Postoperative complications have been majorly attributed to nutritional depletion. There has been a link between poor pre-operative nutritional status to an increase in the poorer surgical outcome and post-operative complications. The research evaluated the literature on pre-operative nutrition in clients undergoing gastrointestinal surgery. It used PICOT in stating the research question in adult patients, the comparison of the effectiveness of preoperative nutrition to lack of nutrition after going through gastrointestinal surgery in establishing a nutritional nourishment level after surgery. The participants used in the study were non-emergency surgical gastrointestinal, and the control group was patients with IE agent or single nutrient intake. The searches were piloted using the following databases EBM Reviews (NHSEED, HTA, CMR, CCTR, DARE, DSR, Cochrane, and AP Journal Club) and AMED, MEDLINE, EMBASE, Sage, DARE, and British Nursing Archive. This systematic review used Pre-operative Nutrition Support in Patients Undergoing Gastrointestinal Surgery article. The study indicated some benefits of administering nutritional support to clients before surgery by use of parenteral nutrition and immune enhancing drinks. However, there was no benefit of enteral or standard oral feeding thus it opens room for more research in the two areas for malnourished patients undergoing GI surgery.
Keywords: Pre-Operative, Nutrition, Gastrointestinal Surgery
Table of Contents
Evidence-Based Quantitative Article 8
Study Approach, Sample Size, and Population Studied 9
Data Collection and Analysis 9
Data Extraction and Management 9
Assessing the Risk of Bias in Included Studies 10
Measures of Treatment Effect 10
Assessment of Heterogeneity 11
Assessment of Reporting Biases 11
Subgroup Analysis and Investigation of Heterogeneity 11
Risk of Bias in Included Studies 13
Other Potential Sources of Bias 14
Application of the Review to Practice 14
Level of Evidence Identified In the Review 15
A Systematic Review of Pre-Operative Nutrition Care for Patients Undergoing Gastrointestinal Surgery
There has been an increase of pre-operative GI surgical patient with malnutrition risks leading to lengthy hospital stays, morbidity and mortality. According to Schiesser et al. (2008), 14% of clients admitted for elective GI surgery are at risk of malnutrition, among them, 40% suffers from post-operative complications which are higher while compared to those who were well nourished. In pre-operative patients, poor nutrition status is well documented, whereby 9% of clients undergoing elective GI surgery had a BMI indicating under-nutrition. 17% lost more than 10% of their body weight, and 54% had lost weight within six months before surgery (Burden, Todd, Hill & Lal, 2010).
Reduced level of nourishment (malnutrition) has been linked to infections and other post-surgery complications on the digestive system. Examples of these other according to da Silveira, de Oliveira Carvalho and Cataneo (2012) complications include bleeding, blood clots, heart failure or tissue breakdown at the surgery site. Russell and Elia (2008) explains that malnutrition is a well-recognized issue in clients undergoing GI operation: where in accordance to a UK survey, 40% of GI disease patients were at risk of malnutrition in comparison to 28% of all hospital admissions (Burden, Todd, Hill & Lal, 2010). Therefore, nutritional support is thus important to clients with GI disease before surgery.
The systematic review explores literature for the provision of extra nourishment to patients before surgery on their digestive tract. It will assist in determining whether the additional nourishment is beneficial in the reduction of infections or other complications. The review looks at all methods that provide artificial nourishment to patients before surgery. It includes nutritional supplements taken as a drink, enteral nutrition (feed is given by a device which delivers nourishment directly into the digestive tract) and parenteral nutrition (nourishment is given directly to the blood stream).
The research question is, in adult patients, the comparison of the effectiveness of preoperative nutrition to lack of nutrition after going through gastrointestinal surgery in establishing a nutritional nourishment level after surgery.
The study’s objective is to assess the literature on pre-operative nutrition in clients undergoing gastrointestinal surgery.
A systematic review using PubMed and the Cochrane Collaboration database articles of pre-operative nutrition in clients undergoing gastrointestinal surgery.
Research sample is adults between 18 to 60years with non-emergency surgical gastrointestinal.
Nutrition support intervention by use of micro and macronutrients via any route. The review will include patients with manipulated intake of diet to increase proteins and calories levels. It will also include patients with nutrition formulation of fat and carbohydrate within four months before surgery and 24 hours after surgery.
The control group was patients with IE agent or single nutrient intake. The control group did not receive any nutrient or received a single nutrient or IE agent within four months before surgery and 24hours after surgery.
Initially, searches were conducted using the following databases EBM Reviews (NHSEED, HTA, CMR, CCTR, DARE, DSR, Cochrane, and AP Journal Club) and AMED, MEDLINE, EMBASE, Sage, DARE, and British Nursing Archive. Keywords were used to search for the relevant article. The review later narrowed to two databases which contained relevant information for the evidence-based research. The two databases are PubMed and the Cochrane Collaboration database.
A randomized controlled trial was used as the inclusion criteria which evaluated the adequate nutritional support of the partakers in GI operations by use of a nutritional formula that was provided by oral, enteral and parenteral routes. The primary outcomes included the duration of hospital stay and post-operative complications.
