Cleveland Clinic Journal of Medicine 2004 Salvino 345 51

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REVIEW REVIEWRICHARD M. SALVINO, MD ROBERT S. DECHICCO, MS, RD, LD, CNSDDOUGLAS L. SEIDNER, MD, CNSP

Department of Gastroenterology, MetroHealth Manager, Nutrition Support Dietetics, Department of Nutrition SupportDirector, Department of Nutrition Support and Vascular

Medical Center, Cleveland, OH and Vascular Access, The Cleveland Clinic FoundationAccess; Program Director, Fellowship in Clinical Nutrition,Department of Gastroenterology and Hepatology,The Cleveland Clinic Foundation

CREDITCMEPerioperative nutrition support:

Who and how

n ABSTRACTPerioperative nutrition support can reduce postoperativecomplications in some malnourished patients, but there

are risks, such as a greater risk of infection. The decisionto use nutrition supporteither total parenteral nutritionor enteral feedingsbefore and after surgery depends onhow severely the patient is malnourished, the type ofsurgical procedure, and whether the surgery is elective.

n KEY POINTSMalnourished patients are at greater risk forperioperative and postoperative morbidity and mortalitycompared with well-nourished patients.

Preoperative nutrition support for 7 to 10 days isbeneficial in severely malnourished patients whose

surgery can be delayed this long.

NUTRITION SUPPORTtotal parenteralnutrition (TPN) and enteral nutrition

(tube feedings)is not for everybody undergoingsurgery. Although giving nutrition support beforeand after surgery can decrease postoperative morbidityand mortality, several well-designed studiesshowed that certain subsets of surgical patientssuffer worse outcomes with TPN than with standard

care.14 Therefore, it is imperative to carefullychoose which patients should receive nutritionsupport and by what route.

In this article we briefly review the literatureon this controversial topic and describemethods for assessing nutritional status anddetermining which patients should receiveperioperative nutrition support. We also discusshow to supply nutrition to patients who


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require perioperative nutrition support.

n MALNUTRITION POSES RISKNutrition support should be considered in postoperativepatients who cannot eat within 7 to 10 days aftersurgery.

Whenever possible, enteral nutrition is preferred overparenteral nutrition, as it is safer and more cost-effective.

Immune-enhancing enteral formulas are intended tobolster the function of the immune system in stressedpatients.

Malnutrition is associated with adverse outcomesin surgical patients. Although it is difficultto establish a causal relationship, it isknown that malnutrition can impair woundhealing and immunocompetence and decreasecardiac and respiratory muscle function.Furthermore, malnourished patients undergoingsurgery have higher rates of morbidity andmortality as well as longer hospital stays comparedwith adequately nourished patients.510

n STUDIES OF PREOPERATIVE TPNAlthough more than 20 studies have examinedthe effects of preoperative TPN, most ofthem were small, the quality varied, and theresults differed. One large study, however, hasprovided valuable information (see below).

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 71 NUMBER 4 APRIL 2004

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PERIOPERATIVE NUTRITION SUPPORT SALVINO AND COLLEAGUESWell-nourishedpatients maydo worsewith TPN

The Veterans Affairs Total ParenteralNutrition Cooperative Study2 included 395malnourished patients who required nonemergencylaparotomies or thoracotomies, but notvascular or cardiac procedures. Patients wererandomly assigned to receive either TPN for 7to 15 days before surgery and 3 days aftersurgery or no perioperative TPN.

At 90 days, there were more infectiouscomplications in the TPN group than in thecontrol group (14.1% vs 6.4%; P = .01), butmore noninfectious complications in the controlgroup (22.2% vs 16.7%; P = .2). The mostcommon infectious complications were pneumoniaand bacteremia, and the most common

noninfectious complications were cardiovascularevents and respiratory failure.

A possible explanation for the greaternumber of infectious complications in theTPN group may be that these patientsreceived a high-calorie regimennearly 45kcal/kg/day, which led in some cases to hyperglycemia,a known risk factor for infections.Furthermore, the excess of infections in theTPN group was all in the subgroups witheither borderline or mild malnutrition. In contrast,severely malnourished patients receiving

TPN had fewer noninfectious complicationsthan controls (5% vs 43%; P = .03) and noincrease in infectious complications. Theseverely malnourished subgroup also had feweroverall major complications with TPN thanthe subgroup without (21% vs 47%; P = .12).

