Nutrisi Perioperatif

dan
Malignancy
J.Iswanto
Surabaya Surgical Update 2017
Shangri-La Hotel 11 Maret 2017
Surabaya
Introduction
• Malnourished or Nutritional risk patient is associated with
higher post-operative morbidity and mortality following
elective surgery, a higher LOS, and increased of hospital cost.
• Prevalence of malnutrition :
* 30 - 40 % of admitted patients.
* 40 % of surgical patients.
• Nutritional therapy isessential in hospitalized patients.

Abdul Latiff, NSM, Ahmad, N; Islahudin,F : Trop. JPharm Res., 2016, : 15(6):1321.
Cerantola. Y et al : Perioperative Nutrition in abdominal surgery. Recommendation and reality, Gastroenterol. Res. And Practice,
2011:1.
The Metabolic Stress Response to Surgery and
Trauma
 The Metabolic Stress Response to Surgery and Trauma

• Neurohormonal response
• Inflammatory response
• Metabolic response
* Ebb phase
* Flow phase
* Anabolic phase

Brunicardi et al. Schwartz’s Principles of Surgery 10th edition.2010. McGraw Hill. Chapter 2. p18
 Perioperative care issues
• Excess iv crystalloid fluid administration during and
after surgery, in patients underwent major GI-
surgery, would result in weight gain caused edema.
• It would recently cause postoperative ileus and
delayed gastric emptying
• It is suggested for fluid restriction to the amount
needed for maintaining salt and water balance.

Weimann, Braga, Harsanyi et al.:

ESPEN Guidelines on Enteral Nutrition, Clinical Nutrition, 2006 (25) :228.
Evidence-based practice
Preadmission
Audit of compliance/ counselling
outcomes Selective bowel-prep
Perioperative
CHO- loading/no fasting
oral nutrition

Early removal of No - premed

catheters/drains No NG tubes

Stimulation of ERAS Thoracic epidural

gut motility Anaesthesia

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 KCH Fearon, 2005.
Physiologic changes in surgicalpatients

• Intestinal permeability in increase 2 – 4-fold in the immediate

postoperative period.
• Nutritional depletion is associated with increase in intestinal
permeability anda decrease of villous height.
• Increase intestinal permeability related to failure of the functiongut
barrier to exclude endogenous bacteria andtoxins
• This gut failure cause SIRS, Sepsis and MOF.

Ward, N : Nutritional support to patients undergoing gastrointestinal surgery, Nutrition J,2003; 2: 2.

 Wound healing

• A complex process of cellular and biochemical events, that are

dependent onthe nutritional substrate available.
• Woundhealing phase is energy demanding.
• Wound healing consist of cell proliferation, protein synthesis and
enzyme activity requires energy and buildingsubstrates.
• Wound healing needs macronutrient : protein or AA, CH and fats,
electrolyte as well as micronutrient
• Malnutrition affects all phase of woundhealing

Wild, Rahbarnia, Kellner, Sobotka : Basics in nutrition and wound healing, Nutrition 2010 (26) : 865
Abdul Latiff, NSM, Ahmad, N; Islahudin,F : Trop. JPharm Res., 2016, : 15(6):1321
 Undernutrition and Wound healing

• Delayed neovascularization and decreased collagensynthesis.

• Prolong phase ofinflammatiom
• Decresed phagocytosis by leucocytes
• Dysfunction of B andT cells
• Decreased mechanical strength of theskin.

Wild, Rahbarnia, Kellner, Sobotka : Basics in nutrition and wound healing, Nutrition 2010 (26) : 862
Nutritional Assessment
Nutritional Assessment
 Protein

• Lymphocytes, leukocytes, phagocytes, monocytes, macrophages,

immune system cells are comprised ofproteins.
• Woundhealing needs supply of proteins.
• Lack of protein decreases the synthesis of collagen and the
production of fibroblasts.
• Methionine, and cysteine have role in collagen synthesis.
• Arginine have a major influence on the proliferation of collagen
accretion and immune reaction.

Wild, Rahbarnia, Kellner, Sobotka : Basics in nutrition and wound healing, Nutrition 2010 (26) : 862
 Macronutrients during Stress
Protein
• Requirements range from 1.2-2.0 g/kg/day duringstress
• Comprise 20%-30% of total calories during stress

Barton RG. Nutr Clin Pract1994;9:127-139

ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA
Carbohydrate : 50 – 60 % of total energy.
Enteral Nutrition Parenteral Nutrition
• Monosaccharides :glucose, • Glucose.
fructose • Fructose
• Disaccharides :Sucrose • Sorbitol and xylitol (polyols).
• Oligosaccharides :Maltodextrin • Infusion rate glucose : ≤ 4 – 5
• Polysaccharides :Starch mg/KgBW/min ± 0.25 – 0.3
g/Kg/h.

