Nutrition optimization prior to surgery

Improved outcomes with perioperative dietitian-led interventions in patients undergoing total joint arthroplasty: A systematic review

Background

Nutritional assessment is important for optimization of patients undergoing elective total joint arthroplasty (TJA). Preoperative nutritional intervention is a potentially modifiable optimization target, but the outcomes of such intervention are not well-studied. The purpose of this study is to assess the impact of nutritional interventions on elective TJA outcomes.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to perform a systematic review of the Ovid Medline, Embase, and Cochrane Library systems. Included studies were comprised of patients greater than 18 years of age undergoing a primary unilateral TJA who received a perioperative dietitian-led intervention. Data analyzed included nutritional intervention protocol, patient demographics, length of stay (LOS), postoperative labs and complications, among others.

Results

Our initial search identified a total of 1766 articles. Four studies representing 5006 patients met inclusion criteria. The studies utilized a protein-dominant diet, with or without a carbohydrate solution accompanied by dietitian assessment or education. The 4 studies found that the intervention group had significantly decreased LOS, fewer albumin infusions, less wound drainage, lower rates of hypocalcemia and hypokalemia, reduced C-reactive protein (CRP) values, improved time out of bed, and decreased overall costs.

Conclusion

The findings support the potential benefits of perioperative dietitian-led intervention on key outcomes for patients undergoing primary TJA. Surgeons should consider nutritional intervention in their preoperative optimization protocols. Future studies could help elucidate the optimum nutritional regimens and monitoring for idealized intervention and surgical timing.

Prospero registration number

CRD4202338494.

Detailed description of multidisciplinary prehabilitation in patients admitted to nerve sparring radical prostatectomy - A randomized feasibility study protocol

Background

Localized prostate cancer treated with radical prostatectomy is highly effective, though severe side-effects are common after the surgery. Prehabilitation is an approach to optimize patient's physical and mental resources before surgery, to improve postoperative outcomes. The feasibility of a multi-modal home-based prehabilitation program, delivered using telehealth in patients awaiting radical prostatectomy is unknown. This paper describes the development of a prehabilitation program for patients awaiting radical prostatectomy.

Method

A model by The Medical Research Council for developing and evaluating complex interventions (MRC Framework) was used in the development process. The Template for Intervention Description and Replication (TIDieR) checklist was applied for ensuring sufficient description of the interventions. A total of 40 patients will be randomized to either intervention or control group. Patients in the control group will follow standard care. The 4-week prehabilitation programme consists of exercise, pelvic floor exercise, sexual counseling, stress management and nutritional support. The interventions are home-based and delivered using telehealth. Feasibility outcomes will include recruitment, attrition rates, adherence, safety and suitability.

Conclusion

We have developed a multimodal prehabilitation programme, which has the potential to bring tangible health benefits to men with prostate cancer awaiting radical prostatectomy. The results of the feasibility study will inform the design of a fully powered randomized controlled trial.

PERIOPERATIVE CARE IN DIGESTIVE SURGERY: THE ERAS AND ACERTO PROTOCOLS - BRAZILIAN COLLEGE OF DIGESTIVE SURGERY POSITION PAPER

BACKGROUND

The concept introduced by protocols of enhanced recovery after surgery modifies perioperative traditional care in digestive surgery. The integration of these modern recommendations components during the perioperative period is of great importance to ensure fewer postoperative complications, reduced length of hospital stay, and decreased surgical costs.

AIMS

To emphasize the most important points of a multimodal perioperative care protocol.

METHODS

Careful analysis of each recommendation of both ERAS and ACERTO protocols, justifying their inclusion in the multimodal care recommended for digestive surgery patients.

RESULTS

Enhanced recovery programs (ERPs) such as ERAS and ACERTO protocols are a cornerstone in modern perioperative care. Nutritional therapy is fundamental in digestive surgery, and thus, both preoperative and postoperative nutrition care are key to ensuring fewer postoperative complications and reducing the length of hospital stay. The concept of prehabilitation is another key element in ERPs. The handling of crystalloid fluids in a perfect balance is vital. Fluid overload can delay the recovery of patients and increase postoperative complications. Abbreviation of preoperative fasting for two hours before anesthesia is now accepted by various guidelines of both surgical and anesthesiology societies. Combined with early postoperative refeeding, these prescriptions are not only safe but can also enhance the recovery of patients undergoing digestive procedures.

CONCLUSIONS

This position paper from the Brazilian College of Digestive Surgery strongly emphasizes that the implementation of ERPs in digestive surgery represents a paradigm shift in perioperative care, transcending traditional practices and embracing an intelligent approach to patient well-being.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Obesity and Malnutrition-Part Four of the Movement Is Life Special ONJ Series

Obesity and malnutrition affect many patients with osteoarthritis and can predispose patients to worse outcomes after total joint arthroplasty (TJA). However, these modifiable risk factors can be addressed in preoperative optimization programs driven by nurse navigators. Our aim is to provide resources and recommendations for nurse navigators when addressing obesity and malnutrition among TJA patients. In addition to discussions with nurse navigators regarding obesity and malnutrition, a literature review was conducted to assess the current practice standards for management. Nurse navigators often had difficulty implementing long-term interventions, but interventions in the literature included medical and bariatric treatments for obesity and more targeted assessment of nutrition status. These findings are incorporated into our recommendations for nurse navigators. Addressing obesity and malnutrition in preoperative optimization can contribute to improved outcomes, as has been demonstrated in current practice and in the literature.

Impact of Preoperative Nutritional Support on Surgical Outcomes in Gastrointestinal Surgeries: A Systematic Review

Malnutrition presents a significant risk to patients undergoing gastrointestinal surgery, with direct consequences on postoperative complication rates, recovery times, and mortality. Our systematic review, guided by PRISMA protocols, examined the impact of preoperative nutritional support on these surgical outcomes. We scrutinized publications from PubMed, Medline, Embase, and the Cochrane Library up to April 2023, including randomized controlled trials, cohort studies, and systematic reviews. The stringent selection process narrowed to 10 studies demonstrating the efficacy of preoperative nutritional support, from oral supplements to enteral and parenteral nutrition, in reducing postoperative complications and length of hospital stays while enhancing recovery rates. The benefits varied, indicating a pressing need for customized nutritional regimens based on patient demographics and surgical specifics. Our findings advocate incorporating individualized nutritional strategies into preoperative care, enhancing patient outcomes. Future research should aim to refine these strategies, focusing on the optimal timing, duration, and type of nutritional support.

Unplanned readmissions following ambulatory spine surgery: assessing common reasons and risk factors

BACKGROUND CONTEXT

Although outpatient spine surgery is becoming increasingly popular in the United States, unplanned readmission following outpatient surgery remains a significant postoperative concern.

PURPOSE

This study aimed to (1) describe the incidence and timing of 30-day unplanned readmission after ambulatory lumbar and cervical spine surgery (2) evaluate the common reasons for readmission, and (3) identify factors associated with readmission in this population.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified in the National Surgical Quality Improvement Program (NSQIP) database.

OUTCOME MEASURES

Hospital readmission within 30 postoperative days.

METHODS

Patients who underwent ambulatory cervical or lumbar spine surgery between 2015 and 2020 were identified using the National Surgical Quality Improvement Program (NSQIP) database. Reasons for and timing of unplanned readmissions were recorded. Multivariable poisson regressions were employed to determine any independent predictors of readmission.

RESULTS

A total of 33,092 ambulatory cervical and 68,115 ambulatory lumbar spine surgery patients were identified. Incidences of 30-day readmission were 3.37% and 3.07% among cervical and lumbar patients, respectively. The most common surgical site-related reasons for readmission included uncontrolled pain, recurrence of disc herniation or major symptom, and postoperative hematoma/seroma. Common nonsurgical site-related reasons included gastrointestinal, neurological, and cardiovascular complications. Factors associated with readmission among cervical patients included age ≥55, BMI ≥35, functional dependence, diabetes, smoking, COPD, and steroid use, whereas factors associated with readmission following lumbar spine surgery included age ≥65, female sex, BMI ≥35, functional dependence, ASA ≥3, diabetes, smoking, COPD, and hypertension (p<.05 for all).

CONCLUSION

This study highlights the common reasons and factors associated with unplanned readmission following ambulatory spine surgery. Consideration of these factors may be critical to ensuring appropriate patient selection for ambulatory spine surgery.

An evidence-based review of optimal perioperative practices in minor hand surgery

BACKGROUND

Like many surgical subspecialties, there have been frequent advancements and discoveries in the field of hand and upper extremity surgery. With a rapidly growing literature base, it can be difficult to remain updated on the latest recommendations.

METHODS

A comprehensive literature search was completed on PubMed using MeSH terms. Topics included nutrition management, anticoagulation, immunosuppressive medication management, antibiotic use, skin preparation, splinting, tourniquet use, and suture choice. Data from articles with a level of evidence 1A-3 C were included.

