NUTRITION Invited Review Clin Sci Nutr 2019; 1(1): 1-10 • DOI: 10.5152/ClinSciNutr.2019.
79
Current approach to perioperative nutrition in the ERAS age
R. Haldun Gündoğdu
ABSTRACT
Enhanced recovery after surgery (ERAS) is a multidisciplinary and multimodal program designed to minimize the response to
surgical trauma and normalize the patient as early as possible. While managing the perioperative process of the patient, ERAS
protocols a change from classical and dogma-based treatments to modern concepts with a radical change. Its basic philosophy is
to provide early recovery by supporting mobilization and gastrointestinal functions without causing complications. This protocol
consists of many different elements, and when they are applied together, they support each other. Nutrition is an important part
of ERAS protocols, and it directly affects clinical outcomes. The recommended perioperative nutritional management algorithm
for patients to be operated with ERAS protocols starts with a routine nutritional assessment and aims at early oral/enteral feeding
at each stage. The aim of this compilation is to review current perioperative nutritional recommendations in the period in which
ERAS protocols are adapted to all areas of surgery.
Keywords: Accelerating postoperative recovery, enteral and parenteral nutrition, ERAS, perioperative nutrition
Introduction increased with the increase of preoper-
ative weight loss in patients undergoing
Of the patients who are admitted to gen- peptic ulcer surgery, and this became
eral surgery clinics, 10%-35% are malnur- a classic book knowledge, with the re-
ished (1-7). Although the primary diseases sults of many subsequent studies paral-
such as cancer, trauma, acute inflamma- lel to this research (16, 17). Malnutrition
tion, obstruction, or fistulas are the lead- increases not only mortality, but also all
ing causes of this condition, advanced infectious complications, total morbidity,
age, a previous chronic disease, and low a prolonged hospital and intensive care
socioeconomic status are additional risk unit stay, and costs (Figure 1). In a study
factors. Moreover, the issue of iatrogenic published in 2011, it was shown that
malnutrition should not be forgotten. The the health expenditures required for the
malnutrition that develops during hos- treatment of patients with malnutrition
pitalization is called “iatrogenic malnu- were as twice as high as those without
trition,” and it is reported to be seen at malnutrition and that malnutrition acted
a rate between 10% and 50% by various as an independent risk factor on mortality
researchers (3, 8). Knowing the causing (18).
factors (Table 1) plays an important role
in preventing the worsening of the nutri- The basic philosophy of enhanced recov-
tional problem, which already exists at the ery after surgery (ERAS) protocols, defined
ORCID ID of the author: time of hospitalization, and in the regula- as the multimodal and evidence-based
H.G. 0000-0002-7021-4827.
tion of appropriate treatment. Malnutri- perioperative care concept, is to reduce
Department of Gastrointestinal tion rates at the time of hospitalization in metabolic stress due to surgical trauma
Surgery, Ankara Şehir Hastanesi, surgical clinics dealing with patients with and to enable the return to normal activity
Ankara, Turkey
cancer range between 50% and 80% (2, as soon as possible by supporting normal-
Submitted: ization of functions in a short time. Pre-
9-14).
15.01.2019
operative optimization, prehabilitation,
Accepted:
12.02.2019
The effect of malnutrition on postopera- perioperative modern nutritional manage-
tive complications and mortality rates has ment, standard anesthesia and analgesia
Corresponding Author:
R. Haldun Gündoğdu long been known (Table 2). In the study regimens, and early mobilization are the
E-mail:
published by Studley et al. (15) in JAMA main components of ERAS protocols (19-
haldun@[Link] in 1936, it was shown that the mortality 24).
Cite this article as: Gündoğdu H. Current approach to perioperative nutrition in the ERAS age. Clin Sci Nutr 2019; 1(1): 1-10.
Content of this journal is licensed under a Creative Commons
Attribution-NonCommercial 4.0 International License.
1
Gündoğdu RH. Current approach to perioperative nutrition in the ERAS age Clin Sci Nutr 2019; 1(1): 1-10
A proper and safe nutritional support during the perioper- Importance of ERAS Protocols
ative period can solve many problems that may arise due ERAS recommends changes for the whole patient’s jour-
to malnutrition. In the period when ERAS protocols are ney, starting from the outpatient clinic before the opera-
on the agenda, the nutritional needs of patients who will
tion and ending up at home after being discharged (Fig-
undergo major surgeries are included in the guidelines of
many associations (25-29). ure 2).
