DIETARY MANAGEMENTS IN

SURGICAL CONDITION
 DIETARY MANAGEMENTS IN
SURGICAL CONDITION
REPORTER
EBORA/FOREL/FUTALAN/GABRIEL/JIAO

PPT
ENCINA/ESPEDIDO/FORONDA/FRANCISCO
 AT THE END OF THE TOPIC THE STUDENT MUST BE ABLE TO

DISCUSS THE IMPORTANT ROLE OF NUTRITIONAL CARE BEFORE AND AFTER RESTATE THE NUTRITIONAL MANAGEMENT ON
SURGERY COMMON SURGICAL CONDITIONS

ENUMERATE THE METABOLIC CHANGES OCCURS IN SURGERY

DIFFERENTIATE BETWEEN PRE-OPERATIVE AND POST OPERATIVE

DIET

DEFINE POST-OPERATIVE ILEUS

IMPORTANT ROLE OF NUTRITIONAL CARE BEFORE/AFTER SURGERY
EBORA,MARIA CRISTINA
IMPORTANT ROLE OF NUTRITIONAL CARE
BEFORE/AFTER SURGERY
➔ Critical for increasing the likelihood of positive outcomes

➔ Prevent or reverse the catabolic effects of disease or injury

➔ Meet the energy requirements for essential metabolic processes , tissue

repair

➔ Meet the substrate requirements for protein synthesis

IMPORTANT ROLE OF NUTRITIONAL CARE BEFORE/AFTER
SURGERY

ASSESS DEGREE OF MALNUTRITION BEFORE SURGERY USING:

➔ History & PE

➔ Nutritional Assessment Scores

➔ Imaging modalities

➔ Anthropometric measurement
Adapted from Heyland DK, Dhaliwal R, Jiang X, et al. Crit Care. 2011;15:R268.
IMPORTANT ROLE OF NUTRITIONAL CARE
BEFORE/AFTER SURGERY

➔ Consider if nutritional supplementation is needed;

➔ Caloric intake

➔ Energy expenditure
HARRIS-BENEDICT EQUATION:
Retrieved from: Schwartz’s Principle of Surgery, 11th Ed.
UNDERWEIGHT PATIENT
• Omega-3 fatty acids

• Arginine

OBESE PATIENT
• High-protein

• Low-fat

• Low-carbohydrate diet

Caloric intake by using 65% to 70% of their REE or 11 to 14 kcal/kg actual body weight per day
ENHANCED RECOVERY AFTER SURGERY (ERAS)

➔ Preoperative
proper nutrition through the day prior to surgery and carbohydrate loading via

clear liquids up to 2 hours prior to surgery

➔ Postoperative
minimize the use of opioid medications that slow gastric/ intestinal transit AND initiate a

regular diet as soon as a few hours postoperatively

METABOLIC CHANGES IN SURGERY
FOREL,KAREN JOY
NUTRITIONAL REQUIREMENTS
Decrease as an individual's body mass decreases, reflecting more
efficient utilization of ingested food and a reduction in work capacity at
the cellular level.

REDUCED CALORIC INTAKE DURING SURGERY:

➔ loss of fat, muscle, skin, bone and viscera, with subsequent
weight loss, and expansion of the ECF compartment
CESSATION OF PERISTALSIS
● Obstipation and intolerance of oral intake
● S. intestine 0-24 hrs/
● Stomach 24-48 hrs.
● Colon 48-72 hrs.
● Most affected parts of the intestine are those that
have been manipulated during the surgery
 CESSATION OF PERISTALSIS

“normal" or "obligatory" postoperative ileus defined as:

The period of time, lasting fewer than four days, from surgery until the
passage of flatus or stool and tolerance of an oral diet.
-
J Gastrointest Surg. 2013 May;17(5):962-72. Epub 2013 Feb 2.
RAPID CHON CATABOLISM
Increased urinary nitrogen excretion (15-25g/d)

Primarily from protein in skeletal muscles

 RAPID CHON CATABOLISM

Each g of urinary nitrogen loss:

