Nutritional Management of the Surgical Patient E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 590

Veröffentlichungsjahr: 2023

Beschreibung

Nutritional Management of the Surgical Patient Manage patient diet and nutrition with this comprehensive guide Nutritional Management of the Surgical Patient provides the first comprehensive evidence-based overview of the nutritional and dietary therapies for surgical patients. It takes clinicians through every stage of surgery, from pre-operative and immediate post-operative care, through to long term recovery and survivorship. This book describes the impact of surgical procedures and their complications and the effect these have on nutritional status as well as the nutritional strategies utilised to manage patients in these settings. The result is a valuable survey of this essential aspect of surgery. Nutritional Management of the Surgical Patient features case studies which capture both typical patients and the more unusual cases to help clinicians understand the impact of nutrition in both circumstances. The textbook also details a range of surgical procedures to support underpinning knowledge of the mechanism behind nutritional intervention. Readers will also find: * Consideration in each chapter of both short- and long-term nutritional management * Discussion of potential long-term complications such as small intestinal bacterial overgrowth, bile acid diarrhoea, micronutrient deficiencies and osteoporosis * Questions to support consolidation of knowledge and promote understanding in clinical context Nutritional Management of the Surgical Patient is a must-have for surgeons, surgical dietitians, trainees and all healthcare professionals involved in the care of surgical patients.

Leseprobe

TABLE OF CONTENTS

COVER

TABLE OF CONTENTS

TITLE PAGE

COPYRIGHT PAGE

CONTRIBUTORS

SECTION 1: INTRODUCTION

CHATPER 1: Introduction

SECTION 2: BEFORE AND DURING SURGERY

CHATPER 2: Nutrition Screening and Assessment

OVERVIEW OF BODY COMPOSITION

NUTRITION‐RELATED SYNDROMES

NUTRITION SCREENING

NUTRITION ASSESSMENT

REFERENCES

CHATPER 3: Nutritional Considerations Prior to Surgery

MALNUTRITION AND SARCOPENIA

PRE‐OPERATIVE NUTRITIONAL TREATMENT STRATEGIES

PRIORITIES FOR FUTURE RESEARCH

REFERENCES

CHATPER 4: Prehabilitation Programmes and Their Impact on Surgical Outcomes

A BRIEF HISTORY OF PREHABILITATION

DEFINING PREHABILITATION

STRATIFIED CARE AND PREHABILITATION

ENHANCED RECOVERY AFTER SURGERY AND PREHABILITATION

HOLISTIC AND PERSON‐CENTRED APPROACHES TO PREHABILITATION

PSYCHOLOGICAL PREPARATION

PREHABILITATION TO SUPPORT BEHAVIOUR CHANGE

FRAMEWORKS FOR PREHABILITATION

PRIME PREHABILITATION FOR SURGERY AT THE ROYAL SURREY HOSPITAL FOUNDATION TRUST

INTERVENTIONS OF PRIME PREHABILITATION

PRIME OUTCOME DATA

CONCLUSION

REFERENCES

CHATPER 5: Enhanced Recovery after Surgery

EARLY ORAL FEEDING

NUTRITIONAL SUPPORT AND ORAL NUTRITION SUPPLEMENTS

ENTERAL NUTRITION

IMMUNO‐NUTRITION

REFERENCES

CHATPER 6: Surgical Terminology and Pre‐operative Considerations

SURGICAL DESCRIPTORS

PRE‐OPERATIVE CONSIDERATIONS

PREHABILITATION

ASSESSING SURGICAL RISK

POST‐OPERATIVE COMPLICATIONS

CONCLUSION

REFERENCES

CHATPER 7: Operating on the Malnourished Patient

ANAEMIA

ELECTROLYTE ABNORMALITIES

REFEEDING SYNDROME

IMPACT OF BODY HABITUS ON ANAESTHESIA

REFERENCES

SECTION 3: IMPACT OF SURGERY

CHATPER 8: Nutritional Management of the Surgical Patient in Critical Care

METABOLIC RESPONSE TO STRESS

FEEDING THE POST‐OPERATIVE SURGICAL PATIENT IN CRITICAL CARE

NUTRITIONAL TARGETS

AREAS FOR FUTURE RESEARCH/QUESTIONS UNANSWERED

ACKNOWLEDGEMENTS

REFERENCES

CHATPER 9: Nutritional Management of Patients Undergoing Head and Neck Cancer Surgery

