title: A comparative analysis of safety and efficacy of different methods of tube placement for enteral feeding following major pancreatic resection. A non-randomized study. A randomised controlled trial of six weeks of home enteral nutrition versus standard care after oesophagectomy or total gastrectomy for cancer: report on a pilot and feasibility study Benefits of maltodextrin intake 2 hours before cholecystectomy by laparotomy in respiratory function and functional capacity: a prospective randomized clinical trial A randomised trial of post-discharge enteral feeding following surgical resection of an upper gastrointestinal malignancy. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Efficacy and Safety of Glutamine-supplemented Parenteral Nutrition in Surgical ICU Patients: An American Multicenter Randomized Controlled Trial Postoperative Nutritional Effects of Early Enteral Feeding Compared with Total Parental Nutrition in Pancreaticoduodectomy Patients: A Prosepective, Randomized Study The effect of nutritional support on the immune function in the acute postoperative period after esophageal cancer surgery: total parenteral nutrition versus enteral nutrition. Guidelines for Perioperative Care in Elective Rectal/Pelvic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations A prospective, randomized, controlled study of ω-3 fish oil fat emulsion-based parenteral nutrition for patients following surgical resection of gastric tumors Effects of preoperative carbohydrates drinks on immediate postoperative outcome after day care laparoscopic cholecystectomy Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study Randomized Clinical Trial: Nasoenteric Tube or Jejunostomy as a Route for Nutrition After Major Upper Gastrointestinal Operations Preoperative Education in Cholecystectomy in the Context of a Multimodal Protocol of Perioperative Care: A Randomized, Controlled Trial Preoperative nutritional support in cancer patients with no clinical signs of malnutrition—prospective randomized controlled trial Effects of preoperative feeding with a whey protein plus carbohydrate drink on the acute phase response and insulin resistance. A randomized trial Safety, feasibility, and tolerance of early oral feeding after colorectal resection outside an enhanced recovery after surgery (ERAS) program Preoperative oral feeding reduces stress response after laparoscopic cholecystectomy. Gastrointestinal tract recovery in patients undergoing bowel resection: results of a randomized trial of alvimopan and placebo with a standardized accelerated postoperative care pathway. A randomized controlled trial evaluating early versus traditional oral feeding after colorectal surgery Safety and efficacy of oral rehydration therapy until 2 h before surgery: a multicenter randomized controlled trial Safety of oral glutamine in the abbreviation of preoperative fasting: a double-blind, controlled, randomized clinical trial. A liberal preoperative fasting regimen improves patient comfort and satisfaction with anesthesia care in day-stay minor surgery. Oral Carbohydrate Supplementation Reduces Preoperative Discomfort in Laparoscopic Cholecystectomy Preoperative Fasting of 2 Hours Minimizes Insulin Resistance and Organic Response to Trauma After Video-Cholecystectomy: A Randomized, Controlled, Clinical Trial 1997 Harry M. Vars Research Award. Does the route of feeding modify gut barrier function and clinical outcome in patients after major upper gastrointestinal surgery? Preoperative Nutrition and Postoperative Discomfort in an ERAS Setting: A Randomized Study in Gastric Bypass Surgery Evaluation of the effects of a preoperative 2-hour fast with maltodextrine and glutamine on insulin resistance, acute-phase response, nitrogen balance, and serum glutathione after laparoscopic cholecystectomy: a controlled randomized trial. Perioperative Enteral Immunonutrition Modulates Systemic and Mucosal Immunity and the Inflammatory Response in Patients With Periampullary Cancer Scheduled for Pancreaticoduodenectomy: A Randomized Clinical Trial The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. Comparative analysis of the efficacy and complications of nasojejunal and jejunostomy on patients undergoing pancreaticoduodenectomy. Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk. A simplified rehabilitation program for patients undergoing elective colonic surgery—randomized controlled clinical trial [The comparison between early enteral nutrition and total parenteral nutrition after total gastrectomy in patients with gastric cancer: the randomized prospective study]. [Feasibility of "no tube no fasting" therapy in thoracolaparoscopic oesophagectomy for patients with oesophageal cancer]. Shrinking preoperative fast time with maltodextrin and protein hydrolysate in gastrointestinal resections due to cancer. Enteral nutrition is superior to total parenteral nutrition for pancreatic cancer patients who underwent pancreaticoduodenectomy. Early initiation of oral feeding following upper gastrointestinal tumor surgery: a randomized controlled trial Randomized clinical trial to compare the length of hospital stay and morbidity for early feeding with opioid-sparing analgesia versus traditional care after open appendectomy. Prehabilitation versus Rehabilitation: A Randomized Control Trial in Patients Undergoing Colorectal Resection for Cancer Randomized clinical trial of the effects of oral preoperative carbohydrates on postoperative nausea and vomiting after laparoscopic cholecystectomy A Prospective Randomized Controlled Trial of Multimodal Perioperative Management Protocol in Patients Undergoing Elective Colorectal Resection for Cancer Enteral Nutrition Enriched With Eicosapentaenoic Acid (EPA) Preserves Lean Body Mass Following Esophageal Cancer Surgery: Results of a Double-Blinded Randomized Controlled Trial Fast Track Postoperative Management after Elective Colorectal Surgery: A Controlled Trail Comparison of Early Mobilization and Diet Rehabilitation Program With Conventional Care After Laparoscopic Colon Surgery: A Prospective Randomized Controlled Trial Oral carbohydrate loading with 18% carbohydrate beverage alleviates insulin resistance. Utility of a perioperative nutritional intervention on postoperative outcomes in high-risk head & neck cancer patients. Randomized controlled trial of preoperative oral carbohydrate treatment in major abdominal surgery Allowing Normal Food at Will After Major Upper Gastrointestinal Surgery Does Not Increase Morbidity: A Randomized Multicenter Trial Randomized clinical trial of the impact of early enteral feeding on postoperative ileus and recovery Effects of preoperative oral carbohydrates and peptides on postoperative endocrine response, mobilization, nutrition and muscle function in abdominal surgery Benefits of post-operative oral protein supplementation in gastrointestinal surgery patients: A systematic review of clinical trials. The Impact of Immunostimulating Nutrition on Infectious Complications After Upper Gastrointestinal Surgery: A Prospective, Randomized, Clinical Trial Randomized clinical trial of new intravenous lipid (SMOFlipid 20%) versus medium-chain triglycerides/long-chain triglycerides in adult patients undergoing gastrointestinal surgery. Impact of home enteral nutrition in malnourished patients with upper gastrointestinal cancer: A multicentre randomised clinical trial.
abstract: CONTEXT Postoperative enteral nutrition is thought to reduce complications and speed recovery after pancreatic resection . There is little evidence on the best route for delivery of enteral nutrition . Currently we use percutaneous transperitoneal jejunostomy or percutaneous transperitoneal gastrojejunostomy , or the nasojejunal route to deliver enteral nutrition , according to surgeon preference . OBJECTIVE To compare morbidity , efficiency , and safety of these three routes for enteral nutrition following pancreaticoduodenectomy . PATIENTS Data were obtained from a prospect ively maintained data base , for all patients undergoing pancreatic resection between January 2007 and June 2008 . One-hundred pancreatic resected patients underwent enteral nutrition : 93 had Whipple 's operations and 7 had total pancreatectomies . INTERVENTION Enteral nutrition was delivered by agreed protocol , starting within 24 h of operation and increasing over 2 - 3 days to meet full nutritional requirement . RESULTS Delivery route of enteral nutrition was : percutaneous transperitoneal jejunostomy in 25 ( 25 % ) , percutaneous transperitoneal gastrojejunostomy in 32 ( 32 % ) and nasojejunal in 43 ( 43 % ) . The incidence of catheter-related complications was higher in percutaneous techniques : 24 % in percutaneous transperitoneal jejunostomy and 34 % in percutaneous transperitoneal gastrojejunostomy as compared to nasojejunal technique ( 12 % ) . Median time to complete establishment of oral intake was 14 , 14 and 10 days in percutaneous transperitoneal jejunostomy , percutaneous transperitoneal gastrojejunostomy , and nasojejunal groups , respectively .  Nasojejunal tubes were removed at median 11 days ( mean 11.5 days ) compared to 5 - 6 weeks for percutaneous transperitoneal jejunostomy and percutaneous transperitoneal gastrojejunostomy . Commonest catheter-related complication in the percutaneous transperitoneal jejunostomy and percutaneous transperitoneal gastrojejunostomy was blockage ( n=6 ; 10.5 % ) , followed by pain after removal of feeding tube at 5 - 6 weeks ( n=5 ; 8.8 % ) , whereas in the nasojejunal group it was blockage ( n=3 ; 7.0 % ) , followed by displacement ( n=2 ; 4.7 % ) . Two patients died postoperatively in this cohort , however , there were no catheter-related mortalities . CONCLUSION Enteral nutrition following pancreatic resection can be delivered in different ways . Nasojejunal feeding was associated with fewest and less serious complications . On current evidence surgeon preference is a reasonable way to decide enteral nutrition but a r and omized controlled trial is needed to address this issue Background Poor nutrition in the first months after oesophago-gastric resection is a contributing factor to the reduced quality of life seen in these patients . The aim of this pilot and feasibility study was to ascertain the feasibility of conducting a multi-centre r and omised controlled trial to evaluate routine home enteral nutrition in these patients . Methods Patients undergoing oesophagectomy or total gastrectomy were r and omised to either six weeks of home feeding through a jejunostomy ( intervention ) , or treatment as usual ( control ) . Intervention comprised overnight feeding , providing 50 % of energy and protein requirements , in addition to usual oral intake . Primary outcome measures were recruitment and retention rates at six weeks and six months . Nutritional intake , nutritional parameters , quality of life and healthcare costs were also collected . Interviews were conducted with a sample of participants , to ascertain patient and carer experiences . Results Fifty-four of 112 ( 48 % ) eligible patients participated in the study over the 20 months . Study retention at six weeks was 41/54 patients ( 76 % ) and at six months was 36/54 ( 67 % ) . At six weeks , participants in the control group had lost on average 3.9 kg more than participants in the intervention group ( 95 % confidence interval [ CI ] 1.6 to 6.2 ) . These differences remained evident at three months ( mean difference 2.5 kg , 95 % CI −0.5 to 5.6 ) and at six months ( mean difference 2.5 kg , 95 % CI −1.2 to 6.1 ) . The mean values observed in the intervention group for mid arm circumference , mid arm muscle circumference , triceps skin fold thickness and right h and grip strength were greater than for the control group at all post hospital discharge time points . The economic evaluation suggested that it was feasible to collect re source use and EQ-5D data for a full cost-effectiveness analysis . Thematic analysis of 15 interviews identified three main themes related to the intervention and the trial : 1 ) a positive experience , 2 ) the reasons for taking part , and 3 ) uncertainty of the study process . Conclusions This study demonstrated that home enteral feeding by jejunostomy was feasible , safe and acceptable to patients and their carers . Whether home enteral feeding as ’ usual practice ’ is a cost-effective therapy would require confirmation in an appropriately powered , multi-centre study .Trial registration UK Clinical Research Network ID 12447 ( main trial , first registered 30 May 2012 ) ; UK Clinical Research Network ID 13361 ( qualitative sub study , first registered 30 May 2012 ) ; Clinical Trials.gov NCT01870817 ( first registered 28 May 2013 ABSTRACT Objective : To evaluate the change in respiratory function and functional capacity according to the type of preoperative fasting . Methods : R and omized prospect i ve clinical trial , with 92 female patients undergoing cholecystectomy by laparotomy with conventional or 2 hours shortened fasting .  