= 6.25 g muscle protein catabolized

= 30 g lean body mass
= 70 mL blood plasma
= 25-50 mL whole blood
 INC. GLUCOSE USAGE IN SURGERY
Hyperglycemia associated with critical illness aka stress
hyperglycemia or stress diabetes

● Increased cortisol
● Catecholamines
● Glucagon
● GH
● Gluconeogenesis
● Glycogenolysis
INC. GLUCOSE IN SURGERY

There was a graded effect, with higher

mortality among patients who had higher blood
glucose levels illustrated by a retrospective
cohort study of 1826 medical and surgical ICU
patients

Mayo Clin Proc. 2003;78(12):1471

Inc. Utilization of Adipose
Adipose cells = main caloric reservoir

Predominant energy source (50% to 80%) in times of major

forms of stress (e.g., trauma, surgery)

Supplies nutrients to other tissues (e.g., lipolysis,

gluconeogenesis, ketone body formation)
 DEHYDRATION
Prolonged operative time

Perspiration, urination, respiration, vomiting, diarrhea,

and insufficient fluid intake
 DEHYDRATION

● Hyperchloremic metabolic acidosis

● Hyponatremia
● Hypokalemia
● Transfusion
● Third-spacing fluid loss
● Gastrointestinal loss
● Urinary loss
 DEHYDRATION

● Brain injury
● Related to tissue injury/ischemia and reperfusion
● Refeeding syndrome
● Acid-base imbalance
● Underlying surgical diseases and their treatment
 CALCIUM LOSS
● Dilutional effect of crystalloid fluids
● Addition of citrate in RBC transfusions
● “Third spacing”
● Phosphate released from cell lysis
● Refeeding syndrome
● Parathyroidectomy
 INC. ASCORBIC ACID USE
DUE TO STRESS

Vit. C - cofactor in a number of enzymatic and chemical pathways

Falls in uncomplicated surgeries due to increased oxidative stress

 ANEMIA FROM IRON AND
VIT.B12 DEFICIENCY

Gastrectomy/bariatric surgery

Small bowel Surgery

 METABOLIC CHANGES IN SURGERY

Post-operative malnutrition depends on:

➔ preexisting nutritional status
➔ nature and complexity of the surgical procedure
➔ degree of postoperative hypermetabolism
➔ ability to consume an optimal number of calories
 INITIAL HOURS AFTER SURGERY
➔ Reduced total body energy expenditure and urinary
nitrogen wasting
➔ Hepatic glycogen stores are rapidly and preferentially
depleted fall of serum glucose concentration
➔ Proteolysis associated with elevated urinary nitrogen
excretion
➔ In prolonged starvation, systemic proteolysis is
reduced vital organs to use ketone bodies as
principal fuel source
Metabolic changes in surgery

Long CL, Schaffel N, Geiger JW, et al: Metabolic

response to injury and illness: estimation of
energy and protein needs from indirect
calorimetry and nitrogen balance, JPEN J
Parenteral-Enteral Nutr. 1979 Nov-
Dec;3(6):452-456.)
PRINCIPLES OF DIET THERAPY
FUTALAN,SAMUEL
 PRE-OPERATIVE CONSIDERATION

THE PRESENCE OF FOOD MAY CAUSE

COMPLICATIONS, SUCH AS:
Usual preparation
For surgery requires nothing to be taken
orally for at least 8 hours before the
procedure.
This protocol is to ensure that the stomach retains
no food during surgery
➔ the aspiration of food particles during
anesthesia or in the course of recovery
from anesthesia if the patient vomits. In
addition, any food present in the stomach
may interfere with the surgical procedure
➔ increase the risk for postoperative
➔ gastric retention and expansion.
 PRE-OPERATIVE CONSIDERATION

Before GI surgery, a fiber-restricted diet may be followed for several days to clear the

surgical site of any food residue Commercial nonresidue elemental formulas can

provide a complete diet in liquid form. These formulas can be administered by tube or

made more palatable for oral use with various flavorings.

