Can Nutrition Benefit Surgical Outcomes?

Most often, nutrition is thought of in terms of chronic disease or weight management in patients who are already experiencing the consequences of their disease. However, it is one of the simplest and most cost-effective ways to improve outcomes for any patient, regardless of their current health status. The two most pertinent examples in orthopaedics are in the instance of presurgical fasting, and in nutrition for optimal injury recovery.

With regards to the former, change is already in the air however we are still a long way off realising this at a systemic rather than an individual practitioner level. Patients are still advised “nil by mouth from midnight” prior to surgery. Whilst this was best practice in 1946, the Australian and New Zealand College of Anaesthetist (ANZCA) guidelines have advanced significantly since then and no longer necessitate, or indeed prescribe this outdated practice. In fact, the ANZCA guidelines explicitly mention that carbohydrate drinks specifically formulated for surgery may be prescribed.

Furthermore, increasingly the evidence suggests that current practice is detrimental both to patient experience and recovery. Fasting, as is presently practiced, not only dehydrates and leaves patients feeling unwell, but it puts them into a catabolic state. This results in subsequent hyperglycaemia, loss of fat and protein stores, and causes insulin resistance, all of which could be prevented with a simple carbohydrate rich drink.[1]

Introducing a perioperative carbohydrate drink metabolically optimises patients by stimulating a meal-like insulin response. Doing so at the beginning of surgery helps avoid insulin resistance following surgery and leads to better patient outcomes[2][3][4] such as preserving muscle mass,[5] and facilitating wound healing[6]. There is a direct relationship between insulin resistance and infectious morbidity, including surgical site infections. Evidence suggests that 50g of maltodextrin taken before surgery is sufficient to ameliorate this. Moreover, patients given a carbohydrate-rich drink prior to surgery went home between 1 and 13 hours sooner.[7]

So how do we define a fluid that is safe for use as a presurgical drink? And whose responsibility is it to ensure that patients are receiving world-class care and opportunities for recovery? The former is a much simpler question to answer. A surgery specific drink is one that:

  • Contains sufficient complex carbohydrate to stimulate a meal-like insulin response
  • Has a pH 7 to cause less damage in the unlikely event of aspiration
  • Has a low osmolality to facilitate rapid gastric emptying
  • Is palatable

There is a particular product on the market which I currently recommend to all of my surgical patients called Dex. Dex is the only surgery specific carbohydrate drink that is Australian-owned, formulated and manufactured. It is also inexpensive, at $1 per serve and is formulated with 100% complex carbohydrates and no artificial sweeteners.

To answer the second question as to responsibility, I believe that this burden rests on everyone’s shoulders. We don’t need to wait for patients to receive their admissions call from the hospital on the day prior to their surgery. We can provide them with this information, and even the carbohydrate drink itself, at little expense, with a simple instruction sheet upfront on the day of their booking.

However, I have only just scratched the surface of this backwards culture that exists in our health system with regards to nutrition. ‘Enhanced Recovery After Surgery’, or ERAS, principles encourage consideration be given to nutrition, and the ERAS Society has gone so far as to develop protocols to this effect.

Postoperative infectious complications are independently associated with increased length of hospital stays and contribute to significant patient morbidity. Furthermore, preoperative nutritional status has also been implicated as an independent risk factor for postoperative morbidity. Surgery places notable stress on the patient’s body, triggering inflammation and impairing immune function.[8] Furthermore, subsequent limb immobilisation, in addition to the normal inflammatory response as a result of tissue injury, result in even greater nutrient needs including total caloric intake and macronutrients such as protein, in particular.[9]

We know that the vast majority of Australians do not consume optimal diets. The leading causes of morbidity in Australia are lifestyle factors, with 31% of disease burden being preventable and a result of modifiable risk factors[10]. As an example, a mere 5% of Australians meet the Australian Dietary Guidelines for recommended daily serves of fruit and vegetables[11]. Our patients also consume more than twice the recommended serves of discretionary foods[12] that are high in what I like to refer to as the holy trinity of weight gain: saturated fats, sugars and salt. We also know that surgical site infections are the most common infections associated with healthcare, and frequently result in longer hospital stays[13]. Whilst we certainly cannot draw conclusions about cause and effect, or even association, there is most certainly an opportunity to provide patients with all of the tools for optimal recovery, which includes addressing their nutritional status prior and subsequent to their surgery. And therein lies the opportunity.

Author: Miriam Pollak ANutr BSc (Phys, Psych) MHumNutr

Miriam is a Canberra-based Nutritionist with a special interest in sports and injury recovery. For more information visit www.nourish-meant.com.au

[1] Li L, Wang Z, Ying X, Tian J, Sun T, Yi K, et al. Preoperative carbohydrate loading for elective surgery: a systematic review and meta-analysis. Surg Today. 2012 Jul;42(7):613-24

[2] Henriksen MG, Hessov I, Dela F, Hansen HV, Haraldsted V, Rodt SA. Effects of preoperative oral carbohydrates and peptides on postoperative endocrine response, mobilization, nutrition and muscle function in abdominal surgery. Acta Anaesthesiologica Scandinavica 2003; 47: 191-9

[3] Li L, Wang Z, Ying X, Tian J, Sun T, Yi K, et al. Preoperative carbohydrate loading for elective surgery: a systematic review and meta-analysis. Surg Today. 2012 Jul;42(7):613-24

[4] Soop M, Nygren J, Thorell A, Weidenhielm L, Lundberg M, Hammarqvist F, Ljungqvist O. Preoperative oral carbohydrate treatment attenuates endogenous glucose release 3 days after surgery. Clin Nutr. 2004 Aug;23(4):733-41

[5] Noblett SE, Watson DS, Hunog H, Daison B, Hainsworth PJ, Horgan AF. Preoperative oral carbohydrate loading in colorectal surgery: a randomized controlled trial. Colorectal Disease 2006;8: 563-9

[6] Pierre EJ, Barrow RE, Hawkins HK, Nguyen TT, Sakurai Y, Desai M, et al. Effects of insulin on wound healing. J Trauma 1998; 44: 342-5

[7] Cochrane Database of Systematic Reviews. Smith MD, McCall J, Plank L, Herbison GP, Soop M, Nygren J. Preoperative carbohydrate treatment for enhancing recovery after elective surgery (Review).

[8] Hegazi RA, Hustead DS, Evans DC. Preoperative standard oral nutrition supplements vs immunonutrition: results of systematic review and meta-analysis. J Am Coll Surg. 2014;219(5):1078-1087.

[9] Tipton KD. Nutritional Support for Exercise-Induced Injuries. Sports Med. 2015; 45 Suppl 1:S93-104.

[10] Australian Institute of Health & Welfare https://www.aihw.gov.au/reports-statistics/health-conditions-disability-deaths/burden-of-disease/overview

[11] Australian Bureau of Statistics http://www.abs.gov.au/ausstats/abs@.nsf/mf/4364.0.55.001

[12] Australian Bureau of Statistics http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.012~2011-12~Main%20Features~Discretionary%20foods~10010

[13] Surgical site infections – Annual Epidemiological Report 2016 [2014 data]. European Centre for Disease Prevention and Control. 2016. https://ecdc.europa.eu/en/publications-data/surgical-site-infections-annual-epidemiological-report-2016-2014-data