Periopperative nutritional Periopperative nutritional support in GI surgerysupport in GI surgery

: : Past, Present, and future on Past, Present, and future on oncology perspective oncology perspective observation and evidence observation and evidence basebase

Sirikan Yamada, MDDivision of Gastrointestinal Surgery and EndoscopyDepartment of SurgeryFaculty of MedicineChiang Mai University, Chiang Mai, Thailand

There is a high incidence of There is a high incidence of malnutrition in hospitalized patients malnutrition in hospitalized patients undergoing gastrointestinal surgeryundergoing gastrointestinal surgery . .

Malnutrition is clearly associated Malnutrition is clearly associated with increased morbidity and with increased morbidity and mortality after major mortality after major gastrointestinal surgerygastrointestinal surgery . .

Cancer cachexia may be an Cancer cachexia may be an immunologic phenomenon. Routine immunologic phenomenon. Routine preoperative TPN may not proper preoperative TPN may not proper for all types of cancer.for all types of cancer.

The efficacy of perioperative nutrition support The efficacy of perioperative nutrition support to reduce surgical complications and mortality to reduce surgical complications and mortality significantly has been an area of active clinical significantly has been an area of active clinical investigation over the past three decadesinvestigation over the past three decades . .

From multiple prospective, randomized trials, From multiple prospective, randomized trials, significant benefit from perioperative significant benefit from perioperative nutritional support has been demonstrated in nutritional support has been demonstrated in severely malnourished patients undergoing severely malnourished patients undergoing major surgerymajor surgery . .

Results of the prospective, randomized trials Results of the prospective, randomized trials studying the effects of perioperative nutrition studying the effects of perioperative nutrition support on patients undergoing support on patients undergoing gastrointestinal surgery are reviewed and gastrointestinal surgery are reviewed and critically analyzedcritically analyzed..

Why ?Why ?

Disease causes starvation and Disease causes starvation and defect of immunitydefect of immunity

Major stress on elective complex Major stress on elective complex GI Surgery; especially, on upper GI Surgery; especially, on upper GI cancer surgeryGI cancer surgery

Underestimation for nutritional Underestimation for nutritional risk by surgeonrisk by surgeon

WHO?WHO?

Nutritional Risk Screening SGA BMI? In ASIAN

Which type of operationWhich type of operationWhich type of formula, Which type of formula, and When?and When?

For Complex Surgery PreparationFor Complex Surgery Preparation Enteral or TPN ?Enteral or TPN ? BOTH !BOTH ! , and Early as soon as possible., and Early as soon as possible.

HOW?HOW?

Need not to do over TPN calory or Need not to do over TPN calory or over feeding.over feeding.

Use the actual weight.Use the actual weight. Normal energy base requirement.Normal energy base requirement.

Immuno-nutritionImmuno-nutrition TPN + glutamine dipeptide in bone TPN + glutamine dipeptide in bone

marrow transplantation patients.marrow transplantation patients. In Esophageal cancer patients, In Esophageal cancer patients,

preoperative TPN + amino acids+ preoperative TPN + amino acids+ certain fatty acids decrease certain fatty acids decrease postoperative infections, and it postoperative infections, and it was improved postoperatively was improved postoperatively when given enteral nutrition when given enteral nutrition supplemented with arginine and supplemented with arginine and omega 3-fatty acidsomega 3-fatty acids

Oncology 1996:10

The effects of perioperative oral enteral support The effects of perioperative oral enteral support with glutaminewith glutamine--added elemental formulas in added elemental formulas in patients with gastrointestinal cancerspatients with gastrointestinal cancers . . A A prospective, randomized, clinical studyprospective, randomized, clinical study

3232 patients with gastrointestinal (GI) s patients with gastrointestinal (GI) s ystem cancer ystem cancer 33%33% of the daily energy of the daily energy

requirements was covered with requirements was covered with

polymeric enteral formulas (Ensure®) polymeric enteral formulas (Ensure®) in the control group (n = in the control group (n =1616 ), and with ), and with

glutamine enriched elemental formul glutamine enriched elemental formul as (Alitraq®) in the study group (n = as (Alitraq®) in the study group (n =

1616 ). ).  ERDEM Nihal Zekiye  ERDEM Nihal Zekiye, 2002, 2002

at the at the4 4 th Surgical Department of the Ankara Numune Research a th Surgical Department of the Ankara Numune Research a nd Education Hospital. In addition to hospital diet nd Education Hospital. In addition to hospital diet

Patients had these regimens Patients had these regimens77 da da ys in the preoperative period and ys in the preoperative period and

1010 days in the postoperative peri days in the postoperative periodod . The effects of additional . The effects of additional eenternter

al feeding support on anthropom al feeding support on anthropom etric and plasma protein levels in etric and plasma protein levels in

the preoperative (days the preoperative (days11 and and77 ) a ) a nd postoperative (days nd postoperative (days11 and and 1010 ) )

periods were assessed In both gr periods were assessed In both groupsoups

no differences were observed among the no differences were observed among the anthropometric assessments, except for the anthropometric assessments, except for the

Nutritional Risk Index. Total protein, albumin, Nutritional Risk Index. Total protein, albumin, transferrin, prealbumin, NRI, and nutritional transferrin, prealbumin, NRI, and nutritional

prognostic index were affirmatively affected by prognostic index were affirmatively affected by bbotot h enteral formulas. h enteral formulas.

***** ***** However, the increments of these parameter However, the increments of these parameter

s were higher and more significant in s were higher and more significant in the study group the study group . Energy, protein, carbohydrate and . Energy, protein, carbohydrate and lipid consumption of the patients were managed as lipid consumption of the patients were managed as

the referred amounts. the referred amounts. - - Pre and post operative- - Pre and post operative nutritional support with glutamine enriched enteral nutritional support with glutamine enriched enteral

formulas had beneficial effects on the patients with formulas had beneficial effects on the patients with GI cancers. GI cancers.

PREVENTION PREVENTION

is better than is better than

ONLY ONLY TREATMENTTREATMENT