HEAD AND NECK CANCERS

GENERAL NUTRITIONAL IMPLICATIONS FOLLOWING SURGICAL INTERVENTION

SURGICAL PROCEDURES

METHODS OF POST‐OPERATIVE NUTRITIONAL SUPPORT

POST‐OPERATIVE COMPLICATIONS AND THEIR NUTRITIONAL MANAGEMENT

REFERENCES

CHATPER 10: Cardiothoracic Surgery and Nutrition

OVERVIEW OF SURGICAL PROCEDURES

NUTRITIONAL IMPLICATIONS

COMPLICATIONS

LONG‐TERM MANAGEMENT POST CARDIAC SURGERY

LONG‐TERM POST‐TRANSPLANT COMPLICATIONS

CHRONIC KIDNEY DISEASE

REFERENCES

CHATPER 11: Nutritional Management of the Surgical Patient

COMMON OPERATIONS AND THEIR ANATOMY

NUTRITIONAL MANAGEMENT OF EARLY COMPLICATIONS

REFERENCES

CHATPER 12: Endoscopic Procedures and Their Implications for Nutrition

ENDOSCOPIC PROCEDURES

COMPLICATIONS

LONG‐TERM MANAGEMENT

REFERENCES

CHATPER 13: Pancreatitis

TYPES OF PANCREATITIS

SURGICAL PROCEDURES FOR ACUTE PANCREATITIS

SURGICAL PROCEDURES FOR CHRONIC PANCREATITIS

NUTRITIONAL MANAGEMENT OF ACUTE PANCREATITIS

NUTRITIONAL MANAGEMENT OF CHRONIC PANCREATITIS

REFERENCES

CHATPER 14: Pancreatic Resection

OVERVIEW OF SURGICAL PROCEDURES

IMPACT OF PANCREATIC RESECTION ON NUTRITION

COMMON POST‐OPERATIVE COMPLICATIONS AND THEIR NUTRITIONAL MANAGEMENT

LONG‐TERM MANAGEMENT

REFERENCES

CHATPER 15: Liver Resection

LIVER PHYSIOLOGY AND ANATOMY

PRE‐OPERATIVE CARE

SURGERY

POST‐OPERATIVE CARE

CONCLUSION

REFERENCES

CHATPER 16: Nutritional Management of the Urological Surgical Patient

OVERVIEW OF SURGICAL PROCEDURE

ENHANCED RECOVERY AFTER SURGERY AND PREHABILITATION

IMPACT ON NUTRITION

COMMON POST‐OPERATIVE COMPLICATIONS AND THEIR NUTRITIONAL MANAGEMENT

AREAS FOR FUTURE RESEARCH

REFERENCES

CHATPER 17: Colorectal Surgery

PRESENTATION AND AETIOLOGY

SURGICAL PROCEDURES

NUTRITIONAL MANAGEMENT IN THE PERI‐OPERATIVE SETTING

LONG‐TERM COMPLICATIONS

CONCLUSION

REFERENCES

CHATPER 18: Nutritional Management of Gynaecological Cancer Patients

DIETARY CONTRIBUTION TO GYNAECOLOGICAL MALIGNANCIES

PRE‐OPERATIVE MALNUTRITION

PRE‐OPERATIVE NUTRITIONAL SUPPORT

OVERVIEW OF SURGICAL PROCEDURES

POST‐OPERATIVE COMPLICATIONS AND IMPACT ON NUTRITION

CONCLUSION

REFERENCES

CHATPER 19: Major Trauma and Surgery

PHYSIOLOGICAL RESPONSE TO INJURY

ROUTES OF NUTRITION

NUTRITIONAL REQUIREMENTS

OVERVIEW OF TRAUMA INJURIES AND SURGERIES

COMMON POST‐OPERATIVE COMPLICATIONS AND THEIR NUTRITIONAL MANAGEMENT

LONG‐TERM NUTRITIONAL BARRIERS AND COMPLICATIONS

AREAS FOR FUTURE RESEARCH

REFERENCES

SECTION 4: CONSEQUENCES OF SURGERY

CHATPER 20: Bowel Obstruction and Dysfunction in Benign and Malignant Disease

PARALYTIC ILEUS

DIAGNOSIS AND INCIDENCE

CAUSES AND RISK FACTORS

MANAGEMENT

BOWEL OBSTRUCTION

AREAS FOR FUTURE RESEARCH

REFERENCES

CHATPER 21: Intestinal Failure and Rehabilitation

MANAGEMENT

LONG‐TERM NUTRITIONAL CONSEQUENCES

AREAS FOR FUTURE RESEARCH

REFERENCES

CHATPER 22: Nutritional Biochemistry in the Post‐operative Patient

TRACE ELEMENTS

VITAMINS

CONCLUSION

REFERENCES

SECTION 5: CONSOLIDATE YOUR LEARNING

CHATPER 23: Test Yourself

INDEX

END USER LICENSE AGREEMENT

List of Tables

Chapter 2

TABLE 2.1 Body composition compartments.

