SURGICAL NUTRITION

PROF NAY AUNG HTUN

PROFESSOR/CONSULTANT SURGEON
DEPARTMENT OF SURGERY
UM2
• In surgical practice malnutrition is common, being present before, or occurring
after, operations in more than 50% of patients

• Increased demands (e.g. multiple trauma, major surgery & sepsis) with
inappropriate intake will result in P.E.M (Protein Energy Malnutrition).

• P.E.M is still a significant problem in hospitals.

• The aim of nutritional support should therefore be to identify the malnourished (or
potentially malnourished) pt and to correct or improved the nutritional status so
that morbidity & mortality are minimized.
Causes of malnutrition

1. Preoperative malnutrition
a. Starvation

i. Difficulty in obtaining food (poverty)

ii. Difficulty in swallowing food (dysphagia)
ii. Difficulty in retaining swallowed food(vomiting)
iv. Self-neglect e.g., in the elderly and in alcoholics
b. Failure of digestion
i. Pancreatic or biliary disease (cholangiohepatitis, Ca. head of pancreas)
ii. Duodenal and jejunal conditions (fistula or blind loop syndrome)

2. Postoperative (post-traumatic) malnutrition

Any delay in return to a normal diet due to
i. Prolong fasting for oesophagectomy operation
ii. Prolong fasting due to complications of surgery (e.g., paralytic ileus from peritonitis)

3. Hypercatabolic state
a. Severe sepsis (subphrenic abscess)
b. Severe trauma (burns)
c. Severe disturbances of major viscera (pancreatitis) etc.
The effects of malnutrition
• Poor wound healing
• Wd dehiscence
• Leaking anastomoses of bowel (fistula, peritonitis)
• Delayed callus formation
• Disordered coagulation (e.g., Vit:K)
• Reduced enzyme synthesis
• Impaired oxidative metabolism of drugs by the liver
• Immunological depression
• Prone to infection
• Decreased tolerance to radiotherapy & cytotoxic chemotherapy
• Severe mental apathy & physical exhaustion of the pt
Assessment
1. Clinical/functional techniques
Clinical history (dietary status, dietary intake, GI symptoms and functional impairment &
body wt change etc.)
Physical signs (hair- alopecia; skin-rashes; mucous membrane- angular stomatitis,
gingivitis, glossitis, nail changes; loss of subcutaneous fat; oedema, sensory change & muscle
wasting etc.)
Dynamometric test (hand grip strength)
2. Body weight & anthropometric techniques
Total body wt can be compared with ideal body wt or the patient's usual (unintentional
wt loss of greater than10% of a patient's usual- poor clinical outcome)
Body weight is frequently corrected for height (BMI, BW in kilograms divided by height
in meters squared; BMI <18.5 is usually taken to indicate nutritional impairment)
Triceps skin fold thickness & mid-arm muscle circumference, which provide rough
estimates of body fat mass & muscle mass (compare with normal values)
3. Laboratory techniques
Biochemical (e.g. serum albumin, thyroid binding pre-albumin, transferrin, retinol binding
protein, & others such as- Haemoglobin, electrolytes etc.)
Immunological ( e.g. lymphocyte count, delayed hypersensitivity skin–testing)
Single parameter assessment is not very sensitive, not specific. All pts should have a
nutritional assessment even for elective procedures.
• Daily requirements

1) Energy requirement
Carbohydrate (4 kcal/g) and lipid (9 kcal/g) are the principal source of energy
Healthy adult requires 20 – 25 kcal/kg/24 hrs
Metabolic stress increases energy requirements considerably (up to 40 kcal/kg/day)

2) Nitrogen requirement
Provision of nitrogen should relate to that of energy
Healthy adult requires1 g of N per 150 kcal/day (equivalent to 12 g of N).
Metabolic stress increases nitrogen requirements (up to 1g per 100 kcal/day)
6.25 g of protein contain 1 g of N (75 g of protein/day)
To maintain the pt's lean body mass, to supply for repair process, to allow active repletion of lean
body mass in the previously compromised patient.

