ESPEN指南：外科临床营养.doc

ESPEN指南：外科临床营养
早期经口喂养是手术患者营养的首选方式。营养疗法可避免大手术后喂养不足的风险。考虑到营养不良和喂养不足是术后并发症的风险因素，早期肠内喂养对于任何有营养风险的手术患者尤为重要，特别是那些进行上消化道手术的患者。该指南的重点是涵盖术后加速康复外科（ERAS）概念和进行大手术患者的特殊营养需求，例如癌症，虽然提供最佳围手术期医疗，但是仍然出现严重并发症。从代谢和营养角度而言，围手术期治疗重点包括：
· 将营养整合入患者整体管理
· 避免长时间术前禁食
· 术后尽早重新建立经口喂养
· 一旦营养风险变得明显，早期开始营养疗法
· 代谢控制，例如血糖
· 减少加重应激相关分解代谢或影响胃肠功能的因素
· 缩短用于术后呼吸机管理的麻醉药物使用时间
· 早期活动以促进蛋白质合成和肌肉功能恢复
缩写
· BM：生物医学终点
· GPP：良好实践要点。根据指南制定小组临床经验推荐的最佳实践方法。
· HE：医疗卫生经济终点
· IE：整合传统终点与患者报告终点
· QL：生活质量
· TF：管饲
该指南共提出37项临床实践推荐意见：
1. 对大多数患者从午夜开始术前禁食是不必要的。被认为无任何误吸风险的手术患者在麻醉前两个小时应喝清流质。麻醉前六小时前应允许进食固体食物（BM、IE、QL）。推荐等级：A，高度共识（97%同意）
2. 为了减少围术期不适症状包括焦虑，前一天晚上和术前两小时应给予经口进食碳水化合物处理（而非夜间禁食）（B，QL）。为改善术后胰岛素抵抗和缩短住院时间，对大手术患者可考虑术前使用碳水化合物（0，BM、HE）。推荐等级：A/B，高度共识（100%同意）在完成过程中由工作小组根据最新荟萃分析下调等级（工作小组内成员100%同意）
3. 一般情况下，术后经口营养摄入应持续不中断（BM、IE）。推荐等级：A，高度共识（90%同意）
4. 建议根据个人耐受性和实施的手术类型来调整经口摄入，特别关注老年患者。推荐等级：GPP，高度共识（100%同意）
5. 大多数患者应在术后数小时内开始经口进食清流质推荐等级：A，高度共识（100%同意）
6. 建议在大手术前后评定营养状况。推荐等级：GPP，高度共识（100%同意）
7. 营养不良患者和存在营养风险的患者有指征进行围手术期营养疗法。如果预计患者在围手术期不能进食超过5天，也应启动围手术期营养疗法。预计患者经口摄入少，不能维持推荐摄入量的50%以上超过7天也是指征。在这些情况下，建议立即给予营养疗法（首选肠内途径ONS或TF）。推荐等级：GPP，高度共识（92%同意）
8. 如果能量和营养需求不能仅通过经口和肠道摄入满足（＜能量需求的50%）超过7天，建议肠内联合肠外营养（GPP）。如果有营养疗法指征，但有肠内营养禁忌证如肠梗阻（A应尽快给予肠外营养（BM）。推荐等级：GPP/A，高度共识（100%同意）
9. 对使用肠外营养，应首选全合一（三腔袋或药房配制），而非多瓶输注系统（BM、HE）。推荐等级：B，高度共识（100%同意）
10. 推荐按标准化操作流程（SOP）进行营养支持，以确保有效的营养支持疗法。推荐等级：GPP，高度共识（100%同意）
11. 对因肠内喂养不足而需要专用PN的患者可考虑静脉补充谷氨酰胺（0，BM、HE）。推荐等级B，共识（76%同意），在完成过程中由工作小组根据最近的PRCT下调等级（工作小组内成员100%同意）
12. 仅对因肠内喂养不足而需要肠外营养的患者应考虑术后肠外营养包括使用ω-3脂肪酸（BM、HE）。推荐等级：B，大多数同意（65%同意）
13. 对接受癌症大手术营养不良的患者应在围手术期或至少术后使用富含免疫营养素（精氨酸、ω-3脂肪酸、核苷酸）的特定配方（B，BM、HE）。目前没有明确的证据表明在围手术期使用这些富含免疫营养素的配方优于标准的口服营养补充剂。推荐等级：B/0，共识（89%同意）
14. 有严重营养风险的患者应在大手术前接受营养疗法（A），即使手术，包括那些癌症，必须推迟（BM）。这个时间为7～14天是合适的。推荐等级：A/0，高度共识（95%同意）
