Stellenwert der prä- und postoperativen Sicht des Chirurgen

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1 Interdisziplinäre Chirurgie Stellenwert der prä- und postoperativen Ernährung Sicht des Chirurgen Kantonsspital Luzern Prof. L. Krähenbühl Chirurgische Klinik Hôpital Cantonal Fribourg

2 Problems in Surgery 1. Infection, sepsis 2. Anastomotic leaks 3. Thrombosis 4. Adhesions Bengmark Stig. Curr Opin Clin Nutr Metab Care 2001;4:571-9

3 Hospital-Infections USA Mio infections/year deaths due to sepsis 70% resistence to 1 antibiotics Infected patients have: hospital stay need 2. or 3.- generation antibiotics (costs ) Sepsis: 10% of ICU stay costs 17 billion $/year year! Burke J et al. NEJM 2003;248: Martin GS et al. NEJM 2003;249:

4 Postoperative Complications Infection! Malnutrition Diabetes hyperglycemia Nicotine-abuse Steroids (systemic) Obesity (BMI>30) Age >70y Blood loss >1.5L Blood transfusion Op-time >4h Hospital stay ICU stay Open vs. laparoscopic Windsor A et al. fit for Surgery London 2003

5 Incidence of Malnutrition Surgery % Medicine % Geriatrics > 50 % morbidity + mortality Naber TJH Am J Clin Nutr 1997; 65:1721

6 Malnutrition - Screening (questionaire on admission/outpatient clinic) BMI < 20.5? Weight loss within 3 months? Lost of appetite? Severity of disease? (ICU, trauma, sepsis) if 1x yes NRS 2002

7 BMI Nutrition & Surgery Malnutrition Patient at Risk Nutritional Risk Screening (NRS 2002) < 18.5 kg/m 2 Weight loss > 5% in 3 months > 10% in 6 months Severity of disease grade 0-3 Amount of food intake Age (Serum Albumin < 75% Norm > 70 Jahre < 3.5 g/dl ) Kondrup J et al. ESPEN Working Group Clin Nutr 2003;22:321

8 Method Prospective screening from to 01.05: All patients admitted to 2 of our 4 surgical units (different conditions) Within 3 days of admission Repeating screening process at weekly intervals or earlier if clinical concern (food intake, weight loss)

9 Method We analyzed 3 subgroups Group 1 Normal Nutrition State (NS) Group 2 at risk patients efficient perioperative nutrition Group 3 at risk patients (>75% intake of estimated caloric need) insufficient perioperative nutrition (<75% intake of estimated caloric need)

10 Method Endpoints Morbidity * Mortality * Length of stay (LOS) * Zurich s criteria according to Dindo D et al. Ann Surg 2004

11 Results 754 Patients Screened (n=155 with NRS > 0) 541 Operated Mean age 56 years (range 15 to 92) 118 Female 43% malnourished (15.6%)

12 Results Gr 1 Gr2 Gr3 n % n % n % Morbidity Grade Grade Grade Grade 3a Grade 3b Grade 4a Grade 4b Grade Total P sign

13 Euro-OOPS at HCF June Euro-OOPS (n=4040) HCF (n=1274) Age (years) BMI Patient at risk 53 (14 95) 24 ( ) 32% 55 (15 95) 25.2 ( ) 19.3% Complications - normal - at risk 13% 32%* 7.2% 23.3%* Deaths - normal - at risk 1% 12%* 0.5% 5%* Hosp-stay (days) - normal - at risk Ø compl. 6.7± ±0.2 + compl. 10.9± ±0.3 Ø compl. 6.1± ±0.8 + compl. 8.3± ±1.6

14 Starvation & Malnutrition (healthy patients) years 14 days years 10 days > 70 years Metabolic stress 5-7 days 5-7 days Beginning of oral nutrition 3-5 days Nussbaum MS Nutrition + Metabolism, 1996

15 Beginning of postop. oral Nutrition (days) 80 ies 90 ies 2005 Esophagus Gastrectomy Whipple Colon Small bowel Laparoscopy Bodoky A Chirurg 1985; 56:644

16 Multimodal Rehabilitation Concept 60 open colon resections fast track Results Pre-op: adequate information! O-24h mobilization 2h po Age liquids 1000ml 74 & 2 years drinks ASA III/IV normal food allowed 30% Defacation 24-48h 48h DK, mobilization 95% >8h Hosp. stay (days) normal food 2000ml 2 (2-6) Morbidity plan discharge8.3% Anastomotic Ab 48h leak PDA, full mobilization 2 (3.3%) Mortality normal food, discharge 2 (3.3%) Rehospitalisation ibuprofen 3x600mg/die 15% po Basse L et al. Ann Surg 2000;232:51

