Diet Therapy for

Surgical Conditions

 Surgery is defined as a planned anatomical alteration of the human organism

designed to arrest, alleviate or eradicate some pathologic process. Modern surgery

underscores the significance of correct diagnosis of the illness and case of the patient
prior to and after surgical procedure. While the success of the operation depends
primarily on a qualified surgical team and the use of modern techniques, the severity
of postoperative complication is linked to other important factors, including nutritional
status. The roles of diet and nutrition support in the pre-operative and post-operative
stages are emphasized.

The Surgical Process

There are three phases of surgical process: 1. pre-operative evaluation and
preparation for surgery, 2. the surgery procedure itself and 3. the postoperative care.
In all these phases, the patient undergoes physiologic and psychological stresses that
require comprehensive care.
Based on the urgency of operation, surgery comes in two forms: emergency and
elective operation. Emergency surgery Is performed when the nature of illness require
an immediate intervention ( such as acute appendicitis ). Thus, there is limited time to
prepare the patient especially when poor nutrition coexists. In contrast, elective
surgery allows reasonable time to prepare the patient before surgery.
The crucial role of nutrition to overall care of surgical patient is well recognized
and in fact, the overall importance of nutritional support to surgery is now considered

Metabolic Response to Surgery

Surgery is accompanied by stress response. It is designed to produce sufficient

calories to meet high metabolic demands from surgery and injury. The stress response
involves an increase in the secretion of epinephrine, norepinephrine and
corticosteroids resulting in breakdown of glycogen, fat stores and body proteins,
especially skeletal muscles. The net effect in severe cases is increased urinary
nitrogen loss, muscle wasting and weight loss.
The stress response is also intended to maintain the blood volume. Antidiuretic
hormone (ADH) secretion increases during the stress response, with decreased urine
output and retention of fluid. In hypovolemia, increased aldosterone secretion occurs
and sodium and fluid are retained.
The catabolic responses to surgery or injury vary depending on the extent of
tissue damaged. Minor surgery (such as a hernia repair) may evoke little systemic
responses, whereas major surgery or accidental injuries (such as a cardiac bypass
surgery or a 60% total body surface flame burn) induce maximal response.
Negative Nitrogen Balance
The loss of nitrogen from the body is primarily the result of increased excretion of urea and
other nitrogenous products in the urine, loss of protein through the injured tissue in individuals with
large open wounds. The pattern of protein breakdown is related to the degree of damage in a doseresponse manner (i.e. the greater the injury, the larger the nitrogen loss). Nitrogen excretion is also
dependent on nutritional state of the patient and the size of the lean body mass. Thus, a muscular,
well nourished person will lose more nitrogen than a depleted individual will after similar,
comparable operation .

Hormonal and
Inflammatory
Response

Initially, insulin levels are low and then they gradually rise, although insulin resistance is
present. The elaboration of the counter regulatory hormones cortisol, glucagon and
cathecolamines is increased, and these factors play a central role in the response.
Inflammatory factors (such as cytokines, leukotrienes, etc.) contribute to the catabolic
response, either directly or indirectly ( stimulating elaboration of catabolic hormones,
causing anorexia through central nervous system mechanism and increasing body
temperature ).
Translocation of the Amino Acids
The metabolic response to surgery is characterized by the breakdown of skeletal
muscle protein and the translocation of the amino acids ( mainly alanine and
glutamine ), to visceral organs and the wound. At these sites, the amino acids serve
to enhance host defenses and support vital organ function and wound repair.
Pre-operative Diet
The pre-operative diet aims to improve the nutritional status of the patient, to
prepare him for nutrient losses during surgery (e.g. protein, water, electrolytes,
protein), to help hasten post-operative recovery, to build up glycogen reserves, and
to strengthen bodily resistance to infections. Weight changes should be affected
during the pre-operative stage. Patients whose weights are nearly within desirable
levels are exposed to less surgical risks than obese or underweight patients. Diabetics
should be especially attended to. Nutritional anemia and other deficiencies should be
corrected prior to surgery.