TABLE 2.2 Nutrition‐related syndromes.

TABLE 2.3 Summary of commonly used nutrition screening tools.

TABLE 2.4 Summary of nutritional and functional markers/indices.

Chapter 3

TABLE 3.1 Aetiology of malnutrition in surgical patients.

Chapter 5

TABLE 5.1 Core elements of enhanced recovery after surgery (ERAS) care, with...

Chapter 7

TABLE 7.1 Causes of anaemia.

TABLE 7.2 Interpretation of serum ferritin levels.

TABLE 7.3 Causes of electrolyte abnormalities.

TABLE 7.4 Risk factors for refeeding syndrome.

Chapter 8

TABLE 8.1 Summary of European Society of Intensive Care Medicine (ESICM) gui...

TABLE 8.2 Common predictive equations used in critical care.

TABLE 8.3 Factors influencing resting energy expenditure (REE).

TABLE 8.4 Protein recommendations for various clinical conditions in critica...

Chapter 9

TABLE 9.1 Nutritional management of post‐operative surgical complications.

Chapter 10

TABLE 10.1 Healthy diet characteristics.

Chapter 11

TABLE 11.1 Summary of enhanced recovery after surgery nutritional recommenda...

Chapter 13

TABLE 13.1 Considerations for nutritional screening in patients with pancrea...

Chapter 17

TABLE 17.1 Colorectal and small bowel operations.

Chapter 18

TABLE 18.1 Dietary contributions to gynaecological malignancies.

TABLE 18.2 Factors contributing to pre‐operative malnutrition in gynaecologi...

Chapter 19

TABLE 19.1 Nutritional composition of fluid losses.

Chapter 20

TABLE 20.1 Royal Surrey four‐step bowel obstruction diet.

Chapter 21

TABLE 21.1 Clinical monitoring requirements of patients with intestinal fail...

TABLE 21.2 Recommendations on fluid and electrolyte requirements for patient...

TABLE 21.3 Dietary management of short bowel intestinal failure.

Chapter 22

TABLE 22.1 Causes of abnormal trace element levels.

TABLE 22.2 Interpreting serum Fe profile results.

TABLE 22.3 Causes of abnormal vitamin levels.

List of Illustrations

Chapter 6

FIGURE 6.1 Anatomical terminology.

FIGURE 6.2 Rockwood score. IADL, instrumental activities of daily living....

Chapter 9

FIGURE 9.1 Anatomy of the head and neck.

Chapter 11

FIGURE 11.1 Anatomy of an Ivor Lewis oesophagectomy with gastric conduit and...

Chapter 12

FIGURE 12.1 Coronal view computed tomography scan showing dilated stomach an...

FIGURE 12.2 Endoscopic ultrasound image showing cyst.

FIGURE 12.3 Computed tomography image demonstrating position of lumen‐apposi...

Chapter 13

FIGURE 13.1 Computed tomographic image of extensive pancreatic collection.

Chapter 14

FIGURE 14.1 Summary of common factors related to malnutrition and pancreatic...

Chapter 15

FIGURE 15.1 Anatomy of the liver.

FIGURE 15.2 Computed tomographic image of bile leak following liver resectio...

Chapter 18

FIGURE 18.1 Ovarian mass occupying most of the abdomen and pelvis and compre...

Chapter 21

FIGURE 21.1 Diagram of ongoing losses.

Guide

Cover Page

Title Page

Copyright Page

Contributors

Table of Contents

Begin Reading

Index

Wiley End User License Agreement

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Nutritional Managementof the Surgical Patient

Edited by

Mary E. Phillips OStJ BSc (Hons) RD DipADP

Advanced Clinical Practitioner and Senior Specialist Dietitian (Hepato‐Pancreatico‐Biliary Surgery)

