preoperative nutritional support is treatment and prevention of malnutrition as surgery often involves prolonged periods of fasting and catabolism [33].…”

“…There is now increasing trend to avoid NGT insertion and allowing oral feeding early postoperatively. There are data available to avoid keeping the patients NBM after major Upper GI, cholecystectomy, colorectal resection, gynecological, urological and vascular surgeries [33]. Early oral food intake or oral nutritional supplement (ONS) on postop day 1 or 2 does not cause increased anastomotic leaks and has been proven to be beneficial in shortening length of stay, early postoperative recovery, resumption of bowel movement, improved outcomes like mortality and morbidity.…”

“…Enteral nutrition support is the preferred method of supplementation. Parenteral nutrition is considered only if the GI tract is not functioning and should be started early if nutritional support is indicated [33]. For the elderly patients, it is recommended to do a comprehensive geriatric assessment on admission which will indicate the presence of nutritional risks, particularly weight loss >5% in 3 months, reduced food intake, disease severity and BMI<20.5kg/m 2 [36].…”

“…Surgery may be postponed to improve the risks unless it is an urgent procedure. For the patients with severe malnutrition, surgical procedures should be limited to minimize tissue injuries in order to reduce stress of surgery and minimize catabolism [33]. For the patients with significant deficit preoperatively, several weeks of supplementation before surgery is ideal to replace the deficit, but is seldom tolerated for various reasons.…”

“…The elderly with sarcopenia are considered high risk. For the patients with severe nutrition risk, malnutrition or are unable to consume the caloric requirements enterally, parenteral nutrition for 7-14 days preoperatively is recommended [33].…”