Diet for elective surgery

In elective surgery, the surgery is planned and there is ample time to apply the prescribed
pre-operative diets. Whenever possible, a high protein, high calories diet with vitamin and
mineral supplementation is recommended. If patient is obese, use a low-calorie diet that
includes carbohydrates adequate for glycogen stores. Intakes of zinc , vitamins C and K should
be adequate.
Diet for Emergency Operations

For emergency cases, parenteral feeding is the fast method of nourishing the patient before
surgery. parenteral means other than the oral route; i.e., subcutaneous, intramuscular or
intravenous ( I.V ) feeding.
Diet immediately before surgery

Light evening meals is prescribed the day before the surgery. This is gradually restricted to
clear liquids and then all foods are withheld for at least 8 hours to empty the stomach. Some
clinicians prescribe a non-residue is clear liquid diet for several days especially when the
surgical site involves the gastrointestinal tract. This eliminates the possibility of inhaling the
vomitus during the anesthesia and reduces the feces in the colon.
In emergency cases, gastric lavage ( gastric suction) is administered to remove
gastrointestinal contents. For gastrointestinal operations, a non-residue diet is given for
several days. Clinically defined or elemental formulas can provide a complete diet in liquid
form.

Post-Operative Diet

In general, nothing is given by mouth (NPO) immediately after the operation.

When the patient has recovered from anesthesia effects or as soon as peristalsis is
evident, a clear liquid diet is given. This is gradually changed to full liquid diet, a soft,
and eventually to a regular diet. Depending on the patients tolerance for oral feeding,
a high calorie, high protein diet is recommended.
The first rule of post-surgical care is to make the patient resume his normal diet
food in the gastrointestinal tract hastens peristalsis and stimulates normal digestive
function. While the best route for food is by mouth, there are cases when this is not
possible. Intravenous or tube feeding are resorted to, ether totally or in part, to
provide nutrients in a hurry. The rule of thumb is when the gut works, use it.

Principle Underlying the Dietary Modifications

Dietary Modifications

A. Pre-Operative Diets

B. Post-Operative Diets

High Calories ( 50% or more than

RENI )

promotes glycogen storage

prevents ketosis
Extra energy for increased
metabolism
Extra CHO spares protein

( Same as in A )

High Protein ( 50% or more than

RENI )

Builds up nitrogen reserves

Increased resistance to infection
Ensures rapid wound healing
Reduces possible edema at the
site of wound
Protects liver against toxic
effects of anesthesia
Promotes regeneration of
hemoglobin

Replaces protein losses

Increases resistance to infection
Promotes wound healing
Restores fluid and electrolyte
balance
Hastens return of muscular
strength
Promotes blood-building

Vitamin and Minerals

Supplementation

Catalyzes metabolic reactions in

general
Regulates fluid and electrolytes
balance
Promotes blood-building and
blood-clotting

(same as in A) plus
Prevents dehydration and shock
during immediate postoperative
stage
Replaces losses during
surgery(e.g. from blood,
drainage, sweat, vomiting , renal
losses)
Promotes wound healing

Liberal Fluid Intake ( total water

intake should equal losses by all
routes )

Regulates fluid and electrolytes

balance
Replaces fluid losses(e.g. blood,
drainage, renal excretion, etc.)

( Same as in A)

Intervals of feeding ( small,

frequent feeding 6 times a day;
more for liquid diets )

Promotes assimilation and

metabolism
Flexible to patients tolerance for
food

( Same as in A)

Food
Exchange

Milk
Vegetable
sA
Vegetable
sB
Fruit
Rice
Meat
Fat
Sugar
Snacks

A High Calorie, High Protein Diet for an Adult

Filipino
( 3000kcal, 100g Pro )
No.
CHO
Pro
Fat
Exchanges (g)
(g)
(g)
per day

3
As desired
2
6
10
7 (5 LF, 2
MF)
10
6
As
needed
Total

36
6
60
230
30
70
432

24
2
20
56
1+
103

30
17
50
1+
98

Energy
(kcal)

