Randomized clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care

Smedley, F; Bowling, Tim; James, Marilyn; Stokes, Elizabeth A; Goodger, C; O’Connor, Olya; Oldale, C; Jones, Peter W.; Silk, D. B. A.

doi:10.1002/bjs.4578

Cited by 210 publications

(218 citation statements)

References 74 publications

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“…This support, mainly intended to compensate for fluid loss (ASPEN Board of Directors, 1993;French Speaking Society for Parenteral and Enteral Nutrition, 1996;Italian Society of Parenteral and Enteral Nutrition, 1996), is insufficient to cover the patients' energy requirements and produces the considerable alterations described in this paper. Extensive work on perioperative multimodal management for surgical patients (Basse et al, 2002Hjort Jakobsen et al, 2004;Smedley et al, 2004) supports the important role of early, complete feeding on surgical recovery, and agrees with our results for a complete parenteral nutrition (PN4).…”

Section: Discussionsupporting

confidence: 85%

Nutritional modulation of protein metabolism after gastrointestinal surgery

et al. 2007

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Background: The metabolic response to surgery includes alterations in protein metabolism, resulting in a net loss of proteins. Protein hypercatabolism is considered an unavoidable consequence of injury, and an important source of morbidity and mortality. Our purpose was to determine the effect of nutrition on protein metabolism following gastrointestinal surgery, and to elucidate whether postoperative protein loss can be prevented with adequate nutritional support. Methods: Patients who had undergone gastrointestinal surgery were given four different parenteral nutritions with increasing glucose, lipid and amino acid content during the 7 days following surgery. Nitrogen balance, protein synthesis and protein breakdown were determined using in vivo stable isotope labelling. Other metabolites (3-methylhistidine, creatinine, urea, cortisol, glucose, insulin, amino acids and C-reactive protein) were measured. Results: A nutrition-dependent alteration of protein metabolism was found in response to surgical injury. Nutrition modified nitrogen balance, whole-body protein breakdown and, to a lesser extent, whole-body protein synthesis and muscle protein breakdown. The low-energy parenteral nutrition without amino acids produced a negative nitrogen balance (postoperative day 7 ¼ À0.381 g protein kg À1 day À1 ) and important alterations in postoperative protein metabolism that did not normalize during the study period (day 7 protein synthesis ¼ 239% and protein breakdown 217% vs preoperative). Patients receiving the two low energy parenteral nutritions containing amino acids had a less negative nitrogen balance (day 7 ¼ À0.011 and À0.133 g protein kg À1 day À1 ) and a transient increase in protein metabolism. The complete parenteral nutrition maintained, during all studied days, protein metabolism parameters within the preoperative reference range (synthesis day 2 ¼ 92%, day 4 ¼ 110% day 7 ¼ 79%; breakdown day 2 ¼ 85%, day 4 ¼ 80%, day 7 ¼ 76% vs preoperative) and a positive nitrogen balance (day 2 ¼ þ 0.0387, day 4 ¼ þ 0.578 and day 7 ¼ þ 0.227 g protein kg À1 day À1 ). Conclusion: Complete nutritional support can prevent protein loss after gastrointestinal surgery and maintain protein metabolism without alterations.

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Section: Discussionsupporting

confidence: 85%

Nutritional modulation of protein metabolism after gastrointestinal surgery

et al. 2007

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“…The latter explanation is supported by an Australian survey of surgeons, which revealed a higher confidence in the surgeons' own judgment than in clinical practice guidelines and other sources of evidence (17). Almost all respondents, who gave preoperative NS, sustained the support in the postoperative period, as also suggested by many authors (18)(19)(20). It is also encouraging that almost 70% of participants prescribed oral NS products after hospital discharge to the patients who received perioperative NS.…”

