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Gastrointestinal Surgical Patients' Outcomes Influenced by Nutrition

AORN Journal, Jan, 2000 by Karla Ernst Reiland

Nutritional deprivation in patients who have elective gastrointestinal surgical procedures is a normal practice. Patients sustaining abdominal trauma injuries, however, who are tube-fed through the small bowel soon after surgery seem to have better outcomes. Physicians are trained to rest the gut to avoid postoperative bowel dysfunction and anastomotic leakage complications. The benefits of nutritional alternatives should be compared with the benefits of surgical nutrition deprivation.

PREOPERATIVE NUTRITION

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Perioperative nutritional intervention may improve the patient's metabolic responses to a gastrointestinal surgical procedure and his or her long-term sequelae.(1) The patient's postoperative course and quality of life are often determined by an adequate perioperative nutritional status assessment and optimized surgical management.

Ideally, patients are evaluated for historic unintentional weight loss during the preoperative assessment. Unnoticed, malnutrition may impede healing and lengthen or preclude postoperative recovery.(2) Nutritional needs occasionally are neglected until they are profound. Total parenteral nutrition (TPN) was instrumental in preventing many of these complications. Total parental nutrition is complex, and it requires expertise to administer it at regular intervals. Monitoring these patients is costly, but routine laboratory tests permit the timely and necessary normalization of nutritional values.

A literature search disclosed one large research study about preoperative nutrition.(3) Results suggest that TPN is not without significant risk. The data suggest that TPN may cause greater morbidity due to septic complications. Patients' preoperative nutritional conditions were categorized as mild, moderate, or severely malnourished. Total parenteral nutrition was administered preoperatively, and complications were monitored. Patients in the mild and moderate groups who received TPN had a marked increase in mortality and infectious complications compared with the untreated patients. Researchers concluded that preoperative TPN should be limited to severely malnourished patients unless specifically indicated.(4) They also determined that TPN therapy, even when administered under controlled conditions, increases infections and should be used with caution.

POSTOPERATIVE NUTRITION FOR TRAUMA PATIENTS

Postoperative nutritional management of trauma patients is advocated in a number of studies.(5) One study found that a patient with an abdominal trauma index (ATI) greater than 24 had far fewer complications when managed with total enteral nutrition (TEN) than with TPN. The ATI is a method of scoring abdominal trauma relating to how many major organs are injured. Index ranges are less than 15 (ie, mild), 15 to 24 (ie, moderate), and 25 to 40 (ie, severe). The study emphasized that if the liver or pancreas were involved, enteral nutrition was an important adjunct in reducing overall complications. The research also noted that TPN therapy was more costly and more likely to cause higher infection rates. The most common septic complication was pneumonia resulting from the translocation of gut bacteria directly to an impaired lung. Pneumonia was the most common septic complication in the enteral therapy groups overall; however, only one-third as many TEN patients were diagnosed with the complication compared with TPN patients.(6)

In another study, patients receiving TEN experienced half of the septic complications as patients receiving TPN (P [is less than] 0.05 for all patients).(7) This research found that TEN reduced complications and could be used safely to immediately support a severely nutritionally distressed patient after trauma and major surgery.

Physicians hesitate to feed patients via the gut after small bowel trauma until peristalsis is proven. The concern is that additional fluid would cause further distention and leakage of bowel contents into the peritoneal cavity. Researchers and clinicians investigating intestinal stability after visceral penetration confirmed that there was early nutritional absorption in the small bowel.(8)

A comparison between patients having TEN and TPN showed that by postoperative day five, TEN restores the normal gut architecture, absorption, and microflora and helps the mucosa withstand bacterial challenges.(9) Although gastric and colonic motility are interrupted when they are injured, the small bowel continues to function after an injury, minimizing sepsis. The gut must keep moving to prevent stasis, noxious, and flora-filled fluid and to assist substrate distribution during TEN feeding. Bowel disuse causes enteric atrophy, leading to substrate stasis. If disuse continues, atrophy allows serious bacterial overgrowth of the sluggish substrate, and the mucosa progressively becomes more permeable to the septic substrate. This process leads to an exponential translocation of bowel bacteria into the mesenteric and systemic drains. As the system succumbs to sepsis, the feasibility and safety of TEN rapidly decrease, and TPN may support, and even save, this very ill patient.

Health Care Industry

Gastrointestinal Surgical Patients' Outcomes Influenced by Nutrition

AORN Journal, Jan, 2000 by Karla Ernst Reiland

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