RESULTS

A total of 42 articles were identified and reviewed to provide evidence for recommendations regarding various aspects of pre-, intra-, and post-operative care.

CONCLUSIONS

The objective of this manuscript is to serve as a resource for evidence-based recommendations by the findings of recent evidence related to perioperative care in elective hand surgery. Additional studies are required in certain areas of the literature in order to provide stronger recommendations.

Enteral nutrition product formulations: A review of available products and indications for use

When oral nutrition is not feasible, enteral nutrition (EN) therapy is often considered the preferred route of nutrition support to meet the nutrient needs of individuals with a functional gastrointestinal tract across multiple levels of care (critical care, acute care, and home care). Enteral formulations have progressively evolved over the last 50 years from the simple blending of hospital food thin enough to run through a feeding tube, to the development of commercial standard formulas, followed by specialized formulas with immune-modulating and disease-specific qualities, to the most recent shift to food-based or blenderized EN composed of natural, whole foods with perceived health benefits. With the vast number of enteral formulations on the market, clinicians may be overwhelmed trying to determine proven vs theoretical benefits. This review is intended to explore differences in enteral formulations, identify implications for clinical practice, and review evidenced-based clinical guidelines to assist clinicians in enteral formula selection.

The effects of hypoalbuminemia in obese patients undergoing total joint arthroplasty

INTRODUCTION

Total joint arthroplasty (TJA) is a highly effective surgery. However, poor nutritional status has been associated with worse outcomes. In orthopedics, nutrition status is commonly evaluated using serum albumin. When albumin levels fall below 3.0 g/dL, wound healing ability becomes impaired. Typically, malnutrition is associated with low BMI, but malnourished patients can also be obese. The goals of this study were to investigate the relationship between malnourishment represented through albumin levels of obese patients and likelihood of postoperative complications.

METHODS

A retrospective review of patients undergoing primary TJA from 2016 to 2020 in the American College of Surgeons National Surgical Quality Improvement Program national database was performed. Patients with an albumin of < 3.5 g/dL were considered to have hypoalbuminemia and those with ≥ 3.5 g/dL were considered normal albumin. Univariate analysis was used to determine demographic and comorbidity differences between those with and without hypoalbuminemia. Outcomes of interest included length of stay, resource utilization, discharge disposition, and unplanned readmissions. Multivariate logistic regression examined albumin as a predictor of increased resource utilization and complications after controlling for possible confounding variables.

RESULTS

Of the 79,784 patients, 4.96% of patients had low albumin. Those with hypoalbuminemia were nearly 1.5 years older than those with normal albumin, were more likely to be black, female, and had an overall increased comorbidity burden as shown by percent of patients with ASA > 3 (all p < 0.001). After risk adjustment, those with hypoalbuminemia and a BMI of 35 + had greater risk of complications and increased resource utilization.

CONCLUSION

Our results demonstrated the prevalence of malnutrition increases as a patient's BMI increases. Further, hypoalbuminemia was associated with increased resource utilization and increased complication rates in all obese patients. We suggest screening albumin levels in obese patients preoperatively to give surgeons the best opportunity to optimize patient nutrition before undergoing surgery.

Frailty assessment has come to stay: Retrospective analysis pilot study of two frailty scales in oncological older patients undergoing colorectal surgery

INTRODUCTION

Colorectal cancer is a disease of the elderly and its main treatment is surgery. Frailty, a clinical syndrome of decreased reserve, increases with age and has been recognized as a predictive factor for postoperative mortality. Our primary objective was to assess the association between two frailty scores and mortality within the first year after surgery, by retrospectively linking frailty scores to mortality data and comparing the strength of their association with mortality to that of the ASA Classification. The frailty scales used were: the Modified Frailty Index (MFI) and, the Risk Analysis Index-A (RAI-A) and the G8 screening test (G8). As secondary objectives, we assessed the relationship of the frailty scales with morbidity and compared all the scales with the ASA.

MATERIAL AND METHODS

We retrospectively studied 172 patients aged 65 years and older who underwent laparoscopic colorectal surgery for cancer between January 2017 and June 2018, following them up for 1year after surgery.

RESULTS

Both morbidity and mortality were significantly associated with all frailty scale scores (p<.001). The more frailty, the greater probability of prolonged hospital stay, complications, readmissions and emergency department visits. Using each scale, patients were categorized into two groups (frail and non-frail patients). The C-indexes for 1-year mortality with the RAI-A and, MFI and G8 were 0.89 and, 0.86 and 0.86 respectively. On the other hand, ASA status is not strongly associated with mortality, with a C-index of .63.

DISCUSSION

Frailty scores should begin to influence medical and surgical strategies and further research is needed to develop guidelines for interventions in geriatric patients.

Development of a Risk Prediction Model for Complications Following Forehead Flaps for Nasal and Periorbital Reconstruction

BACKGROUND

Forehead flaps are a workhorse for nasal reconstruction, but complications occur in up to 30% of patients and risk factors are not well characterized. This study aimed to identify risk factors for complications, and provide clinicians a method to stratify patient risk to facilitate shared decision-making.

MATERIALS AND METHODS

This retrospective study included patients who underwent forehead flaps between 2007 and 2020. Demographic and treatment characteristics were abstracted, in addition to clinical outcomes data. Multivariable regression was conducted, with step-wise variable elimination to determine inclusion in the final model. From the final regression, a risk-stratification scheme was developed.

RESULTS

One hundred ninety-seven patients underwent forehead flap reconstruction, with a mean age of 68.5 years. Mean follow-up time was 42 months. There were 50 (25.4%) patients who developed a complication, including impaired nasal function (18.8%), flap congestion (5.1%), infection (2.5%), poor donor site healing (2.5%) wound dehiscence (2.0%), and flap congestion (1.5%). On univariate analysis, female sex, immunosuppression, prior radiotherapy, and larger resection area were associated with complications ( P <0.05). On multivariable analysis, female sex [odds ratio (OR): 3.89, P <0.001], hypoalbuminemia (OR: 3.70, P =0.01), and prior wide local excision (OR: 3.62, P =0.04) were predictors of complications. A clinical calculator was developed incorporating these risk factors, with a C-statistic of 0.85, indicating strong predictive value.

CONCLUSIONS

We conducted the most comprehensive review of risk factors for the development of complications after forehead flap reconstruction. From this analysis, a novel, implementable, risk-stratification scheme was developed to equip surgeons with the ability to provide individualized risk assessment to patients and address preoperative comorbidities to optimize outcomes.

Effectiveness of intensive perioperative nutrition therapy among adults undergoing gastrointestinal and oncological surgery in a public hospital: study protocol for a pragmatic randomized control trial

Background

Perioperative malnutrition is common in patients undergoing gastrointestinal-oncology surgery and is associated with longer hospital stays, increased postoperative complications, poorer quality of life, and lower survival rates. Current practice emphasizes the role of early perioperative nutrition therapy as an early intervention to combat the postoperative complications of patients and the implementation is now widely adopted. However, there is still a lack of research on determining the effectiveness of intensive nutrition therapy and providing ONS perioperative locally. This becomes the significance of this study and serves as a basis for management and guideline in the local hospital settings.

Methods

This is a pragmatic randomized control trial study where elective admitted patients will be randomly divided into the intervention (SS) or control (NN) group. All data will be collected during a face-to-face interview, anthropometric measurement, blood sampling (albumin, white blood count, hemoglobin, and c-reactive protein), handgrip strength, and postoperative complications. Group SS will be receiving a tailored lifestyle and intensively supplemented with oral nutrition support as compared to Group NN that will receive standard medical care. The primary outcome for this study is the length of stay in the hospital. Additional outcome measures are changes in biochemical profile and nutritional and functional status. The effects of intervention between groups on the outcome parameters will be analyzed by using the SPSS General Linear Model (GLM) for the repeated measure procedure.

Discussion

The intervention implemented in this study will serve as baseline data in providing appropriate nutritional management in patients undergoing gastrointestinal and oncological surgery.

Trial registration

ClinicalTrials.gov Protocol Registration and Results System (PRS) NCT04347772. Registered on 20 November 2019.

Preoperative Evaluation and Management of Patients With Select Chronic Gastrointestinal, Liver, and Renal Diseases

Patients with chronic gastrointestinal, hepatic, and renal disease are frequently encountered in clinical practice. This is due in part to the rising prevalence of risk factors associated with these conditions. These patients are increasingly being considered for surgical intervention and are at higher risk for multiple perioperative complications. Many are able to safely undergo surgery but require unique considerations to ensure optimal perioperative care. In this review, we highlight relevant perioperative physiology and outline our approach to the evaluation and management of patients with select chronic gastrointestinal, hepatic, and renal diseases. A comprehensive preoperative evaluation with a multidisciplinary approach is often beneficial, and specialist involvement should be considered. Intraoperative and postoperative plans should be individualized based on the unique medical and surgical characteristics of each patient.