Nutrition is one of the main elements of ERAS protocols
since it includes important issues such as preoperative
fasting, oral carbohydrate loading, optimizing preopera- Malnutrition
tive nutritional status, and early oral feeding. Therefore,
the issue of perioperative nutrition management for pa-
tients to be operated with ERAS protocols should be re-
viewed in the light of current information.
Morbidity ↑ Mortality
↑
Table 1. Iatrogenic malnutrition factors Wound healing
Treatment
Infections ↑
Lack of recording the body weight Complications ↑
↑ Length of stay
Lack of a clear description of responsibilities Convalescence in hospital
Lack of nutritional knowledge
Frequent fasting of the patient for examination
purposes
Continuous blood-letting for examinations
Poor documentation of food intake QUALITY
Loss of appetite due to environmental changes COST
OF LIFE
Surgery in a malnourished patient
Figure 1. Results of malnutrition
Postoperative long-term use of glucose and saline
solutions
Delayed nutritional support leading to irreversible
depletion
A patient’s journey through surgery
Table 2. Effects of malnutrition on surgical outcomes
Preoperative preparation
Continuous nursing unit
• Impaired wound healing
Out patient clinic
Surgical ward
Surgery and anesthesia
o Opening of incision
o Leakage from the anastomosis Home
• Decreased resistance to infections
o Postoperative pneumonia
o Postoperative wound infection
o Increase in intraabdominal infections
o Postoperative urinary infection Recovery period
• Impairment of adaptability
o Insufficiency in adaptation after intestinal resections
o Prolonged paralytic ileus Audit compliance and outcomes
• Delay in recovery
• Pressure ulcers Figure 2. The journey of a surgical patient
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Clin Sci Nutr 2019; 1(1): 1-10 Gündoğdu RH. Current approach to perioperative nutrition in the ERAS age
One of the most important factors in the improvement af- tion in the last 30 years, and as a result of this, mortality
ter surgery is to fight against the metabolic trauma caused rates have been reduced (41). However, the same success
by surgery. ERAS aims to reduce the metabolic response could not be achieved with the complication rates arising
to trauma thanks to modern surgery, anesthesia, analge- with the coexisting problems such as obesity, diabetes,
sia, and some support applications. Thus, the process will modern lifestyle, hypertension, and old age. In this sense,
end up with less damage and a quick recovery. The im- all patients who are to undergo major surgery should be
portant point to note is that ERAS are not only surgeon’s operated after their general conditions are maximized to
non-traditional practices, but also the performance of a achieve success. In the recent years, the concept of pre-
trained team (23, 24, 26). Although there are the contri- habitation that is recommended to be performed in the
butions of different team members in the process from preoperative period has been developed instead of the
the hospital admission to full recovery, surgeons, anesthe- concept of postoperative rehabilitation (42).
siologists, and nurses come to the forefront as the main
actors. Under the leadership of these basic members of Patients with diabetes should be well prepared preoper-
the team, all health professionals who will take part in the
atively and should be closely monitored in the postop-
process should audit at least once in 15 days and evaluate
erative period. Patients with high levels of glycosylated
the results and conduct training activities.