Heyland et al11 did a meta-analysis of 27randomized studies of perioperative TPN andconcluded that TPN had no effect on mortalitybut was associated with fewer major complications.

Subgroup analysis showed a trend towardfewer deaths and complications in TPNpatients in studies published before 1988 (thehalfway point of the analysis) but not later.Although the reason for the difference inresults before and after this time was notentirely evident to the authors, they speculatedthat it was because the later studies were ofhigher quality.


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Klein et al12 analyzed 22 studies andfound that malnourished patients receivingTPN for 7 to 10 days before surgery had a 10%absolute reduction in postoperative complications.

Koretz et al13 reached contrary conclusionsin a meta-analysis for the AmericanGastroenterological Association PositionPaper on TPN, finding that preoperative TPNdid not have any effect on perioperative complications.

Comment. The reason for the differingfindings among the three meta-analyses is thatKoretz et al combined studies using TPN withstudies using only protein-sparing therapy(< 10 kcal/kg/day of nonprotein energy).Furthermore, despite using similar inclusioncriteria, Koretz et al included 23 studies intheir analysis that the other meta-analyses didnot. Some of these 23 studies were not randomizedcontrolled trials, and others wererepeat presentations of the same data.

These meta-analyses, moreover, pointout an inherent weakness and limitation ofall meta-analyses: differences among thestudies in patient populations and treatments.Only Heyland et al11 attempted toaccount for such heterogeneity in their subgroupanalyses (ie, by grouping studies containingonly malnourished patients and comparingthese trials with other trials). Theseinvestigators also developed a scoring systemto assess the methodologic quality of theindividual studies, and used it to adjust the

results in their analysis.

STUDIES OF PREOPERATIVEENTERAL NUTRITIONFew studies examined enteral nutrition in preoperativepatients.

Lim et al14 found lower morbidity andmortality rates in patients receiving TPN vsenteral nutrition, but the differences were notstatistically significant.

Sako et al15 found no differences in ratesof postoperative complications and mortalityin patients who received preoperative TPN vsthose who received enteral nutrition.

STUDIES OF POSTOPERATIVE TPNNumerous small studies examined the effectsof postoperative TPN.


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Yamada et al16 found that cancer patientsreceiving postoperative TPN vs oral intakehad fewer postoperative complications, a



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higher survival rate, and higher body weights,serum albumin levels, and total lymphocytecounts. The likely reason for the better survivalrate was that TPN allowed the patientsto tolerate more chemotherapy.

Collins et al17 found that postoperativepatients had faster wound-healing rates and alower incidence of postoperative sepsis withTPN vs an amino acid solution or oral intake.

However, both of these studies, while statisticallysignificant, were quite small (23 and30 patients, respectively).

Preshaw et al,18 on the other hand, foundno reduction in the rate of colonic fistulasafter colonic anastomosis with 6 days of postoperativeTPN vs oral intake alone.

Woolfson and Smith19 found no differencein morbidity and mortality rates aftermajor thoracoabdominal procedures in

patients treated with 7 days of postoperativeTPN vs controls who received the standardpostoperative fluid regimen.

Unlike the Veterans Affairs Group, whichstratified patients on the basis of nutritionalstatus, these latter two studies looked atpatients who were well-nourished or whosenutritional status was unspecified.

Torosian20 reviewed eight prospectiverandomized trials of postoperative TPN.Pooled analysis showed an overall 10%

greater incidence of complications in patientsreceiving TPN.

Klein et al,12 in another meta-analysis,also found a 10% greater incidence of complicationsin patients receiving routine postoperativeTPN.

STUDIES OF POSTOPERATIVEENTERAL NUTRITIONFew studies examined the use of postoperativeenteral nutrition. Some found that it improved

wound healing, reduced septic complications,reduced length of stay, and reduced the hyper-metabolic responseenergy requirements thatexceed the patients usual basal energy expenditure.2126

However, a review of five studies thatprospectively compared postoperative enter-al and parenteral nutrition head-to-headreported similar rates of morbidity and mortality.


