Tech Coloproctol (2014) 18:1137–1138 DOI 10.1007/s10151-014-1205-1

COCHRANE DIGEST

Pre-operative nutrition support in patients undergoing gastrointestinal surgery A. Horgan

Received: 15 May 2014 / Accepted: 16 May 2014 / Published online: 26 August 2014 Ó Springer-Verlag Italia Srl 2014

Abridged abstract Burden 1, Todd C, Hill J, Lal S. Pre-operative nutrition support in patients undergoing gastrointestinal surgery. Cochrane Database Syst Rev. 2012 Nov 14;11:CD008879. doi:10.1002/14651858.CD008879. Background Whether or not nutritional intervention should be initiated earlier in the pre-operative period remains unclear. Objectives To review the literature on pre-operative nutritional support in patients undergoing gastrointestinal surgery (GI). Data collection and analysis Meta-analyses were undertaken on trials evaluating immune-enhancing (IE) nutrition, standard oral supplements, enteral and parenteral nutrition (PN) which were administered pre-operatively. Main results Seven trials evaluating IE nutrition were included in the review, of which 6 were combined in a meta-analysis. These studies showed a low-to-moderate level of heterogeneity and significantly reduced total postoperative complications (risk ratio [RR] 0.67 CI 0.53–0.84). Three trials evaluating PN were included in a meta-analysis and a significant reduction in post-operative complications was demonstrated (RR 0.64 95 % CI 0.46–0.87) with low heterogeneity, in predominantly malnourished participants. Two trials evaluating enteral nutrition (RR 0.79, 95 % CI 0.56–1.10) and 3 trials evaluating standard oral supplements (RR 1.01 95 % CI 0.56–1.10) were included, neither of which showed any difference in the primary outcomes.

A. Horgan (&) The Newcastle Upon Tyne Hospitals NHS Trust, The Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK e-mail: [email protected]

Author’s conclusions There have been significant benefits demonstrated with pre-operative administration of IE nutrition in some high-quality trials. However, bias was identified which may limit the generalizability of these results to all GI surgical candidates and the data needs to be placed in context with other recent innovations in surgical management (e.g. ERAS). Some unwanted effects have also been reported with components of IE nutrition in critical care patients and it is unknown whether there would be detrimental effects by administering IE nutrition to patients who could require critical care support after their surgery. The studies evaluating PN demonstrated that the provision of PN to predominantly malnourished surgical candidates reduced post-operative complications; however, these data may not be applicable to current clinical practice, not least because they have involved a high degree of ‘hyperalimentation’. Trials evaluating enteral or oral nutrition were inconclusive and further studies are required to select GI surgical patients for these nutritional interventions.

Invited commentary Enhanced Recovery Guidelines advise against prolonged pre-operative fasting and support the use of pre-operative carbohydrate loading in order to promote patient wellbeing and reduce post-operative insulin resistance. However, the use of pre-operative nutritional support in surgical patients is less well supported. The evidence is poor and, in many cases, outdated. This review brings together the relevant trials which attempt to answer the question of whether or not patients would benefit from pre-operative nutritional support prior to Gastrointestinal Surgery. To most GI surgeons, pre-operative nutritional support refers to a period of administration of supplementary

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calories, by enteral or parenteral route, prior to performing surgery in order to correct malnutrition and reduce the incidence of post-operative complications. It does not generally include the use of immune-enhancing agents such as arginine or the use of carbohydrate loading with Maltodextrans in order to reduce post-operative insulin resistance. The concern of the GI surgeon is to determine whether it is beneficial to the patient to delay surgery in order to provide supplementary nutrition. Whether or not we should routinely use pre-operative parenteral nutrition, as concluded in the review, is of academic interest. The studies cited are more than 20 years old and have been superseded by more recent guidelines regarding the use of parenteral feeding. In addition, there were a number of confounding variables to be considered and it is unclear whether such benefits would be observed in the modern surgical era of Enhanced Recovery. The remainder of the review examines the evidence available regarding the benefits of pre-operative enteral nutrition in patients undergoing GI surgery, including nasogastric administration or the use of oral supplements. As the authors comment, it is difficult to reach a conclusion from these studies. Some include patients who are malnourished, others exclude these patients. All trials used different methods to assess nutritional status. There is a

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high risk of bias with a lack of blinding, incomplete outcome data and lack of information regarding whether or not Enhanced Recovery protocols were in place. The trials involving the use of oral supplements were carried out, for the main part, on well-nourished patients and, unsurprisingly, showed no benefit. Most would agree that the evidence, to date, is not strong enough to support a period of enteral nutrition prior to surgical intervention, in the absence of malnutrition. The only consistent studies in malnourished patients looked at the use of parenteral nutrition and although these did show a reduction in overall post-operative complication, it was noted that there was an increase in the rate of infective complications. I would summarise that pre-operative parenteral nutrition should be considered only in exceptional circumstances and immune-enhancing agents require further evaluation before being incorporated into routine practice. There is no evidence to support the use of pre-operative enteral nutrition. The evidence suggests that it is of no use in the well-nourished patient. Further trials are needed to evaluate the use of pre-operative enteral nutrition in the malnourished patient in the setting of an Enhanced Recovery patient care pathway. Conflict of interest

None.

Pre-operative nutrition support in patients undergoing gastrointestinal surgery.

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