Perioperative Nutrition: Critical considerations before and after ostomy surgery

Article reprint courtesy of The Phoenix (link to www.phoenixuoaa.org) magazine, America’s leading ostomy publication. Use code SAVE20 to save 20% on a digital subscription.

By Amalia Karlin, The Ostomy Dietitian

Nutrition status prior to and post-surgery can impact health outcomes and should be evaluated by the care team to prevent deleterious effects of malnutrition. It is well understood that morbidity in the hospitalized patient is compromised in the presence of malnutrition. It is also associated with longer hospital stays and higher readmission rates. Malnourished patients are at greater risk of developing complications, including delayed wound healing and increased risk of infections.

Importance of Protein

There are varying ways to define malnutrition, but for the purpose of this discussion it will be interpreted as an inadequate intake of protein and total calories, also known as protein-calorie malnutrition (PCM). Insufficient intake of protein and calories is associated with many chronic health conditions, but it is especially of concern with conditions that affect the gastrointestinal system, like colorectal cancer and Inflammatory Bowel Disease (IBD). These patients often avoid eating, sometimes for years on end, to try and prevent symptoms like abdominal pain, nausea, vomiting, and diarrhea. Poor intake, however, is only one contributing factor to malnutrition prior to surgery.

Malnutrition due to poor oral intake is compounded by the presence of ongoing inflammation. Systemic inflammation in this population alters the body’s metabolism and changes the way the body prioritizes nutrients. For example, as a part of the inflammatory immune response the body produces proteins called acute phase proteins. The body prioritizes making these acute phase proteins in response to inflammation, so if protein intake from the diet is poor, the body will break down lean body mass to get the protein it needs. Lean body mass includes muscle, bone, organs, ligaments, and tendons. 

Compromising lean body mass prior to surgery can negatively impact surgical outcomes. This is why even individuals who are obese with poor muscle mass can still be considered malnourished. Without ample stores of lean body mass, the ability to fight infectious and heal wounds will be compromised. There must be enough lean body mass to withstand the body’s demands in times of illness, surgical recovery, or even just the demands of everyday life. 

This is not to say that fat mass doesn’t have significance as well. When systemic inflammation is present, the body will rely on triglycerides as a primary energy source. Triglycerides are a type of fat and will be pulled from adipose stores in the body. This reaffirms the significance of not only sustaining adequate lean body mass, but also a healthy body weight prior to surgery. So, how do patients evaluate these components of their nutrition status prior to elective ostomy surgery? How do they ensure that they are going into surgery with the best odds for a fast recovery and successful wound healing?

ERAS Protocol

In 1997, a group of general surgeons with a background in colorectal surgery created a model of care called Enhanced Recovery After Surgery, commonly referred to as ERAS. The purpose of the ERAS program is to improve patient outcomes by taking a multidisciplinary approach to addressing health factors before, during, and after surgery. The most current ERAS guidelines for elective colorectal surgery highlight multiple nutrition related interventions both pre-op and post-op that can really benefit patients going in for ostomy surgery.

Prior to surgery, one of the most beneficial nutrition interventions as dictated by the ERAS protocol would be malnutrition screening. Multiple screening tools can be used to screen for malnutrition, but the barrier to being screened and treated for malnutrition is the absence of a multidisciplinary team approach to patient care. 

For example, it can be quite common for both IBD and cancer patients to report losing a considerable amount of weight, unintentionally, leading up to surgery. Weight loss is such an easy calculable nutrition evaluation tool. Patients often volunteer that information up themselves. An unintentional weight loss of just 5% increases the risk of complications. 

Patients with this knowledge should ask their care team to evaluate their significant weight loss prior to surgery and not just have it be noted it in their chart. The nutrition intervention for a patient deemed malnourished can be as simple as drinking an oral nutrition supplement daily 7-10 days leading up to surgery. According to the ERAS protocol, starting an oral intervention 7-10 days prior is associated with a reduced prevalence in infectious complications.

The 24 Hours Before Surgery

Another component of ERAS patients can inquire about, is their nutrition protocol 24 hours prior to surgery. It is recommended that fasting of solids prior to surgery in certain cases should now be shortened to 6 hours and for clear liquids only 2 hours. In addition to shortening the fasting windows, instructing patients to consume a high carbohydrate drink 2-3 hours before anesthesia is administered can reduce the catabolic response after surgery. It can spare the body’s precious lean body mass and muscle strength. It has also been shown to reduce postoperative insulin resistance in addition to improving general well-being. It is like carbohydrate loading before a marathon. Preparing for and recovering from surgery is a marathon all on its own!

Postoperative Care

Immediately after surgery the care team will take measures to manage fluid and electrolyte balance, manage blood sugars and nausea, and prevent the possibility of an ileus. These nutrition related interventions are usually managed by way of IV fluids. The resumption of an oral diet however, will look different for each patient and will depend on many factors. Nevertheless, the overarching goal is the same and that is to resume an oral diet as early as possible. Any delay in resuming an oral diet is associated with delayed recovery times and increased risk of infectious complications. Early introduction of an oral diet also helps the return of bowel function, which is key to qualifying for discharge. Early mobilization after colorectal surgery works similarly to support the return of gastrointestinal function and is also suggested by the ERAS protocol.

While there is still more research to be done, targeting ileostomy and colostomy surgery specifically, there are already existing components of perioperative nutrition that can be improved upon. The healthcare system will never be as invested in regulating the ERAS protocol as patients are devoted to their own health, well-being, and successful recovery from surgery. Individuals preparing to go into elective ostomy surgery should be direct with their providers about addressing their nutrition prior to and post-surgery.

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