Surgical Nutrition

Mei-Due Yang M.D., PhD.

Department of Surgery
China Medical University Hospital
 Contents
• Physiologic changes in fasting and stress
• Malnutrition
• Indications/complications of EN and PN
• Supplements of macronutrients/micronutrients
• Case discussion
• Q&A
cf: Pinterest
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Physiological Changes

TNF,IL-1,IL-6 etc.
 Contents
• Physiologic changes in fasting and stress
• Malnutrition: complication? mortality?
• Indications/complications for EN and PN
• Supplements of macronutrients/micronutrients
• Case discussion
• Q&A
5W-1H & PDCA
• 5W-1H:
who: malnourished ?...
when: duration?..
where: GI tract? HBP?...
why: physiological ? mental ? disease? complication?
what: has been done?
how to solve
• Plan-Do-Check-Act
8
Malnutrition:defintion
•Weight loss >10-15% within six months, >5% in a month
•BMI <18.5 kg/m2
•SGA Grade C or NRS >5 (subjective global assessment,
nutritional risk screening)
•Serum albumin <3.5 g/d l(with no evidence of hepatic or renal
dysfunction) , pre-albumin: <18mg/dL
 Screening procedures
• By Nurse-in-charge: screening
• By Doctor: Intern/Resident/Attending Physician
• By Dietitian: assessment, counseling /instruction

• BMI, SGA, serum albumin/pre-albumin, CRP

• China Medical University Hospital Score System

(admission note, based on NRS 2002)

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At the moment of
diagnosis During treatment

Simple methods

Ask ! Patient history: body weight, food intake….

Weight loss:
> 10% vs the usual weight over a 6 months period
> 5% in a month (serious malnutrition)
Body mass index (BMI): < 18,5 kg/m2
NRI – Nutritional risk index
SGA – Subjective global assessment
Albumin level: < 3,5g/dL ( 35 g/L ), Prealbumin: <18mg/dL

• Lymphocyte count: < 1.500 / mm3 Cholesterol :<150mg/dL

Transferrin: < 200mg/dl
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 Contents
• Physiologic changes in fasting and stress
• Malnutrition
• Indications/complications of EN and PN
• Supplements of macronutrients/micronutrients
• Case discussion
• Q&A
 Route for providing nutrition

• Oral nutrition: Per Os (mouth)

• Enteral nutrition (tube fed): NG, PEG, ND, NJ

• Parenteral nutrition: PPN, TPN

 Indications for Enteral
Nutrition
Oncology Intensive Care
• Tumor/cachexia • Unconsciousness
• obstructions in the GI tract • Catabolism
• chemo or radiation enteritis • Multiple Trauma
• Burns
Gastroenterology
• Crohn’s disease Surgery
• pancreatic insufficiency • pre & Postoperative nutrition
• short bowel syndrome • short bowel syndrome
• HIV/AIDS
Pediatrics
Neurology • Cystic fibrosis
• Parkinson’s disease • Cerebral disorders
• Multiple sclerosis • Celiac disease
• Apoplexy • Cachexia
• Convalescence
Standard procedures of tube feeding
• Enteral feeding is ordered by medical officers/dietitians

• Trained registered nurses and medical officers insert fine

bore gastric tubes
• Radiological verification of tube position is essential before
enteral feeding
• Patients must be on a fluid balance chart whilst receiving
enteral feeding
• The tube should be flushed with 10-20ml of sterile H2O
before and after administration of medication.
Early Postinjury Enteral Nutrition

Higher TLC
Better nitrogen balance
Less septic complications
Cost saving
 Enteral Nutrition Should Not Be Used in
The Following Clinical Setting

Absolute Contraindications:
 Complete mechanical intestinal obstruction
 Ileus
 Intestinal hypomotility
 Severe diarrhea (resistance to pharmacologic therapy)
 Severe acute pancreatitis
 Hypovolemic or septic shock
 Major upper gastrointestinal hemorrhages
 Inability to gain safe access
 Enteral Nutrition Should Not Be Used in
The Following Clinical Setting

Relative Contraindications:
 High output external fistulas (> 800ml/ day)
 Significant bowel wall edema
 Nutrient infusion proximal to recent gastrointestinal
anastomosis
 Not desired by the patient for legal guardian
 Prognosis does not warrant aggressive nutrition support

Evaluating metabolism and energy requirements

• Harris-Benedict Equation • Indirect Calorimetry

• Nitrogen balance • Serum proteins :

albumin, pre-albumin
 Formula of Regular EN

• Polymeric
• Semi-elemental
• Elemental
 Disease Specific Formula
Diabetes formulas
Dialysis formula
COPD formula
Oncology formula
Immune enhancing formulas
Complications of Enteral Nutrition

