Clinical Review

Fit for surgery: An expert panel review on optimising patients prior to surgery, with a particular focus on nutrition

A. Windsor¹ M. Braga²  R. Martindale³  P. Buenos⁴  R. Tepaske⁵  L. Kraehenbuehl⁶  

A. Weimann⁷

¹St Mark’s Hospital, London, UK

²San Raffaele University, Milan, Italy

³Medical College of Georgia, Augusta, Georgia, USA

⁴Hospital Tulle, Correze, France

⁵Academic Medical Centre, University of Amsterdam, Netherlands

⁶Hospital Cantonal, Fribourg, Switzerland

⁷Stadtisches Klinikum “St Georg” Leipzig, Germany

Correspondence to: A. Windsor, St Mark’s Hospital, Watford Road, Harlow, Middlesex, HA1 3UJ, UK Email: alwindsor@aol.com

Introduction How should we assess nutritional state? Do immunonutrients have a role  in preparing patients for surgery? When should immunonutrition be administered? Recommendations References

Keywords: Immunosuppression, enteral nutrition, elective surgery, post-operative infections, immunonutrition Surg J R Coll Surg Edinb Irel., 1 December 2004, 315-319

This article represents the views of an international group of surgeons on the need for pre-operative optimisation of patient’s nutritional status prior to elective surgery as a means of reducing postoperative infective complications

Disclosure of financial support: This article is based on the proceedings of a meeting sponsored by Novartis Medical Nutrition, held in Maidenhead, UK on 2/3 May 2003.

INTRODUCTION

Despite significant changes in elective surgical care, operative technique and newer antimicrobial agents, surgical complications and, in particular, those that are infectious in origin, remain common, adding to length of hospital stay, healthcare costs and potential excess mortality. Furthermore, rates of nosocomial infections are rising in surgical and intensive care units and the apparent increase in both Gram-positive and Gramnegative resistant bacteria is of particular concern, making the prevention of infection a major surgical issue.¹

The causes of infectious surgical complications are multi-factorial and dependent to an extent on the primary surgical pathology, and the type and magnitude of the operation. Nevertheless, there is growing evidence that traumatic and surgical insult is associated with a period of relative immune suppression, which may expose patients to subsequent risk of infection.² In addition, there is growing evidence to show that modulation of patients’perioperative immune function offers an opportunity to reduce post-operative infectious complications.

In addition, surgeons are increasingly under pressure to reduce healthcare costs with healthcare payers and providers in many countries encouraging medical and surgical staff to reduce patients’ length of stay in hospital, particularly for elective surgery. There is, therefore, an imperative to reduce the potential for post-operative complications, particularly nosocomial infections.

There is a growing trend towards managed perioperative care, which offers the potential for patients to be discharged, fully mobilised and eating a normal diet within 24-48 hours in certain major surgical procedures, provided appropriate pre-operative optimisation is achieved.³

In preparing patients for surgery, surgical teams are well aware of the need to:

• exercise appropriate surgical judgement

• provide full information to patients and obtain informed consent

• rationalise patients’ drug use (particularly steroids and oral contraceptive use) and lifestyle factors such as smoking etc

• optimise patients in terms of cardiovascular and respiratory comorbidities.

However, surveys of clinical practice suggest that the nutritional state of patients is often overlooked in pre-surgical assessment, particularly in patients with cancer among whom cachexia is often evident.⁴

Malnutrition is common among hospitalised patients and in the community, while patients’ nutritional status often declines during hospital stay.5,6 Both malnutrition and weight loss are associated with alterations in cellular physiology and organ function, which are of importance for the surgical patient. Pre-operative malnutrition compromises surgical outcome while preoperative weight loss can lead to increased postoperative morbidity and mortality.^7-9

There is evidence to support the provision of nutritional support in severely malnourished patients prior to surgery; where possible nutrition should be delivered via an oral or enteral route as parenteral support appears to be associated with an increase in non-line associated infections.^10-12 In animal models, parenteral nutrition is associated with failure of the gut barrier function, potentially allowing bacterial overgrowth, loss of gut mucosal immunity and mucosal atrophy and an exaggerated acute phase response.¹³ By contrast, enteral feeding positively influences gut barrier function, maintaining normal flora and mucosal immunity and is associated with a diminished acute phase response.