Royal Surrey NHS Foundation Trust

Guildford, UK

This edition first published 2023© 2023 John Wiley & Sons Ltd

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

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Library of Congress Cataloging‐in‐Publication DataNames: Phillips, Mary E. (Mary Elizabeth), editor.Title: Nutritional management of the surgical patient / [edited by] Mary E. Phillips.Description: Hoboken, NJ : Wiley‐Blackwell, 2023. | Includes index. | Summary: “Nutrition in the surgical patient explains the role of clinical nutrition in patients undergoing surgery to their gastro‐intestinal tract and within the thoracic and abdominal cavities. This book will provide an overview of assessment, current practice and considerations in the management of the surgical patient for clinicians working in clinical nutrition”– Provided by publisher.Identifiers: LCCN 2023003632 (print) | LCCN 2023003633 (ebook) | ISBN 9781119809098 (paperback) | ISBN 9781119809104 (adobe pdf) | ISBN 9781119809111 (epub) | ISBN 9781119809128 (obook)Subjects: MESH: Nutrition Therapy | Perioperative Care | Nutrition Assessment | Nutritional StatusClassification: LCC RM217 (print) | LCC RM217 (ebook) | NLM WB 400 | DDC 615.8/54–dc23/eng/20230317LC record available at https://lccn.loc.gov/2023003632LC ebook record available at https://lccn.loc.gov/2023003633

Cover Design: WileyCover Images: © David Malan/Getty Images; DIGICOMPHOTO/Getty Images

Contributors

Lindsey AllanDepartment of Nutrition and DieteticsRoyal Surrey NHS Foundation TrustGuildford, UK

Maria AshworthAcademic Department of Gynae‐oncologyRoyal Surrey NHS Foundation TrustGuildford, UK

Neil BibbyDepartment of Nutrition and DieteticsManchester University Hospitals NHS Foundation TrustManchester, UK

Jayanta ChatterjeeAcademic Department of Gynae‐oncologyRoyal Surrey NHS Foundation TrustGuildford, UK

Wissam Abou ChedidDepartment of UrologyRoyal Surrey NHS Foundation TrustGuildford, UK

Alison CulkinDepartment of Nutrition and DieteticsSt Mark’s HospitalLondon Northwest Healthcare University TrustLondon, UK

Nárbhla DonnellyDepartment of Nutrition and DieteticsGuy’s and St Thomas’ NHS Foundation Trust;Department of Nutrition and DieteticsThe Royal London HospitalBarts Health NHS TrustLondon, UK

Adam FramptonDepartment of HPB SurgeryRoyal Surrey NHS Foundation TrustGuildford, UK

Oonagh GriffinDepartment of Nutrition and DieteticsSt Vincent’s University Hospital;School of Physiotherapy, Public Health and Sports ScienceUniversity College DublinDublin, Ireland

Fiona HuddyDepartment of Nutrition and DieteticsRoyal Surrey NHS Foundation TrustGuildford, UK

Jeremy R. HuddyDepartment of SurgeryFrimley Health NHS TrustCamberley, UK

Chris JonesDepartment of AnaestheticsRoyal Surrey NHS Foundation TrustGuildford, UK

Rajiv LahiriDepartment of HPB SurgeryRoyal Surrey NHS Foundation TrustGuildford, UK

Anne LanganDepartment of Nutrition and DieteticsGuy’s and St Thomas’ NHS Foundation Trust;Department of Nutrition and DieteticsThe Royal London HospitalBarts Health NHS TrustLondon, UK

Evanna LeavyIntestinal Failure & Gastrointestinal SurgerySt George’s University Hospitals NHS Foundation TrustLondon, UK

John S. LeedsHPB UnitFreeman Hospital;Population Health Sciences InstituteNewcastle UniversityNewcastle upon Tyne, UK

Callum LivingstoneClinical Biochemistry DepartmentRoyal Surrey NHS Foundation TrustGuildford, UK

Rebekah LordDepartment of Nutrition and DieteticsManchester University Hospitals NHS Foundation TrustManchester, UK

Thanuya MahendranAcademic Department of Gynae‐oncologyRoyal Surrey NHS Foundation TrustGuildford, UK

Ashleigh MaskeDepartment of Nutrition and DieteticsManchester University Hospitals NHS Foundation TrustManchester, UK

Helen McNamaraDepartment of Occupational TherapyRoyal Surrey NHS Foundation TrustGuildford, UK

Nabeel MeraliDepartment of HPB SurgeryRoyal Surrey NHS Foundation TrustGuildford, UK

Gregory J NasonDepartment of UrologyRoyal Surrey NHS Foundation TrustGuildford, UK

Ann‐Marie NixonDepartment of Nutrition and DieteticsWythenshawe HospitalManchester University NHS Foundation TrustManchester, UK

Katy O’RourkeDepartment of AnaestheticsRoyal Surrey NHS Foundation TrustGuildford, UK

