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During the 1960–1970s we learnt how artificial feeding could rescue a few severely undernourished patients. Next, research characterised the integrative biochemistry of illness and sought ways by which the catabolic responses could be influenced nutritionally and hormonally. More recently the large proportion of hospital patients suffering from undernutrition, as judged by both weight for height and by micronutrient status, has become widely appreciated and there has been an interest in more routine supplementation of hospital patients. As the practice of supplementation increases there has been a growing need for randomised controlled trials to assess its clinical effectiveness. But applying rigorous clinical endpoints such as mortality, morbidity, or duration of stay in randomised controlled trials of a secondary treatment such as nutritional support is difficult because the endpoints are easily confounded by primary treatments and other factors.
The physiological effects of undernutrition in the otherwise normal human have been well known for about 50 years.1 As far as sip supplements are concerned there is now excellent evidence that they do not simply replace the intake of normal food but effectively increase nutrient intake and improve nutritional status.2
Surgeons and gastroenterologists need to know the best nutritional strategies for patients undergoing major abdominal surgery. Preoperative undernutrition has long been known to predict poor surgical outcome. Preoperative feeding can reduce the increased risk of postoperative complications in nutritionally depleted patients. Enteral feeding is at least as good as parenteral feeding in this context3 but it is not clear if the time cost of preoperative feeding is justified by its being more effective than early postoperative support. Postoperatively, parenteral feeding should not be used routinely because it increases complication rates in well nourished patients4-6 and this technique should be reserved for the severely undernourished and those unable to take nutrients enterally during a prolonged and complicated postoperative course . However, routine very early postoperative enteral feeding of complete polymeric feeds (unlike “immune enhanced” feeds)7 has been effective in reducing postoperative complications.8 Furthermore, encouraging the intake of sipfeed supplements containing a full and balanced complement of nutrients as the patient begins to eat9 10 seems to reduce even early postoperative complications whether or not the patient is undernourished. Although undernutrition correlates with length of stay, it may be asking much of a routine nutritional supplement to reduce this given that modern average surgical lengths of stay are little over a week.
In the surgical context sip supplements could benefit the patient not only by reducing postoperative complications and hospital stay but also by speeding recovery after discharge from hospital. One study tested the idea that convalescence might be hastened with sip supplements but was unable to demonstrate such an effect as judged by a “well being” visual analogue score.9 In this study postoperative complications and convalescent weight loss were reduced significantly by supplementation.
The randomised controlled trial described by Beattieet al in this issue ofGut 11 (page 813) also concentrates on postoperative convalescence. From a total of nearly 2500 patients admitted for elective gastrointestinal or vascular surgery to Ninewells Hospital, Dundee, 450 were screened; 109 were included of whom 101 completed the study and contributed to the results. Patients were either underweight on admission or had lost 5% or more of their body weight from admission to the eight postoperative day and represented a smaller proportion of undernourished patients than had previously been seen at Ninewells.12 On resumption of oral feeding postoperatively, patients were randomised to receive or not to receive a nutritionally complete liquid supplement of 400 ml (600 kcal). Patients continued on the supplements during the remainder of their admission and during convalescence at home for 10 weeks. Antibiotic use was marginally reduced, length of stay (which seems long in this study) was not altered but, most strikingly, patients regained weight much quicker and had improved physical and mental quality of life scores by the end of the study.
The trial deserves close scrutiny. As the authors emphasised, it was not analysed on an intention to treat basis and this will worry some. This group used a body mass index (BMI) of <20 kg/m2(which is close to the fifth centile for an adult British population) or the 15thcentile for arm anthropometric measurements. The arm anthropometric inclusion data and the perioperative weight loss criteria contrived to include about 20% of patients with a BMI above 20. It is not clear whether such patients fared differently from the more clearly undernourished; personal communication from the authors suggests not. The age difference between the groups was unfortunate and may produce some bias.
None the less the study is an important reminder to surgeons of the prolonged impact of surgery on weight and quality of life after discharge from hospital and demonstrates a potential need for continued care as patients move from the surgical ward back to the community. Weight loss in the control group continued for eight weeks (longer by several weeks than was found in the control group of Keeleet al's study9), but was reversing at two to four weeks with nutritional intervention.
Much is made of the economical advantages to the NHS of rapid hospital turnover but less often is the economic impact of illness and surgery on the patient.A faster convalescence time should be an important goal for every surgical team, and hospital dietitians linking with community services may be in a position to help deliver this. We can be confident that such an approach will speed up regain in weight, but whether this speeds general convalescence remains a matter of dispute between this study and that of Keele et al.
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