15. 只要可行，应首选经口/肠内途径（A，BM、HE、QL）。推荐等级：A，高度共识（100%同意）
16. 当患者从正常的食物中获取的能量不能满足需求，建议鼓励这些患者术前采取口服营养补充剂，不管他们的营养状况如何。推荐等级：GPP，共识（86%同意）
17. 术前应对所有营养不良的癌症患者和进行腹部大手术的高风险患者给予口服营养补充剂（BM、HE）。患肌肉减少症的老年人是一群特殊的高风险患者。推荐等级：A，高度共识（97%同意）
18. 免疫调节型口服营养补充剂包括精氨酸、ω-3脂肪酸和核苷酸可首选（0，BM、HE），术前使用5～7天（GPP）。推荐等级：0/GPP，大多数同意，64%同意
19. 术前肠内营养/口服营养补充剂应在入院前使用，以避免不必要的住院治疗和降低院内感染的风险（BM、HE、QL）。推荐等级：GPP，高度共识（91%同意）
20. 术前PN只用于营养不良患者或存在严重营养风险而能量需求不能通过EN完全满足的患者（A，BM）。建议使用7～14天。推荐等级：A/0，高度共识（100%同意）
21. 对不能早期开始经口营养摄入、经口摄入不足（＜50%）超过7天的患者应尽早启动TF（24小时内）。特别高风险人群包括：接受头颈部或胃肠癌症大手术的患者（A，BM）严重创伤包括颅脑损伤的患者（A，BM）手术时有明显营养不良的患者（A，BM，GPP）推荐等级：A/GPP，高度共识（97%同意）
22. 对大多数患者，标准整蛋白配方是合适的。为避免因技术原因堵管和感染风险，一般不建议使用厨房制备的膳食（匀浆膳）进行TF。推荐等级：GPP，高度共识（94%同意）
23. 至于营养不良患者的特殊方面，对所有接受上消化道和胰腺大手术患者进行TF应考虑放置鼻空肠管（NJ）或行针刺导管空肠造口术（NCJ，BM）。推荐等级：B，高度共识（95%同意）
24. 如有TF指征，应在术后24小时内启动（BM）。推荐等级：A，高度共识（91%同意）
25. 建议以较慢的输注速率开始TF（如10～最大20ml/h），由于肠道耐受性有限，增加输注速率要谨慎、个体化。达到目标摄入量的时间差别会很大，可能需要5～7天。推荐等级：GPP，共识（85同意）
26. 如果必须长期TF（＞4周），如重症颅脑损伤，建议经皮置管（如经皮内镜下胃造口—PEG）。推荐等级：GPP，高度共识（94%同意）
27. 如必要，在住院期间定期评定营养状况，建议围手术期接受营养疗法和通过经口途径仍不能满足能量需求的患者出院后继续营养疗法包括合理的膳食指导。推荐等级：GPP，高度共识（97%同意）
28. 营养不良是影响移植后预后的主要因素，因此建议对营养状况进行监测。对营养不良患者，建议给予额外的口服营养补充剂甚至TF。推荐等级：GPP，高度共识（100%同意）
29. 在对等待移植的患者进行监测时，必须定期评定营养状况和给予合理的膳食指导建议。推荐等级：GPP，高度共识（100%同意）
30. 对活体供者和受者的推荐意见与腹部大手术患者相同。推荐等级：GPP，高度共识（97%同意）
31. 心脏、肺、肝、胰、肾移植术后，建议在24小时内尽早摄入正常食物或进行肠内营养。推荐等级：GPP，高度共识（100%同意）
32. 即使在小肠移植后，肠内营养也可尽早启动，但在第一周内加量应非常小心。推荐等级：GPP，高度共识（93%同意）
33. 必要时应肠内联合肠外营养。建议对所有移植患者进行长期营养监测和合理的膳食指导。推荐等级：GPP，高度共识（100%同意）
34. 减肥手术后建议早期经口摄入。推荐等级：0，高度共识（100%同意）
35. 简单的减肥手术不需要肠外营养。推荐等级：0，高度共识（100%同意）
36. 万一出现较大并发症需要再次开腹手术，可考虑使用鼻空肠管/针刺导管空肠造口术。推荐等级：0，共识（87%同意）
37. 更多的推荐意见与那些接受腹部大手术的患者相同。推荐等级：0，高度共识（94%同意）
Clin Nutr. 2017 Jun;36(3):623-650.

