NUTRITIONAL SUPPORT

UPPER GASTRO
INTESTINAL SURGERY
Dr. dr. Agi Satria Putranto, SpB-KBD
Nutritional Support in Surgery
• Nutrition support is recommended when the
nutrition status is so compromised that
patients are at a high risk of complications, or
cannot comply with the oncologic therapy as
reported in the clinical practice ESPEN
guidelines

American Cancer Society. Colorectal Cancer Facts & Figures 2017 - 2019. Atlanta. 2017;1–40.
 Anatomy
Upper gastrointestinal
Oropharynx
Esophagus
Stomach
duodenum
Anatomy
 Prevalence of Malnutrition
• The prevalence of • esophagus and/or
malnutrition by diseases: stomach, 60.2%;
• head and neck, 48.9%; • pancreas, 66.7%;
• leukemia/lymphoma, • breast, 20.5%;
34.0%; • ovaries/uterus, 44.8%;
• lung, 45.3%; • prostate, 13.9%.
• colon/rectum, 39.3%;

Hebuterne et al. Prevalence of Malnutrition and Current Use of Nutrition

Support in Patients With Cancer. Journal of Parenteral and Enteral Nutrition
2014; 38 (2) : 196–204
Introduction
• The end result of advanced diseases of the
upper gastrointestinal tract, whether benign or
malignant, is weight loss, protein-energy
malnutrition, micronutrient deficiencies and
increase LOS.
• Complexity of resections and reconstructions
• Resulting nutritional implications before and
after surgery place the patient at risk for
malnutrition.
Esofagokolojejunostomi
Roux-en-Y
 ERAS
Enhanced Recovery After Surgery (ERAS) is an evidence based
multimodal perioperative protocol focused on stress reduction
and the promotion of a return to function.

ERAS has been proven to lower both recovery time and

postoperative complication rates while being cost-effective at
the same time.
Key components of ERAS protocol
Nutritional support
• Moderate or severe malnourished with
physiological disorders

* Well or mild malnourished ussualy without

physiological disorders
Enhanced Recovery after Surgery
(ERAS) in selective patients
• Preoperative carbohydrate loading (800 ml of a
12.5% carbohydrate drink the night before
surgery and 400 ml the following morning 2 h
prior to induction of anesthesia)
• Reduce the insulin resistance and tissue
glycosylation caused by the surgery, help in
postoperative glucose control, and sustain
normal bowel function 
 A Nutritional risk screening (NRS)
Assessment of Anthropometric Laboratory
nutritional intake measurements measurements
• Nutritional history • Body height • Complete blood
• Subjective Global • Daily weight counts
Assessment • Body mass index • Serum protein
• Mid arm (albumin,
circumference prealbumin)
• Calf • Transferrin, TIBC
circumference • Urinary creatinine
• Skin fold thickness • Serum cholesterol,
triglycerides
• Serum electrolytes
• CRP

Lloyd DAJ, Gabe SM, Windsor ACJ. Nutrition and management of enterocutaneous fistula. Br J Surg . 2006; 93:1045-55
Badrasawi M, Shahar S, Sagap I. Nutritional management in enterocutaneous fistula. What is the evidence? Malays J Med Sci. 2015 Jul-Aug; 22(4):6-16
Malnutrition
Acute, chronic, mixed malnourished

• Option 1: BMI < 18,5

• Option 2 : combined: unplanned weight loss >
10% or >5% over 3 months and reduced BMI or
a low fat free mass index (FFMI)
• preoperative albumin < 3 g/dl, prealbumin,
transferrin, total lymphocyte count
Preoperative nutrition period
• Providing enteral formulas as oral nutritional
supplements (ONS) for 7 - 10 days
decreases wound complications, length of
stay, duration on ventilator, and anastomotic
leaks.
• If oral or EN contraindicated  PN
• Preoperative nutritional supplementation is
obviously not possible for emergency UGI
surgical procedures.
Malnourished patients
• Nasojejunal tube (NJ) or needle catheter
jejunostomy (NCJ) should be considered for all
candidates for tube feeding undergoing major
upper gastrointestinal surgery
• Enteral feeding immediately following major
upper GI surgery is a suitable alternative to
parenteral feeding.
Imunonutrition
• Omega 3 fatty acid
• Glutamin
• Nucleotides
• Merupakan nutrisi enteral tinggi protein dengan tambahan immunonutrients
• Mengandung 16 gram protein / serving (63 gram dalam 200 mL air)
• Setiap saji mengandung :
Glutamine 2,5 g/saji.
BCAA 1,8 g/saji
Omega 3 0,1 g/saji
Nucleotide
• Kemasan : 190 gram
• Takaran saji : 5 sendok takar (63 gram) dalam 200 mL air
• Kerapatan kalori : 1 kkal/mL (250 kkal / saji)
• Varian : vanila
• Indikasi : criticall ill, luka bakar >20%
Postoperative nutrition period
• Appetite and diet intake decline during
recovery
• Early oral or EN should be given if not
contraindicated
• EN can be safely initiated 6 h after surgery via a
jejunostomy tube
• PN should be stop if oral or EN intake adequate
Postoperative nutrition
• To be considered in partial/total gastrectomy
• Post gastrectomy syndrome:
• - Dumping (early or late)
• - Small gastric remnant
• - Gastric atony
• Disturbed gastric function and motility
• Loss of duodenal route
Precaution
• Malabsorbtion : iron, vitamin B12 or folate have
been reported after resection gastric surgery 
anemia
Conclusion
• Morbidity and mortality UGI related moderate
and severe malnourished with physiologcal
disorders
• Perioperative nutritional support related good
outcome
• Early postoperative nutrition reduces surgical
trauma-related high metabolism, maintains the
function of the intestinal mucosal barrier and
decreases the incidence of intestinal-borne
infections, improving the recovery of patients
 THANK YOU
TERIMA KASIH
 PRE Operative
PRE Operative Care
planning

Manage PRE Operative

Affecting Factors evaluation
PERIOPERATIVE
CARE

POST Operative POST Operative

complication management

POST Operative
problems
Clear Liquid Diet
Acceptable food items
Water (plain, carbonated or flavored)
Fruit juices without pulp, such as apple or white grape
Fruit-flavored beverages, such as fruit punch or
lemonade
Carbonated drinks, including dark sodas (cola and root
beer)
Plain gelatin
Tea or coffee without milk or cream
Strained tomato or vegetable juice
Sports drinks
Clear, fat-free broth
Hard candy, such as lemon drops or peppermint
rounds
Ice pops without milk, bits of fruit, seeds or nuts
(except red)
http://www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in-depth/clear-liquid-diet/art-20048505