The variables measured were the peak expiratory flow , forced expiratory volume in the first second , forced vital capacity , dominant h and grip strength , and non-dominant h and grip strength . Evaluations were performed 2 hours before induction of anesthesia and 24 hours after the operation . Results : The two groups were similar in preoperative evaluations regarding demographic and clinical characteristics , as well as for all variables . However , postoperatively the group with shortened fasting had higher values than the group with conventional fasting for lung function tests peak expiratory flow ( 128.7±62.5 versus 115.7±59.9 ; p=0.040 ) , forced expiratory volume in the first second ( 1.5±0.6 versus 1.2±0.5 ; p=0.040 ) , forced vital capacity ( 2.3±1.1 versus 1.8±0.9 ; p=0.021 ) , and for muscle function tests dominant h and grip strength ( 24.9±6.8 versus 18.4±7.7 ; p=0.001 ) and non-dominant h and grip strength ( 22.9±6.3 versus 17.0±7.8 ; p=0.0002 ) . In the intragroup evaluation , there was a decrease in preoperative compared with postoperative values , except for dominant h and grip strength ( 25.2±6.7 versus 24.9±6.8 ; p=0.692 ) , in the shortened fasting group . Conclusion : Abbreviation of preoperative fasting time with ingestion of maltodextrin solution is beneficial to pulmonary function and preserves dominant h and grip strength BACKGROUND Patients undergoing upper gastrointestinal surgery often eat poorly post-operatively , despite dietetic input . A pilot study was conducted to examine the benefit of a 6 week nutritional supplementation via a feeding jejunostomy on fatigue , quality of life and independent living . METHODS A feeding jejunostomy was placed routinely at oesophagectomy or total gastrectomy for cancer . At discharge , patients were r and omised to nutritional supplementation ( 600 kcal/day ) via their feeding jejunostomies or no jejunal supplement . Patients were assessed at discharge and 3 , 6 , 12 and 24 weeks following discharge for fatigue ( MFI-20 ) , quality of life ( QLQ-OES18 ) , health economic analysis ( EQ5D ) as well as completing a two-day dietary diary . RESULTS 44 patients ( M : F , 29:15 ) were r and omised , 23 received jejunal supplements . There were no differences between the groups . Percentage of calculated energy requirement received was greater in the supplemented group at weeks 3 and 6 ( p < 0.0001 ) . Oral energy intake was not different between the groups at any time period . After hospital discharge , there were no differences in MFI-20 , EQ5D and QLQ-OES18 scores at any time point . From hospital discharge fatigue improved and plateaued at 6 weeks ( p < 0.05 for both groups ) , independence at 12 weeks ( p < 0.05 for both groups ) . No improvement was seen in quality of life until 24 weeks in the active group alone ( p < 0.02 ) and not at all in the control group . CONCLUSIONS Addition of jejunal feeding is effective in providing patients with an adequate energy intake . Increased energy intake however , produced no obvious improvement in measures of fatigue , quality of life or health economics This document represents the first collaboration between 2 organizations — the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine — to describe best practice s in nutrition therapy in critically ill children . The target of these guidelines is intended to be the pediatric critically ill patient ( > 1 month and 2–3 days in a PICU admitting medical , surgical , and cardiac patients . In total , 2032 citations were scanned for relevance . The PubMed / MEDLINE search result ed in 960 citations for clinical trials and 925 citations for cohort studies . The EMBASE search for clinical trials culled 1661 citations . In total , the search for clinical trials yielded 1107 citations , whereas the cohort search yielded 925 . After careful review , 16 r and omized controlled trials and 37 cohort studies appeared to answer 1 of the 8 preidentified question groups for this guideline . We used the GRADE criteria ( Grading of Recommendations , Assessment , Objective : To determine whether glutamine (GLN)-supplemented parenteral nutrition ( PN ) improves clinical outcomes in surgical intensive care unit ( SICU ) patients . Summary Background Data : GLN requirements may increase with critical illness . GLN-supplemented PN may improve clinical outcomes in SICU patients . Methods : A parallel-group , multicenter , double-blind , r and omized , controlled clinical trial in 150 adults after gastrointestinal , vascular , or cardiac surgery requiring PN and SICU care . Patients were without significant renal or hepatic failure or shock at entry . All received isonitrogenous , isocaloric PN [ 1.5 g/kg/d amino acids ( AAs ) and energy at 1.3 × estimated basal energy expenditure ] . Controls ( n = 75 ) received st and ard GLN-free PN ( STD-PN ) ; the GLN group ( n = 75 ) received PN containing alanyl-GLN dipeptide ( 0.5 g/kg/d ) , proportionally replacing AA in PN ( GLN-PN ) . Enteral nutrition ( EN ) was advanced and PN weaned as indicated . Hospital mortality and infections were primary endpoints . Results : Baseline characteristics , days on study PN and daily macronutrient intakes via PN and EN , were similar between groups . There were 11 hospital deaths ( 14.7 % ) in the GLN-PN group and 13 deaths in the STD-PN group ( 17.3 % ; difference , −2.6 % ; 95 % confidence interval , −14.6 % to 9.3 % ; P = 0.66 ) . The 6-month cumulative mortality was 31.4 % in the GLN-PN group and 29.7 % in the STD-PN group ( P = 0.88 ) . Incident bloodstream infection rate was 9.6 and 8.4 per 1000 hospital days in the GLN-PN and STD-PN groups , respectively ( P = 0.73 ) . Other clinical outcomes and adverse events were similar . Conclusions : PN supplemented with GLN dipeptide was safe , but did not alter clinical outcomes among SICU patients The benefits of early enteral feeding ( EEN ) have been demonstrated in gastrointestinal surgery . But , the impact of EEN has not been eluci date d yet . We assessed the postoperative nutritional status of patients who had undergone pancreaticoduodenectomy ( PD ) according to the postoperative nutritional method and compared the clinical outcomes of two methods . A prospect i ve r and omized trial was undertaken following PD . Patients were r and omly divided into two groups ; the EEN group received the postoperative enteral feed and the control group received the postoperative total parenteral nutrition ( TPN ) management .  Thirty-eight patients were included in our analyses . The first day of bowel movement and time to take a normal soft diet was significantly shorter in EEN group than in TPN group . Prealbumin and transferrin were significantly reduced on post-operative day ( POD ) 7 and were slowly recovered until POD 90 in the TPN group than in the EEN group . EEN group rapidly recovered weight after POD 21 whereas it was gradually decreased in TPN group until POD 90 . EEN after PD is associated with preservation of weight compared with TPN and impact on recovery of digestive function after PD BACKGROUND Enteral nutrition ( EN ) is now used more frequently than total parenteral nutrition ( TPN ) for nutritional support after resection for esophageal cancer . But consensus regarding which type of nutrition should be used does not exist . We studied the effect of TPN and EN on patients ' nutritional status and immune function in the immediate postoperative period after esophageal cancer resection . METHODS We enrolled 30 patients ( 27 men and 3 women ) who underwent subtotal esophagectomy .  The patients were r and omly assigned to TPN or EN group . Either TPN or EN was begun on postoperative day 1 . On postoperative days 1 , 3 , and 7 , three endpoints were measured : albumin , C-reactive protein , and Th1/Th2 balance . RESULTS All patients completed the study .  Anastomotic leaks occurred in 6 patients in the TPN group and 7 patients in the EN group . Albumin , Th1/Th2 balance , and C-reactive protein did not differ between the groups . Th1/Th2 balance was not different regardless of the preoperative treatment or complications . CONCLUSIONS No differences in immune function , nutritional state , or inflammatory response were seen between patients supported with TPN and those supported with EN . The results of our study suggest that perioperative nutritional support can be safely performed either with TPN or EN Background This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery , and to provide grade d recommendations for items for an evidence d-based enhanced recovery protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omized controlled trials and large prospect i ve cohorts . For each item of the perioperative treatment pathway , available English- language literature was examined , review ed and grade d. A consensus recommendation was reached after critical appraisal of the literature by the group . Results For most of the protocol items , recommendations are based on good- quality trials or meta-analyses of good- quality trials ( evidence grade : high or moderate ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , European Society for Clinical Nutrition and Metabolism ( ESPEN ) and International Association for Surgical Metabolism and Nutrition ( IASMEN ) present a comprehensive evidence -based consensus review of perioperative care for rectal surgery Background Nutrients such as ω-3 fatty acids including fish oil components eicosapentaenoic acid ( EPA ) and docosahexaenoic acid ( DHA ) suppress the growth and promote apoptosis of tumor cells , improve immune function and reduce the effects of systemic inflammatory response syndrome . We sought to investigate the effect of ω-3 fish oil fat emulsion-based parenteral nutrition ( PN ) on nutritional state , immune function , inflammatory reaction , expression of tumor factors and complication incidence in patients after surgical resection of gastric cancer . Methods Forty-eight patients after surgical operation of gastric tumor in hospital were r and omly divided into the control group and intervention group . Patients in both groups were treated with iso-nitrogen and iso-caloric parenteral nutrition support . In addition , the intervention group received ω-3 fish oil fat emulsion and the control group received soybean oil . The indicators of nutrition , immune function and inflammation in the two groups were detected on the day before the operation and postoperative day 6 . The rate of complication was compared between the two groups . Results There was no significant difference in nutritional state , liver function and renal function between the two groups ( P > 0.05 ) . However , the levels of inflammatory markers were significantly decreased ( P < 0.01 ) , and the rate of complication was also decreased in the intervention group as compared with the control group . Conclusions ω-3 fish oil fat emulsion-based parenteral nutrition alleviates the inflammatory reaction and reduces the rate of inflammatory complications Background Postoperative nausea and vomiting is the most common cause for unexpected hospital admission of patients undergoing day care surgery . Overnight fasting changes patient metabolic state and influences their perioperative stress response . Preoperative carbohydrate loading may have accelerated recovery and better overall outcome after major abdominal surgery . The aim of the study was to investigate the effects of preoperative carbohydrate-rich drinks on postoperative nausea and vomiting and pain after day care laparoscopic cholecystectomy . Methods A total of 120 patients posted for day care laparoscopic cholecystectomy were included in the study and were r and omized into three groups . Group A (Cases)—receiving the carbohydrate-rich drink before surgery ( CHO ) , group B (placebo)—receiving the placebo drink before surgery and group C (controls)—fasting from midnight before surgery .  