Anaesthetic Approach to Enhanced Recovery after Surgery for Kidney Transplantation: A Narrative Review

Enhanced recovery after surgery (ERAS) protocols are designed to reduce medical complications, the length of hospital stays (LoS), and healthcare costs. ERAS is considered safe and effective for kidney transplant (KTx) surgery. KTx recipients are often frail with multiple comorbidities. As these patients follow an extensive diagnostic pathway preoperatively, the ERAS protocol can ideally be implemented at this stage. Small singular changes in a long perioperative pathway can result in significant positive outcomes. We have investigated the current evidence for an ERAS pathway related to anaesthetic considerations in renal transplant surgery for adult recipients.

Case Series of Skull Base Meningioma Resection in the Octogenarian Population

Introduction The geriatric population is the fastest growing segment of the American population, and octogenarians are increasingly seen by neurosurgeons for relatively common lesions such as meningiomas. Unfortunately, providers do not have clear data to guide decision-making regarding these lesions, particularly if they involve the skull base. Current research in outcomes among the elderly looks at a wide range of ages, often anyone older than 65. Previous studies in octogenarians report a wide-range of mortality rates and do not focus on skull base lesions. This paper strives to clarify the experiences and outcomes of octogenarians.

Patients and Methods This retrospective series reviews skull base tumor surgeries performed at a single academic institution over the past 15 years in octogenarian patients. Primary endpoint was 30-day mortality; however, potential risk factors, perioperative morbidity, postdischarge disposition, and longer term follow-up were also captured. Multivariate logistic regression was performed to identify relevant perioperative and medical characteristics that increases the risk of adverse events.

Results Fourteen patients underwent craniotomies for skull base procedures with an average age of 84.5, with a 14% 30-day mortality rate. One patient required a tracheostomy on discharge and approximately half were able to either go home or rehabilitation after their procedure. On statistical analysis, there were no noted characteristics that predisposed any of the patients to a poorer outcome.

Conclusion Octogenarian patients were able to tolerate surgery for skull base meningiomas resection. This outcome data may be used to inform surgical decision and guide conversation with patients and their families.

Cerrahi Süreçte Hasta Beslenmesinde Güncel Yaklaşımlar

Cerrahi travma, oluşturduğu nörohormonal stres yanıtla homeostazı tehdit eden katabolik bir süreç başlatır. Cerrahi travma sonrası derlenme, yalnızca teknik cerrahi becerilere değil, aynı zamanda hastanın metabolik durumunun ve uygun beslenme desteğinin sağlanmasına da bağlıdır. Beslenme, ameliyat sonrası derlenme açısından önemli olmasına rağmen cerrahi hastalarda sıklıkla göz ardı edilmektedir. Açlık ve cerrahi stres, katabolik reaksiyonu başlatarak organ disfonksiyonuna, yara iyileşmesinde gecikmeye, ameliyat sonrası enfeksiyonlara morbidite ve mortalite artışına, hastane yatışında uzamaya ve maliyet artışına neden olmaktadır. Perioperatif süreçte beslenme ile ilişkili komplikasyonların önlenmesinde kanıt temelli doğru beslenme uygulamaları olumlu hasta sonuçlarını desteklemektedir. Ameliyat sürecinde güncel yaklaşımlar ve kanıta dayalı uygulamalar ile hastanın doğru beslenmesi sağlanarak, katabolizmanın azaltılması ve anabolizmanın desteklenmesi ile ameliyat sonrası daha hızlı bir iyileşme sağlanabilir. Cerrahi hastasının beslenmesi multidisipliner bir ekip yaklaşımını gerektirir. Cerrahi stres sürecinin azaltılmasında multidisipliner ekipte anahtar rolü olan hemşireler, güncel beslenme önerileri çerçevesinde hastanın beslenmesini optimal düzeyde desteklemelidirler. Bu derlemenin amacı, cerrahi girişim geçiren hastada beslenme yönetiminin önemini vurgulamak, perioperatif süreçte doğru beslenmeyi güncel uygulamalarla ortaya koymaktır.

STRONG for Surgery & Strong for Life - against all odds: intensive prehabilitation including smoking, nutrition, alcohol and physical activity for risk reduction in cancer surgery - a protocol for an RCT with nested interview study (STRONG-Cancer)

Background

There is a large unused potential for risk reduction in the preoperative period via effective lifestyle intervention targeting co-existing risky lifestyles: Smoking, malNutrition, obesity, risky Alcohol intake and insufficient Physical activity (SNAP).

This trial compares the efficacy of the integrated STRONG programme with standard care on preoperative risk reduction and secondly on SNAP factor improvement and frailty, postoperative complications and quality of life. A nested interview study explores the patient preferences and the multi-perspective view of patients, relatives and health professionals.

Methods

In total, 42 surgical patients with ≥1 SNAP factor are allocated to individually tailored STRONG programme or usual care during adjuvant chemotherapy prior to radical bladder cancer surgery. The STRONG programme has ≥6 weekly sessions with patient education, motivational and pharmaceutical support. It is based on intensive smoking and alcohol cessation interventions reporting perioperative quit rates > 50%.

Surgical risk reduction is measured as ≥1 step for 1 or more risky lifestyles on the ASA-score, secondly as having no risky SNAP factors, and as any SNAP improvement. The outcomes are validated by measurements and biomarkers. Postoperative complications are categorised according to the Clavien-Dindo classification. Health-related quality of life is measured by EQ-5D.

The patients are followed up after 6 weeks at surgery and 6 weeks and 6 months postoperatively.

A representative sample of the participants, their relatives and the clinical staff are interviewed until data saturation. Transcription, triangulated analyses and data management are conducted using NVivo computer software.

Discussion

The surgical agenda is characterised by fixed dates for surgery focusing on clear risk reduction within a short time. This requires a clinical useful lifestyle intervention programme with a high effect and coverage as well as containing all SNAP factors and tailored to individual needs.

The STRONG programme seems to meet these requirements. After development in multi-professional collaboration, STRONG is delivered by a specially trained nurse as part of the surgical patient journey.

Overall, this study will bring important new knowledge about risk reduction in a frail patient group undergoing major cancer surgery.

Trial registration

Registration at www.clintrials.gov (NCT04088968)

The manuscript form from https://trialsjournal.biomedcentral.com/bmc/journal and the SPIRIT guidelines are followed.

Does Preoperative Estimated Glomerular Filtration Rate (eGFR) Predict Short-Term Surgical Outcomes in Patients Undergoing Pancreatic Resections?

INTRODUCTION

Preoperative eGFR has been found to be a reliable predictor of post-operative outcomes in patients with normal creatinine levels who undergo surgery. The aim of our study was to evaluate the impact of preoperative eGFR levels on short-term post-operative outcomes in patients undergoing pancreatectomy.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) pancreatectomy file (2014-2017) was queried for all adult patients (age ≥ 18) who underwent pancreatic resection. Patients were stratified into two groups based on their preoperative eGFR (eGFR < 60 mL/min/1.73m² and eGFR ≥ 60 mL/min/1.73m²). Outcome measures included post-operative pancreatic fistula, discharge disposition, hospital length of stay, 30-day readmission rate, and 30-day morbidity and mortality. Multivariate logistic regression analysis was performed.

RESULTS

A total of 21,148 were included in the study of which 12% (n = 2256) had preoperative eGFR < 60 mL/min/1.73m². Patients in the eGFR < 60 group had prolonged length of stay, were less likely to be discharged home, had higher minor and major complication rates, and higher rates of mortality. On logistic regression analysis, lower preoperative eGFR (< 60 mL/min/1.73m²) was associated with higher odds of prolonged length of stay [aOR: 1.294 (1.166-1.436)], adverse discharge disposition [aOR: 1.860 (1.644-2.103)], minor [aOR: 1.460 (1.321-1.613)] and major complications [aOR: 1.214 (1.086-1.358)], bleeding requiring transfusion [aOR: 1.861 (1.656-2.091)], and mortality [aOR: 2.064 (1.523-2.797)].

CONCLUSION

Preoperative decreased renal function measured by eGFR is associated with adverse outcomes in patients undergoing pancreatic resection. The results of this study may be valuable in improving preoperative risk stratification and post-operative expectations.

Teaching Wound Care to Family Caregivers: An overview of methods to use to promote wound healing

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. The articles in this new installment of the series provide simple and useful instructions that nurses should reinforce with family caregivers who perform wound care tasks. Each article also includes an informational tear sheet-Information for Family Caregivers-that contains links to instructional videos. To use this series, nurses should read the article first, so they understand how best to help family caregivers, and then encourage caregivers to watch the videos and ask questions. For additional information, see Resources for Nurses.

Nutrition delivery and growth outcomes in infants with long-gap esophageal atresia who undergo the Foker process

BACKGROUND

Predictors of growth outcomes in patients with long-gap esophageal atresia (LGEA) are not known. We examined nutrition and growth in-hospital and post-discharge in LGEA patients who underwent the Foker Process (FP).

