Nutritional Management of the Surgical Patient

Mary E. Phillips, OStJ BSc (Hons), RD DipADP is an Advanced Clinical Practitioner and Senior Specialist Dietitian in Hepato-Pancreatico-Biliary Surgery, Royal Surrey NHS Foundation Trust, Guildford, UK.

Contributors xv

Section 1 Introduction 1

Chapter 1 Introduction 3

Section 2 Before and During Surgery 5

Chapter 2 Nutrition Screening and Assessment 7
Sara Smith

Overview of Body Composition 8

Nutrition-Related Syndromes 8

Nutrition Screening 8

Nutrition Assessment 12

References 14

Chapter 3 Nutritional Considerations Prior to Surgery 17
Oonagh Griffin

Malnutrition and Sarcopenia 18

Incidence 18

Impact of Malnutrition and Sarcopenia on Surgical Outcomes 19

Malnutrition 19

Sarcopenia and Sarcopenic Obesity 19

Pre-operative Nutritional Treatment Strategies 20

Carbohydrate Loading 20

Liver Shrinkage Diets 20

Priorities For Future Research 21

References 21

Chapter 4 Prehabilitation Programmes and Their Impact on Surgical Outcomes 25
Helen McNamara

A Brief History of Prehabilitation 25

Defining Prehabilitation 26

Stratified Care and Prehabilitation 26

Enhanced Recovery After Surgery and Prehabilitation 27

Holistic and Person-Centred Approaches To Prehabilitation 27

Psychological Preparation 28

Prehabilitation to Support Behaviour Change 28

Frameworks for Prehabilitation 28

Prime Prehabilitation for Surgery at The Royal Surrey Hospital Foundation Trust 28

Interventions of Prime Prehabilitation 29

Group Programmes 29

One-to-One Consultations 29

Home Exercise Programmes 29

Friends and Family 29

Nutritional Support 29

Peer Support 30

Prime Outcome Data 30

Conclusion 30

References 31

Chapter 5 Enhanced Recovery after Surgery 33
Neil Bibby, Rebekah Lord, and Ashleigh Maske

Early Oral Feeding 35

Nutritional Support and Oral Nutrition Supplements 36

Enteral Nutrition 36

Immuno-nutrition 37

References 40

Chapter 6 Surgical Terminology and Pre-operative Considerations: A Guide for Non-Surgeons 42
Rajiv Lahiri

Surgical Descriptors 42

Key Suffixes in Surgical Terminology 42

Terms to Explain Positioning 43

Pre-operative Considerations 43

Prehabilitation 46

Assessing Surgical Risk 46

Emergency Patients 46

High-Risk Patients 47

Intra-operative Risk Assessment 47

Post-operative Complications 48

Fistula 48

Collections 48

Anastomotic Leak 48

Chyle Leak 49

Conclusion 49

Acknowledgements 49

References 49

Chapter 7 Operating on the Malnourished Patient 51
Katy O’Rourke and Chris Jones

Anaemia 51

Electrolyte Abnormalities 53

Sodium 53

Potassium 55

Calcium 55

Magnesium 56

Phosphate 56

Refeeding Syndrome 57

Hyperglycaemia 60

Impact of Body Habitus on Anaesthesia 61

Obesity 61

Consequences of Obesity during Anaesthesia 61

The Underweight Patient 61

Consequences of Malnutrition during Anaesthesia 61

References 64

Section 3 Impact of Surgery 67

Chapter 8 Nutritional Management of the Surgical Patient in Critical Care 69
Nárbhla Donnelly and Anne Langan

Metabolic Response to Stress 70

Feeding The Post-operative Surgical Patient in Critical Care 70

Enteral Nutrition 71

Parenteral Nutrition 72

Feeding While Receiving Inotrope and Vasopressor Support 72

Nutritional Targets 73

Determining Energy Targets 73

Protein Targets 74

Areas for Future Research/Questions Unanswered 75

Acknowledgements 79

References 79

Chapter 9 Nutritional Management of Patients Undergoing Head and Neck Cancer Surgery 83
Cathy Skea

Head and Neck Cancers 83

Laryngeal Cancer 84

Hypopharyngeal Cancer 85

Oropharyngeal Cancer 85

Oral Cavity Cancer 85

General Nutritional Implications Following Surgical Intervention 85

Surgical Procedures 86

Glossectomy 86

Total Laryngectomy 86

Pharyngo-Laryngo-Oesophagectomy 86

Methods of Post-operative Nutritional Support 87

Early Oral Feeding 87

Enteral Feeding 87

Route of Delivery 87

Choice of Formulae 87

Parenteral Nutrition 87

Post-operative Complications and their Nutritional Management 88

Fistulae/Wound Breakdown 88

Dysphagia Due to Delayed Wound Healing Resulting in Dysphagia 88

Pseudo-epiglottis 88

Nasal Regurgitation/Gastro-oesophageal Reflux 88

Chylous Fistula (Chyle Leak) 89

Long-Term Management of Oesophageal Strictures 89

References 95

Chapter 10 Cardiothoracic Surgery and Nutrition 97
Rupal Patel and Ann-Marie Nixon

