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327
23 Surgical Nutrition
23.5 Intestinal Failure
Before one can discuss how to correct malnutrition in the perioperative period by
altering a diet, supplementing a diet, or using artifi cial nutrition either enterally or
parenterally, it is fundamental to understand the concept of intestinal failure [
17 ]
(Box 23.9 ).
Intestinal failure is not the sole preserve of national intestinal failure units special-
izing in home parenteral nutrition for people with type 3 intestinal failure due to cata-
strophic bowel loss. The above defi nitions by Jeejeebhoy and Gatt [ 18, 19 ] demonstrate
that this is not the case, but rather intestinal failure is the bread and butter of day to day
colorectal surgery, whether it be obstruction, ileus, or a proximal enterocutaneous
fi stula [ 20 ] . In the context of nutritional support, it is critically important to realize
when the gut has not failed but is merely not accessed. Put at its simplest, if the gut is
not working or cannot be accessed then it cannot be used to feed the patient. It is gen-
erally agreed that whenever possible, nutritional support of malnourished patients
should be by the enteral route [ 21 ] . This may require some imaginative ways of
accessing and securing access to the proximal gut. This may be by an NG tube secured
with a nasal bridle, a percutaneous or open gastrostomy, a radiologically guided per-
cutaneous jejunostomy, or by intubating a proximal stoma (fi stuloclysis). In general,
parenteral nutrition should be reserved for malnourished patients with intestinal fail-
ure or previously normally nourished patients who have new onset intestinal failure or
their gut cannot be accessed [ 22 ] . It does not have to be exclusively one or the other,
and some of the study design in the published literature is naive in this context as
oftentimes the optimal approach is a combination of enteral and parenteral support.
23.6 Preoperative Nutritional Care in the Malnourished
Patient
There is a fundamental and basic premise here, namely, that correcting the nutri-
tional defi cit will improve outcomes. Moreover, it has been shown to be cost effec-
tive by its effects on reducing complications and reducing length of stay. This is
Box 23.9: Working Defi nitions of Intestinal Failure
Gastrointestinal function inadequate to maintain the nutrition and hydra-
tion of the individual without supplements given orally or intravenously
Jeejeebhoy 2005
Inability to tolerate 80% of nutritional requirements delivered enterally for
a minimum of 48 hours
Gatt 2010
328
C.J. Walsh
certainly the case for severely malnourished patients but becomes harder to prove
when the degree of malnutrition is less marked. Assuming therefore that there is a
signifi cant degree of malnutrition in a patient awaiting elective surgery, how should
one go about correcting this? Should it be done by delivering artifi cial nutrition
enterally or parenterally? The answer is that one has to fi rst ask the fundamental
question: Does the malnourished patient have intestinal failure? If not, they should
be nourished enterally, and if they have intestinal failure, then the parenteral route
is preferable. Meta-analyses have shown that enteral nutrition is associated with
fewer septic complications, reduced cost, and shorter hospital stay, so enteral
should be the preferred option whenever possible. One cannot choose this route if
there is intestinal failure, and you will need to use parenteral nutrition (PN). It has
been demonstrated that signifi cantly improved outcomes associated with preopera-
tive PN seem to be limited to severely malnourished patients, and that the PN
needs to be for 7–10 days before surgery. Conversely, using PN in well-nourished
or mildly malnourished patients is associated with either no benefi t or increased
morbidity [
23 ] .
23.7 Alcohol
While not normally the preserve of the nutritionist and not usually discussed in the
context of surgical nutrition, alcohol management is wholly justifi ed in this dis-
cussion on how to improve outcomes after colorectal surgery by altering what we
eat and drink before surgery. It is well known that cirrhotics have exceptionally
poor outcomes after colorectal surgery. It is less well known, however, that com-
mon or garden noncirrhotic heavy drinkers also have poorer outcomes [ 24 ] . The
mechanism of this is uncertain but is arguably not related simply to portal venous
pressures or hepatic function and may be related in part to micronutrient
defi ciency.
Advice on reducing alcohol intake preoperatively should be a fundamental
component of the package of nutritional care in the preoperative phase of an
enhanced recovery program. Allied to this should be the prescription of micronu-
trient supplements including multivitamins, minerals, and trace elements for these
patients.
Key Point
Excessive alcohol use an important risk factor for anastomotic leak in col-
orectal surgery.