510
32
240
1000
337
450
120
293
3022

Meal pattern
Breakfast:
Fruit
Cereal
Protein dish
Bread
Butter
Beverage(milk)
Sugar 1 tbsp.
Morning snack:
Protein source
Bread-butter
Fruit juice
Lunch:
Soup
Main dish w/ vegetables and
cooking fat
Salad
Rice
Dessert(fruit)
Afternoon snack:
Milk source
Rice exchange
Supper:
Soup
Main dish w/ vegetables &
cooking fat
Rice
Dessert(milk containing)
Bedtime snack:
Milk beverage w/ sugar
Rice exchange
Protein source

No. of exchange

Sample menus

2
1
1
1
2
1
3

Orange juice, 1 tall glass

Champorado w/ milk & sugar
Toasted dilis
Ensaymada butter

1
2
2

Egg sandwish w/ mayonaise

2(meat)
3(fat)
3
2
1
2

Milk

Pineapple juice, 1 tall glass

Chicken tinola w/sili leaves
broth
Thigh -1 large; sayote-1 cup
Fried fleshy fish-with sliced
tomatoes
Rice
Lacatan 1 large
Milk shake and sponge cake

2
3
3
1-3
2
1

Almondigas soup
Beef asado with carrots one
half c
Rice
Custard
Milo with milk
Crackers
Cheese

Intravenous Solution
Name and Type

Indication for Use

A. Dextrose 5%
10%
20%
30%

Source of readily absorbable glucose for quick energy. For

prevention of dehydration, excess protein catabolism,
ketosis. Replacement of fluid losses.

B. Dextrose 5% in Lactated
Ringers solution

Dehydration of any type to replace extracellular fluid loss

as in burns, fractures, CV emergencies, metabolic
acidosis, diarrhea.

C. Intrapersol with Dextrose

D. multi-Ion MB in D5 water

E. Multisol-R/Multisol-R in D5
water
F. Multisol M in D5 water
G. Multisol MK in D5 water
H. Onkovertin 70 in Dextrose
5%

Renal failure. Poisoning with barbiturates or other

systemic agents which are dialyzable or which cause
acute renal insufficiency or failure; intractable edema,
hepatic coma, hypocalcemia, hyperkalemia, azotemia
and uremia.
Used as pediatric replacement solution in the treatment
of diarrhea and dehydration.
Provides the principal ions of normal plasma in almost
the same proportions as normal plasma. Replacement of
acute losses of extracellular fluid volume in surgery,
trauma, burns, or shock.
To maintain fluid and electrolyte with restricted oral
intake.
For patients under stress or when there are losses of
gastric, intestinal or biliary secretions or in potassium
losing disease state.
Volume replacement for immediate treatment of shock,
thrombo-prophylaxis; pre-operative hemo-dilution.

Blenderized Tube Feeding

Approximate Composition of this Blenderized
Feeding
Calories
Protein
Fat
Carbohydrate
Calcium
Phosphorus
Iron

2000 kcal
98g
65g
255g
1.8g
1.8g
24 mg

Potassium
Sodium
Vitamin A
Thiamin
Niacin
Niacin
Ascorbic acid

4.2g
1.1g
5228 IU
1.5mg
3.0mg
3.0mg
203mg

Enteral Nutrition Support

Tube feeding is method of introducing food through a tube to persons with a functional
gastrointestinal tract either as a supplemental nourishment or as the only source of nutrient
intake. The indications for tube feeding are listed in Table 12.5.
The dietary prescription for tube feeding should be specific in kind, amount, strength or
dilution, and total volume for 24 hours. The route of feeding recommended feeding intervals
and volume per feeding should be clearly stated.

Table 12.5. Indication for Use of Tube

feeding

Inability to ingest food normally

Stupor, unconsciousness, coma,
cerebrovascular accidents
Inflammation in central nervous system
Cerebral neoplasm
Fracture of mandible
Oropharyngial neoplasm
Head and neck surgery
Dysphagia
Radiation to head or neck
Chemotherapy
Multiple sclerosis
Physiologic deterrents to food
intake
Nausea or vomiting in pregnancy, drug
reactions, radiation or chemotherapy
Dumping syndrome
Obstruction of gastrointestinal
tract
( if access is below obstruction )
Esophageal stricture or neoplasm
Spasm of pylorus
Neoplasm, foreign body or other
obstruction of stomach or intestine
Psychiatric illness
Anorexia nervosa
Depression
Diversion of flow ( fistulas )

