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ESPEN guideline: Clinical nutrition in surgery

ESPEN guideline: Clinical nutrition in surgeryArved Weimanna,*, Marco Bragab, Franco Carlic, Takashi Higashiguchid,Martin H bnere, Stanislaw Klekf, Alessandro Lavianog, Olle Ljungqvisth, Dileep N. Loboi,Robert Martindalej, Dan L. Waitzbergk, Stephan C. Bischoffl, Pierre SingermaKlinik f r Allgemein-, Viszeral- und Onkologische Chirurgie, Klinikum St. Georg gGmbH, Delitzscher Stra e 141, 04129 Leipzig, GermanybSan Raffaele Hospital, Via Olgettina 60, 20132 Milan, ItalycDepartment of Anesthesia of McGill University, School of nutrition , Montreal General Hospital, Montreal, CanadadDepartment of surgery &Palliative Medicine, Fujita Health University School of Medicine, Toyoake, Aichi, JapaneService de chirurgie visc erale, Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011 Lausanne, SwitzerlandfGeneral and Oncology surgery Unit, Stanley Dudrick's Memorial H

tries across several surgical specialties. They were developed in colonic operations [11,14e17] and are now being applied to all major operations. ERAS programmes have been also successful in promoting rapid “functional” recovery after gastrectomy [18], pancreatic resections [19,20], pelvic

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Transcription of ESPEN guideline: Clinical nutrition in surgery

1 ESPEN guideline: Clinical nutrition in surgeryArved Weimanna,*, Marco Bragab, Franco Carlic, Takashi Higashiguchid,Martin H bnere, Stanislaw Klekf, Alessandro Lavianog, Olle Ljungqvisth, Dileep N. Loboi,Robert Martindalej, Dan L. Waitzbergk, Stephan C. Bischoffl, Pierre SingermaKlinik f r Allgemein-, Viszeral- und Onkologische Chirurgie, Klinikum St. Georg gGmbH, Delitzscher Stra e 141, 04129 Leipzig, GermanybSan Raffaele Hospital, Via Olgettina 60, 20132 Milan, ItalycDepartment of Anesthesia of McGill University, School of nutrition , Montreal General Hospital, Montreal, CanadadDepartment of surgery &Palliative Medicine, Fujita Health University School of Medicine, Toyoake, Aichi, JapaneService de chirurgie visc erale, Centre Hospitalier Universitaire Vaudois (CHUV)

2 , Rue du Bugnon 46, 1011 Lausanne, SwitzerlandfGeneral and Oncology surgery Unit, Stanley Dudrick's Memorial Hospital, 15 Tyniecka Street, 32-050 Skawina, Krakau, PolandgDipartimento di Medicina Clinica, Universita La Sapienza Roma, UOD Coordinamento Attivit a Nutrizione Clinica, Viale dell'Universit a, 00185 Roma, ItalyhDepartment of surgery , Faculty of Medicine and Health, Orebro University, Orebro, SwedeniGastrointestinal surgery , National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitalsand University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UKjOregon Health&Science University, 3181 SW Sam Jackson Park Rd.

3 , L223A, Portland, OR 97239, USAkDepartment of Gastroenterology, School of Medicine, LIM-35, University of Sao Paulo, GanepeHuman nutrition , Sao Paulo, BrazillInstitut f r Ern ahrungsmedizin (180), Universit at Hohenheim, 70593 Stuttgart, GermanymInstitute for nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva 49100, Israelarticle infoArticle history:Received 11 February 2017 Accepted 13 February 2017 Keywords:SurgeryERASP erioperative nutritionEnteral nutritionParenteral nutritionPrehabilitationsummaryEarly oral feeding is the preferred mode of nutrition for surgical patients.

4 Avoidance of any nutritionaltherapy bears the risk of underfeeding during the postoperative course after major surgery . Consideringthat malnutrition and underfeeding are risk factors for postoperative complications, early enteral feedingis especially relevant for any surgical patient at nutritional risk, especially for those undergoing uppergastrointestinal surgery . The focus of this guideline is to cover nutritional aspects of the Enhanced Re-covery After surgery (ERAS) concept and the special nutritional needs of patients undergoing majorsurgery, for cancer, and of those developing severe complications despite best perioperative a metabolic and nutritional point of view, the key aspects of perioperative care include.

5 Integration of nutrition into the overall management of the patient avoidance of long periods of preoperative fasting re-establishment of oral feeding as early as possible after surgery start of nutritional therapy early, as soon as a nutritional risk becomes apparent metabolic control of blood glucose reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function minimized time on paralytic agents for ventilator management in the postoperative period early mobilisation to facilitate protein synthesis and muscle functionThe guideline presents 37 recommendations for Clinical practice.

6 2017 European Society for Clinical nutrition and Metabolism. Published by Elsevier Ltd. All rightsreserved.*Corresponding author. Fax: 49 341 909 H Singer).Contents lists available atScienceDirectClinical Nutritionjournal homepage: 2017 European Society for Clinical nutrition and Metabolism. Published by Elsevier Ltd. All rights nutrition 36 (2017) 623e6501. Preliminary remarksePrinciples of metabolic andnutritional careIn order to make proper plans for the nutritional support ofpatients undergoing surgery , it is essential to understand the basicchanges in metabolism that occur as a result of injury, and that acompromised nutritional status is a risk factor for postoperativecomplications.

7 Starvation during metabolic stress from any type ofinjury differs from fasting under physiological conditions[1]. Sur-gery itself leads to inflammation corresponding with the extent ofthe surgical trauma, and leads to a metabolic stress response. Toachieve appropriate healing and functional recovery ( restitutio adintegrum ) a metabolic response is necessary, but this requiresnutritional therapy especially when the patient is malnourishedand the stress/inflammatory response is prolonged. The negativeeffect of long term caloric and protein deficits on outcome forcritically ill surgical patients has been shown again recently[2].

8 Thesuccess of surgery does not depend exclusively on technical sur-gical skills, but also on metabolic interventional therapy, taking intoaccount the ability of the patient to carry a metabolic load and toprovide appropriate nutritional support. In patients with cancer,management during the perioperative period may be crucial forlong-term outcome[3,4]. surgery , like any injury, elicits a series of reactions includingrelease of stress hormones and inflammatory mediators, cyto-kines. The cytokine response to infection and injury, the so-called Systemic Inflammatory Response Syndrome , has a major impacton metabolism.

9 The syndrome causes catabolism of glycogen, fatand protein with release of glucose, free fatty acids and amino acidsinto the circulation, so that substrates are diverted from theirnormal purpose of maintaining peripheral protein (especiallymuscle) mass, to the tasks of healing and immune response[5,6].The consequence of protein catabolism is the loss of muscle tissuewhich is a short and long-term burden for functional recoverywhich is considered the most important target[7]. In order to spareprotein stores, lipolysis, lipid oxidation, and decreased glucoseoxidation are important survival mechanisms[8].

10 Nutritionaltherapy may provide the energy for optimal healing and recovery,but in the immediate postoperative phase may only minimallycounteract muscle catabolism, or not at all. To restore peripheralprotein mass the body needs to deal with the surgical trauma andpossible infection adequately. Nutritional support/intake andphysical exercise are prerequisites to rebuild peripheral proteinmass/body cell undergoing surgery may suffer from chronic low-gradeinflammation as in cancer, diabetes, renal and hepatic failure[9].Other non-nutritional metabolic factors interfering with anadequate immune response have to be taken into account and,whenever possible, corrected or ameliorated before surgery .