*Filip Biernacki1, Jacek Sobocki1, 2
Why preoperative nutrition matters in colorectal surgery
Znaczenie żywienia przedoperacyjnego w chirurgii kolorektalnej
1Clinical Department of General Surgery and Clinical Nutrition, Prof. W. Orłowski Independent Public Clinical Hospital, Centre of Postgraduate Medical Education in Warsaw
2Department of General Surgery and Clinical Nutrition, Centre of Postgraduate Medical Education in Warsaw
Streszczenie
Żywienie przedoperacyjne jest istotnym elementem prehabilitacji i wywiera wpływ na występowanie powikłań po operacjach wewnątrz jamy brzusznej w ramach chirurgii kolorektalnej. Ważnym elementem przygotowania pacjenta do operacji jest odpowiednio wczesne przeprowadzenie oceny stanu odżywienia w oparciu o zwalidowane narzędzia, a następnie wdrożenie odpowiedniego postępowania i monitorowanie postępów. Indywidualne zaplanowanie odpowiedniej interwencji żywieniowej przez wykwalifikowanego dietetyka klinicznego we współpracy z chirurgiem, określenie zapotrzebowania na energię, białko i inne składniki odżywcze w oparciu o aktualny stan chorego oraz jego pojemność metaboliczną, jak również wybór drogi podaży mają kluczowe znaczenie dla przebiegu operacji i okresu rekonwalescencji. Dzięki odpowiednim działaniom możliwe jest przeciwdziałanie lub leczenie niedożywienia, dzięki czemu można dokonać optymalizacji antropometrycznych oraz biochemicznych wykładników stanu odżywienia. Wpływa to m.in. na: poprawę wydolności układu immunologicznego, zmniejszenie ilości powikłań pooperacyjnych i wydajniejszy proces gojenia ran. Pozwala to również na obniżenie śmiertelności i kosztów leczenia. Optymalną drogą żywienia jest droga doustna z użyciem preparatów FSMP lub żywienie dojelitowe. W szczególnych przypadkach, kiedy nie ma możliwości pokrycia zapotrzebowania drogą przewodu pokarmowego oraz istnieją ku temu obiektywne przeciwwskazania, istnieje możliwość wdrożenia żywienia pozajelitowego.
Summary
Preoperative nutrition is an essential component of prehabilitation and plays a crucial role in reducing complications following intra-abdominal colorectal surgery. A critical component of preoperative patient preparation is the early assessment of nutritional status using validated tools, followed by the implementation of tailored interventions and continuous progress monitoring. Individualised planning of nutritional intervention by a qualified clinical dietitian, in collaboration with the surgeon, is crucial for surgical outcomes and recovery. The process involves assessing the patient’s energy, protein, and nutrient requirements based on their current condition and metabolic capacity, as well as selecting the appropriate route of nutrient delivery. Through appropriate interventions, it is possible to prevent or treat malnutrition, thereby optimising anthropometric and biochemical markers of nutritional status. This contributes to enhanced immune function, fewer postoperative complications, and improved wound healing. Additionally, it leads to reduced mortality rates and decreased treatment costs. The optimal route of nutrition is the oral route, with Food for Special Medical Purposes (FSMPs), or enteral nutrition. In specific cases where gastrointestinal nutrition is either insufficient or contraindicated, parenteral nutrition may be implemented.
Introduction
Surgical treatment imposes a substantial burden on the body, affecting energy expenditure, metabolism, and physiological function. To optimise surgical preparation, minimise treatment-related complications, and improve outcomes, prehabilitation and the ERAS (Enhanced Recovery After Surgery) protocol are recommended. A key component of preoperative preparation is tailored nutritional therapy, which should be customised to the patient’s individual needs and capabilities. The primary objective is to maintain or enhance the patient’s nutritional status, thereby improving treatment outcomes for the underlying condition. Appropriately planned nutritional management decreases mortality rates, reduces the risk of postoperative complications, accelerates recovery, and shortens hospital stays. It also provides tangible benefits to the healthcare system by reducing patient treatment costs.
