Cerrahi Hastalarda Malnütrisyon ve Beslenme Desteği

Yıl 2013, Cilt: 13 Sayı: 1, 33 - 39, 01.01.2013

Ersin Dumlu Birkan Bozkurt Mehmet Tokaç Gülten Kıyak Alper Özkardeş Samet Yalçın Mehmet Kılıç

Öz

Malnütrisyon, cerrahi hastalarda mortalite ve morbiditeyi etkileyen önemli bir unsurdur. Bireyin gereksinimleri ve cerrahi durumuna bağlı olarak, beslenme oral takviyeler, enteral veya parenteral yoldan sağlanabilir. Enteral beslenmenin, parenteral beslenmeye göre daha ucuz, daha güvenli ve “daha fizyolojik” olduğu büyük ölçüde kabul edilmiştir, ancak çalışmalar bunun her zaman böyle olmadığını göstermektedir.Bu makalede, cerrahi beslenme temelleri irdelenmiş ve enterale karşı parenteral beslenmenin destekleyici kanıtları değerlendirilmiştir.

Anahtar Kelimeler

cerrahi, beslenme, malnütrisyon

Malnutrition and Nutrition Supplementation In Surgical Patients

Öz

Malnutrition is associated with significant morbidity and mortality in surgical patients . Nutrition can be delivered by oral supplements, enteral or parenteral feeding, the route depending on an individual’s requirements and surgical condition. Enteral feeding has largely been regarded as superior to parenteral feeding, as it is cheaper, safer and “more physiological” but studies show this is not always the case. This article reviews the basics of surgical nutrition and assesses the evidence supporting enteral versus parenteral nutrition.

