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  • 1. Gustafsson, Ulf O.
    et al.
    Ljungqvist, Olle
    Örebro University, School of Health and Medical Sciences.
    Perioperative nutritional management in digestive tract surgery2011In: Current opinion in clinical nutrition and metabolic care, ISSN 1363-1950, E-ISSN 1473-6519, Vol. 14, no 5, p. 504-509Article in journal (Refereed)
    Abstract [en]

    Purpose of review This article reviews the recent research on perioperative nutrition in digestive tract surgery in the light of modern perioperative care principles, that is, enhanced recovery after surgery (ERAS). Four major directions of research emerge: detecting malnutrition, perioperative hyperglycemia/insulin resistance, enteral/parenteral nutrition and immunonutrition. Recent findings For preoperative nutritional screening/assessment, current data cannot single out superiority for SGA questionnaire, nutritional risk score, Reilly's nutritional risk score or nutritional risk index in the ability to predict nutrition-related complications. The use of ERAS elements to reduce surgical stress and preclude postoperative insulin resistance has recently been clearly linked to reductions in adverse outcomes. There are specific situations in which enteral nutrition is contraindicated and criterias for preoperative and postoperative parenteral nutrition in undernourished patients are defined in guidelines recently available. Several controlled randomized studies and systematic reviews indicate that immune nutrition formulas reduce both morbidity and length of stay after major abdominal surgery. Summary To reduce surgical stress, insulin resistance, unnecessary protein losses and postoperative complications, the use of an ERAS protocol is important. Current data shows that the use of perioperative immunonutrition diets for major abdominal surgery is beneficial. Further research on nutritional assessment tools to predict who is at risk for postoperative complications is needed.

  • 2.
    Nygren, Jonas
    et al.
    Centre of Gastrointestinal Disease, Karolinska Institute at Ersta Hospital, Huddinge University Hospital, Stockholm; Centre of Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Thorell, Anders
    Centre of Gastrointestinal Disease, Karolinska Institute at Ersta Hospital, Huddinge University Hospital, Stockholm.
    Ljungqvist, Olle
    Centre of Gastrointestinal Disease, Karolinska Institute at Ersta Hospital, Huddinge University Hospital, Stockholm.
    New developments facilitating nutritional intake after gastrointestinal surgery2003In: Current opinion in clinical nutrition and metabolic care, ISSN 1363-1950, E-ISSN 1473-6519, Vol. 6, no 5, p. 593-7Article, review/survey (Refereed)
    Abstract [en]

    Purpose of review: Conventional perioperative care includes a period of semistarvation before bowel function returns and adequate oral intake is allowed. It has been clearly shown that there is no need for restriction in oral intake after, at least lower, gastrointestinal surgery, and that early oral feeding does not increase the risk for dehiscense of the anastomosis. In contrast, early feeding reduces postoperative complications. Even if early oral intake is allowed, however, it is common that side effects such as nausea and vomiting prevent patients from reaching the target energy intakes. Thus, developing routines and treatments that promote sufficient early oral intake after surgery and maintain adequate energy intake in the postoperative period are probably of great importance for the outcome from surgery.

    Recent findings: There are a number of factors which may facilitate early oral intake after gastrointestinal surgery including effective pain relief using epidural anaesthesia while avoiding opioids, minimizing sodium and fluid administration perioperatively and substantially reducing preoperative fasting. In addition, sufficient preoperative information, intensive mobilization, energy-dense hospital food and oral supplements may all contribute to improved energy intake after surgery.

    Summary: In general, there is a great need for randomized controlled trials examining factors important for the regulation of oral intake after surgery and also the effects of early oral intake after upper gastrointestinal surgery. Future areas of research may also include regulation of appetite and use of peripherally acting opioid antagonists.

  • 3.
    Rooyackers, Olav
    et al.
    Centre for Surgical Sciences, Karolinska Institutet, Stockholm; Department of Anesthesiology and Intensive Care, Karolinska University Hospital, Huddinge.
    Thorell, Anders
    Centre of Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Nygren, Jonas
    Centre of Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Ljungqvist, Olle
    Centre of Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Microdialysis methods for measuring human metabolism2004In: Current opinion in clinical nutrition and metabolic care, ISSN 1363-1950, E-ISSN 1473-6519, Vol. 7, no 5, p. 515-21Article in journal (Refereed)
    Abstract [en]

    Purpose of review: To discuss the advantages and limitations of the microdialysis technique as a diagnostic and research tool using recent findings on human metabolism.

    Recent findings: Results from several studies have supported the potential of microdialysis as a diagnostic tool for metabolic monitoring in difficult accessible tissues (brain, liver, intestine). However, despite promising results, no clear diagnostic measures have yet emerged. Several studies combining microdialysis with stable isotope tracers have shown that this approach has great potential for studying human metabolism non-invasively in specific tissue beds in a more dynamic way.

    Summary: Bearing in mind the limitations and assumptions, the microdialysis technique is a useful tool in investigations of human metabolism. Its main advantages are that it can be used safely with low-grade invasiveness in humans, and thereby allows continuous sampling over prolonged periods of time from specific tissues without taking any biopsies. At present, microdialysis would seem to be useful as a diagnostic tool when integrated in the total clinical, physiological and pharmacological evaluation. Within human metabolic research, microdialysis has been and will be a very useful technique.

  • 4.
    Soop, Mattias
    et al.
    Karolinska Institute, CLINTEC, Karolinska University Hospital, Huddinge; Centre for Gastrointestinal Disease, Ersta Hospital, Stockholm; Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA.
    Nygren, Jonas
    Karolinska Institute, CLINTEC, Karolinska University Hospital, Huddinge; Centre for Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Thorell, Anders
    Karolinska Institute, CLINTEC, Karolinska University Hospital, Huddinge; Centre for Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Ljungqvist, Olle
    Karolinska Institute, CLINTEC, Karolinska University Hospital, Huddinge; Centre for Gastrointestinal Disease, Ersta Hospital, Stockholm.
    Stress-induced insulin resistance: recent developments2007In: Current opinion in clinical nutrition and metabolic care, ISSN 1363-1950, E-ISSN 1473-6519, Vol. 10, no 2, p. 181-6Article in journal (Refereed)
    Abstract [en]

    Purpose of review: Interest in stress-induced insulin resistance has increased during the past 5 years. Relevant clinical and mechanistic investigations during the past year will be reviewed.

    Recent findings: Recent trials of intensive insulin therapy in intensive care units have brought attention to a high incidence of hypoglycemic episodes with such treatment. The clinical relevance of such hypoglycemia has been shown to be minor, however. Furthermore, animal and in-vitro work further supports the finding that glucose control, rather than glycemia-independent effects of insulin, is the primary mechanism of action of intensive insulin therapy. In elective surgery, cohort studies show an association between intraoperative hyperglycemia and postoperative morbidity. Beneficial effects of preoperative oral carbohydrate treatment on immunocompetence and cardiac contractility have been demonstrated. Laparoscopic segmental colectomy was associated with considerably attenuated derangements in glucose metabolism compared with conventional, open surgery.

    Summary: Better methods of insulin dosing and administration and glucose monitoring are warranted to further minimize the risks of intensive insulin therapy. In elective surgery, perioperative measures such as preoperative oral carbohydrate treatment and laparoscopic techniques attenuate metabolic and other physiological derangements and such methods should be integrated into perioperative care protocols to minimize morbidity and enhance recovery.

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