Benefits Of Preoperative Nutritional Support In Patients Of Digestive Surgery

by Dr. Benny Philippi

Patients with significant gastro intestinal disease who are going for surgery were usually mayor digestive surgery. They were patients with weight lost or protein energy malnutrition, these will develop further nutritional state degradation. In well-nourished patients who got an uncomplicated surgery the grade of post operative malnutrition is mild and accepted as a surgical risk. Perioperative nutritional support was already known as a nutritional support procedure which is effective and cost benefit in reducing postoperative morbidity and mortality. Malnutrition had a significant relationship with the surgical outcome, in terms of wound infection/dehisence, sepsis, multiorgandisfunction and mortality. In this communication we will discussed about the role and benefit of preoperative nutritional support in digestive surgery. And the most important part of this method of nutritional support is the identification of patients who will benefit from their surgical procedures. The task is to identify patients at high risk for postoperative complications. Nutritional problems in digestive surgery: Patients presenting for mayor digestive surgery are usually suffering from malignancy and severe inflamation of the gastrointestinaltract. These patients come with upper GI dyspepsia, anorexia, diarrhoea, bleeding and protein calory malnutrition. These phenomena were due to the catabolic state of the primary disease and the inadequate nutritional intake. A study of the preoperative nutritional state of patients under going elective mayor digestive surgery at RSCM Hospital, with albumin as a parameter in 1989 found that 35.1% had moderate and 10.8% had severe malnutrition. Another study with the same method at RSCM Hospital 1997, in-patients undergoing emergency and elective mayor digestive surgery, conclude that 37%

were malnourished. (Fanani, 1999). These patients suffered from postoperative complications as wound infection/dehiscence and sepsis, with 14% mortality. In 1987 we performed a study of preoperative nutritional support and immediate enteral nutritional support in digestive surgery cases, from this study we found that our oesophageal resection cases had no anastomotic leaks incomparison with cases before we peform preoperative nutritional support (Philippi, 1987). James Gibbs 1999 from the National VA Multicenter Surgical Risk Study Concluded that serum albumin concentration is a better predictor of surgical outcames than many other preoperative patients characteristic.

Surgical metabolism in protein energy malnutrition. Windsor and Hill 1998 observe that moderate to severe protein energy malnutrition affects fat and protein turnover with an enhanced reliance on fat as an energy substrate. In-patients with gastrointestinal malignancy or inflammation, the catabolism process produces a further protein and fat depletion. Cellular function is altered with deficits in membrane potential, alteration in cellular hydration, reduction in key enzymes of glucose oxidation and deficits in high energy phosphates; these effect result in physiological and psychological impairment, skeletal muscle dysfunction, defect in respiratory dysfunction and immune dysfunction (Hill). Patient at high risk for postoperative complication. With identifying patients at high risk by using nutritional state, it is possible to select patients for preoperative nutritional support. These parameters/variables had been studied as a univariate or multivariate method. The Prognostic Nutritional Index (PNI) from Buzby 1980 which uses anthropometry, delayed hypersensitivity skin test and plasma protein, as the parameters, indicate nutritional support prior to surgery. Hill 1986 in his study concludes that weight loss and anthropometric indices are not clear parameters of risk, whereas grip strength and plasma protein are more sensitive. From these studies above in RSCM Hospital, PNI and Hill, we could conclude that a holistic clinical

evaluation is the most important assessment for identifying patients indicated for preoprative nutritional support. In this communication the author recommended: A history of more than 2 weeks in adequate food intake, weight loss more that 10% or 10% below ideal weight and plasma albumin content below 3g%; as an indication for pre operative nutritional support. Method of preoprative nutritional support: From clinical experiences we know that the period for preoperative nutritional support was limited and no longer than 2 weeks, wheter it was parenteral or enteral. Hill (1991) observed that by 2 weeks parenteral or enteral nutritional support, a moderate to severe marasmus case would expected to increase 5% body protein store; and in a few days of nutritional support there are substantial improvements (10-20%) in many physiological functions which are clinically significant. For practical reason, the simplified decision tree for indicating preoperative nutritional support from Hill is applicable.

References: 1. Fanani A, Lalisang T.J.M.: Status Gizi Pra Bedah Penderita Operasi Perust Dewasa Berdasarkan Kadar Albumin, presented at MABI, Jakarta July 1999. (un published). 2. Philippi B., Pusponegoro A.D.: Nutrisi Enteral Dalam Bedah Digestif. Cermin Dunia Kedokteran 1987; 42: 19-21. 3. Gibbs J. et al : Preoperative Serum Albumin Level as a Predictor of Operative Mortality and Morbidity. Arch. Surg. 1999; 134 : 36 42. 4. Hill G.L.: Disorders of Nutrition and Metabolism in Clinical Surgery; 1st edition. Churchill Livingstone, 1992.