Anahtar Kelimeler

surgery, nutrition, malnutrition

Kaynakça

• Studley HO. Percentage of weight loss: a basic indicator of surgical risk in patients with chronic peptic ulcer. JAMA 1936; 106: 458.
• McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. BMJ 1994; 308: 945-948
• Hill GL, Blackett RL, Pickford I et al. Malnutrition in surgical patients: an unrecognised problem. Lancet 1977; 1: 689-692.
• Stratton RJ, Elia M. Who benefits from nutritional support: what is the evidence? Eur J Gastroenterol Hepatol 2007:19; 353-358.
• BAPEN Malnutrition Universal Screening Tool (MUST). Available at www.bapen.org.uk/must_tool.html (Accessed 27th December 2007).
• Windsor JA, Hill GL. Weight loss with physiologic impairment: a basic indicator of surgical risk. Ann Surg 1988; 207: 290-291.
• Detsky AS, McLaughlin JR, Baker JP. What is subjective global assessment of nutritional status? JPEN 1987; 11: 8Gibbs J, Cull W, Henderson W, et al. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg 1999; 134: 36-42.
• The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. Perioperative total parenteral nutrition in surgical patients. NEJM 1991; 325: 525-532.
• Schofield WN. Predicting basal metabolic rate, new standards and review of previous work. Hum Nutr Clin Nutr 1985; 39S: 5-41.
• Potter JM. Oral supplements in the elderly. Curr Opin Clin Nutr Metab Care 2001; 4: 21-28.
• Smedley F, Bowling T, James M et al. Randomised clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care. Br J Surg 2004; 91: 983-990
• McWhirter JP, Pennington CR. A comparison between oral and nasogastric nutritional supplements in malnourished patients. Nutrition 1996; 12: 502-506.
• Cabre E, Gassull MA. Complications of enteral feeding. Nutrition 1993; 9: 1-9.
• Lewis SJ, Egger M, Sylvester PA, et al. Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ 2001; 323: 773-776.
• Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med 2001;29: 2264-2270.
• Heyland DK, Montalvo M, MacDonald S, et al. A review of RCTs of surgical patients. Can J Surg 2001;44: 102-111.
• Fan ST, Lo CM, Lai EC, et al. Perioperative nutritional support in patients undergoing hepatectomy for hepatocellular carcinoma. NEJM 1994; 331: 1547-1552.
• Bozzetti F, Gavazzi C, Miceli R et al. Perioperative total parenteral nutrition in malnourished gastrointestinal cancer patients; a randomised clinical trial. JPEN 2000; 24: 7-14.
• The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. Perioperative total parenteral nutrition in surgical patients. NEJM 1991; 325: 525-532.
• Sandstrom R, Drott C, Hyltander A. The effect of postoperative intravenous feeding (TPN) on outcome following major surgery evaluated in a randomised study. Ann Surg 1993; 217: 185-195.
• Brennan MF, Pisters PWT, Posner M et al. Aprospective randomised trial of total parenteral nutrition after major pancreatic resection for malignancy. Ann Surg 1994; 220: 436-4
• Lipman TO. Grains or veins: is enteral nutrition really better than parenteral nutrition? A look at the evidence. JPEN 1998; 22: 167-182.
• Botterill I, Miller G, Dexter S, Martin I. Lesson of theweek: deaths after delayed recognition of percutaneous endoscopic gastrostomy tube migration. BMJ 1998; 317: 524-5
• Ghabril MS, Aranda-Michel J, Scolapio JS. Metabolic and catheter complications of parenteral nutrition. Current Gastroenterology Reports 2004; 6: 327-334.
• Li M, Specian RD, Berg RD et al, Deitch EA. Effects of protein malnutrition on the intestinal mucosal barrier to the translocation of indigenous flora in mice. JPEN 1989; 13: 572-578.
• Mainous M, Xu DZ, Lu Q, et al. Oral-TPN-induced bacterial translocation and impaired immune defences are reversed by refeeding. Surgery 1991; 110: 277-283.
• Gatt M, Reddy BS, MacFie J. Bacterial translocation in the critically ill – evidence and methods of prevention. Aliment Pharmacol Ther 2007; 25: 741-757.
• Sedman PC, MacFie J, Palmer MD, et al. Preoperative total parenteral nutrition is not associated with mucosal atrophy or bacterial translocation in humans. Br J Surg 1995; 82: 1663-1667.
• Lipman TO. Bacterial translocation and enteral nutrition in humans. An outsider looks in. JPEN 1995;19: 156-165.
• MacFie J. Enteral versus parenteral nutrition. Br J Surg 2000; 87: 1121-1122.
• Heyland DK, MacDonald S, Keefe L, et al. Total parenteral nutrition in the critically ill patient: a metaanalysis. JAMA 1998; 280: 2013-2019.
• Lobo DN, Memon MA, Allison SP, et al. Evolution of nutritional support in acute pancreatitis. Br J Surg 2000; 87: 695-707.
• Sax HC, Warner BW, Talamini MA et al. Early total parenteral nutrition in acute pancreatitis: lack of beneficial effects. Am J Surg 1987; 153: 117-124.
• McLave SA, Greene LM, Snider HL et al. Comparison of the safety of early enteral versus parenteral nutrition in mild acute pancreatitis. JPEN 1997; 21: 14-20.
• Windsor AC, Kanwar S, Li AG et al. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. Gut 1998; 42: 431-435.
• Kalfarentzos F, Kahagias J, Mead N, et al. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomised trial. Br J Surg 1997; 84: 1665-1669.
• Moore FA, Moore EE, Jones TN, et al. TEN versus TPN following major abdominal trauma: reduced septic morbidity. J Trauma 1989; 29: 916-923.
• Kudsk KA, Croce A, Fabian TC et al. Enteral versus parenteral feeding. Ann Surg 1992; 215: 503-513.
• Cerra FB, McPherson JP, Konstantinides F et al. Enteral nutrition does not prevent multiple organ failure syndrome after sepsis. Surgery 1988; 104: 727-733.
• Newsholme P. Why is L-glutamine metabolism important to cells of the immune system in health, post injury, surgery or infection? J Nutr 2001; 131: 2523SNovak F, Heyland DK, Avenell A, et al. Glutamine supplementation in serious illness: a systematic review of the evidence. Crit Care Med 2002; 30: 2022-2029.
• Marik PE. Arginine: too much of a good thing may be bad! Crit Care Med 2006; 34: 2844-2847.
• Heyland DK, Novak F, Drover JW, et al. Should immunonutrition become routine in critically ill patients? A systematic review of the evidence. JAMA 2001; 286: 944-9
• Grimble RF. Immunonutrition. Curr Opin Gastroenterol 2005; 21: 216-222.
• Yazışma Adresi / Correspondence: Dr Ersin Gurkan DUMLU Atatürk Eğitim ve Araştırma Hastanesi Genel Cerrahi Kliniği e-posta: [e-mail] Tel: [phone]