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Colectomy Management
P. Riobó, O. Sánchez Vilar, R. Burgos* and A. Sanz**
Endocrinology and Nutrition Service. Jimenez Diaz Foundation. Madrid. *Nutrition Unit. German Trias and Pujol Hospital.
Barcelona. **Nutrition Unit. Hospital Miguel Servet. Saragossa. Spain.
Summary
Colorectal surgery is one of the most frequently
performed surgical procedures on the digestive
tract. The colon plays an important role in
maintaining fluid and electrolyte balance, since it
has a great capacity for absorbing water, which
can be altered by surgery. In relation to artificial
nutritional support, it should be administered,
whenever possible, through the enteral route. PN
is only indicated postoperatively when major
complications occur in association with intestinal
failure. Early post-surgery EN, or oral supplements,
appear to be beneficial. Pouchitis occurs after
proctocolectomy with ileo-anal anastomosis with
pouch formation, in patients with ulcerative colitis,
and responds to treatment with antibiotics,
steroids, and probiotics.
(Nutr Hosp.2007;22:135-44)
Keywords:Colorectal surgery. Colectomy. Nutritional
support.
Introduction
Colorectal surgery is one of the most
frequently performed surgical procedures on the
digestive tract. Complications such as suture
dehiscence, intra-abdominal abscesses, and
peritonitis may occur. Therefore, it is necessary
to ensure an adequate supply of nutrients, as
part of the overall therapeutic plan.
Colon and rectal surgery can be partial
(sigmoidectomy, hemicolectomy, etc.) or total, affecting
Correspondence:Pilar Riobo.
Associate Chief.
Endocrinology and Nutrition Service.
Jimenez Diaz Foundation.
Reyes Católicos Avenue.
28040 Madrid.
E-mail: priobo@fjd.es
Received: 11-II-2007.
Accepted: 16-III-2007.
Nutr Hosp. 2007;22(Suppl. 2):135-44
ISSN 0212-1611 • CODEN NUHOEQ
SVR 318
COLECTOMY MANAGEMENT
Abstract
Colorectal surgery is one of the most frequently
performed surgical procedures on the
gastrointestinal tract. The large bowel plays an
important role in maintaining water and
electrolyte balance due to its high capacity of
water absorption that may be altered with surgery.
Artificial nutritional support should be
administered, whenever possible, and is well
managed with through the enteral route. PN is
indicated only at post-surgery when there are
major complications associated with intestinal
failure. Early post-surgery EN, or oral supplements,
seems to be beneficial. Pouchitis occurs after
proctocolectomy with ileoanal anastomosis with
the creation of a reservoir in patients with
ulcerative colitis, and is well managed with
antibiotic therapy, steroids, and probiotics.
(Nutr Hosp.2007;22:135-44)
Keywords:Colorectal surgey. Colectomy. Nutritional
support.
including the colon (total colectomy), the colon and
the rectum (proctocolectomy) and in some cases it
includes exeresis of the anus (abdominal-peritoneal
amputation). The extent of the resections depends
on both the cause and its location and extent.
Intestinal transit can be restored either by means
of digestive anastomoses or by performing
ostomies.1In some cases, a temporary stoma is
performed to later restore continuity by
performing an anastomosis between the two ends
of the affected intestine.
Total or partial resection of the large intestine
can compromise its absorptive capacity and cause
the fecal volume to increase considerably and its
consistency and composition to vary, which can
cause hydroelectrolytic imbalances. Initially, these
changes are attempted to be avoided or
ameliorated by dietary modifications.
The most common causes of surgical treatment
in this intestinal segment are: colorectal cancer,
135
colonic diverticular disease, intestinal volvulus,
usually in the cecum and sigmoid colon-
ulcerative colitis, colorectal polyposis, colonic
angiodysplasia, ischemic colitis, actinic colitis,
and fistulas. In Spain, colorectal neoplasia is the
second cause of death due to neoplasia and the
first in the case of the population without
smoking. Currently this surgery can be done
laparoscopically, which has cosmetic advantages
and allows faster recovery, but requires great
experience. Usually, the weight of the patients is
mostly within the normal range, and there is
usually no malnutrition. Nutritional repletion of
severely malnourished patients undergoing
chemotherapy may improve their clinical
outcome but, on the other hand, in non-
malnourished patients,
Another cause for colectomy is inflammatory bowel
disease (IBD). It is indicated when medical treatment
fails, or when faced with specific complications.
Surgery in ulcerative colitis (UC) practically eliminates
the disease, unlike Crohn's disease (CD), which can
come back in the future (recurrence). Almost 70-90%
of patients with CD must undergo surgery throughout
their evolution. Surgery in CD is almost always
elective. As is already known, CD is highly variable in
terms of location, complications... so the surgical
technique to be used is highly variable. If the
involvement is of the colon and/or rectum, it may be
segmental or diffuse (pancolitis). In the first case, the
technique to be used is resection of the affected
intestinal segment and anastomosis. In the second
case and if the rectum is healthy and there is no
perianal disease, a total colectomy with ileorectal
anastomosis can be performed, although recurrence
rates with this technique are high; but if the rectum is
diseased or there is poor function in the sphincter of
the anus or there is serious perianal disease (around
it) the best option is to remove the colon, rectum and
anus (coloproctectomy) leaving a definitive ileostomy.
Around, approximately 25%-45% of patients with
ulcerative colitis (UC) will need surgical treatment.
During an acute outbreak, the indication for surgery
depends fundamentally on its severity and the
response to steroid and immunosuppressive
treatment. Until the beginning of the 1980s, the
technique of choice was total coloproctectomy with
ileostomy, which consisted of removing the entire
colon, rectum and anus, leaving a hole through which
the intestine was exteriorized in the abdomen (stoma),
or an ileostomy. This operation means that the patient
is the bearer of a permanent stoma with the
consequent problems, especially social ones, that it
entails and is not well accepted by the patient. For
these reasons, techniques were designed to maintain
intestinal continuity, preserving the anus and joining
that ileum to it, forming an ileal bag or reservoir to
perform the functions of the rectum. This inter-