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WHO SHOULD RECEIVENUTRITION SUPPORT?Nutrition support is indicated in patients whoare unable or unwilling to consume, digest,and assimilate adequate nutrients orally.However, not all patients who cannot eat fora few days are candidatesonly those inwhom the benefits outweigh the risks.

How long a patient can go without adequatenutritional intake without increasingsurgical risk is unknown. Most well-nourishedpatients recover well without nutrition forseveral days after surgery while receiving standardintravenous fluids and then slowly reintroducingan oral diet. Moreover, some surgicalpatients do worse with TPN than withstandard care.2,3 This is likely because nutritionsupport carries inherent risks such ascatheter sepsis, hyperglycemia, electrolyteabnormalities, and liver dysfunction.

Who should receivepreoperative nutrition support?

There are three main criteria in determining ifa patient should receive preoperative nutritionsupport:

The patient must be severely malnourished.28The procedure should be one in which

nutrition support has been shown toimprove clinical outcome, eg, a majorthoracoabdominal procedureThe surgery should be elective and safe todelay for 7 to 10 daysthe length of timethat preoperative nutrition supportshould be given.Enteral or parenteral? Nutrition supportshould preferably be given through the enter-al route if reliable access to the gastrointestinaltract can be obtained and formula toleranceis demonstrated. If this is not possible,

TPN is the preferred route of feeding.

Who should receivepostoperative nutrition support?

Candidates for postoperative nutrition supportare not always obvious at the time ofsurgery. Often, the patients postoperativerecovery needs to be monitored for severaldays before the need for nutrition support


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becomes apparent.

Overfeedingmay be worsethanmalnutrition



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PERIOPERATIVE NUTRITION SUPPORT SALVINO AND COLLEAGUESTABLE 1tors such as liver dysfunction, edema, or ascites.The Prognostic Nutrition Index30 was

Degree of malnutrition:

developed to prospectively predict the risk of

Current vs usual and ideal body weight

postoperative complications in surgical

DEGREE OF % OF IDEAL % OF USUAL patients on the basis of nutritional parametersMALNUTRITION BODY WEIGHT* BODY WEIGHT

alone. It uses a combination of nutritional

Mild 80%90% 90%95%Moderate 70%79% 80%89%Severe < 70% < 80%

*Ideal body weight can be determined by a variety of formulas. While all of the

formulas have their shortcomings, the method proposed by Hamwi32 is the mostcommon:

Men: 106 pounds for the first 5 feet of height plus 6 pounds for each additionalinchWomen: 100 pounds for the first 5 feet of height plus 5 pounds for each additionalinch

ADAPTED FROM GRANT JP. NUTRITION ASSESSMENT BY BODY COMPARTMENT ANALYSIS.IN: GRANT JP. HANDBOOK OF TOTAL PARENTERAL NUTRITION.PHILADELPHIA: WB SAUNDERS COMPANY, 1992: 20.

As a general rule, postoperative nutritionsupport should be started only if the patientcannot tolerate an oral diet 7 to 10 days aftersurgery if mildly malnourished, or 5 to 7 daysafter surgery if severely malnourished.20

On the other hand, postoperative nutritionsupport should be considered sooner ifTo avoid the you believe that the patientwill not be able toresume oral intake within 7 to 10 days after

refeeding

surgery.29

syndrome, Whenever possible, enteral nutrition ispreferred over parenteral nutrition, as it is

start at 1/2

associated with equal or better outcomes andthe energy is safer and more cost-effective.


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requirement

n HOW TO ASSESS NUTRITIONAL STATUSfor 3 to 5 daysA comprehensive nutrition assessment isessential before surgery, since it helps in estimatingsurgical risk and in determiningwhether a patient is a candidate for nutritionsupport. It should determine whether thepatient is malnourished and, if so, to whatdegree. Generally, the severity of malnutritionis proportional to the level of surgical risk.7,8,30Since no single test can accurately determinenutritional status, clinicians must look atseveral markers. Laboratory tests such as serumalbumin and anthropometric measurementssuch as weight have been traditionally used toassess nutritional status. Unfortunately, thesemarkers can be influenced by nonnutritional fac

markers: serum albumin, serum transferrin, tricepsskinfold measurement, and skin tests for

delayed hypersensitivity. It was originally validatedin studies of gastrointestinal surgerypatients and has since been shown to be of usein many other surgical populations. However,it is not widely used in clinical practice.