3) Vitamins, minerals & trace elements

Key components of all nutritional regimens
Vitamins function as metabolic coenzymes (vit B & K), cofactors in wd healing (vit C) &
antioxidants (vit C & E)
Trace elements also act as cofactors (copper) & also form components of body tissue.
ENTERAL NUTRITION

Indication

• Functioning gastrointestinal (GI) tract but unable to meet nutritional needs orally:
• Neurological disorders (e.g., stroke, ALS, coma)
• Swallowing disorders (e.g., head and neck cancers)
• Prolonged anorexia
• Major burns or trauma with high metabolic demands
• Intubated/ventilated patients in ICU
• Malabsorption with preserved GI function (e.g., Crohn’s disease)
• Distal, low-output (<200 ml) enterocutaneous fistulas
• To enhance adaptation for massive enterectomy
Absolute Contraindications

Absolute Contraindications
•Complete mechanical bowel obstruction
•Severe gastrointestinal bleeding
•Severe hemodynamic instability or shock
•Intestinal ischemia
•High-output proximal enterocutaneous fistula (if not bypassed)
•Intractable vomiting or diarrhea
•Peritonitis
•Short bowel syndrome
 Relative Contraindications
•Severe pancreatitis (depending on location and tolerance)
•Severe malabsorption syndromes
•Poor absorption due to short bowel (<100 cm of small bowel)
•High risk of aspiration (may still use jejunal feeding with caution)

Note: Even in some conditions above, feeding distal to the problem (e.g., jejunal
feeding in gastric outlet obstruction) may still be possible
Route of administration

•May be administered orally or through feeding tubes inserted into the stomach or small intestine via the nose or via the abdominal wall
1) Oral supplements (provide 200 kcal & 2 g of N in each 200 ml.)

2) Nasoenteric feeding (nasogastric, nasoduodenal & nasojejunal) & tube enterostomy

(Percutaneous endoscopic gastrostomy & tube jejunostomy)
•Fine- bore nasogastric feeding
Indicated for non gastric atony or non paresis patient
position is confirmed by aspiration of gastric contents & auscultation of the epigastrium or X-ray to confirm tube position
•Nasoduodenal or nasojejunal feeding
Indicated in gastric atony or paresis pt.
Positioning of feeding tube- remain a problem
Manipulation under metoclopramide (or)
Manipulation under fluoroscopy (or)
Placement at laparotomy (for post op feeding is anticipated)
Endoscopic positioning etc.

3) PEG Percutaneous endoscopically placed gastrostomies)

•Technique of choice for long term EN (>6 weeks).
•Lower morbidity & mortality compared with conventional.

4) NCJ (Needle Catheter Jejunostomy) - in conditions where nasogastric feeding cannot be used eg. Obstruction, fistula or recently formed
anoastomosis of the upper GI tract
•

Types of enteral diet-3 main types

1. Polymeric diets
2. Monomeric/Predigested (elemental) diets
3. Disease specific diets
• Types of Enteral Nutrient Formulas
Enteral formulas are designed to meet the patient’s nutritional needs and match their digestive and
absorptive capabilities.

• 1. Polymeric Formulas
Most commonly used (standard)
Contains whole proteins, complex carbs, and long-chain fats
Requires normal digestive function
Examples: Ensure®, Nutren®

• 2. Elemental (Monomeric) Formulas

Contains amino acids, simple sugars, and minimal fat
Used in malabsorption syndromes, short bowel syndrome, pancreatitis
Easier to absorb
Examples: Vivonex®, Peptamen®

• 3. Semi-elemental (Oligomeric) Formulas

Contains peptides (partially hydrolyzed proteins), medium-chain triglycerides
Moderate digestibility
Used when partial GI function remains
Examples: Peptamen®, Vital®
• 4. Disease-Specific Formulas
Tailored for patients with specific conditions:
Renal failure: Low electrolyte, low protein (e.g., Nepro®)
Hepatic failure: Low aromatic amino acids, high branched-chain amino acids
(e.g., NutriHep®)
Pulmonary disease (COPD): Low carbohydrate, high fat (e.g., Pulmocare®)
Diabetes: Controlled carbs, high fiber (e.g., Glucerna®)
•
5. Immune-modulating Formulas
Contain added arginine, glutamine, omega-3 fatty acids, antioxidants
Used in critically ill or post-operative patients to reduce infection and improve
outcomes
• Complications of EN