Postoperative nausea and vomiting and visual analogue score for pain were noted and analyzed for 24 h. Results Mean score of nausea in 0–4 h in group A was significantly lower as compared to group B and group C ( p = 0.001 ) . Difference in mean score of nausea in 4–12 and 12–24 h between groups was not significant ( p = 0.066 ) , ( p = 0.257 ) . Mean score of vomiting in 0–4 and 4–12 h in group A was significantly less than that of group B and group C ( p = 0.004 ) , ( p = 0.001 ) . Mean score of pain in group A was significantly less when compared to group B and group C in 0–4 h ( p = 0.001 ) and 4–12 h ( 0.005 ) . Conclusion Perioperative consumption of a carbohydrate-rich drink can minimize postoperative nausea , vomiting and pain in patients undergoing outpatient cholecystectomy . Consumption of carbohydrate drinks up to 2 h prior to surgery is not associated with additional complications Background Patients undergoing colorectal cancer resections are at risk for delayed recovery . Prehabilitation aims to enhance functional capacity preoperatively for better toleration of surgery and to facilitate recovery . The authors previously demonstrated the limited impact of a prehabilitation program using exercise alone . They propose an exp and ed trimodal prehabilitation program that adds nutritional counseling , protein supplementation , and anxiety reduction to a moderate exercise program . This study aim ed to estimate the impact of this trimodal program on the recovery of functional capacity compared with st and ard surgical care . Methods Consecutive patients were enrolled in this pre- and postintervention study over a 23-month period . The postoperative recovery for 42 consecutive patients enrolled in the prehabilitation program was compared with that of 45 patients assessed before the intervention began . The primary outcome was functional walking capacity ( 6-min walk test [ 6MWT ] ) . The secondary outcomes included self-reported physical activity ( CHAMPS question naire ) and health-related quality of life ( SF-36 ) . Data are expressed as mean ± st and ard deviation or median ( interquartile range [ IQR ] ) and were analyzed using Chi-square and Student ’s t test . All p values lower than 0.05 were considered significant . Results The prehabilitation and control groups were comparable in terms of age , gender , body mass index ( BMI ) and American Society of Anesthesiology ( ASA ) class . There was no difference in walking capacity at the first assessment ( 6MWT distance , 422 ± 87 vs 402 ± 57 m ; p = 0.21 ) . During the prehabilitation period lasting a median of 33 days ( range , 21–46 days ) , functional walking capacity improved by 40 ± 40 m ( p < 0.01 ) . The postoperative complication rates and the hospital length of stay were similar . The patients in the prehabilitation program had better postoperative walking capacity at both 4 weeks ( mean difference , 51.5 ± 93 m ; p = 0.01 ) and 8 weeks ( mean difference , 84.5 ± 83 m ; p < 0.01 ) . At 8 weeks , 81 % of the prehabilitated patients were recovered compared with 40 % of the control group ( p < 0.01 ) . The prehabilitation group also reported higher levels of physical activity before and after surgery . Conclusion In this pilot study , a 1-month trimodal prehabilitation program improved postoperative functional recovery . A r and omized trial is ongoing ( NCT01356264 ) Abstract Background Curative treatment of upper gastrointestinal tract neoplasms is complex and associated with high morbidity and mortality . In general , the patients are already malnourished , and early postoperative enteral nutrition is recommended . However , there is no consensus concerning the best enteral access route in these cases . Methods A prospect i ve r and omized trial was performed from 2008 to 2012 with 59 patients who underwent esophagectomy , total gastrectomy , or pancreaticoduodenectomy .  In all , 4 patients declined to participate , and 13 did not meet the inclusion criteria and were excluded . Of the 42 included patients , 21 had nasoenteric tubes , and 21 had a jejunostomy . Results The two groups were similar in demographic and clinical aspects . The nasoenteric ( NE ) and jejunostomy groups underwent early enteral therapy in 71 and 62 % of cases ( p > 0.05 ) , respectively . The median length of enteral therapy use was less in the NE group ( 5.0 vs. 8.5 days ) , but the difference was not statistically significant . The NE group required introduction of parenteral therapy more frequently than the jejunostomy group ( p < 0.05 ) . Complications related to the enteral route occurred in 38.0 and 28.5 % of patients ( p > 0.05 ) in the NE and jejunostomy groups , respectively . In the NE group , there were four losses and four tube obstructions . In the jejunostomy group , there were two losses , four obstructions , and two cases of leakage around the tube . In the latter group , patients who underwent therapy for a longer time had tubal complications ( p < 0.05 ) and longer intensive care unit and hospital stays ( p < 0.05 ) . Conclusion The two enteral routes were associated with the same number of complications . However , the presence of a jejunostomy allowed enteral therapy for longer periods , especially in patients with complications , thus avoiding the need for parenteral nutrition Abstract Background Preoperative education is a key point in multimodal protocol s of perioperative care . We investigated whether preoperative education for patients undergoing open cholecystectomy would reduce the incidence of perioperative symptoms . Methods This was a r and omized , single-blinded , clinical trial that included adult ( 18–65 years old ) c and i date s for elective open cholecystectomy . All patients took part in the ERAS/ACERTO protocol of perioperative care except that only the intervention group received preoperative education .  The main endpoints of the study were the presence and intensity of postoperative symptoms ( e.g. , nausea , vomiting , pain ) measured by a visual analogue scale , 24 h after the operation . Results A total of 74 patients ( 34 in the intervention group , 40 in the control group ) completed the study . The intervention group had significantly lower median ( interquartile range ) scores for nausea [ 0 ( 4 ) vs. 2.5 ( 5.8 ) , p = 0.04 ] and pain [ 0.2 ( 2.3 ) vs. 3.1 ( 3.45 ) , p < 0.01 ] than the controls . High well-being ( score ≥6 ) was reported by 79.4 % ( 27 patients ) of the intervention group in contrast to 57.5 % ( 23 patients ) of the controls ( p = 0.04 ) . Conclusions Preoperative education is highly effective in the context of a multimodal protocol for enhancing the recovery of patients su bmi tted to open cholecystectomy Purpose Preoperative nutrition is beneficial for malnourished cancer patients . Yet , there is little evidence whether or not it should be given to nonmalnourished patients . The aim of this study was to assess the need to introduce preoperative nutritional support in patients without malnutrition at qualification for surgery . Methods This was a prospect i ve , two-arm , r and omized , controlled , open-label study . Patients in interventional group received nutritional supplementation for 14 days before surgery , while control group kept on to their everyday diet . Each patient ’s nutritional status was assessed twice — at qualification ( weight loss in 6 months , laboratory parameters : albumin , total protein , transferrin , and total lymphocyte count ) and 1 day before surgery ( change in body weight and laboratory parameters ) . After surgery , all patients were followed up for 30 days for postoperative complications . Results Fifty-four patients in interventional and 48 in control group were analyzed . In postoperative period , patients in control group suffered from significantly higher ( p < 0.001 ) number of serious complications compared with patients receiving nutritional supplementation . Moreover , levels of all laboratory parameters declined significantly ( p < 0.001 ) in these patients , while in interventional arm were stable ( albumin and total protein ) or raised ( transferrin and total lymphocyte count ) . Conclusions Preoperative nutritional support should be introduced for nonmalnourished patients as it helps to maintain proper nutritional status and reduce number and severity of postoperative complications compared with patients without such support Background Prolonged preoperative fasting increases insulin resistance and current evidence recommends carbohydrate ( CHO ) drinks 2 hours before surgery . Our hypothesis is that the addition of whey protein to a CHO-based drink not only reduces the inflammatory response but also diminish insulin resistance . Methods Seventeen patients scheduled to cholecystectomy or inguinal herniorraphy were r and omized and given 474 ml and 237 ml of water ( CO group ) or a drink containing CHO and milk whey protein ( CHO-P group ) respectively , 6 and 3 hours before operation . Blood sample s were collected before surgery and 24 hours afterwards for biochemical assays . The endpoints of the study were the insulin resistance ( IR ) , the prognostic inflammatory and nutritional index ( PINI ) and the C-reactive protein (CRP)/albumin ratio . A 5 % level for significance was established . Results There were no anesthetic or postoperative complications . The post-operative IR was lower in the CHO-P group when compared with the CO group ( 2.75 ± 0.72 vs 5.74 ± 1.16 ; p = 0.03 ) . There was no difference between the two groups in relation to the PINI . The CHO-P group showed a decrease in the both CRP elevation and CRP/albumin ratio ( p < 0.05 ) . The proportion of patients who showed CRP/albumin ratio considered normal was significantly greater ( p < 0.05 ) in the CHO-P group ( 87.5 % ) than in the CO group ( 33.3 % ) . Conclusions Shortening the pre-operative fasting using CHO and whey protein is safe and reduces insulin resistance and postoperative acute phase response in elective moderate operations . Trial registration Clinical Trail.gov Introduction It is generally believed that resumption of feeding after colorectal resection is indicated only after recovery of bowel function . This study was design ed to verify safety , feasibility , and tolerance of early oral postoperative feeding ( EOF ) outside an enhanced recovery after surgery ( ERAS ) program . Material s and methods One hundred patient c and i date s to elective colorectal resection were prospect ively enrolled in an EOF program . Feeding was started on postoperative day ( POD ) 1 with oral nutritional supplement ( ONS ) . On POD 2 , patients had normal food plus ONS to reach 1,000–1,200 kcal/day with progressive increase until 1,800–2,000 kcal/day . Results were compared with historical controls ( n = 100 ) in whom oral feeding was allowed only after full bowel function recovery . The ERAS program was not applied in both groups . Results The EOF group had a better recovery of short half-life protein synthesis compared with the control group ( P < 0.001 ) . Stool canalization occurred after a median of 3 days ( range , 1–6 days ) in the EOF group versus 5 days ( range , 2–8 days ) in the control group ( P = 0.001 ) . The feeding protocol was completed in 89 patients within POD 5 . Tolerance to resumption of feeding was similar in the two groups . The overall rate of postoperative complication was 22 % in the EOF group vs. 27 % in the control group ( P = 0.51 ) . The median length of hospitalization was 9 days ( range , 6–25 days ) in the EOF group vs. 12 days ( range , 6–31 days ) in controls ( P = 0.01 ) . Conclusions EOF after colorectal operations is feasible and safe outside an ERAS program BACKGROUND / AIMS Fasting period before surgery may change metabolic status of the patient and have influence on perioperative stress response . The aim of the study was to investigate effects of preoperative carbohydrate-rich beverage on stress response after laparoscopic cholecystectomy . METHODOLOGY Patients admitted for laparoscopic cholecystectomy were included into study and they were r and omized into a group that was fed prior to surgery and in a group that was in the regime of nothing by mouth from the evening one day before surgery .  