Alessandro ParenteDepartment of HepatopancreatobiliarySurgery and Liver TransplantationUniversity Hospitals BirminghamNHS Foundation TrustBirmingham, UK;Institute of Immunology and ImmunotherapyUniversity of BirminghamBirmingham, UK

Rupal PatelDepartment of Nutrition and DieteticsRoyal Brompton and Harefield HospitalsGuy’s and St Thomas’ NHS Foundation TrustLondon, UK

Krishna PatilDepartment of UrologyRoyal Surrey NHS Foundation TrustGuildford, UK

Matthew J.A. PerryDepartment of UrologyRoyal Surrey NHS Foundation TrustGuildford, UK

Mary E. PhillipsDepartment of Nutrition and DieteticsRoyal Surrey NHS Foundation TrustGuildford, UK

Sarah Powell‐BrettDepartment of Hepatopancreatobiliary Surgery and Liver TransplantationUniversity Hospitals Birmingham NHS Foundation TrustBirmingham, UK

Charles RaynerDepartment of SurgeryRoyal Surrey NHS Foundation TrustGuildford, UK

Keith J. RobertsDepartment of Hepatopancreatobiliary Surgery and Liver Transplantation, University Hospitals Birmingham NHS Foundation Trust Birmingham, UK;Institute of Immunology and Immunotherapy University of BirminghamBirmingham, UK

Cathy SkeaClinical Lead DietitianDepartment of Nutrition and DieteticsRoyal Victoria Hospital, BelfastBelfast Health and Social Care TrustBelfast, Northern Ireland

Sara SmithSchool of Health SciencesQueen Margaret UniversityEdinburgh, UK

Naomi WestranDepartment of Nutrition and DieteticsRoyal Surrey NHS Foundation TrustGuildford, UK

Jennifer WetherdenMajor Trauma & Critical CareSt George’s University Hospitals NHS Foundation TrustLondon, UK

SECTION 1INTRODUCTION

CHATPER 1Introduction

Welcome to this book exploring the nutritional management of the surgical patient.

An understanding of anatomy and surgical procedures is vital to ensure that nutritional management meets the needs of the surgical patient. This book is designed to give all surgical dietitians, surgical trainees, and gastroenterology trainees specialising in nutrition an overview of the impact of surgery on nutritional status and an insight into the nutritional management of complex conditions.

My first experience of the impact of surgery on nutrition came early in my career. As a junior dietitian I was referred a patient (Mr A) who had lost 50% of his body weight in three years.

Mr A came to my clinic in a wheelchair, very frail, weighing barely 40 kg. A detailed dietary history demonstrated that he consumed more than enough energy and protein to be gaining weight. Unfortunately, as he had continued to lose weight despite reporting compliance with nutritional advice and oral supplement drinks, it had been assumed that he was non‐compliant. He had a good appetite, was not vomiting, but he did report he had rather frequent stools.

He was rather embarrassed to discuss this, but we eventually established that he was actually having his bowels open more than 10 times a day and was passing bright orange/yellow oily stool with visible food particles.

When I took a clinical history, he told me he had had an operation for a tumour on his pancreas four years ago, and a year after that an operation on his back. This wound had never healed and was still being dressed daily by district nurses.

I had never heard of a pancreatico‐duodenectomy, so headed to the library (Google was not around back then!). Mr A was taking 10 000 units of enzymes with each meal, none with snacks, nor the supplement drinks he had been given. I had carried out my undergraduate dissertation in cystic fibrosis, so was familiar with pancreatic enzymes, and the much higher doses used there. After lengthy discussions with a very supportive GP (who had also never prescribed enzymes before) and Mr A's consultant surgeon, we escalated his enzyme dose. After several dose increases, we finally stopped the weight loss, restored normal bowel function, and the wound on his back started to heal, but we couldn't achieve weight gain. Hence, we brought Mr A into hospital to establish nasogastric feeding. After six months of overnight tube feeding at home with a semi‐elemental feed, Mr A walked into clinic at 65 kg having spent the weekend building a shed for his neighbour, and the wound on his back had healed.

Sadly, this story does not have an entirely happy ending, as nine months after, in his words, ‘getting his life back’ he developed liver metastases and quickly succumbed to his disease. We were able to give him nine months of good quality of life, but he lived for over five years after his cancer surgery. If we knew then what we know now, I suspect he could have had the full five years of good quality of life.