1.Related to Feeding tube

Malposition (into trachea & bronchi)
Dislodgement/migration
Aspiration
Peritonitis
Fistula formation
Intestinal obstruction
Tube blockage

2. Related to feeding regimen

Feed intolerance (diarrhea, vomiting, bloating & regurgitation)
Hyperglycaemia
Enteric infection (from diet, from reservoirs & from giving sets)
Vitamins, mineral & trace element deficiency
PARENTERAL NUTRITION (TPN/PN)

Indications
• Non-functional or inaccessible GI tract:
• Severe pancreatitis
• Bowel obstruction
• Severe short bowel syndrome
• High-output enterocutaneous fistula
• Severe GI bleeding
• Intractable vomiting/diarrhea
• Post-operative patients with prolonged ileus
PARENTERAL NUTRITION (TPN/PN)
Contraindications

• Functional and accessible GI tract (Enteral nutrition preferred)

• Hemodynamic instability (risk of poor perfusion to vital organs,
increased infection risk)
• Uncontrolled hyperglycemia (until optimized)
• Severe electrolyte imbalances (e.g., hypokalemia, hypophosphatemia
—must be corrected first)
• Volume overload (e.g., congestive heart failure, pulmonary edema—
risk with fluid-rich PN)
Relative Contraindications
• Short expected survival where benefits don’t outweigh risks
• Lack of central venous access (for TPN)
• Untrained staff or insufficient monitoring resources
• Severe liver dysfunction (risk of worsening hepatic injury with long-term PN)
Routes
• Peripheral Parenteral Nutrition (PPN):
• Short-term, lower osmolarity solutions via peripheral vein

• Total Parenteral Nutrition (TPN):

• Long-term, high-osmolarity solutions via central venous catheter (CVC) or
peripherally inserted central catheter (PICC)
Types of Parenteral Nutrition
PN solutions are classified based on composition and route of administration.
1. Peripheral Parenteral Nutrition (PPN)
• Administered via peripheral vein
• Short-term use (≤7–10 days)
• Lower osmolarity (<900 mOsm/L)
• Limited in calories and protein
• Suitable for mild to moderate malnutrition or supplementation

2. Total Parenteral Nutrition (TPN)

• Administered via central venous access (e.g., subclavian, internal jugular, PICC)
• Long-term use
• High osmolarity (>1800 mOsm/L)
• Can meet full nutritional needs
• For severe malnutrition, GI failure, or prolonged NPO status
Types by Composition
Macronutrients
• Carbohydrates: Dextrose (main energy source)
• Proteins: Amino acid solutions (essential and non-essential)
• Fats: Intravenous lipid emulsions (soybean oil, MCT, olive oil, fish oil)

Micronutrients
• Electrolytes: Na⁺, K⁺, Cl⁻, Mg²⁺, Ca²⁺, PO₄³⁻
• Vitamins: Water- and fat-soluble vitamins
• Trace elements: Zinc, copper, manganese, selenium, chromium

Fluids
• Water to meet fluid requirements, usually adjusted to body weight and fluid status
Specialized Formulations

• Customized TPN (compounded): Tailored to patient’s individual needs

• Standardized (premixed): Ready-to-use, for stable patients or emergency use
• Disease-specific TPN:
• Hepatic dysfunction: adjusted amino acid profile
• Renal failure: low volume, low electrolyte load
• Critically ill: immune-modulating additives (e.g., glutamine, omega-3)
• Complications

1. Access related complications

Injuries to artery, vein, thoracic duct, pleura, stellate ganglion, brachial plexus & heart.
Cardiac arrhythmias

2. Related to Feeding catheter

Air embolism
Catheter related infections
Infective endocarditis
Central venous/cardiac thrombosis
Thrombotic catheter occlusion
Catheter migration/embolus

3. Related to feeding regimen

Hyperglycaemia/Hypoglycaemia
Non-diabetic ketoacidosis
Electrolyte abnormalities
Hypertriglyceridaemia
Hyperchloraemic acidosis
Vitamins, mineral & trace element deficiency Cholestasis