Concentrations of C-reactive protein and cortisol , were measured before and subsequently up to 48 h postoperatively . RESULTS Postoperative serum C-reactive protein increased significantly in both groups , but the increase was more evident in the group with fasting protocol both 24 and 48 hours postoperatively . In fed patients cortisol concentration measured in the afternoon immediately after the operation showed physiological decline . In patients with fasting protocol postoperative cortisol values rise above the values measured in the morning . CONCLUSIONS Preoperative feeding has advantage over overnight fasting by reducing preoperative discomfort in patients after laparoscopic cholecystectomy . In fed patients , smaller increase in C-reactive protein and better regulation of cortisol levels are an indicator of decreased perioperative stress response OBJECTIVE To investigate the efficacy and safety of alvimopan , 12 mg , administered orally 30 to 90 minutes preoperatively and twice daily postoperatively in conjunction with a st and ardized accelerated postoperative care pathway for managing postoperative ileus after bowel resection . DESIGN , SETTING , AND PATIENTS This multicenter , r and omized , placebo-controlled , double-blind , phase 3 trial enrolled adult patients undergoing partial bowel resection with primary anastomosis by laparotomy and scheduled to receive intravenous , opioid-based , patient-controlled analgesia .  A st and ardized accelerated postoperative care pathway including early ambulation , oral feeding , and postoperative nasogastric tube removal was used to facilitate gastrointestinal ( GI ) tract recovery in all of the patients . MAIN OUTCOME MEASURES The primary end point was time to GI-2 recovery ( toleration of solid food and first bowel movement ) . Secondary end points included time to GI-3 recovery ( toleration of solid food and first flatus or bowel movement ) , hospital discharge order written , and actual hospital discharge . Postoperative length of hospital stay based on calendar day of hospital discharge order written , opioid consumption , and overall postoperative ileus-related morbidity were recorded . RESULTS Alvimopan , 12 mg , was well tolerated and significantly accelerated GI-2 recovery , GI-3 recovery , and actual hospital discharge compared with a st and ardized accelerated postoperative care pathway alone ( hazard ratio = 1.5 , 1.5 , and 1.4 , respectively ; P < .001 for all ) . Time to hospital discharge order written as measured by hazard ratio ( 1.4 ) and by postoperative calendar days ( mean for alvimopan , 5.2 days ; mean for placebo , 6.2 days ) was also accelerated . Opioid consumption was comparable between groups , and alvimopan was associated with reduced postoperative ileus-related morbidity compared with placebo . CONCLUSIONS Alvimopan , 12 mg , administered 30 to 90 minutes before and twice daily after bowel resection is well tolerated , accelerates GI tract recovery , and reduces postoperative ileus-related morbidity without compromising opioid analgesia OBJECTIVE : This prospect i ve r and omized clinical study was conducted to evaluate the safety and tolerability of early oral feeding after colorectal operations . METHODS : A total of 199 patients underwent colorectal surgery and were r and omly assigned to  early feeding ( n = 99 ) or a regular diet ( n = 100 ) . Patients ' characteristics , diagnoses , surgical procedures , comorbidity , bowel movements , defecation , nasogastric tube reinsertion , time of tolerance of solid diet , complications , and length of hospitalization were assessed . RESULTS : The two groups were similar in terms of gender , age , diagnosis , surgical procedures , and comorbidity . In the early feeding group , 85.9 % of patients tolerated the early feeding schedule . Bowel movements ( 1.7±0.89 vs. 3.27±1.3 ) , defecation ( 3.4±0.77 vs. 4.38±1.18 ) and time of tolerance of solid diet ( 2.48±0.85 vs. 4.77±1.81 ) were significantly earlier in the early feeding group . There was no change between the groups in terms of nasogastric tube reinsertion , overall complication or anastomotic leakage . Hospitalization ( 5.55±2.35 vs. 9.0±6.5 ) was shorter in the early feeding group . CONCLUSIONS : The present study indicated that early oral feeding after elective colorectal surgery was not only well tolerated by patients but also affected the postoperative outcomes positively . Early postoperative feeding is safe and leads to the early recovery of gastrointestinal functions Purpose In many countries , patients are generally allowed to have clear fluids until 2–3 h before surgery . In Japan , long preoperative fasting is still common practice . To shorten the preoperative fasting period in Japan , we tested the safety and efficacy of oral rehydration therapy until 2 h before surgery . Methods Three hundred low-risk patients scheduled for morning surgery in six university-affiliated hospitals were r and omly assigned to an oral rehydration solution ( ORS ) group or to a fasting group . Patients in the ORS group consumed up to 1,000 ml of ORS containing balanced glucose and electrolytes : 500 ml between 2100 the night before surgery and the time they woke up the next morning and 500 ml during the morning of surgery until 2 h before surgery . Patients in the fasting group started fasting at 2100 the night before surgery . Primary endpoints were gastric fluid volume and pH immediately after anesthesia induction . Several physiological measures of hydration and electrolytes including the fractional excretion of sodium ( FENa ) and the fractional excretion of urea nitrogen ( FEUN ) were also evaluated . Results Mean ( SD ) gastric fluid volume immediately after anesthesia induction was 15.1 ( 14.0 ) ml in the ORS group and 17.5 ( 23.2 ) ml in the fasting group ( P = 0.30 ) . The mean difference between the ORS group and fasting group was −2.5 ml . The 95 % confidence interval ranged from −7.1 to + 2.2 ml and did not include the noninferior limit of + 8 ml . Mean ( SD ) gastric fluid pH was 2.1 ( 1.9 ) in the ORS group and 2.2 ( 2.0 ) in the fasting group ( P = 0.59 ) . In the ORS group , mean FENa and FEUN immediately after anesthesia induction were both significantly greater than those in the fasting group ( P < 0.001 for both variables ) . The ORS group reported they had been less thirsty and hungry before surgery ( P < 0.001 , 0.01 ) . Conclusions Oral rehydration therapy until 2 h before surgery is safe and feasible in the low-risk Japanese surgical population . Physicians are encouraged to use this practice to maintain the amount of water in the body and electrolytes and to improve the patient ’s comfort INTRODUCTION No study so far has tested a beverage containing glutamine 2 h before anesthesia in patients undergoing surgery . OBJECTIVES The aim of the study was to investigate : 1 ) the safety of the abbreviation of preoperative fasting to 2 h with a carbohydrate-L-glutamine-rich drink ; and 2 ) the residual gastric volume ( RGV ) measured after the induction of anesthesia for laparoscopic cholecystectomies . METHODS R and omized controlled trial with 56 women ( 42 ( 17 - 65 ) years-old ) su bmi tted to elective laparoscopic cholecystectomy . Patients were r and omized to receive either conventional preoperative fasting of 8 hours ( fasted group , n = 12 ) or one of three different beverages drunk in the evening before surgery ( 400 mL ) and 2 hours before the initiation of anesthesia ( 200 mL ) . The beverages were water ( placebo group , n = 12 ) , 12.5 % ( 240 mOsm/L ) maltodextrine ( carbohydrate group , n = 12 ) or the latter in addition to 50 g ( 40 g in the evening drink and 10 g in the morning drink ) of L-glutamine ( glutamine group , n = 14 ) . A 20 F nasogastric tube was inserted immediately after the induction of general anesthesia to aspirate and measure the RGV . RESULTS Fifty patients completed the study . None of the patients had either regurgitation during the induction of anesthesia or postoperative complications . The median ( range ) of RGV was 6 ( 0 - 80 ) mL. The RGV was similar ( p = 0.29 ) between glutamine group ( 4.5 [ 0 - 15 ] mL ) , carbohydrate group ( 7.0 [ 0 - 80 ] mL ) , placebo group ( 8.5 [ 0 - 50 ] mL ) , and fasted group ( 5.0 [ 0 - 50 ] mL ) . CONCLUSION The abbreviation of preoperative fasting to 2 h with carbohydrate and L-glutamine is safe and does not increase the RGV during induction of anesthesia BACKGROUND The aim of this study was to evaluate whether a single preoperative limited oral intake of a carbohydrate drink could improve perioperative patient comfort and satisfaction with anesthesia care in elective day-stay ophthalmologic surgery . METHODS A single-center , prospect i ve , r and omized clinical trial was conducted in a university hospital . The study included ASA I-III patients undergoing ophthalmologic surgery . Patients undergoing both general anesthesia and local anesthesia were included in the study . The control group fasted in accordance to nil per os after midnight , while patients in the experimental group received 200 mL of a carbohydrate drink 2 h before the operation . Both groups were allowed to drink and eat until midnight ad libitum . Patient characteristics , subjective perceptions , taste of the drink , and satisfaction with anesthesia care were ascertained using a question naire administered three times : after the anesthesiologist 's visit , before surgery and before discharge from the ward to assess patient comfort . An analysis of variance and the Mann-Whitney U-test were used for statistical analysis . RESULTS A total of 123 patients were included and 109 patients were r and omly assigned to one of two preoperative fasting regimens . Patients drinking 200 mL 2 h before surgery were not as hungry ( P<0.05 ) , not as thirsty preoperatively ( P<0.001 ) and not as thirsty after surgery ( P<0.05 ) , result ing in increased postoperative satisfaction with anesthesia care ( P<0.05 ) . CONCLUSION St and ardized limited oral preoperative fluid intake increases patient comfort and satisfaction with anesthesia care and should be a part of modern day-stay ophthalmologic surgery ABSTRACT The aim of this study was to investigate the effects of oral carbohydrate solution ( CHO ) on perioperative discomfort , biochemistry , hemodynamics , and patient satisfaction in elective surgery patients under general anesthesia . Sixty cases in ASA I-II group who were planned to have operation under general anesthesia were included in the study . The cases were r and omly divided into two groups having 30 subjects in each . The patients in the study group were given CHO in the evening prior to the surgery and 2–3 hr before the anesthesia while routine fasting was applied in the control group . In the study group ; 2–3 hr before the surgery ; malaise , thirst , hunger , and weakness ; just before the surgery malaise , thirst , hunger , and fatigue ; 2 hr after the operation thirst , hunger , weakness , and concentration difficulty ; 24 hr after the operation malaise and weakness were found significantly lower . Fasting blood glucose ( FBG ) level was found to be higher in the control group at the 90th min of the operation . Gastric volumes were higher in the control group ; gastric pH values were found significantly higher in the study group . The level of anxiety and depression risk rate were found lower in the study group . In conclusion , preoperative CHO  reduces perioperative discomfort and improves perioperative well being when compared to overnight fasting Background Studies showing the improvement of insulin sensitivity by reducing the term of preoperative fasting are mostly done in