Impairment of digestion and or

absorption
Pancreatic insufficiency; carcinoma
Chronic pancreatitis
Bile salt insufficiency
Bile acid-induced diarrhea; blind loop
syndrome
Short bowel syndrome
Gluten enteropathy
Crohns disease
Dissacharidase deficiency
Radiation damage
Abetalipoproteinemia
Obstruction of lymph flow
Protein-calorie malnutrition
Hypermetabolic state
Burns
Trauma
Surgery
Fever
Intestinal surgery
Preparation for hemorrhoidectomy
Preparation for instestinal surgery
Transition from total parenteral
nutrition to conventional foods
Renal failure
Hepatic failure
Inborn errors of metabolism

Characteristic of tube feeding and preparation

Tube feeding may be prepared from liquid foods using calculated formulas, from commercial preparations,
or from regular or natural foods liquefied in a homogenizer or blender, and thus, called blenderized feeding. A
satisfactory tube feeding must be nutritionally adequate, except for prescribed modifications for specific
nutrients. It must be inexpensive, easily prepared, and stored. It should be well tolerated by the patient with no
reaction in the gastrointestinal tract to cause flatulence, diarrhea, vomiting, etc. The mixture should pass the
2mm tube with relative ease. The prepared dilution is 1kcal/ml. the total volume should not exceed 2300 ml/day
or 100ml/hr.
Choosing tube feeding preparation
physical properties the physical properties to be considered in tubefeeding formulas are osmolality,
renal solute load, residue and viscosity.
The osmolality involves the concentration of solute per unit of solvent and is measured in terms of
milliosmoles per kilogram of water (mOsm/kg). The osmolality is the measure of the ability of a solution to lose
or draw water through a semi-permeable membrane. A formulas with high osmolality, administered quickly, will
draw fluid in to intestine and may result in cramps, nausea, vomiting or diarrhea. Osmolality is a critical factor
for individual who had gastric surgery, and those using jejunostomy feeding tubes. Osmolality may not be a
problem if the formula is administered slowly or by a constant drip. Generally, the lower the osmolality of the
formula, the more rapidly it can be infused.
A well balanced diet of natural foodstuff has an osmolality of approximately 600 mOsm/kg of water
compared woth serum which is approximately 300 mOsm/kg of water. The osmolality of tubefeedings is
increased by the presence of free amino-acids, monosaccharides, disaccharides and electrolytes. Fats whole
protein and starches are less osmotically active.
The renal solute load (RSL) refers to the amount of urea, sodium, potassium and chloride in the urine. If
the renal solute load is especially high, a large quantity of water must be provided to excrete it. If this water is
not given, the patient will become dehydrate. Patients receiving formulas with a high RSL must monitored
carefully for signs of dehydration especially infants, those with impaired renal concentration ability and those
with increased fluid losses from vomiting diarrhea, burns and fever.
The terms residue pertains to the amount of bulk remaining in the intestinal tract following digestion,
especially the undigested and unabsorbed component if food. A reduction or absence of residue remaining in the
intestine is desirable in some preoperative and postoperative patients, for patients with gastrointestinal
disorders such as Crohns diseased or colitis, and for patients in transition between intravenous and tube