329
23 Surgical Nutrition
23.8 Postoperative Nutritional Support
Modern day colorectal practice includes early postoperative enteral nutrition [ 25 ] ,
ideally in the context of an enhanced recovery program (ERP). Patients having
routine major elective surgery, performed laparoscopically or by laparotomy,
should be eating and drinking as soon as possible after surgery and certainly
within 24 h. In conjunction with this, the rate of intravenous fl uid administration
should be reduced. In particular, it is important to remember that excess intrave-
nous saline can cause bowel edema and impede return of normal intestinal func-
tion [
26 ] . Traditional teaching about restricting early oral postoperative fl uids and
diet appears to be incorrect. It is safe for patients with small intestinal and col-
orectal anastomoses to eat immediately after surgery. Indeed there are proven
benefi ts in terms of wound healing and prevention of infections. One does not
need to await bowel sounds or the passage of fl atus per rectum let alone a bowel
action. That said, a number of centers with experience of early diet in the context
of an enhanced recovery program recognize the problem of postoperative nausea
and vomiting. This needs careful attention to detail with antiemetics, prokinetics,
opiate avoidance, or even nasogastric decompression being part of the unit’s ERP
pathway.
There is little place for artifi cial nutrition postoperatively except in the con-
text of the severely malnourished patient or if the surgery or complications of
surgery are likely to cause intestinal failure beyond 5 days. Occasionally, for
whatever reason, patients may struggle with diet, and oral dietary supplements
may be used. The severely malnourished patient may benefi t from parenteral
nutrition or combined enteral and parenteral nutrition depending on their specifi c
circumstances. The combination allows them to derive the luminal mucosal ben-
efi ts of enteral feeding but with the certainty of what has been prescribed actu-
ally being delivered. Parenteral nutrition may also be important if there is
intestinal failure postoperatively regardless of whether there was malnutrition
preoperatively or not.
23.9 Preoperative Nutritional Care in the Normally
Nourished Patient
It is now apparent that even short-term preoperative fasting can have a signifi cant
impact on surgical outcomes [ 27 ] . Importantly, this is true for normally nourished
patients also. Historical animal studies showed that survival from both burn injury
and hypovolemia was signifi cantly less likely when associated with fasting prior to
the insult. Animals fed prior to the insult often survived, while those who were
starved did not. A hemorrhagic shock model was reported that showed 100%
330
C.J. Walsh
mortality in fasted animals and 100% survival in fed animals [ 28 ] . An endotox-
emia model showed that the fasted group had 200% greater mortality than fed
group [ 29 ] . In a further hemorrhagic shock model, the fasted group were all dead
at 3 h, while in a group given an intravenous glucose infusion prior to onset of
shock all survived [
30 ] .
It was demonstrated that the underlying biochemical mechanism of the survival
benefi t in fed animals was directly related to the capacity to release glucose from
liver glycogen stores and that availability of glycogen was a critical factor. An
underlying principle emerged that animals responded differently to a given stress
when stressed in the fed or the starved state.
While it was known from Studley’s work [
1 ] in the 1930s that severely malnour-
ished patients had poorer outcomes after gastrectomy, the concept of the nutritional
status of the patient in the immediate preoperative period being important to out-
come was not appreciated. Overnight fasting of elective surgical patients had been
dogma almost since the birth of general anesthesia, but the results from these animal
studies led to a challenge to the perceived wisdom of overnight fasting and sug-
gested that patients may be in a better metabolic state to withstand the stress of
elective surgery if they were operated on in the fed state. The fi rst studies in the
1970s used infusions of 20% glucose in fasted preoperative patients and demon-
strated reduced protein loss. At around the same time, studies using insulin in
stressed surgical and trauma patients had also shown benefi ts. These studies and
others demonstrated that insulin resistance was key in the outcome from surgical
stress [ 27 ] . Human studies demonstrated that the degree of insulin resistance was
determined by the magnitude of the surgical stress. Studies using 20% glucose infu-
sions reduced insulin resistance but had practical limitations and were not well tol-
erated. This led to the development of a preoperative carbohydrate drink instead
[ 31 ] . This had to be developed to have suffi cient carbohydrate to achieve a rise in
insulin levels to change metabolism from a fasted to a fed state but at the same time
be of suffi ciently low osmolality to permit gastric emptying and be safe preopera-
tively. Thus, the complex carbohydrate formula that satisfi ed these various require-
ments was developed for preoperative care. Subsequent studies showed that it led to
similar reductions in insulin resistance as the 20% glucose infusions had done.
Many trials in different surgical subspecialities demonstrated a reduction in insulin
resistance using preoperative complex carbohydrate drinks. This is the rationale for
the inclusion of preoperative carbohydrate loading in enhanced recovery programs.