METHODS

Single-center, retrospective cohort study of infants with LGEA undergoing primary (non-rescue) FP from 2014 to 2020. Weight-for-age z scores (WAZ, 0 = average), macronutrient prescription, anthropometry, and clinical variables were collected. Longitudinal median regression evaluated differences in WAZ over time. Multivariable median regression examined variables associated with change in WAZ at 1 year.

RESULTS

45 patients met criteria, with median (IQR) age at repair of 4 (2, 5.8) months and WAZ of -0.96 (-1.55, -0.40). On admission, 11% were moderately (WAZ < -2) and 9% were severely (WAZ < -3) malnourished. Lower admission WAZ was significantly associated with improvement in WAZ at 1-year follow-up (p = 0.002); EA type (59% type A), esophageal leak (16%), median days paralyzed (13), ventilated (21), on parenteral nutrition (35), or to full enteral nutrition (35) were not associated with change in WAZ. Median WAZ remained stable while in-hospital, and patients maintained their growth curves through 3-year follow-up.

CONCLUSION

Throughout infancy, most primary FP LGEA patients have weight for age that is below average. Using targeted nutritional intervention, those who present with malnutrition can still achieve adequate growth despite prolonged and complicated hospital courses.

Clinical and biomarker assessment of frailty in liver transplantation

PURPOSE OF REVIEW

Liver cirrhosis results in progressive decline, or frailty, which leads to poor outcomes and decreased survival. Multiple biomarkers and clinical assessment tools for quantifying frailty in liver transplant candidates exist, but a universal scoring protocol is lacking. Criteria vary between studies and correlation with patient outcome is not always clear. This review aims to summarize the pertinent biomarkers and assessment tools of frailty in cirrhosis.

RECENT FINDINGS

As cirrhosis progresses, the resultant 'frailty' is an inseparable independent predictor of pre and posttransplant mortality. Pro-inflammatory, neuroendocrine, and adipokine factors are dysregulated - leading to paradoxical anorexia and downregulation of orexigenic signals. The resulting catabolic utilization of amino and fatty acids leads to progressive malnutrition and sarcopenia. Both functional and imaging criteria define sarcopenia in cirrhotic patients, and degree of debilitation correlates with mortality. Liver-disease-specific frailty biomarkers and scoring tools are optimal to assess physical dysfunction in cirrhotics to promote early diagnosis and intervention.

SUMMARY

Liver cirrhosis and resulting frailty are progressive and portend a poor patient prognosis. A comprehensive, validated algorithm for detecting and quantifying frailty specific to liver disease would allow for standardization and facile application in the clinical setting. Early diagnosis is key for timely intervention and improved patient outcomes.

Perioperative Immunonutrition in Elderly Patients Undergoing Total Hip and Knee Arthroplasty: Impact on Postoperative Outcomes

BACKGROUND

Arthroplasties in elderly patients are surgeries performed to ensure their quality of life. Perioperative care with specific nutrients can improve nutrition status and metabolic response to orthopedic surgeries, such as total knee arthroplasty (TKA) and total hip arthroplasty (THA).

METHODS

Retrospective study with elderly patients divided into 2 groups: control and immunonutrition. The immunonutrition group was instructed to start oral intake of the nutrition supplement 5 days before and to resume it 5 days after arthroplasty (200 mL, 3 times per day). The following were analyzed as primary and secondary outcomes: length of stay (LOS), infectious and noninfectious complications, need for intensive care unit (ICU), transfusion requirement, and C-reactive protein.

RESULTS

A total of 3015 elderly patients met the inclusion criteria: control group (n = 1398) and immunonutrition group (n = 1617). Overall, 81.2% were women and mean age was 72.6 ± 6.9 years. Immunonutrition group had a shorter LOS in hours (32.0 ± 19.4 vs 56.0 ± 26.4; P < .001) and lower rates of infectious complications (2.2% vs 4.6%; P < .001). Noninfectious complications and need for ICU also had lower rates in the immunonutrition group. In the logistic regression analysis, immunonutrition reduced the chance of infectious complications by 55% (odds ratio [OR], 0.45; 95% CI, 0.30-0.68; P < .001) even after adjusting for variables (OR, 0.45; 95% CI, 0.28-0.71; P < .001).

CONCLUSION

Perioperative immunonutrition in elderly patients undergoing THA or TKA may shorten postoperative LOS and reduce infectious and noninfectious complications and transfusion requirement.

Bridging intestinal failure with Teduglutide - A case report

Introduction and importance

Intestinal failure (IF) describes the state of a person's gastrointestinal absorption capabilities becoming unable to absorb fluids and nutrients needed to sustain normal physiology, leading to severe comorbidities and if left untreated, to death. IF is most commonly seen as a result of short bowel syndrome (SBS).

Teduglutide is a glucagon-like peptide 2 (GLP-2) analogue used in the treatment of patients with SBS and intestinal failure (IF) as a way to reduce the need for parenteral support. Teduglutide leads to the growth of intestinal mucosa by stimulating intestinal crypt cell growth and inhibiting enterocyte apoptosis. It is usually prescribed as a final treatment step after the diagnosis of SBS-IF is made.

Case presentation

In this case report we present a novel strategy for using teduglutide as a bridging therapy to intestinal reconstruction. The patient achieved enteral autonomy preoperatively, underwent surgery, and remained in enteral autonomy after intestinal reconstruction.

Clinical discussion

Teduglutide has been previously exclusively used as continuous therapy in SBS-IF, this is the first reported case of using teduglutide as bridging to intestinal reconstruction. The hypothesis of this approach was to achieve an adequate nutritional status for reconstruction without the disadvantages of parenteral support.

Conclusion

The controlled application of teduglutide can provide the benefits of preoperative nutritional optimization without the disadvantages of parenteral support and at the same time facilitate an earlier and easier intestinal reconstruction.

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Teduglutide can be used to reduce parenteral support in SBS-IF patients awaiting intestinal reconstruction

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Teduglutide can be used preoperatively to optimize a patient's nutritional status

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Using teduglutide as bridging therapy to surgery prevents patients from experiencing parenteral nutrition-associated complications

Hypoalbuminemia Predicts Serious Complications Following Elective Bariatric Surgery

PURPOSE

The aims of this study were to (1) characterize the prevalence of hypoalbuminemia (HA), (2) compare complication rates among HA and non-HA patients, and (3) determine the influence of HA on postoperative complications and 30-day mortality among bariatric surgery patients.

MATERIALS AND METHODS

Data was extracted from the MBSAQIP registry from 2015 to 2018. A presurgical serum albumin level of [Formula: see text] 3.5 g/dL was used to organize the patient population into HA and non-HA cohorts. Bivariate analysis and multivariable logistic regression modeling were used.

RESULTS

Of 590,971 patients, 42,618 (7.2%) were identified as having serum albumin levels [Formula: see text] 3.5 g/dL. HA patients were younger (44.0 + / - 11.9 vs. 44.5 + / - 12.0 years; p < 0.0001), were of increased BMI (48.5 + / - 9.0 kg/m² vs. 45.1 + / - 7.7 kg/m²; p < 0.0001), and had a lower baseline functional status (1.6% vs. 1.0% dependent or partially dependent; p < 0.0001). HA patients had more anastomotic leaks (0.46% vs. 0.38%; p = 0.02), deep surgical site infections (0.37% vs. 0.24%; p < 0.0001), and composite serious complications (4.4% vs. 3.3%; p < 0.0001). At 30-day post-operation, complications including need for reintervention (1.6% vs. 1.2%; p < 0.0001), readmission (4.8% vs. 3.7%; p < 0.0001), and mortality (0.14% vs. 0.086%; p = 0.001) were all more prevalent among HA patients. After functional status, HA was the strongest modifiable predictor of serious complications but was not predictive of 30-day mortality.

CONCLUSION

We identified HA as one of the greatest modifiable factors predictive of serious complications. Adoption of strategies to identify and improve preoperative serum albumin levels may reduce overall serious complications among elective bariatric surgery patients.

Risk factors for anastomotic leakage after surgical resections for esophageal cancer

PURPOSE

Surgery for esophageal cancer is a challenging procedure that is associated with a high rate of complications such as sepsis, nutritional disorders, and anastomotic leakage (AL). The rate of complications following esophageal surgery rises exponentially in the presence of risk factors. This study aims to identify the risk factors for AL following esophageal cancer surgery.

METHODS

In this retrospective study, we recorded comorbidities, tumor specific factors, nutritional status, and surgical complications of all patients who underwent surgical resections for esophageal cancers between January 2015 and December 2019. The occurrence of potential risk factors for AL was compared between groups with and without AL. We analyzed the categorical variables by Chi-square or Fisher's exact test, and the continuous variable by the Mann-Whitney U test and multivariable regression analyses.

RESULTS

From 92 patients, AL was found in 12 (13%) patients. All cases with AL had hypoproteinemia; a protein level < 5 g/dl was an independent risk factor for AL (p value 0.009). The logistic regression analysis showed a positive correlation between hypoproteinemia and AL (coefficient 1.83, significance 0.01). Additionally, squamous cell carcinoma (SCC) of the esophagus had a positive correlation with AL (coefficient 1.89, significance 0.01).