PRE-OPERATIVE
Factors that determines the pre-operative diet

Type of surgery

a. Minor surgery

b. Major surgery

Urgency of the Surgery

a.Emergency

b.Elective Surgery

Metabolic circumstances before the surgery

PRE-OPERATIVE
MAJOR PROBLEMS :

A. UNDERNOURISHED

 lack of nutrients necessary for surgery recovery, protein Deficiency is the most common among these patients, low

protein storage may predispose the patient to shock

 Less detoxification of aesthetic agent by the liver, Increased edema at the incision site decreased antibody formation

and the last factor increases risk for infection.

 Intravenous feeding of solutions that are more concentrated in nutrients prior to surgery is one way to replenish.

 Aggressive oral nutrition, although more time consuming, can accomplish the same goals.
MAJOR PROBLEMS :

B. OBESITY

PRE-OPERATIVE
 Higher health risk in surgery. Excess fats complicate surgery, puts strain on the heart, increases risk of

infection and respiratory problems and delay healing.

 The risk of delay healing Risk of dehiscence and evisceration are greater in obese patients.

 Pre-existing conditions such as hypertension and diabetes mellitus which are prevalent in such

conditions are also increases risks.

 High in the essential nutrients should be attempted. Starvation or fad diets are obviously not

recommended preoperatively.
 PRE-OPERATIVE DIET
A. HIGH CALORIE

Fortify the patient to withstand the stress of surgery

B. HIGH PROTEIN

Protein deficiencies among pediatric and geriatric hospital patients are not uncommon, particularly among the

critically ill patients. Every patient facing surgery must be equipped with adequate body protein to counteract

blood losses that occur during surgery and to prevent tissue catabolism during the immediate postoperative

period
C. High Carbohydrates

− To provide externa energy for the increased metabolism carbohydrate intake should be
adequate to maintain optimal glycogen stores in the liver as a necessary resource for
immediate energy

− To spare body proteins

− To promote glycogen stores in the liver

− To prevent ketosis

D.Adequate fat

− To contribute to the total caloric requirement without too much bulk

E. INCREASED VITAMINS:

When increased protein and energy are necessary, the appropriate intake of vitamins and minerals
involved in protein and energy metabolism (e.g., B-complex vitamins) must also be supplied. Any
specifically identified deficiency states (e.g., iron-deficiency anemia) should be corrected. In
addition, electrolyte and water balance is necessary to prevent dehydration.

F. INCREASED MINERALS SPECIALLY PHOSPHORUS AND POTASSIUM, SODIUM AND

CHLORIDE

 for electrolyte balance, to make up for loss due to breakdown of body tissues, and to make up

 for loses via urine and sweat; iron due to anemia

 POST OPERATIVE
The postoperative diet will depends on the type of surgery and functioning of the GI tract.

THE KEY OBJECTIVES OF POSTOPERATIVE NUTRITIONAL CARE ARE:

➔ Maintenance of body fluid and electrolyte balance

➔ Adequate calorie and protein intake

➔ Adequate total nutrient intake to promote wound healing and resumption of normal activities.
CALORIES
 For elective surgery the required energy postoperatively will increase by only 10% if no
complications.For multiple fractures or trauma the energy requirement will increase by 10 – 25%

PROTEIN

 Optimal protein intake during the postoperative recovery period is important for all patients. Protein
is needed to replace losses that occur during surgery and to meet the increased demands of the
healing process.

Caloric requirements (35 – 45 cal per kg desirable body weight per day ) Protein ( 1.0 – 1.5 g per kg DBW per day.)
VITAMINS

ASCORBIC ACID DEFICIENCY

associated with the delay wound healing It is required for the synthesis of collagen and collagen

precursors for wound healing 1000mg or more daily maybe required in extreme conditions

VITAMIN A DEFICIENCY

 may interfere with wound healing necessary for normal epithelialization .

 Helps to prevent gastric stress ulceration

VITAMIN K DEFICIENCY

 may result hypoprothrombinemia with a resultant defect in clotting.