Viscosity refers to be resistance of a fluid to flow. Formulas containing larger molecules, such as whole
protein compared to amino acids, and formulas that have a higher caloric content per unit volume tent to
be more viscous. The viscosity of the formula and the caliber of the tube must be compatible. More viscous
formulas require a larger tube which is also generally less comfortable for patients. in tube feeding; both
the quantity and type of ingredients must be considered in relation to patients specific needs.
Nutrient contribution. Caloric density considers the energy value of the food in relation to volume.
Most tubfeeding yield 1 kcal/ml, but 1.5 and 2.0 kcal/ml formulas are available. These are useful for
patients with high caloric needs and limited appetites or volume tolerance. The more calorically dense
formulas also have high osmolarity and high RSL. Precautions must be taken to prevent dehydration and
the patient must be monitored carefully.
Carbohydrates may come from many sources including, fruits, cereals, vegetables, corn syrup, glucose,
sucrose, lactose, oligosaccharides and dextrins. Cornstarch , maltodextrins and oligosaccharides
saccharides have been used to provide carbohydrate while minimizing formulas osmolality and sweetness.
For patients who develop lactose intolerance, lactose free formulas are used.
Dietary fiber is present is formulas containing fruits, vegetables and cereals. Dietary fiber can be
increased by adding banana flakes, applesauce, pureed fruits or tender leafy vegetables and are beneficial
for patients with diarrhea and constipation.
Protein may be supplied in formulas as whole protein, hydrolyzed protein, or as free amino acids. A
formulas low in protein is administered to individuals with renal or hepatic impairment. A high protein
formula may be indicated for individuals who are manourished, for septic or pre and post-surgical cases or
for those who have experienced trauma. Individuals receiving high-protein formulas, particularly those who
are unconscious, who cannot communicate thirst, should be monitored for adequate water intake and fluid
and electrolyte balance.
Fat adds calories to formulas. It is generally provided in the form of vegetables oils, which contain glycerol
and long chain fatty acids and are called long chain triglycerides(LCT). If fat malabsorption is present, a
formula low in fat, or one that contains medium chain triglycerides (MCT) in place of long chain fatty acids
is indicated. LCT does not add to formula osmolality. Formulas containing MCT must contain some LCT to
provide the required essential fatty acids.
Vitamins, Minerals and Trace Elements: these nutrients are generally provided in commercial formulas
in amounts to meet recommended dietary allowances. Certain individuals with malabsorption or for those
under stress may be getting inadequate amounts of these nutrients and should be monitored and

Cost and Preparation Time

House blenderized formulas prepared from regular foods permit flexibility in meeting needs, are
relatively inexpensive, and are more psychologically acceptable since the formula can be perceived as
regular food.
In preparing tube feeding it is advisable to observe the following:
1. Use enough liquid for better blending and liquefying (see recommended dilutions in Table 12.5)
2. Plains pasteurized milk is not recommended because the butterfat tends to clump the blender. Use
homogenized milk instead.
3. Avoid coarse, fibrous foods that tent to clog the blender. Use low-fiber fruits and vegetables, strain
after blending.
4. For convenience, baby foods in bottles may be used.
5. Keep prepared blended foods refrigerated until use. Discard formulas after 24 hours.
To prevent bacterial contamination during preparation, the following will be most useful:
6. Use feeding containers that are closed to reduce the risk of airborne organism contamination.
7. Never add new formulas to old ones.
8. Extension tubing administration set and bag should be changed daily.
9. Prepared formulas should be refrigerated if not used immediately.
10.Feeding formulas should not be allowed to hang for longer than 8-hours.
Tube feeding should not be warmed before use. A chilled or cold formulas can be fed without problems
if administered slowly. Heating the mixture may result in destruction of water-soluble vitamins,
coagulation of protein, clogging of nasogastric tubes and coagulation of the formula.
Intervals of Feeding and Administration
Tube feeding may be given as continuous drip or at intervals throughout the day. The feeding
regimen should be adjusted to the patients condition, nutritive and dietary prescription by the
doctor. To initiate tube-feeding, use dilute mixture at first about half to concentration. Try 50 ml of
the mixture at hourly intervals, then gradually increased the concentration and volume until the
patients can tolerate 2000ml at 2-3 hours intervals. Do not exceed over 300ml of feeding of 3 to
4hour intervals. However, if pumps are used, formula need to be diluted.
For the continuous drip method, the flow of the tubefeeding should be very slow at first, then,
increased gradually but kept in constant, steady rate. Total volume should not exceed 100 ml per
hour. Additional water should be given as needed to meet fluid requirements. As patients condition
improves and whether possible, food should be given orally. Again, small amount of liquid food is
gradually introduced, increasing the volume and consistency, until part of the days feeding is by