Roll forward more than 20 years and I am now privileged to work in a fully inclusive surgical multidisciplinary team, where collaborative working supports the early identification and management of the nutritional consequences of surgery, but I still see evidence of cases like Mr A's in clinical practice. So, this book is my attempt at filling what I see is still a gap in education in both dietetics and medicine.

Surgical procedures are becoming more complex and post‐operative management is evolving to include more therapeutic nutritional management. The advent of immuno‐nutrition, a greater understanding of the microbiome, the impact of sarcopenia, and continued improvements in survivorship following extensive cancer surgery mean we still have a lot to learn. I imagine the content of this book will change considerably in editions to come.

I would like to thank everyone who took the time to write chapters for this book, and the team at Wiley for their support, especially with all the stress of the global pandemic, which in hindsight was not the best time to undertake this project! I am delighted that we have been able to present a truly multiprofessional approach to nutrition.

So, this book is dedicated to Mr A, without whom I would not be in the job I am in now; to Professor Nariman Karanjia, who had the foresight to include a dietitian in the development of our tertiary hepato‐pancreato‐biliary centre 20 years ago, (and gave me the job!); and to Tanya Klopper, my manager, who has always supported me, however crazy some of my ideas may seem. Finally, thank you to my family, to whom I owe a massive debt of gratitude for putting up with the late nights and weekends of editing and listened to random sentences while I tried to get the wording right. As a consequence, I am the proud parent to teenagers who can pronounce encephalopathy and pancreatico‐duodenectomy!

I hope this book is useful, and I welcome any suggestions for the next edition.

Happy reading

Mary E. Phillips

Advanced Clinical Practitioner/Senior Specialist Dietitian (hepato‐pancreatico‐biliary surgery)

SECTION 2BEFORE AND DURING SURGERY

CHATPER 3Nutritional Considerations Prior to Surgery

Oonagh Griffin

Department of Nutrition and Dietetics, St Vincent’s University Hospital, Dublin, Ireland

School of Physiotherapy, Public Health and Sports Science, University College Dublin, Dublin, Ireland

KEY POINTS

Malnutrition is prevalent in surgical populations, especially in patients with underlying malignant disease.

Both malnutrition and sarcopenia increase the risk of post‐operative morbidity and reduce overall survival.

Pre‐operative nutrition screening should be universally applied to allow timely identification and treatment of malnutrition.

The goal of nutritional support should focus on appropriate nutritional therapy to optimise surgical readiness, minimise starvation, prevent post‐operative malnutrition, and support anabolism for recovery.

Malnutrition is prevalent in pre‐operative patients, with studies demonstrating that nearly half of all patients are malnourished on admission to hospital [1, 2]. International collaborative projects such as ‘NutritionDay’ have allowed annual surveys of the nutritional status of hospitalised inpatients, demonstrating significant determinants of malnutrition as predictors of prolonged length of stay, morbidity, and mortality [3, 4]. Recently the Global Leadership Initiative on Malnutrition (GLIM) consensus criteria for the diagnosis of malnutrition have been developed and proposed by the European Society for Clinical Nutrition and Metabolism (ESPEN), moving the diagnostic criteria beyond phenotypical criteria such as weight loss or low body mass index (BMI), and considering the impact of aetiological criteria such as malabsorption and inflammation [5] (see Chapter 2). Indeed, surgical illness is often an instance where both the phenotypical and aetiological causes of malnutrition occur simultaneously, especially where there is underlying cancer or autoimmune disease. The aetiology of malnutrition in surgical patients is outlined in Table 3.1.

TABLE 3.1 Aetiology of malnutrition in surgical patients.

Inadequate nutritional intake

Malabsorption

Impaired nutrient assimilation

Pain

Gastrointestinal resection

Sepsis

Dysphagia

Autoimmune disease e.g. inflammatory bowel disease, coeliac disease

Insulin resistance

Hypermetabolism

Ischaemia

Cancer cachexia

Nausea and vomiting (disease or treatment induced)