The article of choice in this review is Pre-operative Nutrition Support in Patients undergoing gastrointestinal surgery. The authors of the article are Burden S, Todd C, Hill J, Lal S and it was published in 2012 by The Cochrane Library.
The after surgery management in gastrointestinal (GI) surgery is well established by protocols of ‘Enhanced Recovery After Surgery’ that starts 24hours before surgery with enteral or early oral or carbohydrates loading feeding which is administered to a patient the first day after the operation. The authors state that there is unclear evidence of whether nutritional interventions are beneficial when initiated earlier before surgery. They explain that poor pre-operative nutritional status is consistently linked to more complications after surgery and poor surgical outcome.
The study’s primary objective is to assess whether nutritional support interventions by use of any route before surgery develop the clinical outcomes in elective GI surgical patients. The secondary objective of the study was determining the benefits of nutritional support intervention to nutritional status or nutritional intake before an elective GI surgery.
The authors ran their searches in March 2011 and updated them on February 2012. The databases used included MEDLINE, British Nursing Index Archive using OvidSP, AMED, EMBASE and EBM Reviews (NHSEED, HTA, CMR, CCTR, DARE, ACP Journal Club, and Cochrane DSR). The article used randomized controlled trials as the inclusion criteria where it assessed the preoperative nutritional support in GI surgical patients by use of a nutritional formula that was generated from an oral, enteral or parenteral route. The primary outcomes consisted of a length of hospital stay and post-operative complications.
The study used conference abstracts of RCTs, published randomized controlled trials that obtained enough data. The populations studied were all non- emergency GI, surgical patients. The search engines identified 9990 articles, and after the screening, 167 were selected as the most suitable articles for the review. After the summaries had been read, there was a selection of 33 articles among which 13 fulfilled the inclusion.
The first step was the screening of abstracts to be included in the review and data extraction was carried out. In every included article, biases were assessed by use of Cochrane Collaboration bias assessment tables.
The title and the abstract were assessed to determine the eligibility and relevance of the articles. All articles that failed to meet the eligibility criteria were not included in the review. However, articles which had insufficient information on their title and abstract were taken for clarification. The full text of the researches was assessed, and data was extracted from the studies that met the inclusion criteria. Nevertheless, there was no translation of language as the study utilized only English articles during the assessment.
There was the development of data collection from which facilitated the collection of data from reports. The form enhanced the evaluation of eligibility as it directly linked the study to the research question. The data extraction form was modified and piloted as needed. In every trial, the following information was recorded:-
The quality of each trial was rated in the given areas; selective outcome reporting, complete outcome data, blinding, allocation concealment, random sequence generation, and other bias sources by use of Cochrane Collaboration’s tool New Reference.
The estimate of treatment effect in the intervention was articulated as a risk ratio (RR) in addition to 95% confidence intervals.
In the outcomes of dichotomous, the treatment effect estimates of the intervention were expressed as RR as well as the to 95% confidence intervals. Standard deviations and mean differences expressed the continuous outcome in summarizing every group’s data.
In the articles, the researchers were contacted for missing data and abstracts where possible.
The clinical heterogeneity was evaluated through the examination of the type of outcomes, interventions, and participants in every study. However, in studies that required comparison of outcome measures, a meta-analysis was conducted.
The study used funnel plot to evaluate publication bias.
The use of meta-analyses was only in studies that reported similar comparisons for the same outcome measures.
Group analysis was conducted on studies that included elective versus semi-elective surgery, participants with cancer and without cancer, malnourished participants, route of feeding and those that stated the use of an ERAS protocol. The included studies failed to facilitate the subgroups’ analysis.
The article undertook a planned sensitivity analysis in the examination of quality differences of the studies and the examination of articles published before and after 1990. The choice of the date was due to the introduction of artificial feeding in 1990 including the type and amount of parenteral and enteral nutrition, feeding tubes, line care, and changes in technology. Where appropriate, sensitivity analysis was conducted of articles that used ERAS protocol. However, the included articles did not facilitate this.
About 9900 titles were identified from databases searches after excluding duplicates; there was an initial screening of 6433 titles. After the initial screening, there was the exclusion of 6266. Later there was abstract screening for 167 types of research, and among them, 33 articles were identified as they met the inclusion criteria. After assessing the complete manuscript, 13 articles were included in the review. There was also the inclusion of seven articles in the trials that evaluated the IE nutrition among them six were combined in the meta-analysis.
The studies indicated low to moderate heterogeneity level as well as lessened total complications after surgery (RR (risk ratio) 0.67 CI 0.53 to 0.84). The meta-analysis included three trials that evaluated PN which demonstrated reduced post-operative complications (RR 0.64 95% CI 0.46 to 0.87) in principally malnourished candidates giving a low heterogeneity. There was also the inclusion of three evaluating standard oral supplement trials (RR 1.01 95% CI 0.56 to 1.10) and two enteral nutrition trials (RR 0.79, 95% CI 0.56 to 1.10) of which neither illustrated any change in primary outcomes.