Carpentier, Sobotka, Soeters : Carbohydrates, in Basics in Clinical Nutrition, 4th Ed. Galen – ESPEN
2011, 254-5.
Lipids - Fattyacids
• Important components of cell membranes.
• Subtrates for eicosanoid synthesis, which promotes the inflammatory
process.
• Shirgel et al,(2008) : gel emulsion of ω-3 FA promotes tissue repair,
dermal angiogenesis and woundhealing.
• 20 – 40 % of total energy intake.
• Maximum recommendation for intravenous lipid infusion: 1.0 – 1.5
g/kg/day
 Lipids :
Enteral Nutrition
Parenteral Nutrition
• Triglycerides
• Model ofintestinal
• Phospholipids chylomicron
• Lipid-soluble vitamins • Core : Triglycerides + lipid-
• Sterol soluble vitamins (some)
• Commercial formula :30 • Surface : phospholipids, free
– 40 % cholesterol, lipid-soluble
• MCT vitamins.
• ω-3 FA in Immune
Enhancing Enteral
Formula.
Carpentier, Sobotka : Lipids, in Basics in Clinical Nutrition, 4th Ed. Galen – ESPEN 2011, 258 - 60.
 Vitamin C
• For hydroxylation of proline and lysine in the synthesis of collagen.
• For optimal immune response, cell mitosis, and monocyte migration
into the wound tissue.
• Monocytetransforms into macrophages during inflammatory phase.

Wild, Rahbarnia, Kellner, Sobotka : Basics in nutrition and wound healing, Nutrition 2010 (26) : 862
 Zinc.

• Zinc is co-factor for many enzymatic reations, that involved in the

biosynthesis of RNA, DNA and proteins.
• Zinc is essential for all proliferatingcells.
• Low zinc status decreases the closure of wound

Wild, Rahbarnia, Kellner, Sobotka : Basics in nutrition and wound healing, Nutrition 2010 (26) : 862
 Iron

• Cofactor of prolyl and lysyl hydrolysis enzymes, which is essential for

the the synthesis ofcollagen.
• Symptoms of iron deficiency : mild fatigue to exhaustion, pallor, sore
tounge, digestive tract disturbances.
• Part of Hemoglobin plays an important role in the Oxygen transport
for wound healing.

Wild, Rahbarnialner, Sobotka : Basics in nutrition and wound healing, Nutrition 2010 (26) : 862
Key Vitamins and Minerals
Vitamin A Wound healing and tissue repair
Vitamin C Collagen synthesis, wound healing
B Vitamins Metabolism, carbohydrate utilization
Pyridoxine Essential for protein synthesis
Zinc Wound healing, immunefunction,
protein synthesis
Vitamin E Antioxidant
Folic Acid, Iron, B12 Required for synthesis and
replacement of red bloodcells

TNT Manual version 2.

 Special Nutrients
• Glutamine : 0.2-0.4 g/KgBW/d ( L-Glutamine = 0.3-06
g/KgBW/d alanyl-Glutamine-peptide)
• ω-3 fatty acids : EPA and DHA.
• Fish oil
• Arginine
• Nucleotides
• Antioxidants : vitamin C, 250 – 1000 mg/d, Vitamin E, 100–
500 mg/d, β-carotene 5-10 mg/d, selenium 100-200 mg/d.

Basics in Clinical Nutrition ESPEN, 4th.Ed. P.290, 292,296,449.

Singer, Berger, van den Berghe et al : ESPEN Guidelines of PN : Intensive care.
Role of Arginine in MetabolicStress

• Provides substrates to immunesystem

• Increases nitrogen retention aftermetabolic
stress
• Improves wound healing in animals models
• Stimulates secretion of growth hormone
and is a precursor for polyamines and nitric
oxide
• Not appropriate for septic orinflammatory
patients
“giving arginine to a septic patient is like putting gasoline on an already
burning fire.

B. Mizock, Medical Intensive Care Unit, Cook County Hospital, Chicago, IL

BarbulA. JPEN 1986;10:227-238; BarbulA, et al. J.Surg Res 1980;29:228-235
 Perioperative Nutritional Support

• Total calorie 20 – 25 Kcal/KgBW/day.

• ESPEN recommendations : rarely > 30 – 35 Kcal/Kg BW/day.
• Protein 1.2 – 2 g/KgBW/day.
• Glucose (CH) 50 – 60 % of total energy intake. ( ~ 7 g/KgBW/d)
• Rate of glucose infusion may not more than 4 – 5 mg/KgBW/min.
• Lipids 20 – 40 % of total calorie intake.
• Rate of infusion of lipids emulsion : LCT ≤ 0.1 g/Kg/h and MCT ≤ 0.15 g/KgBW/h.
• Vitamins, mineral and trace element as same as RDA.