Section: Discussionsupporting

confidence: 59%

Surgeons’ approach toward clinical nutrition: A survey-based study

et al. 2017

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Surgeons' approach toward clinical nutrition: A survey-based study INTRODUCTIONIt is a well-known fact that surgical patients with a suboptimal nutritional status have impaired wound healing, impaired immune responses, increased organ dysfunction, delayed recovery, and increased morbidity and mortality (1, 2). However, even though the prevalence of malnutrition is high and may exceed 60% in patients undergoing gastrointestinal or major elective surgeries, many cases of malnutrition probably go unnoticed and untreated in surgical wards (3-6). As the attending specialist, the surgeon must organize nutritional screening and treatment of the patients in a surgical clinic. This necessitates surgeons to have sufficient knowledge of nutrition and to be very sensitive about the nutritional status of their patients. Unfortunately, limited data on the degree of attention paid to this important subject by surgeons suggests that the awareness of nutritional principles may be insufficient among this group of clinicians (5-7). This study displays the results of a survey designed to define the current attitudes of Turkish surgeons toward nutritional screening and support. MATERIAL AND METHODSA questionnaire consisting of 13 multiple choice questions was designed by the study authors to investigate the surgeons' approaches to perioperative nutritional screening and therapy of the general surgery patient (Appendix). This survey was e-mailed to 1500 general surgeons, all of whom had already finished the training program in surgery and were working in different hospitals in the Turkish Republic. A cover letter that stood for an informed consent was also attached to this e-mail explaining the purpose of this project and assuring the participants of anonymity.Since this study was based on a survey answered by doctors, no approval was obtained from any ethics committees; however, the study was conducted according to the Helsinki Declaration.Only the surgeons who stated that they screened the nutritional status of their patients were asked to answer the questions from 5 to 11 as it was essential to take part in nutritional screening in daily clinical practice to answer these questions.The answers of each surgeon were stored in a database and cross-queries were made over these responses. The surgeons who were working in state hospitals were compared with the surgeons working in teaching Objective: Although many surgical patients face postoperative problems due to a poor nutritional status, there is evidence that many cases of malnutrition still go unnoticed and untreated in surgical wards. This study aims to define the current attitudes of surgeons toward nutritional screening and support. Material and Methods:A questionnaire with 13 questions was e-mailed to 1500 surgeons. Cross-queries were made over the responses. Results:The response rate was 20.9%. Most of the respondents (89.5%) implemented nutritional screening. However, only 24.6% of these surgeons screened every patient for malnutrition. The time to initiate nutritional suppor...

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“…There is evidence that early and adequate treatment of malnutrition is fundamental for improving patients' prognosis and well-being, and international evidence-based guidelines have been developed to standardise nutritional therapy (Lochs, 2006). Several clinical trials have shown that supplementation with ONS are beneficial in the perioperative setting (Beattie et al, 2000;Smedley et al, 2004). However, the impact on clinical routine still remains moderate.…”

Section: Discussionmentioning

confidence: 99%

Cost-effectiveness of a 3-month intervention with oral nutritional supplements in disease-related malnutrition: a randomised controlled pilot study

et al. 2011

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Background/Objectives: Nutritional intervention with oral nutritional supplements (ONS) has been shown to increase quality of life in malnourished patients. We investigated whether post-hospital supplementation with ONS is cost-effective according to international benchmarks in malnourished patients. Subjects/Methods: In total, 114 malnourished patients (50.6±16.1 years, 57 female) with benign gastrointestinal disease were included and randomised to receive either ONS for 3 months and dietary counselling at discharge (intervention, n ¼ 60) or only dietary counselling at discharge (control group, n ¼ 54). Nutritional status was assessed with Subjective Global Assessment. Intervention patients documented daily intake of ONS; quality of life was assessed with Short-Form (SF)-36 Health Survey and SF-36 values were transformed into health-status utilities. Quality-adjusted life years (QALYs) were calculated by adopting the area under the curve method. We used two different pricing scenarios for ONS (minimum price: h2.30 and maximum: h2.93/ tetrapack). The incremental cost-effectiveness ratio (ICER) of supplementation with ONS was calculated for both price scenarios. All analyses were corrected for age and gender. Results: Intervention patients consumed 2.4 ± 0.8 ONS per day. Intervention and control patients did not differ in their health status utilities at baseline (0.594 ± 0.017 vs 0.619 ± 0.018), but after 3 months, the health status utilities were significantly higher in intervention patients than in control patients (0.731 ± 0.015 vs 0.671 ± 0.016, P ¼ 0.028). Intervention was associated with significantly higher costs (ICER: h9497 and h12 099/additional QALY, respectively) but deemed cost-effective according to international thresholds (oh50 000/QALY). Conclusions: A 3-month intervention with ONS increases quality of life in malnourished patients. This treatment appears to be cost-effective according to international benchmarks.

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Randomized clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care

Abstract: Perioperative oral nutritional supplementation started before hospital admission for lower gastrointestinal tract surgery significantly diminished the degree of weight loss and incidence of minor complications, and was cost-effective.

Cited by 210 publications

References 74 publications

Nutritional modulation of protein metabolism after gastrointestinal surgery

Nutritional modulation of protein metabolism after gastrointestinal surgery

Surgeons’ approach toward clinical nutrition: A survey-based study

Cost-effectiveness of a 3-month intervention with oral nutritional supplements in disease-related malnutrition: a randomised controlled pilot study

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