136 Nutr Hosp. 2007;22(Suppl. 2):135-44
The technique known as restorative
coloproctectomy or coloproctectomy with ileo-anal
reservoir has now become the technique of choice
in ulcerative colitis. The first panproctocolectomy
with pouch formation was performed by Nils Kock
in 1968.two, and was followed by the classic
description by Park and Nicholls in 19783, currently
being considered as the surgery of choice in
ulcerative colitis, in an attempt to avoid a
permanent stoma. However, this technique has a
high rate of long-term complications (mainly
pouchitis) and more interventions than
proctocolectomy with ileostomy, and there are few
differences regarding quality of life.4. This
operation should not be performed in cases where
the anal sphincter does not work properly or in
very elderly patients. Different types of reservoir
have been devised (J, S, W, H) but none has proven
to be superior to another, the most used being the
“J” reservoir. This technique also has its problems,
such as a greater number of bowel movements (it
is usual to have 4-8 bowel movements per day) and
tenesmus, urgency and even fecal incontinence, as
well as inflammation of the reservoir, fistulas, etc.
Another intervention with few indications is total
colectomy with ileorectal anastomosis. This
technique requires a healthy rectum that could
become diseased in the future. Its advantage is
that by not removing the rectum we avoid
damaging nerves very close to it that control
urination and sexual function,
pathophysiology
The gastrointestinal tract secretes about 7
liters of fluid each day, most of which is
reabsorbed, leaving only about 200 cc of water
in the stool. The colon plays a key role in
maintaining the fluid and electrolyte balance of
the body. In addition, it also participates in the
absorption of nutrients such as water, sodium
and short-chain fatty acids, from bacterial
fermentation of indigestible carbohydrates. The
colon receives approximately 1,500 ml/day of
secretions from the gastrointestinal tract.
However, only about 100-150 ml of fluid per day
is excreted with the stool, as the rest is absorbed
in the colon. In case of total or partial colectomy,
the unabsorbed water is eliminated with the
feces. This entails changes in the volume and
consistency of feces,
Sodium is absorbed mostly in the jejunum, but
also in the colon, where the remaining 90% of
sodium is recovered by an active Na+/K+ ATPase-
dependent mechanism, and is not accompanied by
anion cotransport. or cation exchange. The
absorption mechanism at the level of the colon is
based on the sodium pump and sodium exchange.
P. Riobo et al.
dio-hydrogen. Chlorine has a very similar pattern to
that of sodium, and could even depend on the same
absorption mechanisms. In case of partial or total
absence of the colon, the excretion of sodium in the
feces will increase as a function of the length resected.
Potassium is mainly absorbed in the jejunum. In
the colon this ion is actively secreted rather than
absorbed. Therefore, in case of colonic surgery, the
potassium balance is hardly disturbed.
The movement of the colon is the main
regulator of the absorptive and secretory
function, while conditioning the bacterial flora,
which is of great importance. In the right colon,
antiperistaltic waves are produced that generate
a retrograde flow of colonic content and
facilitate bacterial fermentation in the cecum.
Most of the absorption takes place in the cecum
and ascending colon, while in the transverse and
descending colon, peristaltic movements propel
the fecal content distally. Therefore, right
hemicolectomies are the partial colon resections
that present the most alterations in intestinal
motility. After a right hemicolectomy, there is an
acceleration of transit due to the loss of the
antiperistaltic mechanism and the increase in
bile salts in the transverse colon.
Soluble fiber is made up of carbohydrates that
cannot be digested by pancreatic and intestinal
enzymes, and therefore cannot be absorbed in
the small intestine and reach the colon in the
form of polymers or oligosaccharides. There
they are fermented by colonic bacteria, mainly in
the cecum, producing short chain fatty acids
(butyric, acetic and propionic), alcohols and two
gases
two
(CO and H). Short-chain fatty acids are
absorbed by the colon, providing a direct source
of energy for the colonocyte. It also makes it
possible to significantly reduce the osmotic load
of the colon, and prevent greater water loss. The
absorption of short-chain fatty acids favors the
colonic absorption of sodium. After colonic
surgery, depending on the segment resected,
The terminal ileum and colon, with their
intestinal bacteria, also have a role in the
enterohepatic circulation of bile acids and
cholesterol metabolism. Proctocolectomy with
construction of an anastomosis, a reservoir, or
with ileorectal anastomosis can decrease the
pool of bile acids. These patients have been
found to have a more favorable lipid profile, due
to increased fecal losses of bile acids, despite an
abnormally high rate of cholesterol synthesis.
5.
Colectomy Management Nutr Hosp. 2007;22(Suppl. 2):135-44
Patients who have undergone a colectomy with
ileorectal anastomosis or with ileostomy are those
who present a more important anatomical alteration,
especially if resection of the distal segment of the
terminal ileum has been performed, where bile
absorption takes place and absence of ileocecal valve.
These patients present an increase in the frequency
and volume of stools, which are of lesser consistency.
In the early stages, up to 1,500 ml of bilious liquid
feces can be expelled daily and more than 10 diarrheal
stools per day. When a significant portion of the
terminal ileum is resected along with the ileocecal
valve, neither the bile salts nor the B vitamins can be
reabsorbed. The latter12
must be supplemented by im
route for life.
Sigmoidectomy is the most frequent of the
colonic resections and in which the colonic
movement pattern is least altered. In the majority
of patients who undergo a left hemicolectomy,
there are normally no problems with hydrosaline
loss or an increase in the number of stools.
Pre-operative nutrition
A small number of patients who are going to
undergo colectomy present malnutrition due to
anorexia, inflammation, restrictive diets, avoidance
behaviors aimed at not triggering digestive
symptoms, episodes of intestinal pseudo-occlusion,
and fasting to carry out complementary tests. But the
usual thing is that they arrive at the surgery with a
good nutritional state.