ESPEN guideline: Clinical nutrition in surgery.

Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale R, Waitzberg DL, Bischoff SC, Singer P.

Klinikum St. Georg, Leipzig, Germany; San Raffaele Hospital, Milan, Italy; McGill University, Montreal General Hospital, Montreal, Canada; Fujita Health University, Toyoake, Aichi, Japan; Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland; Stanley Dudrick's Memorial Hospital, Skawina, Krakau, Poland; Universita "La Sapienza" Roma, Roma, Italy; Orebro University, Orebro, Sweden; Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK; Oregon Health & Science University, Portland, OR, USA; University of Sao Paulo, Sao Paulo, Brazil; Universitat Hohenheim, Stuttgart, Germany; Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include:

· integration of nutrition into the overall management of the patient
· avoidance of long periods of preoperative fasting
· re-establishment of oral feeding as early as possible after surgery
· start of nutritional therapy early, as soon as a nutritional risk becomes apparent
· metabolic control e.g. of blood glucose
· reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function
· minimized time on paralytic agents for ventilator management in the postoperative period
· early mobilisation to facilitate protein synthesis and muscle function The guideline presents 37 recommendations for clinical practice.

BM: biomedical endpoints
GPP: Good practice points. Recommended best practice based on the clinical experience of the guideline development group
HE: health care economy endpoint
IE: integration of classical and patient-reported endpoints
QL: quality of life
TF: tube feeding

