Surgery

Clinical Nutrition 28 (2009) 378–386

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Clinical Nutrition
journal homepage: http://www.elsevier.com/locate/clnu

ESPEN Guidelines on Parenteral Nutrition: Surgery
M. Braga a, O. Ljungqvist b, P. Soeters c, K. Fearon d, A. Weimann e, F. Bozzetti f
a

Department of Surgery, San Raffaele University, Milan, Italy Division of Surgery, KarolinskaInstitutet, Stockholm, Sweden c Department of Surgery, Academic Hospital Maastricht, The Netherlands d Professor of Surgical Oncology, University of Edinburgh, Scotland, UK e Department of General Surgery, Klinikum St. Georg, Leipzig, Germany f Department of Surgery, General Hospital Prato, Italy
b

a r t i c l e i n f o
Article history: Received 4 February 2009 Accepted 1 April 2009 KeywordsParenteral nutrition Energy Lipid Protein Amino acids

s u m m a r y
In modern surgical practice it is advisable to manage patients within an enhanced recovery protocol and thereby have them eating normal food within 1–3 days. Consequently, there is little room for routine perioperative artificial nutrition. Only a minority of patients may benefit from such therapy. These are predominantly patientswho are at risk of developing complications after surgery. The main goals of perioperative nutritional support are to minimize negative protein balance by avoiding starvation, with the purpose of maintaining muscle, immune, and cognitive function and to enhance postoperative recovery. Several studies have demonstrated that 7–10 days of preoperative parenteral nutrition improves postoperativeoutcome in patients with severe undernutrition who cannot be adequately orally or enterally fed. Conversely, its use in well-nourished or mildly undernourished patients is associated with either no benefit or with increased morbidity. Postoperative parenteral nutrition is recommended in patients who cannot meet their caloric requirements within 7–10 days orally or enterally. In patients who requirepostoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice. The main consideration when administering fat and carbohydrates in parenteral nutrition is not to overfeed the patient. The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements. Underconditions of severe stress requirements may approach 30 kcal/kg ideal body weights. In those patients who are unable to be fed via the enteral route after surgery, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basis. Ó 2009 European Society for Clinical Nutrition and Metabolism. All rights reserved.Preliminary remarks In modern surgical practice it is advisable to manage patients within an enhanced recohave them eating normal food within 1–3 days. Consequently, there is little room for routine perioperative artificial nutrition. Only a minority of patients may benefit from such therapy. These are predominantly patients who are at risk of developing complications after surgery, namely patientswho have suffered substantial weight loss, have very low body mass index (BMI) (under 18.5–22 kg/m2 depending on age) or exhibit inflammatory activity. Once patients have developed infectious complications artificial nutritional support is generally required. It is difficult, if not ethically unacceptable, to randomize this subgroup into those that do or do not receive nutritional support.
E-mailaddress: espenjournals@espen.org.

The main goals of perioperative nutritional support are to minimize negative protein balance by avoiding starvation, with the purpose of maintaining muscle, immune, and cognitive function and to enhance postoperative recovery. Energy substrates can be given either by the enteral or parenteral route. Several studies1–24 have suggested a better outcome when at...