Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (82 page)
Read Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice Online
Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Certain nutrients can have effects on cellular and tissue function. Some of these nutrients modulate immune and inflammatory responses if given in excess of normal intake or requirements. The use of nutrients (‘nutriceuticals’) in this way has been termed ‘nutritional pharmacology’. Examples and specific effects include:
L
-arginine – stimulates aspects of immune function, improves nitrogen retention after surgery, enhances wound healing;
58,
59
L
-glutamine – stimulates immune function, reduces nitrogen loss postoperatively, may be important in maintaining gut-barrier function;
60
branched-chain amino acids – may control protein synthesis in muscle and stimulate whole-body protein synthesis, especially in severely traumatised patients;
61
essential fatty acids – stimulation or inhibition of immune function, anti-inflammatory effects;
62,
63
polyribonucleotides and ribonucleic acid – stimulate immune function;
vitamins, trace elements – stimulation of immune function, antioxidant effects, wound healing;
selenium – stimulation of immune function, prevention of tissue damage, anti-inflammatory effects;
64
The clinical benefits of supplementation with key nutrients have, however, been difficult to demonstrate.
Several studies have evaluated the use of combinations of key nutrients in clinical practice in patients with critical illnesses (trauma, surgery for malignant disease, burns), but particularly in upper gastrointestinal cancer. A combination of
L
-arginine,
n
-3 essential fatty acids and ribonucleic acid is commercially available (Impact; Sandoz Nutrition, Minneapolis, MN, USA) and has been used in many trials. The supplemented nutrition has been given in the postoperative period (nasoenteric tube or feeding jejunostomy), starting within 12–48 hours of the critical events and continued for several days.
The first meta-analysis of the studies that have compared supplemented nutritional versus standard nutritional diets (
Figs 17.2
and
17.3
) showed that supplemented nutrition had clinical benefits:
66
Figure 17.2
Effect of immune-enhancing diets on the incidence of major infective complications (wound infections, intra-abdominal abscesses, pneumonia, septicaemia). Expt, patients receiving immune-enhancing diets; Ctrl, patients receiving standard nutrition; n, number of events; N, number of patients in each group on an intention-to-treat basis; OR, odds ratio; CI, confidence interval. (Study sources are given in Heys et al.
60
).
Reproduced from Heys SD, Walker LG, Smith IC et al. Enteral nutritional supplementation with key nutrients in patients with critical illness and cancer. A meta-analysis of randomised controlled clinical trials. Ann Surg 1999; 229:467–77. With permission from Wolter Kluwers Health.
Figure 17.3
Effect of immune-enhancing diets on the length of hospital stay. WMD, weighted mean difference; CI, confidence interval. (Study sources are given in Heys et al.
66
)
Reproduced from Heys SD, Walker LG, Smith IC et al. Enteral nutritional supplementation with key nutrients in patients with critical illness and cancer. A meta-analysis of randomised controlled clinical trials. Ann Surg 1999; 229:467–77. With permission from Wolter Kluwers Health.
reduction in infectious complications (wound infections, intra-abdominal abscesses, septicaemia), with an odds ratio of 0.47 (95% CI 0.32–0.70);
reduction in length of hospital stay, with a weighted mean difference of − 2.4 days (95% CI − 4 to − 1).
However, there was no significant difference in mortality. A subsequent meta-analysis of 17 trials has confirmed this benefit.
67
Many of these studies had methodological limitations but, nevertheless, the role of immunonutrition in critically ill patients was further investigated by ESPEN
56
(
www.espen.org/Education/documents/ENICU.pdf
). The conclusion drawn from the consensus based on the available evidence was that an immune-modulating nutrition (enriched with arginine, nucleotides and omega-3 fatty acids) was beneficial and recommended for the following:
patients with mild sepsis (APACHE II score < 15);
patients undergoing elective major intra-abdominal surgery for cancer to receive 5–7 days of immune-enhancing nutrition (arginine, omega-3 fatty acids and polyribonucleotides);
patients with acute respiratory distress syndrome (ARDS) should receive enteral nutrition supplemented with omega-3 fatty acids and antioxidants.
In addition, there were situations identified where immunonutrition should not be given due to potentially adverse effects:
patients with severe sepsis;
patients unable to tolerate more than 700 mL/day of immunonutrition.
Immune-modulating nutrition is associated with a reduction in septic complications and a reduced hospital stay. It should be considered in patients with mild sepsis (APACHE II score < 15), patients undergoing elective major intra-abdominal surgery for cancer and in patients with ARDS.
56,
66,
67
Key points
Malnutrition is associated with loss of body weight and impairments in organ function.
The metabolic changes that occur in patients undergoing surgery or in those who have experienced trauma and sepsis can be compounded by inadequate nutritional support.