hemoglobin (HBA1c) preoperatively remain approximate-
ly 1 mmol/L higher than patients with normal preopera-
ERAS protocols go beyond the traditional and even dog-
matic surgical and anesthetic applications, and they bring
innovations that can be described as radical. The proto- Table 3. Components of ERAS protocol
col includes more than 20 evidence-based elements to Preoperative Intraoperative Postoperative
be applied in the perioperative period (Table 3) (23, 24,
26, 30, 31). These elements are grouped together by the Preadmission Surgical Blood sugar
ERAS Association in a way to include minor differences in counseling incisions management
guidelines prepared according to systems ([Link] Preoperative Prevention of Postoperative
[Link]/guidelines/list-of-guidelines/). mechanical bowel intraoperative non-opioid
preparation hypothermia analgesia
It is not possible to obtain good results by using one or
more of the elements included in ERAS protocols. When No prolonged Mid-thoracic Early removal of
all of the recommendations are implemented by a trained fasting epidural urinary catheter
team, the contributions to the postoperative recovery preoperatively analgesia
process are seen. Each element has a synergical effect on Preoperative oral Short-acting Stimulation of
another. The key issues such as proper management of
carbohydrate anesthesia gut motility
pain, early mobilization, and providing early oral feeding
loading protocol
through the proper management of gastrointestinal mo-
tility are supported by the use of many other elements. Assessment of Prevention of Early feeding
nutritional status and postoperative / early enteral
In all recently published meta-analyses, it has been shown nutritional support if nausea and nutrition if
that the duration of hospitalization is reduced by 2-3 days, necessary vomiting necessary
and the complications decrease by 30%-50% by applying
Preoperative Perioperative Early
ERAS protocols in major surgeries (32-35). The effect of
optimization fluid mobilization
adherence to protocols on the results is very clear. Mortal-
management
ity decreases by 42%-50% when the compliance to ERAS
is higher than 70% (36, 37). As the cost analysis of ERAS Prehabilitation No drains Early discharge
protocols was puplished, it was understood that it also criteria
provided a very important advantage in this sense (38,
No premedication Laparoscopic Audit of
39). In particular, the cost analysis from the Canadian Al-
and robotic compliance and
berta hospital chain was impressive, and it showed a profit
surgery outcomes
of $2800-5900 per patient with ERAS protocols (40).
Thromboprophylaxis No nasogastric
Prehabilitation tubes
The necessity of medical optimization before surgery has
Antimicrobial
gained a general acceptance. There have been many im-
prophylaxis
provements in preoperative cardio-pulmonary prepara-
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Gündoğdu RH. Current approach to perioperative nutrition in the ERAS age Clin Sci Nutr 2019; 1(1): 1-10
tive HbA1c levels, and additionally, more complications However, it should always be kept in mind that serum al-
develop in these patients (43). As recommended in many bumin levels alone are not indicator of the nutritional sta-
guidelines, the blood glucose level should be aimed at tus (48). Although albumin is a good laboratory parameter
around 140-180 mg/dL. Patients should be operated after for postoperative morbidity, it does not give a clear infor-
the preparations are completed in the areas such as quit- mation about the nutritional status due to its distribution
ting cigarette smoking and alcohol consumption 4 weeks in a large pool in the body, long half-life, and due to its
prior to the operation, exercise programs, reducing the changing levels in many diseases.
risk of co-morbid diseases by conducting required consul-
tations, and many other similar subjects. There is an indication of a nutritional plan in a patient who
is unable to take 60% of his or her normal food for longer
Preoperative Nutritional Management than 10 days in the preoperative period (29). In addition,
Surgical trauma results in significant endocrine and met- even if no specific malnutrition is detected, there is an in-
abolic changes that increase catabolism. It also disrupts dication for perioperative nutritional support in a patient
the immune response and reduces insulin resistance. In who is expected not be able to take food orally for more
addition, inadequate food intake over 14 days causes an than 7 days.
increase in morbidity and mortality (25). Planned or un-
planned fasting along with surgical trauma results in an There are different approaches to preparing the patient
increased nutritional risk. With the widespread use of neo- for surgery in terms of nutrition, which can be used in
adjuvant chemo-radiotherapy in cancer patients, an addi- combination (25, 29, 49):
tional burden to the deterioration of the nutritional status
has emerged for patients receiving these treatments (44). • Nutritional support if severe metabolic risk exists,
• Metabolic preparation (oral carbohydrate administra-
The European “NutritionDay” data of approximately tion),
15,000 patients indicated the metabolic risk as a factor • Immunological modulation.
affecting hospital mortality, especially in the elderly (45).