Nutritional treatment in the pre-surgical phase is a
controversial issue. A low-residue diet accompanied by
mechanical bowel preparation was usually
recommended in order to reduce the fecal bolus. This
is achieved by eliminating foods that are difficult to
digest and absorb, such as fiber, the connective tissue
of meat and milk, during the 2-3 days before. It is also
recommended to eliminate fats because they can
delay gastric emptying6. But this diet is clearly
incomplete. For this reason, other authors propose
using a liquid enteral diet, without residue, orally for
2-3 days beforehand. In 2 recent meta-analyses7The
efficacy of colon preparation has been evaluated, and
it has been shown that mechanical cleansing of the
colon increases the risk of anastomotic leakage, and
there is a tendency for more complications such as
surgical wound infection, septic complications,
reinterventions and higher mortality. It is also
uncomfortable for the patient. Therefore, they
conclude that it should not be carried out
8.
In another study, the administration of a carbohydrate
solution three hours before surgery has been associated
with a decrease in postoperative insulin resistance, an
improvement in patient satisfaction before and after the
intervention, and a reduction in the average length of
stay. 9.
137
postoperative phase
After surgery, especially in the case of ileostomy,
proximal colon resection, and in the presence of
high-output fistulae, care must be taken when
signs of dehydration appear. But it has also been
described that an excess of liquids in the
postoperative period can translate into negative
effects in the evolution10. In a clinical trial with 20
patients who underwent hemicolectomy or
sigmoidectomy, the administration of 3 liters of
serum therapy, compared to 2 liters, was
associated with a longer mean stay, decreased
albuminemia, weight gain, time of serum therapy
and start of solid intake, delayed gastric emptying
and days to first bowel movement
eleven
Malnutrition can occur due to decreased
nutrient intake and increased energy and
nutrient requirements due to metabolic stress
caused by any intervention. The decrease in the
absorption of short-chain fatty acids, due to
colectomy, also influences.
Symptoms will depend on the type of
intervention. For example, after a right
hemicolectomy with ileocolic anastomosis, the
antiperistaltic mechanism of the cecum and the
ileocecal valve are lost; if part of the distal ileum
has also been resected, a greater influx of
unabsorbed bile salts into the transverse colon is
generated. As a result of all this, choleretic
diarrhea may appear if it depends on the
malabsorption of bile salts. When it comes to an
ileostomy or subtotal colectomy with ileorectal
anastomosis, the volume and frequency of stools
increases and their consistency decreases. In
this case it is very difficult to recover the normal
pattern. However, after a sigmoidectomy there is
usually no alteration of intestinal transit.
oral nutrition
The oral diet in the immediate postoperative period
depends on the extension of the resected colon segment,
on whether there is continuity with the rest of the
intestine or, on the contrary, on the location of the
ostomy. The objective is to reduce diarrhea, and
therefore, the loss of fluids and electrolytes and increase
the consistency of the stool.12. Depending on the parched
section, the diet will be different. For example, in
sigmoidectomies and left hemicolectomy, it is not
necessary to follow a special diet. In general, the more
proximal the ostomy, the lower fiber content the diet will
provide. The purpose is to slow down intestinal transit. In
the case of right hemicolectomy with ileo-colic
anastomosis, or total colectomy with ileo-anal
anastomosis, a low-residue diet is usually necessary.
13Sometimes it is necessary to use oral rehydration
solutions, antiperistaltic drugs (codeine and
loperamide) and pharmacological fiber supplements
138 Nutr Hosp. 2007;22(Suppl. 2):135-44
soluble. These recommendations may be transitory,
depending on how the rest of the remaining intestine
adapts, so, depending on the evolution of each
patient, the diet will be modified at an individual level,
in order to tolerate a diet that is as similar as possible
to a balanced diet. In the case of presenting gases and
unpleasant odors, the most flatulent foods should be
avoided.
A low-residue diet will be indicated when the
patient with a descending colostomy or
sigmoidostomy presents stools of a semi-liquid
consistency; also in the postoperative period of a
transverse colostomy, an ascending colostomy
or a right hemicolectomy with ileo-colic
anastomosis. After a few days, when the patient
eats a complete diet, the fiber intake will be
adjusted according to individual needs. Over
time, the remaining intestine adapts and these
patients can tolerate a balanced diet. General
recommendations for diet are shown in Table I.14
Recommended, limited, and discouraged foods
are shown in Table II.
Table I
Nutritional recommendations for the patient with
colectomy
• Drinking coffee and carbonated drinks is discouraged.
• Season dishes with salt, unless expressly indicated by
your doctor.
• Meals of little amount and several times a day: the ideal is to
distribute the daily diet in 6 meals.
• Avoid fried, battered, or stewed foods.
• Do not eat very hot or very cold food.
• Try to eat slowly and in a quiet environment
• Chew well, since the food is more crushed, digestion
is facilitated and the chances of obstruction of the
stoma are reduced.
• Rest up to half an hour after main meals.
• Eliminate insoluble fiber.
• Reduce total fat intake, especially those that most
stimulate bile secretion.
• Reduce the intake of lactose (milk and derivatives except
yogurt) and gradually reintroduce it according to tolerance.
• Eliminate flatulent foods: carbonated drinks, cabbage,
cauliflower, Brussels sprouts, broccoli, legumes, peas,
broad beans, asparagus, nuts and onions.
• Minimum water supply of 1.5 liters per day, divided into
small intakes throughout the day.
• Reducing the volume of dinner helps reduce
nocturnal excretion of feces.
• Foods that give a more solid consistency are rice,
potatoes, pasta, semolina, bread, applesauce, ripe
bananas and soft cheese.
• Foods that produce odor are the following: garlic,
asparagus, fish, eggs and onions. Parsley, butter
and yogurt reduce the smell.
P. Riobo et al.
 Table II
Advised, limited or discouraged foods during the 2-3 months after a colectomy (with or without ostomy).
Adapted from M. Planas (ref 12) and Solá i Saló (ref 13)