 Vit K is for the normal clotting of the blood

THIAMINE, RIBOFLAVIN & NIACIN

provides essential coenzyme factors to metabolize carbohydrates and protein

Requirement for thiamine is doubled in hypermetabolic states – fever,

trauma,hyperthyroidism, etc.
MINERALS

ZINC

 Help the process of wound healing in patients who have low serum zinc levels It is necessary for amino

acid metabolism and synthesis of collagen precursors

IRON

 to combat anemia 20 mg/day

FLUIDS

 Immediately following an operation the patient should be supplied with sufficient fluids to maintain

normal water and electrolyte balance. 5% dextrose in Lactate- Ringer’s solution is used for the first 2 days

after operation
FOODS

AS SOON AS BOWEL SOUNDS RETURN AFTER OPERATION, PATIENT SHOULD BE GIVEN:

• clear liquid diet for few meals

• Then full liquid diet can be given for a day

• Followed by soft diet

• Full diet generally on 5th or 6th postoperative day.

To meet calorie, protein and carbohydrate needs, generous amount of high quality protein such as milk,

meat and eggs and simple carbohydrate foods are needed.

FEEDING THE PATIENT IMMEDIATELY AFTER THE
OPERATION:

• Since a patient usually cannot tolerate solid food immediately after an operation it is withheld anywhere

from a few hours to two or three days.

• A feeding that is too early may nauseate the patient and cause vomiting and possible aspiration.

• This results in further fluid and electrolyte losses, discomfort, and potential pneumonia.
FEEDING THE PATIENT IMMEDIATELY AFTER THE
OPERATION:
FOLLOWING OUTLINE LISTS THE VARIOUS TYPES OF DIETARY SUPPORT THAT CAN BE USED DURING THIS SHORT PART OF THE POSTOPERATIVE

PERIOD.

1. No food by mouth (NPO)

2. Intravenous feeding: blood transfusion, fluids and electrolytes 5% dextrose, vitamin and mineral supplements

protein sparing solutions (with or without intralipid) combinations of above

FEEDING THE PATIENT IMMEDIATELY AFTER THE
OPERATION:

THE FOLLOWING OUTLINE LISTS THE VARIOUS TYPES OF DIETARY SUPPORT THAT CAN BE USED DURING THIS SHORT PART OF

THE POSTOPERATIVE PERIOD.

3. Oral feeding routine hospital progressive liquid diets with or without supplement, liquid-protein supplements

with or without nonprotein calories, combinations of above

4. A combination of oral and intravenous feedings

POST-OPERATIVE ILEUS
GABRIEL ,CAMILLE
POST-OPERATIVE ILEUS

➔ Most significant cause is the use of narcotics for analgesia

➔ frequent, frustrating occurrence for patients and surgeons after abdominal surgery.

➔ Despite significant research investigating how to reduce this multi-factorial phenomenon, a

single strategy has not been shown to reduce POI’s significant effects on length of stay (LOS)

and hospital costs

POST-OPERATIVE ILEUS

➔ Strategies that target inflammation and pain reduction such as NSAID use, epidural analgesia, and

laparoscopic techniques will reduce POI but are accompanied by a simultaneous reduction in opioid

use.

➔ Many has suggested that POI is actually a mandatory phase of recovery

◆ small intestine - 0 to 24 hrs

◆ Stomach - 24 to 48 hrs

◆ Colon - 48 to 72 hrs

➔ abnormal if it is still present after 5 days.

