Metabolisme dan Perubahan

fungsi Saluran Cerna, serta Gizi

Optimal pada Perioperatif Bedah
Digestif

Aries Budianto
Divisi Bedah Digestif
Departemen Bedah RSSA/FKUB
Ariesb.bdmlg@gmail.com
 Perubahan Metabolisme ->
trauma/operatif
Perubahan fungsi
pencernaan
Optimalisasi nutrisi
perioperatif bedah digestif
 Stressors in surgery
Pain
Hypoxemia
Anaesthesia

Overhydration
Systemic
inflammation Dehydration

Immobilization
Stressors Starvation

Hypothermia
Tissue injury

Opioids Impaired tissue

perfusion
Blood Blood
transfusion loss
 Impact of malnutrition on
mortality after surgery

Preop weight loss Postop mortality

<20% 3.5%
>20% 33%
Studley HO JAMA 1936
Nutritional Goals in the
Perioperative Period
 Complications of Abdominal
Operations for Malignancy
100
% 90
P 80
a 70
60
t
50
i 40 Well nourished
Malnourished
e 30
n 20
t 10
s 0 Post-Operative
Complication Rate
Mortality

Meguid et al, Am J Surg 1988; 341-345

Perubahan Metabolisme
TRAUMA

NEURO

ENDOCRIN

IMMU
NOLO
GIC

Modified from: Samy et al. Critical Role of Hormones in Traumatic Injury and Outcome
In Vincent (ed) Yearbook of Intensive Care and Emergency Medicine 2003
EBB & FLOW PHASE
1930: Sir David Cuthberstson

PHASES OF THE PHYSIOLOGICAL RESPONSE TO INJURY

Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26th ed, CRC Press 2013
EBB PHASE
Characteristic by:
Hypovolemia
Decrease BMR
Reduced cardiac output
Hypothermia
Lactic acidosis
Regulated by:
Catecholamine, cortisol & aldosterone
Purpose: Conserve both circulating volume & energy store for
recovery and repair

Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26th ed, CRC Press 2013
FLOW PHASE
Characterized by:
Tissue edema (vasodilatation & capillary leak)
Hypermetabolism
Increased cardiac output
Raise body temperature
Leukocytosis
Increased O2 consumption
Increased gluconeogenesis
Purpose: Mobilization of body energy stores for
recovery and repair. Replacement of lost or damage
tissue

Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26th ed, CRC Press 2013
FLOW PHASE

Catabolic phase (lasting 3-10 days)

Anabolic phase

Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26th ed, CRC Press 2013
CATABOLIC PHASE OF FLOW
PHASE
Lasting approximately 3-10 days
Increase production of counter-regulatory hormones
(catecholamine, cortisol, insulin & glucagon)
Increase production of inflammatory cytokines (IL-1, IL-6 &
TNF)
Significant fat and protein mobilization
Significant weight loss and increased urinary nitrogen excretion
Insulin resistance
If aggravated by neuroendocrine & inflammatory stress
response vicious catabolic cycle.

Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26th ed, CRC Press 2013
INSULIN RESISTANCE
Pro-inflammatory cytokine & decreased responsiveness of
insulin-regulated glucose transporter protein:
Insulin resistance
Increased glucose production
Following routine upper abdominal surgery insulinHYPERGLYCEMIA
resistance
may persist for approximately 2 weeks
Maintenance normal glucose level using insulin reduce both
morbidity & mortality

Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26th ed, CRC Press 2013
CHANGES IN BODY COMPOSITION FOLLOWING
MAJOR SURGERY/CRITICALLY ILLNESS

Catabolism leads to a decrease in fat mass and skeletal

muscle mass
Body weight may paradoxically increase because of
expansion of extra cellular fluid space

Fearon K. Metobolic response to injury. In Williams et.al. (eds).textbook

Bailey & Love Short Practice of Surgery
th
26 ed, CRC Press 2013
MACRONUTRIENT METABOLISM IN MAYOR TRAUMA
 MACRONUTRIENT METABOLISM IN SEPSIS
Hill GL. Disorder of nutrition and metabolism in Clinical Surgery 1992)
Changes in body weight after serious sepsis, after uncomplicated surgery and in
total starvation

Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26th ed, CRC Press 2013
Factors that exacerbate the metabolic response to surgical injury including
hypothermia, controlled pain, starvation, immobilization, sepsis and medical
complication

Fearon K. Metobolic response to injury. In Williams et.al. (eds). Bailey & Love Short Practice of Surgery
26th ed, CRC Press 2013
Perubahan fungsi
Saluran Cerna
Optimalisasi nutrisi
perioperatif
 Malnutrition

wound healing muscle

strength
Catabolic circle respiratory problems
anastomotic dehiscence
pneumonia

diminished immune defense

septic complications
multiple organ dysfunction

length of hospital stay mortality

Goals of Nutritional Therapy

Acute/Short-term
Preserve function
Minimise complications
Avoid overload
Correct mineral, micronutrient and electrolyte balance
Medium to Long-term
Restore function
Improve quality of life
 Screening and Assessment

Screening : to identify high-risk patients (BMI

within 24 hours)
Assessment: to identify and optimize or
prehabilitate patients at nutritional risk for the
stress of surgery
Perioperative nutrition th/ reduces major
postoperative morbidity by 50%.
 Nutritional Risk Screening
NRS 2002

Nutritional Risk Score

BMI < 20.5 kg /m2

Weight loss > 5% within 3 months

Diminished food intake

Severity of disease
Kondrup et al, Clin Nutr 2003; 22: 415 - 421
Potential Causes of Pre-op
Malnutrition

neoplasm,
an inability to swallow,
a lack of access to nutrition,
gastrointestinal tract dysfunction
Methods of Nutritional Assessment

The Malnutrition Universal Screening Tool,

The Nutritional Risk Index,
The Nutritional Risk Screening (NRS-2002)
Level I Evidence
The Mini Nutritional Assessment,
The Subjective Global Assessment (simplest)
 Definition of Patients at
Severe Nutritional Risk

BMI < 18.5 kg/m2

Weight loss > 10 - 15 %

within 6 months

Serum-albumin < 30 g/l

(exclusion of hepatic and/or renal
disease)

Clin Nutr 2006; 25: 224-244

 ESPEN-Guidelines Enteral Nutrition
Surgery including Organ Transplantation

From a metabolic and nutritional point of view the

key factors for the perioperative care include:

1. Avoidance of long periods of pre operative

2. Reestablishing oral feeding as early as possible
after surgery
3. Integrate nutritional care into the overall
management of the patient
Weimann et al, Clin Nutr 2017; 36;623-650
 ESPEN Guidelines Enteral Nutrition
Surgery including Organ Transplantation

When is perioperative nutritional support indicated?

Inadequate oral intake for >14 days:
Higher mortality (Ib).
EN indicated
If anticipated that the patient will be unable to eat for
> 7 days perioperatively.
In patients who cannot maintain oral intake above
60 % of recommended intake for > 10 days.

In these situations nutritional support (by the enteral route if

possible) should be initiated without delay (C).

Weimann et al, Clin Nutr 2017; 36: 623-650

 Nutritional Goals in the
Preoperative Period

Aims:

Short term substitution of nutritional risk

Metabolic conditioning
Immunologic conditioning
 ESPEN Guidelines on
Parenteral Nutrition
Surgery

When is preoperative PN indicated?

In severely undernourished patients who

cannot be adequately orally or enterally fed
(Grade A)

Braga et al, Clin Nutr 2009; 28: 378 - 386

 Preoperative Nutrition

Who: Patients with severe nutritional

risk before major elective surgery (A)
When: 7-14 days preop (C )
How much: Whenever possible via
the enteral route - 1.3 x REE
(C )

ESPEN Guidelines Enteral Nutrition 2006 and 2009

 ESPEN Guidelines
Enteral Nutrition
Surgery including Organ Transplantation

Is postoperative interruption of oral nutrition

intake generally necessary after surgery?
In general, interruption of nutritional intake is
unnecessary after surgery (A).
Oral intake should, however, be adapted to
individual tolerance and to the type of surgery
carried out (C).
Oral intake, including clear fluids, can be initiated
within hours after surgery in most patients
undergoing colon resections (A).

Clin Nutr 2006; 25: 224-244

 ESPEN Guidelines
on Parenteral Nutrition
Surgery

When is postoperative PN indicated?