History and physical examination.Equations such as the Prognostic NutritionIndex should not replace a thorough historyand physical examination. In fact, a carefulpatient history and physical examinationalone may be a more valuable assessment ofnutritional status than objective markers.

Subjective global assessment, a clinicaltechnique based on the history and physicalexamination alone, has been developed andvalidated. This technique categorizes patientsas well nourished, malnourished, or severelymalnourished.7,8,31 The most significant determinantsof this scoring system are muscle wasting,loss of subcutaneous tissue, and weight loss.

Baker et al7 demonstrated that patientscategorized as severely malnourished by subjectiveglobal assessment had significantly

higher rates of infection and antibiotic useand longer hospitalizations than well-nourishedand mildly malnourished patients.

Anthropometric measurements such asweight are useful in assessing nutritional statusin combination with a patient history andphysical examination.

How much weight has been lost in what time?


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Loss of more than 10% of usual body weightwithin 6 months is considered severe and isassociated with increased morbidity and mortality,as is 7.5% in 3 months, 5% in 1 month,or 2% in 1 week.9

What is the patients current weight as a percentof his or her ideal body weight32 or usualweight? Patients weighing less than 70% oftheir ideal weight or less than 80% of theirusual weight are considered severely malnourished(TABLE 1).33

Laboratory tests such as visceral proteinstatus testing can also help determine the



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degree of malnutrition.

Serum albumin is helpful in assessing malnutrition,and low levels are associated withincreased morbidity and mortality in surgicalpatients.5,10,34

Serum transferrin levels, with a shorterhalf-life than albumin, are more sensitive tothe short-term response of a patient to nutritionsupport as long as any underlying injuryor insult is resolved.

We use serum transferrin levels, althoughsome clinicians prefer prealbumin as a markerof short-term changes in nutrition status. Eachhas its inherent advantages and disadvantagesbut they have important characteristics incommon. All visceral protein levels decreasewith the physiologic stress of an injuryresponse, and this decrease correlates with themorbidity and mortality of the patients illness.In addition, the magnitude of depletion

roughly corresponds to the degree of malnutrition(TABLE 2) These markers can be used tohelp identify candidates for nutrition supportand to follow patientsresponses to nutritionsupport as long as the underlying illness hasbeen treated or resolved.

However, it is important to be aware of non-nutritional factors such as fluid status and liverfunction that can influence visceral protein levels,and not to use visceral protein status as thesole criterion for assessing nutritional depletion.

HOW MUCH NUTRITION SUPPORTTO GIVE?If perioperative nutrition support is deemednecessary, how much does the patient need?There are several ways to calculate this.

Calories. Up to 25 to 35 kcal/kg/day or

1.5 to 1.75 times the basal energy expenditure.The basal energy expenditure is calculated bythe Harris-Benedict equation:Men 66.47 + 13.75W + 5H 6.76A;

Women 655.1 + 9.56W + 1.85 H 4.68A;where W = weight in kg, H = height in cm,and A = age in years.

Protein: 1.5 to 2 g/kg/day.Use adjusted body weightif the patient is overweight

In calculating how much nutritional support


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to give, if the patient is at or below his or her

TABLE 2Determining degree of malnutritionusing visceral protein levels

ALBUMIN TRANSFERRIN(G/DL) (MG/DL)

Normal 3.55.0 200400Mild malnutrition 2.83.4 150199Moderate malnutrition 2.12.7 100149Severe malnutrition < 2.1 < 100

ADAPTED FROM RUSSELL MK, MCADAMS MP. LABORATORY MONITORING OF NUTRITIONALSTATUS. IN: MATARESE LE, GOTTSCHLICH MM, EDITORS: CONTEMPORARY NUTRITION SUPPORT.PHILADELPHIA: W.B. SAUNDERS, 1998: 4763.

ideal body weight, one should use the patientscurrent weight. But if the patient is overweight(> 120% of ideal body weight), oneshould use the adjusted body weight.