It has been shown to lead to better postoperative muscle function and reduced mus-
cle loss, while meta-analysis has demonstrated shorter hospital stays. Insulin resis-
tance has also been shown to be lowered by epidural anesthesia, and when
preoperative carbohydrate loading is combined with epidural analgesia, a dramatic
reduction in insulin resistance after major colorectal surgery can occur. The com-
bined principles are well laid out in a consensus review of optimal perioperative
care in colorectal surgery published on behalf of the ERAS (enhanced recovery
after surgery) group [
32 ] (Box 23.10 ).
331
23 Surgical Nutrition
It remains to be seen whether there is a signifi cant difference in outcome between
malnourished and normally nourished patients if operated on in the context of an
enhanced recovery program designed to reduce insulin resistance to an absolute
minimum.
23.10 Immunonutrition
The malnourished patient may be treated preoperatively with a recognized benefi t
by enteral supplements. One has a choice between traditional enteral feeds or feeds
supplemented by immunonutrients such as omega-3 fatty acids, arginine, as well as
purine nucleotides. Studies on enteral preoperative supplementation of malnour-
ished patients using commercial preparations of immunonutrients have shown sig-
nifi cant advantages over normal isocaloric and isonitrogenous preparations
particularly in upper GI cancer surgery. Prospective randomized trials have shown a
reduction in postoperative infectious complications and length of stay [ 33 ] .
Moreover, preoperative enteral immunonutrition has been shown to be as effective
as perioperative administration. Recent work on immunonutrition in this patient
cohort suggests that the benefi ts may also be seen in normally nourished patients. If
this fi nding is substantiated, this will present an interesting new debate because,
while it is very well established that severely malnourished patients will benefi t
from preoperative nutrition support, the best approach to the mildly malnourished
or normally nourished is much less certain (Box 23.11 ).
Box 23.10: Insulin Resistance
Reduced by preoperative carbohydrate loading
Reduced by epidural anesthesia
Reducing insulin resistance reduces complications
Independent risk factor for length of stay in elective surgery
Box 23.11: Summit on Immune-Enhancing Enteral Therapy
(San Diego 2000)
Immunotherapy was recommended for moderately or severely malnour-
ished patients undergoing elective upper GI surgery and severely malnour-
ished patients undergoing lower GI surgery.
JPEN 25: 2 Suppl 2001
332
C.J. Walsh
The most recent meta-analysis [ 34 ] included 21 randomized controlled trials
enrolling a total of 2,730 patients and assessed the clinical impact of perioperative
enteral immunonutrition in elective major gastrointestinal surgery. This is an impor-
tant meta-analysis because, unlike previous studies, it only looked at perioperative
patients and not a mixture of surgical and critical care patients. Immunonutrition
signifi cantly reduced overall complications when used before surgery, both before
and after surgery or after surgery alone. The authors concluded that perioperative
enteral immunonutrition decreases morbidity and hospital stay but not mortality after
major gastrointestinal surgery and concluded that its routine use can be recommended.
How this translates into colorectal practice alone as opposed to upper GI cancer sur-
gery remains to be seen. It will also be very interesting to see if immunonutrients
continue to demonstrate a benefi t in the context of the reduced surgical stress associ-
ated with enhanced recovery programs including preoperative carbohydrate loading,
epidural anesthesia for open surgery, or regional blocks for a laparoscopic approach.
23.11 Parenteral Nutrition
Modern day parenteral nutrition should be managed by a multidisciplinary nutrition
support team. They will help the surgical team decide whether the patient needs artifi -
cial nutritional support at all, and if so, whether it needs to be parenteral, and if so, then
what should be delivered and how. In general terms, one needs to try to avoid over
providing macronutrients and under providing micronutrients. Nutritional require-
ments will be worked out by the nutrition team using formulae and equations such as
the commonly used Schofi eld equation. The nutrition support team will then work
with the surgical team to fi nd the best way to deliver the calculated prescription taking
into account the patient’s fl uid balance, their comorbidities, and their venous access.
Delivery of parenteral nutrition is never an emergency, but it should be possible to
get someone started fairly swiftly using peripheral PN (PPN). This may be the sole
method of delivery in some patients, or they may go on to be fed by a peripherally
inserted central catheter (PICC) particularly if they go on to have type 2 intestinal
failure (PN required for >28 days). Many centers now use PICC lines very success-
fully for long periods, but if patients are to be fed for months or have to have home
PN, they will probably be better served by a centrally inserted central line. In patients
who have multilumen central lines placed for hemodynamic monitoring and who
need to start on PN, one can either use PPN or a dedicated lumen from the multilumen
line until a formal dedicated feeding line is organized. This again is something for the
nutrition team to evaluate in conjunction with the surgical and or critical care teams.
