Applied nutritional investigationImpact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk
Introduction
Preoperative malnutrition is common in surgical patients and has been associated with poor clinical outcomes [1]. A study by the Veterans Affairs Administration has shown that preoperative parenteral nutrition decreases the rate of complications in severely malnourished patients but not in borderline or mildly malnourished patients [2]. A meta-analysis was performed of 13 prospective randomized trials in which most subjects were at least moderately malnourished according to weight loss, plasma proteins, or prognostic indices. Five trials found significantly fewer postoperative complications in patients who received preoperative nutritional support, and the pooled results indicated that total parenteral nutrition (TPN) therapy decreased the overall risk of postoperative complications by approximately 10% [3]. Although these studies were criticized for inadequate sample sizes, imprecise definitions of complications, and diverse definitions of malnutrition, there was a consensus that the effectiveness of preoperative nutrition was confined to a limited group of patients with severe malnutrition [4], [5].
The search has continued for more accurate methods of preoperative nutritional assessment and for better identifying the specific subsets of patients who might be best served by preoperative nutritional support. Kondrup et al. [6] established the Nutritional Risk Screening Tool 2002 (NRS-2002), which was validated against 128 previous trials of nutritional support and clinical outcomes from the literature. The results from the validation study showed that artificial nutritional support was associated with positive outcomes such as a lower complication rate in patients at nutritional risk [6]. Furthermore, prospective cohort studies have shown that patients at nutritional risk as defined by the NRS-2002 are more likely to have unfavorable clinical outcomes and nutritional support improves outcomes in such patients [7], [8]. The NRS-2002 was recommended by the Europe Society of Parenteral and Enteral Nutrition for use in hospitalized patients [9].
However, there have been no studies on the effect of preoperative nutritional support in patients at nutritional risk as defined by the NRS-2002. A randomized controlled trial would be the best study design, but assigning parenteral and enteral nutrition randomly to patients at severe nutritional risk raises ethical concerns. Therefore, we conducted this multicenter, prospective cohort study to evaluate the impact of preoperative nutritional support on clinical outcomes in patients at nutritional risk. The primary endpoint was the complication rate and the second endpoint was the length of stay (LOS). The protocol was carried out in teaching hospitals in Beijing, China.
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Patients
A consecutive series of patients admitted for intra-abdominal surgery were recruited from March to July 2007 in the Peking Union Medical College Hospital (PUMCH) and from January to July 2008 in the Beijing University Third Hospital (BUTH). The two hospitals are within research-intensive universities in Beijing, China. The following inclusion criteria were used to identify patients eligible for this study: 1) admission for non-emergency abdominal surgery, 2) age 18 to 80 y, 3) well oriented to
Patients
Of the patients admitted to the department of abdominal surgery during the study period, three patients in the PUMCH and seven patients in the BUTH declined to participate in the study. Fifty-three patients were excluded because of an LOS shorter than 4 d (41 cases of laparoscopic cholecystectomy and 12 cases of appendectomy). Therefore, 1085 patients who met the inclusion criteria were recruited, including 340 patients in the PUMCH and 745 patients in the BUTH. The male:female ratio was 1.2:1
Discussion
The association between preoperative malnutrition and a poor clinical outcome suggests that providing perioperative nutritional support could benefit malnourished patients undergoing surgery. However, the implementation of adequate preoperative nutritional support leads to postponed surgery and extra costs for the artificial nutrition. The consensus based on existing studies is toward providing nutritional support for 7 to 10 d before surgery in severely malnourished patients [4], [5]. However,
Conclusion
To our knowledge, this is the first study to evaluate the effect of preoperative nutritional support on clinical outcomes in patients at nutritional risk as defined by the NRS-2002. Of the patients with an NRS score of at least 5, a lower complication rate was found in patients who received preoperative nutritional support. In addition, the hospital LOS was not prolonged by the preoperative nutritional support because of the shorter postoperative hospital LOS in the preoperative nutrition
Acknowledgments
The authors appreciate the staffs in the Peking Union Medical College Hospital and Beijing University Third Hospital for their cooperation and support.
References (17)
- et al.
Prevalence of malnutrition in surgical patients: evaluation of nutritional support and documentation
Clin Nutr
(1999) - et al.
Nutrition support in clinical practice: review of published data and recommendations for future research directions
Clin Nutr
(1997) - et al.
ESPEN guidelines on enteral nutrition: surgery including organ transplantation
Clin Nutr
(2006) - et al.
Nutritional Risk Screening (NRS 2002): a new method based on an analysis of controlled clinical trials
Clin Nutr
(2003) - et al.
Comparison of nutritional risk screening tools for predicting clinical outcomes in hospitalized patients
Nutrition
(2010) - et al.
Impact of nutritional support on clinical outcome in patients at nutritional risk: a multicenter, prospective cohort study in Baltimore and Beijing teaching hospitals
Nutrition
(2010) - et al.
ESPEN guidelines for nutrition screening 2002
Clin Nutr
(2003) - et al.
Introductory to the ESPEN guidelines on enteral nutrition: terminology, definitions and general topics
Clin Nutr
(2006)
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The present study was supported by the China Medical Board of Boston in the United States (grant CMB04-797) and the Chinese Society of Parenteral and Enteral Nutrition in China (grant CSPEN 2005-1).