The high-risk patients in hospitals are mostly in the surgi- Postponement of the operation to complete the ener-
cal, oncology, and geriatric clinics, and in intensive care gy-protein deficiency or at least stop the hypercatabolic
units. The factors affecting the complication rates in hos- process is discussed only when there is a serious malnutri-
pitals are the severity of the disease, age over 70 years, tion or metabolic risk. If there is an indication of nutritional
surgery, and cancer. Considering the demographic devel- support, enteral route should be preferred. Enteral nutri-
opments in the Western world, surgeons must also deal tion should be performed before hospitalization to pre-
with the risk in elderly patients undergoing major cancer vent nosocomial infections. At this point, oral nutritional
surgery. Nutritional management is therefore an interdis- supplements (ONS) have an important role (29, 50, 51).
ciplinary field and has become a “necessity” for resource
savings in the period of limitations in the health economy. In severe malnutrition, parenteral nutrition is recom-
Nutritional risk screening should definitely be performed mended in patients who can not be fed orally or enterally
at the time of hospitalization, and it should also involve enough (52, 53). There is an indication of parenteral nu-
the metabolic aspect of the surgery. There are many trition in patients with malnutrition, for whom enteral nu-
screening tools, but the Nutrition Risk Screening (NRS- trition is not appropriate or in whom there is intolerance,
2002) method is the one that has been officially proposed including patients who have an impaired gastrointestinal
and validated by the European Society for Parenteral, En- system (GIS) function due to postoperative complications
teral Nutrition (ESPEN) (46). High complication rates were and who cannot receive and absorb adequate oral/enter-
found in patients who were determined to be at risk with al nutrition. Combined enteral-parenteral nutrition should
NRS. Preoperative tomography has been proven to be be considered in patients who cannot meet 60%-75% of
a valuable method in the detection of sarcopenia in pa- their energy requirement by enteral route (29, 54). Oral
tients with sarcopenic cancer (47). or parenteral nutrition support is usually maintained for
approximately 7-14 days (14, 29, 48).
Serious metabolic risk should be considered in the pres-
ence of one or more of the following criteria: Obese patients constitute another group that is often ne-
glected by surgeons. Many physicians think these patients
• Weight loss >10%-15% are an energy and protein store and believe that there is
• Body mass index <18.5 kg/m2 no need for an aggressive nutritional therapy in the pre-
• Serum albumin <30 g/L operative period. However, most these patients have sar-
4
Clin Sci Nutr 2019; 1(1): 1-10 Gündoğdu RH. Current approach to perioperative nutrition in the ERAS age
copenic obesity, and their dry body masses are very low. or needle catheter jejunostomy (NCJ) placement as an
This poses a serious risk for postoperative complications. enteral access is also suitable (64). After surgery, enteral
In fact, when mortality is considered in surgical intensive tube feeding is started within 24 h and at a low rate (5-10
care patients, morbid obesity is an independent predictor mL/h). The rate of administration is increased 10-20 mL/h
(55). per day. GI tolerance should be monitored carefully by
performing abdominal examination. The most important
Keeping patients hungry at the preoperative night affects issue that distresses clinicians is that it is not easy to dis-
postoperative insulin resistance and negatively affects the tinguish GI intolerance due to early feeding and the early
results (56). The metabolic burden provided by perioper- postoperative complications of major abdominal surgery.
ative hypoglycemia due to one-night fasting was clearly In such a situation, taking the easy ways such as interrupt-
demonstrated, and the dogmatic information about pre- ing feeding does not solve the problem. There are two
operative fasting has changed completely (56, 57). Con- critical moves to achieve optimal bowel functions. Early
sumption of oral solid foods at night and liquids up to 2-3 delivery of nutrients to the intestines and early correction
h prior to surgery does not increase the risk of aspiration of the changes in the pH or electrolytes (potassium>4
during anesthesia. Oral use of sugary fluids can be rec- mEq/L, magnesium>2 mEq/L) are very important.
ommended for many patients because it does not pre-
vent gastric emptying. It was shown that the oral solution Postoperative early feeding, which is one of the most im-
containing 12.5% maltodextrin as the main substance de- portant components of achieving the targeted result with
creases preoperative thirst, hunger, anxiety (58), and post- ERAS protocols, is supported by the combined use of
operative insulin resistance (56). Oral carbohydrate ad- some other elements included in the application. Thus,
ministration reduces postoperative nitrogen and protein while long-term ileus is prevented, it is also possible to in-
loss (59), resulting in improved preservation of lean body crease tolerance to early oral food intake. Early oral food
mass and muscle strength (60). Patients who will undergo intake is facilitated by many applications, such as avoiding
surgery should be given 800 mL of carbohydrate-rich liq- preoperative fasting, analgesia at the mid-thoracic level,
uid food until midnight preoperatively and 400 mL 2-3 h modern anesthesia management, target-specific periop-
before the operation to ensure metabolic toughness. This erative fluid therapy, and early mobilization.