food group recommended limited discouraged

Dairy products Special lactose-free milk fresh cheeses Milk

Cured cheese Cream and milk cream
Melted cheese Very fatty cheeses
plain yogurt yogurt with fruit

meat lean meats Lamb or pork meat sausages

Cooked ham with visible fat pates
Serrano ham defatted very tough meats
White fish and stringy
Eggs Blue fish and seafood

cereals, legumes, Pasta breakfast cereals Whole grains and their

tubers Rice derivatives
Tapioca Legumes (all)
White bread and biscuits
Potatoes

Vegetables and vegetables cooked carrot all in general very stringy vegetables
(artichokes, cabbage,…)

Fruits Quince Ripe banana Other raw fruits

Fruits in syrup, baked or boiled striped apple

Beverages Water Wine (with meals) Carbonated drinks

infusions Coffee
Fat-free strained broths Alcoholic drinks
Coffee high grade
Fruit juice

Fatty foods olive and sunflower oil butter and margarine Mayonnaise
Nuts

sweets and pastries Homemade meringues and biscuits honey and sugar chocolate and cocoa
Maria type biscuits Candy Confectionery and pastries in
general
whole grain crackers

condiments and others Salt Vinegar cooked dishes

Aromatic herbs Soups and other
precooked dishes
commercial sauces

In cases with diarrhea, or with a very high
volume of liquid feces that cause dehydration, it
is useful:
• Administer drugs that slow down peristalsis
(diphenoxylate, loperamide).
• Add soluble fiber supplements before main
meals: hydrolyzed guar gum (benefiber),
guar gum, plantago ovata (plantaben), etc.
• Take 1 liter of rice water (boil for 20 minutes,
over medium heat, 50 g of rice and a carrot-
large peeled horia in a liter and a half of salted
water. Strain and let cool).
• Do not eat vegetables or salads, except small
amounts of boiled carrots.
• Do not drink milk or yogurt. You can drink lactose-
free milk (Resource Sinlac, Diarical).
In case of resection of the terminal ileum, with
reconstruction of the transit or ileostomy, they must be
supplemented with vitamin
12
B, injected intramuscularly
(1,000 gammas per month) for life. In addition you can

