The most recent 2017 nutritional recommendations from the European Society of Parenteral and Enteral Nutrition (ESPEN) for surgical patients1 indicates that early oral feeding is the preferred mode of nutrition for surgical patients. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery after Surgery (ERAS) evidence-based surgical treatment protocol. Danone Nutricia Research has played an important role in the development of the ERAS programme and still supports its worldwide rollout.
In the 1990s, Danone Nutricia Research recognised that surgical patients were at risk of malnutrition and that this was associated with poor clinical outcomes after surgery. We started pioneering by studying the effect of oral nutritional supplementation before or after surgery and before and after surgery on clinical outcomes. These published studies with Nutricia’s oral nutritional supplements showed improved recovery of surgical patients by means of fewer complications, reduced hospital stay and increased muscle strength.2,3,4
Later, insights into the metabolic stress of surgical patients taught us that fasting before surgery causes additional metabolic stress in surgery, resulting in increased post-operative insulin resistance, associated with worse clinical outcomes.5,6 Therefore, although fasting before surgery was routine practice in order to have an empty stomach at time of anaesthesia (to prevent risk of vomiting, aspiration and pneumonia), this appeared to not be the optimal way to prepare for surgery.7,8
Together with experts in this field, Danone Nutricia Research developed a breakthrough innovative nutritional solution allowing surgical patients to drink up to two hours before surgery instead of fasting. The product was designed in such a way that it results in an anabolic metabolic response as a result of fasting and will be emptied from the stomach in order to have an empty stomach at the time of anaesthesia. This is contrasting a catabolic response. A metabolic process can be categorized as anabolic or catabolic. With anabolism molecules are built from smaller units. With catabolism macromolecules are detached. Safety and efficacy of this carbohydrate-containing product has been tested by many different experiments and randomised clinical trials, starting with animal studies9, healthy volunteer studies10 and studies in surgical patients11,12. These studies show that pre-operative carbohydrate loading can reduce the post-operative metabolic stress (less insulin resistance)11,13 and improve pre-operative well-being with less post-operative nausea and vomiting14 and reduced hospital stay.15,16
The benefits of oral nutritional supplementation and pre-operative carbohydrate loading have led to recommendations in 2006 by ESPEN17 to use oral nutritional supplements and pre-operative carbohydrate loading for surgical patients.
Around the same time, a group of European surgeons used evidence-based practice to treat surgical patients and developed the ERAS protocol (following the Fast Track protocol developed by Kehlet18, a concept of enhanced recovery after surgery), which also included peri-operative nutritional support19. The efficacy of this ERAS protocol, including the use of Nutricia’s oral nutritional supplements and pre-operative carbohydrate loading, has been studied in many different European hospitals by comparing with traditional care. Meta-analysis of the results show a reduction in rate of complications and hospital length of stay.20
The ERAS Society has published various recommendations also including one for bariatric surgery.21 Danone Nutricia Research is still supporting the ERAS Society via an unrestricted educational grant in order to further roll out evidence-based treatment as best care practice in order to improve the recovery of surgical patients.
“Nutrition should be integrated into the overall management of the patient”
ESPEN guideline: Clinical nutrition in surgery6