patients undergoing major operations . More information about the role of shortened preoperative fasting in perioperative metabolism is needed for such elective minor/moderate abdominal procedures as laparoscopic cholecystectomy . We investigated the influence of a carbohydrate-rich drink given 2 h before laparoscopic cholecystectomy on insulin resistance and the metabolic response to trauma . Methods A group of 21 female c and i date s ( 18–65 years old ) for elective laparoscopic cholecystectomy were r and omized to either an 8 h fasting group ( control group : n = 10 ) or to a group receiving 200 ml of a carbohydrate beverage containing 12.5 % ( 25 g , 50 kcal per 100 ml and approximately 285 mOsm ) of maltodextrine 2 h before operation ( CHO group : n = 11 ) . Blood sample s for various biochemical assays were collected both at induction of anesthesia and after the 10th postoperative hour . Insulin resistance was assessed by the HOMA-IR equation ( Insulin ( μU/ml ) × blood glucose (mg/dl)/405 ) . Results There were no postoperative complications . Seventy percent ( 7/10 ) of the controls and 27.3 % ( 3/11 ) of the CHO group experienced at least one episode of vomiting ( RR = 2.42 , 95 % Confidence Interval [ CI ] = 0.88–6.68 ; P = 0.08 ) . Biochemical analysis showed that serum glucose ( P < 0.01 ) , insulin ( P < 0.01 ) , lactate/pyruvate ratio ( P = 0.03 ) , and triglycerides ( P < 0.01 ) for the control group were higher than for the CHO group . The value of HOMA-IR was significantly greater ( P = 0.03 ) in the conventionally fasted patients than in the CHO group . Conclusions Abbreviation of the period of preoperative fasting and administration of a carbohydrate beverage diminishes insulin resistance and the organic response to trauma BACKGROUND Direct experimental evidence suggests that total enteral nutrition ( TEN ) reduces septic morbidity compared with bowel rest and total parenteral nutrition ( TPN ) and that mucosal support and maintenance of gut barrier function is a key mechanism . This effect is supported indirectly by clinical studies , but this question has not previously been investigated directly in the postoperative patient . This study examined the hypothesis that early enteral feeding after major upper gastrointestinal surgery may modulate gut barrier function and decrease the risk of major infective complications compared with bowel rest and parenteral nutrition . METHODS A r and omized clinical trial of 67 patients ( TPN = 34 ; TEN = 33 ) fed postoperatively for 7 days was performed . Thirty-day major morbidity and mortality were monitored . Intestinal permeability was measured using the lactulose/mannitol test preoperatively and on postoperative days 1 and 7 . Systemic anti-endotoxin core immunoglobulin G and M antibodies and serum albumin and C-reactive protein were quantified at these time points . RESULTS No clinical benefit was observed in patients fed enterally compared with the parenterally fed group . Intestinal permeability was increased on the 1st postoperative day in association with evidence of endotoxin exposure . By day 7 , enteral feeding compared with parenteral feeding had failed to significantly influence any of the gut barrier or systemic parameters . CONCLUSIONS This r and omized controlled trial of  TEN vs TPN after major upper gastrointestinal surgery failed to show a clinical benefit for the enteral route . Moreover , enteral nutrition did not modulate gut barrier function postoperatively Background Many patients experience postoperative nausea and vomiting ( PONV ) . Preoperative treatment with carbohydrate solutions seems to improve the course after different types of surgery . This study was undertaken to investigate the potential value of different models for preoperative hydration/nutrition , in addition to our ERAS ( enhanced recovery after surgery ) protocol . Methods Ninety non-diabetic women planned for elective laparoscopic gastric bypass and aged 18–65 years were included . All were on preoperative low-calorie diet ( LCD ) . They were r and omized into three arms , either a carbohydrate-rich drink , a protein-enriched drink , or tap water and instructed to drink 800 and 200 mL 16 and 2 h , respectively , prior to operation . Risk factors for PONV were recorded preoperatively . All patients were operated before lunch and received 1500–2000 mL of Ringer-Acetate solution during the 24–30-h postoperative hospital time . Four variables ( nausea , pain , tiredness , and headache ) were registered on 100-mm visual analog scales six times over 22 h. The need for additional medication was registered . Results Out of 90 patients , 73 complete data sets were obtained . Nausea peaked at 7 p.m. but with no statistically significant differences between groups for any of the variables . Pain peaked the first 2 h postoperatively , remained longer , and had not returned to baseline values at 6 a.m. the morning after surgery but with no difference between groups . Conclusions Inside our ERAS protocol , additional preoperative carbohydrate- or protein-enriched fluid treatment did not further reduce immediate patient discomfort in laparoscopic gastric bypass surgery BACKGROUND Prolonged preoperative fasting increases insulin resistance ( IR ) . The authors investigated whether an abbreviated preoperative fast with glutamine ( GLN ) plus a carbohydrate (CHO)-based beverage would improve the organic response after surgery . METHODS Forty-eight female patients ( 19 - 62 years ) were r and omized to either st and ard fasting ( control group ) or to fasting with 1 of 3 different beverages before video-cholecystectomy .  Beverages were consumed 8 hours ( 400 mL ; placebo group : water ; GLN group : water with 50 g maltodextrine plus 40 g GLN ; and CHO group : water with 50 g maltodextrine ) and 2 hours ( 200 mL ; placebo : water ; GLN : water with 25 g maltodextrine plus 10 g GLN ; and CHO : water with 25 g maltodextrine ) before anesthesia . Blood sample s were collected pre- and postoperatively . RESULTS The mean ( SEM ) postoperative homeostasis model assessment -insulin resistance was greater ( P < .05 ) in control patients ( 4.3 [ 1.3 ] ) than in the other groups ( placebo , 1.6 [ 0.3 ] ; CHO , 2.3 [ 0.4 ] ; and GLN , 1.5 [ 0.1 ] ) . Glutathione was significantly higher ( P < .01 ) in the GLN group than in both CHO and control groups . Interleukin-6 increased in all groups except the GLN group . The C-reactive protein/albumin ratio was higher ( P < .05 ) in controls than in CHO and GLN groups . The nitrogen balance was less negative in GLN ( -2.5 [ 0.8 ] gN ) than in both placebo ( -9.0 [ 2 ] gN ; P = .001 ) and control ( -6.6 [ 0.4 ] gN ; P = .04 ) groups . CONCLUSIONS Preoperative intake of a GLN-enriched CHO beverage appears to improve IR and antioxidant defenses and decreases the inflammatory response after video-cholecystectomy Objectives Nutritional deficiencies and immune dysfunction in cancer patients may contribute to postoperative septic morbidity . This trial compared the effects of perioperative enteral immunonutrition ( EIN ) versus st and ard enteral nutrition ( SEN ) on systemic and mucosal immunity in patients undergoing pancreaticoduodenectomy for periampullary cancer . Methods Thirty-seven patients were r and omized ( EIN , n = 17 ; SEN , n = 20 ) to receive feed for 14 days preoperatively and 7 days postoperatively . Mediators of systemic immunity ( interleukin 1&agr ; , tumor necrosis factor & agr ; , lymphocytes subsets , and complement components ) and of mucosal immunity in duodenal biopsies , nutritional markers and parameters were evaluated . Results The groups were comparable for demographics , the concentrations of mediators of systemic and mucosal immunity at time of recruitment , and for the duration and amount of feed received . Preoperative EIN rather than SEN was associated with significant reductions in plasma tumor necrosis factor & agr ; and total hemolytic complement . Enteral immunonutrition – fed patients had significantly higher total lymphocyte count on the third postoperative day and significantly greater rise in CD4/CD8 ratio from day 3 to day 7 postoperatively compared with SEN-fed patients . Conclusions The perioperative administration of EIN rather than SEN is associated with a favorable modulation of the inflammatory response and enhancement of systemic immunity in patients undergoing pancreaticoduodenectomy for periampullary cancer Most systematic review s rely substantially on the assessment of the method ological quality of the individual trials . The aim of this study was to obtain consensus among experts about a set of generic core items for quality assessment of r and omized clinical trials ( RCTs ) . The invited participants were experts in the field of quality assessment of RCTs . The initial item pool contained all items from existing criteria lists . Subsequently , we reduced the number of items by using the Delphi consensus technique . Each Delphi round comprised a question naire , an analysis , and a feedback report . The feedback report included staff team decisions made on the basis of the analysis and their justification . A total of 33 international experts agreed to participate , of whom 21 completed all question naires . The initial item pool of 206 items was reduced to 9 items in three Delphi rounds . The final criteria list ( the Delphi list ) was satisfactory to all participants . It is a starting point on the way to a minimum reference st and ard for RCTs on many different research topics . This list is not intended to replace , but rather to be used alongside , existing criteria lists BACKGROUND The efficacy and feeding-related complications of a nasojejunal feeding tube and jejunostomy after pancreaticoduodenectomy ( PD ) was investigated with a r and omized , controlled clinical trial at the Affiliated Drum Tower Hospital . METHODS Sixty-eight patients who underwent PD in the Department of Hepatobiliary Surgery were r and omly divided into 2 groups : 34 patients received enteral feeding via a nasojejunal tube ( NJT group ) and 34 patients received enteral feeding via a jejunostomy tube ( JT group ) . The assessment of clinical outcome was based on postoperative investigation of complications . The second part of the assessment included tube related complications and an index on catheter efficiency . RESULTS There were 15 cases with infectious complications in the JT group and 13 cases in the NJT group , and there was no significant difference in the rate of infectious complications between the 2 groups . The rate of intestinal obstruction and delayed gastric emptying was significantly decreased in the NJT group ( P < .05 ) . Catheter-related complications were more common in the JT group as compared with the NJT group ( 35.3 % vs 20.6 % , P < .05 ) . The time for removal of the feeding tube and nasogastric tube was significantly decreased in the NJT group . The postoperative hospital stay in the NJT group was significantly decreased ( P < .05 ) , and there was no hospital mortality in this study . CONCLUSION Nasojejunal feeding is safer than jejunostomy , and it is associated with only minor complications . Nasojejunal feeding can significantly decrease the incidence of delayed gastric emptying and shorten the postoperative hospital stay OBJECTIVE This multicenter , prospect i ve cohort study evaluated the effect of preoperative nutritional support in abdominal surgical patients at nutritional risk as defined by the Nutritional Risk Screening Tool 2002 ( NRS-2002 ) . METHODS A consecutive series of patients admitted for selective abdominal surgery in the Peking Union Medical College Hospital and the Beijing University Third Hospital in Beijing , China were recruited from March 2007 to July 2008 . Data were collected on the nutritional risk screening ( NRS-2002 ) , the application of perioperative nutritional support , surgery , complications , and length of stay . A minimum of 7 d of parenteral nutrition or enteral nutrition before surgery was considered adequate preoperative nutritional support . RESULTS In total 1085 patients were recruited , and 512 of them were at nutritional risk . Of the 120 patients with an NRS score at