CONCLUSION

In our study, hypoproteinemia and SCC were significant risk factors for AL after esophageal cancer surgery. Optimization of preoperative hypoproteinemia using a standardized nutritional protocol is recommended. More research is essential to determine the correlation of SCC with AL.

The state of nutrition in medical education in the United States

Despite the significant impact diet has on health, there is minimal nutrition training for medical students. This review summarizes published nutrition learning experiences in US medical schools and makes recommendations accordingly. Of 902 articles, 29 met inclusion criteria, describing 30 learning experiences. Nutrition learning experiences were described as integrated curricula or courses (n = 10, 33%), sessions (n = 17, 57%), or electives (n = 3, 10%). There was heterogeneity in the teaching and assessment methods utilized. The most common was lecture (n = 21, 70%), often assessed through pre- and/or postsurveys (n = 19, 79%). Six studies (26%) provided experience outcomes through objective measures, such as exam or standardized patient experience scores, after the nutrition learning experience. This review revealed sparse and inconsistent data on nutrition learning experiences. However, based on the extant literature, medical schools should build formal nutrition objectives, identify faculty and physician leadership in nutrition education, utilize preexisting resources, and create nutrition learning experiences that can be applied to clinical practice.

Nutritional Considerations and Strategies to Facilitate Injury Recovery and Rehabilitation

Nutritional interventions are not commonly a standard of care in rehabilitation interventions. A nutritional approach has the potential to be a low-cost, high-volume strategy that complements the existing standard of care. In this commentary, our aim is to provide an evidence-based, practical guide for athletes with injuries treated surgically or conservatively, along with healing and rehabilitation considerations. Injuries are a normal and expected part of exercise participation. Regardless of severity, an injury typically results in the athlete's short- or long-term removal from participation. Nutritional interventions may augment the recovery process and support optimal healing; therefore, incorporating nutritional strategies is important at each stage of the healing process. Preoperative nutrition and nutritional demands during rehabilitation are key factors to consider. The physiological response to wounds, immobilization, and traumatic brain injuries may be improved by optimizing macronutrient composition, caloric consumption, and nutrient timing and using select dietary supplements. Previous research supports practical nutrition recommendations to reduce surgical complications, minimize deficits after immobilization, and maximize the chance of safe return to play. These recommendations include identifying the individual's caloric requirements to ensure that energy needs are being met. A higher protein intake, with special attention to evenly distributed consumption throughout the day, will help to minimize loss of muscle and strength during immobilization. Dietary-supplement strategies may be useful when navigating the challenges of appropriate caloric intake and timing and a reduced appetite. The rehabilitation process also requires a strong nutritional plan to enhance recovery from injury. Athletic trainers, physical therapists, and other health care professionals should provide basic nutritional recommendations during rehabilitation, discuss the timing of meals with respect to therapy, and refer the patient to a registered dietitian if warranted. Because nutrition plays an essential role in injury recovery and rehabilitation, nutritional interventions should become a component of standard-of-care practice after injury. In this article, we address best practices for implementing nutritional strategies among patients with athletic injuries.

The Need for Nutritional Education Reform in US Medical Education System

BACKGROUND

To compare the setting, quality, and utility of nutritional education received by general surgery residents and faculty surgeons and their perceptions and challenges in managing patient nutritional needs.

METHODS

Cross-sectional analysis utilizing anonymous survey data distributed by the Association of Program Directors in Surgery (APDS) to its affiliated general surgery residency programs.

RESULTS

90.2% (n = 65) of residents and 85.7% (n = 24) of faculty surgeons reported having received nutritional education. The majority (78%) of respondents utilize patient nutrition on a regular basis (monthly or more often), with 54% reporting utilization daily or weekly. Overall, 65% of respondents reported experiencing challenges in managing patient nutritional needs, and 86% agreed that additional nutritional education during training would assist with patient care. Residents and faculty surgeons both significantly reported challenges in determining which specific nutritional formula to use (X² = 22.414, P = .049). Residents were associated with reporting challenges in successfully managing oral, enteral, and parenteral routes of nutrition (X² = 16.241, P = .023).

CONCLUSIONS

Despite receiving nutritional education, the majority of surgery residents and faculty surgeons report difficulty in managing their patients nutritional needs. Surgery residents report difficulties with all delivery modes of nutrition, including oral, parenteral, and enteral. Revising medical school nutritional education competencies to focus on more practical aspects of nutrition, reform of formal course format, greater interprofessional collaboration with dieticians starting at the student level, and enforcement of nutritional education requirements by medical school and residency program accrediting bodies can serve to advance physicians' nutritional knowledge and improve patient outcomes.

Pre-operative Hypoalbuminemia Is Associated with Complications Following Proximal Humerus Fracture Surgery: An Analysis of 919 Patients

BACKGROUND

Proximal humerus fractures are among the most common presenting fractures to orthopedic surgeons in the USA. Hypoalbuminemia is accepted as a nutrition marker associated with post-operative complications following common orthopedic interventions.

QUESTIONS/PURPOSES

Thus, the authors sought to (1) describe the national demographic trends of patients undergoing surgical fixation for proximal humerus fracture and (2) investigate the association between pre-operative hypoalbuminemia, a malnutrition marker, and post-operative complications within 1 year of surgical intervention.

METHODS

The PearlDiver Humana Claims Database was queried to identify a nationally representative cohort of patients who underwent surgical intervention for proximal humerus fractures from 2008 to 2015. Demographic and comorbid characteristics were collected. Pearson's χ-squared analysis was used to compare rates of 90-day and 1-year outcomes between hypoalbuminemia (albumin ≤ 3.5 mg/dL) and control groups. Multivariate logistic regression was then used to determine the isolated effect that hypoalbuminemia had on post-operative outcomes.

RESULTS

Of the 3337 patients identified, 919 (27.5%) had available serum albumin data. Seventy (7.6%) patients had hypoalbuminemia. Hypoalbuminemia was more likely to be associated with post-operative sepsis (7.1% vs. 1.5%, respectively) and pneumonia (15.7% vs. 4.6) compared with controls. Additionally, hypoalbuminemia was associated with increased 90-day rates of discharge to extended care (4.3% vs. 0.8), emergency room visits (38.6% vs. 21.7), and total cost ($24,051.96 ± 24,972.74 vs. $15,429.74 ± 24,492.30).

CONCLUSION

Our study suggests hypoalbuminemia is associated with an increased risk of complications, specifically pneumonia and sepsis, and total health care costs in patients undergoing surgery for proximal humerus fractures. These findings provide insight for individualized patient care that will aid in evaluating the potential risk of surgical complications in an effort to improve outcomes and reduce costs.

Perioperative immunonutrition in hepatectomy: A systematic review and meta-analysis

Backgrounds/Aims

The role of immunonutrition (IMN) after liver resections or hepatectomies remains unclear and controversial. We undertook a systematic review to evaluate the effects of IMN on clinical outcomes of patients undergoing hepatectomy.

Methods

Main electronic databases were searched for randomised trials reported clinical outcomes or effects of IMN. The systematic review was conducted in accordance with the PRISMA guideline and meta-analysis was analysed using fixed or random-effects models.

Results

Eleven RCTs were identified. A total of 1084 patients (529 IMN and 555 Control) were included in the final pooled analysis. Of these patients, 43% (440/1016) underwent major hepatectomies and the majority are for hepatocellular carcinoma (90%, 956/1055) with Child-Pugh A disease (89%, 793/894). IMN significantly reduced post-operative wound infection (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.43 to 0.96; p=0.03). IMN also had a shorter hospital stay (MD -4.97 days, 95% CI -8.23 to -1.72; p=0.003). There was no statistically significant in other post-operative morbidities and mortality.

Conclusions

Wound infection rate was not significantly different between oral and parenteral IMN group. The length of hospital stay was significantly lower in parenteral IMN group than in oral IMN group. The mortality rates were not affected. Immunonutrition should be recommended routinely as part of the nutritional support in the Enhanced Recovery after Surgery (ERAS) protocol for hepatectomy.

Trends and Novel Research in Hospital Nutrition Care: A Narrative Review of Leading Clinical Nutrition Journals

Hospital malnutrition is a longstanding problem that continues to be underrecognized and undertreated. The aim of this narrative review is to summarize novel, solution-focused, recent research or commentary to update providers on the prevention of iatrogenic malnutrition as well as the detection and treatment of hospital malnutrition. A narrative review was completed using the top 11 clinically relevant nutrition journals. Of the 13,850 articles and editorials published in these journals between 2013 and 2019, 511 were related to hospital malnutrition. A duplicate review was used to select (n = 108) and extract key findings from articles and editorials. Key criteria for selection were population of interest (adult hospital patients, no specific diagnostic group), solution-focused, and novel perspectives. Articles were categorized (6 classified in >1 category) as Screening and Assessment (n = 17), Standard (n = 25), Advanced (n = 12) and Specialized Nutrition Care (n = 8), Transitions (n = 15), Multicomponent (n = 21), Education and Empowerment (n = 9), Economic Impact (n = 3), and Guidelines (n = 4) for summarizing. Research advances in screening implementation, standard nutrition care, transitions, and multicomponent interventions provide new strategies to consider for malnutrition prevention (iatrogenic), detection, and care. However, several areas requiring further research were identified. Specifically, larger and more rigorous studies that examine health outcomes and economic analyses are urgently needed.