- In undernourished patients in whom enteral nutrition is not
feasible or not tolerated (Grade A)
- In patients with postoperative complications impairing gastro-
intestinal function who are unable to receive and absorb
adequate amounts of oral/enteral feeding for at least 7 days
(Grade A).
In patients who inquire postoperative artificial nutrition, enteral
feeding or a combination of enteral and supplementary
Parenteral feeding is the first choice (Grade A).

Braga et al, Clin Nutr 2009; 28: 378 - 386

 Nutritional Goals in the
Perioperative Period

Nutritional monitoring
and follow-up after discharge
 Nutritional Goals in
the Perioperative Period
The Ultimate Nutritional Goal

To provide optimal nutrition

to all patients ,
under all conditions,
at all times
Stanley J. Dudrick,

JPEN 2005; 29: 272-287

 Conclusions

Nutritional status is a prognostic factor in

surgical patients
Nutritional screening is essential in order to
identify metabolic risk patients early before
surgery
Nutritional support is required if a longer period
of inadequate oral intake has to be anticipated
 Conclusions

The enteral route should be preferred

If caloric supply is inadequate, the
combination of enteral and parenteral
nutrition will be advantageous
Guideline Update in progress
HOW DO WE DO
ENHANCED
RECOVERY?
 RATIONALE
What stops patients going home after
major GI surgery?

Pain
Lack of G.I. Function
Immobility
Multi-disciplinary team

Nurses
Dieticians
Physiotherapy
Occupational therapy
Pain team
Theatre staff
Anaesthetists
Surgeons
 STRATEGIC PLAN
C
L Surgery H
I Preop D Ward Home
N
I Anesthesia U
C

PATIENTS JOURNEY

Audit of compliance & outcomes

 Evidence-based practice
Preadmission
Audit of compliance/ counselling
outcomes Selective bowel-prep
Perioperative
CHO- loading/no fasting
oral nutrition
No - premed
Early removal of
catheters/drains No NG tubes

Stimulation of ERAS Thoracic epidural

Anaesthesia
gut motility

Prevention of Short-acting
nausea and vomiting Anaesthetic agent

Non-opial oral Avoidance of

Analgetics/NSA ID`s Sodium/fluid overload
Standard Short incisions
mobilisation Warm air body
heating in theatre
 Peri-operative nutritional care within
ERAS

Reduce stress, promote anabolism (minimal access,

epidurals, CHO loading, early mobilisation)
Make the gut work as soon as possible (epidurals, fluid
balance, laxation, ONS?)
Use the gut (food or ONS?)
 Postoperative laxatives promote
gastrointestinal function

46 appendicectomy 60
patients double-
blindly randomised 50
to: 40
Time (hours) 30 *** Placebo
Postoperative low- Laxative

dose bisacodyl 10 mg 20
BID (n=23) 10

0
Placebo (n=23) Gas Stool
Medians, *** P<0.001, Mann-Whitney U-test

Olsen Ugeskr Laeger 1985;39:3070-1

Can we use the gut
earlier within ERAS?
 Does ERAS work?
Oral Food intake

Day 1 Day 2 Day 3

Nygren et al, Dis Cor Rect 2009: 52, 1-8
With integrated nutritional and
metabolic care (ERAS) in the
peri-op period, can we improve
clinical outcomes?
 Total LOS with ERAS

Total hospital stay, median values

9
8
7
Days post-op

6
5
4
3
2
1
0
Traditional 2002-2003 2004 Early Denmark
care Introducing ERAS
ERAS
RANDOMISED TRIALS?

ERAS versus tradition!

ERAS in upper GI surgery

8 studies in pancreatic resection

4 studies in liver resection
7 studies in esophageal resection
5 studies in gastric resection

The implementation of several items

of ERAS was feasible and safe:
- Decrease of LoS in the hospital
- Postoperative complications
- Reduction of hospital costs
- No increase in mortality and readmission rates

Dorcaratto, Grande and Pera, Dig Surg 2013

Summary: ERAS
MULTIMODAL
MULTIDISCIPLINARY
EVIDENCE BASED
PROTOCOL DRIVEN
EDUCATION INTENSE
IMPLEMENTATION CYCLED
AUDITED
CARE PATHWAY TO RECOVERY

www.erassociety.org