Mechanical
Gastrointestinal
Metabolic
 Early Nutrition Post-OP

• Oxidative stress !
• How early is early ?
• Bowel movement?
• Flatulence?
• Severity of disease ?
• Anesthesia ?
• Confidence of surgeon?
Return of Normal Peristalsis

Small intestine: 2 to 6 hours

Stomach: 24 to 48 hours
Large intestine: 3 to 4 days
The Role of Parenteral Nutrition in
Clinical Nutritional Therapy
Role of Parenteral Nutrition
• Inadequate gut function
• Gastrointestinal injury or failure
• Severe fluid restrictions
• Diarrhea or abdominal distension
• Intolerance to tube feeds
 Parenteral Nutrition Indication

Pre-OP nutritional support: PPO, GI tract cancer.

Post-OP nutritional support:

NPO due to paralytic ileus, mechanical obstruction.

Chemotherapy
thory
Hospice care: supportive care for terminal ill.

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981025 28
 Indications For TPN:
Group I：patients who can not take anything by
mouth (for an extended period of time (NPO)

• Prolonged post-operative ileus

• Intestinal obstruction (mechanical)
• Patients with intractable vomiting (most often
secondary to combined chemotherapy and radiation
therapy)
• Perioperatve nutritional support
• G-l bleeding
 Group II：patients who will benefit
from NPO therapy where bowel rest is
indicated

• Severe pancreatitis
• Ulcerative colitis
• Short bowel syndrome
• Regional enteritis (Crohn’s disease)
• GI fistula
 Group III: Patients in whom EN
will not suffice
• Developmental abnormalities of the GI tract
• Extensive burns, trauma or sepsis
• Malabsorption
• Perioperative nutrition support
• G-l bleeding
• Chronic liver disease
Group IV: patients who can eat but refuse
to do so for prolonged period of time

• Anorexia nervosa
• Geriatric patients
• Profound depressive illness
 Group V: untreatable cancer
patients who can not take anything
by mouth

• Terminal stage for hospice

• 3-6 months
 Parenteral Nutrition
• Mixture of amino acid and high
concentration glucose
• Fat emulsion
• Electrolytes
ready-to-use
Compounding
• Minerals all-in-one

• Trace elements

• TPN, PPN
• SPN: supplemental
• HPN: Home
Combined PPN
and EN for
postoperative
nutrition
support

35
Complications
 Contents
• Physiologic changes in fasting and stress
• Malnutrition
• Indications/complications of EN and PN
• Supplements of macronutrients/micronutrients
• Q&A
Methods for Determining Caloric Needs

• Indirect calorimetry: ICU

• Harris-Benedict (BEE) x stress factor x

activity factor

• 25-30 kcal/kg body weight

Macronutrients
• Carbohydrates
• primary energy source, provide 45% to 65% of calories
• Each gram of enteral and parenteral carbohydrate provides 4 kcal and 3.4
kcal of energy, respectively.
• Fats
• provide 20% to 35% of calories
• each gram of fat provides 9 kcal of energy
• 1g/Kg/day
• Protein
• provide 10% to 35% of calories
• each gram of protein provides 4 kcal of energy
• 0.8g/kg/day
Metabolic Response to Starvation and injury:
Nutritional Requirements

Injury Stress Factors

Minor surgery 1.00-1.10
Long bone fracture 1.15-1.30
Cancer 1.10-1.30
Peritonitis/sepsis 1.10-1.30
Severe infection/trauma 1.20-1.40
Multi-organ failure syndrome 1.20-1.40
Burns 1.20-2.00
 Marcronutrients during stress
Carbohydrate
– Minimum of 100 g/day is required to prevent
ketosis
– Carbohydrate level in diet should provide 60-70%
of non-protein calories during stress
– Glucose intake should not exceed 5 mg/kg/min
 Parenteral Nutritional Formula
• Lipids
Less hyperglycemia
Lower serum insulin levels
Less risk of hepatic damage
 Macronutrients During Stress

Protein
Requirement range from
• 1.2-2.0 g/kg/day in stress

Protein should comprise approximately

• 20% of total calories during stress
Long-term Effects of Parenteral Nutrition

• Intestinal atrophy, bacterial translocation

• Risk of catheter related infections
• Metabolic bone disease
• Liver dysfunction
• Financial constraints
• Poor quality of life
• Cholelithiasis
 Metabolic Response to
Overfeeding

• Hyperglycemia
• Hypertriglyceridemia
• Hypercapnia
• Fatty liver
 Disadvantages of Parenteral
Nutrition over Enteral Nutrition
 Septic complications ? (CRS)
 Gut mucosal integrity ?
 Immune function ?
 Liver dysfunction ?
 Metabolic bone disorder ?
 Cost-effectiveness ?
 QOL ?
Impact of Artificial Nutrition on Patient
with Cancer (GI, H&N….)

