Gastrointestinal Surgical Patients' Outcomes Influenced by Nutrition

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

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.

POSTOPERATIVE NUTRITION FOR PATIENTS ELECTING TO HAVE GASTROINTESTINAL SURGERY

Postoperative nutritional management of the patient who has undergone a gastrointestinal surgical procedure should be considered.(10) Published research relating to the care of this population seems somewhat weaker, older, and more anecdotal than the post-traumatic population analyses, when surgical techniques and nutritional management were probably practiced by memory and derived by tradition.(11)

One study found no clinical difference between TPN and TEN in postoperative complication rates.(12) Current literature attributes the improved outcome relating to morbidity and mortality to improved surgical technique.(13) Another study demonstrates that enteral nutrition is one surpassing factor in reducing postoperative complications.(14)

Beginning postoperative enteral therapy. Small bowel function returns one to two hours after a surgical procedure, allowing fluid and nutrition to be administered. Researchers report bowel function is not adversely affected by a longer duration of surgery.(15) Bowel function can be evaluated by myoelectric activity. Physicians place electrodes on the seromuscular layer of the patient's gastrointestinal tract at the end of a surgical procedure to evaluate peristaltic activity. This confirms that audible bowel sounds do not correlate with the return of bowel function.(16) After surgery, gastric and colonic motility do not rebound as quickly as the small bowel. These organs need to remain decompressed and drained to optimize early function.

A patient's metabolic need increases when nutrition is electively withheld. An estimated 10% of lean muscle mass can be lost before wound healing and immunity are compromised. This loss can happen in five to seven days.(17) Time is critical if form and function are to be preserved.

Choosing enteral therapy. If gastrointestinal surgical procedures can be anticipated, then preoperative consideration of nutritional management, need, and alternatives help optimize results. Enteric intubation--a step often overlooked during preoperative planning--can be done intraoperatively. This therapy can be safely used for most patients who have gastric surgical procedures with an anticipated nutrition deprivation that may last more than five days. It is not always known which patients will need this support. The patients' prealbumin, albumin, and transferrin levels are the best indicators and provide opportunities to alleviate these specific nutritional needs.(18)

Postoperatively, nutrition management choices are limited if no planning has occurred. A jejunostomy tube insertion can be planned preoperatively to gain easy access to provide nutritional support during gastrointestinal surgical procedures. The increasing availability of TPN and its relatively easy administration make this a preferred route of nutrition, but the specter of complications and its high cost should make it the last choice.

Nutrition is sometimes a neglected care parameter in the surgical suite and the postoperative ward. Using energy the body diverts from the liver, muscles, and fat has subtle, but profound, effects on body homeostasis and influences healing and recovery time. The viscera is essential in supporting tissue growth. Its vital absorptive process maintains protein metabolism. Nutrition must be stressed during the preoperative evaluation. Ignoring or neglecting nutritional management and the patient's ongoing evaluation predisposes the bowel to atrophy and malfunction, including the translocation of bowel bacteria that might exponentially increase the rate of postoperative complications.(19)

Total enteral nutrition should be used in preference to TPN, except when less than 10 cm of bowel remain or multiple inoperable obstructions exist. Reducing serious complications with less cost and easier administration makes TEN a feasible first choice. Figure 1 shows acute care TPN and TEN cost comparisons of equipment, nursing time, laboratory studies, and amino acid solutions !n Pennsylvania Hospital, Philadelphia.

[Figure 1 ILLUSTRATION OMITTED]

SUMMARY

Nutritional support is sometimes an overlooked aspect of care in the patient undergoing a gastrointestinal surgical procedure. Postoperative complications forced us to acknowledge the importance of feeding the patient and to implement patient feeding. Continuing reluctance to use TEN as a route of nutrition in the postoperative patient is not supported by our current knowledge. Distressing diarrhea after enteral intubation is a deterrent to its use and is often the reason TEN is discontinued or not used. More research should focus on the best methods to achieve optimal nutrition using TEN in gastrointestinal surgical patients. Nutrition needs are paramount preoperatively. Surgical team members might consider access during the procedure, allowing TEN to be an easier, more effective, and less costly management option. Perioperative RNs and advanced practice nurses can improve surgical outcomes by maximizing surgical patients' nutritional status.