Colectomy Management Nutr Hosp. 2007;22(Suppl. 2):135-44 139

Administration of cholestyramine may be necessary to
chelate bile salts and prevent biliary diarrhea.
After the first 2-3 months, an attempt is made to
gradually reintroduce, if they feel good, the foods
that are not recommended. We must continue to
avoid whole grains and products that contain them,
legumes and fibrous vegetables. Vegetables, fruits
and vegetables must be consumed in moderation.
At first take the boiled dishes. If you tolerate the
diet well, you can introduce simple stews (potatoes
stewed with meat or fish) prepared with little oil.
For the introduction of vegetables in the diet: you
can introduce small amounts (50 g) of cooked
vegetables, at first in the form of puree, if they do
not make you feel bad. As you tolerate them, you
can increase the amount and type of vegetables.
You can take natural yogurt and after a few days
introduce small amounts of milk (half a glass),
A diet rich in fiber is recommended in colonic
resection with descending colostomy and in the
presence of a sigmoidostomy, as well as in all cases
that evolve with constipation once other possible
causes unrelated to food have been ruled out. A
diet rich in fiber is considered one that provides
between 30 and 40 g of dietary fiber each day.
Above this amount, it does not provide additional
benefits, and discomfort may appear, such as a
feeling of fullness, abdominal distension and
meteorism.
The increase in fiber is mainly at the expense of
insoluble fiber (cellulose, hemicellulose, and lignin), which
increases weight and gives volume to feces, decreases the
intraluminal pressure of the remaining colon, and
decreases transit time. The greatest contribution in fiber
is achieved by increasing the intake of whole grain bread
and cereals, legumes, vegetables, fruits and bran.
It is advisable to increase the intake of foods
rich in fiber gradually in order to minimize
gastrointestinal discomfort. An adequate intake
of liquid foods and water is also important to
achieve a correct use of fiber intake as well as
the regular practice of exercise within the
individual possibilities of each patient.
The use of transition diets, starting oral
feeding with a liquid diet and progressing to a
complete diet, is common, although there is no
scientific evidence to justify it. Several studies
have shown that early oral intake is safe, even
after colon surgery with anastomosis. In a
clinical trial on open colorectal surgery, it was
shown that, with regard to the introduction of
food after the first defecation, liquid tolerance 4
hours after surgery, followed by solid food the
day after, decreased the average stay of the
operated patientsfifteen. Early enteral nutrition has
also been used, and in the context of treatment
140 Nutr Hosp. 2007;22(Suppl. 2):135-44
perioperative multifactorial 16. Nausea, vomiting
Cough or adynamic ileus can be minimized with the
use of prokinetics or thoracic epidural anesthesia with
or without small doses of opiates.
parenteral nutrition
in a review17Some years ago, it was established that
the use of parenteral nutrition is not indicated for all
patients who are not severely malnourished, since it
increases the risk of complications. However, the
intake of macronutrients was excessive in relation to
what is currently indicated (1-2 g of protein, 30-50
non-protein kcal). In our country, the Nutritional
Support Unit of the Vall d'Hebrón General University
Hospital in Barcelona has communicated its
experience after the implementation of a nutritional
action protocol for patients with colon cancer,
demonstrating that it improves the cost/effectiveness
ratio of this treatment18. They have compared the
situation prior to the implementation of the protocol
and at one and two years. They analyzed the
nutritional status at admission and discharge, the use
of PN, hospital stay (EH), preoperative stay (POE), and
the presence of complications. Most of the patients
were well nourished at admission, but during the first
period (PRE, prior to the implementation of the
protocol) the patients significantly worsened their
nutritional status at discharge. After the
implementation of the protocol, there was a marked
decrease in the use of PN, especially in normally
nourished patients, from the PRE period, from 80% to
11.3%. The overall HE decreased significantly. It was
confirmed again that normally nourished patients who
take PN present more complications compared to
those who do not take it.
At the Bellvitge University Hospital, a nutrition
it has been said
19
protocol for colorectal pathology susceptible to
laparoscopic surgery has been outlined. It is based on
home preparation that allows surgery without prior
admission. Intestinal decontamination is performed in
the operating room prior to surgery. Thanks to less
invasive surgical techniques, and the use of new
anesthetic drugs and analgesia without opiates“
Multimodal surgical strategies” it is possible to twenty
minimize paralytic ileus and termesis, and therefore,
allows early intraluminal nutrition. The patient's
functional recovery is faster, and the subjective feeling
of well-being improves. In addition, nutritional
support with polymeric formulas without fiber or
digestive tract residues, allows early nutrition of the
patient since they are absorbed in the proximal
segments of the small intestine.
In phase I, lasting 7 days, the preparation is
carried out at home, with a diet low in residues and
insoluble fiber, supplemented with 400 mL of a
hyperproteic polymeric formula without lactose or
fiber, colon cleansing two days before surgery and
hydration with water, sugary infusions and broths
P. Riobo et al.
vegetables. In phase II, in the immediate
postoperative period, a liquid diet is maintained for
3 days with a polymeric diet without fiber. In phase
III, a semi-solid diet without residues is given, a
nutritional formula and the progressive
reintroduction of food intake is started. They
present their results with this protocol, and feeding
could be started at 24 hours in 63% of patients, and