Pancreatic insufficiency

Refeeding syndrome

Anorexia

Radiation enteropathy

Food aversion/dietary restrictions, including unpleasant eating environment

Biliary obstruction

Psychosocial factors e.g. underlying disability, poverty, inadequate food supply

Significant small bowel oedema

Emotional distress and anxiety

Malnutrition in surgical patients typically manifests as decreased nutritional intake, unintentional weight loss, and/or loss of muscle mass and function (or sarcopenia). Regardless of baseline BMI, sarcopenia has been shown to be a negative prognostic factor for patients undergoing major abdominal surgery [6], while cancer patients with both obesity and sarcopenia [7] endured the most severe outcomes [8–10]. Sarcopenic obesity has recently been defined as the coexistence of excess adiposity and low muscle mass/function [11, 12]. In addition to sarcopenic obesity, increased adipose deposition in both muscle and lean tissue structures such as muscle – manifesting as myosteatosis – is recognised as an adverse prognostic feature, with studies suggesting that computed tomography (CT)‐based muscle radiodensity or attenuation may be superior to CT‐based muscle mass assessment as a surrogate for muscle function and strength [13]. Muscle attenuation or radiodensity is reduced by adipose tissue infiltration of muscle, a known consequence of ageing. Increased accumulation of lipid within muscle has also been demonstrated in patients with increased inflammation associated with cachexia [14], and is associated with reduced muscle contractility and power [13]. Transcriptomic analysis of rectus abdominal muscle biopsies taken from patients at the time of cancer resection highlighted that sarcopenia and myosteatosis are distinct biological profiles; increased inflammation and decreased muscle synthesis were observed in patients with sarcopenia, while disruption of oxidative phosphorylation and lipid accumulation were seen in patients with low muscle radiodensity [15]. Nevertheless, the revised European Working Group on Sarcopenia in Older People diagnostic criteria for sarcopenia prioritise measurement of strength and function over mass when assessing for sarcopenia [16].

MALNUTRITION AND SARCOPENIA

Incidence

The incidence of malnutrition in hospitalised patients ranges from 15% to 60%, with higher estimates seen in patients with cancer (in excess of 70%) [17]. Up to 54% of patients undergoing surgery for head and neck cancer have been found to be malnourished prior to surgery, while 53% were sarcopenic [18]. One‐third of patients with resectable lung cancer were sarcopenic prior to surgery [19], while the prevalence of pre‐operative sarcopenia in patients undergoing transcatheter aortic valve implantation ranged between 21% and 70% [20]. Applying the GLIM criteria, one‐third of patients undergoing major abdominal surgery for cancer were found to be malnourished [21]. Two different nutritional assessment tools (Patient‐Generated Subjective Global Assessment [PG‐SGA] and Nutritional Risk Screening [NRS 2002]) were used to prospectively evaluate the nutritional status of nearly 1500 patients with oesophageal cancer and it was found that the incidence of malnutrition was 76% and 50%, respectively [22]. A systematic review evaluating the prevalence of sarcopenia in patients with gastrointestinal (GI) and hepato‐pancreato‐biliary (HPB) cancers found wide variation in the reported prevalence of sarcopenia (17–79%) [23]. More than half (52%) of patients with oesophageal cancer undergoing oesophagectomy were found to be sarcopenic [24]. The prevalence of sarcopenia among patients prior to surgery for gynaecological malignancy ranged between 38% and 55% [25].

Impact of Malnutrition and Sarcopenia on Surgical Outcomes

Malnutrition

A study that prospectively assessed the nutritional status of patients with GI cancer undergoing major abdominal surgery found that pre‐operative malnutrition, assessed using the GLIM criteria, was an independent predictor of post‐operative pulmonary complications. Moreover, patients diagnosed with severe malnutrition had an increased risk of 90‐day all‐cause mortality [21]. Another study evaluated the prevalence of pre‐operative malnutrition, assessed using the NRS 2002, in patients undergoing GI cancer surgery who were in treated in the intensive care unit (ICU) post surgery. The authors found that 85% of patients were malnourished, with multivariable regression analysis showing that malnutrition was an independent risk factor for higher complications, infections, mortality, prolonged ventilator dependence, and ICU stay [26]. Malnutrition, assessed using GLIM criteria combined with serum albumin, was independently associated with higher post‐operative morbidity and mortality in patients who underwent emergent GI surgery [27]. Malnutrition has been shown to increase the risk of surgical site infection following spinal surgery [28].