practice has also been shown to significantly shorten the
duration of hospital stay after surgery (57). Intravenous However, oral nutrition is unfortunately still delayed for
glucose infusion may be used in very few patients who some reasons (Table 4) (48). By changing a number of
cannot take food orally or enterally. traditional, harmful, and unnecessary routines, the fac-
tors that prevent the transition to normal nutrition can be
Postoperative Period solved in the early period.
In the majority of patients after major abdominal sur-
gery, the stomach returns to normal myoelectric functions Parenteral Nutrition
within 24-48 h, the small intestines return to propulsive While emphasizing the most important aims of ERAS pro-
function within 12-24 h, and the colon returns to normal tocols as giving oral food as soon as possible, using the
contractility within 48-72 h. Therefore, cessation of oral digestive tract effectively, and early discharge, a ques-
food after surgery in many patients is unnecessary, and tion such as “Does parenteral nutrition still exist in this
it can be resumed within a few hours after surgery. It was algorithm?” may come to mind. However, it is seen that
shown48 that a 75%-90% success rate was achieved when it holds its own position in the recommendations made
the feeding was started within 6-24 h postoperatively. It is for perioperative period in the current guidelines (25, 29).
now information based on clear evidence that early oral/ There is a need for preoperative parenteral nutrition in pa-
enteral nutrition reduces infectious complications, reg- tients with malnutrition who cannot receive oral feeding
ulates the metabolic response to surgery, and shortens for 7 days for various reasons, and postoperative paren-
hospital stay (61-63). It was also shown that the anasto- teral nutrition is needed in patients in whom oral/enteral
motic leakage did not increase after GI tract operations feeding cannot be started within 7 days due to compli-
with early feeding. Therefore, there is no valid reason cations. In addition, in the daily practice, there are many
for fasting for a long time after surgery. Oral feeding can patients in whom it is required to use both enteral and
be started without delay even after the operations with parenteral nutrition.
GIS anastomosis. In patients undergoing upper GI anas-
tomosis, enteral nutrition can be performed via a tube Discharge and Follow-Up
placed distal to the anastomosis, and these patients may The follow-up of the nutritional status, including written
also drink ONS. In these patients, the nasojejunal tube monitorization of oral food intake, after major abdominal
5
Gündoğdu RH. Current approach to perioperative nutrition in the ERAS age Clin Sci Nutr 2019; 1(1): 1-10
acids, fiber, prebiotics, probiotics, various antioxidants,
Table 4. Factors that prevent early oral feeding
and glutathione. The prominent biochemical effects of
• Lack of understanding well the potential benefits of these formulas are increasing the cell membrane stabili-
early feeding ty, supporting gastrointestinal mucosal integrity, enhance
cellular immune response, and increase the blood flow
• Poor understanding the postoperative ileus
in ischemic tissues. Thus, it is aimed to decrease post-
• Unnecessarily waiting for the markers that are thought operative infective complications and general morbidity
to show bowel activity as clinical results. Regardless of the nutritional status of
• Concern about complications the patient, there is strong evidence that preoperative
o Aspiration pharmaconutrition reduces the length of hospital stay
o Bowel ischemia and postoperative complications (66-70). The SONVI
o Fear that feeding may cause anastomotic leakage study showed that postoperative complications could be
reduced by the combined use of ERAS protocols and im-
• Lack of feeding tube placement protocols mune nutrients (71). In a recently published meta-analysis,
• Lack of communication among team members the effect of different combinations of immune nutrients
on mortality, morbidity, and the length of hospitalization
in patients undergoing major abdominal surgery was in-
surgery is a very important responsibility. Diet counseling,
vestigated (72). The results of a total of 7116 patients in
which is to be performed clearly enough for the patient, is
83 randomized controlled trials were evaluated. It was
also recommended. Oral calorie intake will be insufficient
found that immune nutrients decreased morbidity, mor-
for months in most patients who undergo GI tract and
tality, and the duration of hospital stay. In the ESPEN and
pancreatic surgery. Reduction in appetite, deterioration of
ASPEN guidelines, it is strongly suggested that pharma-
enteral tolerance due to “dumping” symptoms, bloating,
and diarrhea are reasons that can cause this situation. If conutrition should be administered for 5-7 days preop-
NCJ is placed during surgery, it should not be removed eratively and for 1 week postoperatively in patients who
during discharge from the hospital. If necessary, 500-1000 are to undergo major cancer surgery (25, 73). It is recom-
kcal/day supplementary enteral nutrition may be given to mended that these products be used in patients who have
patient through NCJ, even if he or she is able to receive a serious risk and will have a major operation (esophagec-
oral food. After being trained, many patients will be able tomy, gastrectomy, pancreatoduodenectomy) due to neck
to do this on their own. Although it is not possible to pre- (laryngectomy, pharyngectomy) and abdominal cancer.