The concept of adjusted body weightassumes that one fourth of the excess weight iscomposed of lean tissue and that a patientshould receive nutrition support only for his orher ideal body weight plus the excess lean tissue.Thus: adjusted body weight = ideal bodyweight + 0.25 (current body weight ideal bodyweight). Whenever

feasible,

Do not overfeed

enteral feeding

Care must be taken not to overfeedpatients(ie, give them more calories than they need) is preferableor to induce a refeeding syndrome.

to TPN

Surgical patients have increased energyrequirements that need to be met but shouldnot be exceeded. Overfeeding with more than35 kcal/kg/day has been shown to causeincreased septic and metabolic complications,

is clearly inferior to optimal nutrition, andmay be as detrimental as the patients underlyingmalnutrition.20

Refeeding syndrome occurs when severelymalnourished patients are abruptly given theirfull energy requirements, whether by enteralfeedings or TPN. Signs and symptoms includefatigue, lethargy, muscle weakness, edema,cardiac arrhythmias, respiratory failure, and


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hemolysis. The cause is a rapid shift of potassium,phosphorous, and magnesium from theextracellular to the intracellular space whenglucose is first given to such patients.

Therefore, when beginning nutrition



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PERIOPERATIVE NUTRITION SUPPORT SALVINO AND COLLEAGUESTABLE 3Typical indications for perioperativenutrition support

Indications for enteral nutrition support

Severe dysphagia or esophageal obstruction

Neurologic and muscular diseases(Guillain-Barr syndrome, myasthenia gravis, amyotrophiclateral sclerosis, severe multiple sclerosis)

Major burns or traumaMild pancreatitis

Indications for total parenteral nutrition

Diffuse peritonitisIntestinal obstructionIntractable vomiting or diarrheaParalytic ileus

Severe acute pancreatitisHigh-output enterocutaneous fistulaBowel ischemiaShort bowel syndromeComplete malignant bowel obstruction

support in a severely malnourished patient,we advise giving one half of his or her energyrequirement for 3 to 5 days while keepingelectrolyte concentrations and fluid balance

Immune-in the normal range before advancing to full

requirements.35

enhancingformulas n ENTERAL OR PARENTERAL NUTRITION?are promising

There is continued debate on how to providebut far from nutritional support: enterally or parenterally.Most experts agree that enteral nutrition

routine

is better than parenteral since it is safer and

more cost-effective. Most comparative studiesof enteral nutrition and parenteral nutrition,however, show that outcomes are comparable

with either route.14,15,21,22,27,36,37Keep in mind that most of the studies ofperioperative feeding used parenteral nutritionin the treatment group and an ad lib oraldiet in the control group. Few studies used asimilar design to compare enteral nutrition in


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the treatment group against an ad lib oral dietin the control group.With this in mind, tube feedings are indicatedin patients with adequate digestive andabsorptive capacity of the gastrointestinaltract but who cannot or will not consume adequatenutrients orally. Specific indications for

tube feedings and TPN are listed in TABLE 3.

Immediately after surgery, tube feedingsmay not be an option due to paralysis of thebowel, but they should be considered oncefunction begins to return. Tube feedings canoften be started even in the absence of bowelsounds or the passage of flatus. In cases inwhich the return of normal gastric emptying isdelayed, enteral feeding into the jejunum is anoption through nasoenteric, gastrojejunostomal,and jejunostomal feeding tubes.

IMMUNONUTRITION:A NEW TYPE OF NUTRITIONAL SUPPORT

Immune-enhancing formulas are intended tobolster the function of the immune system instressed patients. These are usually enteral formulasthat contain supplemental arginine,RNA, and omega-3 fatty acids. This is a relativelynew area of research, having onlyemerged in the last 10 years.

There are now numerous studies dealingwith the use of these formulas in perioperativepatients.

Daly et al38 studied such a formula in

patients undergoing elective surgery for gastrointestinalmalignancies and found fewer infectiousand wound complications in the group thatreceived the formula (11% vs 37%; P = .02).