Basics in Clinical Nutrition, ESPEN, 4th Ed. p. 255, 260-1,

Terapi Nutrisi pada Malignancy
 Cancer Cachexia is defined:
• Multifactorial syndrome defined by an ongoing loss of skeletal muscle
mass ( with or without loss of fat mass) that cannot be fully reversed by
conventional nutritional support and leads to progressive functional
impairment.
• Its pathophysiology is characterized by a negative protein and energy
balance driven by a variable combination of reduced food intake and
abnormal metabolism.
• Cytokines are a major driving force in the development of cancer
cachexia, such as : TNF-α, IL-2, IL-8,IFN-γ.

Fearon, K; Strasser .F; Anker. S,D et al : Definition and classification of Cancer Cachexia: An International Consensus. Lancet
Oncol, 2011; 12 : 489-95. (www.ncbi.nlm.nih.gov/pubmed)
Bozzetti, F : Cancer Cachexia in : Basics in Clinical Nutrition Ed. Sobotka .L, 4th Ed. ESPEN 2011p.584.
 Refractory Cachexia
Precachexia Cachexia
- Variable degree of
- Weight loss ≤ 5% - Weight Loss > 5% Cachexia
- Weight Loss > 2% - Cancer disease both
Normal - Anorexia
+ BMI < 20 kg/m2 procatabolic and not Death
- Metabolic Change + Sarcopenia. responsive to anticancer
- Often reduced treatment
food intake - Low performance status
- Systemic - < 3 monthsexpected
Inflammation survival

Sauer,A.C and Voss, A.C : Improving Outcomes with Nutrition in Patients with Cancer, white
paper. Abbot OnLine,
Fearon, K; Strasser .F; Anker. S,D et al : Definition and classification of Cancer Cachexia: An
International Consensus. Lancet Oncol, 2011; 12 : 489-95(Original)
Cancer Cachexia

• Stage I : weight loss < 10 %,and no symptoms

• Stage II : weight loss < 10 % and or moresymptoms
• Stage III : weight loss ≥ 10 % and no symptom
• Stage IV : weight loss ≥ 10 % and one or more symptoms.

Bozzetti, F : Cancer Cachexia in : Basics in Clinical Nutrition Ed. Sobotka .L, 4th Ed. ESPEN 2011p.584.
 Indication Nutrition for Cancer patient.
ESPEN recommendation :
• To reduce operative risk by :
- correcting malnutrition
- potentiating immune response
- maintaining the gut activity
• To increase patient’s tolerance to aggressive cancer treatmentin
malnourished patients.
• To maintain patient’s live if there is intestinal failure caused of -
radiation therapy, surgical therapy, bowel obstruction

Bozzetti, F and Meyenfeldt, MF : Nutritional support in Cancer Patients, BASICS IN CLINICAL NUTRITION, 4th Ed., Editor : Lubos
Sobotka, ESPEN 2011. p576.
 ESPEN :Glutamine
• There is insufficient evidence to recommend
Glutamine supplementation during conventional
cytotoxic or targetedtherapy.
• Level of evidence :Low.
• Strenght of recommendation :None.

26th ESPEN Congress , Geneve, 20

 ESPEN Guidelines : Enteral Nutrition
Perioperative
• Patient with severe nutritional risk benefit from Nutritional support 10
– 14d prior to major surgery, even if surgery has to be delayed. (Grade
A).
During Radiotherapy , Radio-chemotherapy, Chemotherapy :
• Routine EN is notrecommended.
• During chemotherapy , routine EN has no effect on tumor response to
chemotherapy or on side effects of chemotherapy.
(Grade C)

Arends, J,Bodogy. G, Bozzetti .F : ESPEN Guidelines on EN : Nonsurgical Oncology, Clin. Nutr. 2006; 25 : 245.
Nutritional Support
Nutrition regimen would provide 30-35 kcal/kgBW/day
Amino acid 1-1.5 g/kgBW/day
Lipids with dose of 1 g/Kg BW/day, consist of LCT/MCT. ( 20 – 40 % of
total calorie intake).
ω-3 fatty acid eicosapentaenoic acid (EPA) should be added in the
formula, because it has been recognized being capable of blocking
cytokine activity
Vitamin, such as Vit. C and mineral are given approximately equal to daily
RDA.
Water and electrolyte should provide for maintaining the water and
electrolyte balance.

Bozzetti, F and Meyenfeldt, MF : Nutritional support in Cancer Patients, BASICS IN CLINICAL NUTRITION, 4th Ed.,
Editor : Lubos Sobotka, ESPEN 2011. p 573 – 82..
Advanced Cancer
Nutritional Support
• Braga et al : pre operative oral administration of Immune
Enhanced Nutrition contains : Arginine, ω-3 FA, Nucleotidefor
5-7 days, 3 x 250 ml reduced post operativemorbidity.
• Route of nutrition can be : Oral, Enteral Nutrition, Parenteral
Nutrition or Combination
• EN is prefered thenPN
• Ethical consideration would be involved especially in terminal
cancer patient

Bozzetti, F and Meyenfeldt, MF : Nutritional support in Cancer Patients, BASICS IN CLINICAL

NUTRITION, 4th Ed., Editor : Lubos Sobotka, ESPEN 2011. p 575.
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