Prehabilitation in colorectal surgery
Prehabilitation is a comprehensive, multidisciplinary approach to preparing patients for surgery, focusing on enhancing their functional capacity before the physiological stress of the procedure (1). It appears to be effective in reducing the incidence of postoperative complications, including those following intra-abdominal surgeries (2, 3), such as colorectal surgery (4-6). Prehabilitation involves a variety of components, including proper nutritional management, physical exercise, psychological support, pharmacotherapy, and the elimination of addictions, all implemented in the weeks leading up to surgery. Nutritional management, a key component of prehabilitation, focuses on preventing and treating malnutrition (7, 8).
Prehabilitation complements the ERAS (Enhanced Recovery After Surgery) protocol to improve treatment outcomes. The integration of the ERAS protocol into daily clinical practice enables the reduction of stress caused by trauma (surgery), decreases the incidence of perioperative complications, accelerates the patient’s return to full activity, shortens hospital stays, enhances the quality of care in surgical wards, and lowers healthcare costs (7).
The safety and efficacy of ERAS protocols in colorectal surgery have been demonstrated in a range of multicentre studies and supported by numerous meta-analyses. ERAS-based care in colorectal and major abdominal surgery has been demonstrated to shorten hospital stays, reduce complications, and lower treatment costs (7).
An example is the randomised, multicentre, international PREHAB clinical trial, which involved adult patients with non-metastatic colorectal cancer. The patients received standard perioperative care, while the study group additionally underwent prehabilitation.
In addition to physical exercise, the intervention included tailored nutritional management supervised by a qualified dietitian. Based on an evaluation of nutritional status and dietary habits, each patient was provided with a protein intake of 1.5 g per kg of body weight. Additionally, trial participants were instructed to consume 30 g of a whey protein supplement within one hour after physical exercise and one hour before bedtime daily. Vitamin D and multivitamin supplements were also prescribed.
A four-week programme for patients undergoing elective resection of non-metastatic colorectal cancer reduced the incidence of severe postoperative complications requiring medical intervention and contributed to faster functional recovery after surgery (9).
Despite the implementation of the ERAS protocol in colorectal surgery, complications may occur in up to 45% of patients. However, this may reflect preoperative factors related to the patient’s condition before surgery. The prognosis is influenced by factors such as circulatory and respiratory function, as well as metabolic capacity. It is important to note that while ERAS primarily targets the intra- and postoperative periods, its effectiveness in enhancing recovery may be limited if patient-related factors are not adequately addressed preoperatively (7). For this reason, prehabilitation, which enhances tolerance to surgical stress, should be considered a complementary approach to the ERAS protocol, which aims to minimise this stress (7).
Following a colorectal cancer diagnosis, the typical waiting period before surgery lasts several weeks, offering an optimal window for comprehensive prehabilitation (10).
Nutritional status assessment
Assessing nutritional status and diagnosing malnutrition are crucial for patients referred for surgical treatment. This approach enables the identification of individuals who are malnourished – or at risk of malnutrition, allowing for the planning of tailored nutritional interventions.
According to the 2021 ESPEN perioperative care guidelines, all patients undergoing surgical treatment should receive nutritional support, with nutritional status assessed both preoperatively and postoperatively (11).
In Poland, the requirement to perform a screening assessment of patients’ nutritional status upon hospital admission is mandated by law and has been in effect since 1 January 2012. Importantly, hospital emergency departments are exempt from the requirement. The assessment must be repeated at least every 14 days (12). If hospitalisation lasts less than three days in ophthalmology, otorhinolaryngology, allergology, orthopaedics, or traumatology departments, the healthcare provider is also exempt from the requirement to assess the patient’s nutritional status. If the hospital stay lasts only one day, a screening assessment of nutritional status is conducted only if weight loss exceeding 5% of usual body weight has occurred within the past six months (12).
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Piśmiennictwo
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