Nutritional requirements must take into consideration the underlying pathophysiological changes.
An assessment of nutritional status should be made in all patients.
If nutritional support is considered necessary, the route and composition of this support should be considered carefully.
Remember re-feeding syndrome and possible thiamine deficiency.
The role of certain key nutrients and their effects, either individually or in combination, on aspects of organ and immune function should be taken into consideration when planning nutritional interventions.
There is now emerging evidence to indicate that manipulating the composition of nutritional support can affect patient outcome.
Careful monitoring of patients receiving nutritional support and the role of the multidisciplinary team is essential for all patients.
1.
Cuthbertson, D.P. Observations on the disturbances of metabolism produced by injury to the limbs.
Q J Med
. 1932;1:233–246.
2.
O'Keefe, S.J.D., Sender, P.M., James, W.P.T. Catabolic loss of body nitrogen in response to surgery.
Lancet
. 1974;ii:1035–1038.
3.
Bergstrom, J., Furst, P., Noree, L.-O., et al. Intracellular free amino acid concentration in human muscle tissue.
J Appl Physiol
. 1973;36:693–698.
4.
Stoner, H.B., Studies on the mechanism of shock. The quantitative aspects of glycogen metabolism after limb ischaemia in the rat.
Br J Exp Pathol
1958;39:635–651.
13607922
5.
Allsop, J.R., Wolfe, R.R., Burke, J.F., Glucose kinetics and responsiveness to insulin in the rat injured by burn.
Surg Gynecol Obstet
1978;147:565–573.
705576
6.
Nordenstrom, J., Carpentier, Y.A., Askanazi, J., et al, Free fatty acid mobilisation and oxidation during total parenteral nutrition in trauma and infection.
Ann Surg
1983;198:725–735.
6416194
7.
Galloway, P., McMillan, D., Sattar, N., Effect of the inflammatory response on trace element and vitamin status.
Ann Clin Biochem
2000;37:289–297.
10817241
8.
Broom, J. Sepsis and trauma. In: Garrow J.S., James W.P.T., eds.
Human nutrition and dietetics
. 9th ed. Edinburgh: Churchill Livingstone; 1993:456–464.
9.
Ayling, R., Marshall, W.
Nutrition and laboratory medicine
. ACB Venture Publications; 2007.
10.
Metropolitan Life Assurance Company.
Statist Bull
. 1959;40:1.
11.
Pettigrew, R.A. Assessment of malnourished patients. In: Burns H.G., ed.
Clinical gastroenterology
. London: BaillièreTindall; 1988:729–749.
12.
Durnin, J.V.G.A., Womersley, J. Body-fat assessed from total body density and its estimation from skin-fold thickness: measurements on 481 men and women aged from 16 to 72 years.
Br J Nutr
. 1987;32:77–97.
13.
Lukaski, H.C., Methods for the assessment of human body composition.
Am J Clin Nutr
1987;46:537–556.
3310598
14.
Kushner, R.E., Kunigk, A., Alspaugh, M., et al, Validation of bioelectrical-impedance analysis as a measurement of change in body composition in obesity.
Am J Clin Nutr
1990;52:219–223.
2197849
15.
Ryan, J.A., Taft, D.A. Preoperative nutritional assessment does not predict morbidity and mortality in abdominal operations.
Surg Forum
. 1980;31:96–98.
16.
Rothschild, M.A., Oratz, M., Schreiber, S.S., Albumin metabolism.
Gastroenterology
1973;64:324–337.
4568596
17.
Fleck, A., Raines, G., Hawker, F., et al. Increased vascular permeability: a major cause of hypoalbuminaemia in disease and injury.
Lancet
. 1985;i:781–784.
18.
Eremin, O., Broom, J. Nutrition and the immune response. In: Eremin O., Sewell H.F., eds.
The immunological basis of surgical science and practice
. Oxford: Oxford University Press; 1992:133–144.
19.
Bistrian, B.R., Blackburn, G.L., Scrimshaw, N.J., et al, Cellular immunity in semistarved hospitalized adults.
Am J Clin Nutr
1975;28:1148–1155.
810018
20.
Seltzer, M.H., Bastidas, J.A., Cooper, D.M., et al. Instant nutritional assessment.
J Parenteral Enteral Nutr
. 1979;3:157–159.
21.
Heys, S.D., Khan, A.L., Eremin, O. Immune suppression in surgery.
Postgrad Surg
. 1995;5:62–67.
22.
Lopes, J., Russke, D.M., Whitwell, J., et al, Skeletal muscle function in malnutrition.
Am J Clin Nutr
1982;36:602–610.
6812409
23.
Daley, B.J., Bistrian, B.R. Nutritional assessment. In: Zaloga G.P., ed.