least 5 , the complication rate was significantly lower in the preoperative nutrition group compared with the control group ( 25.6 % versus 50.6 % , P = 0.008 ) . The postoperative hospital stay was significantly shorter in the preoperative nutrition group than in the control group ( 13.7 ± 7.9 versus 17.9 ± 11.3 d , P = 0.018 ) . Of the 392 patients with an NRS score from 3 to 4 , the complication rate and the postoperative hospital stay were similar between patients with and those without preoperative nutritional support ( P = 1.0 and 0.770 , respectively ) . CONCLUSION This finding suggests that preoperative nutritional support is beneficial to patients with an NRS score at least 5 by lowering the complication rate Background We have proposed a simplified perioperative rehabilitation program for elective colonic surgery that is focused on early oral nutrition and that could reduce hospital stay and postoperative ileus time without raising complications and readmission rates . Patients and methods Fifty-four patients admitted for elective colonic surgery were prospect ively r and omized into two groups : ( 1 ) an early feeding group (EFG)—on the first postoperative day , patients initially received a oral liquid diet and were advanced to a regular diet within the next 24 h as tolerated and at their discretion ; ( 2 ) a traditional care group— patients were managed by nothing per orus until the elimination of the first flatus and then su bmi tted to an oral liquid diet , followed by a regular diet within the next 24 h as described for the EFG . All patients followed a well-defined , simplified rehabilitation program . Results Patients ' baseline characteristics were similar in the two groups . Hospital stay was significantly lower in the EFG ( 4.0 [ ±3.7 ] versus 7.6 [ ±8.1 ] days ; p = 0.000 ) . Diet tolerance and progression were similar between groups . Time to first flatus after surgery was significantly lower in the EFG ( 1.5 [ ±0.5 ] versus 2.0 [ ±0.7 ] days ; p = 0.019 ) . Complication and readmission rates were similar in both groups . Conclusions Early oral nutrition associated with a simplified perioperative rehabilitation program reduces postoperative length of hospital stay and ileus time after elective colonic resection without increasing rates of complications or readmissions BACKGROUND / AIMS Early enteral nutrition ( EEN ) has benefits in reducing infectious complication , length of stay ( LOS ) and preserving liver function . There are few data about the effect of EEN in the patients who had total gastrectomy . The aim of this r and omized and prospect i ve study was to evaluate the effect of EEN after total gastrectomy on nutritional status , liver function , complications and LOS , compared to total parenteral nutrition ( TPN ) in patients with gastric cancer . METHODS Among 56 patients with gastric cancer , 36 and 20 were r and omly assigned to EEN and TPN groups , and finally 17 and 16 completed EEN and TPN schedules , respectively . The nutritional parameters , liver function , LOS and abdominal symptoms were compared between 2 groups on pre-operative day and post-operative 7th day . RESULTS There was no significant difference in the nutritional parameters , liver function between EEN and TPN groups . Vomiting and abdominal distention were more frequent in EEN than TPN group ( 2 vs. 0 cases , p=0.485 ; 1 vs. 0 case , p=1.000 , respectively ) , while increased AST , ALT and total bilirubin were more common in TPN than EEN group ( 4 vs. 2 cases , p=0.398 ; 1 vs. 0 case , p=0.485 , respectively without statistical significance ) . LOS was shorter in EEN than TPN group without statistical significance ( 12 vs. 13 days , p=0.289 ) . CONCLUSIONS No significant differences were found in the nutritional status parameters , liver function , complications and LOS between EEN and TPN groups on 7th day after total gastrectomy . Further large scale studies on the advantages and disadvantages of EEN after total gastrectomy are warranted OBJECTIVE To investigate the feasibility of no nasogastric intubation and early oral feeding at will after thoracolaparoscopic esophagectomy for patients with esophageal cancer . METHODS Between January 2013 and January 2014 , the feasibility of no nasogastric intubation and early oral feeding at postoperative day(POD ) 1 after thoracolaparoscopic esophagectomy was prospect ively investigated in 156 patients ( trial group ) with esophageal cancer in the Henan Cancer Hospital . One hundred and sixty patients previously managed in the same unit who were treated routinely after thoracolaparoscopic esophagectomy were served as control group . RESULTS Of 156 patients of trial group , 6(3.8 % ) patients could not take food early as planned because of postoperative complications . The overall complication rate in trial group was 19.2%(30/156 ) , which was 25.0%(30/160 ) in control group ( P=0.217 ) . The anastomotic leakage in trial group and control group was 2.6%(4/156 ) and 4.3%(7/160 ) respectively ( P=0.380 ) . Compared with control group , time to first flatus [ ( 2.1±0.9 ) d vs. ( 3.3±1.1 ) d , P<0.001 ] , bowel movement [ ( 4.4±1.3 ) d vs. ( 6.6±1.0 ) d , P<0.001 ] and postoperative hospital stay [ ( 8.3±3.2 ) d vs. ( 10.4±3.6 ) d , P<0.001 ] were significantly shorter in trial group . CONCLUSIONS No nasogastric intubation and early oral feeding postoperatively in patients with thoracolaparoscopic esophagectomy  is feasible and safe . This management can shorten postoperative hospital stay and fasten postoperative bowel function recovery OBJECTIVE Prolonged preoperative fasting increases postoperative hospital length of stay and current evidence recommends patients drink a carbohydrate-based liquid drink 2 h before surgery . The aim of this study was to investigate whether the addition of hydrolyzed protein to a carbohydrate-based drink would reduce both the inflammatory response and hospital length of stay . METHODS We evaluated 22 patients of both sexes , undergoing gastrointestinal resection due to cancer . Patients were r and omized into two groups : control group ( n = 12 ; 6 - 8 h fast ) and the intervention group ( n = 10 ; fasted to solids for 6 h ; and given a beverage containing 11 % pea protein hydrolysate and 89 % carbohydrates ( 79 % maltodextrin and 21 % sucrose ) , 400 mL the night before and 200 mL 3 h before surgery . Blood sample s were collected the morning before surgery and on postoperative day 2 . RESULTS Overall mortality was 4.5 % ( one case , control group ) . The duration of postoperative hospital stay was twofold longer in the control group ( P = 0.04 ) . A significant increase of serum C-reactive protein/albumin ratio was observed in controls compared with the intervention group ( P = 0.04 ) . CONCLUSION The abbreviation of preoperative fasting time to 3 h using a solution containing carbohydrates and hydrolyzed pea proteins reduces the acute-phase inflammatory response and decreases the postoperative length of stay in patients undergoing major surgery for a malignancy OBJECTIVE To determine the effects of total parenteral nutrition ( TPN ) and enteral nutrition ( EN ) on biochemical and clinical outcomes in pancreatic cancer patients who underwent pancreaticoduodenectomy . METHODS From the year 2006 to 2008 , 60 patients who underwent pancreaticoduodenectomy in Tianjin Third Central Hospital were enrolled in this study . They were r and omly divided into the EN group and the TPN group . The biochemical and clinical parameters were recorded and analyzed between the two groups . RESULTS There was no significant difference in the nutritional status , liver and kidney function , and blood glucose levels between the TPN and EN groups on the preoperative day , the 1st and 3 rd postoperative days . However , on the 7th postoperative day , there was significant difference between the two groups in 24 h urinary nitrogen , serum levels of , total protein ( TP ) , transferrin ( TF ) , alanine aminotransferase ( ALT ) , aspartate aminotransferase ( AST ) , alkaline phosphatase ( ALP ) , and γ-glutamyl transpeptadase ( GGT ) , blood urea nitrogen ( BUN ) and creatinine ( Cr ) . On the 14th postoperative day , there was a significant difference between the two groups in terms of urinary levels of 24 h nitrogen , TP , TF , retinol binding protein , ALT , AST , ALP , GGT , total bilirubin , direct bilirubin , BUN , Cr , and glucose . The incidence of delayed gastric emptying in the EN and TPN groups was 0 % and 20 % , respectively . Moreover , the incidence of pancreatic fistulas and hemorrhages in the EN group were 3.6 % and 3.6 % , versus 26.7 % and 30 % in the TPN group , respectively . CONCLUSIONS EN is better than TPN for pancreatic cancer patients who received pancreaticoduodenectomy Objectives Despite increasing trends toward the early initiation of oral feeding after gastrointestinal ( GI ) surgeries , current evidence has not been convincing . The present r and omized clinical trial aim ed to compare the clinical outcomes of early oral feeding ( EOF ) with late oral feeding ( LOF ) following surgery for upper GI tumors . Methods One hundred and nine consecutive patients with esophageal or gastric tumors undergoing surgical resection in two hospitals in Tehran , Iran , were enrolled in this prospect i ve r and omized controlled trial , and were r and omly assigned to a group starting EOF on the first postoperative day and another group that remained nil by mouth until the return of bowel sounds ( LOF group ) . The clinical and surgical outcomes were compared between the two groups . Results The clinical outcomes were significantly better in the patients in the EOF group ( p < 0.05 ) . Repeated nil per os ( 14.8 vs. 30.9 % ) and re-hospitalization ( 1.8 vs. 7.3 % ) were more common in LOF group ( p < 0.0001 ) . Additionally , gas passage , nasogastric tube ( NGT ) discharge , a decrease in intravenous serum to less than 1000 ml per day , the time to start a soft diet and hospital discharge following surgery occurred significantly earlier in the EOF group than in the LOF group ( p < 0.0001 ) . Conclusion Early oral feeding after the surgical resection of esophageal and gastric tumors is safe , and is associated with favorable early in-hospital outcomes and a sooner return to physiological GI function and hospital discharge BACKGROUND & AIMS Fast track protocol s have been successfully used in abdominal surgery but there are no r and omized trials on fast track after appendectomy . The aim of this study was to evaluate the safety and feasibility of fast track perioperative care protocol including early feeding with opioid-sparing analgesia after open appendectomy . METHODS We r and omly allocated 62 consecutive patients who underwent appendectomy to an early feeding with opioid-sparing analgesia and traditional care group .  