Current Issue

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.

Citation of Articles Reviewed:

Gao X, Liu Y, Zhang L, et al. Effect of Early vs Late Supplemental Parenteral Nutrition in Patients Undergoing Abdominal Surgery: A Randomized Clinical Trial. JAMA Surg. 2022;157(5):384-393. doi:10.1001/jamasurg.2022.0269

Ljungqvist O, Gustafsson UO, Lobo DN. Early Postoperative Supplementary Parenteral Nutrition. JAMA Surg. 2022;157(5):393-394. doi:10.1001/jamasurg.2022.0266

Commentary by: Brian G. Harbrecht, MD, FACS

Defining the optimal nutritional regimen for postoperative and critically ill surgical patients remains elusive despite advancements in perioperative care. While techniques like early nutrition, pharmaconutrition, hypocaloric feeding, preoperative optimization, and supplemental/total parenteral nutrition have been explored, their results are often inconclusive.^1,2 Gao et al. posit that improving postoperative caloric delivery via parenteral supplementation may reduce postoperative infections.³ This is a promising approach, and their prospective randomized trial attempts to address this hypothesis. However, the study leaves several key details about patient management unexplained, making it difficult to assess the impact of their findings fully.

The study cohort did not focus on malnourished patients, the group with the strongest evidence for proactive perioperative nutritional therapy. Subjects were deemed “at-risk” for malnutrition using the nutrition risk screening (NRS), but the threshold used was lower than commonly recommended² and might be met simply by ICU admission. This raises the question of how “at-risk” subjects truly were compared to other major elective surgery patients. Similarly, the entry criterion of less than 30% of predicted caloric needs by day two is incomplete. Most subjects had gastric (39%) or colorectal (35%) cancer surgery. Yet, the use of gastrostomy/jejunostomy tubes, motility agents, regional anesthesia, or standardized enteral nutrition programs remains unreported, obscuring the degree to which enteral nutrition was prioritized.

The authors reference the Enhanced Recovery After Surgery (ERAS) Society guidelines for nutritional therapy. However, Figure 2 implies that the ERAS emphasis on initiating oral intake within 24 hours was not followed, as goal enteral calories were not met until >7 days post-surgery. While the authors state that enteral nutrition began within 24 hours, the reasons for unsuccessful calorie delivery are unexplained. Data on enteral feeding intolerance (including its definition) and whether physician decisions were a contributing factor is lacking. The association between increased caloric delivery and reduced nosocomial infection is shown. Notably, most infections were pneumonia, yet Table 2 data does not account for subjects with a mean 2.5-week hospitalization. Curiously, there were no length of stay or hospital cost differences between groups, which is surprising given the role of infections and complications in determining these metrics.

This complex, multi-center trial on a vital aspect of perioperative management deserves recognition. However, the accompanying editorial correctly identifies the absence of key patient management and study details. This inhibits a complete understanding of how these findings translate into surgical practice, particularly as ERAS principles gain broader acceptance in elective cancer surgery.

References

1. Lobo DN, Gianotti L, Adiamah A, et al. Perioperative nutrition: Recommendations from the ESPEN expert group. Clin Nutr. 2020;39(11):3211-3227. doi:10.1016/j.clnu.2020.03.038
2. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN) [published correction appears in JPEN J Parenter Enteral Nutr. 2016 Nov;40(8):1200]. JPEN J Parenter Enteral Nutr. 2016;40(2):159-211. doi:10.1177/0148607115621863
3. Gao X, Liu Y, Zhang L, et al. Effect of Early vs Late Supplemental Parenteral Nutrition in Patients Undergoing Abdominal Surgery: A Randomized Clinical Trial. JAMA Surg. 2022;157(5):384-393. doi:10.1001/jamasurg.2022.0269

The SRGS Recommended Reading List is a summary of the most pertinent articles cited in each issue; the editor has carefully selected a group of current, classic, and seminal articles for further study in certain formats of SRGS. The citations below are linked to their abstracts on PubMed, and free full texts are available where indicated.

SRGS has obtained permission from journal publishers to reprint these articles. Copying and distributing these reprints is a violation of our licensing agreement with these publishers and is strictly prohibited.

McClave SA, Lowen CC, Martindale RG. The 2016 ESPEN Arvid Wretlind lecture: The gut in stress. Clin Nutr. 2018;37(1):19-36. doi:10.1016/j.clnu.2017.07.015

McClave et al. provide a succinct overview of how microbiome alterations, particularly the rise of pathobionts, coupled with intestinal barrier breakdown and increased permeability, profoundly shape both the physiological and immunological responses in critical illness.

Wischmeyer PE, Bear DE, Berger MM, et al. Personalized nutrition therapy in critical care: 10 expert recommendations. Crit Care. 2023;27(1):261. Published 2023 Jul 4. doi:10.1186/s13054-023-04539-x

Wischmeyer and coauthors offer a comprehensive set of ten recommendations for optimizing nutritional care in the critical care environment. This article stresses the importance of prioritizing early nutritional assessment for critically ill patients, followed by rapid, protocol-driven implementation of enteral or parenteral nutrition. Focused monitoring and selective use of pharmacologic agents are advised to maximize nutritional support benefits.

Volkert D, Beck AM, Cederholm T, et al. ESPEN practical guideline: Clinical nutrition and hydration in geriatrics. Clin Nutr. 2022;41(4):958-989. doi:10.1016/j.clnu.2022.01.024

Under the auspices of ESPEN, Volkert and colleagues present a comprehensive framework for addressing the unique nutritional and hydration needs of geriatric patients. Key contributions include detailed assessment strategies, interventions specific to age-related physiological changes, and practical monitoring protocols tailored for this vulnerable population.

Marcolini EG, Putnam AT, Aydin A. History and Perspectives on Nutrition and Hydration at the End of Life. Yale J Biol Med. 2018;91(2):173-176. Published 2018 Jun 28.

Marcolini and colleagues delve into the multifaceted ethical complexities surrounding artificial nutrition and hydration (ANH) decisions for terminally ill patients. Their work emphasizes the critical need for clear communication strategies between patients, families, and healthcare providers. A focus on patient autonomy, respecting diverse cultural and religious values, and weighing the potential burdens of ANH against the possibility of comfort or increased suffering are key themes addressed in the article.