DIETARY MANAGEMENT FOR RECOVERY
IN GENERAL, THE FOLLOWING DIET PRESCRIPTION SHOULD SATISFY MOST CLINICAL CONDITIONS THAT INVOLVE

TRAUMA:

➔ 1. 40-50 kcal/kg body weight/d

➔ 2. 12%-15% of total calories as protein

➔ 3. Well-balanced intakes of the established RDAs/DRIs

➔ 4. Carefully monitored intakes of vitamins A, K, C, B12; folic acid; and the minerals, iron and zinc
SOME FOOD SOURCES OF THE NUTRIENTS IDENTIFIED AS ESSENTIAL TO A SUCCESSFUL
SURGERY

Protein Vitamin C (ascorbic acid) Vitamin A

- Milk - Citrus fruit - Liver
- Eggs - Sweet and hot pepper - Cheese
- Meat - Strawberries - Butter
- Fish - Broccoli - Oily fish (salmon & tuna)
- Poultry - Tomatoes Vitamin K
- Vegetable - Green leafy vegetables
- Grains - Fruits
- Nuts - Cereals

Vitamin B ⮚ Riboflavin ⮚ Niacin

⮚ Thiamine • Milk & milk products • Liver
• Pork • Oyster • Tuna
• Oyster • Enriched breads and • Peanut
• Cereals cereals • Peanut butter
• Peas
• Pork
NUTRITIONAL MANAGEMENT OF COMMON SURGICAL CONDITION
JIAO,JANE BERNADETTE
NUTRITIONAL MANAGEMENT OF COMMON SURGICAL CONDITION

IMPORTANCE OF NUTRITIONAL MANAGEMENT DURING RECOVERY:

1. Helps incisions to heal fast

2. Provides raw materials for the immune system against infections

3. Increases level of energy

4. Promotes skin, nerves, blood vessels, muscles and bones repairs

TONSILLECTOMY
GENERAL: COLD AND MILD FLAVORED FOODS ARE RECOMMENDED

POST-OPERATIVE MEALS (24 HOURS PERIOD):

➔ Cold milk

➔ Milk beverages like malted milk and eggnogs

➔ Chocolate and vanilla ice cream

➔ Fruit juice

Warm fluids to be started on the second day.

GASTRIC SURGERY
Metabolic changes:

1. Absence of hydrochloric acid and pepsin

2. Defective mixing of food with digestive juices leads to impairment of fat utilization

3. Impairment of protein digestion

4. Increased intestinal motility

5. Less absorption of iron that leads to hypochromic anemia

6. Absence of gastric juice and intrinsic factor of castle that binds vit.B12 for normal absorption

results in a macrocytic anemia unless vitamin is given parenterally

POSTGASTRECTOMY
Usual cause of malnutrition, underweight and frustration. Proteins and fats are recommended

whereas liquids to be taken in between beals without food.

ACHIEVING OR MAINTAINING THE OPTIMAL WEIGHT AND NUTRITIONAL STATUS OF THE PATIENTS DIET SHOULD BE:

➔ moderate fat (30-40% of calories)

➔ Low in simple carbohydrates

➔ High in protein (20% of calories)

Milk intake in small amounts.

RECTAL SURGERY
Initiated by clear fluid diet to full liquid diet (omit milk) then low residue diet until patient is fully

healed.

FOODS THAT PRODUCE BULKY STOOLS:

➔ Milk

➔ Potatoes

➔ Eggs

➔ Cheese

➔ Butter, Lard
BURNS
NUTRITIONAL CARE:

1. High calorie (Females 22kcal/day; males 25kcal/day, these patients required 40kcal per percentage

point of burned total body surface area)

- to meet the demands of increased metabolism and insure optimal utilization of protein for

tissue repair.

2. High protein is increased from normal 0.8g/kcal/day to approximately 2.5g/kcal/day in severely burned

patients

● To connect negative nitrogen balance, promote wound healing & increase resistance to

infection
BURNS CONTD
3. High carbohydrates, during the hypermetabolic phase of burn injury (0-14 days), the ability to metabolize

fat is restricted, so a diet that derives calories primarily from carbohydrates is preferred.

- To provide the needed calorie and spare body protein

4. Fat is moderately increased to contribute to the total caloric requirement

5. Vitamins are increased

- To promote wound healing and proper utilization of protein and carbohydrates

6. Fluid and electrolytes are increased

- The burn patient should also be given supplemental arginine, nucleotides and omega-3

polyunsaturated fat to stimulate and maintain immunocompetence.