The study was not blinded regarding the mode of postoperative rehabilitation . Clinical primary endpoint was length of postoperative hospital stay . Secondary endpoints were morbidity rate , time to bowel sounds and passage of flatus or stools , tolerance of solid diet and facial visual pain score . RESULTS The mean length of primary hospital stay was significantly shorter in the early feeding with opioid-sparing analgesia than in traditional care group ( 2.2 versus 4.0 days , P<0.001 ) . No significant differences were seen between groups regarding demographics , degree of pathological changes in the appendix , and in the secondary endpoints such as morbidity , frequency of vomiting , visual facial pain score , time to first flatus or stools , resumption of bowel sounds and toleration of solid diet . CONCLUSIONS This study indicates that early feeding and opioid-sparing analgesia after open appendectomy is safe and reduces length of hospital stay without deterioration of pain control Background : The preoperative period ( prehabilitation ) may represent a more appropriate time than the postoperative period to implement an intervention . The impact of prehabilitation on recovery of function al exercise capacity was thus studied in patients undergoing colorectal resection for cancer . Methods : A parallel-arm single-blind superiority r and omized controlled trial was conducted . Seventy-seven patients were r and omized to receive either prehabilitation ( n = 38 ) or rehabilitation ( n = 39 ) . Both groups received a home-based intervention of moderate aerobic and resistance exercises , nutritional counseling with protein supplementation , and relaxation exercises initiated either 4 weeks before surgery ( prehabilitation ) or immediately after surgery ( rehabilitation ) , and continued for 8 weeks after surgery . Patients were managed with an enhanced recovery pathway . Primary outcome was functional exercise capacity measured using the vali date d 6-min walk test . Results : Median duration of prehabilitation was 24.5 days . While awaiting surgery , functional walking capacity increased ( ≥20 m ) in a higher proportion of the prehabilitation group compared with the rehabilitation group ( 53 vs. 15 % , adjusted P = 0.006 ) . Complication rates and duration of hospital stay were similar . The difference between baseline and 8-week 6-min walking test was significantly higher in the prehabilitation compared with the rehabilitation group ( + 23.7 m [ SD , 54.8 ] vs. −21.8 m [ SD , 80.7 ] ; mean difference 45.4 m [ 95 % CI , 13.9 to 77.0 ] ) . A higher proportion of the prehabilitation group were also recovered to or above baseline exercise capacity at 8 weeks compared with the rehabilitation group ( 84 vs. 62 % , adjusted P = 0.049 ) . Conclusion : Meaningful changes in postoperative functional exercise capacity can be achieved with a prehabilitation program A carbohydrate‐rich drink ( CHO ) has been shown to reduce preoperative discomfort . It was hypothesized that it may also reduce postoperative nausea and vomiting ( PONV ) Objective : A prospect i ve r and omized controlled trial ( RCT ) of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer . Aims : This study evaluates the use of a multimodal package in colorectal cancer surgery in the context of an RCT . Methods : Patients for elective resection for colorectal cancer were offered trial entry . Participants were stratified by sex and requirement for a total mesorectal excision and central ly r and omized .  Multimodal patients received intravenous fluid restriction , unrestricted oral intake with prokinetic agents , early ambulation , and fixed regimen epidural analgesia . Control patients received intravenous fluids to prevent oliguria , restricted oral intake until return of bowel motility , and weaning regimen epidural analgesia . Adherence to both regimens was reinforced using a daily checklist and protocol guidance sheets . Discharge decision was made using preagreed criteria . The primary endpoint was postoperative stay , and achievement of independence milestones . Secondary endpoints were postoperative complications , readmission rates , and mortality . Analysis was by intention to treat . Results : Seventy patients were recruited . Approximately one fourth underwent TME . Median ages were similar ( 69.3 vs. 73.0 years ) . The median stay was significantly reduced in the multimodal group ( 5 vs. 7 days ; P < 0.001 , Mann-Whitney U test ) . Patients in the control arm were 2.5 times as likely to require a postoperative stay of more than 5 days . Patients in the multimodal group had less cardiorespiratory and anastomotic complications but more readmissions . There were 2 deaths , both controls . Conclusions : This RCT provides level 1b evidence that a multimodal management protocol can significantly reduce postoperative stay following colorectal cancer surgery . Morbidity and mortality are not increased Background : Esophagectomy represents an exemplar of controlled major trauma , with marked metabolic , immunologic , and physiologic changes as well as an associated high incidence of complications . Eicosapentaenoic acid ( EPA ) enriched enteral nutrition ( EN ) modulates immune function and limits catabolism in patients with advanced cancer , but its impact in the peri-operative period is unclear . Objectives : To examine the effects of perioperative EPA enriched EN on the metabolic , nutritional , and immuno-inflammatory response to esophagectomy , and on postoperative complications . Methods : In a double-blind design , patients were r and omized to a st and ard EN formula or a formula enriched with 2.2 g EPA/d for 5 days preoperatively ( orally ) and 21 days postoperatively ( jejunostomy ) . Segmental bioelectrical impedance analysis was performed preoperatively and on POD 21 . Postoperative complications were monitored , as well as the acute phase response , coagulation markers , and serum cytokines . Results : Fifty-three patients ( 28 EPA , 25 st and ard ) completed the study , and both groups were well matched . Serum and peripheral blood mononuclear cell ( P BMC ) membrane EPA levels were significantly increased in the EPA group . There was no difference in the incidence of major complications . The EPA group maintained all aspects of body composition postoperatively , whereas patients in the st and ard EN group lost significant amounts of fat-free mass ( 1.9 kg , P = 0.030 ) compared with the EPA group [ leg ( 0.3 kg , P = 0.05 ) , arm ( 0.17 kg , P = 0.01 ) , and trunk ( 1.44 kg , P = 0.03 ) ] . The EPA group had a significantly ( P < 0.05 ) attenuated stress response for TNFα , IL-10 , and IL-8 compared with the st and ard group . Conclusions : EPA supplemented early EN is associated with preservation of lean body mass post esophagectomy compared with a st and ard EN . These properties may merit longer-term study to address its impact on recovery of function and quality of life in models of complex surgery or multimodal cancer treatment regimens In the attempt to reduce postoperative complications and costs and improve outcomes , the concept of fast track surgery has been proposed . Improvements in anesthesia techniques and a better underst and ing of the pathophysiologic events occurring during and after surgery have made it possible . A group of patients undergoing colorectal resections with a fast track approach were investigated ; specifically , the effects on postoperative morbidity , resumption of intestinal function , and duration of hospitalization .  Fifty patients were managed according to a protocol , which included epidural analgesia , early ambulation , and oral feeding ( fast track group ) ;  they were compared with 50 patients managed with a different protocol : no epidural analgesia , early ambulation , and early oral diet ( control group ) . Primary outcome end-points reported include morbidity , time to passage of flatus and stool , and length of hospital stay . Fourteen complications occurred in the fast track group and 13 in the control group ( P = not significant ( NS ) ) . Resumption of intestinal function occurred after 3 days , and length of hospital stay was 5 days in the fast track group compared with 4 and 7 days respectively in control patients ( P = NS , P < 0.01 ) . Patients undergoing elective colorectal resections can be managed safely with fast track protocol s reducing hospital stay PURPOSE : Although laparoscopic surgery may permit earlier recovery compared with open surgery , no published r and omized controlled trial has investigated the benefit of a multimodal rehabilitation program after laparoscopic colonic resection . This study aim ed to evaluate the efficacy of a rehabilitation program after laparoscopic colon surgery in the context of a r and omized controlled trial . METHODS : Between September 2007 and October 2009 , 100 patients who had received laparoscopic colon surgery  were selected for the study and r and omly assigned on a 1:1 basis to a rehabilitation program group with early mobilization and diet ( n = 46 ) or conventional care group ( n = 54 ) . The rehabilitation program group received early oral feeding , early ambulation , and regular laxative . The primary outcome was recovery time , measured with criteria of tolerable diet for 24 hours , safe ambulation , analgesic-free , and afebrile status without major complications . Secondary outcomes were postoperative hospital stay , complications , quality of life by Short Form 36 , pain by visual analog scale , and readmission . This study was registered ( ID number NCT00606944 , http://register . clinical trials.gov ) . RESULTS : Recovery time was shorter in the rehabilitation program group than in the conventional care group ( median ( interquartile range ) , 4 ( 3–5 ) d vs 6 ( 5–7 ) d , respectively ; P < .0001 ) . There was no difference in postoperative hospital stay between the 2 groups ( rehabilitation program group , 7 ( 6–8 ) d vs conventional care group , 8 ( 7–9 ) d ; P = .065 ) . There was no difference in complication rates between the rehabilitation program group and conventional care group ( 10.9 % vs 20.4 % , respectively ; P = .136 ) . Quality of life and pain were similar in both groups . There were no readmissions or mortality . CONCLUSIONS : A rehabilitation program with early mobilization and diet after laparoscopic colon surgery results in reduced recovery time without increased complications . These results suggest that a multimodal rehabilitation program may increase the short-term benefits after laparoscopic colon surgery Preoperative 12.6 % oral carbohydrate loading is an element of the Enhanced Recovery After Surgery ( ERAS ) protocol aim ed at alleviating postoperative insulin resistance ; however , in Japan , beverages with 18 % carbohydrate content are generally used for preoperative carbohydrate loading . We investigated the effect of 18 % carbohydrate loading on alleviating insulin resistance .  Six healthy volunteers participated in this crossover-r and omized study and were segregated into 2 groups : volunteers in the carbohydrate-loading group ( group A ) who fasted from after 9 pm and ingested 375 mL of a beverage containing 18 % carbohydrate ( ArginaidWaterTM ; Nestle , Tokyo , Japan ) between 9 pm and 12 pm , and 250 mL of the same liquid at 6:30 am . Volunteers in control group ( group B ) drank only water . At 8:30 am , a hyperinsulinemic normoglycemic clamp was initiated . Glucose infusion rate ( GIR ) and levels of ketone bodies and cytokines ( IL-1β , IL-6 , and TNF-α ) before clamping were evaluated . p<0.05 was considered statistically significant . Levels of blood glucose , insulin , and cytokines at the start of the clamp were similar in both the groups . The GIR in group A was significantly higher than that in group B ( 11.5±2.4 vs 6.2±2.2 mg/kg/min , p=0.005 ) , while blood ketone body levels were significantly lower in group A ( 22±4 vs 124±119 μmol/L , p=0.04 ) . Preoperative 18 % carbohydrate loading could prevent the decrease in insulin sensitivity and suppress catabolism in healthy volunteers .  Thus , carbohydrate loading with a beverage with 18 % carbohydrate content might contribute to improvements in perioperative management OBJECTIVES Investigate both the utility and feasibility of perioperative nutritional supplementation with an arginine-enriched immunonutrition formula to high-risk head and neck cancer surgical patients and examine its effects on acute post-operative clinical outcomes . MATERIAL S & METHODS This prospect i ve , non-r and omized , interventional cohort study compared high-risk head and neck cancer surgical patients who consumed a pre- and post-operative arginine-based nutritional supplement to those that did not . Outcome measures included post-operative complications , length of hospitalization , readmission rates and measurement of nutritional biomarkers . RESULTS 195 high-risk head and neck cancer surgical patients were enrolled . 