Braga et al (1998)39 concluded thatenhanced enteral formulas can lead to a shorterlength of stay and less-severe infections insurgical patients.

Heyland et al,40 in a meta-analysis, suggestedthat immune-enhancing formulas mayhave a favorable impact on the rate of postoperative

infectious complications and on lengthof stay.

Braga et al (2002)41 demonstratedreduced complications and hospital length ofstay in patients given immunonutrition ascompared to standard enteral nutrition.

The Summit on Immune-EnhancingEnteral Therapy42 recommended these formulas


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for specific groups of patients, includingmalnourished patients undergoing electivegastrointestinal surgery. However, the recommendationsof this meeting are not officiallyendorsed by the American Society forParenteral and Enteral Nutrition.

Although these formulas are promising,



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their use is far from routine and should not be specific formulas content and proposed indi

attempted without a clear understanding of a cations.

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malignancy. Ann Surg 1994; 220:436444.5.Reinhardt GF, Myscofski JW, Wilkens DB, et al. Incidence and mortalityof hypoalbuminemic patients in hospitalized veterans. J ParenterEnteral Nutr 1980; 4:357359.6.Seltzer MH, Slocum BA, Cataldi-Betcher EL, et al. Instant assessment:absolute weight loss and surgical mortality. J Parenter Enteral Nutr1982; 6:218221.7.Baker JP, Detsky AS, Wesson DE, et al. Nutritional assessment. Acomparison of clinical judgment and objective measurements. N EnglJ Med 1982; 306:969972.

8.Detsky AS, Baker JP, ORourke K, et al. Predicting nutrition-associatedcomplications for patients undergoing gastrointestinal surgery. JParenter Enteral Nutr 1987; 11:440446.9.Windsor JA, Hill GL. Weight loss with physiologic impairment: a basicindicator of surgical risk. Ann Surg 1988; 207:290296.10.Yamanaka H, Nishi M, Kanemaki T, et al. Preoperative nutritionalassessment to predict postoperative complications in gastric cancer. JParenter Enteral Nutr 1989; 13:286291.11.Heyland D, Montalvo M, MacDonald S, et al. Total parenteral nutrition

in the surgical patient: a meta-analysis. Can J Surg 2001;44:102111.12.Klein S, Kinney J, Jeejeebhoy K, et al. Nutrition support in clinicalpractice: review of published data and recommendations for futureresearch directions. J Parenter Enteral Nutr 1997; 21:133156.13.Koretz R, Lipman T, Klein S. AGA technical review of parenteralnutrition. Gastroenterology 2001; 121:9701001.14.


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Lim STK, Choa RG, Lam KM, et al. Total parenteral nutrition versusgastrostomy in the preoperative preparation of patients with carcinomaof the esophagus. Br J Surg 1981; 68:6972.15.Sako K, Lore JM, Kaufman S, et al. Parenteral hyperalimentation insurgical patients with head and neck cancer: a randomized study. JSurg Oncol 1981; 16:391402.16.Yamada N, Koyama H, Hioki K, et al. Effect of postoperative totalparenteral nutrition as an adjunct to gastrectomy for advanced gastriccarcinoma. Br J Surg 1983; 70:267274.17.Collins JP, Oxby CB, Hill GL. Intravenous amino acids and intravenoushyperalimentation as protein-sparing therapy after major surgery. Acontrolled clinical trial. Lancet 1978; 1:788791.18.Preshaw RM, Attisha RP, Hollingsworth WJ, Todd JD. Randomizedsequential trial of parenteral nutrition in healing of colonic anastomosesin man. Can J Surg 1979; 22:437439.19.Woolfson AMJ, Smith JAR. Elective nutritional support after majorsurgery: a prospective randomized trial. Clin Nutr 1989; 8:1521.20.Torrosian M. Perioperative nutrition support for patients undergoing

gastrointestinal surgery: critical analysis and recommendations.World J Surg 1999; 23:565569.21.Kudsk KA, Croce MA, Fabian TC, et al. Enteral versus parenteralfeeding: effects on septic morbidity after blunt and penetratingabdominal trauma. Ann Surg 1992; 215:503515.22.Moore EE, Jones TN. Benefits of immediate jejunostomy feedingafter major abdominal trauma: a prospective, randomized trial. JTrauma 1986; 26:874881.23.Graham TW, Zadrozny DB, Harrington T. The benefits of early jejunalhyperalimentation in the head-injured patient. Neurosurgery 1989;