at 48 hours in 32%. Hospital discharge was
achieved in 3-5 days in 60% of patients, and
between 6-10 days in 28%; in 12% it was delayed
more than 20 days due to complications. The
progressive regimens were well tolerated by all
patients, without diarrhea; the number of stools
varied between 2-4 of normal soft consistency. The
authors conclude that early nutrition in colorectal
surgery is possible,
Enteral nutrition
EN in the postoperative period offers controversial
results. In a review containing three clinical trials on
patients with gastrointestinal carcinoma or colorectal
carcinoma, 5 to 10 days of postoperative enteral
nutrition did not lead to differences in morbidity and
mortality. However, individual studies have shown
benefits, even after early introduction. Thus, nutrition
through the nasojejunal route, started within 3-4
hours after surgery, versus fluid therapy for 3-5 days
after gastrointestinal resection, increased nitrogen
balance and decreased the number of complications.
In a study in patients with colonic resections, the
administration of enteral nutrition with a
nasoduodenal tube (1.5 kcal/mL) from 4 hours after
surgery achieved a reduction in postoperative
complicationstwenty-one. In another study, enteral
nutrition by nasojejunal tube, started on the same day
as surgery, showed a trend towards fewer
complications and a shorter mean stay22. A beneficial
trend, although not statistically significant, has also
been observed in insulin resistance, mean hospital
stay and infections, after the establishment of
complete nutrition through the nasojejunal route on
the same day of surgery.
Recent studies have shown a reduction in
hospital stay and postoperative complications in
elderly patients who underwent laparoscopic
colectomy, and the shorter stay and lower
morbidity have been attributed to the
laparoscopic approach. However, it is also
possible that the best results are due to early
postoperative feeding. In another study, patients
with elective open colectomy were given early
feeding. The protocol consisted of liquids on
postoperative day 2, and a basal diet on day 3.
Among the 87 patients included, the most
frequent intervention was right hemicolectomy
(53%). Overall, 89.6% tolerated early feeding.
Only 5 patients (5.7%) initial-
Colectomy Management Nutr Hosp. 2007;22(Suppl. 2):135-44
they tolerated but were readmitted for ileus.
Only 10.4% did not tolerate early nutrition.
Hospital stay was 3.9 days. There were 15
postoperative complications in 13 patients
(14.9%), the most common being urinary
retention. The authors conclude that in patients
undergoing open colectomy, early feeding
results in decreased hospital stay and low
morbidity. Results are similar to laparoscopic
23.
colectomy
Several studies have assessed the effects of using
hyperprotein oral supplements versus a regular diet
or dietary advice 2 to 4 months after surgery24. In
general, it has been shown: less weight loss25,
increased lean mass and reduced number of
complications26. There is no agreement between them
whether or not supplementation improves muscle
strength or quality of life27. When benefits have been
seen, they have only been demonstrated in
malnourished subjects.
In summary, in relation to artificial nutritional
support, it can be concluded that it is indicated in
severely malnourished patients undergoing colorectal
surgery, since it improves after prognosis. It must also
be considered whenever oral intake is not achieved in
7-10 days in normonourished patients or in 5-7 days in
malnourished patients. Perioperative nutritional
support should be administered, whenever possible,
through the enteral route. PN is only indicated
postoperatively when major complications occur in
association with intestinal failure. Early post-surgery
EN, or late oral supplements, seem to be more
beneficial in colorectal surgery than in surgery. The
implementation of a specific nutritional support
protocol makes it possible to reduce PN and shorten
hospital stay.
pouchitis
Pouchitis is the most frequent complication after
proctocolectomy with ileo-anal anastomosis, and with
pouch formation (IPAA). It is an idiopathic chronic
inflammation that occurs in up to 60% of patients after
this anastomosis in ulcerative colitis and has specific
clinical characteristics. This surgical technique is the 28.
technique of choice in most patients with ulcerative
colitis who require colectomy for disease refractory to
medical treatment or for complications such as
dysplasia. However, it rarely occurs in patients
undergoing this same surgery for familial
adenomatous polyposis. IPAA patients typically have
4-8 bowel movements per day with semi-formed
stools. When pouchitis is present, there is an increase
in the frequency of stools that become liquid and are
accompanied by abdominal cramps, urgency and
tenesmus and occasionally, bleeding and fever. Fecal
incontinence is not uncommon after IPAA, but it is 29.
almost the norm if there is pouchitis. This inconti-
141
nence clearly affects the quality of life of
patients. Rarely, in case of acute pouchitis, IV
rehydration and antibiotic treatment are
necessary. Extraintestinal manifestations may
also be seen. If pouchitis is suspected, the
diagnosis should be confirmed by endoscopy
and mucosal biopsy. Most patients with acute
pouchitis respond well to a course of antibiotic
therapy.
The pathophysiology of pouchitis is not fully
understood.30. The fact that pouchitis occurs almost
exclusively in IPAA patients from ulcerative colitis
suggests a genetic factor. Furthermore, it does not
occur until the ileostomy is closed and the ileal
content comes into contact with the bag,
suggesting that bacterial antigens are important in
developing the inflammatory process. It is not clear
whether pouchitis is caused by bacterial
overgrowth or by the presence of abnormal
bacteria. Sulfate-producing bacteria appear to exist
only in the bursae of patients with ulcerative colitis.
31. The effluent flora of the bag contains a higher
ratio of anaerobes to aerobes and more bacteroid
and bifido bacteria. Antibiotic treatment decreases
