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Intravenous nutritional support and the surgeon: Where next?

Irish Journal of Medical Science volume 161, pages 401–403 (1992)Cite this article

Summary

Over the past twenty five years the development of total parenteral nutrition has in many ways revolutionised the practice of surgery. It has enhanced survival in otherwise high mortality operations such as oesophageal surgery, especially with anastomotic complications. It has changed significantly the management of fistulae, either post operative or associated with diseases such as Crohn's enteritis. Here a basic general principle is applied—that a fistula will close if there is no distal obstruction and the throughput can be diminished. This can be achieved by withholding oral feeding and using the parenteral route. It has allowed survival in the short gut syndrome from whatever cause and it is interesting to see the degree of “intestinal adaptation” that occurs once the first critical year is survived with the help of intravenous nutrition. The assessment of nutritional status is difficult and while the level of serum albumin may be taken as a clinical standard, it is obvious that many patients survive extensive surgery with low albumin levels and also that there appears to be a lag period to the restoration of albumin levels, even with otherwise successful nutritional support and with other parameters being satisfactory. Even complex formulae using a combination of laboratory and antropometric parameters is not fully satisfactory as an absolute assessment of nutritional status. It is now interesting to see that nutrition can affect both immune competence and even carcinogenesis. The lipid element in intravenous nutrition may cause dysfunction of immunity and vitamin status, gastric and platelet function with impaired oxygen diffusion leading to increased wedge pressures. The role of glutamine is fascinating and may be involved in maintaining the integrity of the gut mucosa with a possible role in prevention of bacterial trans-location and sepsis and also as a scavenger in peroxidase injury which can occur with a variety of oxygen free radical reactions. Arginine may be immunotrophic in enhancing Tlymhocyte activity and growth hormone may be helpful in reducing severe protein catabolism. Future development therefore, will focus on further definition of the role of these agents with possible expansion in the efficacy of parenteral nutrition. As with any benefit there must be a note of caution and accurate prescription can be critical-while nutritional support is often important in intensive care unit patients, overfeeding can result in excessive CO2 production leading to difficulty in weaning from ventilatory support.

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Affiliations

  1. Regional Hospital, University College, Dublin

    Dermot J. Hehir

  2. Cork and Mater Hospital, University College, 47 Eccles Street, Dublin 7

    Thomas F. Gorey

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  1. Dermot J. Hehir
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  2. Thomas F. Gorey
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Hehir, D.J., Gorey, T.F. Intravenous nutritional support and the surgeon: Where next?. I.J.M.S. 161, 401–403 (1992). https://doi.org/10.1007/BF02996202

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  • DOI: https://doi.org/10.1007/BF02996202

Keywords

  • Total Parenteral Nutrition
  • Nutritional Support
  • Parent Enteral
  • Azelaic Acid
  • Subjective Global Assessment