25:729735.24.Dominioni L, Trocki O, Mochizuki H, et al. Prevention of severe post-burn hypermetabolism and catabolism by immediate intragastricfeeding. J Burn Care Rehabil 1984; 5:106112.25.Jensen GL, Sporay G, Whitmire S, et al. Intraoperative placement ofthe nasoenteric feeding tube: a practical alternative? J ParenterEnteral Nutr 1995; 19:244247.26.Schroeder D, Gillanders L, Mahr K, et al. Effects of immediate postoperativeenteral nutrition on body composition, muscle function,and wound healing. J Parenter Enteral Nutr 1991; 15:376383.

27.Campos ACL, Meguid M. A critical appraisal of the usefulness ofperioperative nutritional support. Am J Clin Nutr 1992; 55:117130.28.Maxfield D, Geehan D, Van Way C. Perioperative nutritional support.Nutr Clin Pract 2001; 16:6973.29.ASPEN Board of Directors and the Clinical Guidelines Task Force.Guidelines for the use of parenteral and enteral nutrition in adultand pediatric patients. J Parenter Enteral Nutr 2002; 26:1SA138SA.


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30.Buzby GP, Mullen JL, Matthews DC, et al. Prognostic nutritionalindex in gastrointestinal surgery. Am J Surg 1980; 139:160167.31.Detsky AS, Baker JP, ORourke K, et al. Predicting nutrition-associatedcomplications for patients undergoing gastrointestinal surgery. JParenter Enteral Nutr 1987; 11:440446.32.Hamwi GJ. Therapy: changing dietary concepts. In: Danowski TS(editor). Diabetes Mellitus: Diagnosis and Treatment. New York:American Diabetes Association, 1964:7378.33.Grant JP. Nutrition assessment by body compartment analysis. In:Grant JP. Handbook of Total Parenteral Nutrition. Philadelphia: WBSaunders Company, 1992:20.34.Gibbs J, Call W, Henderson W, et al. Preoperative serum albuminlevel as a predictor of operative mortality and morbidity. Resultsfrom the national VA Surgical Risk Study. Arch Surg 1999;134:3642.35.Apovian CM, McMahon M, Bistrian BR. Guidelines for refeeding themarasmic patient. Crit Care Med 1990; 18:10301033.36.

Reilly JJ, Hull SF, Albert N, et al. Economic impact of malnutrition: amodel system for hospitalized patients. J Parenter Enteral Nutr1988; 12:371376.37.Pacelli F, Bossola M, Papa V, et al. Enteral vs. parenteral nutritionafter major abdominal surgery: an even match. Arch Surg 2001;136:933936.38.Daly J, Lieberman M, Goldfine J, et al. Enteral nutrition with supplementalarginine, RNA, and omega-3 fatty acids in patients afteroperation: Immunologic, metabolic, and clinical outcome. Surgery1992; 112:5667.39.

Braga M, Gianotti L, Vignali A, et al. Artificial nutrition after majorabdominal surgery: impact of route of administration and compositionof the diet. Crit Care Med 1998; 26:2430.40.Heyland DK, Novak F, Drover JW, et al. Should immunonutritionbecome routine in critically ill patients? A systematic review of theevidence. JAMA 2001; 286:944953.41.Braga M, Gianotti L, Nespoli L, et al. Nutritional approach in malnourishedsurgical patients: a prospective randomized study. ArchSurg 2002; 137:174180.42.Proceedings from Summit on Immune-Enhancing Enteral Therapy,

May 2526, 2000, San Diego, California, USA. J Parenter EnteralNutr 2001; 25(suppl 2):S1S63.ADDRESS: Douglas L. Seidner, MD, Department of Gastroenterology andHepatology, A30, The Cleveland Clinic Foundation, 9500 Euclid Avenue,Cleveland, OH 44195.



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Documents

Cleveland Clinic Journal of Medicine 2004 Salvino 345 51