the total bacterial count and can selectively
eradicate certain pathogens.32. Published risk
factors for the development of pouchitis include
extensive or severe ulcerative colitis, young age at
diagnosis, gender, presence of extraintestinal
manifestations of inflammatory bowel disease.
Primary sclerosing cholangitis, consumption of
nonsteroidal anti-inflammatory drugs, positivity for
perinuclear antineutrophil cytoplasmic antibodies
(ANCA), and polymorphisms in the interleukin 1 and
TNF receptor antagonist gene. Smoking and
fulminant colitis as an indication for
proctocolectomy seem to be protective factors.
Diagnosis is established by endoscopy of the bursa,
in which inflammatory changes with edema,
friability, loss of the vascular pattern, ulcerations,
and allows the evaluation of the ileum and the
rectal sleeve if it exists. Some ulcers along the
staple line in the pouch are common, but by
themselves they do not indicate the presence of
pouchitis. Endoscopy with a gastroscope is
recommended because of its smaller size and
greater flexibility. Bursa biopsy allows differential
diagnosis with Crohn's disease, cytomegalovirus
infection, and ischemia. A biopsy should be
performed even when the endoscopic appearance
is normal, since some patients may have few
symptoms but with evidence of active inflammation
in the biopsy. When biopsiing, the area around the
staple line should be avoided. Histological
examination shows the changes of acute
inflammation including pro-neutrophil infiltration,
crypt abscesses and mucosal ulceration. There may
be chronic inflammatory changes in the ileal
pouches that reflect the effect of fetal ectasia.
142 Nutr Hosp. 2007;22(Suppl. 2):135-44
chronic cal and therefore pouchitis should not
be diagnosed in the absence of acute
inflammation. Measurement of faecal lactoferrin
33.
has been suggested to be an indicator of
inflammation in IPAA patients. However,
elevated levels of faecal lactoferrin do not
differentiate from Crohn's disease. Occasionally,
it may be interesting to perform a pouchogram
with contrast x-rays of the pouch to assess
strictures and pouch emptying, or a pelvic MRI
when the patient has perianal fistulae, fecaluria,
pneumaturia, vaginal discharge of feces … Some
patients may have difficulty emptying the bag
because it is too large or because of damage to
enteric nerves during bag construction, or
because of pelvic floor dysfunction,
Regarding treatment, most patients respond to
metronidazole (750-1000 mg/day) or ciprofloxacin
(1000 mg/day). However, few randomized
controlled trials have been conducted. In a
crossover trial, metronidazole was superior to
placebo in improving symptoms, but there was no
histological improvement.3. 4. Patients with
recurrences or chronic forms need maintenance
antibiotics. Topical or oral steroids (budesonide)
have also been used with mixed results. It is an
option for the few cases of poor response to
antibiotic treatment35. Recent studies have shown
that changing the flora of the bursa may be helpful
in maintaining remission. In a study with 40
patients in remission, and randomly assigned to
placebo or Probiotics (lactobacilli, bifidobacteria
and streptococcus), a recurrence rate of 15% with
Probiotics and 100% with placebo was
demonstrated at 9 months36. However, there are
also studies with negative results. In another
controlled study, patients who had undergone IPAA
were prophylactically treated with probiotics or
placebo. The incidence of pouchitis in the first year
was also decreased with probiotics (10%vs40%).
Furthermore, the probiotic group also had
decreased stool frequency, with no histologic
evidence of pouchitis.
QUESTIONS
1. Regarding the functions of the colon, mark the
incorrect answer:
a. Has a role in potassium absorption
b. Has a role in absorbing water
c. Has a role in the absorption of short-chain
fatty acids
d. Has a role in sodium absorption
e. Controls bowel movements
1st
P. Riobo et al.
2. Regarding nutritional support in colon
surgery;
a. Parenteral nutrition can improve evolution
and reduce hospital stay
b. Patients often have very poor nutritional
status
c. Early enteral nutrition cannot be used if
anastomoses have been performed
d. It is indicated in patients with severe malnutrition
3. Regarding pouchitis, point out what is not
correct:
a. It is common in patients undergoing a total
colectomy with a reservoir for ulcerative
colitis or familial adenomatous polyposis.
b. The treatment of choice is metronidazole.
c. In resistant cases, budesonide can be used.
d. Probiotics decrease the rate of recurrence
and. Probiotics can decrease the number of bowel
movements
3rd
4. In relation to artificial nutritional support in patients
undergoing colorectal surgery, point out what is false:
a. It is indicated in severely malnourished patients.
b. It should always be considered that oral intake is not
achieved in 7-10 days in normonourished patients or in
5-7 days in malnourished patients.
c. PN is only indicated in the postoperative
period when major complications occur in
association with intestinal failure.
d. Oral supplementation in the late postoperative
period is not indicated.
and. The implementation of a specific protocol of
nutritional support, allows to reduce the PN and
shortens the hospital stay
4.d.
5. In cases with diarrhea, it is not useful:
a. Administer drugs that slow peristalsis
b. Add soluble fiber supplements before main
meals
c. Take astringent foods (rice water, cooked
carrot...)
d. Eat whole grains as a source of insoluble
fiber
and. drink lactose-free milk
5d
6. Among the most common causes of colectomy are
a. Colorectal cancer
b. Diverticular disease of the colon
c. Ulcerative colitis, colorectal polyposis
d. colonic angiodysplasia
and. All of them
6. e.
Colectomy Management Nutr Hosp. 2007;22(Suppl. 2):135-44
References
1. Rolandelli RH, Roslyn JJ. Colon and rectum. In: Townsend CM,
(ek) Sabinston Texbook of surgery. The biological basis of
modern surgical practice. Philadelphia Saunders, 2001:
929-973.
2. Hulten L. Proctocolectomy and ileostomy to pouch surgery for