However, routine pre-operative feeding is rare, possibly due to limited knowledge of recent scientific data and historical controversy over early published data.¹⁴ Much of the latter was retrospective and based on small sample sizes conducted in heterogeneous populations.¹¹It is also a consequence of the failure to assess patients’ nutritional state.¹⁵

HOW SHOULD WE ASSESS NUTRITIONAL STATE?

There is no ‘gold standard’ for determining nutritional status. At present, the subjective global assessment (SGA), which classifies patients subjectively on the basis of data obtained from history and physical examination, is the only tool that is accepted worldwide.¹⁶ Review of the medical history includes an assessment of weight and weight change, dietary intake, gastrointestinal symptoms, disease state, and the patient’s functional status. The physical examination looks for negative changes in body composition such as loss of subcutaneous fat or muscle wasting, and signs of nutrition-related oedema. After evaluation, the patient is classified as well nourished, mild-to-moderately malnourished or severely malnourished.

The patient’s body mass index (BMI; kg/ m2) provides a useful objective comparison of weight status within and between adult patients and an indication of nutritional status, identifying those at increased risk of morbidity and mortality and who should be prioritised for nutritional intervention (Table 2). However, patients may have acute energy deficiency even though their BMI remains in the normal range, while obese patients may be malnourished. Therefore, BMI should not be the only indicator used in nutritional assessment. Weight loss over time may be a more useful indicator as the more rapid the decline in weight, the greater the proportion of lean to fat tissue that is lost. Very rapid weight loss - within days rather than weeks - is most likely to be due to loss of fluid (Table 3).

Serum albumin levels <35g/l indicate raised risk in patients with no renal or liver disease or who are not dehydrated. Low pre-operative albumin levels correlate with the risk of post-operative complications.¹⁸ In patients undergoing elective oesophageal, gastric, pancreaticoduodenal or colon surgery hypoalbuminuria is associated with increased mortality and risk of pneumonia, anastomotic leak, abscess, respiratory failure and death. As albumin levels drop there is an increase in resource utilisation, length of intensive care and hospital stay, total parenteral nutritional utilisation and a delay to resumption of an oral diet.¹⁹

An ESPEN working group has recently established a nutritional risk screening system based on a retrospective analysis of controlled trials that involves assessment of four risk factors (weight loss, amount of food intake, BMI and disease severity) using a patient questionnaire.²⁰ Patients undergoing major abdominal surgery are classified as nutritionally at risk if they have experienced weight loss of >5% in the preceding three months, or have a BMI of <20.5 kg/m2, or have a food intake below 75% of their normal requirement in the preceding week. All patients over the age of 70 undergoing major abdominal surgery would be considered to be nutritionally at risk.

DO IMMUNONUTRIENTS HAVE A ROLE IN PREPARING PATIENTS FOR ELECTIVE SURGERY?

Patients undergoing major elective procedures for gastrointestinal disease are at increased risk for post-operative complications. Randomised trials have shown that early postoperative feeding of malnourished patients undergoing elective abdominal surgery with an enteral formula enriched with immune-enhancing nutrients such as arginine, ribonucleic acid and omega-3 fatty acids improves the post-operative depression of immunological and nutritional variables, compared with standard formulas.^21-23

In these trials, treatment was also associated with significantly reduced post-operative infection rates and length of hospital stay.^21,23 Furthermore, in the elective surgical setting, pre-operative feeding may enhance these beneficial effects in general and head and neck surgery, even in normally nourished high risk groups.^25,26

Meta-analyses confirm significant overall benefit from enterally delivered immunonutrition in reducing infectious complications, hospital stay and ventilator days.^11,12,27 The greatest benefit appears to be in surgical patients rather than critically ill or trauma patients.^12,27 Therefore, while there is evidence to support the use of immunonutrition in elective surgery, at present, there is still controversy of its use in other settings (JPEN Guidelines).