The Influence of Pretherapeutic and Preoperative Sarcopenia on Short-Term Outcome after Esophagectomy

Simple Summary

Although introducing minimally invasive surgery reduced postoperative morbidity after esophagectomy esophageal cancer still is a malignancy with poor prognosis. This study aimed to investigate whether preoperative sarcopenia has an influence on short-term postoperative outcome after esophagectomy in esophageal cancer patients. Our findings suggest that preoperative sarcopenia is no independent prognostic factor for postoperative outcome after esophagectomy but that patients’ nutritional status consists of more factors than only body mass index (BMI) and muscle mass. Prehabilitation and preoperative optimization of the patients’ nutritional status seems to be an important factor for short-term postoperative outcome after esophagectomy.

Abstract

By introducing minimally invasive surgery the rate of postoperative morbidity in esophageal cancer patients could be reduced. But esophagectomy is still associated with a relevant risk of postoperative morbidity and mortality. Patients often present with nutritional deficiency and sarcopenia even at time of diagnosis. This study focuses on the influence of skeletal muscle index (SMI) on postoperative morbidity and mortality. Fifty-two patients were included in this study. SMI was measured using computer tomographic images at the time of diagnosis and before surgery. Then, SMI and different clinicopathological and demographic features were correlated with postoperative morbidity. There was no correlation between SMI before neoadjuvant therapy (p = 0.5365) nor before surgery (p = 0.3530) with the short-term postoperative outcome. Regarding cholesterol level before surgery there was a trend for a higher risk of complications with lower cholesterol levels (p = 0.0846). Our findings suggest that a low preoperative SMI does not necessarily predict a poor postoperative outcome in esophageal cancer patients after esophagectomy but that there are many factors that influence the nutritional status of cancer patients. To improve nutritional status, cancer patients at our clinic receive specialized nutritional counselling during neoadjuvant treatment as well as after surgery.

Incidence and risk factors for surgical site infection following elective foot and ankle surgery: a retrospective study

Background

This study aimed to investigate the incidence of surgical site infection (SSI) in elective foot and ankle surgeries and identify the associated risk factors.

Methods

This was designed as a retrospective study, including patients who underwent elective surgery of foot and ankle between July 2015 and June 2018. Data on demographics, comorbidities, and perioperative parameters were collected from the medical records, the laboratory report, the operation report, and the outpatient follow-up registration database. SSI was defined in accordance with the Center for Disease Control criteria. Univariate and multivariate logistic regression analyses were used to identify the independent risk factors for SSI.

Results

A total of 1201 patients undergoing 1259 elective foot/ankle surgeries were included, of whom 26 (2.1%) had an SSI, representing an incidence rate of 1.3% for superficial SSI and 0.8% for deep SSI, respectively. The results for organism culture showed Pseudomonas aeruginosa in 7 cases, methicillin-resistant Staphylococcus aureus (MRSA) in 6, methicillin-susceptible Staphylococcus aureus (MSSA) in 5, methicillin-resistant coagulase-negative Staphylococci (MRCNS) in 2, Escherichia coli in 2, and Proteus mirabilis in 1 case. Five factors were identified to be independently associated with SSI, including prolonged preoperative stay (OR, 1.21; 95% CI, 1.09 to 1.30), allograft or bone substitute (OR, 3.76; 95% CI, 1.51 to 5.30), elevated FBG level (OR, 1.17; 95% CI, 1.04 to 1.26), lower ALB level (OR, 2.33; 95% CI, 1.19 to 3.05), and abnormal NEUT count (OR, 1.72; 95% CI, 1.27 to 2.12).

Conclusions

SSI following elective foot and ankle surgeries is low, but relatively high in forefoot surgeries, requiring particular attention in clinical practice. Although most not modifiable, these identified factors aid in risk assessment of SSI and accordingly stratifying patients and therefore should be kept in mind.

Inhibition of Angiotensin Converting Enzyme Impairs Anti-staphylococcal Immune Function in a Preclinical Model of Implant Infection

Background: Evidence suggests the renin-angiotensin system (RAS) plays key immunomodulatory roles. In particular, angiotensin-converting enzyme (ACE) has been shown to play a role in antimicrobial host defense. ACE inhibitors (ACEi) and angiotensin receptor blockers (ARB) are some of the most commonly prescribed medications, especially in patients undergoing invasive surgery. Thus, the current study assessed the immunomodulatory effect of RAS-modulation in a preclinical model of implant infection.

Methods:In vitro antimicrobial effects of ACEi and ARBs were first assessed. C57BL/6J mice subsequently received either an ACEi (lisinopril; 16 mg/kg/day), an ARB (losartan; 30 mg/kg/day), or no treatment. Conditioned mice blood was then utilized to quantify respiratory burst function as well as Staphylococcus aureus Xen36 burden ex vivo in each treatment group. S. aureus infectious burden for each treatment group was then assessed in vivo using a validated mouse model of implant infection. Real-time quantitation of infectious burden via bioluminescent imaging over the course of 28 days post-procedure was assessed. Host response via monocyte and neutrophil infiltration within paraspinal and spleen tissue was quantified by immunohistochemistry for F4/80 and myeloperoxidase, respectively.

Results: Blood from mice treated with an ACEi demonstrated a decreased ability to eradicate bacteria when mixed with Xen36 as significantly higher levels of colony forming units (CFU) and biofilm formation was appreciated ex vivo (p < 0.05). Mice treated with an ACEi showed a higher infection burden in vivo at all times (p < 0.05) and significantly higher CFUs of bacteria on both implant and paraspinal tissue at the time of sacrifice (p < 0.05 for each comparison). There was also significantly decreased infiltration and respiratory burst function of immune effector cells in the ACEi group (p < 0.05).

Conclusion: ACEi, but not ARB, treatment resulted in increased S. aureus burden and impaired immune response in a preclinical model of implant infection. These results suggest that perioperative ACEi use may represent a previously unappreciated risk factor for surgical site infection. Given the relative interchangeability of ACEi and ARB from a cardiovascular standpoint, this risk factor may be modifiable.

Preoperative Treatment of Malnutrition and Sarcopenia in Cardiac Surgery: New Frontiers

Cardiac surgery is performed more often in a population with an increasing number of comorbidities. Although these surgeries can be lifesaving, they disturb homeostasis and may induce a temporary overall loss of physiologic function. The required postoperative intensive care unit and hospital stay often lead to a mid- to long-term decline of nutritional and physical status, mental health, and health-related quality of life. Prehabilitation before elective surgery might be an opportunity to optimize the state of the patient. This article discusses current evidence and potential effects of preoperative optimization of nutrition and physical status before cardiac surgery.

Prehabilitation Program Improves Outcomes of Patients Undergoing Elective Liver Resection

BACKGROUND

Preoperative phase can be effectively used by multidisciplinary teams to optimize the surgical candidate to improve perioperative outcomes. The aim of our study was to evaluate the impact of prehabilitation program (PP) in patients undergoing elective liver resection (LR).

METHODS

This was a prospective study including patients undergoing elective LR from February 2016 to October 2017. Outcomes of patients enrolled into PP were compared with patients receiving standard care. PP involved physiotherapist, dietitian, and case managers along with surgical and anesthetic services. Postoperative morbidity, length of stay, 90-day mortality, readmission rate, quality of life, and cost were measured.

RESULTS

Seventy patients were enrolled into PP and compared with 34 patients receiving standard care. Median Charlson comorbidity index was higher in PP group (4 versus 3, P = 0.03). PP showed reduction in overall morbidity (30% versus 52.9%, P = 0.02) and social issues (nil versus 3, P = 0.03). Quality of life survey showed improved social well-being. A tendency to cost savings was observed in prehabilitation group with 16.5% ($1359) cost reduction (median cost $6892 versus $8251, P = 0.07).

CONCLUSIONS

PP improves outcomes in patients undergoing elective LR.

Hypoalbuminemia Is Associated With Increased Postoperative Mortality and Complications in Hand Surgery

Background: Malnutrition has been associated with increased perioperative morbidity and mortality in orthopedic surgery. This study was designed with the hypothesis that preoperative hypoalbuminemia, a marker for malnutrition, is associated with increased complications after hand surgery. Methods: A retrospective cohort study of 208 hand-specific Current Procedural Terminology codes was conducted with the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2013. In all, 629 patients with low serum albumin were compared with 4079 patients with normal serum albumin. The effect of hypoalbuminemia was tested for association with 30-day postoperative mortality, and major and minor complications. Results: Hypoalbuminemia was independently associated with emergency surgery, diabetes mellitus, dependent functional status, hypertension, end-stage renal disease, current smoking status, and anemia. Patients with hypoalbuminemia had a higher rate of mortality, minor complications, and major complications. Conclusions: Hypoalbuminemia is associated with an increased risk of postoperative morbidity and mortality in patients undergoing hand surgery. As such, increased focus on perioperative nutrition optimization may lead to improved outcomes for patients undergoing hand surgery.