Overview of Surgical Procedures 97

Cardiac 97

Cardiopulmonary Bypass 98

Coronary Artery Bypass Grafting 98

Valve Replacement Surgery 98

Aortic Surgeries 98

Thoracic Surgery 98

Cardiothoracic Transplant 99

Nutritional Implications 99

Cardiac Surgery 99

Fluid Management 99

Thoracic Surgery 100

Cardiothoracic Transplant 100

Body Composition and Weight Management 100

Food Safety 100

Complications 100

Gut Ischaemia 100

Vocal Cord Palsy 101

Chylothorax 101

Parenteral Nutrition 102

Octreotide 102

Monitoring 102

Surgical and Radiological Interventions 102

Long-Term Management 102

Cardioprotective Diet and Weight 102

Cardiac Rehabilitation 102

Long-Term Post-Transplant Complications 103

Hypertension, Dyslipidaemia, and Diabetes 103

Chronic Kidney Disease 104

Osteoporosis and Vitamin D 104

Further Research 107

References 108

Chapter 11 Nutritional Management of the Surgical Patient: Oesophago-gastric Surgery 110
Charles Rayner and Fiona Huddy

Common Operations and Their Anatomy 111

Oesophagectomy 111

Gastrectomy – Total or Subtotal 112

Nutritional Optimisation and Prehabilitation 112

Post-operative Nutrition Support 113

Dietary Reintroduction 114

Nutritional Management of Early Complications 114

Anastomotic Leak 114

Chyle Leak 115

Post-operative Ileus 115

Adjuvant Oncological Treatments 115

Nutritional Management of Late Complications 115

Poor Oral Intake and Anorexia 115

Dysphagia Due to Anastomotic Stricture 116

Dumping Syndrome 116

Malabsorptive Syndromes 117

Pancreatic Exocrine Insufficiency 117

Small Intestinal Bacterial Overgrowth 117

Bile Acid Malabsorption 117

Micronutrient Deficiencies 117

References 120

Chapter 12 Endoscopic Procedures and Their Implications for Nutrition 123
John S. Leeds

Endoscopic Procedures 124

Endoscopic Retrograde Cholangiopancreatography 124

Endoscopic Ultrasound 124

Cyst Drainage and Necrosectomy 125

Biliary Access and Drainage 125

Facilitation of Endoscopy in Patients with Surgically Altered Anatomy 126

Endoscopic Ultrasound–Guided Gastroenterostomy 126

Oesophageal Stent 126

Endoscopic Insertion of Feeding Tubes 126

Duodenal Stent 127

Complications 127

Managing Duodenal Perforation 128

Long-Term Management 128

References 130

Chapter 13 Pancreatitis 132
Mary E. Phillips

Types Of Pancreatitis 132

Acute Pancreatitis 132

Chronic Pancreatitis 133

Acute on Chronic Pancreatitis 133

Surgical Procedures for Acute Pancreatitis 133

Drainage of Collections/Necrosectomy 133

Embolisation 134

Laparoscopic Cholecystectomy 134

Other Surgical Procedures 134

Surgical Procedures for Chronic Pancreatitis 134

Nutritional Management of Acute Pancreatitis 134

Timing of Nutritional Intervention 134

Route of Feeding 134

Formulation of Enteral Feed 135

Probiotics 135

Oral Diet 135

Pancreatic Exocrine Insufficiency 135

Diabetes 136

Lifestyle Advice 136

Nutritional Management of Chronic Pancreatitis 136

Nutritional Assessment 136

Oral Diet 137

Tube Feeding 137

Pancreatic Exocrine Insufficiency 137

Diabetes 137

Lifestyle Advice and Long-Term Follow-Up 137

References 138

Chapter 14 Pancreatic Resection 141
Alessandro Parente, Sarah Powell-Brett, and Keith J. Roberts

Overview of Surgical Procedures 141

Pancreatico-duodenectomy 142

Distal Pancreatectomy 142

Total Pancreatectomy 142

Central Pancreatectomy 142

Drainage Procedures 143

Impact of Pancreatic Resection on Nutrition 143

Pre-operative Malnutrition and Pancreatic Exocrine Insufficiency 143

Post-operative Pancreatic Exocrine Insufficiency 143

Consequences of Pancreatic Exocrine Insufficiency and Malnutrition Following Pancreatic Resection 144