Nutrition in critical care
. St Louis: Mosby Year Book; 1994:28.
24.
Hill, G., Windsor, J.A. Nutritional assessment in clinical practice.
Nutrition
. 1995;11(Suppl.):198–201.
25.
Johnson, L.R., Copeland, E.M., Dudrick, S.J., et al, Structural and hormonal alterations in the gastrointestinal tract of parenterally fed rats.
Gastroenterology
1975;68:1177–1183.
805078
26.
Levine, G.M., Deren, J.J., Steiger, E., et al, Role of oral intake in maintenance of gut mass and disaccharide activity.
Gastroenterology
1974;67:975–982.
4214726
27.
Wilmore, D., Smith, R., O'Dwyer, S., et al, The gut: a central organ after sepsis.
Surgery
1988;104:917–923.
3055397
28.
Fong, Y., Marano, M.A., Barber, A., et al, Total parenteral nutrition and bowel rest modify the metabolic response to endotoxin in humans.
Ann Surg
1989;210:449–456.
2508583
29.
Grimble, G.K., Payne-James, J.J., Rees, R.G.P., et al.
Nutrition support
. London: Medical Tribune UK; 1989. [p. 32–51].
30.
Gayle, D., Pinchcofsky-Devlin, R.D., Kaminski, M.V. Visceral protein increase associated with interrupted versus continuous enteral hyperalimentation.
J Parenteral Enteral Nutr
. 1985;9:474–476.
31.
ASPEN Board of Directors The Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients.
J Parenter Enteral Nutr
. 2002;26S:1SA–138SA.
32.
Adam, A. Insertion of long term central venous catheters: time for a new look.
Br Med J
. 1995;311:341–342.
33.
Robertson, L.J., Mauro, M.A., Jaques, P.F., Radiologic placement of Hickman catheters.
Radiology
1989;170:1007.
2916052
34.
Lameris, J.S., Post, P.J.M., Zonderland, H.M., et al. Percutaneous placement of Hickman catheters: comparison of sonographically guided and blinded techniques.
Am J Roentgenol
. 1990;155:1097–1099.
35.
Maki, D.G., Ringer, M., Evaluation of dressing regimens for prevention of infection with peripheral intravenous catheters.
JAMA
1987;258:2396–2403.
3118061
36.
Andrews, P.J.D., Avenell, A., Noble, D.W., et al. Randomised trial of glutamine and selenium supplemented parenteral nutrition for critically ill patients.
Br Med J
. 2011;342:695.
37.
Levinson, M.R., Groeger, J.S., Jeevanandam, M., et al. Free fatty acid turnover and lipolysis in septic mechanically ventilated cancer-bearing humans.
Metabolism
. 1988;37:618–625.
38.
Shaw, J.H.F., Woolfe, R.R., Energy and protein metabolism in sepsis and trauma.
Aust N Z J Surg
1987;57:41–47.
3555434
39.
Venus, B., Patel, C.B., Mathru, M., et al. Pulmonary effects of lipid infusion in patients with acute respiratory failure (abstract).
Crit Care Med
. 1984;12:293.
40.
Seidner, D.L., Mascioli, E.A., Istfan, N.W., et al. Effects of long chain triacylglycerol emulsions on reticuloendothelial system function in humans.
J Parenteral Enteral Nutr
. 1989;13:614–619.
41.
www.nice.org.uk/CG32
[accessed 12.01.13].
NICE guidance on nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition, including guidelines for the role and function of multidisciplinary nutritional support teams.
42.
Heyland, D.K., Montalvo, M., MacDonald, S., et al, Total parenteral nutrition in the surgical patient: a meta-analysis.
Can J Surg
2001;44:102–111.
11308231
A meta-analysis of randomised controlled trials of parenteral nutritional support that attempts to draw together the evidence as to which patients benefit from TPN.
43.
Weimann, A., Braga, M., Harsanyi, L., et al, ESPEN Guidelines on Enteral Nutrition: surgery including organ transplantation.
Clin Nutr
. 2006;25(2):224–244.
16698152
Evidence-based guidelines summarising the current evidence and making recommendations for clinical practice in patients during the perioperative period.
44.
Croad, N.R. The management of acute severe pancreatitis.
Br J Intensive Care
. 1999;2:38–45.
45.
Kanwar, A., Windsor, A.C.J., Li, A., et al. Benefits of early enteral nutrition in acute pancreatitis.
Br J Surg
. 1997;84:875.
46.
McClave, S.A., Chang, W.K., Dhaliwal, R., et al. Nutrition support in acute pancreatitis: a systematic review of the literature.
J Parenter Enteral Nutr
. 2006;30:143–156.