Bolus feeding refers to rapid installation of feeding into the GI tract by syringe or funnel. The majority
of patients seldom tolerated this method. Patients on enteral feeding may experience complication as a
result of the formula, its administration or handling. Table 12.6 gives a list of potential complication and
suggestion for resolving these complications.
Table 12.6. Enteral Feeding Complications and Suggestion for Solution
Complication
Diarrhea

Aspiration

Clogged Tubes

Constipation

Suggestion for Resolving Problem

Assess the administration of the enteral formula. Formula should be
administered at room temperature. Assess the volume of the bolus feedings,
drip rate of the drip feeding, and the number of ccs per hour for pump
administration.
Assess handling technique of the formula, tubing, addition of medications
and fluids. Is there a possibility of contamination ? Could medication be the
cause of the diarrhea ( antibiotics, stool softeners, laxatives or other
medications that may cause diarrhea)?
Assess for fever, potential of flu or other illness. Consider a stool sample to
assess for clostridium difficile toxin.
Assess for lactose intolerance
If diarrhea is severe, consider holding tube feeding for 12 hrs giving only
clear liquids.
Assess osmolality of the feeding
Consider a fiber containing formula to increase bulk of the stool
If diarrhea continues, request an antidiarrheal medication and refer to
physician
Head of bed should be elevated to 30-45 degrees to avoid aspiration
Gastric residuals should be checked prior to feeding
Enteral feedings should be held if gastric residuals are greater than 100150cc, or per physicians order.
Enteral tube replacement should be checked if aspiration is suspected
Consider post pyloric placement of tube if aspiration is a reoccuring problem
Flush tube with 50-1150cc of fluid before and after administration of formula
or addition of medications
Avoid the use of juice, carbonated beverages or sugary fluids to flush the
tube
Avoid use of crushed medications
Liquid medications may contain sorbital, which may clog tubes
Provide adequate fluids

Abdominal
Distention
Nausea/Vomiting

Contamination of
Formula

Assess volume of formula administered for a short time

Assess possibility of lactose intolerance if client is receiving lactose
containing formula
Assess for intolerance to fiber containing formula of appropriate
Consider holding feeding for 12 hours or until excessive vomiting passes
Check residual and tube placement
Assess volume of feeding administered for a short time
Consider anti-nauseant, or anti-emetic or anti-gas medication
A change in formula may be necessary. Assess for elemental formula. Refer
to physician
Closed systems are ideal for avoiding potential contamination. They can
hang for up to 24-48 hours (see manufacturers information for details)
Avoid addition of liquids, medications or new formula in a bag that has
been hanging for a period of time
If open systems are used, formula should not hang more than 4-8 hrs or
according to manufacturer. If enteral bags are filled by nursing staff do not
allow nursing to add new formula to old formula (topping off the bag).
Always clean tops of cans before opening
Clean poles and surrounding areas often
Discard unused formula
Use sanitary techniques for mixing and administering formula.

Parenteral Feeding
Pre-surgical and post-surgical feedings are given in a variety of ways that
should be specific to each individual depending on the factors like the patients
nutritional status, ability to swallow, level of digestion and absorption, presence of
nausea, vomiting, anorexia and location of surgery, etc.
The oral route is always preferred, but if the patients cannot tolerate normal
eating, parenteral feeding is the alternative solutions. Parenteral feeding is a means
of providing the nutrients by routes other than the mouth and digestive tract, such
as subcutaneous, intramuscular or intravenous feeding.
Parenteral feeding can used in addition to enteral feedings or used alone. If
parenteral feeding is the main source if nutrition, other nutrients have to be given
via the small veins, usually in the arm ( peripheral, parenteral nutrition of PPN), or
centrally into the superior or inferior vena cava or the jugular vein. (centralparenteral nutrition or CPN) is also called total parenteral nutrition (TPN) or
intravenous hyperalimentation (IVH). The decision to use PPN or CPN is based on
the number of calories needed and the osmolality of the solution. TPN solutions are
Diet Therapy for Specific Surgical Conditions
best prepared by the experts such as a pharmacist pr in industrial laboratories. A
physician trained in this area prescribe and guides the use of TPN.
The main objective of dietary modification on specific surgical conditions ( such as
tonsillectomy, colostomy, rectal surgery, gastric resection, etc. ) is to rest the organ
involved and avoid irritation at the site of the resection. It also promotes rapid wound
healing and replaces nutrient losses.