17 Major Abdominal Surgery + Trauma (esophagus, stomach, pancreas) nil by mouth > 7 days enteral enteral tube EN parenteral central line TPN

18 TPN vs. EN: Meta-Analysis 8 trials (trauma, burn s, abdominal) TPN EN (112) (118) Infection 35 %* 18 % Mortality 6 % 5 % ICU stay (d) 7.3* 4.4 Hosp. stay (d) 22* 17 *p<0.05 Alexander JW Ann Surg 1980; 192:505 Moore FA Ann Surg 1992;216:172

21 Pre- and Perioperative Immunonutrition Author Journal Year Surgery N Outcome Braga Arch Surg 99 GI-Surgery 206 Infection Senkal Arch Surg 99 Surgery 154 Infection Synderman Riso Tapaske Gianotti Braga Laryng Clin Nutr Lancet Gastro Arch Surg HNO-Ca Surgery Cardiac GI-Surgery GI-Surgery Infection Infection Infection Infection Infection

22 Immunonutrition: Meta-Analysis Author Journal Patients (n) Trials Outcome Heys Ann Surg infection 99 mortality Beale CCM infection 99 hosp.stay vent. days Heyland JAMA infection 01 hosp. stay? mortality

23 Elective Surgery Pre-Op Peri-Op Post-Op

24 Benefit: Immunonutrition Immunological and metabolic effects with immunonutrition become 3 5 days later evident, late infection! % % 17% frequency of late postop. Infectious and wound complications after day 5 IMPACT Control Senkal M, Eur J Surg, 1995 Crit Care Med, 1997

25 Perioperative Immunonutrition (cancer patients) 206 patients (colon, stomach, pancreas) randomized trial 1l/d Impact or standard formula for 7 days preoperative Infections 20 Hospital stay 25% 20% 15% 10% 11% 24% Impact Control % 0% 0 Impact Control p<0.05 Impact vs. Control Braga M. et al. Arch Surg, 1999

26 Perioperative Immunonutrition Impact (cancer patients) IEF (n=14) IEF + Gly (n=17) CON (n=15) Age (years) 64.4 (30-84) 57.1 (33-77) 63.0 (47-79) BMI (kg/m 2 ) 23.7± ± ±3.3 Malnutrition (%) 64% 41% 60% Karnofsky index 76±10 80±7 74±14 Gastrectomy (n) Whipple (n)

27 Perioperative Immunonutrition Impact (cancer patients) IEF (n=14) IEF + Gly (n=17) CON (n=15) Infections 2 (14%) 5 (29%) 10 (67%) Other complications 6 (43%) 8 (47%) 10 (67%) Pat. without complications 7 (50%) 9 (53%) 5 (33%) Mortality 1 (7%) 0 0 ICU-days 1.9±1.3* 2.2±1.1* 5.9±0.8 Hosp-days 19.7±2.3* 20.1±1.3* 29.1±3.6

28 Perioperative Immunonutrition Impact (cancer patients) Endotoxin concentration Endotoxin EU/mL IEF IEF + glycine CON 0 Baseline IO 1 IO 2 POD 1 POD 2

29 Perioperative Immunonutrition & Malnutrition (> 10% weight loss) Periop kon (n=50) Periop Imp (n=50) CON po (n=50) Gastrectomy 19 (38%) 18 (36%) 19 (38%) Whipple 20 (40%) 21 (42%) 18 (36%) Others (colon etc.) 11 (22%) 11 (22%) 13 (26%) Morbidity 14 (24%)* 9 (18%)* 29 (42%) Infection 8 (16%)* 5 (10%)* 12 (24%) Mortality Hosp-days 13.2* 12* 15.3 Braga M. et al. Arch Surg, 2002

30 Oral Supplements + Surgery (cancer patients, no malnutrition) Oral Imp 5d (n=102) Periop Imp (n=101) CON (n=102) Gastrectomy 48 (47%) 46 (46%) 44 (43%) Whipple 28 (27%) 27 (27%) 26 (26%) Others (colon etc.) 26 (26%) 28 (27%) 32 (31%) Morbidity 36 (35%)* 34 (34%)* 49 (48%) Infection 14 (14%)* 16 (16%)* 31 (30%) Mortality Hosp-days 11.6* 12.2* 14 Gianotti L et al. Gastroenterology 2002

31 Indication Perioperative Immunonutrition (abdominal surgery) Severe malnutrition 2-3 weeks nutrition delayed surgery Mild-moderate malnutrition oral Impact 5 days + enteral 7 days po No malnutrition & oral Impact 5 days high risk of infection Windsor R et al. fit for surgery London 2003

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