The article used a total of 1192 participants who were included in trials analysis as they had relevant data on pre-operative nutritional support. The PN trials included 260 participants, standard oral nutritional supplements trials had 263 participants, the IE nutrition trials had 549 participants, and enteral nutrition trials had 120 participants. They collected data on methodology, administration, outcomes, details of nutritional substrates, types of participants, and location of surgery from each study. The researchers included one unpublished study which allowed analysis with other trials. All trials used in the research included post-operative complications as an outcome.
The research illustrated that immune enhancing drink (oral drinks with added nutrients) that assists in fighting infections administered before surgery reduce total complications. In the study, total complications were reduced by 42% in the control group to 27% of the group that received the immune enhancing drink. On the other hand, infections were reduced from 27% in the control group to 14% to the cluster that received the immune enhancing drink. The total complications were reduced from 45% by parenteral nutrition in the control group to 28% to the group that received parenteral nutrition. However, the study illustrated no benefits on both standard supplements drinks and enteral feeding.
Six of the included trials were described using sequence generation while two trials used allocation concealment. The method of allocation concealment and sequence generation was not reported in the remaining trials.
Blinding was only carried out on two trials only as in other trials it is hard to blind the intervention especially while comparing parenteral and enteral nutrition. Due to the remaining studies not reporting blinding of participants or researchers, there was a high risk of bias.
Several trials reported unclear risk or high risk of attrition bias due to the recruitment of participants who did not have an elective GI surgery thus were not involved in the analysis. Nutritional intervention is a form of supportive therapy, and if patients fail to undergo surgery, there can be no evaluation of postoperative complications. Due to this, there was an occurrence of post-randomization exclusions among four of the trials. Bias in the research also occurred due in four trials due to no diagnosis of malignancy, minimum oral intake of the intervention, uncontrolled blood sugar levels, emergency surgery to relieve the obstruction, GI bleeding, and exclusion of participants who received parenteral nutrition or postoperative enteral.
All the trials included in the article reported at least one among the mentioned primary outcomes in its methodology.
Even though some trials principally included participants with malignant pathology, there was the exclusion of patients who had received pre-operative immunosuppressive treatment, radiotherapy or chemotherapy. This introduces an external bias thus affecting generalization of results. Another bias possibility was the enrolment of few malnourished participants as the majority of trials had well-nourished patients. Therefore, participants who were likely to benefit from the nutritional support were not included in the majority of these studies. Over the last decade, there is a change of perioperative surgical management due to technological advances as well as the advent of ERAS in the assessment, formulation, and delivery of nutritional substrates which introduces in the body evidence temporal bias.
The ERAS continues to increase during the management of clients undertaking a GI operational process. ERAS comprises of recommendations on feeding with pre-operative carbohydrate loading and post-operative nutritional management. There lacks a consensus on nutrition intervention before a patient undergoes an elective GI surgery. Due to this gap, the review is useful as it tries to fill the gap by evaluating the nutritional support intervention administered by any route before surgery. This will assist assessing if the intervention improves the elective GI surgical patients’ clinical outcomes. The review also determined the benefits of nutritional support interventions to nutritional status or nutritional intake before carrying out an elective GI surgery.
The study has generated some benefits of administering nutritional support to clients before surgery by use of parenteral nutrition and immune enhancing drinks. There was no benefit of enteral or standard oral feeding thus it opens room for more research in the two areas, for malnourished patients undergoing GI surgery.
The presented knowledge is applicable in the current management of GI surgical patients about standard supplements and IE nutrition. The pre-operative IE nutrition results favor the intervention that compares the control of infectious and non-infectious complications in primarily well-nourished surgical participants and where there are no severe co-morbidities. There are inconclusive effects on the duration of hospital stay in pre-operative IE. There is no evaluation of Immune-nutrition in combination with ERAS programs, and it demonstrates no benefit of improving the nutritional status of malnourished or weight losing patients before surgery. According to the study, surgical participants with high post-operative complications risks are not included in the majority of IE research. The data that relates to preoperative enteral nutrition and oral supplements are not conclusive. There was a positive effect for pre-operative PN on total complications and not on infectious complications in primarily malnourished candidates.
Burden, S., Todd, C., Hill, J., & Lal, S. (2010). Preoperative Nutrition in Patients Undergoing Gastrointestinal Surgery. Cochrane Database Of Systematic Reviews. http://dx.doi.org/10.1002/14651858.cd008879
da Silveira, R., de Oliveira Carvalho, P., & Cataneo, A. (2012). Interventions for reducing diarrhoea in patients receiving chemotherapy for colorectal cancer. Cochrane Database Of Systematic Reviews. http://dx.doi.org/10.1002/14651858.cd009615
Russell, C., & Elia, M. (2008). Nutritional screening survey in the UK in 2008. BAPEN. BAPEN.Schiesser, M., Muller, S., Kirchhoff, P., Breitenstein, S., Schäfer, M., & Clavien, P. (2008). Assessment of a novel screening score for nutritional risk in predicting complications in gastro-intestinal surgery. Clinical Nutrition, 27(4), 565-570
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