Tonsillectomy and Adenectomy

The first day after the surgery, start with ice chips or sips of cold water progressing with plain
gelatin, cold milk and non-irritating fruit juices. Avoid milk products only if patient cannot tolerate them.
The second day, cold liquids, gelatin, ice creams and popsicles are added. Chocolate products and red
colored beverages (including red gelatin) are not given because they may mask bleeding. On the third and
the fourth day, strained warm cream soups, fruits and vegetable purees, strained warm cereals, milk,
cheese, butter, rice porridge (lugao) and mashed potatoes are added to the cold liquid diet. This diet is
inadequate in all nutrients and is usually ordered for only one or two days following surgery. It is low in
iron, thiamin, ascorbic acid and folic acid. After the fourth day a soft to light diet is prescribed according
to individual tolerance. The patients should be able to resume a normal diet after a week, some as early as
the 6th day. Adequate daily fluid intake ( 3 L for adults and 2 L for children per day ) is important. Avoid hot,
spicy foods, raw vegetables, toast and crackers, citrus fruits and other related foods until full recovery.
Surgery in the Mouth, Neck and Esophagus
After the surgery in the mouth, neck and esophagus, the patient has difficulty in chewing and or
swallowing. Tube feeding is therefore required. Parenteral feedings may be indefinitely prolonged if surgery
is extensive or major. As the patients condition improves, tube feedings become supplemental and oral
feeding gradually initiated progressing from clear to full liquids, then soft to light and finally to regular
diets.
Gastric Surgery as Gastrectomy
A partial gastric resection poses less dietary problems compared to a total gastrectomy.
Removal of the stomach in part or as a whole reduces not only the reservoir of food but production of
pepsin and HCL, resulting in reduced protein digestion. Intestinal motility is increased and there is
defective mixing of food woth the intestinal juices. Fat digestion is also impaired due to reduced biliary
and pancreatic juices, and insufficient mixing of enzymes with the food. Lack of HCL and the intrinsic
factor found in the stomach leads to reduced utilization of iron and vitamin B12, 50% of patients often lose
weight after gastric surgery.
After surgery, the diet will generally progress as follows:
1. Ice help in mouth or small sips of water. Some patient tolerate warm water better than ice or cold
water.
2. Increase in amounts of fluid given
3. Bland foods/solid foods as tolerated

The guidelines must be tailored to each patients needs such as surgery, food tolerances and
intolerances and nutritional problems and deficiencies:
1. Diet should be low in simple carbohydrate but should be high in complex carbohydrates, high
in protein and moderate in fat.
2. Liquids should be given 30-60minutes after each meal.
3. Small frequent feeding should be given , the number of which depends on the patients
tolerance to specific portions of food.
4. Small amount of milk of milk maybe tolerated than large amounts . If there is milk
intolerance ,lactose free products maybe used.
5. Foods should be eaten slowly and chewed well.
6. If there is steatorrhea, use of medium chain triglycerides and MCT oil may be indicated.
7. If dumping is a problem, it may help to lie down immediately after meals to retard transit
to the small bowel.
8. The dietary fiber pectin, found in fruits and vegetables, may be helpful in the treatment of
dumping syndrome. Pectin delays gastric emptying time reduces the glycemic response and
slows down carbohydrate absorption.
9. All food and drink should be moderate in temperature. Cold drinks tend to cause increased
gastric activity.
Dumping Syndrome
Individuals who have had gastrectomy may experience the dumping syndrome characterized
be nausea, weakness, syncope and diarrhea. This happens when the stomach contents are
emptied into the jejunum at an abnormally fast rate. The guidelines of the post-gastrectomy
diet for dumping syndrome ( especially in cases of total gastrectomy ) are follows:
10.Small frequent feeding 5-6 times per day
11.Restricted liquid or a dry diet. Avoid fluid at least one hour before and after a meal.
12.Low fiber low residue diet ( avoid milk, raw fruits and vegetables high in fiber)
13.Low carbohydrates to prevent dumping of readily utilized carbohydrates in the jejunum. This
causes disruption in the water balance leading to the withdrawal of fluid from the blood to
the intestine.