• Cancer cachexia: 2-3wks

• Preoperative: 1-2 wks
• Postoperative: ASAP (EN, PN, SPN)
• Chemotherapy: SPN
• Radiation therapy: EN
Nutrition therapy in radiotherapy patients

• Head and neck cancer:

NPC
Buccal cancer
Tongue cancer
Pharyngeal cancer
Laryngeal cancer

• Esophageal cancer
 Nutrition therapy in radiotherapy
patients
• Obstruction: Total? • 有通路就利用
Partial?
• Timing: • Per os :always inadequate
Pre-R/T? • NG tube feeding
During R/T? • Gastrostomy feeding:
Post-R/T? PEG
• Surgery ? CCRT? PG
Adjuvant R/T? Mini-laparotomy G
• Jejunostomy feeding
• A.E.A.P
 Gastrostomy tube
placement

Mini-laparotomy PEG
 Malignancy-associated gastroparesis

• Is common among patients with UGI tract tumors

(gastric, pancreatic, esophageal, and biliary)
• Pancreatic cancer often present with nausea and vomiting
in the absence of mechanical obstruction.
• May also have a more generalized disorder of GI motility,
with components of dysphagia and abnormal small bowel
motility (intestinal pseudo-obstruction, "functional
ileus").

Schraml FV et al.: Clin Nucl Med 2005; 30:574.

Leung VK, et al.: Hong Kong Med J 2003; 9:296.
Leung J et al.: Dig Dis Sci 2009; 54:401.
 胃切除病人的營養問題
• 切除範圍 • 傾食症候群
• 胃腸道重建方式 • 體重減輕
• 術前、術後營養問題 • 脂肪痢
• 迷走神經 • 腹瀉
• 含乳糖食物 • 貧血: 鐵、B12、葉酸、
• 進食速度與量 蛋白質
• 膳食纖維 • 代謝性骨病變(軟骨症
或骨質疏鬆)
• 益生菌、益菌生
Standard and pylorus-preserving Whipple procedure 53
 Fistula (廔管)
• Enterocutaneous Fistula (腸皮廔管
ECF): abnormal communication
between bowel and skin

• External fistula: ECF

• Internal fistula:
rectovaginal, rectovesical

• End fistula or side fistula

• TPN
 Ischemic Bowel Disease
• Heart disease: Af, Rheumatic
heart disease, etc.
(心臟瓣膜疾病、心律不整等)
• Thyroid disease: Graves’ disease
(甲狀腺機能亢進)
• Thromoembolism (血栓症)
SMV, SMA, celiac artery
(腹腔腸動脈靜脈)
• Aged people
 Short bowel syndrome (SBS, 短腸症候群)

• 腸道因先天或後天因素
大量切除
• 一般的定義是指剩餘的
腸道大人小於150-180公
分；小孩小於75-100公
分
• Syndrome: abdominal
pain, fullness, bloating,
diarrhea, mal-absorption
• TPN==EN+PPN==EN
 Route for HPN
• Access to the SVC(superior vena cava)
should be the first choice for CVAD
placement, via the internal jugular vein or
subclavian vein.

• Tunneled CVAD (central venous access

device) or totally implanted CVADs shall
be used for long-term HPN. (eg. Hickman
catheter or port A catheter)

• Peripherally inserted central venous

catheters (PICCs) can be used if the
duration of HPN is estimated to be less
than six months.
Enhanced Recovery
After Surgery (ERAS)
concept
Clinical Nutrition 40 (2021)
4745e4761
 Just remind you……
• Recognize malnutrition and don’t let it worse.
• Perioperative nutrition therapy is worthy of
selective patients
• Early nutrition treatment after surgery
• EN→ EN+PN →TPN
 Useful webs and journals
• TSPEN (Taiwan Society for Enteral and
Parenteral Nutrition台灣靜脈暨腸道營養醫
學會)
• ESPEN: Clinical Nutrition
• ASPEN: JPEN
• Critical Care Medicine
 Strategies of nutritional therapy
to treat malnutrition
Artificial Nutrition

enteral parenteral
Way of administration
- peripherally (PPN)
oral - centrally (CPN)

Tube feeding PN
Normal diet Nutrient-defined diets Amino acids
Hospital diet chemically defined diets Carbohydrates
Diet counseling Supplements Lipids
Supplements Electrolytes
Vitamines
Trace elements 62
 Nutritional Therapy
↓
Personalized Medicine

63
 Nutrition Support Team

Physician

NST
Pharmaci
st Patient Nurse

Dietitian
64
Q&A