Current updated position evaluating evidence for clinical nutritional support in patients with acute pancreatitis.
47.
Dickinson, R.J., Ashton, M.G., Axon, A.T.R., et al, Controlled trial of intravenous hyperalimentation as an adjunct to the routine therapy of acute colitis.
Gastroenterology
1980;79:1199–1204.
6777233
48.
Muller, J.M., Keller, H.W., Erasmi, H., et al. Total parenteral nutrition as sole therapy in Crohn's disease: a prospective study.
Br J Surg
. 1983;70:40–43.
49.
Jones, V.A. Comparison of total parenteral nutrition and enteral diet in induction of remission in Crohn's disease: long term maintenance of remission by personalised food exclusion.
Dig Dis Sci
. 1987;32(Suppl.):1005–1075.
50.
Zachos, M., Tondeur, M., Griffiths, A.M. Enteral nutrition therapy for induction of remission in Crohn's disease.
Cochrane Database Syst Rev
. 2001. [CD000542].
51.
Akobeng, A.K., Thomas, A.G. Enteral nutrition for maintenance of remission in Crohn's disease.
Cochrane Database Syst Rev
. 2007. [CD005984].
52.
Chapman, R., Foran, R., Dunphey, J.E., Management of intestinal fistulas.
Am J Surg
1964;108:157–164.
14195208
53.
Lloyd, D.A., Gabe, S.M., Windsor, A.C., Nutrition and management of enterocutaneous fistula.
Br J Surg
2006;93:1045–1055.
16804873
54.
Windle, E.M., Glutamine supplementation in critical illness: evidence, recommendations, and implications for clinical practice in burns care.
J Burn Care Res
2006;27:764–772.
17091069
55.
Wasiak, J., Cleland, H., Jeffery, R. Early versus late enteral nutrition in adults with burn injury: a systematic review.
J Hum Nutr Rev
. 2007;20:75–83.
56.
Kreymann, K.G., Berger, M.M., Deutz, N.E.P., et al, ESPEN Guidelines on Enteral Nutrition: intensive care.
Clin Nutr
2006;25:210–223.
16697087
Evidence-based guidelines summarising the current evidence and making recommendations for clinical practice.
57.
Chiarelli, A., Siliprandi, L. Burns. In: Zagola G.P., ed.
Nutrition in critical care
. St Louis: Mosby Year Book; 1994:587–597.
58.
Brittenden, J., Park, K.G.M., Heys, S.D., et al, 1-Arginine stimulates host defences in patients with breast cancer.
Surgery
1994;115:205–212.
8310409
59.
Brittenden, J., Heys, S.D., Ross, J.A., et al, Nutritional pharmacology: effects of
L
-arginine on host defences, responses to trauma and tumour growth.
Clin Sci
1994;86:123–132.
8143422
60.
Heys, S.D., Park, K.G.M., Garlick, P.J., et al, Nutrition and malignancy: implications for surgical practice.
Br J Surg
1992;79:614–623.
1643468
61.
Heys, S.D., Gough, D.B., Kahn, A.L., et al, Nutritional pharmacology and malignant disease: a therapeutic modality in patients with cancer?
Br J Surg
1996;83:608–619.
8689201
62.
Purasiri, P., Murray, A., Richardson, S., et al. Modulation of cytokine production in vivo by dietary essential fatty acids in patients with colorectal cancer.
ClinSci
. 1994;87:711–717.
63.
Purasiri, P., McKechnie, A., Heys, S.D., et al, Modulation in vitro of human natural cytotoxicity, lymphocyte proliferative response to mitogens and cytokine production by essential fatty acids.
Immunology
1997;92:166–172.
9415022
64.
Avenell, A., Noble, D.W., Barr, J., et al. Selenium supplementation for critically ill adults.
Cochrane Database Syst Rev
. 4, 2004. [CD003703].
65.
Chen, W.J., Yeh, S.L., Effects of fish oil in parenteral nutrition.
Nutrition
2003;19:275–279.
12620534
66.
Heys, S.D., Walker, L.G., Smith, I.C., et al, Enteral nutritional supplementation with key nutrients in patients with critical illness and cancer. A meta-analysis of randomised controlled clinical trials.
Ann Surg
1999;229:467–477.
10203078
This is the first meta-analysis that indicated that immunonutrition could result in clinically important benefits for patients in terms of reduction in infectious complications postoperatively.
67.
Heyland, D.K., Novak, F., Drover, J.W., et al, Should immunonutrition become routine in critically ill patients?
JAMA
2001;286:944–953.
11509059
This is an updated meta-analysis of randomised controlled trials that confirms the previous meta-analysis and extends it further by examining different subgroups of patients in an attempt to try to understand further which patients are the most likely to benefit from immunonutrition.