Ostomies
An ostomy is the surgical procedure of creating an opening of the stomach
wall of the abdomen. It is a procedure that brings movement of the GI tract usually
intestinal to the skin surface. The main purpose is to evacuate stools or move the
bowels when the normal route via the colon, rectum and anus is not medically
allowed. Immediately after the surgery, IV feeding is given for 2 to 3 days until
bowel sounds return.
Start with clear liquid diet and progress gradually to one low in residue.
Then give a soft or low fiber diet as tolerated. Gradually introduce fiber as
tolerated. Avoid tough skin from fruits and vegetables and other foods that may
cause stoma obstruction. Take plenty of fluids ( at least 8 to 10 cups per day )
especially of the ostomy output is excessive. When steatorrhea occurs, restrict fat
and use MCT oil. A liberal supply of calories and protein ( at least 1.5 times the
recommended nutrient intakes) will speed up recovery and prevent weight loss.
In all cases, small frequent feedings are recommended. In ileostomy, MCT
diet (medium chain triglycerides) is prescribe and fat soluble vitamins ADEK are
supplemented. If there is increased fluid loss, both water intake and electrolytes
are replenished.
Rectal Surgery
This condition refers to any operation done the rectum, as in rectal cancer or
hemorrhoidectomy. A clear liquid diet is given within the first 24 hours after the
operation, followed by a non-residue diet. In hemorrhoidectomy, diet is progressed
from clear to full liquid omitting milk, then a low-residue diet until wound has
healed and the patient can tolerate the regular diet. The use of mineral oil for a
few days, helps, but should not be prolonged since mineral oils interfere with the
utilization of fat soluble vitamins and some minerals. Some physician prescribe a

Fractures and other Mechanical Trauma

Current studies indicate that a unique metabolic reaction is triggered by

trauma and stress. This condition is sometimes called a hyper-metabolic state.
Shock, multiple fractures, major burns, anesthesia and major surgery are some of
these cases when patients could be in hyper-metabolic states.
Diet should be quite high in calories, proteins and fluids. Traumatic injury
would need 35-40 kcal/kg body weight per day. An example of a diet prescription
is 3000 kcal and 120 g protein. Vitamin and mineral supplementation is required,
particularly calcium, phosphorus and magnesium (for calcification), vitamin D (for
efficient utilization of the mineral) and vitamin C (for intercellular cementing
substance.
Burns

Burns refer to tissue injury or destruction caused by excessive heat, caustics

(acid or alkalis), friction, electricity or radiation. Treatment involves relief of pain
and shock, prevention of infection, actual care for the thermal injuries and plastic
surgery later as needed. In cases of serious burns, the loss of skin surface leads to
enormous losses of fluid, electrolytes and proteins. Water moves from other
tissues to the burn site in an effort to compensate for the loss, which only
compound the problem. This fluid loss can reduce the blood volume and thus
blood pressure, as well as urine output.
Fluids and electrolytes are replaced by intravenous therapy immediately to
prevent shock. Glucose is not included in these fluids for the first 2 or 3 days after
the burn because it could cause hyperglycemia.

Wound healing
Wound is a physical injury to the body tissues disrupting the normal
continuity of structure. Wound healing involves tissue synthesis and occurs in
two phases. Initial wound healing occurs readily during a period of negative
energy balance; subsequent healing occurs between the fifteenth day after
surgery or trauma.
Diet therapy. Increased protein of 1.2-2.0 g/kg body weight is required to
promote wound healing and preserve tissue integrity. Sufficient energy about 2535 kcal/kg body weight is considered necessary to meet metabolic needs and to
prevent protein from being utilized as fuel. Zinc, vitamin A and vitamin C are also
necessary for continued wound healing. Other nutrients required in wound
healing include arginine, magnesium, and selenium. In general, all nutrients
related to immune function are needed to hasten wound healing. The provision of
sufficient fluid is also necessary. Adjunctive enteral support may be necessary to
facilitate wound healing, particularly when oral intake is suboptimal.