1. Preoperative fasting from midnight is unnecessary in most patients. Patients undergoing surgery, who are considered to have no specific risk of aspiration, shall drink clear fluids until two hours before anaesthesia. Solids shall be allowed until six hours before anaesthesia (BM, IE, QL). Grade of recommendation A - strong consensus (97% agreement)
2. In order to reduce perioperative discomfort including anxiety oral preoperative carbohydrate treatment (instead of overnight fasting) the night before and two hours before surgery should be administered (B) (QL). To impact postoperative insulin resistance and hospital length of stay, preoperative carbohydrates can be considered in patients undergoing major surgery (0) (BM, HE). Consensus Conference: Grade of recommendation A/B - strong consensus (100% agreement)- downgraded by the working group during the finalization process according to the very recent meta-analysis (with 100% agreement within the working group members)
3. In general, oral nutritional intake shall be continued after surgery without interruption (BM, IE). Grade of recommendation A - strong consensus (90% agreement)
4. It is recommended to adapt oral intake according to individual tolerance and to the type of surgery carried out with special caution to elderly patients. Grade of recommendation GPP - strong consensus (100% agreement)
5. Oral intake, including clear liquids, shall be initiated within hours after surgery in most patients. Grade of recommendation A - strong consensus (100% agreement)
6. It is recommended to assess the nutritional status before and after major surgery. Grade of recommendation GPP - strong consensus (100% agreement)
7. Perioperative nutritional therapy is indicated in patients with malnutrition and those at nutritional risk. Perioperative nutritional therapy should also be initiated, if it is anticipated that the patient will be unable to eat for more than five days perioperatively. It is also indicated in patients expected to have low oral intake and who cannot maintain above 50% of recommended intake for more than seven days. In these situations, it is recommended to initiate nutritional therapy (preferably by the enteral route - ONS-TF) without delay. Grade of recommendation GPP - strong consensus (92% agreement)
8. If the energy and nutrient requirements cannot be met by oral and enteral intake alone (<50% of caloric requirement) for more than seven days, a combination of enteral and parenteral nutrition is recommended (GPP). Parenteral nutrition shall be administered as soon as possible if nutrition therapy is indicated and there is a contraindication for enteral nutrition, such as in intestinal obstruction (A) (BM). Grade of recommendation GPP/A - strong consensus (100% agreement)
9. For administration of parenteral nutrition an all-in-one (three-chamber bag or pharmacy prepared) should be preferred instead of multibottle system (BM, HE). Grade of recommendation B - strong consensus (100% agreement)
10. Standardised operating procedures (SOP) for nutritional support are recommended to secure an effective nutritional support therapy. Grade of recommendation GPP - strong consensus (100% agreement)
11. Parenteral glutamine supplementation may be considered in patients who cannot be fed adequately enterally and, therefore, require exclusive PN (0) (BM, HE). Consensus Conference: Grade of recommendation B - consensus (76% agreement) - downgraded by the working group during the finalization process according to the recent PRCT (with 100% agreement within the working group members).
12. Postoperative parenteral nutrition including omega-3-fatty acids should be considered only in patients who cannot be adequately fed enterally and, therefore, require parenteral nutrition (BM, HE). Grade of recommendation B - majority agreement (65% agreement)
13. Peri- or at least postoperative administration of specific formula enriched with immunonutrients (arginine, omega-3-fatty acids, ribonucleotides) should be given in malnourished patients undergoing major cancer surgery (B) (BM, HE). There is currently no clear evidence for the use of these formulae enriched with immunonutrients vs. standard oral nutritional supplements exclusively in the preoperative period. Grade of recommendation B/0 - consensus (89 agreement)
14. Patients with severe nutritional risk shall receive nutritional therapy prior to major surgery (A) even if operations including those for cancer have to be delayed (BM). A period of 7-14 days may be appropriate. Grade of recommendation A/0 - strong consensus (95% agreement)
15. Whenever feasible, the oral/enteral route shall be preferred (A) (BM, HE, QL). Grade of recommendation A - strong consensus (100% agreement)
16. When patients do not meet their energy needs from normal food it is recommended to encourage these patients to take oral nutritional supplements during the preoperative period unrelated to their nutritional status. Grade of recommendation GPP - consensus (86% agreement)
17. Preoperatively, oral nutritional supplements shall be given to all malnourished cancer and high-risk patients undergoing major abdominal surgery (BM, HE). A special group of high-risk patients are the elderly people with sarcopenia. Grade of recommendation A - strong consensus (97% agreement)
18. Immune modulating oral nutritional supplements including arginine, omega-3 fatty acids and nucleotides can be preferred (0) (BM, HE) and administered for five to seven days preoperatively (GPP). Grade of recommendation 0/GPP - majority agreement, 64% agreement
19. Preoperative enteral nutrition/oral nutritional supplements should preferably be administered prior to hospital admission to avoid unnecessary hospitalization and to lower the risk of nosocomial infections (BM, HE, QL). Grade of recommendation GPP - strong consensus (91% agreement)
20. Preoperative PN shall be administered only in patients with malnutrition or severe nutritional risk where energy requirement cannot be adequately met by EN (A) (BM). A period of 7-14 days is recommended. Grade of recommendation A/0 - strong consensus (100% agreement)
21. Early tube feeding (within 24 h) shall be initiated in patients in whom early oral nutrition cannot be started, and in whom oral intake will be inadequate (<50%) for more than 7 days. Special risk groups are: patients undergoing major head and neck or gastrointestinal surgery for cancer (A) (BM) patients with severe trauma including brain injury (A) (BM) patients with obvious malnutrition at the time of surgery (A) (BM) (GPP). Grade of recommendation A/GPP - strong consensus (97% agreement)
22. In most patients, a standard whole protein formula is appropriate. For technical reasons with tube clotgging and the risk of infection the use of kitchen-made (blenderized) diets for tube feeding is not recommended in general. Grade of recommendation GPP - strong consensus (94% agreement)
23. With special regard to malnourished patients, placement of a nasojejunal tube (NJ) or needle catheter jejunostomy (NCJ) should be considered for all candidates for tube feeding undergoing major upper gastrointestinal and pancreatic surgery (BM). Grade of recommendation B - strong consensus (95% agreement)
24. If tube feeding is indicated, it shall be initiated within 24 h after surgery (BM). Grade of recommendation A - strong consensus (91% agreement)
25. It is recommended to start tube feeding with a low flow rate (e.g. 10 - max. 20 ml/h) and to increase the feeding rate carefully and individually due to limited intestinal tolerance. The time to reach the target intake can be very different, and may take five to seven days. Grade of recommendation GPP - consensus (85% agreement)
26. If long term TF (>4 weeks) is necessary, e.g. in severe head injury, placement of a percutaneous tube (e.g. percutaneous endoscopic gastrostomy - PEG) is recommended. Grade of recommendation GPP - strong consensus (94% agreement)
27. Regular reassessment of nutritional status during the stay in hospital and, if necessary, continuation of nutrition therapy including qualified dietary counselling after discharge, is advised for patients who have received nutrition therapy perioperatively and still do not cover appropriately their energy requirements via the oral route. Grade of recommendation GPP - strong consensus (97% agreement)
28. Malnutrition is a major factor influencing outcome after transplantation, so monitoring of the nutritional status is recommended. In malnutrition, additional oral nutritional supplements or even tube feeding is advised. Grade of recommendation GPP - strong consensus (100% agreement)
29. Regular assessment of nutritional status and qualified dietary counselling shall be required while monitoring patients on the wa