Other Nutritional Considerations 145

Common Post-operative Complications and Their Nutritional Management 145

Post-Pancreatectomy Haemorrhage 145

Delayed Gastric Emptying 145

Post-operative Pancreatic Fistula 145

Bile Leak 146

Chyle Leak 146

Long-Term Management 146

Diabetes after Pancreatic Surgery 146

Pancreatic Enzyme Replacement Therapy 146

References 149

Chapter 15 Liver Resection 153
Nabeel Merali and Adam Frampton

Liver Physiology and Anatomy 153

Pre-operative Care 154

Embolisation 154

Pre-operative Nutrition 154

Surgery 155

Indications for Surgery 155

Contraindications to Surgery 155

Operative Description 155

Post-operative Care 156

Post-operative Nutritional Support 156

Post-operative Complications 156

Ascites 156

Ileus 156

Haemorrhage 157

Bile Leak 157

Bile Reinfusion 157

Liver Failure 157

Small-for-Size Syndrome 158

Conclusion 158

References 160

Chapter 16 Nutritional Management of the Urological Surgical Patient 162
Gregory J. Nason, Wissam Abou Chedid, Matthew J.A. Perry, and Krishna Patil

Overview Of Surgical Procedure 162

Enhanced Recovery after Surgery and Prehabilitation 163

Impact On Nutrition 164

Pre-operative Nutritional Support 164

Post-operative Nutrition 165

Common Post-operative Complications and Their Nutritional Management 165

Ileus 165

Metabolic Acidosis 165

Areas for Future Research 166

References 166

Chapter 17 Colorectal Surgery 169
Mary E. Phillips and Jeremy R. Huddy

Presentation and Aetiology 169

Colorectal Cancer 170

Inflammatory Bowel Disease 170

Other Colorectal Conditions 173

Small Bowel Conditions 173

Surgical Procedures 174

Nutritional Management in the Peri-operative Setting 174

Stoma Management 174

High-Output Stoma 175

Low-Residue Diet 175

Ileus 175

Short Bowel Syndrome 175

Long-Term Complications 176

Kidney Stones 176

Bile Acid Malabsorption 176

Low Anterior Resection Syndrome 176

Pouchitis 176

Conclusion 176

References 176

Chapter 18 Nutritional Management of Gynaecological Cancer Patients 178
Thanuya Mahendran, Maria Ashworth, Mary E. Phillips, and Jayanta Chatterjee

Dietary Contribution to Gynaecological Malignancies 178

Pre-operative Malnutrition 179

Pre-operative Nutritional Support 179

Immuno-nutrition 180

Overview Of Surgical Procedures 181

Endometrial Cancer 181

Cervical Cancer 181

Ovarian Cancer 181

Primary Debulking Surgery 181

Interval Debulking Surgery 181

Primary or Interval Debulking Surgery with Bowel Resection and Stoma Formation 182

Bowel Obstruction and Palliative Resection 182

Post-operative Complications and Impact on Nutrition 182

Chyle Leak 183

Short Bowel Syndrome 183

Conclusion 183

References 184

Chapter 19 Major Trauma and Surgery 187
Jennifer Wetherden and Evanna Leavy

Physiological Response to Injury 188

Routes of Nutrition 188

Nutritional Requirements 189

Overview of Trauma Injuries and Surgeries 189

Patient and Injury Characteristics 189

Types of Injury 189

Types of Surgery 190

Abdominal Trauma 190

Maxillofacial Trauma 191

Chest Trauma and Thoracic Surgery 191

Orthopaedic Surgery 191

Common Post-operative Complications and Their Nutritional Management 192

Paralytic Ileus 192

Nutritional Losses 192

Long-Term Nutritional Barriers and Complications 192

Impaired Mobility 192

Weight Management 193

Micronutrients and Wound Healing 193

Areas For Future Research 193

References 196

Section 4 Consequences of Surgery 199

Chapter 20 Bowel Obstruction and Dysfunction in Benign and Malignant Disease 201
Lindsey Allan and Naomi Westran

Paralytic Ileus 201

Diagnosis and Incidence 201

Causes and Risk Factors 202

Management 203

Bowel Obstruction 203

Causes and Incidence 203

Diagnosis 204

Surgical Management 204

Nutritional Management 204

Areas for Future Research 206

References 206

Chapter 21 Intestinal Failure and Rehabilitation 210
Alison Culkin

Management 211

Sepsis 211

Nutrition Assessment 211

Nutrition Support 212

Fluid and Electrolytes 213

Parenteral Nutrition 213

Enteral Nutrition 213

Oral Nutrition 214

Anatomy 215

Surgical Management 215

Prehabilitation 215

Long-Term

Nutritional Consequences 215

Renal Issues 215

Intestinal Failure–Associated Liver Disease 216

Micronutrient Deficiencies 216

Areas for Future Research 216

References 218

Chapter 22 Nutritional Biochemistry in the Post-operative Patient 220
Callum Livingstone

Trace Elements 221

Zinc (Zn) 221

Copper (Cu) 225

Selenium (Se) 226

Manganese (Mn) 226

Iron (Fe) 227

Vitamins 227

Thiamine (Vitamin B1) 231

Vitamin B12 (Cyanocobalamin) 231

Folate 231

Vitamin A 232

Vitamin D 232

Vitamin E 233

Conclusion 234

References 235

Section 5 Consolidate Your Learning 239

Chapter 23 Test Yourself 241

Index 245