Perioperative nutritional support

Malnutrition is associated with increased postoperative complications in surgical patients [113]. Numerous studies have evaluated preoper-ative and postoperative nutritional support with controversial results. RCTs [114-116] and a meta-analysis [117] indicate clear preoperative total parenteral nutrition (TPN) benefits in a selected group of the most severely malnourished patients. In addition, Klein and others in a consensus statement concluded that malnourished patients receiving 7 to 10 days of TPN before surgery had a 10% absolute reduction in postoperative complications [22].

The largest and most cited study on perioperative nutritional support is the VA TPN Cooperative Study [114]. In this study, the most severely malnourished male patients had fewer non-infectious and overall complications, but no change in the length of stay. Furthermore, the mildly malnourished subgroups who received TPN had increased infectious complications. Heyland et al. concluded that the study showed no effect on mortality [117].

Selection bias is likely responsible for much of the inconclusiveness regarding the benefits of nutritional support in the perioperative setting [118, 119]. In addition, evidence is lacking that nutritional support affects outcomes favorably, partly because of difficulty finding accurate measures of nutritional outcome. Thus, some authors argue that a lack of clear-cut benefits exists in groups other than selected groups [120]. This has prompted investigators to carefully select the most beneficial candidates, including patients with major trauma, severely malnourished patients undergoing elective surgery, and well-nourished minimally stressed patients unable to eat for 7 to 10 days postoperatively. Most comparative studies show enteral nutrition to be equal to parenteral nutrition. In a prospective study of well-nourished patients with a gastrointestinal malignancy undergoing elective surgery, Gianotti showed a decreased length of stay with 7 days of preoperative oral supplementation consisting of omega-3 fatty acids, arginine, and nucleotides [121].

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