The impact of personalized nutritional support on postoperative outcome within the enhanced recovery after surgery (ERAS) program for liver resections: results from the NutriCatt protocol

BACKGROUND

Malnutrition in liver surgery is correlated with higher postoperative complications and longer length of hospital stay (LOHS), the same items that ERAS programs try to optimize. However, to date, standardized dietary protocols have not been defined within ERAS programs. Aim of this study was to evaluate the impact on LOHS and postoperative complications, of a personalized nutritional protocol (NutriCatt) with diet and oral branched-chain amino acid (BCAA) supplementation, adopted within the ERAS program.

METHODS

1960 consecutive liver resections were performed from January 2000 to September 2018.

EXCLUSION CRITERIA

perihilar cholangiocarcinoma, simultaneous colorectal and liver resections. Four groups for analysis: resections before 2009 (1st period); from 2009 to 2016 (2nd period, including laparoscopic resections); between 2016 and September 2017 (ERAS); after September 2017 (ERAS + NutriCatt).

RESULTS

LOHS declined (p < 0.0001), from a median of 10 days (1st period) to 8, 7 and 6 in 2nd period, ERAS and ERAS + NutriCatt groups, respectively. At multivariable analysis for risk of LOHS > 8 days, the 2nd period, ERAS and ERAS + NutriCatt groups showed a protective effect. These results were confirmed for both minor and major resections. LOHS was significantly lower in ERAS + Nutricatt group than in ERAS group, without increasing risk of postoperative complications, although the rate of laparoscopic resections was similar in these two groups and complexity of liver resections was significantly higher in the last period.

CONCLUSIONS

Adoption of a personalized nutritional protocol with BCAA supplementation within the ERAS program for liver resections was a safe and effective approach that may impact on reducing the LOHS.

Hypoalbuminemia and obesity class II are reliable predictors of peri-prosthetic joint infection in patient undergoing elective total knee arthroplasty

Background

Malnutrition is a common and modifiable risk factor for postoperative complications and adverse outcomes in orthopedics. The purpose of this study was to identify biomarkers of malnutrition in patients undergoing elective total knee arthroplasty (TKA) that are predictive of adverse in-hospital postoperative complications, to facilitate the identification of at-risk patients for nutritional optimization before surgery.

Methods

A total of 624 patients who underwent elective TKA between 2013 and 2017 were evaluated; potential biomarkers of preoperative malnutrition, including hypoalbuminemia (serum albumin < 3.5 g/dL), total lymphocyte count (TLC < 1500 cells/mm³), and body mass index (BMI), were assessed for any association with in-hospital postoperative complications.

Results

The prevalence of hypoalbuminemia, low TLC, overweight, obesity class I, and obesity class II were, respectively 2.72%, 33.4%, 14.8%, 44.5%, and 26.9%. There was a significant association between hypoalbuminemia and obesity class II (BMI ≥ 30.0 kg/m²) with rates of peri-prosthetic joint infection, and no significant association between such complications and low TLC, overweight, or obesity class I. Logistic regression analysis showed that patients with hypoalbuminemia or being in obesity class II with gouty arthritis were more likely to suffer from peri-prosthetic joint infection.

Conclusions

Hypoalbuminemia and obesity class II together is a reliable biomarker of preoperative malnutrition for predicting peri-prosthetic joint infection after elective TKA, whereas low TLC, overweight, and obesity class I were not significantly associated with an increased risk of such complications.

The Role of Preoperative Parenteral Nutrition

Malnutrition is associated with poor surgical outcomes, and therefore optimizing nutritional status preoperatively is very important. The purpose of this paper is to review the literature related to preoperative parenteral nutrition (PN) and to provide current evidence based guidance. A systemic online search of PubMed, Medline, and Cochrane Databases from January 1990 to February 2020 was done. Sixteen studies were included in this narrative review, including four meta-analyses and twelve clinical trials. The majority of studies have demonstrated benefits of preoperative PN on postoperative outcomes, including reduced postoperative complications (8/10 studies) and postoperative length of stay (3/4 studies). Preoperative PN is indicated in malnourished surgical patients who cannot achieve adequate nutrient intake by oral or enteral nutrition. It can be seen that most studies showing benefits of preoperative PN often included patients with upper gastrointestinal cancer and inflammatory bowel disease (10/12 studies), which gastrointestinal problems are commonly seen and enteral nutrition may be not feasible. When preoperative PN is indicated, adequate energy and protein should be provided, and patients should receive at least seven days of PN prior to surgery. The goal of preoperative PN is not weight regain, but rather repletion of energy, protein, micronutrients, and glycogen stores. Complications associated with preoperative PN are rarely seen in previous studies. In order to prevent and mitigate the potential complications such as refeeding syndrome, optimal monitoring and early management of micronutrient deficiencies is required.

Preoperative frailty assessment combined with prehabilitation and nutrition strategies: Emerging concepts and clinical outcomes

Important elements of the preoperative assessment that should be addressed for the older adult population include frailty, comorbidities, nutritional status, cognition, and medications. Frailty has emerged as a plausible predictor of adverse outcomes after surgery. It is present in older patients and is characterized by multisystem physiologic decline, increased vulnerability to stressors, and adverse clinical outcomes. Preoperative preparation may include a prehabilitation program, which aims to address nutritional insufficiencies, modify chronic polypharmacy, and enhance physical and respiratory conditions prior to hospital admission. Special considerations are taken for particularly high-risk patients, where the approach to prehabilitation can address specific, individual risk factors. Identifying patients who are nutritionally deficient allows practitioners to intervene preoperatively to optimize their nutritional status, and different strategies are available, such as immunonutrition. Previous studies have shown an association between increased frailty and the risk of postoperative complications, morbidity, hospital length of stay, and 30-day and long-term mortality following general surgical procedures. Evidence from numerous studies suggests a potential benefit of including a standard assessment of frailty as part of the preoperative workup of older adult patients. Studies addressing validated frailty assessments and the quantification of their predictive capabilities in various surgeries are warranted.

Macronutrients in Parenteral Nutrition: Amino Acids

The right amount and quality of amino acids (AAs) supplied to patients on parenteral nutrition (PN) reduces muscle mass loss, may preserve or even increase it, with significant clinical benefits. Several industrial PN mixtures are available so that nutrition specialists can choose the product closest to the patient's needs. In selected cases, there is the possibility of personalizing compounded mixtures in a hospital pharmacy that completely meets the individual nutritional needs of PN patients. This narrative review deals with the AA solutions used in PN mixtures. The physiology, the methods to calculate the AA needs, and the AA and energy requirements suggested by scientific guidelines for each patient type are also reported.

Role of Hypoalbuminemia as an Independent Predictor of 30-Day Postoperative Complications Following Surgical Fixation of Ankle Fractures

BACKGROUND

Malnutrition is known to be negatively associated with outcomes after multiple orthopedic procedures. We hypothesized that admission albumin levels, as a marker for malnutrition, would correlate with postoperative outcomes. The purpose of this study was to investigate this relationship following surgery for ankle fracture.

METHODS

This is a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients undergoing operative fixation of an ankle fracture were identified. A total of 6138 patients with albumin available for analysis were identified. Baseline patient information, preoperative serum albumin levels, 30-day postoperative complications, readmission, reoperation, and length of stay data were then collected. Poisson regression with robust error variance was performed to assess the effect of preoperative serum albumin level on postoperative outcomes.

RESULTS

The mean albumin level was 3.86 g/dL and 20.3% (1246/6138) of patients with available albumin levels were hypoalbuminemic. Multivariate analysis revealed that an albumin level <3.5 g/dL was an independent risk factor for complications (relative risk [RR], 1.42; 95% confidence interval [CI], 1.13-1.78; P = .002) and readmission (RR, 1.54; 95% CI, 1.13-2.08; P = .006). Additionally, when analyzed as a continuous variable, albumin level was negatively correlated with risk of mortality (RR, 0.37; 95% CI, 0.19-0.72; P = .003). Patients with hypoalbuminemia also had significantly longer lengths of stay (4.5 vs 2.1 days; P < .001).

CONCLUSION

While complication rates after fixation of ankle fractures remain low, hypoalbuminemia was a predictor of postoperative course. Malnutrition, therefore, may help inform the decision between surgical and conservative management of patients with ankle fractures potentially amenable to nonoperative management. Additionally, hypoalbuminemia should trigger heightened awareness and prophylactic therapy where appropriate.

LEVEL OF EVIDENCE

Level III, comparative study.