Sarcopenia and Sarcopenic Obesity

A retrospective cohort study evaluating the impact of pre‐operative sarcopenic obesity, assessed by CT, was associated with an increased risk of gastric leak after sleeve gastrectomy [29]. One study evaluating both pre‐operative body composition and longitudinal changes post oesophagectomy for adenocarcinoma found that pre‐operative sarcopenia was associated with an increased risk of major post‐operative morbidity, while those with pre‐operative sarcopenic obesity endured prolonged hospitalisation post surgery [30]. Sarcopenia was found to be an independent unfavourable prognostic factor for patients with non‐small cell lung cancer treated surgically [19]. A meta‐analysis evaluated the impact of sarcopenia on survival in head and neck cancers, and found that sarcopenia was an adverse prognostic factor for patients treated surgically [31]. Patients with rectal cancer who proceeded to surgery following neo‐adjuvant chemoradiotherapy were evaluated by researchers who sought to investigate the impact of pre‐operative muscle measures on post‐operative outcome. Patients with sarcopenic obesity and low muscle attenuation endured a higher rate of post‐operative complications [32]. A systematic review evaluating the impact of pre‐operative nutritional status on post‐operative complications in bladder cancer found that increased BMI and sarcopenia increased the rate of complications after radical cystectomy for bladder cancer; sarcopenia was also identified as an adverse prognostic indicator for five‐year survival [33]. Sarcopenic obesity was an independent risk factor for 30‐day mortality in critically ill patients with intra‐abdominal sepsis who required surgical intervention [34], and reduced survival in patients undergoing liver transplantation [35]. Sarcopenia was associated with poorer clinical functional outcome following surgery for distal radial fractures [36], and an increased risk of inpatient, 30‐day, and one‐year mortality in trauma patients [37].

PRE‐OPERATIVE NUTRITIONAL TREATMENT STRATEGIES

Surgical trauma induces a state of metabolic activation that parallels the extent of surgery, and is characterised by hormonal, haematological, metabolic, and immunological changes [38, 39]. Adequate pre‐operative physiological reserve is required to meet the functional demands of the surgical stress response, including increased cardiac output and delivery of oxygen [39–41]. Nutritionally relevant clinical consequences of the surgical stress response include hyperglycaemia and whole‐body protein catabolism [39]. In the peri‐operative period, nutritional goals should focus on evaluating the patient for pre‐existing malnutrition, and nutritional therapy to optimise surgical readiness, minimise starvation, prevent post‐operative malnutrition, and support anabolism for recovery [40].

While there has been significant interest in the physiological and pharmacological management of the surgical patient, the importance of peri‐operative nutrition optimisation is poorly recognised [42]. A key recommendation of multiple surgical nutrition guidelines is the integration of routine nutrition screening (using a validated nutrition screening tool) in pre‐operative assessment [43–45]. Where patients are identified as being nutritionally at risk, patients should be referred to a registered dietitian for comprehensive nutritional assessment and an individualised nutrition care plan [38, 45]. Where possible the enteral route should be used for the provision of any necessary nutrition support, including oral nutritional supplements and enteral tube feeding [44]. ESPEN recommends that all patients undergoing surgery for cancer, whether curative or palliative, should be managed within an enhanced recovery after surgery (ERAS) programme [46, 47], and for upper GI patients suggests that pre‐operative oral/enteral immuno‐nutrition should be considered (arginine, omega‐3 fatty acids, and nucleotides). A Cochrane review that evaluated pre‐operative nutrition support in patients undergoing GI surgery raised concerns about the impact of bias on studies that evaluated the impact of pre‐operative immuno‐nutrition, alongside the potential for detrimental effects in patients who required critical care support post‐operatively [48]. Pre‐operative parenteral nutrition should only be used in patients with malnutrition where energy requirements cannot be adequately or safely met with enteral nutrition, and a period of 7–14 days is recommended [45]. Contraindications to enteral nutrition for surgical patients include intestinal obstruction or ileus, severe shock, intestinal ischaemia, high‐output fistula, and severe intestinal haemorrhage [44].

Carbohydrate Loading

Pre‐operative carbohydrate loading the evening prior to and the morning of surgery is designed to ameliorate post‐operative insulin resistance in non‐diabetic patients and any subsequent need for aggressive insulin therapy. While no influence has been shown in post‐operative complication rates, pre‐operative carbohydrate loading has been shown to reduce post‐operative length of stay [44], and to improve insulin resistance and indices of patient comfort following surgery [49], and has thus been incorporated into many ERAS protocols (see Chapter 5).

Liver Shrinkage Diets

For some (non‐time sensitive) major elective surgery, a delay may be appropriate to allow patients with class II or III obesity (BMI >35 kg/m2) to achieve weight loss [43]. Very low‐calorie diets (VLCD), or so‐called liver shrinkage diets, are commonly employed prior to bariatric surgery. The rationale is that the resultant loss of hepatic steatosis will allow reduction in the left lobe of the liver, improving the mobility of the liver to allow safer laparoscopic access to the stomach [50], with a randomised control trial demonstrating that a pre‐operative VLCD reduced the difficulty of surgery and improvement in long‐term outcomes [51]