Enteral nutrition in HPB surgery: past and future
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Perioperative nutrition has, during the past century, been transformed from a tool to provide calorie and nitrogen support to a tool to boost the immune system and increase resistance to complications. Despite all the progress in medicine and surgery, perioperative morbidity, the rate of infections, thrombosis, and the development of serosal adhesions has remained the same as long as can be judged, or at least during the past 80 years. Most prone to develop complications are persons above the age of 65 and persons with depressed immunity. About 80% of the immune system is localized in the gastrointestinal tract, which offers great opportunities for modulation through enteral nutrition. As the stomach has a tendency to develop postoperative paralysis, tube feeding is often necessary. In 1918, Andresen demonstrated the advantages of enteral nutrition, which already started on the operating table. Mulholland and colleagues and Rhoads and co-workers demonstrated, during the 1940s, certain advantages of enteral tube feeding. Also, the works by Alexander, Fischer, and Ryan, and their co-workers supported the value of early enteral feeding, and suggested enteral feeding as an effective tool to boost the immune system. It was, however, works published in the early 1990s, by Moore and colleagues and by Kudsk and colleagues, which made surgeons more aware of the advantages of early enteral nutrition. Surgery in the hepatobiliary pancreatic field is known to have a high rate of complications. Uninterrupted perioperative nutrition, i.e., nutrition during the night before, during surgery, and immediately after, offers a strong tool to prevent complications. It is essential that the nutrition also provides food for the colon, e.g., fiber and healthy bacteria (probiotics) to ferment the fiber and boost the immune system.
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