Factors predicting one-year post-surgical mortality amongst older Asian patients undergoing moderate to major non-cardiac surgery - a retrospective cohort study

BACKGROUND

While short-term perioperative outcomes have been well studied in Western surgical populations, the aim of this study is to look at the one-year perioperative mortality and its associated factors in an Asian surgical population after non-cardiac surgery.

METHODS

A retrospective cohort study of 2163 patients aged above 45 undergoing non-cardiac surgery in a university-affiliated tertiary hospital from January to July 2015 was performed. Relevant demographic, clinical and surgical data were analysed to elicit their relationship to mortality at one year after surgery. A univariate analysis was first performed to identify significant variables with p-values ≤ 0.2, which were then analysed using Firth multiple logistic regression to calculate the adjusted odds ratio.

RESULTS

The one-year mortality in our surgical population was 5.9%. The significant factors that increased one-year mortality include smoking (adjusted OR 2.17 (1.02-4.45), p = 0.044), anaemia (adjusted OR 1.32 (1.16-1.47), p < 0.001, for every 1 g/dL drop in haemoglobin level), lower BMI (adjusted OR 0.93 (0.87-0.98), p = 0.005, for every 1 point increase in BMI), Malay and Indian ethnicity (adjusted OR 2.68 (1.53-4.65), p = 0.001), peripheral vascular disease (adjusted OR 4.21 (1.62-10.38), p = 0.004), advanced age (adjusted OR 1.04 (1.01-1.06), p = 0.004, for every one year increase in age), emergency surgery (adjusted OR 2.26 (1.29-3.15), p = 0.005) and malignancy (adjusted OR 3.20 (1.85-5.52), p < 0.001).

CONCLUSIONS

Our study shows that modifiable risk factors such as malnutrition, anaemia and smoking which affect short term mortality extend beyond the immediate perioperative period into longer term outcomes. Identification and optimization of this subset of patients are therefore vital. Further similar large studies should be done to develop a risk scoring system for post-operative long-term outcomes. This would aid clinicians in risk stratification, counselling and surgical planning, which will help in patients' decision making and care planning.

The Role of Malnutrition in Ninety-Day Outcomes After Total Joint Arthroplasty

BACKGROUND

Research has linked malnutrition to more complications in total joint arthroplasty (TJA) patients. The role of preoperative albumin in predicting length of stay (LOS) and 90-day outcomes remains understudied. Often, an albumin cut-off ≤3.5 g/dL is used as proxy for malnutrition, although this value remains understudied. This preoperative level may be missing some patients at risk for adverse events post TJA.

METHODS

TJA patients at a single institution from 2013 to 2018 were reviewed for preoperative albumin level. In total, 4047 cases (total knee arthroplasty: 2058; total hip arthroplasty: 1989) had available data, including 90-day readmissions, 90-day emergency department (ED) visits, and postoperative LOS.

RESULTS

About 5.6% experienced a readmission and 9.6% had at least one ED visit within 90 days. Overall prevalence of malnutrition was 3.6%, and this cohort experienced a longer average LOS (3.5 vs 2.2 days, P < .0001) and was more likely to experience a readmission (16% vs 5%, P < .0001) or ED visit (18% vs 9%, P = .0005). Additionally, albumin ≤3.5 g/dL was correlated with more frequent discharge to skilled nursing facility/rehab (30.8% vs 14.7%, P < .0001), increased risk for 90-day readmission with univariable (odds ratio [OR] 1.79, P < .0001) and multivariable logistic regression (OR 1.55, P < .0001), and increased risk for 90-day ED visits with univariable (OR 1.62, P < .0001) and multivariable regression (OR 1.35, P < .0001). The optimal albumin cut-off was 3.94 g/dL in a univariable model for 90-day readmission.

CONCLUSION

Screening for malnutrition may serve a role in preoperative evaluation. An albumin cutoff value of 3.5 g/dL may miss some at-risk patients.

The Impact of Preoperative Immunonutrition and Standard Polymeric Supplements on Patient Outcomes After Pelvic Exenteration Surgery, Taking Compliance Into Consideration: A Randomized Controlled Trial

BACKGROUND

The effect of immunonutrition vs standard polymeric nutrition in the preoperative phase on patient outcomes is still unclear, which could be due to contributing factors such as poorly reported compliance and unequal provision of protein, energy, and volume. The aim of this study was to examine the effects of preoperative immunonutrition compared with standard polymeric supplements matched for energy, protein, volume, length of stay, and postoperative complications in pelvic exenteration surgery, taking into consideration compliance.

METHODS

This was a single-blinded, randomized, controlled trial in patients undergoing pelvic exenteration surgery. Fifty-two participants were randomly assigned to consume 3 immunonutrition supplements/d for 5 days preoperatively, and 56 participants were randomly assigned to consume 3 standard polymeric supplements/d for 5 days preoperatively. Primary and secondary outcome measures were assessed. Compliance with each nutrition regime was recorded during the intervention, and subanalysis was conducted.

RESULTS

There was no significant difference between immunonutrition and standard polymeric supplements on length of stay (P = 0.988) or postoperative complications (P = 0.179) after pelvic exenteration surgery. Compliance with nutrition supplements was significantly less in malnourished (n = 33) compared with well-nourished participants (n = 74) (P = 0.016). Compliance varied between study groups, although not significant.

CONCLUSION

Preoperative immunonutrition did not significantly impact length of stay or postoperative complications compared with standard polymeric supplements after pelvic exenteration surgery, despite controlling for protein, energy, and volume. Compliance, protein, and energy may considerably impact the effect of immunonutrition, particularly in malnourished patients.

The Effect of Malnutrition on Postoperative Complications Following Surgery for Distal Radius Fractures

PURPOSE

Malnutrition is known to negatively affect outcomes after arthroplasty, hip fracture, and spine surgery. Although distal radius fracture surgery may be considered in a similar patient cohort, the effect of malnutrition in this scenario is unknown. We hypothesized that admission serum albumin level, as a marker for malnutrition, would correlate with the rate of postoperative complications following surgery for distal radius fracture.

METHODS

We performed a retrospective cohort study of the American College of Surgeons National Surgery Quality Improvement database. Patients undergoing open reduction and internal fixation of a distal radius fracture were identified using Current Procedural Terminology codes. We excluded patients who were septic at presentation, were multiply injured, or had open fractures. We collected patient demographics, length of stay, 30-day complications, reoperation, and readmission rates. We performed multivariable linear regression analysis controlling for age, sex, body mass index, operative time, discharge destination, and modified Frailty Index score.

RESULTS

We identified 1,989 patients (mean age, 56 years; range, 18-90 years) with available albumin levels, and 14.7% had hypoalbuminemia (albumin, < 3.5 g/dL). Multivariable regression revealed that malnourished patients had higher rates of postoperative complications (6.5% vs 1.3%; odds ratio [OR] 4.88; 95% confidence interval [95% CI], 2.47-9.66). Specifically, these patients had increased rates of Clavien-Dindo IV (life-threatening) complications (2.4% vs 0%), readmission (7.2% vs 2%; OR, 3.37; 95% CI, 1.88-6.03), and mortality (1.7% vs 0.1%; OR, 9.23; 95% CI, 1.55-54.87). Malnourished patients had significantly longer length of stay (3.55 vs 0.73 days). Albumin concentration was inversely associated with risk of death (OR, 0.12; 95% CI, 0.03-0.52).

CONCLUSIONS

Malnutrition, indicated by albumin less than 3.5 g/dL, is a powerful predictor of uncommon, but important, postoperative complications, including mortality, following surgery for distal radius fracture. Evaluation of preoperative albumin level may, therefore, help surgeons provide individualized counseling and more accurately stratify the risk of patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Role and impact of multimodal prehabilitation for gynecologic oncology patients in an Enhanced Recovery After Surgery (ERAS) program

Patients undergoing major surgery are predisposed to a decrease in functional capacity as a response to surgical stress that can delay post-operative recovery. A prehabilitation program consists of patient preparation strategies before surgery, and include pre-operative measures to improve functional capacity and enhance post-operative recovery. Multimodal prehabilitation may include exercise, nutritional counseling, psychological support, and optimization of underlying medical conditions, as well as cessation of unfavorable health behaviors such as smoking and drinking. Currently, there are no standardized guidelines for prehabilitation, and the existent studies are heterogeneous; however, multimodal approaches are likely to have a greater impact on functional outcomes than single management programs. We have reviewed the literature on prehabilitation in general, and in gynecologic surgery in particular, to identify tools to establish an optimal prehabilitation program within an Enhanced Recovery After Surgery (ERAS) protocol for gynecologic oncology patients. We suggest a safe, reproducible, functional, and easy-to-apply multimodal prehabilitation program for gynecologic oncology practice based on patient-tailored pre-operative medical optimization, physical training, nutritional counseling, and psychological support. The analysis of the prehabilitation program implementation in an ERAS protocol should undergo further research in order to test the efficacy on surgical outcome and recovery after surgery.