NOTES

(1.) R Baigrie, P Devitt, S Watkin, "Enteral versus parenteral nutrition after esophagogastric surgery: A prospective randomized comparison," Australian and New Zealand Journal of Surgery 66 (October 1996) 668-670.

(2.) The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group, "Perioperative total parenteral nutrition in surgical patients," New England Journal of Medicine 325 (Aug 22, 1991) 525-532.

(3.) Ibid.

(4.) Ibid.

(5.) F A Moore et al, "Early enteral feeding, compared with parenteral, reduces postoperative septic complications: The results of a meta-analysis," Annals of Surgery 216 (August 1992) 172-183; K Kudsk et al, "Enteral versus parenteral feeding: Effects on septic morbidity after blunt and penetrating abdominal trauma," Annals of Surgery 215 (May 1992) 503-513; F A Moore et al, "TEN versus TPN following major abdominal trauma--reduced septic morbidity" The Journal of Trauma 29 (July 1989) 916-923.

(6.) Kudsk et al, "Enteral vs parenteral feeding: Effects on septic morbidity after blunt and penetrating abdominal trauma," 503-513.

(7.) Moore et al, "Early enteral feeding, compared with parenteral, reduces postoperative septic complications: The results of a meta-analysis," 172-183.

(8.) Kudsk et al, "Enteral vs parenteral feeding: Effects on septic morbidity after blunt and penetrating abdominal trauma," 503-513.

(9.) Ibid.

(10.) J V Reynolds et al, "Does the route of feeding modify gut barrier function and clinical outcome in patients after major upper gastrointestinal surgery?" Journal of Parenteral and Enteral Nutrition 21 (July/August 1997) 196-201; R Beier-Holgersen, S Boesby, "Influence of postoperative enteral nutrition on postsurgical infections," Gut 39 (December 1996) 833-835; Baigrie, Devitt, Watkin, "Enteral versus parenteral nutrition after esophagogastric surgery: A prospective randomized comparison," 668-670; C Carr et al, "Randomised trial of safety and efficacy of immediate postoperative enteral feeding in patients undergoing gastrointestinal resection," The British Medical Journal 312 (April 1996) 869-871; R Bower et al, "Postoperative enteral versus parenteral nutrition," The Archives of Surgery 121 (September 1986) 1040-1045.

(11.) Baigre, Devitt, Watkin, "Enteral versus parenteral nutrition after esophagogastric surgery: A prospective randomized comparison," 668-670.

(12.) Reynolds, "Does the route of feeding modify gut barrier function and clinical outcome in patients after major upper gastrointestinal surgery?" 196-201.

(13.) Baigre, Devitt, Watkin, "Enteral versus parenteral nutrition after esophagogastric surgery: A prospective randomized comparison," 668-670.

(14.) Carr et al, "Randomised trial of safety and efficacy of immediate postoperative enteral feeding in patients undergoing gastrointestinal resection," 869-871.

(15.) P Charney, R Martindale, "Early postoperative enteral nutrition: Feasibility and recommendations," Essential News for Dietitians From Sandoz Nutrition 13 (1994) 1-8.

(16.) Ibid.

(17.) J Williamson, "Physiologic stress: Trauma, sepsis, bums and surgery," in Krause's Food, Nutrition, & Diet Therapy, eighth ed, L K Mahan, M T Arlin, eds (Philadelphia: W B Saunders Co, 1992) 491-503.

(18.) The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group, "Perioperative total parenteral nutrition in surgical patients," 525-532.

(19.) Baigre, Devitt, Watkin, "Enteral versus parenteral nutrition after esophagogastric surgery: A prospective randomized comparison," 668-670.

Karla Ernst Reiland, RN, MSN, CRNP, is a surgical acute care nurse practitioner at Pennsylvania Hospital, Philadelphia. She also is a preadmission testing nurse practitioner and emergency nurse at Pennsylvania Hospital.

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