23.12 Refeeding Syndrome
Malnourished patients use less carbohydrate and more fat and protein for energy.
Insulin secretion is decreased. Tolerance for carbohydrates may be impaired as may
tolerance of fl uid loads. Sudden presentation of food, usually but not exclusively
333
23 Surgical Nutrition
related to parenteral nutrition, may induce a sudden shift from fat to carbohydrate
metabolism. There is a sudden increase in insulin levels associated with intracellu-
lar movement of glucose, phosphate, potassium, magnesium, and thiamine. This
can result in fl uid and electrolyte abnormalities characterized by hypophosphatemia,
hypokalemia, hypomagnesemia, fl uid overload, and glucose intolerance, the so-
called refeeding syndrome [
35 ] . The major symptoms are lethargy, confusion,
weakness, and respiratory failure. Rhabdomyolysis, arrhythmias, seizures, coma,
and sudden death may occur. Patients at risk of refeeding syndrome need to be iden-
tifi ed. Measures to avoid refeeding syndrome need to be taken with gradual intro-
duction of parenteral and enteral nutrition with reduced caloric loads in severely
malnourished patients [ 2 ] . Patients need careful observation with monitoring and
correction of electrolyte abnormalities (Box 23.12 ) .
References
1. Studley HO. Percentage of weight loss. A basic indicator of surgical risk in patients with
chronic peptic ulcer. JAMA. 1936;106(6):458–60.
2. Nutritional support in adults. NICE guidance CG32.
http://www.nice.org.uk/CG32 accessed
Dec 2011.
3. Lassen K, Hanneman P, Ljungqvist O, et al. Patterns in current perioperative practice: survey
of colorectal surgeons in fi ve northern European countries. BMJ 2005;330:1420–21.
Box 23.12: Prevention and Treatment of Refeeding Syndrome
Identify at risk malnourished patients.
Artifi cial feeding should be started at a reduced calorifi c rate.
Monitor electrolytes and fl uid balance.
Intravenous phosphate is required as oral supplementation is inadequate.
CG032 NICE Guideline Feb 2006
Key Points
Malnutrition is associated with poor surgical outcomes. •
Identifying and correcting macronutrient and micronutrient defi ciencies in •
the preoperative period will lead to fewer postoperative complications, shorter
length of stay, and improved patient outcomes from colorectal surgery.
Preload elective patients with carbohydrate to reduce insulin resistance and •
improve postoperative recovery.
Consider immunonutrients preoperatively. •
Learn to recognize intestinal failure. •
Use the nutrition support team particularly in patients who need PN. •
Avoid refeeding syndrome by gradual introduction of nutrients to those at •
risk.
334
C.J. Walsh
4. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. BMJ.
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23 Surgical Nutrition
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S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_24, © Springer-Verlag London Limited 2012
24.1 Introduction
Diverticular disease is a common disease. It predominantly affects people over the
age of 60 years, who live in a Western society and have a slight female preponder-
ance. It is increasing in prevalence and is thought to affect up to 60% of this popula-
tion [ 1 ] . Given its high prevalence in society, it is surprisingly indolent condition
with complications arising in only a small minority of patients [ 2 ] .
The morbidity and mortality associated with this condition is proportional to the
degree of sepsis at the time of presentation in a potentially old and frail patient with
multiple medical comorbidities. The decision to operate has always been controversial,
but more recent evidence suggests that this decision should be made on an individual
patient basis. In addition, there is a growing place for laparoscopic management [ 3 ] .
24.2 Pathology
It is thought that a low fi ber diet results in a high intraluminal pressure in the com-
paratively narrow sigmoid colon [ 4 ] . Over time, this can result in mucosal hernia-
tion through weak points in the bowel wall. These weak points are adjacent to
penetrating arteries passing through the circular muscle, generally in the sigmoid
colon. Diverticular disease, less commonly, also occurs elsewhere in the colon.
Other risk factors include:
C. McCarthy • N. Hennessy • B. Fozard , M.B.B.S, FRCS (Eng.), MS (Lon) (*)
Department of Colorectal Surgery , Royal Bournemouth Hospital ,
Castle Lane East , Bournemouth, Dorset , BH7 7DW , UK
e-mail: basil.fozard@rbh.nhs.uk
Chapter 24
Diverticular Disease
Catherine McCarthy , Niklas Hennessy , and Basil Fozard
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