59 % of the patients used the nutritional supplement , 41 % did not . Of the 80 patients who did not receive the immunonutrition formula , 38 ( 47.5 % ) experienced post-operative complications of all types as compared to 29 of the 115 ( 25.2 % ) patients who did consume the product ( p=0.0021 ) . Pharyngeal leaks or fistulas were the most common post-operative complications in both groups and more common in patients who did not receive supplementation ( p=0.007 ) . Length of stay was on average 2.8 days longer in patients who did not have enhanced nutrition ( p=0.02 ) , while readmission rates between the two groups were similar ( p=0.91 ) . Measurements of nutritional biomarkers were not reported secondary to low collection rates . CONCLUSION Enhanced perioperative nutrition may result in significant reductions of post-operative fistula formations and decreased length of stay in a high-risk head and neck cancer population , even in the setting of poor compliance . The potential quality improvement in both patient care and healthcare cost is both real and significant Major surgery is associated with postoperative insulin resistance which is attenuated by preoperative carbohydrate ( CHO ) treatment . The effect of this treatment on clinical outcome after major abdominal surgery has not been assessed in a double‐blind r and omized trial Objective : The aim of this trial was to investigate whether a routine of allowing normal food at will increases morbidity after major upper gastrointestinal ( GI ) surgery . Summary Background Data : Nil-by-mouth with enteral tube feeding is widely practice d for several days after major upper GI surgery . After other abdominal operations , normal food at will has been shown to be safe and to improve gut function . Methods : Patients were r and omly assigned to a routine of nil-by-mouth and enteral tube feeding by needle-catheter jejunostomy ( ETF group ) or normal food at will from the first day after major upper GI surgery . Primary end point was rate of major complications and death . Secondary outcomes were minor complications and adverse events , bowel function , and length of stay . All patients were invited to a follow-up at 8 weeks after discharge from the hospital . Results : Four hundred fifty-three patients who underwent major open upper GI surgery in 5 centers were enrolled between 2001 and 2006 . Four hundred forty-seven patients were correctly r and omized . Of 227 patients 76 ( 33.5 % ) had major complications in the ETF group compared with 62 ( 28.2 % ) of 220 patients allowed normal food at will ( P = 0.26 , 95 % CI for the difference in rate from −3.3 to 13.9 ) . In the ETF group , 36 ( 15.9 % ) patients were reoperated compared with 29 ( 13.2 % ) in the group allowed normal food at will ( P = 0.50 ) and 30-day mortality was 10 ( 4.4 % ) of 227 and 11 ( 5.0 % ) of 220 patients , respectively ( P = 0.83 ) . Time to resumed bowel function was significantly in favor of allowing normal food at will ( P = 0.01 ) , as were the total number of major complications , length of stay , and rate of postdischarge complications . Conclusions : Allowing patients to eat normal food at will from the first day after major upper GI surgery does not increase morbidity compared with traditional care with nil-by-mouth and enteral feeding Postoperative convalescence is mainly determined by the extent and duration of postoperative ileus . This r and omized clinical trial evaluated the effects of  early oral feeding  on functional gastrointestinal recovery and quality of life Background : Surgery is succeeded by long‐lasting state of relative peripheral insulin resistance , which is reduced by giving glucose infusion or oral carbohydrate‐rich drinks immediate before operating instead of fasting . The aim of the present study was to investigate whether oral carbohydrate or carbohydrate with peptide drinks preoperatively instead of fasting would improve postoperative voluntary muscle strength , nutritional intake and ambulation , decrease postoperative fatigue , anxiety and discomfort , and reduce the endocrine response to surgery AIM To evaluate published trials examining oral post-operative protein supplementation in patients having undergone gastrointestinal surgery and assessment of reported results . METHODS Data base search es ( MEDLINE , BIOSIS , EMBASE , Cochrane Trials , Cinahl , and CAB ) , search es of reference lists of relevant papers , and expert referral were used to identify prospect i ve r and omized controlled clinical trials . The following terms were used to locate articles : " oral ' ' or " enteral ' ' and " postoperative care ' ' or " post-surgical ' ' and " proteins ' ' or " milk proteins ' ' or " dietary proteins ' ' or " dietary supplements ' ' or " nutritional supplements ' ' . In data bases that allowed added limitations , results were limited to clinical trials that studied humans , and publications between 1990 and 2014 . Quality of collated studies was evaluated using a qualitative assessment tool and the collective results interpreted . RESULTS Search es identified 629 papers of which , following review , 7 were deemed eligible for qualitative evaluation . Protein supplementation does not appear to affect mortality but does reduce weight loss , and improve nutritional status . Reduction in grip strength deterioration was observed in a majority of studies , and approximately half of the studies described reduced complication rates . No changes in duration of hospital stay or plasma protein levels were reported . There is evidence to suggest that protein supplementation should be routinely provided post-operatively to this population . However , despite comprehensive search es , clinical trials that varied only the amount of protein provided via oral nutritional supplements ( discrete from other nutritional components ) were not found . At present , there is some evidence to support routinely prescribed oral nutritional supplements that contain protein for gastrointestinal surgery patients in the immediate post-operative stage . CONCLUSION The optimal level of protein supplementation required to maximise recovery in gastrointestinal surgery patients is effectively unknown , and may warrant further study Background and Aim : Immunomodulating nutrition is supposed to reduce the number of complications and lengthen of hospital stay during the postoperative period in patients after major gastrointestinal surgery . The aim of the study was to assess the clinical effect of immunostimulatory enteral and parenteral nutrition in patients undergoing resection for gastrointestinal cancer in the group of well-nourished patients . Material and Methods : Between June 1 , 2001 , and December 31 , 2005 , a group of 214 well-nourished patients was initially assessed ( 150 men , 64 women , mean age 61.2 years ) to participate in the study . Nine patients were subsequently excluded and the remaining 205 subjects were r and omly assigned in a 2 × 2 factorial design into 4 study groups , ie , st and ard enteral nutrition ( n = 53 ) , immunomodulating enteral nutrition ( n = 52 ) , st and ard parenteral nutrition ( n = 49 ) , and immunomodulating enteral nutrition ( n = 51 ) . The study was design ed to test the hypothesis that immunonutrition and enteral nutrition would reduce the incidence of infectious complications after upper gastrointestinal surgery ; the secondary objective of the study was to evaluate the effect of nutritional intervention on overall morbidity and mortality rates , and hospital stay . The study was registered in the Clinical Trials Data base – number NCT 00558155 . Results : The overall morbidity rate was 33 % and the incidence of individual complications was comparable between all groups . Infectious complications occurred in 26 of 102 patients given st and ard diets and in 22 of 103 patients receiving immunomodulatory formulas ( odds ratio 0.81 ; 95 % CI , 0.43–1.50 ) . There were no significant differences between infectious complications in patients using parenteral nutrition ( 22 of 100 patients ) and parenteral formulas ( 26 of 105 , odds ratio 1.14 ; 95 % CI , 0.61–2.14 ) . Neither immunostimulating formulas nor enteral feeding significantly affected secondary outcome measures , including overall morbidity and mortality rates , and hospital stay . Conclusions : Our study failed to demonstrate any clear advantage of routine postoperative immunonutrition in patients undergoing elective upper gastrointestinal surgery . Both enteral and parenteral treatment options showed similar efficacy , tolerance , and effects on protein synthesis .  Parenteral nutrition composed according to contemporary rules showed similar efficiency to enteral nutrition . However , because of its cost-efficiency , enteral therapy should be considered as the treatment of choice in all patients requiring nutritional therapy BACKGROUND SMOFlipid 20 % is intravenous lipid emulsion ( ILE ) containing long-chain triglycerides ( LCT ) , medium-chain triglycerides ( MCT ) , olive oil , and fish oil as a mixed emulsion containing α-tocopherol . The aim was to assess the efficacy of this new ILE in gastrointestinal surgery compared with MCT/LCT . METHODS In this prospect i ve study , 40 patients were r and omized to SMOFlipid 20 % or MCT/LCT ( Lipovenoes 20 % ) group . Clinical and biochemistry data were collected . Inflammatory markers ( CRP , IL-6 , IL-10 , TNF-α , TGF-β1 ) and oxidative stress ( ROS and superoxide ) were measured . RESULTS Thirty-five patients ( 17 males and 18 females ) with a mean age of 57 years completed the study . The patients ' demographic characteristics ( age , gender , height , body weight , and BMI ) were similar without significant differences between groups . The increment of triglyceride on day 6 from baseline was significantly lower in SMOFlipid group than in Lipovenoes MCT/LCT group . Inflammatory markers , as well as superoxide radical and total oxygen radical were not different between groups . CONCLUSIONS Despite the comparable effect on inflammatory response , because of its well-balanced fatty acid pattern , relatively low n-6:n-3 ratio , and high vitamin E content , SMOFlipid had a better triglyceride-lowering effect as compared with MCT/LCT in adult patients undergoing gastrointestinal surgery BACKGROUND Weight loss is frequent in patients with gastrointestinal ( GI ) cancer . Nutritional status deteriorates throughout anti-cancer treatment , mostly after major surgery , increasing complications , reducing tolerance and worsening the final prognosis . Enteral nutrition is safe and effective in malnourished patients undergoing major GI surgery . R and omised trials aim ed at investigating the effects of home enteral nutrition ( HEN ) in post-surgical patients with GI cancer are lacking . This study compares HEN and counselling in limiting weight loss during oncologic treatment . PATIENTS AND METHODS Patients with upper GI cancer and c and i date to major surgery were included in the protocol when the nutritional risk screening ( NRS 2002 ) score was ≥3 . All patients were supported with enteral nutrition through a jejunostomy after surgery and r and omly assigned to continue enteral nutrition or receiving nutritional counselling after discharge . Nutritional and performance status , quality of life ( QoL ) and tolerance to cancer treatment have been evaluated at 2 and 6 months after discharge . RESULTS Seventy-nine patients were r and omised ; 38 continued enteral nutrition at home and 41 patients received nutritional counselling only . After 2 months , patients on HEN  maintained their mean body weight , while patients in the nutritional counselling group showed a weight loss of 3.6 kg . Patients supported on HEN had a higher chance to  complete chemotherapy  as planned ( 48 % versus 34 % ) . QoL was not worsened by HEN . No complications were reported . CONCLUSIONS HEN is a simple and feasible treatment to support malnourished patients with upper GI cancer after major surgery and during chemotherapy in order to limit further weight loss
target: this guideline reflects the recommendations of the group of specialists of the Brazilian College of Surgeons , the Brazilian Society of Parenteral and Enteral Nutrition and the ACERTO Project for nutritional interventions in the perioperative period of Elective General Surgery .
  The prescription of these recommendations can accelerate the postoperative recovery of patients su bmi tted to elective general surgery , with decrease in morbidity , length of stay and rehospitalization , and consequently , of costs
background: OBJECTIVE to present recommendations based on the ACERTO Project ( Acceleration of Total Post-Operative Recovery ) and supported by evidence related to perioperative nutritional care in General Surgery elective procedures .