ulcerative colitis.World J Surg1968; 335-41.
3. Parks Ag, Nicholls J. Proctocolectomy without ileostomy for
ulcerative colitis.Br Med J1978; 2:85-88.
4. Camilleri_Brennan J, Munro A, Steele R. Does an ileoanal pouch
offer a better quality of life than a permanent ileostomy for
patients with ulcerative colitis?J Gastrointestinal Surg2003;
7:814-9.
5. Nissinen MJ, Gylling H, Jarvinen HJ, Miettinen TA.Dig Dis
abd Sci2004; 49:1444-53.
6. Matía P, Cabrerizo L. Nutritional support in patients with colon
surgery. In: Manual of nutrition and metabolism. Bellido and
DeLuis Eds. Diaz de Santos. Madrid 2006.
7. Bucher P, Mermillod B, Gervz P. Morel P. Mechanical bowel
preparation for elective colorectal surgery. A meta-analysis.
Arch Surg2004; 139:1359-1365.
8. Roumen RM: Meta-analysis of randomized clinical trials of
colorectal surgery with or without mechanical bowel
preparation.Br J Surg2005; 92:253.
9. Nygren J, Thorell A, Ljungqvist O. Preoperative oral
carbohydrate nutrition: an update.Curr Opin Clin Nutr Metab
Care 2001;4:255-9.
10. Sitges-Serra A, Franch-arcas G. Fluid and sodium problems in
perioperative feeding: what further studies need to be done?
Curr Opin Clin Nutr Metab Care1998; 1:9-14.35.
11. Lobo Dn, Bostock KS, Neal KR, Perkins AC, Rowlands BJ, Allison
SP. Effect of salt and water balance on recovery of
gastrointestinal function after elective colonic resection: a
randomized controlled trial.Lancet2002; 359:1812-8.
12. Planas M, Puiggros C, De Lara F, Espín E. Nutritional
recommendations in the postoperative period of ileostomy,
colectomy and colostomy. . In: Manual of recommendations for
hospital discharge. Leon Sanz M, Celaya S, eds. Barcelona.
Novartis Consumer Health SA: 2001; 13-18.
13. ME Saló i Solá. Diet in intestinal resection. In: Salas-Salvado J,
Bonada A, Trallero R, Saló ME (eds). Nutrition and clinical
dietetics. Barcelona. Mason 2002: 475-487.
14. Stewart BT, Woods RJ, Collopy BT, Fink RJ, Macakay JR, Deck JO.
Early feeding after elective open colorectal resections: a
prospective randomized trial.Aust NZJ Surg1998; 68:125-8.
15. Kehlet H, Wilmore DW. Randomized clinical trial of the effects
of immediate enteral nutrition on metabolic responses to
major colorectal surgey in an enhanced recovery protocol.
Multimodal strategies to improve surgical outcome.Am J
Surg 2002; 182:630-41.
16. Klein S, Kinney J, Jeejeebhoy K, Alpers D, Hellerstein M, Murray
M, Twomey P. Nutrition support in clinical practice: review of
Publisher data and recommendations for future research
directions. National Institutes of Health. American society for
Parenteral and Enteral Nutrition and American Society for
Clinical Nutrition.JPEN1997; 21:133-156.
17. Nutritional action in elective surgery for colorectal cancer.
Burgos R, Peñalva A, Espin E, Armengol M, Roselló J, Planas
M.3.Nutr Hosp2003; Volume XVIII. Suppl. 1.
18. Fernandez de Bustos A, Creus Costas G, Pujol Gebelli J, Virgili
Casas N, Pita Merce AM. Per os early nutrition for colorectal
pathology susceptible of laparoscopy-assisted surgery. Nutr
Hosp2006 Mar-Apr; 21(2):173-8.
19. Bradram P, Funch-Jensen P, Kehlet H: Rapid rehabilitation in
elderly patients after laparscopic colonic resection.Br J Surg
2000; 87:1540-1545.
20. Beber-Holgersen R, Boesny S: Influence of postoperative enteral nutrition
on postsurgical infections.gutnineteen ninety six; 39:833-5.
21. Soop M, Carison GL, Hopkinson J, Clarke S, Thorell A, Nygren J
et al. Randomized Clinical Trial of the effects of immediate
enteral nutrition on metaboic responses to greater
143
 colorectal surgery in an enhanced recovery protocol.Br J Suez
2004; 91:1138-45.
22. DiFronzo LA, Yamin N, Patel K, O'Connell TX. Benefits of early
feeding and early hospital discharge in elderly patients
undergoing open colon resection.J Am Coll Surg2003 Nov;
197(5):747-52.
23. Deele AM, Bray MJ, Emery PW, Duncan HK, Silk DB. Two phase
randomized controlled clinical trial of postoperative oral
dietary supplements in surgical patients.gut1997; 40:393-9.
24. Beattie AH, Prach At, Baxter JP, Pennington CR. A randomized
controlled trial evaluating the use of enteral nutritional
supplements postoperatively in malnourished surgical
patients.gut2000; 46:813-8.
25. Keele AM, Bray MJ, Emery PW, Duncan HK, Silk DB. Two phase
randomized controlled clinical trial of postoperative oral
dietary supplements in surgical patients.gut1997; 40:393-9.
26. Jensen MB, Hessov I. Randomization to nutritional intervention
at home did not imporve postoperative function, fatigue or
well-being.Br J Surg1997; 84:113-8.
27. Sandborn WJ. Pouchitis following ileal pouch-anal anastomosis:
definition, pathogenesis and treatment.Gastroenterology 1994;
107:1856-60.
28. Pardis DS, Sandborn WJ. Systematic review: the management
of pouchitis.Aliment Pharmacol Ther2006; 23:1087-1096.
144 Nutr Hosp. 2007;22(Suppl. 2):135-44
29. Sandborn WJ, Pardi DS. Clinical management of pouchitis.
Gastroenterology2004; 127:1809-14.
30. Duffy M, O'Mahony L, Coffey JC, et al. Sulfate-reducing bacteria
colonize pouches formed for ulcerative colitis but not for
familial adenomatous polyposis.Dis Colon Rectum2002;
45:384-8.
31. Gosselink MP, Schouten WR, Van Lieshout LM et al. Eradication
of pathogenic bacteria and restoration of normal pouch
flora: comparison of metronidazole and ciprofloxacin in the
treatment of pouchitis.Dis Colon Rectum2004; 47:1519-25.
32. Parsi MA, Shen B, Achkar JP et al. Fecal lactoferrin for diagnosis
of symptomatic patients with ileal pouch-anal anastomosis.
Gastroenterology2004; 126:1280-6.
33. Mimura T, Rizzello F, Helwig U et al. Four-week open-label trial
of metronidazole and ciprofloxacin for the treatment of
recurrent or refractory pouchitis.Aliment Pharmacol Ther
2002; 16909-17.
34. Gionchetti P, Rizzello F, Morselli C et al. Eight-week trial of oral
budesonide for the treatment of refractory pouchitis.
Gastroenterology2004; 126:A123.
35. Gionchetti P, Rizzello F, Helwig U et al. Prophylaxis of pouchitis
onset with probiotic therapy: a double-blind, placebo-
controlled trial.Gastroenterology2003; 124:1202-9.
P. Riobo et al.