WHEN SHOULD IMMUNONUTRITION BE ADMINISTERED?

Post-operative supplementation alone generally reduces only late post-operative infectious complications. It takes around five days for immune-enhancing nutrients to become incorporated into the host tissues and alter inflammatory mediators and fatty acid profiles. As the impairment of the host defence mechanisms occurs immediately after surgery, immunonutrients should be given prior to surgery. This allows control of the early post-operative immune impairment, with modulation of the post-operative inflammatory response, enhancement of cell-mediated immunity and the synthesis of short half-life proteins and up-regulation of gut microperfusion and oxygen metabolism.^28,29

In prospective randomised trials, this approach has consistently demonstrated significant reductions in overall complication rates in patients with gastrointestinal cancer.^25,30,31 This has been associated with subsequent significant reduction of healthcare costs.^30,32

Furthermore, prospective trials have confirmed that pre-operative supplementation with immunonutrients is as effective as perioperative supplementation in improving the immunometabolic response and reducing postoperative complications in well-nourished patients.³³ Perioperative immunonutrition is a more effective approach than pre-operative immunonutrition or standard enteral nutrition for reducing post-operative complications and length of stay in malnourished patients.³⁴ 

Therefore, pre-operative supplementation with immunonutrition should be targeted to patients undergoing abdominal surgery for cancer, particularly those who are malnourished pre-operatively and postoperatively, and those patients at risk for postoperative infections.³⁵

RECOMMENDATIONS

Trials of immunonutrients clearly suggest beneficial outcomes in elective surgical patients. However, doubts remain about the use of immunonutrition in the most critically ill patients, particularly those with severe sepsis.

In light of the current evidence, the use of immunonutrition in elective surgical practice should be limited to those patients who are at high risk for post-operative infections, whether due to:

• malnutrition or other patient characteristics

• the surgical procedure the patient is to receive.

In order to ensure that patients undergoing elective procedures are “fit for surgery”, all members of the multidisciplinary team should understand that adequate nutrition contributes to a successful surgical outcome enabling patients to cope with the relative immunosuppression associated with surgery. The routine perioperative work-up of all patients undergoing major abdominal elective surgery should, therefore, include nutritional assessment with the aim of identifying malnutrition. Malnourished patients are readily characterised by:

• BMI of <18.5 kg/m2

• recent (1-2 months) weight loss exceeding 5% of usual body weight or

• serum albumin levels <35g/l, in the absence of renal or hepatic disease.

Such patients are at increased risk for postoperative infectious complications and may benefit from nutritional intervention using immune-enhancing feeds.

Where pre-operative malnutrition is severe, surgery may need to be delayed for two to three weeks while the patient undergoes further nutritional assessment and enteral feeding. If malnutrition is only mild to moderate, then surgery should go ahead as planned. However, these patients are likely to benefit from being prepared for surgery by administration of an oral immunonutrition beginning five days before surgery (e.g. IMPACT). This diet should continue post-operatively for five to seven days in these patients, and may require placement of a naso-jejunal tube to allow enteral access.³⁴

In addition, well-nourished patients who are at risk from post-operative infections due to their surgery or their illness will also benefit from oral immunonutrition for five days prior to surgery, in addition to their normal diet.³³ In this setting, it is not necessary to continue post-operative supplementation.

Post-operative infection rates vary considerably between units. All surgeons should identify which patients and which procedures are associated with a high rate of post-operative infection in their unit. Where there is a significant rate of infections they should consider offering nutritional supplementation using an immunonutrition formula.

Copyright 18 October 2004

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