vent more weight loss, it has been proved that it can be
reduced with oral supplementation. Even if patients with In a recent meta-analysis that examined many aspects of
malnutrition in the preoperative period (especially those pharmaconutrition, 19 randomized controlled trials were
operated for upper GIS cancer) are managed without any evaluated, and with the conclusion that it reduced wound
problems during the period at the hospital, they should infections and hospital stay, it was suggested to be a part
be discharged with ONS prescription, after explaining the of the ERAS program in the upper GI cancer surgery (74).
correct and appropriate usage, and with the recommen-
dations that they should be consumed as a supplement The subject of the recent discussion is related to the tim-
to normal food for 4-8 weeks. The quality of life is also ing of pharmaconutrition. It is examined whether the re-
significantly better in patients in whom supplementation sults are affected by its administration in the preoperative,
is administered. postoperative, or perioperative period. While the benefits
of perioperative pharmaconutrition were supported in a
The Role of Pharmaconutrition recent meta-analysis, it was shown that only preoperative
In recent years, the effects of some nutrients used for administration did not affect the outcomes (68). In anoth-
nutrition support in the perioperative period on the im- er meta-analysis published in the same year, it was found
mune system have been investigated and discussed more that there was no difference between standard oral sup-
seriously. There are different views on terminology, but plements and immune nutrients in terms of the effect on
when mentioning the effects of nutrients on the immune outcomes, when they remained limited within the preop-
system, “pharmaconutrition” may be a more appropriate erative period (75).
nomenclature.
The impacts of these specific products on the cost were
The main nutritional elements that affect the immune sys- also discussed and evaluated in many studies. Contrary
tem in various ways and about which investigations are to popular belief, these formulas have been shown to be
made are arginine, glutamine, nucleotides, omega-3 fatty cost-effective in many studies. In a systematic review of
6
Clin Sci Nutr 2019; 1(1): 1-10 Gündoğdu RH. Current approach to perioperative nutrition in the ERAS age
All patients who will undergo major abdominal surgery
Routine nutritional assessment using NRS
No No
Severe malnutrition Gastrointestinal cancer surgery NRS ≥3
Yes Yes Yes
Postpone surgery 5-7 days of 5-7 days of 5-7 days of
2 weeks of oral/enteral preoperative preoperative preoperative
nutrition immunonutrition SEN IN
Surgery with ERAS protocols
Consider placment of nasoenteral or percutaneous feeding tube, if
A) postoperative fasting will be prolonged, or
B) there will be insufficient food intake.
High probability:
A) postoperative fasting will be prolonged, or
B) there will be insufficient food intake
Yes No
EN until sufficient food intake Early oral feeding according to ERAS protocols
or Plan oral supplementation at the
combined NS or PN time of discharge
Figure 3. Perioperative nutritional planning algorithm
cost analysis of perioperative pharmaconutrition in pa- Conflict of Interest: The author have no conflicts of interest to
tients undergoing GI cancer surgery, there were six pro- declare.
spective, randomized, controlled trials evaluated (76).
Financial Disclosure: The author declared that this study has
Compared to standard oral supplements, it was shown
received no financial support.
that special products were more advantageous in terms
of the total costs.
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