The Role of Preoperative Parenteral Nutrition

Abstract

Malnutrition is associated with poor surgical outcomes, and therefore optimizing nutritional status preoperatively is very important. The purpose of this paper is to review the literature related to preoperative parenteral nutrition (PN) and to provide current evidence based guidance. A systemic online search of PubMed, Medline, and Cochrane Databases from January 1990 to February 2020 was done. Sixteen studies were included in this narrative review, including four meta-analyses and twelve clinical trials. The majority of studies have demonstrated benefits of preoperative PN on postoperative outcomes, including reduced postoperative complications (8/10 studies) and postoperative length of stay (3/4 studies). Preoperative PN is indicated in malnourished surgical patients who cannot achieve adequate nutrient intake by oral or enteral nutrition. It can be seen that most studies showing benefits of preoperative PN often included patients with upper gastrointestinal cancer and inflammatory bowel disease (10/12 studies), which gastrointestinal problems are commonly seen and enteral nutrition may be not feasible. When preoperative PN is indicated, adequate energy and protein should be provided, and patients should receive at least seven days of PN prior to surgery. The goal of preoperative PN is not weight regain, but rather repletion of energy, protein, micronutrients, and glycogen stores. Complications associated with preoperative PN are rarely seen in previous studies. In order to prevent and mitigate the potential complications such as refeeding syndrome, optimal monitoring and early management of micronutrient deficiencies is required.

Effect of Early Peripheral Parenteral Nutrition Support in an Enhanced Recovery Program for Colorectal Cancer Surgery: A Randomized Open Trial

“…It is thus necessary to improve the nutritional status of these patients with short-term nutritional supplementation. PN provides an adequate and reliable amount of macronutrients and micronutrients, and the intravenous route of administration of nutrients may also allow for rapid improvement in nitrogen balance, increased muscle mass, faster recovery from surgery, improved immune function, and a decrease in the number of general and infectious complications [22]. Low preoperative serum levels of total proteins, albumin, prealbumin, or transferrin have been associated with increased surgical infections, increased morbidity and mortality, and increased hospital stay [23][24][25].…”

Perioperative Nutritional Optimization in Inflammatory Bowel Diseases: When and How?

“…6 Total parenteral nutrition (TPN) is indicated for patients who do not meet daily nutritional needs through oral and/or enteral food, have severe malnutrition, or those with intestinal obstruction, high-output fistulas, severe bleeding, or when the microbiota is dysfunctional during periods of disease activity. 6,16,17 The use of preoperative TPN is directly related to a decrease in postoperative complications such as anastomotic dehiscences, thromboembolic events, and septic complications in malnourished patients with CD. 22 A meta-analysis study showed that nutritional support by enteral or parenteral nutrition in the preoperative period reduces complications in the postoperative period in IBD patients.…”

“…1 The purpose of TPN in the preoperative period is to restore energy and protein storage, reduce and/or correct micronutrient deficiencies, in addition to preventing postsurgical malnutrition in patients at nutritional risk. 17 The duration of TPN in the preoperative period generally varies from 5 to 90 days, and most studies show a period of 7 to 14 days as the ideal. 12,17,23 The association of EEN and TPN should be considered in patients who need nutritional support of more than 60% for the daily needs that cannot be achieved by EEN alone.…”

“…5,6,16 The calorie intake recommended by ESPEN for patients with IBD is 25 to 30 Kcal/Kg/day and 1.5 g/Kg/day for protein requirements. 10,11,17 The International Anesthesia Research Society (2018), on the other hand, recommends a protein supply above 1.2 g/Kg/day with the use of whey protein and casein, as they have a greater effect on muscle synthesis. 12 Exclusive enteral nutrition (EEN), either with elementary (amino acids), semi-elementary (oligopeptides), or polymeric (whole proteins) formulas, can be used for preoperative optimization in complications such as enterocutaneous fistulas.…”

Comparison of Two Malnutrition Assessment Scales in Predicting Postoperative Complications in Elderly Patients Undergoing Noncardiac Surgery

“…Nutrition support in malnourished patients can reduce the risk of postoperative complications such as surgical site infections and gastrointestinal complications (6)(7)(8). Selection of proper assessment tools is the key step for early diagnosis and treatment of malnutrition (9).…”