CASE
 A 50 year old male call center agent ,5’8 with a weight of 61 kg

 Admitted Due to 8-week history of bloody diarrhea.

 2 years ago was Diagnosed with ulcerative colitis

 Remained in remission until the gradual onset of bloody diarrhea.

 Bowel frequency was 20 times per day

 Associated with significant abdominal pain and weight loss.

 Failed to achieve symptom started on intravenous steroids, topical therapy and anti-

tumour necrosis factor therapy

VITAL SIGNS: IMAGING TEST
 Abdominal Ultrasound and Xray-(Unremarkable)
 Heart Rate 102/Min
 Illeo-colonoscopy rectum was normal with edema, erythema,
 Blood Pressure 110/80 multiple ulcerative punched-out lesions with necrotic and
 Respiratory Rate 24/Min hemorrhagic surface
 Colonic biopsy revealed focal erosion and focal crytitis , an
PHYSICAL EXAMINATION
increased infiltration of lymphocyets, polymorphs, eosinophils in
 Mildly pale and febrile
the lamina propria
 No clubbing, Lymphadenopathy
and Skin lesion

LABORATORY: Surgery was suggested and done. Her symptoms had

improved by the time of her outpatient review 2 weeks
 Stool Microscopy: Numerous Pus later
cells
 Blood,Stool and Urine
Culture(Unremarkable)
 EXCHANGE CARBS PROTEIN FATS CALORIE

VEG A 1 - - - -

VEG B 10 3X10 = 30 1X10= 10 - 16X10= 160

FRUITS 6 10X6= 60 - - 40X6= 240

MILK 1 12 8 10 170

RICE 10 23X10= 230 2X10= 20 - 100X10= 1000

MEAT 6 - 8X6 = 46 4X6= 24 68X6= 408

FAT 5 - - 5X5= 25 45X5= 225

TOTAL 39 320 86 59 2203

 B.FAST SNACK LUNCH SNACK DINNER TOTAL

VEG A 1 1 1

VEG B 10 1 6 3 10

FRUITS 6 1 1 1 1 2 6

MILK 1 1 1

RICE 10 2 2 3 1 2 10

MEAT 6 1 2 3 6

FAT 5 1 2 2 5
 B.FAST SNACK LUNCH SNACK DINNER TOTAL

1 1 cup banana blossoms 1

3 cups toge sprout

10 1 cup remolatsa 3 cups carrot 10
and 3 cups kadios

2 mango
6 3 tbsp fruit cocktail 1 small atis 1 date 24 pcs grapes 6
chips

½ cup whole milk,

1 1
evaporated, undiluted

2 cups 1 ½ cup rice,

10 2 pcs pandesal 1pc kamote 2 cups mike bihon 10
baby corn cooked

6 ½ cup cottage cheese 2 pcs tokwa 1 ½ chicken breast 6

5 1 strip bacon 4 sitsaron 1 medium avocado 5

LOW RESIDUE DIET

 Recommended amount of dietary fiber is only 14 grams per 1000 calories

 Helps to heal the bowl by reducing the amount of indigestible fibers

 Improvement with a low fermentable oligo-, di-, and monosaccharides and polyols

(FODMAP) diet.

 In the setting of IBD, this may involve removing one particular food from the diet

for a period of time and observing whether symptoms resolve during that time.

Conversely, it may also involve introducing one new food at a time to identify foods

that precipitate symptoms.

 LOW CARBOHYDRATE DIET HIGH PROTEIN

 Specific Carbohydrate Diet (SCD), wherein it is a very  Inc . of protein intake of 1-1.5g/DBW/d
restrictive low-carbohydrate diet  to promote wound healing
 promoted for multiple chronic and autoimmune diseases,
including IBD.
 It does not allow for the intake of processed foods due to
additives. The diet does allow for the intake of unprocessed
meats, poultry, fish, eggs, honey, non-canned vegetables,
some legumes, fruits, nuts, homemade yogurt, and some
lower-lactose cheeses.
THANK YOU